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Xu S, He K. Hemophagocytic lymphohistiocytosis after solid organ transplantation: A challenge for clinicians. Transpl Immunol 2024; 83:102007. [PMID: 38307154 DOI: 10.1016/j.trim.2024.102007] [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: 02/21/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/04/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare inflammatory disorder with a high mortality rate and a wide range of symptoms. Solid organ transplantation, which provides patients with a unique immunosuppressive state, is a less common predisposing factor for HLH. HLH after solid organ transplantation (HLH-SOT) is very rare and fatal. It is hard to diagnose and treat and extremely understudied. The use of immunosuppressants makes the situation of HLH-SOT more complex. This review summarizes the existing literature on HLH after solid organ transplantation and describes its triggers and symptoms, focusing on its diagnosis and treatment. We performed a literature search of case reports, case series, letters to the editor, and clinical quizzes describing patients with HLH after solid organ transplantation (HLH-SOT). We provide recommendations on the diagnosis protocol and treatment strategy based on the existing evidence.
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Affiliation(s)
- Shanshan Xu
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Engineering Research Center of Transplantation and Immunology, Shanghai, China; Shanghai Institute of Transplantation, Shanghai, China
| | - Kang He
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Engineering Research Center of Transplantation and Immunology, Shanghai, China; Shanghai Institute of Transplantation, Shanghai, China.
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Valdés Francí E, Perez Flores I, Candel FJ, Moreno de la Higuera MA, Romero NC, Rodríguez Cubillo B, Lucena Valverde R, Sánchez Fructuoso AI. Hemophagocytic syndrome triggered by donor-transmitted toxoplasmosis as a complication in same-donor recipients of renal transplantation: Case report and review of the literature. Transpl Infect Dis 2021; 23:e13732. [PMID: 34533259 DOI: 10.1111/tid.13732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 07/16/2021] [Accepted: 09/05/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hemophagocytic syndrome (HPS) is an infrequent complication of transplantation caused by an inflammatory response with a benign proliferation of macrophages and defective lytic capability of T lymphocytes and NK cells that can lead to multiorgan failure. Transplant patients are particularly exposed as a result of the increased risk of both infections and malignancies derived from immunosuppressive drugs. There is no consensus for therapy or immunosuppression; mortality is high. We report a case and present a review of all cases of HPS occurring in solid organ transplant recipients. CASE REPORT: We report two cases of infection by Toxoplasma gondii transmitted by the kidney allograft. One of the recipients was seronegative before transplantation and developed disseminated primary toxoplasmosis. An immune reaction compatible with an HPS ensued. Both were treated with Trimethoprim/sulfamethoxazole, immunosuppression was tapered, and after a 2-week period a complete response was obtained. CONCLUSION HPS presents therapeutic challenges in the context of transplantation. If HPS is suspected, the search of a very likely underlying infection should be central to the management.
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Affiliation(s)
- Elena Valdés Francí
- Nephrology Department, Clínico San Carlos University Hospital, Madrid, Spain
| | - Isabel Perez Flores
- Nephrology Department, Clínico San Carlos University Hospital, Madrid, Spain
| | - Francisco Javier Candel
- Department of Clinical Microbiology and Infectious Diseases, Clínico San Carlos University Hospital, Madrid, Spain
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Nieto-Ríos JF, Morales-Contreras CL, Chacón-Jaimes DC, Benavides-Henao DA, Bello-Márquez DC, Serna-Higuita LM. Linfohistiocitosis hemofagocítica en trasplante renal. IATREIA 2019. [DOI: 10.17533/udea.iatreia.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
La linfohistiocitosis hemofagocítica (LHH) posterior al trasplante renal hace referencia a un estado hiperinflamatorio grave, asociado a la activación no controlada de los linfocitos T citotóxicos y macrófagos por causa infecciosas y/o secundaria al tratamiento inmunosupresor. Las causas más prevalentes dentro de las infecciones son la histoplasmosis, la tuberculosis y las infecciones por virus herpes. Se caracteriza por fiebre, organomegalias, citopenias, hiperferritinemia, hipertrigliceridemia y/o hipofibrinogenemia; puede acompañarse con hemofagocitosis documentada en la médula ósea, el hígado u otros órganos. Su curso puede ser fulminante con progresión a falla multisistémica y la muerte.El tratamiento va enfocado a controlar tempranamente la causa desencadenante, reducir la inmunosupresión y controlar la inflamación. En pocos casos es necesario el uso de otros inmunosupresores, quimioterapia o, en situaciones muy seleccionadas, se puede requerir el trasplante de médula ósea.
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Jarchin L, Chu J, Januska M, Merola P, Arnon R. Autoimmune hemolytic anemia: An unusual presentation of hemophagocytic lymphohistiocytosis in a pediatric post-liver transplant patient. Pediatr Transplant 2018; 22:e13281. [PMID: 30129086 DOI: 10.1111/petr.13281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/09/2018] [Accepted: 07/24/2018] [Indexed: 01/19/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH), a rare condition characterized by immune dysfunction with uncontrolled activation of macrophages and hypersecretion of cytokines, has only been reported in a small number of pediatric patients following solid organ transplant (SOT). The diagnosis of HLH after SOT is especially difficult, as several of the diagnostic criteria, including fever, splenomegaly, and cytopenias, are nonspecific and can be seen with other post-transplant complications. Autoimmune hemolytic anemia (AIHA) has also been reported after pediatric SOT and is thought to be related to immunosuppression, specifically tacrolimus. Although HLH and AIHA have been separately described following SOT, there have been no reports of them occurring together in post-liver transplant (LT) patients. We report the first case of autoimmune hemolysis as the presenting symptom of HLH in a pediatric post-LT patient.
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Affiliation(s)
- Lauren Jarchin
- Division of Pediatric Gastroenterology, Mount Sinai Medical Center, New York City, New York
| | - Jaime Chu
- Recanati/Miller Transplantation Institute at Mount Sinai, Mount Sinai Medical Center, New York City, New York
| | - Megan Januska
- Department of Pediatrics, Mount Sinai Medical Center, New York City, New York
| | - Pamela Merola
- Division of Pediatric Hematology-Oncology, Mount Sinai Medical Center, New York City, New York
| | - Ronen Arnon
- Recanati/Miller Transplantation Institute at Mount Sinai, Mount Sinai Medical Center, New York City, New York
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Lima VDACDC, Gouvêa ALF, Menezes P, Santos JDF, Rochael MC, Carvalho FR, Almeida JR, Lugon JR. Hemophagocytic lymphohistiocytosis, a rare condition in renal transplant - a case report. ACTA ACUST UNITED AC 2018; 40:423-427. [PMID: 30328466 PMCID: PMC6533997 DOI: 10.1590/2175-8239-jbn-2018-0012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 07/07/2018] [Indexed: 11/30/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an uncommon and life-threating
condition characterized by major immune activation and massive cytokine
production by mononuclear inflammatory cells, due to defects in cytotoxic
lymphocyte function. It is even more unusual in renal transplant recipients, in
which it is often associated with uncontrolled infection. The mortality is high
in HLH and differential diagnosis with sepsis is a challenge. The approach and
management depend on the underlying trigger and comorbidities. We report a case
of a 50-year-old renal transplant female admitted with fever and malaise 3
months post-transplant and presenting anemia, fever, hypertriglyceridemia, high
levels of serum ferritin, and positive CMV antigenemia. Urine was positive for
decoy cells and BKV-DNA. Graft biopsy showed CMV nephritis. Both blood and urine
cultures where positive for E. coli. Hemophagocytosis was
confirmed by bone marrow aspiration. Immunosuppression was reduced, and the
patient received high-dose intravenous immunoglobulin and dexamethasone, with
complete response after 3 weeks. We highlight the importance of early diagnosis
and proper management of a rare and serious condition in a renal transplant
patient, which can allow a favorable clinical course and improve survival
rate.
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Affiliation(s)
| | | | - Paulo Menezes
- Universidade Federal Fluminense, Niterói, RJ, Brasil
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