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Gopal A, Kim SJ. Hemophagocytic Lymphohistiocytosis in a Remote Kidney Transplant Recipient Triggered by HSV Infection With Complete Recovery: An Educational Case Report. Can J Kidney Health Dis 2024; 11:20543581241253921. [PMID: 38799982 PMCID: PMC11119350 DOI: 10.1177/20543581241253921] [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: 01/27/2024] [Accepted: 04/15/2024] [Indexed: 05/29/2024] Open
Abstract
Rationale Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease characterized by excessive immune activation. It is more commonly seen in children but increasingly recognized in adults. Primary HLH relies on a genetic predisposition, whereas secondary HLH develops in the context of infections, malignancies, or autoimmune diseases. Hemophagocytic lymphohistiocytosis has been rarely described in patients on immunosuppressive therapy after kidney transplant. Here, we describe a case of HLH in a patient with a remote history of kidney transplant, triggered by a viral infection. Presenting Concerns A 45-year-old female, with a kidney transplant in 2009 for IgA nephropathy, presented with fever, vomiting, and back pain of 1-week duration. She was on triple immunosuppression consisting of daily doses of prednisone 5 mg, azathioprine 100 mg, and tacrolimus extended release 1 mg, and a baseline creatinine of 130 µmol/L. Diagnosis Initial investigations showed anemia, leukopenia, elevated serum creatinine, transaminitis, and markedly increased ferritin of 67 600 µg/L which prompted a bone marrow biopsy to rule out HLH. The bone marrow showed an increased proportion of CD68+ cells (macrophages) with more than 5 in 1000 hemophagocytic macrophages. Her soluble IL-2 receptor (CD25) level was 3406 pg/mL (606-2299 pg/mL) which was mildly elevated. She fulfilled 4 of the 8 criteria for HLH and with an H score was 223 which suggested a diagnosis of HLH with 96.9% probability. An extensive secondary workup for possible triggers for HLH led to a swab from genital ulcers that was positive for herpes simplex virus (HSV) type 2. The polymerase chain reaction (PCR) in the blood for HSV type 2 was also positive. Interventions Given the diagnosis of HSV type 2 as the putative trigger for HLH, she was started on parenteral acyclovir for 2 weeks followed by oral valacyclovir for 2 more weeks. In the context of infection, the azathioprine was stopped while low-dose steroid and tacrolimus were continued. Outcomes With the initiation of treatment for HSV infection, leukopenia, creatinine, and transaminases improved along with ferritin levels. At her 6-month follow-up, her blood counts and liver enzymes had normalized, and ferritin was 566 µg/L. Teaching points Hemophagocytic lymphohistiocytosis is a rare disease in kidney transplant recipients with a high mortality rate. It can occur even in remote kidney transplant recipients so a high degree of suspicion is necessary to lead to a prompt diagnosis. Infections are common triggers for secondary HLH. Early identification and treatment of the triggering infection may improve outcomes.
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Affiliation(s)
- Anjana Gopal
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - S. Joseph Kim
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
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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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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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Masood M, Siddique A, Krishnamoorthi R, Kozarek RA. Liver Dysfunction in Adult Hemophagocytic Lymphohistiocytosis: A Narrative Review. Adv Ther 2024; 41:553-566. [PMID: 38145441 DOI: 10.1007/s12325-023-02768-8] [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: 11/07/2023] [Accepted: 12/08/2023] [Indexed: 12/26/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening condition that has been increasingly recognized in adults and is characterized by a hyperinflammatory state due to immune dysregulation. Its nonspecific presentation, the lack of clinician familiarity given its rarity, and shared clinical features with sepsis and other syndromes can lead to a delay in diagnosis and a poor prognosis. Significant liver function abnormalities as the initial manifestation of HLH are uncommon and can range from mild elevation of aminotransferases to fulminant hepatic failure with high mortality rates. The authors encountered a case of adult HLH mimicking acute viral hepatitis in which a markedly elevated ferritin level led to a prompt diagnosis, early initiation of treatment, and a successful outcome. Clinicians, including gastroenterologists and hepatologists, are often called upon to evaluate patients with abnormal liver tests and may lack experience in the early diagnosis and management of liver dysfunction in the context of HLH. Thus, we expand our reporting to a narrative review of literature which explores the pathogenesis of HLH, challenges associated with its diagnosis, previous reports of liver disease associated with the syndrome, recommended treatments for the familial and adult variations including the role of liver transplantation, and the outcomes of these treatments.
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Affiliation(s)
- Muaaz Masood
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Asma Siddique
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Rajesh Krishnamoorthi
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA
| | - Richard A Kozarek
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, Seattle, WA, USA.
- Center for Interventional Immunology, Benaroya Research Institute, Virginia Mason Franciscan Health, 1201 Ninth Ave, Seattle, WA, 98101, USA.
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Qiu Q, Li D, Chen Y, Song Y, Lou S, Zhou K, Deng J. Clinical features and prognostic risk prediction of adult hemophagocytic lymphohistiocytosis: a 9-year retrospective study. Ann Hematol 2023; 102:2671-2682. [PMID: 37464139 DOI: 10.1007/s00277-023-05368-2] [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: 02/07/2023] [Accepted: 07/11/2023] [Indexed: 07/20/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) has a low incidence and high mortality. In order to improve our understanding of the clinical features and prognostic risk factors of adult HLH, we analyzed the clinical characteristics and prognostic risk factors of adult HLH and developed a prognostic model to predict the overall survival (OS) of adult HLH. The clinical characteristics and survival statistics of adult patients with HLH identified at The Second Affiliated Hospital of Chongqing Medical University between February 2012 and October 2020 were retrospectively analyzed to constitute the primary cohort, while patients between 25 October 2020 and 20 March 2023 were collected at the same institution as a validation cohort for the prospective study. A total of 142 patients met the inclusion criteria, with 72 and 70 in the primary cohort and validation cohort respectively. In the primary cohort, the median OS was 102 days, with 37.5%, 34.5%, and 28.7% 1-, 2-, and 3-year OS, respectively. Univariate analysis showed that age, interleukin-10 (IL-10), interleukin-2 receptor (IL-2R), prothrombin time (PT), and indirect bilirubin (IBiL) were correlated with prognosis. Multivariate analysis showed that IL-10 and PT were independent factors affecting OS in adult patients with HLH. A prognostic model consisting of IL-2R, PT, and IL-10 and a corresponding prognostic nomogram were developed adopting the principle of minimum value of Akaike information criterion(AIC). The model has a high prediction accuracy letter (C-index = 0.708). The AUC values of 1-year, 2-year, and 3-year were 0.826, 0.865, and 0.882, correspondingly. In the validation cohort, all patients were divided into high-risk and low-risk groups, and the risk of death was significantly higher in the high-risk group than in the low-risk group (p < 0.01). The calibration curve for the model shows that the Nomogram constructed in this study is very reliable to predict the OS of HLH patients. IL-10 and PT have significant prognostic value in adult HLH. The prognostic model and the nomogram built in this study can forecast the OS of adult HLH patients.
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Affiliation(s)
- Qunxiang Qiu
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Dan Li
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Ying Chen
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Ying Song
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Shifeng Lou
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Kang Zhou
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
| | - Jianchuan Deng
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
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Chen X, Wang S, Yang J, Wang X, Yang L, Zhou J. The predictive value of hematological inflammatory markers for acute kidney injury and mortality in adults with hemophagocytic Lymphohistiocytosis: A retrospective analysis of 585 patients. Int Immunopharmacol 2023; 122:110564. [PMID: 37451019 DOI: 10.1016/j.intimp.2023.110564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/22/2023] [Accepted: 06/22/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare immunological hyperactivation-related disease with a high mortality rate. The purpose of this study was to examine the relationship between complete blood count parameters and the occurrence of acute kidney injury (AKI) and mortality in patients with HLH. METHODS We included 585 adult patients with HLH. Logistic regression models for AKI and 28-day mortality were developed. RESULTS Multivariate logistic regression models revealed that hemoglobin (HB) ≤ 7.3 g/dl (adjusted OR, 1.651; 95% CI, 1.044-2.612), hemoglobin-to-red blood cell distribution width ratio (HRR) < 0.49 (adjusted OR, 1.692), neutrophil-to-lymphocyte ratio (NLR) ≥ 3.15 (adjusted OR, 1.697), and neutrophil-to-lymphocyte-platelet ratio (NLPR) ≥ 11.0 (adjusted OR, 1.608) were independent risk factors for the development of AKI. Moreover, lower platelet levels (31 × 109/L < platelets < 84 × 109/L, adjusted OR, 2.133; platelets ≤ 31 × 109/L, adjusted OR, 3.545) and higher red blood cell distribution width-to-platelet ratio (RPR) levels (0.20 < RPR < 0.54, adjusted OR, 2.595; RPR ≥ 0.54, adjusted OR, 4.307), lymphocytes ≤ 0.34 × 109/L (adjusted OR, 1.793), NLPR ≥ 11.0 (adjusted OR, 2.898), and the aggregate index of systemic inflammation (AISI) ≤ 7 (adjusted OR,1.778) were also independent risk factors for 28-day mortality. Furthermore, patients with AKI had a worse prognosis than those without AKI (P < 0.05). CONCLUSION In patients with HLH, hematological parameters are of great value for the early identification of patients at high risk of AKI and 28-day mortality.
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Affiliation(s)
- Xuelian Chen
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Siwen Wang
- Department of Occupational Disease and Toxicosis/Nephrology, West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jia Yang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Wang
- Department of Pediatric Nephrology, West China Second Hospital, Sichuan University, Chengdu, China
| | - Lichuan Yang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Jiaojiao Zhou
- Department of Medical Ultrasound, West China Hospital, Sichuan University, Chengdu, China.
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Abdelhay A, Mahmoud AA, Al Ali O, Hashem A, Orakzai A, Jamshed S. Epidemiology, characteristics, and outcomes of adult haemophagocytic lymphohistiocytosis in the USA, 2006-19: a national, retrospective cohort study. EClinicalMedicine 2023; 62:102143. [PMID: 37599909 PMCID: PMC10432999 DOI: 10.1016/j.eclinm.2023.102143] [Citation(s) in RCA: 1] [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: 05/02/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023] Open
Abstract
Background Haemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening syndrome characterized by an excessive inflammatory response. Limited data exist on adult HLH. Methods In this national, retrospective cohort study, we analysed data from the US National Inpatient Sample database collected between October 1, 2006 and December 31, 2019. Using the International Classification of Diseases (ICD) codes, we identified all adult patients who were admitted non-electively with the diagnosis of HLH. We described demographic characteristics, triggers, and associated conditions. Trends of diagnosis, treatment, and in-hospital mortality were analysed using joinpoint models. In-hospital mortality rates were compared using multivariable logistic regression models that adjusted for demographic characteristics and associated conditions. Finally, we described resource utilization outcomes including cost of hospitalization and length of stay. Findings We identified 16,136 non-elective adult HLH admissions. The population pyramid showed a bimodal distribution, with peaks in young adults (16-30 years) and older adults (56-70 years). Joinpoint regression analysis revealed a significant increase in HLH incidence per 100,000 admissions over the study period (Average Annual Percent Change [APC] = 25.3%, p < 0.0001), and no significant change in rates of in-hospital mortality (slope = -0.01; p = 0.95) or administration of in-hospital HLH treatment (slope = 0.46, p = 0.20). The most common associated conditions were malignancy (4953 admissions [30.7%]), infections (3913 admissions [24.3%]), autoimmune conditions (3362 admissions [20.8%]), organ transplant status (639 admissions [4%]), and congenital immunodeficiency syndromes (399 admissions [2.5%]). In-hospital mortality was higher in older adults and males. Furthermore, Congenital immunodeficiency syndromes had the worst in-hospital mortality rate (mortality rate 31.1%, adjusted OR 2.36 [1.56-3.59]), followed by malignancies (mortality rate 28.4%, adjusted OR 1.80 [1.46-2.22]), infections (mortality rate 21.4%, adjusted OR 1.33 [1.10-1.62]), other/no trigger (mortality rate 13.6%, adjusted OR 0.73 [0.58-0.92]), autoimmune (mortality rate 13%, adjusted OR 0.72 [0.57-0.92]), and post-organ transplant status (mortality rate 14.1%, adjusted OR 0.64 [0.43-0.97]). The overall mean length of stay was 14.3 ± 13.9 days, and the mean cost of hospitalization was $54,900 ± 59,800. Interpretation We provide insight into the burden of adult HLH in the USA. The incidence has been increasing and the outcomes remain dismal. This signifies the growing need for the development of updated diagnosis and treatment protocols that are specific to adult HLH. Funding None.
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Affiliation(s)
- Ali Abdelhay
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Amir A. Mahmoud
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Omar Al Ali
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Anas Hashem
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Abdullah Orakzai
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Saad Jamshed
- Division of Hematology and Oncology, Rochester Regional Health, Rochester, NY, USA
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"A Dangerous Black Box:" Idiopathic Hemophagocytic Lymphohistiocytosis in Adult Patients-A Case Report and Review of the Literature. Case Rep Hematol 2022; 2022:5867129. [PMID: 36510501 PMCID: PMC9741541 DOI: 10.1155/2022/5867129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 11/20/2022] [Accepted: 11/22/2022] [Indexed: 12/05/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare potentially life-threatening condition characterized by aberrant inflammation that can be related to genetic or sporadic forms. In both forms, triggering factors may be involved. Early detection of the underlying cause is crucial for therapeutic decision, while early intervention might be associated with better outcomes. The largest descriptions in the literature on HLH refer to pediatric cases. Adolescents and adults may also be affected, but there is scarce evidence regarding their diagnosis and management. We describe here the case of a 68-year-old Swiss woman with HLH, in whom an extensive search for underlying causes was performed, but neither trigger nor pathogenic variant was found. An early intervention first with dexamethasone and later with cyclosporine was performed. The patient showed a favorable response and did not require further hospitalization; however, one year after diagnosis, it was not possible to suspend cyclosporine due to recurrence of laboratory inflammation signs by drug tapering. The occurrence of HLH idiopathic forms represents a challenge; failure to identify the underlying triggering cause generates uncertainty, endless diagnostic investigations, and consequently additional delays in the treatment. This manuscript addresses the difficulties on this issue.
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Yildiz H, Castanares-Zapatero D, d’Abadie P, Bailly S, Yombi JC. Hemophagocytic Lymphohistiocytosis in Adults: A Retrospective Study in a Belgian Teaching Hospital. Int J Gen Med 2022; 15:8111-8120. [PMID: 36389021 PMCID: PMC9653050 DOI: 10.2147/ijgm.s388880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/03/2022] [Indexed: 11/09/2022] Open
Abstract
Introduction Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease, which can be primary (due to genetic mutation) or secondary to malignancy, infection and rheumatologic diseases. Data concerning Belgian patients with adult HLH are lacking. Methods This retrospective study was performed in a teaching hospital in Belgium. All cases of adult HLH, from December 2010 to April 2022, were reviewed. Patients with more than five HLH-2004 criteria and/or HScore >80% were included in the study. The objective of our study was to describe clinical and biological characteristics of patients with HLH and attempt to look for variables associated with mortality. Results Fifty-two patients were included in the final analysis. Mean age (SD) of patients was 48 (18) years old, and 29 patients were of male gender (56%). The underlying diseases associated with HLH were malignancy (M-HLH) in 22 patients, infection related HLH in 20 patients, rheumatologic disease related HLH in 7 patients, idiopathic in 2 patients and secondary to pregnancy in 1 patient. Overall mortality, mortality at 30 days and 90 days were 24/52 (46%), 13/52 (25%) and 4/52 (10%), respectively. In univariate analysis, malignancy, male sex, age and disseminated intravascular coagulation (DIC) were associated with mortality (p < 0.05). In multivariate analysis, only age was significantly associated with mortality (odds ratio, 1.053; 95% confidence interval, 1.016–1.092; p 0.005). Conclusion In our study, the most frequent triggers were malignancy and infectious agent followed by rheumatologic disease. Risk factors for mortality were age, male sex, malignancy and DIC, but only age remained significant in multivariate analysis. Treatment guidelines are mainly based on pediatric patients, and it is important for physician to describe adult patients’ outcome to better understand this disease and adapt treatment.
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Affiliation(s)
- Halil Yildiz
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, UClouvain, Bruxelles, Belgium
- Correspondence: Halil Yildiz, Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, UClouvain, 10 Av Hippocrate, Bruxelles, 1200, Belgium, Email
| | | | - Philippe d’Abadie
- Department of Nuclear Medicine, Cliniques Universitaires Saint-Luc, UClouvain, Bruxelles, Belgium
| | - Sarah Bailly
- Department of Hematology, Cliniques Universitaires Saint-Luc, UClouvain, Bruxelles, Belgium
| | - Jean Cyr Yombi
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, UClouvain, Bruxelles, Belgium
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Wang D, Tong X, Liu S, Zhang W, Wang L, Zhang S, Zhang T, Wang Q, Fan H. Clinical characteristics and risk factors for 90-day overall survival among 204 adult patients with secondary hemophagocytic lymphohistiocytosis: Experience from a single-center retrospective study. Front Med (Lausanne) 2022; 9:774959. [PMID: 36300188 PMCID: PMC9589347 DOI: 10.3389/fmed.2022.774959] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/12/2022] [Indexed: 11/22/2022] Open
Abstract
Objectives To describe the clinical characteristics of secondary hemophagocytic lymphohistiocytosis (HLH) among adult patients, investigate its risk factors for 90-day overall survival (OS) from diagnosis, and establish a new prognostic model applicable to adult patients with secondary HLH. Methods We conducted a retrospective cohort study of 204 adult patients with secondary HLH, between January 2010 and December 2020. All patients met at least five HLH-2004 criteria. Clinical features, laboratory results, treatments, and clinical outcomes of the patients were reviewed. Prognostic factors associated with 90-day overall survival from diagnosis were screened using Cox proportional hazard models. Results The most common trigger was malignancy (61.3%). Multivariate analysis showed that age, coagulopathy, levels of hemoglobin, aspartate aminotransferase (AST), lactate dehydrogenase (LDH), creatinine, ferritin, and prothrombin time (PT) were independent prognostic factors for 90-day OS from the diagnosis of HLH. Based on the above risk factors, the patients were further divided into two groups: low-risk (≤4 risk factors) and high-risk (>4 risk factors), with overall 90-day survival rates of 82.7 and 28.1%, respectively (P < 0.001). Conclusion Patients with older age, coagulopathy, lower hemoglobin, and AST levels, elevated LDH, creatinine and ferritin levels, and prolonged PT tended to have a worse prognosis. Moreover, our prognostic model provides the possibility of forecasting the clinical outcome of adult secondary HLH patients, although a larger sample, multicenter, randomized controlled clinical study is needed to verify the accuracy of the prognostic model.
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Affiliation(s)
- Dongguang Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Xiang Tong
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Sitong Liu
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Wentao Zhang
- College of Computer Science, Sichuan University, Chengdu, China
| | - Lian Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Shijie Zhang
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Tianli Zhang
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Qian Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Hong Fan
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China,*Correspondence: Hong Fan
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Jin Z, Suolitiken D, Wang Y, Wang Z. The diagnostic importance of multiple cytokines in adult hemophagocytic lymphohistiocytosis. J Clin Lab Anal 2022; 37:e24669. [PMID: 36036769 PMCID: PMC10156101 DOI: 10.1002/jcla.24669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 08/03/2022] [Accepted: 08/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a category of immunological illnesses that cause out-of-control T cells and macrophages to release life-threatening cytokines. The HLH-2004 diagnostic criteria are the gold standard for HLH diagnosis, but there is a need to investigate the usefulness of various cytokines for HLH diagnosis. METHODS Patients admitted to Beijing Friendship Hospital of Capital Medical University from January 2016 to December 2020 were included in this retrospective study, with 166 patients with confirmed HLH and 142 febrile patients requiring differential diagnosis completing the sum. Multiplex cytokine assays using multifactor liquid phase microarray technology-based multifactor liquid phase microarray technology were used to detect 33 cytokines. Twenty-eight cytokines detected using the Luminex analytical platform technology were ultimately included in the analysis. RESULTS Interleukin-1 receptor antagonist (IL-1 RA), IL-18, interferon-γ (IFN-γ), and interferon-induced protein 10 (IP-10) regulated upon activation normal T cell expressed and secreted (RANTES), eotaxin, growth-related oncogene α (GRO-α), and macrophage inflammatory protein-1 α (MIP-1α) were higher in the HLH group than in the non-HLH group, and the differences were statistically significant. Among them, the area under the curve (AUC) for IL-18 for HLH diagnosis was reported for the first time as 82.69%, with a sensitivity of 76.32% and a specificity of 79.61%; the AUC of IL-1 RA was 72.34%, with a sensitivity of 62.71% and a specificity of 75.97%; and the AUC of IP-10 was 71.73%, with a sensitivity of 60.14% and a specificity of 75.15%. Moreover, the AUC of the combined diagnostic tests for IL-1 RA, IL-18, IFN-γ, IP-10, and RANTES was 99.6%, with a sensitivity of 95.8% and a specificity of 98.6%. CONCLUSION Our study concluded that multiple cytokines are valid biological markers for the diagnosis of HLH. The findings of this study remain to be validated in an external dataset.
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Affiliation(s)
- Zhili Jin
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Dina Suolitiken
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yini Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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12
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Shen Z, Jin Y, Sun Q, Zhang S, Chen X, Hu L, He C, Wang Y, Liu Q, Zhang H, Liu X, Wang L, Jiao J, Miao Y, Gu W, Wang F, Wang C, Shi Y, Ye J, Zhu T, Sun C, Song X, Xu L, Yan D, Sun H, Cao J, Li D, Li Z, Wang Z, Huang S, Xu K, Sang W. A Novel Prognostic Index Model for Adult Hemophagocytic Lymphohistiocytosis: A Multicenter Retrospective Analysis in China. Front Immunol 2022; 13:829878. [PMID: 35251016 PMCID: PMC8894441 DOI: 10.3389/fimmu.2022.829878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 01/28/2022] [Indexed: 11/13/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an immune disorder with rapid progression and poor survival. Individual treatment strategy is restricted, due to the absence of precise stratification criteria. In this multicenter retrospective study, we aimed to develop a feasible prognostic model for adult HLH in China. A total of 270 newly diagnosed patients of adult HLH were retrieved from the Huaihai Lymphoma Working Group (HHLWG), of whom 184 from 5 medical centers served as derivation cohort, and 86 cases from 3 other centers served as validation cohort. X-Tile program and Maxstat analysis were used to identify optimal cutoff points of continuous variables; univariate and multivariate Cox analyses were used for variable selection, and the Kaplan–Meier curve was used to analyze the value of variables on prognosis. The C-index, Brier Score, and calibration curve were used for model validation. Multivariate analysis showed that age, creatinine, albumin, platelet, lymphocyte ratio, and alanine aminotransferase were independent prognostic factors. By rounding up the hazard ratios from 6 significant variables, a maximum of 9 points was assigned. The final scoring model of HHLWG-HPI was identified with four risk groups: low risk (≤3 pts), low-intermediate risk (4 pts), high-intermediate risk (5-6 pts), and high risk (≥7 pts), with 5-year overall survival rates of 68.5%, 35.2%, 21.3%, and 10.8%, respectively. The C-indexes were 0.796 and 0.758 in the derivation and validation cohorts by using a bootstrap resampling program. In conclusion, the HHLWG-HPI model provides a feasible and accurate stratification system for individualized treatment strategy in adult HLH.
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Affiliation(s)
- Ziyuan Shen
- Department of Epidemiology and Biostatistics, School of Public Health, Xuzhou Medical University, Xuzhou, China
| | - Yingliang Jin
- Center for Medical Statistics and Data Analysis, School of Public Health, Xuzhou Medical University, Xuzhou, China
| | - Qian Sun
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Shuo Zhang
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xi Chen
- Department of Epidemiology and Biostatistics, School of Public Health, Xuzhou Medical University, Xuzhou, China
| | - Lingling Hu
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Chenlu He
- Department of Epidemiology and Biostatistics, School of Public Health, Xuzhou Medical University, Xuzhou, China
| | - Ying Wang
- Department of Personnel, Suqian First Hospital, Suqian, China
| | - Qinhua Liu
- Department of Hematology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Hao Zhang
- Department of Hematology, The Affiliated Hospital of Jining Medical University, Jining, China
| | - Xin Liu
- Department of Hematology, The Affiliated Hospital of Jining Medical University, Jining, China
| | - Ling Wang
- Department of Hematology, Taian Central Hospital, Taian, China
| | - Jun Jiao
- Department of Hematology, Taian Central Hospital, Taian, China
| | - Yuqing Miao
- Department of Hematology, Yancheng First People’s Hospital, Yancheng, China
| | - Weiying Gu
- Department of Hematology, The First People’s Hospital of Changzhou, Changzhou, China
| | - Fei Wang
- Department of Hematology, The First People’s Hospital of Changzhou, Changzhou, China
| | - Chunling Wang
- Department of Hematology, Huai’an First People’s Hospital, Huai’an, China
| | - Yuye Shi
- Department of Hematology, Huai’an First People’s Hospital, Huai’an, China
| | - Jingjing Ye
- Department of Hematology, Qilu Hospital of Shandong University, Jinan, China
| | - Taigang Zhu
- Department of Hematology, The General Hospital of Wanbei Coal-Electric Group, Suzhou, China
| | - Cai Sun
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xuguang Song
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Linyan Xu
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Dongmei Yan
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Haiying Sun
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Jiang Cao
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Depeng Li
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhenyu Li
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Shuiping Huang
- Center for Medical Statistics and Data Analysis, School of Public Health, Xuzhou Medical University, Xuzhou, China
- *Correspondence: Wei Sang, ; Kailin Xu, ; Shuiping Huang,
| | - Kailin Xu
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
- *Correspondence: Wei Sang, ; Kailin Xu, ; Shuiping Huang,
| | - Wei Sang
- Department of Hematology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
- *Correspondence: Wei Sang, ; Kailin Xu, ; Shuiping Huang,
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13
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Koumadoraki E, Madouros N, Sharif S, Saleem A, Jarvis S, Khan S. Hemophagocytic Lymphohistiocytosis and Infection: A Literature Review. Cureus 2022; 14:e22411. [PMID: 35345677 PMCID: PMC8942143 DOI: 10.7759/cureus.22411] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 02/19/2022] [Indexed: 11/21/2022] Open
Abstract
Hemophagocytic lymphocytosis (HLH) is a life-threatening, underdiagnosed syndrome caused by the excessive release of inflammatory mediators. Primary lymphocytosis is usually seen in young children and is associated with genetic defects, while secondary lymphocytosis is presented in adults due to malignancy, rheumatic disease, or infection. The aim of this study is to describe the infectious agents that trigger HLH in the adult population and provide diagnostic and treatment guidelines for this life-threatening syndrome. We conducted a literature review using PubMed as our basic database. We collected papers from the past six years that studied infectious agents that triggered HLH and described the most recommended treatment options for this serious condition. A total of 32 studies were included for this literature review.HLH is considered a syndrome with variable symptoms, and clinicians should be familiar with its complexity and the pathologies that could contribute to its presentation. Collaboration between physicians and awareness are basic steps for the management of patients with HLH.
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Affiliation(s)
- Evgenia Koumadoraki
- Pathology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Nikolaos Madouros
- Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Shayka Sharif
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Amber Saleem
- Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sommer Jarvis
- Anatomy/Cell Biology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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14
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Harada T, Tsuboi I, Hino H, Yuda M, Hirabayashi Y, Hirai S, Aizawa S. Age-related exacerbation of hematopoietic organ damage induced by systemic hyper-inflammation in senescence-accelerated mice. Sci Rep 2021; 11:23250. [PMID: 34853370 PMCID: PMC8636590 DOI: 10.1038/s41598-021-02621-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 11/16/2021] [Indexed: 12/11/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening systemic hyper-inflammatory disorder. The mortality of HLH is higher in the elderly than in young adults. Senescence-accelerated mice (SAMP1/TA-1) exhibit characteristic accelerated aging after 30 weeks of age, and HLH-like features, including hematopoietic organ damage, are seen after lipopolysaccharide (LPS) treatment. Thus, SAMP1/TA-1 is a useful model of hematological pathophysiology in the elderly with HLH. In this study, dosing of SAMP1/TA-1 mice with LPS revealed that the suppression of myelopoiesis and B-lymphopoiesis was more severe in aged mice than in young mice. The bone marrow (BM) expression of genes encoding positive regulators of myelopoiesis (G-CSF, GM-CSF, and IL-6) and of those encoding negative regulators of B cell lymphopoiesis (TNF-α) increased in both groups, while the expression of genes encoding positive-regulators of B cell lymphopoiesis (IL-7, SDF-1, and SCF) decreased. The expression of the GM-CSF-encoding transcript was lower in aged mice than in young animals. The production of GM-CSF by cultured stromal cells after LPS treatment was also lower in aged mice than in young mice. The accumulation of the TNF-α-encoding transcript and the depletion of the IL-7-encoding transcript were prolonged in aged mice compared to young animals. LPS dosing led to a prolonged increase in the proportion of BM M1 macrophages in aged mice compared to young animals. The expression of the gene encoding p16INK4a and the proportion of β-galactosidase- and phosphorylated ribosomal protein S6-positive cells were increased in cultured stromal cells from aged mice compared to those from young animals, while the proportion of Ki67-positive cells was decreased in stromal cells from aged mice. Thus, age-related deterioration of stromal cells probably causes the suppression of hematopoiesis in aged mice. This age-related latent organ dysfunction may be exacerbated in elderly people with HLH, resulting in poor prognosis.
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Affiliation(s)
- Tomonori Harada
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Isao Tsuboi
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Hirotsugu Hino
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Miyuki Yuda
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yoko Hirabayashi
- Center for Biological Safety and Research, National Institute of Health Sciences, Kawasaki, 210-9501, Japan
| | - Shuichi Hirai
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Shin Aizawa
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
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15
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Aziz A, Castaneda EE, Ahmad N, Veerapalli H, Rockferry AG, Lankala CR, Hamid P. Exploring Macrophage Activation Syndrome Secondary to Systemic Lupus Erythematosus in Adults: A Systematic Review of the Literature. Cureus 2021; 13:e18822. [PMID: 34804679 PMCID: PMC8592789 DOI: 10.7759/cureus.18822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 10/16/2021] [Indexed: 02/06/2023] Open
Abstract
Among the autoimmune (AI) diseases, systemic lupus erythematosus (SLE) is known to mimic various disease processes and this can lead to under-diagnosis of macrophage activation syndrome (a dire complication). We aimed at performing a systematic review to identify trigger factors that could lead to the development of macrophage activation syndrome (MAS) in patients with SLE as well as identify factors that can affect mortality. We searched the following databases to extract relevant articles: PubMed, ScienceDirect, Cochrane library, Pro-Quest, and Google Scholar. We used search terms including but not limited to hemophagocytic syndromes OR hemophagocytic lymphohistiocytosis OR macrophage activation syndrome OR HLH OR secondary hemophagocytic lymphohistiocytosis AND systemic lupus erythematosus OR SLE. We screened the articles first by titles and abstracts and later by full text. After the application of our eligibility criteria, we identified eight studies to include in our final synthesis. The studies showed that lupus flare itself, as well as, time to onset and high systemic lupus erythematosus disease activity index (SLEDAI) scores, were major risk factors that led to the development of MAS. In addition, infections followed by drugs, underlying malignancy, and pregnancy were other potential trigger factors identified. Studies also detected that MAS development led to high intensive care unit (ICU) admissions and in-hospital mortalities with C-reactive protein (CRP) levels, age, presence of infection, leukopenia, thrombocytopenia, MAS throughout the hospital stay, and high liver function tests (LFTs) as signs of poor prognosis. Additionally, ferritin levels, LFTs, and triglyceride levels formed an important part of diagnostic criteria. However, our review was limited due to the absence of prospective studies and heterogeneity in the studies seen. More studies need to be done to identify various factors leading to hemophagocytic lymphohistiocytosis (HLH) in autoimmune diseases with validated criteria for MAS secondary to autoimmune diseases.
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Affiliation(s)
- Afia Aziz
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Everardo E Castaneda
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Noorain Ahmad
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Harish Veerapalli
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Amy G Rockferry
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Chetan Reddy Lankala
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Pousette Hamid
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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16
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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: 37] [Impact Index Per Article: 12.3] [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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17
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An Atypical Presentation of Hemophagocytic Lymphohistiocytosis (HLH) Secondary to Occult Hodgkin Lymphoma. Case Rep Hematol 2021; 2021:6672257. [PMID: 34341690 PMCID: PMC8325589 DOI: 10.1155/2021/6672257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 07/05/2021] [Accepted: 07/19/2021] [Indexed: 11/18/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening syndrome of immune system dysregulation characterized by the phagocytosis of various cells by histiocytes in the bone marrow. HLH can present in one of the two ways: primary HLH, which is caused by mutations in genes essential to T and NK-cell function, and secondary HLH, typically caused by Epstein-Barr virus (EBV) infection or malignancy. Because of the rapid progression and high mortality of this disease, prompt diagnosis is essential to good outcomes. Here, we report the 2-month clinical course of a patient who presented with altered mental status and recurrent fever of unknown origin. Initially, he did not meet diagnostic criteria for HLH and had a negative bone marrow biopsy; however, he eventually progressed to full-blown HLH secondary to occult Hodgkin lymphoma. This case is unusual for the slow and smoldering course of the patient's disease and highlights the importance of aggressively searching for potential malignancies to ensure the initiation of definitive therapy as soon as possible.
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18
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Vathenen R, Rokadiya S, Lambourne J. Disseminated adenovirus infection twenty-five years post heart-lung transplant complicated by haemophagocytic lymphohistiocytosis. CLINICAL INFECTION IN PRACTICE 2021. [DOI: 10.1016/j.clinpr.2021.100067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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19
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Naymagon L, Tremblay D, Mascarenhas J. The Efficacy of Etoposide-Based Therapy in Adult Secondary Hemophagocytic Lymphohistiocytosis. Acta Haematol 2021; 144:560-568. [PMID: 33827086 DOI: 10.1159/000514920] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/02/2021] [Indexed: 12/18/2022]
Abstract
Data supporting the use of etoposide-based therapy in hemophagocytic lymphohistiocytosis (HLH) arise largely from pediatric studies. There is a lack of comparable data among adult patients with secondary HLH. We conducted a retrospective study to assess the impact of etoposide-based therapy on outcomes in adult secondary HLH. The primary outcome was overall survival. The log-rank test was used to compare Kaplan-Meier distributions of time-to-event outcomes. Multivariable Cox proportional hazards modeling was used to estimate adjusted hazard ratios (HRs) with 95% confidence intervals (CIs). Ninety adults with secondary HLH seen between January 1, 2009, and January 6, 2020, were included. Forty-two patients (47%) received etoposide-based therapy, while 48 (53%) received treatment only for their inciting proinflammatory condition. Thirty-three patients in the etoposide group (72%) and 32 in the no-etoposide group (67%) died during follow-up. Median survival in the etoposide and no-etoposide groups was 1.04 and 1.39 months, respectively. There was no significant difference in survival between the etoposide and no-etoposide groups (log-rank p = 0.4146). On multivariable analysis, there was no association between treatment with etoposide and survival (HR for death with etoposide = 1.067, 95% CI: 0.633-1.799, p = 0.8084). Use of etoposide-based therapy was not associated with improvement in outcomes in this large cohort of adult secondary HLH patients.
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Affiliation(s)
- Leonard Naymagon
- Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, New York, USA
| | - Douglas Tremblay
- Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, New York, USA
| | - John Mascarenhas
- Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, New York, USA
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20
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Coppola A, Chey C, O'Donovan E, Rahman M. A rare cause of acute liver failure due to haemophagocytic lymphohistiocytosis secondary to diffuse large B-cell lymphoma. JRSM Open 2021; 12:2054270420983623. [PMID: 33717491 PMCID: PMC7930656 DOI: 10.1177/2054270420983623] [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] [Indexed: 01/11/2023] Open
Abstract
Acute liver failure is a life-threatening condition commonly caused by drug-induced hepatotoxicity or viral hepatitides. However, there are a number of rarer causes such as haemophagocytic lymphohistiocytosis. Haemophagocytic lymphohistiocytosis is a syndrome of uncontrolled immune cell activation, triggered by infection or malignancy, which carries a high mortality. Whilst mild to moderate liver injury is commonly seen with haemophagocytic lymphohistiocytosis, acute liver failure has rarely been reported in adults. We present a case of a 74-year-old man with acute liver failure secondary to haemophagocytic lymphohistiocytosis triggered by undiagnosed large B-cell lymphoma. Initially treated for biliary sepsis, there was a delay in the diagnosis of haemophagocytic lymphohistiocytosis and despite initiating chemotherapy, he died soon after. This case highlights the importance of considering haemophagocytic lymphohistiocytosis as a rare cause of acute liver failure, as given the life-threatening potential of haemophagocytic lymphohistiocytosis, a prompt diagnosis may allow early initiation of chemotherapy for any chance of survival.
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Affiliation(s)
- Andrew Coppola
- Department of Surgery and Cancer, Imperial College London Faculty of Medicine, London SW7 2BU, UK
| | - Chia Chey
- Department of Gastroenterology, Surrey and Sussex Healthcare NHS Trust, Surrey RH1 5RH, UK
| | - Emma O'Donovan
- Department of Haematology, Surrey and Sussex Healthcare NHS Trust, Surrey RH1 5RH, UK
| | - Monira Rahman
- Department of Gastroenterology, Surrey and Sussex Healthcare NHS Trust, Surrey RH1 5RH, UK
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21
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Tang S, Li S, Zheng S, Ding Y, Zhu D, Sun C, Hu Y, Qiao J, Fang H. Understanding of cytokines and targeted therapy in macrophage activation syndrome. Semin Arthritis Rheum 2020; 51:198-210. [PMID: 33385860 DOI: 10.1016/j.semarthrit.2020.12.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/01/2020] [Accepted: 12/21/2020] [Indexed: 12/29/2022]
Abstract
Macrophage activation syndrome (MAS) is a potentially life-threatening complication of systemic autoinflammatory/autoimmune diseases, generally systemic juvenile idiopathic arthritis and adult-onset Still's disease. It is characterized by an excessive proliferation of macrophages and T lymphocytes. Recent research revealed that cytokine storm with elevated pro-inflammatory cytokines, including IFN-γ, IL-18, and IL-6, may be central to the pathogenesis of MAS. Though the mainstream of MAS treatment remains corticosteroids and cyclosporine, targeted therapies with anti-cytokine biologics are reported to be promising for controlling systemic inflammation in MAS.
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Affiliation(s)
- Shunli Tang
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Sheng Li
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Siting Zheng
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuwei Ding
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dingxian Zhu
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chuanyin Sun
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yongxian Hu
- Department of Hematology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianjun Qiao
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Hong Fang
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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Gandhi S, Pandey MR, Attwood K, Ji W, Witkiewicz AK, Knudsen ES, Allen C, Tario JD, Wallace PK, Cedeno CD, Levis M, Stack S, Funchain P, Drabick JJ, Bucsek MJ, Puzanov I, Mohammadpour H, Repasky EA, Ernstoff MS. Phase I Clinical Trial of Combination Propranolol and Pembrolizumab in Locally Advanced and Metastatic Melanoma: Safety, Tolerability, and Preliminary Evidence of Antitumor Activity. Clin Cancer Res 2020; 27:87-95. [PMID: 33127652 DOI: 10.1158/1078-0432.ccr-20-2381] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/09/2020] [Accepted: 10/21/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Increased β-adrenergic receptor (β-AR) signaling has been shown to promote the creation of an immunosuppressive tumor microenvironment (TME). Preclinical studies have shown that abrogation of this signaling pathway, particularly β2-AR, provides a more favorable TME that enhances the activity of anti-PD-1 checkpoint inhibitors. We hypothesize that blocking stress-related immunosuppressive pathways would improve tumor response to immune checkpoint inhibitors in patients. Here, we report the results of dose escalation of a nonselective β-blocker (propranolol) with pembrolizumab in patients with metastatic melanoma. PATIENTS AND METHODS A 3 + 3 dose escalation study for propranolol twice a day with pembrolizumab (200 mg every 3 weeks) was completed. The primary objective was to determine the recommended phase II dose (RP2D). Additional objectives included safety, antitumor activity, and biomarker analyses. Responders were defined as patients with complete or partial response per immune-modified RECIST at 6 months. RESULTS Nine patients with metastatic melanoma received increasing doses of propranolol in cohorts of 10, 20, and 30 mg twice a day. No dose-limiting toxicities were observed. Most common treatment-related adverse events (TRAEs) were rash, fatigue, and vitiligo, observed in 44% patients. One patient developed two grade ≥3 TRAEs. Objective response rate was 78%. While no significant changes in treatment-associated biomarkers were observed, an increase in IFNγ and a decrease in IL6 was noted in responders. CONCLUSIONS Combination of propranolol with pembrolizumab in treatment-naïve metastatic melanoma is safe and shows very promising activity. Propranolol 30 mg twice a day was selected as RP2D in addition to pembrolizumab based on safety, tolerability, and preliminary antitumor activity.
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Affiliation(s)
- Shipra Gandhi
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York.
| | - Manu R Pandey
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Kristopher Attwood
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Wenyan Ji
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Agnieszka K Witkiewicz
- Center for Personalized Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Erik S Knudsen
- Center for Personalized Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Cheryl Allen
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Joseph D Tario
- Department of Flow Cytometry, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Paul K Wallace
- Department of Flow Cytometry, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Carlos D Cedeno
- Department of Flow Cytometry, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Maria Levis
- Clinical Research Service, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Suzanne Stack
- Clinical Research Service, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Pauline Funchain
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Joseph J Drabick
- Division of Hematology and Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Mark J Bucsek
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Hemn Mohammadpour
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Elizabeth A Repasky
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Marc S Ernstoff
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York.,Division of Cancer Treatment and Diagnosis/Developmental Therapy Program-ImmunoOncology Branch, NIH/NCI, Bethesda, Maryland
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23
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Zhou J, Zhou J, Wu ZQ, Goyal H, Xu HG. A novel prognostic model for adult patients with Hemophagocytic Lymphohistiocytosis. Orphanet J Rare Dis 2020; 15:215. [PMID: 32819431 PMCID: PMC7439554 DOI: 10.1186/s13023-020-01496-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 08/07/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Hemophagocytic Lymphohistiocytosis (HLH) is a type of rare disease with low survival rate. We aimed to develop a model to evaluate the six-month prognosis in adult HLH patients. The data at discharge (will be called as post-treatment) for newly diagnosed adult HLH patients was collected and independent prognostic variables were selected for inclusion in the model. RESULTS Three laboratory markers were confirmed to be the independent risk factors (ferritin: hazard ratio (HR) 0.101, 95% confidence interval (CI) 0.036-0.282, P<0.001; platelets: HR 4.799, 95% CI 1.884-12.223, P = 0.001; alanine aminotransferase (ALT): HR 0.423, 95% CI 0.180-0.997, P = 0.049). These were included in the final clinical prediction model. Receiver operating characteristic (ROC) curves disclosed that this model had a better discrimination (area under the curve (AUC) = 0.842, 95% CI 0.773-0.910, P < 0.001) than each of them alone and the calibration curves aligned completely with the model predictions and actual observations. Kaplan-Meier curves revealed a significant difference in the overall survival (OS) in patients stratified by the model with higher values associated with a better OS. CONCLUSION These results point out that serum ferritin, platelets and ALT levels are independent elements of OS in adult patients with HLH, and that the proposed model have a better prognostic value than any of these markers alone.
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Affiliation(s)
- Jun Zhou
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jing Zhou
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zhi-Qi Wu
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hemant Goyal
- The Wright Center of Graduate Medical Education, Scranton, USA
| | - Hua-Guo Xu
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.
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24
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Prognostic Value of Blood-Based Inflammatory Biomarkers in Secondary Hemophagocytic Lymphohistiocytosis. J Clin Immunol 2020; 40:718-728. [DOI: 10.1007/s10875-020-00801-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 05/28/2020] [Indexed: 10/24/2022]
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25
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Zhao Y, Lu D, Ma S, Li L, Zhu J, Zhou D, Zheng Y, Yang X, Zhu L, Zhu M, Xie M, Sun J, Ye X, Xie W. Risk factors of early death in adult patients with secondary hemophagocytic lymphohistiocytosis: a single-institution study of 171 Chinese patients. ACTA ACUST UNITED AC 2020; 24:606-612. [PMID: 31474196 DOI: 10.1080/16078454.2019.1660458] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Adult secondary hemophagocytic lymphohistiocytosis (HLH) is a potentially life-threatening syndrome characterized by excessive activation of mononuclear-phagocytic system resulting in hyperinflammatory response. To date, the factors influencing early death of HLH are still not fully elucidated. Patients and Methods: We did a retrospective study of 171 adult patients with newly diagnosed HLH at our institution from January 2012 to April 2018. All patients' clinical features, laboratory findings, treatments and prognosis were reviewed. Results: The median age was 49 years (range, 18-88 years), and 110 (64.3%) were male. The major underlying trigger of HLH was malignancy (88/171, 51.5%), especially non-Hodgkin lymphoma. In a multivariate analysis, age ≥54 years (P = 0.002), platelet ≤39.5 × 109/L (P = 0.028), activated partial thromboplastin time (APTT) ≥54 sec (P = 0.048), triglyceride ≥3.23 mmol/L (P < 0.001), lactate dehydrogenase (LDH) ≥1300 U/L (P = 0.012) and malignancy (P = 0.001) were significantly associated with early death in HLH. Then, patients were classified into four groups according to the number of risk factors at the time of diagnosis: low risk (zero, one or two risk factors), low intermediate risk (three risk factors), high intermediate risk (four risk factors) and high risk (at least five risk factors), with the 30-day overall survival (OS) of 92.4%, 58.8%, 30.0% and 4.8%, respectively (P < 0.001). Conclusions: Patients with old age, thrombocytopenia, prolonged APTT, hypertriglyceridemia, elevated LDH and malignancy had inferior survival. It is important to identify those patients at risk of early death, which may guide treatment and reduce mortality.
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Affiliation(s)
- Yanchun Zhao
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Danlei Lu
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Shanshan Ma
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Li Li
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Jingjing Zhu
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - De Zhou
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Yanlong Zheng
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Xiudi Yang
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Lixia Zhu
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Mingyu Zhu
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Mixue Xie
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Jianai Sun
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Xiujin Ye
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Wanzhuo Xie
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
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26
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Yildiz H, Van Den Neste E, Defour JP, Danse E, Yombi JC. Adult haemophagocytic lymphohistiocytosis: a Review. QJM 2020; 115:hcaa011. [PMID: 31943120 DOI: 10.1093/qjmed/hcaa011] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/30/2019] [Accepted: 12/21/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disorder characterized by hyperimmune response. The mortality is high despite progress being made in the diagnosis and treatment of the disease. AIM This review aimed to update knowledge on adult HLH pathophysiology, identifiy the numerous causes, and help clinicians make early diagnosis and initiate treatment. DESIGN AND METHODS Using Embase, we searched relevant articles published from January 1, 2010 to October 31, 2019, with the MESH term « hemophagocytic lymphohistiocytosis; macrophagic activation syndrome, adult ». RESULTS The mean age at presentation is about 50 years, with a male predominance. The most frequent disease associations are haematological diseases, viral or bacterial infections, and autoimmune diseases. The pathophysiologic mechanism is probably the combination of inherited genetic mutations and extrinsic triggers. The mortality rate is 26.5% to 74.8%. H-score is more efficient than HLH-2004 criteria to identify HLH, with diagnostic sensitivity and specificity 90% and 79%, respectively.18F-FDG PET/CT is potentially useful for detecting underlying disease and the extent of secondary HLH. Disease-specific treatment should be given as soon as possible. Treatment with corticosteroids combined or not with etoposide is the mainstay of treatment. Monoclonal antibodies and JAK pathway inhibitors show promise of being effective. CONCLUSION In adult HLH, infectious diseases, autoimmune disease and malignancy should be suspected so that disease-specific treatment can be given promptly. Treatment with corticosteroids combined or not with etoposide is the mainstay of treatment, but new therapies show promise of being effective.
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Affiliation(s)
- Halil Yildiz
- Department of Internal medicine and Infectious diseases, Cliniques Universitaires Saint-Luc, Université de Louvain, 10 Av hippocrate, Bruxelles
| | - Eric Van Den Neste
- Department of Hematology, Cliniques Universitaires Saint-Luc, Université de Louvain, 10 Av hippocrate, Bruxelles
| | - Jean Philippe Defour
- Department of laboratory and immunohematology, Cliniques Universitaires Saint-Luc, Université de Louvain, 10 Av hippocrate, Bruxelles
| | - Etienne Danse
- Department of Radiology, Cliniques Universitaires Saint-Luc, Université de Louvain, 10 Av hippocrate, Bruxelles
| | - J C Yombi
- Department of Internal medicine and Infectious diseases, Cliniques Universitaires Saint-Luc, Université de Louvain, 10 Av hippocrate, Bruxelles
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27
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Kalmuk J, Matar S, Feng G, Kilb E, Lim MY. Parvovirus B19-induced hemophagocytic lymphohistiocytosis: Case report and review of the literature. Clin Case Rep 2019; 7:2076-2081. [PMID: 31788255 PMCID: PMC6878072 DOI: 10.1002/ccr3.2401] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 05/27/2019] [Accepted: 05/28/2019] [Indexed: 12/21/2022] Open
Abstract
HLH is a catastrophic and likely underdiagnosed pathology with multiple triggers including infection. PVB19 can cause persistent marrow infection leading to HLH despite negative acute serologic markers making timely diagnosis difficult. Increased awareness of PVB19-HLH is warranted given its potentially lethal nature and the careful interpretation required with serologic markers.
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Affiliation(s)
- James Kalmuk
- Department of Internal MedicineMedical University of South CarolinaCharlestonSCUSA
| | - Sara Matar
- Department of Hematology/OncologyMedical University of South CarolinaCharlestonSCUSA
| | - Gong Feng
- Department of Pathology and Laboratory MedicineMedical University of South CarolinaCharlestonSCUSA
| | - Edward Kilb
- Department of Pulmonary and Critical Care MedicineMedical University of South CarolinaCharlestonSCUSA
| | - Ming Y. Lim
- Department of Hematology/OncologyMedical University of South CarolinaCharlestonSCUSA
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28
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Brito-Zerón P, Kostov B, Moral-Moral P, Martínez-Zapico A, Díaz-Pedroche C, Fraile G, Pérez-Guerrero P, Fonseca E, Robles A, Vaquero-Herrero MP, Calvo MA, Forner MJ, Morcillo C, Larrañaga J, Rodriguez-Carballeira M, Ruiz-Muñoz M, Hurtado-García R, Prieto-González S, Aguilar AA, Caminal-Montero L, Hernández-Jiménez P, Fernández-Viagas CR, Castro P, Massó VM, Flores-Chavez A, Ramos-Casals M. Prognostic Factors of Death in 151 Adults With Hemophagocytic Syndrome: Etiopathogenically Driven Analysis. Mayo Clin Proc Innov Qual Outcomes 2018; 2:267-276. [PMID: 30225460 PMCID: PMC6132215 DOI: 10.1016/j.mayocpiqo.2018.06.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 06/24/2018] [Accepted: 06/27/2018] [Indexed: 01/09/2023] Open
Abstract
Objective To characterize the etiologies and clinical features at diagnosis of patients with hemophagocytic lymphohistiocytosis (HLH) and correlate these baseline features with survival using an etiopathogenically guided multivariable model. Patients and Methods The Spanish Group of Autoimmune Diseases HLH Study Group, formed in 2013, is aimed at collecting adult patients with HLH diagnosed in internal medicine departments between January 3, 2013, and October 28, 2017. Results The cohort consisted of 151 patients (91 men; mean age, 51.4 years). After a mean follow-up of 17 months (range, 1-142 months), 80 patients died. Time-to-event analyses for death identified a worse survival curve for patients with neoplasia (P<.001), mixed microbiological infections (P=.02), and more than 1 infection (P=.01) and glucocorticoid monotherapy (P=.02). According to univariate analyses, platelets of less than 100,000/mm3 (hazard ratio [HR], 3.39; 95% CI, 1.37-8.40), leukopenia (HR, 1.81; 95% CI, 1.01-3.23), severe hyponatremia (HR, 1.61; 95% CI, 1.02-2.54), disseminated intravascular coagulation (HR, 1.87; 95% CI, 1.05-3.34), bacterial infection (HR, 1.99; 95% CI, 1.09-3.63), mixed microbiological infections (HR, 3.42; 95% CI, 1.38-8.46), and 2 or more infectious triggers (HR, 2.95; 95% CI, 1.43-6.08) were significantly associated with death. In contrast, peripheral adenopathies (HR, 0.63; 95% CI, 0.40-0.98) and the immunosuppressive drug/intravenous immunoglobulin/biological therapies (HR, 0.44; 95% CI, 0.20-0.96) were protective against all-cause mortality. Multivariable Cox proportional hazards regression analysis identified 2 or more infectious triggers (HR, 3.14; 95% CI, 1.28-7.68) as the only variable independently associated with death. Conclusion The mortality rate of adult patients diagnosed with HLH exceeds 50%. Infection with more than 1 microbiological agent was the only independent variable associated with mortality irrespective of the underlying disease, epidemiological profile, clinical presentation, and therapeutic management.
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Affiliation(s)
- Pilar Brito-Zerón
- Autoimmune Diseases Unit, Department of Medicine, Hospital CIMA-Sanitas, Barcelona, Spain
| | - Belchin Kostov
- Laboratory of Autoimmune Diseases Josep Font, CELLEX-IDIBAPS, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain.,Primary Healthcare Transversal Research Group, IDIBAPS, Barcelona, Spain
| | - Pedro Moral-Moral
- Immunopathology Section, Department of Internal Medicine, Hospital Universitari i Politècnic La Fe, Departament de Salut Valencia La Fe, Valencia, Spain
| | - Aleida Martínez-Zapico
- Autoimmune Diseases Unit, UGC Internal Medicine, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Carmen Díaz-Pedroche
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Guadalupe Fraile
- Department of Internal Medicine, Hospital Ramón y Cajal, Madrid, Spain
| | | | - Eva Fonseca
- Department of Internal Medicine, Hospital de Cabueñes, Gijón, Spain
| | - Angel Robles
- Department of Internal Medicine, Hospital La Paz, Madrid, Spain
| | - María P Vaquero-Herrero
- Department of Internal Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - María Andrés Calvo
- Department of Internal Medicine, Hospital Rio Hortega Valladolid, Valladolid, Spain
| | - María José Forner
- Department of Internal Medicine, Hospital Clínico de Valencia, Valencia, Spain
| | - Cesar Morcillo
- Autoimmune Diseases Unit, Department of Medicine, Hospital CIMA-Sanitas, Barcelona, Spain
| | - José Larrañaga
- Department of Internal Medicine, Hospital Xeral, Vigo, Spain
| | | | - Manuel Ruiz-Muñoz
- Department of Internal Medicine, Hospital Universitario Fundacion Alcorcón, Alcorcón, Spain
| | | | | | - Asun Aljibe Aguilar
- Immunopathology Section, Department of Internal Medicine, Hospital Universitari i Politècnic La Fe, Departament de Salut Valencia La Fe, Valencia, Spain
| | - Luis Caminal-Montero
- Autoimmune Diseases Unit, UGC Internal Medicine, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | | | - Pedro Castro
- Medical Intensive Care Unit, Department of Medicine, ICMiD, Hospital Clínic, Barcelona, Spain
| | - Victoria Morell Massó
- Immunopathology Section, Department of Internal Medicine, Hospital Universitari i Politècnic La Fe, Departament de Salut Valencia La Fe, Valencia, Spain
| | - Alejandra Flores-Chavez
- Laboratory of Autoimmune Diseases Josep Font, CELLEX-IDIBAPS, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain.,Biomedical Research Unit 02, Clinical Epidemiology Research Unit, UMAE, Specialties Hospital, Western Medical Center, Mexican Institute for Social Security (IMSS), Guadalajara, Mexico.,Postgraduate Program of Medical Science, University Center for Biomedical Research (CUIB), University of Colima, Colima, Mexico
| | - Manuel Ramos-Casals
- Laboratory of Autoimmune Diseases Josep Font, CELLEX-IDIBAPS, Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain.,Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain.,Department of Medicine, University of Barcelona, Barcelona, Spain
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