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Li Y, Li S, Lu N, Wang W, Wang D. Secondary hemophagocytic lymphohistiocytosis in pediatric patients with visceral leishmaniasis and Epstein-Barr virus infection. Ann Hematol 2024; 103:1541-1547. [PMID: 38467825 DOI: 10.1007/s00277-024-05695-y] [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: 11/10/2023] [Accepted: 03/02/2024] [Indexed: 03/13/2024]
Abstract
Visceral leishmaniasis-associated hemophagocytic lymphohistiocytosis (VL-HLH) is indistinguishable from those of HLH of other etiologies due to the overlap symptoms, posing a serious threat to life. In this study, we aimed to provide insights for early diagnosis and improve outcomes in pediatric patients with VL-HLH. We retrospectively analyzed the clinical and laboratory data of 10 pediatric patients with VL-HLH and 58 pediatric patients with Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis (EBV-HLH). The median time from symptom onset to cytopenia in patients with VL-HLH and EBV-HLH was 11 days (interquartile range, 7-15 days) and five days (interquartile range, 3.75-9.25 days) (P = 0.005). Both groups showed liver injury and increased lactate dehydrogenase levels; however the levels of aspartate aminotransferase, alanine aminotransferase, direct bilirubin, and lactate dehydrogenase in patients with VL-HLH were significantly lower than those in patients with EBV-HLH (P < 0.05). The fibrinogen and triglyceride levels were almost normal in VL-HLH patients but were significantly altered in EBV-HLH cases ( P < 0.05). The positive rate of first bone marrow microscopy examination, anti-rK39 IgG detection, and blood metagenomic next-generation sequencing was 50%, 100%, and 100%, respectively. After VL diagnosis, eight patients were treated with sodium stibogluconate and two were treated with liposomal amphotericin B. All the patients with VL-HLH recovered. Our study demonstrates that regular triglyceride and fibrinogen levels in pediatric patients with VL-HLH may help in differential diagnosis from EBV-HLH. VL-HLH is milder than EBV-HLH, with less severe liver injury and inflammatory responses, and timely treatment with antileishmanial agents is essential to improve the outcomes of pediatric patients with VL-HLH.
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Affiliation(s)
- Yuanfang Li
- Department of Pediatrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Sanjing Li
- Department of Infectious Diseases, The Sixth People's Hospital of Zhengzhou, Zhengzhou, China
| | - Nadan Lu
- Department of Pediatrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Weilin Wang
- Department of Pediatrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dao Wang
- Department of Pediatrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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2
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Goto Y, Ito T, Ghosh S, Mukherjee B. Access and utilization of host-derived iron by Leishmania parasites. J Biochem 2023; 175:17-24. [PMID: 37830941 PMCID: PMC10771036 DOI: 10.1093/jb/mvad082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/02/2023] [Accepted: 10/05/2023] [Indexed: 10/14/2023] Open
Abstract
Iron is involved in many biochemical processes including oxygen transport, ATP production, DNA synthesis and antioxidant defense. The importance of iron also applies to Leishmania parasites, an intracellular protozoan pathogen causing leishmaniasis. Leishmania are heme-auxotrophs, devoid of iron storage proteins and the heme synthesis pathway. Acquisition of iron and heme from the surrounding niche is thus critical for the intracellular survival of Leishmania inside the host macrophages. Moreover, Leishmania parasites are also exposed to oxidative stress within phagolysosomes of macrophages in mammalian hosts, and they need iron superoxide dismutase for overcoming this stress. Therefore, untangling the strategy adopted by these parasites for iron acquisition and utilization can be good targets for the development of antileishmanial drugs. Here, in this review, we will address how Leishmania parasites acquire and utilize iron and heme during infection to macrophages.
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Affiliation(s)
- Yasuyuki Goto
- Laboratory of Molecular Immunology, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Tatsumi Ito
- Laboratory of Molecular Immunology, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Souradeepa Ghosh
- School of Medical Science and Technology, Indian Institute of Technology Kharagpur, Kharagpur, West Bengal, India
| | - Budhaditya Mukherjee
- School of Medical Science and Technology, Indian Institute of Technology Kharagpur, Kharagpur, West Bengal, India
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3
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Veras PST, de Santana MBR, Brodskyn CI, Fraga DBM, Solcà MS, De Menezes JPB, Leite BMM, Teixeira HMP. Elucidating the role played by bone marrow in visceral leishmaniasis. Front Cell Infect Microbiol 2023; 13:1261074. [PMID: 37860064 PMCID: PMC10582953 DOI: 10.3389/fcimb.2023.1261074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/08/2023] [Indexed: 10/21/2023] Open
Abstract
Leishmaniasis is a widespread group of infectious diseases that significantly impact global health. Despite high prevalence, leishmaniasis often receives inadequate attention in the prioritization of measures targeting tropical diseases. The causative agents of leishmaniasis are protozoan parasites of the Leishmania genus, which give rise to a diverse range of clinical manifestations, including cutaneous and visceral forms. Visceral leishmaniasis (VL), the most severe form, can be life-threatening if left untreated. Parasites can spread systemically within the body, infecting a range of organs, such as the liver, spleen, bone marrow and lymph nodes. Natural reservoirs for these protozoa include rodents, dogs, foxes, jackals, and wolves, with dogs serving as the primary urban reservoir for Leishmania infantum. Dogs exhibit clinical and pathological similarities to human VL and are valuable models for studying disease progression. Both human and canine VL provoke clinical symptoms, such as organ enlargement, fever, weight loss and abnormal gamma globulin levels. Hematologic abnormalities have also been observed, including anemia, leukopenia with lymphocytosis, neutropenia, and thrombocytopenia. Studies in dogs have linked these hematologic changes in peripheral blood to alterations in the bone marrow. Mouse models of VL have also contributed significantly to our understanding of the mechanisms underlying these hematologic and bone marrow abnormalities. This review consolidates information on hematological and immunological changes in the bone marrow of humans, dogs, and mice infected with Leishmania species causing VL. It includes findings on the role of bone marrow as a source of parasite persistence in internal organs and VL development. Highlighting gaps in current knowledge, the review emphasizes the need for future research to enhance our understanding of VL and identify potential targets for novel diagnostic and therapeutic approaches.
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Affiliation(s)
- Patricia Sampaio Tavares Veras
- Laboratory of Parasite - Host Interaction and Epidemiology, Gonçalo Moniz Institute-Fiocruz Bahia, Salvador, Bahia, Brazil
- National Institute of Science and Technology of Tropical Diseases, National Council for Scientific Research and Development (CNPq), Salvador, Brazil
| | - Maria Borges Rabêlo de Santana
- Laboratory of Parasite - Host Interaction and Epidemiology, Gonçalo Moniz Institute-Fiocruz Bahia, Salvador, Bahia, Brazil
| | - Claudia Ida Brodskyn
- Laboratory of Parasite - Host Interaction and Epidemiology, Gonçalo Moniz Institute-Fiocruz Bahia, Salvador, Bahia, Brazil
| | - Deborah Bittencourt Mothé Fraga
- Laboratory of Parasite - Host Interaction and Epidemiology, Gonçalo Moniz Institute-Fiocruz Bahia, Salvador, Bahia, Brazil
- Department of Preventive Veterinary Medicine and Animal Production, School of Veterinary Medicine and Animal Science, Federal University of Bahia, Salvador, Brazil
| | - Manuela Silva Solcà
- Laboratory of Parasite - Host Interaction and Epidemiology, Gonçalo Moniz Institute-Fiocruz Bahia, Salvador, Bahia, Brazil
- Department of Preventive Veterinary Medicine and Animal Production, School of Veterinary Medicine and Animal Science, Federal University of Bahia, Salvador, Brazil
| | | | - Bruna Martins Macedo Leite
- Laboratory of Parasite - Host Interaction and Epidemiology, Gonçalo Moniz Institute-Fiocruz Bahia, Salvador, Bahia, Brazil
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4
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Goto Y, Mizobuchi H. Pathological roles of macrophages in Leishmania infections. Parasitol Int 2023; 94:102738. [PMID: 36738983 DOI: 10.1016/j.parint.2023.102738] [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: 10/27/2022] [Revised: 01/31/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023]
Abstract
Macrophages are the major host cells for Leishmania parasites, and determine the fate of infection by either limiting or allowing growth of the parasites, resulting in development or control of leishmaniasis, respectively. They also play important roles in causing pathological outcomes during Leishmania infection. The pathophysiology is complex and include a wide variety of molecular and cellular responses including enhancement of inflammatory responses by releasing cytokines, causing damages to surrounding cells by reactive oxygen species, or disordered phagocytosis of other cells. It is of note that disease severity in leishmaniasis sometimes does not correlate with parasite burdens, indicating that pathological roles of macrophages are not necessarily linked to their parasite-killing activities that are often defined by M1/M2 status. Here, we review the roles of macrophages in leishmaniasis with a focus on their pathological mechanisms in disease development.
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Affiliation(s)
- Yasuyuki Goto
- Laboratory of Molecular Immunology, Graduate School of Agricultural and Life Sciences, The University of Tokyo, 1-1-1 Yayoi, Bunkyo-ku, Tokyo 113-8657, Japan.
| | - Haruka Mizobuchi
- Laboratory of Molecular Immunology, Graduate School of Agricultural and Life Sciences, The University of Tokyo, 1-1-1 Yayoi, Bunkyo-ku, Tokyo 113-8657, Japan
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Visceral Leishmaniasis: Epidemiology, Diagnosis, and Treatment Regimens in Different Geographical Areas with a Focus on Pediatrics. Microorganisms 2022; 10:microorganisms10101887. [PMID: 36296164 PMCID: PMC9609364 DOI: 10.3390/microorganisms10101887] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/17/2022] [Accepted: 09/17/2022] [Indexed: 11/17/2022] Open
Abstract
Visceral Leishmaniasis (VL) is a vector-borne disease caused by an intracellular protozoa of the genus Leishmania that can be lethal if not treated. VL is caused by Leishmania donovani in Asia and in Eastern Africa, where the pathogens’ reservoir is represented by humans, and by Leishmania infantum in Latin America and in the Mediterranean area, where VL is a zoonotic disease and dog is the main reservoir. A part of the infected individuals become symptomatic, with irregular fever, splenomegaly, anemia or pancytopenia, and weakness, whereas others are asymptomatic. VL treatment has made progress in the last decades with the use of new drugs such as liposomal amphotericin B, and with new therapeutic regimens including monotherapy or a combination of drugs, aiming at shorter treatment duration and avoiding the development of resistance. However, the same treatment protocol may not be effective all over the world, due to differences in the infecting Leishmania species, so depending on the geographical area. This narrative review presents a comprehensive description of the clinical picture of VL, especially in children, the diagnostic approach, and some insight into the most used pharmacological therapies available worldwide.
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Abstract
Leishmaniasis is a zoonotic and vector-borne infectious disease that is caused by the genus Leishmania belonging to the trypanosomatid family. The protozoan parasite has a digenetic life cycle involving a mammalian host and an insect vector. Leishmaniasisis is a worldwide public health problem falling under the neglected tropical disease category, with over 90 endemic countries, and approximately 1 million new cases and 20,000 deaths annually. Leishmania infection can progress toward the development of species–specific pathologic disorders, ranging in severity from self-healing cutaneous lesions to disseminating muco-cutaneous and fatal visceral manifestations. The severity and the outcome of leishmaniasis is determined by the parasite’s antigenic epitope characteristics, the vector physiology, and most importantly, the immune response and immune status of the host. This review examines the nature of host–pathogen interaction in leishmaniasis, innate and adaptive immune responses, and various strategies that have been employed for vaccine development.
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A Brief Report and Mini-Review of Visceral Leishmaniasis-associated Hemophagocytic Lymphohistiocytosis in Children. J Pediatr Hematol Oncol 2021; 43:e223-e226. [PMID: 32049769 DOI: 10.1097/mph.0000000000001747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 01/23/2020] [Indexed: 12/29/2022]
Abstract
We present the case of a 7-year-old boy who fulfilled the diagnostic criteria for hemophagocytic lymphohistiocytosis (HLH). Prompt visualization of his bone marrow confirmed the diagnosis of visceral leishmaniasis (VL). He responded well to treatment with liposomal amphotericin-B. The patient had a false-negative enzyme-linked immunosorbent assay for Leishmania infantum and a false-positive immunoglobulin M test for Epstein Barr virus (EBV). Because age at presentation is similar in children with VL and familial HLH for whom EBV is the usual trigger, ruling out VL is extremely important because nonspecific serologic tests for EBV can lead to the inappropriate diagnosis of EBV-driven primary HLH and to the administration of unnecessary immunochemotherapy.
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Xu XJ, Tang YM. Dilemmas in diagnosis and management of hemophagocytic lymphohistiocytosis in children. World J Pediatr 2020; 16:333-340. [PMID: 31506890 DOI: 10.1007/s12519-019-00299-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 07/26/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening entity which is characterized by severe hyperinflammation. Now the HLH-2004 protocol has been widely accepted and clinically used; however, many questions still remain in clinical practice. In this review, we discuss the dilemmas in the diagnosis and treatment of HLH in children. DATA SOURCES Original research for articles and literature reviews published in PubMed was carried out using the key term "hemophagocytic lymphohistiocytosis". RESULTS As the gene sequencing technology progresses, the range of causal mutations and primary HLH has been redefined. The monoallelic variants may contribute to the pathogenesis of the disease. Many conditions without defective cytotoxicity of T or NK cells may lead to HLH, such as primary immunodeficiency (PID) and dysregulated immune activation or proliferation (DIAP). HLH shares overlapping clinical and laboratory characteristics with severe sepsis, but usually the single values are more pronounced in HLH than sepsis. H score is another approach to help the diagnosis of secondary HLH. Specific Th1/Th2 cytokine patterns are very helpful tools to differentiate HLH (reactivation of HLH) from sepsis. Moreover, it also has been used successfully to stratify the therapy intensity. The treatment of HLH should consider underlying diseases, triggers and severity. HLH-94 is recommended for patients who need etoposide-based therapy. CONCLUSIONS Dramatic progress has been made during the past decades in understanding the pathophysiology of HLH. However, diagnosis and treatment of HLH remain with many dilemmas because of the heterogeneous nature of the disease. Better understanding new gene defects and more effective diagnostic approaches and salvage regimens are goals for the future.
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Affiliation(s)
- Xiao-Jun Xu
- Division of Hematology-Oncology, Children's Hospital, Zhejiang University School of Medicine, Key Laboratory of Reproductive Genetics of Ministry of Education, Zhejiang University, Hangzhou, 310003, China
| | - Yong-Min Tang
- Division of Hematology-Oncology, Children's Hospital, Zhejiang University School of Medicine, Key Laboratory of Reproductive Genetics of Ministry of Education, Zhejiang University, Hangzhou, 310003, China.
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Carvalho FHGD, Lula JF, Teles LDF, Caldeira AP, Carvalho SFGD. Hemophagocytic lymphohistiocytosis secondary to visceral leishmaniasis in an endemic area in the north of Minas Gerais, Brazil. Rev Soc Bras Med Trop 2020; 53:e20190491. [PMID: 32578702 PMCID: PMC7310370 DOI: 10.1590/0037-8682-0491-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 04/29/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Visceral leishmaniasis (VL) is an ill-studied disease that is endemic to several regions of Brazil. It is often complicated by hemophagocytic lymphohistiocytosis (HLH), a potentially fatal disorder resulting from excessive non-malignant activation/proliferation of T lymphocytes and macrophages. Considering the overlapping clinical and laboratory characteristics of these diseases, diagnosing HLH is a challenge. Therefore, tracking the association between VL and HLH is necessary in endemic areas. Although HLH can be inapparent and resolve with antileishmanicides, this may not always occur. HLH causes high lethality; therefore, immunosuppressive therapy should be instituted immediately in order to avoid a fatal outcome. METHODS: We described the epidemiological, clinical, laboratory, and therapeutic profile of this association in a region of Brazil endemic for VL. RESULTS We presented 39 patients with this association in a retrospective cohort of 258 children who were admitted from January 2012 to June 2017. Of the 39 patients, 31 were from urban areas (79.5%), and 21 (53%) were males. The mean age and weight were 2.86 (2.08) years and 14.03 (5.96) kg, respectively. The main symptoms were fever (100%), hepatosplenomegaly (100%), pallor of the skin and mucosa (82.5%), edema (38.5%), bleeding (25%), and jaundice (7.5%). Hemophagocytosis was identified in 16/37 (43.24%) patients, and direct examination revealed that 26/37 (70.27%) patients were positive for VL. The patients were treated as recommended by the Ministry of Health. CONCLUSIONS It was observed that HLH is a common complication in endemic areas, and its diagnosis must consider the overlapping of clinical characteristics and pancytopenia.
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Affiliation(s)
| | | | - Leandro de Freitas Teles
- Unimontes, Hospital Universitário Clemente de Faria, Montes Claros, MG, Brasil.,Fundação Hemominas, Montes Claros, MG, Brasil
| | | | - Sílvio Fernando Guimarães de Carvalho
- Unimontes, Hospital Universitário Clemente de Faria, Montes Claros, MG, Brasil.,Unimontes, Departamento de Saúde da Mulher e da Criança, Montes Claros, MG, Brasil
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Johnson SM, Gilmour K, Samarasinghe S, Bamford A. Haemophagocytic lymphohistiocytosis complicating visceral leishmaniasis in the UK: a case for detailed travel history, a high index of suspicion and timely diagnostics. BMJ Case Rep 2019; 12:12/7/e228307. [PMID: 31296633 DOI: 10.1136/bcr-2018-228307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 4-month-old male infant presented acutely unwell with fever. He was initially treated for sepsis but failed to improve with IV broad spectrum antibiotics. Haemophagocytic lymphohistiocytosis (HLH) was diagnosed due to his fever, pancytopenia, splenomegaly, hypertriglyceridaemia, hypofibrinogenaemia and significant hyperferritinaemia. An array of differentials for HLH including both immunological and infectious causes were considered and excluded. He had travelled to Madrid, and hence visceral leishmaniasis (VL) was suspected, but was not confirmed on the initial bone marrow aspirate (BMA) microscopy or culture. He improved with empirical treatment with dexamethasone and liposomal amphotericin B. VL was later confirmed on BMA PCR. He made a good recovery and remained well at 12 month follow-up. Non-endemic countries need rapid and sensitive VL diagnostics. A thorough travel history and high clinical index of suspicion are necessary to avoid the pitfall of treatment with intense immunosuppression recommended in treatment guidelines for HLH.
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Affiliation(s)
- Sarah May Johnson
- Paediatric Infectious Diseases, Great Ormond Street Hospital, London, UK.,Paediatric Infectious Diseases, Royal Free London NHS Foundation Trust, London, UK
| | - Kimberly Gilmour
- Immunology, Great Ormond Street Hospital, London, UK.,Infection, Immunity, Inflammation, Great Ormond Street Institute of Child Health, London, UK
| | | | - Alasdair Bamford
- Paediatric Infectious Diseases, Great Ormond Street Hospital, London, UK.,Infection, Immunity, Inflammation, Great Ormond Street Institute of Child Health, London, UK
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Recommendations for the management of hemophagocytic lymphohistiocytosis in adults. Blood 2019; 133:2465-2477. [PMID: 30992265 DOI: 10.1182/blood.2018894618] [Citation(s) in RCA: 515] [Impact Index Per Article: 103.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 04/12/2019] [Indexed: 12/11/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome induced by aberrantly activated macrophages and cytotoxic T cells. The primary (genetic) form, caused by mutations affecting lymphocyte cytotoxicity and immune regulation, is most common in children, whereas the secondary (acquired) form is most frequent in adults. Secondary HLH is commonly triggered by infections or malignancies but may also be induced by autoinflammatory/autoimmune disorders, in which case it is called macrophage activation syndrome (MAS; or MAS-HLH). Most information on the diagnosis and treatment of HLH comes from the pediatric literature. Although helpful in some adult cases, this raises several challenges. For example, the HLH-2004 diagnostic criteria developed for children are commonly applied but are not validated for adults. Another challenge in HLH diagnosis is that patients may present with a phenotype indistinguishable from sepsis or multiple organ dysfunction syndrome. Treatment algorithms targeting hyperinflammation are frequently based on pediatric protocols, such as HLH-94 and HLH-2004, which may result in overtreatment and unnecessary toxicity in adults. Therefore, dose reductions, individualized tailoring of treatment duration, and an age-dependent modified diagnostic approach are to be considered. Here, we present expert opinions derived from an interdisciplinary working group on adult HLH, sponsored by the Histiocyte Society, to facilitate knowledge transfer between physicians caring for pediatric and adult patients with HLH, with the aim to improve the outcome for adult patients affected by HLH.
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George JT, Sadiq M, Sigamani E, Mathuram AJ. Visceral leishmaniasis with haemophagocytic lymphohistiocytosis. BMJ Case Rep 2019; 12:12/2/e226361. [PMID: 30765439 DOI: 10.1136/bcr-2018-226361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 27-year-old man presented with high-grade intermittent fever for 4 months, generalised fatigue for 2 months, intermittent gum bleeds for 1 month and loss of weight of 15 kg. He appeared cachectic with generalised wasting, had pallor and features of reticuloendothelial system proliferation. His liver span was 17 cm. He had massive splenomegaly. His cardiovascular, respiratory and neurological examination were normal. He was diagnosed to have visceral leishmaniasis (VL) based on bone marrow (BM) examination that showed Leishmania donovani (LD) bodies and was treated with liposomal amphotericin (LA). During the course of therapy, he developed bleeding from various mucosal and venepuncture sites. His further evaluation, which included a repeat BM aspirate, showed haemophagocytes. Final diagnosis made was VL with secondary haemophagocytic lymphohistiocytosis. He was continued on LA with intravenous hydrocortisone. He developed refractory distributive shock with multiorgan dysfunction and succumbed to his illness.
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Affiliation(s)
- John Titus George
- Department of General Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Mohammad Sadiq
- Department of General Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Elanthenral Sigamani
- Department of Pathology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Alice Joan Mathuram
- Department of General Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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Complex Investigation of a Pediatric Haematological Case: Haemophagocytic Syndrome Associated with Visceral Leishmaniasis and Epstein⁻Barr (EBV) Co-Infection. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15122672. [PMID: 30486459 PMCID: PMC6313770 DOI: 10.3390/ijerph15122672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 11/19/2018] [Accepted: 11/21/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Visceral leishmaniasis (VL) is an anthropozoonosis caused by an intracellular parasite belonging to the genus Leishmania. In the Mediterranean region, L. donovani and L. infantum are responsible for VL and dogs are the main reservoir. Haemophagocytic lymphohistiocytosis (HLH) represents a complication of VL and consists of unrestrained activation and proliferation of lymphocytes and macrophages, leading to uncontrolled immune activation. Haemophagocytic lymphohistiocytosis may also develop during viral infection, and Epstein⁻Barr virus (EBV) infection is one of the main HLH causes. Macrophage haemophagocytosis in the bone marrow aspirate is pathognomonic. CASE PRESENTATION The case involves a 19-month-old male infant presenting with a high persistent fever with a fluctuating pattern, pancytopaenia, hepatosplenomegaly, and a high triglyceride level. Initial investigations showed an EBV infection. Considering the persistent signs and symptoms, bone marrow aspiration was performed and confirmed the suspicion of HLH. In addition, the presence of Leishmania infection was shown. The patient was treated with liposomal amphotericin B and had complete resolution of his symptoms. CONCLUSION Diagnosis of VL represents a demanding challenge in endemic and non-endemic areas. Our case demonstrates that leishmaniasis should always be considered in the differential diagnosis in patients presenting with hepatosplenomegaly and cytopaenia with a persistent fever, even in cases of infectious mononucleosis. Moreover, the execution of bone marrow aspiration should not be delayed in order to diagnose and treat at an early stage the potential occurrence of VL, especially if complicated with HLH.
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Meléndez-Lazo A, Ordeix L, Planellas M, Pastor J, Solano-Gallego L. Clinicopathological findings in sick dogs naturally infected with Leishmania infantum : Comparison of five different clinical classification systems. Res Vet Sci 2018; 117:18-27. [DOI: 10.1016/j.rvsc.2017.10.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 10/29/2017] [Accepted: 10/30/2017] [Indexed: 10/18/2022]
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Ragab G, Atkinson TP, Stoll ML. Macrophage Activation Syndrome. THE MICROBIOME IN RHEUMATIC DISEASES AND INFECTION 2018. [PMCID: PMC7123081 DOI: 10.1007/978-3-319-79026-8_14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH), or termed macrophage activation syndrome (MAS) when associated with rheumatic disorders, is a frequently fatal complication of infections, rheumatic disorders, and hematopoietic malignancies. Clinically, HLH/MAS is a life-threatening condition that is usually diagnosed among febrile hospitalized patients (children and adults) who commonly present with unremitting fever and a shock-like multiorgan dysfunction scenario. Laboratory studies reveal pancytopenia, elevated liver enzymes, elevated markers of inflammation (ESR, CRP), hyperferritinemia, and features of coagulopathy. In about 60% of cases, excess hemophagocytosis (macrophages/histiocytes engulfing other hematopoietic cell types) is noted on biopsy specimens from the bone marrow, liver, lymph nodes, and other organs. HLH/MAS has been hypothesized to occur when a threshold level of inflammation has been achieved, and genetic and environmental risk factors are believed to contribute to the hyperinflammatory state. A broad variety of infections, from viruses to fungi to bacteria, have been identified as triggers of HLH/MAS, either in isolation or in addition to an underlying inflammatory disease state. Certain infections, particularly by members of the herpesvirus family, are the most notorious triggers of HLH/MAS. Treatment for infection-triggered MAS requires therapy for both the underlying infection and dampening of the hyperactive immune response.
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Affiliation(s)
- Gaafar Ragab
- Faculty of Medicine, Cairo University, Cairo, Egypt
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Hemophagocytic Lymphohistiocytosis: A Confusing Problem of the Diagnosis of Visceral Leishmaniasis. Indian J Hematol Blood Transfus 2018; 34:161-162. [DOI: 10.1007/s12288-017-0838-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 06/07/2017] [Indexed: 10/19/2022] Open
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Buatois V, Chatel L, Cons L, Lory S, Richard F, Guilhot F, Johnson Z, Bracaglia C, De Benedetti F, de Min C, Kosco-Vilbois MH, Ferlin WG. Use of a mouse model to identify a blood biomarker for IFNγ activity in pediatric secondary hemophagocytic lymphohistiocytosis. Transl Res 2017; 180:37-52.e2. [PMID: 27559680 PMCID: PMC7185816 DOI: 10.1016/j.trsl.2016.07.023] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 07/27/2016] [Accepted: 07/27/2016] [Indexed: 02/01/2023]
Abstract
Life-threatening cytokine release syndromes include primary (p) and secondary (s) forms of hemophagocytic lymphohistiocytosis (HLH). Below detection in healthy individuals, interferon γ (IFNγ) levels are elevated to measurable concentrations in these afflictions suggesting a central role for this cytokine in the development and maintenance of HLH. Mimicking an infection-driven model of sHLH in mice, we observed that the tissue-derived levels of IFNγ are actually 500- to 2000-fold higher than those measured in the blood. To identify a blood biomarker, we postulated that the IFNγ gene products, CXCL9 and CXCL10 would correlate with disease parameters in the mouse model. To translate this into a disease relevant biomarker, we investigated whether CXCL9 and CXCL10 levels correlated with disease activity in pediatric sHLH patients. Our data demonstrate that disease control in mice correlates with neutralization of IFNγ activity in tissues and that the 2 chemokines serve as serum biomarkers to reflect disease status. Importantly, CXCL9 and CXCL10 levels in pediatric sHLH were shown to correlate with key disease parameters and severity in these patients. Thus, the translatability of the IFNγ-biomarker correlates from mouse to human, advocating the use of serum CXCL9 or CXCL10 as a means to monitor total IFNγ activity in patients with sHLH.
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Key Words
- hlh, hemophagocytic lymphohistiocytosis
- phlh, primary hemophagocytic lymphohistiocytosis
- shlh, secondary hemophagocytic lymphohistiocytosis
- ifnγ, interferon γ
- tlrs, toll-like receptors
- tnfα, tumor necrosis factor α
- mifnγ, mouse ifnγ
- alt, alanine transaminase
- ldh, lactate dehydrogenase
- mrna, messenger rna
- qpcr, quantitative pcr
- il-6, interleukin 6
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Affiliation(s)
| | | | - Laura Cons
- Novimmune S.A., Plan-les-Ouates, Switzerland
| | | | | | | | - Zoë Johnson
- Novimmune S.A., Plan-les-Ouates, Switzerland
| | - Claudia Bracaglia
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Fabrizio De Benedetti
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Ospedale Pediatrico Bambino Gesù, Rome, Italy
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Gaifer Z, Boulassel MR. Leishmania Infantum and Epstein-Barr Virus Co-Infection in a Patient with Hemophagocytosis. Infect Dis Rep 2016; 8:6545. [PMID: 28191297 PMCID: PMC5226040 DOI: 10.4081/idr.2016.6545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 10/04/2016] [Accepted: 10/16/2016] [Indexed: 11/23/2022] Open
Abstract
The authors describe a rare case of a 27- year old previously healthy male presenting with high grade fever, pancytopenia, hepatosplenomegaly, high levels of ferritin and triglyceride, suggesting a diagnosis of hemophagocytic lymphohistiocytosis (HLH) syndrome. Other investigations showed a positive Leishmania infantum serology and high Epstein-Barr virus (EBV) viremia. The diagnosis of a visceral leishmaniasis was confirmed by bone morrow biopsy, which showed Leishman-Donovan bodies and evidence of HLH. The patient received liposomal amphotericin B and he had a complete resolution of his symptoms and clearance of EBV viremia. This case of HLH associated with visceral leishmaniasis and EBV co-infection raises the question about the significance of EBV in patients with HLH. The treatment of actual etiological agent can lead to complete cure while using current recommend chemotherapy for HLH-related EBV in a patient with hidden infection may have deleterious effects.
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Affiliation(s)
| | - Mohamed-Rachid Boulassel
- Department of Hematology; Department of Allied Health Sciences, Sultan Qaboos University, Sultanate of Oman
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Goto Y, Cheng J, Omachi S, Morimoto A. Prevalence, severity, and pathogeneses of anemia in visceral leishmaniasis. Parasitol Res 2016; 116:457-464. [PMID: 27822583 DOI: 10.1007/s00436-016-5313-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 10/26/2016] [Indexed: 01/22/2023]
Abstract
Anemia is a typical symptom during visceral leishmaniasis (VL). We performed a systematic analysis of the literature on anemia in VL to understand the prevalence, severity, and possible mechanisms. Anemia is very common in VL patients with an overall prevalence higher than 90 %. The degree of anemia in VL is moderate to severe (hemoglobin level ∼7.5 g/dl), and the status can be recovered by treatment with antileishmanial drugs within a certain period of time. Possible pathogeneses of anemia in VL based on clinical observations included anti-RBC antibodies, dysfunction in erythropoiesis, and hemophagocytosis in the bone marrow or spleen, while hemolysis is a more likely cause than dyserythropoiesis. In hamsters with experimental VL, hemophagocytosis induced by immune complex and changes on erythrocyte membrane is speculated as the pathogenesis for anemia. In contrast, our recent study on murine VL indicated that hemophagocytosis contributes to anemia in contrast to lower contribution of anti-RBC antibodies or dysfunction in erythropoiesis. Together, hemophagocytosis is most likely associated with anemia in VL, and elucidation of the immunological mechanisms may lead to development of novel interventions to manage the symptom.
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Affiliation(s)
- Yasuyuki Goto
- Laboratory of Molecular Immunology, Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan.
| | - Jingjie Cheng
- Laboratory of Molecular Immunology, Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan.,Faculty of Medicine, Imperial College London, London, England
| | - Satoko Omachi
- Laboratory of Molecular Immunology, Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan
| | - Ayako Morimoto
- Laboratory of Molecular Immunology, Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan
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Morimoto A, Omachi S, Osada Y, Chambers JK, Uchida K, Sanjoba C, Matsumoto Y, Goto Y. Hemophagocytosis in Experimental Visceral Leishmaniasis by Leishmania donovani. PLoS Negl Trop Dis 2016; 10:e0004505. [PMID: 26942577 PMCID: PMC4778860 DOI: 10.1371/journal.pntd.0004505] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 02/10/2016] [Indexed: 11/17/2022] Open
Abstract
Hemophagocytosis is a phenomenon in which macrophages phagocytose blood cells. There are reports on up-regulated hemophagocytosis in patients with infectious diseases including typhoid fever, tuberculosis, influenza and visceral leishmaniasis (VL). However, mechanisms of infection-associated hemophagocytosis remained elusive due to a lack of appropriate animal models. Here, we have established a mouse model of VL with hemophagocytosis. At 24 weeks after infection with 1 x 107Leishmania donovani promastigotes, BALB/cA mice exhibited splenomegaly with an average tissue weight per body weight of 2.96%. In the tissues, 28.6% of macrophages contained phagocytosed erythrocytes. All of the hemophagocytosing macrophages were parasitized by L. donovani, and higher levels of hemophagocytosis was observed in heavily infected cells. Furthermore, more than half of these hemophagocytes had two or more macrophage-derived nuclei, whereas only 15.0% of splenic macrophages were bi- or multi-nuclear. These results suggest that direct infection by L. donovani causes hyper-activation of host macrophages to engulf blood cells. To our knowledge, this is the first report on hemophagocytosis in experimental Leishmania infections and may be useful for further understanding of the pathogenesis. Anemia is one of the major clinical manifestations during visceral leishmaniasis (VL), whereas mechanisms behind this symptom remain elusive. To get a better understanding of the responsible mechanism(s), we have developed for the first time a mouse model of VL exhibiting anemia. Mice chronically infected with L. donovani had low hematocrit, hemoglobin and erythrocyte counts while having up-regulated erythropoiesis, suggesting hemolytic events due to infection. We propose here that hemophagocytosis is one of the hemolytic events associated with anemia in the infected mice. The spleen is the major place for hemophagocytosis; there, multinucleated giant cells heavily infected with amastigotes are markedly observed and are the major cell type phagocytosing erythrocytes. These results suggest that heavy infection of macrophages with Leishmania parasites triggers phagocytosis of erythrocytes resulting in anemia during murine VL. Because hemophagocytosis has been reported in human VL cases, reproduction of the pathology in mice may facilitate an understanding of the mechanisms leading to anemia during VL.
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Affiliation(s)
- Ayako Morimoto
- Laboratory of Molecular Immunology, Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Satoko Omachi
- Laboratory of Molecular Immunology, Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Yasutaka Osada
- Laboratory of Molecular Immunology, Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - James K Chambers
- Laboratory of Veterinary Pathology, Department of Veterinary Medical Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Kazuyuki Uchida
- Laboratory of Veterinary Pathology, Department of Veterinary Medical Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Chizu Sanjoba
- Laboratory of Molecular Immunology, Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Yoshitsugu Matsumoto
- Laboratory of Molecular Immunology, Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Yasuyuki Goto
- Laboratory of Molecular Immunology, Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
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Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a serious complication of visceral leishmaniasis (VL). The aim of this study is to describe demographical, clinical and laboratory features of HLH in children with VL. METHODS This is a retrospective cohort of children with HLH and VL admitted to a tertiary hospital in Northeast, Brazil, from January 2012 to April 2014. Clinical and laboratory data at admission and during hospital stay were reviewed. Acute kidney injury (AKI) was defined according to the pediatric Risk, Injury, Failure, Loss, End-stage kidney disease criteria. RESULTS A total 127 VL children were admitted, and 35 children had diagnosis of HLH. Mean age was 4.2 ± 4.3 years, with 62.9% males. Mean hospital stay was 29 ± 12 days. Main signs and symptoms were fever (100%), splenomegaly (94.2%) and hepatomegaly (60%). Laboratory findings showed pancytopenia, albumin 3.03 ± 0.77 g/dL, fibrinogen 236.1 ± 117.2 mg/dL, total calcium 8.2 ± 1.2 mEq/L, lactate dehydrogenase 1804 ± 1019 mg/dL, alkaline phosphatase 1275.4 ± 2160.5 IU/L, total bilirubin 1.9 ± 2.4 mg/dL, direct bilirubin 0.67 ± 1.02 mg/dL, indirect bilirubin 1.2 ± 2.2 mg/dL, aspartate aminotransferase 140.0 ± 145.3 IU/L, alanine aminotransferase 71.4 ± 81.1 IU/L, ferritin 4296.5 ± 8028.8 ng/dL and triglycerides 333 ± 141 mg/dL. AKI was observed in 16 children (45.7%), predominantly mild forms (93.75% "risk"). AKI group presented lower levels of platelets (69,131 ± 40,247 vs. 138,678 ± 127,494/mm, P = 0.035) than non-AKI. No patient required dialysis and there was no death. CONCLUSIONS HLH was not a rare complication of VL. Main symptoms were compatible with both VL and HLH. Main laboratory findings reflected HLH pathophysiology. Mild forms of AKI were a common complication of HLH. Despite the disease severity and complications, mortality was low.
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Mouri O, Benhamou M, Leroux G, Chartrel N, Devidas A, Thellier M, Amoura Z, Costedoat-Chalumeau N, Buffet P. Spontaneous remission of fully symptomatic visceral leishmaniasis. BMC Infect Dis 2015; 15:445. [PMID: 26499862 PMCID: PMC4619209 DOI: 10.1186/s12879-015-1191-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 10/07/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Visceral leishmaniasis (VL), i.e., infection with Leishmania sp. associated with high fever, weight loss, massive splenomegaly and markedly altered laboratory parameters, is generally fatal if untreated. The possibility of transient spontaneous remission of fully symptomatic visceral leishmaniasis (VL) has been mentioned but, to our knowledge) has never been documented. CASE PRESENTATION We report the first documented history of a patient with overt, confirmed VL experiencing a complete remission in the absence of any anti-leishmanial therapy. The diagnosis of VL at the time of the self-resolving episode was strongly suspected based on clinical presentation and presence of antileishmanial antibody, then unequivocally confirmed years later by the presence of an amastigote on a stored smear and the positive quantitative PCR with Leishmania-specific primers from the material scraped from this same slide CONCLUSION This report demonstrates that complete spontaneous remission may occur in patients with overt, fully symptomatic VL. VL should therefore be considered in cases of self-resolving or relapsing episodes of fever of unknown origin. Confirmation should be based on both serological tests and specific PCR on a blood sample.
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Affiliation(s)
- Oussama Mouri
- AP-HP, Hôpital Pitié-Salpêtrière, Service de Parasitologie, F-75013, Paris, France.
| | - Mathilde Benhamou
- AP-HP, Hôpital Cochin, Service de Rééducation et Réadaptation, F-75014, Paris, France.
| | - Gaëlle Leroux
- AP-HP, Hôpital Pitié-Salpêtrière, Service de Médecine Interne, F-75013, Paris, France.
| | - Nathalie Chartrel
- AP-HP, Hôpital Pitié-Salpêtrière, Service de Parasitologie, F-75013, Paris, France.
| | - Alain Devidas
- Hopital Sud Francilien, Service d'Hématologie, Corbeil-Essonnes, France.
| | - Marc Thellier
- AP-HP, Hôpital Pitié-Salpêtrière, Service de Parasitologie, F-75013, Paris, France. .,UPMC Université Paris 06, Centre Immunologie et Maladies Infectieuses, F-75005, Paris, France.
| | - Zahir Amoura
- AP-HP, Hôpital Pitié-Salpêtrière, Service de Médecine Interne, F-75013, Paris, France.
| | - Nathalie Costedoat-Chalumeau
- AP-HP, Hôpital Cochin, Service de Médecine Interne. Centre de référence maladies auto-immunes et systémiques rares, Service de Médecine Interne, F-75014, Paris, France.
| | - Pierre Buffet
- AP-HP, Hôpital Pitié-Salpêtrière, Service de Parasitologie, F-75013, Paris, France. .,UPMC Université Paris 06, Centre Immunologie et Maladies Infectieuses, F-75005, Paris, France.
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Ranjan P, Kumar V, Ganguly S, Sukumar M, Sharma S, Singh N, Vikram NK, Pati HP, Sood R. Hemophagocytic Lymphohistiocytosis Associated with Visceral Leishmaniasis: Varied Presentation. Indian J Hematol Blood Transfus 2015; 32:351-4. [PMID: 27408434 DOI: 10.1007/s12288-015-0541-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 04/13/2015] [Indexed: 11/27/2022] Open
Abstract
Visceral leishmaniasis (VL) is endemic in many parts of India. Rarely, it may be complicated by hemophagocytic lymphohistiocytosis (HLH) that has varied presentation and course. We describe two cases of VL complicated by HLH that were markedly different in clinical presentation, course and management. First case presented with Fever of unknown origin whereas second case had fever with severe bleeding manifestations. VL was diagnosed by bone marrow aspiration and serum rk39 immunodiagnostic test respectively in these cases. HLH was diagnosed by HLH 2004 diagnostic criteria. VL was treated by intravenous amphotericin B in both cases. HLH was managed by treating primary disease in the first case whereas steroid was given for management in the second case. High index of suspicion is crucial for early diagnosis of HLH to reduce morbidity and mortality.
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Affiliation(s)
- Piyush Ranjan
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Vivek Kumar
- Medical Intern, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Shuvadeep Ganguly
- Medical Intern, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - M Sukumar
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Sanchit Sharma
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Neha Singh
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Naval K Vikram
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Hara Prasad Pati
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Rita Sood
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, 110029 India
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Koster KL, Laws HJ, Troeger A, Meisel R, Borkhardt A, Oommen PT. Visceral Leishmaniasis as a Possible Reason for Pancytopenia. Front Pediatr 2015; 3:59. [PMID: 26176005 PMCID: PMC4483513 DOI: 10.3389/fped.2015.00059] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 06/10/2015] [Indexed: 11/26/2022] Open
Abstract
Leishmaniasis is caused by different species of the protozoa, Leishmania, and frequently found in South-Western Asia, Eastern Africa, Brazil, and Mediterranean countries. Leishmania are transmitted to humans by the bite of sandflies. After weeks to months, unspecific symptoms may occur, accompanied by more specific findings like pancytopenia and organomegaly. We report two children with pancytopenia and hepato-/splenomegaly: a 1-year-old boy was first diagnosed with an Adenovirus-infection, accompanied by fever, pancytopenia, and hepatosplenomegaly who had spent his summer vacation in Spain and a 3-year-old boy of Macedonian origin who was first diagnosed with a Parvovirus B19-infection again accompanied by splenomegaly and pancytopenia. In both children, leukemia was excluded by an initial bone marrow puncture. As fever was still persistent weeks after the children's first hospital stay, both children received antibiotics empirically without sustainable effect. While different autoantibodies were present in both children, an immunosuppressive therapy was initiated in the younger boy without therapeutic success. A second bone marrow puncture was performed and Leishmania were finally detected morphologically and proven serologically. After weight-adjusted treatment with liposomal Amphotericin B for 10 days, both children recovered completely without relapse. Aim of this report is to broaden the spectrum of differential diagnoses in children with pancytopenia, splenomegaly, and fever to visceral leishmaniasis particularly when travel history is positive for the Mediterranean area. The infection may mimic more common diseases, such as leukemia, viral infections, or autoimmune diseases, because polyclonal B cell activation and other mechanisms may lead to multiple positive serologic tests. Both cases illustrate typical pitfalls and shall encourage taking Leishmaniasis into diagnostic consideration.
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Affiliation(s)
- Kira-Lee Koster
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Center of Child and Adolescent Health, Heinrich-Heine University Düsseldorf , Düsseldorf , Germany
| | - Hans-Jürgen Laws
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Center of Child and Adolescent Health, Heinrich-Heine University Düsseldorf , Düsseldorf , Germany
| | - Anja Troeger
- Department of Pediatric Hematology and Oncology, Center for Pediatrics, University of Bonn , Bonn , Germany
| | - Roland Meisel
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Center of Child and Adolescent Health, Heinrich-Heine University Düsseldorf , Düsseldorf , Germany
| | - Arndt Borkhardt
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Center of Child and Adolescent Health, Heinrich-Heine University Düsseldorf , Düsseldorf , Germany
| | - Prasad Thomas Oommen
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Center of Child and Adolescent Health, Heinrich-Heine University Düsseldorf , Düsseldorf , Germany
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Gabbay LB, Leite CDC, Andriola RS, Pinho PDC, Lucato LT. Histiocytosis: a review focusing on neuroimaging findings. ARQUIVOS DE NEURO-PSIQUIATRIA 2014; 72:548-58. [PMID: 25054989 DOI: 10.1590/0004-282x20140063] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 04/23/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Histiocytosis is a systemic disease that usually affects the central nervous system. The aim of this study is to discuss the neuroimaging characteristics of Langerhans cell histiocytosis (LCH), the most common of these diseases; and the non-Langerhans cells histiocytosis (NLCH), which includes entities such as hemophagocytic syndrome, Erdheim-Chester and Rosai-Dorfman diseases. METHOD Literature review and illustrative cases with pathologic confirmation. RESULTS In LCH, the most common findings are 1) osseous lesions in the craniofacial bones and/or skull base; 2) intracranial, extra-axial changes; 3) intra-axial parenchymal changes (white and gray matter); 4) atrophy. Among the NLCH, diagnosis usually requires correlation with clinical and laboratory criteria. The spectrum of presentation includes intraparenchymal involvement, meningeal lesions, orbits and paranasal sinus involvement. CONCLUSION It is important the recognition of the most common imaging patterns, in order to include LCH and NLCH in the differential diagnosis, whenever pertinent.
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Affiliation(s)
- Larissa Barcessat Gabbay
- Instituto de Radiologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Cláudia da Costa Leite
- Departamento de Radiologia, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Ranieli Saraiva Andriola
- Instituto de Radiologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Paula da Cunha Pinho
- Instituto de Radiologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, Brazil
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Melchionda F, Varani S, Carfagnini F, Belotti T, Di Muccio T, Tigani R, Bergamaschi R, Pession A. Spleen nodules: a potential hallmark of Visceral Leishmaniasis in young children. BMC Infect Dis 2014; 14:620. [PMID: 25496484 PMCID: PMC4270008 DOI: 10.1186/s12879-014-0620-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 11/07/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Visceral leishmaniasis (VL) is a severe disease caused by Leishmania infantum in the Mediterranean basin, and is associated with considerable morbidity and mortality. Infantile VL may begin suddenly, with high fever and vomiting, or insidiously, with irregular daily fever, anorexia, and marked splenomegaly. Delays in diagnosis of VL are common, highlighting the need for increased awareness of clinicians for VL in endemic European countries. CASE PRESENTATION We report 4 cases of young children in northern Italy presenting with persistent fever of unknown origin and diagnosed with VL by serological and molecular methods. At the time of diagnosis, these patients showed an unusual echographic pattern characterized by multiple iso-hypoechoic nodules associated with splenomegaly. CONCLUSION We suggest that detection of spleen nodules represents a signature of VL in infants, thus helping to diagnose systemic Leishmania infantum infection in children.
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Affiliation(s)
- Fraia Melchionda
- Pediatric Hematology and Oncology Unit St. Orsola-Malpighi Hospital University of Bologna, Via Massarenti 11, Bldg 13, Bologna, 40138, Italy.
| | - Stefania Varani
- Unit of Clinical Microbiology, Regional Reference Centre for Microbiological Emergencies (CRREM), St. Orsola-Malpighi University Hospital, Bologna, Italy. .,Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy.
| | - Filomena Carfagnini
- Pediatric Radiology Unit, St. Orsola-Malpighi Hospital University of Bologna, Bologna, Italy.
| | - Tamara Belotti
- Pediatric Hematology and Oncology Unit St. Orsola-Malpighi Hospital University of Bologna, Via Massarenti 11, Bldg 13, Bologna, 40138, Italy.
| | - Trentina Di Muccio
- Unit of Vector-Borne Diseases and International Health, MIPI Department, Istituto Superiore di Sanità, Rome, Italy.
| | - Roberto Tigani
- Unit of Clinical Microbiology, Regional Reference Centre for Microbiological Emergencies (CRREM), St. Orsola-Malpighi University Hospital, Bologna, Italy.
| | - Rosalba Bergamaschi
- Pediatric Unit, St. Orsola-Malpighi Hospital University of Bologna, Bologna, Italy.
| | - Andrea Pession
- Pediatric Hematology and Oncology Unit St. Orsola-Malpighi Hospital University of Bologna, Via Massarenti 11, Bldg 13, Bologna, 40138, Italy.
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Hemophagocytic lymphohistiocytosis in imported pediatric visceral leishmaniasis in a nonendemic area. J Pediatr 2014; 165:147-153.e1. [PMID: 24797953 DOI: 10.1016/j.jpeds.2014.03.047] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 02/28/2014] [Accepted: 03/26/2014] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To describe characteristics of visceral leishmaniasis-associated hemophagocytic lymphohistiocytosis (HLH) with focus on diagnostic clues and pitfalls, including the frequency of central nervous system (CNS) involvement, and to determine the efficacy of liposomal amphotericin B (L-AmB). STUDY DESIGN We retrospectively analyzed clinical and laboratory features, diagnostic procedures, and treatment of 13 patients with HLH with imported visceral leishmaniasis, reported to the German HLH reference center (1999-2012). RESULTS The spectrum of presentations was indistinguishable from patients with hereditary HLH or with acquired HLH because of infections with other pathogens. In 8 patients, disease onset occurred before the age of 2 years, coinciding with the typical age of manifestation of primary HLH. Two patients had mild nonspecific CNS findings. Misleading antiviral IgM (n = 6) and autoantibodies (n = 2) led to inaccurate interpretation of the etiology of HLH, sometimes with inappropriate therapeutic consequences. False negative results for Leishmania were obtained by initial bone marrow microscopy in 6/13, serology in 1/12, bone marrow culture in 2/5, and polymerase chain reaction of peripheral blood in 1/3 patients, and all bone marrow samples tested were Leishmania-positive by polymerase chain reaction (n = 7). L-AmB was administered to 12 patients, 5 of whom had no prior HLH-directed immunosuppressive therapy; sodium stibogluconate was administered to 1 patient. Persistent remission was achieved in 11 cases. Two patients required repeated or prolonged L-AmB therapy. CONCLUSIONS Awareness of diagnostic pitfalls may save patients from unnecessary toxic treatment. CNS involvement is rare. L-AmB shows efficacy in visceral leishmaniasis-associated HLH.
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Radujkovic A, Hundemer M, Eisenbach C, Luft T, Penzel R, Goldschmidt H, Ho AD, Bellos F. Visceral leishmaniasis in a patient with relapsed multiple myeloma receiving high-dose melphalan and autologous stem cell transplant. Leuk Lymphoma 2014; 55:2967-9. [DOI: 10.3109/10428194.2014.911862] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Sieni E, Cetica V, Hackmann Y, Coniglio ML, Da Ros M, Ciambotti B, Pende D, Griffiths G, Aricò M. Familial hemophagocytic lymphohistiocytosis: when rare diseases shed light on immune system functioning. Front Immunol 2014; 5:167. [PMID: 24795715 PMCID: PMC3997030 DOI: 10.3389/fimmu.2014.00167] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 03/29/2014] [Indexed: 12/03/2022] Open
Abstract
The human immune system depends on the activity of cytotoxic T lymphocytes (CTL), natural killer (NK) cells, and NKT cells in order to fight off a viral infection. Understanding the molecular mechanisms during this process and the role of individual proteins was greatly improved by the study of familial hemophagocytic lymphohistiocytosis (FHL). Since 1999, genetic sequencing is the gold standard to classify patients into different subgroups of FHL. The diagnosis, once based on a clinical constellation of abnormalities, is now strongly supported by the results of a functional flow-cytometry screening, which directs the genetic study. A few additional congenital immune deficiencies can also cause a resembling or even identical clinical picture to FHL. As in many other rare human disorders, the collection and analysis of a relatively large number of cases in registries is crucial to draw a complete picture of the disease. The conduction of prospective therapeutic trials allows investigators to increase the awareness of the disease and to speed up the diagnostic process, but also provides important functional and genetic confirmations. Children with confirmed diagnosis may undergo hematopoietic stem cell transplantation, which is the only cure known to date. Moreover, detailed characterization of these rare patients helped to understand the function of individual proteins within the exocytic machinery of CTL, NK, and NKT cells. Moreover, identification of these genotypes also provides valuable information on variant phenotypes, other than FHL, associated with biallelic and monoallelic mutations in the FHL-related genes. In this review, we describe how detailed characterization of patients with genetic hemophagocytic lymphohistiocytosis has resulted in improvement in knowledge regarding contribution of individual proteins to the functional machinery of cytotoxic T- and NK-cells. The review also details how identification of these genotypes has provided valuable information on variant phenotypes.
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Affiliation(s)
- Elena Sieni
- Department Pediatric Hematology Oncology, Azienda Ospedaliero-Universitaria Meyer Children Hospital , Florence , Italy
| | - Valentina Cetica
- Department Pediatric Hematology Oncology, Azienda Ospedaliero-Universitaria Meyer Children Hospital , Florence , Italy ; Pediatric Hematology Oncology Network, Istituto Toscano Tumori (I.T.T.) , Florence , Italy
| | - Yvonne Hackmann
- Cambridge Institute for Medical Research, University of Cambridge Biomedical Campus , Cambridge , UK
| | - Maria Luisa Coniglio
- Department Pediatric Hematology Oncology, Azienda Ospedaliero-Universitaria Meyer Children Hospital , Florence , Italy
| | - Martina Da Ros
- Department Pediatric Hematology Oncology, Azienda Ospedaliero-Universitaria Meyer Children Hospital , Florence , Italy
| | - Benedetta Ciambotti
- Department Pediatric Hematology Oncology, Azienda Ospedaliero-Universitaria Meyer Children Hospital , Florence , Italy
| | - Daniela Pende
- Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliera Universitaria San Martino-Istituto Nazionale per la Ricerca sul Cancro , Genoa , Italy
| | - Gillian Griffiths
- Cambridge Institute for Medical Research, University of Cambridge Biomedical Campus , Cambridge , UK
| | - Maurizio Aricò
- Pediatric Hematology Oncology Network, Istituto Toscano Tumori (I.T.T.) , Florence , Italy
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van Griensven J, Carrillo E, López-Vélez R, Lynen L, Moreno J. Leishmaniasis in immunosuppressed individuals. Clin Microbiol Infect 2014; 20:286-99. [DOI: 10.1111/1469-0691.12556] [Citation(s) in RCA: 227] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Defective UNC13D gene-associated familial hemophagocytic lymphohistiocytosis triggered by visceral leishmaniasis: a diagnostic challenge. J Pediatr Hematol Oncol 2014; 36:e42-5. [PMID: 23774160 DOI: 10.1097/mph.0b013e31829b7f22] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Visceral leishmaniasis (VL) triggered genetic hemophagocytic lymphohistiocytosis (HLH) is clinically challenging. OBSERVATIONS One-year-old VL-HLH patient improved after liposomal-amphotericin-B therapy, but subsequently deteriorated, although bone marrow amastigotes disappeared. Symptoms resolved after 8 weeks of HLH-2004 therapy but recurred upon cessation. Homozygous UNC13D gene 627delT mutation was identified however stem cell donor was unavailable. The patient died at age 4 years after central nervous system attacks and HLH recurrences. CONCLUSIONS VL in HLH patients does not exclude a genetic etiology and requires structured clinical management. VL should be excluded in all HLH patients in endemic regions before immunochemotherapy, which is recommended for VL-HLH patients unresponsive to VL treatment and/or reactivated.
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Visentin S, Baudesson de Chanville A, Loosveld M, Chambost H, Barlogis V. La leishmaniose viscérale infantile, une cause de syndrome d’hémophagocytose lympho-histiocytaire facilement curable. Arch Pediatr 2013; 20:1225-1229. [DOI: 10.1016/j.arcped.2013.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 08/26/2013] [Indexed: 01/19/2023]
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Affiliation(s)
- Deepali Jain
- Department of PathologyMaulana Azad Medical College, New Delhi, India
| | - Tejinder Singh
- Department of PathologyMaulana Azad Medical College, New Delhi, India
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Visceral leishmaniasis presenting with paroxysmal cold haemoglobinuria. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2013; 12 Suppl 1:s141-3. [PMID: 23867185 DOI: 10.2450/2013.0034-13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 04/09/2013] [Indexed: 11/21/2022]
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Abstract
Hemophagocytic lymphohistiocytosis (HLH) associated with visceral leishmaniasis (VL) is a very rare phenomenon. We report the first known North American case in a 21 month old boy. He was initially diagnosed with Epstein Barr virus (EBV) triggered HLH and treated with the international treatment protocol, HLH-2004. Stem cell transplant was planned due to repeated reactivations of disease, but his pretransplant bone marrow revealed an unexpected protozoan-Leishmania donovani. Treatment with liposomal amphotericin B led to resolution of all manifestations of HLH. We discuss how the clinical and laboratory features of both entities can closely mimic each other and are extremely difficult to differentiate. This case also raises the question of whether to screen all children with suspected HLH for Leishmania in a non endemic area.
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Cançado GGL, Freitas GG, Faria FHF, de Macedo AV, Nobre V. Hemophagocytic lymphohistiocytosis associated with visceral leishmaniasis in late adulthood. Am J Trop Med Hyg 2013; 88:575-7. [PMID: 23324220 DOI: 10.4269/ajtmh.12-0563] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
We describe a case of hemophagocytic lymphohistiocytosis related to visceral leishmaniasis in late adulthood. Because clinical features of visceral leishmaniasis can mimic those of hemophagocytic lymphohistiocytosis, diagnosing leishmaniasis as the underlying etiology can be quite challenging. In our case, treatment with amphotericin B resulted in a dramatic resolution of clinical abnormalities.
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Debate around infection-dependent hemophagocytic syndrome in paediatrics. BMC Infect Dis 2013; 13:15. [PMID: 23324497 PMCID: PMC3549728 DOI: 10.1186/1471-2334-13-15] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Accepted: 01/11/2013] [Indexed: 02/08/2023] Open
Abstract
Background Hemophagocytic syndrome (HPS) is clinically defined as a combination of fever, liver dysfunction, coagulation abnormalities, pancytopenia, progressive macrophage proliferation throughout the reticuloendothelial system, and cytokine over-production, and may be primary or secondary to infectious, auto-immune, and tumoral diseases. The most consistent association is with viral infections but, as it is still debated whether any micro-organisms are involved in its pathogenesis, we critically appraised the literature concerning HPS and its relationship with infections. Discussion Infection-dependent HPS has been widely observed, but there are no data concerning its incidence in children. A better understanding of the pathophysiology of HPS may clarify the interactions between the immune system and the variously implicated potential infectious agents. Epstein-Barr virus (EBV) infection has been prominently associated with HPS, with clonal proliferation and the hyperactivation of EBV-infected T cells. However, a number of other viral, bacterial, fungal, and parasitic infections have been reported in association with HPS. In the case of low-risk HPS, corticosteroids and/or intravenous immunoglobulin or cyclosporine A may be sufficient to control the biological process, but etoposide is recommended as a means of reversing infection-dependent lymphohistiocytic dysregulation in high-risk cases. Summary HPS is a potential complication of various infections. A polymerase chain reaction search for infectious agents including EBV, cytomegalovirus and Leishmania is recommended in clinical settings characterised by non-remitting fever, organomegaly, cytopenia and hyperferritinemia.
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Lehmberg K, Ehl S. Diagnostic evaluation of patients with suspected haemophagocytic lymphohistiocytosis. Br J Haematol 2012. [PMID: 23206255 DOI: 10.1111/bjh.12138] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome characterized by severely disturbed immune homeostasis. It can affect all age groups. Diagnostic evaluation of the patient with suspected HLH has to address three main questions: (i) does the patient have HLH? There is no simple diagnostic test, but a number of clinical and laboratory criteria define this clinical syndrome. (ii) Can a trigger be identified? A variety of infections, malignant or autoimmune diseases can contribute to the disturbed immune homeostasis with important consequences for treatment. (iii) Does the patient suffer from a genetic disease predisposing to HLH? Recent advances in the understanding of the genetic and pathophysiological basis of HLH have enabled a better and more rapid answer to this question, which is relevant for prognosis and the decision to perform haematopoietic stem cell transplantation. This review summarizes the current diagnostic approach to the patient with HLH.
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Affiliation(s)
- Kai Lehmberg
- Department of Paediatric Haematology and Oncology, University Medical Centre, Hamburg, Germany
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Sieni E, Cetica V, Mastrodicasa E, Pende D, Moretta L, Griffiths G, Aricò M. Familial hemophagocytic lymphohistiocytosis: a model for understanding the human machinery of cellular cytotoxicity. Cell Mol Life Sci 2012; 69:29-40. [PMID: 21990010 PMCID: PMC11114696 DOI: 10.1007/s00018-011-0835-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 09/13/2011] [Accepted: 09/13/2011] [Indexed: 02/03/2023]
Abstract
Cytotoxic T lymphocytes, natural killer cells, and NKT cells are effector cells able to kill infected cells. In some inherited human disorders, a defect in selected proteins involved in the cellular cytotoxicity mechanism results in specific clinical syndromes, grouped under the name of familial hemophagocytic lymphohistiocytosis. Recent advances in genetic studies of these patients has allowed the identification of different genetic subsets. Additional genetic immune deficiencies may also induce a similar clinical picture. International cooperation and prospective trials resulted in refining the diagnostic and therapeutic approach to these rare diseases with improved outcome but also with improved knowledge of the mechanisms underlying granule-mediated cellular cytotoxicity in humans.
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Affiliation(s)
- Elena Sieni
- Dipartimento Oncoematologia Pediatrica e Cure Domiciliari, Azienda Ospedaliero-Universitaria Meyer, Viale Pieraccini, 24, 50139 Florence, Italy
| | - Valentina Cetica
- Dipartimento Oncoematologia Pediatrica e Cure Domiciliari, Azienda Ospedaliero-Universitaria Meyer, Viale Pieraccini, 24, 50139 Florence, Italy
| | - Elena Mastrodicasa
- S.C. di Oncoematologia Pediatrica con Trapianto di CSE, Ospedale “S.M. della Misericordia” A.O, Perugia, Italy
| | - Daniela Pende
- A.O.U. San Martino-IST, Istituto Nazionale Ricerca sul Cancro, Genoa, Italy
| | | | - Gillian Griffiths
- Cambridge Institute for Medical Research, Addenbrooke’s Hospital, Cambridge, CB2 0XY UK
| | - Maurizio Aricò
- Dipartimento Oncoematologia Pediatrica e Cure Domiciliari, Azienda Ospedaliero-Universitaria Meyer, Viale Pieraccini, 24, 50139 Florence, Italy
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Skram MK, Bjering S, Hermansen NO, Dini L, Hellebostad M. A 15-month-old girl with fever and pancytopenia. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2011; 131:2482-6. [PMID: 22170136 DOI: 10.4045/tidsskr.11.0387] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
A 15 month-old girl was admitted after a couple of months' history of illness with remittent fever, increasing pallor and a swollen abdomen. On admission she was highly febrile, with palpably enlarged liver and spleen. Blood tests revealed pancytopenia, a high CRP level and a high serum ferritin level. We describe the diagnostic evaluation, interpretation and treatment.
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Affiliation(s)
- Marius Kurås Skram
- Department of Paediatric Medicine, Oslo University Hospital, Ullevål, Norway
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The hematopathologist as detective. J Hematop 2011. [DOI: 10.1007/s12308-011-0098-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Gholam C, Grigoriadou S, Gilmour KC, Gaspar HB. Familial haemophagocytic lymphohistiocytosis: advances in the genetic basis, diagnosis and management. Clin Exp Immunol 2011; 163:271-83. [PMID: 21303357 DOI: 10.1111/j.1365-2249.2010.04302.x] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Familial haemophagocytic lymphohistiocytosis (FHL) is a rare autosomal recessive disorder of immune dysregulation associated with uncontrolled T cell and macrophage activation and hypercytokinaemia. The incidence of FHL is 0·12/100·000 children born per year, with a male to female ratio of 1:1. The disease is classified into six different types based on genetic linkage analysis and chromosomal localization; five specific genetic defects have been identified, which account for approximately 90% of all patients. Type 1 is due to an as yet unidentified gene defect located on chromosome nine. Type 2 is caused by mutations in the perforin (PRF1) gene, type 3 by mutations in the Munc-13-4 (UNC13D) gene, type 4 by mutations in the syntaxin 11 (STX11) gene and the recently described type 5 due to mutations in the gene encoding syntaxin binding protein 2 (STXBP-2). The incidence of the five types varies in different ethnic groups. The most common presenting features are pyrexia of unknown origin, pronounced hepatosplenomegaly and cytopenias. Neurological features tend to present later and are associated with poor prognosis. Absent or decreased lymphocyte cytotoxicity is the cellular hallmark of FHL. Biochemical features such as hyperferritinaemia, hypertriglyceridaemia and hypofibrinogenaemia are usually present, along with high levels of soluble interleukin 2 receptor in the blood and cerebrospinal fluid. Bone marrow aspirate may demonstrate the characteristic haemophagocytes, but initially is non-diagnostic in two-thirds of patients. Established international clinical, haematological and biochemical criteria now facilitate accurate clinical diagnosis. The disease is fatal unless a haematopoietic stem cell transplant (HSCT) is performed. The introduction of HSCT has dramatically improved the prognosis of the disease. However, the mortality of the disease is still significantly high and a number of challenges remain to be addressed. Active disease at the time of the transplant is the major significant poor prognostic factor. Delayed diagnosis, after irreversible organ damage has occurred, especially neurological damage, disease reoccurrence and pre-transplant mortality, remain a concern.
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Affiliation(s)
- C Gholam
- Department of Dermatology, Great Ormond Street Hospital NHS Trust, London, UK
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Deak E, Jayakumar A, Cho KW, Goldsmith-Pestana K, Dondji B, Lambris JD, McMahon-Pratt D. Murine visceral leishmaniasis: IgM and polyclonal B-cell activation lead to disease exacerbation. Eur J Immunol 2010; 40:1355-68. [PMID: 20213734 DOI: 10.1002/eji.200939455] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
In visceral leishmaniasis, the draining LN (DLN) is the initial site for colonization and establishment of infection after intradermal transmission by the sand fly vector; however, little is known about the developing immune response within this site. Using an intradermal infection model, which allows for parasite visceralization, we have examined the ongoing immune responses in the DLN of BALB/c mice infected with Leishmania infantum. Although not unexpected, at early times post-infection there is a marked B-cell expansion in the DLN, which persists throughout infection. However, the characteristics of this response were of interest; as early as day 7 post-infection, polyclonal antibodies (TNP, OVA, chromatin) were observed and the levels appeared comparable to the specific anti-leishmania response. Although B-cell-deficient JhD BALB/c mice are relatively resistant to infection, neither B-cell-derived IL-10 nor B-cell antigen presentation appear to be primarily responsible for the elevated parasitemia. However, passive transfer and reconstitution of JhD BALB/c with secretory immunoglobulins, (IgM or IgG; specific or non-specific immune complexes) results in increased susceptibility to L. infantum infection. Further, JhD BALB/c mice transgenetically reconstituted to secrete IgM demonstrated exacerbated disease in comparison to WT BALB/c mice as early as 2 days post-infection. Evidence suggests that complement activation (generation of C5a) and signaling via the C5a receptor (CD88) is related to the disease exacerbation caused by IgM rather than cytokine levels (IL-10 or IFN-gamma). Overall these studies indicate that polyclonal B-cell activation, which is known to be associated with human visceral leishmaniasis, is an early and intrinsic characteristic of disease and may represent a target for therapeutic intervention.
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Affiliation(s)
- Eszter Deak
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT 06520-8034, USA
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Parodi A, Davì S, Pringe AB, Pistorio A, Ruperto N, Magni-Manzoni S, Miettunen P, Bader-Meunier B, Espada G, Sterba G, Ozen S, Wright D, Magalhães CS, Khubchandani R, Michels H, Woo P, Iglesias A, Guseinova D, Bracaglia C, Hayward K, Wouters C, Grom A, Vivarelli M, Fischer A, Breda L, Martini A, Ravelli A. Macrophage activation syndrome in juvenile systemic lupus erythematosus: a multinational multicenter study of thirty-eight patients. ACTA ACUST UNITED AC 2010; 60:3388-99. [PMID: 19877067 DOI: 10.1002/art.24883] [Citation(s) in RCA: 166] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To describe the clinical and laboratory features of macrophage activation syndrome as a complication of juvenile systemic lupus erythematosus (SLE). METHODS Cases of juvenile SLE-associated macrophage activation syndrome were provided by investigators belonging to 3 pediatric rheumatology networks or were found in the literature. Patients who had evidence of macrophage hemophagocytosis on bone marrow aspiration were considered to have definite macrophage activation syndrome, and those who did not have such evidence were considered to have probable macrophage activation syndrome. Clinical and laboratory findings in patients with macrophage activation syndrome were contrasted with those of 2 control groups composed of patients with active juvenile SLE without macrophage activation syndrome. The ability of each feature to discriminate macrophage activation syndrome from active disease was evaluated by calculating sensitivity, specificity, and area under the receiver operating characteristic curve. RESULTS The study included 38 patients (20 with definite macrophage activation syndrome and 18 with probable macrophage activation syndrome). Patients with definite and probable macrophage activation syndrome were comparable with regard to all clinical and laboratory features of the syndrome, except for a greater frequency of lymphadenopathy, leukopenia, and thrombocytopenia in patients with definite macrophage activation syndrome. Overall, clinical features had better specificity than sensitivity, except for fever, which was highly sensitive but had low specificity. Among laboratory features, the best sensitivity and specificity was achieved using hyperferritinemia, followed by increased levels of lactate dehydrogenase, hypertriglyceridemia, and hypofibrinogenemia. Based on the results of statistical analysis, preliminary diagnostic guidelines for macrophage activation syndrome in juvenile SLE were developed. CONCLUSION Our findings indicate that the occurrence of unexplained fever and cytopenia, when associated with hyperferritinemia, in a patient with juvenile SLE should raise the suspicion of macrophage activation syndrome. We propose preliminary guidelines for this syndrome in juvenile SLE to facilitate timely diagnosis and correct classification of patients.
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Affiliation(s)
- Alessandro Parodi
- Istituto di Ricovero e Cura a Carattere Scientifico G. Gaslini, Genoa, Italy
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Dhingra K, Gupta P, Saroha V, Setia N, Khurana N, Singh T. Morphological findings in bone marrow biopsy and aspirate smears of visceral kala azar: A review. INDIAN J PATHOL MICR 2010; 53:96-100. [DOI: 10.4103/0377-4929.59193] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Abstract
We report 3 cases of Visceral leishmaniasis, who presented with unusual clinical manifestations. One child was diagnosed as hemophagocytic syndrome; another masqueraded with features of leukemoid changes alongwith hemophagocytosis and trilineage myelodysplasia; the third case presented with pyothorax. All the three patients showed amastigote forms of Leishmania donovani and positive serology (rk39 antigen). They showed complete clinical, hematological and parasitological resolution with Amphotericin B therapy.
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Dapena Díaz J, Díaz de Heredia Rubio C, Bastida Vila P, Llort Sales A, Elorza Álvarez I, Olivé Oliveras T, Sánchez de Toledo Codina J. Síndrome hemofagocítico: expresión de diversas entidades nosológicas. An Pediatr (Barc) 2009; 71:110-6. [DOI: 10.1016/j.anpedi.2009.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 04/14/2009] [Accepted: 04/16/2009] [Indexed: 11/30/2022] Open
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Levy L, Nasereddin A, Rav-Acha M, Kedmi M, Rund D, Gatt ME. Prolonged fever, hepatosplenomegaly, and pancytopenia in a 46-year-old woman. PLoS Med 2009; 6:e1000053. [PMID: 19365537 PMCID: PMC2661247 DOI: 10.1371/journal.pmed.1000053] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Liran Levy and colleagues discuss the differential diagnosis, investigation, and management of a 46-year-old woman with fever, weakness, night sweats, and weight loss.
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Affiliation(s)
- Liran Levy
- Department of Internal Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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50
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Weisfeld-Adams JD, Frank Y, Havalad V, Hojsak JM, Posada R, Kaicker SM, Wistinghausen B. Diagnostic challenges in a child with familial hemophagocytic lymphohistiocytosis type 3 (FHLH3) presenting with fulminant neurological disease. Childs Nerv Syst 2009; 25:153-9. [PMID: 19023578 DOI: 10.1007/s00381-008-0744-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND Familial hemophagocytic lymphohistiocytosis (FHLH) is an autosomal recessively inherited multisystem disease characterized by fever, rash, splenomegaly, cytopenias, and variable central nervous system (CNS) manifestations. CASE HISTORY We report the case of a 3-year-old boy who presented with splenomegaly and normocytic anemia 4 months after returning to the US from a region endemic for Leishmania infection. The child later developed progressive neurological impairment and had radiologic evidence of widespread demyelinating disease. Gene studies showed homozygosity for a mutation at Munc13-4, confirming FHLH type 3. DISCUSSION The diagnostic uncertainty that accompanies FHLH was compounded by our patient's travel history and CNS disease mimicking acute disseminated encephalomyelitis (ADEM). Diagnostic criteria for hemophagocytic lymphohistiocytosis were not consistently met, despite aggressive disease. CONCLUSIONS FHLH may present with fulminant demyelinating disease, mimicking ADEM, and without necessarily meeting previously defined clinical and laboratory criteria. We strongly recommend expeditious molecular testing and genetic counseling for FHLH mutations in cases of undiagnosed inflammatory CNS disease in the pediatric population.
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Affiliation(s)
- James D Weisfeld-Adams
- Department of Human Genetics and Genomic Sciences, Kravis Children's Hospital at Mount Sinai Medical Center, New York, NY 10029-6574, USA.
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