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Marwah V, Choudhary R, Kumar TA, Sharma M. Haemophagocytic lymphohistiocytosis post-ChAdOx1 nCoV-19 vaccine: A rare case. THE NATIONAL MEDICAL JOURNAL OF INDIA 2024; 37:90-92. [PMID: 39222526 DOI: 10.25259/nmji_ms_466_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
The severe acute respiratory syndrome coronavirus 2 pandemic started in December 2019, spread like wildfire and took an immense toll on human life. ChAdOx1 nCoV-19 vaccine was used worldwide for the prevention of Covid-19. Covid-19 has been implicated in the causation of severe haemophagocytic lymphohistiocytosis (HLH) syndrome. However, the same has not been reported with ChAdOx1 nCoV-19 vaccine in the literature. We report a young man who developed secondary HLH post-ChAdOx1 nCoV-19 vaccination.
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Affiliation(s)
- Vikas Marwah
- Department of Pulmonary, Critical Care and Sleep Medicine, Army Institute of Cardiothoracic Sciences, Pune, Maharashtra, India
| | - Robin Choudhary
- Department of Pulmonary, Critical Care and Sleep Medicine, Army Institute of Cardiothoracic Sciences, Pune, Maharashtra, India
| | - Tentu Ajai Kumar
- Department of Pulmonary, Critical Care and Sleep Medicine, Army Institute of Cardiothoracic Sciences, Pune, Maharashtra, India
| | - Manish Sharma
- Department of Pathology, Army Institute of Cardiothoracic Sciences, Pune, Maharashtra, India
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Benevenuta C, Mussinatto I, Orsi C, Timeus FS. Secondary hemophagocytic lymphohistiocytosis in children (Review). Exp Ther Med 2023; 26:423. [PMID: 37602304 PMCID: PMC10433411 DOI: 10.3892/etm.2023.12122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 06/16/2023] [Indexed: 08/22/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening condition characterized by hyperinflammation in an uncontrolled and ineffective immune response. Despite great improvement in diagnosis and treatment, it still represents a challenge in clinical management, with poor prognosis in the absence of an aggressive therapeutic approach. The present literature review focuses on secondary HLH at pediatric age, which represents a heterogeneous group in terms of etiology and therapeutic approach. It summarizes the most recent evidence on epidemiology, pathophysiology, diagnosis, treatment and prognosis, and provides a detailed description and comparison of the major subtypes of secondary HLH. Finally, it addresses the open questions with a focus on diagnosis and new treatment insights.
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Affiliation(s)
- Chiara Benevenuta
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
| | - Ilaria Mussinatto
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
| | - Cecilia Orsi
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
| | - Fabio S. Timeus
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
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Jeyakanthan T, Ladel L, Khandpur B, Tan WY, Nasir SA. Coronavirus Does It Again: Post-COVID-19 Hemophagocytic Lymphohistiocytosis (HLH). Cureus 2023; 15:e35275. [PMID: 36968874 PMCID: PMC10036136 DOI: 10.7759/cureus.35275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 02/23/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a hematological disorder that results from an uncontrolled activation of the immune system, which can then lead to multisystem organ failure. Given the nonspecific nature of this illness, it can go undetected for too long, thereby causing permanent damage to organ systems. In adults, HLH has been associated with a number of infectious etiologies, particularly viral infections. Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has led to a global pandemic and has been associated with acute respiratory distress syndrome (ARDS). Among its other manifestations, COVID-19 has also been linked to HLH. In this report, we describe a case of a male patient who presented with multisystem organ failure and was found to have HLH. Since no clear etiology for his HLH could be elicited, it was determined to be a result of his recent COVID-19 infection.
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Santos IO, Neto RP, Bom APKP. Hemophagocytic lymphohistiocytosis: a case series analysis in a pediatric hospital. Hematol Transfus Cell Ther 2023; 45:32-37. [PMID: 34183298 PMCID: PMC9938491 DOI: 10.1016/j.htct.2021.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/02/2021] [Accepted: 04/14/2021] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a rare clinical laboratory condition with high mortality rates, resulting from ineffective overactivation of the immune system. Data in the Brazilian literature is scarce, contributing to the challenge in standardizing conducts and performing an early diagnosis of HLH. OBJECTIVE To describe the clinical, laboratory, and evolutionary findings on HLH patients treated at a pediatric hospital. METHODS This is an observational, cross-sectional and retrospective study on children diagnosed with HLH, hospitalized between 2009 and 2019. The diagnostic criteria were those described in the Histiocyte Society protocol. The authors evaluated HLH patient laboratory tests, myelograms and bone marrow biopsies, clinical characteristics and therapy. RESULTS Twenty-three patients were included, 52.2% of whom were males. The age at diagnosis ranged from one to one hundred and eighty months. Four cases were classified as Primary HLH and nineteen, as Secondary HLH. The main triggers were infections and rheumatological diseases. All children had bicytopenia, and 95.4% had hyperferritinemia. Nineteen patients had liver dysfunction, sixteen had neurological disorders and fourteen had kidney injury. Pulmonary involvement was seen in 61.9%, acting as a worse prognosis for death (p = 0.01). Nine patients underwent the immuno-chemotherapy protocol proposed in the HLH 2004. The time to confirm the diagnosis varied from five to eighty days. The lethality found was 56.3%. CONCLUSIONS The present study is the most extensive retrospective exclusively pediatric study published in Brazil to date. Despite the limitations, it was possible to demonstrate the importance of discussing HLH as a pediatric emergency.
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Affiliation(s)
| | | | - Ana Paula Kuczynski Pedro Bom
- Hospital Pequeno Prínicpe, Curitiba, PR, Brazil,Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, PR, Brazil
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Mohamed Jiffry MZ, Ahmed-khan M, Vargas J, Thomas T, Josey S. Hemophagocytic Lymphohistiocytosis in a Patient With Post-acute COVID-19 Infection. Cureus 2022; 14:e31451. [DOI: 10.7759/cureus.31451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2022] [Indexed: 11/15/2022] Open
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Ioannou M, Zacharouli K, Doukas SG, Diamantidis MD, Tsangari V, Karakousis K, Koukoulis GK, Vageli DP. Hemophagocytic lymphohistiocytosis diagnosed by bone marrow trephine biopsy in living post-COVID-19 patients: case report and mini-review. J Mol Histol 2022; 53:753-762. [PMID: 35699822 PMCID: PMC9192937 DOI: 10.1007/s10735-022-10088-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/31/2022] [Indexed: 12/15/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) constitutes a life-threatening inflammatory syndrome. Postmortem histological findings of bone marrow (BM) from COVID-19 patients showed histiocytosis and hemophagocytosis and supported the hypothesis that secondary HLH (sHLH) may be triggered by SARS-CoV-2 infection. However, there are a limited number of sHLH cases in which trephine has been performed in living post-COVID-19 patients. Here we present a recent case and a mini-review of sHLH diagnosed by trephine biopsy in living patients after COVID-19. An 81-year-old man with a past medical history of hypertension, diabetes, ischemic stroke, was referred to the hospital to evaluate leukocytosis, pyuria, and elevation of inflammatory markers four weeks after recovering from COVID-19. Computed tomography of the abdomen did not reveal focal signs of infection or hepatosplenomegaly. The patient received intravenous meropenem and two packed red blood cell units. Leukocytes and C-reactive protein were gradually decreased. A BM biopsy was performed and the patient was discharged on cefixime. BM smear revealed severe anemia, lymphopenia, and dysplastic morphologic findings of erythroblasts, neutrophils, and megakaryocytes. Trephine biopsy revealed hypercellular marrow dyserythropoiesis, plasmacytosis, lymphocytosis, histiocytosis, hemophagocytosis, and the absence of granulomas or carcinoma. Immunohistochemistry documented a mixed population of T lymphocytes (CD3+) and B lymphocytes (CD20+). Strong positivity for CD68 confirmed histiocytosis. CD138 κ, λ staining proved polyclonal plasmacytosis. Perl's staining showed excess hemosiderin deposits. Based on our findings, we document sHLH in trephine BM biopsy of a living post-COVID-19 patient and persistent leukocytosis, underscoring the diagnostic value of trephine biopsy in preventing life-threatening conditions such as COVID-19.
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Affiliation(s)
- Maria Ioannou
- Department of Pathology, Faculty of Medicine, Medical School, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larissa, Greece
| | - Konstantina Zacharouli
- Department of Pathology, Faculty of Medicine, Medical School, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larissa, Greece
| | - Sotirios G Doukas
- Department of Toxicology Department of Forensic Sciences and Laboratory of Toxicology, Medical School, University of Crete, 71003, Heraklion, Greece
- Department of Medicine, Rutgers/Saint Peter's University Hospital, 08901, New Brunswick, NJ, USA
| | - Michael D Diamantidis
- Thalassemia and Sickle Cell Disease Unit, Department of Hematology, General Hospital of Larissa, Larissa, Greece
| | - Vaya Tsangari
- Department of Pathology, Faculty of Medicine, Medical School, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larissa, Greece
| | | | - George K Koukoulis
- Department of Pathology, Faculty of Medicine, Medical School, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larissa, Greece
| | - Dimitra P Vageli
- Department of Pathology, Faculty of Medicine, Medical School, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larissa, Greece.
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Gautam S, Sharma G, Singla S, Garg S. Case Report: Secondary Hemophagocytic Lymphohistiocytosis (sHLH) and Candida auris Fungemia in Post-acute COVID-19 Syndrome: A Clinical Challenge. Front Med (Lausanne) 2022; 9:835421. [PMID: 35783658 PMCID: PMC9247387 DOI: 10.3389/fmed.2022.835421] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/28/2022] [Indexed: 12/21/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection causes a disease (COVID-19) with multisystem involvement. The world is now entering a phase of post-COVID-19 manifestations in this pandemic. Secondary hemophagocytic lymphohistiocytosis (sHLH) is a life-threatening hyperinflammatory event triggered by viral infections, including SARS-CoV-2. Both Multisystem Inflammatory Syndrome-Adults (MIS-A) and Cytokine Storm Syndrome (CSS) are considered close differentials of sHLH and add to the spectrum of Post-acute COVID-19 syndrome (PACS). In this report, we presented the case of a middle-aged Asian man who was initially discharged upon recovery from severe COVID-19 infection after 17 days of hospitalization to a private institute and later came to our hospital 13 days post-discharge. Here, he was diagnosed with sHLH, occurring as an extension of CSS, with delayed presentation falling within the spectrum of PACS. The diagnosis of sHLH was made holistically with the HLH-2004 criteria. Our patient initially responded to intravenous immunoglobulin (IVIG) and dexamethasone, later complicated by disseminated Candida auris infection and had a fatal outcome. Though many cases of HLH during active COVID-19 and a few cases post COVID-19 recovery have been reported, based on H-score, which has limitations as a diagnostic tool. We report the first case report of post-COVID-19 sHLH using the HLH-2004 criteria, complicated by disseminated Candidemia, emphasizing that the care of patients with COVID-19 does not conclude at the time of hospital discharge. We highlight the importance of surveillance in the post-COVID phase for early detection of sHLH which may predispose to fatal opportunistic infections (OIs).
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Affiliation(s)
- Sachin Gautam
- Department of Internal Medicine, Maulana Azad Medical College and Associated Lok Nayak Hopital, New Delhi, India
| | - Gaurav Sharma
- Department of Internal Medicine, Maulana Azad Medical College and Associated Lok Nayak Hopital, New Delhi, India
| | - Sumeet Singla
- Department of Internal Medicine, Maulana Azad Medical College and Associated Lok Nayak Hopital, New Delhi, India
| | - Sandeep Garg
- Department of Internal Medicine, Maulana Azad Medical College and Associated Lok Nayak Hopital, New Delhi, India
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Hromić-Jahjefendić A, Barh D, Ramalho Pinto CH, Gabriel Rodrigues Gomes L, Picanço Machado JL, Afolabi OO, Tiwari S, Aljabali AAA, Tambuwala MM, Serrano-Aroca Á, Redwan EM, Uversky VN, Lundstrom K. Associations and Disease-Disease Interactions of COVID-19 with Congenital and Genetic Disorders: A Comprehensive Review. Viruses 2022; 14:910. [PMID: 35632654 PMCID: PMC9146233 DOI: 10.3390/v14050910] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/23/2022] [Accepted: 04/25/2022] [Indexed: 02/06/2023] Open
Abstract
Since December 2019, the COVID-19 pandemic, which originated in Wuhan, China, has resulted in over six million deaths worldwide. Millions of people who survived this SARS-CoV-2 infection show a number of post-COVID complications. Although, the comorbid conditions and post-COVID complexities are to some extent well reviewed and known, the impact of COVID-19 on pre-existing congenital anomalies and genetic diseases are only documented in isolated case reports and case series, so far. In the present review, we analyzed the PubMed indexed literature published between December 2019 and January 2022 to understand this relationship from various points of view, such as susceptibility, severity and heritability. Based on our knowledge, this is the first comprehensive review on COVID-19 and its associations with various congenital anomalies and genetic diseases. According to reported studies, some congenital disorders present high-risk for developing severe COVID-19 since these disorders already include some comorbidities related to the structure and function of the respiratory and cardiovascular systems, leading to severe pneumonia. Other congenital disorders rather cause psychological burdens to patients and are not considered high-risk for the development of severe COVID-19 infection.
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Affiliation(s)
- Altijana Hromić-Jahjefendić
- Department of Genetics and Bioengineering, Faculty of Engineering and Natural Sciences, International University of Sarajevo, Hrasnicka Cesta 15, 71000 Sarajevo, Bosnia and Herzegovina
| | - Debmalya Barh
- Institute of Integrative Omics and Applied Biotechnology (IIOAB), Nonakuri, Purba Medinipur 721172, India
- Department of Genetics, Ecology and Evolution, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil; (L.G.R.G.); (S.T.)
| | - Cecília Horta Ramalho Pinto
- Department of Biochemistry and Immunology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil;
| | - Lucas Gabriel Rodrigues Gomes
- Department of Genetics, Ecology and Evolution, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil; (L.G.R.G.); (S.T.)
| | - Jéssica Lígia Picanço Machado
- Department of Bioinformatics, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil;
| | - Oladapo Olawale Afolabi
- Department of Physiology and Biophysics, Pharmacology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil;
| | - Sandeep Tiwari
- Department of Genetics, Ecology and Evolution, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil; (L.G.R.G.); (S.T.)
| | - Alaa A. A. Aljabali
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Yarmouk University, P.O. Box 566, Irbid 21163, Jordan
| | - Murtaza M. Tambuwala
- School of Pharmacy and Pharmaceutical Science, Ulster University, Coleraine BT52 1SA, UK;
| | - Ángel Serrano-Aroca
- Biomaterials and Bioengineering Laboratory, Centro de Investigación Traslacional San Alberto Magno, Universidad Católica de Valencia San Vicente Mártir, c/Guillem de Castro 94, 46001 Valencia, Spain;
| | - Elrashdy M. Redwan
- Department of Biological Science, Faculty of Science, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
- Therapeutic and Protective Proteins Laboratory, Protein Research Department, Genetic Engineering and Biotechnology Research Institute, City for Scientific Research and Technology Applications, New Borg EL-Arab 21934, Alexandria, Egypt
| | - Vladimir N. Uversky
- Department of Molecular Medicine and USF Health Byrd Alzheimer’s Institute, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA;
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Nasir S, Khan SR, Iqbal R, Hashmi AP, Moosajee M, Nasir N. Inactivated COVID-19 vaccine triggering hemophagocytic lymphohistiocytosis in an immunocompetent adult - A case report. J Clin Transl Res 2022; 8:152-155. [PMID: 35475272 PMCID: PMC9035139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/10/2022] [Accepted: 03/11/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND AND AIM Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome that is induced by hyper-activated macrophages, cytotoxic T cells, and reduced natural killer cell activity. A 46-year-old gentleman presented to us with complaints of intermittent fever for the past 2 weeks associated with fatigue along with oral ulcers and skin rashes which resolved spontaneously. These symptoms started after he received the second dose of the BBIP-CorV COVID-19 vaccine. His complete blood picture showed pancytopenia. A detailed infectious disease workup was unrevealing; however, his bone marrow biopsy revealed increased histiocyte activity, with some showing hemophagocytosis and dysplasia. Immunohistochemistry profile demonstrated strong CD 68 positivity. Further investigations showed raised serum ferritin and fasting triglyceride levels. He was immediately started on dexamethasone acetate at a dose of 10 mg/m2, after which his clinical symptoms, as well as his blood parameters, improved remarkably. This is the first documented case in Pakistan. CONCLUSION The data from clinical trials support the general safety profile of inactivated COVID-19 vaccines. We endorse its mass implementation. However, we believe that robust data need to be generated to evidence any adverse events, especially those with serious outcomes. Physicians should be aware of inactivated COVID-19 vaccine as a possible trigger for HLH and start prompt treatment, resulting in favorable outcomes. RELEVANCE FOR PATIENTS The presentation of HLH may vary and can present in an immunocompetent patient with no underlying risk factor. HLH should be kept in differentials when a patient presents with pancytopenia with a recent history of receiving COVID-19 vaccination. Steroids play a major role in the treatment of HLH, and definitive diagnosis and early treatment improve clinical outcomes.
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Affiliation(s)
- Saad Nasir
- Department of Medical Oncology, Aga Khan University Hospital, Karachi, Pakistan
| | - Saqib Raza Khan
- Department of Medical Oncology, Aga Khan University Hospital, Karachi, Pakistan,Corresponding author: Saqib Raza Khan Aga Khan University Hospital, Karachi, Pakistan. E-mail:
| | - Rodaba Iqbal
- Department of Medical Oncology, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Munira Moosajee
- Department of Medical Oncology, Aga Khan University Hospital, Karachi, Pakistan
| | - Noreen Nasir
- Department of Medical Oncology, Aga Khan University Hospital, Karachi, Pakistan
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Naqvi WA, Bhutta MJ. Hemphagocytic Lymphohistiocytosis Secondary to COVID-19: A Case Report. Cureus 2021; 13:e19292. [PMID: 34900473 PMCID: PMC8648286 DOI: 10.7759/cureus.19292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2021] [Indexed: 12/20/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is categorized into primary HLH and secondary HLH. Primary or familial HLH is an autosomal recessive disorder due to mutation in immune regulatory genes. Secondary HLH is an uncommon hyperinflammatory disease triggered by a critical illness (malignancies or viral infection) that induces an uncontrollable excessive immune response, which results in multiorgan failure. Due to the rarity of the syndrome, HLH is associated with worse outcomes. Severe coronavirus disease-19 (COVID-19) is identified as a trigger of HLH, and published literature suggests that patients with severe COVID-19 are at high risk of developing HLH. COVID-19-associated HLH is rarely reported in the literature. Herein we present a case of secondary HLH due to COVID-19 presented in the emergency department with prolonged non-resolving fever.
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Affiliation(s)
- Warda A Naqvi
- Infectious Diseases, Shifa International Hospital, Islamabad, PAK
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Runge E, Stoffel S, Rendo M, Beeler BW. Neutropenic Fever in a Patient With SARS-CoV-2-Induced Hemophagocytic Lymphohistiocytosis (HLH). Cureus 2021; 13:e20101. [PMID: 34993040 PMCID: PMC8720238 DOI: 10.7759/cureus.20101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2021] [Indexed: 11/13/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a severe systemic inflammatory syndrome that is often fatal. In the adult population, it is believed to develop secondary to immune dysregulation due to rheumatologic, infectious, malignant, and recently, immunomodulatory drugs. It has been well documented that infectious etiologies can lead to HLH however to date there is a paucity of case reports of HLH stemming from the 2019 novel coronavirus (SARS-CoV-2). Furthermore, it is well established that overlap exists between the extensive hyper-inflammatory syndromes produced from both HLH and severe COVID-19 infection. Here, we present a case of COVID-19-associated HLH with recurrent neutropenic fever in a patient with controlled follicular non-Hodgkin lymphoma who received treatment with etoposide after continued hospital admissions with refractory medical treatment.
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Leem G, Cheon S, Lee H, Choi SJ, Jeong S, Kim ES, Jeong HW, Jeong H, Park SH, Kim YS, Shin EC. Abnormality in the NK-cell population is prolonged in severe COVID-19 patients. J Allergy Clin Immunol 2021; 148:996-1006.e18. [PMID: 34339730 PMCID: PMC8324384 DOI: 10.1016/j.jaci.2021.07.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 06/27/2021] [Accepted: 07/21/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Our understanding of adaptive immune responses in patients with coronavirus disease 2019 (COVID-19) is rapidly evolving, but information on the innate immune responses by natural killer (NK) cells is still insufficient. OBJECTIVE We aimed to examine the phenotypic and functional status of NK cells and their changes during the course of mild and severe COVID-19. METHODS We performed RNA sequencing and flow cytometric analysis of NK cells from patients with mild and severe COVID-19 at multiple time points in the course of the disease using cryopreserved PBMCs. RESULTS In RNA-sequencing analysis, the NK cells exhibited distinctive features compared with healthy donors, with significant enrichment of proinflammatory cytokine-mediated signaling pathways. Intriguingly, we found that the unconventional CD56dimCD16neg NK-cell population expanded in cryopreserved PBMCs from patients with COVID-19 regardless of disease severity, accompanied by decreased NK-cell cytotoxicity. The NK-cell population was rapidly normalized alongside the disappearance of unconventional CD56dimCD16neg NK cells and the recovery of NK-cell cytotoxicity in patients with mild COVID-19, but this occurred slowly in patients with severe COVID-19. CONCLUSIONS The current longitudinal study provides a deep understanding of the NK-cell biology in COVID-19.
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Affiliation(s)
- Galam Leem
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Shinhye Cheon
- Division of Infectious Diseases, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hoyoung Lee
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - Seong Jin Choi
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - Seongju Jeong
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - Eui-Soon Kim
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - Hye Won Jeong
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Hyeongseok Jeong
- Division of Infectious Diseases, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Su-Hyung Park
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - Yeon-Sook Kim
- Division of Infectious Diseases, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea.
| | - Eui-Cheol Shin
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Korea.
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Paluszkiewicz P, Martuszewski A, Majcherek M, Kucharska M, Bogucka-Fedorczuk A, Wróbel T, Czyż A. Hemophagocytic Lymphohistiocytosis Secondary to Peripheral T Cell Lymphoma with Rapid Onset and Fatal Progression in a Young Patient: A Case Report and Review of the Literature. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e932765. [PMID: 34588412 PMCID: PMC8488189 DOI: 10.12659/ajcr.932765] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Constant stimulation of lymphocytes and histiocytes can result in hemophagocytic lymphohistiocytosis (HLH), which can be primary or secondary (sHLH). The main causes of sHLH are infections and hematological malignancies, especially non-Hodgkin lymphoma. Despite new insights into the pathogenesis of HLH, the diagnosis and treatment of this immune disorder remain a great challenge. CASE REPORT We present a case of a young adult without comorbidities whose clinical course was nonspecific for several months and resulted in late diagnosis of HLH secondary to peripheral T cell lymphoma (PTCL). The etiological factor of recurring fever, hepatosplenomegaly, and deteriorating condition was unidentified for a long time before fatal sHLH was finally diagnosed. The patient was treated according to the HLH-2004 protocol; however, he did not achieve any response. Unfortunately, due to nonspecific symptoms, lack of lymphadenopathy for a long time, and negative positron emission tomography results, the diagnosis of PTCL was established only after the patient's death. CONCLUSIONS It should be emphasized that early diagnosis is crucial for better prognosis of patients with sHLH. Bone marrow biopsy is worth considering in patients with prolonged fever of unknown origin, hyperferritinemia, splenomegaly, and unexplained cytopenia of 2 or more lineages. Despite the existence of diagnostic and therapeutic protocols available in the literature, the prompt diagnosis and treatment of HLH remains a great challenge. More precise and specific diagnostic tools for HLH are needed.
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Affiliation(s)
| | | | - Maciej Majcherek
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wrocław Medical University, Wrocław, Poland
| | - Marta Kucharska
- Clinic of Infectious Diseases and Hepatology, Wrocław Medical University, Wrocław, Poland
| | - Aleksandra Bogucka-Fedorczuk
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wrocław Medical University, Wrocław, Poland
| | - Tomasz Wróbel
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wrocław Medical University, Wrocław, Poland
| | - Anna Czyż
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wrocław Medical University, Wrocław, Poland
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14
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Kalita P, Laishram D, Dey B, Mishra J, Barman B, Barman H. Secondary Hemophagocytic Lymphohistiocytosis in Post-COVID-19 Patients: A Report of Two Cases. Cureus 2021; 13:e17328. [PMID: 34557370 PMCID: PMC8450015 DOI: 10.7759/cureus.17328] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2021] [Indexed: 12/28/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a disease that can affect both children and adults. HLH can be categorized as primary or secondary. Secondary HLH (sHLH) may be secondary to various viral infections. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus infection is a pandemic with multi-system involvement. HLH in COVID-19 positive patients is a recognized entity. However, in post-COVID-19 patients who have recovered and are negative by serological tests and reverse transcription-polymerase chain reaction test may present with sHLH due to dysregulation of the immune system. We highlight this unusual finding of post-COVID-19 sHLH in two cases, who were diagnosed by the new revised H-score.
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Affiliation(s)
- Pranjal Kalita
- Pathology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, IND
| | - Devina Laishram
- Pathology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, IND
| | - Biswajit Dey
- Pathology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, IND
| | - Jaya Mishra
- Pathology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, IND
| | - Bhupen Barman
- Internal Medicine, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, IND
| | - Himesh Barman
- Paediatrics, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, IND
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15
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Barth RF, Buja LM, Barth AL, Carpenter DE, Parwani AV. A Comparison of the Clinical, Viral, Pathologic, and Immunologic Features of Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), and Coronavirus 2019 (COVID-19) Diseases. Arch Pathol Lab Med 2021; 145:1194-1211. [PMID: 34232978 DOI: 10.5858/arpa.2020-0820-sa] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT -The purpose of this review is to compare three coronavirus diseases: severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and coronavirus disease 2019 (COVID-19) caused by SARS-CoV, MERS-CoV, and SARS-CoV-2 viruses, respectively. OBJECTIVE -To cover the following topics: clinical considerations, viral characteristics, pathology, immune response, pathogenesis, and the prognosis associated with each coronavirus human disease in humans. DATA SOURCES -Clinically, flu-like symptoms are usual at the time of presentation for all 3 diseases, but these vary from asymptomatic to severe multi-system involvement. The pathology associated with symptomatic SARS and COVID-19 has been well described, the most prominent of which is diffuse alveolar damage (DAD). The immune response to each of these viruses is highly complex and includes both humoral and cellular components that can have a significant impact on prognosis. In severe cases of COVID-19, a dysregulated innate host immune system can initiate a hyperinflammatory syndrome dominated by endothelial dysfunction that can lead to a hypercoagulable state with microthrombi, resulting in a systemic micro- and macro-vascular disease. CONCLUSIONS -The SARS and MERS epidemics have been limited, involving 7,500 and 2,500 individuals, respectively. In contrast, COVID-19 has resulted in a worldwide pandemic with over 177 million cases and 3.9 million deaths as of June 15, 2021, and fatality rates ranging from <0.1% to ~10% depending upon the country. Ending on a positive note, the development of a number of vaccines, at least six of which now are in clinical use, should mitigate and eventually control the devastating COVID-19 pandemic.
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Affiliation(s)
- Rolf F Barth
- Department of Pathology (RF Barth, Parwani), S.P. Technical Editor (Retired) Departments of Neurosurgery and Radiation Oncology (Carpenter), The Ohio State University Columbus, Ohio
| | - L Maximillian Buja
- Department of Pathology and Laboratory Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas (Buja)
| | - Alison L Barth
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA (AL Barth)
| | - David E Carpenter
- Department of Pathology (RF Barth, Parwani), S.P. Technical Editor (Retired) Departments of Neurosurgery and Radiation Oncology (Carpenter), The Ohio State University Columbus, Ohio
| | - Anil V Parwani
- Department of Pathology (RF Barth, Parwani), S.P. Technical Editor (Retired) Departments of Neurosurgery and Radiation Oncology (Carpenter), The Ohio State University Columbus, Ohio
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16
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Verma DP, Dandu H, Yadav G, Verma SP. Complicated case of COVID-19 disease with overlapping features of thrombotic thrombocytopenic purpura and haemophagocytic lymphohistiocytosis. BMJ Case Rep 2021; 14:14/5/e242202. [PMID: 34011641 PMCID: PMC8137254 DOI: 10.1136/bcr-2021-242202] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Haemophagocytic lymphohistiocytosis has been reported as an uncommon complication of severe COVID-19 disease while thrombotic thrombocytopenic purpura has been rarely reported. Here, we are reporting a 21-year-old man who developed a combination of these complications during the hospital stay in the post-COVID-19 recovery period. He presented with fever and bilateral COVID-19-related pneumonia requiring invasive ventilation. His hospital course was complicated by the development of pneumothorax, ventilator-associated pneumonia, thrombotic thrombocytopenic purpura and haemophagocytic lymphohistiocytosis. He received remdesivir, IVIG, steroid, fresh frozen plasma and supportive care but had a fatal outcome.
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Affiliation(s)
- Durga Prasad Verma
- Clinical Hematology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Himanshu Dandu
- Medicine, King Georges Medical University, Lucknow, Uttar Pradesh, India
| | - Geeta Yadav
- Pathology, King Georges Medical University, Lucknow, Uttar Pradesh, India
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17
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Naous E, Nassani BM, Yaghi C, Nasr F, Medlej R. Hemophagocytic lymphohistiocytosis, a new cause of death during 'post-acute COVID-19 syndrome?' A case report. J Hematop 2021; 14:229-233. [PMID: 33897909 PMCID: PMC8057656 DOI: 10.1007/s12308-021-00452-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 04/14/2021] [Indexed: 12/13/2022] Open
Abstract
'Post-acute coronavirus disease 2019 (COVID-19) syndrome' is a new term that was coined to describe a constellation of persistent symptoms and new complications following recovery from COVID-19 initial illness. Identifying post-COVID-19 complications is crucial for early diagnosis and subsequent initiation of therapies to ensure more favorable outcomes. Severe COVID-19-related hemophagocytic lymphohistiocytosis (HLH) has been previously described during the acute phase of the infection. It is characterized by hyperinflammation, multi-organ involvement, and hemophagocytosis. We report the case of a 69-year-old woman who presented, two weeks after recovery from COVID-19, with hyperosmolar state and high inflammatory markers. Bone marrow aspirate, flow cytometry, extensive viral panel and total body scan were performed. Review of bone marrow aspirate smear showed hemophagocytosis. Flow cytometry, viral panel, and total body scan were normal. The diagnosis of post COVID-19-related HLH was made. Unfortunately, the patient died despite adequate treatment. To our knowledge, this is the first case establishing a high probability of COVID-19-related HLH given its occurrence two weeks following a documented biological and clinical recovery. Awareness and early recognition of HLH features following COVID-19 recovery should prompt timely initiation of therapy.
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Affiliation(s)
- Elie Naous
- Department of Internal Medicine, Endocrinology Division, Hotel Dieu de France Hospital, Beirut, Lebanon
- Saint Joseph University, Beirut, Lebanon
| | - Bertha-Maria Nassani
- Department of Internal Medicine, Endocrinology Division, Hotel Dieu de France Hospital, Beirut, Lebanon
- Saint Joseph University, Beirut, Lebanon
| | - Cesar Yaghi
- Saint Joseph University, Beirut, Lebanon
- Department of Internal Medicine, Gastroenterology Division, Hotel Dieu de France, Beirut, Lebanon
| | - Fadi Nasr
- Saint Joseph University, Beirut, Lebanon
- Department of Internal Medicine, Hematology Oncology Division, Hotel Dieu de France, Beirut, Lebanon
| | - Rita Medlej
- Department of Internal Medicine, Endocrinology Division, Hotel Dieu de France Hospital, Beirut, Lebanon
- Saint Joseph University, Beirut, Lebanon
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18
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Michaelis S, Pichler A, Stelzer I, Tinchon C, Enko D. Concomitant immune thrombocytopenia and bone marrow hemophagocytosis in a patient with SARS-CoV-2. Clin Chem Lab Med 2021; 59:e358-e361. [PMID: 33721917 DOI: 10.1515/cclm-2021-0169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/09/2021] [Indexed: 12/18/2022]
Affiliation(s)
- Simon Michaelis
- Institute of Clinical Chemistry and Laboratory Medicine, General Hospital Hochsteiermark, Leoben, Austria
| | - Angelika Pichler
- Department of Hemato-Oncology, General Hospital Hochsteiermark, Leoben, Austria
| | - Ingeborg Stelzer
- Institute of Clinical Chemistry and Laboratory Medicine, General Hospital Hochsteiermark, Leoben, Austria
| | - Christoph Tinchon
- Department of Hemato-Oncology, General Hospital Hochsteiermark, Leoben, Austria
| | - Dietmar Enko
- Institute of Clinical Chemistry and Laboratory Medicine, General Hospital Hochsteiermark, Leoben, Austria.,Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
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19
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Gasorelin/prednisolone. REACTIONS WEEKLY 2020. [PMCID: PMC7726305 DOI: 10.1007/s40278-020-87001-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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