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Masood M, Siddique A, Krishnamoorthi R, Kozarek RA. Liver Dysfunction in Adult Hemophagocytic Lymphohistiocytosis: A Narrative Review. Adv Ther 2024; 41:553-566. [PMID: 38145441 DOI: 10.1007/s12325-023-02768-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 12/08/2023] [Indexed: 12/26/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening condition that has been increasingly recognized in adults and is characterized by a hyperinflammatory state due to immune dysregulation. Its nonspecific presentation, the lack of clinician familiarity given its rarity, and shared clinical features with sepsis and other syndromes can lead to a delay in diagnosis and a poor prognosis. Significant liver function abnormalities as the initial manifestation of HLH are uncommon and can range from mild elevation of aminotransferases to fulminant hepatic failure with high mortality rates. The authors encountered a case of adult HLH mimicking acute viral hepatitis in which a markedly elevated ferritin level led to a prompt diagnosis, early initiation of treatment, and a successful outcome. Clinicians, including gastroenterologists and hepatologists, are often called upon to evaluate patients with abnormal liver tests and may lack experience in the early diagnosis and management of liver dysfunction in the context of HLH. Thus, we expand our reporting to a narrative review of literature which explores the pathogenesis of HLH, challenges associated with its diagnosis, previous reports of liver disease associated with the syndrome, recommended treatments for the familial and adult variations including the role of liver transplantation, and the outcomes of these treatments.
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Affiliation(s)
- Muaaz Masood
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Asma Siddique
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Rajesh Krishnamoorthi
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Richard A Kozarek
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA.
- Center for Interventional Immunology, Benaroya Research Institute, Virginia Mason Franciscan Health, 1201 Ninth Ave, Seattle, WA, 98101, USA.
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2
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Simard C, Tardif ML. Hemophagocytic lymphohistiocytosis in pregnancy evolving towards fulminant hepatitis. Obstet Med 2022; 15:208-211. [PMID: 36262816 PMCID: PMC9574453 DOI: 10.1177/1753495x21999914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 11/19/2020] [Accepted: 02/09/2021] [Indexed: 09/03/2023] Open
Abstract
Background Hemophagocytic lymphohistiocytosis is a rare disorder, especially in pregnancy, characterized by excessive immune activation leading to hemophagocytic activity. Case Report A 34-year-old woman presented at 31 weeks' gestation with fever, cytopenias, hyperferritinemia and fulminant hepatitis. Bone marrow biopsy was non-contributory, and no trigger was identified. Liver biopsy confirmed the diagnosis of hemophagocytic lymphohistiocytosis, and she received dexamethasone and etoposide, which was changed to anakinra to allow breastfeeding. Prompt diagnosis and treatment of hemophagocytic lymphohistiocytosis is crucial to the survival of pregnant women, but no consensus exists regarding the most appropriate therapy during pregnancy. Conclusion Hemophagocytic lymphohistiocytosis is life-threatening and associated with significant morbidity and mortality. Important treatment considerations in pregnancy include maternal health, fetal prematurity and treatment toxicity. Anakinra has been successfully used in pregnancy and provides a promising alternative.
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Affiliation(s)
- Camille Simard
- Department of Medicine, McGill University, Montreal,
Canada
| | - Marie-Lou Tardif
- Division of Obstetric Medicine, Department of Obstetrics and
Gynecology, CHU Sainte-Justine, Montreal, Canada
- Department of Medicine, Université de Montréal, Montreal,
Canada
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3
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Ren W, Yang S, Liu H, Pan Z, Li Z, Qiao P, Ma H. Case report and literature review: Hemophagocytic lymphohistiocytosis in a pregnant woman with systemic lupus erythematosus with Syntaxin 11 gene defect. Front Oncol 2022; 12:937494. [PMID: 35965579 PMCID: PMC9367683 DOI: 10.3389/fonc.2022.937494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/28/2022] [Indexed: 11/30/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis is an extremely rare occurrence during pregnancy. Early recognition of its signs and symptoms is critical for early intervention, and delays in diagnosis may be life-threatening. A 23-year-old nulliparous woman presented with a persistent fever as high as 39°C with bilateral edema of the lower limbs at 24 weeks of gestation. Typical laboratory findings included pancytopenia, high triglycerides, ferritin, transaminases, bilirubin, and hypoproteinemia. Active systemic lupus erythematosus was diagnosed using an autoimmune work-up and a Systemic Lupus Erythematosus Disease Activity Index 2000 score of 17 points. Her bone marrow aspirate revealed prominent hemophagocytosis; hence, HLH was confirmed. Genetic tests showed mutations in Syntaxin 11 mutations. Considering the potential impact of drugs on the fetus, the patient and her family members chose to terminate the pregnancy through medical induction of labor. Afterwards, her condition improved with immunosuppressive therapy.
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Affiliation(s)
- Wei Ren
- Department of Gynaecology and Obstetrics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Siyuan Yang
- College of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Haiying Liu
- Department of Gynaecology and Obstetrics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Zhenglun Pan
- Department of Rheumatism and Immunology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Zhao Li
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Peng Qiao
- Department of Gynaecology and Obstetrics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Qingdao, China
- *Correspondence: Peng Qiao, ; Hui Ma,
| | - Hui Ma
- Department of Gynaecology and Obstetrics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Qingdao, China
- *Correspondence: Peng Qiao, ; Hui Ma,
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4
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Fávero Vanraes L, Beckers V, Van Berkel K, Gucciardo L, Faron G. Haemophagocytic lymphohistiocytosis during pregnancy: a case presentation and literature review. CASE REPORTS IN PERINATAL MEDICINE 2022. [DOI: 10.1515/crpm-2021-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
Haemophagocytic lymphohistiocytosis (HLH) is a potentially fatal disorder of the immune system that typically occurs in the paediatric population. Diagnosing this rare disease in the adult population is challenging, particularly during pregnancy.
Case presentation
We present a case of a gravid patient developing HLH at week 13 of gestation undergoing a medical termination of pregnancy at 27 weeks due to anhydramnios and associated stopped foetal growth.
Conclusions
Disease triggers could vary from a simple viral infection to the pregnancy as such causing the disorder. Treatment should benefit the mother and limit the foetal harm.
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Affiliation(s)
- Larissa Fávero Vanraes
- Department of Gynaecology and Obstetrics , Vrije Universiteit Brussel, Brussels Health Campus , Brussels , Belgium
| | - Veerle Beckers
- Division of Haematology, Department of Internal Medicine , Vrije Universiteit Brussel, Brussels Health Campus , Brussels , Belgium
| | - Kim Van Berkel
- Department of Medical Genetics , Vrije Universiteit Brussel, Brussels Health Campus , Brussels , Belgium
| | - Leonardo Gucciardo
- Division of Prenatal Medicine and Obstetrics, Department of Gynaecology and Obstetrics , Vrije Universiteit Brussel, Brussels Health Campus , Brussels , Belgium
| | - Gilles Faron
- Division of Prenatal Medicine and Obstetrics, Department of Gynaecology and Obstetrics , Vrije Universiteit Brussel, Brussels Health Campus , Brussels , Belgium
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5
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Liu C, Gao J, Liu J. Management of hemophagocytic lymphohistiocytosis in pregnancy: Case series study and literature review. J Obstet Gynaecol Res 2022; 48:610-620. [PMID: 34978123 PMCID: PMC9303886 DOI: 10.1111/jog.15133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 12/03/2021] [Accepted: 12/07/2021] [Indexed: 12/15/2022]
Abstract
Aim The diagnosis and treatment of hemophagocytic lymphohistiocytosis (HLH) in pregnancy is challenging due to its rarity. We aim to analyze and summarize the clinical characteristics of HLH in pregnancy, and to discuss effective diagnostic and treatment options. Methods Thirteen patients with HLH during pregnancy who were diagnosed and treated at the Peking Union Medical College Hospital of the Chinese Academy of Medical Sciences from January 2000 to December 2019 were studied retrospectively. We collected data on treatment regimens and on maternal and pregnancy outcomes. Results All patients had a singleton pregnancy, with a median age of 28 years (range, 22–33 years) and a median gestational age of 23 weeks (7–36 weeks). Twelve patients received corticosteroids, and four patients (with/without intravenous immunoglobulin) showed a curative effect. Two patients who were treated with dexamethasone and etoposide after termination of pregnancy achieved complete remission. Two patients attained remission after termination of pregnancy. Four pregnant women died, and the mortality rate was 30.8% (4/13). Fetal or neonatal death up to 1 week after delivery occurred in eight (61.5%) pregnancies. Conclusions Early diagnosis and treatment are important for maternal survival, and corticosteroids are the first choice for most patients with HLH during pregnancy. For patients who do not respond to corticosteroids, etoposide and termination of pregnancy may be life‐saving.
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Affiliation(s)
- Congcong Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jinsong Gao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Juntao Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Takahashi M, Makino S, Iizuka H, Noguchi M, Yoshida K. Chronic active Epstein-Barr virus-associated secondary hemophagocytic lymphohistiocytosis in pregnancy: a case report. BMC Pregnancy Childbirth 2021; 21:681. [PMID: 34620104 PMCID: PMC8495184 DOI: 10.1186/s12884-021-04150-4] [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] [Received: 07/28/2021] [Accepted: 09/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Secondary hemophagocytic lymphohistiocytosis (sHLH) is a rare and fatal disease characterized by uncontrolled immune cell activation that can lead to a cytokine storm. Unfortunately, this condition can occur even during pregnancy, threatening both maternal and fetal lives. CASE PRESENTATION A 23-year-old nulliparous woman at 26 weeks of gestation presented with continuous fever, coughing, and sore throat. Upon arrival at our hospital, her temperature was >38°C and laboratory findings indicated cytopenia (neutrophil count, 779/μL; hemoglobin level, 10.2 g/dL; platelet count, 29,000/μL), elevated ferritin level (1,308 ng/mL), and elevated soluble interleukin-2 receptor level (11,200 U/mL). Computed tomography showed marked splenomegaly. Bone marrow examination revealed hemophagocytosis, and blood examination showed a plasma Epstein-Barr virus (EBV) DNA level of 8.9 × 105 copies/μg. The monoclonal proliferation of EBV-infected T cells was confirmed by Southern blotting, and the patient was diagnosed with chronic active EBV-associated sHLH and T-cell lymphoproliferative disease. Immediately after admission, the patient's condition suddenly deteriorated. She developed shock and disseminated intravascular coagulation, requiring endotracheal intubation along with methylprednisolone pulse and etoposide therapy. Although the patient recovered, she delivered a stillborn baby. After delivery, she was treated with reduced-dose dexamethasone, etoposide, ifosfamide, and carboplatin (DeVIC) and steroid (dexamethasone), methotrexate, ifosfamide, L-asparaginase, and etoposide (SMILE) chemotherapies. Five months after diagnosis, she received human leukocyte antigen-haploidentical allogeneic bone marrow transplantation from her sister. She remains in remission for 5 months from the time of transplantation to the present. CONCLUSIONS sHLH, which may cause maternal and fetal death, should be carefully considered in critically ill pregnant women, particularly those presenting with continuous fever and cytopenia.
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Affiliation(s)
- Masaya Takahashi
- Department of Obstetrics and Gynecology, Juntendo University Urayasu Hospital, Chiba, Urayasu City, Japan
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Juntendo University Urayasu Hospital, Chiba, Urayasu City, Japan.
| | - Hiroko Iizuka
- Department of Hematology, Juntendo University Urayasu Hospital, Urayasu City, Chiba, Japan
| | - Masaaki Noguchi
- Department of Hematology, Juntendo University Urayasu Hospital, Urayasu City, Chiba, Japan
| | - Koyo Yoshida
- Department of Obstetrics and Gynecology, Juntendo University Urayasu Hospital, Chiba, Urayasu City, Japan
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7
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Wilson-Morkeh H, Frise C, Youngstein T. Haemophagocytic lymphohistiocytosis in pregnancy. Obstet Med 2021; 15:79-90. [DOI: 10.1177/1753495x211011913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/19/2021] [Accepted: 03/25/2021] [Indexed: 12/17/2022] Open
Abstract
Haemophagocytic lymphohistiocytosis is a life-threatening systemic inflammatory syndrome defined by persistent fever, cytopenia and multi-organ dysfunction. Primary haemophagocytic lymphohistiocytosis classically presents in childhood as a result of genetically abnormal perforin or inflammasome function, leading to the aberrant release of pro-inflammatory cytokines causing a hyperinflammatory state. Secondary haemophagocytic lymphohistiocytosis is an acquired phenomenon occurring at any age as a result of immune dysregulation to a specific trigger such as infection, haematological malignancy or autoimmune disease. Secondary haemophagocytic lymphohistiocytosis occurring in the pregnant woman represents a diagnostic challenge and carries a significant mortality. This has led to its first inclusion in the fourth Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the United Kingdom annual maternal report in 2017. This article presents an overview of haemophagocytic lymphohistiocytosis, reviews the literature on haemophagocytic lymphohistiocytosis in pregnancy, suggests diagnostic pathways and explores the safety and efficacy of existing and potential treatment strategies for haemophagocytic lymphohistiocytosis occurring during pregnancy.
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Affiliation(s)
- Harold Wilson-Morkeh
- Department of Rheumatology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Charlotte Frise
- Fetal-Maternal Medicine Unit, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
- De Swiet’s Obstetric Medicine Centre, Imperial College Healthcare NHS Trust, Queen Charlotte’s and Chelsea Hospital, London, UK
| | - Taryn Youngstein
- Department of Rheumatology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
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8
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Grigorieva KN, Bitsadze VO, Khizroeva JK, Tretyakova MV, Blinov DV, Tsibizova VI, Ponomarev DA, Shkoda AS, Orudzhova EA, Grandone E, Rizzo G, Makatsariya AD. Macrophage activation syndrome in COVID-19. OBSTETRICS, GYNECOLOGY AND REPRODUCTION 2021. [DOI: 10.17749/2313-7347/ob.gyn.rep.2021.217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The novel coronavirus epidemic is characterized by high rates of morbidity and relatively high mortality. Laboratory test results in patients include leukopenia, an increase in liver function tests and ferritin levels reaching hundreds, and sometimes thousands of units. These data remind us about the macrophage activation syndrome (MAC). Secondary hemophagocytic lymphohistiocytosis syndrome, MAC, which pathogenesis is based on a defect in the mechanisms of T-cell cytotoxicity and decreased level of natural killer cells associated with the defect in the perforin-encoding gene as well as hyperproduction of a number of cytokines – interleukin (IL)-1â, tumor necrosis factor-á, etc. by T-lymphocytes and histiocytes, indirectly leading to the activation of macrophages and production of proinflammatory cytokines, in particular IL-6 hyperproduction. MAC is one of "hyperferritinemic syndromes". These disorders have similar clinical and laboratory manifestations, and they also respond to similar treatments, suggesting that hyperferritinemia may be involved in the overall pathogenesis and is characterized by elevated ferritin level and cytokine storm. Despite the fact that data on the immune and inflammatory status in patients with COVID-19 have only started to appear, it is already clear that hyperinflammation and coagulopathy affect the disease severity and increase the risk of death in patients infected with SARS-CoV-2. Hence, understanding the pathogenesis of the novel coronavirus infection can help in its early diagnostics and treatment.
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Affiliation(s)
| | | | | | | | - D. V. Blinov
- Institute for Preventive and Social Medicine; Lapino Clinic Hospital, MD Medical Group
| | - V. I. Tsibizova
- Almazov National Medical Research Centre, Health Ministry of Russian Federation
| | - D. A. Ponomarev
- Vorokhobov City Clinical Hospital № 67, Moscow Healthcare Department
| | - A. S. Shkoda
- Vorokhobov City Clinical Hospital № 67, Moscow Healthcare Department
| | - E. A. Orudzhova
- Vorokhobov City Clinical Hospital № 67, Moscow Healthcare Department
| | - E. Grandone
- Sechenov University; Tor Vergata University of Rome
| | - G. Rizzo
- Sechenov University; Tor Vergata University of Rome
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9
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Duan W, Xiao ZH, Yang LG, Luo HY. Kikuchi's disease with hemophagocytic lymphohistiocytosis: A case report and literature review. Medicine (Baltimore) 2020; 99:e23500. [PMID: 33371072 PMCID: PMC7748204 DOI: 10.1097/md.0000000000023500] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/04/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Kikuchi's disease (KD) is a rare form of necrotizing lymphadenitis that rarely occurs in association with hemophagocytic lymphohistiocytosis (HLH) in children. PATIENT CONCERNS We report the case of a 4-year-5-month-old boy who suffered from fever, cervical lymphadenopathy, pancytopenia, hypertriglyceridemia, splenomegaly, low NK cell activity. DIAGNOSES A diagnosis of KD with HLH was made based on the results of biopsy of cervical lymph node and HLH-2004 trial guidelines. INTERVENTIONS The patient was treated with corticosteroids, cyclosporine, etoposide, continuous hemodiafiltration (HDF), and plasma exchange (PE). OUTCOMES He showed a complete response to therapy, and his condition gradually improved. He was discharged on day 45 after admission due to his good recovery status. CONCLUSION HLH can be associated with KD, especially in childhood, and may have an aggressive clinical course. Continuous HDF and PE and chemotherapy should be reserved for those patients who fail to respond to IVIG and corticosteroids.
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10
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Wang S, Wu J, Jing X, Zhang Y, Tang H, Wu J. Etoposide combined with ruxolitinib for refractory hemophagocytic lymphohistiocytosis during pregnancy: a case report and literature review. ACTA ACUST UNITED AC 2020; 24:751-756. [PMID: 33138732 DOI: 10.1080/16078454.2020.1838708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an immune-mediated disorder caused by uncontrolled inflammatory responses and the activation of T lymphocytes. This life-threatening disease, characterized by fever, cytopenia and hepatosplenomegaly, is extremely rare during pregnancy with high mortality. Despite the improvement of treatment regimen in recent years, HLH is still a great challenge for clinicians. Here, we described a 26-year-old woman who admitted to our hospital at her first pregnancy with pyrexia. Her condition continued to deteriorate after receiving broad-spectrum antimicrobials, presenting with fever, pancytopenia, hepatosplenomegaly, ferritin ≥ 500 μg/L, hemophagocytosis and low NK-cell activity. HLH was eventually diagnosed by clinical manifestation and laboratory examination results. Then the patient recovered well after treatment with etoposide combined with ruxolitinib therapy and underwent successful induced-labor operation. Additionally, we summarized similar cases from the literature to improve the management of HLH during pregnancy. In conclusion, this study highlights the challenges and difficulties in the diagnosis and management of patients with HLH during pregnancy. Moreover, this is the first case report of etoposide combined with ruxolitinib in the treatment of patients with refractory secondary HLH during pregnancy.
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Affiliation(s)
- Shuoshan Wang
- Department of General Medicine, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Jingguo Wu
- Department of General Medicine, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Xiaoli Jing
- Department of General Medicine, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Yongwei Zhang
- Department of General Medicine, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Hao Tang
- Department of Emergency, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Junlin Wu
- Department of Emergency, The First Affiliated Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
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11
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Cheng J, Niu J, Wang Y, Wang C, Zhou Q, Chen Y, Zhang Y, Lin J, Di W. Hemophagocytic lymphohistiocytosis in pregnancy: a case report and review of the literature. J OBSTET GYNAECOL 2019; 40:153-159. [PMID: 31215279 DOI: 10.1080/01443615.2019.1601168] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Jie Cheng
- Department of Gynecology and Obstetrics, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jiaxin Niu
- Department of Gynecology and Obstetrics, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - You Wang
- Department of Gynecology and Obstetrics, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Chuan Wang
- Department of Gynecology and Obstetrics, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Qiong Zhou
- Department of Gynecology and Obstetrics, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yunyan Chen
- Department of Gynecology and Obstetrics, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yu Zhang
- Department of Gynecology and Obstetrics, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jianhua Lin
- Department of Gynecology and Obstetrics, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wen Di
- Department of Gynecology and Obstetrics, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
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12
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Song Y, Wang Z, Hao Z, Li L, Lu J, Kang H, Lu Y, You Y, Li L, Chen Q, Chen B. Requirement for etoposide in the treatment of pregnancy related hemophagocytic lymphohistiocytosis: a multicenter retrospective study. Orphanet J Rare Dis 2019; 14:50. [PMID: 30777105 PMCID: PMC6380007 DOI: 10.1186/s13023-019-1033-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 02/11/2019] [Indexed: 11/20/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a rare severe clinical syndrome. HLH manifesting during pregnancy has been paid much attention in recent years. Despite the specificity of pregnancy-related HLH, there has not been any consensus regarding its treatment. According to a previous study, corticosteroid/IVIG is the mainstream therapy; however, the efficacy is controversial. Etoposide is an important agent in the HLH-94 regimen; nevertheless, its use is limited because of possible toxicity to the fetus. Methods: In this study, we summarized 13 cases from 4 medical institutions from April 2011 to April 2018. Treatment regimens and outcomes were observed. Results The median age was 26 (20–36) years old. The median gestational age was 28 (10–35) weeks. In these 13 patients, 10 were treated with methylprednisolone/IVIG and was effective in only two patients. In 6 patients who used etoposide during their treatment, all achieved remission. The median time from onset of disease to use of etoposide was 36 (17–131) days. Five of these 6 patients were treated with corticosteroids with/without IVIG before etoposide. One patient with pulmonary tuberculosis and one with lymphoma were treated according to etiology and achieved long survival. Conclusion For treatment of pregnancy-related HLH, particularly for patients who do not respond to corticosteroids/IVIG therapy, etoposide should be used bravely. Nevertheless, suitable dosages and toxic and side-effects require further clinical observation.
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Affiliation(s)
- Yue Song
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, YongAn Road 95th Xicheng District, Beijing, 100050, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, YongAn Road 95th Xicheng District, Beijing, 100050, China.
| | - Zengping Hao
- Department of Obstetrics and Gynecology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lihong Li
- Department of Hematology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Junli Lu
- Department of Obstetrics and Gynecology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Hongjun Kang
- Department of Hematology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yanping Lu
- Department of Obstetrics and Gynecology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yanqin You
- Department of Obstetrics and Gynecology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Lijuan Li
- Department of Intensive Care Unit, China-Japan Friendship Hospital, Beijing, China
| | - Qingyun Chen
- Department of Obstetrics and Gynecology, China-Japan Friendship Hospital, Beijing, China
| | - Bo Chen
- Department of Obstetrics and Gynecology, China-Japan Friendship Hospital, Beijing, China
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13
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Sarkissian S, Khan Y, Farrell D, Constable D, Brem E. Hemophagocytic lymphohistiocytosis in the setting of HELLP Syndrome. Clin Case Rep 2018; 6:2466-2470. [PMID: 30564350 PMCID: PMC6293182 DOI: 10.1002/ccr3.1828] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 07/12/2018] [Accepted: 08/19/2018] [Indexed: 12/13/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyper activation of the immune system. Rare cases associated with HELLP syndrome and other similar conditions in pregnancy have been reported. Despite the improved survival rates with etoposide and dexamethasone-based regimens, HLH remains a challenging disease. Experience in pregnant patients is exceedingly rare.
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Affiliation(s)
| | - Yasir Khan
- Division of Hematology and Oncology, Department of MedicineUniversity of California, IrvineIrvineCalifornia
| | - Daniel Farrell
- Department of PathologyUniversity of California, IrvineIrvineCalifornia
| | - David Constable
- Division of Infectious Disease, Department of MedicineUniversity of California, IrvineIrvineCalifornia
| | - Elizabeth Brem
- Division of Hematology and Oncology, Department of MedicineUniversity of California, IrvineIrvineCalifornia
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Neistadt B, Carrubba A, Zaretsky MV. Natural killer/T-cell lymphoma and secondary haemophagocytic lymphohistiocytosis in pregnancy. BMJ Case Rep 2018; 2018:bcr-2018-224832. [PMID: 30219776 DOI: 10.1136/bcr-2018-224832] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a rare and potentially fatal disorder. It is challenging to diagnose due to its rarity and variation in clinical presentation, laboratory abnormalities and underlying aetiologies. A reproductive-aged woman, gravida 2 para 1001 at 27 weeks gestation presented with fever, hypotension and subacute upper respiratory infection. She delivered a male infant by caesarean section secondary to fetal distress. Subsequently, she was diagnosed with T-cell lymphoma and secondary HLH. Despite management with supportive care and multiple chemotherapeutic agents, she ultimately died of multiorgan failure. Patients with HLH secondary to malignancy have a particularly poor prognosis. This case highlights the importance of considering secondary HLH in the differential diagnosis of a patient with fever, pancytopenia and systemic symptoms of unclear aetiology in pregnancy.
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Affiliation(s)
- Barbara Neistadt
- Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Aakriti Carrubba
- Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael V Zaretsky
- Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado, USA.,Colorado Fetal Care Center, Children's Hospital of Colorado, Aurora, Colorado, USA
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Yildiz H, Vandercam B, Thissen X, Komuta M, Lanthier N, Debieve F, Dahlqvist G. Hepatitis during pregnancy: A case of hemophagocytic lymphohistiocytosis. Clin Res Hepatol Gastroenterol 2018; 42:e49-e55. [PMID: 29239849 DOI: 10.1016/j.clinre.2017.10.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 10/24/2017] [Indexed: 02/04/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare but severe and potentially fatal syndrome that can occur during pregnancy. A 36 years-old woman, at 29 weeks of gestation, presented with itchiness and jaundice since a week. On clinical examination she was apyrexial and frankly icteric. Laboratory data showed evidence of acute hepatitis. A complete work-up was made excluding viral hepatitis (HAV, HEV, HBV, HCV, HHV6, CMV, EBV) and autoimmune liver disease. Liver diseases related to pregnancy were not completely excluded. A liver biopsy was performed and firstly interpreted as showing features of acute hepatitis. The clinical situation worsened, she developed fever with signs of fetal distress and emergent delivery was done. A second look at the liver biopsy showed features compatible with HLH, which was also confirmed on bone marrow biopsy. Extensive work-up with exclusion of infectious and malignant diseases, lead us to the diagnosis of HLH secondary to pregnancy and short term steroid therapy was started. She then completely recovered and didn't present any relapse after 4 months of follow up. HLH during pregnancy is very rare and this is the first case of HLH presenting as acute hepatitis and diagnosed on a liver biopsy.
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Affiliation(s)
- Halil Yildiz
- Department of internal medicine and infectiology, cliniques universitaires St Luc, 10, avenue hippocrate, 1200 Brussels, Belgium.
| | - Bernard Vandercam
- Department of internal medicine and infectiology, cliniques universitaires St Luc, 10, avenue hippocrate, 1200 Brussels, Belgium
| | - Xave Thissen
- Department of internal medicine and infectiology, cliniques universitaires St Luc, 10, avenue hippocrate, 1200 Brussels, Belgium
| | - Mina Komuta
- Department of pathology, cliniques universitaires St Luc, 1200 Brussels, Belgium
| | - Nicolas Lanthier
- Department of gastroenterology, cliniques universitaires St Luc, 1200 Brussels, Belgium
| | - Frederic Debieve
- Department of gynecology and obstetric, cliniques universitaires St Luc, 1200 Brussels, Belgium
| | - Geraldine Dahlqvist
- Department of gastroenterology, cliniques universitaires St Luc, 1200 Brussels, Belgium
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He M, Jia J, Zhang J, Beejadhursing R, Mwamaka Sharifu L, Yu J, Wang S, Feng L. Pregnancy-associated hemophagocytic lymphohistiocytosis secondary to NK/T cells lymphoma: A case report and literature review. Medicine (Baltimore) 2017; 96:e8628. [PMID: 29381934 PMCID: PMC5708933 DOI: 10.1097/md.0000000000008628] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
RATIONALE Hemophagocytic lymphohistiocytosis (HLH) occurs primarily in pediatric population, or secondary to malignancy, infection, or autoimmune disease. This disease is rare and prognosis is generally poor. Only a small number of cases during pregnancy have been reported in literature. PATIENT CONCERNS We report a case of pregnancy-associated HLH secondary to natural killer (NK)/T cells lymphoma. She was admitted at 30 weeks and 3 days of pregnancy with complaints of abdominal pain and fever as high as 39.2°C. The patient was found to have splenomegaly, pancytopenia, and acute hepatic failure. DIAGNOSES A subsequent bone marrow biopsy revealed focal hemophagocytosis and atypical lymphoid cells. The splenic pulp also contained a large number of tissue cells proliferating and devouring mature red blood cells, lymphocytes, and cell debris. On the basis of these findings, we diagnosed the case as pregnancy-associated hemophagocytic lymphohistiocytosis secondary to NK/T cells lymphoma. INTERVENTIONS Treatment consisted with dexamethasone and etoposide in combination with rituximab. OUTCOMES Due to timely termination of pregnancy, the neonate was in good condition. However, the patient died on the 18th day postoperation due to multiorgan failure. LESSONS We recommend that HLH be considered as differential diagnosis in a pregnant patient complaining of persistent fever, cytopenia, or declining clinical condition despite delivery of the baby. Prompt diagnosis and treatment is essential and fetal outcomes should also be considered. The decision to terminate a pregnancy and initiate chemotherapy during pregnancy with malignancy-associated HLH (M-HLH) needs to be further investigated in a larger cohort.
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