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Carol HA, Mayer AS, Zhang MS, Dang V, Varghese J, Martinez Z, Schneider C, Baker JE, Tsoukas P, Behrens EM, Cron RQ, Diorio C, Henderson LA, Schulert G, Lee P, Kernan KF, Canna SW. Hyperferritinemia Screening to Aid Identification and Differentiation of Patients with Hyperinflammatory Disorders. J Clin Immunol 2024; 45:4. [PMID: 39264477 DOI: 10.1007/s10875-024-01797-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 08/29/2024] [Indexed: 09/13/2024]
Abstract
High ferritin is an important and sensitive biomarker for the various forms of hemophagocytic lymphohistiocytosis (HLH), a diverse and deadly group of cytokine storm syndromes. Early action to prevent immunopathology in HLH often includes empiric immunomodulation, which can complicate etiologic work-up and prevent collection of early/pre-treatment research samples. To address this, we instituted an alert system at UPMC Children's Hospital where serum ferritin > 1000 ng/mL triggered real-time chart review, assessment of whether the value reflected "inflammatory hyperferritnemia (IHF)", and biobanking of remnant samples from consenting IHF patients. We extracted relevant clinical data; periodically measured serum total IL-18, IL-18 binding protein (IL-18BP), and CXCL9; retrospectively classified patients by etiology into infectious, rheumatic, or immune dysregulation; and subjected a subgroup of samples to a 96-analyte biomarker screen. 180 patients were identified, 30.5% of which had IHF. Maximum ferritin levels were significantly higher in patients with IHF than with either hemoglobinopathy or transplant, and highly elevated total IL-18 levels were distinctive to patients with Stills Disease and/or Macrophage Activation Syndrome (MAS). Multi-analyte analysis showed elevation in proteins associated with cytotoxic lymphocytes in all IHF samples when compared to healthy controls and depression of proteins such as ANGPT1 and VEGFR2 in samples from hyperferritinemic sepsis patients relative to non-sepsis controls. This real-time IFH screen proved feasible and efficient, validated prior observations about the specificity of IL-18, enabled early sample collection from a complex population, suggested a unique vascular biomarker signature in hyperferritinemic sepsis, and expanded our understanding of IHF heterogeneity.
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Affiliation(s)
- Hallie A Carol
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Adam S Mayer
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Rheumatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael S Zhang
- Division of Pediatric Allergy/Immunology, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Vinh Dang
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- RK Mellon Institute for Pediatric Research & Pediatric Rheumatology, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jemy Varghese
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Zachary Martinez
- Division of Pediatric Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Corinne Schneider
- RK Mellon Institute for Pediatric Research & Pediatric Rheumatology, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joy Elizabeth Baker
- Division of Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Paul Tsoukas
- Division of Pediatric Rheumatology, Hospital for Sick Children, Toronto, ON, Canada
| | - Edward M Behrens
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Randy Q Cron
- Division of Pediatric Rheumatology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Caroline Diorio
- Division of Pediatric Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Grant Schulert
- Division of Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Pui Lee
- Division of Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Kate F Kernan
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Scott W Canna
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
- RK Mellon Institute for Pediatric Research & Pediatric Rheumatology, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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Ruffer N, Kosch R, Weisel K, Kötter I, Krusche M. [Hemophagocytic lymphohistiocytosis and macrophage activation syndrome : A multidisciplinary challenge]. Z Rheumatol 2024; 83:376-386. [PMID: 38267764 DOI: 10.1007/s00393-023-01472-w] [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] [Accepted: 11/15/2023] [Indexed: 01/26/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome that is characterized by hyperferritinemia, cytopenia, disseminated intravascular coagulopathy and functional disorders of the liver and the central nervous system. The term macrophage activation syndrome is predominantly used for secondary HLH in the context of autoimmune diseases (e.g., systemic juvenile idiopathic arthritis). In addition, malignancies and genetic inborn errors of immunity can predispose to the development of HLH. Infections (e.g., Epstein-Barr virus) in turn represent possible triggers of an acute episode. Due to the unspecific manifestation of the disease, a systematic evaluation of the organ systems is recommended in the clinical and laboratory analytical clarification of hyperinflammatory syndromes. In general, the treatment should be carried out by a multidisciplinary team with expertise in rheumatology, hematological oncology, infectious diseases and intensive care medicine. The primary treatment of HLH usually consists of glucocorticoids and in cases of a rapid deterioration of the condition anakinra (interleukin 1 block) and intravenous immunoglobulins can be employed. Treatment of the underlying disease should be consequently carried out in parallel, together with antimicrobial treatment.
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Affiliation(s)
- Nikolas Ruffer
- Sektion Rheumatologie und entzündliche Systemerkrankungen, III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Ricardo Kosch
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Katja Weisel
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Ina Kötter
- Sektion Rheumatologie und entzündliche Systemerkrankungen, III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Martin Krusche
- Sektion Rheumatologie und entzündliche Systemerkrankungen, III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
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Cox MF, Mackenzie S, Low R, Brown M, Sanchez E, Carr A, Carpenter B, Bishton M, Duncombe A, Akpabio A, Kulasekararaj A, Sin FE, Jones A, Kavirayani A, Sen ES, Quick V, Dulay GS, Clark S, Bauchmuller K, Tattersall RS, Manson JJ. Diagnosis and investigation of suspected haemophagocytic lymphohistiocytosis in adults: 2023 Hyperinflammation and HLH Across Speciality Collaboration (HiHASC) consensus guideline. THE LANCET. RHEUMATOLOGY 2024; 6:e51-e62. [PMID: 38258680 DOI: 10.1016/s2665-9913(23)00273-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/01/2023] [Accepted: 10/04/2023] [Indexed: 01/24/2024]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome characterised by persistently activated cytotoxic lymphocytes and macrophages, which, if untreated, leads to multiorgan dysfunction and death. HLH should be considered in any acutely unwell patient not responding to treatment as expected, with prompt assessment to look for what we term the three Fs-fever, falling blood counts, and raised ferritin. Worldwide, awareness of HLH and access to expert management remain inequitable. Terminology is not standardised, classification criteria are validated in specific patient groups only, and some guidelines rely on specialised and somewhat inaccessible tests. The consensus guideline described in this Health Policy was produced by a self-nominated working group from the UK network Hyperinflammation and HLH Across Speciality Collaboration (HiHASC), a multidisciplinary group of clinicians experienced in managing people with HLH. Combining literature review and experience gained from looking after patients with HLH, it provides a practical, structured approach for all health-care teams managing adult (>16 years) patients with possible HLH. The focus is on early recognition and diagnosis of HLH and parallel identification of the underlying cause. To ensure wide applicability, the use of inexpensive, readily available tests is prioritised, but the role of specialist investigations and their interpretation is also addressed.
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Affiliation(s)
- Miriam F Cox
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Strachan Mackenzie
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ryan Low
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Michael Brown
- Division of Infection, University College London Hospitals NHS Foundation Trust, London, UK
| | - Emilie Sanchez
- Department of Clinical Virology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Aisling Carr
- Centre for Neuromuscular Diseases, National hospital of Neurology and Neurosurgery, London, UK
| | - Ben Carpenter
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mark Bishton
- Department of Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Andrew Duncombe
- Department of Haematology, University Hospital Southampton, Southampton, UK
| | - Akpabio Akpabio
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, UK
| | | | - Fang En Sin
- Department of Rheumatology, North Bristol NHS Trust, UK
| | - Alexis Jones
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Akhila Kavirayani
- Department of Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ethan S Sen
- Department of Paediatric Rheumatology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Vanessa Quick
- Department of Rheumatology, Bedfordshire Hospitals NHS Trust, Luton, UK
| | - Gurdeep S Dulay
- Department of Rheumatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Sam Clark
- Department of Critical Care, University College London Hospitals NHS Foundation Trust, London, UK
| | - Kris Bauchmuller
- Department of Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rachel S Tattersall
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jessica J Manson
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK.
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Rousset M, Orr K, Gartstein E, Anthony A, Brady S, Rios A, Guirola R, Perez M, Eames G, Howrey R, Trinkman H, Chaimowitz N, Diaz M, Ray A. Implementing a Disease-specific Multidisciplinary Team and Order Set for Hemophagocytic Lymphohistiocytosis in a Pediatric Hospital. J Pediatr Hematol Oncol 2023; 45:e892-e898. [PMID: 37611248 DOI: 10.1097/mph.0000000000002746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/06/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVE To improve outcomes of hemophagocytic lymphohistiocytosis (HLH), prompt recognition and treatment are necessary. A HLH multidisciplinary team was implemented at our institution, and we established an electronic order set to foster uniformity in the diagnostic approach. The goal of this study is to capture the impact of this diagnostic tool. METHODS This is a retrospective study analyzing the utilization of a HLH-specific order set since time of implementation in June 2019 through December 2022. The trends in the utilization of the order set by providers were analyzed to evaluate the awareness and effectiveness of this tool. RESULTS The order set was utilized 50 times, most commonly by hematology/oncology (50%) and infectious disease (26%). Utilization by providers on newly presenting patients included 4 times in the year 2019, 12 times in 2020, 16 times in 2021, and 18 times in 2022. Utilization was associated with the diagnosis of HLH in 9 patients (18%). CONCLUSION Implementation of an HLH-specific order set facilitated a systematic method to approach patients with suspected HLH. The utilization of the order set displayed an upward trend over time, indicating support of this tool among these providers. This tool can increase awareness and early identification of HLH.
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Affiliation(s)
- Meaghan Rousset
- Anne Burnett Marion School of Medicine at Texas Christian University
| | - Kaci Orr
- Texas A&M Health Science Center School of Medicine, Bryan, TX
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Degar BA, Halyabar O, Hazen MM, Henderson LA. Dr. Degar et al reply. J Rheumatol 2023; 50:968-969. [PMID: 36379573 DOI: 10.3899/jrheum.221078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Barbara A Degar
- Department of Pediatric Oncology, Dana Farber Cancer Institute
| | - Olha Halyabar
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Melissa M Hazen
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lauren A Henderson
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA.
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Affiliation(s)
- Meaghan Rousset
- Anne Burnett Marion School of Medicine at Texas Christian University
| | - Anish Ray
- Department of Pediatric Hematology/Oncology, Cook Children's Medical Center, Fort Worth, Texas.
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