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Armstrong A, Tang Y, Mukherjee N, Zhang N, Huang G. Into the storm: the imbalance in the yin-yang immune response as the commonality of cytokine storm syndromes. Front Immunol 2024; 15:1448201. [PMID: 39318634 PMCID: PMC11420043 DOI: 10.3389/fimmu.2024.1448201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 08/22/2024] [Indexed: 09/26/2024] Open
Abstract
There is a continuous cycle of activation and contraction in the immune response against pathogens and other threats to human health in life. This intrinsic yin-yang of the immune response ensures that inflammatory processes can be appropriately controlled once that threat has been resolved, preventing unnecessary tissue and organ damage. Various factors may contribute to a state of perpetual immune activation, leading to a failure to undergo immune contraction and development of cytokine storm syndromes. A literature review was performed to consider how the trajectory of the immune response in certain individuals leads to cytokine storm, hyperinflammation, and multiorgan damage seen in cytokine storm syndromes. The goal of this review is to evaluate how underlying factors contribute to cytokine storm syndromes, as well as the symptomatology, pathology, and long-term implications of these conditions. Although the recognition of cytokine storm syndromes allows for universal treatment with steroids, this therapy shows limitations for symptom resolution and survival. By identifying cytokine storm syndromes as a continuum of disease, this will allow for a thorough evaluation of disease pathogenesis, consideration of targeted therapies, and eventual restoration of the balance in the yin-yang immune response.
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Affiliation(s)
- Amy Armstrong
- Department of Cell Systems and Anatomy, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
- Department of Microbiology, Immunology, and Molecular Genetics, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
| | - Yuting Tang
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Neelam Mukherjee
- Department of Microbiology, Immunology, and Molecular Genetics, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
- Department of Urology, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
| | - Nu Zhang
- Department of Microbiology, Immunology, and Molecular Genetics, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
| | - Gang Huang
- Department of Cell Systems and Anatomy, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
- Department of Microbiology, Immunology, and Molecular Genetics, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
- Department of Pathology & Laboratory Medicine, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
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2
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Aires BP, Wobma H, Samad A, Chandler MT, Chang MH, Dedeoglu F, Fishman MP, Klouda T, Levin J, Halyabar O, Saleeb SF, Tworetzky W, Son MBF, Newburger JW, Casey A, Henderson LA. Severe Features of Systemic Juvenile Idiopathic Arthritis in Patients With Congenital Heart Disease. J Rheumatol 2024; 51:811-817. [PMID: 38825355 PMCID: PMC11296918 DOI: 10.3899/jrheum.2024-0180] [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] [Accepted: 05/21/2024] [Indexed: 06/04/2024]
Abstract
OBJECTIVE To describe the clinical features of patients with congenital heart disease (CHD) who subsequently developed systemic juvenile idiopathic arthritis (sJIA). METHODS We conducted a retrospective review of patients diagnosed with CHD and sJIA at our institution. Detailed clinical, laboratory, and radiographic data were collected from the medical record and reviewed with each patient's primary medical team. RESULTS Five patients with sJIA and CHD were identified. Each child had a unique cardiac anatomy, but all the patients required surgical repair during the first year of life. Four children had thymectomies at the time of cardiac surgery. Classic signs of sJIA such as fever (n = 5), rash (n = 5), and arthritis (n = 4) developed after surgical intervention in all the patients. The individuals in this cohort displayed risk factors associated with severe sJIA, including disease onset before 2 years of age (n = 5), elevated interleukin 18 levels (n = 5), baseline eosinophilia prior to initiation of biologic disease-modifying antirheumatic drugs (n = 4), and positivity for HLA-DRB1*15:01 alleles (n = 4). Macrophage activation syndrome (MAS) occurred in 3 patients and sJIA-associated lung disease (sJIA-LD) was identified in 4 patients. Two children died from complications of their cardiac and/or pulmonary disease. CONCLUSION We identified an association between CHD and severe forms of sJIA. Although these findings will need to be confirmed in larger, multicenter cohorts, the results highlight the importance of considering a diagnosis of sJIA in children with CHD and remaining vigilant for complications such as MAS and sJIA-LD.
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Affiliation(s)
- Barbara Pontes Aires
- B. Pontes Aires, MD, Department of Pediatrics, Tufts Medical Center, Tufts University School of Medicine, and Department of Pediatrics, Boston Children's Hospital
| | - Holly Wobma
- H. Wobma, MD, PhD, M.T. Chandler, MD, MPH, M.H. Chang, MD, PhD, F. Dedeoglu, MD, O. Halyabar, MD, M.B.F. Son, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Harvard Medical School
| | - Aaida Samad
- A. Samad, MD, M.P. Fishman, MD, T. Klouda, DO, J. Levin, MD, MBI, A. Casey, MD, Division of Pulmonary Medicine, Boston Children's Hospital, Harvard Medical School
| | - Mia T Chandler
- H. Wobma, MD, PhD, M.T. Chandler, MD, MPH, M.H. Chang, MD, PhD, F. Dedeoglu, MD, O. Halyabar, MD, M.B.F. Son, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Harvard Medical School
| | - Margaret H Chang
- H. Wobma, MD, PhD, M.T. Chandler, MD, MPH, M.H. Chang, MD, PhD, F. Dedeoglu, MD, O. Halyabar, MD, M.B.F. Son, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Harvard Medical School
| | - Fatma Dedeoglu
- H. Wobma, MD, PhD, M.T. Chandler, MD, MPH, M.H. Chang, MD, PhD, F. Dedeoglu, MD, O. Halyabar, MD, M.B.F. Son, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Harvard Medical School
| | - Martha P Fishman
- A. Samad, MD, M.P. Fishman, MD, T. Klouda, DO, J. Levin, MD, MBI, A. Casey, MD, Division of Pulmonary Medicine, Boston Children's Hospital, Harvard Medical School
| | - Timothy Klouda
- A. Samad, MD, M.P. Fishman, MD, T. Klouda, DO, J. Levin, MD, MBI, A. Casey, MD, Division of Pulmonary Medicine, Boston Children's Hospital, Harvard Medical School
| | - Jonathan Levin
- A. Samad, MD, M.P. Fishman, MD, T. Klouda, DO, J. Levin, MD, MBI, A. Casey, MD, Division of Pulmonary Medicine, Boston Children's Hospital, Harvard Medical School
| | - Olha Halyabar
- H. Wobma, MD, PhD, M.T. Chandler, MD, MPH, M.H. Chang, MD, PhD, F. Dedeoglu, MD, O. Halyabar, MD, M.B.F. Son, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Harvard Medical School
| | - Susan F Saleeb
- S.F. Saleeb, MD, W. Tworetzky, MD, J.W. Newburger, MD, MPH, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wayne Tworetzky
- S.F. Saleeb, MD, W. Tworetzky, MD, J.W. Newburger, MD, MPH, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary Beth F Son
- H. Wobma, MD, PhD, M.T. Chandler, MD, MPH, M.H. Chang, MD, PhD, F. Dedeoglu, MD, O. Halyabar, MD, M.B.F. Son, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Harvard Medical School
| | - Jane W Newburger
- S.F. Saleeb, MD, W. Tworetzky, MD, J.W. Newburger, MD, MPH, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alicia Casey
- A. Samad, MD, M.P. Fishman, MD, T. Klouda, DO, J. Levin, MD, MBI, A. Casey, MD, Division of Pulmonary Medicine, Boston Children's Hospital, Harvard Medical School
| | - Lauren A Henderson
- H. Wobma, MD, PhD, M.T. Chandler, MD, MPH, M.H. Chang, MD, PhD, F. Dedeoglu, MD, O. Halyabar, MD, M.B.F. Son, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Harvard Medical School;
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3
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Pegoraro F, Chinnici A, Beneforti L, Tanturli M, Trambusti I, De Fusco C, Micalizzi C, Barat V, Cesaro S, Gaspari S, Dell'Acqua F, Todesco A, Timeus F, Aricò M, Favre C, Tondo A, Coniglio ML, Sieni E, Working Group AH. Outcome of primary hemophagocytic lymphohistiocytosis: a report on 143 patients from the Italian Registry. Haematologica 2024; 109:2515-2524. [PMID: 38385274 PMCID: PMC11290506 DOI: 10.3324/haematol.2023.283893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 02/12/2024] [Indexed: 02/23/2024] Open
Abstract
Primary hemophagocytic lymphohistiocytosis (pHLH) is a severe, life-threatening hyperinflammatory syndrome caused by defects in genes of the granule-dependent cytotoxic pathway. Here we investigated the clinical presentation and outcome in a large cohort of 143 patients with pHLH diagnosed in the last 15 years and enrolled in the Italian registry. The median age at diagnosis was 12 months (interquartile range, 2-81), and 92 patients (64%) fulfilled the HLH-2004 criteria. Of 111 patients who received first-line combined therapy (HLH-94, HLH-2004, Euro-HIT protocols), 65 (59%) achieved complete response and 21 (19%) partial response. Thereafter, 33 patients (30%) reactivated, and 92 (64%) received hematopoietic stem cell transplantation, 78 of whom (85%) survived and were alive at a median follow-up from diagnosis of 67 months. Thirty-six patients (25%) died before hematopoietic stem cell transplantation and 14 (10%) after. Overall, 93 patients (65%) were alive after a median follow-up of 30 months. Unadjusted predictors of non-response were age <6 months and high ferritin and bilirubin levels, while predictors of pre-transplant and overall mortality were high ferritin and bilirubin levels. At multivariable analysis, high levels of ferritin predicted non-response, while high levels of bilirubin predicted pre-transplant and overall mortality. Despite recent advances in therapeutic management, pHLH remains a life-threatening condition with significant early mortality. Liver dysfunction is the main predictor of poor prognosis.
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Affiliation(s)
- Francesco Pegoraro
- Department of Health Sciences, University of Florence, Florence, Italy; Pediatric Hematology Oncology, Meyer Children's Hospital IRCCS, Florence
| | - Aurora Chinnici
- Pediatric Hematology Oncology, Meyer Children's Hospital IRCCS, Florence, Italy; Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence
| | - Linda Beneforti
- Pediatric Hematology Oncology, Meyer Children's Hospital IRCCS, Florence, Italy; Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence
| | - Michele Tanturli
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence
| | - Irene Trambusti
- Pediatric Hematology Oncology, Meyer Children's Hospital IRCCS, Florence, Italy; Department of Clinical and Experimental Medicine, University of Pisa, Pisa
| | - Carmela De Fusco
- Pediatric Oncology, AORN Santobono-Pausilipon, Pausilipon Hospital, Naples
| | | | - Veronica Barat
- Pediatric Hematology Oncology, Stem Cell Transplantation and Cell Therapy Division, A.O. Città della Salute e della Scienza-Ospedale Infantile Regina Margherita, Turin
| | - Simone Cesaro
- Paediatric Haematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona
| | - Stefania Gaspari
- Pediatric Hematology Oncology, Cellular and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome
| | - Fabiola Dell'Acqua
- Department of Pediatrics, Fondazione MBBM, University of Milano-Bicocca, Monza
| | | | | | - Maurizio Aricò
- Pediatrics, S. Spirito Hospital, Azienda Sanitaria Locale Pescara, Pescara
| | - Claudio Favre
- Pediatric Hematology Oncology, Meyer Children's Hospital IRCCS, Florence
| | - Annalisa Tondo
- Pediatric Hematology Oncology, Meyer Children's Hospital IRCCS, Florence
| | | | - Elena Sieni
- Pediatric Hematology Oncology, Meyer Children's Hospital IRCCS, Florence.
| | - Aieop Histiocytosis Working Group
- Antonino Trizzino, Simona Gobbi, Fraia Melchionda, Marco Zecca, Elena Mastrodicasa, Massimo Provenzi, Monica Cellini, Daniela Onofrillo, Marco Rabusin, Bernd Raffeiner, Rosamaria Mura, Vito Miraglia, Alessandra Tozzo
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4
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Guan X, Guo H, Guo Y, Han Q, Li Z, Zhang C. Perforin 1 in Cancer: Mechanisms, Therapy, and Outlook. Biomolecules 2024; 14:910. [PMID: 39199299 PMCID: PMC11352983 DOI: 10.3390/biom14080910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 07/22/2024] [Accepted: 07/24/2024] [Indexed: 09/01/2024] Open
Abstract
PRF1 (perforin 1) is a key cytotoxic molecule that plays a crucial role in the killing function of natural killer (NK) cells and cytotoxic T lymphocytes (CTLs). Recent studies have focused on PRF1's role in cancer development, progression, and prognosis. Studies have shown that aberrant PRF1 expression has a significant role to play in cancer development and progression. In some cancers, high expression of the PRF1 gene is associated with a better prognosis for patients, possibly because it helps enhance the body's immune response to tumors. However, some studies have also shown that the absence of PRF1 may make it easier for tumors to evade the body's immune surveillance, thus affecting patient survival. Furthermore, recent studies have explored therapeutic strategies based on PRF1, such as enhancing the ability of immune cells to kill cancer cells by boosting PRF1 activity. In addition, they have improved the efficacy of immunotherapy by modulating its expression to enhance the effectiveness of the treatment. Based on these findings, PRF1 may be a valuable biomarker both for the treatment of cancer and for its prognosis in the future. To conclude, PRF1 has an important biological function and has clinical potential for the treatment of cancer, which indicates that it deserves more research and development in the future.
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Affiliation(s)
- Xiaoya Guan
- Shanxi Key Laboratory of Otorhinolaryngology Head and Neck Cancer, First Hospital of Shanxi Medical University, Taiyuan 030001, China; (H.G.); (Y.G.); (Q.H.); (Z.L.)
- Shanxi Province Clinical Medical Research Center for Precision Medicine of Head and Neck Cancer, First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Huina Guo
- Shanxi Key Laboratory of Otorhinolaryngology Head and Neck Cancer, First Hospital of Shanxi Medical University, Taiyuan 030001, China; (H.G.); (Y.G.); (Q.H.); (Z.L.)
- Shanxi Province Clinical Medical Research Center for Precision Medicine of Head and Neck Cancer, First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Yujia Guo
- Shanxi Key Laboratory of Otorhinolaryngology Head and Neck Cancer, First Hospital of Shanxi Medical University, Taiyuan 030001, China; (H.G.); (Y.G.); (Q.H.); (Z.L.)
- Shanxi Province Clinical Medical Research Center for Precision Medicine of Head and Neck Cancer, First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Qi Han
- Shanxi Key Laboratory of Otorhinolaryngology Head and Neck Cancer, First Hospital of Shanxi Medical University, Taiyuan 030001, China; (H.G.); (Y.G.); (Q.H.); (Z.L.)
- Shanxi Province Clinical Medical Research Center for Precision Medicine of Head and Neck Cancer, First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Zhongxun Li
- Shanxi Key Laboratory of Otorhinolaryngology Head and Neck Cancer, First Hospital of Shanxi Medical University, Taiyuan 030001, China; (H.G.); (Y.G.); (Q.H.); (Z.L.)
- Shanxi Province Clinical Medical Research Center for Precision Medicine of Head and Neck Cancer, First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Chunming Zhang
- Shanxi Key Laboratory of Otorhinolaryngology Head and Neck Cancer, First Hospital of Shanxi Medical University, Taiyuan 030001, China; (H.G.); (Y.G.); (Q.H.); (Z.L.)
- Shanxi Province Clinical Medical Research Center for Precision Medicine of Head and Neck Cancer, First Hospital of Shanxi Medical University, Taiyuan 030001, China
- Department of Otolaryngology Head & Neck Surgery, First Hospital of Shanxi Medical University, Taiyuan 030001, China
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5
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Nyvlt P, Schuster FS, Ihlow J, Heeren P, Spies C, Hiesgen J, Schenk T, von Brünneck AC, Westermann J, Brunkhorst FM, La Rosée P, Janka G, Lachmann C, Lachmann G. Value of hemophagocytosis in the diagnosis of hemophagocytic lymphohistiocytosis in critically ill patients. Eur J Haematol 2024; 112:917-926. [PMID: 38368850 DOI: 10.1111/ejh.14185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Ferritin is an established biomarker in the diagnosis of secondary hemophagocytic lymphohistiocytosis (HLH), which is diagnosed by the HLH-2004 criteria. Among these criteria, detection of hemophagocytosis through invasive procedures may delay early life saving treatment. Our aim was to investigate the value of hemophagocytosis in diagnosing HLH in critically ill patients. METHODS In this secondary analysis of a retrospective observational study, we included all patients aged ≥18 years and admitted to any adult ICU at Charité-Universitätsmedizin Berlin between January 2006 and August 2018, who had hyperferritinemia (≥500 μg/L) and underwent bone marrow biopsy during their ICU course. RESULTS Two hundred fifty-two patients were included, of whom 31 (12.3%) showed hemophagocytosis. In multivariable logistic regression analysis, maximum ferritin was independently associated with hemophagocytosis. By removing hemophagocytosis from HLH-2004 criteria and HScore, prediction accuracy for HLH diagnosis was only marginally decreased compared to the original scores. CONCLUSIONS Our results strengthen the diagnostic value of ferritin and underline the importance of considering HLH diagnosis in patients with high ferritin but only four fulfilled HLH-2004 criteria, when hemophagocytosis was not assessed or not detectable. Proof of hemophagocytosis is not required for a reliable HLH diagnosis.
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Affiliation(s)
- Peter Nyvlt
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Friederike S Schuster
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Jana Ihlow
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Pathology, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Patrick Heeren
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Claudia Spies
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Josephine Hiesgen
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Thomas Schenk
- Department of Hematology and Oncology, Universitätsklinikum Jena, Jena, Germany
| | - Ann-Christin von Brünneck
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Pathology, Berlin, Germany
| | - Jörg Westermann
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Hematology, Oncology and Tumorimmunology, Berlin, Germany
| | - Frank M Brunkhorst
- Center for Clinical Studies, Department of Anesthesiology and Intensive Care Medicine, Universitätsklinikum Jena, Jena, Germany
| | - Paul La Rosée
- Klinik für Innere Medizin II, Schwarzwald-Baar-Klinikum, Villingen-Schwenningen, Germany
| | - Gritta Janka
- Clinic of Pediatric Hematology and Oncology, University Medical Center Eppendorf, Hamburg, Germany
| | - Cornelia Lachmann
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM, CVK), Berlin, Germany
- Berlin Institute of Health (BIH) at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gunnar Lachmann
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM, CVK), Berlin, Germany
- Berlin Institute of Health (BIH) at Charité-Universitätsmedizin Berlin, Berlin, Germany
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6
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Elgaali E, Mezzavilla M, Ahmed I, Elanbari M, Ali A, Abdelaziz G, Fakhro KA, Saleh A, Ben-Omran T, Almulla N, Cugno C. Genetic background of primary and familial HLH in Qatar: registry data and population study. Front Pediatr 2024; 12:1326489. [PMID: 38808104 PMCID: PMC11130942 DOI: 10.3389/fped.2024.1326489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 04/08/2024] [Indexed: 05/30/2024] Open
Abstract
Background Familial hemophagocytic lymphohistiocytosis (FHLH) is an inherited life-threatening disease. Five types are identified, with the addition of congenital immunodeficiency syndromes in which HLH is a typical manifestation. The literature on this disease is very scarce in the Middle East, with only a few scattered reports. Methods We report detailed demographic, clinical, and genomic data from 28 patients diagnosed with primary and familial HLH over the last decade in Qatar. An evaluation was performed of allele frequencies of deleterious variants from 12 primary and familial HLH causative genes on the Qatar Genome Programme (QGP) cohort of 14,669 Qatari individuals. Results The genetic diagnosis was obtained in 15 patients, and four novel mutations in Perforin 1 (PRF1), UNC13D, LYST, and RAB27A genes were found. We identified 22,945 low/high/moderate/modifier impact variants significantly enriched in the QGP in those 12 genes. The variants rs1271079313 in PRF1 and rs753966933 in RAB27A found in our patient cohort were significantly more prevalent in the QGP compared to the Genome Aggregation Database (gnomAD) database, with a high carrier frequency in the Qatari population. Conclusions We established the first primary and familial HLH Registry in the Gulf Region and identified novel possibly pathogenic variants present at higher frequency in the Qatari population, which could be used for screening purposes. Raising awareness about primary and familial HLH and implementing screening activities in the Qatari highly inbred population could stem into more comprehensive premarital and prenatal evaluations and faster diagnosis.
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Affiliation(s)
- Elkhansa Elgaali
- Pediatric Hematology and Oncology Department, Sidra Medicine, Doha, Qatar
| | | | - Ikhlak Ahmed
- Research Department, Sidra Medicine, Doha, Qatar
| | | | - Aesha Ali
- Research Department, Sidra Medicine, Doha, Qatar
| | | | | | - Ayman Saleh
- Pediatric Hematology and Oncology Department, Sidra Medicine, Doha, Qatar
| | - Tawfeg Ben-Omran
- Division of Genetic and Genomic Medicine, Sidra Medicine, Doha, Qatar
- Department of Medical Genetics, Hamad Medical Corporation, Doha, Qatar
| | - Naima Almulla
- Pediatric Hematology and Oncology Department, Sidra Medicine, Doha, Qatar
| | - Chiara Cugno
- Pediatric Hematology and Oncology Department, Sidra Medicine, Doha, Qatar
- Research Department, Sidra Medicine, Doha, Qatar
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7
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Holloway A, Ahmed S, Manson JJ. Does your unwell patient have haemophagocytic lymphohistiocytosis? Br J Hosp Med (Lond) 2024; 85:1-12. [PMID: 38557089 DOI: 10.12968/hmed.2023.0394] [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: 04/04/2024]
Abstract
Haemophagocytic lymphohistiocytosis is a severe systemic hyperinflammatory syndrome characterised by dysregulation of immune cells and excessive production of cytokines, also known as a cytokine storm. It has distinctive clinical features with fever, hyperferritinaemia and falling blood counts. In adults, this usually occurs secondary to an underlying driver or trigger including infection, malignancy or rheumatic diseases. Prompt treatment with immunomodulatory therapy, including corticosteroids and the recombinant IL-1 receptor antagonist anakinra, is recommended to switch off the cytokine storm. Etoposide-based regimens are sometimes needed, and newer therapies such as emapalumab and JAK inhibitors are increasingly being used. The incidence of haemophagocytic lymphohistiocytosis has increased significantly over the last 20 years which may partly reflect increased awareness of the condition. Although relatively rare, haemophagocytic lymphohistiocytosis can be encountered by a broad range of hospital physicians, so knowing how to diagnose and treat this condition is essential. This article reviews the pathogenesis, clinical features, causes, diagnosis and treatment of haemophagocytic lymphohistiocytosis to improve physician recognition and management of this condition to improve future patient outcomes.
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Affiliation(s)
- Amelia Holloway
- Department of Rheumatology, Kings College Hospital, London, UK
| | - Saad Ahmed
- Department of Rheumatology, Addenbrookes Hospital, Cambridge, UK
| | - Jessica J Manson
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
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8
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Stadermann A, Haar M, Riecke A, Mayer T, Neumann C, Bauer A, Schulz A, Nagarathinam K, Gebauer N, Böhm S, Groß M, Grunert M, Müller M, Witte H. Late Onset of Primary Hemophagocytic Lymphohistiocytosis (HLH) with a Novel Constellation of Compound Heterozygosity Involving Two Missense Variants in the PRF1 Gene. Int J Mol Sci 2024; 25:2762. [PMID: 38474010 DOI: 10.3390/ijms25052762] [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: 12/23/2023] [Revised: 02/12/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare but in most cases life-threatening immune-mediated disease of the hematopoietic system frequently associated with hematologic neoplasms. Here, we report on a case in which we detected a novel constellation of two missense variants affecting the PRF1 gene, leading to de novo primary HLH. Diagnostics included a comprehensive clinical work-up and standard methods of hematopathology as well as extended molecular genomics based on polymerase chain reaction (PCR) reactions and the calculation of three-dimensional molecule reconstructions of PRF1. Subsequently, a comprehensive review of the literature was performed, which showed that this compound heterozygosity has not been previously described. The patient was a 20-year-old female. Molecular diagnostics revealed two heterozygous missense variants in the PRF1 gene (A91V and R104C) on exon 2. Apart from the finding of two inconclusive genetic variants, all clinical criteria defined by the HLH study group of Histiocyte Society were met at initial presentation. The final diagnosis was made in cooperation with the Consortium of German HLH-reference centers. Here, chemotherapy did not lead to sufficient sustained disease control. Therefore, the decision for allogenic hematopoietic stem cell transplantation (alloHSCT) was made. Hitherto, the duration of response was 6 months. Due to severe and unmanageable hepatic graft-versus-host disease (GvHD), the patient died. We report on a novel constellation of a compound heterozygosity containing two missense variants on exon 2 of the PRF1 gene. To the authors' best knowledge, this is the first presentation of a primary HLH case harboring this genomic constellation with late-onset clinical manifestation.
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Affiliation(s)
- Alina Stadermann
- Department of Hematology and Oncology, Bundeswehrkrankemhaus Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Markus Haar
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251 Hamburg, Germany
| | - Armin Riecke
- Department of Hematology and Oncology, Bundeswehrkrankemhaus Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Thomas Mayer
- Department of Hematology and Oncology, Bundeswehrkrankemhaus Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Christian Neumann
- Department of Hematology and Oncology, Bundeswehrkrankemhaus Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Arthur Bauer
- Department of Hematology and Oncology, Bundeswehrkrankemhaus Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Ansgar Schulz
- Department of Pediatric Medicine, University Hospital Ulm, Eythstraße 24, 89075 Ulm, Germany
| | - Kumar Nagarathinam
- Institute of Biochemistry, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Niklas Gebauer
- Department of Hematology and Oncology, University Hospital Schleswig-Holstein Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Svea Böhm
- Institute for Immunodeficiency, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 115, 79106 Freiburg, Germany
- Division of Pediatric Stem Cell Transplantation and Immunology, Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Miriam Groß
- Institute for Immunodeficiency, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 115, 79106 Freiburg, Germany
| | - Michael Grunert
- Department of Nuclear Medicine, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
- Department of Nuclear Medicine, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Matthias Müller
- Department of Hematology and Oncology, Bundeswehrkrankemhaus Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Hanno Witte
- Department of Hematology and Oncology, Bundeswehrkrankemhaus Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
- Department of Hematology and Oncology, University Hospital Schleswig-Holstein Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
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Jevtic D, da Silva MD, Haylock AB, Nordstrom CW, Oluic S, Pantic N, Nikolajevic M, Nikolajevic N, Kotseva M, Dumic I. Hemophagocytic Lymphohistiocytosis (HLH) in Patients with Tick-Borne Illness: A Scoping Review of 98 Cases. Infect Dis Rep 2024; 16:154-169. [PMID: 38525759 PMCID: PMC10961790 DOI: 10.3390/idr16020012] [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: 12/13/2023] [Revised: 02/15/2024] [Accepted: 02/18/2024] [Indexed: 03/26/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) secondary to tick-borne infections is a rare but potentially life-threatening syndrome. We performed a scoping review according to PRISMA guidelines to systematically analyze the existing literature on the topic. A total of 98 patients were included, with a mean age of 43.7 years, of which 64% were men. Most cases, 31%, were reported from the USA. Immunosuppression was present in 21.4%, with the most common cause being previous solid organ transplantation. Constitutional symptoms were the most common, observed in 83.7% of the patients, while fever was reported in 70.4% of cases. Sepsis was present in 27.6%. The most common laboratory abnormalities in this cohort were thrombocytopenia in 81.6% of patients, while anemia, leukopenia, and leukocytosis were observed in 75.5%, 55.1%, and 10.2%, respectively. Liver enzyme elevation was noted in 63.3% of cases. The H-score was analyzed in 64 patients, with the mean value being 209, and bone marrow analysis was performed in 61.2% of patients. Ehrlichia spp. was the main isolated agent associated with HLH in 45.9%, followed by Rickettsia spp. in 14.3% and Anaplasma phagocytophilum in 12.2%. Notably, no patient with Powassan virus infection or Lyme borreliosis developed HLH. The most common complications were acute kidney injury (AKI) in 35.7% of patients, shock with multiple organ dysfunction in 22.5%, encephalopathy/seizure in 20.4%, respiratory failure in 16.3%, and cardiac complications in 7.1% of patients. Treatment included antibiotic therapy alone in 43.9%, while 5.1% of patients were treated with immunosuppressants alone. Treatment with both antibiotics and immunosuppressants was used in 51% of patients. Appropriate empiric antibiotics were used in 62.2%. In 43.9% of cases of HLH due to tick-borne disease, patients received only antimicrobial therapy, and 88.4% of those recovered completely without the need for immunosuppressive therapy. The mortality rate in our review was 16.3%, and patients who received inappropriate or delayed empiric therapy had a worse outcome. Hence, we suggest empiric antibiotic treatment in patients who are suspected of having HLH due to tick-borne disease or in whom diagnostic uncertainty persists due to diagnostic delay in order to minimize mortality.
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Affiliation(s)
- Dorde Jevtic
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.J.); (A.B.H.)
- Department of Medicine, NYC Health + Hospitals/Elmhurst, New York, NY 11373, USA
| | | | - Alberto Busmail Haylock
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.J.); (A.B.H.)
- Department of Medicine, NYC Health + Hospitals/Elmhurst, New York, NY 11373, USA
| | - Charles W. Nordstrom
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA;
- Mayo Clinic College of Medicine and Science, Rochester, MN 55902, USA
| | - Stevan Oluic
- Department of Internal Medicine, Mayo Clinic Health System, Mankato, MN 56001, USA;
| | - Nikola Pantic
- Clinic of Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia;
| | - Milan Nikolajevic
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.N.); (N.N.)
| | - Nikola Nikolajevic
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.N.); (N.N.)
| | - Magdalena Kotseva
- Internal Medicine Residency, Franciscan Health, Olympia Fields, Chicago, IL 60461, USA;
| | - Igor Dumic
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA;
- Mayo Clinic College of Medicine and Science, Rochester, MN 55902, USA
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10
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Nagaraj CB, Brightman DS, Rea H, Wakefield E, Harkavy NVG, Dyer L, Zhang W. Detection of a novel gross deletion in the UNC13D gene ends the diagnostic odyssey for a family with familial hemophagocytic lymphohistiocytosis 3. BMC Pediatr 2024; 24:34. [PMID: 38212754 PMCID: PMC10782673 DOI: 10.1186/s12887-023-04510-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 12/26/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Familial hemophagocytic lymphohistiocytosis (FHL) is an immunological disorder characterized by overactivation of macrophages and T lymphocytes. This autosomal recessive condition has been characterized into multiple types depending on the genetic etiology. FHL type 3 is associated with bi-allelic pathogenic variants in the UNC13D gene. CASE PRESENTATION We present a 12-year diagnostic odyssey for a family with FHL that signifies the advances of FHL genetic testing in a clinical genetic diagnostic laboratory setting. We describe the first case of a large UNC13D gross deletion in trans to a nonsense variant in a family with FHL3, which may have been mediated by Alu elements within introns 12 and 25 of the UNC13D gene. CONCLUSIONS This case highlights the importance of re-evaluating past genetic testing for a patient and family as test technology evolves in order to end a diagnostic odyssey.
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Affiliation(s)
- Chinmayee B Nagaraj
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7016, Cincinnati, OH, 45229, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Diana S Brightman
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7016, Cincinnati, OH, 45229, USA
| | - Hannah Rea
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7016, Cincinnati, OH, 45229, USA
| | - Emily Wakefield
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7016, Cincinnati, OH, 45229, USA
| | - Nina V G Harkavy
- Department of OB/GYN, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
| | - Lisa Dyer
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7016, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Wenying Zhang
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7016, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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11
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Silverman ED. The History of Macrophage Activation Syndrome in Autoimmune Diseases. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:21-31. [PMID: 39117805 DOI: 10.1007/978-3-031-59815-9_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
In 1979, it became recognized in the literature that what we call hemophagocytic lymphohistiocytosis (HLH) was a nonmalignant disease of histiocytes. Subsequently a familial form and a secondary form of HLH were differentiated. When HLH is secondary to an autoimmune disease, rheumatologists refer to this entity as macrophage activation syndrome (MAS) to differentiate it from HLH itself. Although the first cases of MAS likely appeared in the literature in the 1970s, it was not until 1985 that the term activated macrophages was used to describe patients with systemic juvenile idiopathic arthritis (sJIA) complicated by MAS and the term macrophage activation syndrome first appeared in the title of a paper in 1993.MAS is one of the many types of secondary HLH and should not be confused with primary HLH. Experience has taught that MAS secondary to different autoimmune diseases is not equal. In the 30 years since initial description in patients with sJIA, the clinical spectrum, diseases associated with MAS, therapy, and understanding the pathogenesis have all made significant gains. The diagnostic/classification criteria for MAS secondary to sJIA, SLE, RA, and KD differ based on the different laboratory abnormalities associated with each (Ahn et al., J Rheumatol 44:996-1003, 2017; Han et al., Ann Rheum Dis 75:e44, 2016; Ravelli et al., Ann Rheum Dis 75:481-489, 2016; Borgia et al., Arthritis Rheumatol 70:616-624, 2018). These examples include the thrombocytosis associated with sJIA, a chronic generalized activation of the immune system, leading to elevations of fibrinogen and sIL-2R, low platelet count associated with SLE, and more acute inflammation associated with KD. Therefore, individual diagnostic criteria are required, and they all differ from the diagnostic criteria for HLH, which are based on a previously non-activated immune system (Ahn et al., J Rheumatol 44:996-1003, 2017; Han et al., Ann Rheum Dis 75:e44, 2016; Ravelli et al., Ann Rheum Dis 75:481-489, 2016; Borgia et al., Arthritis Rheumatol 70:616-624, 2018; Henter et al., Pediatr Blood Cancer 48:124-131, 2007). This helps to explain why the HLH diagnostic criteria do not perform well in MAS.The initial treatment remains high-dose steroids and IVIG followed by the use of a calcineurin inhibitor for resistant cases. IVIG can be used if there is a concern about malignancy to wait for appropriate investigations or with steroids. Interluekin-1 inhibition is now the next therapy if there is a failure to respond to steroids and calcineurin inhibitors. Advances in understanding the mechanisms leading to MAS, which has been greatly aided by the use of mouse models of MAS and advances in genome sequencing, offer a bright future for more specific therapies. More recent therapies are directed to specific cytokines involved in the pathogenesis of MAS and can lead to decreases in the morbidity and mortality associated with MAS. These include therapies directed to inhibiting the JAK/STAT pathway and/or specific cytokines, interleukin-18 and gamma interferon, which are currently being studied in MAS. These more specific therapies may obviate the need for nonspecific immunosuppressive therapies including high-dose prolonged steroids, calcineurin inhibitors, and etoposide.
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Affiliation(s)
- Earl D Silverman
- Hospital for Sick Children (SickKids), University of Toronto, Toronto, ON, Canada.
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12
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Thiebaut L, Pasquier G, Theret S, Russello J. [Hemophagocytic lymphohistiocytosis: A retrospective analysis of 66 patients]. Rev Med Interne 2024; 45:6-12. [PMID: 37932192 DOI: 10.1016/j.revmed.2023.10.440] [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: 04/29/2023] [Revised: 07/02/2023] [Accepted: 10/12/2023] [Indexed: 11/08/2023]
Abstract
CONTEXT Hemophagocytic lymphohistiocytosis is a rare syndrome with a poor prognosis, characterized by an uncontrolled dysregulation of the immune system. The rarity of this disease makes it difficult to obtain large cohorts. In this study, we analyzed the data of 66 patients: the objective was to describe the epidemiological, clinical, biological and therapeutic characteristics and to compare our results with those already published. METHODS We conducted a retrospective study at the University Hospital of Montpellier from 2015 to 2021. Patients were included when the diagnosis of HLH was mentioned on the hospitalization report and when the HSCORE was higher than 50% (169). Prognostic analyses were performed by comparing the patients who died from HMH to those who didn't. RESULTS The mean age the 66 patients included was 49.2 years, 62% were men. The percentage of deaths was 45.9%. Lymphoma was the main etiology, followed by infections, then autoimmune/autoinflammatory diseases. Fever, splenomegaly, hepatomegaly and organ failure were the main clinical manifestations. Pancytopenia was present in 62% of cases. Ferritin, triglycerides, LDH and AST were highly increased. Advanced age, associated lymphoma, and the severity of cytopenias were linked to a poor prognosis. DISCUSSION The study of the clinico-biological, epidemiological and survival data of the patients in our cohort allowed us to confirm previously published data but also to discuss some of them.
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Affiliation(s)
- L Thiebaut
- Laboratoire d'hématologie, CHU de Montpellier, 80, avenue Augustin-Fliche, 34090 Montpellier, France.
| | - G Pasquier
- Laboratoire de parasitologie-mycologie, CHU de Montpellier, 39, avenue Charles-Flahault, 34295 Montpellier, France
| | - S Theret
- Pharmacie hospitalière, CHU de Montpellier, 80, avenue Augustin-Fliche, 34090 Montpellier, France
| | - J Russello
- Laboratoire d'hématologie, CHU de Montpellier, 80, avenue Augustin-Fliche, 34090 Montpellier, France
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13
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Janka GE. History of Hemophagocytic Lymphohistiocytosis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:9-19. [PMID: 39117804 DOI: 10.1007/978-3-031-59815-9_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a severe cytokine storm syndrome (CSS), which until the turn of the century, was barely known but is now receiving increased attention. The history of HLH dates back to 1939 when it was first described in adults, to be followed in 1952 by the first description of its primary, familial form in children. Secondary forms of HLH are far more frequent and occur with infections, malignancies, metabolic diseases, iatrogenic immune suppression, and autoinflammatory/autoimmune diseases. Identification of the genetic defects leading to the defective function of natural killer (NK) cells and cytotoxic T cells as well as the corresponding mouse models have revolutionized our understanding of HLH and of immune function. Diagnosis relies on clinical and laboratory criteria; functional and genetic tests can help separate primary from secondary forms. Treatment with immunochemotherapy and hematopoietic stem cell transplantation has considerably improved survival in children with primary HLH, a formerly uniformly fatal disease.
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Affiliation(s)
- Gritta E Janka
- University Medical Center Hamburg, Department of Pediatric Hematology and Oncology, Hamburg, Germany.
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14
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Schulert GS, Zhang K. Genetics of Acquired Cytokine Storm Syndromes : Secondary HLH Genetics. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:103-119. [PMID: 39117810 DOI: 10.1007/978-3-031-59815-9_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Secondary hemophagocytic lymphohistiocytosis (sHLH) has historically been defined as a cytokine storm syndrome (CSS) occurring in the setting of triggers leading to strong and dysregulated immunological activation, without known genetic predilection. However, recent studies have suggested that existing underlying genetic factors may synergize with particular diseases and/or environmental triggers (including infection, autoimmune/autoinflammatory disorder, certain biologic therapies, or malignant transformation), leading to sHLH. With the recent advances in genetic testing technology, more patients are examined for genetic variations in primary HLH (pHLH)-associated genes, including through whole exome and whole genome sequencing. This expanding genetic and genomic evidence has revealed HLH as a more complex phenomenon, resulting from specific immune challenges in patients with a susceptible genetic background. Rather than a simple, binary definition of pHLH and sHLH, HLH represents a spectrum of diseases, from a severe complication of common infections (EBV, influenza) to early onset familial diseases that can only be cured by transplantation.
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Affiliation(s)
- Grant S Schulert
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Kejian Zhang
- Sema4 and Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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15
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Samar MR, Shoaib D, e Zehra N, Moosajee M. Late-onset Familial Hemophagocytic Lymphohistiocytosis in a survivor of Hodgkin's Lymphoma. Leuk Res Rep 2023; 21:100394. [PMID: 38628817 PMCID: PMC11019264 DOI: 10.1016/j.lrr.2023.100394] [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: 08/02/2023] [Accepted: 10/20/2023] [Indexed: 04/19/2024] Open
Abstract
Hemophagocytic Lymphohistiocytosis is an inflammatory condition which results in over activation of the immune system. It could be either sporadic or familial. The familial subtype is linked with various genetic mutations and is commonly a disease of the young. Here we report a case of HLH in an adult, occurring in the background of a successfully treated hematological malignancy. Upon workup, he was also found to have pathogenic STXBP2 mutation, suggesting HLH of familial origin. To date, only few cases of adult-onset familial HLH have been brought to light.
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Affiliation(s)
- Mirza Rameez Samar
- Department of Oncology, The Aga Khan University Hospital, Karachi, Pakistan
| | - Daania Shoaib
- Department of Oncology, The Aga Khan University Hospital, Karachi, Pakistan
| | - Nida e Zehra
- Department of Oncology, The Aga Khan University Hospital, Karachi, Pakistan
| | - Munira Moosajee
- Department of Oncology, The Aga Khan University Hospital, Karachi, Pakistan
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16
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Xin X, Wang N, Zhang Y. Hemophagocytic lymphohistiocytosis with a hemizygous PRF1 c.674G>A mutation. Am J Med Sci 2023; 366:387-394. [PMID: 37467895 DOI: 10.1016/j.amjms.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/23/2023] [Accepted: 07/14/2023] [Indexed: 07/21/2023]
Abstract
Hemophagocytic lymphohistiocytosis(HLH) is a rare highly-fatal disease presenting with fever, hepatosplenomegaly, and pancytopenia and has a poor prognosis. Homozygous or semi-zygous or complex heterozygous variants can cause familial HLH and heterozygous carriers are frequently seen in secondary HLH. A 42-year-old male patient was admitted to the hospital for persistent fever, fatigue, and splenomegaly. Investigations revealed hypertriglyceridemia, hyperlactatemia dehydrogenaseemia, hyperferritinemia, and elevated levels of soluble cluster of differentiation 25. We found a heterozygous mutation of PRF1: c.674G>A (p.R225Q) through next-generation sequencing technology of hemophagocytic-lymphohistiocytosis-related genes. After a brief remission with dexamethasone and etoposide-based therapy, the disease relapsed quickly, and an allogeneic hematopoietic stem cell transplant was performed to achieve complete remission. To date, the patient's condition was in complete remission. Our study detected a rare missense mutation in the PRF1 gene in a patient with HLH disease and the c.674G>A mutation may be rated as a possible pathogenic variant.
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Affiliation(s)
- Xiangke Xin
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Na Wang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yicheng Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
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17
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Yu MZ, Wu L, Zhang J, Wang JS, Wang YN, Wang Z. [Clinical characteristics of primary hemophagocytic lymphohistiocytosis associated with perforin gene deficiency: a single-center retrospective study]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:572-577. [PMID: 37749038 PMCID: PMC10509624 DOI: 10.3760/cma.j.issn.0253-2727.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Indexed: 09/27/2023]
Abstract
Objective: This study aimed to investigate the clinical characteristics of patients diagnosed with primary hemophagocytic lymphohistiocytosis (pHLH) associated with perforin gene deficiency. Methods: We retrospectively analyzed the clinical data of 16 pHLH patients associated with perforin gene deficiency at Beijing Friendship Hospital, Capital Medical University, from April 2014 to August 2021. The mutation sites, mutation types, family history, clinical characteristics, and prognosis of the patients were assessed. Results: A total of 16 patients, including ten males and six females, with a median onset age of 17.5 years (range: 4-42 years), were enrolled in this study. Sixteen different mutations were identified, consisting of 11 missense mutations, one nonsense mutation, two frameshift mutations, and two in-frame mutations. All patients harbored at least one deleterious missense mutation, with the most common mutation sites being c.1349C>T (p.T450M) and c.503G>A (p.S168N). Decreased natural killer (NK) cell activity was observed in 11 patients, reduced perforin protein expression in ten patients, concurrent Epstein-Barr virus (EBV) infection at onset in eight patients, a family history in two patients, and central nervous system involvement in four patients. Eleven cases underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT), with eight cases surviving. The median survival time of non-transplanted patients was eight months (range: 4-18 months), while that of transplanted patients was reported as "not reached". Conclusions: Emphasizing the diagnosis of pHLH in adults with perforin gene deficiency. In addition, it should be noted that EBV infection can potentially act as a triggering factor in such disease, and allo-HSCT exerts a substantial effect on the prognosis of patients.
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Affiliation(s)
- M Z Yu
- Department of Hematology, Benjing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - L Wu
- Department of Hematology, Benjing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - J Zhang
- Department of Hematology, Benjing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - J S Wang
- Department of Hematology, Benjing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Y N Wang
- Department of Hematology, Benjing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Z Wang
- Department of Hematology, Benjing Friendship Hospital, Capital Medical University, Beijing 100050, China
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18
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Zeylabi F, Nameh Goshay Fard N, Parsi A, Pezeshki SMS. Bone marrow alterations in COVID-19 infection: The root of hematological problems. Curr Res Transl Med 2023; 71:103407. [PMID: 37544028 DOI: 10.1016/j.retram.2023.103407] [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: 05/30/2023] [Revised: 07/04/2023] [Accepted: 07/24/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION The 2019 coronavirus disease (COVID-19) is a respiratory infection caused by the SARS-CoV-2 virus with a significant impact on the hematopoietic system and homeostasis. The effect of the virus on blood cells indicates the involvement of the bone marrow (BM) as the place of production and maturation of these cells by the virus and it reminds the necessity of investigating the effect of the virus on the bone marrow. METHOD To investigate the effects of COVID-19 infection in BM, we reviewed literature from the Google Scholar search engine and PubMed database up to 2022 using the terms "COVID-19; SARS-CoV-2; Bone marrow; Thrombocytopenia; Hemophagocytosis; Pancytopenia and Thrombocytopenia. RESULTS Infection with the SARS-CoV-2 virus is accompanied by alterations such as single-line cytopenia, pancytopenia, hemophagocytosis, and BM necrosis. The presence of factors such as cytokine release syndrome, the direct effect of the virus on cells through different receptors, and the side effects of current treatments such as corticosteroids are some of the important mechanisms in the occurrence of these alterations. CONCLUSION To our knowledge, this review is the first study to comprehensively investigate BM alterations caused by SAR-CoV-2 virus infection. The available findings show that the significant impact of this viral infection on blood cells and the clinical consequences resulting from them are deeper than previously thought and it may be rooted in the changes that the virus causes in the BM of patients.
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Affiliation(s)
- Fatemeh Zeylabi
- Cellular and Molecular Research Center, Basic Health Sciences Institute, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Najmeh Nameh Goshay Fard
- Thalassemia & Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Abazar Parsi
- Alimentary Tract Research Center, Clinical Sciences Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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19
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Chinnici A, Beneforti L, Pegoraro F, Trambusti I, Tondo A, Favre C, Coniglio ML, Sieni E. Approaching hemophagocytic lymphohistiocytosis. Front Immunol 2023; 14:1210041. [PMID: 37426667 PMCID: PMC10324660 DOI: 10.3389/fimmu.2023.1210041] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/08/2023] [Indexed: 07/11/2023] Open
Abstract
Hemophagocytic Lymphohistiocytosis (HLH) is a rare clinical condition characterized by sustained but ineffective immune system activation, leading to severe and systemic hyperinflammation. It may occur as a genetic or sporadic condition, often triggered by an infection. The multifaceted pathogenesis results in a wide range of non-specific signs and symptoms, hampering early recognition. Despite a great improvement in terms of survival in the last decades, a considerable proportion of patients with HLH still die from progressive disease. Thus, prompt diagnosis and treatment are crucial for survival. Faced with the complexity and the heterogeneity of syndrome, expert consultation is recommended to correctly interpret clinical, functional and genetic findings and address therapeutic decisions. Cytofluorimetric and genetic analysis should be performed in reference laboratories. Genetic analysis is mandatory to confirm familial hemophagocytic lymphohistiocytosis (FHL) and Next Generation Sequencing is increasingly adopted to extend the spectrum of genetic predisposition to HLH, though its results should be critically discussed with specialists. In this review, we critically revise the reported laboratory tools for the diagnosis of HLH, in order to outline a comprehensive and widely available workup that allows to reduce the time between the clinical suspicion of HLH and its final diagnosis.
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Affiliation(s)
- Aurora Chinnici
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
- Department of Pediatric Hematology Oncology, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Linda Beneforti
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
- Department of Pediatric Hematology Oncology, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Francesco Pegoraro
- Department of Pediatric Hematology Oncology, Meyer Children’s Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Irene Trambusti
- Department of Pediatric Hematology Oncology, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Annalisa Tondo
- Department of Pediatric Hematology Oncology, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Claudio Favre
- Department of Pediatric Hematology Oncology, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Maria Luisa Coniglio
- Department of Pediatric Hematology Oncology, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Elena Sieni
- Department of Pediatric Hematology Oncology, Meyer Children’s Hospital IRCCS, Florence, Italy
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20
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Brauer N, Maruta Y, Lisci M, Strege K, Oschlies I, Nakamura H, Böhm S, Lehmberg K, Brandhoff L, Ehl S, Parvaneh N, Klapper W, Fukuda M, Griffiths GM, Hennies HC, Niehues T, Ammann S. Immunodeficiency with susceptibility to lymphoma with complex genotype affecting energy metabolism ( FBP1, ACAD9) and vesicle trafficking (RAB27A). Front Immunol 2023; 14:1151166. [PMID: 37388727 PMCID: PMC10303925 DOI: 10.3389/fimmu.2023.1151166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/16/2023] [Indexed: 07/01/2023] Open
Abstract
Introduction Inborn errors of immunity (IEI) are characterized by a dysfunction of the immune system leading to increased susceptibility to infections, impaired immune regulation and cancer. We present a unique consanguineous family with a history of Hodgkin lymphoma, impaired EBV control and a late onset hemophagocytic lymphohistiocytosis (HLH). Methods and results Overall, family members presented with variable impairment of NK cell and cytotoxic T cell degranulation and cytotoxicity. Exome sequencing identified homozygous variants in RAB27A, FBP1 (Fructose-1,6-bisphosphatase 1) and ACAD9 (Acyl-CoA dehydrogenase family member 9). Variants in RAB27A lead to Griscelli syndrome type 2, hypopigmentation and HLH predisposition. Discussion Lymphoma is frequently seen in patients with hypomorphic mutations of genes predisposing to HLH. We hypothesize that the variants in FBP1 and ACAD9 might aggravate the clinical and immune phenotype, influence serial killing and lytic granule polarization by CD8 T cells. Understanding of the interplay between the multiple variants identified by whole exome sequencing (WES) is essential for correct interpretation of the immune phenotype and important for critical treatment decisions.
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Affiliation(s)
- Nina Brauer
- Department of Pediatrics, Helios Klinikum, Krefeld, Germany
| | - Yuto Maruta
- Department of Integrative Life Sciences, Graduate School of Life Sciences, Tohoku University, Sendai, Japan
| | - Miriam Lisci
- Department of Medicine, Cambridge Institute for Medical Research, University of Cambridge, Cambridge, United Kingdom
- Department of Immunobiology, University of Lausanne, Epalinges, Switzerland
| | - Katharina Strege
- Department of Medicine, Cambridge Institute for Medical Research, University of Cambridge, Cambridge, United Kingdom
| | - Ilske Oschlies
- Department of Pathology, Haematopathology Section and Lymph Node Registry, University Hospitals Schleswig-Holstein, Christian-Albrecht University, Kiel, Germany
| | - Hikari Nakamura
- Department of Integrative Life Sciences, Graduate School of Life Sciences, Tohoku University, Sendai, Japan
| | - Svea Böhm
- Division of Pediatric Stem Cell Transplantation and Immunology, Clinic of Pediatric Hematology and Oncology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Kai Lehmberg
- Division of Pediatric Stem Cell Transplantation and Immunology, Clinic of Pediatric Hematology and Oncology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Leon Brandhoff
- Cologne Center for Genomics, University Hospital Cologne, Cologne, Germany
| | - Stephan Ehl
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nima Parvaneh
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran
| | - Wolfram Klapper
- Department of Pathology, Haematopathology Section and Lymph Node Registry, University Hospitals Schleswig-Holstein, Christian-Albrecht University, Kiel, Germany
| | - Mitsunori Fukuda
- Department of Integrative Life Sciences, Graduate School of Life Sciences, Tohoku University, Sendai, Japan
| | - Gillian M. Griffiths
- Department of Medicine, Cambridge Institute for Medical Research, University of Cambridge, Cambridge, United Kingdom
| | - Hans Christian Hennies
- Cologne Center for Genomics, University Hospital Cologne, Cologne, Germany
- Department of Biological and Geographical Sciences, University of Huddersfield, Huddersfield, United Kingdom
| | - Tim Niehues
- Department of Pediatrics, Helios Klinikum, Krefeld, Germany
| | - Sandra Ammann
- Department of Medicine, Cambridge Institute for Medical Research, University of Cambridge, Cambridge, United Kingdom
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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21
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Gray PE, David C. Inborn Errors of Immunity and Autoimmune Disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1602-1622. [PMID: 37119983 DOI: 10.1016/j.jaip.2023.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 04/01/2023] [Accepted: 04/21/2023] [Indexed: 05/01/2023]
Abstract
Autoimmunity may be a manifestation of inborn errors of immunity, specifically as part of the subgroup of primary immunodeficiency known as primary immune regulatory disorders. However, although making a single gene diagnosis can have important implications for prognosis and management, picking patients to screen can be difficult, against a background of a high prevalence of autoimmune disease in the population. This review compares the genetics of common polygenic and rare monogenic autoimmunity, and explores the molecular mechanisms, phenotypes, and inheritance of autoimmunity associated with primary immune regulatory disorders, highlighting the emerging importance of gain-of-function and non-germline somatic mutations. A novel framework for identifying rare monogenic cases of common diseases in children is presented, highlighting important clinical and immunologic features that favor single gene disease and guides clinicians in selecting appropriate patients for genomic screening. In addition, there will be a review of autoimmunity in non-genetically defined primary immunodeficiency such as common variable immunodeficiency, and of instances where primary autoimmunity can result in clinical phenocopies of inborn errors of immunity.
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Affiliation(s)
- Paul Edgar Gray
- Sydney Children's Hospital, Randwick, NSW, Australia; Western Sydney University, Penrith, NSW, Australia.
| | - Clementine David
- Sydney Children's Hospital, Randwick, NSW, Australia; The School of Women's & Children's Health, University of New South Wales, Randwick, NSW, Australia
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22
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Rocco JM, Laidlaw E, Galindo F, Anderson M, Rupert A, Higgins J, Sortino O, Ortega-Villa AM, Sheikh V, Roby G, Kuriakose S, Lisco A, Manion M, Sereti I. Severe Mycobacterial Immune Reconstitution Inflammatory Syndrome (IRIS) in Advanced Human Immunodeficiency Virus (HIV) Has Features of Hemophagocytic Lymphohistiocytosis and Requires Prolonged Immune Suppression. Clin Infect Dis 2023; 76:e561-e570. [PMID: 36048425 PMCID: PMC10169423 DOI: 10.1093/cid/ciac717] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/16/2022] [Accepted: 08/29/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND People with HIV and mycobacterial infections can develop immune reconstitution inflammatory syndrome (IRIS) after starting antiretroviral therapy (ART). Severe mycobacterial IRIS has an overlapping clinical phenotype with hemophagocytic lymphohistiocytosis (HLH). We evaluated the pathophysiologic similarities between mycobacterial IRIS and HLH to identify clinical and immune predictors of mycobacterial IRIS severity. METHODS HLH criteria were applied to a longitudinal cohort of 80 patients with HIV (CD4 <100 cells/µL) and mycobacterial infections. Participants were subdivided into IRIS meeting HLH criteria (HLH-IRIS), IRIS without HLH (IRIS), and those without IRIS (non-IRIS). Clinical outcomes were evaluated by regression analyses. Soluble biomarkers and T-cell subsets were assessed at baseline and IRIS-equivalent time points. RESULTS HLH-IRIS patients required corticosteroids more frequently (OR: 21.5; 95%CI: 5.6-114.8) and for longer duration (21.2; 95%CI: 10.7-31.7 weeks) than those not meeting HLH criteria. Utilizing decision tree analyses, hemoglobin <9.2 g/dL was the best predictor of HLH-IRIS before ART, whereas ferritin, CXCL9 and sCD25 were most diagnostic for HLH at IRIS onset. At the IRIS timepoint, but not baseline, HLH-IRIS patients had lower regulatory and higher activated T cells along with greater production of IFNγ-IL-18 axis biomarkers compared with both IRIS and non-IRIS groups. Principal component analysis corroborated the distinct clustering of HLH-IRIS patients. CONCLUSIONS Severe mycobacterial IRIS and HLH have an overlapping pathogenesis involving IFNγ and unopposed T-cell activation causing severe inflammatory disease clinically distinguished by hyperferritinemia (hyperferritinemic IRIS [FIRIS]). Hemoglobin, ferritin, CXCL9, and sCD25 identify high-risk patients and may improve risk stratification and therapeutic strategies for mycobacterial IRIS.
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Affiliation(s)
- Joseph M Rocco
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Elizabeth Laidlaw
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Frances Galindo
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Megan Anderson
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Adam Rupert
- Leidos Biomedical Research, Inc, Frederick, Maryland, USA
| | | | - Ornella Sortino
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Ana M Ortega-Villa
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Virginia Sheikh
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Gregg Roby
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Safia Kuriakose
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Andrea Lisco
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Maura Manion
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Irini Sereti
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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23
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Scarcella A, Marrani E, Coniglio ML, Simonini G, Sieni E. Kikuchi-Fujimoto disease complicated with hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer 2023; 70:e30222. [PMID: 36715142 DOI: 10.1002/pbc.30222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 01/31/2023]
Affiliation(s)
- Antonio Scarcella
- Pediatric Residency, IRCCS Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Edoardo Marrani
- Rheumatology Unit, ERN ReCONNET Center, IRCCS Meyer Children's University Hospital, Florence, Italy
| | - Maria Luisa Coniglio
- Department of Paediatric Oncohematology, IRCCS Meyer Children's University Hospital, Florence, Italy
| | - Gabriele Simonini
- Rheumatology Unit, ERN ReCONNET Center, IRCCS Meyer Children's University Hospital, NEUROFARBA Department, University of Florence, Florence, Italy
| | - Elena Sieni
- Department of Paediatric Oncohematology, IRCCS Meyer Children's University Hospital, Florence, Italy
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24
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Ręka G, Stefaniak M, Lejman M. Novel Molecular Therapies and Genetic Landscape in Selected Rare Diseases with Hematologic Manifestations: A Review of the Literature. Cells 2023; 12:cells12030449. [PMID: 36766791 PMCID: PMC9913931 DOI: 10.3390/cells12030449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/25/2023] [Accepted: 01/26/2023] [Indexed: 02/03/2023] Open
Abstract
Rare diseases affect less than 1 in 2000 people and are characterized by a serious, chronic, and progressive course. Among the described diseases, a mutation in a single gene caused mastocytosis, thrombotic thrombocytopenic purpura, Gaucher disease, and paroxysmal nocturnal hemoglobinuria (KIT, ADAMTS13, GBA1, and PIG-A genes, respectively). In Castleman disease, improper ETS1, PTPN6, TGFBR2, DNMT3A, and PDGFRB genes cause the appearance of symptoms. In histiocytosis, several mutation variants are described: BRAF, MAP2K1, MAP3K1, ARAF, ERBB3, NRAS, KRAS, PICK1, PIK3R2, and PIK3CA. Genes like HPLH1, PRF1, UNC13D, STX11, STXBP2, SH2D1A, BIRC4, ITK, CD27, MAGT1, LYST, AP3B1, and RAB27A are possible reasons for hemophagocytic lymphohistiocytosis. Among novel molecular medicines, tyrosine kinase inhibitors, mTOR inhibitors, BRAF inhibitors, interleukin 1 or 6 receptor antagonists, monoclonal antibodies, and JAK inhibitors are examples of drugs expanding therapeutic possibilities. An explanation of the molecular basis of rare diseases might lead to a better understanding of the pathogenesis and prognosis of the disease and may allow for the development of new molecularly targeted therapies.
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Affiliation(s)
- Gabriela Ręka
- Independent Laboratory of Genetic Diagnostics, Medical University of Lublin, A. Gębali 6, 20-093 Lublin, Poland
- Correspondence:
| | - Martyna Stefaniak
- Student Scientific Society of Independent Laboratory of Genetic Diagnostics, Medical University of Lublin, A. Gębali 6, 20-093 Lublin, Poland
| | - Monika Lejman
- Independent Laboratory of Genetic Diagnostics, Medical University of Lublin, A. Gębali 6, 20-093 Lublin, Poland
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25
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Tomomasa D, Hiejima E, Miyamoto T, Tanita K, Matsuoka M, Niizato D, Mitsuiki N, Isoda T, Yasumi T, van Zelm MC, Morio T, Kanegane H. Recurrent tandem duplication of UNC13D in familial hemophagocytic lymphohistiocytosis type 3. Clin Immunol 2022; 242:109104. [PMID: 36041693 DOI: 10.1016/j.clim.2022.109104] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 11/03/2022]
Abstract
Familial hemophagocytic lymphohistiocytosis type 3 is a fatal inborn error of immunity due to abnormal cytotoxic activity of T and NK cells and is caused by variants in UNC13D, which encodes Munc13-4. One published case was reported to carry a tandem duplication of UNC13D exons 7-12, and we here present another case with the exact same duplication breakpoints. The patient carried the tandem duplication from maternal origin, and a c.2346_2349 variant on the paternal allele. Single nucleotide polymorphism analysis around UNC13D revealed that the allele with tandem duplication was most likely a founder allele. Transposable element analysis showed that the breakpoints occurred within Alu elements in introns 12 and 6. Multiple sequence alignment revealed that Alu elements containing the truncated points are highly homologous. Sequence homology was thought to be a factor predisposing to the tandem duplication variant.
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Affiliation(s)
- Dan Tomomasa
- Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Eitaro Hiejima
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takayuki Miyamoto
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kay Tanita
- Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Masaki Matsuoka
- Department of Pediatrics, Toho University Omori Medical Center, Tokyo, Japan
| | - Daiki Niizato
- Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Noriko Mitsuiki
- Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Takeshi Isoda
- Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Takahiro Yasumi
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Menno C van Zelm
- Department of Immunology and Pathology, Central Clinical School, Monash University and Alfred Hospital, Melbourne, VIC, Australia
| | - Tomohiro Morio
- Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Hirokazu Kanegane
- Department of Child Health and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan.
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26
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Bi X, Zhang Q, Chen L, Liu D, Li Y, Zhao X, Zhang Y, Zhang L, Liu J, Wu C, Li Z, Zhao Y, Ma H, Huang G, Liu X, Wang QF, Zhang R. NBAS, a gene involved in cytotoxic degranulation, is recurrently mutated in pediatric hemophagocytic lymphohistiocytosis. J Hematol Oncol 2022; 15:101. [PMID: 35902954 PMCID: PMC9331571 DOI: 10.1186/s13045-022-01318-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/12/2022] [Indexed: 11/10/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH), particularly primary HLH (pHLH), is a rare, life-threatening disease. Germline genetic deficiency of 12 known HLH genes impairs cytotoxic degranulation in natural killer (NK) cells or cytotoxic T lymphocytes (CTLs) and contributes to pHLH development. However, no pathogenic mutations in these HLH genes are found in nearly 10% of HLH patients, despite a strong suspicion of pHLH, suggesting that the underlying genetic basis of HLH is still unclear. To discover novel susceptibility genes, we first selected 13 children with ppHLH (presumed primary HLH patients in the absence of detectable known HLH gene variants) and their parents for initial screening. Whole-genome sequencing (WGS) in one trio and whole-exome sequencing (WES) in twelve trios revealed that two ppHLH patients carried biallelic NBAS variants, a gene that is involved in Golgi-to-endoplasmic reticulum (ER) retrograde transport upstream of the degranulation pathway. Additionally, two candidate genes, RAB9B and KLC3, showed a direct relationship with known HLH genes in protein-protein interaction (PPI) network analysis. We analyzed NBAS, RAB9B, KLC3 and known HLH genes in an independent validation cohort of 224 pediatric HLH patients. Only biallelic NBAS variants were identified in three patients who harbored no pathogenic variants in any of the known HLH genes. Functionally, impaired NK-cell cytotoxicity and degranulation were revealed in both NBAS biallelic variant patients and in an NBAS-deficient NK-cell line. Knockdown of NBAS in an NK-cell line (IMC-1) using short hairpin RNA (shRNA) resulted in loss of lytic granule polarization and a decreased number of cytotoxic vesicles near the Golgi apparatus. According to our findings, NBAS is the second most frequently mutated gene (2.11%) in our HLH cohort after PRF1. NBAS deficiency may contribute to the development of HLH via a dysregulated lytic vesicle transport pathway.
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Affiliation(s)
- Xiaoman Bi
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, 100101, China.,China National Center for Bioinformation, Beijing, 100045, China.,University of Chinese Academy of Sciences, Beijing, 100049, China.,Key Laboratory of Tropical Translational Medicine of Ministry of Education, College of Biomedical Information and Engineering, Hainan Medical University, Haikou, 571199, China
| | - Qing Zhang
- Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Lei Chen
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, 100101, China.,China National Center for Bioinformation, Beijing, 100045, China.,University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Dan Liu
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, 100101, China.,China National Center for Bioinformation, Beijing, 100045, China
| | - Yueying Li
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, 100101, China.,China National Center for Bioinformation, Beijing, 100045, China
| | - Xiaoxi Zhao
- Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Ya Zhang
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, 100101, China.,China National Center for Bioinformation, Beijing, 100045, China.,University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Liping Zhang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Jingkun Liu
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, 100101, China.,China National Center for Bioinformation, Beijing, 100045, China.,University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Chaoyi Wu
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, 100101, China.,China National Center for Bioinformation, Beijing, 100045, China.,University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Zhigang Li
- Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Yunze Zhao
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Honghao Ma
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Gang Huang
- Divisions of Pathology and Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
| | - Xin Liu
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, 100101, China. .,China National Center for Bioinformation, Beijing, 100045, China. .,University of Chinese Academy of Sciences, Beijing, 100049, China.
| | - Qian-Fei Wang
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, 100101, China. .,China National Center for Bioinformation, Beijing, 100045, China. .,University of Chinese Academy of Sciences, Beijing, 100049, China.
| | - Rui Zhang
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.
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27
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Bolivar-Wagers S, Larson JH, Jin S, Blazar BR. Cytolytic CD4 + and CD8 + Regulatory T-Cells and Implications for Developing Immunotherapies to Combat Graft-Versus-Host Disease. Front Immunol 2022; 13:864748. [PMID: 35493508 PMCID: PMC9040077 DOI: 10.3389/fimmu.2022.864748] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/16/2022] [Indexed: 02/03/2023] Open
Abstract
Regulatory T-cells (Treg) are critical for the maintenance of immune homeostasis and tolerance induction. While the immunosuppressive mechanisms of Treg have been extensively investigated for decades, the mechanisms responsible for Treg cytotoxicity and their therapeutic potential in regulating immune responses have been incompletely explored and exploited. Conventional cytotoxic T effector cells (Teffs) are known to be important for adaptive immune responses, particularly in the settings of viral infections and cancer. CD4+ and CD8+ Treg subsets may also share similar cytotoxic properties with conventional Teffs. Cytotoxic effector Treg (cyTreg) are a heterogeneous population in the periphery that retain the capacity to suppress T-cell proliferation and activation, induce cellular apoptosis, and migrate to tissues to ensure immune homeostasis. The latter can occur through several cytolytic mechanisms, including the Granzyme/Perforin and Fas/FasL signaling pathways. This review focuses on the current knowledge and recent advances in our understanding of cyTreg and their potential application in the treatment of human disease, particularly Graft-versus-Host Disease (GVHD).
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Affiliation(s)
| | | | | | - Bruce R. Blazar
- Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN, United States
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Allogeneic hematopoietic stem cell transplantation for adult HLH: a retrospective study by the chronic malignancies and inborn errors working parties of EBMT. Bone Marrow Transplant 2022; 57:817-823. [PMID: 35332305 DOI: 10.1038/s41409-022-01634-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 01/20/2022] [Accepted: 03/02/2022] [Indexed: 12/14/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH; hemophagocytic syndrome) is a rare syndrome of potentially fatal, uncontrolled hyperinflammation. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is indicated in primary, recurrent or progressive HLH, but information about its outcomes in the adult population is limited. We obtained data about 87 adult (≥18 years of age) patients retrospectively reported to the EBMT. The median survival time was 13.9 months. The three and five-year overall survival (OS) was 44% (95% CI 33-54%). Among 39 patients with a follow-up longer than 15 months, only three died. Relapse rate was 21% (95% CI 13-30%), while NRM reached 36% (95% CI 25-46%). Younger patients (<30 years of age) had better prognosis, with an OS of 59% (95% CI 45-73%) at three and five years vs 23% (95% CI 8-37%) for older ones. No difference in survival between reduced and myeloablative conditioning was found. To our knowledge, this is the largest report of adult HLH patients who underwent allo-HSCT. Patients who survive the first period after this procedure can expect a long disease-free survival. Both reduced intensity and myeloablative conditioning have therapeutic potential in adult HLH.
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Cooray S, Sabanathan S, Hacohen Y, Worth A, Eleftheriou D, Hemingway C. Treatment Strategies for Central Nervous System Effects in Primary and Secondary Haemophagocytic Lymphohistiocytosis in Children. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00705-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Purpose of Review
This review presents an appraisal of current therapeutic options for the treatment of central nervous system haemophagocytic lymphohistiocytosis (CNS-HLH) in the context of systemic disease, as well as when CNS features occur in isolation. We present the reader with a diagnostic approach to CNS-HLH and commonly used treatment protocols. We discuss and evaluate newer treatments on the horizon.
Recent Findings
Mortality is high in patients who do not undergo HSCT, and while larger studies are required to establish benefit in many treatments, a number of new treatments are currently being evaluated. Alemtuzumab is being used as a first-line treatment for CNS-HLH in a phase I/II multicentre prospective clinical trial as an alternative to traditional HLH-1994 and 2004 protocols. It has also been used successfully as a second-line agent for the treatment of isolated CNS-HLH that is refractory to standard treatment. Ruxolitinib and emapalumab are new immunotherapies that block the Janus kinase—Signal Transducer and Activator of Transcription (JAK-STAT) pathway that have shown efficacy in refractory HLH, including for CNS-HLH disease.
Summary
Treatment of CNS-HLH often requires HLH-94 or 2004 protocols followed by haematopoietic stem cell transplantation (HSCT) to maintain remission, although relapse can occur, particularly with reduced intensity conditioning if donor chimerism falls. CNS features have been shown to improve or stabilise following HSCT in CNS-HLH in the context of systemic disease and in isolated CNS-HLH. Encouraging reports of early cohort studies suggest alemtuzumab and the Janus kinase (JAK) inhibitor ruxolitinib offer potential salvage therapy for relapsed and refractory CNS-HLH. Newer immunotherapies such as tocilizumab and natalizumab have been shown to be beneficial in sporadic cases. CNS-HLH due to primary gene defects may be amenable to gene therapy in the future.
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Wilson C, Lee WI, Cook MC, Smyth L, Talaulikar D. Correlation of haemophagocytosis with clinical criteria of haemophagocytic lymphohistiocytosis and recommendations for bone marrow reporting. Pathology 2021; 54:434-441. [PMID: 34711415 DOI: 10.1016/j.pathol.2021.07.015] [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: 02/08/2021] [Revised: 07/18/2021] [Accepted: 07/28/2021] [Indexed: 10/20/2022]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a rare condition resulting from a dysregulated inflammatory response. Currently there are no guidelines on the reporting of haemophagocytosis on bone marrow biopsy (BM) and lack of evidence on correlation between haemophagocytosis with the clinical diagnostic criteria for HLH. We aimed to assess if the amount of haemophagocytosis identified in the BM correlates with HLH-2004 criteria. Secondary aims were to evaluate inter-observer variability in reporting haemophagocytosis, and to formulate recommendations for screening in bone marrow specimens. A retrospective review of bone marrow biopsies from adult patients under investigation for HLH was undertaken independently by two haematopathologists who were blinded to the original biopsy report. The average number of actively haemophagocytic cells in each slide were quantified. Cases with discordance pertaining to the degree of haemophagocytosis were reviewed by both assessors to reach a consensus. Sixty-two specimens from 59 patients were available for assessment. An underlying haematological condition was identified in 34 cases (58%). There was a significant association between the amount of haemophagocytosis identified on the aspirate samples and the number of HLH-2004 criteria met (p<0.0001). In patients where haemophagocytosis was present (n=31), there was a correlation between the amount of haemophagocytosis and ferritin (p=0.041). Based on our review, we have made recommendations for the reporting of BM haemophagocytosis. Our findings indicate that the amount of haemophagocytosis present on BM samples correlates with the number of HLH-2004 criteria. We found marked interobserver variability which we anticipate can be rectified with our recommendations for reporting.
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Affiliation(s)
- C Wilson
- Haematology Department, Canberra Hospital, Garran, ACT, Australia
| | - W I Lee
- Immunology Department, Canberra Hospital, Garran, ACT, Australia
| | - M C Cook
- Immunology Department, Canberra Hospital, Garran, ACT, Australia; Australian National University Medical School, Acton, ACT, Australia
| | - L Smyth
- Australian National University Medical School, Acton, ACT, Australia
| | - D Talaulikar
- Haematology Department, Canberra Hospital, Garran, ACT, Australia; Australian National University Medical School, Acton, ACT, Australia.
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31
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Bąbol-Pokora K, Wołowiec M, Popko K, Jaworowska A, Bryceson YT, Tesi B, Henter JI, Młynarski W, Badowska W, Balwierz W, Drabko K, Kałwak K, Maciejka-Kembłowska L, Pieczonka A, Sobol-Milejska G, Kołtan S, Malinowska I. Molecular Genetics Diversity of Primary Hemophagocytic Lymphohistiocytosis among Polish Pediatric Patients. Arch Immunol Ther Exp (Warsz) 2021; 69:31. [PMID: 34677667 PMCID: PMC8536594 DOI: 10.1007/s00005-021-00635-4] [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: 04/16/2021] [Accepted: 09/10/2021] [Indexed: 06/12/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a clinical syndrome of life-threatening inflammation caused by an excessive, prolonged and ineffective immune response. An increasing number of HLH cases is recognized in Poland, but the genetic causes of familial HLH (FHL) have not been reported. We investigated the molecular genetics and associated outcomes of pediatric patients who met HLH criteria. We studied 54 patients with HLH, 36 of whom received genetic studies. Twenty-five patients were subjected to direct sequencing of the PRF1, UNC13D, STX11, XIAP and SH2D1A genes. Additionally, 11 patients were subjected to targeted next-generation sequencing. In our study group, 17 patients (31%) were diagnosed with primary HLH, with bi-allelic FHL variants identified in 13 (36%) patients whereas hemizygous changes were identified in 4 patients with X-linked lymphoproliferative diseases. In addition, one patient was diagnosed with X-linked immunodeficiency with magnesium defect, Epstein–Barr virus infection and neoplasia due to a hemizygous MAGT1 variant; another newborn was diagnosed with auto-inflammatory syndrome caused by MVK variants. The majority (65%) of FHL patients carried UNC13D pathogenic variants, whereas PRF1 variants occurred in two patients. Novel variants in UNC13D, PRF1 and XIAP were detected. Epstein–Barr virus was the most common trigger noted in 23 (65%) of the patients with secondary HLH. In three patients with secondary HLH, heterozygous variants of FHL genes were found. Overall survival for the entire study group was 74% with a median of 3.6 years of follow-up. Our results highlight the diversity of molecular causes of primary HLH in Poland.
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Affiliation(s)
- Katarzyna Bąbol-Pokora
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, Lodz, Poland
| | - Magdalena Wołowiec
- Department of Pediatrics, Hematology and Oncology, Medical University of Warsaw, Żwirki i Wigury 63A, 02-091, Warsaw, Poland
| | - Katarzyna Popko
- Department of Laboratory Diagnostics and Clinical Immunology of Developmental Age, Medical University of Warsaw, Warsaw, Poland
| | - Aleksandra Jaworowska
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, Lodz, Poland
| | - Yenan T Bryceson
- Department of Medicine, Centre for Hematology and Regenerative Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Bianca Tesi
- Department of Medicine, Centre for Hematology and Regenerative Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Jan-Inge Henter
- Department of Medicine, Centre for Hematology and Regenerative Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Wojciech Młynarski
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, Lodz, Poland
| | - Wanda Badowska
- Division of Pediatric Hematology and Oncology, Children Hospital, Olsztyn, Poland
| | - Walentyna Balwierz
- Department of Pediatrics Oncology and Hematology, University Children's Hospital, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - Katarzyna Drabko
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, Medical University of Lublin, Lublin, Poland
| | - Krzysztof Kałwak
- Department of Pediatric Stem Cell Transplantation, Hematology and Oncology, Medical University, Wroclaw, Poland
| | | | - Anna Pieczonka
- Department of Pediatric Oncology, Hematology and Transplantology, University of Medical Sciences, Poznan, Poland
| | - Grażyna Sobol-Milejska
- Department of Pediatrics, Hematology and Oncology, Medical University of Silesia, Silesia, Poland
| | - Sylwia Kołtan
- Department of Pediatrics, Hematology and Oncology, Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz, Bydgoszcz, Poland
| | - Iwona Malinowska
- Department of Pediatrics, Hematology and Oncology, Medical University of Warsaw, Żwirki i Wigury 63A, 02-091, Warsaw, Poland.
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Viñas-Giménez L, Rincón R, Colobran R, de la Cruz X, Celis VP, Dapena JL, Alsina L, Sayós J, Martínez-Gallo M. Case Report: Characterizing the Role of the STXBP2-R190C Monoallelic Mutation Found in a Patient With Hemophagocytic Syndrome and Langerhans Cell Histiocytosis. Front Immunol 2021; 12:723836. [PMID: 34630398 PMCID: PMC8496341 DOI: 10.3389/fimmu.2021.723836] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/02/2021] [Indexed: 11/29/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory disorder. HLH can be considered as a threshold disease depending on the trigger and the residual NK-cell cytotoxicity. In this study, we analyzed the molecular and functional impact of a novel monoallelic mutation found in a patient with two episodes of HLH. A 9-month-old child was diagnosed at 2 months of age with cutaneous Langerhans cell histiocytosis (LCH). After successful treatment, the patient developed an HLH episode. At 16 month of age, the patient went through an HSCT losing the engraftment 5 months later concomitant with an HLH relapse. The genetic study revealed a monoallelic mutation in the STXBP2 gene (.pArg190Cys). We transfected COS7 cells to analyze the STXBP2-R190C expression and to test the interaction with STX11. We used the RBL-2H3 cell line expressing STXBP2-WT-EGFP or R190C-EGFP for degranulation assays. Mutation STXBP2-R190C did not affect protein expression or interaction with syntaxin-11. However, we have demonstrated that STXBP2-R190C mutation diminishes degranulation in the RBL-2H3 cell line compared with the RBL-2H3 cell line transfected with STXBP2-WT or nontransfected. These results suggest that STXBP2-R190C mutation acts as a modifier of the degranulation process producing a decrease in degranulation. Therefore, under homeostatic conditions, the presence of one copy of STXBP2-R190 could generate sufficient degranulation capacity. However, it is likely that early in life when adaptive immune system functions are not sufficiently developed, an infection may not be resolved with this genetic background, leading to a hyperinflammation syndrome and eventually develop HLH. This analysis highlights the need for functional testing of new mutations to validate their role in genetic susceptibility and to establish the best possible treatment for these patients.
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Affiliation(s)
- Laura Viñas-Giménez
- Immunology Division, Hospital Universitari Vall d'Hebron (HUVH), Jeffrey Model Foundation Excellence Center, Barcelona, Spain.,Diagnostic Immunology Research Group Vall d'Hebron Research Institute (VHIR), Barcelona, Spain.,Department of Cell Biology, Physiology and Immunology, Autonomous University of Barcelona (UAB), Barcelona, Spain
| | - Rafael Rincón
- Immunology Division, Hospital Universitari Vall d'Hebron (HUVH), Jeffrey Model Foundation Excellence Center, Barcelona, Spain
| | - Roger Colobran
- Immunology Division, Hospital Universitari Vall d'Hebron (HUVH), Jeffrey Model Foundation Excellence Center, Barcelona, Spain.,Diagnostic Immunology Research Group Vall d'Hebron Research Institute (VHIR), Barcelona, Spain.,Department of Cell Biology, Physiology and Immunology, Autonomous University of Barcelona (UAB), Barcelona, Spain.,Genetics Department, Hospital UniversitariVall d'Hebron (HUVH), Barcelona, Spain
| | - Xavier de la Cruz
- Research Unit in Translational Bioinformatics in Neurosciences, Universitat Autònoma de Barcelona, Barcelona, Spain.,Institut Catala per la Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Verónica Paola Celis
- Hematology Department, Pediatric Cancer Center, Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain
| | - José Luis Dapena
- Hematology Department, Pediatric Cancer Center, Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain
| | - Laia Alsina
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, University of Barcelona, Pediatric Research Institute Sant Joan de Déu, Barcelona, Spain
| | - Joan Sayós
- Immune Regulation and Immunotherapy Group, CIBBIM-Nano medicine, Vall d'Hebron Institut de Recerca, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Mónica Martínez-Gallo
- Immunology Division, Hospital Universitari Vall d'Hebron (HUVH), Jeffrey Model Foundation Excellence Center, Barcelona, Spain.,Diagnostic Immunology Research Group Vall d'Hebron Research Institute (VHIR), Barcelona, Spain.,Department of Cell Biology, Physiology and Immunology, Autonomous University of Barcelona (UAB), Barcelona, Spain
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33
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Tariq H, Pearse W, Moravek MR, Gao J, Chen YH, Chen QC. Refractory hemophagocytic lymphohistiocytosis in an adult patient with occult ALK-Positive anaplastic large cell lymphoma and a heterozygous MEFV mutation. Leuk Lymphoma 2021; 63:495-498. [PMID: 34612144 DOI: 10.1080/10428194.2021.1984458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Hamza Tariq
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - William Pearse
- Robert H Lurie Comprehensive Cancer Center, Chicago, IL, USA
| | - Michael Robert Moravek
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Juehua Gao
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Yi-Hua Chen
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Qing Ching Chen
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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34
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Xinh PT, Chuong HQ, Diem TPH, Nguyen TM, Van ND, Mai Anh NH, Nghia H, Vu HA. Spectrum mutations of PRF1, UNC13D, STX11, and STXBP2 genes in Vietnamese patients with hemophagocytic lymphohistiocytosis. Int J Lab Hematol 2021; 43:1524-1530. [PMID: 34339548 DOI: 10.1111/ijlh.13674] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/24/2021] [Accepted: 07/24/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The prevalence of gene mutations in hemophagocytic lymphohistiocytosis (HLH) varied between studies. Thus far, data on the genetic background of HLH in Vietnamese patients are limited. METHODS We recruited 94 HLH patients and analyzed for the 4 genes using Sanger sequencing technology. RESULTS Pathogenic variants were observed in 36 (38.29%) patients, including 27 in UNC13D, 5 in STXBP2, 3 in PRF1, and 2 in STX11 (one patient with digenic variants in both UNC13D and STX11). Monoallelic variants accounted for 77.8% of all cases with mutation. A total of 23 different types of pathogenic variants were documented in the 4 genes tested, including 15 in UNC13D, 3 in PRF1, 3 in STXBP2, and 2 in STX11. Interestingly, the novel splicing variant c.3151G>A in UNC13D was recurrently identified in 8 unrelated patients. CONCLUSION Vietnamese patients with HLH showed a distinct genetic variant spectrum, in which UNC13D is the predominant genetic lesion associated with HLH.
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Affiliation(s)
- Phan Thi Xinh
- Department of Hematology, Faculty of Medicine, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam.,Ho Chi Minh City Blood Transfusion and Hematology Hospital, Ho Chi Minh City, Vietnam
| | - Ho Quoc Chuong
- Center for Molecular Biomedicine, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam.,Faculty of Biology, Biotechnology, University of Science, Vietnam National University, Ho Chi Minh City, Vietnam
| | | | - Tuan Minh Nguyen
- Children's Hospital 1, Department of Hematology, Ho Chi Minh City, Vietnam
| | - Nguyen Dinh Van
- Department of Oncology and Hematology, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | | | - Huynh Nghia
- Department of Hematology, Faculty of Medicine, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam.,Ho Chi Minh City Blood Transfusion and Hematology Hospital, Ho Chi Minh City, Vietnam
| | - Hoang Anh Vu
- Center for Molecular Biomedicine, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
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Luo H, Liu D, Liu W, Wang G, Chen L, Cao Y, Wei J, Xiao M, Liu X, Huang G, Wang W, Zhou J, Wang QF. Germline variants in UNC13D and AP3B1 are enriched in COVID-19 patients experiencing severe cytokine storms. Eur J Hum Genet 2021; 29:1312-1315. [PMID: 33867526 PMCID: PMC8053565 DOI: 10.1038/s41431-021-00886-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 03/16/2021] [Accepted: 04/01/2021] [Indexed: 01/03/2023] Open
Abstract
Critically ill coronavirus disease 2019 (COVID-19) is characterized by severe cytokine storms, a hyperinflammatory condition intimately related to the development of fatal outcomes. Why some individuals seem particularly vulnerable to severe cytokine storms is still unknown. Primary immunodeficiency (PID)-related genes are inherited factors that dysregulate host inflammatory responses to infection, especially hemophagocytic lymphohistiocytosis (HLH)-related genes, established as contributors to the development of excessive cytokine storms. We analyzed the association between PID gene variants with severe cytokine storms in COVID-19. We conducted whole-exome sequencing in 233 hospitalized COVID-19 patients and identified four PID gene (UNC13D, AP3B1, RNF168, DHX58) variants were significantly enriched in COVID-19 patients experiencing severe cytokine storms. The total percentage of COVID-19 patients with variants in UNC13D or AP3B1, two typical HLH genes, was dramatically higher in high-level cytokine group than in low-level group (33.3 vs. 5.7%, P < 0.001). Germline variants in UNC13D and AP3B1 were associated with the development of severe cytokine storms, fatal outcomes in COVID-19. These findings advance the understanding of individual susceptibility to severe cytokine storms and help optimize the current management of COVID-19.
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Affiliation(s)
- Hui Luo
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Dan Liu
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, China
- China National Center for Bioinformation, Beijing, China
| | - Wenbing Liu
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, China
- China National Center for Bioinformation, Beijing, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Gaoxiang Wang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Liting Chen
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yang Cao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jia Wei
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Min Xiao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xin Liu
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, China
- China National Center for Bioinformation, Beijing, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Gang Huang
- Divisions of Pathology and Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Wei Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
| | - Jianfeng Zhou
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
| | - Qian-Fei Wang
- CAS Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, China.
- China National Center for Bioinformation, Beijing, China.
- University of Chinese Academy of Sciences, Beijing, China.
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Elalfy MS, Ragab IA, AbdelAal NM, Mahfouz S, Rezk AR. Study of the diagnostic criteria for hemophagocytic lymphohistiocytosis in neonatal and pediatric patients with severe sepsis or septic shock. Pediatr Hematol Oncol 2021; 38:486-496. [PMID: 33622175 DOI: 10.1080/08880018.2021.1887983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Septic shock is a major public health concern. However, the clinical and laboratory criteria for sepsis overlap with those for hemophagocytic lymphohistiocytosis (HLH), and their differentiation can be challenging. The aim of this study was to compare HLH criteria among patients diagnosed with neonatal sepsis and childhood sepsis and to study the outcomes in patients fulfilling the diagnostic criteria for HLH. A cross-sectional study included 50 neonates and children with severe sepsis and/or septic shock. Clinical and laboratory data and HLH diagnostic criteria were studied in relation to patients outcome. Of all patients, 18% fulfilled three of the eight HLH diagnostic criteria, 2% fulfilled four criteria, and 4% fulfilled five criteria. All patients who fulfilled three or more of the criteria died. Mortality was higher in the presence of more positive HLH criteria and in pediatric age groups. However, the distributions of the HLH criteria were comparable for pediatric and neonatal patients with severe sepsis/septic shock, and their mortality rates were not significantly different when based on the criteria.
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Affiliation(s)
- Mohsen S Elalfy
- Department of Pediatrics, Department of Hematology-Oncology, Neonatal Intensive Care Unit and Pediatric Intensive Care Unit, Ain Shams University, Cairo, Egypt
| | - Iman A Ragab
- Department of Pediatrics, Department of Hematology-Oncology, Neonatal Intensive Care Unit and Pediatric Intensive Care Unit, Ain Shams University, Cairo, Egypt
| | - NourEldin M AbdelAal
- Department of Pediatrics, Department of Hematology-Oncology, Neonatal Intensive Care Unit and Pediatric Intensive Care Unit, Ain Shams University, Cairo, Egypt
| | - Sara Mahfouz
- Department of Pediatrics, Department of Hematology-Oncology, Neonatal Intensive Care Unit and Pediatric Intensive Care Unit, Ain Shams University, Cairo, Egypt
| | - Ahmed R Rezk
- Department of Pediatrics, Department of Hematology-Oncology, Neonatal Intensive Care Unit and Pediatric Intensive Care Unit, Ain Shams University, Cairo, Egypt
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Ahmari AA, Alsmadi O, Sheereen A, Elamin T, Jabr A, El-Baik L, Alhissi S, Saud BA, Al-Awwami M, Fawaz IA, Ayas M, Siddiqui K, Hawwari A. Genetic and clinical characteristics of pediatric patients with familial hemophagocytic lymphohistiocytosis. Blood Res 2021; 56:86-101. [PMID: 34083498 PMCID: PMC8246041 DOI: 10.5045/br.2021.2020308] [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: 12/03/2020] [Revised: 05/02/2021] [Accepted: 05/18/2021] [Indexed: 12/15/2022] Open
Abstract
Background Our study was designed to investigate the frequencies and distributions of familial hemophagocytic lymphohistiocytosis (FHL) associated genes in Saudi patients. Methods FHL associated gene screening was performed on 87 Saudi patients who were diagnosed with hemophagocytic lymphohistiocytosis (HLH) between 1995 and 2014. The clinical and biochemical profiles were also retrospectively captured and analyzed. Results Homozygous mutations and mono-allelic variants were identified in 66 (75.9%) and 3 (3.5%) of the study participants, respectively. STXBP2 was the most frequently mutated gene (36% of patients) and mutations in STXBP2 and STX11 accounted for 58% of all FHL cases and demonstrated a specific geographical pattern. Patients in the FHL group presented at a significantly younger age than those belonging to the unknown-genetics group (median, 3.9 vs. 9.4 mo; P=0.005). The presenting clinical features were similar among the various genetic groups and the 5-year overall survival (OS) was 55.4% with a 5.6 year median follow-up. Patients with PRF1 mutations had a significantly poorer 5-year OS (21.4%, P=0.008) and patients undergoing hematopoietic stem cell transplant (72.4%) had a significantly better 5-year OS (66.5% vs. 0%, P=0.001). Conclusion Our study revealed the predominance of the STXBP2 mutations in Saudi patients with FHL. A genetic diagnosis was possible in 80% of the cohort and our data showed improved survival in FHL patients who underwent hematopoietic stem cell transplant.
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Affiliation(s)
- Ali Al Ahmari
- Department of Pediatric Hematology/Oncology, King Faisal Specialist Hospital and Research Center, Saudi Arabia.,College of Medicine, AlFaisal University, Riyadh, Saudi Arabia
| | - Osama Alsmadi
- Section of Immunogenetics, Department of Genetics, Research Center, King Faisal Specialist Hospital and Research Center, Saudi Arabia.,Cell Therapy, Applied Genomics, King Hussein Cancer Center, Amman, Jordan
| | - Atia Sheereen
- Section of Immunogenetics, Department of Genetics, Research Center, King Faisal Specialist Hospital and Research Center, Saudi Arabia
| | - Tanziel Elamin
- Section of Immunogenetics, Department of Genetics, Research Center, King Faisal Specialist Hospital and Research Center, Saudi Arabia
| | - Amal Jabr
- Section of Immunogenetics, Department of Genetics, Research Center, King Faisal Specialist Hospital and Research Center, Saudi Arabia
| | - Lina El-Baik
- Section of Immunogenetics, Department of Genetics, Research Center, King Faisal Specialist Hospital and Research Center, Saudi Arabia
| | - Safa Alhissi
- Section of Immunogenetics, Department of Genetics, Research Center, King Faisal Specialist Hospital and Research Center, Saudi Arabia
| | - Bandar Al Saud
- Department of Pediatric Allergy/Immunology, King Faisal Specialist Hospital and Research Center, Saudi Arabia
| | - Moheeb Al-Awwami
- Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center, Saudi Arabia
| | - Ibrahim Al Fawaz
- Department of Pediatric Hematology/Oncology, King Faisal Specialist Hospital and Research Center, Saudi Arabia.,College of Medicine, AlFaisal University, Riyadh, Saudi Arabia
| | - Mouhab Ayas
- Department of Pediatric Hematology/Oncology, King Faisal Specialist Hospital and Research Center, Saudi Arabia.,College of Medicine, AlFaisal University, Riyadh, Saudi Arabia
| | - Khawar Siddiqui
- Department of Pediatric Hematology/Oncology, King Faisal Specialist Hospital and Research Center, Saudi Arabia
| | - Abbas Hawwari
- Section of Immunogenetics, Department of Genetics, Research Center, King Faisal Specialist Hospital and Research Center, Saudi Arabia.,King Abdullah International Medical Research Center (KAIMRC), King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City Hospital, Al-Ahsa, Saudi Arabia
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Gao L, Yang L, Huang L, Xiao Y, Deng J, Zheng M, Luo H, Jiang L, Xiao M, Li C, Zhou J. Clinical and genetic features of Epstein-Barr virus-triggered late-onset primary hemophagocytic lymphohistiocytosis: Ten pedigrees study. Clin Transl Med 2021; 11:e393. [PMID: 34185399 PMCID: PMC8161514 DOI: 10.1002/ctm2.393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 04/03/2021] [Accepted: 04/07/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Lili Gao
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Li Yang
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Liang Huang
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Yi Xiao
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Jinniu Deng
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Miao Zheng
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Hui Luo
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Lijun Jiang
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Min Xiao
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Chunrui Li
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Jianfeng Zhou
- Department of HematologyTongji Hospital of Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiChina
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Stem cell transplantation for children with hemophagocytic lymphohistiocytosis: results from the HLH-2004 study. Blood Adv 2021; 4:3754-3766. [PMID: 32780845 DOI: 10.1182/bloodadvances.2020002101] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/14/2020] [Indexed: 12/14/2022] Open
Abstract
We report the largest prospective study thus far on hematopoietic stem cell transplantation (HSCT) in hemophagocytic lymphohistiocytosis (HLH), a life-threatening hyperinflammatory syndrome comprising familial/genetic HLH (FHL) and secondary HLH. Although all patients with HLH typically need intensive anti-inflammatory therapy, patients with FHL also need HSCT to be cured. In the international HLH-2004 study, 187 children aged <18 years fulfilling the study inclusion criteria (5 of 8 diagnostic criteria, affected sibling, or molecular diagnosis in FHL-causative genes) underwent 209 transplants (2004-2012), defined as indicated in patients with familial/genetic, relapsing, or severe/persistent disease. Five-year overall survival (OS) post-HSCT was 66% (95% confidence interval [CI], 59-72); event-free survival (EFS) was 60% (95% CI, 52-67). Five-year OS was 81% (95% CI, 65-90) for children with a complete response and 59% (95% CI, 48-69) for those with a partial response (hazard ratio [HR], 2.12; 95% CI, 1.06-4.27; P = .035). For children with verified FHL (family history/genetically verified, n = 134), 5-year OS was 71% (95% CI, 62-78) and EFS was 62% (95% CI, 54-70); 5-year OS for children without verified FHL (n = 53) was significantly lower (52%; 95% CI, 38-65) (P = .040; HR, 1.69; 95% CI, 1.03-2.77); they were also significantly older. Notably, 20 (38%) of 53 patients without verified FHL had natural killer cell activity reported as normal at diagnosis, after 2 months, or at HSCT, suggestive of secondary HLH; and in addition 14 (26%) of these 53 children had no evidence of biallelic mutations despite having 3 or 4 FHL genes analyzed (natural killer cell activity not analyzed after 2 months or at HSCT). We conclude that post-HSCT survival in FHL remains suboptimal, and that the FHL diagnosis should be carefully investigated before HSCT. Pretransplant complete remission is beneficial but not mandatory to achieve post-HSCT survival. This trial was registered at www.clinicaltrials.gov as #NCT00426101.
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40
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Identification of germline variants in adults with hemophagocytic lymphohistiocytosis. Blood Adv 2021; 4:925-929. [PMID: 32150605 DOI: 10.1182/bloodadvances.2019001272] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 01/29/2020] [Indexed: 12/13/2022] Open
Abstract
Key Points
Some germline variants are predicted to disrupt protein function in HLH-associated genes. Such variants are neither enriched in adult-onset HLH nor associated with specific clinical or laboratory features of HLH.
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Yildiz H, Bailly S, Van Den Neste E, Yombi JC. Clinical Management of Relapsed/Refractory Hemophagocytic Lymphohistiocytosis in Adult Patients: A Review of Current Strategies and Emerging Therapies. Ther Clin Risk Manag 2021; 17:293-304. [PMID: 33888986 PMCID: PMC8056168 DOI: 10.2147/tcrm.s195538] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/25/2021] [Indexed: 01/12/2023] Open
Abstract
Introduction Haemophagocytic lymphohistiocytosis (HLH) is a severe disorder with high mortality. The aim of this review is to update clinical management of relapsed/refractory HLH in adults, with a focus on current and new therapies. Methods We searched relevant articles in Embase and PUBMED with the MESH term “hemophagocytic lymphohistiocytosis; refractory; relapsing; adult.” Results One hundred eight papers were found; of these, 22 were retained for this review. The treatment of HLH in adult is based on the HLH-94 regimen. The response rate is lower than in pediatric patients, and 20–30% are refractory to this therapy. DEP regimen and allogenic hematopoietic stem cell transplantation (HSCT) are associated with complete response and partial response in 27% and 49.2%, respectively. However, many patients fail to achieve a stable condition before HSCT, and mortality is higher in them. New drugs have been developed, such as emapalumab, ruxolitinib, and alemtuzumab, and they may be used as bridges to the curative HSCT. They are relatively well tolerated and have few or mild side effects. With these agents, the rate of partial response ranges from 14.2% to 100%, while the rate of complete response is highly variable according to study and medication used. The number of patients who achieved HSCT ranged from 44.8% to 77%, with a survival rate of 55.9% to 100%. However, the populations in these studies are mainly composed of mixed-age patients (pediatric and adult patients), and studies including only adult patients are scarce. Conclusion Relapsed or refractory HLH in adult patients is associated with poor outcome, and consolidation with HSCT may be required in some cases. Mortality related to HSCT is mainly due to active HLH disease before HSCT and post HSCT complications. New drugs, such as empalumab, ruxolitinib, and alemtuzumab are interesting since these agents may be used as bridges to HSCT with increases in the numbers of patients proceeding to HSCT and survival rate.
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Affiliation(s)
- Halil Yildiz
- Departement of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint Luc, Bruxelles, Belgique
| | - Sarah Bailly
- Departement of Hematology, Cliniques Universitaires Saint Luc, Bruxelles, Belgique
| | - Eric Van Den Neste
- Departement of Hematology, Cliniques Universitaires Saint Luc, Bruxelles, Belgique
| | - Jean Cyr Yombi
- Departement of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint Luc, Bruxelles, Belgique
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Liu XY, Nie YB, Chen XJ, Gao XH, Zhai LJ, Min FL. Adult onset type 2 familial hemophagocytic lymphohistiocytosis with PRF1 c.65delC/c.163C>T compound heterozygous mutations: A case report. World J Clin Cases 2021; 9:2289-2295. [PMID: 33869605 PMCID: PMC8026822 DOI: 10.12998/wjcc.v9.i10.2289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 01/19/2021] [Accepted: 02/01/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Familial hemophagocytic lymphohistiocytosis (FHL) is a primary immunodefici-ency disease caused by gene defects. The onset of FHL in adolescents and adults may lead clinicians to ignore or even misdiagnose the disease. To the best of our knowledge, this is the first report to detail the clinical features of type 2 FHL (FHL2) with compound heterozygous perforin (PRF1) defects involving the c.163C>T mutation, in addition to correlation analysis and a literature review.
CASE SUMMARY We report a case of a 27-year-old male patient with FHL2, who was admitted with a persistent fever and pancytopenia. Through next-generation sequencing technology of hemophagocytic lymphohistiocytosis (HLH)-related genes, we found compound heterozygous mutations of PRF1: c.65delC (p.Pro22Argfs*29) (frameshift mutation, paternal) and c.163C>T (p.Arg55Cys) (missense mutation, maternal). Although he did not receive hematopoietic stem cell transplantation, the patient achieved complete remission after receiving HLH-2004 treatment protocol. To date, the patient has stopped taking drugs for 15 mo, is in a stable condition, and is under follow-up observation.
CONCLUSION The delayed onset of FHL2 may be related to the PRF1 mutation type, pathogenic variation pattern, triggering factors, and the temperature sensitivity of some PRF1 mutations. For individual, the detailed reason for the delay in the onset of FHL warrants further investigation.
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Affiliation(s)
- Xin-Yi Liu
- Department of Hematology, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu Province, China
| | - Yan-Bo Nie
- Gene Sequencing Laboratory, Tianjin SINO-US-Diagnostics Co.Ltd, Tianjin 300000, China
| | - Xue-Jing Chen
- Flow Cytometry Laboratory, Tianjin SINO-US-Diagnostics Co.Ltd, Tianjin 300000, China
| | - Xiao-Hui Gao
- Department of Hematology, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu Province, China
| | - Li-Jia Zhai
- Department of Hematology, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu Province, China
| | - Feng-Ling Min
- Department of Hematology, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu Province, China
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Abstract
Macrophage activation syndrome is a severe yet under-recognized complication encountered in pediatric rheumatology. It manifests as secondary hemophagocytic lymphohistiocytosis leading to a hyper-inflammatory state resulting from an underlying cytokine storm. If unchecked, it may lead to multiorgan failure and mortality. Early diagnosis and timely initiation of specific therapy is pivotal for a successful outcome. This review outlines the key clinical and laboratory features and management of macrophage activation syndrome.
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Affiliation(s)
- Narendra Kumar Bagri
- Division of Pediatric Rheumatology, Department of Pediatrics, AIIMS, New Delhi; India. Correspondence to: Dr Narendra Kumar Bagri, Associate Professor, Division of Pediatric Rheumatology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110 027, India.
| | - Latika Gupta
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ethan S Sen
- Department of Pediatric Rheumatology, Great North Children's Hospital, and Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - A V Ramanan
- Department of Pediatric Rheumatology, University Hospitals Bristol NHS Foundation Trust and Translational Health Sciences, University of Bristol, Bristol, UK
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Functional and genetic testing in adults with HLH reveals an inflammatory profile rather than a cytotoxicity defect. Blood 2021; 136:542-552. [PMID: 32356861 DOI: 10.1182/blood.2019003664] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 03/23/2020] [Indexed: 12/23/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory condition. Primary HLH occurs early in life as a result of monogenic biallelic mutations affecting lymphocyte cytotoxicity. Secondary HLH occurs mostly in adults secondary to infection, lymphoma, or rheumatic disease. In this latter setting, lymphocyte cytotoxicity status is not known. We conducted a systematic evaluation of natural killer (NK) cell cytotoxicity in adult patients with secondary HLH. Adult patients with secondary HLH were prospectively studied ex vivo for total lymphocyte count and subtype, NK cell phenotype, perforin expression and degranulation, and natural or antibody-dependent cell cytotoxicity, in comparison with patients affected by the same underlying disease without HLH (disease controls [DCs]) and with healthy controls (HCs). Screening for variants of cytotoxity genes was systematically performed. 68 patients were included in the HLH group and 34 each in the DC and HC groups. In HLH patients, severe and transient lymphopenia, activated NK cell phenotype (eg, increased CD69, ICAM-1, HLADR, and CCR5 expression), and decreased capacity of interferon γ production were observed; mean perforin expression was normal; and degranulation tests and NK cell cytotoxicity were not different from those in DCs. A monoallelic variant of uncertain significance affecting a lymphocyte cytotoxicity gene or the perforin variant A91V was observed in almost 50% of the patients. We detected no major intrinsic cytotoxicity dysfunction in secondary HLH patients compared with DCs and no predicted pathogenic gene variant. The activated NK phenotype profile associated with decreased interferon γ production seems similar to those of other hyperinflammatory diseases such as sepsis or systemic juvenile idiopathic arthritis.
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45
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Shabrish S, Kelkar M, Yadav RM, Bargir UA, Gupta M, Dalvi A, Aluri J, Kulkarni M, Shinde S, Sawant-Desai S, Kambli P, Hule G, Setia P, Jodhawat N, Gaikwad P, Dhawale A, Nambiar N, Gowri V, Pandrowala A, Taur P, Raj R, Uppuluri R, Sharma R, Kini P, Sivasankaran M, Munirathnam D, Vedam R, Vignesh P, Banday A, Rawat A, Aggarwal A, Poddar U, Girish M, Chaudhary A, Sampagar A, Jayaraman D, Chaudhary N, Shah N, Jijina F, Chandrakla S, Kanakia S, Arora B, Sen S, Lokeshwar M, Desai M, Madkaikar M. The Spectrum of Clinical, Immunological, and Molecular Findings in Familial Hemophagocytic Lymphohistiocytosis: Experience From India. Front Immunol 2021; 12:612583. [PMID: 33746956 PMCID: PMC7973116 DOI: 10.3389/fimmu.2021.612583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/04/2021] [Indexed: 11/26/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of immune dysregulation characterized by hyperactivation of the immune system, excessive cytokine secretion and severe systemic inflammation. HLH is classified as familial (FHL) when associated with mutations in PRF1, UNC13D, STX11, and STXBP2 genes. There is limited information available about the clinical and mutational spectrum of FHL patients in Indian population. This study is a retrospective analysis of 101 molecularly characterized FHL patients over the last 10 years from 20 different referral centers in India. FHL2 and FHL3 together accounted for 84% of cases of FHL in our cohort. Patients belonging to different FHL subtypes were indistinguishable based on clinical and biochemical parameters. However, flow cytometry-based assays viz. perforin expression and degranulation assay were found to be specific and sensitive in diagnosis and classification of FHL patients. Molecular characterization of respective genes revealed 76 different disease-causing mutations including 39 (51%) novel mutations in PRF1, UNC13D, STX11, and STXBP2 genes. Overall, survival was poor (28%) irrespective of the age of onset or the type of mutation in our cohort. Altogether, this article sheds light on the current scenario of FHL in India. Our data reveal a wide genetic heterogeneity of FHL in the Indian population and confirms the poor prognosis of FHL. This study also emphasizes that though mutational analysis is important for diagnostic confirmation of FHL, flow cytometry based assays help significantly in rapid diagnosis and functional validation of novel variants identified.
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Affiliation(s)
- Snehal Shabrish
- Department of Pediatric Immunology and Leukocyte Biology, Indian Council of Medical Research-National Institute of Immunohaematology, Mumbai, India
| | - Madhura Kelkar
- Department of Pediatric Immunology and Leukocyte Biology, Indian Council of Medical Research-National Institute of Immunohaematology, Mumbai, India
| | - Reetika Malik Yadav
- Department of Pediatric Immunology and Leukocyte Biology, Indian Council of Medical Research-National Institute of Immunohaematology, Mumbai, India
| | - Umair Ahmed Bargir
- Department of Pediatric Immunology and Leukocyte Biology, Indian Council of Medical Research-National Institute of Immunohaematology, Mumbai, India
| | - Maya Gupta
- Department of Pediatric Immunology and Leukocyte Biology, Indian Council of Medical Research-National Institute of Immunohaematology, Mumbai, India
| | - Aparna Dalvi
- Department of Pediatric Immunology and Leukocyte Biology, Indian Council of Medical Research-National Institute of Immunohaematology, Mumbai, India
| | - Jahnavi Aluri
- Department of Pediatric Immunology and Leukocyte Biology, Indian Council of Medical Research-National Institute of Immunohaematology, Mumbai, India
| | - Manasi Kulkarni
- Department of Pediatric Immunology and Leukocyte Biology, Indian Council of Medical Research-National Institute of Immunohaematology, Mumbai, India
| | - Shweta Shinde
- Department of Pediatric Immunology and Leukocyte Biology, Indian Council of Medical Research-National Institute of Immunohaematology, Mumbai, India
| | - Sneha Sawant-Desai
- Department of Pediatric Immunology and Leukocyte Biology, Indian Council of Medical Research-National Institute of Immunohaematology, Mumbai, India
| | - Priyanka Kambli
- Department of Pediatric Immunology and Leukocyte Biology, Indian Council of Medical Research-National Institute of Immunohaematology, Mumbai, India
| | - Gouri Hule
- Department of Pediatric Immunology and Leukocyte Biology, Indian Council of Medical Research-National Institute of Immunohaematology, Mumbai, India
| | - Priyanka Setia
- Department of Pediatric Immunology and Leukocyte Biology, Indian Council of Medical Research-National Institute of Immunohaematology, Mumbai, India
| | - Neha Jodhawat
- Department of Pediatric Immunology and Leukocyte Biology, Indian Council of Medical Research-National Institute of Immunohaematology, Mumbai, India
| | - Pallavi Gaikwad
- Department of Pediatric Immunology and Leukocyte Biology, Indian Council of Medical Research-National Institute of Immunohaematology, Mumbai, India
| | - Amruta Dhawale
- Department of Pediatric Immunology and Leukocyte Biology, Indian Council of Medical Research-National Institute of Immunohaematology, Mumbai, India
| | - Nayana Nambiar
- Department of Pediatric Immunology and Leukocyte Biology, Indian Council of Medical Research-National Institute of Immunohaematology, Mumbai, India
| | - Vijaya Gowri
- Department of Immunology, Bai Jerbai Wadia Hospital for Children, Mumbai, India
| | - Ambreen Pandrowala
- Department of Bone Marrow Transplant, Bai Jerbai Wadia Hospital for Children, Mumbai, India
| | - Prasad Taur
- Department of Immunology, Bai Jerbai Wadia Hospital for Children, Mumbai, India
| | - Revathi Raj
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospitals, Chennai, India
| | - Ramya Uppuluri
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Apollo Hospitals, Chennai, India
| | - Ratna Sharma
- Comprehensive Thalassemia Care, Pediatric Hematology-Oncology & Bone Marrow Transplantation Centre, Mumbai, India
| | - Pranoti Kini
- Comprehensive Thalassemia Care, Pediatric Hematology-Oncology & Bone Marrow Transplantation Centre, Mumbai, India
| | - Meena Sivasankaran
- Department of Pediatric Hemato-Oncology, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | | | - Ramprasad Vedam
- Medgenome Labs Pvt Ltd., Narayana Health City, Bommasandra, India
| | - Pandiarajan Vignesh
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aaqib Banday
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Rawat
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ujjal Poddar
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Meenakshi Girish
- Department of Pediatrics, All India Institute of Medical Sciences, Nagpur, India
| | - Abhijit Chaudhary
- Department of Pediatrics, All India Institute of Medical Sciences, Nagpur, India
| | | | - Dharani Jayaraman
- Department of Pediatrics, Sri Ramchandra Institute of Higher Education and Research, Chennai, India
| | - Narendra Chaudhary
- Department of Pediatrics, All India Institute of Medical Sciences, Bhopal, India
| | | | | | - S Chandrakla
- Department of Haematology, Seth G. S. Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Swati Kanakia
- Lilavati Hospital and Research Centre, Mumbai, India
| | - Brijesh Arora
- Department of Pediatric Oncology, Tata Memorial Hospital, Mumbai, India
| | - Santanu Sen
- Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | | | - Mukesh Desai
- Department of Immunology, Bai Jerbai Wadia Hospital for Children, Mumbai, India
| | - Manisha Madkaikar
- Department of Pediatric Immunology and Leukocyte Biology, Indian Council of Medical Research-National Institute of Immunohaematology, Mumbai, India
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Goudouris ES. Immunodeficiencies: non-infectious manifestations. J Pediatr (Rio J) 2021; 97 Suppl 1:S24-S33. [PMID: 33176164 PMCID: PMC9432189 DOI: 10.1016/j.jped.2020.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Classical immunodeficiencies are mainly characterized by infectious conditions. In recent years, manifestations related to allergy, inflammation, autoimmunity, lymphoproliferation, and malignancies related to this group of diseases have been described. The text intends to make an update on the non-infectious manifestations of the primary defects of the immune system. SOURCE OF DATA Searches were carried out in the PubMed database for review articles published in the last five years, in English, French, or Spanish, using the terms "allergy," "inflammation," "autoimmunity," "lymphoproliferation," "cancer," AND "immunodeficiency" or "primary immunodeficiency" or "inborn errors of immunity" NOT "HIV". SYNTHESIS OF DATA Non-infectious manifestations characterize the primary defects in which there is dysregulation of the immune system. The most common manifestations of autoimmunity in this group of diseases are autoimmune cytopenias. Exacerbated inflammatory processes, benign lymphoproliferation, and propensity to malignancy of the lymphoreticular system are related to several diseases in this group. Severe manifestations of atopy or food allergy characterize some immunodeficiencies. Disorders of inborn immunity of the autoinflammatory type are characterized by an aseptic inflammatory process in the absence of autoimmunity, with fever and recurrent manifestations in different organs. CONCLUSIONS Not only infectious conditions should raise the suspicion of immunodeficiencies, but also manifestations of allergy, inflammation, autoimmunity, lymphoproliferation, or cancer, especially if they are recurrent, associated to each other, affecting young patients, or in severe and/or difficult to treat conditions.
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Affiliation(s)
- Ekaterini Simões Goudouris
- Universidade Federal do Rio de Janeiro, Instituto de Puericultura e Pediatria Martagão Gesteira (IPPMG), Faculdade de Medicina, Departamento de Pediatria, Rio de Janeiro, RJ, Brazil.
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47
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Saettini F, Castelli I, Provenzi M, Fazio G, Quadri M, Cazzaniga G, Sala S, Dell'Acqua F, Sieni E, Coniglio ML, Pezzoli L, Iascone M, Vendemini F, Balduzzi AC, Biondi A, Rizzari C, Bonanomi S. A novel homozygous disruptive PRF1 variant (K285Sfs*4) causes very early-onset of familial hemophagocytic lymphohystiocytosis type 2. Pediatr Hematol Oncol 2021; 38:174-178. [PMID: 32696691 DOI: 10.1080/08880018.2020.1793849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- F Saettini
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, Monza, Italy
| | - I Castelli
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, Monza, Italy
| | - M Provenzi
- Pediatric Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - G Fazio
- Centro Ricerca Tettamanti, University of Milan Bicocca, Monza, Italy
| | - M Quadri
- Centro Ricerca Tettamanti, University of Milan Bicocca, Monza, Italy
| | - G Cazzaniga
- Centro Ricerca Tettamanti, University of Milan Bicocca, Monza, Italy.,Department of Medicine and Surgery, University of Milan Bicocca, Monza, Italy
| | - S Sala
- Centro Ricerca Tettamanti, University of Milan Bicocca, Monza, Italy
| | - F Dell'Acqua
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, Monza, Italy
| | - E Sieni
- Department of Paediatric Oncohematology, Meyer Children's University Hospital, Florence, Italy
| | - M L Coniglio
- Department of Paediatric Oncohematology, Meyer Children's University Hospital, Florence, Italy
| | - L Pezzoli
- Molecular Genetics Laboratory, USSD LGM, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - M Iascone
- Molecular Genetics Laboratory, USSD LGM, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - F Vendemini
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, Monza, Italy
| | - A C Balduzzi
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, Monza, Italy
| | - A Biondi
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, Monza, Italy.,Centro Ricerca Tettamanti, University of Milan Bicocca, Monza, Italy
| | - C Rizzari
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, Monza, Italy
| | - S Bonanomi
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, Monza, Italy
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48
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Keenan C, Nichols KE, Albeituni S. Use of the JAK Inhibitor Ruxolitinib in the Treatment of Hemophagocytic Lymphohistiocytosis. Front Immunol 2021; 12:614704. [PMID: 33664745 PMCID: PMC7923355 DOI: 10.3389/fimmu.2021.614704] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/22/2021] [Indexed: 12/17/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare hyperinflammatory syndrome driven by overactive T cells and macrophages that abundantly secrete numerous pro-inflammatory cytokines, including interferon (IFN)-gamma, interleukin (IL)-1-beta, IL-2, IL-6, IL-10, IL-18, and tumor necrosis factor (TNF). The release of these and other cytokines underlies many of the clinical and pathologic manifestations of HLH, which if left untreated, can lead to multi-organ failure and death. The advent of etoposide-based regimens, such as the Histiocyte Society HLH-94 and HLH-2004 protocols, has substantially decreased the mortality associated with HLH. Nevertheless, the 5-year survival remains low at ~60%. To improve upon these results, studies have focused on the use of novel cytokine-directed therapies to dampen inflammation in HLH. Among the agents being tested is ruxolitinib, a potent inhibitor of the Janus Kinase (JAK) and Signal Transducer and Activation of Transcription (STAT) pathway, which functions downstream of many HLH-associated cytokines. Here, we review the basic biology of HLH, including the role of cytokines in disease pathogenesis, and discuss the use of ruxolitinib in the treatment of HLH.
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Affiliation(s)
- Camille Keenan
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Kim E Nichols
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Sabrin Albeituni
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States
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49
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Botto LD, Meeths M, Campos-Xavier B, Bergamaschi R, Mazzanti L, Scarano E, Finocchi A, Cancrini C, Zirn B, Kühnle I, Kramm CM, Alanay Y, Jones WD, Irving M, Sabir A, Henter JI, Borgström B, Nordgren A, Hammarsjö A, Putti C, Mozzato C, Zuccarello D, Nishimura G, Bonafè L, Grigelioniene G, Unger S, Superti-Furga A. Chondrodysplasia and growth failure in children after early hematopoietic stem cell transplantation for non-oncologic disorders. Am J Med Genet A 2021; 185:517-527. [PMID: 33398909 DOI: 10.1002/ajmg.a.62021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/10/2020] [Accepted: 11/27/2020] [Indexed: 11/09/2022]
Abstract
Bone dysplasias (osteochondrodysplasias) are a large group of conditions associated with short stature, skeletal disproportion, and radiographic abnormalities of skeletal elements. Nearly all are genetic in origin. We report a series of seven children with similar findings of chondrodysplasia and growth failure following early hematopoietic stem cell transplantation (HSCT) for pediatric non-oncologic disease: hemophagocytic lymphohistiocytosis or HLH (five children, three with biallelic HLH-associated variants [in PRF1 and UNC13D] and one with HLH secondary to visceral Leishmaniasis), one child with severe combined immunodeficiency and one with Omenn syndrome (both children had biallelic RAG1 pathogenic variants). All children had normal growth and no sign of chondrodysplasia at birth and prior to their primary disease. After HSCT, all children developed growth failure, with standard deviation scores for height at or below -3. Radiographically, all children had changes in the spine, metaphyses and epiphyses, compatible with a spondyloepimetaphyseal dysplasia. Genomic sequencing failed to detect pathogenic variants in genes associated with osteochondrodysplasias. We propose that such chondrodysplasia with growth failure is a novel, rare, but clinically important complication following early HSCT for non-oncologic pediatric diseases. The pathogenesis is unknown but could possibly involve loss or perturbation of the cartilage-bone stem cell population.
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Affiliation(s)
- Lorenzo D Botto
- Division of Genetic Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Marie Meeths
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, and Clinical Genetics, Karolinska University Laboratory and Karolinska University Hospital, Stockholm, Sweden.,Theme of Children's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Belinda Campos-Xavier
- Division of Genetic Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Rosalba Bergamaschi
- Department of Pediatrics, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Laura Mazzanti
- Department of Pediatrics, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Emanuela Scarano
- Department of Pediatrics, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Andrea Finocchi
- Immunology and Infectious Diseases Unit, University-Hospital Pediatric Department (DPUO), Bambino Gesù Children's Hospital, IRCSS, Rome, Italy.,Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Caterina Cancrini
- Immunology and Infectious Diseases Unit, University-Hospital Pediatric Department (DPUO), Bambino Gesù Children's Hospital, IRCSS, Rome, Italy.,Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Birgit Zirn
- Genetikum Stuttgart, Genetic Counselling and Diagnostics, Stuttgart, Germany
| | - Ingrid Kühnle
- Division of Pediatric Hematology and Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Christof Maria Kramm
- Division of Pediatric Hematology and Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Yasemin Alanay
- Department of Pediatrics, Pediatric Genetics Unit, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Wendy D Jones
- North East Thames Regional Genetics Service, Great Ormond Street Hospital, London, UK
| | - Melita Irving
- Clinical Genetics Department, Guy's and St Thomas' NHS Hospital, London, UK.,Division of Medical and Molecular Genetics, King's College London, UK
| | - Ataf Sabir
- Clinical Genetics Department, Guy's and St Thomas' NHS Hospital, London, UK
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Theme of Children's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Birgit Borgström
- Department of Oncology-Pathology, Karolinska Institutet, Solna, Sweden
| | - Ann Nordgren
- Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, and Clinical Genetics, Karolinska University Laboratory and Karolinska University Hospital, Stockholm, Sweden
| | - Anna Hammarsjö
- Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, and Clinical Genetics, Karolinska University Laboratory and Karolinska University Hospital, Stockholm, Sweden
| | - Caterina Putti
- Pediatric Onco-Hematology Unit, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Chiara Mozzato
- Clinical Genetics and Epidemiology Unit, Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
| | - Daniela Zuccarello
- Clinical Genetics and Epidemiology Unit, Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
| | - Gen Nishimura
- Center for Intractable Diseases, Saitama Medical University Hospital, Saitama, Japan
| | - Luisa Bonafè
- Division of Genetic Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Giedre Grigelioniene
- Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, and Clinical Genetics, Karolinska University Laboratory and Karolinska University Hospital, Stockholm, Sweden
| | - Sheila Unger
- Division of Genetic Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Andrea Superti-Furga
- Division of Genetic Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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50
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Kwak A, Jung N, Shim YJ, Kim HS, Lim HJ, Lee JM, Heo MH, Do YR. A retrospective analysis of etiology and outcomes of hemophagocytic lymphohistiocytosis in children and adults. Yeungnam Univ J Med 2020; 38:208-218. [PMID: 33242384 PMCID: PMC8225498 DOI: 10.12701/yujm.2020.00591] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 09/25/2020] [Indexed: 12/16/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a rare but severe, life-threatening inflammatory condition if untreated. We aimed to investigate the etiologies, outcomes, and risk factors for death in children and adults with HLH. Methods The medical records of patients who met the HLH criteria of two regional university hospitals in Korea between January 2001 and December 2019 were retrospectively investigated. Results Sixty patients with HLH (35 children and 25 adults) were included. The median age at diagnosis was 7.0 years (range, 0.1–83 years), and the median follow-up duration was 8.5 months (range, 0–204 months). Four patients had primary HLH, 48 patients had secondary HLH (20 infection-associated, 18 neoplasm-associated, and 10 autoimmune-associated HLH), and eight patients had HLH of unknown cause. Infection was the most common cause in children (14/35, 40.0%), whereas neoplasia was the most common cause in adults (13/25, 52.0%). Twenty-eight patients were treated with HLH-2004/94 immunochemotherapy. The 5-year overall survival (OS) rate for all HLH patients was 59.9%. The 5-year OS rates for patients with primary, infection-associated, neoplasm-associated, autoimmune-associated, and unknown cause HLH were 25.0%, 85.0%, 26.7%, 87.5%, and 62.5%, respectively. Using multivariate analysis, neoplasm-induced HLH (p=0.001) and a platelet count <50×109/L (p=0.008) were identified as independent risk factors for poor prognosis in patients with HLH. Conclusion Infection was the most common cause of HLH in children, while it was neoplasia in adults. The 5-year OS rate for all HLH patients was 59.9%. HLH caused by an underlying neoplasm or a low platelet count at the time of diagnosis were risk factors for poor prognosis.
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Affiliation(s)
- Abraham Kwak
- Department of Pediatrics, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Nani Jung
- Department of Pediatrics, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Ye Jee Shim
- Department of Pediatrics, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Heung Sik Kim
- Department of Pediatrics, Keimyung University Daegu Dongsan Hospital, Daegu, Korea
| | - Hyun Ji Lim
- Department of Pediatrics, Yeungnam University Hospital, Daegu, Korea
| | - Jae Min Lee
- Department of Pediatrics, Yeungnam University College of Medicine, Daegu, Korea
| | - Mi Hwa Heo
- Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Young Rok Do
- Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
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