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Ruscitti P, Di Cola I, Di Muzio C, Italiano N, Ursini F, Giacomelli R, Cipriani P. Expanding the spectrum of the hyperferritinemic syndrome, from pathogenic mechanisms to clinical observations, and therapeutic implications. Autoimmun Rev 2022; 21:103114. [PMID: 35595050 DOI: 10.1016/j.autrev.2022.103114] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 05/15/2022] [Indexed: 01/19/2023]
Abstract
From the introduction of hyperferritinemic syndrome concept, a growing body of evidence has suggested the role of ferritin as a pathogenic mediator and a relevant clinical feature in the management of patients with inflammatory diseases. From a pathogenic point of view, ferritin may directly stimulate the aberrant immune response by triggering the production of pro-inflammatory mediators in inducing a vicious pathogenic loop and contributing to the occurrence of cytokine storm syndrome. The latter has been recently defined as a clinical picture characterised by elevated circulating cytokine levels, acute systemic inflammatory symptoms, and secondary organ dysfunction beyond that which could be attributed to a normal response to a pathogen It is noteworthy that the occurrence of hyperferritinemia may be correlated with the development of the cytokine storm syndrome in the context of an inflammatory disease. In addition to adult onset Still's disease, macrophage activation syndrome, catastrophic anti-phospholipids syndrome, and septic shock, recent evidence has suggested this association between ferritin and life-threatening evolution in patients with systemic lupus erythematosus, with anti-MDA5 antibodies in the context of poly-dermatomyositis, with severe COVID-19, and with multisystem inflammatory syndrome. The possible underlying common inflammatory mechanisms, associated with hyperferritinemia, may led to the similar clinical picture observed in these patients. Furthermore, similar therapeutic strategies could be suggested inhibiting pro-inflammatory cytokines and improving long-term outcomes in these disorders. Thus, it could be possible to expand the spectrum of the hyperferritinemic syndrome to those diseases burdened by a dreadful clinical picture correlated with hyperferritinemia and the occurrence of the cytokine storm syndrome. In addition, the assessment of ferritin may provide useful information to the physicians in clinical practice to manage these patients. Therefore, ferritin may be considered a relevant clinical feature to be used as biomarker in dissecting the unmet needs in the management of these disorders. Novel evidence may thus support an expansion of the spectrum of the hyperferritinemic syndrome to these diseases burdened by a life-threatening clinical picture correlated with hyperferritinemia and the occurrence of the cytokine storm syndrome.
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Affiliation(s)
- Piero Ruscitti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.
| | - Ilenia Di Cola
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Claudia Di Muzio
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Noemi Italiano
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Francesco Ursini
- Rheumatology Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy; Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Roberto Giacomelli
- Rheumatology and Immunology Unit, Department of Medicine, University of Rome Campus Biomedico, Rome, Italy
| | - Paola Cipriani
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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2
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A Case of Hemophagocytic Lymphohistiocytosis Triggered by Disseminated Tuberculosis and Hairy Cell Leukaemia after SARS-CoV2 Infection. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12020564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hemophagocytic Lymphohistiocytosis (HLH) is a rare but life-threatening disease that can occur either as a primary condition or as a consequence of a variety of triggers, including infectious diseases. Here we present a case of secondary HLH triggered by systemic Mycobacterium tuberculosis infection in a 59-year-old immunocompromised Hairy Cell Leukemia and previous SARS-CoV2 infected patient. This case report underlines the role of Etoposide-based chemotherapy in treating the severe inflammation that is the defining factor of HLH, suggesting how, even when such therapy is not effective, it may still give the clinicians time to identify the underlying condition and start the appropriate targeted therapy. Moreover, it gives insight on our decision to treat the underlying haematological condition with a BRAF-targeted therapy rather than purine analog-based chemotherapy to reduce the risk of future severe infections.
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3
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Choy KW, Sezgin G, Wijeratne N, Calleja J, Liwayan R, Rathnayake G, McFarlane R, McNeil A, Doery JCG, Lu Z, Markus C, Loh TP. Assessment of analytical bias in ferritin assays and impact on functional reference limits. Pathology 2021; 54:302-307. [PMID: 34538480 DOI: 10.1016/j.pathol.2021.06.123] [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: 04/02/2021] [Revised: 06/02/2021] [Accepted: 06/08/2021] [Indexed: 11/18/2022]
Abstract
Serum ferritin is currently the recommended laboratory test to investigate iron deficiency. There have been efforts to standardise serum ferritin assays with implementation of traceability to the World Health Organization reference standard. We evaluate the analytical bias among five widely used commercial ferritin assays in Australia. The relationship between serum ferritin and erythrocyte parameters was recently explored to derive functional reference limits. Residual patient serum specimens were analysed by five participating laboratories that utilised a different ferritin assay, Abbott, Beckman Coulter, Roche, Siemens, and Ortho. Using data mining approach, functional reference limits for Siemens, Abbott, and Ortho serum ferritin methods were derived and compared. At clinically relevant ferritin decision points, compared to the Beckman method, the Roche assay showed higher results ranging from 6 μg/L (31%) at the lowest decision point to 575 μg/L (57%) at the highest decision point. In contrast, the Ortho method underestimated ferritin results at lower decision points of 20 and 30 μg/L, with estimated ferritin results of 16 μg/L (-19%) and 27 μg/L (-12%), respectively. The Abbott and Siemens assays showed a positive bias which was introduced at differing decision points. The comparison of the Siemens and Ortho methods presents similar inflection points between the two assays in the establishment of functional reference limits for serum ferritin. There remain significant biases among some of the commonly used commercial ferritin assays in Australia. More studies are needed to assess if functional reference limits are a way to overcome method commutability issues.
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Affiliation(s)
- Kay Weng Choy
- Northern Pathology Victoria, Northern Health, Epping, Vic, Australia.
| | - Gorkem Sezgin
- Faculty of Medicine, Health, and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Nilika Wijeratne
- Dorevitch Pathology, Heidelberg, Vic, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Vic, Australia
| | - John Calleja
- Melbourne Pathology, Collingwood, Vic, Australia
| | - Rachelle Liwayan
- Northern Pathology Victoria, Northern Health, Epping, Vic, Australia
| | - Geetha Rathnayake
- Territory Pathology, Royal Darwin Hospital, Darwin, NT, Australia; University and Northern Territory Medical Program, Royal Darwin Hospital Campus, Darwin, NT, Australia
| | - Robert McFarlane
- Territory Pathology, Royal Darwin Hospital, Darwin, NT, Australia
| | - Alan McNeil
- Dorevitch Pathology, Heidelberg, Vic, Australia
| | | | - Zhong Lu
- Monash Pathology, Monash Health, Clayton, Vic, Australia
| | - Corey Markus
- Flinders University College of Medicine and Public Health, Adelaide, SA, Australia
| | - Tze Ping Loh
- Department of Laboratory Medicine, National University Hospital, Singapore
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4
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Plays M, Müller S, Rodriguez R. Chemistry and biology of ferritin. Metallomics 2021; 13:6244244. [PMID: 33881539 PMCID: PMC8083198 DOI: 10.1093/mtomcs/mfab021] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 04/09/2021] [Indexed: 02/07/2023]
Abstract
Iron is an essential element required by cells and has been described as a key player in ferroptosis. Ferritin operates as a fundamental iron storage protein in cells forming multimeric assemblies with crystalline iron cores. We discuss the latest findings on ferritin structure and activity and its link to cell metabolism and ferroptosis. The chemistry of iron, including its oxidation states, is important for its biological functions, its reactivity, and the biology of ferritin. Ferritin can be localized in different cellular compartments and secreted by cells with a variety of functions depending on its spatial context. Here, we discuss how cellular ferritin localization is tightly linked to its function in a tissue-specific manner, and how impairment of iron homeostasis is implicated in diseases, including cancer and coronavirus disease 2019. Ferritin is a potential biomarker and we discuss latest research where it has been employed for imaging purposes and drug delivery.
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Affiliation(s)
- Marina Plays
- Chemical Biology of Cancer Laboratory, Institut Curie, 26 rue d'Ulm, 75005 Paris, France.,Centre national de la recherche scientifique UMR 3666, Paris, France.,Institut national de la santé et de la recherche médicale U1143, Paris, France.,PSL Université Paris, Paris, France
| | - Sebastian Müller
- Chemical Biology of Cancer Laboratory, Institut Curie, 26 rue d'Ulm, 75005 Paris, France.,Centre national de la recherche scientifique UMR 3666, Paris, France.,Institut national de la santé et de la recherche médicale U1143, Paris, France.,PSL Université Paris, Paris, France
| | - Raphaël Rodriguez
- Chemical Biology of Cancer Laboratory, Institut Curie, 26 rue d'Ulm, 75005 Paris, France.,Centre national de la recherche scientifique UMR 3666, Paris, France.,Institut national de la santé et de la recherche médicale U1143, Paris, France.,PSL Université Paris, Paris, France
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5
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Lu M, Xie Y, Guan X, Wang M, Zhu L, Zhang S, Ning Q, Han M. Clinical analysis and a novel risk predictive nomogram for 155 adult patients with hemophagocytic lymphohistiocytosis. Ann Hematol 2021; 100:2181-2193. [PMID: 33977332 DOI: 10.1007/s00277-021-04551-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/02/2021] [Indexed: 12/16/2022]
Abstract
Recently, more and more attention has been paid on adult hemophagocytic lymphohistiocytosis (HLH), a disease with complicated symptoms and high mortality. In order to analyze the clinical characteristics and prediction risk factors of mortality, we designed a retrospective study with 1-year follow-up and included 155 patients admitted to Tongji Hospital diagnosed as HLH. One hundred seven patients formed the training cohort for nomogram development, and 48 patients formed the validation cohort to confirm the model's performance. All patients' clinical characteristics, laboratory results, medical records, and prognosis were analyzed. Among all the 107 patients in the training cohort, 46 were male and 61 were female, with the median age of 49.0 (IQR 31.0-63.0). The 1-year mortality rate was 43.9% (47/107) and 45.8% (22/48) in the training and validation cohort, respectively. And further multivariate logistic regression analysis in the training cohort showed that male (odds ratio 5.534, 95% CI 1.507-20.318, p = 0.010), altered mental status (11.876, 1.882-74.947, p = 0.008), serum ferritin ≥ 31,381 μg/L (8.273, 1.855-36.883, p = 0.006), and IL-6 ≥ 18.59 pg/mL (19.446, 1.527-247.642, p = 0.022) were independent risk factor of mortality. A nomogram included the four prediction factors mentioned above was also tabled to help clinicians evaluate the probability of poor outcome. Area under the receiver operating characteristic curve (AUROC) analysis, calibration curves, and decision curve analysis (DCA) certify the accuracy and the clinical usefulness of the nomogram. Our research reveals that male, altered mental status, serum ferritin ≥ 31,381 µg/L, and IL-6 ≥ 18.59 pg/mL are four independent predictors for poor prognosis. Doctors should pay more attention to patients with altered mental status, high serum ferritin, and IL-6 level, who have a higher risk of death.
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Affiliation(s)
- Mengxin Lu
- Department and Institute of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yanghao Xie
- Department and Institute of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xiaoxu Guan
- Department and Institute of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Ming Wang
- Department and Institute of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Lin Zhu
- Department and Institute of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Shen Zhang
- Department and Institute of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Qin Ning
- Department and Institute of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Meifang Han
- Department and Institute of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Debaugnies F, Mahadeb B, Nagant C, Meuleman N, De Bels D, Wolff F, Gottignies P, Salaroli A, Borde P, Voué M, Corazza F. Biomarkers for Early Diagnosis of Hemophagocytic Lymphohistiocytosis in Critically Ill Patients. J Clin Immunol 2021; 41:658-665. [PMID: 33417087 DOI: 10.1007/s10875-020-00950-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/16/2020] [Indexed: 01/21/2023]
Abstract
Many biomarkers have been proposed for the diagnosis of secondary hemophagocytic lymphohistiocytosis (HLH) in adults, but comparative studies are lacking. We analyzed ferritin, glycosylated ferritin, soluble CD25, CD163 and CD14, IL-6, IFN-γ, IL-18, IL-10, IL-1ß, IL-12p70, IL-17α, IP-10, and CXCL9 levels to differentiate HLH from sepsis in critically ill patients. Of 120 patients, HLH was confirmed for 14 patients. Among the biomarkers tested, ferritin, IL-18, and glycosylated ferritin were the most efficient parameters for early diagnosis of HLH. With a sensitivity set at 85%, ferritin, IL-18, and glycosylated ferritin were the biomarkers with the highest specificity: 84, 79, and 71% respectively. Combining IL-18 with the HScore provided a new score with an increased specificity compared to the HScore alone, 86% compared to 70% with a sensitivity set at 100%. A distinct cytokine pattern was highlighted in patients with malignancy-triggered HLH, with highly increased levels of INF-ɣ and CXCL9, compared to HLH secondary to infection. This is the largest study available to date, comparing diagnostic biomarkers for HLH on a cohort of critically ill adult patients. Serum ferritin was the most discriminating parameter for early diagnosis of secondary HLH. IL18*HScore was identified as a highly potential score.
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Affiliation(s)
- France Debaugnies
- Laboratory of Translational Research, Centre Hospitalier Universitaire Brugmann, Université libre de Bruxelles, Brussels, Belgium.
- Medical Biology Department, Laboratoire National de Santé, Dudelange, Luxembourg.
| | - Bhavna Mahadeb
- Microbiology Department, LHUB-ULB, Université libre de Bruxelles, Brussels, Belgium
| | - Carole Nagant
- Immunology Department, LHUB-ULB, Université libre de Bruxelles, Brussels, Belgium
| | | | - David De Bels
- Department of Intensive Care, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium
| | - Fleur Wolff
- Clinical Chemistry Department, LHUB-ULB, Université libre de Bruxelles, Brussels, Belgium
| | | | - Adriano Salaroli
- Hematology Department, Jules Bordet Institute, Brussels, Belgium
| | - Patricia Borde
- Medical Biology Department, Laboratoire National de Santé, Dudelange, Luxembourg
| | - Michel Voué
- Physics of Materials and Optics Unit, University of Mons, Mons, Belgium
| | - Francis Corazza
- Laboratory of Translational Research, Centre Hospitalier Universitaire Brugmann, Université libre de Bruxelles, Brussels, Belgium
- Immunology Department, LHUB-ULB, Université libre de Bruxelles, Brussels, Belgium
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7
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Kappert K, Jahić A, Tauber R. Assessment of serum ferritin as a biomarker in COVID-19: bystander or participant? Insights by comparison with other infectious and non-infectious diseases. Biomarkers 2020; 25:616-625. [PMID: 32700561 DOI: 10.1080/1354750x.2020.1797880] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The 2019 coronavirus disease (COVID-19) caused by the SARS-CoV-2 virus has an impact on all aspects of patient care. Serum ferritin generally represents a biomarker of choice when iron deficiency is suspected. However, ferritin is also an acute-phase-protein exhibiting elevated serum concentration in various inflammatory diseases. Here we focus on the role of serum ferritin for diagnostic and clinical management of patients with COVID-19 in comparison with other infectious and non-infectious diseases. METHODS We examined scientific articles listed in PubMed reporting on ferritin in various infectious and non-infectious diseases. We then compared these results with nine current COVID-19 ferritin reports published in 2020. RESULTS Several non-infectious, as well as non-COVID-19 infectious diseases, are characterised by a partly dramatic elevation of serum ferritin levels. All COVID-19 studies published between February and May 2020, which documented laboratory serum ferritin, indicate ferritin as a biomarker of COVID-19 severity in hospitalised patients. CONCLUSIONS Serum ferritin may be considered both a prognostic and stratifying biomarker that can also contribute to therapeutic decision-making concerning patients with COVID-19. It should be emphasised, however, that most scientific reports refer to cohorts in the Asian region. Further validation in other cohorts is urgently required.
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Affiliation(s)
- Kai Kappert
- Institute of Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Labor Berlin - Charité Vivantes GmbH, Berlin, Germany
| | - Amir Jahić
- Institute of Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Labor Berlin - Charité Vivantes GmbH, Berlin, Germany
| | - Rudolf Tauber
- Institute of Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Labor Berlin - Charité Vivantes GmbH, Berlin, Germany
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8
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Lee WI, Talaulikar D, Cook MC. Retrospective single-centre analysis of diagnostic approach to adult-onset haemophagocytic lymphohistiocytosis. Intern Med J 2020; 51:939-947. [PMID: 32388900 DOI: 10.1111/imj.14891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 04/10/2020] [Accepted: 04/27/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Haemophagocytic lymphohistiocytosis (HLH) is a rare disorder with a poor prognosis characterised by substantial immune activation leading to end-organ failure. In childhood, genetic defects that impair cytotoxic function of natural killer cells and T cells. (HLH) are often identified. In adults, clinical manifestations are similar to those observed in children but the aetiology is often unclear. AIMS To evaluate whether poor prognosis for adult HLH is in part due to lack of awareness of the disorder, which results in incomplete investigation and failure to implement timely treatment. METHODS We performed a retrospective case series of adult-onset HLH in a tertiary hospital in Australia. We evaluated clinical characteristics, treatment and outcome, and related these to application of standard diagnostic criteria for HLH. RESULTS In our centre, incomplete assessment of HLH criteria was common. Serum ferritin was the criterion most commonly assessed. Hyperferritinaemia ≥10 000 μg/L was highly sensitive in detecting patients with adult-onset HLH; however, the majority of patients who had hyperferritinaemia ≥10 000 μg/L did not have adult-onset HLH. CONCLUSION The present study highlights the importance of comprehensive application of diagnostic criteria to improve accuracy and timelines of the diagnosis of adult onset HLH.
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Affiliation(s)
- Wei-I Lee
- Department of Immunology, Canberra Hospital, Australia
| | | | - Matthew C Cook
- Department of Immunology, Canberra Hospital, Australia.,Centre for Personalised Immunology, John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia
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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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10
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Lachmann G, Knaak C, von Haefen C, Paeschke N, Meisel C, Nyvlt P, Schuster FS, Piper SK, Kruppa J, Vorderwülbecke G, Balzer F, La Rosée P, Schenk T, Unterwalder N, Kölsch U, Lachmann N, Akyüz L, Brunkhorst FM, Volk HD, Keh D, Spies C. Diagnostic biomarkers for adult haemophagocytic lymphohistiocytosis in critically ill patients (HEMICU): a prospective observational study protocol. BMJ Open 2019; 9:e032695. [PMID: 31666276 PMCID: PMC6830715 DOI: 10.1136/bmjopen-2019-032695] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Haemophagocytic lymphohistiocytosis (HLH) in adults is characterised by toxic immune activation and a sepsis-like syndrome, leading to high numbers of undiagnosed cases and mortality rates of up to 68%. Early diagnosis and specific immune suppressive treatment are mandatory to avoid fatal outcome, but the diagnostic criteria (HLH-2004) are adopted from paediatric HLH and have not been validated in adults. Experimental studies suggest biomarkers to sufficiently diagnose HLH. However, biomarkers for the diagnosis of adult HLH have not yet been investigated. METHODS AND ANALYSIS The HEMICU (Diagnostic biomarkers for adult haemophagocytic lymphohistiocytosis in critically ill patients) study aims to estimate the incidence rate of adult HLH among suspected adult patients in intensive care units (ICUs). Screening for HLH will be performed in 16 ICUs of Charité - Universitätsmedizin Berlin. The inclusion criteria are bicytopaenia, hyperferritinaemia (≥500 µg/L), fever or when HLH is suspected by the clinician. Over a period of 2 years, we expect inclusion of about 100 patients with suspected HLH. HLH will be diagnosed if at least five of the HLH-2004 criteria are fulfilled, together with an expert review; all other included patients will serve as controls. Second, a panel of potential biomarker candidates will be explored. DNA, plasma and serum will be stored in a biobank. The primary endpoint of the study is the incidence rate of adult HLH among suspected adult patients during ICU stay. Out of a variety of measured biomarkers, this study furthermore aims to find highly potential biomarkers for the diagnosis of adult HLH in ICU. The results of this study will contribute to improved recognition and patient outcome of adult HLH in clinical routine. ETHICS AND DISSEMINATION The institutional ethics committee approved this study on 1 August 2018 (Ethics Committee of Charité - Universitätsmedizin Berlin, EA4/006/18). The results of the study will be disseminated in an international peer-reviewed journal and presented at international conferences. TRIAL REGISTRATION NUMBER NCT03510650.
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Affiliation(s)
- Gunnar Lachmann
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Cornelia Knaak
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Clarissa von Haefen
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Nadine Paeschke
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christian Meisel
- Department of Immunology, Labor Berlin - Charité Vivantes GmbH, Berlin, Germany
| | - Peter Nyvlt
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Friederike S Schuster
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sophie K Piper
- Berlin Institute of Health, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jochen Kruppa
- Berlin Institute of Health, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Gerald Vorderwülbecke
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Felix Balzer
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Paul La Rosée
- Klinik für Innere Medizin II, Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany
| | - Thomas Schenk
- Department of Hematology and Oncology, Universitätsklinikum Jena, Jena, Germany
| | - Nadine Unterwalder
- Department of Immunology, Labor Berlin - Charité Vivantes GmbH, Berlin, Germany
| | - Uwe Kölsch
- Department of Immunology, Labor Berlin - Charité Vivantes GmbH, Berlin, Germany
| | - Nils Lachmann
- Institute for Transfusion Medicine, H&I Laboratory, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Levent Akyüz
- Institute for Medical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Frank M Brunkhorst
- Center for Clinical Studies, Department of Anesthesiology and Intensive Care Medicine, Universitätsklinikum Jena, Jena, Germany
| | - Hans-Dieter Volk
- Institute for Medical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Didier Keh
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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11
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Singh PK, Kodati R, Rohilla M, Sharma P. Hemophagocytic lymphohistiocytosis: a rare association with pulmonary cryptococcosis. BMJ Case Rep 2019; 12:12/8/e230255. [PMID: 31401574 DOI: 10.1136/bcr-2019-230255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an inflammatory syndrome characterised by unregulated macrophage and T-lymphocyte activation, resulting in cytokine overproduction and subsequent histiocytic phagocytosis. Here we report a case of pulmonary cryptococcosis, in a 59-year-old diabetic patient, with no other risk factors whose clinical course was complicated by secondary hemophagocytosis. Even after addressing the primary underlying illness (pulmonary cryptococcosis), his clinical condition continued to worsen. After excluding the other causes of HLH and possible reasons of his clinical worsening, glucocorticoids were added following which the patient experienced a remarkable improvement in his clinical and laboratory parameters. To our knowledge, this is the first case report of HLH being caused by pulmonary cryptococcosis and only second case report of cryptococcosis being complicated with HLH (previous report being associated with meningoencephalitic cryptococcosis).
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Affiliation(s)
- Pawan Kumar Singh
- Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kodati
- Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rohilla
- Department of Cytology and Gynecological Pathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Prashant Sharma
- Haematology Department, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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12
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Antonelli G, Sciacovelli L, Aita A, Bozzato D, Plebani M. The pathway for introducing novel examination procedures in routine practice in accordance with ISO 15189:2012: 17-Hydroxy progesterone, dehydroepiandrosterone sulphate and vitamin D as examples. Ann Clin Biochem 2019; 56:548-555. [PMID: 30974962 DOI: 10.1177/0004563219835582] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background In a medical laboratory, changes may be made to the analytical phase of diagnostic testing whenever a new test or the issue of a ‘new generation’ kit or new diagnostic system is required. In such cases, ISO 15189:2012 accreditation can assist laboratory professionals. The aim of the present study was to propose a working pathway for introducing new examination procedures into clinical practice in accordance with the ISO 15189:2012 standard, through the exemplars of 17-hydroxy progesterone, dehydroepiandrosterone sulphate and vitamin D. Methods The working pathway includes the following steps: (i) analysing examination procedures under evaluation, (ii) analysing examination procedures currently in use, (iii) verifying metrological traceability, (iv) verifying examination procedures and (v) evaluating comparability of results. Results The analysis of instructions for use issued by manufacturers revealed that metrological traceability was reported only for vitamin D. The imprecision verification was satisfactory, the imprecision obtained by the laboratory in terms of total imprecision always being less than the specified total imprecision. In only one case (IQC level 1, 17-hydroxy progesterone), the total upper verification limit was calculated. The trueness verification was satisfactory for all examination procedures, except for 17-hydroxy progesterone (second material). Passing–Bablok regression analyses in the comparability study demonstrated significant differences for all the examination procedures. Conclusions The working pathway described for examination procedures in routine practice is in accordance with the requirements of ISO 15189:2012 accreditation and takes feasibility into account (as its main goal), based on the cost/patient benefit ratio.
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Affiliation(s)
- Giorgia Antonelli
- 1 Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Laura Sciacovelli
- 2 Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy
| | - Ada Aita
- 1 Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Dania Bozzato
- 1 Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Mario Plebani
- 1 Department of Medicine - DIMED, University of Padova, Padova, Italy.,2 Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy
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13
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Titov A, Petukhov A, Staliarova A, Motorin D, Bulatov E, Shuvalov O, Soond SM, Piacentini M, Melino G, Zaritskey A, Barlev NA. The biological basis and clinical symptoms of CAR-T therapy-associated toxicites. Cell Death Dis 2018; 9:897. [PMID: 30181581 PMCID: PMC6123453 DOI: 10.1038/s41419-018-0918-x] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/15/2018] [Accepted: 06/21/2018] [Indexed: 12/11/2022]
Abstract
Currently, immunotherapy is attracting a lot of attention and may potentially become a leading approach in the treatment of cancer. One emerging therapeutic, the chimeric-antigen receptor T-cell adoptive immunotherapy (CAR-T) is showing remarkable efficacy in the treatment of several B-cell malignancies. The popularity of CAR-T has been founded on two CAR T-cell products recently approved by FDA (during 2017) in the treatment of relapsed/refractory B-cell acute lymphoblastic leukemia and B-cell lymphoma. However, their toxicities observed in clinical trials were extremely significant and in some cases even fatal with no approved algorithms for toxicity prediction being available to date. A deeper understanding of the biological basis of such complications is the key to prompt and comprehensive clinical management. Here we review the wide spectrum of effects associated with CAR T cell therapy with a major focus on the pathogenesis of cytokine release syndrome and neurotoxicity as the most common, potentially life-threatening effects of this treatment. We discuss the basis of clinical management and the existing models that predict the severity of toxicity, as well as the key factors that modulate this event. Finally, we will summarize the literature detailing universal allogenic CAR T-cells and their toxicity profile.
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Affiliation(s)
- Aleksei Titov
- Almazov National Medical Research Centre, St. Petersburg, Russia, 197341
| | - Alexey Petukhov
- Almazov National Medical Research Centre, St. Petersburg, Russia, 197341.,Institute of Cytology of the Russian Academy of Science, St. Petersburg, Russia, 194064.,Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russia, 420008
| | - Alena Staliarova
- Belarussian Research Center for Pediatric Oncology, Hematology and Immunology, 223053, Borovliani, Republic of Belarus
| | - Dmitriy Motorin
- Almazov National Medical Research Centre, St. Petersburg, Russia, 197341
| | - Emil Bulatov
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russia, 420008
| | - Oleg Shuvalov
- Institute of Cytology of the Russian Academy of Science, St. Petersburg, Russia, 194064
| | - Surinder M Soond
- Institute of Cytology of the Russian Academy of Science, St. Petersburg, Russia, 194064
| | - Mauro Piacentini
- Institute of Cytology of the Russian Academy of Science, St. Petersburg, Russia, 194064.,University of Rome Tor Vergata, 00173, Rome, Italy
| | - Gerry Melino
- Institute of Cytology of the Russian Academy of Science, St. Petersburg, Russia, 194064.,University of Rome Tor Vergata, 00173, Rome, Italy
| | - Andrey Zaritskey
- Almazov National Medical Research Centre, St. Petersburg, Russia, 197341
| | - Nickolai A Barlev
- Institute of Cytology of the Russian Academy of Science, St. Petersburg, Russia, 194064. .,Moscow Institute of Physics and Technology, Dolgoprudny, Moscow, Russia, 141701.
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14
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Lange AV, Kazi S, Chen W, Barnes A. Fatal case of macrophage activation syndrome (MAS) in a patient with dermatomyositis and cytomegalovirus (CMV) viraemia. BMJ Case Rep 2018; 2018:bcr-2018-225231. [PMID: 30061130 PMCID: PMC6067131 DOI: 10.1136/bcr-2018-225231] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2018] [Indexed: 12/17/2022] Open
Abstract
We describe a case of an adult with dermatomyositis (DM) who presents with a rash, high fevers, tachycardia and hypotension, initially concerning for an infectious aetiology or a DM flare. She was found to have cytomegalovirus viraemia which improved after starting valganciclovir. After extensive workup and lack of improvement with broad-spectrum antimicrobial therapy, intravenous immunoglobulin and steroids, the patient was diagnosed with macrophage activation syndrome after bone marrow biopsy and levels of soluble CD25 (soluble interleukin (IL)-2 receptor) and IL2 were obtained. Unfortunately, despite therapy with dexamethasone, anakinra and etoposide, the patient decompensated and the patient's family opted for comfort care. The patient subsequently expired in the intensive care unit.
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Affiliation(s)
| | - Salahuddin Kazi
- Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Weina Chen
- Pathology, Univ Texas SW Med Ctr Dallas, Dallas, Texas, USA
| | - Arti Barnes
- Infectious Diseases, University of Texas Southwestern, Dallas, Texas, USA
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15
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Comparing hemophagocytic lymphohistiocytosis in pediatric and adult patients. Curr Opin Allergy Clin Immunol 2018; 17:405-413. [PMID: 28957822 DOI: 10.1097/aci.0000000000000405] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Hemophagocytic lymphohistiocytosis (HLH) has long been thought of primarily as a pediatric disease. However, this syndrome may occur secondary to underlying malignancies, infections, and autoimmune diseases, in adult patients. Here, we seek to highlight similarities and differences between pediatric and adult HLH, knowledge gaps, and areas of active research. RECENT FINDINGS Malignancy is a more frequent driver of HLH in adults, present in nearly half. Prognosis is poor as compared with nonmalignant HLH. Prognosis in adults is generally worse than pediatric patients, suggesting that age and other comorbid illnesses not surprisingly affect the outcome of HLH. Diagnostic and treatment approaches are more variable in adults, likely contributing to poorer outcomes. The frequency of mutations in HLH-causing genes is higher than had been anticipated in adults, although with a higher frequency of uniallelic and hypomorphic mutations than in children. SUMMARY Optimizing diagnostic criteria for earlier detection may benefit both children and adults. Standardizing treatment approaches in adults will be more difficult because of the variability in triggering illnesses, but a more standardized or algorithmic approach will likely be beneficial. More research into the role of uniallelic and hypomorphic mutations in adults is necessary, to understand treatment and prognostic implications.
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