1
|
Deza Leon M, Otto WR, Danziger-Isakov L, Kumar A, Scaggs Huang F. Infectious Diseases Evaluation of the Child With Suspected Hemophagocytic Lymphohistiocytosis. J Pediatric Infect Dis Soc 2024; 13:220-227. [PMID: 38263470 DOI: 10.1093/jpids/piae007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/22/2024] [Indexed: 01/25/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of excessive and maladaptive inflammation. In this review, we discuss how the clinical and laboratory features of HLH overlap with infection and propose a diagnostic and treatment strategy to identify patients with infections mimicking HLH.
Collapse
Affiliation(s)
- Maria Deza Leon
- Division of Infectious Disease, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - William R Otto
- Division of Infectious Disease, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lara Danziger-Isakov
- Division of Infectious Disease, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ashish Kumar
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Felicia Scaggs Huang
- Division of Infectious Disease, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| |
Collapse
|
2
|
Lv K, Cheng X, Zhou Y, Yu M, Wang S, Shen H, Li F. Patients with Hemophagocytic Lymphohistiocytosis Who Need Intensive Care Can Be Successfully Rescued by Timely Using Etoposide-Based HLH Regimens. Int J Gen Med 2024; 17:431-446. [PMID: 38333019 PMCID: PMC10850986 DOI: 10.2147/ijgm.s443774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/28/2024] [Indexed: 02/10/2024] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) patients who need intensive care usually have multiple organ failure and poor prognosis. However, the clinical characteristics, therapeutic efficacy and outcome in these critically ill HLH patients have remained unclear. Methods We performed a retrospective study of 50 critically ill HLH patients from September 2013 to October 2022. Patients' information was collected, and the overall survival rate was estimated. Results Fifty HLH patients need intensive care, and the median sequential organ failure assessment (SOFA) score was 8. 66.00% patients had septic shock, 60.00% had disseminated intravascular coagulation (DIC) and 56.00% had acute respiratory distress syndrome (ARDS). 64.00% patients needed vasoactive drugs, 60.00% needed invasive or non-invasive positive pressure mechanical ventilation, and 12.00% needed continuous renal replacement therapy (CRRT). Among 18 patients received the etoposide-based regimens, the median time for 17 patients to remove ECG monitoring was 13 days (4-30 days); the median time to remove respiratory support in 10 patients was 8.5 days (4-21 days); the median time for 5 patient to convert from dominant DIC to non-dominant DIC was 4 days (1-14 days) and the median time for 6 patients to stop using vasoactive drugs was 10 days (2-14 days). After 4 weeks of treatment, 7 patients were evaluated as NR, 6 achieved PR, and 5 could not be evaluated. The ORR was 55.56%. Up to the last follow-up, the OS rate of patients receiving etoposide-based regimens was 66.67%. In contrast, all 32 HLH patients in other groups died. Univariate analysis showed that PCT > 0.5 ug/L, PT prolonged > 6 s, TBil > 25umol/L, respiratory failure, renal failure, liver failure and did not receive etoposide- based regimens were the negative factors affecting survival (P = 0.001, 0.017, 0.043, 0.001, 0.000, 0.029, 0.000). Conclusion HLH patients who need intensive care timely used etoposide-based HLH regimens might rescue critically ill patients successfully.
Collapse
Affiliation(s)
- Kebing Lv
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Xiaoye Cheng
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
- Jiangxi Clinical Research Center for Hematologic Disease, Nanchang, People’s Republic of China
- Institute of Lymphoma and Myeloma, Nanchang University, Nanchang, People’s Republic of China
| | - Yulan Zhou
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
- Jiangxi Clinical Research Center for Hematologic Disease, Nanchang, People’s Republic of China
- Institute of Lymphoma and Myeloma, Nanchang University, Nanchang, People’s Republic of China
| | - Min Yu
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
- Jiangxi Clinical Research Center for Hematologic Disease, Nanchang, People’s Republic of China
- Institute of Lymphoma and Myeloma, Nanchang University, Nanchang, People’s Republic of China
| | - Shixuan Wang
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
- Jiangxi Clinical Research Center for Hematologic Disease, Nanchang, People’s Republic of China
- Institute of Lymphoma and Myeloma, Nanchang University, Nanchang, People’s Republic of China
| | - Huimin Shen
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Fei Li
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
- Jiangxi Clinical Research Center for Hematologic Disease, Nanchang, People’s Republic of China
- Institute of Lymphoma and Myeloma, Nanchang University, Nanchang, People’s Republic of China
| |
Collapse
|
3
|
Knauft J, Schenk T, Ernst T, Schnetzke U, Hochhaus A, La Rosée P, Birndt S. Lymphoma-associated hemophagocytic lymphohistiocytosis (LA-HLH): a scoping review unveils clinical and diagnostic patterns of a lymphoma subgroup with poor prognosis. Leukemia 2024; 38:235-249. [PMID: 38238443 PMCID: PMC10844097 DOI: 10.1038/s41375-024-02135-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/21/2023] [Accepted: 01/04/2024] [Indexed: 02/07/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome driven by pathologic activation of cytotoxic T-lymphocytes and macrophages. Despite advances in diagnostics and management, adult patients with lymphoma-associated HLH (LA-HLH) harbor particularly poor prognosis and optimal treatment remains challenging. As systematic data on LA-HLH are scarce, we aimed to synthesize research evidence by thorough analysis of the published literature in PubMed (MEDLINE-database) within the context of a scoping review. Of 595 search results, 132 articles providing information on 542 patients were reviewed and analyzed. Median patient age was 60 years (range, 18-98) with male predominance (62.7%). B- and T-NHL were equally represented (45.6% and 45.2%), Hodgkin's lymphoma was reported in 8.9% of the cases. The majority of patients (91.6%) presented in Ann-Arbor-Stages III and IV, and bone marrow infiltration was observed in a significant proportion of patients (61.5%). Soluble CD25 levels were markedly elevated (median 10,000 U/ml), with levels beyond 10,000 U/ml indicating unfavorable prognosis for 30-day and overall survival. 66.8% of the patients died after median 5.1 months. LA-HLH remains a clinical challenge requiring specialized management. Timely diagnosis and appropriate lymphoma-specific treatment are of utmost importance to enhance patient outcomes.
Collapse
Affiliation(s)
- Johanna Knauft
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Thomas Schenk
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Thomas Ernst
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Ulf Schnetzke
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Andreas Hochhaus
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Paul La Rosée
- Klinik für Innere Medizin II, Onkologie, Hämatologie, Immunologie, Infektiologie und Palliativmedizin, Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany
| | - Sebastian Birndt
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany.
| |
Collapse
|
4
|
Cox MF, Mackenzie S, Low R, Brown M, Sanchez E, Carr A, Carpenter B, Bishton M, Duncombe A, Akpabio A, Kulasekararaj A, Sin FE, Jones A, Kavirayani A, Sen ES, Quick V, Dulay GS, Clark S, Bauchmuller K, Tattersall RS, Manson JJ. Diagnosis and investigation of suspected haemophagocytic lymphohistiocytosis in adults: 2023 Hyperinflammation and HLH Across Speciality Collaboration (HiHASC) consensus guideline. THE LANCET. RHEUMATOLOGY 2024; 6:e51-e62. [PMID: 38258680 DOI: 10.1016/s2665-9913(23)00273-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/01/2023] [Accepted: 10/04/2023] [Indexed: 01/24/2024]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome characterised by persistently activated cytotoxic lymphocytes and macrophages, which, if untreated, leads to multiorgan dysfunction and death. HLH should be considered in any acutely unwell patient not responding to treatment as expected, with prompt assessment to look for what we term the three Fs-fever, falling blood counts, and raised ferritin. Worldwide, awareness of HLH and access to expert management remain inequitable. Terminology is not standardised, classification criteria are validated in specific patient groups only, and some guidelines rely on specialised and somewhat inaccessible tests. The consensus guideline described in this Health Policy was produced by a self-nominated working group from the UK network Hyperinflammation and HLH Across Speciality Collaboration (HiHASC), a multidisciplinary group of clinicians experienced in managing people with HLH. Combining literature review and experience gained from looking after patients with HLH, it provides a practical, structured approach for all health-care teams managing adult (>16 years) patients with possible HLH. The focus is on early recognition and diagnosis of HLH and parallel identification of the underlying cause. To ensure wide applicability, the use of inexpensive, readily available tests is prioritised, but the role of specialist investigations and their interpretation is also addressed.
Collapse
Affiliation(s)
- Miriam F Cox
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Strachan Mackenzie
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ryan Low
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Michael Brown
- Division of Infection, University College London Hospitals NHS Foundation Trust, London, UK
| | - Emilie Sanchez
- Department of Clinical Virology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Aisling Carr
- Centre for Neuromuscular Diseases, National hospital of Neurology and Neurosurgery, London, UK
| | - Ben Carpenter
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mark Bishton
- Department of Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Andrew Duncombe
- Department of Haematology, University Hospital Southampton, Southampton, UK
| | - Akpabio Akpabio
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, UK
| | | | - Fang En Sin
- Department of Rheumatology, North Bristol NHS Trust, UK
| | - Alexis Jones
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Akhila Kavirayani
- Department of Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ethan S Sen
- Department of Paediatric Rheumatology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Vanessa Quick
- Department of Rheumatology, Bedfordshire Hospitals NHS Trust, Luton, UK
| | - Gurdeep S Dulay
- Department of Rheumatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Sam Clark
- Department of Critical Care, University College London Hospitals NHS Foundation Trust, London, UK
| | - Kris Bauchmuller
- Department of Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rachel S Tattersall
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jessica J Manson
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK.
| |
Collapse
|
5
|
Nguyen TH, Kumar D, Prince C, Martini D, Grunwell JR, Lawrence T, Whitely T, Chappelle K, Chonat S, Prahalad S, Briones M, Chandrakasan S. Frequency of HLA-DR +CD38 hi T cells identifies and quantifies T-cell activation in hemophagocytic lymphohistiocytosis, hyperinflammation, and immune regulatory disorders. J Allergy Clin Immunol 2024; 153:309-319. [PMID: 37517575 PMCID: PMC10823038 DOI: 10.1016/j.jaci.2023.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/13/2023] [Accepted: 07/12/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Quantifying T-cell activation is essential for the diagnosis and evaluation of treatment response in various hyperinflammatory and immune regulatory disorders, including hemophagocytic lymphohistiocytosis. Plasma soluble IL-2 receptor (sIL-2R) is a well-established biomarker for evaluating systemic T-cell activation. However, the limited availability of sIL-2R testing could result in delayed diagnosis. Furthermore, high sIL-2R levels may not always reflect T-cell activation. OBJECTIVES To address these limitations, this study investigated whether cell surface markers of T-cell activation, HLA-DR, and CD38, as assessed by flow cytometry, could be used to quantify systemic T-cell activation in a variety of inflammatory disease states and examine its correlation with sIL-2R levels. METHODS Results for sIL-2R, CXCL9, and ferritin assays were obtained from patient's medical records. Frequency of HLA-DR+CD38high(hi) T-cells was assessed in different T-cell subsets using flow cytometry. RESULTS In this study's cohort, activation in total CD8+ T (r = 0.65; P < .0001) and CD4+ (r = 0.42; P < .0001) T-cell subsets significantly correlated with plasma sIL-2R levels. At the disease onset, the frequency of HLA-DR+CD38hi T cells in CD8+ T (r = 0.65, P < .0001) and CD4+ T (r = 0.77; P < .0001) effector memory (TEM) compartments correlated strongly with sIL-2R levels. Evaluation of T-cell activation markers in follow-up samples also revealed a positive correlation for both CD4+ TEM and CD8+ TEM activation with sIL-2R levels; thus, attesting its utility in initial diagnosis and in evaluating treatment response. The frequency of HLA-DR+CD38hi T-cells in the CD8+ TEM compartment also correlated with plasma CXCL9 (r = 0.42; P = .0120) and ferritin levels (r = 0.32; P = .0037). CONCLUSIONS This study demonstrates that flow cytometry-based direct T-cell activation assessed by HLA-DR+CD38hi T cells accurately quantifies T-cell activation and strongly correlates with sIL-2R levels across a spectrum of hyperinflammatory and immune dysregulation disorders.
Collapse
Affiliation(s)
- Thinh H Nguyen
- Aflac Cancer and Blood Disorder Center, and the Divisions of Children's Healthcare of Atlanta, Atlanta; Department of Pediatrics, Emory University School of Medicine, Atlanta
| | - Deepak Kumar
- Aflac Cancer and Blood Disorder Center, and the Divisions of Children's Healthcare of Atlanta, Atlanta; Department of Pediatrics, Emory University School of Medicine, Atlanta
| | - Chengyu Prince
- Aflac Cancer and Blood Disorder Center, and the Divisions of Children's Healthcare of Atlanta, Atlanta
| | - Dylan Martini
- Department of Pediatrics, Emory University School of Medicine, Atlanta
| | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University School of Medicine, Atlanta; Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta
| | - Taylor Lawrence
- Aflac Cancer and Blood Disorder Center, and the Divisions of Children's Healthcare of Atlanta, Atlanta
| | - Trenton Whitely
- Aflac Cancer and Blood Disorder Center, and the Divisions of Children's Healthcare of Atlanta, Atlanta
| | - Karin Chappelle
- Aflac Cancer and Blood Disorder Center, and the Divisions of Children's Healthcare of Atlanta, Atlanta
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorder Center, and the Divisions of Children's Healthcare of Atlanta, Atlanta; Department of Pediatrics, Emory University School of Medicine, Atlanta
| | - Sampath Prahalad
- Department of Pediatrics, Emory University School of Medicine, Atlanta; Pediatric Rheumatology, Children's Healthcare of Atlanta, Atlanta
| | - Michael Briones
- Aflac Cancer and Blood Disorder Center, and the Divisions of Children's Healthcare of Atlanta, Atlanta; Department of Pediatrics, Emory University School of Medicine, Atlanta
| | - Shanmuganathan Chandrakasan
- Aflac Cancer and Blood Disorder Center, and the Divisions of Children's Healthcare of Atlanta, Atlanta; Department of Pediatrics, Emory University School of Medicine, Atlanta.
| |
Collapse
|
6
|
Alende-Castro V, Alonso-Sampedro M, Fernández-Merino C, Sopeña B, Vidal C, Gude F, Gonzalez-Quintela A. Factors influencing serum concentrations of soluble interleukin-2 receptor: a general adult population study. ALL LIFE 2023. [DOI: 10.1080/26895293.2023.2169958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Affiliation(s)
- Vanessa Alende-Castro
- Department of Internal Medicine, Complejo Hospitalario Universitario, University of Santiago de Compostela, Spain
| | - Manuela Alonso-Sampedro
- Department of Clinical Epidemiology, Complejo Hospitalario Universitario, Santiago de Compostela, Spain
| | | | - Bernardo Sopeña
- Department of Internal Medicine, Complejo Hospitalario Universitario, University of Santiago de Compostela, Spain
| | - Carmen Vidal
- Department of Allergy, Complejo Hospitalario Universitario, Santiago de Compostela, Spain
| | - Francisco Gude
- Department of Clinical Epidemiology, Complejo Hospitalario Universitario, Santiago de Compostela, Spain
| | - Arturo Gonzalez-Quintela
- Department of Internal Medicine, Complejo Hospitalario Universitario, University of Santiago de Compostela, Spain
| |
Collapse
|
7
|
Verkamp B, Zoref-Lorenz A, Francisco B, Kieser P, Mack J, Blackledge T, Brik Simon D, Yacobovich J, Jordan MB. Early response markers predict survival after etoposide-based therapy of hemophagocytic lymphohistiocytosis. Blood Adv 2023; 7:7258-7269. [PMID: 37903321 PMCID: PMC10698531 DOI: 10.1182/bloodadvances.2023010546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 09/29/2023] [Accepted: 10/01/2023] [Indexed: 11/01/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome that is most commonly treated with etoposide and dexamethasone. This standard of care therapy has improved survival, but ∼15% of patients still die in the first months after diagnosis, and poor responses prompting salvage therapy are frequent. Thus, identifying patients at risk promptly is likely to improve outcomes. We conducted a multi-institutional, retrospective study of pediatric and young adults treated per HLH-94 or HLH-2004 from 2010 to 2019 to identify patients at risk for early mortality. Biweekly data during the first 100 days of treatment were analyzed using receiver operating curves to define optimal prognostic indicators and their thresholds. The primary end point was survival to bone marrow transplant (BMT) or ∼1 year if no BMT was pursued. Eighty-nine patients met the study inclusion criteria. Pre-BMT mortality was 13% (n = 12), and overall mortality was 27% (n = 24). Laboratory markers measured on day 7 of therapy more efficiently predicted outcomes than did either pretreatment or later assessments. The most potent day 7 unfavorable marker was improvement in soluble CD25 (sCD25) of less than 25% from pretherapy levels. Absolute sCD25 level, platelet count, absolute lymphocyte count, and blood urea nitrogen were also discriminatory markers (area under the curve ≥ 0.7). The presence of ≥3 of these unfavorable markers was strongly associated with pre-BMT mortality (accuracy, 0.93). Thus, serial monitoring of sCD25 and assessment of other early (day 7) response markers optimally predicts prognosis with etoposide-based therapy and may indicate the need for earlier use of alternative, response-adapted therapeutic strategies for HLH.
Collapse
Affiliation(s)
- Bethany Verkamp
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Adi Zoref-Lorenz
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Brenton Francisco
- Department of Pediatrics, Mount Sinai Kravis Children’s Hospital, New York, NY
| | - Pearce Kieser
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Joana Mack
- Division of Hematology and Oncology, Arkansas Children’s Hospital, Little Rock, AR
| | - Tucker Blackledge
- Division of Hematology and Oncology, Arkansas Children’s Hospital, Little Rock, AR
| | - Dafna Brik Simon
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Hematology Oncology, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel
| | - Joanne Yacobovich
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Hematology Oncology, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel
| | - Michael B. Jordan
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Division of Bone Marrow Transplantation and Immune Deficiency, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| |
Collapse
|
8
|
Yang H, Cao Y, Liu J, Liu Y, Yang B, Ling Y, Fu Y, Liu Y, Gu W. Clinical characteristics and prognostic factors of 75 cases with acquired hemophagocytic syndrome. Hematology 2023; 28:2247887. [PMID: 37594301 DOI: 10.1080/16078454.2023.2247887] [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: 03/14/2023] [Accepted: 08/10/2023] [Indexed: 08/19/2023] Open
Abstract
OBJECTIVES The study's aim was to enhance awareness of acquired hemophagocytic syndrome (HPS) in adults by analyzing clinical features, and investigating the relationship between factors such as the Systemic Inflammation Index (SII) and the prognosis of HPS. METHODS Clinical characteristics, survival data, and prognostic factors of 75 HPS patients admitted to our hospital between January 2012 and October 2022 were analyzed. RESULTS In the high SII group, red blood cells, white blood cells, platelets, neutrophils, fibrinogen, and CD4 + cell activity were higher, and survival time was longer compared to the low SII group. Conversely, total bilirubin and direct bilirubin were higher in the low SII group (P ≤ 0.05). After applying the log-Rank or Breslow tests, HPS patients in the high SII group and those following the HLH-2004 protocol experienced a notably longer survival time. (χ2 = 4.291, P < 0.05; χ2 = 5.210, P < 0.05). Patients with poor prognosis showed higher age of onset, elevated levels of total, direct, and indirect bilirubin, and a greater rate of EBV infection, but reduced levels of red blood cells, platelets, hemoglobin, albumin, globulin, and HLH-2004 protocol usage rate(P < 0.05). Multivariate analysis and ROC curve results indicate that special attention is needed for patients with platelets < 42.5 × 109/L, albumin < 27.7 g/L, fibrinogen < 1.085 g/L, those not following the HLH-2004 protocol, and those who are EBV (+). DISCUSSION AND CONCLUSION Early diagnosis and following the HLH-2004 protocol are essential for patients with HPS clinical manifestations to improve prognosis. Additional research is necessary to examine the link between SII and HPS patients' prognosis.
Collapse
Affiliation(s)
- Haonan Yang
- Department of Hematology, The Third Affiliated Hospital of Soochow University, Changzhou, People's Republic of China
| | - Yang Cao
- Department of Hematology, The Third Affiliated Hospital of Soochow University, Changzhou, People's Republic of China
| | - Juan Liu
- Department of Hematology, The Third Affiliated Hospital of Soochow University, Changzhou, People's Republic of China
| | - Yue Liu
- Department of Hematology, The Third Affiliated Hospital of Soochow University, Changzhou, People's Republic of China
| | - Bin Yang
- Department of Hematology, The Third Affiliated Hospital of Soochow University, Changzhou, People's Republic of China
| | - Yun Ling
- Department of Hematology, The Third Affiliated Hospital of Soochow University, Changzhou, People's Republic of China
| | - Yuanjing Fu
- Department of Hematology, The Third Affiliated Hospital of Soochow University, Changzhou, People's Republic of China
| | - Yan Liu
- Department of Hematology, The Third Affiliated Hospital of Soochow University, Changzhou, People's Republic of China
| | - Weiying Gu
- Department of Hematology, The Third Affiliated Hospital of Soochow University, Changzhou, People's Republic of China
| |
Collapse
|
9
|
Kanda N, Yamaguchi R, Yamamoto Y, Matsumura M, Hatakeyama S. Performance of serum soluble interleukin-2 receptor as a diagnostic marker for lymphoma in patients with fever. Sci Rep 2023; 13:18784. [PMID: 37914769 PMCID: PMC10620379 DOI: 10.1038/s41598-023-44123-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 10/04/2023] [Indexed: 11/03/2023] Open
Abstract
There have been few reports on the diagnostic performance of soluble interleukin-2 receptor (sIL-2R) for lymphoma. A cross-sectional study was conducted at a university hospital; all patients who were admitted to the Division of General Internal Medicine and underwent serum sIL-2R testing were included. Patients were divided into two groups based on the presence of fever (≥ 38.0 °C). Among 602 patients, 421 had fever and 76 were diagnosed with lymphoma (48 of the 76 were in the febrile group). In all patients, the area under the receiver operating characteristic curve (AUROC) of sIL-2R for the diagnosis of lymphoma was 0.81 [95% confidence interval (CI), 0.75-0.87]. The AUROC was significantly higher in the febrile group (0.88; 95% CI, 0.81-0.94) than in the afebrile group (0.75; 95% CI, 0.65-0.85). In the febrile group, the sensitivity and specificity were 81.2% and 82.3%, respectively, with an optimal cutoff value of 3,250 U/mL. In the afebrile group, they were 89.3% and 54.9%, respectively, with a cutoff value of 868 U/mL. Serum sIL-2R showed high performance as an adjunctive diagnostic marker for lymphoma, particularly among febrile patients. Different cutoff values should be used for patients with and without fever to maximize diagnostic performance.
Collapse
Affiliation(s)
- Naoki Kanda
- Division of General Medicine, Center for Community Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
| | - Ryota Yamaguchi
- Division of General Medicine, Center for Community Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
| | - Yu Yamamoto
- Division of General Medicine, Center for Community Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
| | - Masami Matsumura
- Division of General Medicine, Center for Community Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
| | - Shuji Hatakeyama
- Division of General Medicine, Center for Community Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
- Division of Infectious Diseases, Jichi Medical University Hospital, Tochigi, Japan.
| |
Collapse
|
10
|
Bai H, Wang Y, Shen L, Luo Y, Tang G, Wang F, Sun Z, Hou H. The signature and predictive value of immune parameters in patients with secondary hemophagocytic lymphohistiocytosis. Immunobiology 2023; 228:152759. [PMID: 37939638 DOI: 10.1016/j.imbio.2023.152759] [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: 06/03/2023] [Revised: 10/22/2023] [Accepted: 10/30/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Secondary hemophagocytic lymphohistiocytosis (sHLH) is a rare but fatal clinical syndrome, characterized by severe immune dysfunction and overwhelming inflammatory response. However, the host immune signature and also its role in predicting the clinical outcome are not fully described. OBJECTIVE The present study aims to investigate the host immune status of sHLH patients in the early stage of the disease, including lymphocyte subsets, phenotypes and cytokines, and also to explore its clinical value in prognosis. METHODS Sixty-four patients with sHLH admitted to a tertiary hospital in central China between 2018 and 2022 were enrolled, of which 21 were deceased. The subsets and phenotypes of lymphocytes, and the levels of cytokines in serum were analyzed. RESULTS In patients with sHLH, the percentages of total T cells, CD8+ T cells, HLA-DR+ T cells, HLA-DR+CD8+ T cells, CD45RO+CD4+ T cells, and the levels of IL-1β, IL-2R, IL-6, IL-8, IL-10 and TNF-α were significantly increased, while the percentages of CD4+ T cells, NK cells, CD45RA+CD4+ T cells, CD45RA+ regulatory T (Treg) cells, the counts of total T cells, total B cells, CD4+ T cells, CD8+ T cells, NK cells, and the ratio of CD4+ T/CD8+ T cells were significantly decreased, compared with healthy controls (HC). In addition, dysregulation of host immune response and high inflammatory status were more obvious in deceased patients than that of survivors. Kaplan-Meier survival analysis and multivariate logistic regression analysis demonstrated that lower levels of CD4+ T cells count and CD28+CD4+ T cells percentage, but higher levels of NK cells percentage and IL-1β were poor prognostic indicators of sHLH. CONCLUSION The evaluation of immunological markers has critical value for selecting prognostic markers and potential treatment target among adults with sHLH.
Collapse
Affiliation(s)
- Huan Bai
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yun Wang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ling Shen
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ying Luo
- Department of Immunology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Guoxing Tang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Wang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ziyong Sun
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Hongyan Hou
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| |
Collapse
|
11
|
Ali M, Sumbul M, Nadeem M. An Unusual Case of Phagocytic Histiocytes on Peripheral Blood Smear of a Patient With Methicillin-Resistant Staphylococcus aureus (MRSA) Endocarditis. Cureus 2023; 15:e49042. [PMID: 38116350 PMCID: PMC10729711 DOI: 10.7759/cureus.49042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2023] [Indexed: 12/21/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare disorder of the immune system that may rapidly progress into life-threatening complications. There is uncontrolled activation of histiocytes and phagocytic macrophages, resulting in excess secretions of cytokines that manifest into systemic hyperinflammation affecting several organs. HLH may present as primary due to underlying familial or genetic causes or as secondary due to underlying conditions such as malignancies, infections, or autoimmune disorders. This case is of a seven-year-old girl who developed culture-proven MRSA infective endocarditis. She received sensitivity-tailored antimicrobial treatment. Initially unremarkable, but later her peripheral blood smear showed the presence of large histiocyte-like cells showing hemophagocytic activity of moderate grade (two to five histiocytes with hemophagocytosis/slide) on the feathered edge of the slide. Peripheral film findings triggered further workup for HLH. Her condition later deteriorated, requiring high-dependency unit care. This case highlights the significance of maintaining a high index of suspicion with subsequent laboratory work in cases that develop cardinal diagnostic criteria for clinical manifestations of HLH. It also emphasizes reviewing the feathered edges of blood smears to prevent overlooking important morphological findings.
Collapse
Affiliation(s)
- Maria Ali
- Hematology, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Maliha Sumbul
- Hematology, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Muhammad Nadeem
- Hematology, National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi, PAK
| |
Collapse
|
12
|
Zhao Z, Li J, Yang L, Ren G, Zhang L, Wang T. Hemophagocytic lymphohistiocytosis and histiocytic necrotizing lymphadenitis secondary to hemodialysis catheter-related bloodstream infection caused by Corynebacterium Striatum. BMC Nephrol 2023; 24:294. [PMID: 37803308 PMCID: PMC10559591 DOI: 10.1186/s12882-023-03356-2] [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: 05/20/2023] [Accepted: 09/30/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND We herein described the coexistence of hemophagocytic lymphohistiocytosis (HLH) and histiocytic necrotizing lymphadenitis, alternatively known as the Kikuchi disease (KD), secondary to hemodialysis catheter-related bloodstream infection (BSI) caused by Corynebacterium striatum. CASE PRESENTATION A patient on maintenance hemodialysis had developed persistent fever and Corynebacterium striatum was subsequently identified from the culture of both catheter tip and peripheral blood. During mitigation of the BSI, however, his fever was unabated and ensuing workup further found thrombocytopenia, hyperferritinemia, hypertriglyceridemia, low NK cell activity and a surge in serum CD25 levels. Moreover, biopsy of the bone marrow and lymph node detected histopathological evidence of hemophagocytosis and KD, respectively. Upon these abnormalities, the title-bound diagnosis was considered and the patient was eventually recovered from the treatment of dexamethasone instead of antibiotics. Consistently, aberrations in his serum CD25 levels and NK cell activity had subsided two months after discharge. CONCLUSIONS Arguably, this encounter offered a unique chance to unravel the principal pathogenic cascade in immunobiology that made the three entities one disease continuum. As such, our work may add new understandings of HLH and/or KD secondary to severe infections in general and excessive release of cytokines in particular among patients with kidney diseases. The resultant early diagnosis is crucial to initiate appropriate treatment and improve the survival of patients with these challenging and potentially life-threatening disorders.
Collapse
Affiliation(s)
- ZhiPeng Zhao
- Graduate School of HeBei Medical University, No.361 East ZhongShan Boulevard, ShiJiaZhuang, 050011, China
- Department of Nephrology, the First Hospital of HeBei Medical University, No.89 DongGang Road, ShiJiaZhuang, 050030, China
| | - Jing Li
- Department of Nephrology, the First Hospital of HeBei Medical University, No.89 DongGang Road, ShiJiaZhuang, 050030, China
| | - Liu Yang
- Department of Hematology, the First Hospital of HeBei Medical University, No.89 DongGang Road, ShiJiaZhuang, 050030, China
| | - GuangWei Ren
- Department of Nephrology, the First Hospital of HeBei Medical University, No.89 DongGang Road, ShiJiaZhuang, 050030, China
| | - LiHong Zhang
- Department of Nephrology, the First Hospital of HeBei Medical University, No.89 DongGang Road, ShiJiaZhuang, 050030, China
| | - Tao Wang
- Department of Nephrology, the First Hospital of HeBei Medical University, No.89 DongGang Road, ShiJiaZhuang, 050030, China.
| |
Collapse
|
13
|
Lim AM, Ghazaleh JR, Cacdac RM, Oberndorf JK, Quizon MRL, Thomas JM. Sepsis as the Grand Mimic of Secondary Hemophagocytic Lymphohistiocytosis: Serratia marcescens Bacteremia with Concomitant Decompensated Cirrhotic Liver Disease. Case Rep Crit Care 2023; 2023:9916937. [PMID: 37675083 PMCID: PMC10480021 DOI: 10.1155/2023/9916937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/29/2023] [Accepted: 08/17/2023] [Indexed: 09/08/2023] Open
Abstract
Secondary hemophagocytic lymphohistiocytosis (HLH) is an elusive entity with sequelae that may be confused with sepsis. We discuss a 45-year-old man with decompensated liver cirrhosis with sepsis treated with broad-spectrum intravenous antibiotics. Further work-up initially supported sepsis-HLH overlap syndrome (SHLHOS) and corticosteroids were added. Ongoing refractory hypotension ensued, and the patient passed within 31 hours of presentation. Based on the patient's overwhelming immune activation and clinical course likely unsalvageable by cytotoxic immunosuppressive agents, the patient was diagnosed with sepsis with acute end organ dysfunction. This case report illustrates both the diagnostic challenge of sepsis versus HLH, which both require very different treatments, and the potential for rapid clinical decline without swift recognition and management of the true pathology.
Collapse
Affiliation(s)
- Anthony M. Lim
- Eisenhower Medical Center, 39000 Bob Hope Drive, Rancho Mirage, CA 92270, USA
| | | | - Robert M. Cacdac
- Eisenhower Medical Center, 39000 Bob Hope Drive, Rancho Mirage, CA 92270, USA
| | - Julia K. Oberndorf
- Eisenhower Medical Center, 39000 Bob Hope Drive, Rancho Mirage, CA 92270, USA
| | | | - Justin M. Thomas
- Eisenhower Medical Center, 39000 Bob Hope Drive, Rancho Mirage, CA 92270, USA
| |
Collapse
|
14
|
Bozgul SMK, Ak G, Soyer NA, Barutcuoglu B, Mercan E, Acar C, Yetişken M, Hekimgil M, Bozkurt D. Biomarker diversity in increased inflammation: Secondary hemophagocytic syndrome vs. systemic inflammatory response syndrome. Int J Lab Hematol 2023; 45:213-220. [PMID: 36437601 DOI: 10.1111/ijlh.13997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 11/16/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Secondary hemophagocytic syndrome (HPS) and systemic inflammatory response syndrome (SIRS) share similar clinical findings as a result of hyperinflammation. Due to high mortality rates in HPS; it is critical to diagnose promptly. Thus, this study aimed to evaluate the diagnostic and prognostic significance of inflammatory markers in these two increased inflammatory states. METHODS We conducted a prospective observational study including patients hospitalized in the intensive care unit of the Internal Medicine Department of Ege University Hospital. RESULTS Thirty-three patients with HPS and 46 patients with SIRS were evaluated. Serum ferritin and sIL-2r levels were significantly higher in the HPS group than in the SIRS group, as expected. Receiver operating curve (ROC) analysis showed that the optimal cutoff for ferritin to distinguish HPS from SIRS was 1703 μg/L (sensitivity: 75%, specificity: 94.1%, area under the curve (AUC): 0.871, p < 0.001), and that for sIL-2r was 5888 U/ml (sensitivity: 45.5%, specificity: 89.1%, AUC: 0.698, and p = 0.001). Temporal changes (Δ) in ferritin were determined as a mortality predictor. When evaluated in terms of prognostic significance in ROC analysis, a decrease in ferritin of less than 38% was the cutoff value (sensitivity: 92.3%, specificity: 76.9%, AUC: 0.888, and p < 0.001), in mortality. Contrarily, neither baseline nor temporal change in sIL-2r did not achieve prognostic significance as a mortality predictor. CONCLUSION In this single-center study, serum ferritin level was found to be a particularly more valuable diagnostic and prognostic marker than sIL-2r in patients with HPS.
Collapse
Affiliation(s)
| | - Gunes Ak
- Faculty of Medicine, Department of Clinical Biochemistry, Ege University, Izmir, Turkey
| | - Nur Akad Soyer
- Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Ege University, Izmir, Turkey
| | - Burcu Barutcuoglu
- Faculty of Medicine, Department of Clinical Biochemistry, Ege University, Izmir, Turkey
| | - Erman Mercan
- Faculty of Medicine, Department of Internal Medicine, Ege University, Izmir, Turkey
| | - Caner Acar
- Faculty of Medicine, Department of Internal Medicine, Ege University, Izmir, Turkey
| | - Merve Yetişken
- Faculty of Medicine, Department of Internal Medicine, Ege University, Izmir, Turkey
| | - Mine Hekimgil
- Faculty of Medicine, Department of Pathology, Ege University, Izmir, Turkey
| | - Devrim Bozkurt
- Faculty of Medicine, Department of Internal Medicine, Ege University, Izmir, Turkey
| |
Collapse
|
15
|
Nickle RA, DeOca KB, Garcia BL, Mannie MD. Soluble CD25 imposes a low-zone IL-2 signaling environment that favors competitive outgrowth of antigen-experienced CD25 high regulatory and memory T cells. Cell Immunol 2023; 384:104664. [PMID: 36642016 PMCID: PMC10257407 DOI: 10.1016/j.cellimm.2023.104664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 10/13/2022] [Accepted: 01/03/2023] [Indexed: 01/07/2023]
Abstract
This study focused on soluble (s)CD25-mediated regulation of IL-2 signaling in murine and human CD4+ T cells. Recombinant sCD25 reversibly sequestered IL-2 to limit acute maximal proliferative responses while preserving IL-2 bioavailability to subsequently maintain low-zone IL-2 signaling during prolonged culture. By inhibiting IL-2 signaling during acute activation, sCD25 suppressed T-cell growth and inhibited IL-2-evoked transmembrane CD25 expression, thereby resulting in lower prevalence of CD25high T cells. By inhibiting IL-2 signaling during quiescent IL-2-mediated growth, sCD25 competed with transmembrane CD25, IL2Rβγ, and IL2Rαβγ receptors for limited pools of IL-2 such that sCD25 exhibited strong or weak inhibitory efficacy in IL-2-stimulated cultures of CD25low or CD25high T cells, respectively. Preferential blocking of IL-2 signaling in CD25low but not CD25high T cells caused competitive enrichment of CD25high memory/effector and regulatory FOXP3+ subsets. In conclusion, sCD25 modulates IL-2 bioavailability to limit CD25 expression during acute activation while enhancing CD25highT-cell dominance during low-zone homeostatic IL-2-mediated expansion, thereby 'flattening' the inflammatory curve over time.
Collapse
Affiliation(s)
- Rebecca A Nickle
- Department of Microbiology and Immunology, Brody School of Medicine, East Carolina University, Greenville, NC, USA.
| | - Kayla B DeOca
- Department of Microbiology and Immunology, Brody School of Medicine, East Carolina University, Greenville, NC, USA.
| | - Brandon L Garcia
- Department of Microbiology and Immunology, Brody School of Medicine, East Carolina University, Greenville, NC, USA.
| | - Mark D Mannie
- Department of Microbiology and Immunology, Brody School of Medicine, East Carolina University, Greenville, NC, USA.
| |
Collapse
|
16
|
Nishiura H, Takahashi M, Iwai T, Uchida J, Nakamura Y. Analysis of Risk Factors for Infusion-Related Reactions Following Rituximab Administration in Patients with Desensitization before Renal Transplantation. Biol Pharm Bull 2023; 46:1332-1337. [PMID: 37661411 DOI: 10.1248/bpb.b23-00157] [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] [Indexed: 09/05/2023]
Abstract
Infusion-related reactions (IRRs) are the major side effects of rituximab administration. Although several studies have reported predictive markers for IRRs in patients with malignancies, there are no such reports for patients without malignancies. Accordingly, we aimed to clarify the predictive markers for rituximab-induced IRRs in renal transplant recipients. This retrospective study included 116 inpatients aged ≥18 years who received an initial dose of 150 mg/m2 of rituximab for desensitization before renal transplantation with loxoprofen and diphenhydramine before rituximab infusion between June 2007 and February 2022. Overall, 45 patients were evaluated and 71 patients were excluded in this study. IRRs were observed in 12 (26.7%) patients. The proportion of men in the IRRs group was significantly higher than that in the non-IRRs group (p = 0.023). Additionally, body weight, body surface area (BSA), and body mass index (BMI) were significantly higher in the IRRs group than in the non-IRRs group (body weight, p = 0.0058; BSA, p = 0.0051; BMI, p = 0.017). Their cutoff values for predicting rituximab-induced IRRs, based on the receiver-operating characteristic curve, were 74.850 kg, 1.910 m2 and 24.164 kg/m2, respectively. In conclusion, the male sex, high actual body weight, BSA, and BMI may be new predictive markers for rituximab-induced IRRs in renal transplant recipients. Therefore, clinicians should carefully monitor patients who receive rituximab before renal transplantation and present with the predictive markers.
Collapse
Affiliation(s)
| | | | - Tomoaki Iwai
- Department of Urology, Osaka Metropolitan University Graduate School of Medicine
| | - Junji Uchida
- Department of Urology, Osaka Metropolitan University Graduate School of Medicine
| | | |
Collapse
|
17
|
Schippers EE, Creemers SG, Paltansing S, van Zaanen HCT, Heijneman JAM. Fatal Hemophagocytic Lymphohistiocytosis in a Patient with Miliary Tuberculosis: a Case Report. SN COMPREHENSIVE CLINICAL MEDICINE 2022; 4:152. [PMID: 35856014 PMCID: PMC9281255 DOI: 10.1007/s42399-022-01232-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 11/24/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome induced by cytotoxic T-cells. Mostly, HLH is secondary to infections, malignancies, or autoimmune disorders. HLH triggered by miliary tuberculosis is rare and mortality rates are high. We report a case of a 58-year-old, Caucasian patient admitted to the ICU with respiratory failure. After extensive tests, the diagnosis of HLH was made. Despite aggressive treatment with antibiotics, etoposide, anakinra, and tocilizumab, our patient succumbed to the illness after 18 days in the ICU. Postmortem, a diagnosis of miliary tuberculosis was made, despite negative PCR and culture of mycobacteria during clinical course. Our case demonstrates the challenges of early diagnosis of HLH and the importance of considering miliary tuberculosis as a possible underlying trigger.
Collapse
Affiliation(s)
- Eva E. Schippers
- Department of Intensive Care, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Sara G. Creemers
- Department of Internal Medicine and Hematology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Sunita Paltansing
- Department of Medical Microbiology and Infection Control, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Henk C. T. van Zaanen
- Department of Internal Medicine and Hematology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Joyce A. M. Heijneman
- Department of Intensive Care, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| |
Collapse
|
18
|
Guild A, Fritch J, Patel S, Reinhardt A, Acquazzino M. Hemophagocytic lymphohistocytosis in trisomy 21: successful treatment with interferon inhibition. Pediatr Rheumatol Online J 2022; 20:104. [PMID: 36401314 PMCID: PMC9673190 DOI: 10.1186/s12969-022-00764-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 10/29/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition of immune dysregulation primarily driven by the cytokine interferon gamma. It can be either a genetic or acquired disorder associated with infection, malignancy, and rheumatologic disorders. Trisomy 21 can express a wide range of phenotypes which include immune dysregulation and shares inherent pathophysiology with a group of disorders termed interferonopathies. Knowledge of this overlap in seemingly unrelated conditions could provide a basis for future research, and most importantly, alternative therapeutic interventions in acute life threatening clinical scenarios. Herein, we describe two patients with trisomy 21 presenting with HLH that was refractory to conventional treatment. Both patients were successfully managed with novel interventions targeting the interferon pathway. CASE PRESENTATION We describe a 17-month-old male and 15-month-old female with trisomy 21 presenting with a myriad of signs and symptoms including fever, rash, cytopenias, and hyperferritinemia, both ultimately diagnosed with HLH. Each had relapsing, refractory HLH over time requiring several admissions to the hospital receiving conventional high dose corticosteroids and interleukin-1 inhibition therapy. Successful steroid-free remission was achieved after targeting interferon inhibition with emapalumab induction followed by long-term maintenance on baricitinib. CONCLUSION To our knowledge, these are the first reported cases of relapsed, refractory HLH in patients with trisomy 21 successfully treated with emapalumab and transitioned to a steroid-sparing regimen with oral baricitinib for maintenance therapy. Trisomy 21 autoimmunity and HLH are both thought to be driven by interferon gamma. Targeting therapy toward interferon signaling in both HLH and autoimmunity in trisomy 21 may have potential therapeutic benefits. Further investigation is needed to determine if trisomy 21 may predispose to the development of HLH given this common pathway.
Collapse
Affiliation(s)
- Allison Guild
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Jordan Fritch
- grid.266813.80000 0001 0666 4105Department of Pediatrics, Division of Hematology Oncology, University of Nebraska Medical Center, Omaha, NE USA
| | - Sachit Patel
- grid.266813.80000 0001 0666 4105Department of Pediatrics, Division of Hematology Oncology, University of Nebraska Medical Center, Omaha, NE USA
| | - Adam Reinhardt
- Department of Rheumatology, Boystown National Research Hospital, Omaha, NE USA
| | - Melissa Acquazzino
- grid.266813.80000 0001 0666 4105Department of Pediatrics, Division of Hematology Oncology, University of Nebraska Medical Center, Omaha, NE USA
| |
Collapse
|
19
|
Jin Z, Suolitiken D, Wang Y, Wang Z. The diagnostic importance of multiple cytokines in adult hemophagocytic lymphohistiocytosis. J Clin Lab Anal 2022; 37:e24669. [PMID: 36036769 PMCID: PMC10156101 DOI: 10.1002/jcla.24669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 08/03/2022] [Accepted: 08/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a category of immunological illnesses that cause out-of-control T cells and macrophages to release life-threatening cytokines. The HLH-2004 diagnostic criteria are the gold standard for HLH diagnosis, but there is a need to investigate the usefulness of various cytokines for HLH diagnosis. METHODS Patients admitted to Beijing Friendship Hospital of Capital Medical University from January 2016 to December 2020 were included in this retrospective study, with 166 patients with confirmed HLH and 142 febrile patients requiring differential diagnosis completing the sum. Multiplex cytokine assays using multifactor liquid phase microarray technology-based multifactor liquid phase microarray technology were used to detect 33 cytokines. Twenty-eight cytokines detected using the Luminex analytical platform technology were ultimately included in the analysis. RESULTS Interleukin-1 receptor antagonist (IL-1 RA), IL-18, interferon-γ (IFN-γ), and interferon-induced protein 10 (IP-10) regulated upon activation normal T cell expressed and secreted (RANTES), eotaxin, growth-related oncogene α (GRO-α), and macrophage inflammatory protein-1 α (MIP-1α) were higher in the HLH group than in the non-HLH group, and the differences were statistically significant. Among them, the area under the curve (AUC) for IL-18 for HLH diagnosis was reported for the first time as 82.69%, with a sensitivity of 76.32% and a specificity of 79.61%; the AUC of IL-1 RA was 72.34%, with a sensitivity of 62.71% and a specificity of 75.97%; and the AUC of IP-10 was 71.73%, with a sensitivity of 60.14% and a specificity of 75.15%. Moreover, the AUC of the combined diagnostic tests for IL-1 RA, IL-18, IFN-γ, IP-10, and RANTES was 99.6%, with a sensitivity of 95.8% and a specificity of 98.6%. CONCLUSION Our study concluded that multiple cytokines are valid biological markers for the diagnosis of HLH. The findings of this study remain to be validated in an external dataset.
Collapse
Affiliation(s)
- Zhili Jin
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Dina Suolitiken
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yini Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
20
|
Practice patterns and outcomes of hemophagocytic lymphohistiocytosis in adults: a 2-decade provincial retrospective review. Ann Hematol 2022; 101:2297-2306. [PMID: 35978181 DOI: 10.1007/s00277-022-04960-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 08/13/2022] [Indexed: 11/01/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a heterogeneous, life-threatening clinical syndrome. There are scarce data on the quality of care in HLH or data comparing treatment patterns and outcomes between different triggers. We aimed to examine quality-of-care indicators and outcomes in adults with various HLH triggers. In this multi-centre retrospective cohort study of adult HLH in the province of Alberta, Canada (1999-2019), we examined quality indicators including diagnostic testing, time to diagnosis and treatment and trigger identification. We also compared treatment regimens and outcomes across HLH triggers. Logistic regression was used to identify predictors of etoposide use. Overall survival (OS) was estimated using the Kaplan-Meier method. We identified 97 patients; 66 (68%) were male. Triggers included malignancy (36%), infection (35%), autoimmune disease (21%) and idiopathic/others (8%). Specialized tests such as sCD25 (53%) and natural killer degranulation assay (19%) were under-performed, as were testing for infectious triggers. Etoposide was administered in only 33 (34%). Neutropenia, hyperbilirubinemia and hyperferritinemia, but not age, sex and comorbidities, were significant predictors of etoposide use. At median follow-up of 32 months, median OS was 18.8 months. Worse OS was seen in malignancy-associated and idiopathic HLH (log-rank P < 0.001). Our study showed low rates of specialized testing such as sCD25 and a low rate of etoposide use. Development of a standardized provincial protocol has the potential to improve quality of care in adult HLH.
Collapse
|
21
|
Nawata A, Shirayama R, Oshida K, Sato T, Ito T, Shiba E, Kusuhara K, Hisaoka M. Catastrophic antiphospholipid syndrome with Epstein-Barr virus-associated hemophagocytosis: A clinicopathological conference. Lupus 2022; 31:1385-1393. [PMID: 35938616 DOI: 10.1177/09612033221118819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a severe variant of antiphospholipid syndrome associated with multiorgan thrombosis in a short term. We present the case of a 14-year-old immunocompetent girl who developed renal, intestinal, and pulmonary infarction; thrombocytopenia; and hemolytic anemia within 1 week. She was diagnosed with thrombotic microangiopathy. Hence, plasma exchange and corticosteroid therapy were initiated, which improved thrombocytopenia. However, the patient's platelet count decreased. Her general condition gradually worsened with eventual death. An autopsy revealed multiple infarctions in the kidneys bilaterally, jejunum, ileum, and pulmonary parenchyma. Microthrombi were not detected. Massive hemophagocytosis was observed in the splenic pulp, lymph nodes, and bone marrow. Several Epstein-Barr viruses (EBVs)-encoded small ribonucleic acid (RNA)-positive lymphocytes were also found in the bone marrow. The presence of antibodies to both viral capsid antigen-immunoglobulin G and EBV nuclear antigen indicated past infection. Antiphospholipid antibody was positive after her death. The patient was finally diagnosed with CAPS and EBV-associated hemophagocytosis, possibly due to EBV reactivation. Establishing a clinical diagnosis of CAPS was relatively difficult because two different causes of thrombocytopenia, CAPS and hemophagocytosis, led to a difficulty in understanding this case's pathogenesis.
Collapse
Affiliation(s)
- Aya Nawata
- Department of Pathology and Oncology, School of Medicine, 13137University of Occupational and Environmental Health, Japan
| | - Rie Shirayama
- Department of Pediatrics, School of Medicine, 13137University of Occupational and Environmental Health, Japan
| | - Koichi Oshida
- Department of Pediatrics, School of Medicine, 13137University of Occupational and Environmental Health, Japan
| | - Tetsuji Sato
- Department of Pediatrics, 13780Kitakyushu City Yahata Hospital, Japan
| | - Takuma Ito
- Department of Pediatrics, School of Medicine, 13137University of Occupational and Environmental Health, Japan
| | - Eisuke Shiba
- Department of Pathology and Oncology, School of Medicine, 13137University of Occupational and Environmental Health, Japan
| | - Koichi Kusuhara
- Department of Pediatrics, School of Medicine, 13137University of Occupational and Environmental Health, Japan
| | - Masanori Hisaoka
- Department of Pathology and Oncology, School of Medicine, 13137University of Occupational and Environmental Health, Japan
| |
Collapse
|
22
|
Bilston L, Croden J, Taparia M, Karkhaneh M, Grossman J, Sun HL. Validation of the HScore and the HLH-2004 diagnostic criteria for the diagnosis of hemophagocytic lymphohistiocytosis in a multicenter cohort. Eur J Haematol 2022; 109:129-137. [PMID: 35434872 DOI: 10.1111/ejh.13779] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 06/14/2023]
Abstract
UNLABELLED Timely diagnosis of hemophagocytic lymphohistiocytosis (HLH) is critical and relies on clinical judgment. The HLH-2004 criteria are commonly used diagnostic criteria, whereas HScore was recently developed for reactive HLH. OBJECTIVE In this external validation study, we sought to compare the diagnostic accuracy of the HLH-2004 criteria and HScore and identify optimal cutoffs stratified by underlying etiology. METHODS In this retrospective cohort of all hospitalized adults in Alberta, Canada, (1999-2019) who had ferritin >500 ng/ml and underwent either biopsies or soluble CD25 testing, we calculated the diagnostic accuracy of HLH-2004 and HScore for the overall population and different etiologies. RESULTS Of 916 patients, 98 (11%) had HLH. HLH-2004 criteria ≥5 predicted HLH with a sensitivity of 91%, specificity of 93%, positive predictive value of 90%, and negative predictive value of 94% (c-statistic 92%). HScore ≥169 predicted HLH with better sensitivity (96%) but reduced specificity (71%), whereas the optimal cutoff ≥200 performed comparably to HLH-2004. HLH-2004 criteria outperformed HScore in most etiologies, whereas HScore improved sensitivity in inflammatory/autoimmune-HLH. The optimal cutoff of HScore was higher in hematopoietic cell transplant due to higher prevalence of fevers and cytopenias. CONCLUSION HLH-2004 criteria and HScore demonstrated excellent discriminatory power in identifying HLH. HScore may improve diagnostic accuracy in autoimmune-HLH.
Collapse
Affiliation(s)
- Lisa Bilston
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Jennifer Croden
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Minakshi Taparia
- Division of Hematology, Department of Medicine, University of Alberta, Edmonton, Canada
| | | | - Jennifer Grossman
- Division of Hematology and Bone Marrow Transplantation, Department of Medicine, University of Calgary, Calgary, Canada
| | - Haowei Linda Sun
- Division of Hematology, Department of Medicine, University of Alberta, Edmonton, Canada
| |
Collapse
|
23
|
Rolsdorph LÅ, Mosevoll KA, Reikvam H. Cytomegalovirus induced hemophagocytic lymphohistiocytosis: diagnostic and treatment challenges for the future. Expert Rev Hematol 2022; 15:667-670. [PMID: 35819263 DOI: 10.1080/17474086.2022.2100341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | - Knut Anders Mosevoll
- Department of Clinical Science, Faculty of Medicine, University of Bergen.,Department of Medicine, Haukeland University Hospital.,Department of Medical Science, Faculty of Medicine, University of Bergen
| | - Håkon Reikvam
- Department of Clinical Science, Faculty of Medicine, University of Bergen.,Department of Medicine, Haukeland University Hospital.,Department of Medical Science, Faculty of Medicine, University of Bergen
| |
Collapse
|
24
|
Cui T, Wang J, Wang Z. The Outcome of Induction Therapy for EBV-Related Hemophagocytic Lymphohistiocytosis: A Model for Risk Stratification. Front Immunol 2022; 13:876415. [PMID: 35860246 PMCID: PMC9289144 DOI: 10.3389/fimmu.2022.876415] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 05/30/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundEpstein–Barr virus (EBV)–related hemophagocytic lymphohistiocytosis (HLH) is an abnormal inflammation caused by EBV infection, which has high mortality during induction therapy.ObjectivesThis study is aimed to build a model to predict the risk of death during induction therapy.MethodsThe patients with EBV-HLH admitted from January 2015 to December 2018 were retrospectively reviewed. The primary outcome was death during induction therapy. The interval from receiving therapy to death or the end of induction therapy was the observing time. The patients admitted from January 2015 to December 2017 were assigned to the primary group, and the patients admitted from January to December 2018 were assigned to the validation group.ResultsWe included 234 patients with EBV-HLH, of whom 65 (27.4%) died during induction therapy. The middle observing time was 25 days. On the basis of the primary group, the multivariate Cox analysis demonstrated age >18 years, blood urea nitrogen, procalcitonin >2 µg/L, serum CD25, and EBV-DNA in peripheral blood mononuclear cell as the risk factors of death during induction therapy. We developed a nomogram integrating the above factors with high predictive accuracy (c-statistic, 0.86) and stratified all patients into the high-risk and the low-risk groups. On the basis of the validation group, the high-risk patients had a higher risk of death (hazard ratio, 4.93; P = 0.012). In the subgroup analysis based on patients receiving etoposide-based strategy, the mortality in high-risk and low-risk patients was 43.9 and 3.1 per 100 person-weeks, respectively.ConclusionWe developed a nomogram for risk stratification of patients with EBV-HLH receiving induction therapy.
Collapse
|
25
|
Yamamoto M, Sato M, Onishi Y, Sasahara Y, Sano H, Masuko M, Nakamae H, Matsuoka K, Ara T, Washio K, Onizuka M, Watanabe K, Takahashi Y, Hirakawa T, Nishio M, Sakashita C, Kobayashi T, Sawada A, Ichinohe T, Fukuda T, Hashii Y, Atsuta Y, Arai A. Registry data analysis of hematopoietic stem cell transplantation on systemic chronic active Epstein-Barr virus infection patients in Japan. Am J Hematol 2022; 97:780-790. [PMID: 35312194 DOI: 10.1002/ajh.26544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 03/15/2022] [Accepted: 03/17/2022] [Indexed: 12/27/2022]
Abstract
The effects of allogeneic hematopoietic stem cell transplantation (allo-HSCT) on systemic chronic active Epstein-Barr virus infection (sCAEBV) are yet to be analyzed in a large number of patients. Using the Japanese registry database, Transplant Registry Unification Management Program, we investigated the outcomes of 102 sCAEBV patients who underwent allo-HSCT. The median age at HSCT was 21 years, and the three-year overall survival (3-year OS) rate was 72.5%. Of the 90 patients whose viral load after allo-HSCT was evaluated, 56 (62.2%) achieved a virological complete response, defined by the complete resolution of disease activity with a significant decrease in EBV-DNA in peripheral blood. The multivariate Cox proportional hazard model indicated that advanced age, in adolescents and young adults (AYA) (age, 15-39) and adults (age, ≥40 years) was a risk factor of poor OS. The hazard ratios (HRs) of the AYA and adult groups were 10.87 (95% confidence interval [CI]: 1.98-59.56, p = .006) and 15.93 (95% CI: 2.45-103.8, p = .004), respectively. Disease activity (HR 5.74), elevated soluble IL-2 receptor (sIL-2R) (≥ median, 691 U/mL) at HSCT (HR 6.93), and conditioning without radiotherapy (HR 3.53) were also independently associated with poor survival. Notably, 79% of radiotherapy doses were less than 6 Gy. Regardless of the presence of hemophagocytic lymphohistiocytosis, the group with a high sIL-2R level (≥2000 U/mL) showed a poorer prognosis. Although allo-HSCT is the only curative therapy for sCAEBV, treatment strategies need to be improved for high-risk patients, especially those with high levels of sIL-2R.
Collapse
Affiliation(s)
- Masahide Yamamoto
- Department of Hematology Tokyo Medical and Dental University (TMDU) Tokyo Japan
| | - Maho Sato
- Department of Hematology/Oncology Osaka Women's and Children's Hospital Izumi Japan
| | - Yasushi Onishi
- Department of Hematology Tohoku University Hospital Sendai Japan
| | - Yoji Sasahara
- Department of Pediatrics Tohoku University Hospital Sendai Japan
| | - Hideki Sano
- Department of Pediatric Oncology Fukushima Medical University Hospital Fukushima Japan
| | - Masayoshi Masuko
- Division of Stem Cell Transplantation Niigata University Medical and Dental Hospital Niigata Japan
| | | | - Ken‐ichi Matsuoka
- Department of Hematology and Oncology Okayama University Hospital Okayama Japan
| | - Takahide Ara
- Department of Hematology Hokkaido University Hospital Sapporo Japan
| | - Kana Washio
- Department of Pediatrics Okayama University Hospital Okayama Japan
| | - Makoto Onizuka
- Department of Hematology/Oncology Tokai University School of Medicine Isehara Japan
| | - Kenichiro Watanabe
- Department of Hematology and Oncology Shizuoka Children's Hospital Shizuoka Japan
| | - Yoshiyuki Takahashi
- Department of Pediatrics Nagoya University Graduate School of Medicine Nagoya Japan
| | - Tsuneaki Hirakawa
- Division of Hematology and Oncology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Miwako Nishio
- Department of Laboratory Molecular Genetics of Hematology, Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University (TMDU) Tokyo Japan
| | - Chizuko Sakashita
- Department of Hematology Tokyo Medical and Dental University (TMDU) Tokyo Japan
| | - Tohru Kobayashi
- Clinical Research Center, National Center for Child Health and Development Tokyo Japan
| | - Akihisa Sawada
- Department of Hematology/Oncology Osaka Women's and Children's Hospital Izumi Japan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology Research Institute for Radiation Biology and Medicine, Hiroshima University Higashihiroshima Japan
| | - Takahiro Fukuda
- Hematopoietic Stem Cell Transplantation Division National Cancer Center Hospital Tokyo Japan
| | - Yoshiko Hashii
- Cancer Immunotherapy/Pediatrics Osaka University Graduate School of Medicine Osaka Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation Nagoya Japan
- Department of Registry Science for Transplant and Cellular Therapy Aichi Medical University School of Medicine Nagakute Japan
| | - Ayako Arai
- Division of Hematology and Oncology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
- Department of Hematological Therapeutics, Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University (TMDU) Tokyo Japan
| |
Collapse
|
26
|
Pannu AK, Bhalla A. Secondary Hemophagocytic Lymphohistiocytosis: Think of the Devil Lurking! Indian J Crit Care Med 2022; 26:545-546. [PMID: 35719433 PMCID: PMC9160628 DOI: 10.5005/jp-journals-10071-24216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
How to cite this article: Pannu AK, Bhalla A. Secondary Hemophagocytic Lymphohistiocytosis: Think of the Devil Lurking! Indian J Crit Care Med 2022;26(5):545–546.
Collapse
Affiliation(s)
- Ashok K Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
- Ashish Bhalla, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India, Phone: +91 9417023973, e-mail:
| |
Collapse
|
27
|
Constantinescu C, Petrushev B, Rus I, Stefanescu H, Frasinariu O, Margarit S, Dima D, Tomuleasa C. Mechanistic Insights in Hemophagocytic Lymphohistiocytosis: Subsequent Acute Hepatic Failure in a Multiple Myeloma Patient following Therapy with Ixazomib-Lenalidomide-Dexamethasone. J Pers Med 2022; 12:jpm12050678. [PMID: 35629101 PMCID: PMC9145580 DOI: 10.3390/jpm12050678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/08/2022] [Accepted: 04/21/2022] [Indexed: 12/16/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, elusive, and life-threatening condition that is characterized by the pathologic and uncontrolled secondary activation of the cytotoxic T-cells, natural killer cells (NK-cells), and macrophages of the innate immune system. This condition can develop in sporadic or familial contexts associated with hematological malignancies, as a paraneoplastic syndrome, or linked to an infection related to immune system deficiency. This leads to the systemic inflammation responsible for the overall clinical manifestations. Diagnosis should be thorough, and treatment should be initiated as soon as possible. In the current manuscript, we focus on classifying the HLH spectrum, describing the pathophysiology and the tools needed to search for and correctly identify HLH, and the current therapeutic opportunities. We also present the first case of a multiple myeloma patient that developed HLH following therapy with the ixazomib-lenalidomide-dexamethasone protocol.
Collapse
Affiliation(s)
- Catalin Constantinescu
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania;
- Department of Anesthesia and Intensive Care, Iuliu Hatieganu University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania;
- Intensive Care Unit, Emergency Hospital, 400006 Cluj-Napoca, Romania
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania;
| | - Bobe Petrushev
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania;
- Department of Pathology, Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400158 Cluj-Napoca, Romania;
| | - Ioana Rus
- Department of Pathology, Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400158 Cluj-Napoca, Romania;
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, 400015 Cluj-Napoca, Romania;
| | - Horia Stefanescu
- Department of Gastroenterology, Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400158 Cluj-Napoca, Romania;
- Department of Gastroenterology, Iuliu Hatieganu University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania
| | - Otilia Frasinariu
- Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Simona Margarit
- Department of Anesthesia and Intensive Care, Iuliu Hatieganu University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania;
- Intensive Care Unit, Octavian Fodor Regional Institute of Gastroenterology and Hepatology, 400349 Cluj-Napoca, Romania
| | - Delia Dima
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, 400015 Cluj-Napoca, Romania;
| | - Ciprian Tomuleasa
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania;
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania;
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, 400015 Cluj-Napoca, Romania;
- Correspondence:
| |
Collapse
|
28
|
Rolsdorph LÅ, Mosevoll KA, Helgeland L, Reikvam H. Concomitant Hemophagocytic Lymphohistiocytosis and Cytomegalovirus Disease: A Case Based Systemic Review. Front Med (Lausanne) 2022; 9:819465. [PMID: 35514747 PMCID: PMC9063453 DOI: 10.3389/fmed.2022.819465] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 03/25/2022] [Indexed: 12/25/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is an immune mediated life-threatening condition. It is driven by an overactivation of the immune system and causes inflammatory tissue damage potentially leading to organ failure and death. Primary HLH is caused by genetic mutations, while secondary HLH is triggered by external factors. Viral infections are a well-known cause of secondary HLH. Cytomegalovirus (CMV) is a virus in the herpes family known to cause HLH in rare cases. Methods We report a recent case of CMV-induced HLH, followed by a systematic review of described cases of this rare disease entity, through a structured search in the medical database PubMed. All articles were assessed on a predetermined set of inclusion criteria. Results A total of 74 patients (age > 18 years) with CMV-related HLH were identified, 29 men, 42 women, and three patients with unspecified gender. Median age was 37.5 years (range 18-80). Sixty-six patients (88%) had one or more comorbid conditions and 22 patients (30%) had inflammatory bowel disease (IBD), the most frequent comorbidity. Forty patients (54%) received some form of immunomodulating treatment prior to HLH development. The general treatment approach was in general dual, consisting of antiviral treatment and specific immunomodulating HLH treatment approaches. Treatment outcome was at 77% survival, while 23% had fatal outcome. Conclusion The findings highlight the importance of early diagnostic work up and treatment intervention. Ability to recognize the characteristic clinical traits and perform specific HLH diagnostic workup are key factors to ensure targeted diagnostic work and treatment intervention for this patient group.
Collapse
Affiliation(s)
- Linn Åsholt Rolsdorph
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Knut Anders Mosevoll
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Lars Helgeland
- Department of Medical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - Håkon Reikvam
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
29
|
Zoref-Lorenz A, Murakami J, Hofstetter L, Iyer S, Alotaibi AS, Mohamed SF, Miller PG, Guber E, Weinstein S, Yacobovich J, Nikiforow S, Ebert BL, Lane A, Pasvolsky O, Raanani P, Nagler A, Berliner N, Daver N, Ellis M, Jordan MB. An improved index for diagnosis and mortality prediction in malignancy-associated hemophagocytic lymphohistiocytosis. Blood 2022; 139:1098-1110. [PMID: 34780598 PMCID: PMC8854682 DOI: 10.1182/blood.2021012764] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 10/28/2021] [Indexed: 11/20/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening inflammatory syndrome that may complicate hematologic malignancies (HMs). The appropriateness of current criteria for diagnosing HLH in the context of HMs is unknown because they were developed for children with familial HLH (HLH-2004) or derived from adult patient cohorts in which HMs were underrepresented (HScore). Moreover, many features of these criteria may directly reflect the underlying HM rather than an abnormal inflammatory state. To improve and potentially simplify HLH diagnosis in patients with HMs, we studied an international cohort of 225 adult patients with various HMs both with and without HLH and for whom HLH-2004 criteria were available. Classification and regression tree and receiver-operating curve analyses were used to identify the most useful diagnostic and prognostic parameters and to optimize laboratory cutoff values. Combined elevation of soluble CD25 (>3900 U/mL) and ferritin (>1000 ng/mL) best identified HLH-2004-defining features (sensitivity, 84%; specificity, 81%). Moreover, this combination, which we term the optimized HLH inflammatory (OHI) index, was highly predictive of mortality (hazard ratio, 4.3; 95% confidence interval, 3.0-6.2) across diverse HMs. Furthermore, the OHI index identified a large group of patients with high mortality risk who were not defined as having HLH according to HLH-2004/HScore. Finally, the OHI index shows diagnostic and prognostic value when used for routine surveillance of patients with newly diagnosed HMs as well as those with clinically suspected HLH. Thus, we conclude that the OHI index identifies patients with HM and an inflammatory state associated with a high mortality risk and warrants further prospective validation.
Collapse
Affiliation(s)
- Adi Zoref-Lorenz
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel
- Division of Immunobiology, Cincinnati Children's Medical Center, Cincinnati, OH
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jun Murakami
- Clinical Laboratory, Transfusion Medicine and Cell Therapy, University of Toyama, Toyama, Japan
| | - Liron Hofstetter
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel
| | | | - Ahmad S Alotaibi
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
- Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Peter G Miller
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Broad Institute of MIT and Harvard, Cambridge, MA
| | - Elad Guber
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pulmonary Institute, Meir Medical Center, Kfar Saba, Israel
| | - Shiri Weinstein
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Internal Medicine "D," Sheba Medical Center, Ramat Gan, Israel
| | - Joanne Yacobovich
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Sarah Nikiforow
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Benjamin L Ebert
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Broad Institute of MIT and Harvard, Cambridge, MA
- Howard Hughes Medical Institute, Bethesda, MD
| | - Adam Lane
- Department of Pediatrics, University of Cincinnati, and Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Oren Pasvolsky
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel
| | - Pia Raanani
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel
| | - Arnon Nagler
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematology Institute, Sheba Medical Center, Ramat Gan, Israel; and
| | - Nancy Berliner
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Naval Daver
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Martin Ellis
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael B Jordan
- Division of Immunobiology, Cincinnati Children's Medical Center, Cincinnati, OH
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| |
Collapse
|
30
|
Peerlings D, Mimpen M, Damoiseaux J. The IL-2 - IL-2 receptor pathway: Key to understanding multiple sclerosis. J Transl Autoimmun 2022; 4:100123. [PMID: 35005590 PMCID: PMC8716671 DOI: 10.1016/j.jtauto.2021.100123] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/20/2021] [Indexed: 12/28/2022] Open
Abstract
The development, progression, diagnosis and treatment of autoimmune diseases, such as multiple sclerosis (MS), are convoluted processes which remain incompletely understood. Multiple studies demonstrated that the interleukin (IL)-2 – IL-2 receptor (IL-2R) pathway plays a pivotal role within these processes. The most striking functions of the IL-2 – IL-2R pathway are the differential induction of autoimmune responses and tolerance. This paradoxical function of the IL-2 – IL-2R pathway may be an attractive therapeutic target for autoimmune diseases such as MS. However, the exact mechanisms that lead to autoimmunity or tolerance remain to be elucidated. Furthermore, another factor of this pathway, the soluble form of the IL-2R (sIL-2R), further complicates understanding the role of the IL-2 – IL-2R pathway in MS. The challenge is to unravel these mechanisms to prevent, diagnose and recover MS. In this review, first, the current knowledge of MS and the IL-2 – IL-2R pathway are summarized. Second, the key findings of the relation between the IL-2 – IL-2R pathway and MS have been highlighted. Eventually, this review may launch broad interest in the IL-2 – IL-2R pathway propelling further research in autoimmune diseases, including MS. The IL-2 – IL-2R pathway determines the balance between immunity and tolerance. The IL-2 – IL-2R pathway is involved in the pathogenesis of multiple sclerosis. The role of soluble IL-2R is controversial and requires further investigation.
Collapse
Affiliation(s)
- Daphne Peerlings
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Max Mimpen
- School for Mental Health and Neuroscience, University of Maastricht, Maastricht, the Netherlands
| | - Jan Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, the Netherlands
| |
Collapse
|
31
|
Liu XQ, Xue S, Xu JB, Ge H, Mao Q, Xu XH, Jiang HD. Clinical characteristics and related risk factors of disease severity in 101 COVID-19 patients hospitalized in Wuhan, China. Acta Pharmacol Sin 2022; 43:64-75. [PMID: 33742107 PMCID: PMC7976686 DOI: 10.1038/s41401-021-00627-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 02/10/2021] [Indexed: 01/08/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) broke out in December 2019. Due its high morbility and mortality, it is necessary to summarize the clinical characteristics of COVID-19 patients to provide more theoretical basis for future treatment. In the current study, we conducted a retrospective analysis of the clinical characteristics of COVID-19 patients and explored the risk factors for the severity of illness. A total of 101 COVID-19 patients hospitalized in Leishenshan Hospital (Wuhan, China) was classified into three sub-types: moderate (n = 47), severe (n = 36), and critical (n = 18); their clinical data were collected from the Electronic Medical Record. We showed that among the 101 COVID-19 patients, the median age was 62 years (IQR 51-74); 50 (49.5%) patients were accompanied by hypertension, while 25 (24.8%) and 22 (21.8%) patients suffered from diabetes and heart diseases, respectively, with complications. All patients were from Wuhan who had a definite history of exposure to the epidemic area. Multivariate logistic regression analysis revealed that older age, diabetes, chronic liver disease, percentage of neutrophils (N%) > 75%, CRP > 4 mg/L, D-dimer > 0.55 mg/L, IL-2R > 710 U/mL, IL-8 > 62 pg/mL, and IL-10 > 9.1 pg/mL were independent variables associated with severe COVID-19. In conclusion, we have identified the independent risk factors for the severity of COVID-19 pneumonia, including older age, diabetes, chronic liver disease, higher levels of N%, CRP, D-dimer, IL-2R, IL-8, and IL-10, providing evidence for more accurate risk prediction.
Collapse
|
32
|
Yao S, Jin Z, He L, Zhang R, Liu M, Hua Z, Wang Z, Wang Y. Clinical Features and Prognostic Risk Prediction of Non-Hodgkin Lymphoma-Associated Hemophagocytic Syndrome. Front Oncol 2021; 11:788056. [PMID: 34938663 PMCID: PMC8685250 DOI: 10.3389/fonc.2021.788056] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background Malignancies, especially lymphoma, are a common cause of adult secondary HLH and an independent risk factor for the prognosis of HLH patients. Methods Patients with lymphoma alone or concurrent lymphoma-associated phagocytic syndrome (LAHS) admitted to Beijing Friendship Hospital from January 2016 to December 2020 were enrolled in this study. Findings There were 348 lymphoma patients, 104 concurrent with LAHS. The pathological type of lymphoma without LAHS was dominated by B-cell lymphoma, while those with LAHS were T/NK-cell lymphoma predominantly (p < 0.001). Superficial lymph node enlargement was more significant in patients with B-LAHS (p = 0.006), while patients with T/NK-LAHS had lower neutrophil counts (p = 0.005), lower fibrinogen levels (p < 0.001), higher transaminase levels, and more co-infection with EBV (p < 0.001). B-LAHS had significantly higher IL-10 levels than with T/NK-LAHS (p = 0.006), and NK/T-LAHS had significantly higher IP-10 levels than other T-LAHS (p = 0.008). Age, platelet count, IPI, history of NK/T lymphoma, and no remission of HLH were independent risk factors for prognosis in patients with non-Hodgkin lymphoma-associated phagocytic syndrome (NHL-LAHS), and a prognostic risk score model for NHL-LAHS was developed. Conclusion LAHS is a life-threatening disease with a poor prognosis. The prognostic risk score model for NHL-LAHS with a good fit and validation for the test has value for clinical application.
Collapse
Affiliation(s)
- Shuyan Yao
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhili Jin
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lingbo He
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ruoxi Zhang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Menghan Liu
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhengjie Hua
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yini Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Department of General Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
33
|
Perazzio SF, Palmeira P, Moraes-Vasconcelos D, Rangel-Santos A, de Oliveira JB, Andrade LEC, Carneiro-Sampaio M. A Critical Review on the Standardization and Quality Assessment of Nonfunctional Laboratory Tests Frequently Used to Identify Inborn Errors of Immunity. Front Immunol 2021; 12:721289. [PMID: 34858394 PMCID: PMC8630704 DOI: 10.3389/fimmu.2021.721289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 10/05/2021] [Indexed: 12/24/2022] Open
Abstract
Inborn errors of immunity (IEI), which were previously termed primary immunodeficiency diseases, represent a large and growing heterogeneous group of diseases that are mostly monogenic. In addition to increased susceptibility to infections, other clinical phenotypes have recently been associated with IEI, such as autoimmune disorders, severe allergies, autoinflammatory disorders, benign lymphoproliferative diseases, and malignant manifestations. The IUIS 2019 classification comprises 430 distinct defects that, although rare individually, represent a group affecting a significant number of patients, with an overall prevalence of 1:1,200-2,000 in the general population. Early IEI diagnosis is critical for appropriate therapy and genetic counseling, however, this process is deeply dependent on accurate laboratory tests. Despite the striking importance of laboratory data for clinical immunologists, several IEI-relevant immunoassays still lack standardization, including standardized protocols, reference materials, and external quality assessment programs. Moreover, well-established reference values mostly remain to be determined, especially for early ages, when the most severe conditions manifest and diagnosis is critical for patient survival. In this article, we intend to approach the issue of standardization and quality control of the nonfunctional diagnostic tests used for IEI, focusing on those frequently utilized in clinical practice. Herein, we will focus on discussing the issues of nonfunctional immunoassays (flow cytometry, enzyme-linked immunosorbent assays, and turbidimetry/nephelometry, among others), as defined by the pure quantification of proteins or cell subsets without cell activation or cell culture-based methods.
Collapse
Affiliation(s)
- Sandro Félix Perazzio
- Division of Rheumatology, Universidade Federal de São Paulo, Sao Paulo, Brazil.,Immunology Division, Fleury Medicine and Health Laboratory, Sao Paulo, Brazil
| | - Patricia Palmeira
- Laboratório de Investigação Médica (LIM-36), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil
| | - Dewton Moraes-Vasconcelos
- Laboratório de Investigação Médica (LIM-56), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil
| | - Andréia Rangel-Santos
- Laboratório de Investigação Médica (LIM-36), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil
| | | | - Luis Eduardo Coelho Andrade
- Division of Rheumatology, Universidade Federal de São Paulo, Sao Paulo, Brazil.,Immunology Division, Fleury Medicine and Health Laboratory, Sao Paulo, Brazil
| | - Magda Carneiro-Sampaio
- Laboratório de Investigação Médica (LIM-36), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil.,Department of Pediatrics, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil
| |
Collapse
|
34
|
Aggarwal A, Cohen E, Figueira M, Sabharwal V, Herlihy JM, Bronwen C, Barnett ED, Pelton SI, Camelo IY. Multisystem Inflammatory Syndrome in an Adult With COVID-19-A Trial of Anakinra: A Case Report. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2021; 29:e420-e423. [PMID: 34803350 PMCID: PMC8594393 DOI: 10.1097/ipc.0000000000001028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
COVID-19 disease has been a pandemic caused by a β-coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A life-threatening multisystem inflammatory syndrome (MIS), secondary to SARS-CoV-2 virus infection, sharing common features with Kawasaki disease shock syndrome, staphylococcal/streptococcal shock syndrome, and macrophage activation syndrome in pediatric patients has been described. A total of 27 cases in adults (MIS-A) with a similar presentation have been reported so far. Here we describe the case of a 21-year-old man admitted with abdominal pain, diarrhea, tachycardia, and low blood pressure. He had elevated troponin, ferritin, and interleukin-2 receptor levels and had evidence of myocarditis. He tested positive for SARS-CoV-2 IgG antibody, and a diagnosis of MIS-A was made. Our case adds to the scant literature on this topic, and to our knowledge, it is the first case where anakinra was administered. He recovered well. MIS-A should be considered when young adults present with multiorgan dysfunction.
Collapse
Affiliation(s)
- Abhimanyu Aggarwal
- From the Department of Infectious Diseases, University of Massachusetts School of Medicine–Baystate Medical Center, Springfield, MA
| | - Ezra Cohen
- Department of Pediatrics, Division of Hospital Medicine
- Department of Pediatrics, Division of Pediatric Rheumatology, Boston University School of Medicine, Boston Medical Center
- Division of Rheumatology, Boston Children's Hospital
| | | | | | | | - Carroll Bronwen
- Division of Pediatric Emergency Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA
| | | | | | - Ingrid Y. Camelo
- Department of Pediatric Infectious Diseases, University of Massachusetts School of Medicine–Baystate Medical Center, Springfield, MA
| |
Collapse
|
35
|
Shiga T, Nozaki Y, Tomita D, Kishimoto K, Hirooka Y, Kinoshita K, Funauchi M, Matsumura I. Usefulness of Interleukin-18 as a Diagnostic Biomarker to Differentiate Adult-Onset Still's Disease With/Without Macrophage Activation Syndrome From Other Secondary Hemophagocytic Lymphohistiocytosis in Adults. Front Immunol 2021; 12:750114. [PMID: 34691064 PMCID: PMC8533049 DOI: 10.3389/fimmu.2021.750114] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/24/2021] [Indexed: 11/19/2022] Open
Abstract
Background Interleukin (IL)-18 is markedly elevated in systemic inflammatory diseases that cause the ‘cytokine storm’ such as adult-onset Still’s disease (AOSD) and hemophagocytic lymphohistiocytosis (HLH). The differences in IL-18 between AOSD and HLH, especially in adults, is uncertain. Macrophage activation syndrome (MAS), a form of secondary HLH, is often difficult to differentiate cases of AOSD that include MAS from other secondary HLH. In this case-control study, we investigated whether serum IL-18 levels could be a useful biomarker for the differential diagnosis of AOSD with or without MAS (AOSD group) and other secondary HLH in adults (adult HLH group). Patients and Methods We enrolled 46 patients diagnosed with AOSD including 9 patients with MAS and 31 patients in the adult HLH group, which excluded AOSD-associated MAS. The clinical features and laboratory data were compared between the AOSD and adult HLH groups. In addition, we subdivided the AOSD group (with or without MAS) and the adult HLH group (whether lymphoma-associated or not) and compared the four groups. A logistic regression analysis was used to identify factors with high efficacy in differentiating the two groups, followed by a receiver operating characteristic (ROC) curve analysis to evaluate the differential diagnostic ability of IL-18. We analyzed the correlation between IL-18 and various laboratory parameters in the AOSD group. Results Serum IL-18 levels of patients in the AOSD groups were significantly higher than those of the adult HLH groups, and were closely correlated with ferritin, soluble interleukin-2 receptor (sIL-2R), and other laboratory data. Univariate and multivariate logistic regression analyses revealed that IL-18, sIL-2R, and ‘arthralgia or arthritis’ are independent factors useful in the differential diagnosis of AOSD from adult HLH. In the differential diagnosis of both groups, the area under the curve obtained from the ROC curve of IL-18 with a cutoff value of 18,550 pg/mL was 0.91 (95% confidence interval 0.83–1.00; sensitivity 90.3%, specificity 93.5%), and the differential diagnosis ability of IL-18 was superior to that of other laboratory data. Conclusions IL-18 could be a useful biomarker for the differential diagnosis of AOSD and adult HLH.
Collapse
Affiliation(s)
- Toshihiko Shiga
- Department of Hematology and Rheumatology, Kindai University School of Medicine, Osaka, Japan
| | - Yuji Nozaki
- Department of Hematology and Rheumatology, Kindai University School of Medicine, Osaka, Japan
| | - Daisuke Tomita
- Department of Hematology and Rheumatology, Kindai University School of Medicine, Osaka, Japan
| | - Kazuya Kishimoto
- Department of Hematology and Rheumatology, Kindai University School of Medicine, Osaka, Japan
| | - Yasuaki Hirooka
- Department of Rheumatology, Kindai University Nara Hospital, Nara, Japan
| | - Koji Kinoshita
- Department of Hematology and Rheumatology, Kindai University School of Medicine, Osaka, Japan
| | - Masanori Funauchi
- Department of Hematology and Rheumatology, Kindai University School of Medicine, Osaka, Japan
| | - Itaru Matsumura
- Department of Hematology and Rheumatology, Kindai University School of Medicine, Osaka, Japan
| |
Collapse
|
36
|
Shin JJ, Jeon S, Unlu S, Par-Young J, Shin MS, Kuster JK, Afinogenova Y, Kang Y, Simonov M, Buller G, Bucala R, Kang I. A distinct association of inflammatory molecules with outcomes of COVID-19 in younger versus older adults. Clin Immunol 2021; 232:108857. [PMID: 34560283 PMCID: PMC8455237 DOI: 10.1016/j.clim.2021.108857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/16/2021] [Accepted: 09/15/2021] [Indexed: 12/19/2022]
Abstract
Aging can alter immunity affecting host defense. COVID-19 has the most devastating clinical outcomes in older adults, raising the implication of immune aging in determining its severity and mortality. We investigated biological predictors for clinical outcomes in a dataset of 13,642 ambulatory and hospitalized adult COVID-19 patients, including younger (age < 65, n = 566) and older (age ≥ 65, n = 717) subjects, with in-depth analyses of inflammatory molecules, cytokines and comorbidities. Disease severity and mortality in younger and older adults were associated with discrete immune mechanisms, including predominant T cell activation in younger adults, as measured by increased soluble IL-2 receptor alpha, and increased IL-10 in older adults although both groups also had shared inflammatory processes, including acute phase reactants, contributing to clinical outcomes. These observations suggest that progression to severe disease and death in COVID-19 may proceed by different immunologic mechanisms in younger versus older subjects and introduce the possibility of age-based immune directed therapies.
Collapse
Affiliation(s)
- Junghee J Shin
- Section of Rheumatology, Allergy & Immunology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Sangchoon Jeon
- Yale University School of Nursing, West Haven, CT 06516, USA
| | - Serhan Unlu
- Section of Rheumatology, Allergy & Immunology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Jennefer Par-Young
- Section of Rheumatology, Allergy & Immunology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Min Sun Shin
- Section of Rheumatology, Allergy & Immunology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
| | - John K Kuster
- Section of Rheumatology, Allergy & Immunology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Yuliya Afinogenova
- Section of Rheumatology, Allergy & Immunology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Yumi Kang
- Department of Internal Medicine, Bridgeport Hospital - Yale New Haven Health, Bridgeport, CT 06610, United States of America
| | - Michael Simonov
- Clinical and Translational Research Accelerator (CTRA), Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Gregory Buller
- Department of Internal Medicine, Bridgeport Hospital - Yale New Haven Health, Bridgeport, CT 06610, United States of America
| | - Richard Bucala
- Section of Rheumatology, Allergy & Immunology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Insoo Kang
- Section of Rheumatology, Allergy & Immunology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520, USA.
| |
Collapse
|
37
|
García-Gasalla M, Ferrer JM, Fraile-Ribot PA, Ferre-Beltrán A, Rodríguez A, Martínez-Pomar N, Ramon-Clar L, Iglesias A, Losada-López I, Fanjul F, Pou JA, Llompart-Alabern I, Toledo N, Pons J, Oliver A, Riera M, Murillas J. Predictive Immunological, Virological, and Routine Laboratory Markers for Critical COVID-19 on Admission. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2021; 2021:9965850. [PMID: 34422145 PMCID: PMC8373501 DOI: 10.1155/2021/9965850] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 07/28/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Early identification of COVID-19 patients at risk of critical illness is a challenging endeavor for clinicians. We aimed to establish immunological, virological, and routine laboratory markers, which, in combination with clinical information, may allow identifying such patients. METHODS Blood tests to measure neutrophil/lymphocyte ratio (NLR) and levels of ferritin, CRP, D-dimer, complement components (C3 and C4), cytokines, and lymphocyte subsets, as well as SARS-Cov-2 RT-PCR tests, were performed in COVID-19-confirmed cases within 48 hours of admission. RT-PCR cycle threshold (Ct) values from oropharyngeal or nasopharyngeal swabs were determined on the day of admission. Symptom severity was categorized as mild (grade 1), severe (grade 2), or critical (grade 3). RESULTS Of 120 patients who were included, 49 had mild, 32 severe, and 39 critical COVID-19. Levels of ferritin >370 ng/mL (OR 16.4, 95% CI 5.3-50.8), D-dimer >440 ng/mL (OR 5.45, 95% CI 2.36-12.61), CRP >7.65 mg/dL (OR 11.54, 95% CI 4.3-30.8), NLR >3.77 (OR 13.4, 95% CI 4.3-41.1), IL-6 >142.5 pg/mL (OR 8.76, 95% CI 3.56-21.54), IL-10 >10.8 pg/mL (OR 16.45, 95% CI 5.32-50.81), sIL-2rα (sCD25) >804.5 pg/mL (OR 14.06, 95% CI 4.56-43.28), IL-1Ra >88.4 pg/mL (OR 4.54, 95% CI 2.03-10.17), and IL-18 >144 pg/mL (OR 17.85, 95% CI 6.54-48.78) were associated with critical COVID-19 in the univariate age-adjusted analysis. This association was confirmed in the multivariate age-adjusted analysis only for ferritin, CRP, NLR, IL-10, sIL-2rα, and IL-18. T, B, and NK cells were significantly decreased in critical patients. SARS-CoV-2 was not detected in blood except in 3 patients who had indeterminate results. RT-PCR Ct values from oropharyngeal or nasopharyngeal swabs on admission were not related to symptom severity. CONCLUSION Ferritin, D-dimer, CRP, NLR, cytokine (IL-18 and IL-10), and cytokine receptor (IL-6, IL1-Ra, and sCD25) test results combined with clinical data can contribute to the early identification of critical COVID-19 patients.
Collapse
Affiliation(s)
- Mercedes García-Gasalla
- Internal Medicine, Hospital Universitari Son Espases-Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Balearic Islands, Spain
| | - Juana M. Ferrer
- Immunology, Hospital Universitari Son Espases-Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Balearic Islands, Spain
| | - Pablo A. Fraile-Ribot
- Microbiology, Hospital Universitari Son Espases-Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Balearic Islands, Spain
| | - Adrián Ferre-Beltrán
- Internal Medicine, Hospital Universitari Son Espases-Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Balearic Islands, Spain
| | - Adrián Rodríguez
- Internal Medicine, Hospital Universitari Son Llàtzer-Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Balearic Islands, Spain
| | - Natalia Martínez-Pomar
- Immunology, Hospital Universitari Son Espases-Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Balearic Islands, Spain
| | - Luisa Ramon-Clar
- Pneumology, Hospital Universitari Son Espases-Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Balearic Islands, Spain
| | - Amanda Iglesias
- CIBER de Enfermedades Respiratorias, Hospital Universitari Son Espases-Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Balearic Islands, Spain
- CIBERES, Madrid, Spain
| | - Inés Losada-López
- Internal Medicine, Hospital Universitari Son Llàtzer-Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Balearic Islands, Spain
| | - Francisco Fanjul
- Internal Medicine, Hospital Universitari Son Espases-Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Balearic Islands, Spain
| | - Joan Albert Pou
- Internal Medicine, Hospital Universitari Son Espases-Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Balearic Islands, Spain
| | | | - Nuria Toledo
- Pneumology, Hospital Universitari Son Espases-Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Balearic Islands, Spain
| | - Jaime Pons
- Immunology, Hospital Universitari Son Espases-Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Balearic Islands, Spain
| | - Antonio Oliver
- Microbiology, Hospital Universitari Son Espases-Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Balearic Islands, Spain
| | - Melchor Riera
- Internal Medicine, Hospital Universitari Son Espases-Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Balearic Islands, Spain
| | - Javier Murillas
- Internal Medicine, Hospital Universitari Son Espases-Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Balearic Islands, Spain
| |
Collapse
|
38
|
Tang N, Huang J, Chen C, Wu X, Xu H, Chen G, Xue H. Polymorphisms and haplotypes of IL2RA, IL10, IFNG, IRF5, and CCR2 are associated with Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis in children. Pediatr Blood Cancer 2021; 68:e29097. [PMID: 34031980 DOI: 10.1002/pbc.29097] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 04/11/2021] [Accepted: 04/14/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Cytokine storms are central to the development of Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis (EBV-HLH). Previous studies have shown that single-nucleotide polymorphisms (SNPs) of cytokine genes may be associated with the development of EBV-HLH in children. As such, we investigated the association between susceptibility to EBV-HLH in children and SNPs and haplotypes of genes encoding interleukin-2 receptor subunit alpha (IL2RA), interleukin-10 (IL10), interferon gamma (IFNG), interferon regulatory factor 5 (IRF5), and C-C chemokine receptor 2 (CCR2). METHODS Sixty-six children with EBV-HLH and 58 healthy EBV-seropositive controls were enrolled in this study. SNPs of IL2RA rs2104286, rs12722489, and rs11594656; IL10 rs1800896, rs1800871, and rs1800872; IFNG rs2430561, IRF5 rs2004640, and CCR2 rs1799864 were assayed and genotyped using the SNaPshot technique. RESULTS Frequencies of the A allele of IL2RA rs2104286 and IL10 rs1800896, and C allele of IL-10 rs1800872 were significantly higher in the EBV-HLH group than in the control group. The AA genotype of IL2RA rs2104286 and IL10 rs1800896, and the CC genotype of IL10 rs1800872 might be associated with a significantly high risk of EBV-HLH. However, the frequencies of genotypes and alleles of IL2RA rs2104286, IL10 rs1800871, IFNG rs2430561, IRF5 rs2004640, and CCR2 rs1799864 were similar in both groups. Additionally, IL2RA AGT (rs2104286-rs12722489-rs11594656) and IL10 ACC (rs1800896-rs1800871-rs1800872) haplotypes were also associated with an increased risk of EBV-HLH. CONCLUSIONS SNPs of IL2RA rs2104286, IL10 rs1800896 and rs1800872 and the haplotypes of IL2RA AGT and IL10 ACC were highly associated with susceptibility to EBV-HLH in children.
Collapse
Affiliation(s)
- Nannan Tang
- Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| | - Junbin Huang
- Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| | - Chun Chen
- Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| | - Xiaojun Wu
- Department of Pediatrics, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Honggui Xu
- Department of Pediatrics, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Guohua Chen
- Department of Pediatrics, Huizhou First Hospital, Huizhou, China
| | - Hongman Xue
- Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| |
Collapse
|
39
|
El-Sayed ZA, El-Owaidy RH, Khamis MA, Rezk AR. Screening of hemophagocytic lymphohistiocytosis in children with severe sepsis in pediatric intensive care. Sci Prog 2021; 104:368504211044042. [PMID: 34519554 PMCID: PMC10402287 DOI: 10.1177/00368504211044042] [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] [Indexed: 11/17/2022]
Abstract
BACKGROUND We sought to screen for clinical and laboratory features of hemophagocytic lymphohistiocytosis among pediatric patients with severe sepsis. METHODS We conducted a retrospective study that analyzed the clinical and laboratory data of 70 pediatric patients who died of severe sepsis. Medical records were revised for the presence of fever, splenomegaly, pancytopenia, hyperferritinemia, hypertriglyceridemia, and hypofibrinogenemia. Soluble CD25 was measured in stored samples. RESULTS Patients' ages ranged between 0.5 and 11 years with median (interquartile range) 2 (1-5). All patients had fever (≥38.5 °C) and pancytopenia, 58 (82.9%) hepatosplenomegaly, 36 (51.4%) lymphadenopathy, 37 (52.9%) had ferritin >500 ng/ml, 20 (28.6%) had fibrinogen <1.5 mg/ml, 14 (20%) had fasting triglycerides >264 mg/dl while 5 (7.1%) had soluble CD25 >2400 U/ml. Twenty-five (35.7%) patients fulfilled at least 5/6 of the hemophagocytic lymphohistiocytosis-2004 diagnostic criteria. Multivariate backward binary logistic regression analysis revealed lymphadenopathy as an independent predictor for hemophagocytic lymphohistiocytosis criteria fulfilment with odds ratio of 23.9. Fibrinogen had the best performance in discriminating hemophagocytic lymphohistiocytosis fulfilling from non-fulfilling groups (cut-off value: <1.8 mg/ml), followed by ferritin/erythrocyte sedimentation rate ratio (cut-off value: >17). CONCLUSION There is a significant clinical and laboratory overlap between hemophagocytic lymphohistiocytosis and severe sepsis, making the syndromes difficult to distinguish. The use of current hemophagocytic lymphohistiocytosis-2004 diagnostic criteria should be applied cautiously in those patients.
Collapse
Affiliation(s)
- Zeinab A El-Sayed
- Pediatric Allergy and Immunology Unit, Children’s Hospital, Ain Shams University, Egypt
| | - Rasha H El-Owaidy
- Pediatric Allergy and Immunology Unit, Children’s Hospital, Ain Shams University, Egypt
| | - Mohammed A Khamis
- Pediatric Nephrology Unit, Children’s Hospital, Ain Shams University, Egypt
| | - Ahmed R Rezk
- Pediatric Intensive Care Unit, Children’s Hospital, Ain Shams University, Egypt
| |
Collapse
|
40
|
Chesner J, Schiano TD, Fiel MI, Crismale JF. Hemophagocytic lymphohistiocytosis occurring after liver transplantation: A case series and review of the literature. Clin Transplant 2021; 35:e14392. [PMID: 34159642 DOI: 10.1111/ctr.14392] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/29/2021] [Accepted: 06/05/2021] [Indexed: 01/19/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease characterized by excessive inflammation and tissue destruction due to a dysregulated immune response. Its secondary form is most commonly triggered by viral infection or malignancy. There have previously been 11 cases of acquired HLH described following liver transplantation in adult transplant recipients, most occurring within the first year following transplantation. Herein, we describe two cases of HLH in liver transplant recipients that both occurred remotely following transplantation. In the first case, HLH was thought to be triggered by the development of a post-transplant lymphoproliferative disorder in a patient who was initially diagnosed with recurrent autoimmune hepatitis. In the second, it was thought to be triggered by a newly acquired human herpesvirus-8 infection. In both cases, the syndrome was not recognized until treatment for the initial putative diagnoses was unsuccessful. Despite treatment, both patients unfortunately died from multiorgan failure. HLH in the post-liver transplant setting is likely under-recognized and has a high mortality; early diagnosis and intervention may lead to improved outcomes.
Collapse
Affiliation(s)
- Jaclyn Chesner
- Department of Medicine, The Mount Sinai Hospital, New York, New York, USA
| | - Thomas D Schiano
- Recanati-Miller Transplantation Institute, The Mount Sinai Hospital, New York, New York, USA
| | - M Isabel Fiel
- Department of Pathology, The Mount Sinai Hospital, New York, New York, USA
| | - James F Crismale
- Recanati-Miller Transplantation Institute, The Mount Sinai Hospital, New York, New York, USA
| |
Collapse
|
41
|
Gera A, Misra A, Tiwari A, Singh A, Mehndiratta S. A hungry Histiocyte, altered immunity and myriad of problems: Diagnostic challenges for Pediatric HLH. Int J Lab Hematol 2021; 43:1443-1450. [PMID: 34118134 DOI: 10.1111/ijlh.13626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 05/04/2021] [Accepted: 05/24/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is an immune deregulation disorder with varied clinical presentation which clinically overlaps with widespread tropical infections. METHODS We conducted a retrospective chart review of children diagnosed with HLH at our center from February-2017 to October-2020. RESULTS Out of the nine diagnosed patients, genetic predisposition was present in three children; two had identified infectious triggers. The mean age of presentation was 30 months with male predominance. The most common clinical findings were fever, organomegaly, and pancytopenia. The median value of fibrinogen was-156 mg/dL, ferritin-12 957 ng/mL and for triglycerides-349 mg/dL, respectively. In children with identified genetic predisposition, serum ferritin levels were usually more than 10 000 ng/mL. The majority of our patients had evidence of hemophagocytosis on bone marrow examination. In our experience, although nonspecific, very high ferritin and serum triglycerides with low fibrinogen in a patient with bi-cytopenia, pancytopenia was the most suggestive evidence of HLH. Genetic evaluation in our series identified three children, one with primary HLH genetic mutation and two with underlying immune deficiency syndrome. The presence of HLH in the accelerated phase of Chediak-Higashi and AD Hyper IgE syndrome with HLH is extremely rare. Leishmaniasis (in nonendemic area) and Ebstein-Barr virus (EBV) was identified as an infectious trigger in two cases. Most of our cases received treatment as per HLH 2004 protocol. Three children died during the initial diagnosis and treatment. HLH with subcutaneous panniculitis-like T-cell lymphoma recovered well. CONCLUSION HLH remains a life-threatening disorder associated with a variety of underlying illnesses as highlighted by our case series.
Collapse
Affiliation(s)
- Akriti Gera
- Department of Pediatrics, VMMC and Safdarjung Hospital, New Delhi, India
| | - Aroonima Misra
- Indian Council of Medical Research, National Institute of Pathology, New Delhi, India
| | - Aditi Tiwari
- Department of Pediatrics, VMMC and Safdarjung Hospital, New Delhi, India
| | - Amitabh Singh
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, VMMC and Safdarjung Hospital, New Delhi, India
| | - Sumit Mehndiratta
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, VMMC and Safdarjung Hospital, New Delhi, India
| |
Collapse
|
42
|
Knight V, Heimall JR, Chong H, Nandiwada SL, Chen K, Lawrence MG, Sadighi Akha AA, Kumánovics A, Jyonouchi S, Ngo SY, Vinh DC, Hagin D, Forbes Satter LR, Marsh RA, Chiang SCC, Willrich MAV, Frazer-Abel AA, Rider NL. A Toolkit and Framework for Optimal Laboratory Evaluation of Individuals with Suspected Primary Immunodeficiency. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3293-3307.e6. [PMID: 34033983 DOI: 10.1016/j.jaip.2021.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/05/2021] [Accepted: 05/05/2021] [Indexed: 12/27/2022]
Abstract
Knowledge related to the biology of inborn errors of immunity and associated laboratory testing methods continues to expand at a tremendous rate. Despite this, many patients with inborn errors of immunity suffer for prolonged periods of time before identification of their underlying condition, thereby delaying appropriate care. Understanding that test selection and optimal evaluation for patients with recurrent infections or unusual patterns of inflammation can be unclear, we present a document that distills relevant clinical features of immunologic disease due to inborn errors of immunity and related appropriate and available test options. This document is intended to serve the practicing clinical immunologist and, in turn, patients by describing best available test options for initial and expanded immunologic evaluations across the disease spectrum. Our goal is to demystify the process of evaluating patients with suspected immune dysfunction and to enable more rapid and accurate diagnosis of such individuals.
Collapse
Affiliation(s)
- Vijaya Knight
- Department of Pediatrics, Section of Allergy and Immunology, University of Colorado School of Medicine, Aurora, Colo
| | - Jennifer R Heimall
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Perlman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | - Hey Chong
- Division of Pulmonary Medicine, Allergy and Immunology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pa
| | - Sarada L Nandiwada
- The Texas Children's Hospital, Section of Immunology, Allergy and Retrovirology, The Baylor College of Medicine and the William T. Shearer Center for Human Immunobiology, Houston, Tex
| | - Karin Chen
- Department of Immunology, University of Washington and Seattle Children's Hospital, Seattle, Wash
| | - Monica G Lawrence
- Division of Asthma, Allergy and Clinical Immunology, University of Virginia, Charlottesville, Va
| | - Amir A Sadighi Akha
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn
| | - Attila Kumánovics
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn
| | - Soma Jyonouchi
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Perlman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | - Suzanne Y Ngo
- Department of Pediatrics, Section of Allergy and Immunology, University of Colorado School of Medicine, Aurora, Colo
| | - Donald C Vinh
- Division of Infectious Diseases, Allergy & Clinical Immunology, Department of Medical Microbiology and Human Genetics, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - David Hagin
- Allergy and Clinical Immunology Unit, Department of Medicine, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lisa R Forbes Satter
- The Texas Children's Hospital, Section of Immunology, Allergy and Retrovirology, The Baylor College of Medicine and the William T. Shearer Center for Human Immunobiology, Houston, Tex
| | - Rebecca A Marsh
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Samuel C C Chiang
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Maria A V Willrich
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn
| | - Ashley A Frazer-Abel
- Division of Rheumatology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo
| | - Nicholas L Rider
- The Texas Children's Hospital, Section of Immunology, Allergy and Retrovirology, The Baylor College of Medicine and the William T. Shearer Center for Human Immunobiology, Houston, Tex.
| |
Collapse
|
43
|
Elsharkawy A, Assem H, Salama M, Mikhael N, Zeid MY, El Chazli Y. Clinical Characteristics and Outcomes of 101 Children with Hemophagocytic Lymphohistiocytosis: A Four-Year Single-Center Experience from Egypt. Pediatr Hematol Oncol 2021; 38:194-207. [PMID: 33150824 DOI: 10.1080/08880018.2020.1825575] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition, arising either due to genetic mutations or from a variety of underlying diseases. This prospective observational study reports the clinical and laboratory data as well as the outcome of pediatric HLH in Egypt. HLH was diagnosed according to the Histiocyte Society HLH-2004 diagnostic criteria conducted at Alexandria University Children's Hospital over four years. One-hundred-one patients were enrolled (44 males and 57 females), and the median age at presentation was 13.1 months (range: 1 day - 181.4 months). Almost 75% of the patients had consanguineous parents, and one-third had a history of an affected family member (HLH or HLH-like illness). The median time interval between the first HLH symptom and diagnosis was 34 days. At diagnosis, patients were preliminarily classified as having primary HLH in 61% of patients and secondary HLH in 39% of patients. The diagnosis was confirmed genetically in 57 patients. Seventy-eight percent of patients received the HLH-94 and HLH-2004 protocols, only seven patients have undergone hematopoietic stem cell transplantation. The overall survival was 26.4% by the end of the study; the most common cause of death was uncontrolled disease activity. This descriptive study, on a large cohort of pediatric HLH in Africa and the Middle East, sheds some light on the epidemiological characteristics of HLH patients and the available diagnostic and therapeutic tools. The mortality rate was considerably high, highlighting the importance of early diagnosis and initiation of appropriate therapy.
Collapse
Affiliation(s)
- Asmaa Elsharkawy
- Department of Pediatrics, Hematology and Oncology Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Hala Assem
- Department of Pediatrics, Hematology and Oncology Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Mostafa Salama
- Department of Pediatrics, Hematology and Oncology Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Neveen Mikhael
- Department of Clinical and chemical pathology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Maha Y Zeid
- Department of Pediatrics, Hematology and Oncology Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Yasmine El Chazli
- Department of Pediatrics, Hematology and Oncology Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| |
Collapse
|
44
|
Smits BM, van Montfrans J, Merrill SA, van de Corput L, van Gijn M, de Vries A, van den Bos C, Abbink F, van der Molen RG, Dors N, Lindemans C, Boelens JJ, Nierkens S. A Minimal Parameter Set Facilitating Early Decision-making in the Diagnosis of Hemophagocytic Lymphohistiocytosis. J Clin Immunol 2021; 41:1219-1228. [PMID: 33779897 PMCID: PMC8310853 DOI: 10.1007/s10875-021-01005-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 02/23/2021] [Indexed: 12/11/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening immune dysregulation syndrome characterized by uncontrolled immune cell activation. Timely diagnosis is important, since early treatment can improve survival rates. However, completing all assessments needed to reach ≥5 positive criteria out of the 8 HLH-2004 criteria can be time consuming and may delay timely initiation of treatment. Hence, we applied a data-driven approach to identify a minimal parameter set for early decision-making towards the initiation of HLH-specific treatment. We retrospectively evaluated 165 patients from five Dutch tertiary hospitals with suspected HLH. Sixteen pHLH (median age 0.5 years) and 70 sHLH patients (median age 8.7 years) were identified using the HLH-2004 criteria. Clustering analysis and multi-receiver operator characteristics were used to identify parameters distinctive of HLH. The presence of either increased ferritin, cytopenia in ≥2 lineages, or splenomegaly distinguished HLH from non-HLH cases with a negative predictive value of 100%. A minimal parameter set consisting of 2 major criteria (phagocytosis and splenomegaly) and 3 minor criteria (cytopenia, increased ferritin, and increased triglycerides/low fibrinogen) predicted HLH with 95% (88-99) sensitivity and 94% (86-98) specificity. This finding was replicated in an independent retrospective validation cohort of 109 US patients (n = 109). By dividing a subset of the HLH-2004 criteria into major and minor criteria, this strategy uses the evaluation of less than 5 criteria to quickly identify patients with HLH. When confirmed in a prospective setting, this approach could be of value for timely diagnosis and treatment of HLH.
Collapse
Affiliation(s)
- Bas M Smits
- Center of Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands.,Department of Pediatric Immunology and Infectious Diseases, UMC Utrecht, Utrecht, The Netherlands
| | - Joris van Montfrans
- Department of Pediatric Immunology and Infectious Diseases, UMC Utrecht, Utrecht, The Netherlands
| | - Samuel A Merrill
- Division of Hematology/Oncology, West Virginia University, Morgantown, WV, USA
| | - Lisette van de Corput
- Center of Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
| | - Mariëlle van Gijn
- Center of Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands.,Department of Medical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Andrica de Vries
- Department of Pediatric Oncology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Cor van den Bos
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Pediatric Oncology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Floor Abbink
- Department of Pediatric Oncology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Renate G van der Molen
- Department of Laboratory Medicine, Laboratory for Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Natasja Dors
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Pediatric Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Jaap J Boelens
- Center of Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Stem Cell Transplantation and Cellular Therapies, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stefan Nierkens
- Center of Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands. .,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
| |
Collapse
|
45
|
Utility of novel T-cell-specific extracellular vesicles in monitoring and evaluation of acute GVHD. Int J Hematol 2021; 113:910-920. [DOI: 10.1007/s12185-021-03113-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 01/08/2023]
|
46
|
Zhou J, Zhou J, Wu ZQ, Goyal H, Xu HG. Ferritin index is a strong prognostic marker in adult hemophagocytic lymphohistiocytosis. Int J Clin Pract 2021; 75:e13704. [PMID: 32931059 DOI: 10.1111/ijcp.13704] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/05/2020] [Indexed: 12/29/2022] Open
Abstract
AIMS The relationship between ferritin levels and survival in adult hemophagocytic lymphohistiocytosis (HLH) has been evaluated in previous studies. However, Admission-to-discharge percentage ferritin reduction (named as ferritin index) level in adult patients with HLH has never been evaluated to predict 6-month survival. METHODS The demographic, laboratory and clinical information of 102 newly diagnosed adult HLH patients were collected. Regression analysis, receiver operating curve and Kaplan-Meier curves were analysed to explore the performance of ferritin levels. RESULTS Ferritin index and discharge ferritin level were significantly different between survivour and non-survivour group (all P < .001). Ferritin index had the highest area under the curve (AUC) for predicting the survival (AUC = 0.802, P < .001) followed by discharge ferritin (AUC = 0.746, P < .001). Kaplan-Meier analysis showed a significant difference in survival according to optimum cutoff values of ferritin index ≥ 10.19% (P < .001) or discharge ferritin ≤ 1056.1 μg/L (P < .001). Multivariate analysis confirmed that ferritin index and discharge ferritin are independent predictors of 6-month survival (ferritin index: odds ratio (HR) 6.237, 95% confidence interval (CI) 2.075-18.774, P = .001; discharge ferritin: HR 6.024, 95% CI 1.894-19.231, P = .002). In addition, the combination of a ferritin index ≥ 10.19% and discharge ferritin ≤ 1056.1 μg/L had a significantly higher 6-month survival (P < .001). CONCLUSION Ferritin index is a better predictor of 6-month survival than admission and discharges ferritin levels in adult patients with HLH.
Collapse
Affiliation(s)
- Jun Zhou
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Zhou
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhi-Qi Wu
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hemant Goyal
- Internal Medicine, Wright Center for Graduate Medical Education, Scranton, PA, USA
| | - Hua-Guo Xu
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| |
Collapse
|
47
|
Kao WY, Lin YF, Chang IW, Chen CL, Tang JH, Chang CC, Chang YJ, Wang W. Interleukin-2 receptor alpha as a biomarker for nonalcoholic fatty liver disease diagnosis. J Chin Med Assoc 2021; 84:261-266. [PMID: 33306598 DOI: 10.1097/jcma.0000000000000469] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Two recent studies in the adult and pediatric Nonalcoholic Steatohepatitis-Clinical Research Network (NASH-CRN) cohorts have shown that soluble interleukin-2 receptor alpha (IL2RA) levels increased with fibrosis severity. However, no hepatic study has been conducted in Asian morbidly obese patients who underwent bariatric surgery. In this study, we proposed IL2RA as a biomarker for nonalcoholic fatty liver disease (NAFLD) diagnosis and performed immunohistochemistry (IHC) staining of IL2RA. METHODS This prospective cohort study enrolled 123 morbidly obese patients who underwent bariatric surgery at Taipei Medical University Hospital from October 2016 to June 2018. During bariatric surgery, all patients underwent a wedge liver biopsy under laparoscopic guidance. The diagnoses of NASH and liver fibrosis were made histologically. In IHC of IL2RA, the number of lymphocytes with IL2RA immunoreactivity was counted in five high-power fields (×400, total: 1.19 mm2). RESULTS Among the 123 patients, the mean age was 35.5 years, mean body mass index (BMI) was 40.6 kg/m2, 87 (70.7%) were female, 25 (20.7%) had diabetes mellitus, and 57 (46.3%; 11 with non-NAFLD and 46 with steatosis) and 66 (53.7%) were included in the non-NASH and NASH groups, respectively. The NASH group had higher IHC of IL2RA than the non-NASH group. In multivariate analysis, IHC of IL2RA (odds ratio, 1.025; 95% confidence interval, 1.006-1.045; p = 0.011) and alanine aminotransferase (ALT; odds ratio, 1.045; 95% confidence interval, 1.018-1.073; p = 0.001) were the independent factors associated with NASH. The area under the receiver operating curve of IL2RA IHC for NASH was 0.627 at the cutoff value of 82 (p = 0.0113). CONCLUSION IL2RA is significantly associated with NASH in morbidly obese patients and would be a useful biomarker for NASH diagnosis.
Collapse
Affiliation(s)
- Wei-Yu Kao
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan, ROC
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
| | - Yuan-Feng Lin
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
| | - I-Wei Chang
- Department of Pathology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
- Department of Clinical Pathology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan, ROC
- Department of Pathology, Taipei Medical University Hospital, Taipei, Taiwan, ROC
- Department of Pathology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan, ROC
| | - Chi-Long Chen
- Department of Pathology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
- Department of Pathology, Taipei Medical University Hospital, Taipei, Taiwan, ROC
| | - Jui-Hsiang Tang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan, ROC
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
| | - Chun-Chao Chang
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan, ROC
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
| | - Yu-Jia Chang
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
| | - Weu Wang
- Division of Digestive Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan, ROC
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
| |
Collapse
|
48
|
McGonagle D, Ramanan AV, Bridgewood C. Immune cartography of macrophage activation syndrome in the COVID-19 era. Nat Rev Rheumatol 2021; 17:145-157. [PMID: 33547426 PMCID: PMC7863615 DOI: 10.1038/s41584-020-00571-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2020] [Indexed: 02/06/2023]
Abstract
A hyperinflammatory 'cytokine storm' state termed macrophage activation syndrome (MAS), culminating from a complex interplay of genetics, immunodeficiency, infectious triggers and dominant innate immune effector responses, can develop across disparate entities including systemic juvenile idiopathic arthritis (sJIA) and its counterpart adult-onset Still disease (AOSD), connective tissue diseases, sepsis, infection, cancers and cancer immunotherapy. Classifying MAS using the immunological disease continuum model, with strict boundaries that define the limits of innate and adaptive immunity, at one boundary is MAS with loss of immune function, as occurs in the 'perforinopathies' and some cases of sJIA-AOSD. Conversely, at the other boundary, immune hypersensitivity with gain of immune function in MHC class II-associated sJIA-AOSD and with chimeric antigen receptor (CAR) T cell therapy also triggers MAS. This provides a benchmark for evaluating severe inflammation in some patients with COVID-19 pneumonia, which cripples primary type I interferon immunity and usually culminates in a lung-centric 'second wave' cytokine-driven alveolitis with associated immunothrombosis; this phenomenon is generally distinct from MAS but can share features with the proposed 'loss of immune function' MAS variant. This loss and gain of function MAS model offers immune cartography for a novel mechanistic classification of MAS with therapeutic implications.
Collapse
Affiliation(s)
- Dennis McGonagle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.
- National Institute for Health Research (NIHR), Leeds Biomedical Research Centre (BRC), Leeds Teaching Hospitals, Leeds, UK.
| | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust & Translational Health Sciences, University of Bristol, Bristol, UK
| | - Charlie Bridgewood
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| |
Collapse
|
49
|
England JT, Abdulla A, Biggs CM, Lee AYY, Hay KA, Hoiland RL, Wellington CL, Sekhon M, Jamal S, Shojania K, Chen LYC. Weathering the COVID-19 storm: Lessons from hematologic cytokine syndromes. Blood Rev 2021; 45:100707. [PMID: 32425294 PMCID: PMC7227559 DOI: 10.1016/j.blre.2020.100707] [Citation(s) in RCA: 109] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A subset of patients with severe COVID-19 develop profound inflammation and multi-organ dysfunction consistent with a "Cytokine Storm Syndrome" (CSS). In this review we compare the clinical features, diagnosis, and pathogenesis of COVID-CSS with other hematological CSS, namely secondary hemophagocytic lymphohistiocytosis (sHLH), idiopathic multicentric Castleman disease (iMCD), and CAR-T cell therapy associated Cytokine Release Syndrome (CRS). Novel therapeutics targeting cytokines or inhibiting cell signaling pathways have now become the mainstay of treatment in these CSS. We review the evidence for cytokine blockade and attenuation in these known CSS as well as the emerging literature and clinical trials pertaining to COVID-CSS. Established markers of inflammation as well as cytokine levels are compared and contrasted between these four entities in order to establish a foundation for future diagnostic criteria of COVID-CSS.
Collapse
Affiliation(s)
- James T England
- Division of Hematology, University of British Columbia, Canada
| | - Alym Abdulla
- Division of Hematology, University of British Columbia, Canada
| | - Catherine M Biggs
- Division of Allergy and Immunology, University of British Columbia, Canada
| | - Agnes Y Y Lee
- Division of Hematology, University of British Columbia, Canada
| | - Kevin A Hay
- Division of Hematology, University of British Columbia, Canada
| | - Ryan L Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Canada
| | - Cheryl L Wellington
- Department of Pathology and Laboratory Medicine, University of British Columbia, Canada
| | - Mypinder Sekhon
- Division of Critical Care Medicine, University of British Columbia, Canada
| | - Shahin Jamal
- Division of Rheumatology, University of British Columbia, Canada
| | - Kamran Shojania
- Division of Rheumatology, University of British Columbia, Canada
| | - Luke Y C Chen
- Division of Hematology, University of British Columbia, Canada
- Centre for Health Education Scholarship, University of British Columbia, Canada
| |
Collapse
|
50
|
Singh D, Raghunathan V, Dhaliwal M, Rastogi N, Chadha R, Yadav SP. Soluble Interleukin-2 Receptor Level as a Marker of Hemophagocytic Lymphohistiocytosis in Children With Severe Dengue. Front Pediatr 2021; 9:721857. [PMID: 34778128 PMCID: PMC8578167 DOI: 10.3389/fped.2021.721857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/20/2021] [Indexed: 01/02/2023] Open
Abstract
Dengue induced-hemophagocytic lymphohistiocytosis (HLH) is increasingly recognized as an important cause of secondary HLH. Early identification of dengue HLH and directed therapy for HLH may help to alter the outcomes in critically ill patients. Soluble interleukin-2 receptor (IL2R) is a useful inflammatory marker and is seen to correlate with HLH disease activity. There is scarcity of data on IL2R in pediatric dengue patients with HLH. All patients (age < 18 years) with severe dengue confirmed by positive dengue IgM ELISA admitted to PICU were retrospectively enrolled. Patientswere screened for presence of HLH according to HLH 2004 criteria. Hemogram, ferritin, fibrinogen, liver, and renal function tests were noted. Patients who met four or more HLH criteria were treated with steroids and IL2R levels were sent to confirm the diagnosis of HLH. Out of 15 patients, nine patients met the criteria of HLH. IL2R levels were high in all HLH patients (mean 51,711, range 18,000-98,715 pg/mL). Mean ferritin levels were high in the HLH group as compared to non-HLH group (mean ferritin 34,593 vs. 3,206 ng/mL; p-value 0.004). Liver dysfunction was notably higher in the HLH group compared to non-HLH group (mean alanine aminotransferase 6,621 U/L vs. 165.6 U/L; p-value 0.04, mean aspartate aminotransferase 2,145 U/L vs. 104.2 U/L; 0.04, bilirubin level 4.2 mg/dL vs. 0.7 mg/dL; p-value 0.03). Four patients in the HLH group had acute kidney injury (AKI) and two required renal replacement therapy in the form of sustained low efficiency dialysis (SLED). Requirement for invasive ventilation was exclusively seen in HLH group and three patients developed ARDS. Two patients each in HLH and non-HLH group had shock requiring vasoactive therapy in addition to fluids. Mean days of ICU and hospital stay were higher in HLH group vs. non-HLH group but not statistically significant (6.4 vs. 4.4; p-value 0.32 and 8.44 vs. 5.6; p-value 0.18 days, respectively). All children in HLH group received steroids as per HLH protocol. In the HLH group, seven survived while two died. In the non-HLH group, all five patients survived. We concluded that IL2R levels are high in dengue HLH and useful for definitive diagnosis. Early recognition of this condition in severe dengue and prompt steroid therapy improves chances of better outcome.
Collapse
Affiliation(s)
| | | | | | | | - Ritu Chadha
- Medanta the Medicity Hospital, Gurgaon, India
| | | |
Collapse
|