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Sztajnbok F, Fonseca AR, Campos LR, Lino K, Rodrigues MCF, Silva RM, de Almeida RG, Perazzio SF, Carvalho MDFF. Hemophagocytic lymphohistiocytosis and macrophage activation syndrome: two rare sides of the same devastating coin. Adv Rheumatol 2024; 64:28. [PMID: 38627860 DOI: 10.1186/s42358-024-00370-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare genetic hyperinflammatory syndrome that occurs early in life. Macrophage activation syndrome (MAS) usually refers to a secondary form of HLH associated with autoimmunity, although there are other causes of secondary HLH, such as infections and malignancy. In this article, we reviewed the concepts, epidemiology, clinical and laboratory features, diagnosis, differential diagnosis, prognosis, and treatment of HLH and MAS. We also reviewed the presence of MAS in the most common autoimmune diseases that affect children. Both are severe diseases that require prompt diagnosis and treatment to avoid morbidity and mortality.
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Affiliation(s)
- Flavio Sztajnbok
- Department of Pediatrics, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
- Pediatric Rheumatology Division, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.
- Rare Diseases Committee, Brazilian Society of Rheumatology (SBR), Rio de Janeiro, Brazil.
| | - Adriana Rodrigues Fonseca
- Department of Pediatrics, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leonardo Rodrigues Campos
- Hospital Universitário Antônio Pedro, Universidade Federal Fluminense, Niterói, Brazil
- Pediatric Rheumatology Committee, Sociedade de Reumatologia do Rio de Janeiro 2022-2024, Rio de Janeiro, Brazil
| | - Kátia Lino
- Hospital Universitário Antônio Pedro, Universidade Federal Fluminense, Niterói, Brazil
| | - Marta Cristine Félix Rodrigues
- Pediatric Rheumatology Division, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Rodrigo Moulin Silva
- Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Rozana Gasparello de Almeida
- Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Sandro Félix Perazzio
- Rare Diseases Committee, Brazilian Society of Rheumatology (SBR), Rio de Janeiro, Brazil
- Division of Rheumatology, Universidade Federal de São Paulo (UNIFESP), Sao Paulo, Brazil
| | - Margarida de Fátima Fernandes Carvalho
- Rare Diseases Committee, Brazilian Society of Rheumatology (SBR), Rio de Janeiro, Brazil
- Division of Pediatric Rheumatology, Universidade Estadual de Londrina (UEL), Paraná, Brazil
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Dangoni GD, Teixeira ACB, da Costa SS, Scliar MO, Carvalho LML, Silva LN, Novak EM, Vince CSC, Maschietto MC, Sugayama SMM, Odone-Filho V, Krepischi ACV. Germline mutations in cancer predisposition genes among pediatric patients with cancer and congenital anomalies. Pediatr Res 2024; 95:1346-1355. [PMID: 38182823 DOI: 10.1038/s41390-023-03000-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/08/2023] [Accepted: 12/20/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Childhood cancer has a poorly known etiology, and investigating the underlying genetic background may provide novel insights. A recognized association exists between non-chromosomal birth defects and childhood cancer susceptibility. METHODS We performed whole-exome sequencing and chromosomal microarray analysis in a cohort of childhood cancer (22 individuals, 50% with congenital anomalies) to unravel deleterious germline variants. RESULTS A diagnostic yield of 14% was found, encompassing heterozygous variants in bona fide dominant Cancer Predisposition Genes (CPGs). Considering candidate and recessive CPGs harboring monoallelic variants, which were also deemed to play a role in the phenotype, the yield escalated to 45%. Most of the deleterious variants were mapped in genes not conventionally linked to the patient's tumor type. Relevant findings were detected in 55% of the syndromic individuals, mostly variants potentially underlying both phenotypes. CONCLUSION We uncovered a remarkable prevalence of germline deleterious CPG variants, highlighting the significance of a comprehensive genetic analysis in pediatric cancer, especially when coupled with additional clinical signs. Moreover, our findings emphasized the potential for oligogenic inheritance, wherein multiple genes synergistically increase cancer risk. Lastly, our investigation unveiled potentially novel genotype-phenotype associations, such as SETD5 in neuroblastoma, KAT6A in gliomas, JAG1 in hepatoblastomas, and TNFRSF13B in Langerhans cell histiocytosis. IMPACT Novel gene-phenotype associations and candidate genes for pediatric cancer were unraveled, such as KAT6A in gliomas, SETD5 in neuroblastoma, JAG1 in hepatoblastomas, and TNFRSF13B in Langerhans cell histiocytosis. Our analysis revealed a high frequency of deleterious germline variants, particularly in cases accompanied by additional clinical signs, highlighting the importance of a comprehensive genetic evaluation in childhood cancer. Our findings also underscored the potential for oligogenic inheritance in pediatric cancer risk. Understanding the cancer etiology is crucial for genetic counseling, often influencing therapeutic decisions and offering valuable insights into molecular targets for the development of oncological therapies.
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Affiliation(s)
- Gustavo D Dangoni
- Human Genome and Stem Cell Research Center, Department of Genetics and Evolutionary Biology, Institute of Biosciences, University of São Paulo, São Paulo, SP, Brazil
| | - Anne Caroline B Teixeira
- Human Genome and Stem Cell Research Center, Department of Genetics and Evolutionary Biology, Institute of Biosciences, University of São Paulo, São Paulo, SP, Brazil
| | - Silvia S da Costa
- Human Genome and Stem Cell Research Center, Department of Genetics and Evolutionary Biology, Institute of Biosciences, University of São Paulo, São Paulo, SP, Brazil
| | - Marília O Scliar
- Human Genome and Stem Cell Research Center, Department of Genetics and Evolutionary Biology, Institute of Biosciences, University of São Paulo, São Paulo, SP, Brazil
| | - Laura M L Carvalho
- Human Genome and Stem Cell Research Center, Department of Genetics and Evolutionary Biology, Institute of Biosciences, University of São Paulo, São Paulo, SP, Brazil
| | - Luciana N Silva
- Department of Pediatrics, Instituto de Tratamento do Câncer Infantil (ITACI), Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Estela M Novak
- Department of Pediatrics, Instituto de Tratamento do Câncer Infantil (ITACI), Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | | | | | - Sofia M M Sugayama
- Department of Pediatrics, Instituto de Tratamento do Câncer Infantil (ITACI), Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Vicente Odone-Filho
- Department of Pediatrics, Instituto de Tratamento do Câncer Infantil (ITACI), Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Ana Cristina V Krepischi
- Human Genome and Stem Cell Research Center, Department of Genetics and Evolutionary Biology, Institute of Biosciences, University of São Paulo, São Paulo, SP, Brazil.
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Ricci S, Sarli WM, Lodi L, Canessa C, Lippi F, Dini D, Ferrari M, Pisano L, Sieni E, Indolfi G, Resti M, Azzari C. HLH as an additional warning sign of inborn errors of immunity beyond familial-HLH in children: a systematic review. Front Immunol 2024; 15:1282804. [PMID: 38415256 PMCID: PMC10896843 DOI: 10.3389/fimmu.2024.1282804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 01/29/2024] [Indexed: 02/29/2024] Open
Abstract
Background Hemophagocytic Lymphohistiocytosis (HLH) is a rare and life-threatening condition characterized by a severe impairment of the immune homeostasis. While Familial-HLH (FHL) is a known cause, the involvement of other Inborn Errors of Immunity (IEI) in pediatric-HLH remains understudied. Objective This systematic review aimed to assess the clinical features, triggers, laboratory data, treatment, and outcomes of pediatric HLH patients with IEI other than FHL (IEInotFHL), emphasizing the importance of accurate identification and management. Methods A systematic search for studies meeting inclusion criteria was conducted in PubMed, EMBASE, MEDLINE, and Cochrane Central. Quality assessment was performed through JBI criteria. Results A comprehensive search yielded 108 records meeting inclusion criteria, involving 178 patients. We identified 46 different IEI according to IUIS 2022 Classification. Combined immunodeficiencies, immune dysregulation disorders, and phagocyte defects were the IEI most frequently associated with HLH. In 75% of cases, HLH preceded the IEI diagnosis, often with an unrecognized history of severe infections. Triggers reflected the specific infection susceptibilities within IEI groups. Liver and central nervous system involvement were less common than in FHL cases. Treatment approaches and outcomes varied, with limited long-term follow-up data, limiting the assessment of therapeutic efficacy across IEI groups. Conclusion A comprehensive evaluation encompassing immunological, infectious, and genetic aspects is essential in pediatric-HLH. Relying solely on FHL or EBV susceptibility disorders tests is insufficient, as diverse other IEI can contribute to HLH. Early recognition of HLH as a potential warning sign can guide timely diagnostic investigations and facilitate tailored therapeutic interventions for improved outcomes. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=371425, PROSPERO, CRD42022371425.
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Affiliation(s)
- Silvia Ricci
- Department of Health Sciences, University of Florence, Florence, Italy
- Immunology Division, Section of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Walter Maria Sarli
- Department of Health Sciences, University of Florence, Florence, Italy
- Immunology Division, Section of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Lorenzo Lodi
- Department of Health Sciences, University of Florence, Florence, Italy
- Immunology Division, Section of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Clementina Canessa
- Immunology Division, Section of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Francesca Lippi
- Immunology Division, Section of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Donata Dini
- Department of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Marta Ferrari
- Department of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Laura Pisano
- Department of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Elena Sieni
- Pediatric Hematology-Oncology Department, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Giuseppe Indolfi
- Department of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
- Department Neurofarba, University of Florence, Florence, Italy
| | - Massimo Resti
- Department of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Chiara Azzari
- Department of Health Sciences, University of Florence, Florence, Italy
- Immunology Division, Section of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
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Chatham WW. Macrophage Activation Syndrome in the Setting of Rheumatic Diseases. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:399-408. [PMID: 39117829 DOI: 10.1007/978-3-031-59815-9_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Patients with established rheumatic disorders may develop complications of macrophage activation syndrome due to severe flares of the underlying disease (adult-onset Still's disease, SLE); however, in most other rheumatic disorders, MAS develops in association with identified viral or other infectious triggers. It is therefore important to pursue appropriate studies to identify potential infectious triggers in rheumatic disease patients who develop MAS. Management is best directed toward treatment of the triggering infections and combinations of high-dose corticosteroids, calcineurin inhibitors, and biologic therapies targeting IL-1 and/or IL-6 to suppress the associated cytokine storm.
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Affiliation(s)
- W Winn Chatham
- Department of Internal Medicine, University of Nevada, Las Vegas, Las Vegas, NV, USA.
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5
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Cerme E, Oztas M, Balkan II, Cetin EA, Ugurlu S. Haemophagocytic lymphohistiocytosis in a patient with familial Mediterranean fever and miliary tuberculosis: a case report. Mod Rheumatol Case Rep 2022; 6:140-144. [PMID: 34549298 DOI: 10.1093/mrcr/rxab026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/02/2021] [Accepted: 08/12/2021] [Indexed: 06/13/2023]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a lethal complication of several infections, especially viral origin. Mycobacterium tuberculosis infection can also lead to HLH, yet it is an uncommon trigger. Considering the role of increased cytokines in HLH, autoinflammatory conditions, such as familial Mediterranean fever (FMF), might contribute to its development. Nevertheless, the possible relationship between FMF and HLH has been suggested only in some case reports. We present a case of FMF who admitted to the hospital with consitutional symptoms and chest pain regarding to recurrent pericarditis. On a blood test, pancytopenia and elevated acute phase reactants were seen. Fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography demonstrated positive FDG uptake sites on both the right and left surrenal glands, the visceral layer of pericard, and reactive lymphadenomegalies at multiple mediastinal regions. Bone marrow biopsy revealed haemophagocytosis. Methylprednisolone treatment was initiated. Despite immunosuppressive treatment, clinical and biochemical parameters deteriorated; thus, a thorax computed tomography was executed. Findings were consistent with miliary tuberculosis infection. M. tuberculosis was detected in blood culture and bronchoalveolar lavage culture material. Also, bone marrow and surrenal biopsy material revealed necrotising caseating granuloma.
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Affiliation(s)
- Emir Cerme
- Department of Internal Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Mert Oztas
- Department of Internal Medicine, Division of Rheumatology, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ilker Inanc Balkan
- Department of Infectious Diseases and Clinical Microbiology, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Esin Aktas Cetin
- Institute of Experimental Medicine (DETAE), Department of Immunology, Istanbul University, Istanbul, Turkey
| | - Serdal Ugurlu
- Department of Internal Medicine, Division of Rheumatology, Istanbul University-Cerrahpasa, Istanbul, Turkey
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6
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Ali FEM, Mohammedsaleh ZM, Ali MM, Ghogar OM. Impact of cytokine storm and systemic inflammation on liver impairment patients infected by SARS-CoV-2: Prospective therapeutic challenges. World J Gastroenterol 2021; 27:1531-1552. [PMID: 33958841 PMCID: PMC8058655 DOI: 10.3748/wjg.v27.i15.1531] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/17/2021] [Accepted: 03/29/2021] [Indexed: 02/06/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a devastating worldwide pandemic infection caused by a severe acute respiratory syndrome namely coronavirus 2 (SARS-CoV-2) that is associated with a high spreading and mortality rate. On the date this review was written, SARS-CoV-2 infected about 96 million people and killed about 2 million people. Several arguments disclosed the high mortality of COVID-19 due to acute respiratory distress syndrome or change in the amount of angiotensin-converting enzyme 2 (ACE2) receptor expression or cytokine storm strength production. In a similar pattern, hepatic impairment patients co-infected with SARS-CoV-2 exhibited overexpression of ACE2 receptors and cytokine storm overwhelming, which worsens the hepatic impairment and increases the mortality rate. In this review, the impact of SARS-CoV-2 on hepatic impairment conditions we overviewed. Besides, we focused on the recent studies that indicated cytokine storm as well as ACE2 as the main factors for high COVID-19 spreading and mortality while hinting at the potential therapeutic strategies.
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Affiliation(s)
- Fares E M Ali
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Al-Azhar University, Assiut Branch, Assiut 71524, Egypt
| | - Zuhair M Mohammedsaleh
- Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, University of Tabuk, Tabuk 71491, Saudi Arabia
| | - Mahmoud M Ali
- Pre-graduated students, Faculty of Pharmacy, Al-Azhar University, Assiut Branch, Assiut 71524, Egypt
| | - Osama M Ghogar
- Pre-graduated students, Faculty of Pharmacy, Al-Azhar University, Assiut Branch, Assiut 71524, Egypt
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7
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Yücel BB, Aydog O, Nalcacioglu H, Yılmaz A. Effectiveness of Canakinumab Treatment in Colchicine Resistant Familial Mediterranean Fever Cases. Front Pediatr 2021; 9:710501. [PMID: 34568239 PMCID: PMC8461313 DOI: 10.3389/fped.2021.710501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 08/12/2021] [Indexed: 11/13/2022] Open
Abstract
Anti-interleukin 1 agents are used successfully in colchicine-resistant or intolerant Familial Mediterranean Fever (FMF) patients. Sixty-five patients with FMF who received canakinumab treatment for at least 6 months due to colchicine resistance or intolerance between 2016 and 2020 in our department were retrospectively analyzed. Canakinumab treatment was given subcutaneously every 4 weeks. After completing monthly canakinumab therapy over 12 months, in patients with complete remission, the dosing interval was extended to every 1.5 months for 6 months, then every 2 months for 6 months, and finally every 3 months for a year. In patients without disease activation, canakinumab treatment was discontinued at the end of 3 years and followed up with colchicine treatment. Patients who had a flare switched to the previous dosing interval. In patients with renal amyloidosis, monthly canakinumab treatment was continued without extending the dose intervals. The mean duration of canakinumab use in our patients was 31.4 ± 10.57 months (6-52 months). The mean age at onset of symptoms was 4.65 ± 3.84 (range, 1-18) years, and the mean age at diagnosis was 5.59 ± 3.9 (range, 4-19) years. Complete remission was achieved in 57 (87.6%) and partial remission in seven (10.7%) patients. One patient was unresponsive to treatment. Canakinumab treatment was discontinued in three patients with complete remission and one patient with drug resistance. Erythrocyte sedimentation rate (ESR) (51.85 ± 15.7 vs. 27.80 ± 13.73 mm/h) and C-reactive protein (CRP) [26 (3-73) vs. 5 (1-48) mg/L] values were compared before and after canakinumab treatment in attack-free periods, a significant decrease was found after canakinumab treatment (p < 0.001, p < 0.001, respectively). Bodyweight Z-scores (respectively -0.80 ± 0.86 vs. -0.49 ± 0.92) were compared, similarly, a statistically significant increase after canakinumab treatment (p < 0.001), but no significant increase in height Z scores (-1.00 ± 0.88 vs. -0.96 ± 0.94) (p = 0.445) was detected. Four patients had FMF-related renal amyloidosis. The decrease in proteinuria with canakinumab treatment was not statistically significant (p = 0.068). Cervical lymphadenitis developed in one and local reactions in two patients. No severe adverse effects requiring discontinuation of canakinumab treatment were observed. Our study showed that canakinumab treatment was highly effective, well-tolerated in pediatric FMF patients, and controlled extension of the canakinumab dose interval was safe.
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Affiliation(s)
- Burcu Bozkaya Yücel
- Department of Pediatric Rheumatology, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
| | - Ozlem Aydog
- Department of Pediatric Rheumatology, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey.,Department of Pediatric Nephrology, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
| | - Hulya Nalcacioglu
- Department of Pediatric Nephrology, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
| | - Ayşegül Yılmaz
- Department of Pediatric Genetics, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
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Maniscalco V, Abu-Rumeileh S, Mastrolia MV, Marrani E, Maccora I, Pagnini I, Simonini G. The off-label use of anakinra in pediatric systemic autoinflammatory diseases. Ther Adv Musculoskelet Dis 2020; 12:1759720X20959575. [PMID: 33149772 PMCID: PMC7580132 DOI: 10.1177/1759720x20959575] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 08/26/2020] [Indexed: 12/19/2022] Open
Abstract
Interleukin 1 (IL-1), a central mediator of innate immunity, is considered a master cytokine of local and systemic inflammation. IL-1 has emerged as pivotal in the pathogenesis of autoinflammatory diseases (AIDs), and blockade of its pathway has become a crucial target for therapy. Anakinra (ANA), a recombinant IL-1β receptor antagonist, was the first anti-IL-1 agent employed in clinical practice. ANA is currently approved for the treatment of rheumatoid arthritis, systemic juvenile idiopathic arthritis, adult-onset Still’s disease, and cryopyrin-associated autoinflammatory syndrome. It has also been successfully used for off-label treatment of various monogenic, polygenic, or undefined etiology systemic AIDs. This review describes currently available evidence for the off-label use of ANA in pediatric rheumatologic diseases. Specifically, the use of ANA in Kawasaki disease, idiopathic recurrent pericarditis, Behçet disease, monogenic AIDs, undifferentiated AIDs, chronic non-bacterial osteomyelitis, macrophage activation syndrome, and febrile infection-related epilepsy, in terms of its safety and efficacy. In selected pediatric rheumatic disorders, the off-label administration of ANA appears to be effective and safe. In order to control severe and/or relapsing disease, ANA should be considered as a valuable treatment option in children suffering from rare inflammatory diseases. However, currently available data consist of retrospective studies and short case series; thus, randomized controlled trials and larger series with long-term follow up are mandatory to better assess the efficacy and cost effectiveness of ANA in these challenging patients.
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Affiliation(s)
- Valerio Maniscalco
- Rheumatology Unit, Meyer Children's University Hospital, Florence, Italy
| | - Sarah Abu-Rumeileh
- Rheumatology Unit, Meyer Children's University Hospital, Florence, Italy
| | | | - Edoardo Marrani
- Rheumatology Unit, Meyer Children's University Hospital, Florence, Italy
| | - Ilaria Maccora
- Rheumatology Unit, Meyer Children's University Hospital, Florence, Italy
| | - Ilaria Pagnini
- Rheumatology Unit, Meyer Children's University Hospital, Florence, Italy
| | - Gabriele Simonini
- Rheumatology Unit, Meyer Children's University Hospital, Viale Gaetano Pieraccini, 24, Firenze, Toscana 50139, Italy
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Macrophage Activation Syndrome in Childhood Inflammatory Disorders: Diagnosis, Genetics, Pathophysiology, and Treatment. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2020. [DOI: 10.1007/s40674-020-00153-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Pal P, Bathia J, Giri PP, Roy M, Nandi A. Macrophage activation syndrome in pediatrics: 10 years data from an Indian center. Int J Rheum Dis 2020; 23:1412-1416. [PMID: 32666639 DOI: 10.1111/1756-185x.13915] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/21/2020] [Accepted: 06/21/2020] [Indexed: 11/29/2022]
Abstract
AIMS Macrophage activation syndrome (MAS) is a dreaded complication of systemic inflammatory diseases and is most commonly seen in systemic juvenile idiopathic arthritis (sJIA). We evaluate the clinical features, laboratory findings and outcomes in pediatric MAS, assess the response to different pharmacological therapies, and finally identify possible factors associated with an unfavorable outcome. METHODS This is a retrospective analysis of data from patients diagnosed as having MAS, admitted between July 2008 and April 2018 into the Department of Pediatric Rheumatology, Institute Of Child Health Kolkata. The data noted were the clinical and laboratory features, treatment details, responses to therapy and outcomes. RESULTS Thirty-one patients were diagnosed as having MAS. Primary illness was sJIA in 26 (84%), systemic lupus erythematosus in 4 (13%) and Kawasaki disease (KD) in 1 (3%). All had fever with varying degrees of multisystemic involvement. Hyperferritinemia was universally present. Pulse methylprednisolone with cyclosporine was used for treating the majority. Ten patients (32%) expired. CONCLUSION Macrophage activation syndrome is a near fatal complication with protean manifestations and multiorgan dysfunction. Hyperferritinemia is characteristic, higher values being associated with increased mortality. Cases resistant to steroids and cyclosporine had a poor prognosis. Late presentations with multiorgan dysfunction were associated with the poorest outcomes.
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Affiliation(s)
- Priyankar Pal
- Pediatric Rheumatology, Institute of Child Health, Kolkata, India
| | - Jigna Bathia
- Deptartment of Pediatrics, Institute of Child Health, Kolkata, India
| | | | - Mandira Roy
- Deptartment of Pediatrics, Institute of Child Health, Kolkata, India
| | - Alolika Nandi
- Deptartment of Pediatrics, Institute of Child Health, Kolkata, India
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11
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Soy M, Keser G, Atagündüz P, Tabak F, Atagündüz I, Kayhan S. Cytokine storm in COVID-19: pathogenesis and overview of anti-inflammatory agents used in treatment. Clin Rheumatol 2020; 39:2085-2094. [PMID: 32474885 PMCID: PMC7260446 DOI: 10.1007/s10067-020-05190-5] [Citation(s) in RCA: 514] [Impact Index Per Article: 128.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 05/01/2020] [Accepted: 05/19/2020] [Indexed: 12/11/2022]
Abstract
COVID-19 infection has a heterogenous disease course; it may be asymptomatic or causes only mild symptoms in the majority of the cases, while immunologic complications such as macrophage activation syndrome also known as secondary hemophagocytic lymphohistiocytosis, resulting in cytokine storm syndrome and acute respiratory distress syndrome, may also occur in some patients. According to current literature, impairment of SARS-CoV-2 clearance due to genetic and viral features, lower levels of interferons, increased neutrophil extracellular traps, and increased pyroptosis and probable other unknown mechanisms create a background for severe disease course complicated by macrophage activation syndrome and cytokine storm. Various genetic mutations may also constitute a risk factor for severe disease course and occurrence of cytokine storm in COVID-19. Once, immunologic complications like cytokine storm occur, anti-viral treatment alone is not enough and should be combined with appropriate anti-inflammatory treatment. Anti-rheumatic drugs, which are tried for managing immunologic complications of COVID-19 infection, will also be discussed including chloroquine, hydroxychloroquine, JAK inhibitors, IL-6 inhibitors, IL-1 inhibitors, anti-TNF-α agents, corticosteroids, intravenous immunoglobulin (IVIG), and colchicine. Early recognition and appropriate treatment of immunologic complications will decrease the morbidity and mortality in COVID-19 infection, which requires the collaboration of infectious disease, lung, and intensive care unit specialists with other experts such as immunologists, rheumatologists, and hematologists.
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Affiliation(s)
- Mehmet Soy
- Internal Medicine and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Division of Rheumatology, Bahcelievler MedicalPark Hospital, Altinbas University (Previously Kemerburgaz University, Istanbul, Turkey
| | - Gökhan Keser
- Internal Medicine and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Division of Rheumatology, Ege University, Izmir, Turkey
| | - Pamir Atagündüz
- Internal Medicine and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Division of Rheumatology, Marmara University, Istanbul, Turkey
| | - Fehmi Tabak
- Internal Medicine and Infectious Disease, Department of Infectious Diseases, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Işık Atagündüz
- Internal Medicine and Hematology, Department of Internal Medicine, Faculty of Medicine, Division of Hematology, Marmara University, Istanbul, Turkey
| | - Servet Kayhan
- Bahcelievler MedicalPark Hospital; Department of Chest Disease, Faculty of Medicine, Altinbas University (Previously Kemerburgaz University), Istanbul, Turkey
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12
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Henderson LA, Cron RQ. Macrophage Activation Syndrome and Secondary Hemophagocytic Lymphohistiocytosis in Childhood Inflammatory Disorders: Diagnosis and Management. Paediatr Drugs 2020; 22:29-44. [PMID: 31732958 PMCID: PMC7334831 DOI: 10.1007/s40272-019-00367-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Macrophage activation syndrome (MAS), a form of secondary hemophagocytic lymphohistiocytosis, is a frequently fatal complication of a variety of pediatric inflammatory disorders. MAS has been most commonly associated with systemic juvenile idiopathic arthritis (sJIA), as approximately 10% of children with sJIA develop fulminant MAS, with another 30-40% exhibiting a more subclinical form of the disease. Children with other rheumatologic conditions such as systemic lupus erythematosus and Kawasaki disease are also at risk for MAS. Moreover, MAS also complicates various genetic autoinflammatory disorders such as gain of function mutations in the cytosolic inflammasome NLRC4, pediatric hematologic malignancies (e.g., T-cell lymphoma), and primary immunodeficiencies characterized by immune dysregulation. Disease-specific and broadly inclusive diagnostic criteria have been developed to facilitate the diagnosis of MAS. Recently, simple screening tools such as the serum ferritin to erythrocyte sedimentation rate ratio have been proposed. Early diagnosis and rapid initiation of immunosuppression are essential for the effective management of MAS. With a better understanding of the pathophysiology of MAS and the advent of novel therapeutics, a broad immunosuppressive approach to treatment is giving way to targeted anti-cytokine therapies. These treatments include agents that block interleukin-1 (IL-1), IL-6, IL-18, interferon-γ, as well as inhibitors of downstream targets of cytokine signaling (e.g., Janus kinases). Increased early recognition of MAS among pediatric inflammatory disorders combined with the use of effective and less toxic cytokine-targeted therapies should lower the mortality of this frequently fatal disorder.
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Affiliation(s)
- Lauren A. Henderson
- Division of Immunology, Boston Children’s Hospital, 1 Blackfan Circle, 10th Floor Karp Family Research Building, Boston, MA 02115, USA
| | - Randy Q. Cron
- Division of Pediatric Rheumatology, Children’s of Alabama, 1600 7th Ave. S., CPPN, suite G10, Birmingham, AL 35233-1711, USA
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Wekell P, Berg S, Karlsson A, Fasth A. Toward an Inclusive, Congruent, and Precise Definition of Autoinflammatory Diseases. Front Immunol 2017; 8:497. [PMID: 28496446 PMCID: PMC5406409 DOI: 10.3389/fimmu.2017.00497] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 04/11/2017] [Indexed: 11/13/2022] Open
Abstract
Autoinflammatory disease was introduced as a concept in 1999, demarcating an entirely new group of diseases in clinical, immunological, and conceptual terms. During recent years, the preconditions for the definition of autoinflammatory conditions have changed. This includes the recent discovery of a number of monogenic autoinflammatory conditions with complex phenotypes that combine autoinflammation with defects of the adaptive and/or innate immune system, resulting in the occurrence of infection, autoimmunity, and/or uncontrolled hyperinflammation in addition to autoinflammation. Further, there are strong indications that classical IL-1-driven autoinflammatory diseases are associated with activation of adaptive immunity. As suggested by this development, we are of the opinion that an all-encompassing definition of autoinflammatory diseases should regard autoinflammatory conditions and innate dysregulation as inseparable and integral parts of the immune system as a whole. Hence, in this article, we try to advance the conceptual understanding of autoinflammatory disease by, proposing a modification of the definition by Daniel Kastner et al., which allows for a congruent and precise description of conditions that expand the immunological spectrum of autoinflammatory disease.
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Affiliation(s)
- Per Wekell
- Department of Pediatrics, NU-Hospital Group, Uddevalla, Sweden.,Department of Pediatrics, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Stefan Berg
- Department of Pediatrics, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden.,The Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Anna Karlsson
- Department of Rheumatology and Inflammation Research, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Anders Fasth
- Department of Pediatrics, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden.,The Queen Silvia Children's Hospital, Gothenburg, Sweden
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14
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Ravelli A, Minoia F, Davì S, Horne A, Bovis F, Pistorio A, Aricò M, Avcin T, Behrens EM, De Benedetti F, Filipovic L, Grom AA, Henter JI, Ilowite NT, Jordan MB, Khubchandani R, Kitoh T, Lehmberg K, Lovell DJ, Miettunen P, Nichols KE, Ozen S, Pachlopnik Schmid J, Ramanan AV, Russo R, Schneider R, Sterba G, Uziel Y, Wallace C, Wouters C, Wulffraat N, Demirkaya E, Brunner HI, Martini A, Ruperto N, Cron RQ. 2016 Classification Criteria for Macrophage Activation Syndrome Complicating Systemic Juvenile Idiopathic Arthritis: A European League Against Rheumatism/American College of Rheumatology/Paediatric Rheumatology International Trials Organisation Collaborative Initiative. Ann Rheum Dis 2016; 75:481-9. [PMID: 26865703 DOI: 10.1136/annrheumdis-2015-208982] [Citation(s) in RCA: 254] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
To develop criteria for the classification of macrophage activation syndrome (MAS) in patients with systemic juvenile idiopathic arthritis (JIA). A multistep process, based on a combination of expert consensus and analysis of real patient data, was conducted. A panel of 28 experts was first asked to classify 428 patient profiles as having or not having MAS, based on clinical and laboratory features at the time of disease onset. The 428 profiles comprised 161 patients with systemic JIA-associated MAS and 267 patients with a condition that could potentially be confused with MAS (active systemic JIA without evidence of MAS, or systemic infection). Next, the ability of candidate criteria to classify individual patients as having MAS or not having MAS was assessed by evaluating the agreement between the classification yielded using the criteria and the consensus classification of the experts. The final criteria were selected in a consensus conference. Experts achieved consensus on the classification of 391 of the 428 patient profiles (91.4%). A total of 982 candidate criteria were tested statistically. The 37 best-performing criteria and 8 criteria obtained from the literature were evaluated at the consensus conference. During the conference, 82% consensus among experts was reached on the final MAS classification criteria. In validation analyses, these criteria had a sensitivity of 0.73 and a specificity of 0.99. Agreement between the classification (MAS or not MAS) obtained using the criteria and the original diagnosis made by the treating physician was high (κ=0.76). We have developed a set of classification criteria for MAS complicating systemic JIA and provided preliminary evidence of its validity. Use of these criteria will potentially improve understanding of MAS in systemic JIA and enhance efforts to discover effective therapies, by ensuring appropriate patient enrollment in studies.
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Affiliation(s)
- Angelo Ravelli
- Università degli Studi di Genova and Istituto Giannina Gaslini, Genoa, Italy
| | | | | | - AnnaCarin Horne
- Karolinska Institute and Karolinska University Hospital Solna, Stockholm, Sweden
| | | | | | | | - Tadej Avcin
- University Children's Hospital, Ljubljana, Slovenia
| | - Edward M Behrens
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Lisa Filipovic
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alexei A Grom
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jan-Inge Henter
- Karolinska Institute and Karolinska University Hospital Solna, Stockholm, Sweden
| | - Norman T Ilowite
- Albert Einstein College of Medicine and Children's Hospital at Montefiore, Bronx, New York, USA
| | - Michael B Jordan
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | | | | - Daniel J Lovell
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Kim E Nichols
- St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Seza Ozen
- Hacettepe University, Ankara, Turkey
| | | | | | - Ricardo Russo
- Hospital de Pediatria Juan P. Garrahan, Buenos Aires, Argentina
| | - Rayfel Schneider
- University of Toronto and Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gary Sterba
- Mount Sinai Medical Center, Miami Beach, Florida, USA
| | | | - Carol Wallace
- Seattle Children's Hospital and University of Washington, Seattle, USA
| | | | - Nico Wulffraat
- Wilhelmina Children's Hospital and University Medical Center Utrecht, Uthrecht, The Netherlands
| | | | - Hermine I Brunner
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alberto Martini
- Università degli Studi di Genova and Istituto Giannina Gaslini, Genoa, Italy
| | | | - Randy Q Cron
- University of Alabama at Birmingham, Birmingham, UK
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15
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Ravelli A, Minoia F, Davì S, Horne A, Bovis F, Pistorio A, Aricò M, Avcin T, Behrens EM, De Benedetti F, Filipovic L, Grom AA, Henter JI, Ilowite NT, Jordan MB, Khubchandani R, Kitoh T, Lehmberg K, Lovell DJ, Miettunen P, Nichols KE, Ozen S, Pachlopnik Schmid J, Ramanan AV, Russo R, Schneider R, Sterba G, Uziel Y, Wallace C, Wouters C, Wulffraat N, Demirkaya E, Brunner HI, Martini A, Ruperto N, Cron RQ. 2016 Classification Criteria for Macrophage Activation Syndrome Complicating Systemic Juvenile Idiopathic Arthritis: A European League Against Rheumatism/American College of Rheumatology/Paediatric Rheumatology International Trials Organisation Collaborative Initiative. Arthritis Rheumatol 2016; 68:566-76. [PMID: 26314788 DOI: 10.1002/art.39332] [Citation(s) in RCA: 316] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 11/30/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To develop criteria for the classification of macrophage activation syndrome (MAS) in patients with systemic juvenile idiopathic arthritis (JIA). METHODS A multistep process, based on a combination of expert consensus and analysis of real patient data, was conducted. A panel of 28 experts was first asked to classify 428 patient profiles as having or not having MAS, based on clinical and laboratory features at the time of disease onset. The 428 profiles comprised 161 patients with systemic JIA-associated MAS and 267 patients with a condition that could potentially be confused with MAS (active systemic JIA without evidence of MAS, or systemic infection). Next, the ability of candidate criteria to classify individual patients as having MAS or not having MAS was assessed by evaluating the agreement between the classification yielded using the criteria and the consensus classification of the experts. The final criteria were selected in a consensus conference. RESULTS Experts achieved consensus on the classification of 391 of the 428 patient profiles (91.4%). A total of 982 candidate criteria were tested statistically. The 37 best-performing criteria and 8 criteria obtained from the literature were evaluated at the consensus conference. During the conference, 82% consensus among experts was reached on the final MAS classification criteria. In validation analyses, these criteria had a sensitivity of 0.73 and a specificity of 0.99. Agreement between the classification (MAS or not MAS) obtained using the criteria and the original diagnosis made by the treating physician was high (κ = 0.76). CONCLUSION We have developed a set of classification criteria for MAS complicating systemic JIA and provided preliminary evidence of its validity. Use of these criteria will potentially improve understanding of MAS in systemic JIA and enhance efforts to discover effective therapies, by ensuring appropriate patient enrollment in studies.
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Affiliation(s)
- Angelo Ravelli
- Università degli Studi di Genova and Istituto Giannina Gaslini, Genoa, Italy
| | | | | | - AnnaCarin Horne
- Karolinska Institute and Karolinska University Hospital Solna, Stockholm, Sweden
| | | | | | | | - Tadej Avcin
- University Children's Hospital, Ljubljana, Slovenia
| | - Edward M Behrens
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Lisa Filipovic
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alexei A Grom
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jan-Inge Henter
- Karolinska Institute and Karolinska University Hospital Solna, Stockholm, Sweden
| | - Norman T Ilowite
- Albert Einstein College of Medicine and Children's Hospital at Montefiore, Bronx, New York
| | | | | | | | | | - Daniel J Lovell
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Kim E Nichols
- St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Seza Ozen
- Hacettepe University, Ankara, Turkey
| | | | | | - Ricardo Russo
- Hospital de Pediatria Juan P. Garrahan, Buenos Aires, Argentina
| | - Rayfel Schneider
- University of Toronto and Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gary Sterba
- Mount Sinai Medical Center, Miami Beach, Florida
| | | | - Carol Wallace
- Seattle Children's Hospital and University of Washington, Seattle
| | | | - Nico Wulffraat
- Wilhelmina Children's Hospital and University Medical Center Utrecht, Uthrecht, The Netherlands
| | | | | | - Alberto Martini
- Università degli Studi di Genova and Istituto Giannina Gaslini, Genoa, Italy
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16
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Abstract
Macrophage activation syndrome (MAS) is a potentially life-threatening complication of rheumatic disorders that occurs most commonly in systemic juvenile idiopathic arthritis. In recent years, there have been several advances in the understanding of the pathophysiology of MAS. Furthermore, new classification criteria have been developed. Although the place of cytokine blockers in the management of MAS is still unclear, interleukin-1 inhibitors represent a promising adjunctive therapy, particularly in refractory cases.
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Affiliation(s)
- Angelo Ravelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Head, Center of Rheumatology, University of Genoa and G. Gaslini Institute, via G. Gaslini 5, Genoa 16147, Italy.
| | - Sergio Davì
- Second Pediatric Division and Rheumatology, G. Gaslini Institute, via G. Gaslini 5, Genoa 16147, Italy
| | - Francesca Minoia
- Second Pediatric Division and Rheumatology, G. Gaslini Institute, via G. Gaslini 5, Genoa 16147, Italy
| | - Alberto Martini
- Department of Pediatrics and Second Pediatric Division and Rheumatology, University of Genoa and G. Gaslini Institute, via G. Gaslini 5, Genoa 16147, Italy
| | - Randy Q Cron
- Director, Division of Pediatric Rheumatology, Children's Hospital of Alabama and University of Alabama at Birmingham, Children's Park Place, Ste. 210 1601 4th Avenue South Birmingham, AL 35233, USA
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17
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Bode SF, Ammann S, Al-Herz W, Bataneant M, Dvorak CC, Gehring S, Gennery A, Gilmour KC, Gonzalez-Granado LI, Groß-Wieltsch U, Ifversen M, Lingman-Framme J, Matthes-Martin S, Mesters R, Meyts I, van Montfrans JM, Pachlopnik Schmid J, Pai SY, Soler-Palacin P, Schuermann U, Schuster V, Seidel MG, Speckmann C, Stepensky P, Sykora KW, Tesi B, Vraetz T, Waruiru C, Bryceson YT, Moshous D, Lehmberg K, Jordan MB, Ehl S. The syndrome of hemophagocytic lymphohistiocytosis in primary immunodeficiencies: implications for differential diagnosis and pathogenesis. Haematologica 2015; 100:978-88. [PMID: 26022711 DOI: 10.3324/haematol.2014.121608] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 05/06/2015] [Indexed: 12/21/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis is a hyperinflammatory syndrome defined by clinical and laboratory criteria. Current criteria were created to identify patients with familial hemophagocytic lmyphohistiocytosis in immediate need of immunosuppressive therapy. However, these criteria also identify patients with infection-associated hemophagocytic inflammatory states lacking genetic defects typically predisposing to hemophagocytic lymphohistiocytosis. These patients include those with primary immunodeficiencies, in whom the pathogenesis of the inflammatory syndrome may be distinctive and aggressive immunosuppression is contraindicated. To better characterize hemophagocytic inflammation associated with immunodeficiencies, we combined an international survey with a literature search and identified 63 patients with primary immunodeficiencies other than cytotoxicity defects or X-linked lymphoproliferative disorders, presenting with conditions fulfilling current criteria for hemophagocytic lymphohistiocytosis. Twelve patients had severe combined immunodeficiency with <100/μL T cells, 18 had partial T-cell deficiencies; episodes of hemophagocytic lymphohistiocytosis were mostly associated with viral infections. Twenty-two patients had chronic granulomatous disease with hemophagocytic episodes mainly associated with bacterial infections. Compared to patients with cytotoxicity defects, patients with T-cell deficiencies had lower levels of soluble CD25 and higher ferritin concentrations. Other criteria for hemophagocytoc lymphohistiocytosis were not discriminative. Thus: (i) a hemophagocytic inflammatory syndrome fulfilling criteria for hemophagocytic lymphohistiocytosis can be the initial manifestation of primary immunodeficiencies; (ii) this syndrome can develop despite severe deficiency of T and NK cells, implying that the pathophysiology is distinct and not appropriately described as "lympho"-histiocytosis in these patients; and (iii) current criteria for hemophagocytoc lymphohistiocytosis are insufficient to differentiate hemophagocytic inflammatory syndromes with different pathogeneses. This is important because of implications for therapy, in particular for protocols targeting T cells.
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Affiliation(s)
- Sebastian Fn Bode
- Center of Chronic Immunodeficiency, University Medical Center Freiburg, Germany Center for Pediatrics and Adolescent Medicine, University Medical Center Freiburg, Germany
| | - Sandra Ammann
- Center of Chronic Immunodeficiency, University Medical Center Freiburg, Germany Faculty of Biology, University of Freiburg, Germany
| | - Waleed Al-Herz
- Department of Pediatrics, Faculty of Medicine, Kuwait University, Safat, Kuwait
| | - Mihaela Bataneant
- Discipline of Pediatrics III, Victor Babes University of Medicine and Pharmacy Timisoara, Romania
| | - Christopher C Dvorak
- Pediatric Allergy, Immunology and Blood and Marrow Transplant Division, UCSF, Benioff Children's Hospital, San Francisco, California, USA
| | - Stephan Gehring
- Center for Pediatrics and Adolescent Medicine, Mainz, Germany
| | - Andrew Gennery
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Kimberly C Gilmour
- Camelia Botnar Laboratories, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Luis I Gonzalez-Granado
- Immunodeficiencies Unit, Hematology & Oncology Unit, Pediatrics, Hospital 12 Octubre, Madrid, Spain
| | - Ute Groß-Wieltsch
- Pediatric Hematology, Oncology and Immunology, Olga Hospital, Stuttgart, Germany
| | - Marianne Ifversen
- Department of Pediatrics, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | | | - Rolf Mesters
- Department of Medicine/Hematology and Oncology, University Hospital Muenster, Germany
| | - Isabelle Meyts
- Department of Pediatrics, Department of Micriobiology and Immunology, University Hospitals Leuven, Katholieke Universiteit Leuven, Belgium
| | - Joris M van Montfrans
- Department of Pediatric Immunology, Wilhelmina Children's, Hospital/University Medical Centre Utrecht, The Netherlands
| | - Jana Pachlopnik Schmid
- Jeffrey Modell Diagnostic Center for Primary Immunodeficiencies, University Children's Hospital Zurich, Switzerland
| | - Sung-Yun Pai
- Division of Hematology-Oncology, Boston Children's Hospital and Department of Pediatric Oncology, Dana-Farber Children's Hospital, Boston, Massachusetts, USA
| | - Pere Soler-Palacin
- Pediatric Infectious Diseases and Immunodeficiencies Unit. Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Spain
| | - Uta Schuermann
- Children's Hospital of Datteln, University of Witten-Herdecke, Datteln, Germany
| | - Volker Schuster
- Hospital for Children and Adolescents, University of Leipzig, Germany
| | - Markus G Seidel
- Pediatric Hematology-Oncology, Medical University of Graz, Austria
| | - Carsten Speckmann
- Center of Chronic Immunodeficiency, University Medical Center Freiburg, Germany Center for Pediatrics and Adolescent Medicine, University Medical Center Freiburg, Germany
| | - Polina Stepensky
- Pediatric Hematology-Oncology and Bone Marrow Transplantation, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | | | - Bianca Tesi
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Thomas Vraetz
- Center for Pediatrics and Adolescent Medicine, University Medical Center Freiburg, Germany
| | | | - Yenan T Bryceson
- Center for Infectious Medicine, Department of Medicine, Karolinska Institutet, University Hospital Huddinge, Stockholm, Sweden
| | - Despina Moshous
- Unit for Pediatric Immunology, Hematology and Rheumatology (UIHR), Hôpital Necker-Enfants Malades, Paris, France
| | - Kai Lehmberg
- Department of Hematology and Oncology, Children's Hospital, University of Hamburg, Germany
| | - Michael B Jordan
- Division of Bone Marrow Transplantation and Immunodeficiency, Cincinnati Children's Hospital Medical Center, University of Cincinnati Medical School, Ohio, USA
| | - Stephan Ehl
- Center of Chronic Immunodeficiency, University Medical Center Freiburg, Germany Center for Pediatrics and Adolescent Medicine, University Medical Center Freiburg, Germany
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Assari R, Ziaee V, Mirmohammadsadeghi A, Moradinejad MH. Dynamic Changes, Cut-Off Points, Sensitivity, and Specificity of Laboratory Data to Differentiate Macrophage Activation Syndrome from Active Disease. DISEASE MARKERS 2015; 2015:424381. [PMID: 26063955 PMCID: PMC4430633 DOI: 10.1155/2015/424381] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 04/03/2015] [Accepted: 04/07/2015] [Indexed: 11/23/2022]
Abstract
PURPOSE To compare the laboratory data and changes in these data between patients with MAS and patients with flare-up of the autoimmune diseases. METHODS In a prospective study, the static laboratory data and dynamic changes in the selected data in 17 consecutive patients with MAS and 53 patients with active disease of SJIA, PJIA, Kawasaki disease, and SLE were compared. The ROC curve analysis was used to evaluate cut-off points, sensitivity, and specificity of the static and dynamic laboratory data to differentiate between MAS and active disease. RESULTS In the MAS group, the mean CRP3, ALT, AST, total bilirubin, ferritin, LDH, PT, PTT, and INR were significantly higher and the mean WBC2, PMN2, Lymph2, Hgb1, 2, 3, ESR2, serum albumin, and sodium were significantly lower than in control group. Some of the important cut-off points were PLT2 < 209000/microliter, AST > 38.5, ALT > 38, WBC < 8200 × 103/UL, ferritin > 5277 ng/mL. CONCLUSION The dynamic changes in some laboratory data, especially PLT, can differentiate between MAS and active disease. The changes in WBC, PMN, and ESR and the levels of the liver enzymes may also be helpful in the early differentiation. Very high levels of ferritin may also help the diagnosis along with other clinical and laboratory signs.
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Affiliation(s)
- Raheleh Assari
- Children's Medical Center, Pediatrics Center of Excellence, Tehran, Iran
| | - Vahid Ziaee
- Pediatric Rheumatology Research Group, Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mohammad-Hassan Moradinejad
- Children's Medical Center, Pediatrics Center of Excellence, Tehran, Iran
- Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran
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19
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Macrophage activation syndrome in the course of monogenic autoinflammatory disorders. Clin Rheumatol 2015; 34:1333-9. [PMID: 25846831 DOI: 10.1007/s10067-015-2923-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 03/15/2015] [Accepted: 03/20/2015] [Indexed: 01/15/2023]
Abstract
An overwhelming activation of cytotoxic T cells and well-differentiated macrophages leading to systemic overload of inflammatory mediators characterizes the so-called macrophage activation syndrome (MAS); this potentially life-threatening clinical entity may derive from several genetic defects involved in granule-mediated cytotoxicity but has been largely observed in patients with juvenile idiopathic arthritis, many rheumatologic diseases, infections, and malignancies. The occurrence of MAS in the natural history or as the revealing clue of monogenic autoinflammatory disorders (AIDs), rare conditions caused by disrupted innate immunity pathways with overblown release of proinflammatory cytokines, has been only reported in few isolated patients with cryopyrin-associated periodic syndrome, mevalonate kinase deficiency, familial Mediterranean fever, and tumor necrosis factor receptor-associated periodic syndrome since 2001. All these patients displayed various clinical, laboratory, and histopathologic features of MAS and have often required intensive care support. Only one patient has died due to MAS. Defective cytotoxic cell function was documented in a minority of patients. Corticosteroids were the first-line treatment, but anakinra was clinically effective in three refractory cases. Even if MAS and AIDs share multiple clinical features as well as heterogeneous pathogenetic scenes and a potential response to anti-interleukin-1 targeted therapies, MAS requires a prompt specific recognition in the course of AIDs due to its profound severity and high mortality rate.
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20
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Woerner A, von Scheven-Gête A, Cimaz R, Hofer M. Complications of systemic juvenile idiopathic arthritis: risk factors and management recommendations. Expert Rev Clin Immunol 2015; 11:575-88. [PMID: 25843554 DOI: 10.1586/1744666x.2015.1032257] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Systemic juvenile idiopathic arthritis (SJIA) is an inflammatory condition characterized by fever, lymphadenopathy, arthritis, rash and serositis. Systemic inflammation has been associated with dysregulation of the innate immune system, suggesting that SJIA is an autoinflammatory disorder. IL-1 and IL-6 play a major role in the pathogenesis of SJIA, and treatment with IL-1 and IL-6 inhibitors has shown to be highly effective. However, complications of SJIA, including macrophage activation syndrome, limitations in functional outcome by arthritis and long-term damage from chronic inflammation, continue to be a major issue in SJIA patients' care. Translational research leading to a profound understanding of the cytokine crosstalk in SJIA and the identification of risk factors for SJIA complications will help to improve long-term outcome.
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Affiliation(s)
- Andreas Woerner
- Pediatric Rheumatology, University of Basel, University Children's Hospital, Basel, Switzerland
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21
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Fujikawa K, Migita K, Shigemitsu Y, Umeda M, Nonaka F, Tamai M, Nakamura H, Mizokami A, Tsukada T, Origuchi T, Yonemitsu N, Yasunami M, Kawakami A, Eguchi K. MEFV gene polymorphisms and TNFRSF1A mutation in patients with inflammatory myopathy with abundant macrophages. Clin Exp Immunol 2014; 178:224-8. [PMID: 24965843 DOI: 10.1111/cei.12407] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2014] [Indexed: 12/29/2022] Open
Abstract
Inflammatory myopathy with abundant macrophages (IMAM) has recently been proposed as a new clinical condition. Although IMAM shares certain similarities with other inflammatory myopathies, the mechanisms responsible for this condition remain unknown. Patients with familial Mediterranean fever (FMF) and tumour necrosis factor receptor-associated periodic syndrome (TRAPS) also often develop myalgia. We therefore investigated the polymorphisms or mutations of MEFV and TNFRSF1A genes in patients with IMAM to identify their potential role in this condition. We analysed the clinical features of nine patients with IMAM and sequenced exons of the MEFV and TNFRSF1A genes. The patients with IMAM had clinical symptoms such as myalgia, muscle weakness, erythema, fever and arthralgia. Although none of the patients were diagnosed with FMF or TRAPS, seven demonstrated MEFV polymorphisms (G304R, R202R, E148Q, E148Q-L110P and P369S-R408Q), and one demonstrated a TNFRSF1A mutation (C43R). These results suggest that MEFV gene polymorphisms and TNFRSF1A mutation are susceptibility and modifier genes in IMAM.
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Affiliation(s)
- K Fujikawa
- Department of Rheumatology, Japan Community Health Care Organization, Isahaya General Hospital, Isahaya, Japan
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22
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Malbora B, Polat E, Akyuz SG. Hemophagocytic lymphohistiocytosis and pelger-huët anomaly associated with colchicine intoxication. Hematol Rep 2014; 6:5356. [PMID: 25013716 PMCID: PMC4091288 DOI: 10.4081/hr.2014.5356] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 04/20/2014] [Accepted: 05/20/2014] [Indexed: 02/07/2023] Open
Abstract
Colchicine is frequently used in the treatment of familial Mediterranean fever (FMF). First symptoms of colchicine intoxication are gastrointestinal disturbances, such as abdominal cramps, diarrhea, pancytopenia and so on. Herein, we report a female FMF patient with pancytopenia and hemophagocytic lymphohitiocytosis (HLH), following colchicine intoxication for committing suicide. To our knowledge, this is the first reported case of a patient with HLH associated with colchicine intoxication.
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Affiliation(s)
- Baris Malbora
- Departments of Pediatric Hematology, Dr. Sami Ulus Research and Training Hospital of Women's and Children's Health and Diseases , Ankara, Turkey
| | - Emine Polat
- Departments of Pediatrics, Dr. Sami Ulus Research and Training Hospital of Women's and Children's Health and Diseases , Ankara, Turkey
| | - Sare Gulfem Akyuz
- Departments of Pediatric Nephrology, Dr. Sami Ulus Research and Training Hospital of Women's and Children's Health and Diseases , Ankara, Turkey
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Shimizu M, Yokoyama T, Tokuhisa Y, Ishikawa S, Sakakibara Y, Ueno K, Yachie A. Distinct cytokine profile in juvenile systemic lupus erythematosus-associated macrophage activation syndrome. Clin Immunol 2013; 146:73-6. [DOI: 10.1016/j.clim.2012.11.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 10/26/2012] [Accepted: 11/07/2012] [Indexed: 11/25/2022]
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Lattanzi B, Davi S, Rosina S, Solari N, Lanni S, Bracciolini G, Martini A, Ravelli A. Macrophage activation syndrome. INDIAN JOURNAL OF RHEUMATOLOGY 2012. [DOI: 10.1016/s0973-3698(12)60026-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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25
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Ravelli A, Grom AA, Behrens EM, Cron RQ. Macrophage activation syndrome as part of systemic juvenile idiopathic arthritis: diagnosis, genetics, pathophysiology and treatment. Genes Immun 2012; 13:289-98. [PMID: 22418018 DOI: 10.1038/gene.2012.3] [Citation(s) in RCA: 265] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Macrophage activation syndrome (MAS) is a severe, frequently fatal complication of systemic juvenile idiopathic arthritis (sJIA) with features of hemophagocytosis leading to coagulopathy, pancytopenia, and liver and central nervous system dysfunction. MAS is overt in 10% of children with sJIA but occurs subclinically in another 30-40%. It is difficult to distinguish sJIA disease flare from MAS. Development of criteria for establishing MAS as part of sJIA are under way and will hopefully prove sensitive and specific. Mutations in cytolytic pathway genes are increasingly being recognized in children who develop MAS as part of sJIA. Identification of these mutations may someday assist in MAS diagnosis. Defects in cytolytic genes have provided murine models of MAS to study pathophysiology and treatment. Recently, the first mouse model of MAS not requiring infection but rather dependent on repeated stimulation through Toll-like receptors was reported. This provides a model of MAS that may more accurately reflect MAS pathology in the setting of autoinflammation or autoimmunity. This model confirms the importance of a balance between pro- and anti-inflammatory cytokines. There has been remarkable progress in the use of anti-pro-inflammatory cytokine therapy, particularly against interleukin-1, in the treatment of secondary forms of MAS, such as in sJIA.
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Affiliation(s)
- A Ravelli
- Department of Pediatrics, Università degli Studi di Genova, Genova, Italy
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