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Masood M, Siddique A, Krishnamoorthi R, Kozarek RA. Liver Dysfunction in Adult Hemophagocytic Lymphohistiocytosis: A Narrative Review. Adv Ther 2024; 41:553-566. [PMID: 38145441 DOI: 10.1007/s12325-023-02768-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 12/08/2023] [Indexed: 12/26/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening condition that has been increasingly recognized in adults and is characterized by a hyperinflammatory state due to immune dysregulation. Its nonspecific presentation, the lack of clinician familiarity given its rarity, and shared clinical features with sepsis and other syndromes can lead to a delay in diagnosis and a poor prognosis. Significant liver function abnormalities as the initial manifestation of HLH are uncommon and can range from mild elevation of aminotransferases to fulminant hepatic failure with high mortality rates. The authors encountered a case of adult HLH mimicking acute viral hepatitis in which a markedly elevated ferritin level led to a prompt diagnosis, early initiation of treatment, and a successful outcome. Clinicians, including gastroenterologists and hepatologists, are often called upon to evaluate patients with abnormal liver tests and may lack experience in the early diagnosis and management of liver dysfunction in the context of HLH. Thus, we expand our reporting to a narrative review of literature which explores the pathogenesis of HLH, challenges associated with its diagnosis, previous reports of liver disease associated with the syndrome, recommended treatments for the familial and adult variations including the role of liver transplantation, and the outcomes of these treatments.
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Affiliation(s)
- Muaaz Masood
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Asma Siddique
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Rajesh Krishnamoorthi
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Richard A Kozarek
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA.
- Center for Interventional Immunology, Benaroya Research Institute, Virginia Mason Franciscan Health, 1201 Ninth Ave, Seattle, WA, 98101, USA.
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2
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An JH, Ahn JH. Postpartum hemophagocytic lymphohistiocytosis: A case report. World J Clin Cases 2023; 11:6183-6188. [PMID: 37731572 PMCID: PMC10507548 DOI: 10.12998/wjcc.v11.i26.6183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/12/2023] [Accepted: 08/15/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Postpartum hemophagocytic lymphohistiocytosis (HLH) is a rare disease with unclear pathophysiology. It is a secondary HLH diagnosed using the pediatric diagnostic criteria; however, the clinical diagnosis of postpartum HLH remains challenging. Hence, HLH may remain undiagnosed, leading to poor patient prognosis. Therefore, improvements in the accuracy of postpartum HLH diagnoses and treatments are necessary. CASE SUMMARY We report the case of a 40-year-old female with postpartum HLH. The patient attended the postpartum care center for 3 wk after giving birth and underwent needle aspiration due to thyroid gland enlargement 11 d before an emergency department visit precipitated by fever and abdominal pain. Since no abnormal emergency room findings were noted, the patient was discharged with a prescription for broad-spectrum antibiotics. Three days later, she returned to the emergency room in a hemodynamically unstable state and was admitted to the intensive care unit with suspected sepsis or hematologic disease. The patient was treated, without effect, for sepsis using broad-spectrum antibiotics, and for suspected hematologic disease with steroid therapy. However, she died due to rapidly worsening symptoms. CONCLUSION Rapid recognition and appropriate treatment of postpartum HLH are needed to improve the prognosis.
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Affiliation(s)
- Ju Ho An
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon 16499, Gyeonggi-do, South Korea
| | - Jung Hwan Ahn
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon 16499, Gyeonggi-do, South Korea
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3
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Geiger AJ, Yasar DG, Sitwala KV. HLH and TET2 Mutation Presenting after First Cycle of CLL Treatment. Clin Med Res 2023; 21:155-158. [PMID: 37985171 PMCID: PMC10659132 DOI: 10.3121/cmr.2023.1804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 03/23/2023] [Accepted: 12/12/2023] [Indexed: 11/22/2023]
Abstract
Here we report development of hemophagocytic lymphohistiocytosis (HLH), along with unmasking of a TET2-mutated myeloid neoplasm, after initial doses of bendamustine and rituximab for longstanding chronic lymphocytic leukemia (CLL). After many years of CLL showing minimally progressive lymphocytosis, the patient's white blood cell count began to decline in parallel with neutrophil count, hemoglobin, and platelet count. Bone marrow biopsy showed partial CLL involvement; bendamustine+rituximab therapy was augmented with granulocyte colony-stimulating factor (g-CSF) and romiplostim to mitigate worsening pancytopenia, without response. Laboratory evaluation revealed a pattern supportive of the clinical impression of HLH, while bone marrow biopsy showed persistent CLL, new reticulin fibrosis, megakaryocytic proliferation, and 32% mutated TET2, but no compelling morphologic evidence of hemophagocytosis. The patient recovered with dexamethasone and g-CSF support.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Lymphohistiocytosis, Hemophagocytic/drug therapy
- Lymphohistiocytosis, Hemophagocytic/pathology
- Rituximab/therapeutic use
- Bendamustine Hydrochloride/therapeutic use
- Granulocyte Colony-Stimulating Factor/therapeutic use
- DNA-Binding Proteins/genetics
- Dioxygenases
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Affiliation(s)
| | - Demet Gokalp Yasar
- Department of Hematology/Oncology, Marshfield Clinic Health System, Marshfield, Wisconsin
| | - Kajal V Sitwala
- Department of Laboratory Medicine, Marshfield Clinic Health System, Marshfield, Wisconsin
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Abstract
For more than 40 years, the epipodophyllotoxin drug etoposide is prescribed to treat cancer. This semi-synthetic compound remains extensively used to treat advanced small-cell lung cancer and in various chemotherapy regimen for autologous stem cell transplantation, and other anticancer protocols. Etoposide is a potent topoisomerase II poison, causing double-stranded DNA breaks which lead to cell death if they are not repaired. It is also a genotoxic compound, responsible for severe side effects and secondary leukemia occasionally. Beyond its well-recognized function as an inducer of cancer cell death (a "killer on the road"), etoposide is also useful to treat immune-mediated inflammatory diseases associated with a cytokine storm syndrome. The drug is essential to the treatment of hemophagocytic lymphohistiocytosis (HLH) and the macrophage activation syndrome (MAS), in combination with a corticosteroid and other drugs. The use of etoposide to treat HLH, either familial or secondary to a viral or parasitic infection, or treatment-induced HLH and MAS is reviewed here. Etoposide dampens inflammation in HLH patients via an inhibition of the production of pro-inflammatory mediators, such as IL-6, IL-10, IL-18, IFN-γ and TNF-α, and reduction of the secretion of the alarmin HMGB1. The modulation of cytokines production by etoposide contributes to deactivate T cells and to dampen the immune stimulation associated to the cytokine storm. This review discussed the clinical benefits and mechanism of action of etoposide (a "rider on the storm") in the context of immune-mediated inflammatory diseases, notably life-threatening HLH and MAS. The question arises as to whether the two faces of etoposide action can apply to other topoisomerase II inhibitors.
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Affiliation(s)
- Christian Bailly
- OncoWitan, Consulting Scientific Office, Lille (Wasquehal) 59290, France; University of Lille, Faculty of Pharmacy, Institut de Chimie Pharmaceutique Albert Lespagnol (ICPAL), 3 rue du Professeur Laguesse, 59000 Lille, France; University of Lille, CNRS, Inserm, CHU Lille, UMR9020 - UMR1277 - Canther - Cancer Heterogeneity, Plasticity and Resistance to Therapies, 59000 Lille, France.
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5
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Domínguez-Rojas J, Caute-Lara J, Caqui-Vilca P, Cruz-Arpi M, Martel-Ramírez C, Quispe-Chipana M, Sánchez-Rodríguez A, Atamari-Anahui N. Hyperferritinemic sepsis secondary to invasive Toxoplasma gondii in a child with untreated HIV. Bol Med Hosp Infant Mex 2023. [PMID: 36917806 DOI: 10.24875/bmhim.22000051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Background Untreated human immunodeficiency virus (HIV)-immunosuppressed pediatric patients show high morbidity and mortality from opportunistic infections. Limited cases of hyperferritinemic sepsis have been described in patients with toxoplasmosis. Case report We describe the case of a 13-year-old female patient with a history of untreated HIV who presented with hyperferritinemic sepsis secondary to Toxoplasma gondii infection and Pneumocystis jirovecci pneumonia. She received ventilatory support, inotropic drugs, treatment for opportunistic germs, and high-dose corticosteroids, but with unfavorable evolution. Conclusions The global approach to sepsis with elevated ferritin guides to using of therapies aimed at neutralizing the severe inflammatory response. A timely diagnosis would allow prompt treatment and minimize complications.
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Affiliation(s)
- Jesús Domínguez-Rojas
- Servicio de Pediatría Clínica, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru.,Servicio de Unidad de Cuidados Intensivos Pediátricos, Instituto Nacional de Salud del Niño-Breña, Lima, Peru.,Servicio de Unidad de Cuidados Intensivos, Hospital Nacional Hipólito Unanue, Lima, Peru
| | - Jackeline Caute-Lara
- Servicio de Unidad de Cuidados Intensivos, Hospital Nacional Hipólito Unanue, Lima, Peru
| | - Patrick Caqui-Vilca
- Servicio de Unidad de Cuidados Intensivos, Hospital Nacional Hipólito Unanue, Lima, Peru
| | - Mario Cruz-Arpi
- Servicio de Unidad de Cuidados Intensivos, Hospital Nacional Hipólito Unanue, Lima, Peru
| | - Carlos Martel-Ramírez
- Servicio de Unidad de Cuidados Intensivos, Hospital Nacional Hipólito Unanue, Lima, Peru
| | - Miguel Quispe-Chipana
- Servicio de Unidad de Cuidados Intensivos, Hospital Nacional Hipólito Unanue, Lima, Peru
| | - Abel Sánchez-Rodríguez
- Servicio de Unidad de Cuidados Intensivos, Hospital Nacional Hipólito Unanue, Lima, Peru
| | - Noé Atamari-Anahui
- Servicio de Unidad de Cuidados Intensivos Pediátricos, Instituto Nacional de Salud del Niño-Breña, Lima, Peru.,Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Vicerrectorado de Investigación, Universidad San Ignacio de Loyola, Lima, Peru
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6
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Malik P, Shroff M. Infection and inflammation: radiological insights into patterns of pediatric immune-mediated CNS injury. Neuroradiology 2023; 65:425-439. [PMID: 36534135 PMCID: PMC9761646 DOI: 10.1007/s00234-022-03100-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022]
Abstract
The central nervous system (CNS) undergoes constant immune surveillance enabled via regionally specialized mechanisms. These include selectively permissive barriers and modifications to interlinked innate and adaptive immune systems that detect and remove an inciting trigger. The end-points of brain injury and edema from these triggers are varied but often follow recognizable patterns due to shared underlying immune drivers. Imaging provides insights to understanding these patterns that often arise from unique interplays of infection, inflammation and genetics. We review the current updates in our understanding of these intersections and through examples of cases from our practice, highlight that infection and inflammation follow diverse yet convergent mechanisms that can challenge the CNS in children.
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Affiliation(s)
- Prateek Malik
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Manohar Shroff
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
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Lee JH, Ha YJ, Kang EH, Chang SH, Lee YJ, sup, 3, sup. A Case of Macrophage Activation Syndrome During the Treatment of Adult-onset Still's Disease With Tocilizumab. J Rheum Dis 2022; 29:123-128. [PMID: 37475901 PMCID: PMC10327616 DOI: 10.4078/jrd.2022.29.2.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/10/2021] [Accepted: 08/17/2021] [Indexed: 07/22/2023]
Abstract
Macrophage activation syndrome (MAS) is a fatal complication of adult-onset Still's disease (AOSD). Although anti-cytokine agents have been recommended for refractory AOSD or complicated with MAS, MAS cases have been rarely reported during anti-cytokine treatment. Herein, we describe the first AOSD case complicated with MAS during the treatment with tocilizumab in Korea. Two years after tocilizumab maintenance therapy, high fever and hypertransaminasemia recurred. MAS was diagnosed based on hyperferritinemia, elevated soluble IL-2 receptor levels, and the presence of hemophagocytic histiocytes in the bone marrow. However, she had normal white blood cell counts and acute phase reactant levels. High-dose glucocorticoid and anakinra therapies were not effective, but her disease improved with etoposide. This case shows that tocilizumab may not prevent MAS development and can modify clinical features making it challenging to diagnose. Cytotoxic therapy such as etoposide may be required in MAS cases that develop during anti-cytokine therapy.
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Affiliation(s)
- Ju Ho Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - You-Jung Ha
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eun Ha Kang
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sung Hae Chang
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Yun Jong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - sup
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - 3
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - sup
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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8
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Yu TY, Lu MY, Lin KH, Chang HH, Chou SW, Lin DT, Jou ST, Yang YL. Outcomes and prognostic factors associated with 180-day mortality in Taiwanese pediatric patients with Hemophagocytic Lymphohistiocytosis. J Formos Med Assoc 2020; 120:1061-1068. [PMID: 33218852 DOI: 10.1016/j.jfma.2020.10.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 07/11/2020] [Revised: 10/21/2020] [Accepted: 10/26/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND/PURPOSE Hemophagocytic lymphohistiocytosis (HLH), a rarely occurring syndrome with various triggers, is associated with early mortality. Owing to a lack of sufficient corresponding data in Taiwan, this study aimed to identify the outcome and potential factors associated with 180-day mortality in pediatric HLH. METHODS This retrospective study analyzed clinical and laboratory data on pediatric patients diagnosed with HLH at our institute (1995-2019). Logistic regression analysis was conducted to determine the associations between various factors and 180-day mortality. RESULTS Overall, 48 patients had HLH; their median age at diagnosis was 5 years (interquartile range: 2-11 years). Clinical presentations and laboratory parameters required for diagnosis included fever (98%), splenomegaly (79%), hyperferritinemia (98%), hemophagocytosis (94%), thrombocytopenia (90%), anemia (63%), hypertriglyceridemia (68%), and neutropenia (57%). The 5-year overall survival (OS) rate was 49%. Of 22 patients who had died at the last follow-up, 15 (68%) died within 180 days after diagnosis. In the multivariate analysis, hemoglobin (odds ratio [OR]: 0.564, p = 0.024) and triglyceride (OR: 1.004, p = 0.049) were significantly associated with 180-day mortality. Higher triglyceride levels at diagnosis were related to significantly lower 180-day OS rates (52.9% vs. 86.1%, p = 0.018). CONCLUSION The overall outcome in our cohort was similar to that reported in some of the largest international cohorts. Hypertriglyceridemia and anemia may be indicative of poor prognoses in pediatric HLH patients independently and may be used to guide treatment strategy formulations for better outcomes.
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Affiliation(s)
- Teng-Yang Yu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Meng-Yao Lu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Kai-Hsin Lin
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsiu-Hao Chang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Shu-Wei Chou
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Dong-Tsamn Lin
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shiann-Tarng Jou
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan.
| | - Yung-Li Yang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Laboratory Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Lee WI, Talaulikar D, Cook MC. Retrospective single-centre analysis of diagnostic approach to adult-onset haemophagocytic lymphohistiocytosis. Intern Med J 2020; 51:939-947. [PMID: 32388900 DOI: 10.1111/imj.14891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 03/26/2019] [Revised: 04/10/2020] [Accepted: 04/27/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Haemophagocytic lymphohistiocytosis (HLH) is a rare disorder with a poor prognosis characterised by substantial immune activation leading to end-organ failure. In childhood, genetic defects that impair cytotoxic function of natural killer cells and T cells. (HLH) are often identified. In adults, clinical manifestations are similar to those observed in children but the aetiology is often unclear. AIMS To evaluate whether poor prognosis for adult HLH is in part due to lack of awareness of the disorder, which results in incomplete investigation and failure to implement timely treatment. METHODS We performed a retrospective case series of adult-onset HLH in a tertiary hospital in Australia. We evaluated clinical characteristics, treatment and outcome, and related these to application of standard diagnostic criteria for HLH. RESULTS In our centre, incomplete assessment of HLH criteria was common. Serum ferritin was the criterion most commonly assessed. Hyperferritinaemia ≥10 000 μg/L was highly sensitive in detecting patients with adult-onset HLH; however, the majority of patients who had hyperferritinaemia ≥10 000 μg/L did not have adult-onset HLH. CONCLUSION The present study highlights the importance of comprehensive application of diagnostic criteria to improve accuracy and timelines of the diagnosis of adult onset HLH.
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Affiliation(s)
- Wei-I Lee
- Department of Immunology, Canberra Hospital, Australia
| | | | - Matthew C Cook
- Department of Immunology, Canberra Hospital, Australia.,Centre for Personalised Immunology, John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia
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10
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Bauchmuller K, Manson JJ, Tattersall R, Brown M, McNamara C, Singer M, Brett SJ. Haemophagocytic lymphohistiocytosis in adult critical care. J Intensive Care Soc 2020; 21:256-268. [PMID: 32782466 DOI: 10.1177/1751143719893865] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a syndrome of severe immune dysregulation, characterised by extreme inflammation, fever, cytopaenias and organ dysfunction. HLH can be triggered by conditions such as infection, autoimmune disease and malignancy, among others. Both a familial and a secondary form have been described, the latter being increasingly recognised in adult patients with critical illness. HLH is difficult to diagnose, often under-recognised and carries a high mortality. Patients can present in a very similar fashion to sepsis and the two syndromes can co-exist and overlap, yet HLH requires specific immunosuppressive therapy. HLH should be actively excluded in patients with presumed sepsis who either lack a clear focus of infection or who are not responding to energetic infection management. Elevated serum ferritin is a key biomarker that may indicate the need for further investigations for HLH and can guide treatment. Early diagnosis and a multidisciplinary approach to HLH management may save lives.
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Affiliation(s)
- Kris Bauchmuller
- Department of Critical Care and Anaesthesia, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jessica J Manson
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Rachel Tattersall
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,Department of Paediatric and Adolescent Rheumatology, Sheffield Children's NHS Trust, Sheffield, UK
| | - Michael Brown
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK.,Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Christopher McNamara
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mervyn Singer
- Division of Medicine, Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - Stephen J Brett
- Department of Surgery and Cancer, Imperial College London, London, UK
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11
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Hrudka J, Eis V, Heřman J, Prouzová Z, Rosenwald A, Duška F. Panniculitis-like T-cell-lymphoma in the mesentery associated with hemophagocytic syndrome: autopsy case report. Diagn Pathol 2019; 14:80. [PMID: 31311562 PMCID: PMC6636044 DOI: 10.1186/s13000-019-0854-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 07/04/2019] [Indexed: 12/14/2022] Open
Abstract
Background Panniculitis-like T-cell lymphoma is an uncommon type of non-Hodgkin lymphoma, occurring usually in the form of nodules within the subcutaneous fat tissue of the extremities or trunk. In the literature, subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is described as a distinct type of T-cell lymphoma with a variable clinical behavior, depending on molecular phenotype of T-cell receptor (TCR) and on the presence or absence of hemophagocytic syndrome. Case presentation We present a bioptic and autoptic case of a 65-years old Caucasian man with panniculitic T-cell lymphoma with morphological and immunohistochemical features of SPTCL, limited to the retroperitoneal and mesenteric mass, i.e. without any cutaneous involvement, and associated with severe hemophagocytic lymphohistiocytosis. Conclusion A panniculitic T-cell lymphoma with morphological and molecular features of SPTCL, which is limited to mesentery, i.e. does not involve subcutaneous fat, seems to be exceedingly rare.
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Affiliation(s)
- Jan Hrudka
- Department of Pathology, Charles University, 3rd Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital, Prague, Czech Republic.
| | - Václav Eis
- Department of Pathology, Charles University, 3rd Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital, Prague, Czech Republic
| | - Josef Heřman
- Department of Pathology, Charles University, 3rd Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital, Prague, Czech Republic
| | - Zuzana Prouzová
- Department of Pathology and Molecular Medicine, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Andreas Rosenwald
- Department of Pathology, Julius-Maximilian University, Faculty of Medicine, Würzburg, Germany
| | - František Duška
- Department of Anaesthesiology and Intensive Care, Charles University, 3rd Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital, Prague, Czech Republic
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12
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Kapoor S, Morgan CK, Siddique MA, Guntupalli KK. Intensive care unit complications and outcomes of adult patients with hemophagocytic lymphohistiocytosis: A retrospective study of 16 cases. World J Crit Care Med 2018; 7:73-83. [PMID: 30596029 PMCID: PMC6305525 DOI: 10.5492/wjccm.v7.i6.73] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 10/21/2018] [Accepted: 11/07/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To study the management, complications and outcomes of adult patients admitted with hemophagocytic lymphohistiocytosis (HLH) in the intensive care unit (ICU).
METHODS We performed a retrospective observational study of adult patients with the diagnosis of “HLH” admitted to the two academic medical ICUs of Baylor College of Medicine between 01/01/2013 to 06/30/2017. HLH was diagnosed using the HLH-2004 criteria proposed by the Histiocyte Society.
RESULTS Sixteen adult cases of HLH were admitted to the medical ICUs over 4 years. Median age of presentation was 49 years and 10 (63%) were males. Median Sequential Organ Failure Assessment (SOFA) score at the time of ICU admission was 10. Median ICU length of stay (LOS) was 11.5 d and median hospital LOS was 29 d. Septic shock and acute respiratory failure accounted for majority of diagnoses necessitating ICU admission. Septic shock was the most common ICU complication seen in (88%) patients, followed by acute kidney injury (81%) and acute respiratory failure requiring mechanical ventilation (75%). Nine patients (56%) developed disseminated intravascular coagulation and eight (50%) had acute liver failure. 10 episodes of clinically significant bleeding were observed. Multi system organ failure was the most common cause of death seen in 12 (75%) patients. The 30 d mortality was 37% (6 cases) and 90 d mortality was 81% (13 cases). There was no difference in mortality based on age (above or less than 50 years), SOFA score on ICU admission (more than or less than 10), immunosuppression, time to diagnose HLH or direct ICU admission versus floor transfer.
CONCLUSION HLH is a devastating disease associated with poor outcomes in ICU. Intensivists need to have a high degree of clinical suspicion for HLH in patients with septic shock/multi system organ failure and progressive bi/pancytopenia who are not responding to standard management in ICU.
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Affiliation(s)
- Sumit Kapoor
- Department of Critical Care Medicine, Montefiore Medical Center, Bronx, NY 10467, United States
| | - Christopher K Morgan
- Department of Pulmonary, Critical Care and Sleep, Baylor College of Medicine, Houston, TX 77030, United States
| | - Muhammad Asim Siddique
- Department of Pulmonary, Critical Care and Sleep, Baylor College of Medicine, Houston, TX 77030, United States
| | - Kalpalatha K Guntupalli
- Department of Pulmonary, Critical Care and Sleep, Baylor College of Medicine, Houston, TX 77030, United States
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Liang J, Qu H, Wang X, Wang A, Liu L, Tu P, Li R, Wang M. Drug Reaction with Eosinophilia and Systemic Symptoms Associated with Reactivation of Epstein-Barr Virus and/or Cytomegalovirus Leading to Hemophagocytic Syndrome in One of Two Patients. Ann Dermatol 2017; 30:71-74. [PMID: 29386835 PMCID: PMC5762479 DOI: 10.5021/ad.2018.30.1.71] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 05/31/2017] [Accepted: 06/05/2017] [Indexed: 12/19/2022] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a hypersensitivity reaction characterized by maculopapular rash, exfoliative dermatitis, lymphadenopathy, fever, eosinophilia, and involvement of internal organs. Evidence for reactivation of herpes family viruses has been observed in some DRESS patients, and activated CD8+ T lymphocytes are largely directed against Epstein-Barr virus. Here, we report two cases complicated with this infection. Both patients received antibiotics and non-steroidal anti-inflammatory drugs. These patients manifested clinically with high fever, facial edema, diffuse pruritic erythroderma and maculopapules over the entire body, purpuric rashes in both lower limbs and lymphadenopathy of cervical and inguinal nodes. Laboratory tests revealed abnormal liver function, blood eosinophils, and ferritin levels. The patients recovered completely; however, the female patient developed hemophagocytic syndrome on the 15th day of illness. She developed new itchy rash, and laboratory tests rapidly worsened with fibrinogen levels dramatically reduced to 0.61 g/L. Bone marrow aspiration revealed an increased number of macrophages with hemophagocytosis and a reversed CD4/CD8 ratio of 0.45. These cases suggest that human herpes virus and coagulation function evaluations are necessary in DRESS patients.
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Affiliation(s)
- Jianhua Liang
- Department of Dermatology, Peking University First Hospital, Beijing, China.,Department of Dermatology, Liaocheng People's Hospital, Shandong, China
| | - Hui Qu
- Department of Dermatology, Peking University First Hospital, Beijing, China.,Beijing Key Laboratory of Molecular Diagnosis of Dermatoses, Beijing, China
| | - Xiaowen Wang
- Department of Dermatology, Peking University First Hospital, Beijing, China.,Beijing Key Laboratory of Molecular Diagnosis of Dermatoses, Beijing, China
| | - Aiping Wang
- Department of Dermatology, Peking University First Hospital, Beijing, China.,Beijing Key Laboratory of Molecular Diagnosis of Dermatoses, Beijing, China
| | - Lingling Liu
- Department of Dermatology, Peking University First Hospital, Beijing, China.,Beijing Key Laboratory of Molecular Diagnosis of Dermatoses, Beijing, China
| | - Ping Tu
- Department of Dermatology, Peking University First Hospital, Beijing, China.,Beijing Key Laboratory of Molecular Diagnosis of Dermatoses, Beijing, China
| | - Ruoyu Li
- Department of Dermatology, Peking University First Hospital, Beijing, China.,Beijing Key Laboratory of Molecular Diagnosis of Dermatoses, Beijing, China
| | - Mingyue Wang
- Department of Dermatology, Peking University First Hospital, Beijing, China.,Beijing Key Laboratory of Molecular Diagnosis of Dermatoses, Beijing, China
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Zarrini P, Mosayebi Z, Ramyar A, Dalili H. Hemophagocytic Lymphohistiocytosis in a Neonate: Case Report. Acta Med Iran 2017; 55:82-84. [PMID: 28188950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2017] [Indexed: 06/06/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of pathologic immune activation, occurring as either a familial disorder or a sporadic condition, in association with a variety of triggers. This article will introduce a neonate with HLH in Iran. We report a case of HLH presenting with respiratory distress and fever, hepatosplenomegaly, jaundice and pancytopenia on the second day of life. Typical clinical and laboratory findings were detected in the neonate. HLH was diagnosed according to HLH-2004 guidelines. In spite of initiating the treatment, the disease did not cure. Post-mortem, extensive hemophagocytosis was found in multiple organs. No specific genetic defect was identified. Since HLH is a potentially lethal childhood illness, early diagnosis of this disorder and commences the therapy is important for pediatricians.
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Affiliation(s)
- Pari Zarrini
- Department of Pediatrics, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ziba Mosayebi
- Department of Pediatrics, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Asghar Ramyar
- Department of Pediatrics, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hosein Dalili
- Department of Pediatrics, Breast Feeding Research Center, Tehran University of Medical Sciences, Tehran, Iran
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15
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Shah AR, Muzzafar T, Assi R, Schellingerhout D, Estrov Z, Tamamyan G, Kantarjian H, Daver N. Hemophagocytic lymphohistiocytosis in adults: An under recognized entity. BBA Clin 2017; 7:36-40. [PMID: 28070498 DOI: 10.1016/j.bbacli.2016.12.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 12/01/2016] [Accepted: 12/15/2016] [Indexed: 11/21/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of severe immune activation with macrophage and T-cell infiltration resulting in, multi organ damage. HLH may be primary or secondary in etiology. A high index of suspicion is essential for early diagnosis and treatment. Diagnostic criteria need to be refined and newer treatment options to be explored in order to improve survival especially in adult HLH and malignancy-associated HLH (M-HLH). We report a case of malignancy associated HLH (M-HLH) in adult treated on one of the only FDA-approved protocols for adult HLH to highlight the diagnostic and therapeutic challenges of this disease entity.
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Nieto JF, Gómez SM, Moncada DC, Serna LM, Hidrón AI. Successful treatment of hemophagocytic lymphohistiocytosis and disseminated intravascular coagulation secondary to histoplasmosis in a patient with HIV/AIDS. Biomedica 2016; 36:9-14. [PMID: 27622618 DOI: 10.7705/biomedica.v36i2.2797] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 08/27/2015] [Indexed: 11/21/2022]
Abstract
Haemophagocytic lymphohistiocytosis is an uncommon syndrome that results from an uncontrolled activation of macrophages and lymphocytes resulting in the compromise of multiple organs that is potentially fatal without timely treatment. It can be hereditary or a secondary result of infectious processes, neoplasms or autoimmune conditions. We present the case of a patient with HIV/AIDS who developed hemophagocytic lymphohistiocytosis as well as disseminated intravascular coagulation associated with histoplasmosis and who was successfully treated with amphotericin B, steroids and transitory dialytic support.
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Abstract
The haemophagocytic syndrome is a unique disease process in which the dysregulation of the patient's immune system leads to an inflammatory storm which rapidly ravages through multiple organ systems, generating life-threatening end-organ dysfunction. Since it usually mimics other conditions frequently encountered in the critical care population - most notably septic shock - its diagnosis is elusive and the condition remains under-recognized and under-reported. We present a concise review of the pathophysiology and clinical features of the heamophagocytic syndrome and discuss the main diagnostic and therapeutic issues relevant to the management of this condition in the critically ill patient. Increasing awareness about the haemophagocytic syndrome amongst intensive care physicians will facilitate earlier recognition and timely management.
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Affiliation(s)
- Ignacio de Asua
- Department of Anaesthetics and Intensive Care, Royal Brompton and Harefield NHS Trust, Harefield, Middlesex, UK
| | - Esteban Ciliberti
- Department of Anaesthetics and Intensive Care, Royal Brompton and Harefield NHS Trust, Harefield, Middlesex, UK
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18
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Min KW, Jung HY, Han HS, Hwang TS, Kim SY, Kim WS, Lim SD, Kim WY. Ileal mass-like lesion induced by Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis in a patient with aplastic anemia. APMIS 2014; 123:81-6. [PMID: 25243347 DOI: 10.1111/apm.12308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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: 07/26/2013] [Accepted: 07/09/2014] [Indexed: 11/29/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening hyperinflammatory syndrome characterized by activated macrophages engulfing erythrocytes, leukocytes, platelets, and their precursor cells in bone marrow, liver, spleen, or lymph nodes. We report a case of Epstein-Barr virus (EBV)-associated HLH unusually presenting as an ileal mass. A 23-year-old man presented initially with persistent fever unresponsive to antibiotics and pancytopenia. A bone marrow aspiration and biopsy were used to diagnose the patient with aplastic anemia and HLH. A relatively well-defined low-density mass was radiologically noted in the terminal ileum, along with enlarged lymph nodes, and was suspected to be malignant lymphoma or an abscess. The ileocecectomy specimen revealed a transmural hemorrhagic infarction with numerous activated macrophages phagocytosing erythrocytes, plasma cells, and lymphocytes, and he was diagnosed with EBV-associated HLH. The patient received an allo-unrelated peripheral blood stem-cell transplantation and expired due to graft-versus-host disease following liver failure. The present case is very unique, in that EBV-associated HLH presented with an unusual ileal mass resulting from hemorrhagic infarction in a patient with aplastic anemia, suggesting variability in the biological behavior of EBV-associated disease.
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Affiliation(s)
- Kyueng-Whan Min
- Department of Pathology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Ho C, Yao X, Tian L, Li FY, Podoltsev N, Xu ML. Marrow assessment for hemophagocytic lymphohistiocytosis demonstrates poor correlation with disease probability. Am J Clin Pathol 2014; 141:62-71. [PMID: 24343738 DOI: 10.1309/ajcpmd5tjefoovbw] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVES To evaluate the amount of hemophagocytosis in 64 marrow core biopsy specimens and aspirates from 58 patients with clinical suspicion for secondary hemophagocytic lymphohistiocytosis (HLH) or reported findings of hemophagocytosis. METHODS A review of medical records assigned patients to a low-risk (45 patients) or high-risk (13 patients) HLH group, and association with histologic findings was examined using the Fisher exact test. RESULTS The amount of hemophagocytosis in aspirate or the core biopsy specimen did not correlate with disease probability (P = .17 and P = .63, respectively). Of the clinical/laboratory criteria assessed, the most significant correlations with HLH were highly elevated ferritin (P = .01), cytopenias (P = .02), and fever (P = .009). CONCLUSIONS Our findings indicated that marrow histologic findings alone do not reliably predict the probability of HLH, and an isolated finding of hemophagocytosis, even when present in a high amount, lacks specificity for HLH.
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Affiliation(s)
- Caleb Ho
- Department of Pathology & Laboratory Medicine, Yale School of Medicine, New Haven, CT
| | - Xiaopan Yao
- Department of Internal Medicine (Medical Oncology), Yale School of Medicine, New Haven, CT
- Yale Comprehensive Cancer Center, New Haven, CT
| | - Ligeng Tian
- Department of Internal Medicine (Medical Oncology), Yale School of Medicine, New Haven, CT
- Department of Internal Medicine (Hematology), Yale School of Medicine, New Haven, CT
| | - Fang-Yong Li
- Yale Comprehensive Cancer Center, New Haven, CT
- Yale Center for Analytical Sciences, New Haven, CT
| | - Nikolai Podoltsev
- Yale Comprehensive Cancer Center, New Haven, CT
- Department of Internal Medicine (Hematology), Yale School of Medicine, New Haven, CT
| | - Mina L. Xu
- Department of Pathology & Laboratory Medicine, Yale School of Medicine, New Haven, CT
- Yale Comprehensive Cancer Center, New Haven, CT
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Fathalla M, Hashim J, Alkindy H, Wali Y. Cerebrospinal fluid involvement in a case of visceral leishmaniasis associated with hemophagocytic lymphohistiocytosis. Sultan Qaboos Univ Med J 2007; 7:253-256. [PMID: 21748112 PMCID: PMC3074877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2007] [Accepted: 09/19/2007] [Indexed: 05/31/2023] Open
Abstract
Hemophagocytic Lymphohistiocytosis (HLH) implies a benign generalized histiocytic proliferate with erythrophagocytosis and it includes familial hemophagocytic lymphohistiocytosis and secondary hemophgocytosis. Spinal fluid changes like mild to moderate pleocytosis (most of the cells are lymphocytes and macrophages) and sometimes hemophagocytosis are seen in primary HLH but are not reported in secondary HLH. Here we report a case of a previously healthy 10 months old male infant who was diagnosed as familial HLH with evidence of CSF hemophagocytosis. He was started on the HLH 2004 treatment protocol with no improvement. A second bone marrow aspiration revealed leshmania donovani antibodies and he was started on anti-leishmania treatment with dramatic response.To the best of our knowledge, this is the first case of secondary HLH with evidence of hemophagocytosis in cerebrospinal fluid.
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