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Fatma A, Raida BS, Mourad C, Ikram D, Zouheir B, Henda E. Performances of the H-score and the HLH-2004 score in the positive diagnosis of secondary hemophagocytic lymphohistiocytosis. Curr Res Transl Med 2024; 72:103430. [PMID: 38266400 DOI: 10.1016/j.retram.2023.103430] [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: 05/24/2023] [Revised: 09/11/2023] [Accepted: 11/06/2023] [Indexed: 01/26/2024]
Abstract
Hemophagocytic lymphocytosis (HLH) is a rare clinical and biological entity that can be life-threatening. Early diagnosis can improve the overall prognosis of HLH. OBJECTIVES The aims of this study are to evaluate the performances of HLH-2004-score and H-score in identifying patients with secondary HLH and to determine an optimal H-score cut-off for our population. METHODS A retrospective study that involved all patients, with images of hemophagocytosis in myelograms analyzed at the laboratory of hematology, followed at these departments: clinical-hematology, internal-medicine, infectious-diseases and gastroenterology, University-Hospital "Hédi-Chaker", Sfax-Tunisia, (June2017-May2021). We identified two groups of patients: "HLH" and "Not-HLH". Then, for each patient, we calculated the HLH-2004-score and the H-score. RESULTS Forty-two patients were included in this study. Twenty-five (60 %) belonging to group "HLH" and seventeen (40 %) to group "Not-HLH" with a mean age (38.72 vs. 39.82 years, p = 0.846) respectively. The study of the performances demonstrated that H-score had better performances. The best cut-off value of H-score for our population was 158.5, allowing a gain in sensitivity (from 92 % to 96 %) compared to the original study cut-off of 169. CONCLUSION Both H-score and HLH-2004-score showed excellent discriminative powers with better performances for H-score. The new H-score cut-off at 158.5 can be applied to our population.
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Affiliation(s)
- Abida Fatma
- Laboratory of Hematology, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Ben Salah Raida
- Department of Internal Medicine, Hedi Chaker University Hospital, Sfax, Tunisia.
| | - Chaari Mourad
- Laboratory of Hematology, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Dammak Ikram
- Laboratory of Hematology, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Bahloul Zouheir
- Department of Internal Medicine, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Elleuch Henda
- Laboratory of Hematology, Hedi Chaker University Hospital, Sfax, Tunisia
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Gioia C, Paroli M, Izzo R, Di Sanzo L, Rossi E, Pignatelli P, Accapezzato D. Pathogenesis of Hemophagocytic Lymphohistiocytosis/Macrophage Activation Syndrome: A Case Report and Review of the Literature. Int J Mol Sci 2024; 25:5921. [PMID: 38892108 PMCID: PMC11173133 DOI: 10.3390/ijms25115921] [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: 04/26/2024] [Revised: 05/27/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition characterized by the uncontrolled activation of cytotoxic T lymphocytes, NK cells, and macrophages, resulting in an overproduction of pro-inflammatory cytokines. A primary and a secondary form are distinguished depending on whether or not it is associated with hematologic, infectious, or immune-mediated disease. Clinical manifestations include fever, splenomegaly, neurological changes, coagulopathy, hepatic dysfunction, cytopenia, hypertriglyceridemia, hyperferritinemia, and hemophagocytosis. In adults, therapy, although aggressive, is often unsuccessful. We report the case of a 41-year-old man with no apparent history of previous disease and an acute onset characterized by fever, fatigue, and weight loss. The man was from Burkina Faso and had made trips to his home country in the previous five months. On admission, leukopenia, thrombocytopenia, increased creatinine and transaminases, LDH, and CRP with a normal ESR were found. The patient also presented with hypertriglyceridemia and hyperferritinemia. An infectious or autoimmune etiology was ruled out. A total body CT scan showed bilateral pleural effusion and hilar mesenterial, abdominal, and paratracheal lymphadenopathy. Lymphoproliferative disease with HLH complication was therefore suspected. High doses of glucocorticoids were then administered. A cytologic analysis of the pleural effusion showed anaplastic lymphoma cells and bone marrow aspirate showed hemophagocytosis. An Epstein-Barr Virus (EBV) DNA load of more than 90000 copies/mL was found. Bone marrow biopsy showed a marrow localization of peripheral T lymphoma. The course was rapidly progressive until the patient died. HLH is a rare but usually fatal complication in adults of hematologic, autoimmune, and malignant diseases. Very early diagnosis and treatment are critical but not always sufficient to save patients.
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Affiliation(s)
| | | | | | | | | | | | - Daniele Accapezzato
- Division of Clinical Immunology, Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy; (C.G.); (M.P.); (R.I.); (L.D.S.); (E.R.); (P.P.)
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Huang S, Liu Y, Yan W, Zhang T, Wang P, Zhu M, Zhang X, Zhou P, Fan Z, Yu H. Single center clinical analysis of macrophage activation syndrome complicating juvenile rheumatic diseases. Pediatr Rheumatol Online J 2024; 22:58. [PMID: 38783316 PMCID: PMC11112803 DOI: 10.1186/s12969-024-00991-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 04/25/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Macrophage activation syndrome (MAS), an example of secondary hemophagocytic lymphohistiocytosis, is a potentially fatal complication of rheumatic diseases. We aimed to study the clinical and laboratory characteristics, treatment schemes, and outcomes of different rheumatic disorders associated with MAS in children. Early warning indicators of MAS have also been investigated to enable clinicians to make a prompt and accurate diagnosis. METHODS Fifty-five patients with rheumatic diseases complicated by MAS were enrolled between January 2017 and December 2022. Clinical and laboratory data were collected before disease onset, at diagnosis, and after treatment with MAS, and data were compared between patients with systemic juvenile idiopathic arthritis (sJIA), Kawasaki disease (KD), and systemic lupus erythematosus (SLE). A random forest model was established to show the importance score of each variable with a significant difference. RESULTS Most (81.8%) instances of MAS occurred during the initial diagnosis of the underlying disease. Compared to the active stage of sJIA, the platelet count, erythrocyte sedimentation rate, and fibrinogen level in sJIA-MAS were significantly decreased, whereas ferritin, ferritin/erythrocyte sedimentation rate, aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, and D-dimer levels were significantly increased. Ferritin level, ferritin/erythrocyte sedimentation rate, and platelet count had the greatest predictive value for sJIA-MAS. The level of IL-18 in the sJIA-MAS group was significantly higher than in the active sJIA group, whereas IL-6 levels were significantly lower. Most patients with MAS were treated with methylprednisolone pulse combined with cyclosporine, and no deaths occurred. CONCLUSIONS Thrombocytopenia, ferritin levels, the ferritin/erythrocyte sedimentation rate, and elevated aspartate aminotransferase levels can predict the occurrence of MAS in patients with sJIA. Additionally, our analysis indicates that IL-18 plays an important role in the pathogenesis of MAS in sJIA-MAS.
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Affiliation(s)
- Shuoyin Huang
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Yingying Liu
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Wu Yan
- Department of Child Health Care, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Tonghao Zhang
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Panpan Wang
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Meifang Zhu
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Xiaohua Zhang
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Peng Zhou
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Zhidan Fan
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China.
| | - Haiguo Yu
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China.
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Maeser A, Biernacka-Zielinska M, Smolewska E. A MASsive attack: a pediatric case of macrophage activation syndrome complicated by DIC as an onset of systemic juvenile idiopathic arthritis successfully treated with anakinra and review of the literature. Rheumatol Int 2024:10.1007/s00296-024-05570-z. [PMID: 38502236 DOI: 10.1007/s00296-024-05570-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 02/26/2024] [Indexed: 03/21/2024]
Abstract
Macrophage activation syndrome (MAS) is one of the most severe complications of systemic juvenile idiopathic arthritis (sJIA). Around 10% of patients with sJIA exhibit systemic symptoms accompanied by macrophage activation syndrome (MAS), but it may occur subclinically in another 30-40%. In this article, we present a case of a 3-year-old girl diagnosed with sever MAS as an onset of sJIA complicated by disseminated intravascular coagulation (DIC). First symptoms of sJIA were observed about 5 months before setting the diagnose, and it was resembling urticaria. A comprehensive allergological diagnostics were conducted, but no cause for the skin changes was identified. A few weeks before admission to the hospital, the girl was presented with a high fever. During the hospital stay, viral, bacterial, and fungal infections were ruled out. However, the findings indicated significantly elevated markers of inflammation (ferritin, CRP, ESR) in the conducted tests. Meanwhile, swelling of the feet and ankle joints was also observed. Based on Ravelli criteria, we set the diagnosis of MAS in a course of sJIA. We implemented treatment with steroid pulses, followed by cyclosporine; however, her clinical condition did not improve. Despite intensive treatment, skin petechiae were observed twice, and laboratory tests revealed a very high INR along with an extremely low level of fibrinogen. The patient required multiple plasma transfusions and clotting factor administrations. Due to the severe condition of the girl, we initiated biological treatment with anakinra, after which the child's condition gradually improved. In this case, we want to present how dynamic and life-threatening the course of MAS can be. In the discussion, we are also comparing our approach and the applied treatment with the currently available knowledge.
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Affiliation(s)
- Anna Maeser
- Department of Pediatric Cardiology and Rheumatology, Medical University of Lodz, Sporna 36/50, 91-738, Lodz, Poland.
| | | | - Elzbieta Smolewska
- Department of Pediatric Cardiology and Rheumatology, Medical University of Lodz, Sporna 36/50, 91-738, Lodz, Poland
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Ruscitti P, Cantarini L, Nigrovic PA, McGonagle D, Giacomelli R. Recent advances and evolving concepts in Still's disease. Nat Rev Rheumatol 2024; 20:116-132. [PMID: 38212542 DOI: 10.1038/s41584-023-01065-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2023] [Indexed: 01/13/2024]
Abstract
Still's disease is a rare inflammatory syndrome that encompasses systemic juvenile idiopathic arthritis and adult-onset Still's disease, both of which can exhibit life-threatening complications, including macrophage activation syndrome (MAS), a secondary form of haemophagocytic lymphohistiocytosis. Genetic insights into Still's disease involve both HLA and non-HLA susceptibility genes, suggesting the involvement of adaptive immune cell-mediated immunity. At the same time, phenotypic evidence indicates the involvement of autoinflammatory processes. Evidence also implicates the type I interferon signature, mechanistic target of rapamycin complex 1 signalling and ferritin in the pathogenesis of Still's disease and MAS. Pathological entities associated with Still's disease include lung disease that could be associated with biologic DMARDs and with the occurrence of MAS. Historically, monophasic, recurrent and persistent Still's disease courses were recognized. Newer proposals of alternative Still's disease clusters could enable better dissection of clinical heterogeneity on the basis of immune cell profiles that could represent diverse endotypes or phases of disease activity. Therapeutically, data on IL-1 and IL-6 antagonism and Janus kinase inhibition suggest the importance of early administration in Still's disease. Furthermore, there is evidence that patients who develop MAS can be treated with IFNγ antagonism. Despite these developments, unmet needs remain that can form the basis for the design of future studies leading to improvement of disease management.
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Affiliation(s)
- Piero Ruscitti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.
| | - Luca Cantarini
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, University of Siena, Siena, Italy
| | - Peter A Nigrovic
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dennis McGonagle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Leeds, UK
- National Institute for Health Research (NIHR) Leeds Biomedical Research Centre (BRC), Leeds Teaching Hospitals, Leeds, UK
| | - Roberto Giacomelli
- Clinical and research section of Rheumatology and Clinical Immunology, Fondazione Policlinico Campus Bio-Medico, Rome, Italy
- Rheumatology and Clinical Immunology, Department of Medicine, University of Rome "Campus Biomedico", School of Medicine, Rome, Italy
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Wen YN, Chen J, Liu F, Ding Y, Yin W. [Clinical features of Kawasaki disease complicated by macrophage activation syndrome: an analysis of 27 cases]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:572-578. [PMID: 37382125 DOI: 10.7499/j.issn.1008-8830.2302015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
OBJECTIVES To investigate the clinical manifestations and laboratory examination results of children with Kawasaki disease complicated by macrophage activation syndrome (KD-MAS), and to provide a basis for identifying early warning indicators for the early diagnosis and treatment of KD-MAS. METHODS A retrospective study was performed on 27 children with KD-MAS (KD-MAS group) and 110 children with KD (KD group) who were admitted to Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, from January 2014 to January 2022. Clinical and laboratory data were compared between the two groups. The receiver operating characteristic (ROC) curve was used to investigate the value of laboratory markers with statistical significance in the diagnosis of KD-MAS. RESULTS Compared with the KD group, the KD-MAS group had significantly higher incidence rates of hepatomegaly, splenomegaly, incomplete KD, no response to intravenous immunoglobulin, coronary artery damage, multiple organ damage, and KD recurrence, as well as a significantly longer length of hospital stay (P<0.05). Compared with the KD group, the KD-MAS group had significantly lower levels of white blood cell count, absolute neutrophil count, hemoglobin, platelet count (PLT), erythrocyte sedimentation rate, serum albumin, serum sodium, prealbumin, and fibrinogen (FIB), a significantly lower incidence rate of non-exudative conjunctiva, and significantly higher levels of C-reactive protein, alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase (LDH), and serum ferritin (SF) (P<0.05). The ROC curve analysis showed that SF, PLT, FIB, and LDH had high value in the diagnosis of KD-MAS, with areas under the curve (AUC) of 0.989, 0.966, 0.932, and 0.897, respectively (P<0.001), and optimal cut-off values of 349.95 μg/L, 159×109/L, 3.85 g/L, and 403.50 U/L, respectively. The combination of SF, PLT, FIB, and LDH had a larger AUC than PLT, FIB, and LDH alone in the diagnosis of KD-MAS (P<0.05), but there was no significant difference in the AUC between the combination of SF, PLT, FIB, and LDH and SF alone (P>0.05). CONCLUSIONS KD-MAS should be considered when children with KD have hepatosplenomegaly, no response to intravenous immunoglobulin, coronary artery damage, and KD recurrence during treatment. SF, PLT, FIB, and LDH are of high value in the diagnosis of KD-MAS, especially SF is of great significance in the diagnosis of KD-MAS.
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Affiliation(s)
- Yi-Ni Wen
- Department of Rheumatology and Immunology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan 430016, China
| | - Jing Chen
- Department of Rheumatology and Immunology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan 430016, China
| | - Fan Liu
- Department of Rheumatology and Immunology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan 430016, China
| | - Yan Ding
- Department of Rheumatology and Immunology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan 430016, China
| | - Wei Yin
- Department of Rheumatology and Immunology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan 430016, China
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Lee PY, Cron RQ. The Multifaceted Immunology of Cytokine Storm Syndrome. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2023; 210:1015-1024. [PMID: 37011407 PMCID: PMC10071410 DOI: 10.4049/jimmunol.2200808] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/20/2022] [Indexed: 04/05/2023]
Abstract
Cytokine storm syndromes (CSSs) are potentially fatal hyperinflammatory states that share the underpinnings of persistent immune cell activation and uninhibited cytokine production. CSSs can be genetically determined by inborn errors of immunity (i.e., familial hemophagocytic lymphohistiocytosis) or develop as a complication of infections, chronic inflammatory diseases (e.g., Still disease), or malignancies (e.g., T cell lymphoma). Therapeutic interventions that activate the immune system such as chimeric Ag receptor T cell therapy and immune checkpoint inhibition can also trigger CSSs in the setting of cancer treatment. In this review, the biology of different types of CSSs is explored, and the current knowledge on the involvement of immune pathways and the contribution of host genetics is discussed. The use of animal models to study CSSs is reviewed, and their relevance for human diseases is discussed. Lastly, treatment approaches for CSSs are discussed with a focus on interventions that target immune cells and cytokines.
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Affiliation(s)
- Pui Y. Lee
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Randy Q. Cron
- Division of Pediatric Rheumatology, Children’s of Alabama, University of Alabama Heersink School of Medicine, Birmingham, AL
- Department of Pediatrics, University of Alabama Heersink School of Medicine, Birmingham, AL
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Bindoli S, Galozzi P, Doria A, Sfriso P. Intravenous anakinra to curb cytokine storm in adult-onset Still's disease and in macrophage activation syndrome: A case series. Joint Bone Spine 2023; 90:105524. [PMID: 36623798 DOI: 10.1016/j.jbspin.2023.105524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 12/14/2022] [Accepted: 12/21/2022] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Adult-onset Still's disease (AOSD) is an auto-inflammatory polygenic disorder, for which the diagnosis is essentially clinical. The exclusion of mimickers [such as common bacterial and viral infections, hematologic malignancies, and, more recently, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)] is necessary to confirm the diagnosis. Anti-interleukin (IL)-1 therapy is considered a treatment milestone for AOSD. Herein, we present a short series of newly-diagnosed AOSD or upcoming macrophage activation syndrome (MAS) cases who received intravenous (IV) anakinra, an IL-1 receptor blocker. METHODS Four patients with newly-diagnosed AOSD or upcoming MAS were treated with IV anakinra at the Rheumatology Unit of Padova University Hospital, Italy. We obtained informed consent from the patients for use of their cases and medical images for publication purposes. RESULTS All patients presented with AOSD or MAS during the COVID-19 pandemic, making diagnosis challenging due to similar immunological and clinical characteristics across both pathologies. All patients presented with hyperpyrexia and elevated inflammatory markers; two patients had a skin rash typically seen in AOSD. IV anakinra slowed down AOSD progression in all patients, prevented severe outcomes and mitigated the risk of multiorgan failure. All cases improved within 24hours of anakinra administration. CONCLUSION We found that administration of anakinra in patients with newly-diagnosed AOSD and/or upcoming MAS reduced hyperinflammation and prevented life-threatening complications. The IV route appears to be preferable in the hospital setting, where comorbidities such as coagulopathies and thrombocytopenia can complicate the use of other routes of administration.
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Affiliation(s)
- Sara Bindoli
- Rheumatology Unit, Department of Medicine (DIMED), University of Padova, via Giustiniani 2, 35128 Padova, Italy
| | - Paola Galozzi
- Rheumatology Unit, Department of Medicine (DIMED), University of Padova, via Giustiniani 2, 35128 Padova, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine (DIMED), University of Padova, via Giustiniani 2, 35128 Padova, Italy
| | - Paolo Sfriso
- Rheumatology Unit, Department of Medicine (DIMED), University of Padova, via Giustiniani 2, 35128 Padova, Italy.
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"A Dangerous Black Box:" Idiopathic Hemophagocytic Lymphohistiocytosis in Adult Patients-A Case Report and Review of the Literature. Case Rep Hematol 2022; 2022:5867129. [PMID: 36510501 PMCID: PMC9741541 DOI: 10.1155/2022/5867129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 11/20/2022] [Accepted: 11/22/2022] [Indexed: 12/05/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare potentially life-threatening condition characterized by aberrant inflammation that can be related to genetic or sporadic forms. In both forms, triggering factors may be involved. Early detection of the underlying cause is crucial for therapeutic decision, while early intervention might be associated with better outcomes. The largest descriptions in the literature on HLH refer to pediatric cases. Adolescents and adults may also be affected, but there is scarce evidence regarding their diagnosis and management. We describe here the case of a 68-year-old Swiss woman with HLH, in whom an extensive search for underlying causes was performed, but neither trigger nor pathogenic variant was found. An early intervention first with dexamethasone and later with cyclosporine was performed. The patient showed a favorable response and did not require further hospitalization; however, one year after diagnosis, it was not possible to suspend cyclosporine due to recurrence of laboratory inflammation signs by drug tapering. The occurrence of HLH idiopathic forms represents a challenge; failure to identify the underlying triggering cause generates uncertainty, endless diagnostic investigations, and consequently additional delays in the treatment. This manuscript addresses the difficulties on this issue.
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Muacevic A, Adler JR, Isayed O, Mahagna S, Bseiso A. The Role of Immune Mechanisms, Inflammatory Pathways, and Macrophage Activation Syndrome in the Pathogenesis of Hemophagocytic Lymphohistiocytosis. Cureus 2022; 14:e33175. [PMID: 36726930 PMCID: PMC9885896 DOI: 10.7759/cureus.33175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2022] [Indexed: 01/01/2023] Open
Abstract
This review article describes the pathophysiology of hemophagocytic lymphohistiocytosis (HLH). The condition is characterized by excessive stimulation of inflammatory cytokines, lymphocytes, and macrophages, leading to hyperinflammatory disorder with immune dysfunction. The main clinical and diagnostic features include fever ≥38.5°C, splenomegaly, hyperferritinemia, cytopenia, hypofibrinogenemia, hemophagocytosis on the bone marrow, low or absent of natural killer (NK) cell activity, and elevated soluble CD25. Various immunological and inflammatory mechanisms are involved in the pathogenesis of HLH. Moreover, the condition can result in multisystem organ failure, contributing to the high mortality rate in hospital settings. A thorough literature search was conducted by collecting data from multiple articles published on PubMed, Medline, and Google Scholar. The article discusses the cellular and molecular pathways that lead to HLH. Due to the high rate of morbidity and mortality, early diagnosis needs to be established. More research pertaining to molecular biology, immunology, and the genetics of HLH is needed to explore the effective management and treatment of this rare disorder.
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Under-Recognized Macrophage Activation Syndrome in Refractory Kawasaki Disease: A Wolf in Sheep's Clothing. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9101588. [PMID: 36291524 PMCID: PMC9600110 DOI: 10.3390/children9101588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/02/2022] [Accepted: 10/19/2022] [Indexed: 11/22/2022]
Abstract
Recognition of macrophage activation syndrome (MAS) in patients with refractory Kawasaki disease (KD) can be challenging. This study aimed to investigate the incidence of MAS in patients with refractory KD and to compare the characteristics of refractory KD and MAS. Medical records of 468 patients diagnosed with KD from January 2010 to December 2019 were retrospectively reviewed. Of the 468 KD patients, 63 were enrolled in the study as a refractory KD group (n = 59) and an MAS group (n = 4). The incidence of MAS was 0.8% (4/468) in patients with KD and 6.3% (4/63) in patients with refractory KD. Compared to the refractory KD group, the MAS group had higher frequencies of incomplete KD, hepatosplenomegaly, third-line treatment, and MAS screening, and showed lower levels of albumin. No significant differences were found in other clinical and laboratory findings. In addition to four patients with MAS, five patients with refractory KD who received third-line treatment showed severe systemic inflammation and organ dysfunction, but only one in five patients underwent MAS screening, including ferritin levels. In conclusion, given the relatively high incidence of MAS in children with refractory KD and the similar phenotype between refractory KD and MAS, we propose that MAS screening should be included in routine laboratory tests for refractory KD.
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Sahba S, Huurnink A, Van den Berg JM, Tuitert B, Vastert SJ, Ten Tusscher GW. Systemic Juvenile Idiopathic Arthritis in two children; case report on clinical course, challenges in diagnosis and the role of FDG‐PET/CT‐scan. Clin Case Rep 2022; 10:e05900. [PMID: 35734189 PMCID: PMC9190680 DOI: 10.1002/ccr3.5900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 11/10/2022] Open
Abstract
Systemic juvenile idiopathic arthritis (sJIA, also called Still's disease) is a rare childhood auto‐inflammatory disease with significant morbidity. This case report illustrates the clinical course and highlights diagnostic challenges. FDG‐PET/CT imaging may be beneficial in the diagnostic process for some cases, in order to achieve rapid diagnosis and early treatment.
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Affiliation(s)
- S. Sahba
- Department of PaediatricsDijklander Hospital HoornHoornThe Netherlands
| | - A. Huurnink
- Department of Nuclear MedicineDijklander Hospital HoornHoornThe Netherlands
| | - J. M. Van den Berg
- Department of Pediatric Immunology, Rheumatology and Infectious DiseasesEmma Children's Hospital, Amsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | - B. Tuitert
- Department of PaediatricsDijklander Hospital HoornHoornThe Netherlands
| | - S. J. Vastert
- Department of Paediatric Rheumatology and ImmunologyWilhelmina Children's Hospital UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - G. W. Ten Tusscher
- Department of PaediatricsDijklander Hospital HoornHoornThe Netherlands
- Department of General PracticeAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
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Vuong NL, Cheung KW, Periaswamy B, Vi TT, Duyen HTL, Leong YS, Binte Hamis ZN, Gregorova M, Ooi EE, Sessions O, Rivino L, Yacoub S. Hyperinflammatory syndrome, natural killer cell function and genetic polymorphisms in the pathogenesis of severe dengue. J Infect Dis 2022; 226:1338-1347. [PMID: 35267010 PMCID: PMC9574659 DOI: 10.1093/infdis/jiac093] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/08/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Severe dengue, characterized by shock and organ dysfunction is driven by an excessive host immune response. We investigated the role of hyperinflammation in dengue pathogenesis. METHODS Patients recruited into an observational study were divided into three plasma leak severity grades. Hyperinflammatory biomarkers were measured at 4 time-points. Frequencies, activation and cytotoxic potential of NK cells were analysed by flow cytometry. RNA was extracted from sorted CD56+ NK cells and libraries prepared using SMART-Seq and sequenced using HiSeq3000 (Illumina). RESULTS 69 patients were included (grade 0: 42, grade 1: 19, grade 2: 8 patients). Patients with grade 2 leakage had higher biomarkers than grade 0, including higher peak ferritin levels (83.3% vs 45.2%) and H scores (median 148.5 vs 105.5). NK cells from grade 2 patients exhibited decreased expression of perforin and granzyme B and activation markers. RNA sequencing revealed three SNPs in NK cell functional genes associated with more severe leakage; NK cell lectin-like receptor K1 gene (KLRK1) and PRF1 gene. CONCLUSIONS Features of hyperinflammation are associated with dengue severity, including higher biomarkers, impaired NK cell function and polymorphisms in genes NK cell cytolyitc function genes (KLRK1 and PRF-1). Trials of immunomodulatory therapy in these patients is now warranted.
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Affiliation(s)
- Nguyen Lam Vuong
- Oxford University Clinical Research Unit; Ho Chi Minh City, Vietnam.,University of Medicine and Pharmacy at Ho Chi Minh City; Ho Chi Minh City, Vietnam
| | | | | | - Tran Thuy Vi
- Oxford University Clinical Research Unit; Ho Chi Minh City, Vietnam
| | | | | | | | | | - Eng Eong Ooi
- Duke-NUS Medical School; Singapore.,Saw Swee Hock School of Public Health, National University of Singapore; Singapore
| | - October Sessions
- Duke-NUS Medical School; Singapore.,Saw Swee Hock School of Public Health, National University of Singapore; Singapore.,Department of Pharmacy, National University of Singapore; Singapore
| | - Laura Rivino
- Duke-NUS Medical School; Singapore.,School of Cellular and Molecular Medicine, University of Bristol; UK
| | - Sophie Yacoub
- Oxford University Clinical Research Unit; Ho Chi Minh City, Vietnam.,Centre for Tropcial Medicine and Global Health, University of Oxford; UK
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14
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Zhang L, Dai L, Li D. Risk factors of early death in pediatric hemophagocytic lymphohistocytosis: Retrospective cohort study. Front Pediatr 2022; 10:1031432. [PMID: 36340709 PMCID: PMC9634417 DOI: 10.3389/fped.2022.1031432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/28/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphocytosis (HLH) is a rare life-threatening hyperinflammatory syndrome in which early mortality remains high in patients with HLH. METHODS We retrospectively collected the medical records of all pediatric patients diagnosed with HLH at the West China Second Hospital of Sichuan University between January 2014 and December 2020. Collect demographic, laboratory, clinical, genetic profiles, treatment information and perform statistical analysis from records. Risk factors for death 30 days after admission were evaluated using a multivariable logistic regression model. RESULTS A total of 110 pediatric HLH patients were enrolled. The median age of patients was 44 months (IQR 23-100.5) and 62 (56.4%) in males. The 30-day mortality rate for admission to this cohort was 34 (30.9%). Multivariate logistic regression analysis showed that heart failure (OR = 13.389, 95% CI, 1.671-107.256, p = 0.015) and hypoproteinemia (OR = 4.841, 95% CI, 1.282-18.288, p = 0.020) were associated with increased early mortality in children with HLH. CONCLUSIONS These identified risk factors may help clinicians stratify patients with HLH and develop targeted treatment strategies. More research is needed to explore the best treatment strategies for patients with HLH to reduce early mortality in patients with HLH.
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Affiliation(s)
- Lijun Zhang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Disease of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Lei Dai
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, Chengdu, China
| | - Deyuan Li
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Disease of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
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15
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Goel R, Eapen CE. Recognizing Dysfunctional Innate and Adaptive Immune Responses Contributing to Liver Damage in Patients With Cirrhosis. J Clin Exp Hepatol 2022; 12:993-1002. [PMID: 34744379 PMCID: PMC8560502 DOI: 10.1016/j.jceh.2021.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/02/2021] [Indexed: 02/07/2023] Open
Abstract
The human host immune system wards off attacks by enemies such as viruses by mounting an inflammatory response which may sometimes injure self-tissues. Dysfunctional immune/inflammatory response by the host may affect the functioning of vital organs. The largest number of innate immune cells in the body resides in the liver. On encountering a new insult or injury to the liver, the innate immune system responds quickly to counter it. Acute liver insults may trigger acute liver failure or acute on chronic liver failure; these disorders are associated with a predominant innate immune response. Activation of the reticuloendothelial system (part of the innate immune response) predicts short-term and medium-term survival in patients with acute on chronic liver failure. Liver diseases associated with an aberrant adaptive immune response like autoimmune hepatitis respond well to treatment with steroids and other immunosuppressants, while those associated with innate immune dysfunction like acute on chronic liver failure do not respond well to steroids; recent reports suggest that the latter disorders may respond to therapeutic plasma exchange. How does the immune system in a patient with liver disease respond to SARS CoV2 infection? While commonly used tests in routine clinical practice provide clues to activation of different arms of immune response in patients with cirrhosis, specialized tests may help characterize this further. This review discusses the tests which reflect aberrant immune responses and treatment of patients with cirrhosis.
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Key Words
- ACLF, acute on chronic liver failure
- AIH, autoimmune hepatitis
- ANCA, anti-neutrophil cytoplasmic antibodies
- APASL, Asia Pacific Association for Study of Liver
- COVID-19, coronavirus disease of 2019
- CRP, C-reactive protein
- DAMPs, damage-associated molecular patterns
- EASL, European Association for Study of Liver
- HLA, human leukocyte antigen
- IgG, immunoglobulin G
- IgG4 RD, IgG4 related disease
- MELD, Model for End-Stage Liver Disease
- NK cells, natural killer cells
- PAMPs, pathogen-associated molecular patterns
- PBC, primary biliary cholangitis
- PSC, primary sclerosing cholangitis
- SARS CoV2, severe acute respiratory syndrome coronavirus 2
- TLR, toll-like receptor
- VWF, von Willebrand factor
- cirrhosis
- immune dysfunction
- investigations
- reticuloendothelial activation
- sMR, soluble mannose receptor
- treatment
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Affiliation(s)
- Ruchika Goel
- Clinical Immunology and Rheumatology Department, Christian Medical College, Vellore, Tamil Nadu, India
| | - Chundamannil Eapen Eapen
- Hepatology Department, Christian Medical College, Vellore, Tamil Nadu, India,Address for correspondence: Dr CE Eapen, Hepatology Department, Christian Medical College, Vellore, Tamil Nadu, 632004, India.
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16
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Grygiel-Górniak B, Shaikh O, Kumar NN, Hsu SH, Samborski W. Use of the rheumatic drug tocilizumab for treatment of SARS-CoV-2 patients. Reumatologia 2021; 59:252-259. [PMID: 34538956 PMCID: PMC8436792 DOI: 10.5114/reum.2021.108554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/19/2021] [Indexed: 11/27/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a highly infectious respiratory disease caused by a new coronavirus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has been observed to vary in its degree of symptoms. One of the most important clinical manifestations is pneumonia and the subsequent worsening of the hyperinflammatory state and cytokine storm. Tocilizumab (TCB) is a recombinant humanized, anti-human monoclonal antibody of the immunoglobulin G1k (IgG1k) subclass that acts against soluble and membrane-bound interleukin six receptors (IL-6R). There is wide use of TCB in rheumatic diseases. However, recently this medication has been used in the treatment of SARS-CoV-2 infection. Tocilizumab application in COVID-19 patients with a high risk of a cytokine storm shows a positive response in reducing the mortality rate. Moreover, TCB minimizes the time needed to recover, improves oxygenation, shortens the duration of vasopressor support, and reduces the likelihood of invasive mechanical ventilation. Therefore we provide an overview of recent studies to understand the efficacy of this drug under various circumstances, including COVID-19 and rheumatic pathologies. This article also explores and integrates the different treatment possibilities in prominent anti-inflammatory and immune-modulatory-related symptoms. The preliminary data demonstrate promising results regarding the efficacy of TCB use in severe COVID-19 patients. Nevertheless, randomized controlled trials, with adequate sample sizes and sufficient follow-up periods, are needed to form conclusions and establish treatment recommendations.
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Affiliation(s)
- Bogna Grygiel-Górniak
- Department of Rheumatology, Rehabilitation and Internal Medicine, Poznan University of Medical Sciences, Poland
| | - Osama Shaikh
- Department of Rheumatology, Rehabilitation and Internal Medicine, Poznan University of Medical Sciences, Poland
| | - Nikita Niranjan Kumar
- Department of Rheumatology, Rehabilitation and Internal Medicine, Poznan University of Medical Sciences, Poland
| | - Shao Heng Hsu
- Department of Rheumatology, Rehabilitation and Internal Medicine, Poznan University of Medical Sciences, Poland
| | - Włodzimierz Samborski
- Department of Rheumatology, Rehabilitation and Internal Medicine, Poznan University of Medical Sciences, Poland
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17
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Sudden Hypotension and Increased Serum Interferon-γ and Interleukin-10 Predict Early Macrophage Activation Syndrome in Patients with Systemic Juvenile Idiopathic Arthritis. J Pediatr 2021; 235:203-211.e3. [PMID: 33581106 DOI: 10.1016/j.jpeds.2021.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 02/02/2021] [Accepted: 02/04/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To identify clinical and laboratory predictors for early macrophage activation syndrome (MAS) associated with systemic juvenile idiopathic arthritis (sJIA). STUDY DESIGN This is a retrospective cohort study of 149 patients with sJIA, of whom 27 had 31 episodes of MAS. We evaluated the clinical and laboratory features of patients with sJIA and MAS and compared them with those without MAS. We focused our analysis on the overall process of MAS development, especially MAS onset. RESULTS As shown in previous studies, we found a high percentage of fever, absence of arthritis, and central nervous system dysfunction at MAS onset in our study cohort. We also found that 35% of patients with MAS had hypotension although not shock, and 22.6% of patients with MAS had gastrointestinal involvement at MAS onset. Compared with patients with MAS without hypotension, patients with MAS and hypotension had greater rates of admission to the intensive care unit; presented with more arthritis, serositis, pneumonia, and gastrointestinal involvement; and had greater white blood cell and absolute neutrophil counts and serum bilirubin levels and lower serum total protein. We confirmed laboratory markers such as platelet counts, lactate dehydrogenase, and aspartate aminotransferase can help to identify early MAS and that ferritin/erythrocyte sedimentation rate ratio of approximately 20.0 had a high diagnostic sensitivity and specificity for MAS. In addition, we discovered that the combination of interferon-γ >17.1 pg/mL and interleukin-10 >7.8 pg/mL appeared to be a good cytokine pattern for the recognition of MAS onset. CONCLUSIONS Sudden hypotension, elevated ferritin/erythrocyte sedimentation rate ratio, and the cytokine pattern of significantly increased interferon-γ and interleukin-10 levels are important markers for early identification of MAS in addition to the traditional characteristics of sJIA-associated MAS.
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18
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Webb BJ. Defining COVID-19-associated hyperinflammatory syndrome in specific populations. LANCET RHEUMATOLOGY 2021; 3:e609-e611. [PMID: 34095856 PMCID: PMC8163291 DOI: 10.1016/s2665-9913(21)00157-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Brandon J Webb
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Medical Center, Salt Lake City, UT 84157, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford Medicine, Palo Alto, CA, USA
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19
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Majumder A, Sen D. An autopsy series of an oft-missed ante-mortem diagnosis: hemophagocytic lymphohistiocytosis. AUTOPSY AND CASE REPORTS 2021; 11:e2021243. [PMID: 33968822 PMCID: PMC8087375 DOI: 10.4322/acr.2021.243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and potentially fatal syndrome resulting from a hyperactivated immune system. Diverse patient profiles and clinical presentations often result in misdiagnosis. This article describes the varied clinical presentations and autopsy findings in three patients with this entity. The etiopathogenesis of HLH, its disparate and confounding clinical features, the diagnostic criteria, and management principles are also briefly reviewed.
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Affiliation(s)
- Anusree Majumder
- Armed Forces Medical College and Command Hospital (Southern Command), Department of Pathology and Laboratory Sciences, Pune, India
| | - Debraj Sen
- Armed Forces Medical College and Command Hospital (Southern Command), Department of Radiodiagnosis and Imaging, Pune, India
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20
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Abstract
Macrophage activation syndrome is a severe yet under-recognized complication encountered in pediatric rheumatology. It manifests as secondary hemophagocytic lymphohistiocytosis leading to a hyper-inflammatory state resulting from an underlying cytokine storm. If unchecked, it may lead to multiorgan failure and mortality. Early diagnosis and timely initiation of specific therapy is pivotal for a successful outcome. This review outlines the key clinical and laboratory features and management of macrophage activation syndrome.
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Affiliation(s)
- Narendra Kumar Bagri
- Division of Pediatric Rheumatology, Department of Pediatrics, AIIMS, New Delhi; India. Correspondence to: Dr Narendra Kumar Bagri, Associate Professor, Division of Pediatric Rheumatology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110 027, India.
| | - Latika Gupta
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ethan S Sen
- Department of Pediatric Rheumatology, Great North Children's Hospital, and Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - A V Ramanan
- Department of Pediatric Rheumatology, University Hospitals Bristol NHS Foundation Trust and Translational Health Sciences, University of Bristol, Bristol, UK
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21
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Macrophage activation syndrome in a newborn: report of a case associated with neonatal lupus erythematosus and a summary of the literature. Pediatr Rheumatol Online J 2021; 19:13. [PMID: 33568193 PMCID: PMC7877111 DOI: 10.1186/s12969-021-00500-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 02/04/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Macrophage activation syndrome (MAS) is a life-threatening hyperinflammatory syndrome and is caused by a severely dysregulated immune response. It has rarely been associated with neonatal lupus. CASE PRESENTATION We present a female neonate with MAS born to a mother who had cutaneous lupus erythematosus with circulating anti-nuclear antibodies (ANA), anti-SSA, anti-SSB and anti-extractable nuclear antigen (anti-ENA) antibodies. Because of neonatal lupus (NLE) with a total atrioventricular block, epicardial pacemaker implantation was required on the sixth day of life. Following surgery she developed non-remitting fever and disseminated erythematous skin lesions. A diagnosis of MAS was made based on these symptoms, with hyperferritinemia, elevated transaminases, hypertriglyceridemia, and a skin biopsy that showed hemophagocytosis. Our patient was treated with steroids for 3 months with good effect. No relapse has occurred. CONCLUSIONS MAS is a rare complication of neonatal lupus that may be difficult to diagnose, but needs to be treated promptly. In this article, pathogenesis and overlap of MAS and hemophagocytic lymphohistiocytosis (HLH) has been described. Diagnosis of MAS can be difficult. Different diagnostic criteria are used in both diagnosing MAS and HLH. Validated criteria for diagnosis of MAS in other disease than systemic onset JIA have not been validated yet. In NLE, diagnosing MAS is even more difficult, since skin lesions are already common in NLE. We show the potential additional value of skin biopsy in diagnosing MAS.
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22
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Shi N, Wang X, Zou L, Yang X, Ma Q, Lu M. Case Report: Macrophage Activation Syndrome and Widespread Neuroimaging Abnormality in Childhood-Onset Systemic Lupus Erythematosus. Front Pediatr 2021; 9:767115. [PMID: 34970517 PMCID: PMC8713754 DOI: 10.3389/fped.2021.767115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/17/2021] [Indexed: 11/13/2022] Open
Abstract
Macrophage activation syndrome (MAS) and widespread brain lesions are rare and severe complications of childhood-onset systemic lupus erythematosus (SLE). We report an 11-year-old girl who presented with recurrent rashes for half a year and fever for 2 weeks. Clinical and laboratory features at admission pointed to the diagnosis of SLE and SLE-associated MAS. Cerebral magnetic resonance imaging taken on day 4 after admission showed abnormal signals. Glucocorticoid therapy was started on day 5. Two days later, the patient appeared weak and ill, then the next day she exhibited dizziness, drowsiness, apathia, and dysarthria. High-dose methylprednisolone, cyclophosphamide, and intravenous immunoglobulin were used to treat the patient, and intrathecal dexamethasone was given. The patient was discharged on day 30 after admission and showed complete clinical resolution and improved magnetic resonance imaging resolution.
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Affiliation(s)
- Nana Shi
- Department of Hematology-Oncology, Children' Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | | | - Lixia Zou
- Department of Rheumatology Immunology and Allergy, Children' Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Xinghui Yang
- Department of Radiology, Children' Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Qian Ma
- Department of Rheumatology Immunology and Allergy, Children' Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Meiping Lu
- Department of Rheumatology Immunology and Allergy, Children' Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
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23
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Han SB, Lee SY. Macrophage activation syndrome in children with Kawasaki disease: diagnostic and therapeutic approaches. World J Pediatr 2020; 16:566-574. [PMID: 32418074 DOI: 10.1007/s12519-020-00360-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 03/18/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Macrophage activation syndrome (MAS) is a rare, life-threatening complication of Kawasaki disease (KD). Early recognition and treatment of MAS are very important, but sometimes it is difficult to distinguish MAS from a severe form of KD. DATA SOURCES A PubMed search was performed in Clinical Queries using the key terms "macrophage activation syndrome or secondary hemophagocytic lymphohistiocytosis (HLH)" and "Kawasaki disease". RESULTS KD patients with MAS show high intravenous immunoglobulin (IVIG) resistance and coronary complications. Mortality is also as high as MAS in other diseases. Persistent fever greater than 10 days is highly associated with development of MAS in KD. Splenomegaly is observed in more than two-thirds of KD patients with MAS. Thrombocytopenia is often the earliest laboratory finding of MAS. Hyperferritinemia is highly specific and sensitive for detecting MAS in KD; so, ferritin levels should be checked if there are unexplained clinical exacerbations in KD patients. Given the under-recognition of MAS in KD, it is prudent to consider resistant KD as occult/subclinical MAS. Many KD patients with MAS have good outcomes on immune modulators. However, if KD patients fulfill the HLH-2004 diagnostic criteria, they may undergo longer and more intensive treatment than needed. CONCLUSIONS The possible existence of MAS should be taken into account when a KD patient shows persistent fever, splenomegaly, thrombocytopenia, hyperferritinemia, or IVIG resistance. The under-diagnosis of MAS in patients with KD is an important issue to be addressed. Therapeutically, however, there is a possibility of over-treatment of MAS in patients with KD.
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Affiliation(s)
- Seung Beom Han
- Department of Pediatrics, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 64 Daeheung-ro, Jung-gu, Daejeon, 34943, Republic of Korea
| | - Soo-Young Lee
- Department of Pediatrics, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 327 Sosa-ro, Wonmi-gu, Bucheon, 14647, Republic of Korea.
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24
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Alijotas-Reig J, Esteve-Valverde E, Belizna C, Selva-O'Callaghan A, Pardos-Gea J, Quintana A, Mekinian A, Anunciacion-Llunell A, Miró-Mur F. Immunomodulatory therapy for the management of severe COVID-19. Beyond the anti-viral therapy: A comprehensive review. Autoimmun Rev 2020; 19:102569. [PMID: 32376394 PMCID: PMC7252146 DOI: 10.1016/j.autrev.2020.102569] [Citation(s) in RCA: 146] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 02/06/2023]
Abstract
Severe Acute Respiratory Syndrome related to Coronavirus-2 (SARS-CoV-2), coronavirus disease-2019 (COVID-19) may cause severe illness in 20% of patients. This may be in part due to an uncontrolled immune-response to SARS-CoV-2 infection triggering a systemic hyperinflammatory response, the so-called "cytokine storm". The reduction of this inflammatory immune-response could be considered as a potential therapeutic target against severe COVID-19. The relationship between inflammation and clot activation must also be considered. Furthermore, we must keep in mind that currently, no specific antiviral treatment is available for SARS-CoV-2. While moderate-severe forms need in-hospital surveillance plus antivirals and/or hydroxychloroquine; in severe and life-threating subsets a high intensity anti-inflammatory and immunomodulatory therapy could be a therapeutic option. However, right data on the effectiveness of different immunomodulating drugs are scarce. Herein, we discuss the pathogenesis and the possible role played by drugs such as: antimalarials, anti-IL6, anti-IL-1, calcineurin and JAK inhibitors, corticosteroids, immunoglobulins, heparins, angiotensin-converting enzyme agonists and statins in severe COVID-19.
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Affiliation(s)
- Jaume Alijotas-Reig
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine-1, Vall d'Hebron University Hospital, Barcelona, Spain; Systemic Autoimmune Research Unit, Vall d'Hebron Reseacrh Institute, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Enrique Esteve-Valverde
- Department of Internal Medicine, Althaia Network Health, Manresa, Barcelona, Spain; Universitat Central de Catalunya, Spain
| | - Cristina Belizna
- Vascular and Coagulation Department, University Hospital Angers, Angers, France; UMR CNRS 6015, Angers, France; INSERM U1083, Angers, France
| | - Albert Selva-O'Callaghan
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine-1, Vall d'Hebron University Hospital, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Josep Pardos-Gea
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine-1, Vall d'Hebron University Hospital, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Angela Quintana
- Systemic Autoimmune Research Unit, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Arsene Mekinian
- Service de Médecine Interne, Centre de référence AO Bradykiniques et compétence Maladies Auto-immunes FAI2R, Hôpital Saint Antoine Hôpitaux Universitaires de l'Est Parisien, Professeur des Universités-Praticien Hospitalier Sorbonne Université, France
| | | | - Francesc Miró-Mur
- Systemic Autoimmune Research Unit, Vall d'Hebron Research Institute, Barcelona, Spain
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25
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Batu ED, Özen S. Implications of COVID-19 in pediatric rheumatology. Rheumatol Int 2020; 40:1193-1213. [PMID: 32500409 PMCID: PMC7270517 DOI: 10.1007/s00296-020-04612-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 05/27/2020] [Indexed: 02/07/2023]
Abstract
COVID-19 (coronavirus disease 2019) pandemic caused by SARS-CoV-2, is a global public health issue threatening millions of lives worldwide. Although the infection is mild in most of the affected individuals, it may cause severe clinical manifestations such as acute respiratory distress syndrome or cytokine storm leading to death. Children are affected less, and most experience a milder disease. As rheumatologists, we deal with the uncontrolled response of the immune system, and most of the drugs we use are either immune modulators or immunosuppressants. Thus, the rheumatologists participate in the multidisciplinary management of COVID-19 patients. On the other hand, our patients with rheumatic diseases constitute a vulnerable group in this pandemic. In this review, a systematic literature search was conducted utilizing MEDLINE/PubMed and Scopus databases, and 231 COVID-19 patients with rheumatic diseases have been identified. Only one of these patients was a child. Among these, 9 (3.9%) died due to COVID-19. In light of the current data, the aspects of COVID-19 resembling rheumatic diseases, the possible reasons for why children are affected less severely, the hypothetic role of available vaccines in preventing COVID-19, the unique position of patients with rheumatic diseases in this pandemic, and the use of anti-rheumatic drugs in COVID-19 treatment are discussed.
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Affiliation(s)
- Ezgi Deniz Batu
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, 06100, Turkey.
| | - Seza Özen
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, 06100, Turkey
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26
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Ruscitti P, Berardicurti O, Di Benedetto P, Cipriani P, Iagnocco A, Shoenfeld Y, Giacomelli R. Severe COVID-19, Another Piece in the Puzzle of the Hyperferritinemic Syndrome. An Immunomodulatory Perspective to Alleviate the Storm. Front Immunol 2020; 11:1130. [PMID: 32574264 PMCID: PMC7270352 DOI: 10.3389/fimmu.2020.01130] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/08/2020] [Indexed: 12/11/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19), an acute respiratory disease caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), has been declared as a worldwide public health emergency. Interestingly, severe COVID-19 is characterized by fever, hyperferritinemia, and a hyper-inflammatory process with a massive release of pro-inflammatory cytokines, which may be responsible for the high rate of mortality. These findings may advocate for a similarity between severe COVID-19 and some challenging rheumatic diseases, such as adult onset Still's disease, secondary hemophagocytic lymphohistiocytosis, and catastrophic anti-phospholipid syndrome, which have been included in the “hyperferritinemic syndrome” category. Furthermore, as performed in these hyper-inflammatory states, severe COVID-19 may benefit from immunomodulatory therapies.
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Affiliation(s)
- Piero Ruscitti
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Onorina Berardicurti
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Paola Di Benedetto
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Paola Cipriani
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Annamaria Iagnocco
- Academic Rheumatology Centre, Università degli Studi di Torino, Turin, Italy
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel.,Laboratory of the Mosaics of Autoimmunity, Saint Petersburg State University, Saint Petersburg, Russia
| | - Roberto Giacomelli
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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Ruscitti P, Berardicurti O, Iagnocco A, Giacomelli R. Cytokine storm syndrome in severe COVID-19. Autoimmun Rev 2020; 19:102562. [PMID: 32376400 PMCID: PMC7252135 DOI: 10.1016/j.autrev.2020.102562] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/16/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Piero Ruscitti
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.
| | - Onorina Berardicurti
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Annamaria Iagnocco
- Academic Rheumatology Centre, Università degli Studi di Torino, Turin, Italy
| | - Roberto Giacomelli
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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Alongi A, Naddei R, De Miglio L, Natoli V, Ravelli A. Macrophage activation syndrome in pediatrics. Pediatr Allergy Immunol 2020; 31 Suppl 24:13-15. [PMID: 32017214 DOI: 10.1111/pai.13158] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 10/24/2019] [Indexed: 11/30/2022]
Abstract
Macrophage activation syndrome (MAS) is a serious, potentially life-threatening, hyperinflammatory condition, which belongs to the spectrum of hemophagocytic lymphohistiocytosis (HLH) and can complicate several immunologic and rheumatic disorders. MAS is characterized by a dysfunctional immune response that is similar to that seen in other forms of HLH. Because MAS may pursue a rapidly fatal course, prompt recognition of its clinical and laboratory features and immediate therapeutic intervention are fundamental. Recently, a set of classification criteria for MAS complicating sJIA has been developed through a multinational collaborative effort. High-dose parenteral corticosteroids remain the mainstay of treatment of MAS.
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Affiliation(s)
| | - Roberta Naddei
- Università degli Studi di Napoli Federico II, Napoli, Italy
| | - Laura De Miglio
- Università degli Studi del Piemonte Orientale, Novara, Italy
| | | | - Angelo Ravelli
- Università degli Studi di Genova, Genoa, Italy.,IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Sechenov First Moscow State Medical University, Moscow, Russian Federation
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Nishino A, Katsumata Y, Kawasumi H, Hirahara S, Kawaguchi Y, Yamanaka H. Usefulness of soluble CD163 as a biomarker for macrophage activation syndrome associated with systemic lupus erythematosus. Lupus 2020; 28:986-994. [PMID: 31246559 DOI: 10.1177/0961203319860201] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We aimed to study the usefulness of serum soluble CD163 (sCD163) as a biomarker for macrophage activation syndrome (MAS) associated with systemic lupus erythematosus (SLE). METHODS Serum sCD163 levels were retrospectively measured by enzyme-linked immunosorbent assay for SLE patients associated with MAS (SLE-MAS), lupus nephritis (LN), or autoimmune hemolytic anemia (AIHA) and/or immune thrombocytopenia (ITP) and healthy controls (HCs). Posttreatment samples were also evaluated in the available SLE-MAS patients. The associations between serum sCD163 levels and clinical information were statistically analyzed. RESULTS The serum sCD163 levels in SLE-MAS, LN and SLE-AIHA/ITP groups were significantly higher than those in HCs (n = 17, 29, 13, and 68, respectively; p < 0.01 for all comparisons). In addition, the serum sCD163 levels in the SLE-MAS group were even higher than those in the LN and SLE-AIHA/ITP groups (p < 0.01 for both comparisons). Serum sCD163 levels were correlated with the SLE Disease Activity Index 2000 scores (r = 0.53), whereas they were not correlated with the serum ferritin levels. With the determined cut-off value, the sensitivity and specificity of serum sCD163 for the diagnosis of SLE-MAS were 59% and 86%, respectively. Retesting showed that the serum sCD163 levels decreased significantly following treatment in parallel with disease amelioration in the SLE-MAS group (p < 0.01). CONCLUSIONS The present study suggests the usefulness of serum sCD163 as a diagnostic and disease-activity biomarker for SLE-associated MAS. Serum sCD163 might also have a different role as a biomarker for SLE-associated MAS than serum ferritin does.
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Affiliation(s)
- A Nishino
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Y Katsumata
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - H Kawasumi
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - S Hirahara
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Y Kawaguchi
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - H Yamanaka
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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30
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Eloseily EM, Weiser P, Crayne CB, Haines H, Mannion ML, Stoll ML, Beukelman T, Atkinson TP, Cron RQ. Benefit of Anakinra in Treating Pediatric Secondary Hemophagocytic Lymphohistiocytosis. Arthritis Rheumatol 2019; 72:326-334. [PMID: 31513353 DOI: 10.1002/art.41103] [Citation(s) in RCA: 175] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 09/05/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess the benefit of the recombinant human interleukin-1 receptor antagonist anakinra in treating pediatric patients with secondary hemophagocytic lymphohistiocytosis (HLH)/macrophage activation syndrome (MAS) associated with rheumatic and nonrheumatic conditions. METHODS A retrospective chart review of all anakinra-treated patients with secondary HLH/MAS was performed at Children's of Alabama from January 2008 through December 2016. Demographic, clinical, laboratory, and genetic characteristics, outcomes data, and information on concurrent treatments were collected from the records and analyzed using appropriate univariate statistical approaches to assess changes following treatment and associations between patient variables and outcomes. RESULTS Forty-four patients with secondary HLH/MAS being treated with anakinra were identified in the electronic medical records. The median duration of hospitalization was 15 days. The mean pretreatment serum ferritin level was 33,316 ng/ml and dropped to 14,435 ng/ml (57% decrease) within 15 days of the start of anakinra treatment. The overall mortality rate in the cohort was 27%. Earlier initiation of anakinra (within 5 days of hospitalization) was associated with reduced mortality (P = 0.046), whereas thrombocytopenia (platelet count <100,000/μl) and STXBP2 mutations were both associated with increased mortality (P = 0.008 and P = 0.012, respectively). In considering patients according to their underlying diagnosis, those with systemic juvenile idiopathic arthritis (JIA) had the lowest mortality rate, with no deaths among the 13 systemic JIA patients included in the study (P = 0.006). In contrast, those with an underlying hematologic malignancy had the highest mortality rate, at 100% (n = 3). CONCLUSION These findings suggest that anakinra appears to be effective in treating pediatric patients with non-malignancy-associated secondary HLH/MAS, especially when it is given early in the disease course and when administered to patients who have an underlying rheumatic disease.
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Affiliation(s)
- Esraa M Eloseily
- University of Alabama at Birmingham School of Medicine and Assiut University Children's Hospital, Assiut, Egypt
| | - Peter Weiser
- University of Alabama at Birmingham School of Medicine
| | | | - Hilary Haines
- University of Alabama at Birmingham School of Medicine
| | | | | | | | | | - Randy Q Cron
- University of Alabama at Birmingham School of Medicine
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A Multicenter Network Assessment of Three Inflammation Phenotypes in Pediatric Sepsis-Induced Multiple Organ Failure. Pediatr Crit Care Med 2019; 20:1137-1146. [PMID: 31568246 PMCID: PMC8121153 DOI: 10.1097/pcc.0000000000002105] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Ongoing adult sepsis clinical trials are assessing therapies that target three inflammation phenotypes including 1) immunoparalysis associated, 2) thrombotic microangiopathy driven thrombocytopenia associated, and 3) sequential liver failure associated multiple organ failure. These three phenotypes have not been assessed in the pediatric multicenter setting. We tested the hypothesis that these phenotypes are associated with increased macrophage activation syndrome and mortality in pediatric sepsis. DESIGN Prospective severe sepsis cohort study comparing children with multiple organ failure and any of these phenotypes to children with multiple organ failure without these phenotypes and children with single organ failure. SETTING Nine PICUs in the Eunice Kennedy Shriver National Institutes of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. PATIENTS Children with severe sepsis and indwelling arterial or central venous catheters. INTERVENTIONS Clinical data collection and twice weekly blood sampling until PICU day 28 or discharge. MEASUREMENTS AND MAIN RESULTS Of 401 severe sepsis cases enrolled, 112 (28%) developed single organ failure (0% macrophage activation syndrome 0/112; < 1% mortality 1/112), whereas 289 (72%) developed multiple organ failure (9% macrophage activation syndrome 24/289; 15% mortality 43/289). Overall mortality was higher in children with multiple organ and the phenotypes (24/101 vs 20/300; relative risk, 3.56; 95% CI, 2.06-6.17). Compared to the 188 multiple organ failure patients without these inflammation phenotypes, the 101 multiple organ failure patients with these phenotypes had both increased macrophage activation syndrome (19% vs 3%; relative risk, 7.07; 95% CI, 2.72-18.38) and mortality (24% vs 10%; relative risk, 2.35; 95% CI, 1.35-4.08). CONCLUSIONS These three inflammation phenotypes were associated with increased macrophage activation syndrome and mortality in pediatric sepsis-induced multiple organ failure. This study provides an impetus and essential baseline data for planning multicenter clinical trials targeting these inflammation phenotypes in children.
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Sun J, Wang JW, Wang R, Zhang H, Sun J. Respiratory failure and macrophage activation syndrome as an onset of systemic lupus erythematosus: A case report. World J Clin Cases 2019; 7:3859-3865. [PMID: 31799315 PMCID: PMC6887615 DOI: 10.12998/wjcc.v7.i22.3859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 10/09/2019] [Accepted: 10/15/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Macrophage activation syndrome (MAS) is defined as a specific secondary hemophagocytic lymphohistiocytosis that refers particularly to those triggered by autoimmune diseases. MAS is a rare and highly lethal complication of systemic lupus erythematosus (SLE), which can be associated with, or mimic, disease flare. However, the data regarding the clinical course, management and outcome of SLE with MAS is limited, especially in adults. Lack of clinical recognition of the disease often leads to poor prognosis.
CASE SUMMARY We report a 36-year-old Chinese woman without relevant past medical history who was admitted to hospital with a 6-d history of jaundice and a high fever of 39.4°C lasting one day. Abdominal magnetic resonance imaging excluded obstructive jaundice, no infection was identified and empiric superior antibiotic treatment (meropenem) showed no clinical improvement. However, newly emerged pancytopenia and respiratory failure endangered the patient’s life. Autoimmune work-up finally led to the diagnosis of SLE, which initially presented as MAS and manifested respiratory failure, although neither bone marrow biopsy nor lymph node biopsy showed hemophagocytosis. To our knowledge, such a scenario has never been reported in detail before. The patient had a favorable reaction to combination treatment with corticosteroid and cyclosporine A and has been in clinical remission during the 1-year follow up period.
CONCLUSION Respiratory failure and MAS can be an onset of SLE. Early diagnosis and appropriate treatment are extremely important for a better prognosis.
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Affiliation(s)
- Juan Sun
- Department of Nephrology and Rheumatology, The Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
| | - Jian-Wen Wang
- Department of Nephrology and Rheumatology, The Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
| | - Rui Wang
- Department of Gastroenterology, The Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
| | - Hao Zhang
- Department of Nephrology and Rheumatology, The Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
| | - Jian Sun
- Department of Nephrology and Rheumatology, The Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
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Macrophage activation syndrome in juvenile dermatomyositis: a systematic review. Rheumatol Int 2019; 40:695-702. [PMID: 31529231 DOI: 10.1007/s00296-019-04442-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 09/04/2019] [Indexed: 12/12/2022]
Abstract
Macrophage activation syndrome (MAS) is a potentially fatal complication of a number of rheumatological conditions, but few studies assessed it in juvenile dermatomyositis (JDM). Indeed, MAS is not considered as a frequent complication of JDM, but its occurrence could be under-estimated. In order to address this issue, we performed a revision of the available medical literature, describing and assessing patients with both MAS and JDM. After retrieving 253 records initially, 11 papers were selected as appropriate for our research objective, which provided a total of 12 patients affected with both MAS and JDM. Our pooled case series suggested that MAS in JDM may not be very rare, even though no final conclusion about its incidence and mortality rate can be made. However, JDM-related MAS seems to be difficult to treat, since methylprednisolone pulse therapy alone was not sufficient in most cases. Moreover, MAS in JDM patients often occurred at the onset of the rheumatic disease, before the final diagnosis of JDM could be established. Finally, MAS criteria validated for systemic Juvenile Idiopathic Arthritis (sJIA) resulted to be a very useful guidance to diagnose MAS in JDM patients as well, but their reliability may not be absolute. Therefore, cohort and multicenter studies are needed to assess the incidence and improve the diagnostic criteria for MAS in JDM patients.
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Çakan M, Karadağ ŞG, Tanatar A, Ayaz NA. The frequency of macrophage activation syndrome and disease course in systemic juvenile idiopathic arthritis. Mod Rheumatol 2019; 30:900-904. [PMID: 31462146 DOI: 10.1080/14397595.2019.1660026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objectives: The aim of this study was to demonstrate the frequency of macrophage activation syndrome (MAS) in systemic juvenile idiopathic arthritis (sJIA) cases, to compare the laboratory tests at the time of diagnosis of sJIA and MAS and to see whether sJIA cases complicated with MAS follow a more severe disease course in the long-term follow-up.Methods: Files of children with sJIA that were followed between May 2010 and September 2017 were reviewed.Results: The cohort consisted of 53 sJIA cases. Mean duration of follow-up was 39.0 ± 24.1 months. The frequency of MAS was 33.9%. Initial laboratory tests at the time of diagnosis of sJIA were compared in between patients with MAS and without MAS. Only ferritin and fibrinogen levels showed significant differences in between the groups (p < .01). Patients who developed MAS had higher ferritin (4482 mg/dL) and lower fibrinogen (371 mg/dL) values than patients without MAS (ferritin 2060 mg/dL, fibrinogen 466 mg/dL) at the time of diagnosis of sJIA. Long-term follow-up results showed that monocyclic course was observed in 45.2%, polycyclic course in 30.1% and persistent course in 24.5% of the cases. It was seen that patients with MAS segregated equally into three groups.Conclusions: Higher ferritin and relatively lower fibrinogen levels at the time of diagnosis of sJIA may be early warning signs of an impending MAS. sJIA patients who develop MAS do not seem to warrant more guarded prognosis in the long-term follow-up.
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Affiliation(s)
- Mustafa Çakan
- Clinic of Pediatric Rheumatology, Kanuni Sultan Süleyman Research and Training Hospital, Istanbul, Turkey
| | - Şerife Gül Karadağ
- Clinic of Pediatric Rheumatology, Kanuni Sultan Süleyman Research and Training Hospital, Istanbul, Turkey
| | - Ayşe Tanatar
- Clinic of Pediatric Rheumatology, Kanuni Sultan Süleyman Research and Training Hospital, Istanbul, Turkey
| | - Nuray Aktay Ayaz
- Clinic of Pediatric Rheumatology, Kanuni Sultan Süleyman Research and Training Hospital, Istanbul, Turkey
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Eloseily EMA, Minoia F, Crayne CB, Beukelman T, Ravelli A, Cron RQ. Ferritin to Erythrocyte Sedimentation Rate Ratio: Simple Measure to Identify Macrophage Activation Syndrome in Systemic Juvenile Idiopathic Arthritis. ACR Open Rheumatol 2019; 1:345-349. [PMID: 31777812 PMCID: PMC6857981 DOI: 10.1002/acr2.11048] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 06/17/2019] [Indexed: 01/22/2023] Open
Abstract
Objective Macrophage activation syndrome (MAS) is a life-threatening complication of systemic juvenile idiopathic arthritis (sJIA). Early diagnosis is critical. Classification criteria for MAS in sJIA perform less well in the setting of cytokine-directed therapies. The goal herein was to explore a simple ratio of serum ferritin to the erythrocyte sedimentation rate (ESR) for diagnosis of MAS in the setting of sJIA, and to assess ferritin alone as a screening tool for identifying MAS of multiple etiologies. Methods Data from a large international cohort of sJIA patients with and without MAS, and from hospitalized patients with systemic infection (SI), were assessed for the ferritin:ESR ratio and ferritin alone to identify MAS among sJIA patients. Moreover, data from a smaller cohort of MAS patients associated with multiple etiologies and febrile hospitalized controls were explored. For both cohorts and controls, receiver operating characteristic curves (ROCs) for the ferritin:ESR ratio and ferritin alone were constructed, and areas under the curves (AUCs) were calculated. The Youden index was used to determine the optimal ferritin:ESR ratio and ferritin alone cut points for diagnosis. Results A ferritin:ESR ratio of 21.5 was 82% sensitive and 78% specific for diagnosing sJIA-MAS versus active sJIA without MAS. Ferritin alone with a set sensitivity of 95% (screening tool) had an 89.3% specificity of identifying all-cause MAS versus febrile hospitalized children. Conclusion The ferritin:ESR ratio is a practical tool for diagnosing MAS among sJIA patients, and serum ferritin alone is a remarkable screening tool for identifying MAS among febrile hospitalized children.
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Affiliation(s)
- Esraa M A Eloseily
- Assiut University, Assiut, Egypt, and Pediatric Rheumatology University of Alabama at Birmingham
| | - Francesca Minoia
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan Italy
| | | | | | - Angelo Ravelli
- Istituto Giannina Gaslini, Genoa, Italy and University of Genova Genoa Italy
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Pestronk A, Sinha N, Alhumayyd Z, Ly C, Schmidt R, Bucelli R. Immune myopathy with large histiocyte-related myofiber necrosis. Neurology 2019; 92:e1763-e1772. [PMID: 30894448 DOI: 10.1212/wnl.0000000000007260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 12/10/2018] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To describe the features of a new, pathologically distinctive, acquired myopathy with an unusual pattern of scattered necrotic muscle fibers that are neighbored, surrounded, or invaded, by large, often multinucleated, histiocytic cells. METHODS Retrospective review of records and muscle pathology of 4 patients. RESULTS Clinical features common to our patients included muscle pain and proximal, symmetric, moderate to severe, weakness in the arms and legs progressing over 1-4 weeks. Patients had other associated systemic disorders, including anemia in all, and hemophagocytic lymphohistiocytosis, hepatic disease, Raynaud phenomenon, metastatic cancer, and cardiomyopathy, in 1 patient each. Serum creatine kinase (CK) levels at presentation were very high, ranging from 10,000 to 102,000 U/L. Three patients improved within 3 months after treatment. Muscle pathology included scattered necrotic muscle fibers with cytoplasm that stained for C5b-9 complement, especially around fiber peripheries, pale on nicotinamide adenine dinucleotide and often dark on hematoxylin & eosin. Large, often multinucleated, cells with features of histiocytes, including anatomical features on electron microscopy and immunostaining for major histocompatibility complex Class I and histiocyte markers (HAM56, CD68, CD163, and S100), were usually closely apposed to the surface of, or invaded, necrotic myofibers. CONCLUSIONS Patients with large-histiocyte-associated myopathy (LHIM) had a subacute onset of proximal predominant weakness, associated systemic disorders, very high serum CK, and a pathologically distinctive pattern of large histiocyte-associated muscle fiber necrosis. LHIM may be caused by an autoimmune, histiocyte-mediated attack directed against muscle fibers.
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Affiliation(s)
- Alan Pestronk
- From the Departments of Neurology (A.P., C.L., R.B.) and Pathology and Immunology (A.P., N.S., R.S.), Washington University School of Medicine, Saint Louis, MO; and Department of Neurology (Z.A.), King Saud University, Riyadh, Saudi Arabia.
| | - Namita Sinha
- From the Departments of Neurology (A.P., C.L., R.B.) and Pathology and Immunology (A.P., N.S., R.S.), Washington University School of Medicine, Saint Louis, MO; and Department of Neurology (Z.A.), King Saud University, Riyadh, Saudi Arabia
| | - Ziad Alhumayyd
- From the Departments of Neurology (A.P., C.L., R.B.) and Pathology and Immunology (A.P., N.S., R.S.), Washington University School of Medicine, Saint Louis, MO; and Department of Neurology (Z.A.), King Saud University, Riyadh, Saudi Arabia
| | - Cindy Ly
- From the Departments of Neurology (A.P., C.L., R.B.) and Pathology and Immunology (A.P., N.S., R.S.), Washington University School of Medicine, Saint Louis, MO; and Department of Neurology (Z.A.), King Saud University, Riyadh, Saudi Arabia
| | - Robert Schmidt
- From the Departments of Neurology (A.P., C.L., R.B.) and Pathology and Immunology (A.P., N.S., R.S.), Washington University School of Medicine, Saint Louis, MO; and Department of Neurology (Z.A.), King Saud University, Riyadh, Saudi Arabia
| | - Robert Bucelli
- From the Departments of Neurology (A.P., C.L., R.B.) and Pathology and Immunology (A.P., N.S., R.S.), Washington University School of Medicine, Saint Louis, MO; and Department of Neurology (Z.A.), King Saud University, Riyadh, Saudi Arabia
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Hemophagocytic Lymphohistiocytosis: Clinical Presentations and Diagnosis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:824-832. [DOI: 10.1016/j.jaip.2018.11.050] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/19/2018] [Accepted: 11/22/2018] [Indexed: 12/17/2022]
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Crayne CB, Albeituni S, Nichols KE, Cron RQ. The Immunology of Macrophage Activation Syndrome. Front Immunol 2019; 10:119. [PMID: 30774631 PMCID: PMC6367262 DOI: 10.3389/fimmu.2019.00119] [Citation(s) in RCA: 401] [Impact Index Per Article: 80.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 01/15/2019] [Indexed: 12/05/2022] Open
Abstract
Synonymous with secondary hemophagocytic lymphohistiocytosis, macrophage activation syndrome (MAS) is a term used by rheumatologists to describe a potentially life-threatening complication of systemic inflammatory disorders, most commonly systemic juvenile idiopathic arthritis (sJIA) and systemic lupus erythematosus (SLE). Clinical and laboratory features of MAS include sustained fever, hyperferritinemia, pancytopenia, fibrinolytic coagulopathy, and liver dysfunction. Soluble interleukin-2 receptor alpha chain (sCD25) and sCD163 may be elevated, and histopathology often reveals characteristic increased hemophagocytic activity in the bone marrow (and other tissues), with positive CD163 (histiocyte) staining. A common hypothesis as to the pathophysiology of many cases of MAS proposes a defect in lymphocyte cytolytic activity. Specific heterozygous gene mutations in familial HLH-associated cytolytic pathway genes (e.g., PRF1, UNC13D) have been linked to a substantial subset of MAS patients. In addition, the pro-inflammatory cytokine environment, particularly IL-6, has been shown to decrease NK cell cytolytic function. The inability of NK cells and cytolytic CD8 T cells to lyse infected and otherwise activated antigen presenting cells results in prolonged cell-to-cell (innate and adaptive immune cells) interactions and amplification of a pro-inflammatory cytokine cascade. The cytokine storm results in activation of macrophages, causing hemophagocytosis, as well as contributing to multi-organ dysfunction. In addition to macrophages, dendritic cells likely play a critical role in antigen presentation to cytolytic lymphocytes, as well as contributing to cytokine expression. Several cytokines, including tumor necrosis factor, interferon-gamma, and numerous interleukins (i.e., IL-1, IL-6, IL-18, IL-33), have been implicated in the cytokine cascade. In addition to broadly immunosuppressive therapies, novel cytokine targeted treatments are being explored to dampen the overly active immune response that is responsible for much of the pathology seen in MAS.
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Affiliation(s)
- Courtney B Crayne
- Pediatric Rheumatology, University of Alabama Birmingham, Birmingham, AL, United States
| | - Sabrin Albeituni
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Kim E Nichols
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Randy Q Cron
- Pediatric Rheumatology, University of Alabama Birmingham, Birmingham, AL, United States
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Cron RQ, Weiser P, Beukelman T. Juvenile Idiopathic Arthritis. Clin Immunol 2019. [DOI: 10.1016/b978-0-7020-6896-6.00053-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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40
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Síndrome de activación macrofágica inducido por administración prolongada de anfotericina-B liposomal. Med Clin (Barc) 2018; 151:84-85. [DOI: 10.1016/j.medcli.2017.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 10/25/2017] [Accepted: 11/02/2017] [Indexed: 11/17/2022]
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41
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Szulawski R, Kourlas PJ, Antonchak M. Macrophage Activation Syndrome (MAS) in a Recently Released Prisoner with Systemic Lupus Erythematosus (SLE). AMERICAN JOURNAL OF CASE REPORTS 2018; 19:734-738. [PMID: 29930239 PMCID: PMC6047585 DOI: 10.12659/ajcr.906154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Patient: Male, 38 Final Diagnosis: Systemic lupus erythematosus • macrophage activation syndrome Symptoms: Altered mental status • diarrhea • fever • nausea • vomiting • weight loss Medication: — Clinical Procedure: — Specialty: Rheumatology
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Affiliation(s)
- Robert Szulawski
- Department of Internal Medicine, University of Pittsburgh Medical Center - Mercy Hospital, Pittsburgh, PA, USA
| | - Peter J Kourlas
- Department of Hematology Oncology, Columbus Oncology and Hematology Associates, Columbus, OH, USA
| | - Marc Antonchak
- Department of Rheumatology, Columbus Arthritis Center, Columbus, OH, USA
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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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Cohen EM, D'Silva K, Kreps D, Son MB, Costenbader KH. Arthritis and use of hydroxychloroquine associated with a decreased risk of macrophage activation syndrome among adult patients hospitalized with systemic lupus erythematosus. Lupus 2018; 27:1065-1071. [PMID: 29451069 DOI: 10.1177/0961203318759428] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Macrophage activation syndrome (MAS) is an uncommon but serious complication of systemic lupus erythematosus (SLE). We aimed to identify factors associated with MAS among adult hospitalized SLE patients. Methods Within the Brigham and Women's Hospital (BWH) Lupus Center Registry, we identified adult SLE patients > age 17 who had been hospitalized from 1970 to 2016, with either ferritin > 5000 ng/ml during admission or "macrophage activation syndrome" or "MAS" in discharge summary. We confirmed MAS by physician diagnosis in medical record review. We matched each hospitalized SLE patient with MAS to four SLE patients hospitalized without MAS (by SLE diagnosis date ±1 year). We employed conditional logistic regression models to identify clinical factors associated with MAS among hospitalized SLE patients. Results Among 2094 patients with confirmed SLE, we identified 23 who had a hospitalization with MAS and compared them to 92 hospitalized without MAS. Cases and controls had similar age at SLE diagnosis (29.0 vs. 30.5, p = 0.60), and hospital admission (43.0 vs. 38.3, p = 0.80), proportion female (78% vs. 84%, p = 0.55), and time between SLE diagnosis and hospitalization (1971 vs. 1732 days, p = 0.84). Arthritis (OR 0.04 (95% CI 0.004-0.35)) and hydroxychloroquine use (OR 0.18 (95% CI 0.04-0.72)) on admission were associated with decreased MAS risk. Admission Systemic Lupus Erythematosus Disease Activity Index scores (30 vs. 19, p = 0.002) and lengths of stay (16 days vs. 3 days, p < 0.0001) were much higher among cases. Death during hospitalization was 19% among cases and 3% among controls ( p = 0.03). Conclusions In this case-control study of hospitalized adult SLE patients, arthritis and hydroxychloroquine use at hospital admission were associated with decreased MAS risk. Further studies are needed to validate these factors associated with lowered MAS risk.
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Affiliation(s)
- E M Cohen
- 1 Division of Immunology, 1862 Boston Children's Hospital , Boston, MA, USA
| | - K D'Silva
- 2 Department of Rheumatology, 1861 Brigham and Women's Hospital , Boston, MA, USA
| | - D Kreps
- 2 Department of Rheumatology, 1861 Brigham and Women's Hospital , Boston, MA, USA
| | - M B Son
- 1 Division of Immunology, 1862 Boston Children's Hospital , Boston, MA, USA
| | - K H Costenbader
- 2 Department of Rheumatology, 1861 Brigham and Women's Hospital , Boston, MA, USA
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Minoia F, Bovis F, Davì S, Insalaco A, Lehmberg K, Shenoi S, Weitzman S, Espada G, Gao YJ, Anton J, Kitoh T, Kasapcopur O, Sanner H, Merino R, Astigarraga I, Alessio M, Jeng M, Chasnyk V, Nichols KE, Huasong Z, Li C, Micalizzi C, Ruperto N, Martini A, Cron RQ, Ravelli A, Horne A, Aggarwal A, Akikusa J, Al-Mayouf S, Alessio M, Anton J, Apaz MT, Astigarraga I, Avcin T, Ayaz NA, Barone P, Bica B, Bolt I, Bovis F, Breda L, Chasnyk V, Cimaz R, Corona F, Cron RQ, Cuttica R, Davì S, Davidsone Z, De Cunto C, De Inocencio J, Demirkaya E, Eisenstein EM, Enciso S, Espada G, Fischbach M, Frosch M, Gallizzi R, Gamir ML, Gao YJ, Griffin T, Grom A, Hashad S, Hennon T, Henter JI, Horne A, Horneff G, Huasong Z, Huber A, Ilowite N, Insalaco A, Ioseliani M, Jeng M, Kapović AM, Kasapcopur O, Khubchandani R, Kitoh T, Koné-Paut I, de Oliveira SKF, Lattanzi B, Lehmberg K, Lepore L, Li C, Lipton JM, Magni-Manzoni S, Maritsi D, Martini A, McCurdy D, Merino R, Micalizzi C, Miettunen P, Minoia F, Mulaosmanovic V, Nichols KE, Nielsen S, Ozen S, Pal P, Prahalad S, Ravelli A, Rigante D, Rumba-Rozenfelde I, Ruperto N, Russo R, Magalhães CS, Sanner H, Sewairi WMS, Shenoi S, Artur Silva C, Stanevicha V, Sterba G, Stine KC, Susic G, Sztajnbok F, Takei S, Trauzeddel R, Tsitsami E, Unsal E, Uziel Y, Vougiouka O, Wallace CA, Weaver L, E. Weiss J, Weitzman S, Wouters C, Wulffraat N, Zletni M, Arico M, Egeler RM, Filipovich AH, Gadner H, Imashuku S, Janka G, Ladisch S, McClain KL, Webb D. Development and Initial Validation of the Macrophage Activation Syndrome/Primary Hemophagocytic Lymphohistiocytosis Score, a Diagnostic Tool that Differentiates Primary Hemophagocytic Lymphohistiocytosis from Macrophage Activation Syndrome. J Pediatr 2017; 189:72-78.e3. [PMID: 28807357 DOI: 10.1016/j.jpeds.2017.06.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 05/02/2017] [Accepted: 06/02/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To develop and validate a diagnostic score that assists in discriminating primary hemophagocytic lymphohistiocytosis (pHLH) from macrophage activation syndrome (MAS) related to systemic juvenile idiopathic arthritis. STUDY DESIGN The clinical, laboratory, and histopathologic features of 362 patients with MAS and 258 patients with pHLH were collected in a multinational collaborative study. Eighty percent of the population was assessed to develop the score and the remaining 20% constituted the validation sample. Variables that entered the best fitted model of logistic regression were assigned a score, based on their statistical weight. The MAS/HLH (MH) score was made up with the individual scores of selected variables. The cutoff in the MH score that discriminated pHLH from MAS best was calculated by means of receiver operating characteristic curve analysis. Score performance was examined in both developmental and validation samples. RESULTS Six variables composed the MH score: age at onset, neutrophil count, fibrinogen, splenomegaly, platelet count, and hemoglobin. The MH score ranged from 0 to 123, and its median value was 97 (1st-3rd quartile 75-123) and 12 (1st-3rd quartile 11-34) in pHLH and MAS, respectively. The probability of a diagnosis of pHLH ranged from <1% for a score of <11 to >99% for a score of ≥123. A cutoff value of ≥60 revealed the best performance in discriminating pHLH from MAS. CONCLUSION The MH score is a powerful tool that may aid practitioners to identify patients who are more likely to have pHLH and, thus, could be prioritized for functional and genetic testing.
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Affiliation(s)
| | | | | | | | | | - Susan Shenoi
- Seattle Children's Hospital and University of Washington, Seattle, WA
| | | | - Graciela Espada
- Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina
| | - Yi-Jin Gao
- Children's Hospital of Fudan University, Shanghai, China
| | - Jordi Anton
- Hospital Saint Joan de Déu, Barcelona, Spain
| | | | - Ozgur Kasapcopur
- Istanbul University, Cerrahpasa Medical School, Istanbul, Turkey
| | - Helga Sanner
- Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | | | - Itziar Astigarraga
- BioCruces Health Research Institute, Cruces University Hospital, University of the Basque Country, Barakaldo, Spain
| | | | | | - Vyacheslav Chasnyk
- Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | | | | | - Caifeng Li
- Beijing Children's Hospital, Beijing, China
| | | | | | | | | | - Angelo Ravelli
- G. Gaslini Institute, Genoa, Italy; University of Genova, Genoa, Italy
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Kumar B, Aleem S, Saleh H, Petts J, Ballas ZK. A Personalized Diagnostic and Treatment Approach for Macrophage Activation Syndrome and Secondary Hemophagocytic Lymphohistiocytosis in Adults. J Clin Immunol 2017; 37:638-643. [PMID: 28871523 DOI: 10.1007/s10875-017-0439-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 08/04/2017] [Indexed: 01/26/2023]
Abstract
OBJECTIVE We assessed the clinical features and outcomes based on therapeutic options adopted during hospital stay for adult patients with macrophage activation syndrome and secondary hemophagocytic lymphohistiocytosis (MAS/sHLH). METHODS We conducted a retrospective chart review of all adult patients (age ≥ 18 years) diagnosed with MAS/sHLH at our center between 2010 and 2015. Inclusion criteria for patients were diagnosis of MAS/sHLH during admission and patients meeting at least 5 out of 8 of Henter's criteria or at least 4 out of 6 of the criteria that were tested. RESULTS Nineteen adult patients with MAS/sHLH met the inclusion criteria from January 2010 to October 2015 (median age 48 years; female 68.4%). Treatment had been personalized, depending on the clinical presentation and course of disease. Majority of the patients received anakinra, cyclosporine, intravenous immunoglobulins (IVIG), and steroids. Fourteen (74%) patients survived, with clinical improvement by the time of discharge. After excluding the three patients with underlying leukemia/lymphoma who opted for palliative care and subsequently died, the survival rate was 88%. CONCLUSION A modified diagnostic and treatment protocol for adult patients with MAS/sHLH that incorporated graded introduction of medications based on clinical presentation and cytokine profile resulted in the best adult survival rate reported in literature.
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Affiliation(s)
- Bharat Kumar
- Division of Immunology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA.
| | | | | | | | - Zuhair K Ballas
- Division of Immunology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
- Iowa City Veterans Affairs Medical Center, Iowa City, IA, USA
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Ahn SS, Hwang SH, Jung SM, Lee SW, Park YB, Yun M, Song JJ. The clinical utility of splenic fluorodeoxyglucose uptake for diagnosis and prognosis in patients with macrophage activation syndrome. Medicine (Baltimore) 2017; 96:e7901. [PMID: 28834911 PMCID: PMC5572033 DOI: 10.1097/md.0000000000007901] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
The aim of the study was to evaluate splenic glucose metabolism in macrophage activation syndrome (MAS), characterized by overwhelming systemic inflammation. Splenic F-fluorodeoxyglucose (FDG) uptake was compared in patients with MAS and sepsis using positron emission tomography/computed tomography (PET/CT).Clinical and FDG-PET/CT findings from patients with MAS and those with culture-proven sepsis were evaluated. The standardized uptake value (SUV) for the spleen and liver were measured. The maximum of the spleen to liver SUV ratio (SLRmax) was calculated as spleen SUVmax/liver SUVmean. The radiological splenic volume was also measured, and splenic metabolic volume (MV) was defined as the total splenic volume with an SLRmean > 1.14. The association between clinical features, laboratory variables, and SLRmax was analyzed.The median SLRmax and splenic MV were significantly higher in patients with MAS (n = 38) than they were in those with sepsis (n = 15) (SLRmax: 1.51 vs 1.09, P = .001; MV: 346.0 vs 154.0, P = .015). Multivariate analyses revealed that SLRmax > 1.31 was useful for discriminating between MAS and sepsis. SLRmax positively correlated with ferritin and lactate dehydrogenase level in MAS. Furthermore, MAS patients with high splenic FDG uptake (SLRmax > 1.72) had higher in-hospital mortality compared to those with moderate to low splenic FDG uptake (P = .013).This study was the first to demonstrate that splenic FDG uptake is significantly elevated in patients with MAS compared to those with sepsis. This may be useful to differentiate between MAS and sepsis, and to predict poor prognosis in patients with MAS.
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Affiliation(s)
- Sung Soo Ahn
- Division of Rheumatology, Department of Internal Medicine
| | | | - Seung Min Jung
- Division of Rheumatology, Department of Internal Medicine
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine
| | - Mijin Yun
- Department of Nuclear Medicine, Severance Hospital
| | - Jason Jungsik Song
- Division of Rheumatology, Department of Internal Medicine
- Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, South Korea
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[Clinical and laboratory features of macrophage activation syndrome]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19. [PMID: 28202118 PMCID: PMC7389461 DOI: 10.7499/j.issn.1008-8830.2017.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To study the clinical and laboratory features of macrophage activation syndrome (MAS) at the early stage of diagnosis, and to explore a method for early identification of MAS. METHODS A retrospective analysis was performed for the demographic data, clinical and laboratory features, and treatment outcomes of 21 MAS patients. RESULTS Of the 21 MAS patients, 14 had systemic juvenile idiopathic arthritis, 5 had Kawasaki disease (KD), and 2 had connective tissue disease (CTD) as primary diseases. The median time of MAS onset was 19 days. The KD patients had the shortest time of MAS onset, while the CTD patients had the longest onset time (P=0.009). The top 10 clinical symptoms were fever (95%), rash (86%), lymph node enlargement (67%), hemophagocytic phenomenon in bone marrow (63%), pulmonary disease (62%), serous effusion (62%), hepatomegaly (52%), cerebrospinal fluid abnormalities (50%), central nervous system damage (43%), and splenomegaly (38%). The median of hemoglobin level was lower than the normal value. The medians of C-reactive protein level and erythrocyte sedimentation rate were higher than the normal values. There were significant increases in serum ferritin, glutamic-pyruvic transaminase, aspartate aminotransferase, lactate dehydrogenase, and triglyceride. The median of fibrinogen level was lower than the normal value. There were significant increases in D-dimer, interleukin-6 (IL-6), interleukin-10 (IL-10), and interferon-γ (IFN-γ). Of the 21 patients, 20 were improved and discharged. CONCLUSIONS If patients with rheumatic disease have persistent fever, hepatic dysfunction, coagulation disorders, multiple organ impairment, significantly increased IL-10 and IFN-γ, and a persistent increase in serum ferritin, the development of MAS should be considered.
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Park JH, Seo YM, Han SB, Kim KH, Rhim JW, Chung NG, Kim MS, Kang JH, Jeong DC. Recurrent macrophage activation syndrome since toddler age in an adolescent boy with HLA B27 positive juvenile ankylosing spondylitis. KOREAN JOURNAL OF PEDIATRICS 2016; 59:421-424. [PMID: 27826329 PMCID: PMC5099290 DOI: 10.3345/kjp.2016.59.10.421] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 08/08/2016] [Accepted: 08/18/2016] [Indexed: 12/16/2022]
Abstract
Recurrent macrophage activation syndrome (MAS) is very rare. We present the case of an adolescent boy with human leukocyte antigen (HLA) B27-positive ankylosing spondylitis (AS), who experienced episodes of recurrent MAS since he was a toddler. A 16-year-old boy was admitted because of remittent fever with pancytopenia and splenomegaly after surgical intervention for an intractable perianal abscess. He had been diagnosed with hemophagocytic lymphohistiocytosis (HLH) 4 different times, which was well controlled with intravenous immunoglobulin and steroids since the age of 3. We were unable to identify the cause for the HLH. He remained symptom-free until the development of back pain and right ankle joint pain with swelling at 15 years of age. He was diagnosed with HLA B27-positive AS with bilateral active sacroiliitis. He showed symptom aggravation despite taking naproxen and methotrexate, and the symptoms improved with etanercept. On admission, his laboratory data showed leukopenia with high ferritin and triglyceride levels. Bone marrow biopsy examination showed histiocytic hyperplasia with hemophagocytosis. There was no evidence of infection. He received naproxen alone, and his symptoms and laboratory data improved without any other immunomodulatory medications. Genetic study revealed no primary HLH or inflammasome abnormalities. In this case, underlying autoimmune disease should have been considered as the cause of recurrent MAS in the young patient once primary HLH was excluded.
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Affiliation(s)
- Joon Hyeong Park
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yu Mi Seo
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Beom Han
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea.; Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ki Hwan Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Woo Rhim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Nack Gyun Chung
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Myung Shin Kim
- Department of Laboratory Medicine, Catholic Genetic Laboratory Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Han Kang
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea.; Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dae Chul Jeong
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea.; Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Shakoory B, Carcillo JA, Chatham WW, Amdur RL, Zhao H, Dinarello CA, Cron RQ, Opal SM. Interleukin-1 Receptor Blockade Is Associated With Reduced Mortality in Sepsis Patients With Features of Macrophage Activation Syndrome: Reanalysis of a Prior Phase III Trial. Crit Care Med 2016; 44:275-81. [PMID: 26584195 DOI: 10.1097/ccm.0000000000001402] [Citation(s) in RCA: 575] [Impact Index Per Article: 71.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the efficacy of anakinra (recombinant interleukin-1 receptor antagonist) in improving 28-day survival in sepsis patients with features of macrophage activation syndrome. Despite equivocal results in sepsis trials, anakinra is effective in treating macrophage activation syndrome, a similar entity with fever, disseminated intravascular coagulation, hepatobiliary dysfunction, cytopenias, and hyperferritinemia. Hence, sepsis patients with macrophage activation syndrome features may benefit from interleukin-1 receptor blockade. DESIGN Reanalysis of deidentified data from the phase III randomized interleukin-1 receptor antagonist trial in severe sepsis. SETTING Multicenter study recruiting through 91 centers from 11 countries in Europe and North America. PATIENTS Sepsis patients with multiorgan dysfunction syndrome and/or shock (original study) were regrouped based on the presence or the absence of concurrent hepatobiliary dysfunction and disseminated intravascular coagulation as features of macrophage activation syndrome. The non-hepatobiliary dysfunction/disseminated intravascular coagulation group included patients with only hepatobiliary dysfunction, only disseminated intravascular coagulation, or neither. INTERVENTION Treatment with anakinra or placebo. MEASUREMENTS AND MAIN RESULTS Main outcome was 28-day mortality. Descriptive and comparative statistics were performed. Data were available for 763 adults from the original study cohort, randomized to receive either anakinra or placebo. Concurrent hepatobiliary dysfunction/disseminated intravascular coagulation was noted in 43 patients (5.6% of total; 18-75 years old; 47% women). The 28-day survival was similar in both anakinra and placebo-treated non-hepatobiliary dysfunction/disseminated intravascular coagulation patients (71.4% vs 70.8%; p = 0.88). Treatment with anakinra was associated with significant improvement in the 28-day survival rate in hepatobiliary dysfunction/disseminated intravascular coagulation patients (65.4% anakinra vs 35.3% placebo), with hazard ratio for death 0.28 (0.11-0.71; p = 0.0071) for the treatment group in Cox regression. CONCLUSIONS In this subgroup analysis, interleukin-1 receptor blockade was associated with significant improvement in survival of patients with sepsis and concurrent hepatobiliary dysfunction/disseminated intravascular coagulation. A prospective randomized trial using features of macrophage activation syndrome for mortality risk stratification should be undertaken to confirm the role of interleukin-1 blockage.
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Affiliation(s)
- Bita Shakoory
- 1Division of Rheumatology, Department of Medicine, George Washington University, Washington, DC. 2Department of Critical Care and Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, PA. 3Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL. 4Department of Clinical Research, Temple University, Philadelphia, PA. 5Division of Infectious Diseases, Department of Medicine, University of Colorado Denver, Aurora, CO. 6University of Alabama at Birmingham, Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL. 7Division of Infectious Diseases, Department of Medicine, Brown University, Providence, RI
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Zhang M, Bracaglia C, Prencipe G, Bemrich-Stolz CJ, Beukelman T, Dimmitt RA, Chatham WW, Zhang K, Li H, Walter MR, De Benedetti F, Grom AA, Cron RQ. A Heterozygous RAB27A Mutation Associated with Delayed Cytolytic Granule Polarization and Hemophagocytic Lymphohistiocytosis. THE JOURNAL OF IMMUNOLOGY 2016; 196:2492-503. [PMID: 26880764 DOI: 10.4049/jimmunol.1501284] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 01/12/2016] [Indexed: 11/19/2022]
Abstract
Frequently fatal, primary hemophagocytic lymphohistiocytosis (HLH) occurs in infancy resulting from homozygous mutations in NK and CD8 T cell cytolytic pathway genes. Secondary HLH presents after infancy and may be associated with heterozygous mutations in HLH genes. We report two unrelated teenagers with HLH and an identical heterozygous RAB27A mutation (c.259G→C). We explore the contribution of this Rab27A missense (p.A87P) mutation on NK cell cytolytic function by cloning it into a lentiviral expression vector prior to introduction into the human NK-92 cell line. NK cell degranulation (CD107a expression), target cell conjugation, and K562 target cell lysis was compared between mutant- and wild-type-transduced NK-92 cells. Polarization of granzyme B to the immunologic synapse and interaction of mutant Rab27A (p.A87P) with Munc13-4 were explored by confocal microscopy and proximity ligation assay, respectively. Overexpression of the RAB27A mutation had no effect on cell conjugate formation between the NK and target cells but decreased NK cell cytolytic activity and degranulation. Moreover, the mutant Rab27A protein decreased binding to Munc13-4 and delayed granzyme B polarization toward the immunologic synapse. This heterozygous RAB27A mutation blurs the genetic distinction between primary and secondary HLH by contributing to HLH via a partial dominant-negative effect.
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Affiliation(s)
- Mingce Zhang
- Division of Pediatric Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233
| | - Claudia Bracaglia
- Divisione di Reumatologia Pediatrica, Ospedale Pediatrico Bambino Gesù, 00165 Rome, Italy
| | - Giusi Prencipe
- Divisione di Reumatologia Pediatrica, Ospedale Pediatrico Bambino Gesù, 00165 Rome, Italy
| | - Christina J Bemrich-Stolz
- Division of Pediatric Hematology-Oncology, University of Alabama at Birmingham, Birmingham, AL 35233
| | - Timothy Beukelman
- Division of Pediatric Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233; Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35294
| | - Reed A Dimmitt
- Division of Pediatric Gastroenterology, University of Alabama at Birmingham, Birmingham, AL 35233
| | - W Winn Chatham
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35294
| | - Kejian Zhang
- Human Genetics, University of Cincinnati, Cincinnati, OH 45229
| | - Hao Li
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35294
| | - Mark R Walter
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL 35294; and
| | - Fabrizio De Benedetti
- Divisione di Reumatologia Pediatrica, Ospedale Pediatrico Bambino Gesù, 00165 Rome, Italy
| | - Alexei A Grom
- Division of Pediatric Rheumatology, University of Cincinnati, Cincinnati, OH 45229
| | - Randy Q Cron
- Division of Pediatric Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233; Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35294;
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