Reactive haemophagocytic syndrome in AIDS

Hemophagocytic syndrome in patients infected with the human immunodeficiency virus: A study of 15 consecutive patients

Objectives

Hemophagocytic syndrome (HPS) is characterized by various clinical and biological data derived from cytokine hyperproduction and cell proliferation. The objectives of this study were to evaluate the epidemiological, etiological, clinical and evolutionary characteristics of patients diagnosed with hemophagocytic syndrome and HIV infection, as well as their comparison with data from the literature.

Methods-

A retrospective descriptive observational study was performed, including all adult patients with a diagnosis of HPS and HIV infection treated in the Infectious Diseases and Tropical Medicine Unit of the Hospital Universitario Insular, Las Palmas, Gran Canaria from June 1, 1998 to December 31, 2018.

Results

An analysis of this series of case reports of 15 patients showed a higher percentage of males than females, with a mean age of 42 years. With respect to the diagnostic criteria for HPS, presence of fever, cytopenias and hyperferritinemia were a constant in all patients. Clinical neurological manifestations were frequent and clinical respiratory signs and symptoms absent. HPS was confirmed in some patients who were not severely immune-depressed and had undetectable viral loads. Furthermore, 40% of cases were not receiving ART. The most frequent triggering causes of HPS were viral, especially HHV-8. In addition, two new HPS triggers were identified: Blastocystis dermatitidis and Mycobacterium chelonae.

Conclusion

Administration of treatment in HPS is arbitrary. This, together with the high mortality rate and the fact that it is underdiagnosed, indicates the importance of conducting future studies.

Haemophagocytic syndrome and HIV

PURPOSE OF REVIEW

Haemophagocytic syndrome (HPS) is a relatively rare complication of HIV infection but one that can take a particularly aggressive and potentially fatal course. The condition may be underrecognized due to the nonspecific nature of the clinical features. This review summarizes the pathogenesis, clinical and diagnostic features, common associations and current options in the management of HPS in the context of HIV infection, with the aim of increasing diagnostic awareness and facilitating early intervention.

RECENT FINDINGS

Our understanding of HPS is being increasingly informed by research into the molecular basis of the familial forms of the condition. The list of associated infections and neoplasms continues to lengthen, although the occurrence of HPS is increasingly recognized in the context of HIV infection alone, occasionally as its initial presentation in acute seroconversion. Diagnostic guidelines have recently been refined and attempts to adapt these to particular patient groups are ongoing. Management of HIV-associated HPS is adapted to the clinical context and may involve treatment of an underlying disorder or immunosuppressive therapy to reduce the activation of macrophages and T cells.

SUMMARY

The spectrum of HIV-related lymphoproliferative disorders continues to expand. Our understanding of their molecular and cellular basis and the role of infectious organisms in their development increasingly shapes and advances our clinical management of these complex conditions.

Acute human immunodeficiency virus syndrome presenting with hemophagocytic lymphohistiocytosis

Hemophagocytic lymphohistiocytosis (HLH) has been described in patients with advanced stages of human immunodeficiency virus (HIV) infection, but rarely occurs during the seroconversion stage of acute HIV infection. We report a case of acute HIV syndrome that presented with virus-associated HLH. The patient recovered spontaneously without any immunomodulating therapy. This case suggests that acute HIV infection should be included in the differential diagnosis of HLH and indicates that HLH associated with acute HIV infection can have a favorable outcome.

Hemophagocytic syndrome: an unusual manifestation of acute human immunodeficiency virus infection

An 18 year-old heterosexual man was hospitalized because of fever, chills, a sore throat, and a dry cough for 8 days. He had had sexual intercourse with a new partner within the 4 months prior to admission. At admission, the patient presented a clinical picture compatible with hemophagocytic syndrome (HPS). The presence of hemophagocytosis was subsequently determined pathologically from bone marrow and lymph node specimens. An exhaustive diagnostic work-up failed to reveal any causative etiology, the symptoms improving after 2 doses of intravenous immunoglobulin (IVIG) infusion, given at a dose of 0.5 mg/kg each, the 2 doses being administered 1 week apart. Three months subsequent to the patient's initial presentation, acute human immunodeficiency virus (HIV) infection was diagnosed, and the patient received highly active antiretrovirus therapy (HAART) from the time of diagnosis. The patient remained well for the following 2 years. HPS in the advanced stages of HIV infection has previously been described, but HPS during seroconversion of an acute form of the infection is rare. We most definitely suggest, however, that acute HIV infection be included in the list of potential causes of HPS. IVIG therapy appears to be an appropriate therapeutic modality, and HAART also is effective, for prevention of recurrence of HPS in a patient with acute HIV infection.

Human Immunodeficiency Virus--Associated Hemophagocytosis with Iron-Deficiency Anemia and Massive Splenomegaly

We present a case of hemophagocytic syndrome in a human immunodeficiency virus-positive man with iron-deficiency anemia that did not respond to highly active antiretroviral therapy. Clinical resolution occurred only after a splenectomy was performed.

Reactive hemophagocytic syndrome in adult systemic disease: report of twenty-six cases and literature review

OBJECTIVE

To analyze specific clinical findings, underlying disorders, treatments, outcomes, and prognostic factors for reactive hemophagocytic syndrome (RHS) in systemic disease.

METHODS

Data were collected using standardized forms as part of a French national survey. Adult cases without an underlying malignancy, diagnosed on bone marrow or lymph node biopsy, were included.

RESULTS

Twenty-six cases (7 men, 19 women, mean age 47.4 +/- 17.7 years) were studied. Systemic diseases included systemic lupus erythematosus (n = 14), rheumatoid arthritis (n = 2), adult onset systemic Still's disease (n = 4), polyarteritis nodosa (n = 2), mixed connective tissue disease (n = 1), pulmonary sarcoidosis (n = 1), systemic sclerosis (n = 1), and Sjögren's syndrome (n = 1). RHS occurred in 2 distinct clinical settings in the course of systemic disease. RHS was associated with an active infection in 15 patients (bacterial infections, 10 cases; viral, 3 cases; tuberculosis, 1 case; and aspergillosis, 1 case) and with the onset of a systemic disease alone in 9 cases. Isolated RHS occurred in 2 cases. The overall mortality rate was 38.5%. Two factors were associated with mortality: corticosteroid treatment at the time of RHS diagnosis, and thrombocytopenia (odds ratio = 28, 95% confidence interval = 13.3-238.9).

CONCLUSIONS

When RHS occurs in the course of an active systemic disease (situation only reported in cases of systemic lupus or adult Still's disease), immunosuppressive therapy should be used. In contrast, when RHS is present concomitantly with an active infection, immunosuppressive therapy needs to be lowered and antibiotic therapy should be instituted.

Haemophagocytic syndrome associated with infections

Haemophagocytic syndromes (HS) are the clinical manifestation of an increased macrophagic activity with haemophagocytosis. Pathophysiology is related to a deregulation of T-lymphocytes and excessive production of cytokines. The main clinicobiological features are fever, hepatosplenomegaly, adenopathies, skin rash, neurological features, cytopenias, hypertriglyceridaemia, hyperferritinaemia and coagulopathy. Diagnosis is based on examination of the bone marrow which shows benign histiocytes actively phagocytosing haemopoietic cells. Acquired HS are mostly associated with an underlying disease such as immunodeficiency, haematological neoplasias and autoimmune diseases. Infection-associated HS was originally described by Risdall in 1979, in viral disease. Since the initial description HS has also been documented in patients with bacterial, parasitic or fungal infections. Epstein-Barr virus (EBV) is the causative agent in most cases. In EBV-associated HS, which sometimes has a fatal course, unregulated T-cell reaction or uncontrolled B-cell proliferation may release cytokines. Management of HS consists of early diagnosis, careful screening for, and prompt treatment of, infections and detection and therapy of any underlying disease. Prognosis of infection-associated haemophagocytic syndrome (IAHS) is better than that in other types of secondary HS. Management of cytokine imbalance should be useful to improve the outcome and reduce the mortality rate in these cases.