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Cerme E, Oztas M, Balkan II, Cetin EA, Ugurlu S. Haemophagocytic lymphohistiocytosis in a patient with familial Mediterranean fever and miliary tuberculosis: a case report. Mod Rheumatol Case Rep 2022; 6:140-144. [PMID: 34549298 DOI: 10.1093/mrcr/rxab026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/02/2021] [Accepted: 08/12/2021] [Indexed: 06/13/2023]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a lethal complication of several infections, especially viral origin. Mycobacterium tuberculosis infection can also lead to HLH, yet it is an uncommon trigger. Considering the role of increased cytokines in HLH, autoinflammatory conditions, such as familial Mediterranean fever (FMF), might contribute to its development. Nevertheless, the possible relationship between FMF and HLH has been suggested only in some case reports. We present a case of FMF who admitted to the hospital with consitutional symptoms and chest pain regarding to recurrent pericarditis. On a blood test, pancytopenia and elevated acute phase reactants were seen. Fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography demonstrated positive FDG uptake sites on both the right and left surrenal glands, the visceral layer of pericard, and reactive lymphadenomegalies at multiple mediastinal regions. Bone marrow biopsy revealed haemophagocytosis. Methylprednisolone treatment was initiated. Despite immunosuppressive treatment, clinical and biochemical parameters deteriorated; thus, a thorax computed tomography was executed. Findings were consistent with miliary tuberculosis infection. M. tuberculosis was detected in blood culture and bronchoalveolar lavage culture material. Also, bone marrow and surrenal biopsy material revealed necrotising caseating granuloma.
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Affiliation(s)
- Emir Cerme
- Department of Internal Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Mert Oztas
- Department of Internal Medicine, Division of Rheumatology, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ilker Inanc Balkan
- Department of Infectious Diseases and Clinical Microbiology, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Esin Aktas Cetin
- Institute of Experimental Medicine (DETAE), Department of Immunology, Istanbul University, Istanbul, Turkey
| | - Serdal Ugurlu
- Department of Internal Medicine, Division of Rheumatology, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Büchi G, Termine G, Orlassino R, Pagliarino M, Boero R, Zappalà C, Grosso E. Hemophagocytic Syndrome in a Case of Splenic Large B-Cell Lymphoma. TUMORI JOURNAL 2018; 82:621-4. [PMID: 9061078 DOI: 10.1177/030089169608200623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A case of splenic large B-cell lymphoma with hemophagocytic syndrome is reported. The difficulties of diagnosis are emphasized especially when peripheral lymph nodes or bone marrow lymphomatous infiltration are not present. Diagnostic criteria for hemophagocytic syndrome and their relationship with the pathogenesis of the disease are also stressed.
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Affiliation(s)
- G Büchi
- Divisione di Medicina Interna, Ospedale Civile di Ivrea, Italy
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Nanno S, Koh H, Katayama T, Hashiba M, Sato A, Makuuchi Y, Nagasaki J, Kuno M, Yoshimura T, Okamura H, Nishimoto M, Hirose A, Nakamae M, Nakane T, Hino M, Nakamae H. Plasma Levels of Presepsin (Soluble CD14-subtype) as a Novel Prognostic Marker for Hemophagocytic Syndrome in Hematological Malignancies. Intern Med 2016; 55:2173-84. [PMID: 27522992 DOI: 10.2169/internalmedicine.55.6524] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective Recent studies suggest that presepsin (soluble CD14-subtype) is a useful diagnostic and prognostic marker for sepsis, with secretion by activated macrophages potentially dependent on phagocytosis of microorganisms. As "hemophagocytosis" is one of the major characteristics in patients with hemophagocytic syndrome (HPS), we hypothesized that presepsin may reflect the phagocytic activity and be a useful prognostic marker for HPS. Therefore, we aimed to assess the prognostic potential of presepsin in secondary HPS in adult patients with hematological malignancies. Methods Between April 2006 and August 2014, we retrospectively examined consecutive patients with HPS whose blood samples were available at our institution and compared the prognostic value of the following in HPS, singly and in combination: plasma presepsin, serum soluble interleukin (IL)-2 receptor (sIL-2R), ferritin, tumor necrosis factor-α (TNF-α), interferon-γ (IFN-γ), IL-6 and IL-10. Results A total of 14 patients were enrolled. The median age of the patients was 46.5 years (range, 22-65). In univariable Cox models, there were no significant variables associated with the prognosis. However, in 12 evaluable patients, only the combination of higher median values of presepsin (>1,935 pg/mL) and sIL-2R (>4,585 U/mL) at the onset of HPS was significantly associated with the 90-day mortality (hazard ratio 14.5; 95% CI, 1.47-143.36; p=0.02). Conclusion These results suggest that a composite model of plasma presepsin and serum sIL-2R levels at the onset of HPS might be a novel predictor of the prognosis of patients with hematological malignancies and secondary HPS.
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Affiliation(s)
- Satoru Nanno
- Hematology, Graduate School of Medicine, Osaka City University, Japan
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Therapeutic role of anakinra, an interleukin-1 receptor antagonist, in the management of secondary hemophagocytic lymphohistiocytosis/sepsis/multiple organ dysfunction/macrophage activating syndrome in critically ill children*. Pediatr Crit Care Med 2014; 15:401-8. [PMID: 24583503 DOI: 10.1097/pcc.0000000000000078] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Secondary hemophagocytic lymphohistiocytosis, macrophage activating syndrome, and sepsis share the same inflammatory phenotype leading often to multiple organ dysfunction syndrome needing intensive care. The goal of this article is to describe our experience with anakinra (Kineret), a recombinant interleukin-1 receptor antagonist, in decreasing the systemic inflammation. DESIGN Retrospective case series. SETTING The PICU at the Helen DeVos Children's Hospital (Grand Rapids, MI). PATIENTS The records of eight critically ill children presumed to have secondary hemophagocytic lymphohistiocytosis at our institution between January 1, 2011, and July 31, 2012, were reviewed. INTERVENTIONS All of the patients were treated with anakinra (Kineret) and in some cases systemic corticosteroids as first-line therapy for secondary hemophagocytic lymphohistiocytosis. MEASUREMENTS AND MAIN RESULTS Patients had a median age of 14 years and a median Pediatric Risk of Mortality score of 11.5. Four were previously healthy and four had underlying diseases that could have made them susceptible to secondary hemophagocytic lymphohistiocytosis. Indications for PICU transfer were respiratory distress 50% (4 of 8), cardiovascular instability 37.5% (3 of 8), and chest pain (1 of 8). Five of the patients (62.5%) were mechanically ventilated and 62.5% (5 of 8) received vasoactive infusions. Inflammatory markers were assessed linearly at the start of therapy and 7 days later. Baseline C-reactive protein was 206 ± 50 mg/L (mean ± SEM) at the start of anakinra and decreased by 67.1% to 68 ± 36 mg/L (p = 0.03). Ferritin decreased by 63.8% to 3,210 ± 1,178 ng/mL (p = 0.30), and fibrinogen decreased by 42% to 158 ± 41 mg/dL (p = 0.03). Absolute neutrophil count (p = 0.38) and absolute lymphocyte count (p = 0.69) did not change significantly. No infections were attributed to anakinra therapy. One patient died long after treatment with anakinra while receiving pre-hematopoietic stem cell transplant chemotherapy. CONCLUSIONS Anakinra could represent a promising therapeutic approach in these life-threatening disorders that are likely underdiagnosed and often difficult to treat.
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Radons J. Inflammatory stress and sarcomagenesis: a vicious interplay. Cell Stress Chaperones 2014; 19:1-13. [PMID: 24046208 PMCID: PMC3857425 DOI: 10.1007/s12192-013-0449-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 07/15/2013] [Accepted: 07/17/2013] [Indexed: 12/15/2022] Open
Abstract
Chronic inflammation represents one of the hallmarks of cancer, but its role in sarcomagenesis has long been overlooked. Sarcomas are a rare and heterogeneous group of tumors of mesenchymal origin accounting for less than 1 % of cancers in adults but 21 % of cancers in the pediatric population. Sarcomas are associated with bad prognosis, and their management requires a multidisciplinary team approach. Several lines of evidence indicate that inflammation has been implicated in sarcomagenesis leading to the activation of the key transcription factors HIF-1, NF- κB, and STAT-3 involved in a complex inflammatory network. In the past years, an increasing number of new targets have been identified in the treatment of sarcomas leading to the development of new drugs that aim to interrupt the vicious connection between inflammation and sarcomagenesis. This article makes a brief overview of preclinical and clinical evidence of the molecular pathways involved in the inflammatory stress response in sarcomagenesis and the most targeted therapies.
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Affiliation(s)
- Jürgen Radons
- multimmune GmbH c/o Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany,
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Le syndrome d’activation lympho-histiocytaire (SALH). ACTA ACUST UNITED AC 2014; 33:26-32. [DOI: 10.1016/j.annfar.2013.11.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 11/26/2013] [Indexed: 11/24/2022]
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Radons J. The role of inflammation in sarcoma. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2014; 816:259-313. [PMID: 24818727 DOI: 10.1007/978-3-0348-0837-8_11] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Sarcomas encompass a heterogenous group of tumors with diverse pathologically and clinically overlapping features. It is a rarely curable disease, and their management requires a multidisciplinary team approach. Chronic inflammation has emerged as one of the hallmarks of tumors including sarcomas. Classical inflammation-associated sarcomas comprise the inflammatory malignant fibrous histiocytoma and Kaposi sarcoma. The identification of specific chromosomal translocations and important intracellular signaling pathways such as Ras/Raf/MAPK, insulin-like growth factor, PI3K/AKT/mTOR, sonic hedgehog and Notch together with the increasing knowledge of angiogenesis has led to development of targeted therapies that aim to interrupt these pathways. Innovative agents like oncolytic viruses opened the way to design new therapeutic options with encouraging findings. Preclinical evidence also highlights the therapeutic potential of anti-inflammatory nutraceuticals as they can inhibit multiple pathways while being less toxic. This chapter gives an overview of actual therapeutic standards, newest evidence-based studies and exciting options for targeted therapies in sarcomas.
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Affiliation(s)
- Jürgen Radons
- Department of Radiotherapy and Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, Munich, Germany,
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Oda Y, Urushidani Y, Ooi S, Endoh A, Nakamura R, Adachi K, Fukushima H. Hemophagocytic lymphohistiocytosis in a rheumatoid arthritis patient treated with infliximab. Intern Med 2012; 51:655-7. [PMID: 22449679 DOI: 10.2169/internalmedicine.51.5687] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare condition with high mortality. We report a case of a 74-year-old woman with rheumatoid arthritis who developed HLH secondary to pyelonephritis due to Escherichia coli infection following infliximab treatment. Bone marrow aspiration showed proliferation of histiocytes with hemophagocytosis. The patient died despite treatment with intravenous antibiotics intravenous methylprednisolone and intravenous immunoglobulin. Cytokine levels were measured and are discussed.
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Affiliation(s)
- Yuzo Oda
- Division of Hematology, Clinical Immunology and Nephrology, Matsue Red Cross Hospital, Japan.
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Kim JM, Kwok SK, Ju JH, Kim HY, Park SH. Reactive hemophagocytic syndrome in adult Korean patients with systemic lupus erythematosus: a case-control study and literature review. J Rheumatol 2011; 39:86-93. [PMID: 22174206 DOI: 10.3899/jrheum.110639] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To determine the characteristics of hemophagocytic syndrome (HPS) in adult Korean patients with systemic lupus erythematosus (SLE). METHODS We reviewed the medical records of 1033 adult patients with SLE for a recent 14-year period and identified 15 patients who had developed HPS. Forty-two age- and sex-matched patients with SLE admitted for other manifestations were included as disease controls. Features of HPS in these patients were analyzed. RESULTS Reactive HPS occurred from some distinct causes during the course of SLE. HPS was associated with SLE in 11 patients (4 at onset of SLE and 7 at SLE flare), infection in 3 patients (2 bacterial infection; 1 viral infection), and drug use (azathioprine) in 1 patient. Common clinical features included fever (93.3%), hepatomegaly (60.0%), and splenomegaly (60.0%). Steroid pulse therapy (46.7%), immunosuppressants (46.7%), and intravenous immunoglobulin (46.7%) were frequently used for treatment of HPS. One patient (6.7%) died. Compared with SLE patients without HPS, those with HPS showed a higher SLEDAI score (p = 0.003) and lower levels of plasma leukocytes (p < 0.001), hemoglobin (p = 0.013), and platelets (p < 0.001) as well as a higher serum C-reactive protein level (p = 0.039) and a lower serum albumin level (p = 0.004). CONCLUSION HPS was observed in 1.5% of adult Korean patients with SLE. The occurrence of HPS was most frequently associated with the SLE disease activity. Profound pancytopenia, a high SLEDAI score, and notable changes in the level of acute-phase reactants can be the characteristics of SLE patients with HPS.
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Affiliation(s)
- Ji-Min Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 505, Banpo-dong, Seocho-gu, Seoul, 137-040, Republic of Korea
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Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare inflammatory disorder with a poor prognosis for affected individuals. To find a means of suppressing the clinical phenotype, we investigated the cellular and molecular mechanisms leading to HLH in Unc13d(jinx/jinx) mice, in which cytolytic function of NK and CD8(+) T cells is impaired. Unc13d(jinx/jinx) mutants infected with lymphochoriomeningitis virus (LCMV) present typical clinical features of HLH, including splenomegaly, elevated serum IFNγ, and anemia. Proteins mediating cell-cell contact, cytokine signaling or Toll-like receptor (TLR) signaling were analyzed. We show that neither the integrin CD18, which is involved in adhesion between antigen-presenting cells and effector T cells, nor tumor necrosis factor (TNF) made nonredundant contributions to the disease phenotype. Disruption of IFNγ signaling reduced immune cell activation in Unc13d(jinx/jinx) mice, but also resulted in uncontrolled viral proliferation and exaggerated release of inflammatory cytokines. Abrogating the function of myeloid differentiation primary response gene 88 (MyD88) in Unc13d(jinx/jinx) mice suppressed immune cell activation and controlled cytokine production in an IL-1 receptor 1 (IL-1R1)-independent way. Our findings implicate MyD88 as the key initiator of myeloid and lymphoid proliferation in HLH, and suggest that blockade of this signaling molecule may reduce immunopathology in patients.
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Abstract
Interleukin (IL)-1 plays an important role not only in the mediation of inflammation but also in the destruction of cartilage and bone. Together with TNF-alpha it is one of the most important cytokines in the pathogenesis of rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA). The first IL-1 antagonist to be approved for RA was Anakinra, an IL-1 receptor antagonist. Anakinra appears to be less effective for RA than TNF blockers. Hence, Anakinra is rarely used for the treatment of RA, but more for the treatment of IL-1-mediated diseases such as autoinflammatory syndromes, adult-onset Still's disease and systemic onset JIA. Two newer IL-1 antagonists have recently been approved for the treatment of CAPS (cryopyrin-associated periodic syndromes): Canakinumab, a fully human IL-1beta antibody, and rilonacept, a fusion protein consisting of the ligand-binding domain of the IL-1 receptor and the IL-1-receptor accessory protein, bound to human IgG1. For RA, there is only one proof-of-concept study to date with canakinumab. There are no prospective data for the treatment of patients with RA who did not respond to or tolerate TNF antagonists; in a retrospective analysis, only 8% of anti-TNF pretreated patients achieved an ACR 20 response.
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Affiliation(s)
- I Kötter
- Interdisziplinäres Zentrum für Rheumatologie, Klinische Immunologie und Autoimmunerkrankungen (INDIRA) und Medizinische Universitätsklinik Abt. II, Universistätsklinikum Tübingen, 72076 Tübingen, Deutschland.
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Nold-Petry CA, Lehrnbecher T, Jarisch A, Schwabe D, Pfeilschifter JM, Muhl H, Nold MF. Failure of interferon gamma to induce the anti-inflammatory interleukin 18 binding protein in familial hemophagocytosis. PLoS One 2010; 5:e8663. [PMID: 20072626 PMCID: PMC2800185 DOI: 10.1371/journal.pone.0008663] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Accepted: 12/07/2009] [Indexed: 11/19/2022] Open
Abstract
Background Familial hemophagocytosis (FHL) is a rare disease associated with defects in proteins involved in CD8+ T-cell cytotoxicity. Hyperactivation of immune cells results in a perilous, Th1-driven cytokine storm. We set out to explore the regulation of cytokines in an FHL patient who was clinically stable on low-dose immunosuppressive therapy after bone marrow transplantation over a six-month period. During this period, chimerism analyses showed that the fraction of host cells was between 1 and 10%. Both parents of the patient as well as healthy volunteers were studied for comparison. Methods/Principal Findings Using ELISA, quantitative real-time PCR, and clinical laboratory methods, we investigated constitutive and inducible cytokines, polymorphisms, and clinical parameters in whole blood and whole blood cultures. Although routine laboratory tests were within the normal range, the chemokines IP-10 and IL-8 as well as the cytokine IL-27p28 were increased up to 10-fold under constitutive and stimulated conditions compared to healthy controls. Moreover, high levels of IFNγ and TNFα were produced upon stimulation. Unexpectedly, IFNγ induction of IL-18 binding protein (IL-18BP) was markedly reduced (1.6-fold vs 5-fold in controls). The patient's mother featured intermediately increased cytokine levels, whereas levels in the father were similar to those in the controls. Conclusions/Significance Since IL-18 plays a major role in perpetuating hemophagocytosis, the failure of IFNγ to induce IL-18BP may constitute a fundamental pathogenetic mechanism. Furthermore, increased production of IL-8 and IL-27 appears to be associated with this disease. Such dysregulation of cytokines was also found in the heterozygous parents, providing a novel insight into genotype-phenotype correlation of FHL which may encourage future research of this rare disease.
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Affiliation(s)
- Claudia A. Nold-Petry
- Pharmazentrum Frankfurt, Johann Wolfgang Goethe-University Hospital, Frankfurt, Germany
- Division of Infectious Diseases, University of Colorado Denver, Aurora, Colorado, United States of America
| | - Thomas Lehrnbecher
- Department of Pediatrics, Johann Wolfgang Goethe-University Hospital, Frankfurt, Germany
| | - Andrea Jarisch
- Department of Pediatrics, Johann Wolfgang Goethe-University Hospital, Frankfurt, Germany
| | - Dirk Schwabe
- Department of Pediatrics, Johann Wolfgang Goethe-University Hospital, Frankfurt, Germany
| | | | - Heiko Muhl
- Pharmazentrum Frankfurt, Johann Wolfgang Goethe-University Hospital, Frankfurt, Germany
| | - Marcel F. Nold
- Pharmazentrum Frankfurt, Johann Wolfgang Goethe-University Hospital, Frankfurt, Germany
- Division of Infectious Diseases, University of Colorado Denver, Aurora, Colorado, United States of America
- * E-mail:
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Kim HW, Choi BS, Kim JH, Shin YM, Lee SJ, Kim SR, Jun JB. A Case of Death Due to Hemophagocytic Lymphohistiocytosis Accompanied by Scrub Typhus. Infect Chemother 2010. [DOI: 10.3947/ic.2010.42.4.266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Hyung Wook Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan, Korea
| | - Bo Sik Choi
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jong Hyung Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan, Korea
| | - Young Min Shin
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan, Korea
| | - Soon Jung Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan, Korea
| | - Sung Ryul Kim
- Department of Laboratory Medicine, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jae-Bum Jun
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan, Korea
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My LT, Lien LB, Hsieh WC, Imamura T, Anh TNK, Anh PNL, Hung NT, Tseng FC, Chi CY, Dao NTH, Le DTM, Thinh LQ, Tung TT, Imashuku S, Thuong TC, Su IJ. Comprehensive analyses and characterization of haemophagocytic lymphohistiocytosis in Vietnamese children. Br J Haematol 2009; 148:301-10. [PMID: 19863536 DOI: 10.1111/j.1365-2141.2009.07957.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a fatal haematological disorder with diverse aetiology. This prospective study was undertaken to characterize HLH cases in Vietnamese children. Clinical and laboratory data, genetic analyses and outcome of the HLH patients were analysed. A total of 33 patients were enrolled from March 2007 to December 2008, with a median age of 3 years. Mutations of the SH2D1A (SAP) and PRF1 genes were detected in one patient, respectively. The virus association was high, up to 63.6% (21/33), including Epstein-Barr virus (19/33), cytomegalovirus (2/33) and dengue virus (2/33). Five patients had malignant lymphoma and two had autoimmune diseases. Twenty-eight patients were treated according to the HLH-2004 protocol. The first response rate was 64.3% (18/28), with an early death rate of 35.7% (10/28). High levels of interferon-gamma, interleukin-10, MIG and interferon-inducible protein-10 (IP-10) were associated with early mortality (P < 0.05). Reactivation among the responders was high (9/18) and the uneventful resolution was low (3/18) after a median follow-up of 35 weeks. In conclusion, the majority of HLH cases are associated with virus infections in Vietnamese children. Familial HLH is rare. The frequent reactivation and high mortality demands a more appropriate therapeutic regimen in tropical areas like Vietnam.
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Affiliation(s)
- Lam T My
- Department of Clinical Haematology, Children Hospital, Ho-Chi-Minh City, Vietnam
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Tateishi Y, Oda S, Sadahiro T, Nakamura M, Hirayama Y, Abe R, Hirasawa H. Continuous hemodiafiltration in the treatment of reactive hemophagocytic syndrome refractory to medical therapy. Transfus Apher Sci 2009; 40:33-40. [DOI: 10.1016/j.transci.2008.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Abiotrophia defectiva endocarditis and associated hemophagocytic syndrome—a first case report and review of the literature. Int J Infect Dis 2008; 12:478-82. [DOI: 10.1016/j.ijid.2008.01.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2007] [Revised: 12/21/2007] [Accepted: 01/14/2008] [Indexed: 11/19/2022] Open
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Tang Y, Xu X, Song H, Yang S, Shi S, Wei J, Pan B, Zhao F, Liao C, Luo C. Early diagnostic and prognostic significance of a specific Th1/Th2 cytokine pattern in children with haemophagocytic syndrome. Br J Haematol 2008; 143:84-91. [PMID: 18673367 DOI: 10.1111/j.1365-2141.2008.07298.x] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The haemophagocytic syndrome (HPS) is a rare but frequently fatal disorder of immune regulation caused by hypercytokinemia. Using cytometric bead array technique, the serum T-helper cell type 1 (Th1) and 2 (Th2) cytokines including interferon-gamma (IFN-gamma), tumour necrosis factor (TNF), interleukin (IL)-10, IL-6, IL-4 and IL-2 were determined in 24 children with de novo HPS and 87 children as control. The median levels of serum IFN-gamma, IL-10 and IL-6 in the acute phase of HPS were 901.7, 879.0 and 63.8 pg/ml, respectively, significantly higher than those after remission, and in the healthy volunteers and patients with viral infection. IL-4 was slightly elevated while IL-2 and TNF were within normal range in acute phase. Patients with bacterial sepsis showed an extremely high level of IL-6 and moderate level of IL-10, whereas IFN-gamma was only slightly elevated. Five patients were diagnosed with HPS according to the Th1/Th2 cytokine pattern 3-13 d earlier than they fulfilled the relevant diagnostic criteria. IL-10 level >2000 pg/ml was an unfavorable prognostic factor for HPS treatment response (P = 0.033) and outcome (P = 0.009). We conclude that the significant increase of IFN-gamma and IL-10 and a slightly increased level of IL-6 is an early, specific and prognostic cytokine pattern for childhood HPS.
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Affiliation(s)
- Yongmin Tang
- Division of Haematology-Oncology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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Behrens EM. Macrophage activation syndrome in rheumatic disease: what is the role of the antigen presenting cell? Autoimmun Rev 2008; 7:305-8. [PMID: 18295734 DOI: 10.1016/j.autrev.2007.11.025] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2007] [Accepted: 11/19/2007] [Indexed: 01/08/2023]
Abstract
Macrophage Activation Syndrome (MAS), alternatively referred to as secondary hemophagocytic lymphohistiocytosis (HLH), is a complication of many rheumatic diseases, most commonly Systemic Juvenile Idiopathic Arthritis (SJIA). MAS consists of a fulminant picture of pan-cytopenia, hectic high fevers, hepatosplenomegaly, lymphadenopathy, rash, and central nervous systemic inflammation. It can arise from genetic defects in the cytotoxic effector response of CD8+ T-cells, resulting in an inability to terminate antigen presentation, which in turn leads to uncontrolled immune activation. However, in the case of most rheumatic diseases, no such defect in cytotoxic killing is present. Little is known about what the contributions from the antigen presenting cells are in the pathogenesis of MAS. In fact, macrophages may be playing a regulatory, anti-inflammatory in MAS. We review the proposed pathogenesis of MAS/HLH, what role macrophages may play in the disease, and the relationship of MAS to its most common associated rheumatic disease, SJIA.
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Affiliation(s)
- Edward M Behrens
- Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, PA 19104-4318, USA.
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Lee HJ, Chung JS, Shin HJ, Choi YJ, Park YE, Kim PJ, Kim ID, Lee EY, Cho GJ. A Case of Hemophagocytic Lymphohistiocytosis Accompanied by Acute Hepatitis A: Review of the Literature. THE KOREAN JOURNAL OF HEMATOLOGY 2007. [DOI: 10.5045/kjh.2007.42.1.62] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Hye-Jeong Lee
- Department of Internal Medicine, College of Medicine, Pusan National University Hospital, Busan, Korea
| | - Joo Seop Chung
- Department of Internal Medicine, College of Medicine, Pusan National University Hospital, Busan, Korea
| | - Ho-Jin Shin
- Department of Internal Medicine, College of Medicine, Pusan National University Hospital, Busan, Korea
| | - Young Jin Choi
- Department of Internal Medicine, College of Medicine, Pusan National University Hospital, Busan, Korea
| | - Young-Eun Park
- Department of Internal Medicine, College of Medicine, Pusan National University Hospital, Busan, Korea
| | - Pyo-Jun Kim
- Department of Internal Medicine, College of Medicine, Pusan National University Hospital, Busan, Korea
| | - Il-Doo Kim
- Department of Internal Medicine, College of Medicine, Pusan National University Hospital, Busan, Korea
| | - Eun-Yup Lee
- Department of Pathology, College of Medicine, Pusan National University Hospital, Busan, Korea
| | - Goon Jae Cho
- Department of Internal Medicine, College of Medicine, Pusan National University Hospital, Busan, Korea
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20
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Brastianos PK, Swanson JW, Torbenson M, Sperati J, Karakousis PC. Tuberculosis-associated haemophagocytic syndrome. THE LANCET. INFECTIOUS DISEASES 2006; 6:447-54. [PMID: 16790385 DOI: 10.1016/s1473-3099(06)70524-2] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Haemophagocytic syndrome is a disorder characterised by fevers, lymphadenopathy, hepatosplenomegaly, cytopenias, and hyperferritinaemia due to dysregulated activation and proliferation of macrophages, leading to uncontrolled phagocytosis of platelets, erythrocytes, lymphocytes, and their haematopoietic precursors throughout the reticuloendothelial system. Primary or familial haemophagocytic syndrome appears to have a genetic aetiology, whereas secondary haemophagocytic syndrome may be associated with malignancy, autoimmune disease, or infection. Epstein-Barr virus is the most common infectious aetiology implicated in haemophagocytic syndrome, but the syndrome has been associated with a variety of other viral, bacterial, and parasitic pathogens. We describe a case of haemophagocytic syndrome associated with disseminated Mycobacterium tuberculosis. We review all cases of M tuberculosis-associated haemophagocytic syndrome reported in the English language literature and discuss important issues pertaining to the epidemiology, diagnosis, and management of this disease.
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Affiliation(s)
- Priscilla K Brastianos
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21231-1002, USA
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21
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Akiyoshi K, Hamada Y, Yamada H, Kojo M, Izumi T. Acute necrotizing encephalopathy associated with hemophagocytic syndrome. Pediatr Neurol 2006; 34:315-8. [PMID: 16638510 DOI: 10.1016/j.pediatrneurol.2005.08.030] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2005] [Revised: 03/22/2005] [Accepted: 08/30/2005] [Indexed: 11/20/2022]
Abstract
A 7-year-old female suddenly exhibited high fever and convulsions, and entered a semi-coma. She also had thrombocytopenia, elevated aminotransferase, prolonged prothrombin time and activated partial thromboplastin time, and hemophagocytes in the bone marrow. The brain magnetic resonance imaging revealed multiple low-intensity areas on the T1-weighted images, and high-intensity areas on the T2-weighted images bilaterally in the thalamus, the dorsal part of the pons, and the cerebellar white matter. The patient was diagnosed as having both acute necrotizing encephalopathy and hemophagocytic syndrome. Serum and cerebrospinal fluid interleukin-6 and tumor necrosis factor-alpha were elevated to the same high levels (serum:cerebrospinal fluid interleukin-6, 103:101 pg/mL; tumor necrosis factor-alpha 753:753 pg/mL). The clinical symptoms and the magnetic resonance imaging findings improved immediately after the administration of dexamethasone. These results suggest that the hypercytokinemia and the hyperpermeability of both the blood-brain barrier and the capillary walls of the central nervous system might be essential in the pathogenesis of acute necrotizing encephalopathy, and that early steroid therapy might be effective in these conditions.
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Affiliation(s)
- Kensuke Akiyoshi
- Division of Pediatrics and Child Neurology, Department of Brain and Nerve Science, Oita University Faculty of Medicine, Hasama, Oita, Japan.
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22
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Kawada JI, Kimura H, Shibata Y, Hara S, Hoshino Y, Kojima S, Nishikawa K, Morishima T. Evaluation of apoptosis in Epstein–Barr virus-associated hemophagocytic lymphohistiocytosis. J Med Virol 2006; 78:400-7. [PMID: 16419109 DOI: 10.1002/jmv.20553] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Epstein-Barr virus (EBV) is known to be a causative agent of hemophagocytic lymphohistiocytosis (HLH). To investigate association of apoptosis in the pathogenesis of EBV-associated HLH, the serum EBV loads, and serum concentrations of soluble tumor necrosis factor receptor 1 (sTNF-R1), soluble Fas ligand, and cytochrome c were examined in 15 patients with EBV-associated HLH and 24 patients with infectious mononucleosis (IM). Levels of sTNF-R1 are known to reflect the biological activity of TNF-alpha and cytochrome c is a specific marker of apoptosis. EBV loads, and concentrations of sTNF-R1 and cytochrome c were significantly higher in patients with EBV-associated HLH than in patients with IM. On the other hand, there were no statistically significant differences in the concentrations of soluble Fas ligand. In patients with EBV-associated HLH, EBV loads, concentrations of sTNF-R1, and cytochrome c were correlated with each other. These results suggest that apoptosis, which is dependent on the EBV load and could be mediated by TNF-alpha, plays a major role in the pathophysiology of EBV-associated HLH.
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Affiliation(s)
- Jun-Ichi Kawada
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
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23
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Verbsky JW, Grossman WJ. Hemophagocytic lymphohistiocytosis: diagnosis, pathophysiology, treatment, and future perspectives. Ann Med 2006; 38:20-31. [PMID: 16448985 DOI: 10.1080/07853890500465189] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening disease in which the immune system becomes overactive due to its inability to effectively respond to infections and/or shut down the immune response to such infections. The discovery of genetic defects in the secretory pathway of natural killer (NK) cells and cytotoxic T cells in some patients with this disease has raised important questions of the role of cytotoxic cells in the control of infections and in immune regulation. This review will give a brief overview of the clinical presentation and accepted treatment of HLH. Furthermore, it will give an in-depth review into the known genetic defects and current knowledge of the pathophysiology of this disorder, and will highlight recent evidence suggesting that cytotoxic defects in CD4+ T regulatory cells may contribute to the pathogenesis of HLH.
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Affiliation(s)
- James W Verbsky
- Division of Rheumatology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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24
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Sanada S, Ookawara S, Shindo T, Morino K, Ishikawa H, Suzuki M. A Case Report of the Effect of Plasma Exchange on Reactive Hemophagocytic Syndrome Associated with Toxic Shock Syndrome. Ther Apher Dial 2004; 8:503-6. [PMID: 15663552 DOI: 10.1111/j.1774-9987.2004.00188.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report here the case of a patient suffering from hemophagocytic syndrome (HPS) associated with toxic shock syndrome (TSS). A 50-year-old man was admitted because of fever, watery diarrhea and shortness of breath. Clinical analysis revealed systemic cyanosis, sunburn-like erythema and septic shock. Staphylococcus aureus was identified from both blood and sputum culture and the serum enterotoxin A antibody test was positive, suggesting that this was a case of TSS. Though the respiratory and hemodynamic status improved by the mechanical ventilation, fluid resuscitation with catecholamine and antibiotic therapy, the platelet count decreased rapidly. Bone marrow aspiration revealed a large quantity of hemophagocytosis by macrophages. This reactive HPS was treated not with immunosuppressive drugs but with therapeutic plasma exchange in order to prevent worsening of S. aureus infection. After plasma exchange, the circulating macrophage colony-stimulating factor (M-CSF) level was reduced and the platelet count increased rapidly. Bacteria associated HPS remains a difficult diagnosis with high mortality and there is a crucial question of whether this should be treated with immunosuppressive drugs. The patient's clinical course would suggest that the therapeutic plasma exchange should be considered as a therapeutic tool for the bacteria associated HPS instead of immunosuppressive drugs.
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Affiliation(s)
- Satoru Sanada
- Department of Internal Medicine, Yamagata Prefectural Central Hospital, Yamagata 990-2292, Japan.
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25
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Kobayashi Y, Mori M, Naruto T, Kobayashi N, Sugai T, Imagawa T, Yokota S. Dynamic movement of cytochrome c from mitochondria into cytosol and peripheral circulation in massive hepatic cell injury. Pediatr Int 2004; 46:685-92. [PMID: 15660868 DOI: 10.1111/j.1442-200x.2004.01980.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND In the process of apoptosis, it is known that the transition of cytochrome c from mitochondria into the cytosol occurs, and tumor necrosis factor (TNF)-alpha is one of the molecules responsible for this event. But in the state of hypercytokine induced by D-galactosamine (D-GaIN)/Lipopolysaccharide (LPS), the localization of cytochrome c is little known. METHODS Rats were administrated with D-GaIN(700 mg/kg)/LPS(200 microg/kg). Blood and tissue samples were collected and examined for levels of pro-inflammatory cytokines, the apoptosis of liver cells, and the localization of cytochrome c. RESULT Before administration of D-GaIN/LPS, cytochrome c was definitely localized in the mitochondria. At 2 h after simultaneous administration of D-GaIN/LPS, cytochrome c had accumulated in the cytosol following abrupt increases of plasma TNF-alpha. Massive cell destruction due to apoptosis proved by Terminal deoxynucleo-tidyl transferase-mediated dUTP nick end labeling staining was observed in liver tissue 4 h later and markedly increased levels of cytochrome c were detected in the plasma 12 h after D-GaIN/LPS administration. CONCLUSION Liver injury induced by simultaneous administration of D-GaIN/LPS was closely associated with the production of TNF-alpha, and also with the dynamic movement of cytochrome c from the mitochondria into the cytosol, and then into the systemic circulation. The detection of plasma cytochrome c levels may be a useful clinical tool for the detection of apoptosis in vivo.
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Affiliation(s)
- Yoshinori Kobayashi
- Department of Pediatrics, Yokohama City University School of Medicine, Yokohama, Japan
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26
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Larroche C, Mouthon L. Pathogenesis of hemophagocytic syndrome (HPS). Autoimmun Rev 2004; 3:69-75. [PMID: 15003190 DOI: 10.1016/s1568-9972(03)00091-0] [Citation(s) in RCA: 169] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2003] [Indexed: 11/24/2022]
Abstract
Hemophagocytic syndrome (HPS) is a clinicopathologic entity characterized by increased proliferation and activation of benign macrophages with hemophagocytosis throughout the reticuloendothelial system. Uncontrolled T-lymphocyte activation is responsible for increased T(H)1 cytokines secretion such as IFN-gamma, IL-12 and IL-18 that promotes macrophage activation. Genetic defects specific for cytotoxic T lymphocytes (CTL) and natural killer (NK) cells have been identified in patients with primary HPS that are responsible for altered cell death and apoptosis induction or target killing. HPS may be secondary to malignancy, infection or autoimmune disease, and mechanisms involved are poorly understood. However, in adult-onset Still's disease, juvenile chronic arthritis and probably systemic lupus erythematosus, IL-18 might play a role in initiating macrophage activation.
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Affiliation(s)
- Claire Larroche
- Department of Internal Medicine, Hôpital Avicenne, 125, rue de Stalingrad, Bobigny 93009, France.
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27
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Huang DB, Wu JJ, Hamill RJ. Reactive hemophagocytosis associated with the initiation of highly active antiretroviral therapy (HAART) in a patient with AIDS. ACTA ACUST UNITED AC 2004; 36:516-9. [PMID: 15307589 DOI: 10.1080/00365540410020569] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Reactive hemophagocytosis has been associated with neoplasia, bacteria, parasitic, and viral infections including human immunodeficiency virus (HIV). Here we present a case of reactive hemophagocytosis associated with the initiation of highly active antiretroviral therapy (HAART), probably representing a syndrome termed the immune reconstitution inflammatory syndrome (IRIS) or immune reconstitution syndrome.
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Affiliation(s)
- David B Huang
- Department of Medicine, Division of Infectious Diseases, Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas 77030, USA
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28
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Babu TGL, Boctor D, Davey A, Bond MC, Jacobson K. Cytomegalovirus-associated hemophagocytic syndrome in a child with Crohn disease receiving azathioprine. J Pediatr Gastroenterol Nutr 2004; 39:418-21. [PMID: 15448434 DOI: 10.1097/00005176-200410000-00020] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- T G Lokesh Babu
- Division of Gastroenterology, BC Children's Hospital, Vancouver, Canada
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29
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Davis MP, Dreicer R, Walsh D, Lagman R, LeGrand SB. Appetite and Cancer-Associated Anorexia: A Review. J Clin Oncol 2004; 22:1510-7. [PMID: 15084624 DOI: 10.1200/jco.2004.03.103] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Appetite is governed by peripheral hormones and central neurotransmitters that act on the arcuate nucleus of the hypothalamus and nucleus tactus solitarius of the brainstem. Cancer anorexia appears to be the result of an imbalance between neuropeptide-Y and pro-opiomelanocortin signals favoring pro-opiomelanocortin. Many of the appetite stimulants redress this imbalance. Most of our understanding of appetite neurophysiology and tumor-associated anorexia is derived from animals and has not been verified in humans. There have been few clinical trials and very little translational research on anorexia despite its prevalence in cancer.
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Affiliation(s)
- Mellar P Davis
- Harry R. Horvitz Center for Palliative Medicine, Department of Hematology/Medical Oncology, FCCP, Cleveland Clinic Foundation, 9500 Euclid Avenue, R35, Cleveland, OH 44195, USA.
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30
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Fardet L, Blum L, Kerob D, Agbalika F, Galicier L, Dupuy A, Lafaurie M, Meignin V, Morel P, Lebbé C. Human herpesvirus 8-associated hemophagocytic lymphohistiocytosis in human immunodeficiency virus-infected patients. Clin Infect Dis 2003; 37:285-91. [PMID: 12856221 DOI: 10.1086/375224] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2002] [Accepted: 02/19/2003] [Indexed: 11/04/2022] Open
Abstract
We retrospectively reviewed 5 cases of hemophagocytic lymphohistiocytosis (HL) associated with human herpesvirus 8 (HHV-8) reactivation in human immunodeficiency virus (HIV)-infected patients. All patients had clinical and biological features characteristic of HL. Pulmonary symptoms were present in all patients and were frequently life threatening. The mean number of HL episodes was 6. Four patients had HL-associated Kaposi sarcoma, and 3 had multicentric Castleman disease. The mean CD4 cell count was 200 cells/mm(3). HIV loads were stable in all patients. All patients had high levels of HHV-8 in peripheral blood mononuclear cells during attacks, and a significant increase in this parameter before the attacks was seen in 3 patients. Although 2 patients died of HL, 3 are still alive and receiving etoposide therapy (mean follow-up, 3 years). HHV-8-related HL is associated with life-threatening symptoms and biological HHV-8 reactivation, and it may be controlled in the long term by etoposide therapy combined with highly active antiretroviral therapy.
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Affiliation(s)
- L Fardet
- Service de Dermatologie, Centre Hospitalier Universitaire Saint Louis, Paris, France
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31
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Karasu Z, Kilic M, Cagirgan S, Lebe E, Yilmaz F, Demirbas T, Tokat Y. Hemophagocytic syndrome after living-related liver transplantation. Transplant Proc 2003; 35:1482-4. [PMID: 12826200 DOI: 10.1016/s0041-1345(03)00511-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hemophagocytic syndrome (HPS) is a life-threatening hematological disorder in immunocompromised patients. Although the number of patients with HPS following liver transplantation is scarce the outcome is usually fatal. We report a patient who developed HPS following living-related liver transplantation (LRLT) and was treated successfully by a combination of intravenous (IV) immunoglobulin (Ig) and granulocyte colony-stimulating factor (GCSF).
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Affiliation(s)
- Z Karasu
- Department of Gastroenterology, Ege University, Izmir, Turkey.
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32
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Ohno T, Ueda Y, Nagai KI, Takahashi T, Konaka Y, Takamatsu T, Suzuki T, Sasada M, Uchiyama T. The serum cytokine profiles of lymphoma-associated hemophagocytic syndrome: a comparative analysis of B-cell and T-cell/natural killer cell lymphomas. Int J Hematol 2003; 77:286-94. [PMID: 12731674 DOI: 10.1007/bf02983788] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
To elucidate the differences in pathogenesis between lymphoma-associated hemophagocytic syndromes (LAHS) of the T-cell/ natural killer cell (T/NK) and B-cell (B) types, we comparatively analyzed the clinical features and serum cytokine profiles of 33 patients with LAHS registered in the Kyoto University Hematology/Oncology Study Group. The serum cytokine levels of each patient group (B-LAHS versus T/NK-LAHS) were expressed as the ratio of the median to the upper normal values of the respective cytokines and were as follows: 19.05 versus 13.99 for soluble interleukin 2 (IL-2) receptor, 0.67 versus 0.67 for granulocyte-macrophage colony-stimulating factor (GM-CSF), 0.64 versus 1.26 for G-CSF, 5.70 versus 3.61 for M-CSF, 1.54 versus 3.39 for interferon gamma (IFN-gamma), 13.17 versus 1.17 for IL-6, 6.88 versus 1.58 for tumor necrosis factor alpha (TNF-alpha), 0.71 versus 0.41 for IL-1beta, 1.99 versus 0.21 for IL-12, and 105.32 versus 29.65 for IL-10. The serum levels of IL-6, TNF-alpha, and IL-10 were significantly higher in the B-LAHS group, whereas those of IFN-y were significantly lower. These differences between the 2 groups may reflect a difference in the pathogenesis Higher serum levels of IL-6, TNF-alpha, and IL-10 may be derived at least partly from neoplastic B-cells themselves In addition, the extremely high serum levels of IL-10 suggest that a compensatory anti-inflammatory process may operate in both groups and give rise to a profound immunosuppressive state and a poor outcome.
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MESH Headings
- Adolescent
- Aged
- Aged, 80 and over
- Case-Control Studies
- Cytokines/blood
- Female
- Histiocytosis, Non-Langerhans-Cell/blood
- Histiocytosis, Non-Langerhans-Cell/etiology
- Histiocytosis, Non-Langerhans-Cell/pathology
- Humans
- Interleukin-10/blood
- Interleukin-6/blood
- Killer Cells, Natural/pathology
- Lymphoma, B-Cell/blood
- Lymphoma, B-Cell/complications
- Lymphoma, B-Cell/immunology
- Lymphoma, T-Cell/blood
- Lymphoma, T-Cell/complications
- Lymphoma, T-Cell/immunology
- Male
- Middle Aged
- Tumor Necrosis Factor-alpha/analysis
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Affiliation(s)
- Tatsuharu Ohno
- Division of Hematology and Immunology, Department of Internal Medicine, Ohtsu Red Cross Hospital, Nagara, Ohtsu, Japan.
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33
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Lay JD, Chuang SE, Rowe M, Su IJ. Epstein-barr virus latent membrane protein-1 mediates upregulation of tumor necrosis factor-alpha in EBV-infected T cells: implications for the pathogenesis of hemophagocytic syndrome. J Biomed Sci 2003; 10:146-55. [PMID: 12607539 DOI: 10.1007/bf02256006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The infection of human T cells by Epstein-Barr virus (EBV) may result in a fatal hemophagocytic syndrome (HS). We have previously shown that EBV can selectively upregulate the tumor necrosis factor-alpha (TNFalpha) gene and lead to activation of macrophages in a manner similar to the pathobiology of HS in EBV-infected T lymphoproliferative disorders (LPDs). This study was designed to further clarify the specific EBV gene product(s) responsible for TNFalpha upregulation. RT-PCR analysis of EBV gene expression was performed on 2 CR2-transfected EBV-infected T lymphoma lines and 2 EBV-infected B cell lines. To identify the EBV gene responsible for upregulation of TNFalpha, 2 reporter recombinant plasmids, pTNF-CAT and pTNFalpha-Luc, were then constructed and cotransfected with the expression plasmids of the EBV latent and lytic genes (EBNA-1, EBNA-2, LMP-1, LMP-2A, and BZLF-1) in both T and B cell lines. Analyses using ELISA and Western blotting were further performed to detect the secreted TNFalpha. The results revealed that EBNA-1 and LMP-1 were consistently expressed in EBV-infected T cell lines (type II latency), while a type III latency with expression of EBNA-1, EBNA-2, LMP-1, and lytic BZLF transcripts was detected in EBV-infected B cell lines. LMP-1 was demonstrated to be the only EBV gene product to transactivate the TNFalpha gene, and this phenomenon was observed only in T, not in B, cells. Enhanced secretion of TNF-alpha protein was also detected in LMP1-transfected T cell lines. We concluded that LMP1 is the candidate protein in the upregulation of the TNFalpha gene in T cells and is probably responsible for the pathogenesis of HS in EBV-infected T lymphoproliferative disorders.
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Affiliation(s)
- Jong-Ding Lay
- Divisions of Cancer Research, National Health Research Institutes, Taipei, Taiwan, ROC
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34
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Shirasaki F, Taniuchi K, Matsushita T, Hamaguhi Y, Takata M, Takehara K. Epstein-Barr virus-associated T-cell lymphoma: a case of eyelid swelling and intramuscular infiltration mimicking dermatomyositis. Br J Dermatol 2002; 147:1244-8. [PMID: 12452878 DOI: 10.1046/j.1365-2133.2002.05037.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Association with Epstein-Barr virus (EBV) infection has been noted in various types of cutaneous lymphoproliferative disorders. We report a 57-year-old Japanese woman with T-cell lymphoma mimicking dermatomyositis that was associated with chronic active EBV infection. She presented with low-grade fever, bilateral erythematous swellings on the eyelids, and necrotic papules on the face. Serum creatine kinase levels were elevated and a diffuse reticular shadow was detected in both lung fields. The infiltrate of atypical lymphocytes found in skin and muscle, which contained EBV-encoded small nuclear RNA-1 and EBV, was also detected in the CD4+ peripheral blood cells. Treatment with prednisolone resolved her lesions with no relapse for 3 years, after which there was a recurrence in her left lung. Combination chemotherapy was not effective against the lung lesion and she died with multiple organ failure 2 months after the recurrence.
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Affiliation(s)
- F Shirasaki
- Department of Dermatology, Graduate School of Medical Science, School of Medicine, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa 920-8641, Japan.
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35
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Kasono K, Nishida J, Tamemoto H, Fudaka K, Namai K, Kajio H, Masatoshi K, Kanazawa Y, Kawakami M. Thiazolidinediones increase the number of platelets in immune thrombocytopenic purpura mice via inhibition of phagocytic activity of the reticulo-endothelial system. Life Sci 2002; 71:2037-52. [PMID: 12175897 DOI: 10.1016/s0024-3205(02)01950-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Thiazolidinediones (TZDs) have broad spectrum of actions, including immunomodulating effects that are dependent or independent of the target nuclear receptor, peroxisome proliferator activated receptor-gamma (PPAR-gamma). In this study, we investigated the effect of TZDs on the platelet numbers in male immune thrombocytopenic purpura (ITP) model mice, (NZW x BXSB)F(1) (W/BF(1)) in vivo, and attempted to clarify the mechanism of action. Seven-day treatment with troglitazone increased platelet counts by 66% compared with those of controls. Within two weeks after the termination of the treatment period, the numbers of platelets were decreased to the level in controls. Pioglitazone showed only weak increasing effect on platelet counts in short-term experiment. However, long-term treatment with the drug resulted in a more pronounced up-regulation of platelets. We next assayed the platelet-associated antibodies (PAA) and the survival rate of antibody-sensitized mouse erythrocytes (Ab-mRBC) in W/BF1 mice. Pioglitazone slightly decreased the production of PAA and significantly elongated the survival period of Ab-mRBC in vivo. These drugs showed dose-dependent inhibitory effects on the cell proliferation and Fcgamma receptor (FcgammaR)-mediated phagocytic activity of macrophage-like cells in vitro. These results suggest that TZDs improve platelet counts in this mouse model mainly by suppressing systemic reticulo-endothelial phagocytic function.
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MESH Headings
- Animals
- Antibody-Dependent Cell Cytotoxicity/drug effects
- Autoantibodies/analysis
- Blood Platelets/drug effects
- Blood Platelets/immunology
- COS Cells
- Disease Models, Animal
- Dose-Response Relationship, Drug
- Erythrocytes/immunology
- Hybridization, Genetic
- Hypoglycemic Agents/pharmacology
- Macrophages/immunology
- Male
- Mice
- Mice, Inbred Strains
- Mononuclear Phagocyte System/drug effects
- Mononuclear Phagocyte System/immunology
- Phagocytosis/drug effects
- Pioglitazone
- Platelet Count
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Receptors, Fc/immunology
- Thiazoles/pharmacology
- Thiazolidinediones
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Affiliation(s)
- Keizo Kasono
- Department of Endocrinology and Metabolism, Jichi Medical School, Omiya Medical Center, 1-847 Amanuma-cho, Saitama 330-8503, Japan
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36
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Abstract
INTRODUCTION Hemophagocytic syndrome results from a inappropriate stimulation of macrophages in bone marrow and lymphoid organs, leading to phagocytosis of blood cells and production of high amounts of pro-inflammatory cytokines. This life-threatening disease combines non-specific clinical signs (fever, cachexia, hepatomegaly, enlargement of spleen and lymph nodes) as well as typical laboratory findings (bi- or pancytopenia, abnormal hepatic tests, hypofibrinemia, elevation of serum LDH, ferritinemia and triglyceride levels). Diagnosis is confirmed by cytological or pathological examination of bone marrow or tissue specimens. Hemophagocytosis may be primitive, essentially in pediatric population, or secondary, related to various situations such as lymphomas, infections (viral, bacterial or parasitic) or auto-immune diseases. Prognosis is poor, depending on the associated disease, with an overall mortality of 50%. CURRENT KNOWLEDGE AND KEY POINTS Recent advances, essentially due to genetic studies of familial hemophagocytic syndrome, have underlined the major role of T lymphocytes and TNF alpha in the pathogenesis of hemophagocytosis. In these pediatric cases, prognosis has dramatically improved since allogenic bone marrow transplantation is performed, raising long-term survival from 10 to 66%. FUTURE PROSPECTS AND PROJECTS In secondary forms of hemophagocytic syndrome, treatment must be symptomatic (transfusion, correction of electrolyte disorders) and etiological (chemotherapy, anti-viral or antibiotic drugs, immunosuppressive therapy). However, prospective trials are necessary to define the best treatment in these cases. New therapeutic options, targeting specific mediators, including TNF alpha, may emerge with the understanding of pathogenesis of hemophagocytic syndrome.
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Affiliation(s)
- A Karras
- Service de néphrologie et de transplantation rénale, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France.
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Abstract
Hemophagocytic lymphohistiocytosis (HLH) is characterized by dysregulated hyperactivation of macrophages and T helper 1 (Th1) cells accompanied by excessive secretion of inflammatory cytokines. Although TNF-alpha and IFN-gamma are known to be important factors for the development of the disease, the mechanism of their overproduction has not been clarified, yet. We measured serum IL-18 levels of patients with HLH to investigate the possible significance of IL-18 in its pathophysiology, especially in IFN-gamma production. IL-18 levels were significantly increased in all patients with HLH compared with healthy controls. A significant correlation was observed between IL-18 and IFN-gamma levels. In addition to IFN-gamma and soluble Fas ligand (sFasL), IL-18 levels significantly correlated with disease activity. IL-18 may play important roles in the pathogenesis of HLH, particularly through induction of Th1 cells. In addition, IL-18 measurement may not only be useful for the diagnosis, but also for the evaluation of disease activity.
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Affiliation(s)
- H Takada
- Department of Pediatrics, Graduate School of Medicine Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
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Al-Hashmi I, Decoteau J, Gruss HJ, Zielenska M, Thorner P, Poon A, Reis M, Freedman M, Lorenzana A. Establishment of a cytokine-producing anaplastic large-cell lymphoma cell line containing the t(2;5) translocation: potential role of cytokines in clinical manifestations. Leuk Lymphoma 2001; 40:599-611. [PMID: 11426532 DOI: 10.3109/10428190109097658] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A permanent cell line, HSC-M1, was established from a child with advanced CD30 (Ki-1)+ anaplastic large-cell lymphoma (ALCL). Clinical features included irritability, fever, weight loss, tender lymphadenopathy, pneumonitis, neutrophilia, and bone marrow erythrophagocytosis. While HSC-M1 cells exhibited an immunophenotype characteristic of ALCL of T-cell lineage, the cell line also demonstrated features of monocyte-macrophage lineage. Cytogenetic and polymerase chain reaction (PCR) analysis of the HSC-M1 cell line and involved bone marrow demonstrated the characteristic non-random chromosomal translocation t(2:5)(p23:q35). Reverse transcriptase PCR for mRNA expression of cytokines and cytokine receptors showed that HSC-M1 cells expressed the message for multiple cytokines and their receptors. Measurement of cytokine levels in serum samples using enzyme-linked immunosorbent assays showed increased concentrations of several cytokines. The increased levels of some cytokines correlated with disease activity and clinical symptoms. Although spontaneous production by HSC-M1 cells of some of these cytokines was demonstrated, the production of others was only detectable after stimulation with exogenous CD30 ligand. With few exceptions, there was good correlation between serum cytokine levels and cytokines produced by HSC-M1 cells. These findings indicate that cytokine production is a feature of ALCL cells and that some of the clinical manifestations in ALCL may result from cytokines produced by either the malignant or accessory cells.
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MESH Headings
- Chromosomes, Human, Pair 2
- Chromosomes, Human, Pair 5
- Cytokines/metabolism
- Humans
- Lymphoma, Large B-Cell, Diffuse/genetics
- Lymphoma, Large B-Cell, Diffuse/metabolism
- Lymphoma, Large B-Cell, Diffuse/pathology
- Translocation, Genetic
- Tumor Cells, Cultured
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Affiliation(s)
- I Al-Hashmi
- Department of Pediatrics, University of Toronto and The Hospital for Sick Children, Ontario, Canada
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Alliot C, Barrios M, Brunel M. Hemophagocytic Syndrome Induced by HIV. ACTA ACUST UNITED AC 2001; 5:475-8. [PMID: 27419351 DOI: 10.1080/10245332.2001.11746545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Hemophagocytic syndrome is an unusual illness due to the proliferation of activated macrophages phagocyting the hematopoietic cells. This syndrome has been reported in association with infectious agents, lymphoproliferative diseases, immunosuppressive conditions or auto-immune illnesses. Cytokines secreted by activated or neoplastic lympho-cytes activate the macrophages. Autocrine and paracrine mechanisms take over and could explain resistance to therapy. Some viruses, including EBV, could upregulate cytokine genes. This report describes an adult with HIV-infection presenting with severe hemophagocytic syndrome in whom an extensive evaluation did not reveal opportunistic disease and suggests that the cause was the HIV. The outcome was fatal and highlights the poor prognosis of hemophagocytic syndrome in this context.
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Affiliation(s)
- C Alliot
- a Department of Internal Medicine , Saint-Eloi University Hospital , 2 Avenue Bertin-Sans, 34 295 Montpellier Cedex 5, France
| | - M Barrios
- b National Institute of Blood Transfusion , 6 Rue Alexandre-Cabanel, 75015 Paris , France
| | - M Brunel
- a Department of Internal Medicine , Saint-Eloi University Hospital , 2 Avenue Bertin-Sans, 34 295 Montpellier Cedex 5, France
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Benveniste O, Dereuddre-Bosquet N, Clayette P, Leport C, Vildé JL, Dormont D. High levels of IL-10 and determination of other cytokines and chemokines in HIV-associated haemophagocytic syndrome. Clin Exp Immunol 2000; 121:320-3. [PMID: 10931148 PMCID: PMC1905689 DOI: 10.1046/j.1365-2249.2000.01288.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Haemophagocytic syndrome (HPS) and HIV infection are both associated with cytokine network dysregulation. We therefore analysed plasma levels and mRNA synthesis in peripheral blood mononuclear cells (PBMC) of cytokines, chemokines and chemokine receptors in one HIV-infected patient with HPS. We compared the results with those for eight HIV-infected patients with similar CD4+ T cell counts (207/mm3 versus controls: median 214/mm3) and plasma virus load (4.1 log copies/ml, versus controls: median 4.2 log copies/ml). The HPS patient had a lower viral DNA load in PBMC and higher plasma levels of interferon-gamma, IL-10, and macrophage inflammatory protein (MIP)-1beta. No difference in plasma tumour necrosis factor-alpha (TNF-alpha), IL-6 and MIP-1alpha concentration was observed between the HPS patient and control patients. No difference was observed in TNF-alpha, IL-1beta, IL-10, IL-4, MIP-1alpha, MIP-1beta, RANTES, CXCR-4, and CCR-5 mRNA levels in PBMC, but IL-6 levels were higher in the HPS patient. Our results emphasize the role of IL-10 in the control of immune hyperactivation that is observed in HPS.
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Affiliation(s)
- O Benveniste
- CEA, Service de Neurovirologie, CRSSA, DRM/DSV, Institut Paris-Sud sur les Cytokines, B.P. 6, Fontenay aux Roses Cedex, France.
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Nahum E, Ben-Ari J, Stain J, Schonfeld T. Hemophagocytic lymphohistiocytic syndrome: Unrecognized cause of multiple organ failure. Pediatr Crit Care Med 2000; 1:51-4. [PMID: 12813287 DOI: 10.1097/00130478-200007000-00010] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE: To describe an often-unrecognized clinical picture of multiple organ failure in hemophagocytic lymphohistiocytic syndrome (HLS). DESIGN: Retrospective chart review. SETTING: A ten-bed pediatric intensive care unit (PICU) in a tertiary children's university hospital. PATIENTS: A total of 11 children (age, 5 months to 13 yrs) who fulfilled the criteria for the diagnosis of familial- or infectious-associated hemophagocytic lymphohistiocytosis and who required intensive care support for organ failure. INTERVENTION: None. MAIN RESULTS: During a 10-yr period, 5,439 children were hospitalized in our PICU. A total of 11 children were diagnosed as suffering with HLS. Of these 11 patients, three (27%) had the familial form and eight had the infectious-associated form. After admission to the PICU, seven patients (63%) were diagnosed as suffering with HLS and each had one or more organ failures (patients 3-7, 9, and 10). All presented with fever, hepatomegaly, and splenomegaly; in addition, all had at least two of the following: anemia, neutropenia, or thrombocytopenia. All 11 had lymphohistiocytic accumulation in bone marrow (n = 10), lymph node (n = 2), lung (n = 2), and/or liver (n = 1). Organ failure was noted most often in the respiratory system (n = 7) attributable to severe, acute respiratory distress syndrome and pleural effusion. Of the 11 patients, six had cardiovascular involvement that manifested as shock in three and as capillary leak syndrome in three. Renal failure occurred in four patients. Of these, two required hemodiafiltration and one required peritoneal dialysis. Liver failure occurred in three and central nervous system involvement and coma in three. Most of the patients required massive therapeutic intervention, including assisted ventilation (n = 6), inotropic support (n = 3), and hemofiltration (n = 3). A total of seven patients (63%) died. CONCLUSIONS: Hemophagocytic lymphohistiocytic syndrome in the pediatric population may have a dramatic clinical picture, with multiple organ failure as a presenting symptom or early in the disease course, mandating intensive support in the PICU.
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Affiliation(s)
- E Nahum
- Intensive Care Unit (Drs. Nahum, Ben-Ari, and Schonfeld) and the Institute of Hematology-Oncology (Dr. Stain), Schneider Children's Medical Center of Israel, Petah Tiqva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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42
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Imashuku S, Hibi S, Kuriyama K, Tabata Y, Hashida T, Iwai A, Kato M, Yamashita N, Oda MUchida M, Kinugawa N, Sawada M, Konno M. Management of severe neutropenia with cyclosporin during initial treatment of Epstein-Barr virus-related hemophagocytic lymphohistiocytosis. Leuk Lymphoma 2000; 36:339-46. [PMID: 10674906 DOI: 10.3109/10428190009148855] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Severe neutropenia (absolute neutrophil count <500/gl) is probably due to the combined effects of dysregulated cytokine production and chemotherapeutic agents, and is one of the risk factors in the initial treatment of patients with Epstein-Barr virus-related hemophagocytic lymphohistiocytosis (EBV-HLH). We report here 9 cases of neutropenic HLH, of which 8 were treated with cyclosporin (CSA, 2-6 mg/kg/day; continuous infusion, or 6 mg/kg/day; per os, for periods ranging from 9 days to >8 weeks) in the initial neutropenic phase during induction treatment using corticosteroids and etoposide. Five of the 6 cases, in which CSA treatment was started early (before the second week of induction), survived the critical period with recovery of neutrophil counts within a week. The remaining 3 cases, in which CSA was introduced later or not at all, died of infection. Based on these results, we recommend a prompt short-term CSA infusion during neutropenic episodes in the most common treatment regimen of etoposide and corticosteroids in patients with HLH. Improved neutrophil recovery as a result of CSA treatment makes it possible to continue immunochemotherapy safely and obtain improved patient outcomes.
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Affiliation(s)
- S Imashuku
- Division of Pediatrics, Children's Research Hospital, Kyoto Prefectural University of Medicine Japan.
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43
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Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an unusual syndrome characterized by fever, splenomegaly, jaundice, and the pathologic finding of hemophagocytosis (phagocytosis by macrophages of erythrocytes, leukocytes, platelets, and their precursors) in bone marrow and other tissues. HLH may be diagnosed in association with malignant, genetic, or autoimmune diseases but is also prominently linked with Epstein-Barr (EBV) virus infection. Hyperproduction of cytokines, including interferon-gamma and tumor necrosis factor-alpha, by EBV- infected T lymphocytes may play a role in the pathogenesis of HLH. EBV-associated HLH may mimic T-cell lymphoma and is treated with cytotoxic chemotherapy, while hemophagocytic syndromes associated with nonviral pathogens often respond to treatment of the underlying infection.
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Affiliation(s)
- D N Fisman
- Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
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Takada H, Ohga S, Mizuno Y, Suminoe A, Matsuzaki A, Ihara K, Kinukawa N, Ohshima K, Kohno K, Kurimoto M, Hara T. Oversecretion of IL-18 in haemophagocytic lymphohistiocytosis: a novel marker of disease activity. Br J Haematol 1999; 106:182-9. [PMID: 10444185 DOI: 10.1046/j.1365-2141.1999.01504.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
We investigated the significance of interleukin (IL)-18 levels in the pathophysiology of haemophagocytic lymphohistiocytosis (HLH). IL-18 levels were significantly elevated in all nine patients with active HLH compared with those of healthy controls. Serial determination of IL-18 levels in three cases, showed a gradual decrease compared with those of IL-12, interferon (IFN)-gamma or soluble Fas ligand (sFasL) in the course of clinical improvement, and seemed to be elevated until complete disappearance of disease activity. IL-18 and IFN-gamma (CC 0.711, P = 0.018), and IFN-gamma and sFasL (CC 0.849, P = 0.0049) levels were significantly correlated. On the other hand, correlation between IL-12 and IFN-gamma, IL-18 and sFasL, or IL-18 and IL-12 was not observed. IL-18, IFN-gamma and sFasL levels significantly correlated with disease activity such as fever and alanine transaminase (ALT) levels. IL-18 mRNA expression was enhanced in spleen, but not in peripheral blood mononuclear cells (MNC), bone marrow MNC, liver from patients of active HLH, or the tumour from a patient with lymphoma-associated haemophagocytic syndrome (LAHS). These results suggest that IL-18 may play important roles in the pathogenesis of HLH, particularly through induction of Th1 cells. IL-18 measurement may be useful for the diagnosis and for the detection of smouldering disease activity.
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Affiliation(s)
- H Takada
- Department of Paediatrics, Faculty of Medicine, Kyushu University, Fukuoka, Japan
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45
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Faurschou M, Nielsen OJ, Hansen PB, Juhl BR, Hasselbalch H. Fatal virus-associated hemophagocytic syndrome associated with coexistent chronic active hepatitis B and acute hepatitis C virus infection. Am J Hematol 1999; 61:135-8. [PMID: 10367794 DOI: 10.1002/(sici)1096-8652(199906)61:2<135::aid-ajh11>3.0.co;2-e] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 28-year-old man was admitted to our department with intermittent fever, hepatosplenomegaly and pancytopenia. Liver parameters and serum ferritin were markedly elevated. Bone marrow biopsy showed hypocellularity, histiocytic hyperplasia, and hemophagocytosis consistent with a virus-associated hemophagocytic syndrome (VAHS). There was serological evidence of chronic active hepatitis B and acute hepatitis C virus infection. The patient died despite aggressive immunosuppressive and supportive treatment. Autopsy revealed signs of acute viral hepatitis with cholestasis. Histiocytes engaged in hemophagocytosis were observed in bone marrow and spleen. The condition was interpreted as VAHS associated with chronic active hepatitis B and acute hepatitis C virus infection. To our knowledge this is the first report of a hemophagocytic syndrome in that setting.
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Affiliation(s)
- M Faurschou
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
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46
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Murase T, Nakamura S. An Asian variant of intravascular lymphomatosis: an updated review of malignant histiocytosis-like B-cell lymphoma. Leuk Lymphoma 1999; 33:459-73. [PMID: 10342574 DOI: 10.3109/10428199909058451] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Malignant histiocytosis-like B-cell lymphoma (MH-like BCL) is characterized clinically by hemophagocytic syndrome (HPS), bone marrow involvement at presentation, and an aggressive clinical course. Yet, it remains an ill-defined disease entity. We recently described five cases of MH-like BCL and suggested that these may be regarded as a peculiar variant of intravascular lymphomatosis (IVL), based on clinical and pathological observation. Interestingly, this type of lymphoma has been reported exclusively among Asians, with few reports from Western countries, and therefore we propose that this variant be noted as an Asian variant of IVL(AIVL). To evaluate the incidence of this variant, we performed a literature search for English or Japanese studies dealing with MH-like BCL or B-cell IVL associated with HPS (IVL with HPS). We found 18 reports of MH-like BCL and 16 reports of IVL with HPS and re-evaluated the clinicopathologic aspects of each study with respect to AIVL. Although several differences were noted, such as gender, presence of respiratory changes, bone marrow invasion and disseminated intravascular coagulopathy, there were also overlapping profiles and they appeared to be consistent with the AIVL single disease entity. Of particular note was the absence of peripheral lymphadenopathy and tumor formation which posed diagnostic problems in the initial phase of the presentations. Thus, based on analysis of the clinical findings of these 34 cases, the diagnostic criteria for AIVL consists primarily of cytopenia (anemia and/or thrombocytopenia), hepatosplenomegaly, absence of peripheral lymphadenopathy and tumor formation, and erythrocyte-hemophagocytosis along with intravascular proliferation of the neoplastic B cells. The pathologic findings of the 19 autopsied cases which fulfilled the criteria are also summarized, and they reveal morphologic, immunologic, and genotypic features of typical IVL.
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MESH Headings
- Asian People
- Histiocytosis, Non-Langerhans-Cell/ethnology
- Histiocytosis, Non-Langerhans-Cell/etiology
- Histiocytosis, Non-Langerhans-Cell/pathology
- Histiocytosis, Non-Langerhans-Cell/physiopathology
- Humans
- Japan/epidemiology
- Lymphoma, B-Cell/ethnology
- Lymphoma, B-Cell/pathology
- Lymphoma, B-Cell/physiopathology
- Lymphoma, Large B-Cell, Diffuse/ethnology
- Lymphoma, Large B-Cell, Diffuse/pathology
- Lymphoma, Large B-Cell, Diffuse/physiopathology
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Affiliation(s)
- T Murase
- Department of Hematology, Toyota Memorial Hospital, Japan
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47
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Endo Y, Kanno K, Takahashi M, Yamaguchi KI, Kohno Y, Fujita T. Molecular Basis of Human Complement C1s Deficiency. THE JOURNAL OF IMMUNOLOGY 1999. [DOI: 10.4049/jimmunol.162.4.2180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Abstract
This is the first report on the molecular basis of human complement C1s deficiency. Two abnormalities in the C1s gene were identified in a Japanese family, including one patient, by using exon-specific PCR, single-strand conformation polymorphism analysis, and nucleotide sequencing. A deletion of 4 bp, TTTG, was identified in exon X when using genomic DNA from the patient, his father, and his paternal grandmother. They were all heterozygous for the mutation. The mutant gene encodes a truncated C1s from the N terminus to the short consensus repeat domain. By further sequencing the PCR products, a nonsense mutation from G to T was identified at codon 608 in exon XII in the patient, his mother, and his sister. They were all heterozygous for the nonsense mutation. The mutant gene encodes a truncated form of C1s that lacks the C-terminal 80 amino acids. These results indicate that the patient was a compound heterozygote with the 4-bp deletion on the paternal allele and the nonsense mutation on the maternal allele. The levels of serum C1s seem to be correlated to the genotypes of the C1s gene in which no C1s was detected in the patient, and one-half of the normal level in the family members who are heterozygous for either mutation. The present study demonstrates that the disease is inherited in an autosomal recessive mode.
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Affiliation(s)
- Yuichi Endo
- *Department of Biochemistry, Fukushima Medical University School of Medicine, 1-Hikarigaoka, Fukushima, Japan; and
| | - Kazuko Kanno
- *Department of Biochemistry, Fukushima Medical University School of Medicine, 1-Hikarigaoka, Fukushima, Japan; and
| | - Minoru Takahashi
- *Department of Biochemistry, Fukushima Medical University School of Medicine, 1-Hikarigaoka, Fukushima, Japan; and
| | - Ken-ichi Yamaguchi
- †Department of Pediatrics, Chiba University School of Medicine, Inohana, Chyuo-ku, Chiba, Japan
| | - Yoichi Kohno
- †Department of Pediatrics, Chiba University School of Medicine, Inohana, Chyuo-ku, Chiba, Japan
| | - Teizo Fujita
- *Department of Biochemistry, Fukushima Medical University School of Medicine, 1-Hikarigaoka, Fukushima, Japan; and
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Chen JS, Lin KH, Lin DT, Chen RL, Jou ST, Su IJ. Longitudinal observation and outcome of nonfamilial childhood haemophagocytic syndrome receiving etoposide-containing regimens. Br J Haematol 1998; 103:756-62. [PMID: 9858227 DOI: 10.1046/j.1365-2141.1998.01026.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The long-term outcome of 22 children treated with etoposide-containing regimens for haemophagocytic syndrome (HS) were longitudinally studied; none of them had a family history of the disease. All patients received etoposide-containing (150 mg/m2/d) regimens, combined, in 16 cases, with intravenous immunoglobulin (IVIG) and prednisolone. Complete remission (CR) was achieved in 12 patients, partial remission in seven, and early mortality occurred in three. Of the 12 CR patients, only four remain alive and disease-free, with a median follow-up of 47.4 months; one CR patient died due to infection and the remaining seven had relapsed diseases. Three patients with a partial response or with relapsed disease progressed to T-cell lymphoma, characterized, in the two cases tested, by clonal chromosomal abnormalities. Epstein-Barr virus (EBV) infection was implicated in disease pathogenesis in 15/22 patients. The overall survival was 45.5%, 40.9% and 40.9% at 1, 3 and 5 years, respectively, and disease-free survival for CR patients at these same times was 45.5%, 36.4% and 36.4%. The etoposide-containing regimen would appear to be an effective initial therapeutic option for childhood HS. However, in view of the frequency of partial remissions and relapsed disease, a more intensive chemotherapy or bone marrow transplantation should be applied. The progression to EBV-containing T-cell lymphoma in three patients is consistent with the previous observation that EBV-associated HS is a potentially malignant disease.
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Affiliation(s)
- J S Chen
- Department of Paediatrics, National Cheng Kung University Hospital, Tainan, Taiwan
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49
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Matsumoto Y, Naniwa D, Banno S, Sugiura Y. The efficacy of therapeutic plasmapheresis for the treatment of fatal hemophagocytic syndrome: two case reports. THERAPEUTIC APHERESIS : OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY FOR APHERESIS AND THE JAPANESE SOCIETY FOR APHERESIS 1998; 2:300-4. [PMID: 10227760 DOI: 10.1111/j.1744-9987.1998.tb00127.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A potentially fatal hemophagocytic syndrome (HPS) has been noted in patients with reactive HPS. We describe 2 patients with reactive HPS treated with a regimen of therapeutic plasmapheresis and evaluate the efficacy of plasmapheresis for fatal HPS. Case 1 was a 31 year-old woman who had been treated for systemic lupus erythematosus (SLE) with corticosteroid hormones and immunosuppressants. She presented with persistent leukopenia and thrombocytopenia with spiking fever. She had an elevated level of serum ferritin, liver dysfunction, coagulopathy, and plasma inflammatory cytokines. Her bone marrow smear disclosed numerous hemophagocytosis of histiocytes. She was administered therapeutic plasmapheresis with total plasma exchange by fresh frozen plasma. There was an immediate and prominent decrease of cytokines, and she completely recovered. Case 2 was a 34 year-old woman who had been receiving high doses of corticosteroids and plasmapheresis for severe Stevens-Johnson's syndrome. After 18 months, she presented with physical and laboratory findings resembling lupus-like conditions and was administered high doses of corticosteroids and immunosuppressants. Human parvovirus B19 infection was detected by IgM and IgG antibodies and viral DNA from a bone marrow sample; moreover, a bone marrow smear disclosed findings of HPS. Repeated therapeutic plasmapheresis was effective for improving her symptoms and laboratory abnormalities; however, she suffered from septic methicilline resistant staphylococcus aureus infection and finally died of a brain hemorrhage resulting from disseminated intravascular coagulation (DIC).
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Affiliation(s)
- Y Matsumoto
- Rheumatology Unit and Internal Medicine, Toyokawa City Hospital, Aich, Japan
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50
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Imashuku S, Hibi S, Tabata Y, Sako M, Sekine Y, Hirayama K, Sakazaki H, Maeda N, Kito H, Shichino H, Mugishima H. Biomarker and morphological characteristics of Epstein-Barr virus-related hemophagocytic lymphohistiocytosis. MEDICAL AND PEDIATRIC ONCOLOGY 1998; 31:131-7. [PMID: 9722893 DOI: 10.1002/(sici)1096-911x(199809)31:3<131::aid-mpo1>3.0.co;2-c] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Viruses may induce primary as well as secondary hemophagocytic lymphohistiocytosis (HLH), but it may not be possible to discriminate between these two in patients with a negative family history. Among these HLH cases, fulminant and fatal virus-associated hemophagocytic syndrome (VAHS) occurs mostly in relation to Epstein-Barr virus (EBV) infection. Although the immunological characteristics of EB-VAHS were previously reported, data on non-EB-VAHS were sporadic and fragmentary. This study has compared the clearly distinguishable groups of EBV-positive vs. EBV-negative HLH cases. PROCEDURE Among 26 patients with EBV-related HLH and 12 patients with non-EBV HLH, peripheral blood mononuclear cell (PBMC) subsets and serum concentrations of cytokines at the active phase of the disease were compared. Blood and bone marrow smears were also compared. RESULTS AND CONCLUSIONS The frequency of the CD3+HLADR+ subset in PBMC (median 34.3% vs. 4.8%), of serum concentrations of interferon (IFN)-gamma (median 105 U/ml vs. 2.4 U/ml), and of soluble interleukin-2-receptor (sIL-2R) (median 14,700 U/ml vs. 3,412 U/ml) were significantly different between these two groups. Morphological characteristics were noted for EBV-related HLH cases. Mortality also differed between these two groups, 9/26 vs. 0/12 (P = 0.05). Data indicate pronounced immunological imbalance and poor prognosis in EBV-related HLH cases. These parameters could be useful for determining an EBV involvement as well as risk factors in the early care and treatment of HLH patients.
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Affiliation(s)
- S Imashuku
- Division of Pediatrics, Children's Research Hospital, Kyoto Prefectural University of Medicine, Japan.
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