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Shakoory B, Geerlinks A, Wilejto M, Kernan K, Hines M, Romano M, Piskin D, Ravelli A, Sinha R, Aletaha D, Allen C, Bassiri H, Behrens EM, Carcillo J, Carl L, Chatham W, Cohen JI, Cron RQ, Drewniak E, Grom AA, Henderson LA, Horne A, Jordan MB, Nichols KE, Schulert G, Vastert S, Demirkaya E, Goldbach-Mansky R, de Benedetti F, Marsh RA, Canna SW. The 2022 EULAR/ACR Points to Consider at the Early Stages of Diagnosis and Management of Suspected Haemophagocytic Lymphohistiocytosis/Macrophage Activation Syndrome (HLH/MAS). Arthritis Rheumatol 2023; 75:1714-1732. [PMID: 37486733 PMCID: PMC11040593 DOI: 10.1002/art.42636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVE Haemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that can develop in most inflammatory contexts. They can progress rapidly, and early identification and management are critical for preventing organ failure and mortality. This effort aimed to develop evidence-based and consensus-based points to consider to assist clinicians in optimising decision-making in the early stages of diagnosis, treatment and monitoring of HLH/MAS. METHODS A multinational, multidisciplinary task force of physician experts, including adult and paediatric rheumatologists, haematologist/oncologists, immunologists, infectious disease specialists, intensivists, allied healthcare professionals and patients/parents, formulated relevant research questions and conducted a systematic literature review (SLR). Delphi methodology, informed by SLR results and questionnaires of experts, was used to generate statements aimed at assisting early decision-making and optimising the initial care of patients with HLH/MAS. RESULTS The task force developed 6 overarching statements and 24 specific points to consider relevant to early recognition of HLH/MAS, diagnostic approaches, initial management and monitoring of HLH/MAS. Major themes included the simultaneous need for prompt syndrome recognition, systematic evaluation of underlying contributors, early intervention targeting both hyperinflammation and likely contributors, careful monitoring for progression/complications and expert multidisciplinary assistance. CONCLUSION These 2022 EULAR/American College of Rheumatology points to consider provide up-to-date guidance, based on the best available published data and expert opinion. They are meant to help guide the initial evaluation, management and monitoring of patients with HLH/MAS in order to halt disease progression and prevent life-threatening immunopathology.
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Affiliation(s)
- Bita Shakoory
- Translational Autoinflammatory Diseases Section, NIH, Bethesda, Maryland
| | - Ashley Geerlinks
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, and Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Marta Wilejto
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Kate Kernan
- Pediatric Critical Care Medicine, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Melissa Hines
- Pediatric Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Micol Romano
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - David Piskin
- Department of Epidemiology and Biostatistics, Western University and Department of Paediatrics, Lawson Health Research Institute, London, Ontario, Canada
| | - Angelo Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Carl Allen
- Pediatric Oncology, Texas Children’s Hospital, Houston
| | - Hamid Bassiri
- Pediatric Infectious Diseases, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Edward M. Behrens
- Pediatric Rheumatology, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Joseph Carcillo
- Pediatric Critical Care Medicine, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Linda Carl
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Winn Chatham
- Rheumatology, University of Alabama at Birmingham
| | - Jeffrey I. Cohen
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland
| | - Randy Q. Cron
- Pediatric Rheumatology, University of Alabama at Birmingham
| | - Erik Drewniak
- Autoinflammatory Alliance, San Francisco, California
| | - Alexei A. Grom
- Pediatric Rheumatology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Lauren A. Henderson
- Pediatric Immunology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Annacarin Horne
- Department of Women’s and Children’s Health, Karolinska Institutet Cancerforskning KI, Stockholm, Sweden
| | - Michael B. Jordan
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Kim E. Nichols
- Division of Cancer Predisposition Department of Oncology, St. Jude Children’s Research Hospital Department of Oncology, Memphis, Tennessee
| | - Grant Schulert
- Pediatric Rheumatology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Sebastiaan Vastert
- Center for Translational Immunology Research, UMC Utrecht, Utrecht, The Netherlands
| | - Erkan Demirkaya
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | | | | | - Rebecca A. Marsh
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Scott W. Canna
- Pediatric Rheumatology, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Shakoory B, Geerlinks A, Wilejto M, Kernan K, Hines M, Romano M, Piskin D, Ravelli A, Sinha R, Aletaha D, Allen C, Bassiri H, Behrens EM, Carcillo J, Carl L, Chatham W, Cohen JI, Cron RQ, Drewniak E, Grom AA, Henderson LA, Horne A, Jordan MB, Nichols KE, Schulert G, Vastert S, Demirkaya E, Goldbach-Mansky R, de Benedetti F, Marsh RA, Canna SW. The 2022 EULAR/ACR points to consider at the early stages of diagnosis and management of suspected haemophagocytic lymphohistiocytosis/macrophage activation syndrome (HLH/MAS). Ann Rheum Dis 2023; 82:1271-1285. [PMID: 37487610 PMCID: PMC11017727 DOI: 10.1136/ard-2023-224123] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/27/2023] [Indexed: 07/26/2023]
Abstract
OBJECTIVE Haemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that can develop in most inflammatory contexts. They can progress rapidly, and early identification and management are critical for preventing organ failure and mortality. This effort aimed to develop evidence-based and consensus-based points to consider to assist clinicians in optimising decision-making in the early stages of diagnosis, treatment and monitoring of HLH/MAS. METHODS A multinational, multidisciplinary task force of physician experts, including adult and paediatric rheumatologists, haematologist/oncologists, immunologists, infectious disease specialists, intensivists, allied healthcare professionals and patients/parents, formulated relevant research questions and conducted a systematic literature review (SLR). Delphi methodology, informed by SLR results and questionnaires of experts, was used to generate statements aimed at assisting early decision-making and optimising the initial care of patients with HLH/MAS. RESULTS The task force developed 6 overarching statements and 24 specific points to consider relevant to early recognition of HLH/MAS, diagnostic approaches, initial management and monitoring of HLH/MAS. Major themes included the simultaneous need for prompt syndrome recognition, systematic evaluation of underlying contributors, early intervention targeting both hyperinflammation and likely contributors, careful monitoring for progression/complications and expert multidisciplinary assistance. CONCLUSION These 2022 EULAR/American College of Rheumatology points to consider provide up-to-date guidance, based on the best available published data and expert opinion. They are meant to help guide the initial evaluation, management and monitoring of patients with HLH/MAS in order to halt disease progression and prevent life-threatening immunopathology.
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Affiliation(s)
- Bita Shakoory
- Translational Autoinflammatory Diseases Section, National Institutes of Health, Bethesda, Maryland, USA
| | - Ashley Geerlinks
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Marta Wilejto
- Hematology/Oncology, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Kate Kernan
- Pediatric Critical Care Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Melissa Hines
- Pediatric Critical Care Medicine, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Micol Romano
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - David Piskin
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Department of Paediatrics, Lawson Health Research Institute, London, Ontario, Canada
| | - Angelo Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Carl Allen
- Pediatric Oncology, Texas Children's Hospital, Houston, Texas, USA
| | - Hamid Bassiri
- Pediatric Infectious Diseases, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Edward M Behrens
- Pediatric Rheumatology, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joseph Carcillo
- Pediatric Critical Care Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Linda Carl
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Winn Chatham
- Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey I Cohen
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Randy Q Cron
- Pediatric Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Erik Drewniak
- Autoinflammatory Alliance, San Francisco, California, USA
| | - Alexei A Grom
- Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Lauren A Henderson
- Pediatric Immunology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Annacarin Horne
- Department of Women's and Children's Health, Karolinska Institutet Cancerforskning KI, Stockholm, Sweden
| | - Michael B Jordan
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Kim E Nichols
- Division of Cancer Predisposition Department of Oncology, St Jude Children's Research Hospital Department of Oncology, Memphis, Tennessee, USA
| | - Grant Schulert
- Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Sebastiaan Vastert
- Center for Translational Immunology Research, UMC Utrecht, The Netherlands
| | - Erkan Demirkaya
- Pediatrics, University of Western Ontario Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Raphaela Goldbach-Mansky
- Translational Autoinflammatory Diseases Section, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Rebecca A Marsh
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Scott W Canna
- Pediatric Rheumatology, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Shakoory B, Geerlinks A, Wilejto M, Kernan K, Demirkaya E, Ravelli A, Sinha R, Goldbach-Mansky R, De Benedetti F, Marsh R, Canna S. POS0339 POINTS TO CONSIDER AT THE EARLIEST STAGES OF THE DIAGNOSIS AND MANAGEMENT OF HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS/MACROPHAGE ACTIVATION SYNDROME (HLH/MAS). Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.5193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundHemophagocytic Lymphohistiocytosis (HLH) and Macrophage Activation Syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that occur in many contexts and are often called by many names. They nevertheless can progress rapidly, and early identification and management are critical for preventing organ failure and mortality.ObjectivesThe purpose of this effort was to develop a series of ‘points to consider’ to assist clinicians at the earliest stages of evaluation and diagnosis, management, and monitoring of patients with HLH/MAS in order to improve patient outcomes.MethodsA working group of adult and pediatric rheumatologists (14), hematologist/oncologists (4), immunologists (2), infectious disease specialists (2), intensivists (3), allied health care professionals (1), and patients/parents (2) formulated relevant research questions for a systematic literature review (SLR). We then used the SLR results, Delphi questionnaires, and consensus methodology to devise and refine overarching and specific ‘points to consider’ statements.ResultsThe group arrived at six overarching statements and 24 specific points-to-consider relevant to early decision-making in diagnostics, initial management, and monitoring of HLH/MAS. Major themes included the a) need for prompt recognition, evaluation, and management of underlying triggers and conditions, b) multi-disciplinary/expert input, and c) early, tailored intervention with the goals of halting disease progression and preventing life- and organ-threatening immunopathologyConclusionThese 2022 EULAR/ACR Points to Consider provide guidance on the initial evaluation, management, and monitoring of patients during the initial consideration of HLH/MAS.Disclosure of InterestsBita Shakoory: None declared, Ashley Geerlinks: None declared, Marta Wilejto: None declared, Kate Kernan: None declared, Erkan Demirkaya: None declared, Angelo Ravelli: None declared, Rashmi Sinha: None declared, Raphaela goldbach-mansky Grant/research support from: SOBI, Novartis, Regneneron, IFM, Lilly, Pfizer, Fabrizio De Benedetti Consultant of: abbvie, sobi, novimmune, novartis, roche, sanofi, Grant/research support from: sobi novimmune novartis roche sanofi, Rebecca Marsh: None declared, Scott Canna Consultant of: Simcha Therapeutics, Grant/research support from: Immvention therapeutics, AB2Bio Ltd, Novartis
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Anderko RR, Gómez H, Canna SW, Shakoory B, Angus DC, Yealy DM, Huang DT, Kellum JA, Carcillo JA, Angus DC, Barnato AE, Eaton TL, Gimbel E, Huang DT, Keener C, Kellum JA, Landis K, Pike F, Stapleton DK, Weissfeld LA, Willochell M, Wofford KA, Yealy DM, Kulstad E, Watts H, Venkat A, Hou PC, Massaro A, Parmar S, Limkakeng AT, Brewer K, Delbridge TR, Mainhart A, Chawla LS, Miner JR, Allen TL, Grissom CK, Swadron S, Conrad SA, Carlson R, LoVecchio F, Bajwa EK, Filbin MR, Parry BA, Ellender TJ, Sama AE, Fine J, Nafeei S, Terndrup T, Wojnar M, Pearl RG, Wilber ST, Sinert R, Orban DJ, Wilson JW, Ufberg JW, Albertson T, Panacek EA, Parekh S, Gunn SR, Rittenberger JS, Wadas RJ, yEdwards AR, Kelly M, Wang HE, Holmes TM, McCurdy MT, Weinert C, Harris ES, Self WH, Phillips CA, Migues RM. Sepsis with liver dysfunction and coagulopathy predicts an inflammatory pattern of macrophage activation. Intensive Care Med Exp 2022; 10:6. [PMID: 35190900 PMCID: PMC8861227 DOI: 10.1186/s40635-022-00433-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/07/2022] [Indexed: 12/30/2022] Open
Abstract
Background Interleukin-1 receptor antagonists can reduce mortality in septic shock patients with hepatobiliary dysfunction and disseminated intravascular coagulation (HBD + DIC), an organ failure pattern with inflammatory features consistent with macrophage activation. Identification of clinical phenotypes in sepsis may allow for improved care. We aim to describe the occurrence of HBD + DIC in a contemporary cohort of patients with sepsis and determine the association of this phenotype with known macrophage activation syndrome (MAS) biomarkers and mortality. We performed a retrospective nested case–control study in adult septic shock patients with concurrent HBD + DIC and an equal number of age-matched controls, with comparative analyses of all-cause mortality and circulating biomarkers between the groups. Multiple logistic regression explored the effect of HBD + DIC on mortality and the discriminatory power of the measured biomarkers for HBD + DIC and mortality. Results Six percent of septic shock patients (n = 82/1341) had HBD + DIC, which was an independent risk factor for 90-day mortality (OR = 3.1, 95% CI 1.4–7.5, p = 0.008). Relative to sepsis controls, the HBD + DIC cohort had increased levels of 21 of the 26 biomarkers related to macrophage activation (p < 0.05). This panel was predictive of both HBD + DIC (sensitivity = 82%, specificity = 84%) and mortality (sensitivity = 92%, specificity = 90%). Conclusion The HBD + DIC phenotype identified patients with high mortality and a molecular signature resembling that of MAS. These observations suggest trials of MAS-directed therapies are warranted. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-022-00433-y.
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Abers MS, Delmonte OM, Ricotta EE, Fintzi J, Fink DL, de Jesus AAA, Zarember KA, Alehashemi S, Oikonomou V, Desai JV, Canna SW, Shakoory B, Dobbs K, Imberti L, Sottini A, Quiros-Roldan E, Castelli F, Rossi C, Brugnoni D, Biondi A, Bettini LR, D’Angio’ M, Bonfanti P, Castagnoli R, Montagna D, Licari A, Marseglia GL, Gliniewicz EF, Shaw E, Kahle DE, Rastegar AT, Stack M, Myint-Hpu K, Levinson SL, DiNubile MJ, Chertow DW, Burbelo PD, Cohen JI, Calvo KR, Tsang JS, Su HC, Gallin JI, Kuhns DB, Goldbach-Mansky R, Lionakis MS, Notarangelo LD. An immune-based biomarker signature is associated with mortality in COVID-19 patients. JCI Insight 2021; 6:144455. [PMID: 33232303 PMCID: PMC7821609 DOI: 10.1172/jci.insight.144455] [Citation(s) in RCA: 222] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/18/2020] [Indexed: 12/25/2022] Open
Abstract
Immune and inflammatory responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) contribute to disease severity of coronavirus disease 2019 (COVID-19). However, the utility of specific immune-based biomarkers to predict clinical outcome remains elusive. Here, we analyzed levels of 66 soluble biomarkers in 175 Italian patients with COVID-19 ranging from mild/moderate to critical severity and assessed type I IFN-, type II IFN-, and NF-κB-dependent whole-blood transcriptional signatures. A broad inflammatory signature was observed, implicating activation of various immune and nonhematopoietic cell subsets. Discordance between IFN-α2a protein and IFNA2 transcript levels in blood suggests that type I IFNs during COVID-19 may be primarily produced by tissue-resident cells. Multivariable analysis of patients' first samples revealed 12 biomarkers (CCL2, IL-15, soluble ST2 [sST2], NGAL, sTNFRSF1A, ferritin, IL-6, S100A9, MMP-9, IL-2, sVEGFR1, IL-10) that when increased were independently associated with mortality. Multivariate analyses of longitudinal biomarker trajectories identified 8 of the aforementioned biomarkers (IL-15, IL-2, NGAL, CCL2, MMP-9, sTNFRSF1A, sST2, IL-10) and 2 additional biomarkers (lactoferrin, CXCL9) that were substantially associated with mortality when increased, while IL-1α was associated with mortality when decreased. Among these, sST2, sTNFRSF1A, IL-10, and IL-15 were consistently higher throughout the hospitalization in patients who died versus those who recovered, suggesting that these biomarkers may provide an early warning of eventual disease outcome.
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Affiliation(s)
- Michael S. Abers
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Ottavia M. Delmonte
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Emily E. Ricotta
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Jonathan Fintzi
- Biostatistics Research Branch, NIAID, NIH, Bethesda, Maryland, USA
| | - Danielle L. Fink
- Neutrophil Monitoring Laboratory, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Adriana A. Almeida de Jesus
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Kol A. Zarember
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Sara Alehashemi
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Vasileios Oikonomou
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Jigar V. Desai
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Scott W. Canna
- Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Bita Shakoory
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Kerry Dobbs
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Luisa Imberti
- CREA Laboratory, Diagnostic Department, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Alessandra Sottini
- CREA Laboratory, Diagnostic Department, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Eugenia Quiros-Roldan
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili di Brescia, Brescia, Italy
| | - Francesco Castelli
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili di Brescia, Brescia, Italy
| | - Camillo Rossi
- Direzione Sanitaria, ASST Spedali Civili di Brescia, Italy
| | - Duilio Brugnoni
- Laboratorio Analisi Chimico-Cliniche, ASST Spedali Civili, Brescia, Italy
| | - Andrea Biondi
- Pediatric Department and Centro Tettamanti-European Reference Network on Paediatric Cancer, European Reference Network on Haematological Diseases, and European Reference Network on Hereditary Metabolic Disorders-University of Milano-Bicocca-Fondazione MBBM, Monza, Italy
| | - Laura Rachele Bettini
- Pediatric Department and Centro Tettamanti-European Reference Network on Paediatric Cancer, European Reference Network on Haematological Diseases, and European Reference Network on Hereditary Metabolic Disorders-University of Milano-Bicocca-Fondazione MBBM, Monza, Italy
| | - Mariella D’Angio’
- Pediatric Department and Centro Tettamanti-European Reference Network on Paediatric Cancer, European Reference Network on Haematological Diseases, and European Reference Network on Hereditary Metabolic Disorders-University of Milano-Bicocca-Fondazione MBBM, Monza, Italy
| | - Paolo Bonfanti
- Department of Infectious Diseases, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | | | - Daniela Montagna
- Laboratory of Immunology and Transplantation, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | | | | | - Emily F. Gliniewicz
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Elana Shaw
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Dana E. Kahle
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Andre T. Rastegar
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Michael Stack
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Katherine Myint-Hpu
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | | | | | - Daniel W. Chertow
- Critical Care Medicine Department, NIH Clinical Center, NIH, Bethesda, Maryland, USA
| | - Peter D. Burbelo
- National Institute of Dental and Craniofacial Research, NIH, Bethesda, Maryland, USA
| | - Jeffrey I. Cohen
- Laboratory of Infectious Diseases, NIAID, NIH, Bethesda, Maryland, USA
| | - Katherine R. Calvo
- Hematology Section, Department of Laboratory Medicine, NIH Clinical Center, NIH, Bethesda, Maryland, USA
| | - John S. Tsang
- Laboratory of Immune System Biology and Clinical Genomics Program, NIAID, NIH, Bethesda, Maryland, USA
- Center for Human Immunology, Autoimmunity, and Inflammation, NIAID, NIH, Bethesda, Maryland, USA
| | | | - Helen C. Su
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - John I. Gallin
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Douglas B. Kuhns
- Neutrophil Monitoring Laboratory, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Raphaela Goldbach-Mansky
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Michail S. Lionakis
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Luigi D. Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
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Kernan KF, Ghaloul-Gonzalez L, Shakoory B, Kellum JA, Angus DC, Carcillo JA. Adults with septic shock and extreme hyperferritinemia exhibit pathogenic immune variation. Genes Immun 2018; 20:520-526. [PMID: 29977033 PMCID: PMC6320733 DOI: 10.1038/s41435-018-0030-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 03/05/2018] [Accepted: 03/16/2018] [Indexed: 01/20/2023]
Abstract
Post-hoc subgroup analysis of the negative trial of
interleukin-1β receptor antagonist (IL1RA) for septic shock suggested
that patients with features of macrophage activation syndrome (MAS) experienced
a 50% relative risk reduction for mortality with treatment. Here we seek
a genetic basis for this differential response. From 1341 patients enrolled in
the ProCESS trial of early goal directed therapy for septic shock, we selected 6
patients with MAS features and the highest ferritin, for whole exome sequencing
(mean 24,030.7 ηg/ml, +/SEM 7,411.1). Eleven rare (minor allele
frequency <5%) pathogenic or likely pathogenic variants causal
for the monogenic disorders of Familial Hemophagocytic Lymphohistiocytosis,
atypical Hemolytic Uremic Syndrome, Familial Mediterranean Fever, and
Cryopyrin-associated Periodic Fever were identified. In these conditions, seven
of the identified variants are currently targeted with IL1RA and four with
anti-C5 antibody. Gene-targeted precision medicine may benefit this subgroup of
patients with septic shock and pathogenic immune variation.
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Affiliation(s)
- Kate F Kernan
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA. .,Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.
| | - Lina Ghaloul-Gonzalez
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.,Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - John A Kellum
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Derek C Angus
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.,Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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7
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Carcillo JA, Sward K, Halstead ES, Telford R, Jimenez-Bacardi A, Shakoory B, Simon D, Hall M. A Systemic Inflammation Mortality Risk Assessment Contingency Table for Severe Sepsis. Pediatr Crit Care Med 2017; 18:143-150. [PMID: 27941423 PMCID: PMC5291785 DOI: 10.1097/pcc.0000000000001029] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES We tested the hypothesis that a C-reactive protein and ferritin-based systemic inflammation contingency table can track mortality risk in pediatric severe sepsis. DESIGN Prospective cohort study. SETTING Tertiary PICU. PATIENTS Children with 100 separate admission episodes of severe sepsis were enrolled. INTERVENTIONS Blood samples were attained on day 2 of sepsis and bi-weekly for biomarker batch analysis. A 2 × 2 contingency table using C-reactive protein and ferritin thresholds was developed. MEASUREMENTS AND MAIN RESULTS A C-reactive protein of 4.08 mg/dL and a ferritin of 1,980 ng/mL were found to be optimal cutoffs for outcome prediction at first sampling (n = 100) using the Youden index. PICU mortality was increased in the "high-risk" C-reactive protein greater than or equal to 4.08 mg/dL and ferritin greater than or equal to 1,980 ng/mL category (6/13 [46.15%]) compared with the "intermediate-risk" C-reactive protein greater than or equal to 4.08 mg/dL and ferritin less than 1,980 ng/mL or C-reactive protein less than 4.08 mg/dL and ferritin greater than or equal to 1,980 ng/mL categories (2/43 [4.65%]), and the "low-risk" C-reactive protein less than 4.08 mg/dL and ferritin less than 1,980 ng/mL category (0/44 [0%]) (odds ratio, 36.43 [95% CI, 6.16-215.21]). The high-risk category was also associated with the development of immunoparalysis (odds ratio, 4.47 [95% CI, 1.34-14.96]) and macrophage activation syndrome (odds ratio, 24.20 [95% CI, 5.50-106.54]). Sixty-three children underwent sequential blood sampling; those who were initially in the low-risk category (n = 24) and those who subsequently migrated (n = 19) to the low-risk category all survived, whereas those who remained in the "at-risk" categories had increased mortality (7/20 [35%]; p < 0.05). CONCLUSIONS A C-reactive protein- and ferritin-based contingency table effectively assessed mortality risk. Reduction in systemic inflammation below a combined threshold C-reactive protein of 4.08 mg/dL and ferritin of 1,980 ng/mL appeared to be a desired response in children with severe sepsis.
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Affiliation(s)
| | | | | | | | | | | | - Dennis Simon
- Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Mark Hall
- Nationwide Children’s Hospital, Columbus, OH
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8
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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: 568] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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9
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Affiliation(s)
- Randy Q Cron
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama;
| | | | - Bita Shakoory
- Department of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | | | - Walter W Chatham
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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10
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Minoia F, Davì S, Horne A, Demirkaya E, Bovis F, Li C, Lehmberg K, Weitzman S, Insalaco A, Wouters C, Shenoi S, Espada G, Ozen S, Anton J, Khubchandani R, Russo R, Pal P, Kasapcopur O, Miettunen P, Maritsi D, Merino R, Shakoory B, Alessio M, Chasnyk V, Sanner H, Gao YJ, Huasong Z, Kitoh T, Avcin T, Fischbach M, Frosch M, Grom A, Huber A, Jelusic M, Sawhney S, Uziel Y, Ruperto N, Martini A, Cron RQ, Ravelli A. Clinical features, treatment, and outcome of macrophage activation syndrome complicating systemic juvenile idiopathic arthritis: a multinational, multicenter study of 362 patients. Arthritis Rheumatol 2015; 66:3160-9. [PMID: 25077692 DOI: 10.1002/art.38802] [Citation(s) in RCA: 261] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 07/24/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To describe the clinical, laboratory, and histopathologic features, current treatment, and outcome of patients with macrophage activation syndrome (MAS) complicating systemic juvenile idiopathic arthritis (JIA). METHODS In this multinational, multicenter study, pediatric rheumatologists and hemato-oncologists entered patient data collected retrospectively into a web-based database. RESULTS A total of 362 patients, 22% of whom had MAS at the onset of systemic JIA, were included in the study by 95 investigators from 33 countries. The most frequent clinical manifestations were fever (96%), hepatomegaly (70%), and splenomegaly (58%). Central nervous system dysfunction and hemorrhages were recorded in 35% and 20% of the patients, respectively. Platelet count and liver transaminase, ferritin, lactate dehydrogenase, triglyceride, and d-dimer levels were the sole laboratory biomarkers showing a percentage change of >50% between the pre-MAS visit and MAS onset. Evidence of macrophage hemophagocytosis was found in 60% of the patients who underwent bone marrow aspiration. MAS occurred most frequently in the setting of active underlying disease, in the absence of a specific trigger. Nearly all patients were given corticosteroids, and 61% received cyclosporine. Biologic medications and etoposide were given to 15% and 12% of the patients, respectively. Approximately one-third of the patients required admission to the intensive care unit (ICU), and the mortality rate was 8%. CONCLUSION This study provides information on the clinical spectrum and current management of systemic JIA-associated MAS through the analysis of a very large patient sample. MAS remains a serious condition, as a sizeable proportion of patients required admission to the ICU or died.
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11
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Zhang M, Behrens EM, Atkinson TP, Shakoory B, Grom AA, Cron RQ. Genetic Defects in Cytolysis in Macrophage Activation Syndrome. Curr Rheumatol Rep 2014; 16:439. [DOI: 10.1007/s11926-014-0439-2] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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12
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Kumar N, Goyal J, Goel A, Shakoory B, Chatham W. Macrophage activation syndrome secondary to human monocytic ehrlichiosis. Indian J Hematol Blood Transfus 2013; 30:145-7. [PMID: 25332563 DOI: 10.1007/s12288-013-0299-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 08/29/2013] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To present a case of human monocytic ehrlichiosis (HME) that was complicated by macrophage activation syndrome (MAS), also known as secondary hemophagocytic lymphohistiocytosis (sHLH). METHODS Data was collected from patient's electronic medical records at the University of Alabama at Birmingham. The patient is a part of a larger cohort of patients with all-cause MAS treated at our center. CASE A 63 year old renal transplant recipient male on maintenance immunosuppressive therapy presented with high grade fever, leukopenia, thrombocytopenia and elevated transaminases and initially met clinical criteria for severe sepsis. On further investigation, clinical and laboratory criteria for MAS were met. He was treated with a combination of doxycycline for HME and a novel combination of anakinra (interleukin-1 receptor antagonist), and high dose corticosteroids. The discussion focuses on clinical presentation, pathogenesis and treatment of MAS with an emphasis on MAS secondary to HME. CONCLUSION Macrophage activation syndrome or sHLH is a dysfunctional, hyperactive and potentially fatal immune system response that results in multi-organ dysfunction. With increasing incidence of Ehrlichia chaffeensis as an emerging pathogen, clinicians should be aware of this fulminant and potentially fatal complication of HME.
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Affiliation(s)
- Nilay Kumar
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294-0012 USA
| | - Jatinder Goyal
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294-0012 USA
| | - Anshum Goel
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294-0012 USA
| | - Bita Shakoory
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35205 USA
| | - Winn Chatham
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35205 USA
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13
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Narongroeknawin P, Patkar NM, Shakoory B, Jain A, Curtis JR, Delzell E, Lander PH, Lopez-Ben RR, Pitt MJ, Safford MM, Volgas DA, Saag KG. Validation of diagnostic codes for subtrochanteric, diaphyseal, and atypical femoral fractures using administrative claims data. J Clin Densitom 2012; 15:92-102. [PMID: 22071028 PMCID: PMC4112756 DOI: 10.1016/j.jocd.2011.09.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Revised: 09/01/2011] [Accepted: 09/01/2011] [Indexed: 11/20/2022]
Abstract
Administrative claims databases have large samples and high generalizability. They have been used to evaluate associations of atypical femoral fractures with bisphosphonates. We developed and assessed accuracy of claims-based algorithms with hospital and physician diagnosis codes for these fractures. Medical records and radiology reports of all adults admitted at University of Alabama at Birmingham Health System from 2004 to 2008 with International Classification of Diseases, Ninth Revision hospital discharges and surgeons' fracture repair codes for subtrochanteric femoral fractures and random sample of other femoral fractures were reviewed. We identified 137 persons with suspected subtrochanteric femoral fractures and randomly selected 50 persons with either suspected diaphyseal femoral fractures or hip fractures other than subtrochanteric and diaphyseal femoral fractures (typical hip fractures). Eleven patients had radiographic features indicative of atypical femoral fractures. The positive predictive value (PPV) of claims-based algorithms varied with primary or secondary positions on discharge diagnoses and the sources of diagnosis codes. The PPV for fractures ranged 69-89% for subtrochanteric femoral, 89-98% for diaphyseal femoral, and 85-98% for typical hip fractures. The PPV of administrative codes for defining a femoral fracture as atypical was low and imprecise. Claims-based algorithms combining hospital discharges with surgeon's diagnosis codes had high PPV to identify the site of subtrochanteric or diaphyseal femoral fractures vs typical hip fractures. However, claims-based data were not accurate in identifying atypical femoral fractures. These claims algorithms will be useful in future population-based observational studies to evaluate associations between osteoporosis medications and subtrochanteric and diaphyseal femoral fractures.
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Affiliation(s)
- Pongthorn Narongroeknawin
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nivedita M. Patkar
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bita Shakoory
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Archana Jain
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeffrey R. Curtis
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elizabeth Delzell
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Philip H. Lander
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert R. Lopez-Ben
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael J. Pitt
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Monika M. Safford
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David A. Volgas
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
| | - Kenneth G. Saag
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Abstract
Belimumab is a human genome derived monoclonal antibody with specificity for BLyS (B lymphocyte stimulator, or B-cell activating factor [BAFF]), a cytokine that promotes the survival and maturation of B cells into antibody-secreting plasmablasts. Recent phase III clinical trials with belimumab in patients with active systemic lupus erythematosus (SLE) have been completed and achieved primary efficacy endpoints employing validated disease activity measures (SLEDAI and BILAG) as well as additional secondary endpoints related to disease flares and sparing of corticosteroid use. Significant decreases in numbers of activated B cells as well as levels of autoantibodies are observed during treatment with belimumab. The majority of observed clinical improvements are observed in musculoskeletal, mucocutaneous, and serologic domains of disease activity; the potential effects on more severe neurologic or renal domains of disease are not known. Treatment with belimumab is well tolerated and has not been associated with significant toxicity.
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Affiliation(s)
- Bita Shakoory
- University of Alabama at Birmingham, Clinical Immunology and Rheumatology/Medicine, Birmingham, AL, USA
| | - Winn Clatham
- University of Alabama at Birmingham, Clinical Immunology and Rheumatology/Medicine, Birmingham, AL, USA
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Shakoory B, Fitzgerald SM, Lee SA, Chi DS, Krishnaswamy G. The role of human mast cell-derived cytokines in eosinophil biology. J Interferon Cytokine Res 2005; 24:271-81. [PMID: 15153310 DOI: 10.1089/107999004323065057] [Citation(s) in RCA: 192] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Eosinophil-mediated diseases, such as allergic asthma, eosinophilic fasciitis, and certain hypersensitivity pulmonary disorders, are characterized by eosinophil infiltration and tissue injury. Mast cells and T cells often colocalize to these areas. Recent data suggest that mast cells can contribute to eosinophil-mediated inflammatory responses. Activation of mast cells can occur by antigen and immunoglobulin E (IgE) via the high-affinity receptor (FcepsilonRI) for IgE. The liberation of proteases, leukotrienes, lipid mediators, and histamine can contribute to tissue inflammation and allow recruitment of eosinophils to tissue. In addition, the synthesis and expression of a plethora of cytokines and chemokines (such as granulocyte-macrophage colony-stimulating factor [GM-CSF], interleukin-1 [IL-1], IL-3, IL-5, tumor necrosis factor-alpha [TNF-alpha], and the chemokines IL-8, regulated upon activation normal T cell expressed and secreted [RANTES], monocyte chemotactic protein-1 [MCP-1], and eotaxin) by mast cells can influence eosinophil biology. Stem cell factor (SCF)-c-kit, cytokine-cytokine receptor, and chemokine-chemokine receptor (CCR3) interactions leading to nuclear factor kappaB (NF-kappaB), mitogen-activated protein kinase (MAPK) expression, and other signaling pathways can modulate eosinophil function. Eosinophil hematopoiesis, activation, survival, and elaboration of mediators can all be regulated thus by mast cells in tissue. Moreover, because eosinophils can secrete SCF, eosinophils can regulate mast cell function in a paracrine manner. This two-way interaction between eosinophils and mast cells can pave the way for chronic inflammatory responses in a variety of human diseases. This review summarizes this pivotal interaction between human mast cells and eosinophils.
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Affiliation(s)
- Bita Shakoory
- Department of Internal Medicine, Division of Allergy and Immunology, East Tennessee State University, Johnson City, TN 37614, USA
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