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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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Sterba G, Sterba Y. Parasitic and Fungal Triggers of Cytokine Storm Syndrome. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:293-305. [PMID: 39117823 DOI: 10.1007/978-3-031-59815-9_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Infections caused by parasites and fungi can trigger the cytokine storm syndrome (CSS). These infections causing CSS can occur together with acquired immunodeficiencies, lymphomas, the use of immunosuppressive medications, transplant recipients, cancer, autoinflammatory, and autoimmune diseases or less frequently in healthy individuals. Histoplasma, Leishmania, Plasmodium, and Toxoplasma are the most frequent organisms associated with a CSS. It is very important to determine a previous travel history when evaluating a patient with a CSS triggered by these organisms as this may be the clue to the causal agent. Even though CSS is treated with specific therapies, an effort to find the causal organism should be carried out since the treatment of the infectious organism may stop the CSS. Diagnosing a CSS in the presence of parasitic or fungal sepsis should also lead to the study of an altered cytotoxic or hemophagocytic response in the susceptible host.
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Santos IO, Neto RP, Bom APKP. Hemophagocytic lymphohistiocytosis: a case series analysis in a pediatric hospital. Hematol Transfus Cell Ther 2023; 45:32-37. [PMID: 34183298 PMCID: PMC9938491 DOI: 10.1016/j.htct.2021.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/02/2021] [Accepted: 04/14/2021] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a rare clinical laboratory condition with high mortality rates, resulting from ineffective overactivation of the immune system. Data in the Brazilian literature is scarce, contributing to the challenge in standardizing conducts and performing an early diagnosis of HLH. OBJECTIVE To describe the clinical, laboratory, and evolutionary findings on HLH patients treated at a pediatric hospital. METHODS This is an observational, cross-sectional and retrospective study on children diagnosed with HLH, hospitalized between 2009 and 2019. The diagnostic criteria were those described in the Histiocyte Society protocol. The authors evaluated HLH patient laboratory tests, myelograms and bone marrow biopsies, clinical characteristics and therapy. RESULTS Twenty-three patients were included, 52.2% of whom were males. The age at diagnosis ranged from one to one hundred and eighty months. Four cases were classified as Primary HLH and nineteen, as Secondary HLH. The main triggers were infections and rheumatological diseases. All children had bicytopenia, and 95.4% had hyperferritinemia. Nineteen patients had liver dysfunction, sixteen had neurological disorders and fourteen had kidney injury. Pulmonary involvement was seen in 61.9%, acting as a worse prognosis for death (p = 0.01). Nine patients underwent the immuno-chemotherapy protocol proposed in the HLH 2004. The time to confirm the diagnosis varied from five to eighty days. The lethality found was 56.3%. CONCLUSIONS The present study is the most extensive retrospective exclusively pediatric study published in Brazil to date. Despite the limitations, it was possible to demonstrate the importance of discussing HLH as a pediatric emergency.
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Affiliation(s)
| | | | - Ana Paula Kuczynski Pedro Bom
- Hospital Pequeno Prínicpe, Curitiba, PR, Brazil,Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, PR, Brazil
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Almajed MR, Cerna-Viacava R, Priessnitz J, Khan N, Zervos M. A Case of Malaria-Associated Hemophagocytic Lymphohistiocytosis. Cureus 2022; 14:e28386. [PMID: 36171833 PMCID: PMC9508862 DOI: 10.7759/cureus.28386] [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] [Accepted: 08/24/2022] [Indexed: 11/05/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an inflammatory syndrome of inappropriate and excessive immune system activation. It often occurs in the setting of viral, bacterial, fungal, and parasitic infections. HLH associated with malaria is very rare, and literature on this association is limited. Significant overlap exists between these two conditions, which makes the diagnosis of HLH superimposed on malaria difficult. We present a case of a patient who recently traveled from Djibouti and was diagnosed with Plasmodium falciparum malaria. She had a transient improvement in response to antimalarial therapy followed by clinical deterioration. This prompted further investigations that revealed the diagnosis of HLH, which was confirmed by an elevated soluble interleukin-2 receptor CD25 (sCD25) level, a specific marker of HLH. Most patients recover with antimalarial therapy, supportive care, and monitoring, whereas some patients require immunosuppressive therapy. Maintaining a high index of suspicion for HLH-associated malaria in at-risk patients allows for early identification and management.
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African Plasmodium vivax malaria improbably rare or benign. Trends Parasitol 2022; 38:683-696. [PMID: 35667992 DOI: 10.1016/j.pt.2022.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/10/2022] [Accepted: 05/10/2022] [Indexed: 11/23/2022]
Abstract
The overwhelming dominance of Duffy blood group negativity among most people living in sub-Saharan Africa has been considered the basis of their protection from endemic Plasmodium vivax malaria. New evidence demonstrates widespread transmission of P. vivax in Duffy-negative Africa, though currently of unknown distribution, magnitude, or consequences. Other new evidence from outside of Africa demonstrates marked tropisms of P. vivax for extravascular tissues of bone marrow and spleen. Those establish states of proliferative infection with low-grade or undetectable parasitemia of peripheral blood causing acute and chronic disease. This review examines the plausibility of those infectious processes also operating in Duffy-negative Africans and causing harm of unrecognized origin.
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Amirifar P, Ranjouri MR, Abolhassani H, Moeini Shad T, Almasi-Hashiani A, Azizi G, Moamer S, Aghamohammadi A, Yazdani R. Clinical, immunological and genetic findings in patients with UNC13D deficiency (FHL3): A systematic review. Pediatr Allergy Immunol 2021; 32:186-197. [PMID: 32679608 DOI: 10.1111/pai.13323] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/03/2020] [Accepted: 07/07/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Familial hemophagocytic lymphohistiocytosis (FHL) is a rare autosomal recessive immune disorder that is caused by mutations in 6 different genes related to the formation and function of secretory lysosomes within cytotoxic T lymphocytes and natural killer (NK) cells. Thus, defect in these genes is associated with the accumulation of antigens due to defective cytotoxic function. FHL type 3 (FHL3) accounts for nearly 30-40% of FHL, and its underlying reason is mutation in UNC13D gene which encodes Munc13-4 protein. METHODS For the first time, we aimed to systematically review clinical features, immunologic data, and genetic findings of patients with FHL3. We conducted electronic searches for English-language articles in PubMed, Web of Science, EMBASE, and Scopus databases to collect comprehensive records related to patients with UNC13D mutations. RESULTS A total of 279 abstracts were initially reviewed for inclusion. Among them, 57 articles corresponding to 322 individual FHL3 patients fulfilled our selection criteria. Finally, 73 and 249 patients were considered as severe and mild feature groups, respectively. Our results confirmed that fever, hepatosplenomegaly, and hemophagocytosis are common clinical features in the disease. Moreover, reduced fibrinogen and NK cell activity, as well as increased ferritin and triglycerides, are important markers for early diagnosis of the FHL3 disease. Investigation of genotype showed that the most prevalent type and zygosity of UNC13D are splice-site errors and compound heterozygous, respectively. CONCLUSION FHL3 patients have a wide range of clinical manifestations, which makes it difficult to diagnose. Therefore, it seems that the sequencing of the entire UNC13D gene (coding and non-coding regions) is the most appropriate way to accurate diagnosis of FHL3 patients.
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Affiliation(s)
- Parisa Amirifar
- Department of Medical Genetics, School of Medicine, Tehran University of medical sciences, Tehran, Iran.,Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Ranjouri
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hassan Abolhassani
- Research Center for Primary Immunodeficiencies, Iran University of medical sciences, Tehran, Iran.,Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Tannaz Moeini Shad
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Gholamreza Azizi
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Non-Communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Soraya Moamer
- School of Public Health, Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Asghar Aghamohammadi
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Yazdani
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
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Obayo A, Sharma K, Mithi C, Riyat M, Mwirigi A. Adult secondary hemophagocytic lymphohistiocytosis. EJHAEM 2020; 1:567-575. [PMID: 35844997 PMCID: PMC9175838 DOI: 10.1002/jha2.113] [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: 09/10/2020] [Revised: 09/24/2020] [Accepted: 09/25/2020] [Indexed: 11/08/2022]
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of excessive inflammation and tissue destruction due to abnormal immune activation. HLH carries a very high mortality, and while delays in patients' presentation to hospital, time to suspicion of HLH, investigation, and initiation of therapy all play a part, mortality remains high even with timely diagnosis and treatment. Classical manifestations of HLH include persistent fever, cytopenias, and liver dysfunction. Case presentation We present four cases of secondary HLH, highlighting the demographic and clinical characteristics of these patients, underlying triggers (including systemic lupus erythematosus, lymphoproliferative disorders, and leishmaniasis), together with challenges associated with the diagnosis and treatment of this rare disorder and a brief review of literature. Conclusion HLH has protean manifestations and requires a high index of suspicion as it can be a great clinical masquerader. Mortality due to multiorgan failure is often high even with early recognition and treatment.
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Affiliation(s)
- Antonina Obayo
- Department of MedicineFaculty of Health SciencesAga Khan University Medical College of East AfricaNairobiKenya
| | - Karishma Sharma
- Department of MedicineFaculty of Health SciencesAga Khan University Medical College of East AfricaNairobiKenya
| | - Caroline Mithi
- Department of MedicineFaculty of Health SciencesAga Khan University Medical College of East AfricaNairobiKenya
| | - Malkit Riyat
- Department of Haematology and Oncology, Faculty of Health SciencesAga Khan University Medical College of East AfricaNairobiKenya
| | - Anne Mwirigi
- Department of Haematology and Oncology, Faculty of Health SciencesAga Khan University Medical College of East AfricaNairobiKenya
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Sharma S, Dawson L. Pancytopenia induced by secondary hemophagocytic lymphohistiocytosis: A rare, overlooked dreadful complication of Plasmodium vivax. Trop Parasitol 2020; 10:50-55. [PMID: 32775294 PMCID: PMC7365499 DOI: 10.4103/tp.tp_44_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 11/01/2019] [Accepted: 11/27/2019] [Indexed: 11/04/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an unusual multifaceted clinicopathological entity that often remains misdiagnosed and can be fatal if not timely detected or treated. It can be familial or associated with different types of infections, autoimmune disorders, and malignancies. Parasitic infection-associated HLH has been rarely documented in the literature with only a handful of them being reported due to Plasmodium vivax infection. We describe an extremely rare case of pancytopenia induced by HLH resulting from P. vivax infection in a 7-year-old girl, which posed as a diagnostic challenge and led to a therapeutic delay.
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Affiliation(s)
- Sonam Sharma
- Department of Pathology, Kalpana Chawla Government Medical College, Karnal, Haryana, India
| | - Leelavathi Dawson
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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9
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Altook R, Ruzieh M, Singh A, Alamoudi W, Moussa Z, Alim H, Safi F, Duggan J. Hemophagocytic Lymphohistiocytosis in the Elderly. Am J Med Sci 2018; 357:67-74. [PMID: 30278875 DOI: 10.1016/j.amjms.2018.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 07/10/2018] [Accepted: 07/10/2018] [Indexed: 12/25/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare disease of massive, dysregulated cytokine release and secondary multiorgan failure and is associated with high mortality. Primary HLH occurs predominately in infants and young children with a genetic predisposition. Acquired HLH is less well characterized and usually occurs in younger adults in the setting of severe inflammation triggered by infection or malignancy. Little is known about the disease in elderly. We report 3 patients >50 years old who presented with multiorgan failure and shock without an identifiable source and were ultimately diagnosed with acquired HLH. We performed a literature review of HLH in adults >50 years of age and identified an additional 68 cases. Mean age was 62 years, with male predominance. Most cases were triggered by infection (49%) followed by malignancy (27%). Nineteen patients were treated with the HLH-94 protocol, 11 received corticosteroids and the remainder received non-HLH specific interventions. Overall mortality was 62%.
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Affiliation(s)
- Reyna Altook
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Mohammed Ruzieh
- Penn State Heart and Vascular Institute, Penn State University, Hershey Pennsylvania.
| | - Avneet Singh
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Wael Alamoudi
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Zeinab Moussa
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Hussam Alim
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Fadi Safi
- Pulmonary and Critical Care Division, Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Joan Duggan
- Infectious Disease Division, Department of Internal Medicine, University of Toledo, Toledo, Ohio
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Zhou M, Li L, Zhang Q, Ma S, Sun J, Zhu L, Lu D, Zhu J, Zhou D, Zheng Y, Yang X, Xie M, Zhu M, Ye X, Xie W. Clinical features and outcomes in secondary adult hemophagocytic lymphohistiocytosis. QJM 2018; 111:23-31. [PMID: 29025045 DOI: 10.1093/qjmed/hcx183] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare clinical syndrome characterized by an infrequent but immune-mediated life-threatening disease, with confusing clinical manifestations, rapidly deteriorating health, high morbidity and mortality and challenging diagnosis. AIM The purpose of this study was to improve the recognition and understanding of HLH. DESIGN Retrospective observational cross-sectional study. METHODS Data were collected for all cases of adult patients diagnosed with HLH in a large cohort managed at a single medical center from January 2011 to December 2015. RESULTS The median age was 52 years (range 18-90 years) and 123 (60.0%) were male. Over 95% patients manifested fever, hyperferritinemia and elevated lactate dehydrogenase. Underlying triggers of HLH were as follows: 119 (58.0%) malignancies, 83 (40.5%) infections, 14 (6.8%) unknown triggers and 14 (6.8%) autoimmune disorders. The median overall survival was 55 days. And elderly patients (age ≥60 years) had a markedly worse survival compared with young patients (age <60 years) (median overall survival 24 days vs. 159 days, respectively; P <0.001). In a multivariable analysis, platelet <40 × 109/l (HR = 2.534; 95% CI 1.152-5.573; P = 0.021), PT prolonged >3 s (HR = 1.909; 95% CI 1.127-3.234; P = 0.016) and malignancy (HR = 1.614; 95% CI 1.008-2.582; P = 0.046) were correlated with poor survival. CONCLUSION HLH adult patients had very complex clinical manifestations as well as underlying diseases. Patients with PLT <40 ×109/l, PT prolonged >3 s and malignancy had inferior survival. It is of great importance to improve our understanding of this syndrome.
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Affiliation(s)
- M Zhou
- Senior Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, Zhejiang, China
- Department of Hematology, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China
| | - L Li
- Senior Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, Zhejiang, China
| | - Q Zhang
- Department of Hematology, The 6th Affiliated Hospital of Wenzhou Medical University, People's Hospital of Lishui, Lishui, Zhejiang, China
| | - S Ma
- Senior Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, Zhejiang, China
| | - J Sun
- Senior Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, Zhejiang, China
| | - L Zhu
- Senior Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, Zhejiang, China
| | - D Lu
- Senior Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, Zhejiang, China
| | - J Zhu
- Senior Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, Zhejiang, China
| | - D Zhou
- Senior Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, Zhejiang, China
| | - Y Zheng
- Senior Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, Zhejiang, China
| | - X Yang
- Senior Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, Zhejiang, China
| | - M Xie
- Senior Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, Zhejiang, China
| | - M Zhu
- Senior Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, Zhejiang, China
| | - X Ye
- Senior Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, Zhejiang, China
| | - W Xie
- Senior Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, Zhejiang, China
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Selvarajan D, Sundaravel S, Alagusundaramoorthy SS, Jacob A. Hemophagocytic lymphohistiocytosis with concurrent malarial infection. BMJ Case Rep 2017; 2017:bcr-2017-221159. [PMID: 28784903 DOI: 10.1136/bcr-2017-221159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Dhileepan Selvarajan
- Department of Internal Medicine, Government Stanley Medical College, Chennai, Tamil Nadu, India
| | | | | | - Aasems Jacob
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, New Jersey, USA
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Muthu V, Dhooria S, Sehgal IS, Agarwal R, Behera D, Varma N. Malaria-associated secondary haemophagocytic lymphohistiocytosis: Report of two cases & a review of literature. Indian J Med Res 2017; 145:399-404. [PMID: 28749405 PMCID: PMC5555071 DOI: 10.4103/ijmr.ijmr_740_15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India
| | - Digambar Behera
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India
| | - Neelam Varma
- Department of Hematology, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India
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Birlutiu V, Birlutiu RM. Sepsis due to Streptococcus pneumoniae associated with secondary hemophagocytic lymphohistiocytosis in a splenectomized patient for spherocytosis: A case report. Medicine (Baltimore) 2017; 96:e7520. [PMID: 28700505 PMCID: PMC5515777 DOI: 10.1097/md.0000000000007520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Hemophagocytic lymphohistiocytosis (HLH) is a syndrome that is characterized by an inappropriate hyperinflammatory immune response - primary, as a consequence of a genetic defect of NK cells and cytotoxic T lymphocytes or - secondary, in the progression of infections, rheumatic or autoimmune diseases, malignancies or metabolic diseases. PATIENT CONCERNS We present the case of a secondary HLH due to Streptococcus pneumoniae infection in a splenectomised patient for spherocytosis, a 37-year-old patient who was splenectomised in childhood for spherocytosis, without immuneprophylaxis induced by antipneumococcal vaccine. OUTCOMES He developed a severe pneumococcal sepsis associated with secondary HLH, with unfavorable outcome and death. LESSONS To our knowledge, just 2 similar cases had been published in the literature, none in which the secondary HLH was the consequence of an invasive pneumococcal infection in a splenectomized patient for spherocytosis, and the association of splenectomy with HLH is surprizin.
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Affiliation(s)
- Victoria Birlutiu
- Faculty of Medicine Sibiu, Lucian Blaga University of Sibiu
- Academic Emergency Hospital Sibiu, Infectious Diseases Clinic, Sibiu
| | - Rares Mircea Birlutiu
- Faculty of Medicine Sibiu, Lucian Blaga University of Sibiu
- Spitalul Clinic de Ortopedie-Traumatologie si TBC Osteoarticular “Foisor” Bucuresti, Romania
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Severe Plasmodium vivax cerebral malaria complicated by hemophagocytic lymphohistiocytosis treated with artesunate and doxycycline. Hematol Oncol Stem Cell Ther 2016; 11:34-37. [PMID: 27514010 DOI: 10.1016/j.hemonc.2016.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 06/18/2016] [Accepted: 06/29/2016] [Indexed: 01/16/2023] Open
Abstract
Malaria-related hemophagocytic lymphohistiocytosis is a rare, potentially fatal, hyperinflammatory disease entity which can be challenging to diagnose and treat. It is usually associated with Plasmodium falciparum infection. It is less frequently associated with Plasmodium vivax. Here we report an unusual case of a 23-year-old healthy Nigerian man who presented with fever, microangiopathic hemolytic anemia, acute renal failure, and confusion, and was diagnosed as having cerebral malaria-related hemophagocytic lymphohistiocytosis caused by P. vivax infection. He was successfully treated with intravenous artesunate and doxycycline with dramatic clinical improvement.
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Ullah W, Abdullah HMA, Qadir S, Shahzad MA. Haemophagocytic lymphohistiocytosis (HLH): a rare but potentially fatal association with Plasmodium vivax malaria. BMJ Case Rep 2016; 2016:bcr-2016-215366. [PMID: 27298293 DOI: 10.1136/bcr-2016-215366] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a potentially fatal syndrome that is caused by an abnormal activation of the immune system. It can present as the primary syndrome or occur secondary to a variety of conditions such as malignancy, autoimmune diseases and infections. We present a case of a man who developed HLH secondary to Plasmodium vivax infection. He presented with symptoms of fever, chills and myalgias. Physical examination revealed significant hepatosplenomegaly. The presence of pancytopaenia, elevated ferritin levels and haemophagocytosis on bone marrow biopsy confirmed the diagnosis of HLH (based on HLH-2004 criteria). There was a significant improvement after the initiation of intravenous antimalarials. No relapses were documented on follow-up. It is imperative that physicians should promptly recognise and treat this rare condition, as a timely intervention can be lifesaving.
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Affiliation(s)
- Waqas Ullah
- Department of Internal Medicine, Khyber Teaching Hospital, Peshawar, Khyber Pakhtunkhwa, Pakistan
| | | | - Shayan Qadir
- Department of Internal Medicine, Khyber Teaching Hospital, Peshawar, Khyber Pakhtunkhwa, Pakistan
| | - Muhammad Asim Shahzad
- Department of Internal Medicine, Hayatabad Medical Complex, Peshawar, Khyber Pakhtunkhwa, Pakistan
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Hemophagocytic Lymphohistiocytosis Complicating Dengue and Plasmodium vivax Coinfection. Case Rep Med 2015; 2015:696842. [PMID: 26504465 PMCID: PMC4609418 DOI: 10.1155/2015/696842] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Revised: 07/26/2015] [Accepted: 08/05/2015] [Indexed: 02/05/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare disorder. Dysfunction of cytotoxic T and natural killer (NK) cells causes uncontrolled activity of lymphocytes and histiocytes which leads to HLH. Infections, malignancies, and autoimmune disorders are associated with development of HLH. Dengue and Plasmodium vivax are rare causes of HLH. We report the first ever case of a young man who developed fatal HLH that complicated Dengue Hemorrhagic Fever (DHF) and Plasmodium vivax infection.
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Abstract
Hemophagocytic lymphohistiocytosis (HLH) covers a wide array of related life-threatening conditions featuring ineffective immunity characterized by an uncontrolled hyperinflammatory response. HLH is often triggered by infection. Familial forms result from genetic defects in natural killer cells and cytotoxic T-cells, typically affecting perforin and intracellular vesicles. HLH is likely under-recognized, which contributes to its high morbidity and mortality. Early recognition is crucial for any reasonable attempt at curative therapy to be made. Current treatment regimens include immunosuppression, immune modulation, chemotherapy, and biological response modification, followed by hematopoietic stem-cell transplant (bone marrow transplant). A number of recent studies have contributed to the understanding of HLH pathophysiology, leading to alternate treatment options; however, much work remains to raise awareness and improve the high morbidity and mortality of these complex conditions.
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Affiliation(s)
- Melissa R George
- Department of Pathology, Penn State Milton S Hershey Medical Center, Hershey, PA, USA
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