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Orth HM, Wiemer D, Schneitler S, Schönfeld A, Holtfreter MC, Gliga S, Fuchs A, Pfäfflin F, Denkinger CM, Kalbitz S, Fritzsche C, Hübner MP, Trauth J, Jensen BEO, Luedde T, Feldt T. Hemophagocytic lymphohistiocytosis-how common and how severe is it as a complication of malaria? Retrospective case series and review of the literature. Infection 2024; 52:471-482. [PMID: 37875775 PMCID: PMC10955030 DOI: 10.1007/s15010-023-02104-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/27/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Infection-associated secondary hemophagocytic lymphohistiocytosis (sHLH) is a potentially life-threatening hyperinflammatory condition caused by various infectious diseases. Malaria has rarely been described as trigger. The aim of this study is to collect data on frequency, clinical spectrum, and outcome of sHLH induced by malaria. METHODS We collected case numbers on malaria and malaria-associated sHLH from specialized centers in Germany from 2015 to 2022. In addition, we conducted a literature search on published cases of malaria-associated sHLH and systematically analyzed the literature regarding clinical and diagnostic criteria. RESULTS We obtained data from 13 centers treating 1461 malaria cases with different Plasmodium species, of which 5 patients (0.34%) also were diagnosed with sHLH. The literature search revealed detailed case reports from further 51 patients and case series comprising the description of further 24 patients with malaria-associated sHLH. Most cases (48/80; 60%) were reported from Asia. The median time interval between onset of malaria symptoms and hospital admission was 7 days. Severe complications of sHLH were documented in 36% (20/56) of patients, including two patients with multiple organ failure in our case series. Only 41% (23/56) of patients received specific treatment for sHLH, nevertheless the mortality rate (CFR) of 5% is lower compared to the CFR reported for sHLH triggered by other infectious diseases (e.g., 25% in sHLH due to EBV infection). CONCLUSION Malaria-associated sHLH appears to have a comparatively good prognosis but may still represent an underdiagnosed and potentially fatal complication of malaria, especially in resource-poor settings.
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Affiliation(s)
- Hans Martin Orth
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany.
| | - Dorothea Wiemer
- Department of Tropical Medicine and Infectious Diseases at the Bernhard Nocht Institute, Bundeswehr Hospital Hamburg, Hamburg, Germany
| | - Sophie Schneitler
- Institute of Medical Microbiology and Hygiene, Saarland University, Homburg/Saar, Germany
| | - Andreas Schönfeld
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Centre Essen, University of Duisburg-Essen DE, Essen, Germany
| | - Martha Charlotte Holtfreter
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Smaranda Gliga
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Andre Fuchs
- Internal Medicine III-Gastroenterology and Infectious Diseases, Augsburg University Hospital, Augsburg, Germany
| | - Frieder Pfäfflin
- Department for Infectious Diseases and Respiratory Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Claudia Maria Denkinger
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Infection Research (DZIF), partner site Heidelberg University Hospital, Heidelberg, Germany
| | - Sven Kalbitz
- Department of Infectious Diseases/Tropical Medicine, Nephrology and Rheumatology, Hospital St. Georg, Leipzig, Germany
| | - Carlos Fritzsche
- Department of Tropical Medicine and Infectious Diseases, Center for Internal Medicine, University of Rostock, Rostock, Germany
| | - Marc P Hübner
- Institute for Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Bonn, Germany
- German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Bonn, Germany
| | - Janina Trauth
- Division of Infectious Diseases, Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus Liebig University Giessen, Giessen, Germany
| | - Björn-Erik Ole Jensen
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Tom Luedde
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Torsten Feldt
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
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Wang L, Hu M, Wu X, Ma L, Yang H. Case Report: Diagnosis and Treatment of Two Clinical Cases of Visceral Leishmaniasis-Related Hemophagocytic Lymphohistiocytosis. Am J Trop Med Hyg 2023; 109:296-300. [PMID: 37429573 PMCID: PMC10397458 DOI: 10.4269/ajtmh.22-0776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 04/06/2023] [Indexed: 07/12/2023] Open
Abstract
Visceral leishmaniasis-related hemophagocytic lymphohistiocytosis (VL-HLH) is a potentially life-threatening secondary hemophagocytic lymphocytic syndrome caused by protozoan parasites of the Leishmania species and transmitted by infected sandflies. Therefore, it is important to be highly vigilant of the infection, particularly the visceral subtype, to share information with the public health system, and to improve the early diagnosis rate so that appropriate treatment can be initiated promptly. We report two isolated cases of VL-HLH. The main clinical manifestations were fever, pancytopenia, splenomegaly, hypofibrinogenemia, and hyperferremia, which meet the HLH-2004 diagnostic criteria. In our experience, anti-HLH treatment was not very effective for either case. No Leishmania organism was found in the first bone marrow smear of either patient. The first patient was diagnosed after identification of Leishmania amastigotes via sternal bone marrow biopsy, rK39 immunochromatography test, and metagenomic next-generation sequencing. The other patient was diagnosed by rK39-rapid diagnostic test and polymerase chain reaction. However, because of the delayed diagnosis in both cases, their conditions continued to deteriorate and both patients eventually died of the disease. Leishmaniasis is a parasitic disease with regional specificity and a low incidence. The occurrence of secondary HLH has a great impact on prognosis. When encountering secondary HLH in clinical practice, leishmaniasis should remain on the list of differential causes. Because of a high mortality rate if diagnosed late, it is crucial to be vigilant of VL-HLH in practice so that early detection, diagnosis, and treatment of the disease can be achieved to reduce adverse patient outcomes.
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Affiliation(s)
- Liuxue Wang
- Department of Hematology, The First Affiliated Hospital and College of Clinical Medicine, Henan University of Science and Technology, Luoyang, China
| | - Meng Hu
- Department of Hematology, The First Affiliated Hospital and College of Clinical Medicine, Henan University of Science and Technology, Luoyang, China
| | - Xusheng Wu
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Limin Ma
- Department of Hematology, The First Affiliated Hospital and College of Clinical Medicine, Henan University of Science and Technology, Luoyang, China
| | - Haiping Yang
- Department of Hematology, The First Affiliated Hospital and College of Clinical Medicine, Henan University of Science and Technology, Luoyang, China
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Yang Y, Yu H, Li C, Gui Z, Chang Y. Specific cytokine patterns in Epstein-Barr virusassociated hemophagocytic lymphohistiocytosis compared to Kawasaki disease in children. Pediatr Hematol Oncol 2023; 40:529-538. [PMID: 37178062 DOI: 10.1080/08880018.2023.2186555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/13/2023] [Accepted: 02/17/2023] [Indexed: 05/15/2023]
Abstract
The aim of the study was to test whether the cytokine profile could be used as a marker to differentiate between Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis (EBV-HLH) and Kawasaki disease (KD). A total of 70 hospitalized children with HLH and KD admitted to hospital for the first time from March 2017 to December 2021 were enrolled in this study. Fifty-five healthy children were enrolled as normal controls. All patients and normal controls were tested for the six cytokines including interleukin-2 (IL-2), interleukin-4 (IL-4), interleukin-6 (IL-6), interleukin-10 (IL-10), tumor necrosis factor-alpha (TNF-α), and interferon-γ (IFN-γ) by flow cytometry. IL-10 and IFN-γ levels were significantly higher in children with EBV-HLH than in the KD, IL-6 was lower in EBV-HLH patients than in the KD. IL-10/IL-6 ratio, IFN-γ/IL-6 ratio and IL10/IFN-γ ratio in children with EBV-HLH were significantly much higher than children in the KD group. When the diagnostic cutoff values of IL-10, IFN-γ, IL-10/IL-6 ratio and IFN-γ/IL-6 ratio were >13.2 pg/ml, >71.0 pg/ml, >0.37 and >1.34, respectively, the sensitivity and specificity of the diagnosis of EBV-HLH disease were 91.7% and 97.1%, 72.2% and 97.1%, 86.1% and 100.0%, and 75.0% and 97.1%, respectively. Notably high IL-10 and IFN-γ and moderately elevated IL-6 suggest the diagnosis of EBV-HLH, while high IL-6 levels with low IL-10 or IFN-γ concentration would suggest KD. Additionally, IL-10/IL-6 ratio or IFN-γ/IL-6 ratio could be used as an index to differentiate between EBV-HLH and KD.
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Affiliation(s)
- Yanli Yang
- Department of Laboratory Medicine, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Hanqing Yu
- Department of Laboratory Medicine, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Chenli Li
- Department of Laboratory Medicine, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Zhen Gui
- Department of Laboratory Medicine, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yong Chang
- Department of Laboratory Medicine, Children's Hospital of Nanjing Medical University, Nanjing, China
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Leishmania Infection during Ruxolitinib Treatment: The Cytokines-Based Immune Response in the Setting of Immunocompromised Patients. J Clin Med 2023; 12:jcm12020578. [PMID: 36675507 PMCID: PMC9866708 DOI: 10.3390/jcm12020578] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/05/2023] [Accepted: 01/09/2023] [Indexed: 01/13/2023] Open
Abstract
Ruxolitinib is a JAK1/2 inhibitor that has revolutionized the approach to myelofibrosis. On the one side, this drug can rapidly improve the symptoms related to the hematological disease; on the other side, the inhibition of JAK1/2 can lead to immunosuppression which may increase the risk of infections, due to a change in the cytokine balance in favor of anti-inflammatory cytokines, to direct inhibition of immune cells, and to the suppression in the production of specific antibodies. In this patient setting, much is known about possible viral and bacterial infections, while little is reported in the literature concerning parasitic infections, specifically leishmaniasis. Leishmania is a parasitic infection that can cause serious problems in immunosuppressed patients. The parasite can invade the bloodstream and cause a wide range of symptoms, including fever, weight loss, and anemia. In severe cases, it can lead to multi-organ failure and, rapidly, death. Early diagnosis and prompt treatment are essential especially for these patients, unable to respond adequately. In this case and the following review of the existing literature, the cytokine kinetics and the production of specific anti-Leishmania antibodies represent characteristic aspects capable of providing a more in-depth understanding of the mechanisms underlying these complex clinical cases in an immunocompromised patient.
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