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Chalipat S, Kulkarni V, Malwade S, Shah P, Bijaspur P. Silvery Gray Hair Syndrome With Hemophagocytic Lymphohistiocytosis: A Case Report. Cureus 2024; 16:e55649. [PMID: 38586648 PMCID: PMC10996885 DOI: 10.7759/cureus.55649] [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: 03/06/2024] [Indexed: 04/09/2024] Open
Abstract
Griscelli syndrome (GS) is a rare autosomal recessive disorder, which has been classified into three subtypes based on clinical and genetic differences. GS subtype 2 is commonly associated with hemophagocytic lymphohistiocytosis (HLH) and recurrent infections due to immunodeficiency. In this study, we describe a four-month-old boy with genetically proven GS2, with neurological and immunological manifestations. He presented with fever, refusal of feeds, drowsiness, and multiple episodes of seizures. Examination revealed hypopigmented skin, silvery gray hair, and organomegaly. The child developed features of HLH, fulfilling clinical and laboratory criteria. Neuroimaging findings were in concordance with HLH of the central nervous system. Microscopic examination of the hair showed clumps of melanin pigment along the hair shaft. All findings were in favor of GS type 2, complicated with HLH, which was later confirmed with a homozygous deletion of the RAB27A gene on exome sequencing. Unfortunately, the baby succumbed to death due to severe sepsis and multiorgan dysfunction. The silvery gray hair, with typical hair microscopic findings, and association with HLH are strong indicators for this potentially fatal condition and aid in prompt diagnosis and initiation of treatment. Hematopoietic stem cell transplantation is the only lifesaving treatment option.
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Affiliation(s)
- Shiji Chalipat
- Pediatrics, Dr. D.Y. Patil Medical College Hospital and Research Center, Dr. D.Y. Patil Vidyapeeth (Deemed to Be University), Pune, IND
| | - Vishwanath Kulkarni
- Pediatrics, Dr. D.Y. Patil Medical College Hospital and Research Center, Dr. D.Y. Patil Vidyapeeth (Deemed to Be University), Pune, IND
| | - Sudhir Malwade
- Pediatrics, Dr. D.Y. Patil Medical College Hospital and Research Center, Dr. D.Y. Patil Vidyapeeth (Deemed to Be University), Pune, IND
| | - Priyanka Shah
- Pediatrics, Dr. D.Y. Patil Medical College Hospital and Research Center, Dr. D.Y. Patil Vidyapeeth (Deemed to Be University), Pune, IND
| | - Prasad Bijaspur
- Pediatrics, Dr. D.Y. Patil Medical College Hospital and Research Center, Dr. D.Y. Patil Vidyapeeth (Deemed to Be University), Pune, IND
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2
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Hung SC, Guimaraes C. Imaging of Childhood Cerebral Vasculitis. Neuroimaging Clin N Am 2024; 34:149-166. [PMID: 37951700 DOI: 10.1016/j.nic.2023.07.005] [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] [Indexed: 11/14/2023]
Abstract
Childhood cerebral vasculitis is a condition that affects the blood vessels in the brain of children and is rare but life-threatening. Imaging plays a crucial role in the diagnosis and monitoring of the disease. This article describes the classification, diagnostic algorithm, and various imaging modalities used in the evaluation of childhood cerebral vasculitis and the imaging findings associated with primary and secondary vasculitis. Understanding the imaging features of this condition can assist in early diagnosis, effective treatment, and improve outcomes.
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Affiliation(s)
- Sheng-Che Hung
- Department of Radiology, University of North Carolina, 2000 Old Clinic, CB# 7510, Chapel Hill, NC 27599, USA.
| | - Carolina Guimaraes
- Department of Radiology, University of North Carolina, 2000 Old Clinic, CB# 7510, Chapel Hill, NC 27599, USA
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Tan HEI, Lakshmanan R, Warne R, Walwyn T, Roebuck D. Neuroimaging manifestations of paediatric histiocytoses. J Med Imaging Radiat Oncol 2023. [PMID: 37964685 DOI: 10.1111/1754-9485.13602] [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: 09/28/2023] [Accepted: 10/23/2023] [Indexed: 11/16/2023]
Abstract
Histiocytoses are rare multi-system disorders marked by abnormal histiocyte cell proliferation, affecting children with diverse clinical presentations. Classified into five groups in 2016, including Langerhans-related (L), cutaneous (C), malignant (M), Rosai-Dorfman disease (R) and haemophagocytic lymphohistiocytosis (H), newer entities such as ALK-positive histiocytosis have also emerged, heralding the era of molecular (sub)classification. Common entities include Langerhans cell histiocytosis (LCH), Erdheim-Chester disease (ECD), Rosai-Dorfman disease (RDD) and haemophagocytic lymphohistiocytosis (HLH). This pictorial essay aids radiologists in recognising and differentiating paediatric histiocytoses based on unique neuroimaging features.
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Affiliation(s)
- Hsern Ern Ivan Tan
- Department of Medical Imaging, Perth Children's Hospital, Perth, Western Australia, Australia
- Department of Medical Imaging, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Rahul Lakshmanan
- Department of Medical Imaging, Perth Children's Hospital, Perth, Western Australia, Australia
- University of Western Australia, Perth, Western Australia, Australia
| | - Richard Warne
- Department of Medical Imaging, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Thomas Walwyn
- University of Western Australia, Perth, Western Australia, Australia
- Department of Oncology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Derek Roebuck
- Department of Medical Imaging, Perth Children's Hospital, Perth, Western Australia, Australia
- University of Western Australia, Perth, Western Australia, Australia
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Sivaramalingam G, VK A, Raghavan B, Govindaraj J. Imaging Spectrum of Neurological Manifestations of Hemophagocytic Lymphohistiocytosis in Pediatrics: A Case Series. Indian J Radiol Imaging 2023; 33:548-554. [PMID: 37811180 PMCID: PMC10556316 DOI: 10.1055/s-0043-1772495] [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] [Indexed: 10/10/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an uncommon condition, which can result either from a primary genetic abnormality affecting children or secondary to various conditions like malignancy or infection predominantly in adults. HLH is associated with immune dysregulation, resulting in an uncontrolled overproduction and infiltration of lymphocytes and histiocytes. The infiltration predominantly involves liver, spleen, lymph nodes, and central nervous system. Neuroimaging features on magnetic resonance imaging are highly nonspecific and variable. The most typical findings include periventricular white matter hyperintensities and diffuse atrophy. Ring or nodular enhancing or nonenhancing focal parenchymal lesions may be seen. Here, we present three pediatric cases of primary HLH with a wide spectrum of imaging findings involving cerebral and cerebellar cortex, white matter, deep gray matter, and brain stem. The findings in these patients range from small nonenhancing hemorrhagic lesions and enhancing small lesions to ill-defined mass with mass effect and midline shift. Lesions in deep gray matter including thalamus, basal ganglia, and also brain stem in HLH are rarely described in literature. Early diagnosis of HLH and timely management can improve the course of the disease.
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Affiliation(s)
| | - Afiya VK
- Department of Radiology, Apollo Speciality Hospital, Chennai, Tamil Nadu, India
| | - Bagyam Raghavan
- Department of Radiology, Apollo Speciality Hospital, Chennai, Tamil Nadu, India
| | - Jayaraj Govindaraj
- Department of Radiology, Apollo Speciality Hospital, Chennai, Tamil Nadu, India
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Gupta N, Hiremath SB, Aviv RI, Wilson N. Childhood Cerebral Vasculitis : A Multidisciplinary Approach. Clin Neuroradiol 2023; 33:5-20. [PMID: 35750917 PMCID: PMC9244086 DOI: 10.1007/s00062-022-01185-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 06/02/2022] [Indexed: 11/26/2022]
Abstract
Cerebral vasculitis is increasingly recognized as a common cause of pediatric arterial stroke. It can present with focal neurological deficits, psychiatric manifestations, seizures, and encephalopathy. The etiopathogenesis of childhood cerebral vasculitis (CCV) is multifactorial, making an inclusive classification challenging. In this review, we describe the common and uncommon CCV with a comprehensive discussion of etiopathogenesis, the role of various imaging modalities, and advanced techniques in diagnosing CCV. We also highlight the implications of relevant clinical, laboratory, and genetic findings to reach the final diagnosis. Based on the clinicoradiological findings, a stepwise diagnostic approach is proposed to facilitate CCV diagnosis and rule out potential mimics. Identification of key clinical manifestations, pertinent blood and cerebrospinal fluid results, and evaluation of central nervous system vessels for common and disease-specific findings will be emphasized. We discuss the role of magnetic resonance imaging, MR angiography, and vessel wall imaging as the imaging investigation of choice, and reservation of catheter angiography as a problem-solving tool. We emphasize the utility of brain and leptomeningeal biopsy for diagnosis and exclusion of imitators and masqueraders.
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Affiliation(s)
- Neetika Gupta
- Department of Medical Imaging, Children’s Hospital of Eastern Ontario (CHEO), University of Ottawa, Ottawa, Ontario Canada
- Clinical Fellow—Pediatric Radiology, Department of Medical Imaging, Children’s Hospital of Eastern Ontario (CHEO), University of Ottawa, Ottawa, Ontario Canada
| | - Shivaprakash B. Hiremath
- Department of Medical Imaging, Division of Neuroradiology, Civic and General Campus, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario Canada
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario Canada
| | - Richard I. Aviv
- Department of Medical Imaging, Division of Neuroradiology, Civic and General Campus, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario Canada
| | - Nagwa Wilson
- Department of Medical Imaging, Children’s Hospital of Eastern Ontario (CHEO), University of Ottawa, Ottawa, Ontario Canada
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Isolated Sixth Nerve Palsies in a Child With Familial Hemophagocytic Lymphohistiocytosis Type 2. J Neuroophthalmol 2023; 43:137-140. [PMID: 36790062 DOI: 10.1097/wno.0000000000001807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
ABSTRACT A previously healthy 2-year-old boy presented with a left sixth cranial nerve palsy. There was a family history of multiple sclerosis and optic neuritis. Neuroimaging showed multiple foci of T2/FLAIR hyperintense signal abnormality in both cerebral hemispheres and in the brainstem. The initial diagnosis was suspicious for demyelinating disease. However, there was no clinical improvement after a course of corticosteroids, and there was no change in his follow-up MRI. He later developed bilateral sixth nerve palsies, with esotropia addressed with bilateral medial rectus botulinum toxin injections. A brain biopsy was planned. However, his 3-month-old sister was separately admitted for fever and pancytopenia. She had markedly elevated ferritin, D-dimer, triglycerides, sIL-2R, CXCL9, and IL-18 and low fibrinogen. Her bone marrow biopsy showed hemophagocytosis. Genetic testing of both siblings revealed biallelic mutations in the PRF1 locus. The final diagnosis of familial hemophagocytic lymphohistiocytosis Type 2 was made. Both siblings underwent chemotherapy. The boy's sixth nerve palsies and MRI abnormalities resolved. Both siblings then went on to undergo bone marrow transplant.
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Malik P, Shroff M. Infection and inflammation: radiological insights into patterns of pediatric immune-mediated CNS injury. Neuroradiology 2023; 65:425-439. [PMID: 36534135 PMCID: PMC9761646 DOI: 10.1007/s00234-022-03100-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022]
Abstract
The central nervous system (CNS) undergoes constant immune surveillance enabled via regionally specialized mechanisms. These include selectively permissive barriers and modifications to interlinked innate and adaptive immune systems that detect and remove an inciting trigger. The end-points of brain injury and edema from these triggers are varied but often follow recognizable patterns due to shared underlying immune drivers. Imaging provides insights to understanding these patterns that often arise from unique interplays of infection, inflammation and genetics. We review the current updates in our understanding of these intersections and through examples of cases from our practice, highlight that infection and inflammation follow diverse yet convergent mechanisms that can challenge the CNS in children.
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Affiliation(s)
- Prateek Malik
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Manohar Shroff
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
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Aydın K, Kılıç B, Topçu Y, Telhan L, Dolu MH, Kartal A. Brain Magnetic Resonance Imaging Findings of Pediatric Hemophagocytic Lymphohistiocytosis Could Be Diagnostic and Life-Saving. Pediatr Neurol 2022; 133:40-47. [PMID: 35753148 DOI: 10.1016/j.pediatrneurol.2022.05.010] [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: 11/17/2021] [Revised: 01/09/2022] [Accepted: 05/25/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare and fatal disease and may also present with central nervous system findings at the beginning without specific diagnostic criteria. Brain magnetic resonance imaging (MRI) findings are diverse and can also be diagnostic. We aimed to emphasize the importance of brain MRI findings in the early diagnosis of this fatal disease. METHODS MRI findings, clinical presentations, treatment response, and prognosis of seven patients with HLH were described. RESULTS There were seven pediatric patients who were initially diagnosed with HLH with neurological findings without systemic signs of HLH: four as primary, two as secondary, and one as possible primary HLH. All patients had contrast-enhancing diffuse cerebellar and brainstem lesions; patchy periventricular and callosal cerebral lesions were observed. Thalamus involvement was found in three (42.8%), corpus callosum involvement in six (85.7%), and cervical spinal involvement in one (14.2%). Patients were followed up with these MRI findings, with prediagnoses of toxic, metabolic, infectious, vascular, and demyelinating diseases. Not all patients met the HLH diagnostic criteria due to incomplete systemic/laboratory findings; therefore, only two were immediately directed for hematopoietic stem cell therapy. Four died shortly after admission, one patient could not be followed up after HLH treatment, and two patients who fulfilled the HLH diagnostic criteria underwent hematopoietic stem cell transplantation and survived. CONCLUSIONS Brain MRI findings, especially in the presence of neurological findings, allow for early diagnosis, which can be life-saving. These common features in brain MRI findings should be evaluated with this suspicion and included in HLH diagnostic criteria.
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Affiliation(s)
- Kürşad Aydın
- Department of Pediatric Neurology, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Betül Kılıç
- Department of Pediatric Neurology, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey.
| | - Yasemin Topçu
- Department of Pediatric Neurology, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Leyla Telhan
- Department of Pediatric Intensive Care Unit, Istanbul Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Merve Hilal Dolu
- Department of Pediatric Neurology, Ondokuz Mayıs University Faculty of Medicine, Samsun, Turkey
| | - Ayşe Kartal
- Department of Pediatric Neurology, Selçuk University Faculty of Medicine, Konya, Turkey
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Yoshida T, Moriya K, Oikawa K, Miura S, Asakura Y, Tanifuji S, Kusano S, Endo M, Akasaka M. Case report: Cerebellar swelling and hydrocephalus in familial hemophagocytic lymphohistiocytosis. Front Pediatr 2022; 10:1051623. [PMID: 36589154 PMCID: PMC9800833 DOI: 10.3389/fped.2022.1051623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/14/2022] [Indexed: 12/23/2022] Open
Abstract
Familial hemophagocytic lymphohistiocytosis (FHL) is a severe inborn error of immunity caused by a genetic defect that impairs the function of cytotoxic T and NK cells. There are only a few reported cases of FHL with diffuse swelling of the cerebellum and obstructive hydrocephalus. We report a case of FHL3 with neurological symptoms associated with cerebellar swelling and obstructive hydrocephalus. A male patient was hospitalized several times due to fever and decreased feeding, hepatosplenomegaly, and cytopenia since the first month of life. At 7 months of age, disturbance of consciousness was seen. Brain magnetic resonance imaging revealed signal intensity in the bilateral cerebellar hemispheres, diffusely increased periventricular white matter, and ventriculomegaly. Although he was treated with methylprednisolone pulse therapy, he was unresponsive to the treatment. He was then transferred to a local hospital after tracheotomy but died. Targeted clinical sequencing revealed a homozygous splice-site mutation in UNC13D. Pediatric hemophagocytic lymphohistiocytosis (HLH) includes some cases of central nervous symptom (CNS)-isolated HLH or CNS HLH preceding systemic lesions, which often do not initially meet the diagnostic criteria for FHL. Patients with FHL initiated by cerebellar symptoms may present with an atypical clinical course for HLH, leading to delayed diagnosis and poor outcomes. Despite the usefulness of a combination of a high percentage of lymphocytes in the peripheral leukocytes, a low lactate dehydrogenase level, and a high sIL-2R/ferritin ratio for identifying FHL, the diagnosis may be missed due to the absence of these results. Presymptomatic diagnosis of FHL by screening of newborns and subsequent early treatment of patients with a predicted poor prognosis may contribute to better outcomes.
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Affiliation(s)
- Taro Yoshida
- Department of Pediatrics, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Kunihiko Moriya
- Department of Pediatrics, School of Medicine, Iwate Medical University, Iwate, Japan.,Department of Pediatrics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Keisuke Oikawa
- Department of Pediatrics, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Shoko Miura
- Department of Pediatrics, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Yoshiko Asakura
- Department of Pediatrics, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Sachiko Tanifuji
- Department of Pediatrics, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Shuji Kusano
- Department of Pediatrics, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Mikiya Endo
- Department of Pediatrics, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Manami Akasaka
- Department of Pediatrics, School of Medicine, Iwate Medical University, Iwate, Japan
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