1
|
Knauft J, Schenk T, Ernst T, Schnetzke U, Hochhaus A, La Rosée P, Birndt S. Lymphoma-associated hemophagocytic lymphohistiocytosis (LA-HLH): a scoping review unveils clinical and diagnostic patterns of a lymphoma subgroup with poor prognosis. Leukemia 2024; 38:235-249. [PMID: 38238443 PMCID: PMC10844097 DOI: 10.1038/s41375-024-02135-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/21/2023] [Accepted: 01/04/2024] [Indexed: 02/07/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome driven by pathologic activation of cytotoxic T-lymphocytes and macrophages. Despite advances in diagnostics and management, adult patients with lymphoma-associated HLH (LA-HLH) harbor particularly poor prognosis and optimal treatment remains challenging. As systematic data on LA-HLH are scarce, we aimed to synthesize research evidence by thorough analysis of the published literature in PubMed (MEDLINE-database) within the context of a scoping review. Of 595 search results, 132 articles providing information on 542 patients were reviewed and analyzed. Median patient age was 60 years (range, 18-98) with male predominance (62.7%). B- and T-NHL were equally represented (45.6% and 45.2%), Hodgkin's lymphoma was reported in 8.9% of the cases. The majority of patients (91.6%) presented in Ann-Arbor-Stages III and IV, and bone marrow infiltration was observed in a significant proportion of patients (61.5%). Soluble CD25 levels were markedly elevated (median 10,000 U/ml), with levels beyond 10,000 U/ml indicating unfavorable prognosis for 30-day and overall survival. 66.8% of the patients died after median 5.1 months. LA-HLH remains a clinical challenge requiring specialized management. Timely diagnosis and appropriate lymphoma-specific treatment are of utmost importance to enhance patient outcomes.
Collapse
Affiliation(s)
- Johanna Knauft
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Thomas Schenk
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Thomas Ernst
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Ulf Schnetzke
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Andreas Hochhaus
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Paul La Rosée
- Klinik für Innere Medizin II, Onkologie, Hämatologie, Immunologie, Infektiologie und Palliativmedizin, Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany
| | - Sebastian Birndt
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany.
| |
Collapse
|
2
|
Hajji M, Barbouch S, Kaaroud H, Ben Abdelghani K, Ben Hamida F, Harzallah A, Abderrahim E. Uncovering the Spectrum of Hemophagocytic Lymphohistiocytosis: A Nephrology Department's Analysis of 14 Cases. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2023; 16:11795476231210137. [PMID: 37920369 PMCID: PMC10619340 DOI: 10.1177/11795476231210137] [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: 05/08/2023] [Revised: 10/10/2023] [Indexed: 11/04/2023]
Abstract
Introduction Hemophagocytic lymphohistiocytosis (HLH) is a disease of multi-organ dysfunction due to excessive immune activation causing widespread inflammation and tissue destruction. It is a severe condition associated with high morbidity and mortality. Early identification is crucial for prompt treatment. The objective of this case series is to underscore the intricacy of managing HLH in individuals with renal dysfunction. Methods This is a retrospective study of patients diagnosed with HLH in a nephrology department over a period of 30 years. We retrospectively reviewed the medical files by applying the Revised HLH-2004 criteria. Results Among the 14 female patients included, the mean age was 45.2 years (range 23-78). Nine patients presented with sudden onset of fever and chills. Physical examination revealed purpura in 3 cases, hepatomegaly and splenomegaly in 6 and 5 cases respectively, and peripheral lymphadenopathy in 1 case. Hemorrhagic complications were observed in 5 cases, hypertriglyceridemia in 9 cases, and hyperferritinemia in all cases. Hypothyroidism was observed in all cases, and impaired renal function was detected in 11 of them, with 5 experiencing it as a result of lupus nephritis, and 1 case attributed to pre-eclampsia. Hemophagocytosis was confirmed through sternal puncture in 11 cases. Treatment involved etiological therapy with corticosteroids and immunosuppressants and/or anti-infectives. Intravenous immunoglobulins were administered in 6 cases, while 2 cases required coagulation factor transfusions. Unfortunately, 9 patients did not survive. Conclusion The study highlights the need for increased awareness and prompt recognition of HLH, particularly in patients with associated renal complications.
Collapse
Affiliation(s)
- Meriam Hajji
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Laboratory of Nephropathology LR00SP01, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Samia Barbouch
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Laboratory of Nephropathology LR00SP01, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Hayet Kaaroud
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Laboratory of Nephropathology LR00SP01, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Khaoula Ben Abdelghani
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Fethi Ben Hamida
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Laboratory of Nephropathology LR00SP01, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Amel Harzallah
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Laboratory of Nephropathology LR00SP01, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| | - Ezzeddine Abderrahim
- Department of Medecine A, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunisia, Tunis University El Manar, Tunis, Tunisia
| |
Collapse
|
3
|
Rumney S, Rajesh A, Brigmon E. Primary Gastrointestinal Diffuse Large B-cell Lymphoma Presenting as Ileal Perforation. Cureus 2023; 15:e37341. [PMID: 37182022 PMCID: PMC10169252 DOI: 10.7759/cureus.37341] [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: 04/09/2023] [Indexed: 05/16/2023] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) is the most common form of non-Hodgkin's lymphoma and can rarely present as a primary gastrointestinal malignancy. Primary gastrointestinal lymphoma (PGIL) is associated with a significant risk of perforation and peritonitis, with high rates of mortality. Here we describe a case of a newly diagnosed PGIL in a previously healthy 22-year-old male presenting for new-onset abdominal pain with diarrhea. Early hospital course was characterized by peritonitis and severe septic shock. Despite multiple surgical interventions and resuscitative efforts, the patient's condition continued to deteriorate until cardiac arrest and death on hospital day five. A diagnosis of DLBCL of the terminal ileum and cecum was made by pathology post-mortem. The prognosis for these patients can be improved through early intervention with chemotherapy regimens and surgical resection of the malignant tissue. This report highlights DLBCL as a rare cause of gastrointestinal perforation that can culminate in precipitous multiorgan failure and death.
Collapse
Affiliation(s)
- Sean Rumney
- General Surgery, University of Texas Health Science Center at San Antonio, San Antonio, USA
| | - Aashish Rajesh
- Surgery, University of Texas Health Science Center at San Antonio, San Antonio, USA
| | - Erika Brigmon
- Surgery, University of Texas Health Science Center at San Antonio, San Antonio, USA
| |
Collapse
|
4
|
Salvati L, Di Renzo A, Moscardelli S, Natali L, Claudio F, Viscido A. Secondary hemophagocytic lymphohistiocytosis: a case report. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021060. [PMID: 33944851 PMCID: PMC8142758 DOI: 10.23750/abm.v92is1.8836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/03/2019] [Indexed: 11/23/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare hematologic syndrome presenting either as an inherited life-threatening inflammatory disorder in children or as a secondary disease in adults. Inherited HLH involves inborn defects in lymphocytes and includes autosomal recessive and X-linked disorders characterized by uncontrolled activation of T cells and macrophages and overproduction of inflammatory cytokines. Secondary or acquired HLH occurs in the settings of infections, systemic connective tissue disease and lymphoid malignancies, possibly due to underlying genetic predisposition to develop HLH. The mechanisms leading to secondary HLH have yet to be fully determined and the disease remains frequently undiagnosed and thereby untreated. Herewith we report the case of an 83-year old Caucasian male who referred to our Division of Internal Medicine and Nephrology due to marked asthenia associated with fever, mental confusion, drowsiness and hyporexia, who was ultimately diagnosed with HLH secondary to anaplastic B cell lymphoma. This case report illustrates the difficulties in the diagnostic workup of HLH, mainly related to early identification of the underlying disease and rapid instauration of appropriate therapy.
Collapse
|
5
|
Malkan UY, Albayrak M, Yildiz A, Maral S, Afacan Ozturk HB, Comert P. A rare case of diffuse large B-cell lymphoma-associated hemophagocytic lymphohistiocytosis. J Oncol Pharm Pract 2020; 27:250-252. [PMID: 32507098 DOI: 10.1177/1078155220929750] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is an aggressive and life-threatening syndrome of excessive immune activation. Herein, we aimed to report a diffuse large B-cell lymphoma (DLBCL) case that was presented as HLH. CASE REPORT A 32-year-old man presented to a hospital with complaints of vomiting, nausea and diarrhea in October 2019. Fever and hepatosplenomegaly was detected in physical investigation. Bone marrow aspiration investigation revealed the hemaphagocytosis. HLH-2004 protocol was started for hemophagocytosis. Whole body magnetic resonance imaging (MR) revealed no lymphadenopathy. Bone marrow biopsy revealed high-grade B-cell lymphoma, favoring DLBCL. There were no pathologic cells in lumber puncture investigation. MANAGEMENT AND OUTCOME He was diagnosed with secondary hemaphagocytic syndrome due to DLBCL, and chemotherapy was switched to rituximab, etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin (R-EPOCH) regimen. After three cycles of R-EPOCH chemotherapy regimen, complete remission was confirmed with positron emission tomography-computerised tomography (PET-CT) scan. DISCUSSION Our patients' findings are suitable for six out of eight criteria of hemaphagocytic syndrome. The H-score of our patient was more than 250, reflecting the >99% probability of HLH syndrome. Compatible with literature knowledge, our patient had responded very well to etoposide-containing regimens. In our patient, no lymphadenopathy was detected by physical examination or MR scan, and the diagnosis of DLBCL was only made by the result of bone marrow investigation. In conclusion, herein, we have reported a DLBCL case that had presented with HLH, and clinicians should be aware that B-cell lymphomas may be the underlying cause of HLH.
Collapse
Affiliation(s)
- Umit Yavuz Malkan
- Department of Hematology, Diskapi Yildirim Beyazit Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Murat Albayrak
- Department of Hematology, Diskapi Yildirim Beyazit Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Abdulkerim Yildiz
- Department of Hematology, Diskapi Yildirim Beyazit Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Senem Maral
- Department of Hematology, Diskapi Yildirim Beyazit Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Hacer Berna Afacan Ozturk
- Department of Hematology, Diskapi Yildirim Beyazit Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Pinar Comert
- Department of Hematology, Diskapi Yildirim Beyazit Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| |
Collapse
|
6
|
Nakayama S, Morita Y, Espinoza JL, Rai S, Taniguchi Y, Taniguchi T, Miyake Y, Tanaka H, Ashida T, Matsumura I. Multiple cytokine-producing aggressive EBV-positive diffuse large B cell lymphoma, not otherwise specified with hemophagocytic syndrome. Ann Hematol 2019; 99:381-383. [PMID: 31768673 DOI: 10.1007/s00277-019-03849-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 11/12/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Shoko Nakayama
- Division of Hematology and Rheumatology, Faculty of Medicine, Kindai University, 377-2, Ono-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan.
| | - Yasuyoshi Morita
- Division of Hematology and Rheumatology, Faculty of Medicine, Kindai University, 377-2, Ono-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Jorge Luis Espinoza
- Division of Hematology and Rheumatology, Faculty of Medicine, Kindai University, 377-2, Ono-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Shinya Rai
- Division of Hematology and Rheumatology, Faculty of Medicine, Kindai University, 377-2, Ono-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Yasuhiro Taniguchi
- Division of Hematology and Rheumatology, Faculty of Medicine, Kindai University, 377-2, Ono-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Takahide Taniguchi
- Division of Hematology and Rheumatology, Faculty of Medicine, Kindai University, 377-2, Ono-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Yoshiaki Miyake
- Division of Hematology and Rheumatology, Faculty of Medicine, Kindai University, 377-2, Ono-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Hirokazu Tanaka
- Division of Hematology and Rheumatology, Faculty of Medicine, Kindai University, 377-2, Ono-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Takashi Ashida
- Division of Hematology and Rheumatology, Faculty of Medicine, Kindai University, 377-2, Ono-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Itaru Matsumura
- Division of Hematology and Rheumatology, Faculty of Medicine, Kindai University, 377-2, Ono-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| |
Collapse
|
7
|
Karras A. Atteinte rénale du syndrome d’activation macrophagique. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Le syndrome d’activation macrophagique (SAM) ou syndrome hémophagocytaire est une pathologie compliquant soit certains déficits immunitaires d’origine génétique, soit certaines maladies hématologiques (essentiellement des lymphomes non hodgkiniens), infectieuses (herpèsvirus, bactéries, parasites) ou auto-immunes (lupus, maladie de Still). Il se caractérise par une suractivation aiguë du système immunitaire et plus particulièrement des lymphocytes T cytotoxiques et des cellules histiocytaires/macrophagiques, déclenchant une production massive de cytokines pro-inflammatoires avec fièvre, pancytopénie, organomégalie, altérations du bilan hépatique et de la coagulation. Une défaillance multiviscérale est fréquente, nécessitant la prise en charge en réanimation et mettant souvent en jeu le pronostic vital, avec une mortalité qui reste dans certains cas à près de 50 %. Le SAM implique souvent le rein, par le biais d’une nécrose tubulaire aiguë, d’une néphropathie interstitielle inflammatoire ou d’une glomérulopathie sévère, responsable de syndrome néphrotique. La mise en évidence de ce syndrome n’est pas toujours facile chez un patient avec un tableau de sepsis ou de choc septique, mais elle peut guider la prise en charge thérapeutique, notamment l’initiation d’un traitement par chimiothérapie ou immunosuppresseurs, selon l’étiologie identifiée.
Collapse
|
8
|
EBV-Associated Lymphoproliferative Disorder and Hemophagocytic Lymphohistiocytosis in a Patient with Severe Celiac Disease. Case Rep Hematol 2018; 2018:6063519. [PMID: 29692937 PMCID: PMC5859865 DOI: 10.1155/2018/6063519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/15/2018] [Accepted: 01/18/2018] [Indexed: 11/25/2022] Open
Abstract
Background Epstein-Barr virus- (EBV-) associated lymphoproliferative disease (LPD) is a rare condition, usually occurring in immunocompromised patients. We report a case of EBV-associated LPD in a patient with severe celiac disease, the first report to describe this syndrome in a patient with this diagnosis. Case Summary A 69-year-old Caucasian woman with recent diagnosis of celiac sprue presented to our hospital with persistent diarrhea, abdominal pain, weight loss, and fatigue despite adherence to gluten-free diet for a number of weeks prior to presentation. She underwent evaluation for occult malignancy and was found to have diffuse intra-abdominal mesenteric lymphadenopathy on CT scan. Biopsy of mesenteric nodes revealed an EBV positive, CD20 positive mixed lymphoproliferative process with T-cell predominance, but without a monoclonal cell population felt to be consistent with EBV-associated LPD. Bone marrow biopsy revealed hemophagocytic lymphohistiocytosis, complicating her course. She was treated with steroids and rituximab but continued to decline, eventually developing MSSA bacteremia and succumbing to her disease. Conclusion To our knowledge, this is the first report of the constellation of celiac sprue, EBV-associated LPD, and hemophagocytic lymphohistiocytosis. Providers caring for patients with severe, uncontrolled celiac disease and adenopathy should consider EBV-associated LPD.
Collapse
|
9
|
Lorenz F, Klimkowska M, Pawłowicz E, Bulanda Brustad A, Erlanson M, Machaczka M. Clinical characteristics, therapy response, and outcome of 51 adult patients with hematological malignancy-associated hemophagocytic lymphohistiocytosis: a single institution experience. Leuk Lymphoma 2018; 59:1840-1850. [PMID: 29295642 DOI: 10.1080/10428194.2017.1403018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an underdiagnosed but life-threatening syndrome of hyperinflammation often occurring in adults with hematological malignancies (hM-HLH). The aim of the study was to describe clinical characteristics, therapy response, and outcome of adults with hM-HLH. The study included 51 adults with hM-HLH aged 23-84 years. Hyperferritinemia ≥500 µg/L was present in 96% of patients. The serum concentration of sIL-2Rα ≥ 2400 U/mL was revealed in 94% of patients. Twenty-three patients (45%) responded to therapy and achieved remission of HLH. The probability of overall survival (OS) at 6, 12, 24, and 60 months after HLH diagnosis were 42, 20, 15, and 15%, respectively. Patients with HLH during chemotherapy showed longer OS (median 124 days) than the patients who had HLH solely attributed to malignancy (median 65 days), but this difference was not statistically significant. Awareness of HLH in lymphoid and myeloid malignancies is crucial for improved survival.
Collapse
Affiliation(s)
- Fryderyk Lorenz
- a Department of Radiation Sciences, Section of Hematology , Umeå University , Umeå , Sweden
| | - Monika Klimkowska
- b Department of Clinical Pathology and Cytology , Karolinska University Hospital Huddinge , Stockholm , Sweden
| | - Ewa Pawłowicz
- c Hematology Center Karolinska and Department of Medicine at Huddinge , Karolinska Institutet, Karolinska University Hospital Huddinge , Stockholm , Sweden.,d Department of Nephrology, Hypertension and Kidney Transplantation , Medical University of Lodz , Lodz , Poland
| | | | - Martin Erlanson
- f Department of Oncology , Norrlands University Hospital , Umeå , Sweden
| | - Maciej Machaczka
- c Hematology Center Karolinska and Department of Medicine at Huddinge , Karolinska Institutet, Karolinska University Hospital Huddinge , Stockholm , Sweden.,g Medical Faculty , University of Rzeszow , Rzeszow , Poland
| |
Collapse
|
10
|
Patel A, Vakiti A, Chilkulwar A, Mewawalla P. Hemophagocytic Lymphohistiocytosis Secondary to Bone Marrow Only B-Cell Lymphoma: A Very Rare Entity With an Even Rarer Presentation. J Hematol 2017; 6:49-51. [PMID: 32300392 PMCID: PMC7155825 DOI: 10.14740/jh324w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 05/19/2017] [Indexed: 11/24/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare hyperinflammatory syndrome. It is categorized as familial or acquired, most commonly caused by infections, malignancies, rheumatologic and immunodeficiency disorders. Irrespective of the etiology, the age at the onset is the strongest prognostic factor, hence it is extremely important to have a high suspicion for HLH, diagnose it promptly and initiate treatment without any delay. We encountered a 70-year-old female patient who initially presented with left-sided facial weakness and pancytopenia, secondary to diffuse stage IV B diffuse large B-cell lymphoma with isolated bone marrow involvement with secondary HLH.
Collapse
Affiliation(s)
- Ami Patel
- Department of Internal Medicine, Allegheny Health Network, 320 East North Avenue, Pittsburgh, PA 15212, USA
| | - Anusha Vakiti
- Department of Internal Medicine, Medstar Washington Hospital Center, 110 Irving Street, NW, Washington, DC 20010, USA
| | - Abhishek Chilkulwar
- Division of Hematology and Stem Cell Transplant, Allegheny Health Network Cancer Institute, 4800 Friendship Avenue, Pittsburgh, PA 15224, USA
| | - Prerna Mewawalla
- Division of Hematology and Stem Cell Transplant, Allegheny Health Network Cancer Institute, 4800 Friendship Avenue, Pittsburgh, PA 15224, USA
| |
Collapse
|
11
|
Liao SH, Chen YK, Yu SC, Wu MS, Wang HP, Tseng PH. An unusual case of primary hepatic lymphoma with dramatic but unsustained response to bendamustine plus rituximab and literature review. SAGE Open Med Case Rep 2017; 5:2050313X17709190. [PMID: 28596829 PMCID: PMC5448865 DOI: 10.1177/2050313x17709190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 04/17/2017] [Indexed: 12/18/2022] Open
Abstract
Objectives: Primary hepatic lymphoma is an uncommon cause of hepatic space-occupying lesions. Methods: We describe the case of a 73-year-old man with primary hepatic lymphoma, who presented with a low-grade fever and lower limb weakness which had progressed in the past 2 months. Results: Abdominal ultrasound and computed tomography showed multiple small hepatic tumors. Echo-guided biopsy of the hepatic tumor demonstrated primary hepatic diffuse large B cell lymphoma. Moreover, bone marrow was uninvolved, but the bone marrow smear disclosed hemophagocytosis, which is uncommon in diffuse large B cell lymphoma. Chemotherapy with bendamustine and rituximab treatment was initiated with a dramatic response: hepatic tumors markedly shrank in size shown by follow-up computed tomography and the patient returned to his normal life. Nevertheless, the response was sustained for only 8 months. Finally, the disease resisted further chemotherapy and this patient died of a severe Klebsiella pneumoniae infection. Conclusion: Chemotherapy with bendamustine and rituximab has shown a dramatic, but not durable, response in the present case with old age and multiple comorbidities.
Collapse
Affiliation(s)
- Sih-Han Liao
- National Taiwan University Cancer Center, Taipei, Taiwan
| | - Yin-Kai Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shan-Chi Yu
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Shiang Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ping-Huei Tseng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| |
Collapse
|
12
|
Clinical utility of soluble interleukin-2 receptor in hemophagocytic syndromes: a systematic scoping review. Ann Hematol 2017; 96:1241-1251. [PMID: 28497365 DOI: 10.1007/s00277-017-2993-y] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 04/11/2017] [Indexed: 12/22/2022]
Abstract
The serum-soluble interleukin-2 receptor (sIL-2r) level is considered an important diagnostic test and disease marker in hemophagocytic syndromes/hemophagocytic lymphohistiocytosis (HPS/HLH). However, this cytokine receptor is rarely measured in clinical practice and has been excluded from recent diagnostic/classification criteria such as the HScore and macrophage activation syndrome (MAS) 16. We performed a systematic scoping review of 64 articles (1975-2016) examining the clinical utility of sIL-2r in HPS/HLH. Twenty-two articles describe sIL-2r as a sensitive diagnostic marker for HLH, but only three distinct datasets actually address sensitivity. The original HLH-2004 Guidelines reported sensitivity of 93% and specificity of 100% for sIL-2r ≥ 2400, based on a pediatric dataset (n = 152) which is published for the first time in this review. Two pediatric studies reported sensitivity of 89% for sIL-2r ≥ 2400 in diagnosis of MAS complicating juvenile idiopathic arthritis (JIA) (n = 27) and 88% for secondary HLH in acute liver failure (n = 9). Twenty articles described sIL-2r as a dynamic marker of disease activity that falls with response to treatment, and 15 described high initial sIL-2r levels >10,000 U/mL as a poor prognostic marker. The ability of sIL-2r to distinguish between subtypes of HPS/HLH was inconsistent. This review confirms the importance of soluble IL-2r as a diagnostic and disease marker in HPS/HLH, but also reveals the need for more primary data about its performance characteristics, particularly in adults. More emphasis should be made in including this simple, inexpensive test in clinical practice and studies of HPS/HLH.
Collapse
|
13
|
Schram AM, Comstock P, Campo M, Gorovets D, Mullally A, Bodio K, Arnason J, Berliner N. Haemophagocytic lymphohistiocytosis in adults: a multicentre case series over 7 years. Br J Haematol 2015; 172:412-9. [PMID: 26537747 DOI: 10.1111/bjh.13837] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 10/01/2015] [Indexed: 12/24/2022]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a syndrome of uncontrolled immune activation that has gained increasing attention over the past decade. Although classically known as a familial disorder of children caused by mutations that affect cytotoxic T-cell function, an acquired form of HLH in adults is now widely recognized. This is often seen in the setting of malignancy, infection or rheumatological disorders. We performed a retrospective review across 3 tertiary care centres and identified 68 adults with HLH. The average age was 53 years (range 18-77 years) and 43 were male (63%). Underlying disorders included malignancy in 33 patients (49%), infection in 22 (33%), autoimmune disease in 19 (28%) and idiopathic HLH in 15 (22%). Patients were treated with disease-specific therapy and immunomodulatory agents. After a median follow-up of 32·2 months, 46 patients had died (69%). The median overall survival was 4 months (95% CI: 0·0-10·2 months). Patients with malignancy had a worse prognosis compared to those without (median survival 2·8 months versus 10·7 months, P = 0·007). HLH is a devastating disorder with a high mortality. Further research is needed to improve treatment and outcomes.
Collapse
Affiliation(s)
- Alison M Schram
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Paige Comstock
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Meghan Campo
- Division of Hematology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Daniel Gorovets
- Department of Radiation Oncology, New York University School of Medicine, New York, NY, USA
| | - Ann Mullally
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kelly Bodio
- Division of Hematology/Oncology, New England Hematology Oncology Associates, Vernon Cancer Center, Newton, MA, USA
| | - Jon Arnason
- Division of Hematology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Nancy Berliner
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
14
|
Zhang L, Zhou J, Sokol L. Hereditary and acquired hemophagocytic lymphohistiocytosis. Cancer Control 2015; 21:301-12. [PMID: 25310211 DOI: 10.1177/107327481402100406] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare but life-threatening hyperinflammatory/hypercytokinemia syndrome clinicopathologically manifested by fever, hepatosplenomegaly, cytopenias, liver dysfunction, and hemophagocytosis. METHODS We searched the medical literature for English-written articles and analyzed data regarding the diagnosis, pathoetiology, prognosis, and management of HLH. RESULTS HLH can be subcategorized into primary/genetic (PHLH) or secondary/acquired (SHLH) according to etiology. PHLH, including familial HLH and inherited immune deficiency syndromes, typically occurs in children harboring underlying genetic defects, whereas SHLH frequently manifests in adults and is associated with infection, autoimmunity, immune suppression, or malignancy. The pathogenesis of HLH is still elusive. Its known mechanisms include somatic mutations in gene coding for proteins implicated in the cytotoxic pathways of cytotoxic T or natural killer cells. The impaired ability of these cells to kill target cells leads to an uncontrolled hypercytokinemia and hyperinflammatory process, triggering hemophagocytosis and multiorgan failure. Corticosteroids, chemotherapy, and immunotherapy are the mainstay therapeutic strategies. The consolidation with allogeneic hematopoietic stem cell transplantation is a potentially curative option for PHLH and refractory or relapsed SHLH. CONCLUSIONS Understanding of the pathophysiology of HLH has improved in the last decade. The establishment of diagnostic and treatment guidelines for PHLH and SHLH has resulted in earlier diagnoses and the rapid initiation of therapy, both of which are associated with favorable outcomes.
Collapse
Affiliation(s)
- Ling Zhang
- Department of Hematopathology and Laboratory Medicine, Moffitt Cancer Center, Tampa, FL 33612, USA.
| | | | | |
Collapse
|
15
|
Parikh SA, Kapoor P, Letendre L, Kumar S, Wolanskyj AP. Prognostic factors and outcomes of adults with hemophagocytic lymphohistiocytosis. Mayo Clin Proc 2014; 89:484-92. [PMID: 24581757 DOI: 10.1016/j.mayocp.2013.12.012] [Citation(s) in RCA: 202] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 11/18/2013] [Accepted: 12/13/2013] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To describe the prognostic factors and outcomes of adults with hemophagocytic lymphohistiocytosis (HLH), a rare disorder caused by pathologic activation of the immune system. PATIENTS AND METHODS The study population consisted of a consecutive cohort of adult (age ≥18 years) patients treated at Mayo Clinic in Rochester, Minnesota, from January 1, 1996, through December 31, 2011, in whom a diagnosis of HLH was suspected and subsequently confirmed by retrospective review using the HLH-04 diagnostic criteria. RESULTS Of 250 adult patients suspected of having HLH, 62 met the HLH-04 diagnostic criteria and were included in the final analysis. The median age was 49 years (range, 18-87 years), and 42 (68%) were male. The underlying cause of HLH was malignant tumor in 32 patients (52%), infection in 21 patients (34%), autoimmune disorder in 5 patients (8%), and idiopathic disease in 4 patients (6%). After a median follow-up of 42 months, 41 patients (66%) had died. The median overall survival of the entire cohort was 2.1 months. The median overall survival of patients with tumor-associated HLH was 1.4 months compared with 22.8 months for patients with non-tumor-associated HLH (P=.01). The presence of a malignant tumor and hypoalbuminemia were significant predictors of inferior survival on multivariate analysis. CONCLUSION In this large series of adults with secondary HLH treated at a single tertiary care center, patients with low serum albumin levels and tumor-associated HLH had a markedly worse survival. Hemophagocytic lymphohistiocytosis remains elusive and challenging to clinicians who must maintain a high index of suspicion. The recent discovery of several novel diagnostic and therapeutic modalities may improve outcomes of adult patients with HLH.
Collapse
Affiliation(s)
| | | | | | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | |
Collapse
|
16
|
Sano H, Kobayashi R, Tanaka J, Hashino S, Ota S, Torimoto Y, Kakinoki Y, Yamamoto S, Kurosawa M, Hatakeyama N, Haseyama Y, Sakai H, Sato K, Fukuhara T. Risk factor analysis of non-Hodgkin lymphoma-associated haemophagocytic syndromes: a multicentre study. Br J Haematol 2014; 165:786-92. [DOI: 10.1111/bjh.12823] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 01/23/2014] [Indexed: 01/13/2023]
Affiliation(s)
- Hirozumi Sano
- Department of Paediatrics; Sapporo Hokuyu Hospital; Sapporo Japan
| | - Ryoji Kobayashi
- Department of Paediatrics; Sapporo Hokuyu Hospital; Sapporo Japan
| | - Junji Tanaka
- Stem Cell Transplantation Centre; Hokkaido University Hospital; Sapporo Japan
| | - Satoshi Hashino
- Stem Cell Transplantation Centre; Hokkaido University Hospital; Sapporo Japan
| | - Shuichi Ota
- Department of Haematology; Sapporo Hokuyu Hospital; Sapporo Japan
| | - Yoshihiro Torimoto
- Third Department of Internal Medicine; Asahikawa Medical College; Sapporo Japan
| | | | - Satoshi Yamamoto
- Department of Haematology; Sapporo City General Hospital; Sapporo Japan
| | - Mitsutoshi Kurosawa
- Department of Haematology; National Hospital Organization Hokkaido Cancer Centre; Sapporo Japan
| | - Naoki Hatakeyama
- Department of Paediatrics; Sapporo Medical College; Sapporo Japan
| | - Yoshihito Haseyama
- Department of Haematology; KKR Sapporo Medical Centre; Tonan Hospital; Sapporo Japan
| | - Hajime Sakai
- Department of Haematology; Teine Keijinkai Hospital; Sapporo Japan
| | - Kazuya Sato
- Department of Haematology; Hokkaido P.W.F.A.C Asahikawa-Kosei General Hospital; Asahikawa Japan
| | - Takashi Fukuhara
- Department of Palliative Care Medicine; Hokkaido P.W.F.A.C Sapporo-Kosei General Hospital; Sapporo Japan
| |
Collapse
|
17
|
Tothova Z, Berliner N. Hemophagocytic Syndrome and Critical Illness: New Insights into Diagnosis and Management. J Intensive Care Med 2014; 30:401-12. [PMID: 24407034 DOI: 10.1177/0885066613517076] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Accepted: 10/31/2013] [Indexed: 02/06/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) comprises a heterogeneous group of diseases that are characterized by a hyperinflammatory state due to uncontrolled T cell, macrophage, and histiocyte activation, accompanied by excessive cytokine production. This rare condition is almost uniformly fatal unless promptly recognized and treated. Much progress has been made in the last two decades in our understanding of the mechanisms underlying familial, and to a lesser extent, acquired cases of HLH. Recurrent mutations in more than 10 different genes have now been identified, involving biological pathways converging on intracellular vesicle trafficking and cytolytic granule exocytosis. Mechanisms underlying the majority of patients with acquired HLH, however, remain elusive, hampering both diagnostic evaluation and therapeutic management of these patients. Given that the majority of intensive care unit (ICU) patients with sepsis or multiorgan failure share many features of HLH, it is especially critical for pediatric and adult intensivists to be able to recognize patients with bona fide HLH and initiate treatment without delay. In this article, we review our current understanding of the pathophysiology, clinical testing, diagnosis, and treatment of patients with HLH, especially as it pertains to the care of critically ill patients in pediatric and medical ICUs.
Collapse
Affiliation(s)
- Zuzana Tothova
- Division of Hematology, Brigham and Women's Hospital, Boston, MA, USA Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Nancy Berliner
- Division of Hematology, Brigham and Women's Hospital, Boston, MA, USA Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| |
Collapse
|
18
|
IP-10/CXCL10 and MIG/CXCL9 as novel markers for the diagnosis of lymphoma-associated hemophagocytic syndrome. Ann Hematol 2013; 93:393-401. [PMID: 23975214 PMCID: PMC3918116 DOI: 10.1007/s00277-013-1878-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Accepted: 08/05/2013] [Indexed: 11/29/2022]
Abstract
Lymphoma-associated hemophagocytic syndrome (LAHS) is a serious disorder, and its early diagnosis and treatment with appropriate chemotherapy are very important. However, reliable markers for early diagnosis of LAHS have not been identified. We screened serum cytokines using a newly introduced assay system, cytometric bead array (CBA), and identified interferon-inducible protein 10 (IP-10)/CXCL10 and monokine induced by interferon gamma (MIG)/CXCL9 as useful markers. Serum concentrations of IP-10 and MIG at the time of LAHS diagnosis were greater than 500 and 5,000 pg/ml, respectively. The sensitivity and specificity for LAHS diagnosis were 100 and 95 %, respectively, when we set the above values as the cut-off levels. Serum levels of these two chemokines were already elevated at the time of admission and significantly decreased after successful treatment, indicating their usefulness for both the diagnosis and therapeutic outcomes for LAHS. IP-10 and MIG were also useful in distinguishing severe from moderate/mild LAHS, and B-cell-type LAHS from T-cell/natural killer cell-type LAHS. Furthermore, IP-10 and MIG were of use to distinguish LAHS from sepsis in patients with hematologic malignancies. Rapid measurement of IP-10 and MIG by CBA appeared to be important for early diagnosis and treatment of LAHS.
Collapse
|
19
|
Oehler E, Soubiran G, Fabiani B, Legrand O, Rio B, Ghawche F. [Macrophage activation syndrome as the presenting manifestation of intravascular lymphoma]. Rev Med Interne 2013; 34:636-40. [PMID: 23660185 DOI: 10.1016/j.revmed.2012.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2012] [Revised: 08/29/2012] [Accepted: 10/01/2012] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Intravascular large B cell lymphoma is a neoplastic cell proliferation leading to the occlusion of the lumen of small vessels. This is a rare haematological malignancy, which is difficult to diagnose because of a heterogeneous clinical presentation. CASE REPORT We report a 62-year-old man who presented a macrophage activation syndrome as the presenting manifestation of an intravascular lymphoma. This association is frequently marked by a greater severity and clinical care requires an early and appropriate treatment. CONCLUSION Due to the polymorphism and the systemic presentation of intravascular large B cell lymphoma, the internist may be confronted with this disease, which is considered to be more severe if associated with a macrophage activation syndrome. Awareness of the intravascular large B cell lymphoma is important because the prognosis depends on the rapidity of the initiation of chemotherapy associated with rituximab.
Collapse
Affiliation(s)
- E Oehler
- Service de médecine interne, centre hospitalier de Polynésie française, 98713 Tahiti, Polynésie française.
| | | | | | | | | | | |
Collapse
|
20
|
Arima H, Maruoka H, Nasu K, Tabata S, Kurata M, Matsushita A, Imai Y, Takahashi T, Ishikawa T. Impact of occult bone marrow involvement on the outcome of rituximab plus cyclophosphamide, doxorubicin, vincristine and prednisone therapy for diffuse large B-cell lymphoma. Leuk Lymphoma 2013; 54:2645-53. [DOI: 10.3109/10428194.2013.788697] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
21
|
Davidson-Moncada JK, McDuffee E, Roschewski M. CD5+ diffuse large B-cell lymphoma with hemophagocytosis. J Clin Oncol 2012. [PMID: 23182983 DOI: 10.1200/jco.2012.44.2301] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jan K Davidson-Moncada
- Department of Hematology/Oncology, Medical Oncology Clinical Research Unit, National Cancer Institute, Bethesda, MD 20892, USA.
| | | | | |
Collapse
|
22
|
Lewkowicz E, Darnige L, Auffret N, Damotte D, Andrieu JM, Jenabian A. Atypical skin lesions revealing an EBV-associated hemophagocytic syndrome after a large B cell lymphoma in complete remission. Leuk Lymphoma 2009; 48:421-4. [PMID: 17325909 DOI: 10.1080/10428190601059811] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
MESH Headings
- Epstein-Barr Virus Infections/complications
- Epstein-Barr Virus Infections/pathology
- Epstein-Barr Virus Infections/virology
- Herpesvirus 4, Human
- Humans
- Lymphohistiocytosis, Hemophagocytic/complications
- Lymphohistiocytosis, Hemophagocytic/pathology
- Lymphohistiocytosis, Hemophagocytic/virology
- Lymphoma, B-Cell/complications
- Lymphoma, B-Cell/pathology
- Lymphoma, B-Cell/virology
- Lymphoma, Large B-Cell, Diffuse/complications
- Lymphoma, Large B-Cell, Diffuse/pathology
- Lymphoma, Large B-Cell, Diffuse/virology
- Male
- Middle Aged
- Remission Induction
- Skin Diseases/etiology
- Skin Diseases/pathology
- Skin Diseases/therapy
Collapse
|
23
|
Haider FS, Smith R, Khan S. Primary hepatic lymphoma presenting as fulminant hepatic failure with hyperferritinemia: a case report. J Med Case Rep 2008; 2:279. [PMID: 18710584 PMCID: PMC2542397 DOI: 10.1186/1752-1947-2-279] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Accepted: 08/19/2008] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Primary hepatic lymphoma is an unusual form of non-Hodgkin's lymphoma that usually presents with constitutional symptoms, hepatomegaly and signs of cholestatic jaundice. Diffuse hepatic infiltration is uncommon and presentation with acute hepatic failure even more rare. The presence of markedly elevated ferritin levels can complicate the evaluation process and suggest alternative diagnoses.We present the case of a middle-aged woman exhibiting pancytopenia, hyperferritinemia and rapidly deteriorating to develop acute hepatic failure. Her initial clinical picture led to a working diagnosis of adult onset Still's disease with probable hemophagocytic syndrome before her worsening liver function necessitated a percutaneous liver biopsy and establishment of the final diagnosis of primary hepatic lymphoma. CONCLUSION Primary hepatic lymphoma is an uncommon malignancy and its manifestation as progressive hepatitis or acute fulminant hepatic failure can be difficult to diagnose. The presence of constitutional symptoms, pancytopenia and high ferritin levels can complicate the evaluation process. A liver biopsy early in the course of liver dysfunction may establish the diagnosis without a higher risk of bleeding complications seen once liver failure sets in.
Collapse
Affiliation(s)
- Fyeza S Haider
- Department of Internal Medicine/Hospitalist Medicine, Geisinger Medical Center, Danville, PA, USA.
| | | | | |
Collapse
|
24
|
Shin HJ, Chung JS, Lee JJ, Sohn SK, Choi YJ, Kim YK, Yang DH, Kim HJ, Kim JG, Joo YD, Lee WS, Sohn CH, Lee EY, Cho GJ. Treatment outcomes with CHOP chemotherapy in adult patients with hemophagocytic lymphohistiocytosis. J Korean Med Sci 2008; 23:439-44. [PMID: 18583880 PMCID: PMC2526520 DOI: 10.3346/jkms.2008.23.3.439] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The objective of the current study was to investigate the treatment outcomes for the use of cyclophosphamide, adriamycin, vincristine, and prednisolone (CHOP) chemotherapy in adult patients with hemophagocytic lymphohistiocytosis (HLH). Seventeen HLH patients older than 18 yr of age were treated with CHOP chemotherapy. A response evaluation was conducted for every two cycles of chemotherapy. With CHOP chemotherapy, complete response was achieved for 7/17 patients (41.2%), a partial response for 3/17 patients (17.6%), and the overall response rate was 58.8%. The median response duration (RD) was not reached and the 2-yr RD rate was 68.6%, with a median follow-up of 100 weeks. Median overall survival (OS) was 18 weeks (95% CI, 6-30 weeks) and the 2-yr OS rate was 43.9%. Reported grade 3 or 4 non-hematological toxicities were increased serum liver enzyme levels and stomatitis. Grade 3 or 4 hematological toxicities were leukopenia (50.8%), anemia (20%), and thrombocytopenia (33.9%). Neutropenic fever was observed in 21.6% of patients (14/65 cycles), and most of the cases were resolved with supportive care including treatment with broad-spectrum antibiotics. CHOP chemotherapy seems to be effective in adult HLH patients and the toxicities are manageable.
Collapse
Affiliation(s)
- Ho-Jin Shin
- Department of Hematology-Oncology, Pusan National University Medical School, Pusan National University Hospital, Busan, Korea
| | - Joo Seop Chung
- Department of Hematology-Oncology, Pusan National University Medical School, Pusan National University Hospital, Busan, Korea
| | - Je-Jung Lee
- Department of Hematology-Oncology, Chonnam National University Medical School, Gwangju; Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Sang Kyun Sohn
- Department of Hematology-Oncology, Kyungpook National University Hospital, Daegu, Korea
| | - Young Jin Choi
- Department of Hematology-Oncology, Pusan National University Medical School, Pusan National University Hospital, Busan, Korea
| | - Yeo-Kyeoung Kim
- Department of Hematology-Oncology, Chonnam National University Medical School, Gwangju; Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Deok-Hwan Yang
- Department of Hematology-Oncology, Chonnam National University Medical School, Gwangju; Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Hyeoung-Joon Kim
- Department of Hematology-Oncology, Chonnam National University Medical School, Gwangju; Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Jong Gwang Kim
- Department of Hematology-Oncology, Kyungpook National University Hospital, Daegu, Korea
| | - Young Don Joo
- Department of Hematology-Oncology, Inje University Busan Paik Hospital, Busan, Korea
| | - Won Sik Lee
- Department of Hematology-Oncology, Inje University Busan Paik Hospital, Busan, Korea
| | - Chang-Hak Sohn
- Department of Hematology-Oncology, Inje University Busan Paik Hospital, Busan, Korea
| | - Eun Yup Lee
- Department of Clinical Pathology, College of Medicine, Pusan National University, Busan, Korea
| | - Goon Jae Cho
- Department of Hematology-Oncology, Pusan National University Medical School, Pusan National University Hospital, Busan, Korea
| |
Collapse
|
25
|
Katsibardi K, Moschovi MA, Theodoridou M, Spanakis N, Kalabalikis P, Tsakris A, Tzortzatou-Stathopoulou F. Enterovirus-associated hemophagocytic syndrome in children with malignancy: report of three cases and review of the literature. Eur J Pediatr 2008; 167:97-102. [PMID: 17318619 DOI: 10.1007/s00431-007-0436-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2006] [Revised: 01/29/2007] [Accepted: 01/30/2007] [Indexed: 12/27/2022]
Abstract
Enteroviruses can cause severe manifestations in children with malignancy. Infection-associated hemophagocytic syndrome (IAHS) due to enterovirus is a rare entity in children. Patients with malignancy and IAHS due to enterovirus were retrospectively evaluated at the University of Athens' Hematology-Oncology pediatric unit within a 6-year period (2000-2006). IAHS occurred in three cases among 56 patients with documented enteroviral infection. The diagnosis of IAHS was confirmed by bone marrow aspiration and biopsy. Nested reverse transcriptase-polymerase chain reaction (RT-PCR), sequencing of the amplified alleles, and immunohistochemistry were performed to document the presence of enterovirus. The type of enterovirus was specified by indirect immunofluorescence assay. At the early phase of the disease, patients presented mild, non-specific viral symptoms, persistent unexplained fever, and pancytopenia. At the late phase, patients had more severe manifestations, such as persistent high fever, diarrhea, weight loss, hepatosplenomegaly, and hepatic dysfunction. The therapeutic approach consisted of supportive care, administration of immunoglobulin (400 mg/kg or 2 g/kg), and pleconaril. All patients had fatal outcome; two patients succumbed to multiorgan failure (MOF), while one patient succumbed to ventricular fibrillation. IAHS usually has fulminant course and leads to severe and life-threatening complications, such as liver failure and MOF. IAHS should always be included in the differential diagnosis of viral syndrome or unexplained fever. The therapeutic approach for IAHS should be administered as early as possible, before the progression to irreversible tissue damage. Early therapeutic intervention involving high doses of immunoglobulin might be beneficial for the patient's outcome.
Collapse
Affiliation(s)
- Katerina Katsibardi
- Hematology-Oncology Unit, First Department of Pediatrics, University of Athens, "Aghia Sophia" Children's Hospital, Thivon & Levadias Ave., Athens 11527, Greece
| | | | | | | | | | | | | |
Collapse
|
26
|
Ishii E, Ohga S, Imashuku S, Yasukawa M, Tsuda H, Miura I, Yamamoto K, Horiuchi H, Takada K, Ohshima K, Nakamura S, Kinukawa N, Oshimi K, Kawa K. Nationwide survey of hemophagocytic lymphohistiocytosis in Japan. Int J Hematol 2007; 86:58-65. [PMID: 17675268 DOI: 10.1532/ijh97.07012] [Citation(s) in RCA: 306] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH), a disorder of the mononuclear phagocyte system, can be classified into two distinct forms: primary HLH (FHL) and secondary HLH. To clarify the epidemiology and clinical outcome for each HLH subtype, we conducted a nationwide survey of HLH in Japan. Since 799 patients were diagnosed in 292 institutions of Japan between 2001 and 2005, the annual incidence of HLH was estimated as 1 in 800,000 per year. Among them, 567 cases were actually analyzed in this study. The most frequent subtype was Epstein-Barr virus (EBV)-associated HLH, followed by other infection- or lymphoma-associated HLH. Age distribution showed a peak of autoimmune disease- and infection-associated HLH in children, while FHL and lymphoma-associated HLH occurred almost exclusively in infants and the elderly, respectively. The 5-year overall survival rate exceeded 80% for patients with EBV- or other infection-associated HLH, was intermediate for those with FHL or B-cell lymphoma-associated HLH, and poor for those with T/NK cell lymphoma-associated HLH (<15%). Although this nationwide survey establishes the heterogeneous characteristics of HLH, the results should be useful in planning prospective studies to identify the most effective therapy for each HLH subtype.
Collapse
Affiliation(s)
- Eiichi Ishii
- Department of Pediatrics, Ehime University Graduate School of Medicine, Ehime, Japan.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Hügle B, Astigarraga I, Henter JI, Porwit-MacDonald A, Meindl A, Schuster V. Simultaneous manifestation of fulminant infectious mononucleosis with haemophagocytic syndrome and B-cell lymphoma in X-linked lymphoproliferative disease. Eur J Pediatr 2007; 166:589-93. [PMID: 17058098 DOI: 10.1007/s00431-006-0290-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2006] [Revised: 08/15/2006] [Accepted: 08/17/2006] [Indexed: 10/24/2022]
Abstract
X-linked lymphoproliferative disease is a rare T and NK cell immune deficiency which most frequently presents as fulminant infectious mononucleosis following infection with the Epstein-Barr virus (EBV). We report the case of a 4-year-old boy from a Spanish family presenting with severe infectious mononucleosis. In the course of the disease he developed hepatic failure, pancytopenia and neurologic impairment, leading to death after less than 2 months. The results of bone marrow biopsy and autopsy indicated a histological diagnosis of both high-grade B-cell lymphoma and virus-associated haemophagocytic syndrome, thereby confirming the simultaneous presence of two different manifestations of X-linked lymphoproliferative disease (XLP) in this patient. The family history revealed four close male relatives dying under similar circumstances, one of whom died following a vaccination against measles. Molecular genetic studies identified a novel mutation in the SH2D1A gene in several members of the family, establishing the diagnosis of XLP. Fatal EBV infection in male infants is highly indicative of XLP. Virus-associated haemophagocytic syndrome and B-cell lymphoma can occur concomitantly and may be difficult to distinguish due to their similar histological pictures.
Collapse
Affiliation(s)
- Boris Hügle
- Department of Pediatrics, University of Leipzig, Oststrasse 21-25, Leipzig, Germany.
| | | | | | | | | | | |
Collapse
|
28
|
Han AR, Lee HR, Park BB, Hwang IG, Park S, Lee SC, Kim K, Lim HY, Ko YH, Kim SH, Kim WS. Lymphoma-associated hemophagocytic syndrome: clinical features and treatment outcome. Ann Hematol 2007; 86:493-8. [PMID: 17347847 DOI: 10.1007/s00277-007-0278-6] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2007] [Accepted: 02/23/2007] [Indexed: 11/25/2022]
Abstract
The clinical features and prognostic factor of lymphoma-associated hemophagocytic syndrome (LAHS), diagnosed according to World Health Organization classification, were investigated by reviewing the clinical records of 29 patients between September 1994 and September 2006. Compared with patients with T or natural killer (NK)/T cell LAHS, patients with B cell LAHS were older (p = 0.022), were less likely to exhibit disseminated intravascular coagulation (DIC; p = 0.011), and had less direct involvement of bone marrow (p = 0.03). Clinical response was achieved in 15 (65.2%) and complete remission (CR) was achieved in 4 (17%) of 23 patients who received chemotherapy. Four patients received high-dose chemotherapy and autologous stem cell transplantation (A-SCT), and three of these four patients showed CR. The median survival was 36 days (95%CI, 20.2-51.8). Univariate analysis showed that poor performance status (p = 0.028), T or NK/T cell lymphoma (p = 0.016), presence of jaundice (p = 0.063), the presence of DIC (p = 0.002), and poor clinical response to treatment (p < 0.001) predicted poor overall survival. These data suggest that the clinical features differ significantly between B cell LAHS and T or NK/T cell LAHS. Intensive treatment including high-dose chemotherapy and A-SCT should be investigated.
Collapse
Affiliation(s)
- A-Reum Han
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Terrier B, Aouba A, Vasiliu V, Charlier C, Delarue R, Buzyn A, Hermine O. Intravascular lymphoma associated with haemophagocytic syndrome: a very rare entity in western countries. Eur J Haematol 2005; 75:341-5. [PMID: 16146541 DOI: 10.1111/j.1600-0609.2005.00519.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Intravascular lymphoma (IVL) is a rare and aggressive disorder, characterised by frequent cutaneous and neurological involvement and medullary infiltration. In rare cases particularly in Asia, IVL can be associated with haemophagocytic syndrome (IVL-HS). Here, we report the case of a 61-year-old Caucasian female who presented with IVL-HS. Bone marrow biopsy showed haemophagocytic features and medullary localisation of a diffuse large B-cell lymphoma. Liver biopsy showed exclusive sinusoidal infiltration by large B cells. Treatment by polychemotherapy associated with rituximab induced a rapid complete remission. Unfortunately, death occurred as a consequence of septic shock. Early recognition of IVL-HS by performing bone marrow biopsy is critical to start rapidly appropriate treatment. The role of rituximab in the management of IVL-HS remains to be established.
Collapse
Affiliation(s)
- Benjamin Terrier
- Department of Adult Haematology, Necker Hospital, 149-161 rue de Sevres, 75743 Paris Cedex 15, France
| | | | | | | | | | | | | |
Collapse
|
30
|
Terrovitis JV, Matsouka C, Anagnostopoulos A, Anastasiou-Nana MI, Dimopoulos AM. Hemophagocytic lymphohistiocytosis after chemotherapy for multiple myeloma. ACTA ACUST UNITED AC 2005; 5:194-6. [PMID: 15636696 DOI: 10.3816/clm.2004.n.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Secondary hemophagocytic lymphohistiocytosis has been reported after infections in immunocompromised hosts or in association with several malignancies. We report a case of secondary hemophagocytic syndrome after chemotherapy for multiple myeloma, which responded dramatically to dexamethasone, etoposide, and cyclosporin A.
Collapse
Affiliation(s)
- John V Terrovitis
- University of Athens School of Medicine, Department of Clinical Therapeutics, Alexandra Hospital, Greece.
| | | | | | | | | |
Collapse
|
31
|
Maeda K, Takahashi T, Saitoh C, Watarai K, Wada K, Tajima K, Harada Y, Hiroshima Y, Yamakawa M. Interdigitating Cell Sarcoma-A report of an autopsy case and literature review-. J Clin Exp Hematop 2005. [DOI: 10.3960/jslrt.45.37] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
|
32
|
Wang S, Degar BA, Zieske A, Shafi NQ, Rose MG. Hemophagocytosis exacerbated by G-CSF/GM-CSF treatment in a patient with myelodysplasia. Am J Hematol 2004; 77:391-6. [PMID: 15551287 DOI: 10.1002/ajh.20202] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We describe a 75-year-old man with neutropenia in whom bone marrow aspirate and biopsy demonstrated hemophagocytosis associated with myelodysplasia (MDS). Therapy with granulocyte-colony stimulating factor (G-CSF) and granulocyte-monocyte-colony stimulating factor (GM-CSF) caused splenomegaly and severe thrombocytopenia, which recurred upon rechallenge. We propose that myeloid growth factors may be detrimental in patients with MDS-associated hemophagocytosis.
Collapse
Affiliation(s)
- Sa Wang
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | | | | | | |
Collapse
|
33
|
Ando K, Miyazawa K, Kuriyama Y, Kimura Y, Mukai K, Ohyashiki K. Hemophagocytic syndrome associated with CD8 positive T-cell chronic lymphocytic leukemia. Leuk Lymphoma 2004; 45:193-8. [PMID: 15061221 DOI: 10.1080/1042819031000123537] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We describe a case of hemophagocytic syndrome (HPS) associated with CD8-positive T-cell chronic lymphocytic leukemia (CD8 + T-CLL). A 68-year-old man with CD8 + T-CLL presented with fever, progressive pancytopenia, and lymphadenopathy. Laboratory findings showed a hyper-ferritinemia, abnormalities of coagulation tests, and liver and renal dysfunction with hypoproteinemia. He did not respond to any treatments and died of respiratory failure 10 days after the admission and 14 months after the onset of CD8 + T-CLL. Pathological findings of the autopsy demonstrated infiltration of CD8 + T-CLL cells in multiple organs along with the increase of histiocytes with prominent hemophagocytosis. Serum concentration levels of IL-6, soluble IL-2 receptor and VEGF were all elevated at admission. These findings revealed that he had a secondary HPS. It was suggested that HPS should be considered in patients with an unexplained cytopenia and a fever during the clinical course of CD8 + T-CLL.
Collapse
Affiliation(s)
- Keiko Ando
- First Department of Internal Medicine, Tokyo Medical University, Tokyo, Japan
| | | | | | | | | | | |
Collapse
|
34
|
Gomyo H, Shimoyama M, Minagawa K, Yakushijin K, Urahama N, Okamura A, Yamamoto K, Ito M, Chihara K, Matsui T. Effective anti-viral therapy for hemophagocytic syndrome associated with B-cell lymphoma. Leuk Lymphoma 2004; 44:1807-10. [PMID: 14692538 DOI: 10.1080/1042819031000103926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
A rheumatoid arthritis (RA) patient treated with low-dose methotrexate (MTX) therapy suffered from hemophagocytic syndrome (HPS) associated with B-cell lymphoma (B-LAHS). Administration of acyclovir and intravenous immunoglobulin promptly resolved laboratory test abnormalities accompanied with HPS. Moreover, hemophagocytic histiocytes and lymphoma cells in the bone marrow disappeared without anti-cancer therapy. Two months after reintroduction of MTX for RA flare, lymphoma re-grew rapidly without bone marrow involvement and HPS. Two cycles of combination chemotherapy induced the lymphoma to a complete remission/unconfirmed (CRu), but then the chemotherapy was discontinued due to severe side effects. In this case, on the basis of RA and MTX induced immunosuppressive state, Epstein-Barr virus (EBV) infection was associated with the development of HPS and lymphoma. Anti-viral therapy alone was effective against HPS and lymphoma at initial presentation and improved her general condition. This case indicates that anti-cancer therapy should be preceded by anti-viral therapy and withdrawal of immunosuppressive therapy in patients under immunosuppressive therapy, as long as the clinical situation permits.
Collapse
Affiliation(s)
- Hiroshi Gomyo
- Hematology/Oncology, Department of Medicine, Kobe University School of Medicine, Chuo-ku, Kobe 650-0017, Japan.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Llado L, Figueras J, Comi S, Torras J, Serrano T, Castellote J, Jaurrieta E. Haemophagocytic syndrome after liver transplantation in adults. Transpl Int 2004. [DOI: 10.1111/j.1432-2277.2004.tb00432.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
36
|
Park JH, Bae JH, Choi YS, Lee HS, Jun JB, Jung S, Yoo DH, Bae SC, Kim TH. Adult-onset Still's disease with disseminated intravascular coagulation and multiple organ dysfunctions dramatically treated with cyclosporine A. J Korean Med Sci 2004; 19:137-41. [PMID: 14966357 PMCID: PMC2822251 DOI: 10.3346/jkms.2004.19.1.137] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Severe systemic manifestations of adult onset Still's disease (AOSD) are often fatal and occasionally related to hemophagocytic syndrome (HS). We describe the case of a 49-yr-old woman with AOSD presenting with non-remitting high fever, confusion, jaundice, hepatosplenomegaly, serositis, azotemia, pancytopenia, coagulopathy with disseminated intravascular coagulation (DIC), hyperferritinemia, acute acalculous cholecystitis and ileocolitis noted in computed tomographic images. The patient had a history of herpes zoster developed prior to the admission, but there is no history of diarrhea or abdominal pain. Although bone marrow examination was not performed due to hemorrhagic diathesis, we suspected AOSD-associated HS on the basis of clinical course without detectable infectious agents in cultures or serologic studies. Intravenous immunoglobulin, pulse methylprednisolone, oral cyclosporine A (CsA) and ceftriaxone brought about transient improvement of fever and confusion, but the disease progressed. After increasing CsA dose, all previously mentioned abnormalities disappeared rapidly. Accordingly, we believe that DIC and multiple organ dysfunctions might have been the complications of HS but not that of sepsis, and that CsA can be used as a first-line therapy in case of life-threatening situations.
Collapse
Affiliation(s)
- Jae-Hong Park
- Division of Rheumatology, The Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
| | - Joong Ho Bae
- Division of Rheumatology, The Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
| | - Yeon-Soo Choi
- Division of Rheumatology, The Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
| | - Hye-Soon Lee
- Division of Rheumatology, The Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
| | - Jae-Bum Jun
- Division of Rheumatology, The Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
| | - Sungsoo Jung
- Division of Rheumatology, The Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
| | - Dae-Hyun Yoo
- Division of Rheumatology, The Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
| | - Sang-Cheol Bae
- Division of Rheumatology, The Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
| | - Tae-Hwan Kim
- Division of Rheumatology, The Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
| |
Collapse
|
37
|
Ohno T, Ueda Y, Nagai KI, Takahashi T, Konaka Y, Takamatsu T, Suzuki T, Sasada M, Uchiyama T. The serum cytokine profiles of lymphoma-associated hemophagocytic syndrome: a comparative analysis of B-cell and T-cell/natural killer cell lymphomas. Int J Hematol 2003; 77:286-94. [PMID: 12731674 DOI: 10.1007/bf02983788] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
To elucidate the differences in pathogenesis between lymphoma-associated hemophagocytic syndromes (LAHS) of the T-cell/ natural killer cell (T/NK) and B-cell (B) types, we comparatively analyzed the clinical features and serum cytokine profiles of 33 patients with LAHS registered in the Kyoto University Hematology/Oncology Study Group. The serum cytokine levels of each patient group (B-LAHS versus T/NK-LAHS) were expressed as the ratio of the median to the upper normal values of the respective cytokines and were as follows: 19.05 versus 13.99 for soluble interleukin 2 (IL-2) receptor, 0.67 versus 0.67 for granulocyte-macrophage colony-stimulating factor (GM-CSF), 0.64 versus 1.26 for G-CSF, 5.70 versus 3.61 for M-CSF, 1.54 versus 3.39 for interferon gamma (IFN-gamma), 13.17 versus 1.17 for IL-6, 6.88 versus 1.58 for tumor necrosis factor alpha (TNF-alpha), 0.71 versus 0.41 for IL-1beta, 1.99 versus 0.21 for IL-12, and 105.32 versus 29.65 for IL-10. The serum levels of IL-6, TNF-alpha, and IL-10 were significantly higher in the B-LAHS group, whereas those of IFN-y were significantly lower. These differences between the 2 groups may reflect a difference in the pathogenesis Higher serum levels of IL-6, TNF-alpha, and IL-10 may be derived at least partly from neoplastic B-cells themselves In addition, the extremely high serum levels of IL-10 suggest that a compensatory anti-inflammatory process may operate in both groups and give rise to a profound immunosuppressive state and a poor outcome.
Collapse
MESH Headings
- Adolescent
- Aged
- Aged, 80 and over
- Case-Control Studies
- Cytokines/blood
- Female
- Histiocytosis, Non-Langerhans-Cell/blood
- Histiocytosis, Non-Langerhans-Cell/etiology
- Histiocytosis, Non-Langerhans-Cell/pathology
- Humans
- Interleukin-10/blood
- Interleukin-6/blood
- Killer Cells, Natural/pathology
- Lymphoma, B-Cell/blood
- Lymphoma, B-Cell/complications
- Lymphoma, B-Cell/immunology
- Lymphoma, T-Cell/blood
- Lymphoma, T-Cell/complications
- Lymphoma, T-Cell/immunology
- Male
- Middle Aged
- Tumor Necrosis Factor-alpha/analysis
Collapse
Affiliation(s)
- Tatsuharu Ohno
- Division of Hematology and Immunology, Department of Internal Medicine, Ohtsu Red Cross Hospital, Nagara, Ohtsu, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Kojima K, Kaneda K, Yasukawa M, Tanaka K, Inoue T, Yamashita T, Dansako H, Sakugawa ST, Kozuka T, Hara M, Tanimoto M. Specificity of polymerase chain reaction-based clonality analysis of immunoglobulin heavy chain gene rearrangement for the detection of bone marrow infiltrate in B-cell lymphoma-associated haemophagocytic syndrome. Br J Haematol 2002; 119:616-21. [PMID: 12437634 DOI: 10.1046/j.1365-2141.2002.03866.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
As a wide range of disorders underlie haemophagocytic syndrome, a rapid distinction between benign polyclonal and malignant monoclonal lymphoid proliferations is critical. We investigated whether polymerase chain reaction (PCR) amplification of immunoglobulin heavy chain gene rearrangement could efficiently detect clonal B-cell populations in non-diagnostic marrow for B-cell lymphoma-associated haemophagocytic syndrome (B-LAHS). On amplifying two DNA samples per biopsy, no reproducible monoclonal PCR result was found in reactive haemophagocytic marrows. In contrast, four out of nine assessable B-LAHS patients with histomorphologically and immunohistochemically lymphoma-free bone marrow showed a reproducible monoclonal immunoglobulin heavy chain gene rearrangement. At the molecular level, two B-LAHS patients had lymphoma-free marrow as demonstrated by patient-specific PCR, suggesting that haemophagocytic marrow is not always associated with lymphoma involvement. PCR-based demonstration of clonal B-cell populations in marrow would add an extra dimension to B-LAHS diagnosis.
Collapse
Affiliation(s)
- Kensuke Kojima
- Department of Medicine II, Okayama University Medical School, Okayama, Japan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Abstract
INTRODUCTION Hemophagocytic syndrome results from a inappropriate stimulation of macrophages in bone marrow and lymphoid organs, leading to phagocytosis of blood cells and production of high amounts of pro-inflammatory cytokines. This life-threatening disease combines non-specific clinical signs (fever, cachexia, hepatomegaly, enlargement of spleen and lymph nodes) as well as typical laboratory findings (bi- or pancytopenia, abnormal hepatic tests, hypofibrinemia, elevation of serum LDH, ferritinemia and triglyceride levels). Diagnosis is confirmed by cytological or pathological examination of bone marrow or tissue specimens. Hemophagocytosis may be primitive, essentially in pediatric population, or secondary, related to various situations such as lymphomas, infections (viral, bacterial or parasitic) or auto-immune diseases. Prognosis is poor, depending on the associated disease, with an overall mortality of 50%. CURRENT KNOWLEDGE AND KEY POINTS Recent advances, essentially due to genetic studies of familial hemophagocytic syndrome, have underlined the major role of T lymphocytes and TNF alpha in the pathogenesis of hemophagocytosis. In these pediatric cases, prognosis has dramatically improved since allogenic bone marrow transplantation is performed, raising long-term survival from 10 to 66%. FUTURE PROSPECTS AND PROJECTS In secondary forms of hemophagocytic syndrome, treatment must be symptomatic (transfusion, correction of electrolyte disorders) and etiological (chemotherapy, anti-viral or antibiotic drugs, immunosuppressive therapy). However, prospective trials are necessary to define the best treatment in these cases. New therapeutic options, targeting specific mediators, including TNF alpha, may emerge with the understanding of pathogenesis of hemophagocytic syndrome.
Collapse
Affiliation(s)
- A Karras
- Service de néphrologie et de transplantation rénale, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | | |
Collapse
|
40
|
Takahashi T, Kazama Y, Shimizu H, Yoshimoto M, Tsujisaki M, Imai K. De novo CD5-positive diffuse large B cell lymphoma solely presenting as multiple subcutaneous nodules. Acta Haematol 2002; 107:230-3. [PMID: 12053152 DOI: 10.1159/000058320] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Lymphomas may involve the subcutaneous tissue as a manifestation of generalized disease. However, they rarely present with multiple involvement of the subcutaneous fat tissue without other sites of the disease. We describe a patient with CD5+ diffuse large B cell lymphoma (DLBL) that was confined to the subcutaneous tissue. A 74-year-old woman with rheumatoid arthritis was admitted because of multiple subcutaneous nodules. The patient had not been treated with cytotoxic drugs or methotrexate. The biopsied specimen disclosed diffuse infiltration of large cells with a starry sky-like appearance. The cells were positive for CD5, CD19, CD20, CD25, IgM, lambda-chain, and negative for CD10, CD23 or cyclin D1. Thus a diagnosis of CD5+ DLBL was made. The patient was treated with a modified CHOP protocol and complete remission was achieved.
Collapse
MESH Headings
- Adipose Tissue/pathology
- Aged
- Antigens, Neoplasm/analysis
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Arthritis, Rheumatoid/complications
- B-Lymphocytes/chemistry
- B-Lymphocytes/pathology
- Biomarkers, Tumor/analysis
- Biopsy
- CD5 Antigens/analysis
- Connective Tissue/pathology
- Cyclophosphamide/administration & dosage
- Doxorubicin/administration & dosage
- Female
- Humans
- Immunophenotyping
- Lymphoma, Large B-Cell, Diffuse/chemistry
- Lymphoma, Large B-Cell, Diffuse/complications
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/pathology
- Neoplastic Stem Cells/chemistry
- Prednisone/administration & dosage
- Remission Induction
- Skin/pathology
- Vincristine/administration & dosage
Collapse
Affiliation(s)
- Tohru Takahashi
- Second Department of Internal Medicine, Tenshi Hospital, Sapporo, Hokkaido, Japan.
| | | | | | | | | | | |
Collapse
|
41
|
Venizelosa ID, Garipidou V, Perifanis V. Hemophagocytic syndrome associated with multiple myeloma. Leuk Lymphoma 2002; 43:897-9. [PMID: 12153183 DOI: 10.1080/10428190290017079] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Hemophagocytic syndrome (HPS) is an uncommon reactive disorder characterized by proliferation of histiocytes that actively engulf other hematopoietic cells causing cytopenia. It complicates several diseases including hematological neoplasias. We report the case of a 54-year-old woman who was admitted to our hospital with fever of unknown origin. Her clinical picture was characterized by renal failure, splenomegaly and pancytopenia. Findings on bone marrow examination showed HPS associated with multiple myeloma. A review of the literature revealed that only one case has previously been published.
Collapse
|
42
|
Rao RD, Morice WG, Phyliky RL. Hemophagocytosis in a patient with chronic lymphocytic leukemia and histoplasmosis. Mayo Clin Proc 2002; 77:287-90. [PMID: 11888034 DOI: 10.4065/77.3.287] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We present a case of hemophagocytosis in the setting of a disseminated Histoplasma infection in a patient with B-cell chronic lymphocytic leukemia (CLL). A 68-year-old man with CLL presented with progressive pancytopenia and fevers after therapy with cyclophosphamide and fludarabine phosphate. Extensive evaluation for a source of infection revealed a pulmonary nodule. A biopsy specimen taken from the nodule showed granulomas containing Histoplasma organisms. A bone marrow biopsy specimen demonstrated disseminated histoplasmosis and intense hemophagocytosis. Antifungal therapy with amphotericin B was initiated, and the fevers and cytopenias resolved. Hemophagocytic syndrome is an uncommon condition with many origins. It is characterized by a proliferation of histiocytes with phagocytosis of formed elements of blood. Clinical manifestations include signs and symptoms of immune activation and decreased peripheral blood cell counts. This condition is often underdiagnosed because clinicians are unfamiliar with it.
Collapse
MESH Headings
- Aged
- Antineoplastic Agents/adverse effects
- Biopsy
- Bone Marrow Examination
- Diagnosis, Differential
- Echocardiography, Transesophageal
- Histiocytosis, Non-Langerhans-Cell/diagnosis
- Histiocytosis, Non-Langerhans-Cell/etiology
- Histiocytosis, Non-Langerhans-Cell/immunology
- Histoplasmosis/complications
- Histoplasmosis/diagnosis
- Histoplasmosis/drug therapy
- Histoplasmosis/immunology
- Humans
- Immunocompromised Host
- Immunohistochemistry
- Leukemia, Lymphocytic, Chronic, B-Cell/blood
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukocyte Count
- Male
- Tomography, X-Ray Computed
Collapse
Affiliation(s)
- Ravi D Rao
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, Minn 55905, USA
| | | | | |
Collapse
|
43
|
Rapoport AP, Cadogan MA, Brown LA. A 78-year-old man with pancytopenia and abnormal lymphocytes. Am J Med Sci 2001; 322:151-5. [PMID: 11570781 DOI: 10.1097/00000441-200109000-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- A P Rapoport
- Department of Medicine, University of Maryland School of Medicine, Baltimore, USA
| | | | | |
Collapse
|