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Slaney ED, Modica R, Woolnough L, Kafisheh D, Bell-Brunson DH, Elder M. Case Report: Refractory macrophage activation syndrome requiring high-dose anakinra, emapalumab, and etoposide therapy in early-onset systemic juvenile idiopathic arthritis associated with adenoviremia. Front Pediatr 2024; 11:1336554. [PMID: 38322244 PMCID: PMC10845352 DOI: 10.3389/fped.2023.1336554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/21/2023] [Indexed: 02/08/2024] Open
Abstract
Macrophage activation syndrome (MAS) is a life-threatening condition characterized by the excessive stimulation of macrophages and T lymphocytes, provoked by infections, malignancy, and autoimmune or autoinflammatory conditions such as systemic juvenile idiopathic arthritis (sJIA). Clinical signs of sJIA may include high-spiking, quotidian fevers, lymphadenopathy, hepatosplenomegaly, and a salmon-colored migratory, evanescent rash. By contrast, MAS is characterized by unremitting fevers and diffuse, fixed, maculopapular rashes. In addition to hepatosplenomegaly and lymphadenopathy, patients with MAS may also have clinical signs of coagulopathy, as well as cardiac, lung, renal, and central nervous system dysfunction. The empiric treatment for MAS is initially high-dose IV corticosteroids, but usually requires addition of immunomodulators such as tacrolimus or a biologic such as Anakinra to control. The addition of immunotherapies for MAS has improved patient outcomes. We present a 2-year-old male patient with a history of early-onset sJIA, who presented with MAS refractory to corticosteroids and anakinra triggered by adenoviremia that required addition of emapalumab to control. We believe this is the first reported case of a combination of immunosuppressive therapy of emapalumab, etoposide, anakinra, tacrolimus, and corticosteroids used in the successful treatment of infection-induced MAS in early-onset sJIA. Given the lack of treatment guidelines and approved therapies for MAS, alternative strategies should be considered for patients with an intractable course.
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Affiliation(s)
| | - Renee Modica
- College of Medicine, University of Florida, Gainesville, FL, United States
- Division of Pediatric Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Leandra Woolnough
- College of Medicine, University of Florida, Gainesville, FL, United States
- Division of Pediatric Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Dina Kafisheh
- College of Medicine, University of Florida, Gainesville, FL, United States
- Division of Pediatric Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Denise Heather Bell-Brunson
- College of Medicine, University of Florida, Gainesville, FL, United States
- Division of Pediatric Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Melissa Elder
- College of Medicine, University of Florida, Gainesville, FL, United States
- Division of Pediatric Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of Florida, Gainesville, FL, United States
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Gao X, Michel K, Griese M. Interstitial Lung Disease in Immunocompromised Children. Diagnostics (Basel) 2022; 13:diagnostics13010064. [PMID: 36611354 PMCID: PMC9818431 DOI: 10.3390/diagnostics13010064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The range of pulmonary complications beyond infections in pediatric immunocompromised patients is broad but not well characterized. Our goal was to assess the spectrum of disorders with a focus on interstitial lung diseases (ILD) in immunodeficient patients. METHODS We reviewed 217 immunocompromised children attending a specialized pneumology service during a period of 23 years. We assigned molecular diagnoses where possible and categorized the underlying immunological conditions into inborn errors of immunity or secondary immunodeficiencies according to the IUIS and the pulmonary conditions according to the chILD-EU classification system. RESULTS Among a wide array of conditions, opportunistic and chronic infections were the most frequent. ILD had a 40% prevalence. Of these children, 89% had a CT available, and 66% had a lung biopsy, which supported the diagnosis of ILD in 95% of cases. Histology was often lymphocyte predominant with the histo-pattern of granulomatous and lymphocytic interstitial lung disease (GLILD), follicular bronchiolitis or lymphocytic interstitial pneumonitis. Of interest, DIP, PAP and NSIP were also diagnosed. ILD was detected in several immunological disorders not yet associated with ILD. CONCLUSIONS Specialized pneumological expertise is necessary to manage the full spectrum of respiratory complications in pediatric immunocompromised patients.
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Affiliation(s)
| | | | - Matthias Griese
- Correspondence: ; Tel.: +49-89-4400-57870; Fax: +49-89-4400-57872
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Bahadir A, Kader Ş, Çebi AH, Erduran E, Mutlu M, Aslan Y. Familial Hemophagocytic Lymphohistiocytosis With Heterozygous STX11 and Homozygous UNC13D Mutations Diagnosed in the Neonatal Period. J Pediatr Hematol Oncol 2022; 44:e866-e868. [PMID: 35293882 DOI: 10.1097/mph.0000000000002449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/18/2022] [Indexed: 11/26/2022]
Abstract
Patients with primary hemophagocytic lymphohistiocytosis may present with different mutations and phenotypic findings. It is usually presented as case reports because of its rare occurrence. Here, we discuss a case diagnosed with familial hemophagocytic lymphohistiocytosis 3, that presented in the neonatal period and was detected to have homozygous UNC13D and heterozygous STX11 mutations.
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Affiliation(s)
- Aysenur Bahadir
- Division of Pediatric Hematology-Oncology, Department of Pediatric Hematology-Oncology
| | - Şebnem Kader
- Division of Neonatology, Department of Neonatology
| | - Alper Han Çebi
- Division of Medical Genetics, Department of Medical Genetics, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Erol Erduran
- Division of Pediatric Hematology-Oncology, Department of Pediatric Hematology-Oncology
| | - Mehmet Mutlu
- Division of Neonatology, Department of Neonatology
| | - Yakup Aslan
- Division of Neonatology, Department of Neonatology
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