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Rodrigues CM, Carvalho AC, Ventura S, Domingues ÂP, Silva A, Ministro P. Persistent Fever after COVID-19 Vaccination in a Patient with Ulcerative Colitis: A Call for Attention. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2024; 31:129-135. [PMID: 38572438 PMCID: PMC10987068 DOI: 10.1159/000530834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/06/2023] [Indexed: 04/05/2024]
Abstract
The development of vaccinations has been game-changing in the ongoing effort to combat the COVID-19 pandemic. Until now, adverse effects are being reported at low frequency, including thrombocytopenia and myocarditis. Careful monitoring for any suspicious symptoms and signs following vaccination is necessary. We report a case of hemophagocytic lymphohistiocytosis (HLH) after mRNA COVID-19 vaccine in a 23-year-old female with ulcerative colitis. Diagnosis was made according to HLH-2004 criteria and the patient was treated with dexamethasone with response. Our report aimed to draw attention to the potential relation between COVID-19 vaccines and HLH and the necessity of continued surveillance, especially in at-risk populations such as those with underlying immune dysregulation.
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Affiliation(s)
| | | | - Sofia Ventura
- Department of Gastroenterology, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | | | - Américo Silva
- Department of Gastroenterology, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Paula Ministro
- Department of Gastroenterology, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
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2
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Cheng W, Xu J, Shu Y, Qiu H, Yin G. Association of a decreased platelet count with poor survival in patients with adult secondary hemophagocytic lymphohistiocytosis. Ann Hematol 2024; 103:1159-1166. [PMID: 38378930 DOI: 10.1007/s00277-024-05663-6] [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: 08/18/2023] [Accepted: 02/13/2024] [Indexed: 02/22/2024]
Abstract
We aimed to examine the association between baseline platelet count (PLT) and the prognosis of adult secondary hemophagocytic lymphohistiocytosis (sHLH). Data from 292 patients with pretreatment platelet counts were retrospectively analysed from January 2016 to December 2020. We categorized platelet count into quartiles. Multivariable Cox proportional hazards models and restricted cubic splines (RCS) were used to evaluate the relationship between platelet count and mortality. During a median follow-up of 53 (interquartile ranges, 17-223) days, a total of 208 deaths occurred. After adjusting for multiple variables, a non-linear and inverse relationship was observed between platelet count and mortality in sHLH patient (P for nonlinearity=0.002). For non- lymphoma-associated haemophagocytic lymphohistiocytosis (non-LHLH), a similar curve was also observed (P for nonlinearity =0.028). Decreased PLT (PLT Q4) was associated with an increased risk of mortality (adjusted hazard ratio: 1.97; 95% confidence interval: 1.28-3.04; Ptrend =0.005). Similar results were observed in the LHLH subgroup (adjusted hazard ratio: 1.84; 95% confidence interval: 1.05-3.24; Ptrend =0.024) but not in the non-LHLH subgroup (Ptrend =0.266). Baseline platelet count demonstrated a nonlinear and inverse association with an increased risk of mortality among adult sHLH patients. This method is used to identify sHLH patients with inferior overall survival due to its low cost and universal availability.
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Affiliation(s)
- Wanying Cheng
- Department of Hematology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi Medical Center, Nanjing Medical University, Wuxi, 214023, China
| | - Ji Xu
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Yongqian Shu
- Department of Oncology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Hongxia Qiu
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
| | - Guangli Yin
- Department of Hematology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
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3
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Böhm S, Wustrau K, Pachlopnik Schmid J, Prader S, Ahlmann M, Yacobovich J, Beier R, Speckmann C, Behnisch W, Ifversen M, Jordan M, Marsh R, Naumann-Bartsch N, Mauz-Körholz C, Hönig M, Schulz A, Malinowska I, Hines M, Nichols KE, Gil-Herrera J, Talano JA, Crooks B, Formankova R, Jorch N, Bakhtiar S, Kühnle I, Streiter M, Nathrath M, Russo A, Dürken M, Lang P, Lindemans C, Henter JI, Lehmberg K, Ehl S. Survival in primary hemophagocytic lymphohistiocytosis, 2016 to 2021: etoposide is better than its reputation. Blood 2024; 143:872-881. [PMID: 37992218 DOI: 10.1182/blood.2023022281] [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: 08/22/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 11/24/2023] Open
Abstract
ABSTRACT Primary hemophagocytic lymphohistiocytosis (pHLH) is a life-threatening hyperinflammatory syndrome that develops mainly in patients with genetic disorders of lymphocyte cytotoxicity and X-linked lymphoproliferative syndromes. Previous studies with etoposide-based treatment followed by hematopoetic stem cell transplantation (HSCT) resulted in 5-year survival of 50% to 59%. Contemporary data are lacking. We evaluated 88 patients with pHLH documented in the international HLH registry from 2016-2021. In 12 of 88 patients, diagnosis was made without HLH activity, based on siblings or albinism. Major HLH-directed drugs (etoposide, antithymocyte globulin, alemtuzumab, emapalumab, ruxolitinib) were administered to 66 of 76 patients who were symptomatic (86% first-line etoposide); 16 of 57 patients treated with etoposide and 3 of 9 with other first-line treatment received salvage therapy. HSCT was performed in 75 patients; 7 patients died before HSCT. Three-year probability of survival (pSU) was 82% (confidence interval [CI], 72%-88%) for the entire cohort and 77% (CI, 64%-86%) for patients receiving first-line etoposide. Compared with the HLH-2004 study, both pre-HSCT and post-HSCT survival of patients receiving first-line etoposide improved, 83% to 91% and 70% to 88%. Differences to HLH-2004 included preferential use of reduced-toxicity conditioning and reduced time from diagnosis to HSCT (from 148 to 88 days). Three-year pSU was lower with haploidentical (4 of 9 patients [44%]) than with other donors (62 of 66 [94%]; P < .001). Importantly, early HSCT for patients who were asymptomatic resulted in 100% survival, emphasizing the potential benefit of newborn screening. This contemporary standard-of-care study of patients with pHLH reveals that first-line etoposide-based therapy is better than previously reported, providing a benchmark for novel treatment regimes.
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Affiliation(s)
- Svea Böhm
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Eppendorf, Hamburg, Germany
| | - Katharina Wustrau
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Eppendorf, Hamburg, Germany
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Jana Pachlopnik Schmid
- Division of Immunology and Children's Research Center, University Children's Hospital Zürich, Zürich, Switzerland
- Pediatric Immunology, University Children's Hospital Zurich-Eleonorenstiftung, Zürich, Switzerland
| | - Seraina Prader
- Division of Immunology and Children's Research Center, University Children's Hospital Zürich, Zürich, Switzerland
- Pediatric Immunology, University Children's Hospital Zurich-Eleonorenstiftung, Zürich, Switzerland
| | - Martina Ahlmann
- Department of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Joanne Yacobovich
- Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Tel Aviv Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Rita Beier
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Carsten Speckmann
- Division of Pediatric Hematology and Oncology Faculty of Medicine, Department of Pediatrics and Adolescent Medicine, University of Freiburg, Freiburg, Germany
- Center for Chronic Immunodeficiency, Institute for Immunodeficiency, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolfgang Behnisch
- Center for Pediatrics and Adolescent Medicine, Hematology/Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Marianne Ifversen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Michael Jordan
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Rebecca Marsh
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Nora Naumann-Bartsch
- Clinic for Children and Adolescents, University Clinic Erlangen, Erlangen, Germany
| | - Christine Mauz-Körholz
- Pediatric Hematooncology, University Children's Hospital Giessen, Giessen, Germany
- Medical Faculty, Martin-Luther University of Halle-Wittenberg, Halle, Germany
| | - Manfred Hönig
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Ansgar Schulz
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Iwona Malinowska
- Department of Oncology, Pediatric Hematology, Clinical Transplantology and Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Melissa Hines
- Division of Critical Care, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
| | - Kim E Nichols
- Division of Critical Care, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
| | - Juana Gil-Herrera
- Immunology, Hospital General Universitario and Instituto de Investigación Sanitaria "Gregorio Marañón," Madrid, Spain
| | - Julie-An Talano
- Pediatric Hematology/Oncology/Blood and Marrow Transplant Division, Medical College of Wisconsin, Madison, WI
| | - Bruce Crooks
- Paediatric Haematology/Oncology, IWK Health Centre, Halifax, NS, Canada
| | - Renata Formankova
- Department of Pediatric Haematology and Oncology, University Hospital Motol Prague, Prague, Czech Republic
| | - Norbert Jorch
- Bielefeld University, University Clinic for Pediatrics, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Shahrzad Bakhtiar
- Center for Pediatric and Adolescent Medicine, Frankfurt University Hospital, Frankfurt, Germany
| | - Ingrid Kühnle
- Division of Pediatric Hematology and Oncology, Göttingen University Medical Center, Göttingen, Germany
| | - Monika Streiter
- Clinic for Pediatrics and Adolescent Medicine, Hematology/Oncology, Klinikum am Gesundbrunnen Heilbronn, Heilbronn, Germany
| | - Michaela Nathrath
- Pediatric Hematology and Oncology, Psychosomatics and Systemic Diseases, Kassel Hospital, Kassel, Germany
- Department of Pediatrics and Children's Cancer Research Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Alexandra Russo
- Center for Pediatric and Adolescent Medicine, Pediatric Hematology/Oncology, University of Mainz, Mainz, Germany
| | - Matthias Dürken
- Department of Pediatrics and Adolescent Medicine, Mannheim University Hospital, Mannheim, Germany
| | - Peter Lang
- Clinic for Children and Adolescents, Department I Hematology/Oncology, Tübingen University Hospital, Tübingen, Germany
| | - Caroline Lindemans
- Department of Pediatrics, University Medical Center Utrecht, Utrecht, The Netherlands
- Princess Máxima Center, Utrecht, The Netherlands
| | - Jan-Inge Henter
- Department of Women's and Children's Health, Childhood Cancer Research Unit, Karolinska Institutet, Stockholm, Sweden
- Theme of Children's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Kai Lehmberg
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Eppendorf, Hamburg, Germany
| | - Stephan Ehl
- Center for Chronic Immunodeficiency, Institute for Immunodeficiency, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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4
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Pei Y, Zhu J, Yao R, Cao L, Wang Z, Liang R, Jia Y, Su Y. Prognostic factors in patients with secondary hemophagocytic lymphohistioc ytosis in a Chinese cohort. Ann Hematol 2024; 103:695-703. [PMID: 38265737 DOI: 10.1007/s00277-023-05567-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 11/24/2023] [Indexed: 01/25/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare hyperinflammatory syndrome with high mortality mediated by an unbridled and persistent activation of cytotoxic T lymphocytes and natural killer cells. However, the influence factors of early death in adult sHLH patients are still not fully elucidated, which need further investigating. We have conducted an observational study of adult HLH patients between January 2016 and December 2022. All patients are enrolled according to HLH-2004 criteria. Clinical manifestations, laboratory data, treatments, and outcomes have been recorded. Influence factors associated with prognosis are calculated by using logistic regression models. Overall, 220 patients enrolled in this study. The etiologies of HLH were divided into five groups including autoimmune-associated hemophagocytic syndrome (AAHS) (n = 90, 40.9%), malignancies (n = 73, 33.2%), EBV-HLH (n = 18, 8.2%), infection excluded EBV (n = 24, 10.9%), and other triggers (n = 15, 6.8%). Among them, EBV-HLH had the highest mortality (77.8%), and AAHS had the lowest mortality (14.4%). Multivariate analysis indicated that age (≥ 38 years old), cytopenia ≥ 2 lines, platelets (≤ 50 × 109/L), aspartate aminotransferase (≥ 135U/L), prothrombin time (≥ 14.9 s) and activated partial thromboplastin time (≥ 38.5s), EBV, and fungal infection are independent risk factors for poor prognosis of HLH. Adult HLH patients with elder age, cytopenia ≥ 2 lines, levels of decreased platelets, increased AST, prolonged PT and APTT, EBV, and fungal infection tend to have a poor prognosis.
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Affiliation(s)
- Yuanyuan Pei
- Department of Emergency, Peking University People's Hospital, Beijing, China
| | - Jihong Zhu
- Department of Emergency, Peking University People's Hospital, Beijing, China
| | - Ranran Yao
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Lingjie Cao
- Department of Emergency, Peking University People's Hospital, Beijing, China
| | - Ziye Wang
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Renge Liang
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Yuan Jia
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China.
| | - Yin Su
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China.
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5
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Khan R, Ji W, Guzman-Rivera J, Madhvi A, Andrews T, Richlin B, Suarez C, Gaur S, Cuddy W, Singh AR, Bukulmez H, Kaelber D, Kimura Y, Ganapathi U, Michailidis IE, Ukey R, Moroso-Fela S, Kuster JK, Casseus M, Roy J, Kleinman LC, Horton DB, Lakhani SA, Gennaro ML. A genetically modulated Toll-like-receptor-tolerant phenotype in peripheral blood cells of children with multisystem inflammatory syndrome. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.02.02.24301686. [PMID: 38370700 PMCID: PMC10871447 DOI: 10.1101/2024.02.02.24301686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
Dysregulated innate immune responses contribute to multisystem inflammatory syndrome in children (MIS-C), characterized by gastrointestinal, mucocutaneous, and/or cardiovascular injury occurring weeks after SARS-CoV-2 exposure. To investigate innate immune functions in MIS-C, we stimulated ex vivo peripheral blood cells from MIS-C patients with agonists of Toll-like receptors (TLR), key innate immune response initiators. We found severely dampened cytokine responses and elevated gene expression of negative regulators of TLR signaling. Increased plasma levels of zonulin, a gut leakage marker, were also detected. These effects were also observed in children enrolled months after MIS-C recovery. Moreover, cells from MIS-C children carrying rare genetic variants of lysosomal trafficking regulator (LYST) were less refractory to TLR stimulation and exhibited lysosomal and mitochondrial abnormalities with altered energy metabolism. Our results strongly suggest that MIS-C hyperinflammation and/or excessive or prolonged stimulation with gut-originated TLR ligands drive immune cells to a lasting refractory state. TLR hyporesponsiveness is likely beneficial, as suggested by excess lymphopenia among rare LYST variant carriers. Our findings point to cellular mechanisms underlying TLR hyporesponsiveness; identify genetic determinants that may explain the MIS-C clinical spectrum; suggest potential associations between innate refractory states and long COVID; and highlight the need to monitor long-term consequences of MIS-C.
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Affiliation(s)
- Rehan Khan
- Public Health Research Institute, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, NJ
| | - Weizhen Ji
- Pediatric Genomics Discovery Program, Department of Pediatrics, Yale University School of Medicine, New Haven, CT 06510
| | - Jeisac Guzman-Rivera
- Public Health Research Institute, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, NJ
| | - Abhilasha Madhvi
- Public Health Research Institute, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, NJ
| | - Tracy Andrews
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ
| | - Benjamin Richlin
- Pediatric Clinical Research Center, and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Christian Suarez
- Pediatric Clinical Research Center, and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Sunanda Gaur
- Department of Pediatrics, Clinical Research Center, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Aalok R Singh
- Maria Fareri Children's Hospital, Valhalla, NY
- New York Medical College, Valhalla, NY
| | - Hulya Bukulmez
- Department of Pediatrics, Division of Rheumatology, MetroHealth System, Cleveland OH
| | - David Kaelber
- Department of Pediatrics, Division of Rheumatology, MetroHealth System, Cleveland OH
- Center for Clinical Informatics Research and Education, MetroHealth System, Cleveland OH
- Department of Internal Medicine, Pediatrics, and Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland OH
| | - Yukiko Kimura
- Hackensack University Medical Center, Hackensack Meridian School of Medicine, Nutley, NJ
| | - Usha Ganapathi
- Public Health Research Institute, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, NJ
| | - Ioannis E Michailidis
- Public Health Research Institute, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, NJ
| | - Rahul Ukey
- Public Health Research Institute, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, NJ
| | - Sandra Moroso-Fela
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - John K Kuster
- Pediatric Genomics Discovery Program, Department of Pediatrics, Yale University School of Medicine, New Haven, CT 06510
| | - Myriam Casseus
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Jason Roy
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ
| | - Lawrence C Kleinman
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Department of Global Urban Health, Rutgers School of Public Health, Piscataway, NJ
| | - Daniel B Horton
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ
| | - Saquib A Lakhani
- Pediatric Genomics Discovery Program, Department of Pediatrics, Yale University School of Medicine, New Haven, CT 06510
| | - Maria Laura Gennaro
- Public Health Research Institute, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, NJ
- Department of Medicine, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, NJ
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6
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Yao S, He L, Zhang R, Liu M, Hua Z, Zou H, Wang Z, Wang Y. Improved hemophagocytic lymphohistiocytosis index predicts prognosis of adult Epstein-Barr virus-associated HLH patients. Ann Med 2023; 55:89-100. [PMID: 36533966 PMCID: PMC9766494 DOI: 10.1080/07853890.2022.2149850] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Epstein-Barr virus (EBV)-associated hemophagocytic lymphohistiocytosis (EBV-HLH) is a common subtype of HLH with heterogeneous clinical presentations from self-limited to death, of which adults are worse than children. OBJECTIVE To establish predictors of mortality risk in adult EBV-HLH patients for timely and appropriate treatment. METHODS Patients with confirmed EBV-HLH admitted to Beijing Friendship Hospital from January 2015 to December 2019 were enrolled and statistical analysis of their laboratory test results was performed. RESULTS Among 246 adult patients with EBV-HLH, the deceased were older (p < 0.05), with fewer blood cells (p < 0.05), poorer renal function (p < 0.01), higher levels of procalcitonin (PCT) (p < 0.01), as well as soluble interleukin-2 receptor (sCD25) (p < 0.01). The overall median survival time of patients was 135 days, 87 days for patients without transplantation and 294 days with transplantation (p < 0.001). A combined index of sCD25, PCT, and estimated glomerular filtration rate (eGFR) was obtained to predict prognosis, named the Improved HLH index (IH index), and patients were divided into three groups meeting IH- (i.e. sCD25 ≤ 18,000 pg/mL, PCT ≤ 1.8 ng/mL, eGFR ≥ 90 mL/min/1.73m2), IH1+ (i.e. only sCD25 > 18,000 pg/mL or only eGFR < 90 mL/min/1.73m2), and IH2+ (i.e. the rest), respectively. In patients with the HScore ≥ 169 or meeting HLH-04, those meeting IH2+ had significantly worse prognoses than those who met IH1+ or IH- (p < 0.001). In the group meeting IH + or IH2+, patients who received allo-HSCT had better prognoses than those who did not (p < 0.05), but there was still a significant difference in prognosis among the three groups in transplanted patients (p < 0.001). CONCLUSION The IH index can early identify adult patients with a poor prognosis of EBV-HLH, initiating timely and appropriate treatment.KEY MESSAGESA combined index of sCD25, PCT, and eGFR was obtained to predict prognosis, named the Improved Hemophagocytic Lymphohistiocytosis index (IH index).IH index can early identify adult patients with a poor prognosis of EBV-HLH, initiating timely and appropriate treatment.
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Affiliation(s)
- Shuyan Yao
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lingbo He
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ruoxi Zhang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Menghan Liu
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhengjie Hua
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Heshan Zou
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yini Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Department of General Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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7
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Wang C, Sun W, Li Z, Wu T, Fang W. Clinical characteristics, treatment, and management of pembrolizumab induced hemophagocytic lymphohistiocytosis. Invest New Drugs 2023; 41:834-841. [PMID: 37897650 DOI: 10.1007/s10637-023-01404-0] [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: 10/06/2023] [Accepted: 10/21/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare and fatal adverse reaction to pembrolizumab. The clinical characteristics of pembrolizumab induced HLH are unknown. Exploring the clinical features of pembrolizumab induced HLH is crucial for the treatment and prevention of immune checkpoint inhibitor-induced HLH. METHODS The literature related to pembrolizumab induced HLH was collected for retrospective analysis by searching the Chinese and English databases from inception until August 31, 2023. RESULTS A total of 24 patients were included, including 17 men (70.8%) with a median age of 61 years (41,80). The time between the last infusion and the start of HLH ranged from 2 to 46 days, with a median time of 14 days. Fever (100%) was the most common symptom, accompanied by splenomegaly (14 cases, 58.3%) and hepatomegaly (6 cases, 25.0%). Laboratory examination revealed revealed anemia (18 cases, 75.0%), leukopenia (12 cases, 50.0%), thrombocytopenia (20 cases, 83.3%), hypertriglyceridemia (11 cases, 45.8%), hypofibrinogenemia (11 cases, 45.8%). decreased natural killer cell function (7 cases, 29.2%), and elevated soluble CD25(15 cases, 62.5%). All patients developed hyperferriinemia, with a median of 30,808 ng/mL (range 1303 ~ 100,000). Bone marrow biopsy showed hemophagocytosis (15 cases, 62.5%). After discontinuation of pembrolizumab and treatment with steroids, etoposide, intravenous immunoglobulin, cytokine blocking, and immunosuppression, 17 patients recovered or improved, and 5 patients eventually died. CONCLUSION HLH should be suspected when unexplained fever, cytopenia, splenomegaly, and elevated aminotransferase occur in patients using pembrolizumab. Screening for risk factors before treatment with pembrolizumab may be necessary to prevent HLH.
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Affiliation(s)
- Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, No. 138 Tongzipo Road, YueLu District, 410013, Changsha, Hunan, China
| | - Wei Sun
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, No. 138 Tongzipo Road, YueLu District, 410013, Changsha, Hunan, China
| | - Zuojun Li
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, No. 138 Tongzipo Road, YueLu District, 410013, Changsha, Hunan, China
| | - Tian Wu
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, No. 138 Tongzipo Road, YueLu District, 410013, Changsha, Hunan, China.
| | - Weijin Fang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, No. 138 Tongzipo Road, YueLu District, 410013, Changsha, Hunan, China.
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8
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Ali SB, Kuss B, Karapetis C, Hughes T, Smith A. Immune checkpoint inhibitor-associated hemophagocytic lymphohistiocytosis in a patient with chronic lymphocytic leukemia. Immunotherapy 2023; 15:1531-1537. [PMID: 37933523 DOI: 10.2217/imt-2023-0140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023] Open
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a rare complication of immune checkpoint inhibitor therapy. A 55-year-old male with stable chronic lymphocytic leukemia presented with fevers and symptomatic anaemia after nine cycles of nivolumab for metastatic melanoma. Investigations were consistent with autoimmune haemolytic anemia and corticosteroids were initiated. Thrombocytopenia and elevated liver enzymes without evidence of chronic lymphocytic leukaemia transformation was present. Ferritin was elevated, and thus HLH was considered and subsequently confirmed on a bone marrow biopsy. Corticosteroid monotherapy was continued, with resolution of fevers and improvement in cytopenias and liver enzymes. A six month corticosteroid tapering regimen was initiated, and he remains in HLH remission. This case highlights the importance of prompt recognition of immune checkpoint inhibitor-related HLH in patients with concurrent haematological malignancy.
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MESH Headings
- Male
- Humans
- Middle Aged
- Lymphohistiocytosis, Hemophagocytic/diagnosis
- Lymphohistiocytosis, Hemophagocytic/drug therapy
- Lymphohistiocytosis, Hemophagocytic/complications
- Immune Checkpoint Inhibitors/therapeutic use
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Nivolumab/adverse effects
- Thrombocytopenia
- Adrenal Cortex Hormones/therapeutic use
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Affiliation(s)
- Syed B Ali
- Department of Clinical Immunology & Allergy, Flinders Medical Centre, Bedford Park, Australia
- School of Medicine & Public Health, Flinders University, Bedford Park, 5042, Australia
| | - Bryone Kuss
- Department of Haematology, Flinders Medical Centre, Bedford Park, 5042, Australia
| | - Chris Karapetis
- Department of Oncology, Flinders Medical Centre, Bedford Park, 5042, Australia
| | - Tiffany Hughes
- Department of Clinical Immunology & Allergy, Flinders Medical Centre, Bedford Park, Australia
- School of Medicine & Public Health, Flinders University, Bedford Park, 5042, Australia
| | - Anthony Smith
- Department of Clinical Immunology & Allergy, Flinders Medical Centre, Bedford Park, Australia
- School of Medicine & Public Health, Flinders University, Bedford Park, 5042, Australia
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9
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Landy E, Varghese J, Dang V, Szymczak-Workman A, Kane LP, Canna SW. Complementary HLH susceptibility factors converge on CD8 T-cell hyperactivation. Blood Adv 2023; 7:6949-6963. [PMID: 37738167 PMCID: PMC10690564 DOI: 10.1182/bloodadvances.2023010502] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 09/24/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening hyperinflammatory syndromes. Familial HLH is caused by genetic impairment of granule-mediated cytotoxicity (eg, perforin deficiency). MAS is linked to excess activity of the inflammasome-activated cytokine interleukin-18 (IL-18). Though individually tolerated, mice with dual susceptibility (Prf1⁻/⁻Il18tg; DS) succumb to spontaneous, lethal hyperinflammation. We hypothesized that understanding how these susceptibility factors synergize would uncover key pathomechanisms in the activation, function, and persistence of hyperactivated CD8 T cells. In IL-18 transgenic (Il18tg) mice, IL-18 effects on CD8 T cells drove MAS after a viral (lymphocytic choriomeningitis virus), but not innate (toll like receptor 9), trigger. In vitro, CD8 T cells also required T-cell receptor (TCR) stimulation to fully respond to IL-18. IL-18 induced but perforin deficiency impaired immunoregulatory restimulation-induced cell death (RICD). Paralleling hyperinflammation, DS mice displayed massive postthymic oligoclonal CD8 T-cell hyperactivation in their spleens, livers, and bone marrow as early as 3 weeks. These cells increased proliferation and interferon gamma production, which contrasted with increased expression of receptors and transcription factors associated with exhaustion. Broad-spectrum antibiotics and antiretrovirals failed to ameliorate the disease. Attempting to genetically "fix" TCR antigen-specificity instead demonstrated the persistence of spontaneous HLH and hyperactivation, chiefly on T cells that had evaded TCR fixation. Thus, drivers of HLH may preferentially act on CD8 T cells: IL-18 amplifies activation and demand for RICD, whereas perforin supplies critical immunoregulation. Together, these factors promote a terminal CD8 T-cell activation state, combining features of exhaustion and effector function. Therefore, susceptibility to hyperinflammation may converge on a unique, unrelenting, and antigen-dependent state of CD8 T-cell hyperactivation.
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Affiliation(s)
- Emily Landy
- Department of Immunology, University of Pittsburgh, Pittsburgh, PA
- Graduate Program in Microbiology and Immunology, University of Pittsburgh, Pittsburgh, PA
| | - Jemy Varghese
- Rheumatology & Immune Dysregulation, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Vinh Dang
- Rheumatology & Immune Dysregulation, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Lawrence P. Kane
- Department of Immunology, University of Pittsburgh, Pittsburgh, PA
| | - Scott W. Canna
- Rheumatology & Immune Dysregulation, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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10
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Li X, Yan H, Xiao Z, Luo T, Xie L, Yang Y, Gong L, Tang Z, Tang M, Huang J, Zhang X, Zheng M, Yao Z, Zang P, Zhu D, Lu X. A Three-Step Screening Procedure for Early Identification of Children at High Risk of Hemophagocytic Lymphohistiocytosis. J Clin Immunol 2023; 43:989-998. [PMID: 36877313 DOI: 10.1007/s10875-023-01458-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 02/24/2023] [Indexed: 03/07/2023]
Abstract
PURPOSE The first step in diagnosing hemophagocytic lymphohistiocytosis (HLH) is to suspect its presence and then order the appropriate diagnostic tests. The development of screening procedures for HLH could facilitate early diagnosis. In this study, we evaluated the utility of fever, splenomegaly, and cytopenias as screening criteria for identifying pediatric HLH at an early stage, built a screening model using commonly measured laboratory parameters, and developed a step-wise screening procedure for pediatric HLH. METHODS The medical records of 83,965 pediatric inpatients, including 160 patients with HLH, were collected retrospectively. The utility of fever, splenomegaly, hemoglobin level, and platelet and neutrophil counts at hospital admission as screening criteria for HLH was evaluated. For HLH patients who might be missed by screening based on the presence of fever, splenomegaly, and cytopenias, a screening model using common laboratory parameters was developed. Following that, a three-step screening procedure was then developed. RESULTS The criteria of cytopenias affecting two or more lineages plus fever or splenomegaly had a sensitivity of 51.9% and a specificity of 98.4% for identifying HLH in pediatric inpatients. Our screening score model comprises six parameters: splenomegaly, platelet count, neutrophil count, albumin level, total bile acid level, and lactate dehydrogenase level. The use of the validation set had a sensitivity of 87.0% and a specificity of 90.6%. A three-step screening procedure has been developed: Step 1: Is fever or splenomegaly present? (Yes: risk for HLH should be considered, go to Step 2; No: less likely HLH); Step 2: Are cytopenias affecting at least two lineages? (Yes: consider HLH; No: go to Step 3); Step 3: Calculate the screening score. Is the sum of the score greater than 37? (Yes: consider HLH; No: less likely HLH). The overall sensitivity and specificity of the three-step screening procedure were 91.9% and 94.4%, respectively. CONCLUSION A significant proportion of pediatric HLH patients present at the hospital without having all three symptoms: fever, splenomegaly, and cytopenias. Our three-step screening procedure, utilizing commonly available clinical and laboratory parameters, can effectively identify pediatric patients who may be at high risk for HLH.
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Affiliation(s)
- Xun Li
- Pediatrics Research Institute of Hunan, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Haipeng Yan
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Zhenghui Xiao
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Ting Luo
- Pediatrics Research Institute of Hunan, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Longlong Xie
- Pediatrics Research Institute of Hunan, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Yufan Yang
- Pediatrics Research Institute of Hunan, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Ling Gong
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Zhexuan Tang
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Minghui Tang
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Jiaotian Huang
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Xinping Zhang
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Mincui Zheng
- Department of Pediatric Hematology, Hunan Children's Hospital, Changsha, China
| | - Zhenya Yao
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Ping Zang
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Desheng Zhu
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Xiulan Lu
- Department of Pediatric Intensive Care Unit (PICU) and Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China.
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11
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Watts S, Diaz M, Teller C, Hamby T, Guirola R, Perez M, Eames G, Howrey R, Rios A, Trinkman H, Ray A. Pediatric Hemophagocytic Lymphohistiocytosis: Formation of an Interdisciplinary HLH Working Group at a Single Institution. J Pediatr Hematol Oncol 2023; 45:e328-e333. [PMID: 36729645 DOI: 10.1097/mph.0000000000002602] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 10/28/2022] [Indexed: 02/03/2023]
Abstract
Fever of unknown origin is a common presentation in children with an extensive differential diagnosis that encompasses multiple specialties. From a hematologic standpoint, the differential includes hyperinflammatory syndrome, such as hemophagocytic lymphohistiocytosis (HLH), among others. Due to the rarity of HLH and nonspecific symptoms at initial presentation, specialists are often consulted later in the disease progression, which complicates disease evaluation further. Cook Children's Medical Center (CCMC) has recently developed a multidisciplinary histiocytic disorder group that is often consulted on cases presenting with fever of unknown origin to increase awareness and potentially not miss new HLH cases. In this study, we examine the clinical presentation and workup of 13 patients consulted by the HLH work group at a single institution and describe the clinical course of 2 patients diagnosed with HLH. The goal of this project was to describe the formation of a disease-specific team and the development of a stepwise diagnostic approach to HLH. A review of the current diagnostic criteria for HLH may be warranted given findings of markers such as soluble IL2 receptor and ferritin as nonspecific and spanning multiple disciplines including rheumatology, infectious disease, and hematology/oncology.
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Affiliation(s)
- Shelley Watts
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center
| | | | | | - Tyler Hamby
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center
- Research Operations
| | | | | | | | | | - Ana Rios
- Pediatric Infectious Disease, Cook Children's Health Care System, Fort Worth, TX
| | | | - Anish Ray
- Departments of Pediatric Hematology/Oncology
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12
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Huerta S, Pérez-Lara L, Pinilla-González A, Morell C, Llorens-Salvador R, Villarroya-Villalba Á, Carreras C, Cernada M. Hemophagocytic Lymphohistiocytosis and Severe Hypoxemia in a Preterm Infant. Pediatr Infect Dis J 2023; 42:271-273. [PMID: 36102741 DOI: 10.1097/inf.0000000000003705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Sergio Huerta
- From the Division of Neonatology, General University Hospital, Castellon, Spain
| | - Laura Pérez-Lara
- Division of Neonatology, La Fe University & Polytechnic Hospital
| | | | - Carlos Morell
- From the Division of Neonatology, General University Hospital, Castellon, Spain
| | | | | | - Carmen Carreras
- Department of Primary Inmunodeficiencies, La Fe University & Polytechnic Hospital, Valencia, Spain
| | - María Cernada
- Division of Neonatology, La Fe University & Polytechnic Hospital
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13
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Li Z, Zhang Q, He H, Sun N, Zhang R, Yang CQ, Zhao LB. Population pharmacokinetics of ruxolitinib in children with hemophagocytic lymphohistiocytosis: focus on the drug-drug interactions. Cancer Chemother Pharmacol 2023; 91:121-132. [PMID: 36510033 DOI: 10.1007/s00280-022-04494-4] [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: 08/17/2022] [Accepted: 11/15/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE The optimal dose regimen of ruxolitinib (RUX) in children with hemophagocytic lymphohistiocytosis (HLH) remains to be determined. The aim was to develop and verify a population pharmacokinetic (PPK) model, and then provide references for the optimization of dose regimen of RUX in children with HLH. METHODS A total of 189 RUX concentrations from 32 children were included. The PPK model was established using the nonlinear mixed-effects model approach. Predictive performance and stability of the final PPK model were evaluated. The exposure of RUX in different clinical scenarios was simulated through Monte Carlo simulations. RESULTS A one-compartment model with first-order absorption and linear elimination was identified to describe the disposition of RUX. The absorption rate constant (Ka) in the final PPK model was 1.05 h-1, and the apparent clearance (CL/F) and volume of distribution (V/F) were 9.80 L/h and 30.6 L, respectively. Coadministration with triazoles (TZS) and azithromycin (AZM) resulted in approximately 31.0% and 32.4% reductions in the CL/F of RUX, respectively. Multiple evaluation procedures showed satisfactory predictive performance and stability of the final model. Monte Carlo simulations showed that the exposure of RUX was significantly affected by the coadministration with TZS and/or AZM under different clinical scenarios. CONCLUSION For the first time, a PPK model of RUX in children with HLH was developed and evaluated. The coadministration with TZS and/or AZM were found to reduce the clearance of RUX in children. These findings could provide new insights for the precise treatment of RUX in children with HLH.
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Affiliation(s)
- Zhuo Li
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, 639 Longmian Avenue, Nanjing, 211198, China
| | - Qing 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
| | - Huan He
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Ning Sun
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, 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
| | - Chang-Qing Yang
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, 639 Longmian Avenue, Nanjing, 211198, China.
| | - Li-Bo Zhao
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.
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14
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Yan H, Mo Y, Liu S, Luo X, Liu L, Zhou L, Zhang X, Chen Y, Cao K. Case report: Hemophagocytic lymphohistiocytosis in a child with primary immunodeficiency infected with Talaromyces marneffei. Front Immunol 2022; 13:1038354. [PMID: 36532052 PMCID: PMC9755863 DOI: 10.3389/fimmu.2022.1038354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/07/2022] [Indexed: 12/04/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening immune-mediated disease that affects patients with known genetic defects and is increasingly found among those with autoimmune diseases and persistent infections. Talaromyces marneffei (TM) is a human opportunistic fungus that commonly infects immunodeficient or immunosuppressed individuals. Few TM-associated secondary HLH cases resulting from autoimmune deficiency have been reported previously. The current case study describes a pediatric patient hospitalized with recurrent fever and lymphadenopathy. The child had abnormal blood cell classification, and microscopy revealed mature granulocytes that phagocytized fungal spores. It was speculated that the patient was infected with TM. The pathogen was detected earlier than the blood culture and confirmed by metagenomic next-generation sequencing. Whole-exome sequencing revealed that the patient had complex mutations associated with immunodeficiency. This included a mutation in exon 3 of the CD40LG gene, c.346G>A, which may be linked to hyper-IgM syndrome, a primary immunodeficiency disease with immunoglobulin conversion recombination defects that could explain the patient's increased susceptibility to serious opportunistic infections. In addition, a heterozygous frameshift variant, c.820dup (p.Asp274GlyfsTer61), was detected in exon 6 of CARD9, a key gene associated with fungal immune surveillance. After 4 days of fungal treatment, the abnormal blood cell clusters disappeared, but other infections occurred in succession for 6 months after rehabilitation. The patient was followed with the aim of providing subsequent immunotherapy. This study found that infection can trigger HLH in HIV-negative individuals, highlighting the importance of early definitive identification of the causative agent and investigation of potential immunodeficiency.
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Affiliation(s)
- Huimin Yan
- Clinical Laboratory, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
| | - Yunjun Mo
- Medical Laboratory, Shenzhen Luohu People’s Hospital, Shenzhen, Guangdong, China
| | - Shilin Liu
- Division of Hematology and Oncology, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
| | - Xiaojuan Luo
- Clinical Laboratory, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
| | - Lianlian Liu
- Clinical Laboratory, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
| | - Lintao Zhou
- Clinical Laboratory, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
| | - Xiuming Zhang
- Medical Laboratory, Shenzhen Luohu People’s Hospital, Shenzhen, Guangdong, China
| | - Yunsheng Chen
- Clinical Laboratory, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China,*Correspondence: Ke Cao, ; Yunsheng Chen,
| | - Ke Cao
- Clinical Laboratory, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China,*Correspondence: Ke Cao, ; Yunsheng Chen,
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15
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Variation of Diagnostic Approaches and Treatment Practices for Hemophagocytic Lymphohistiocytosis/Macrophage Activation Syndrome Among Pediatric Subspecialists. J Pediatr 2022; 255:65-71.e6. [PMID: 36328191 DOI: 10.1016/j.jpeds.2022.10.022] [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: 06/20/2022] [Revised: 10/17/2022] [Accepted: 10/26/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To assess the diagnostic and treatment practices among a variety of subspecialists at pediatric institutions in the US. STUDY DESIGN Using a web-based survey, we assessed the consultation, diagnostic, and treatment preferences of providers from the different pediatric subspecialties who care for pediatric patients with hemophagocytic lymphohistiocytosis (HLH)/macrophage activating syndrome (MAS). Domains included demographics, provider training level and specialty, experience and comfort level with the diagnosis and treatment of HLH/MAS, and institutional approaches toward the diagnosis and management of HLH/MAS. Participants also were given 2 case scenarios: one describing Epstein-Barr virus-associated HLH and another describing an underlying rheumatologic condition with MAS. RESULTS Of 263 respondents, 23%, 29%, 39%, and 7% identified as hematology/oncology, rheumatology, general pediatrics/critical care/hospitalist, and allergy/immunology, respectively. For Epstein-Barr virus/HLH, hematology/oncology was the preferred first consultant by most respondents other than rheumatologists, of whom only 47% agreed. For MAS, 92% of respondents from all specialties favored a rheumatology consultation. Preferred diagnostic tests varied by subspecialty, with hematology/oncology more likely than rheumatology to order an infectious workup, natural killer cell function, soluble interleukin-2 receptor, bone marrow biopsy, and genetic testing. First-line therapy also varied, with hematology/oncology preferring dexamethasone and etoposide and rheumatology more often preferring methylprednisolone and anakinra. One-half of respondents were unaware of institutional algorithms for diagnosis and treatment of HLH/MAS. Most (85.6%) favored the development of treatment algorithms for HLH/MAS, and 90% supported a multidisciplinary approach. CONCLUSIONS Current consulting patterns, diagnostic workup, and treatment approaches of HLH/MAS vary by specialty, highlighting the need for standardized management algorithms and institutional multidisciplinary HLH/MAS teams.
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16
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Li XY, Zhu SM, Li XY, Dong RS, Zhang AA, Li SJ, Geng YL. Reactive Hemophagocytic Lymphohistiocytosis Secondary to Ovarian Adenocarcinoma: A Rare Case Report. J Inflamm Res 2022; 15:5121-5128. [PMID: 36097636 PMCID: PMC9464022 DOI: 10.2147/jir.s376756] [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: 06/07/2022] [Accepted: 08/09/2022] [Indexed: 11/23/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH), a syndrome of immune hyperactivation and abnormal regulation that causes life-threatening inflammation, is mainly characterized by fever, hepatosplenomegaly, cytopenia, and other symptoms. Reactive HLH (rHLH) is typically secondary to immune deregulation caused by underlying rheumatologic, infectious, or malignant conditions. Malignancy-associated HLH (M-HLH) continues to be a critical health problem worldwide. Most malignancies associated with HLH are hematologic tumors, and M-HLH in non-hematologic tumors very rarely occurs. Case Report A 34-year-old Chinese woman had a history of persistent fever, acute dizziness, and bicytopenia. She was found to have developed bilateral ovarian cancer. Additional tests showed splenomegaly, hemophagocytes in the bone marrow, low natural killer activity, and hyperferritinemia, which met the diagnostic criteria put forth in the Histiocyte Society HLH-2004. The patient was treated with correcting anemia, increased platelets, and glucocorticoid therapy but showed no response. She progressively deteriorated and died 55 days later. Conclusion Hemophagocytic lymphohistiocytosis related to a solid tumor is extremely rare. To the best of the authors’ knowledge, the present case was the first to report rHLH secondary to ovarian adenocarcinoma. It is very significant for a better understanding of the disease mechanisms of HLH and should attract the attention of hematologists and other clinicians as the condition progresses and the cost of treating it increases.
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Affiliation(s)
- Xiao-Yan Li
- Department of Laboratory Medicine, Shanxi Province Fenyang Hospital, Fenyang, 032200, People's Republic of China
| | - Shu-Min Zhu
- Department of Laboratory Medicine, The First Hospital of Hebei Medical University, Shijiazhuang, 050031, People's Republic of China
| | - Xin-Yuan Li
- Department of Laboratory Medicine, The First Hospital of Hebei Medical University, Shijiazhuang, 050031, People's Republic of China
| | - Rui-Sheng Dong
- Department of Imaging Medicine, Shanxi Province Fenyang Hospital, Fenyang, 032200, People's Republic of China
| | - Ai-Ai Zhang
- Department of Laboratory Medicine, Shanxi Province Fenyang Hospital, Fenyang, 032200, People's Republic of China
| | - Shu-Jing Li
- Department of Radiology, The First Hospital of Hebei Medical University, Shijiazhuang, 050031, People's Republic of China
| | - Yu-Lan Geng
- Department of Laboratory Medicine, The First Hospital of Hebei Medical University, Shijiazhuang, 050031, People's Republic of China
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17
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Li X, Yan H, Xiao Z, Luo T, Xie L, Yang Y, Gong L, Tang Z, Huang J, Zhang X, Zheng M, Yao Z, Zang P, Zhu D, Lu X. Development of a screening score for Hemophagocytic Lymphohistiocytosis among pediatric patients with acute infection of Epstein-Barr virus. Front Immunol 2022; 13:981251. [PMID: 36172365 PMCID: PMC9510983 DOI: 10.3389/fimmu.2022.981251] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/24/2022] [Indexed: 11/17/2022] Open
Abstract
Background and aims Deciding when to suspect hemophagocytic lymphohistiocytosis (HLH) and perform diagnostic tests in patients with acute infection of Epstein-Barr virus (EBV) is challenging, given the high prevalence of EBV infection, the life-threatening risk of EBV-HLH, the relatively low incidence of EBV-HLH, and the wide spectrum of disease presentations. The aim of this study was to develop an EBV-HLH screening model for pediatric patients diagnosed with acute infection of EBV. Methods An inpatient cohort with 3183 pediatric patients who were diagnosed with active infection of EBV was used to construct and validate the EBV-HLH screening score model. The model parameters were selected from common laboratory parameters using the method of Akaike Information Criterion-optimal selection through cross-validation under logistic regression. Performance of the score was evaluated and compared with the performance of screening methods using the number of cytopenias lineages. Results The EBV-HLH screening score has five parameters, including hemoglobin, platelet, neutrophil, albumin, and lactate dehydrogenase. Using a cut-of value of 29, the scoring model had a sensitivity of 89.2% and a specificity of 89.5% in the validation set. The false negative rate, false positive rate, positive predictive value, and negative predictive value in the validation set was 10.8%, 10.5%, 26.8%, and 99.5%, respectively, similar to that of the training set. Conclusions With five common laboratory parameters, the EBV-HLH score provides a simple tool to assist the identification of EBV patients who require further evaluation of HLH. Further studies are needed to evaluate the generalizability of the score and optimize the diagnose process for EBV-HLH.
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Affiliation(s)
- Xun Li
- Pediatrics Research Institute of Hunan Province and Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Haipeng Yan
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
| | - Zhenghui Xiao
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
| | - Ting Luo
- Pediatrics Research Institute of Hunan Province and Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Longlong Xie
- Pediatrics Research Institute of Hunan Province and Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Yufan Yang
- Pediatrics Research Institute of Hunan Province and Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Ling Gong
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
| | - Zhexuan Tang
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
| | - Jiaotian Huang
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
| | - Xinping Zhang
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
| | - Mincui Zheng
- Department of Pediatric Hematology, Hunan Children’s Hospital, Changsha, China
| | - Zhenya Yao
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
| | - Ping Zang
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
| | - Desheng Zhu
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
| | - Xiulan Lu
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
- *Correspondence: Xiulan Lu,
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18
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He Y, Hui Y, Liu H, Wu Y, Sang H, Liu F. Adult-Onset Familial Hemophagocytic Lymphohistiocytosis Presenting with Annular Erythema following COVID-19 Vaccination. Vaccines (Basel) 2022; 10:vaccines10091436. [PMID: 36146514 PMCID: PMC9501607 DOI: 10.3390/vaccines10091436] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/22/2022] [Accepted: 08/22/2022] [Indexed: 11/23/2022] Open
Abstract
Familial hemophagocytic lymphohistiocytosis (HLH) is a rare genetic and life-threatening immunodeficiency disease. Here, we present a 38-year-old male who initially developed multiple annular to irregular erythema accompanied by a fever after COVID-19 vaccination. He was diagnosed with HLH with evidence of leukocytopenia in a full blood test, elevations of ferritin and sCD25, decreased NK cell function, and hemophagocytosis of a bone marrow biopsy specimen. A genetic examination revealed two probable disease-causing heterozygous mutations on UNC13D associated with type 3 familial HLH. A review of the case reports relevant to HLH following COVID-19 vaccination and the cutaneous manifestations of HLH with genetic defects suggests the necessity that individuals with preexisting immune dysregulation or diseases not classified should be cautious about COVID-19 vaccination and reminds clinicians that various recalcitrant skin lesions may be a sign of HLH.
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Affiliation(s)
- Yifan He
- Department of Dermatology, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China
| | - Yun Hui
- Department of Dermatology, Jinling Hospital, Nanjing University, Nanjing 210002, China
| | - Haibo Liu
- Department of Dermatology, Jinling Hospital, Nanjing University, Nanjing 210002, China
| | - Yifan Wu
- Department of Dermatology, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China
| | - Hong Sang
- Department of Dermatology, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China
- Department of Dermatology, Jinling Hospital, Nanjing University, Nanjing 210002, China
- Correspondence: (H.S.); (F.L.)
| | - Fang Liu
- Department of Dermatology, Jinling Hospital, Nanjing University, Nanjing 210002, China
- Correspondence: (H.S.); (F.L.)
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19
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Higuchi T, Izawa K, Miyamoto T, Honda Y, Nishiyama A, Shimizu M, Takita J, Yasumi T. An efficient diagnosis: A patient with X-linked inhibitor of apoptosis protein (XIAP) deficiency in the setting of infantile hemophagocytic lymphohistiocytosis was diagnosed using high serum interleukin-18 combined with common laboratory parameters. Pediatr Blood Cancer 2022; 69:e29606. [PMID: 35187790 DOI: 10.1002/pbc.29606] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Toru Higuchi
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto City, Kyoto, Japan.,Department of Pediatrics, Shiga Medical Center for Children, Moriyama, Shiga, Japan
| | - Kazushi Izawa
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto City, Kyoto, Japan
| | - Takayuki Miyamoto
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto City, Kyoto, Japan
| | - Yoshitaka Honda
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto City, Kyoto, Japan.,Institute for the Advanced Study of Human Biology (ASHBi), Kyoto University, Kyoto City, Kyoto, Japan
| | - Atsuko Nishiyama
- Department of Pediatrics, Nara Prefecture General Medical Center, Nara, Japan
| | - Masaki Shimizu
- Department of Child Health and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Junko Takita
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto City, Kyoto, Japan
| | - Takahiro Yasumi
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto City, Kyoto, Japan
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20
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Hemophagocytic Lymphohistiocytosis Associated With Hemolytic Uremic Syndrome in a Child: A Case Report and Systematic Literature Review. J Pediatr Hematol Oncol 2022; 44:e905-e910. [PMID: 35731942 DOI: 10.1097/mph.0000000000002265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/08/2021] [Indexed: 11/26/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disorder resulting from excessive activation and nonmalignant proliferation of T-lymphocytes and macrophages. Hemolytic uremic syndrome (HUS) is a disease characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. Reports pertaining to the association between HLH and HUS are rarely published; however, we report on a 4-year-old boy who was diagnosed with both conditions and treated successfully with high-dose steroid and intravenous immunoglobulin. Differentiating HUS from HLH can be challenging because of their clinical similarities. Therefore, prompt diagnosis and immunosuppressive treatment are essential and life-saving to these patients.
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21
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Li Z, Sun N, Zhang Q, Ma HH, Wang D, Zhao YZ, Yang CQ, Zhang R, Zhao LB. Development and application of an LC-MS/MS method for pharmacokinetic study of ruxolitinib in children with hemophagocytic lymphohistiocytosis. ANALYTICAL METHODS : ADVANCING METHODS AND APPLICATIONS 2022; 14:2293-2303. [PMID: 35635540 DOI: 10.1039/d2ay00533f] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Ruxolitinib (RUX), a small molecule inhibitor of JAK1/JAK2, has been identified as the possible novel targeted agent for the treatment of hemophagocytic lymphohistiocytosis (HLH). However, due to the lack of randomized clinical trials (RCTs), it is extremely difficult to determine the effective therapeutic dose for RUX in HLH patients, especially in pediatric patients. At the same time, the clinical response of pediatric patients to RUX varies greatly among individuals according to several case reports. Therefore, it is imperative to investigate the pharmacokinetic and pharmacodynamic characteristics of RUX in HLH children, and this must be based on a satisfactory method to determine the concentration of RUX. Owing to several limits of published analytical methods, herein, we describe a novel liquid chromatography tandem mass spectrometry (LC-MS/MS) method for monitoring RUX in children's plasma samples. The protein precipitation method using methanol was used for sample cleanup. The analytes were separated by gradient elution in which 2.0 mM ammonium acetate in distilled water and acetonitrile were used as mobile phases. In the positive electrospray ionization (ESI+) mode, the m/z 307.1 → 186.0 and 316.1 → 185.9 ion pair transitions of RUX and RUX-d9 were used for the qualitative and quantitative analysis, respectively. The calibration curves of RUX were linear in the concentration range from 0.5 to 400 ng mL-1. The intra- and inter-batch precision, accuracy, recovery, dilution completeness, and stability of this method were all within acceptable standards, and no matrix effects or residues were found. This method was successfully applied to the clinical pharmacokinetic study of RUX in 32 children with HLH. The pharmacokinetic parameters of HLH children after a single dose of RUX and the steady state plasma concentration after multiple administrations were proposed through this method. Most importantly, it was found that the age and serum creatinine (SCr) of children with HLH had a significant and complex impact on the in vivo process of RUX after the single as well as multiple administrations of RUX.
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Affiliation(s)
- Zhuo Li
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, 100045, China.
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing 210009, China
| | - Ning Sun
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, 100045, 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, 100045, China
| | - Hong-Hao 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, 100045, China.
| | - Dong Wang
- 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, 100045, China.
| | - Yun-Ze 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, 100045, China.
| | - Chang-Qing Yang
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing 210009, 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, 100045, China.
| | - Li-Bo Zhao
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, 100045, China.
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22
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Bahadir A, Kader Ş, Çebi AH, Erduran E, Mutlu M, Aslan Y. Familial Hemophagocytic Lymphohistiocytosis With Heterozygous STX11 and Homozygous UNC13D Mutations Diagnosed in the Neonatal Period. J Pediatr Hematol Oncol 2022; 44:e866-e868. [PMID: 35293882 DOI: 10.1097/mph.0000000000002449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/18/2022] [Indexed: 11/26/2022]
Abstract
Patients with primary hemophagocytic lymphohistiocytosis may present with different mutations and phenotypic findings. It is usually presented as case reports because of its rare occurrence. Here, we discuss a case diagnosed with familial hemophagocytic lymphohistiocytosis 3, that presented in the neonatal period and was detected to have homozygous UNC13D and heterozygous STX11 mutations.
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Affiliation(s)
- Aysenur Bahadir
- Division of Pediatric Hematology-Oncology, Department of Pediatric Hematology-Oncology
| | - Şebnem Kader
- Division of Neonatology, Department of Neonatology
| | - Alper Han Çebi
- Division of Medical Genetics, Department of Medical Genetics, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Erol Erduran
- Division of Pediatric Hematology-Oncology, Department of Pediatric Hematology-Oncology
| | - Mehmet Mutlu
- Division of Neonatology, Department of Neonatology
| | - Yakup Aslan
- Division of Neonatology, Department of Neonatology
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23
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Li X, Yan H, Luo T, Xiao Z, Gong L, Huang J, Zhang X, Zheng M, Yao Z, Zang P, Zhu D, Lu X. Fulfillment status of hypertriglyceridemia and hypofibrinogenemia in children with hemophagocytic lymphohistiocytosis and risks of multiple organ dysfunction syndrome and early mortality. Orphanet J Rare Dis 2022; 17:161. [PMID: 35410268 PMCID: PMC8996201 DOI: 10.1186/s13023-022-02315-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 03/29/2022] [Indexed: 12/26/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disorder. How to stratify high risk patients is one of the current challenges for the treatment of HLH. HLH patients usually fulfill multiple but not all eight diagnostic criteria. Different combinations of the fulfilled criteria may naturally cluster into previously undescribed subsets or phenotypes that may have different pathophysiology and demonstrate different risks for a poor outcome. The objectives of this study were to identify HLH subgroups according to the fulfillment of diagnostic criteria and evaluate the risk of multiple organ dysfunction syndrome (MODS) and 30-day mortality for subgroups. We retrospectively collect medical records of patients with discharge diagnosis of HLH between June 2015 and October 2018 from a tertiary children’s hospital in China. Latent class analysis was used to identify class defining variables from HLH diagnostic items, and subgroups were defined according to different combinations of the class defining variables. Results Triglyceride and fibrinogen were identified as the class defining variables. When evaluated in combinations, patients with hypertriglyceridemia and normal fibrinogen levels during hospitalization had the lowest risks for MODS (27.8%, OR = 1) and 30-day mortality (18.8%, OR = 1), and patients with normal triglyceride and hypofibrinogenemia had the highest risks for MODS (86.2%, OR = 16.24, P = 0.0002) and 30-day mortality (57.1%, OR = 5.78, P = 0.0187). The fulfillment status of hypertriglyceridemia and hypofibrinogenemia within 72 h of hospital admission was also associated with the risk of adverse outcomes. Conclusions The fulfillment status of hypertriglyceridemia and hypofibrinogenemia were associated with the risks of MODS and 30-day mortality among pediatric HLH patients. Further studies are needed to validate this association and investigate its clinical utility in the severity evaluation for HLH. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02315-8.
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24
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Characteristics and prognostic value of pleural effusion in secondary hemophagocytic lymphohistiocytosis. Int J Hematol 2022; 116:102-109. [PMID: 35338447 PMCID: PMC8956144 DOI: 10.1007/s12185-022-03333-9] [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: 10/25/2021] [Revised: 03/10/2022] [Accepted: 03/10/2022] [Indexed: 12/04/2022]
Abstract
The clinical features of patients with secondary hemophagocytic lymphohistiocytosis (sHLH) complicated with pleural effusion have rarely been evaluated. We retrospectively analyzed 203 patients newly diagnosed with sHLH from July 2015 to July 2019 according to the HLH-2004 protocol. Baseline characteristics, laboratory results, and imaging were reviewed. Pleural effusion was found in 58.6% of the studied sHLH population, and characteristic imaging findings were minimal volume and bilaterality. Patients with pleural effusion had lower PLT counts, HB levels and ALB levels as well as higher sCD25 levels than those without pleural effusion (all p values < 0.05). Multivariate analyses showed that lg(sCD25) and PLT ≤ 65 × 109/L were significant risk factors for developing pleural effusion in sHLH. Regarding prognostic value, survival analysis showed a lower survival probability for patients with pleural effusion than for those without pleural effusion (median OS, 90 vs. 164 days, p = 0.028). In multivariate analysis, pleural effusion was an independent prognostic factor for overall survival (OS) (HR 2.68; 95% CI 1.18–6.11, p = 0.019). Pleural effusion is frequently found in patients with sHLH and is associated with greater inflammation and worse outcomes.
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25
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Xu L, Liu X, Wang Y, Wang Y, Chu X, Chen L. Successful treatment of hemophagocytic syndrome in a patient with T cell lymphoma, EBV infection, and bone marrow necrosis: A case report. Medicine (Baltimore) 2022; 101:e28943. [PMID: 35244052 PMCID: PMC8896522 DOI: 10.1097/md.0000000000028943] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 02/09/2022] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Hemophagocytic syndrome (HPS) is associated with a high mortality rate, and Epstein-Barr virus infection and hematological malignancies, especially T/natural killer cell lymphomas, are the most common causes; however, due to the complexity of clinical manifestations, the diagnosis is usually delayed. There are few reports of lymphoma-associated HPS (LAPS) in combination with bone marrow necrosis, and there is still no standard treatment for LAPS. PATIENT CONCERNS A 64-year-old man developed a fever, mild jaundice, fatigue, and bone pain. Positron emission tomography and bone marrow biopsy with immunohistochemistry were performed. DIAGNOSIS Imaging analysis and bone marrow examinations were compatible with HPS, T-cell lymphoma, and bone marrow necrosis. INTERVENTIONS The patient received combination therapy of rituximab and Cyclophosphamide, epirubicin, vincristine, glucocorticoid, etoposide. OUTCOMES The patient achieved complete remission and a disease-free survival of 52 months. LESSONS HPS and its potential diseases should be diagnosed and treated as soon as possible. Clinicians should be aware of the presence of lymphoma in patients with HPS. Rituximab plays an important role in the prognosis of HPS, particularly Epstein-Barr virus positivity. Cyclophosphamide, epirubicin, vincristine, glucocorticoid remains an effective regimen for the treatment of T-cell LAPS. This study provides a better understanding of the diagnosis and treatment of LAPS.
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Affiliation(s)
- Lingling Xu
- Department of Hematology, Yantai Yuhuangding Hospital Affilliated to Qingdao University, Yantai, China
| | - Xianqi Liu
- Department of Burn and Plastic Surgery, Yantai Yeda Hospital Affilliated to Binzhou Medical College, Yantai, China
| | - Yan Wang
- Department of Hematology, Yantai Yuhuangding Hospital Affilliated to Qingdao University, Yantai, China
| | - Yanming Wang
- Department of Hematology, Yantai Yuhuangding Hospital Affilliated to Qingdao University, Yantai, China
| | - Xiaoxia Chu
- Department of Hematology, Yantai Yuhuangding Hospital Affilliated to Qingdao University, Yantai, China
| | - Liming Chen
- Department of Hematology, Yantai Yuhuangding Hospital Affilliated to Qingdao University, Yantai, China
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26
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Wang C, Fan Z, He Y, Fang W, Sun W, Li Z. Analysis of the clinical characteristics of lamotrigine-induced haemophagocytic lymphohistiocytosis. J Clin Pharm Ther 2022; 47:745-751. [PMID: 35023173 DOI: 10.1111/jcpt.13602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/13/2021] [Accepted: 12/23/2021] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Lamotrigine is currently known to be related to haemophagocytic lymphohistiocytosis (HLH). Knowledge regarding the association between HLH and lamotrigine is mainly based on case reports. The purpose of this study was to evaluate the clinical characteristics of lamotrigine-induced HLH. METHODS We collected literature from 1994 to 31 August 2020 in Chinese and English on HLH induced by lamotrigine for retrospective analysis. RESULTS AND DISCUSSION A total of 17 patients (12 men and 5 women) from 15 studies were included, with a median age of 29 years old (range 4-47). Symptoms of lamotrigine-induced HLH were reported to have occurred within 6-24 days following treatment initiation. Six cases reported doses that ranged from 25 mg every other day to 800 mg once daily. The major clinical features of lamotrigine-induced HLH are fever, cytopenia, rash and hyperferritinaemia. Bone marrow showed haemophagocytosis. Fifteen patients improved with drug discontinuation, and 2 patients eventually died. WHAT IS NEW AND CONCLUSION Hemophagocytic lymphohistiocytosis is a potentially serious adverse reaction to lamotrigine (LTG). Patients should be informed that if they experience any symptoms of HLH while taking lamotrigine, they should immediately seek medical attention.
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Affiliation(s)
- Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Zhiqiang Fan
- Department of Pharmacy, The First Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Yang He
- Department of Pharmacy, The First Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Weijin Fang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Wei Sun
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Zuojun Li
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
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27
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Li Y, Sun C, Cui L, Wang Q. NLRC4 Gene Single Nucleotide Polymorphisms Are Associated with the Prognosis of Hemophagocytic Lymphohistiocytosis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2021:8581746. [PMID: 34925545 PMCID: PMC8683185 DOI: 10.1155/2021/8581746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 11/23/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyze and study the correlation between NLR family CARD domain-containing 4 (NLRC4) gene single nucleotide polymorphisms and the prognosis of patients with hemophagocytic lymphohistiocytosis (HLH). METHODS In this study, we retrospectively studied the clinical data of 62 HLH patients, including 40 males and 22 females. The genomic DNA was extracted, and the genotypes at rs385076 locus and rs479333 locus of the NLRC4 gene were analyzed. The level of blood interleukin-18 (IL-18) was analyzed by enzyme-linked immunosorbent assay (ELISA). RESULTS Compared with the TT genotype at the NLRC4 gene rs385076 locus, the mortality of HLH patients with TC genotype and CC genotype was higher (RR = 3.205, 95% CI: 1.277-4.788, p = 0.012; RR = 3.052, 95% CI: 1.098-4.753, p = 0.031). Taking the CC genotype at rs479333 of the NLRC4 gene as a reference, HLH patients with CG genotype and GG genotype had a higher risk of death (RR = 3.475, 95% CI: 1.488-5.775, p = 0.003; RR = 2.986, 95% CI: 1.014-5.570, p = 0.047). NLRC4 gene rs385076 T>C and rs479333 C>G were significantly related to the poor prognosis of HLH patients. The area under the curve (AUC) of the receiver operating curve (ROC) for the prognostic outcome of HLH with serum IL-18 level was 0.6813 (95% CI: 0.5365-0.8260, p = 0.0189). NLRC4 gene rs385076 T>C and rs479333 C>G were related to higher serum IL-18 levels. CONCLUSION NLRC4 gene rs385076 T>C and rs479333 C>G are related to the poor prognosis of HLH patients.
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Affiliation(s)
- Yan Li
- Department of Hematology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Chengdong Sun
- Department of Infectious Diseases, Beijing Jishuitan Hospital, Beijing 100096, China
| | - Liying Cui
- Department of Hematology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Qiuying Wang
- Department of Hematology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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28
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Perazzio SF, Palmeira P, Moraes-Vasconcelos D, Rangel-Santos A, de Oliveira JB, Andrade LEC, Carneiro-Sampaio M. A Critical Review on the Standardization and Quality Assessment of Nonfunctional Laboratory Tests Frequently Used to Identify Inborn Errors of Immunity. Front Immunol 2021; 12:721289. [PMID: 34858394 PMCID: PMC8630704 DOI: 10.3389/fimmu.2021.721289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 10/05/2021] [Indexed: 12/24/2022] Open
Abstract
Inborn errors of immunity (IEI), which were previously termed primary immunodeficiency diseases, represent a large and growing heterogeneous group of diseases that are mostly monogenic. In addition to increased susceptibility to infections, other clinical phenotypes have recently been associated with IEI, such as autoimmune disorders, severe allergies, autoinflammatory disorders, benign lymphoproliferative diseases, and malignant manifestations. The IUIS 2019 classification comprises 430 distinct defects that, although rare individually, represent a group affecting a significant number of patients, with an overall prevalence of 1:1,200-2,000 in the general population. Early IEI diagnosis is critical for appropriate therapy and genetic counseling, however, this process is deeply dependent on accurate laboratory tests. Despite the striking importance of laboratory data for clinical immunologists, several IEI-relevant immunoassays still lack standardization, including standardized protocols, reference materials, and external quality assessment programs. Moreover, well-established reference values mostly remain to be determined, especially for early ages, when the most severe conditions manifest and diagnosis is critical for patient survival. In this article, we intend to approach the issue of standardization and quality control of the nonfunctional diagnostic tests used for IEI, focusing on those frequently utilized in clinical practice. Herein, we will focus on discussing the issues of nonfunctional immunoassays (flow cytometry, enzyme-linked immunosorbent assays, and turbidimetry/nephelometry, among others), as defined by the pure quantification of proteins or cell subsets without cell activation or cell culture-based methods.
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Affiliation(s)
- Sandro Félix Perazzio
- Division of Rheumatology, Universidade Federal de São Paulo, Sao Paulo, Brazil.,Immunology Division, Fleury Medicine and Health Laboratory, Sao Paulo, Brazil
| | - Patricia Palmeira
- Laboratório de Investigação Médica (LIM-36), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil
| | - Dewton Moraes-Vasconcelos
- Laboratório de Investigação Médica (LIM-56), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil
| | - Andréia Rangel-Santos
- Laboratório de Investigação Médica (LIM-36), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil
| | | | - Luis Eduardo Coelho Andrade
- Division of Rheumatology, Universidade Federal de São Paulo, Sao Paulo, Brazil.,Immunology Division, Fleury Medicine and Health Laboratory, Sao Paulo, Brazil
| | - Magda Carneiro-Sampaio
- Laboratório de Investigação Médica (LIM-36), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil.,Department of Pediatrics, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil
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29
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Characterization of HLH-Like Manifestations as a CRS Variant in Patients Receiving CD22 CAR T-Cells. Blood 2021; 138:2469-2484. [PMID: 34525183 DOI: 10.1182/blood.2021011898] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 08/26/2021] [Indexed: 11/20/2022] Open
Abstract
CAR T-cell toxicities resembling hemophagocytic lymphohistiocytosis (HLH) occur in a subset of patients with cytokine release syndrome (CRS). As a variant of conventional CRS, a comprehensive characterization of CAR T-cell associated HLH (carHLH) and investigations into associated risk factors are lacking. In the context of 59 patients infused with CD22 CAR T-cells where a substantial proportion developed carHLH, we comprehensively describe the manifestations and timing of carHLH as a CRS variant and explore factors associated with this clinical profile. Amongst 52 subjects with CRS, 21 (40.4%) developed carHLH. Clinical features of carHLH included hyperferritinemia, hypertriglyceridemia, hypofibrinogenemia, coagulopathy, hepatic transaminitis, hyperbilirubinemia, severe neutropenia, elevated lactate dehydrogenase and occasionally hemophagocytosis. Development of carHLH was associated with pre-infusion NK-cell lymphopenia and higher bone marrow T/NK-cell ratio, which was further amplified with CAR T-cell expansion. Following CRS, more robust CAR T-cell and CD8 T-cell expansion in concert with pronounced NK-cell lymphopenia amplified pre-infusion differences in those with carHLH without evidence for defects in NK-cell mediated cytotoxicity. CarHLH was further characterized by persistent elevation of HLH-associated inflammatory cytokines, which contrasted with declining levels in those without carHLH. In the setting of CAR T-cell mediated expansion, clinical manifestations and immunophenotypic profiling in those with carHLH overlap with features of secondary HLH, prompting consideration of an alternative framework for identification and management of this toxicity profile to optimize outcomes following CAR T-cell infusion.
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Zhang FJ, Huang GQ, Li J, Xu J, Li XM, Wang AM. Clinical Characteristics of Adult Hemophagocytic Lymphohistiocytosis in the Emergency Department. Int J Gen Med 2021; 14:4687-4694. [PMID: 34447263 PMCID: PMC8384344 DOI: 10.2147/ijgm.s326270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/11/2021] [Indexed: 01/01/2023] Open
Abstract
Purpose To determine the clinical manifestations and results of adult hemophagocytic lymphohistiocytosis (HLH) patients in our emergency department. Methods We retrospectively evaluated patients with HLH from 1 April 2018 to 31 December 2020. The clinical data of these patients (basic information, symptoms, vital signs, laboratory results, HLH diagnostic criteria, H Score, main treatments, outcomes) were collected. Results Thirty-three patients (23 males and 10 females; 40.55±18.78 years) with 34 clinical episodes (one male had two clinical episodes and died during the second episode) were enrolled. Twenty-five patients were placed in a “survivor” group, and nine patients were categorized into a “deceased” group. Fever, splenomegaly, hemoglobin <90 g/L and platelet count <100×109/L most commonly met the diagnostic standard for HLH. The H Score results in the survival group and deceased group was 212.4±37.18 and 252.1±40.95, respectively. Viral infection was the most common reason for HLH, followed by immune-system disease and cancer. Laboratory tests showed that deceased-group patients had multiple-organ dysfunction. Multivariate logistic regression showed that the lactate dehydrogenase (lactate dehydrogenase) level (P = 0.039; odds ratio, 0.999) was significantly related to death. Conclusion In the emergency department, HLH should be considered for critically ill patients with fever, splenomegaly, low hemoglobin and low platelet count. The H Score might be useful to diagnose HLH quickly. In our study, 26.47% of HLH patients died in the emergency department, and patients with a significantly increased lactate dehydrogenase level had a markedly increased risk of death.
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Affiliation(s)
- Fang-Jie Zhang
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, People's Republic of China
| | - Guo-Qing Huang
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, People's Republic of China
| | - Jia Li
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, People's Republic of China
| | - Ji Xu
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, People's Republic of China
| | - Xiang-Min Li
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, People's Republic of China
| | - Ai-Min Wang
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, People's Republic of China
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Zhou Y, Kong F, Wang S, Yu M, Xu Y, Kang J, Tu S, Li F. Increased levels of serum interleukin-10 are associated with poor outcome in adult hemophagocytic lymphohistiocytosis patients. Orphanet J Rare Dis 2021; 16:347. [PMID: 34348761 PMCID: PMC8336343 DOI: 10.1186/s13023-021-01973-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 07/19/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Interleukin-10 (IL-10) is an independent factor for predicting adverse outcomes in pediatric patients with hemophagocytic lymphohistiocytosis (HLH). However, little is known about its prognostic value in adult patients. METHODS This single center retrospective study was conducted to explore the prognostic value of IL-10 in 101 adults newly diagnosed with HLH. The serum interleukin levels were quantitatively determined by chemiluminescence using cytokine profiling kits. RESULTS Serum IL-10 levels were significantly increased in adult HLH patients. Elevated IL-10 levels was correlated with lower concentrations of hemoglobin (r = - 0.279, P = 0.005). IL-10 levels were significantly lower in patients with macrophage activation syndrome (MAS) than in those with infection-associated HLH (IAHS) and malignancy-associated HLH (MAHS) (P = 0.033, P = 0.012). Patients with MAS had relatively longer survival than those with IAHS and MAHS (P < 0.001). Univariate analysis indicated that hemoglobin < 8.2 g/dL, platelets < 40 × 109/L, lactate dehydrogenase ≥ 700 IU/L, albumin < 28 g/L, post-treatment ferritin > 1050 µg/L and IL-10 ≥ 129 pg/mL were poor prognostic factors for survival. However, multivariate analysis revealed that only high serum IL-10 levels (≥ 129 pg/mL) at diagnosis and high post-treatment ferritin levels (> 1050 µg/L) were independent risk factors for poor overall survival in adult HLH patients (HR: 4.087, 95% CI 2.064-8.090, P < 0.001; HR 3.814, 95% CI 2.042-7.126, P < 0.001, respectively). CONCLUSIONS Our results suggest that higher serum IL-10 levels might be a prognostic marker in adult HLH patients.
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Affiliation(s)
- Yulan Zhou
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.,Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Nanchang, 330006, Jiangxi, China
| | - Fancong Kong
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.,Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Nanchang, 330006, Jiangxi, China
| | - Shixuan Wang
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.,Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Nanchang, 330006, Jiangxi, China
| | - Min Yu
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.,Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Nanchang, 330006, Jiangxi, China
| | - Yawen Xu
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.,Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Nanchang, 330006, Jiangxi, China
| | - Jing Kang
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.,Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Nanchang, 330006, Jiangxi, China
| | - Songtao Tu
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.,Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Nanchang, 330006, Jiangxi, China
| | - Fei Li
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China. .,Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Nanchang, 330006, Jiangxi, China.
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Ponnatt TS, Lilley CM, Mirza KM. Hemophagocytic Lymphohistiocytosis. Arch Pathol Lab Med 2021; 146:507-519. [PMID: 34347856 DOI: 10.5858/arpa.2020-0802-ra] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening disorder of immune regulation that can eventually result in end-organ damage and death. HLH is characterized by uncontrolled activation of cytotoxic T lymphocytes, natural killer cells, and macrophages that can lead to a cytokine storm. The diagnosis of HLH is often challenging due to the diverse clinical manifestations and the presence of several diagnostic mimics. The prognosis is generally poor, warranting rapid diagnosis and aggressive management. OBJECTIVE.— To provide a comprehensive review of the pathogenesis, clinical features, diagnosis, and management of HLH. DATA SOURCES.— Peer-reviewed literature. CONCLUSIONS.— HLH is a condition where a complete understanding of the pathogenesis, early diagnosis, and proper management has an important role in determining patient outcome. Genetic mutations causing impairment in the function of cytotoxic T lymphocytes and natural killer cells have been identified as the root cause of familial HLH; however, the specific pathogenesis of acquired HLH is unclear. The HLH-2004 protocol used in the diagnosis of HLH was originally developed for the pediatric population. The HLH-2004 protocol still forms the basis of the diagnosis of HLH in adults, although its use in adults has not been formally validated yet. Treatment of HLH is primarily based on the HLH-94 protocol, which involves suppressing the inflammatory response, but the treatment needs to be modified in adults depending on the underlying cause and comorbidities.
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Affiliation(s)
- Tanya Sajan Ponnatt
- From the Department of Pathology, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois
| | - Cullen M Lilley
- From the Department of Pathology, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois
| | - Kamran M Mirza
- From the Department of Pathology, Loyola University Chicago, Health Sciences Campus, Maywood, Illinois
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Bedouelle E, Ben Said B, Tetart F, Milpied B, Welfringer-Morin A, Maruani A, Catteau B, Dezoteux F, Staumont-Sallé D, Mazereeuw-Hautier J, Abasq C, Chiaverini C, Delaunay J, Mallet S, Sterling B, Puzenat E, Raynal M, Collet E, Bernier C. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): Series of 49 French Pediatric Cases. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:267-274.e5. [PMID: 34332174 DOI: 10.1016/j.jaip.2021.07.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 06/23/2021] [Accepted: 07/02/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare and potentially fatal adverse reaction. It can be difficult to diagnose, even more so among children, because symptoms may mimic other commonly encountered pediatric conditions. OBJECTIVE To describe clinical and laboratory features of DRESS syndrome in the pediatric population (age ≤18 years) and establish causative agents and treatment modalities. METHODS This was a multicenter retrospective study of probable and definite DRESS cases (Registry of Sever Cutaneous Adverse Reaction score ≥ 4) in children hospitalized in 15 French university hospitals between 2000 and 2020. RESULTS We included 49 cases. All children had fever and rash, 69.4% had lymphadenopathy, and 65.3% had facial edema. The most common organ affected was the liver (83.7%). Treatment consisted of topical corticosteroid in only 30.6% and systemic corticosteroid in 55.1%; 12.2% received intravenous immunoglobulin. Among probable and likely culprit drugs, 65% were antibiotics and 27.5% were antiepileptics, median time to DRESS symptom onset after initiation of 15 days (13 days with antibiotics and 21 days with antiepileptics). Twenty-seven children had allergy assessment for causative agents, 65.4% of whom had positive tests. CONCLUSIONS Culprit drugs are frequently antibiotics and antiepileptic drugs, and onset is often less than 2 weeks after treatment starts, especially with antibiotics. Treatment with topical corticosteroids appears to be sufficient in the least severe cases. Treatment by systemic corticosteroid therapy remains the reference treatment in case of severe organ damage.
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Affiliation(s)
- Eve Bedouelle
- Service de Dermatologie, Hôtel Dieu, Centre Hospitalier Universitaire de Nantes, Nantes, France.
| | - Benoit Ben Said
- Service de Dermatologie, Centre Hospitalier Universitaire de Lyon, Lyon, France
| | - Florence Tetart
- Service de Dermatologie, Centre Hospitalier Universitaire de Rouen, Rouen, France; Centre Erik Satie, Unité d'Allergologie, Centre Hospitalier Universitaire de Rouen, Rouen, France
| | - Brigitte Milpied
- Service de Dermatologie et Dermatologie Pédiatrique, Hôpital Saint-André et Pellegrin, Bordeaux, France
| | - Anne Welfringer-Morin
- Service de Dermatologie, Centre de Référence des Génodermatoses et des Maladies Rares à Expression Cutanée, Assistance Publique Hôpitaux de Paris, Hôpital Necker-Enfants Malades Université de Paris, Paris, France
| | - Annabel Maruani
- Université de Tours, INSERM 1246-SPHERE, Service de Dermatologie, Unité de Dermatologie Pédiatrique, Centre Hospitalier Universitaire de Tours, Tours, France
| | - Benoit Catteau
- Service de Dermatologie Center Hospitalier Universitaire de Lille, Université de Lille, Institute for Translational Research in Inflammation, INSERM, Lille, France
| | - Frédéric Dezoteux
- Service de Dermatologie Center Hospitalier Universitaire de Lille, Université de Lille, Institute for Translational Research in Inflammation, INSERM, Lille, France
| | - Delphine Staumont-Sallé
- Service de Dermatologie Center Hospitalier Universitaire de Lille, Université de Lille, Institute for Translational Research in Inflammation, INSERM, Lille, France
| | | | - Claire Abasq
- Service de Dermatologie, Centre Hospitalier Régional Universitaire de Brest, Brest, France
| | | | - Juliette Delaunay
- Service de Dermatologie, Centre Hospitalier Universitaire d'Angers site Larrey, Angers, France
| | - Stéphanie Mallet
- Service de Dermatologie et Cancérologie Cutanée, Hôpital de la Timone, Assistance Publique Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Benoit Sterling
- Services de Pédiatrie et Pneumologie Pédiatrique, Hôpital de La Timone-Enfants et Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Eve Puzenat
- Service de Dermatologie, Centre Hospitalier Régional Universitaire de Besançon, Besançon, France
| | - Margot Raynal
- Service de Dermatologie, Centre Hospitalier Universitaire de Rouen, Rouen, France
| | - Evelyne Collet
- Service de Dermatologie, Hôpital Le Bocagen, Centre Hospitalier Régional Universitaire de Dijon, Dijon, France
| | - Claire Bernier
- Service de Dermatologie, Hôtel Dieu, Centre Hospitalier Universitaire de Nantes, Nantes, France.
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Nguyen MHN, Baker M, Spoden T, Rivera-Valenzuela MG, Azmeh R. Hemophagocytic lymphohistiocytosis in adult and pediatric patients: Perspectives from a tertiary care center. Ann Allergy Asthma Immunol 2021; 127:507-509. [PMID: 34273483 DOI: 10.1016/j.anai.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/26/2021] [Accepted: 07/12/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Minh H N Nguyen
- Department of Medicine, Western Michigan University School of Medicine, Kalamazoo, Michigan; Department of Pediatrics and Adolescent Medicine, Western Michigan University School of Medicine, 1000 Oakland Drive, Kalamazoo, Michigan, 49008.
| | - Melissa Baker
- Department of Medicine, Western Michigan University School of Medicine, Kalamazoo, Michigan
| | - Tahnee Spoden
- Department of Pediatrics and Adolescent Medicine, Western Michigan University School of Medicine, 1000 Oakland Drive, Kalamazoo, Michigan, 49008
| | - Maritza Gisel Rivera-Valenzuela
- Department of Pediatrics and Adolescent Medicine, Western Michigan University School of Medicine, 1000 Oakland Drive, Kalamazoo, Michigan, 49008
| | - Roua Azmeh
- Department of Pediatrics and Adolescent Medicine, Western Michigan University School of Medicine, 1000 Oakland Drive, Kalamazoo, Michigan, 49008
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35
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Su T, Xiong W, Xu Y, Lu Y. Allopurinol-induced drug reaction with eosinophilia and systemic symptoms syndrome associated with reactivation of Epstein-Barr virus leading to secondary hemophagocytic lymphohistiocytosis in an HLA-B*5801-negative patient. Indian J Dermatol Venereol Leprol 2021; 87:545-548. [PMID: 34219434 DOI: 10.25259/ijdvl_925_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/01/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Ting Su
- Department of Dermatology The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wenjie Xiong
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yang Xu
- Department of Dermatology The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yan Lu
- Department of Dermatology The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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36
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Nelson BE, Hong A, Dekmezian M, Jana B. Standard-Dose Rituximab as Effective Therapy for Treating Malignancy-Related Hemophagocytic Lymphohistiocytosis in the Eldery: A Case Report. Case Rep Oncol 2021; 14:1066-1070. [PMID: 34326743 PMCID: PMC8299410 DOI: 10.1159/000517023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 11/19/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome involving uncontrolled inflammation due to widespread activation of immune response. HLH can be inherited or acquired secondary to infection, autoimmune, or oncologic processes such as small lymphocytic lymphoma (SLL) or chronic lymphocytic leukemia (CLL). There has been minimal documentation of HLH secondary to SLL/CLL, and results of treatment have been largely unsuccessful. This case describes a critically ill elderly patient with HLH caused by SLL/CLL who was successfully treated with standard-dose rituximab and regained a high quality of life.
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Affiliation(s)
- Blessie Elizabeth Nelson
- Department of Hematology & Oncology, University of Texas Medical Branch, Galveston, Texas, USA.,School of Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Angelina Hong
- School of Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Mhair Dekmezian
- Department of Pathology, Mainland Medical Center, Texas City, Texas, USA
| | - Bagi Jana
- Department of Hematology & Oncology, MD Anderson Cancer Center, Houston, Texas, USA
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37
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Nixon A, Roddick E, Moore K, Wild D. A qualitative investigation into the impact of hemophagocytic lymphohistiocytosis on children and their caregivers. Orphanet J Rare Dis 2021; 16:205. [PMID: 33957935 PMCID: PMC8101208 DOI: 10.1186/s13023-021-01832-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/20/2021] [Indexed: 11/30/2022] Open
Abstract
Background Primary hemophagocytic lymphohistiocytosis (pHLH) is a rare and life-threatening disorder, which usually occurs during infancy or early childhood and is characterized by abnormal activation of the immune system. However, the burden of pHLH on children and their families has not been previously evaluated. This qualitative study investigated the impact of pHLH and its treatment on the physical, emotional, and social well-being of patients and caregivers in the USA and UK using interviews to provide a comprehensive insight from the perspective of the caregivers and young survivors. Results Twenty-one caregivers were enrolled (median [range] age, 41.1 [26–58] years) and represented 20 patients, four from the UK and 16 from the USA. At enrollment, 17 of the 20 patients were alive with a median [range] age of 12.75 [5–31] years at a mean [range] of 7.8 [0.6–11.6] years after diagnosis. In addition, four adult survivors (median [range] age, 23.3 [21–30] years) were also enrolled (total participants n = 25). From noticing initial symptoms to receiving a diagnosis, caregivers reported a mean (range) of 25.9 (0–258) months. pHLH and its treatment had a substantial and long-lasting impact on patients and caregivers, affecting their physical, emotional and social well-being, family relationships, friendships, and ability to work and study. Many of the experiences reported were negative, even after curative treatment, and some participants experienced long-lasting physical and emotional issues. The most noticeable impact of pHLH for patients was on their physical well-being, whereas for caregivers it was emotional well-being. Across all participants there was a sense of isolation due to the illness and its treatment, particularly regarding the patient being immunocompromised and the fear of infection. Areas having a major impact and considered in need of improvement included: delays in diagnosis, lack of patient-specific information on pHLH and a lack of support and understanding about the condition. Conclusions pHLH placed a substantial burden on patients and caregivers, which for some were long-lasting. This was compounded by the lack of awareness and understanding of pHLH by healthcare professionals, and a lack of accessible information for those affected by pHLH. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-01832-2.
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Affiliation(s)
- Annabel Nixon
- Chilli Consultancy, The Old Fire Station, 2 Salt Lane, Salisbury, SP1 1JS, UK.
| | - Elina Roddick
- Chilli Consultancy, The Old Fire Station, 2 Salt Lane, Salisbury, SP1 1JS, UK
| | - Karen Moore
- Chilli Consultancy, The Old Fire Station, 2 Salt Lane, Salisbury, SP1 1JS, UK
| | - Diane Wild
- Chilli Consultancy, The Old Fire Station, 2 Salt Lane, Salisbury, SP1 1JS, UK
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38
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Im HJ, Kang SH. Treosulfan-Based Conditioning Regimen for Hematopoietic Stem Cell Transplantation in Pediatric Patients with Hemophagocytic Lymphohistiocytosis. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2021. [DOI: 10.15264/cpho.2021.28.1.28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ho Joon Im
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children’s Hospital, Seoul, Korea
| | - Sung Han Kang
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children’s Hospital, Seoul, Korea
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Vicenzi P, Jiwani Z, Guirola R, Hamby T, Ray A. Comment on: The use of anakinra in the treatment of secondary hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer 2021; 68:e28813. [PMID: 33200506 DOI: 10.1002/pbc.28813] [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] [Received: 11/01/2020] [Accepted: 11/02/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Paige Vicenzi
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, Texas
| | - Zahra Jiwani
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Ricardo Guirola
- Department of Pediatric Rheumatology, Cook Children's Health Care System, Fort Worth, Texas
| | - Tyler Hamby
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, Texas.,Department of Research Operations, Cook Children's Health Care System, Fort Worth, Texas
| | - Anish Ray
- Department of Pediatric Hematology/Oncology, Cook Children's Health Care System, Fort Worth, Texas
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40
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Interleukin-18 and cytotoxic impairment are independent and synergistic causes of murine virus-induced hyperinflammation. Blood 2021; 136:2162-2174. [PMID: 32589707 DOI: 10.1182/blood.2019003846] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 06/02/2020] [Indexed: 11/20/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening hyperinflammatory syndromes typically associated with underlying hematologic and rheumatic diseases, respectively. Familial HLH is associated with genetic cytotoxic impairment and thereby to excessive antigen presentation. Extreme elevation of serum interleukin-18 (IL-18) has been observed specifically in patients with MAS, making it a promising therapeutic target, but how IL-18 promotes hyperinflammation remains unknown. In an adjuvant-induced MAS model, excess IL-18 promoted immunopathology, whereas perforin deficiency had no effect. To determine the effects of excess IL-18 on virus-induced immunopathology, we infected Il18-transgenic (Il18tg) mice with lymphocytic choriomeningitis virus (LCMV; strain Armstrong). LCMV infection is self-limited in wild-type mice, but Prf1-/- mice develop prolonged viremia and fatal HLH. LCMV-infected Il18-transgenic (Il18tg) mice developed cachexia and hyperinflammation comparable to Prf1-/- mice, albeit with minimal mortality. Like Prf1-/- mice, immunopathology was largely rescued by CD8 depletion or interferon-γ (IFNg) blockade. Unlike Prf1-/- mice, they showed normal target cell killing and normal clearance of viral RNA and antigens. Rather than impairing cytotoxicity, excess IL-18 acted on T lymphocytes to amplify their inflammatory responses. Surprisingly, combined perforin deficiency and transgenic IL-18 production caused spontaneous hyperinflammation specifically characterized by CD8 T-cell expansion and improved by IFNg blockade. Even Il18tg;Prf1-haplosufficient mice demonstrated hyperinflammatory features. Thus, excess IL-18 promotes hyperinflammation via an autoinflammatory mechanism distinct from, and synergistic with, cytotoxic impairment. These data establish IL-18 as a potent, independent, and modifiable driver of life-threatening innate and adaptive hyperinflammation and support the rationale for an IL-18-driven subclass of hyperinflammation.
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41
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Pascarella A, Bracaglia C, Caiello I, Arduini A, Moneta GM, Rossi MN, Matteo V, Pardeo M, De Benedetti F, Prencipe G. Monocytes From Patients With Macrophage Activation Syndrome and Secondary Hemophagocytic Lymphohistiocytosis Are Hyperresponsive to Interferon Gamma. Front Immunol 2021; 12:663329. [PMID: 33815425 PMCID: PMC8010171 DOI: 10.3389/fimmu.2021.663329] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/01/2021] [Indexed: 12/28/2022] Open
Abstract
Objective To investigate the activation of the IFNγ signaling pathway in monocytes of patients with secondary hemophagocytic lymphohistiocytosis (sHLH)/macrophage activation syndrome (MAS) and to evaluate whether levels of phosphorylated STAT1 represent a biomarker for the identification of patients at early stages of the disease. Methods Fresh whole blood samples from pediatric patients with active sHLH/MAS, not receiving (n=10) and receiving glucocorticoids (n=14) at time of sampling, were prospectively collected. As disease control groups, patients with active systemic juvenile idiopathic arthritis (sJIA) without MAS, patients with sHLH/MAS in remission and patients with other rheumatic diseases were also sampled. Whole blood cells were left unstimulated or stimulated with increasing concentrations of IFNγ for 10 minutes and the intracellular Tyrosine (701)-phosphorylated STAT1 (pSTAT1) levels were evaluated in monocytes by flow cytometry. Results Monocytes from untreated sHLH/MAS patients showed significantly higher basal levels of pSTAT1 compared to those observed in monocytes from glucocorticoid-treated sHLH/MAS patients and from all the other disease controls. In addition, a significant increase in responsiveness to IFNγ, as assessed by increased levels of pSTAT1 following ex vivo stimulation, was observed in monocytes from untreated sHLH/MAS patients. pSTAT1 levels in monocytes distinguished patients with sHLH/MAS not treated with glucocorticoids from patients with active sJIA or with other rheumatic diseases [AUC, 0.93; 95% confidence interval 0.85-1.00, p<0.001]. Statistically significant correlations between IFNG mRNA levels in whole blood cells, circulating IFNγ levels and pSTAT1 levels in sHLH/MAS monocytes were found. Conclusion Our data demonstrating higher basal levels of pSTAT1 as well as a hyperreactivity to IFNγ stimulation in monocytes from patients with sHLH/MAS point to perturbations in the activation of downstream IFNγ signaling pathway as a contributor to the hyperinflammation occurring in these patients. Finally, the observation that glucocorticoids affect pSTAT1 levels in vivo, makes it difficult to consider the measurement of pSTAT1 levels as a biomarker to identify patients at early stages of sHLH/MAS in clinical practice.
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Affiliation(s)
- Antonia Pascarella
- Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Claudia Bracaglia
- Laboratory of Immuno-Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Ivan Caiello
- Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Alessia Arduini
- Laboratory of Immuno-Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Gian Marco Moneta
- Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | | | - Valentina Matteo
- Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Manuela Pardeo
- Laboratory of Immuno-Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Fabrizio De Benedetti
- Laboratory of Immuno-Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Giusi Prencipe
- Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
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Zhang Q, Yan C, Xu L, Xie W, Li J, Zhang W, Xu H, Zhang H. The Treatment Effect of Protamine on Severe Coagulopathy in Epstein-Barr Virus-Associated Hemophagocytic Lymphohistiocytosis: Case Reports and Literature Review. Indian J Hematol Blood Transfus 2021; 37:90-95. [PMID: 33707840 DOI: 10.1007/s12288-020-01308-6] [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: 08/02/2019] [Accepted: 06/12/2020] [Indexed: 11/26/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening disease, which is characterized by severe systemic inflammation with cytokine storm as well as histologic evidence of hemophagocytosis. Besides, coagulopathy and hemorrhages are two common severe complications in HLH patients. Recent literatures indicate that Epstein-Barr virus (EBV) infection is one of the important triggers for the disease. In the study, we present three cases of EBV related HLH (EBV-HLH) with coagulopathy in patients with distinct backgrounds. Case 1 is a 45-year-old female diagnosed with EBV associated NK/T cell lymphoproliferative disorder (EBV-T/NK-LPD) and EBV-HLH. Case 2 is a 17-year-old male with a diagnosis of EBV-T-LPD and EBV-HLH. Case 3 is a 51-year-old male and also diagnosed with EBV-T-LPD and EBV-HLH. All cases were given with treatment with HLH-94 protocol, and the symptoms of the three patients improved. Furthermore, during the treatment, protamine, which has not been reported in the literature previously, was given to the three cases with EBV-HLH, and our results showed that after treatment with protamine, the coagulopathy and bleedings in these patients were improved rapidly. Unfortunately, the three patients relapsed soon and died despite intensive treatment. However, these cases suggest that protamine may serve as a potential treatment option for coagulation associated with EBV-HLH. Besides, the study helps us improve the understanding of the EBV-HLH related coagulation disorders, and provide a potential strategy for future treatment of the disease.
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Affiliation(s)
- Qian Zhang
- Department of Hematology, Peking University Shenzhen Hospital, Road Lianhua #1120, Shenzhen, 518036 Guangdong China
| | - CunLiang Yan
- Department of Clinical Laboratory, Peking University Shenzhen Hospital, Shenzhen, 518036 Guangdong China
| | - Lei Xu
- Department of Hematology, Peking University Shenzhen Hospital, Road Lianhua #1120, Shenzhen, 518036 Guangdong China
| | - Wenyue Xie
- Department of Clinical Laboratory, Peking University Shenzhen Hospital, Shenzhen, 518036 Guangdong China
| | - JinMeng Li
- Department of Hematology, Peking University Shenzhen Hospital, Road Lianhua #1120, Shenzhen, 518036 Guangdong China
| | - Wenli Zhang
- Department of Hematology, Peking University Shenzhen Hospital, Road Lianhua #1120, Shenzhen, 518036 Guangdong China
| | - HaiChan Xu
- Department of Hematology, Peking University Shenzhen Hospital, Road Lianhua #1120, Shenzhen, 518036 Guangdong China
| | - HongYu Zhang
- Department of Hematology, Peking University Shenzhen Hospital, Road Lianhua #1120, Shenzhen, 518036 Guangdong China
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Machlańska A, Helbig G, Chromik K, Zapała M, Zwiernik B, Selmaj K. Hemophagocytic lymphohistiocytosis associated with ocrelizumab treatment in a patient with multiple sclerosis. Mult Scler 2021; 27:1803-1805. [PMID: 33666121 DOI: 10.1177/1352458521993070] [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] [Indexed: 11/17/2022]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rarely recognized hyperinflammatory condition of high death risk. OBJECTIVE The objective was to describe a case of HLH in a patient with multiple sclerosis (MS) treated with ocrelizumab. METHODS Clinical observation, laboratory testing, and use of HLH-2004 criteria for HLH diagnosis. RESULTS A 32-year-old Caucasian female developed HLH during ocrelizumab treatment. She met six of the eight HLH criteria including fever, splenomegaly, cytopenia, hypertriglyceridemia and hypofibrinogenemia, high serum ferritin level, and low natural killer (NK) cells. CONCLUSION HLH should be considered in the differential diagnosis in MS patients displaying a fever and malaise syndrome following administration of ocrelizumab.
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Affiliation(s)
| | - Grzegorz Helbig
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice, Poland
| | - Karolina Chromik
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice, Poland
| | - Magdalena Zapała
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice, Poland
| | - Bartosz Zwiernik
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice, Poland
| | - Krzysztof Selmaj
- Center of Neurology, Lodz, Poland/ Department of Neurology, University of Warmia & Mazury Olsztyn, Poland
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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: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 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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45
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De Rose DU, Coppola M, Gallini F, Maggio L, Vento G, Rigante D. Overview of the rarest causes of fever in newborns: handy hints for the neonatologist. J Perinatol 2021; 41:372-382. [PMID: 32719496 DOI: 10.1038/s41372-020-0744-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/23/2020] [Accepted: 07/17/2020] [Indexed: 12/17/2022]
Abstract
Neonatal causes of fever are a major source of concern for clinicians. If fever is combined with organ-specific sterile inflammatory manifestations the suspicion of autoinflammatory disorders should be considered, and the list of such conditions starting in the neonatal period includes chronic infantile neurological cutaneous articular syndrome, mevalonate kinase deficiency, deficiency of the interleukin-1 receptor antagonist, otulipenia, STING-associated vasculopathy with onset in infancy and Blau syndrome. Other causes of noninfectious fever that can rarely occur in newborns are Kawasaki disease, Behçet's disease, and hemophagocytic lymphohistiocytosis. Diagnosis of these exceptionally rare disorders is challenging for neonatologists. An early recognition of these complex diseases might lead to use more specific or rational drugs preventing permanent consequences. This review focuses on the rarest causes of fever occurring in the neonatal age with the aim of portraying many protean clinical pictures associated with fever and reviewing the potential available treatments.
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Affiliation(s)
- Domenico Umberto De Rose
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy. .,Department of Medical and Surgical Neonatology, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy.
| | - Maria Coppola
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Francesca Gallini
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Maggio
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Vento
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Donato Rigante
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
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Guo HY, Sun J, Su Y, Zhang Q, Hua R, Xia X, Fang D. Thrombotic microangiopathy led to acute kidney injury in an infant with hemophagocytic lymphohistiocytosis: A case report. Exp Ther Med 2021; 21:396. [PMID: 33680118 PMCID: PMC7918195 DOI: 10.3892/etm.2021.9827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 09/18/2020] [Indexed: 11/05/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare but fatal clinical syndrome frequently complicated by acute kidney injury (AKI) and acute tubular necrosis. Renal thrombotic microangiopathy (TMA) is a specific pathological feature of childhood HLH and few cases have been reported among infants. The present study presents a rare case of HLH with TMA in an infant. A 15-month-old infant with a week-long history of fever was admitted to hospital. The infant presented with AKI and subsequently a reduction in platelet and hemoglobin levels. TMA was diagnosed by kidney biopsy and the clinical, laboratory and bone marrow biopsy findings met the criteria of HLH. Due to a progressive increase in serum creatinine levels, hemodialysis was initiated on the second day following admission. Dexamethasone was administered to treat both the fever and HLH. The patient's body temperature returned to a normal range and platelet and hemoglobin levels were stable after 14 days of admission. Renal function stabilized on day 21. The results of genetic testing did not identify any disease-related variations. Childhood HLH is a severe condition and mortality can be reduced by early diagnosis and correct treatment. For patients with HLH and AKI, the possible role of TMA should be considered. Renal biopsy can help to identify the cause of AKI and can be performed when the patient's condition is stable.
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Affiliation(s)
- Hai-Yan Guo
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
| | - Jingmin Sun
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
| | - Yue Su
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast BT12 6BA, Northern Ireland, UK
| | - Qin Zhang
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
| | - Ran Hua
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
| | - Xun Xia
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
| | - Deng Fang
- Department of Nephrology, Anhui Provincial Children's Hospital, Hefei, Anhui 230022, P.R. China
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Li X, Yan H, Xiao Z, Zhang X, Huang J, Xiang ST, Zheng M, Yao Z, Zang P, Zhu D, Li L, Lu X. Diagnostic Time Lag of Pediatric Haemophagocytic Lymphohistiocytosis and Patient Characteristics: A Retrospective Cohort Study. Front Pediatr 2021; 9:692849. [PMID: 34222154 PMCID: PMC8247774 DOI: 10.3389/fped.2021.692849] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/25/2021] [Indexed: 12/14/2022] Open
Abstract
The difficulties and challenges of applying the HLH-2004 diagnostic criteria to early identification and diagnosis of haemophagocytic lymphohistiocytosis have been fully addressed in previous studies. However, the distribution of the diagnostic time lag of haemophagocytic lymphohistiocytosis and related patient characteristics remain unclear. This study investigated the time lags between symptom onset and diagnosis and between hospital admission and diagnosis among pediatric patients with haemophagocytic lymphohistiocytosis, and identified factors that associated with a shorter or longer diagnostic time lag. The cohort of patients with haemophagocytic lymphohistiocytosis was drawn from a tertiary children's hospital and consisted of 122 pediatric patients. The distributions of symptom-to-diagnosis and admission-to-diagnosis time lags were assessed. Clinical characteristics within 48 h of admission and the fulfillment of HLH-2004 diagnostic criteria were compared among admission-to-diagnosis time lag categories. Logistic regression analyses were conducted to identify factors associated with an admission-to-diagnosis time lag >3 days. The median interval from first symptom onset to HLH diagnosis was 12 days (range 4-71 days) and the median interval from hospital admission to HLH diagnosis was 2 days (range 0-23 days). The following factors were negatively associated with admission-to-diagnosis > 3 days: Epstein-Barr virus infection; admission through pediatric intensive care unit; diagnosis established without NK-cell activity and soluble CD25 tests; the performance of all readily available diagnostic tests for HLH (within 48 and 72 h); concurrent fever, splenomegaly, and cytopenias within 48 h; hemophagocytosis, hypertriglyceridemia and/or hypofibrinogenemia within 48 h; and elevated ferritin, total bilirubin, alanine aminotransferase, and prothrombin time within 48 h. Our findings suggest that performance of adequate diagnostic tests for HLH is essential for early diagnosis of HLH. Once suspected, immediate and adequate diagnostic tests for HLH should be arranged for PICU patients. Improvements in diagnostic procedures and monitoring plans are needed to promote early diagnosis of HLH.
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Affiliation(s)
- Xun Li
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, Changsha, China
| | - Haipeng Yan
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, China
| | - Zhenghui Xiao
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, China
| | - Xinping Zhang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, China
| | - Jiaotian Huang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, China
| | - Shi-Ting Xiang
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, Changsha, China
| | - Mincui Zheng
- Department of Pediatric Hematology, Hunan Children's Hospital, Changsha, China
| | - Zhenya Yao
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, China
| | - Ping Zang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, China
| | - Desheng Zhu
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, China
| | - Liping Li
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, Changsha, China
| | - Xiulan Lu
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, China
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Squire JD, Vazquez SN, Chan A, Smith ME, Chellapandian D, Vose L, Teppa B, Hanson IC, Chinn IK, Forbes-Satter L, Seeborg FO, Nicholas SK, Martinez CA, Allen CE, Connors TJ, Satwani P, Shtessel M, Ale H, Noroski LM, Rider NL, Milner JD, Leiding JW. Case Report: Secondary Hemophagocytic Lymphohistiocytosis With Disseminated Infection in Chronic Granulomatous Disease-A Serious Cause of Mortality. Front Immunol 2020; 11:581475. [PMID: 33362767 PMCID: PMC7756012 DOI: 10.3389/fimmu.2020.581475] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/20/2020] [Indexed: 01/09/2023] Open
Abstract
Chronic granulomatous disease (CGD) is a primary immune deficiency due to defects in phagocyte respiratory burst leading to severe and life-threatening infections. Patients with CGD also suffer from disorders of inflammation and immune dysregulation including colitis and granulomatous lung disease, among others. Additionally, patients with CGD may be at increased risk of systemic inflammatory disorders such as hemophagocytic lymphohistiocytosis (HLH). The presentation of HLH often overlaps with symptoms of systemic inflammatory response syndrome (SIRS) or sepsis and therefore can be difficult to identify, especially in patients with a primary immune deficiency in which incidence of infection is increased. Thorough evaluation and empiric treatment for bacterial and fungal infections is necessary as HLH in CGD is almost always secondary to infection. Simultaneous treatment of infection with anti-microbials and inflammation with immunosuppression may be needed to blunt the hyperinflammatory response in secondary HLH. Herein, we present a series of X-linked CGD patients who developed HLH secondary to or with concurrent disseminated CGD-related infection. In two patients, CGD was a known diagnosis prior to development of HLH and in the other two CGD was diagnosed as part of the evaluation for HLH. Concurrent infection and HLH were fatal in three; one case was successfully treated, ultimately receiving hematopoietic stem cell transplantation. The current literature on presentation, diagnosis, and treatment of HLH in CGD is reviewed.
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Affiliation(s)
- Jacqueline D Squire
- Division of Allergy and Immunology, Department of Pediatrics, University of South Florida, St. Petersburg, FL, United States
| | - Stephanie N Vazquez
- Graduate Medical Education, Memorial Healthcare System, Hollywood, FL, United States
| | - Angela Chan
- Division of Allergy/Immunology and Rheumatology, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, United States
| | - Michele E Smith
- Division of Critical Care Medicine, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, United States
| | - Deepak Chellapandian
- Blood and Marrow Transplant, Johns Hopkins-All Children's Hospital, St. Petersburg, FL, United States
| | - Laura Vose
- Critical Care Medicine, Johns Hopkins-All Children's Hospital, St. Petersburg, FL, United States
| | - Beatriz Teppa
- Critical Care Medicine, Johns Hopkins-All Children's Hospital, St. Petersburg, FL, United States
| | - I Celine Hanson
- Sections of Immunology Allergy and Retrovirology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Ivan K Chinn
- Sections of Immunology Allergy and Retrovirology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Lisa Forbes-Satter
- Sections of Immunology Allergy and Retrovirology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Filiz O Seeborg
- Sections of Immunology Allergy and Retrovirology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Sarah K Nicholas
- Sections of Immunology Allergy and Retrovirology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Caridad A Martinez
- Division of Pediatric Hematology/Oncology, Texas Children's Hospital Cancer Center, Houston, TX, United States
| | - Carl E Allen
- Division of Pediatric Hematology/Oncology, Texas Children's Hospital Cancer Center, Houston, TX, United States
| | - Thomas J Connors
- Division of Critical Care Medicine, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, United States
| | - Prakash Satwani
- Division of Hematology/Oncology, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, United States
| | - Maria Shtessel
- Division of Allergy/Immunology and Rheumatology, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, United States
| | - Hanadys Ale
- Division of Allergy and Immunology, Joe DiMaggio Children's Hospital, Hollywood, FL, United States
| | - Lenora M Noroski
- Sections of Immunology Allergy and Retrovirology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Nicholas L Rider
- Sections of Immunology Allergy and Retrovirology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Joshua D Milner
- Division of Allergy/Immunology and Rheumatology, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, United States
| | - Jennifer W Leiding
- Division of Allergy and Immunology, Department of Pediatrics, University of South Florida, St. Petersburg, FL, United States
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Almalky M, Saleh SHA, Baz EG, Fakhr AE. Novel mutation in perforin gene causing familial hemophagocytic lymphohistiocytosis type 2 in an Egyptian infant: case report. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2020. [DOI: 10.1186/s43042-020-00067-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of pathological immune activation characterized by clinical signs and symptoms of extreme inflammation. It results from the uninhibited proliferation and activation of cells of the macrophage lineage and leads to the production of excess amounts of pro-inflammatory cytokines. The familial form of HLH disease is due to mutations in several genes necessary for natural killer (NK) cell and T cell granule-mediated cytotoxic function. These genes are involved in sorting, trafficking, docking, and fusion of cytotoxic granules containing granzymes A and B and perforin to the cell membrane of the target cell (using the proteins LYST, AP-3 complex, Rab27a, Munc 13–4, Munc 18–2, syntaxin 11). Defect in any of those proteins results in defective cytotoxicity. Consequently, genes included in these steps play valuable roles in the pathogenesis of familial HLH disease including perforin (PRF1) gene in which defect causes familial HLH type 2 (FHL2).
Case presentation
A 2-year-old boy suffered from hepatosplenomegaly and fever. He fulfilled the required criteria for the diagnosis of HLH according to HLH-2004 diagnostic criteria. We screened the patient for the presence of mutations in the coding exons and of PRF1 gene by PCR amplification of genomic DNA followed by direct sequencing of the PCR products. We report a novel homozygous deletion/insertion frameshift mutation in PRF1 gene (M28393: exon 2: c.536delAinsCG p.F178fs). We treated him with HLH 2004 protocol of treatment and showed a remarkable response with resolution of fever and decrement in the size of hepatosplenomegaly.
Conclusions
Our study discovered a novel frameshift mutation in PRF1 gene in an infant with HLH disease, and it is the first report of this type of mutation in Egyptian patients with this disease.
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50
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Trovik LH, Sandnes M, Blomberg B, Holmaas G, Ahmed AB, Tvedt THA, Vintermyr O, Reikvam H. Hemophagocytic lymphohistiocytosis and miliary tuberculosis in a previously healthy individual: a case report. J Med Case Rep 2020; 14:217. [PMID: 33172493 PMCID: PMC7655140 DOI: 10.1186/s13256-020-02555-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/11/2020] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare heterogenous genetic or acquired hyperinflammatory syndrome associated with a high degree of morbidity and mortality. HLH has clinical manifestations related to abnormal prolonged activation of T lymphocytes and macrophages with an excess of proinflammatory cytokines. The main causes of secondary HLH are malignancies and infectious diseases. CASE PRESENTATION The patient was a 54-year-old man, originally from Eastern Africa, who had lived in Northern Europe for 30 years. Here we describe the clinical features, laboratory parameters, diagnostic workup, management and outcome data of a previously healthy 54-year-old man diagnosed with HLH secondary to tuberculosis. The patient was initially treated for a community-acquired pneumonia. He developed multiorgan failure with acute respiratory distress syndrome, hypertransaminasemia, and kidney and bone marrow dysfunction. The clinical course together with a simultaneous increase in serum ferritin raised the suspicion of HLH. The patient fulfilled seven out of eight diagnostic criteria for HLH. A thorough diagnostic workup with respect to HLH and a potential underlying disease was initiated. Cultivation of bronchoalveolar lavage fluid, stool and urine, and polymerase chain reaction of epithelioid cell granulomas in the bone marrow were all positive for Mycobacterium tuberculosis. He was treated for both HLH and tuberculosis, and he survived without any sequelae. CONCLUSIONS We present one of few published cases of a patient who survived HLH triggered by miliary tuberculosis. The current case illustrates the need for awareness of these two diagnoses, and the timely initiation of specific and supportive treatment to reduce mortality.
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Affiliation(s)
| | - Miriam Sandnes
- Department of Clinical Science, Institute of Clinical Science, University of Bergen, Bergen, Norway
| | - Bjørn Blomberg
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Institute of Clinical Science, University of Bergen, Bergen, Norway
| | - Gunhild Holmaas
- Department of Surgical Services, Haukeland University Hospital, Bergen, Norway
| | | | | | - Olav Vintermyr
- Department of Pathology, Haukeland University Hospital, Bergen, Norway.,Departemnt of Medical Science, University of Bergen, Bergen, Norway
| | - Håkon Reikvam
- Department of Medicine, Haukeland University Hospital, Bergen, Norway. .,Department of Clinical Science, Institute of Clinical Science, University of Bergen, Bergen, Norway.
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