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Kilich G, Perelygina L, Sullivan KE. Rubella virus chronic inflammatory disease and other unusual viral phenotypes in inborn errors of immunity. Immunol Rev 2024; 322:113-137. [PMID: 38009321 DOI: 10.1111/imr.13290] [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: 11/28/2023]
Abstract
Infectious susceptibility is a component of many inborn errors of immunity. Nevertheless, antibiotic use is often used as a surrogate in history taking for infectious susceptibility, thereby disadvantaging patients who present with viral infections as their phenotype. Further complicating clinical evaluations are unusual manifestations of viral infections which may be less familiar that the typical respiratory viral infections. This review covers several unusual viral phenotypes arising in patients with inborn errors of immunity and other settings of immune compromise. In some cases, chronic infections lead to oncogenesis or tumor-like growths and the conditions and mechanisms of viral-induced oncogenesis will be described. This review covers enterovirus, rubella, measles, papillomavirus, and parvovirus B19. It does not cover EBV and hemophagocytic lymphohistiocytosis nor lymphomagenesis related to EBV. EBV susceptibility has been recently reviewed. Our goal is to increase awareness of the unusual manifestations of viral infections in patients with IEI and to describe treatment modalities utilized in this setting. Coincidentally, each of the discussed viral infections can have a cutaneous component and figures will serve as a reminder of the physical features of these viruses. Given the high morbidity and mortality, early recognition can only improve outcomes.
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Affiliation(s)
- Gonench Kilich
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ludmila Perelygina
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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2
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Avrusin IS, Abramova NN, Belozerov KE, Bregel LV, Efremova OS, Vilnits AA, Konstantinova JE, Isupova EA, Kornishina TL, Masalova VV, Kalashnikova OV, Chasnyk VG, Aleksandrovich YS, Ivanov DO, Kostik MM. Using HScore for Evaluation of Hemophagocytosis in Multisystem Inflammatory Syndrome Associated with COVID-19 in Children. Biomedicines 2024; 12:294. [PMID: 38397896 PMCID: PMC10886863 DOI: 10.3390/biomedicines12020294] [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: 12/30/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/25/2024] Open
Abstract
Hemophagocytic syndrome is a key point in the pathogenesis of severe forms of multisystem inflammatory syndrome associated with COVID-19 in children (MIS-C). The factors associated with hemophagocytosis in patients with MIS-C were assessed in the present study of 94 boys and 64 girls ranging in age from 4 months to 17 years, each of whose HScore was calculated. In accordance with a previous analysis, patients with HScore ≤ 91 (n = 79) and HScore > 91 (n = 79) were compared. Patients with HScore > 91 had a higher frequency of symptoms such as cervical lymphadenopathy, dry cracked lips, bright mucous, erythema/swelling of hands and feet, peeling of fingers, edematous syndrome, hepatomegaly, splenomegaly, and hypotension/shock. They also had a higher erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and D-dimer levels, and a tendency to anemia, thrombocytopenia, and hypofibrinogenemia. They more often needed acetylsalicylic acid and biological treatment and were admitted to ICU in 70.9% of cases. Conclusion: The following signs of severe MIS-C were associated with HScore > 91: myocardial involvement, pericarditis, hypotension/shock, and ICU admission.
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Affiliation(s)
- Ilia S. Avrusin
- Hospital Pediatrics, Saint Petersburg State Pediatric Medical University, Saint Petersburg 194100, Russia; (K.E.B.); (E.A.I.); (T.L.K.); (V.V.M.); (O.V.K.); (V.G.C.)
| | - Natalia N. Abramova
- Intensive Care Unit Department, Saint Petersburg State Pediatric Medical University, Saint Petersburg 194100, Russia; (N.N.A.); (Y.S.A.)
| | - Konstantin E. Belozerov
- Hospital Pediatrics, Saint Petersburg State Pediatric Medical University, Saint Petersburg 194100, Russia; (K.E.B.); (E.A.I.); (T.L.K.); (V.V.M.); (O.V.K.); (V.G.C.)
| | - Liudmila V. Bregel
- Department of Pediatrics, Irkutsk State Medical Academy of Postgraduate Education, Branch of Russian Medical Academy of Continuous Professional Education, Irkutsk 664049, Russia; (L.V.B.); (O.S.E.)
- Department of Cardiology, Irkutsk Regional Children’s Hospital, Irkutsk 664022, Russia
| | - Olesya S. Efremova
- Department of Pediatrics, Irkutsk State Medical Academy of Postgraduate Education, Branch of Russian Medical Academy of Continuous Professional Education, Irkutsk 664049, Russia; (L.V.B.); (O.S.E.)
- Department of Cardiology, Irkutsk Regional Children’s Hospital, Irkutsk 664022, Russia
| | - Alla A. Vilnits
- Pediatric Infectious Department, Saint Petersburg State Pediatric Medical University, Saint Petersburg 194100, Russia;
- Pediatric Research and Clinical Center for Infection Diseases, Saint Petersburg 197022, Russia;
| | - Julia E. Konstantinova
- Pediatric Research and Clinical Center for Infection Diseases, Saint Petersburg 197022, Russia;
| | - Eugenia A. Isupova
- Hospital Pediatrics, Saint Petersburg State Pediatric Medical University, Saint Petersburg 194100, Russia; (K.E.B.); (E.A.I.); (T.L.K.); (V.V.M.); (O.V.K.); (V.G.C.)
| | - Tatiana L. Kornishina
- Hospital Pediatrics, Saint Petersburg State Pediatric Medical University, Saint Petersburg 194100, Russia; (K.E.B.); (E.A.I.); (T.L.K.); (V.V.M.); (O.V.K.); (V.G.C.)
| | - Vera V. Masalova
- Hospital Pediatrics, Saint Petersburg State Pediatric Medical University, Saint Petersburg 194100, Russia; (K.E.B.); (E.A.I.); (T.L.K.); (V.V.M.); (O.V.K.); (V.G.C.)
| | - Olga V. Kalashnikova
- Hospital Pediatrics, Saint Petersburg State Pediatric Medical University, Saint Petersburg 194100, Russia; (K.E.B.); (E.A.I.); (T.L.K.); (V.V.M.); (O.V.K.); (V.G.C.)
| | - Vyacheslav G. Chasnyk
- Hospital Pediatrics, Saint Petersburg State Pediatric Medical University, Saint Petersburg 194100, Russia; (K.E.B.); (E.A.I.); (T.L.K.); (V.V.M.); (O.V.K.); (V.G.C.)
| | - Yuriy S. Aleksandrovich
- Intensive Care Unit Department, Saint Petersburg State Pediatric Medical University, Saint Petersburg 194100, Russia; (N.N.A.); (Y.S.A.)
| | - Dmitri O. Ivanov
- Neonatology Department, Saint Petersburg State Pediatric Medical University, Saint Petersburg 194100, Russia
| | - Mikhail M. Kostik
- Hospital Pediatrics, Saint Petersburg State Pediatric Medical University, Saint Petersburg 194100, Russia; (K.E.B.); (E.A.I.); (T.L.K.); (V.V.M.); (O.V.K.); (V.G.C.)
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Löfstedt A, Jädersten M, Meeths M, Henter JI. Malignancy-associated hemophagocytic lymphohistiocytosis in Sweden: incidence, clinical characteristics, and survival. Blood 2024; 143:233-242. [PMID: 37595287 PMCID: PMC10808245 DOI: 10.1182/blood.2023020715] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/31/2023] [Accepted: 07/31/2023] [Indexed: 08/20/2023] Open
Abstract
ABSTRACT We evaluated malignancy-associated hemophagocytic lymphohistiocytosis (mal-HLH) in Sweden regarding population-based incidence, clinical features, and survival. From 1997 to 2018, we identified 307 adults (≥18 years old) and 9 children (209 males, 107 females; P < .001) with both an HLH-related diagnosis and malignant disease, corresponding to 0.19 per 100 000 adults annually (0.15/100 000 for the entire population), increasing from 0.026 (1997-2007) to 0.34 (2008-2018) (P < .001). In the latest 7-year period (2012-2018), the annual incidence was 0.45 per 100 000 adults (n = 246). This incidence varied between the 6 health care regions in Sweden, from 0.18 to 0.71 (Region Stockholm) per 100 000 adults annually (P < .001), likely due to variable awareness. Mal-HLH was reported in 0.6% of all hematological malignancies, with the highest proportion (2.5%) in young males. Among the 316 patients, the 1-month probability of survival, likely representing the HLH episode, increased significantly from 52% (95% confidence interval [CI], 40-63) (1997-2007) to 71% (95% CI, 65-76) (2008-2018), whereas 2-year survival remained poor (25%; 95% CI, 20-30). Altogether, 52% were lymphomas, 29% leukemias, 8% other hematological malignancies, and 11% solid tumors. Males were more affected than females by mal-HLH, also taking the over-representation of males with hematological malignancies into account (P = .0012). Validation by medical-file reviews revealed 13% over-reporting of HLH. We conclude that the annual mal-HLH incidence has increased 10-fold and was at least 0.71 per 100 000 adults from 2012 to 2018, that is, 0.62 per 100 000 adults considering 13% estimated HLH over-reporting, and that early survival improved significantly, likely due to increased awareness and more HLH-directed therapy.
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Affiliation(s)
- Alexandra Löfstedt
- Department of Women’s and Children’s Health, Childhood Cancer Research Unit, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgrens Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Martin Jädersten
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Center for Hematology and Regenerative Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Marie Meeths
- Department of Women’s and Children’s Health, Childhood Cancer Research Unit, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgrens Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Jan-Inge Henter
- Department of Women’s and Children’s Health, Childhood Cancer Research Unit, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgrens Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
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Abbasi AM, Shaikh MU, Shariq M, Arif MS, Arshad A, Raheem A, Ali N. Outcome of patients with primary and secondary hemophagocytic lymphohistiocytosis: A retrospective analysis from a tertiary care center. Medicine (Baltimore) 2023; 102:e34898. [PMID: 37904401 PMCID: PMC10615402 DOI: 10.1097/md.0000000000034898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/03/2023] [Indexed: 11/01/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a progressive and potentially life-threatening disorder. It is classified into primary and secondary HLH. The objective of our study was to determine the outcome of primary and secondary HLH in pediatric and adult patients based on HScore and treatment modality. We conducted a retrospective analysis done from July 2010 to June 2020. Variables analyzed included age, gender and history of death in siblings. HScore was used for disease classification while clinical and laboratory findings which were required to fulfill the HScore diagnostic criteria were also recorded. Continuous variables were summarized as median and categorical variables as frequencies and percentages. Categorical variables were compared using chi-square test and Fisher Exact test. Significance of different variables between primary and secondary HLH was calculated using independent-samples t test. A P value of < .05 was taken as significant. A total of 51 patients were included in the analysis (41 in primary and 10 in secondary HLH group). In primary HLH, 36 patients were in the pediatric age group and 12.2% had a history of death in sibling. All 41 patients had increased ferritin and decreased fibrinogen levels. The overall survival in primary HLH was 44%. In the secondary HLH group, viral infections were the most common etiology and ferritin was increased as well. The overall survival in secondary HLH was 60%. The median survival was 15 ± 4.8 months. The overall survival of both groups combined was 53%. Primary HLH should be considered in pediatric patients who present with pancytopenia and hepatosplenomegaly. In centers where genetic testing is not available, HScore along with serum ferritin and fibrinogen is a good substitute for disease classification.
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Affiliation(s)
| | - Mohammad Usman Shaikh
- Department of Pathology and Laboratory Medicine/Oncology, Aga Khan University Karachi, Karachi, Pakistan
| | - Muhammad Shariq
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | | | - Ainan Arshad
- Department of Internal Medicine, Aga Khan University Karachi, Karachi, Pakistan
| | - Ahmed Raheem
- Department of Emergency Medicine, Aga Khan University Karachi, Karachi, Pakistan
| | - Natasha Ali
- Department of Pathology and Laboratory Medicine/Oncology, Aga Khan University Karachi, Karachi, Pakistan
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5
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Benevenuta C, Mussinatto I, Orsi C, Timeus FS. Secondary hemophagocytic lymphohistiocytosis in children (Review). Exp Ther Med 2023; 26:423. [PMID: 37602304 PMCID: PMC10433411 DOI: 10.3892/etm.2023.12122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 06/16/2023] [Indexed: 08/22/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening condition characterized by hyperinflammation in an uncontrolled and ineffective immune response. Despite great improvement in diagnosis and treatment, it still represents a challenge in clinical management, with poor prognosis in the absence of an aggressive therapeutic approach. The present literature review focuses on secondary HLH at pediatric age, which represents a heterogeneous group in terms of etiology and therapeutic approach. It summarizes the most recent evidence on epidemiology, pathophysiology, diagnosis, treatment and prognosis, and provides a detailed description and comparison of the major subtypes of secondary HLH. Finally, it addresses the open questions with a focus on diagnosis and new treatment insights.
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Affiliation(s)
- Chiara Benevenuta
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
| | - Ilaria Mussinatto
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
| | - Cecilia Orsi
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
| | - Fabio S. Timeus
- Department of Pediatrics, Azienda Sanitaria Locale Torino 4, Chivasso Hospital, I-10034 Turin, Italy
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Zhang X, Wang J, Huang X, Zhu Y, Zhu Y, Tang L, Cai H, Fang X, Huang L. Case Report: Parvovirus B19 infection complicated by hemophagocytic lymphohistiocytosis in a heart-lung transplant patient. Front Immunol 2023; 14:1099468. [PMID: 36825017 PMCID: PMC9941661 DOI: 10.3389/fimmu.2023.1099468] [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] [Received: 11/15/2022] [Accepted: 01/26/2023] [Indexed: 02/10/2023] Open
Abstract
Immunosuppressed patients can contract parvovirus B19, and some may experience hemophagocytic lymphohistiocytosis (HLH). Herein, we describe the first report of hemophagocytic lymphohistiocytosis in a heart-lung transplant patient with concomitant parvovirus B19 infection. The patient was treated with intravenous immune globulin (IVIG) and the features of HLH were remission. This instance emphasizes the significance of parvovirus B19 monitoring in transplant patients with anemia; if HLH complicates the situation, IVIG may be an adequate remedy. Finally, a summary of the development in diagnosing and managing parvovirus B19 infection complicated by HLH is provided.
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Affiliation(s)
- Xuewu Zhang
- Department of Critical Care Units, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Department of Hematology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Zhejiang Provincial Key Laboratory of Hematopoietic Malignancy, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jingxia Wang
- Department of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiaohan Huang
- Department of Nephrology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yue Zhu
- Department of Critical Care Units, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yijing Zhu
- Department of Hematology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Lingling Tang
- Department of Infectious Diseases, Shulan (Hangzhou) Hospital, Zhejiang Shuren University of Shulan International Medical College, Hangzhou, China
| | - Hongliu Cai
- Department of Critical Care Units, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Laboratory of Clinical Evaluation Technology for Medical Devices of Zhejiang Province, Hangzhou, China
| | - Xueling Fang
- Department of Critical Care Units, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lingtong Huang
- Department of Critical Care Units, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Shanina EV, Breker F, Lysov NA, Shanin VY, Ponomareva YV, Supil'nikov AA. Chemotherapy-Induced Broadly Reactive Autoantibodies in a Colon Cancer Patient. BULLETIN OF THE MEDICAL INSTITUTE "REAVIZ" (REHABILITATION, DOCTOR AND HEALTH) 2022. [DOI: 10.20340/vmi-rvz.2023.1.clin.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
The link between cancer and autoimmunity is well known. However, the extent to which chemotherapy induces autoimmune responses is still unclear. Here, we quantified IgM responses to various human tissues and patient tumors before and during adjuvant chemotherapy (seven cycles of the FOLFIRI plus cetuximab regimen) with metastasized colorectal cancer. IgM levels against all tissues tested increased shortly after the first cycle and further increased in the second and third cycles. Autoimmune responses then declined during cycles four through seven, but remained above baseline for most tissues. Our results suggest that chemotherapy can induce wide-reactive autoimmune responses. Monitoring self-reactive IgM responses during treatment may help alleviate the side effects associated with autoimmunity.
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8
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Muacevic A, Adler JR, Lysov N, Shanin V. Chemotherapy-Induced, Broadly Reactive Autoantibodies in a Colon Cancer Patient. Cureus 2022; 14:e31954. [PMID: 36582563 PMCID: PMC9795272 DOI: 10.7759/cureus.31954] [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: 11/25/2022] [Indexed: 11/29/2022] Open
Abstract
The link between cancer and autoimmunity is well-established. For example, increased levels of autoantibodies are frequently found in cancer patients, and autoimmune diseases are linked to an increased risk for certain neoplasms. However, the extent to which chemotherapy induces autoimmune reactions remains largely elusive. Here, we quantified immunoglobulin M (IgM) responses to various human tissues and the patient's tumor before and during adjuvanted chemotherapy (seven cycles of the FOLFIRI regimen (folinic acid/fluorouracil/irinotecan) plus cetuximab) of a patient with metastasized colon cancer. IgM levels against all investigated tissues increased shortly after the first cycle and were further boosted by cycles two and three. Autoimmune responses then decreased during cycles four to seven but remained above baseline levels for most tissues. Our findings suggest that chemotherapy can induce broadly reactive autoimmune responses. Monitoring self-reactive IgM responses during treatment may help alleviate autoimmunity-related adverse events.
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Taylor ML, Hoyt KJ, Han J, Benson L, Case S, Chandler MT, Chang MH, Platt C, Cohen EM, Day-Lewis M, Dedeoglu F, Gorman M, Hausmann JS, Janssen E, Lee PY, Lo J, Priebe GP, Lo MS, Meidan E, Nigrovic PA, Roberts JE, Son MBF, Sundel RP, Alfieri M, Yeun JC, Shobiye DM, Degar B, Chang JC, Halyabar O, Hazen MM, Henderson LA. An Evidence-Based Guideline Improves Outcomes for Patients With Hemophagocytic Lymphohistiocytosis and Macrophage Activation Syndrome. J Rheumatol 2022; 49:1042-1051. [PMID: 35840156 PMCID: PMC9588491 DOI: 10.3899/jrheum.211219] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To compare clinical outcomes in children with hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) who were managed before and after implementation of an evidence-based guideline (EBG). METHODS A management algorithm for MAS-HLH was developed at our institution based on literature review, expert opinion, and consensus building across multiple pediatric subspecialties. An electronic medical record search retrospectively identified hospitalized patients with MAS-HLH in the pre-EBG (October 15, 2015, to December 4, 2017) and post-EBG (January 1, 2018, to January 21, 2020) time periods. Predetermined outcome metrics were evaluated in the 2 cohorts. RESULTS After the EBG launch, 57 children were identified by house staff as potential patients with MAS-HLH, and rheumatology was consulted for management. Ultimately, 17 patients were diagnosed with MAS-HLH by the treating team. Of these, 59% met HLH 2004 criteria, and 94% met 2016 classification criteria for MAS complicating systemic juvenile idiopathic arthritis. There was a statistically significant reduction in mortality from 50% before implementation of the EBG to 6% in the post-EBG cohort (P = 0.02). There was a significant improvement in time to 50% reduction in C-reactive protein level in the post-EBG vs pre-EBG cohorts (log-rank P < 0.01). There were trends toward faster time to MAS-HLH diagnosis, faster initiation of immunosuppressive therapy, shorter length of hospital stay, and more rapid normalization of MAS-HLH-related biomarkers in the patients post-EBG. CONCLUSION While the observed improvements may be partially attributed to advances in treatment of MAS-HLH that have accumulated over time, this analysis also suggests that a multidisciplinary treatment pathway for MAS-HLH contributed meaningfully to favorable patient outcomes.
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Affiliation(s)
- Maria L Taylor
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Kacie J Hoyt
- K.J. Hoyt, MSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, and Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Joseph Han
- J. Han, BS, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Leslie Benson
- L. Benson, MD, M. Gorman, MD, Division of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Siobhan Case
- S. Case, MD, M.H. Chang, MD, PhD, P.A. Nigrovic, MD, Division of Immunology, Boston Children's Hospital, and Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mia T Chandler
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Margaret H Chang
- S. Case, MD, M.H. Chang, MD, PhD, P.A. Nigrovic, MD, Division of Immunology, Boston Children's Hospital, and Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts
| | - Craig Platt
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Ezra M Cohen
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Megan Day-Lewis
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Fatma Dedeoglu
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Mark Gorman
- L. Benson, MD, M. Gorman, MD, Division of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Jonathan S Hausmann
- J.S. Hausmann, MD, Division of Immunology, Boston Children's Hospital, and Division of Rheumatology and Clinical Immunology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Erin Janssen
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Pui Y Lee
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Jeffrey Lo
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Gregory P Priebe
- G.P. Priebe, MD, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Mindy S Lo
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Esra Meidan
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Peter A Nigrovic
- S. Case, MD, M.H. Chang, MD, PhD, P.A. Nigrovic, MD, Division of Immunology, Boston Children's Hospital, and Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jordan E Roberts
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Mary Beth F Son
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Robert P Sundel
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Maria Alfieri
- M. Alfieri, MPH, J. Chan Yeun, MSPH, D.M. Shobiye, MPH, Department of Pediatric Quality Program, Boston Children's Hospital, Boston, Massachusetts
| | - Jenny Chan Yeun
- M. Alfieri, MPH, J. Chan Yeun, MSPH, D.M. Shobiye, MPH, Department of Pediatric Quality Program, Boston Children's Hospital, Boston, Massachusetts
| | - Damilola M Shobiye
- M. Alfieri, MPH, J. Chan Yeun, MSPH, D.M. Shobiye, MPH, Department of Pediatric Quality Program, Boston Children's Hospital, Boston, Massachusetts
| | - Barbara Degar
- B. Degar, MD, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joyce C Chang
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Olha Halyabar
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Melissa M Hazen
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Lauren A Henderson
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts;
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10
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Hemophagocytic Lymphohistiocytosis in the Setting of Therapy-Induced Acute Myeloid Leukemia: An Autopsy Report. Diseases 2022; 10:diseases10030054. [PMID: 35997359 PMCID: PMC9397008 DOI: 10.3390/diseases10030054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/09/2022] [Accepted: 08/17/2022] [Indexed: 11/16/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyper-inflammatory disorder that occurs due to immunologic dysregulation. HLH can be primary (hereditary) or secondary to infections, autoimmune diseases, immune deficiencies, metabolic diseases, drugs, or malignancies. Lymphoid neoplasms mostly accompany malignancy-associated HLH. We present a case of a 12-year-old boy with a history of precursor B lymphoblastic leukemia (B-ALL), who subsequently developed chemotherapy-induced acute myeloid leukemia (t-AML). The patient was admitted for febrile neutropenia and initial laboratory tests revealed hemophagocytic lymphohistiocytosis (HLH). The hospital course was complicated by multiple infections and septic shock. The patient received several broad-spectrum antimicrobials, dexamethasone, as well as a pericardial drain to drain the hemorrhagic pericardial effusion. Despite intervention, the patient expired, and an autopsy was performed. We provide a synopsis of the main autopsy findings.
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11
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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.
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12
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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.
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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:
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13
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West J, Card TR, Bishton MJ, Lanyon P, Ban L, Bythell M, Elliss-Brookes L, Manson JJ, Nanduri V, Rankin J, Tattersall RS, Crooks CJ. Incidence and survival of haemophagocytic lymphohistiocytosis: A population-based cohort study from England. J Intern Med 2022; 291:493-504. [PMID: 34875131 DOI: 10.1111/joim.13432] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Haemophagocytic lymphohistiocytosis (HLH) is a rare hyper-inflammatory condition with poor outcomes. OBJECTIVES Few population-based estimates of the incidence and survival in adults exist. We aimed to provide these data for England. METHODS We used population-based linked data from primary care, secondary care, cancer registries and mortality databases in England to identify people diagnosed with HLH between 1 January 2000 and 31 December 2016. We calculated annual incidence rates by age and sex, modelled change in incidence over time with Poisson regression, calculated overall 1-year survival using Kaplan-Meier methods and estimated adjusted hazard ratios (HRs) of death using a Cox proportional hazards model. RESULTS We identified 214 patients with HLH. The reported age and sex-adjusted incidence increased twofold over the period, from around one to around two per million. Incidence was highest in those below 1 year (14.6 per million) and ≥75 years (2.2 per million), and lowest in those aged 15-44 years (0.8 per million). One-year survival varied by age and sex from 77% (95% confidence interval [CI] 63%-86%) in those <15 years to 30% (95% CI 14%-49%) in those ≥75. In patients with haematological cancer, the adjusted HR for death was 2.60 (95% CI 1.45-4.66) compared to patients with no malignant or rheumatological disease. CONCLUSION The incidence of HLH diagnosis in England has increased between 2000 and 2016 and occurs in all ages with varying underlying diseases. One-year survival varies substantially, being particularly poor in those aged over 75 years and those with haematological malignancy.
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Affiliation(s)
- Joe West
- Population and Lifespan Sciences, University of Nottingham, Nottingham, UK.,NIHR Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK.,National Disease Registration Service, NHS Digital, Leeds, UK
| | - Tim R Card
- Population and Lifespan Sciences, University of Nottingham, Nottingham, UK.,NIHR Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Mark J Bishton
- Department of Haematology, Nottingham City Hospital, Nottingham, UK
| | - Peter Lanyon
- Population and Lifespan Sciences, University of Nottingham, Nottingham, UK.,NIHR Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Lu Ban
- Evidera by PPD, London, UK
| | - Mary Bythell
- National Disease Registration Service, NHS Digital, Leeds, UK
| | | | - Jessica J Manson
- Department of Rheumatology, University College London Hospitals, London, UK
| | - Vasanta Nanduri
- Department of Paediatrics, Watford General Hospital, Watford, UK
| | - Judith Rankin
- National Disease Registration Service, NHS Digital, Leeds, UK.,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Rachel S Tattersall
- Department of Rheumatology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Colin J Crooks
- NIHR Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK.,National Disease Registration Service, NHS Digital, Leeds, UK.,Translational Medical Sciences, University of Nottingham, Nottingham, UK
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14
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Zhang Q, Lin Y, Bao Y, Jin Y, Ye X, Tan Y. Analysis of Prognostic Risk Factors and Establishment of Prognostic Scoring System for Secondary Adult Hemophagocytic Syndrome. Curr Oncol 2022; 29:1136-1149. [PMID: 35200596 PMCID: PMC8871039 DOI: 10.3390/curroncol29020097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/30/2021] [Accepted: 02/07/2022] [Indexed: 12/27/2022] Open
Abstract
Introduction: The objective of this paper is to identify the prognostic risk factors of secondary adult hemophagocytic syndrome (HLH) in hospitalized patients and establish a simple and convenient prognostic scoring system. Method:We reviewed 162 adult patients secondary with HLH treated in Zhejiang Cancer Hospital and the First Affiliated Hospital of Medical College of Zhejiang University from January 2014 to December 2018 were enrolled to form the test group; from January 2019 to February 2021, 162 adult patients in the hospitals constituted the validation group. The HLH prognosis scoring system was constructed according to the risk factors, and the patients were divided into three risk groups: low risk, medium risk, and high risk. The scoring system was verified by Kaplan–Meier method and log rank test survival analysis. The discrimination ability was evaluated according to the receiver operating characteristic (ROC) curve. Results: Univariate and multivariate analysis showed that the independent risk factors for the prognosis of HLH were male sex, activated partial prothrombin time (APTT) greater than 36 s, lactate dehydrogenase (LDH) greater than 1000 U/L, and C-reactive protein (CRP) greater than 100 mg/L. The area under the ROC curve was 0.754 (95% Cl: 0.678–0.829). The patients were divided into a low-risk group (0–1), a medium-risk group (2–4), and a high-risk group (5–6). The 5-year overall survival (OS) rate were 87.5%, 41.8% and 12.8%, respectively (p < 0.001). The area under ROC curve was 0.736 (95% Cl: 0.660–0.813) in the validation group, and the 2-year OS of patients in low-risk, medium-risk and high-risk groups were 88.0%, 45.1% and 16.7%, respectively (p < 0.001). Conclusion:The new prognostic scoring system can accurately predict the prognosis of secondary adult HLH and can further provide basis for the accurate treatment of secondary adult HLH.
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Affiliation(s)
- Qiaolei Zhang
- Department of Hematology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou 310022, China; (Q.Z.); (Y.L.); (Y.B.); (Y.J.)
- Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou 310000, China
| | - Youyan Lin
- Department of Hematology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou 310022, China; (Q.Z.); (Y.L.); (Y.B.); (Y.J.)
- Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou 310000, China
| | - Yejiang Bao
- Department of Hematology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou 310022, China; (Q.Z.); (Y.L.); (Y.B.); (Y.J.)
- Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou 310000, China
| | - Yuan Jin
- Department of Hematology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou 310022, China; (Q.Z.); (Y.L.); (Y.B.); (Y.J.)
- Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou 310000, China
| | - Xiujin Ye
- Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou 310058, China;
| | - Yamin Tan
- Department of Hematology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou 310022, China; (Q.Z.); (Y.L.); (Y.B.); (Y.J.)
- Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou 310000, China
- Correspondence:
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15
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Gupta A, Mathiyazhagan G, Rahman K, Nityanand S. Acute lymphoblastic leukemia masquerading as hemophagocytic lymphohistiocytosis. J Cancer Res Ther 2022; 18:774-776. [DOI: 10.4103/jcrt.jcrt_679_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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16
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Stanevich OV, Fomina DS, Bakulin IG, Galeev SI, Bakin EA, Belash VA, Kulikov AN, Lebedeva AA, Lioznov DA, Polushin YS, Shlyk IV, Vorobyev EA, Vorobyeva SV, Surovceva TV, Bakulina NV, Lysenko MA, Moiseev IS. Ruxolitinib versus dexamethasone in hospitalized adults with COVID-19: multicenter matched cohort study. BMC Infect Dis 2021; 21:1277. [PMID: 34937556 PMCID: PMC8693127 DOI: 10.1186/s12879-021-06982-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 12/15/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Several anti-cytokine therapies were tested in the randomized trials in hospitalized patients with severe acute respiratory syndrome coronavirus 2 infection (COVID-19). Previously, dexamethasone demonstrated a reduction of case-fatality rate in hospitalized patients with respiratory failure. In this matched control study we compared dexamethasone to a Janus kinase inhibitor, ruxolitinib. METHODS The matched cohort study included 146 hospitalized patients with COVID-19 and oxygen support requirement. The control group was selected 1:1 from 1355 dexamethasone-treated patients and was matched by main clinical and laboratory parameters predicting survival. Recruitment period was April 7, 2020 through September 9, 2020. RESULTS Ruxolitinib treatment in the general cohort of patients was associated with case-fatality rate similar to dexamethasone treatment: 9.6% (95% CI [4.6-14.6%]) vs 13.0% (95% CI [7.5-18.5%]) respectively (p = 0.35, OR = 0.71, 95% CI [0.31-1.57]). Median time to discharge without oxygen support requirement was also not different between these groups: 13 vs. 11 days (p = 0.13). Subgroup analysis without adjustment for multiple comparisons demonstrated a reduced case-fatality rate in ruxolitnib-treated patients with a high fever (≥ 38.5 °C) (OR 0.33, 95% CI [0.11-1.00]). Except higher incidence of grade 1 thrombocytopenia (37% vs 23%, p = 0.042), ruxolitinib therapy was associated with a better safety profile due to a reduced rate of severe cardiovascular adverse events (6.8% vs 15%, p = 0.025). For 32 patients from ruxolitinib group (21.9%) with ongoing progression of respiratory failure after 72 h of treatment, additional anti-cytokine therapy was prescribed (8-16 mg dexamethasone). CONCLUSIONS Ruxolitinib may be an alternative initial anti-cytokine therapy with comparable effectiveness in patients with potential risks of steroid administration. Patients with a high fever (≥ 38.5 °C) at admission may potentially benefit from ruxolitinib administration. Trial registration The Ruxolitinib Managed Access Program (MAP) for Patients Diagnosed With Severe/Very Severe COVID-19 Illness NCT04337359, CINC424A2001M, registered April, 7, 2020. First participant was recruited after registration date.
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Affiliation(s)
- O V Stanevich
- Pavlov University, Saint-Petersburg, Russian Federation.
| | - D S Fomina
- State City Hospital №52, Moscow, Russian Federation.,First Sechenov Moscow State Medical University of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - I G Bakulin
- North-Western State Medical University Named After I.I. Mechnikov, Saint-Petersburg, Russian Federation
| | - S I Galeev
- State City Hospital №20, Saint-Petersburg, Russian Federation
| | - E A Bakin
- Pavlov University, Saint-Petersburg, Russian Federation
| | - V A Belash
- Pavlov University, Saint-Petersburg, Russian Federation
| | - A N Kulikov
- Pavlov University, Saint-Petersburg, Russian Federation
| | - A A Lebedeva
- Pavlov University, Saint-Petersburg, Russian Federation
| | - D A Lioznov
- Pavlov University, Saint-Petersburg, Russian Federation
| | - Yu S Polushin
- Pavlov University, Saint-Petersburg, Russian Federation
| | - I V Shlyk
- Pavlov University, Saint-Petersburg, Russian Federation
| | - E A Vorobyev
- Pavlov University, Saint-Petersburg, Russian Federation
| | - S V Vorobyeva
- Pavlov University, Saint-Petersburg, Russian Federation
| | - T V Surovceva
- State City Hospital №20, Saint-Petersburg, Russian Federation
| | - N V Bakulina
- North-Western State Medical University Named After I.I. Mechnikov, Saint-Petersburg, Russian Federation
| | - M A Lysenko
- State City Hospital №52, Moscow, Russian Federation.,Pirogov Russian National Research Medical University (RNRMU) of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - I S Moiseev
- Pavlov University, Saint-Petersburg, Russian Federation
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17
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Han HJ, Hong KT, Park HJ, Kim BK, An HY, Choi JY, Kang HJ. Hemophagocytic Lymphohistiocytosis as Initial Presentation of Malignancy in Pediatric Patients: Rare but Not to Be Ignored. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8121083. [PMID: 34943279 PMCID: PMC8699877 DOI: 10.3390/children8121083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/17/2021] [Accepted: 11/22/2021] [Indexed: 06/14/2023]
Abstract
It is complicated to establish a consensus on the management and diagnosis of malignancy-triggered hemophagocytic lymphohistiocytosis (M-HLH) in children, as an initial presentation of malignancy is complicated. In this paper, we analyze the clinical characteristics and outcomes of eight pediatric patients in which M-HLH was the initial presentation of malignancy. All patients had hematologic malignancies: three subcutaneous panniculitis-like T-cell lymphomas, two acute lymphoblastic leukemias, two anaplastic large cell lymphomas, and a systemic EBV + T-cell lymphoma of childhood. The incidence rate of M-HLH among leukemia and malignant lymphoma patients in our institution was 1.9%. From the initial diagnosis of HLH, the median time taken to be diagnosed as a malignancy was about 1.3 months. The majority of patients received HLH-targeted immunosuppression and/or etoposide at first. The patients' clinical response to treatment for HLH and malignancies were varied. Five out of the eight patients died, one of whom died due to HLH-related cerebral edema after the initiation of chemotherapy. The median overall survival was 1.6 years. In order to improve the survival rate, the early detection of M-HLH, rapid screening for malignancy, and complete control of M-HLH with HLH-directed therapy followed by a thorough response monitoring are required.
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Affiliation(s)
- Hye-ji Han
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
| | - Kyung Taek Hong
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
| | - Hyun Jin Park
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
| | - Bo Kyung Kim
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
| | - Hong Yul An
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
| | - Jung Yoon Choi
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
| | - Hyoung Jin Kang
- Departments of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-j.H.); (H.J.P.); (B.K.K.); (H.Y.A.); (J.Y.C.); (H.J.K.)
- Cancer Research Institute, Seoul National University, Seoul 03080, Korea
- Wide River Institute of Immunology, Hongcheon 25159, Korea
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18
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Yamada N, Yamasaki K, Yamamoto N, Kuki I, Sakuma H, Hara J. Chemotherapy-induced autoimmune-mediated encephalitis during germinoma treatment. Brain Dev 2021; 43:967-971. [PMID: 34092404 DOI: 10.1016/j.braindev.2021.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/28/2021] [Accepted: 05/16/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Autoimmune mediated encephalitis (AME), which includes autoantibody-associated encephalitis and acute disseminated encephalomyelitis, is a common cause of encephalitis as well as infectious encephalitis in children. AME may be triggered by autoimmune responses to paraneoplastic syndromes and infections. Infectious encephalitis associated with an immunocompromised status caused by anti-cancer chemotherapy is well recognized; however, there have been few reports on the relationship between AME and chemotherapy. CASE REPORT A ten-year-old previously healthy, developmentally normal girl was diagnosed with a pure germinoma in the suprasellar region. Following 30 days of induction chemotherapy, she developed a depressed level of consciousness with accompanying right hemiplegia, aphasia, and unexplained fever. Cerebrospinal fluid (CSF) analysis revealed positive oligoclonal bands and elevated neopterin levels. Neither atypical cells suggesting tumor exacerbation nor pathogens known to cause encephalitis were identified in the CSF. She was administrated immunosuppressive therapy and her symptoms rapidly improved. No known autoantibodies associated with autoantibody-associated encephalitis were identified in blood or CSF. However, the presence of oligoclonal bands and elevated neopterin levels in the CSF, and the favorable response to immunosuppressive therapy were consistent with an AME diagnosis. Thirteen days after the third course of chemotherapy, the patient developed a depressed level of consciousness again. Due to the recurrence of encephalitis, re-administration of immunosuppressive therapy was performed, which led to improvement in her symptoms. Recurrence of encephalitis has not occurred for 1 year after completion of chemotherapy. CONCLUSION The chemotherapy-induced abnormal immune response might have triggered the AME.
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Affiliation(s)
- Naoki Yamada
- Department of Pediatric Hematology and Oncology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan.
| | - Kai Yamasaki
- Department of Pediatric Hematology and Oncology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan
| | - Naohiro Yamamoto
- Department of Child Neurology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan
| | - Ichiro Kuki
- Department of Child Neurology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan
| | - Hiroshi Sakuma
- Department of Child Brain Project, Tokyo Metropolitan Institute of Medical Science, 2-1-6 Kamikitazawa, Setagaya-ku, Tokyo 156-8506, Japan
| | - Junichi Hara
- Department of Pediatric Hematology and Oncology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan
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19
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Bishton MJ, Stilwell P, Card TR, Lanyon P, Ban L, Elliss-Brookes L, Manson J, Nanduri V, Earp K, Flower L, Amarnani R, Rankin J, Sen ES, Tattersall RS, Crooks CJ, Aston J, Siskova V, West J, Bythell M. A validation study of the identification of haemophagocytic lymphohistiocytosis in England using population-based health data. Br J Haematol 2021; 194:1039-1044. [PMID: 34386978 DOI: 10.1111/bjh.17768] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/28/2021] [Indexed: 11/29/2022]
Abstract
We assessed the validity of coded healthcare data to identify cases of haemophagocytic lymphohistiocytosis (HLH). Hospital Episode Statistics (HES) identified 127 cases within five hospital Trusts 2013-2018 using ICD-10 codes D76.1, D76.2 and D76.3. Hospital records were reviewed to validate diagnoses. Out of 74 patients, 73 were coded D76.1 or D76.2 (positive predictive value 89·0% [95% Confidence Interval {CI} 80·2-94·9%]) with confirmed/probable HLH. For cases considered not HLH, 44/53 were coded D76.3 (negative predictive value 97·8% [95% CI 88·2-99·9%]). D76.1 or D76.2 had 68% sensitivity in detecting HLH compared to an established active case-finding HLH register in Sheffield. Office for National Statistics (ONS) mortality data (2003-2018) identified 698 patients coded D76.1, D76.2 and D76.3 on death certificates. Five hundred and forty-one were coded D76.1 or D76.2 of whom 524 (96·9%) had HLH in the free-text cause of death. Of 157 coded D76.3, 66 (42·0%) had HLH in free text. D76.1 and D76.2 codes reliably identify HLH cases, and provide a lower bound on incidence. Non-concordance between D76.3 and HLH excludes D76.3 as an ascertainment source from HES. Our results suggest electronic healthcare data in England can enable population-wide registration and analysis of HLH for future research.
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Affiliation(s)
- Mark J Bishton
- Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | | | - Tim R Card
- Population and Lifespan Sciences, University of Nottingham, Nottingham, UK.,NIHR Biomedical Research Centre, Nottingham, UK
| | - Peter Lanyon
- Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | - Lu Ban
- Evidera by PPD, London, UK
| | | | | | | | - Kate Earp
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - Judith Rankin
- Public Health England, London, UK.,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ethan S Sen
- Great North Children's Hospital, Newcastle upon Tyne, UK.,Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | | | - Colin J Crooks
- Public Health England, London, UK.,NIHR Biomedical Research Centre, Nottingham, UK.,Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | | | | | - Joe West
- Public Health England, London, UK.,Population and Lifespan Sciences, University of Nottingham, Nottingham, UK.,NIHR Biomedical Research Centre, Nottingham, UK
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20
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Hemophagocytic lymphohistiocytosis in advanced melanoma treated with dabrafenib and trametinib combination: two cases. Melanoma Res 2021; 30:519-523. [PMID: 32784332 DOI: 10.1097/cmr.0000000000000690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) has been only rarely reported in patients with BRAF-mutated advanced melanoma treated with targeted therapies and never with first-line dabrafenib/trametinib combination thus far. Two patients treated with first-line dabrafenib and trametinib combination therapy for metastatic melanoma presented with sudden occurrence of fever, cytopenia, rhabdomyolysis, hepatic cytolysis, hypertriglyceridemia and very high ferritin levels after few weeks of treatment, associated with concomitant epstein-barr virus (EBV) reactivation in one patient. In both cases, drug-induced HLH was primarily considered owing to a high H-score and the absence of other etiology. Patients rapidly improved after treatment discontinuation associated with oral steroids in one patient and did not relapse after subsequent treatment resumption with a concurrent anti-BRAF/anti-MEK combination. In metastatic melanoma HLH may occur either spontaneously in the absence of any treatment as a paraneoplastic condition, related to an intercurrent infection or drug-induced mainly with various immunotherapy or with dabrafenib and trametinib following immunotherapy. However, such observations are scarce and these are the first cases of HLH occurring during first-line treatment with dabrafenib and trametinib in advanced melanoma to our knowledge. Pathomechanisms remain to be elucidated since triggering factors may encompass the treatment itself but also other significant actors including viral reactivation along with the underlying disease. The liability of treatment should be considered in cases of HLH occurring in patients with advanced melanoma successfully treated with a combined targeted therapy. A rechallenge with a concurrent anti-BRAF/anti-MEK can be proposed in this setting.
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21
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A Sinister Trail of Infections in a Young Boy. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2021. [DOI: 10.1097/ipc.0000000000000977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Hansen S, Alduaij W, Biggs CM, Belga S, Luecke K, Merkeley H, Chen LYC. Ruxolitinib as adjunctive therapy for secondary hemophagocytic lymphohistiocytosis: A case series. Eur J Haematol 2021; 106:654-661. [PMID: 33523540 DOI: 10.1111/ejh.13593] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a cytokine storm syndrome associated with mortality rates of up to 88%. Standard therapy with high-dose glucocorticoids and etoposide used in adults is extrapolated from pediatric trials, with significant toxicity in older patients and those with poor performance status. The JAK1/2 inhibitor ruxolitinib has recently gained attention as a treatment option for HLH due to its broad cytokine-modulating abilities and safety profile. Herein we report our center's experience using ruxolitinib in the treatment of adult-onset secondary HLH. CASE SERIES We report four patients with profound secondary HLH provoked by diverse triggers, including invasive pulmonary aspergillosis on background systemic lupus erythematosus, disseminated tuberculosis, and T-cell lymphoma treated with ruxolitinib as monotherapy or combination therapy in upfront and salvage settings. RESULTS All four patients had rapid, sustained improvement in clinical status, inflammatory markers, and hematological cell counts followed by durable remission. Three patients developed manageable infectious complications postruxolitinib. CONCLUSIONS This series demonstrates the effective use of JAK inhibition with ruxolitinib to control pathological immune activation in critically ill patients with secondary HLH and otherwise limited therapeutic options. JAK inhibition is also an area of urgent investigation for the treatment of cytokine storm associated with COVID-19.
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Affiliation(s)
- Sarah Hansen
- Department of Medicine, Division of Rheumatology, University of British Columbia, Vancouver, BC, Canada
| | - Waleed Alduaij
- Department of Medicine, Division of Hematology, University of British Columbia, Vancouver, BC, Canada.,Centre for Lymphoid Cancer, British Columbia Cancer, Vancouver, BC, Canada
| | - Catherine M Biggs
- Department of Pediatrics, Division of Allergy & Immunology, University of British Columbia, Vancouver, BC, Canada
| | - Sara Belga
- Department of Medicine, Division of Infectious Diseases, University of British Columbia, Vancouver, BC, Canada
| | - Kai Luecke
- Centre for Lymphoid Cancer, British Columbia Cancer, Vancouver, BC, Canada
| | - Hayley Merkeley
- Department of Medicine, Division of Hematology, University of British Columbia, Vancouver, BC, Canada
| | - Luke Y C Chen
- Department of Medicine, Division of Hematology, University of British Columbia, Vancouver, BC, Canada
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23
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Dudda M, Mann C, Heinz J, Schmidgen I, Weid F, Kühn M, Saloga J, Grabbe S, Loquai C. Hemophagocytic lymphohistiocytosis of a melanoma patient under BRAF/MEK-inhibitor therapy following anti-PD1 inhibitor treatment: a case report and review to the literature. Melanoma Res 2021; 31:81-84. [PMID: 33234845 DOI: 10.1097/cmr.0000000000000703] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare but life-threatening condition. HLH in infants and young children is usually inherited, which is then classified as primary HLH. Secondary HLH, in contrast, is caused by many different conditions such as infections, cancer or medication and affects mostly adults. HLH is a hyperinflammatory condition, which may mimic an acute septic shock. We report on a 68-year-old patient with malignant melanoma with lymph node metastases. Due to the lymphogenic progression, treatment was switched from nivolumab to dabrafenib and trametinib. Twenty-one days after initiation of BRAF/MEK inhibitor therapy, the patient presented to our emergency department with clinical signs of infection such as fever and fatigue. Laboratory tests showed excessive inflammation levels without identifying an underlying pathogen. Two days later, the patient developed an increasing pancytopenia. After extending the diagnosis, we found very high ferritin levels, hypertriglyceridemia, hypofibrinogenemia and a soluble CD25 receptor. Based on the laboratory results, prolonged fever and splenomegaly, we were able to diagnose HLH as the underlying condition. We immediately initiated treatment with intravenous prednisone, which remarkably improved the clinical symptoms. After full recovery, we reinitiated anti-tumor treatment with vemurafenib and cobimetinib, which was tolerated without side effects. Due to the relatively nonspecific nature of the clinical signs and symptoms and the significant overlap with other diseases such as sepsis, the diagnosis of HLH is often delayed. This explains, in part, the high morbidity and mortality rate. Our case shows that early treatment with steroids is effective. However, much work remains in order to raise awareness and improve the understanding of the pathophysiology of this condition.
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Affiliation(s)
| | | | | | | | | | - M Kühn
- Internal Medicine, University Medical Center Mainz, Germany
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24
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Tang S, Li S, Zheng S, Ding Y, Zhu D, Sun C, Hu Y, Qiao J, Fang H. Understanding of cytokines and targeted therapy in macrophage activation syndrome. Semin Arthritis Rheum 2020; 51:198-210. [PMID: 33385860 DOI: 10.1016/j.semarthrit.2020.12.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/01/2020] [Accepted: 12/21/2020] [Indexed: 12/29/2022]
Abstract
Macrophage activation syndrome (MAS) is a potentially life-threatening complication of systemic autoinflammatory/autoimmune diseases, generally systemic juvenile idiopathic arthritis and adult-onset Still's disease. It is characterized by an excessive proliferation of macrophages and T lymphocytes. Recent research revealed that cytokine storm with elevated pro-inflammatory cytokines, including IFN-γ, IL-18, and IL-6, may be central to the pathogenesis of MAS. Though the mainstream of MAS treatment remains corticosteroids and cyclosporine, targeted therapies with anti-cytokine biologics are reported to be promising for controlling systemic inflammation in MAS.
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Affiliation(s)
- Shunli Tang
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Sheng Li
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Siting Zheng
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuwei Ding
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dingxian Zhu
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chuanyin Sun
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yongxian Hu
- Department of Hematology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianjun Qiao
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Hong Fang
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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25
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Huang Z, Jia Y, Zuo Y, Wu J, Lu A, Zhang L. Malignancy-associated hemophagocytic lymphohistiocytosis in children: a 10-year experience of a single pediatric hematology center. Hematology 2020; 25:389-399. [PMID: 33161882 DOI: 10.1080/16078454.2020.1833505] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective: Malignancy-associated hemophagocytic lymphohistiocytosis (M-HLH) in children is a relatively rare but life-threatening secondary hemophagocytic lymphohistiocytosis (sHLH). Until now, only a limited number of cases regarding children with M-HLH has been reported. Methods: We conducted a retrospective study of 27 children with M-HLH, who admitted to our center between July 2007 and October 2019. The clinical data and laboratory data were analyzed. Results: The median age of the children with M-HLH was 7 years. Underlying diseases included myeloid malignancy (n = 6), lymphoid malignancy (n = 18) and unknown type lymphoma (n = 3). The one-year mortality rate was 56%. All patients had persistent fever. The clinical manifestations included hepatomegaly (89%), splenomegaly (67%) and central nervous system symptoms (56%). Thirteen children (48%) had Epstein-Barr virus (EBV) infection. No significant differences were observed between EBV-positive and negative M-HLH patients in terms of most clinical indicators. However, EBV-positive M-HLH patients showed prolonged activated partial thromboplastin time (APTT) and more hemophagocytosis in the bone marrow (BM) in contrast to EBV-negative patients. Eighteen patients (67%) received the HLH-94/04 regimen as the initial treatment. There were no significant differences in the overall survival (OS) between EBV-positive and negative patients. Patients with prolonged APTT had a significantly poorer OS than other patients (p = 0.012). Conclusions: The M-HLH children with EBV infection are more likely to have prolonged APTT and more hemophagocytosis in BM. The M-HLH children had a poor prognosis, especially those with prolonged APTT.
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Affiliation(s)
- Zhizhuo Huang
- Department of Pediatrics, Peking University People's Hospital, Beijing, People's Republic of China
| | - Yueping Jia
- Department of Pediatrics, Peking University People's Hospital, Beijing, People's Republic of China
| | - Yingxi Zuo
- Department of Pediatrics, Peking University People's Hospital, Beijing, People's Republic of China
| | - Jun Wu
- Department of Pediatrics, Peking University Shougang Hospital, Beijing, People's Republic of China
| | - Aidong Lu
- Department of Pediatrics, Peking University People's Hospital, Beijing, People's Republic of China
| | - Leping Zhang
- Department of Pediatrics, Peking University Shougang Hospital, Beijing, People's Republic of China
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26
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Hiser W, Landgarten M, Zhou XJ. Hemophagocytic syndrome with histiocytic glomerulopathy associated with ovarian serous carcinoma. Proc (Bayl Univ Med Cent) 2020; 34:153-155. [PMID: 33456183 DOI: 10.1080/08998280.2020.1805715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Histiocytic glomerulopathy, an entity characterized by glomerular infiltration by foamy histiocytes with endothelial injury, has recently been reported as a manifestation of hemophagocytic syndrome. We report a case of histiocytic glomerulopathy in a woman receiving chemotherapy for ovarian serous carcinoma with proteinuria in whom hemophagocytic syndrome was not clinically suspected.
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Affiliation(s)
- Wesley Hiser
- Department of Pathology, Baylor University Medical Center, Dallas, Texas.,Renal Path Diagnostics, Pathologists BioMedical Laboratories/PathGroup, Lewisville, Texas
| | | | - Xin Jin Zhou
- Department of Pathology, Baylor University Medical Center, Dallas, Texas.,Renal Path Diagnostics, Pathologists BioMedical Laboratories/PathGroup, Lewisville, Texas
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27
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Pawińska-Wa Sikowska K, Cwiklinska M, Wyrobek E, Balwierz W, Bukowska-Strakova K, Dluzniewska A, Gozdzik J, Drabik G, Rygielska M, Stepien K, Skoczen S. Disseminated Juvenile Xanthogranuloma and Hemophagocytic Lymphohistiocytosis Developed During Treatment of Acute Lymphoblastic Leukemia: Case Report. Front Oncol 2020; 10:921. [PMID: 32719740 PMCID: PMC7350519 DOI: 10.3389/fonc.2020.00921] [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: 02/14/2020] [Accepted: 05/11/2020] [Indexed: 12/02/2022] Open
Abstract
The association between acute lymphoblastic leukemia (ALL), non-Langerhans cell histiocytosis (non-LCH), and hemophagocytic lymphohistiocytosis (HLH), to the best of our knowledge, has not been published to date. Juvenile xanthogranuloma (JXG), as a type of non-LCH, is usually a benign disease limited to the skin. Systemic involvement is rarely reported. The present case report describes a 15-year-old boy diagnosed with disseminated JXG involving skin and bone marrow concurrent with severe symptoms of HLH during ALL therapy. Examination of immunoglobulin heavy chain genes in B-cell precursor leukemic blasts and histiocytes in the skin and bone marrow revealed identical rearrangements, confirming clonal relationship between both diseases. Implementation of corticosteroids, vinblastine, etoposide, cyclosporine, and tocilizumab resulted in partial skin lesion resolution with no improvement of bone marrow function; therefore, hematopoietic stem cell transplantation (HSCT) was eventually performed. The patient's hematological and general status has improved gradually; however, remarkable recovery of skin lesions was observed after empirical antitubercular therapy. Mycobacterium spp. infection should be considered as a possible secondary HLH trigger. Triple association of ALL, non-LCH, and HLH highlights heterogeneity of histiocytic disorders and possible common origin of dendritic and lymphoid cells.
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Affiliation(s)
- Katarzyna Pawińska-Wa Sikowska
- Department of Pediatric Oncology and Hematology, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland.,Department of Oncology and Hematology, University Children's Hospital of Krakow, Krakow, Poland
| | - Magdalena Cwiklinska
- Department of Pediatric Oncology and Hematology, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland.,Department of Oncology and Hematology, University Children's Hospital of Krakow, Krakow, Poland
| | - Elzbieta Wyrobek
- Department of Oncology and Hematology, University Children's Hospital of Krakow, Krakow, Poland
| | - Walentyna Balwierz
- Department of Pediatric Oncology and Hematology, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland.,Department of Oncology and Hematology, University Children's Hospital of Krakow, Krakow, Poland
| | - Karolina Bukowska-Strakova
- Department of Clinical Immunology and Transplantation, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Agnieszka Dluzniewska
- Department of Clinical Immunology and Transplantology, Stem Cell Transplant Center, University Children's Hospital of Krakow, Jagiellonian University Medical College, Krakow, Poland
| | - Jolanta Gozdzik
- Department of Clinical Immunology and Transplantology, Stem Cell Transplant Center, University Children's Hospital of Krakow, Jagiellonian University Medical College, Krakow, Poland
| | - Grazyna Drabik
- Department of Pathology, University Children's Hospital of Krakow, Krakow, Poland
| | - Monika Rygielska
- Department of Biochemistry, University Children's Hospital of Krakow, Krakow, Poland
| | - Konrad Stepien
- Student Scientific Group of Pediatric Oncology and Hematology, Jagiellonian University Medical College, Krakow, Poland
| | - Szymon Skoczen
- Department of Pediatric Oncology and Hematology, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland.,Department of Oncology and Hematology, University Children's Hospital of Krakow, Krakow, Poland
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28
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Farias MG, Freitas PAC, Spagnol F, Souza MVD, Alegretti AP, Riegel M, Taniguchi ANR, Daudt LE. HEMOPHAGOCYTOSIS BY BLASTS IN A CHILD WITH ACUTE MONOCYTIC LEUKEMIA AFTER CHEMOTHERAPY. ACTA ACUST UNITED AC 2020; 39:e2019290. [PMID: 32638943 PMCID: PMC7333940 DOI: 10.1590/1984-0462/2021/39/2019290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/09/2019] [Indexed: 11/22/2022]
Abstract
Objective: To describe the case of a child who presented hemophagocytic
lymphohistiocytosis (HLH) associated with acute monocytic leukemia after
chemotherapy, with hemophagocytosis caused by leukemic cells. Case description: In a university hospital in Southern Brazil, a 3-year-old female was
diagnosed with acute monocytic leukemia with normal karyotype. The
chemotherapy regimen was initiated, and she achieved complete remission six
months later, relapsing after four months with a complex karyotype involving
chromosomes 8p and 16q. The bone marrow showed vacuolated blasts with a
monocytic aspect and evidence of hemophagocytosis. The child presented
progressive clinical deterioration and died two months after the
relapse. Comments: HLH is a rare and aggressive inflammatory condition characterized by
cytopenias, hepatosplenomegaly, fever, and hemophagocytosis in the bone
marrow, lymph nodes, spleen, and liver. Although rare, malignancy-associated
HLH (M-HLH) is fatal. The patient in this case report met five out of the
eight established criteria for HLH. The evolution of the patient’s
karyotype, regardless of the diagnostic profile, seemed secondary to the
treatment for acute monocytic leukemia. In this case, the cytogenetic
instability might have influenced the abnormal behavior of leukemic cells.
This is a rare case of HLH in a child with acute monocytic leukemia.
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Affiliation(s)
| | | | - Fabiane Spagnol
- Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | | | | | - Mariluce Riegel
- Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
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29
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Henderson LA, Cron RQ. Macrophage Activation Syndrome and Secondary Hemophagocytic Lymphohistiocytosis in Childhood Inflammatory Disorders: Diagnosis and Management. Paediatr Drugs 2020; 22:29-44. [PMID: 31732958 PMCID: PMC7334831 DOI: 10.1007/s40272-019-00367-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Macrophage activation syndrome (MAS), a form of secondary hemophagocytic lymphohistiocytosis, is a frequently fatal complication of a variety of pediatric inflammatory disorders. MAS has been most commonly associated with systemic juvenile idiopathic arthritis (sJIA), as approximately 10% of children with sJIA develop fulminant MAS, with another 30-40% exhibiting a more subclinical form of the disease. Children with other rheumatologic conditions such as systemic lupus erythematosus and Kawasaki disease are also at risk for MAS. Moreover, MAS also complicates various genetic autoinflammatory disorders such as gain of function mutations in the cytosolic inflammasome NLRC4, pediatric hematologic malignancies (e.g., T-cell lymphoma), and primary immunodeficiencies characterized by immune dysregulation. Disease-specific and broadly inclusive diagnostic criteria have been developed to facilitate the diagnosis of MAS. Recently, simple screening tools such as the serum ferritin to erythrocyte sedimentation rate ratio have been proposed. Early diagnosis and rapid initiation of immunosuppression are essential for the effective management of MAS. With a better understanding of the pathophysiology of MAS and the advent of novel therapeutics, a broad immunosuppressive approach to treatment is giving way to targeted anti-cytokine therapies. These treatments include agents that block interleukin-1 (IL-1), IL-6, IL-18, interferon-γ, as well as inhibitors of downstream targets of cytokine signaling (e.g., Janus kinases). Increased early recognition of MAS among pediatric inflammatory disorders combined with the use of effective and less toxic cytokine-targeted therapies should lower the mortality of this frequently fatal disorder.
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Affiliation(s)
- Lauren A. Henderson
- Division of Immunology, Boston Children’s Hospital, 1 Blackfan Circle, 10th Floor Karp Family Research Building, Boston, MA 02115, USA
| | - Randy Q. Cron
- Division of Pediatric Rheumatology, Children’s of Alabama, 1600 7th Ave. S., CPPN, suite G10, Birmingham, AL 35233-1711, USA
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30
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Pan H, Huo Y, Sun L. Comparison between clinical features and prognosis of malignancy- and non-malignancy-associated pediatric hemophagocytic lymphohistiocytosis. BMC Pediatr 2019; 19:468. [PMID: 31783813 PMCID: PMC6883520 DOI: 10.1186/s12887-019-1702-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 08/30/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The differences between the clinical characteristics and survival time in malignancy- and non-malignancy-associated secondary hemophagocytic lymphohistiocytosis (HLH) are unclear. Here, we describe the clinical characteristics, prognostic factors, and survival outcomes of malignancy-associated HLH compared to that of non-malignancy-associated HLH. METHODS We retrospectively analyzed 91 pediatric patients with HLH (age < 14 years) at the Affiliated Hospital of Qingdao University Pediatric Department between January 2005 and October 2016. The patients were divided into the malignancy-associated group (n = 22) and non-malignancy-associated group (n = 69, also considered the control group). The clinical features were compared using the Mann-Whitney U and χ2 tests. The overall survival time was compared using log rank and Mann-Whitney U tests. RESULTS Hemoglobin (HGB; p = 0.004), alanine aminotransferase (ALT; p = 0.002), and aspartate aminotransferase (AST; p = 0.001) levels in the malignancy-associated group differed from that in the non-malignancy-associated group. The mean survival times were 26.9 ± 3.82 months (malignancy-associated HLH) and 35.03 ± 2.19 months (non-malignancy-associated HLH). The overall survival time between the two groups was not statistically significantly different (p = 0.055). Univariate analysis showed that disseminated intravascular coagulation (DIC) score > 5 (p = 0.001), albumin < 25 g/L (p = 0.000), HGB < 60 g/L (p = 0.001), and platelet count (PLT) < 30 × 109/L (p = 0.042) correlated with prognosis. Multivariate Cox analysis showed that albumin < 25 g/L (p = 0.017), HGB < 60 g/L (p = 0.027), and bone marrow hemophagocytosis (p = 0.034) correlated with worse prognosis. CONCLUSIONS Patients with non-malignancy-associated HLH do not have better survival, although their prognosis is relatively better in clinical practice. A higher DIC score at diagnosis and lower albumin, HGB, and PLT levels are negative prognostic factors in malignancy-associated HLH.
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Affiliation(s)
- Hua Pan
- Department of Paediatric Hematology, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong, China
| | - Yongmin Huo
- Department of Paediatrics, Women and Children's Health Care Hospital of Linyi, 187 Qiyang Road, Linyi, 276000, Shandong, China
| | - Lirong Sun
- Department of Paediatric Hematology, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong, China.
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31
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Georgiadou S, Gatselis NK, Stefos A, Zachou K, Makaritsis K, Rigopoulou EI, Dalekos GN. Efficient management of secondary haemophagocytic lymphohistiocytosis with intravenous steroids and γ-immunoglobulin infusions. World J Clin Cases 2019; 7:3394-3406. [PMID: 31750324 PMCID: PMC6854401 DOI: 10.12998/wjcc.v7.i21.3394] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/20/2019] [Accepted: 10/15/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Secondary haemophagocytic lymphohistiocytosis (sHLH) is a rare life-threatening condition mainly associated with underlying infections, malignancies, and autoimmune or immune-mediated diseases.
AIM To analyse all sHLH cases that were diagnosed and managed under real-world circumstances in our department focusing on the treatment schedule and the outcome.
METHODS Prospectively collected data from all adult patients fulfilling the criteria of sHLH who diagnosed and managed from January 1, 2010 to June 1, 2018, in our department of the tertiary care university hospital of Larissa, Greece, were analysed retrospectively (n = 80; 52% male; median age: 55 years). The electronic records and/or written charts of the patients were reviewed for the demographic characteristics, clinical manifestations, underlying causes of sHLH, laboratory parameters, treatment schedule and 30-d-mortality rate. Most of patients had received after consent intravenous γ-immunoglobulin (IVIG) for 5 d (total dose 2 g/kg) in combination with intravenous steroid pulses followed by gradual tapering of prednisolone.
RESULTS Seventy-five patients (94%) reported fever > 38.5 °C, 47 (59%) had liver or spleen enlargement and 76 (95%) had ferritin > 500 ng/mL including 20 (25%) having considerably high levels (> 10000 ng/mL). Anaemia and thrombocytopenia occurred in 72% and leucopoenia in 47% of them. Underlying infections were diagnosed in 59 patients (74%) as follows: leishmaniasis alone in 15/80 (18.9%), leishmaniasis concurrently with Coxiella Burnetti or non-Hodgkin lymphoma in 2/80 (2.5%), bacterial infections in 14/80 (17.5%) including one case with concurrent non-Hodgkin lymphoma, viral infections in 13/80 (16.3%), fungal infections in 2/80 (2.5%), infections by mycobacteria in 1/80 (1.3%) and unidentified pathogens in 12/80 (15%). Seventy-two patients (90%) had received combination treatment with IVIG and intravenous steroids. Overall, sHLH resolved in 76% of patients, 15% died within the first month but 82.5% of patients were still alive 6 mo after diagnosis. Univariate analysis showed older age, anaemia, thrombocytopenia, low fibrinogen, disseminated intravascular coagulation (DIC), and delay of diagnosis as factors that negatively affected remission. However, multivariate analysis showed low platelets and DIC as the only independent predictors of adverse outcome.
CONCLUSION sHLH still carries a remarkable morbidity and mortality. Underlying infections were the major cause and therefore, they should be thoroughly investigated in patients with sHLH. Early recognition and combination treatment with IVIG and corticosteroids seem an efficient treatment option with successful outcome in this life-threatening condition.
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Affiliation(s)
- Sarah Georgiadou
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
| | - Nikolaos K Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
- Institute of Internal Medicine and Hepatology, University Hospital of Larissa, Larissa 41447, Greece
| | - Aggelos Stefos
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
| | - Kalliopi Zachou
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
- Institute of Internal Medicine and Hepatology, University Hospital of Larissa, Larissa 41447, Greece
| | - Konstantinos Makaritsis
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
- Institute of Internal Medicine and Hepatology, University Hospital of Larissa, Larissa 41447, Greece
| | - Eirini I Rigopoulou
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
- Institute of Internal Medicine and Hepatology, University Hospital of Larissa, Larissa 41447, Greece
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa 41110, Greece
- Institute of Internal Medicine and Hepatology, University Hospital of Larissa, Larissa 41447, Greece
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32
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Cui J, Yan W, Xie H, Xu S, Wang Q, Zhang W, Ni A. Cytomegalovirus antigenemia in patients with autoimmune and non-autoimmune diseases in Beijing: A 10-year single hospital experience. PLoS One 2019; 14:e0221793. [PMID: 31461496 PMCID: PMC6713388 DOI: 10.1371/journal.pone.0221793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 08/14/2019] [Indexed: 01/22/2023] Open
Abstract
Background Primary cytomegalovirus (CMV) infection is prevalent worldwide and usually results in latency in immunocompetent populations. Reactivation of latent CMV can cause life-threatening complications in immunocompromised hosts. Methods We used the CMV Brite assay to test CMV antigenemia (pp65) in whole blood samples from 22,192 patients with or without autoimmune diseases in Beijing during 2008–2018. Results The overall prevalence of CMV antigenemia was 19.5% (9.7%, males; 26.0%, females). The prevalence of CMV antigenemia was 35.1%, 58.6% and 11.4% in whole patients with autoimmune diseases, in patients with systemic lupus erythematosus (SLE) and in patients with non-SLE autoimmune diseases, respectively. All patients with non-autoimmune diseases, patients with HIV/AIDS or transplantation were found to have 5.0%, 27% or 14.8%, respectively. Patients≤20 years with SLE had a significantly higher prevalence of CMV antigenemia than did all SLE patients, on average. Patients>51 years with non-SLE autoimmune diseases had a significantly higher prevalence than did all patients with non-SLE autoimmune diseases, on average. The prevalence of CMV antigenemia in patients admitted to intensive-care units (ICUs) were 9.2%, which was significantly higher than that among all patients with non-autoimmune diseases. Patients with SLE had 23.8% of negative conversion of CMV antigenemia, significantly lower than the percentage of patients with non-SLE autoimmune (64.3%) and non-autoimmune (61.0%) diseases. The mean number of days to negative conversion of CMV antigenemia in patients with SLE was 35.3±35.8 days, which was significantly longer than that in patients with non-SLE autoimmune diseases (15.4±11.9 days) and non-autoimmune diseases (13.6±7.7 days). Conclusions CMV antigenemia is found more likely in women than in men, more prevalently in patients with SLE than those with HIV/AIDS or transplant recipients, more frequently in patients admitted to ICUs. Patients with SLE had prolonged CMV antigenemia. The role of CMV appears important in SLE.
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Affiliation(s)
- Jingtao Cui
- Department of Clinical Laboratories, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenjuan Yan
- Department of Clinical Laboratories, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongjie Xie
- Department of Clinical Laboratories, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shaoxia Xu
- Department of Clinical Laboratories, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiaofeng Wang
- Department of Clinical Laboratories, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weihong Zhang
- Department of Clinical Laboratories, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Anping Ni
- Department of Clinical Laboratories, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- * E-mail:
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Cader FZ, Colmenero I, Mussai F. Hemophagocytic Lymphohistiocytosis Associated With 2 Cases of Pediatric Lymphocyte-depleted Classic Hodgkin Lymphoma. J Pediatr Hematol Oncol 2019; 41:e341-e345. [PMID: 30601404 DOI: 10.1097/mph.0000000000001398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and often fatal syndrome of abnormal T-cell activation and cytokine production, which can be familial or secondary in nature. Although HLH can occur concomitantly with lymphomas, the development of HLH alongside Hodgkin lymphoma in children is unusual. Here we report the diagnostic evaluation and clinical course of 2 pediatric cases of HLH secondary to lymphocyte-depleted classic Hodgkin lymphoma. These cases highlight the need to be vigilant for this rare presentation and the difficulties in managing these patients.
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Affiliation(s)
- Fathima Z Cader
- Birmingham Children's Hospital, Steelhouse Lane, Birmingham, UK
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34
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Kollipara V, Hussain S, Franco-Palacios D, Sofi U. A case series of endemic infections associated hemophagocytic lymphohistiocytosis (HLH) mimicking severe sepsis syndrome. Respir Med Case Rep 2019; 27:100854. [PMID: 31193414 PMCID: PMC6529707 DOI: 10.1016/j.rmcr.2019.100854] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 05/06/2019] [Indexed: 12/01/2022] Open
Affiliation(s)
- Venkateswara Kollipara
- Department of Pulmonary and Critical Care Medicine, Carilion Clinic - Virginia Tech, Roanoke, VA, 24014, USA
| | - Shahzad Hussain
- Department of Pulmonary and Critical Care Medicine, Carilion Clinic - Virginia Tech, Roanoke, VA, 24014, USA
| | - Domingo Franco-Palacios
- Department of Pulmonary and Critical Care Medicine, Carilion Clinic - Virginia Tech, Roanoke, VA, 24014, USA
| | - Umar Sofi
- Department of Pulmonary and Critical Care Medicine, Carilion Clinic - Virginia Tech, Roanoke, VA, 24014, USA
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35
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Oguz MM, Sahin G, Altinel Acoglu E, Polat E, Yucel H, Oztek Celebi FZ, Unsal H, Akcaboy M, Sari E, Senel S. Secondary hemophagocytic lymphohistiocytosis in pediatric patients: a single center experience and factors that influenced patient prognosis. Pediatr Hematol Oncol 2019; 36:1-16. [PMID: 30821552 DOI: 10.1080/08880018.2019.1572253] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening syndrome of excessive immune activation. Secondary HLH syndrome develops as a complication of infection, drugs, rheumatologic conditions, or malignancy. The main objectives of this work were to identify the etiology of secondary HLH and prognostic factors associated with mortality. Patients diagnosed with secondary HLH, between January 2011 and December 2016, were retrospectively included in this study. We analyzed clinical and laboratory findings as well as prognostic factors from 24 pediatric patients diagnosed with secondary HLH. The mean age of patients at the time of diagnosis was 79.9 ± 68.7 months (range: 2-202) and 54.2% of the patients were male. The most frequent HLH-2004 criterion was fever (100%). Underlying triggers of HLH were as follows: 13 (54.1%) infections, juvenile idiopathic arthritis in 5 patients (20.8%), drugs in 3 patients (12.5%), malignancies in 2 (0.8%), Kawasaki disease in 1 (0.4%) patient, and 1 (0.4%) with unknown triggers. The median time of diagnosis was 3 days (1-67 days). Overall, the mortality rate was 20.8%. In our logistic regression model, factors associated with mortality were decreased albumin levels (OR1 = 2.3[1.48-3.43]) and etoposide usage (OR2 = 1.22 [1.14-1.89]). The patient's 30-day survival was inferior among patients whose albumin level was 2 g/dL or less compared to those over 2 g/dL. Increased awareness of the underlying condition is critical in HLH patients. Our study emphasizes the prognostic significance of albumin level.
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Affiliation(s)
- Melahat Melek Oguz
- a Department of Pediatrics , Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital , Ankara , Turkey
| | - Gurses Sahin
- b Department of Pediatric Hematology and Oncology , Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital , Ankara , Turkey
| | - Esma Altinel Acoglu
- a Department of Pediatrics , Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital , Ankara , Turkey
| | - Emine Polat
- a Department of Pediatrics , Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital , Ankara , Turkey
| | - Husniye Yucel
- a Department of Pediatrics , Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital , Ankara , Turkey
| | - Fatma Zehra Oztek Celebi
- a Department of Pediatrics , Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital , Ankara , Turkey
| | - Hilal Unsal
- a Department of Pediatrics , Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital , Ankara , Turkey
| | - Meltem Akcaboy
- a Department of Pediatrics , Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital , Ankara , Turkey
| | - Eyup Sari
- a Department of Pediatrics , Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital , Ankara , Turkey
| | - Saliha Senel
- a Department of Pediatrics , Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital , Ankara , Turkey
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Strenger V, Kessler HH, Stelzl E, Aberle SW, Keldorfer M, Zach K, Karastaneva A, Sperl D, Lackner H, Benesch M, Urban C, Dornbusch HJ. Enterovirus infections in pediatric hematologic/oncologic patients. Pediatr Blood Cancer 2019; 66:e27448. [PMID: 30270558 DOI: 10.1002/pbc.27448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 08/16/2018] [Accepted: 08/17/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Enteroviruses (EV) are a large group of Picornaviruses associated with respiratory, gastrointestinal, and neurologic symptoms in the immunocompetent host. Little is known about the epidemiologic and clinical impact in pediatric hematologic/oncologic patients. PROCEDURE From 2001 through 2017, different clinical specimens were collected from pediatric hematologic/oncologic patients and were tested for enteroviral RNA. RESULTS Of 13 004 specimens collected from 761 patients, 38 (0.3%) obtained from 14 patients (1.8%) tested positive for EV RNA. Viral shedding was observed without viremia and vice versa. None of 80 cerebrospinal fluid specimens obtained from 60 patients with neurologic symptoms were positive for EV RNA. None of 14 patients positive for EV RNA showed EV-specific symptoms. In 11/14 patients, EV RNA was found to be negative in the follow-up specimen. The remaining patient with a severe primary immune deficiency showed repeated positive EV RNA results for >5 years. CONCLUSIONS In this pediatric hematologic/oncologic cohort, EV infection occurred rarely and without related symptoms. Specimens concurrently obtained from one patient are commonly not in accordance with each other. In the vast majority of patients, EV RNA appears to turn negative in the follow-up specimen. EV infections seem to have a low impact in this patient cohort.
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Affiliation(s)
- Volker Strenger
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Harald H Kessler
- Molecular Diagnostics Laboratory, Diagnostic and Research Center for Molecular Biomedicine, Medical University of Graz, Graz, Austria
| | - Evelyn Stelzl
- Molecular Diagnostics Laboratory, Diagnostic and Research Center for Molecular Biomedicine, Medical University of Graz, Graz, Austria
| | - Stephan W Aberle
- Center for Virology, Medical University of Vienna, Vienna, Austria
| | - Markus Keldorfer
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Klara Zach
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Anna Karastaneva
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Daniela Sperl
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Herwig Lackner
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Martin Benesch
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Christian Urban
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Hans Jürgen Dornbusch
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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