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Lafarge A, Chean D, Whiting L, Clere-Jehl R. Management of hematological patients requiring emergency chemotherapy in the intensive care unit. Intensive Care Med 2024; 50:849-860. [PMID: 38748265 PMCID: PMC11164740 DOI: 10.1007/s00134-024-07454-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/18/2024] [Indexed: 05/30/2024]
Abstract
Hematological malignancies may require rapid-onset treatment because of their short doubling time, notably observed in acute leukemias and specific high-grade lymphomas. Furthermore, in targeted onco-hematological scenarios, chemotherapy is deemed necessary as an emergency measure when facing short-term, life-threatening complications associated with highly chemosensitive hematological malignancies. The risks inherent in the disease itself, or in the initiation of treatment, may then require admission to the intensive care unit (ICU) to optimize monitoring and initial management protocols. Hyperleukocytosis and leukostasis in acute leukemias, tumor lysis syndrome, and disseminated intravascular coagulation are the most frequent onco-hematological complications requiring the implementation of emergency chemotherapy in the ICU. Chemotherapy must also be started urgently in secondary hemophagocytic lymphohistiocytosis. Tumor-induced microangiopathic hemolytic anemia and plasma hyperviscosity due to malignant monoclonal gammopathy represent infrequent yet substantial indications for emergency chemotherapy. In all cases, the administration of emergency chemotherapy in the ICU requires close collaboration between intensivists and hematology specialists. In this review, we provide valuable insights that aid in the identification and treatment of patients requiring emergency chemotherapy in the ICU, offering diagnostic tools and guidance for their overall initial management.
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Affiliation(s)
- Antoine Lafarge
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France.
| | - Dara Chean
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France
| | - Livia Whiting
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France
| | - Raphaël Clere-Jehl
- Médecine Intensive et Réanimation, Hôpital de Hautepierre, University Hospital of Strasbourg, Strasbourg, France
- Laboratoire d'ImmunoRhumatologie Moléculaire, INSERM (French National Institute of Health and Medical Research), UMR_S1109, Centre de Recherche d'Immunologie et d'Hématologie, University of Strasbourg, Strasbourg, France
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2
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Mohyeldin M, Shrivastava S, Allu SVV. Ibrutinib and atrial fibrillation: An in-depth review of clinical implications and management strategies. World J Cardiol 2024; 16:269-273. [PMID: 38817647 PMCID: PMC11135330 DOI: 10.4330/wjc.v16.i5.269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/23/2024] [Accepted: 05/14/2024] [Indexed: 05/23/2024] Open
Abstract
Ibrutinib, a targeted therapy for B-cell malignancies, has shown remarkable efficacy in treating various hematologic cancers. However, its clinical use has raised concerns regarding cardiovascular complications, notably atrial fibrillation (AF). This comprehensive review critically evaluates the association between ibrutinib and AF by examining incidence, risk factors, mechanistic links, and management strategies. Through an extensive analysis of original research articles, this review elucidates the complex interplay between ibrutinib's therapeutic benefits and cardiovascular risks. Moreover, it highlights the need for personalized treatment approaches, vigilant monitoring, and interdisciplinary collaboration to optimize patient outcomes and safety in the context of ibrutinib therapy. The review provides a valuable resource for healthcare professionals aiming to navigate the intricacies of ibrutinib's therapeutic landscape while prioritizing patient well-being.
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Affiliation(s)
- Moiud Mohyeldin
- Internal Medicine, University of Medical Sciences and Technology, Khartoum 11111, Sudan.
| | - Shitij Shrivastava
- Internal Medicine, Bronxcare Health System, Bronx, NY 10457, United States
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3
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Wang H, Wang Y, Liu H, Li X, Sun C, Pang Z, Zhang B, Hu Y. Ruxolitinib-loaded cytokine nanosponge alleviated the cytokine storm and dampened macrophage overactivation for the treatment of hemophagocytic lymphohistiocytosis. Int J Pharm 2024; 657:124127. [PMID: 38621611 DOI: 10.1016/j.ijpharm.2024.124127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/30/2024] [Accepted: 04/13/2024] [Indexed: 04/17/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening clinical syndrome characterized by a positive feedback loop between cytokine storm and macrophages and lymphocytes overactivation, which could serve as a valid therapeutic target for HLH treatment. In this study, the clinically extensively used JAK1/2 inhibitor ruxolitinib was encapsulated into macrophage membrane-coated nanoparticles (M@NP-R) with high drug-loading efficiency for targeted HLH treatment. In vitro and in vivo studies demonstrated that M@NP-R not only efficiently adsorbed extracellular proinflammation cytokines, like IFN-γ and IL-6 to alleviate the cytokine storm, but also effectively dampened macrophage activation and proliferation by intracellular JAK/STAT signaling pathway inhibition. M@NP-R treatment significantly ameliorated the clinical and laboratory manifestations of HLH in mouse models, including trilineage cytopenia, hypercytokinemia, organomegaly, hepatorenal dysfunction, and tissue inflammation. Importantly, M@NP-R significantly enhanced the survival of the lethal HLH mice. Altogether, M@NP-R successfully blocked the positive feedback loop between the cytokine storm and macrophage overactivation by depleting extracellular inflammatory cytokines and inhibiting the intracellular JAK/STAT signaling pathway, both of which worked synergistically in HLH treatment. As ruxolitinib has already been extensively used in clinics with favorable safety, and M@NP is biodegradable and highly biocompatible, M@NP-R has good prospects for clinical translation.
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Affiliation(s)
- Honglan Wang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei 430022, China; Key Laboratory of Molecular Biological Targeted Therapies of the Ministry of Education
| | - Yiwei Wang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei 430022, China; Key Laboratory of Molecular Biological Targeted Therapies of the Ministry of Education
| | - Huiwen Liu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei 430022, China; Key Laboratory of Molecular Biological Targeted Therapies of the Ministry of Education
| | - Xuejing Li
- School of Pharmacy, Fudan University, Key Laboratory of Smart Drug Delivery, Ministry of Education, 826 Zhangheng Road, Shanghai 201203, China
| | - Chunyan Sun
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei 430022, China; Key Laboratory of Molecular Biological Targeted Therapies of the Ministry of Education
| | - Zhiqing Pang
- School of Pharmacy, Fudan University, Key Laboratory of Smart Drug Delivery, Ministry of Education, 826 Zhangheng Road, Shanghai 201203, China.
| | - Bo Zhang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei 430022, China; Key Laboratory of Molecular Biological Targeted Therapies of the Ministry of Education.
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei 430022, China; Key Laboratory of Molecular Biological Targeted Therapies of the Ministry of Education.
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4
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Guo T, Liu Z, Chen Y, Cheng Y, He K, Lin X, Wang M, Sun Y. Hemophagocytic lymphohistiocytosis during treatment of intracranial multifocal germinoma: a case report and literature review. Front Oncol 2024; 14:1264926. [PMID: 38532931 PMCID: PMC10963405 DOI: 10.3389/fonc.2024.1264926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 02/19/2024] [Indexed: 03/28/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH), also known as hemophagocytic syndrome (HPS), is a benign histiocytosis with hyperreactive proliferation of the mononuclear phagocyte system caused by immune function abnormalities, which often occurs under the background of genetic mutations, inflammation, infection or tumors. Because the research on malignancy-associated HLH (M-HLH) is focused on hematological malignancies, reports on HLH secondary to solid tumors are rare. In this case, we report a 14-year-old girl who developed HLH during treatment for intracranial multifocal germinoma, and the disease was controlled after hormone combined with etoposide(VP-16) and other related treatments. To our knowledge, there have been no documented cases of HLH caused by intracranial multifocal germinoma.
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Affiliation(s)
- Ting Guo
- Department of Clinical Laboratory, Fengcheng Hospital of Fengxian District, Shanghai, China
| | - Zichun Liu
- Department of Clinical Laboratory, Fengcheng Hospital of Fengxian District, Shanghai, China
| | - Yixin Chen
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yangyang Cheng
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Kaitong He
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xin Lin
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Mingzhu Wang
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yihua Sun
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
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5
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Rocco JM, Inglefield J, Yates B, Lichtenstein DA, Wang Y, Goffin L, Filipovic D, Schiffrin EJ, Shah NN. Free interleukin-18 is elevated in CD22 CAR T-cell-associated hemophagocytic lymphohistiocytosis-like toxicities. Blood Adv 2023; 7:6134-6139. [PMID: 37389815 PMCID: PMC10582359 DOI: 10.1182/bloodadvances.2023010708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/06/2023] [Accepted: 06/06/2023] [Indexed: 07/01/2023] Open
Affiliation(s)
- Joseph M. Rocco
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Jon Inglefield
- Applied Developmental Research Directorate, Leidos Biomedical Research Inc, Frederick National Laboratory for Cancer Research, National Cancer Institute, Frederick, MD
| | - Bonnie Yates
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Daniel A. Lichtenstein
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH
- Department of Pediatrics, Cincinnati Children’s Hospital, University of Cincinnati, Cincinnati, OH
| | - Yanyu Wang
- Applied Developmental Research Directorate, Leidos Biomedical Research Inc, Frederick National Laboratory for Cancer Research, National Cancer Institute, Frederick, MD
| | | | | | | | - Nirali N. Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
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6
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Zhang Q, Zhu L, Zhou D, Li L, Xie W, Tan Y, Ye X. Risk factors and prognosis of early death in secondary hemophagocytic lymphohistiocytosis. Ann Hematol 2023; 102:2301-2308. [PMID: 37266671 DOI: 10.1007/s00277-023-05153-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/24/2023] [Indexed: 06/03/2023]
Abstract
The aim of our study was to summarize the clinical characteristics of early death patients with newly diagnosed secondary hemophagocytic lymphohistiocytosis (sHLH), analyze the risk factors of early death, and analyze the survival of patients. The clinical characteristics of 324 newly diagnosed sHLH patients admitted to the First Affiliated Hospital of Zhejiang University Medical College and Zhejiang Provincial Cancer Hospital from January 2014 to February 2021 were analyzed retrospectively. Analyze the independent risk factors of early death, compare the secondary diseases and treatment methods of patients with early death group and non early death group, and analyze the survival of all patients with sHLH. Among the 324 newly diagnosed patients with sHLH, 134 died early, with an early mortality rate of 41.4%. Comparing the clinical characteristics of patients with early death group and patients with non early death group, logistic regression model was used to conduct multifactor analysis. Age > 60 years, Plt ≤ 20.0 × 109/L, APTT > 36.0 s and LDH > 1000.0 U/L were independent risk factors for early death of newly diagnosed sHLH patients (P < 0.05). Comparing the secondary diseases and treatment methods between early death group and non early death group, the proportion of sHLH patients secondary to lymphoma was higher in early death group than that in non early death group (P < 0.05). The proportion of sHLH patients secondary to connective tissue disease and infection was lower in early death group than that in non early death group (P < 0.05), and the proportion of sHLH patients used hormone combined chemotherapy was lower in early death group than that in non early death group (P < 0.05). The median follow-up time of all patients was 12.0 (1-65) months. The 5-year OS rates of patients with age > 60 years and age ≤ 60 years were 25.8% and 49.6% respectively (P < 0.001); The 5-year OS rates of patients with Plt > 20.0 × 109/L and Plt ≤ 20.0 × 109/L were 52.5% and 25.5% respectively (P < 0.001); The 5-year OS rates of patients with APTT > 36.0 s and APTT ≤ 36.0 s were 34.5% and 57.4% respectively (P < 0.001); The 5-year OS rates of patients with LDH > 1000.0 U/L and LDH ≤ 1000.0 U/L were 23.3% and 56.3% respectively (P < 0.001). Age > 60 years, Plt ≤ 20.0 × 109/L, APTT > 36.0 s and LDH > 1000.0 U/L are independent risk factors for early death of sHLH patients. The early mortality of lymphoma associated HLH (LA-HLH) patients is high, and early use of hormone combined chemotherapy can reduce the early mortality.
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Affiliation(s)
- Qiaolei Zhang
- Department of Hematology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), No.38 Guangji Road, banshanqiao, Gongshu District, Hangzhou, 310003, Zhejiang, China
- Institute of Cancer and Basic Medicine(IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Lixia Zhu
- Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, No.79 Qingchun Road Hangzhou, Hangzhou, 310003, Zhejiang, China
| | - De Zhou
- Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, No.79 Qingchun Road Hangzhou, Hangzhou, 310003, Zhejiang, China
| | - Li Li
- Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, No.79 Qingchun Road Hangzhou, Hangzhou, 310003, Zhejiang, China
| | - Wanzhuo Xie
- Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, No.79 Qingchun Road Hangzhou, Hangzhou, 310003, Zhejiang, China
| | - Yamin Tan
- Department of Hematology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), No.38 Guangji Road, banshanqiao, Gongshu District, Hangzhou, 310003, Zhejiang, China.
- Institute of Cancer and Basic Medicine(IBMC), Chinese Academy of Sciences, Hangzhou, China.
| | - Xiujin Ye
- Department of Hematology, The First Affiliated Hospital of Medical School of Zhejiang University, No.79 Qingchun Road Hangzhou, Hangzhou, 310003, Zhejiang, China.
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Chao S, Al-Saheli ZI, Zhao W, Ghosh S, Dabak V. ALK-Positive Anaplastic Large Cell Lymphoma Associated With Hemophagocytic Lymphohistiocytosis. Cureus 2023; 15:e41427. [PMID: 37426397 PMCID: PMC10323050 DOI: 10.7759/cureus.41427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2023] [Indexed: 07/11/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) has been rarely reported as a complication of anaplastic large cell lymphoma (ALCL), especially in the adult population. We herein present a case of a young woman who presented with multiorgan failure and disseminated intravascular hemolysis and was later found to have ALCL-associated HLH. We also review the current literature on ALCL-associated HLH in adult patients, with their respective treatments and outcomes. We discuss the challenges associated with the diagnosis of lymphoma in the setting of HLH and multiorgan failure. Further, given its high mortality rates, we highlight the importance of promptly identifying and treating the underlying etiology of HLH.
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Affiliation(s)
- Shing Chao
- Internal Medicine, Henry Ford Health System, Detroit, USA
| | | | - Wei Zhao
- Hematology and Oncology, Henry Ford Health System, Detroit, USA
| | - Shamila Ghosh
- Pathology and Laboratory Medicine, Henry Ford Health System, Detroit, USA
| | - Vrushali Dabak
- Hematology and Oncology, Henry Ford Health System, Detroit, USA
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8
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Cytokine nanosponges suppressing overactive macrophages and dampening systematic cytokine storm for the treatment of hemophagocytic lymphohistiocytosis. Bioact Mater 2023; 21:531-546. [PMID: 36185750 PMCID: PMC9508173 DOI: 10.1016/j.bioactmat.2022.09.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 08/12/2022] [Accepted: 09/09/2022] [Indexed: 11/29/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a highly fatal condition with the positive feedback loop between continued immune cell activation and cytokine storm as the core mechanism to mediate multiple organ dysfunction. Inspired by macrophage membranes harbor the receptors with special high affinity for proinflammation cytokines, lipopolysaccharide (LPS)-stimulated macrophage membrane-coated nanoparticles (LMNP) were developed to show strong sponge ability to both IFN-γ and IL-6 and suppressed overactivation of macrophages by inhibiting JAK/STAT signaling pathway both in vitro and in vivo. Besides, LMNP also efficiently alleviated HLH-related symptoms including cytopenia, hepatosplenomegaly and hepatorenal dysfunction and save the life of mouse models. Furthermore, its sponge effect also worked well for five human HLH samples in vitro. Altogether, it's firstly demonstrated that biocompatible LMNP could dampen HLH with high potential for clinical transformation, which also provided alternative insights for the treatment of other cytokine storm-mediated pathologic conditions such as COVID-19 infection and cytokine releasing syndrome during CAR-T therapy. LMNP functioned better as a multiple-cytokine sponging tool when compared with conventional macrophage coated nanoparticles. LMNP sponged inflammation cytokines and suppressed macrophage overactivation by inhibiting JAK/STAT signaling pathway. LMNP calmed down systematic cytokine storm and dampened HLH in HLH mice models. LMNP also worked well in sponging cytokines in human HLH samples which indicated high potential of clinical transformation.
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La Marle S, Richard-Colmant G, Fauvernier M, Ghesquières H, Hot A, Sève P, Jamilloux Y. Mortality and Associated Causes in Hemophagocytic Lymphohistiocytosis: A Multiple-Cause-of-Death Analysis in France. J Clin Med 2023; 12:jcm12041696. [PMID: 36836229 PMCID: PMC9967667 DOI: 10.3390/jcm12041696] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 01/26/2023] [Accepted: 02/07/2023] [Indexed: 02/22/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome with an overall mortality rate of 40%. A multiple-cause-of-death analysis allows for the characterization of mortality and associated causes over an extended period. Death certificates, collected between 2000 and 2016 by the French Epidemiological Centre for the Medical Causes of Death (CepiDC, Inserm), containing the ICD10 codes for HLH (D76.1/2), were used to calculate HLH-related mortality rates and to compare them with the general population (observed/expected ratios, O/E). HLH was mentioned in 2072 death certificates as the underlying cause of death (UCD, n = 232) or as a non-underlying cause of death (NUCD, n = 1840). The mean age at death was 62.4 years. The age-standardized mortality rate was 1.93/million person-years and increased over the study period. When HLH was an NUCD, the most frequently associated UCDs were hematological diseases (42%), infections (39.4%), and solid tumors (10.4%). As compared to the general population, HLH decedents were more likely to have associated CMV infections or hematological diseases. The increase in mean age at death over the study period indicates progress in diagnostic and therapeutic management. This study suggests that the prognosis of HLH may be at least partially related to coexisting infections and hematological malignancies (either as causes of HLH or as complications).
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Affiliation(s)
- Solène La Marle
- Département de Médecine Interne, Hôpital de la Croix Rousse—Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69002 Lyon, France
| | - Gaëlle Richard-Colmant
- Département de Médecine Interne, Hôpital de la Croix Rousse—Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69002 Lyon, France
| | - Mathieu Fauvernier
- Département de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69000 Lyon, France
| | - Hervé Ghesquières
- Département d’Hématologie, Hôpital Lyon Sud—Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69495 Lyon, France
| | - Arnaud Hot
- Département de Médecine Interne, Hôpital Edouard Herriot—Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69003 Lyon, France
| | - Pascal Sève
- Département de Médecine Interne, Hôpital de la Croix Rousse—Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69002 Lyon, France
| | - Yvan Jamilloux
- Département de Médecine Interne, Hôpital de la Croix Rousse—Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69002 Lyon, France
- Lyon Immunopathology Federation (LIFE), Université Claude Bernard-Lyon 1, 69000 Lyon, France
- Correspondence: ; Tel.: +33-426-732-636
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Abdel-Azim H, Dave H, Jordan K, Rawlings-Rhea S, Luong A, Wilson AL. Alignment of practices for data harmonization across multi-center cell therapy trials: a report from the Consortium for Pediatric Cellular Immunotherapy. Cytotherapy 2022; 24:193-204. [PMID: 34711500 PMCID: PMC8792313 DOI: 10.1016/j.jcyt.2021.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 08/13/2021] [Accepted: 08/27/2021] [Indexed: 02/03/2023]
Abstract
Immune effector cell (IEC) therapies have revolutionized our approach to relapsed B-cell malignancies, and interest in the investigational use of IECs is rapidly expanding into other diseases. Current challenges in the analysis of IEC therapies include small sample sizes, limited access to clinical trials and a paucity of predictive biomarkers of efficacy and toxicity associated with IEC therapies. Retrospective and prospective multi-center cell therapy trials can assist in overcoming these barriers through harmonization of clinical endpoints and correlative assays for immune monitoring, allowing additional cross-trial analysis to identify biomarkers of failure and success. The Consortium for Pediatric Cellular Immunotherapy (CPCI) offers a unique platform to address the aforementioned challenges by delivering cutting-edge cell and gene therapies for children through multi-center clinical trials. Here the authors discuss some of the important pre-analytic variables, such as biospecimen collection and initial processing procedures, that affect biomarker assays commonly used in IEC trials across participating CPCI sites. The authors review the recent literature and provide data to support recommendations for alignment and standardization of practices that can affect flow cytometry assays measuring immune effector function as well as interpretation of cytokine/chemokine data. The authors also identify critical gaps that often make parallel comparisons between trials difficult or impossible.
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Affiliation(s)
- Hisham Abdel-Azim
- Cancer and Blood Disease Institute, Children's Hospital of Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Hema Dave
- Center for Cancer and Blood Disorders, Children's National Hospital, George Washington School of Medicine, Washington, DC, USA
| | - Kimberly Jordan
- Department of Immunology and Microbiology, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado, USA
| | - Stephanie Rawlings-Rhea
- Seattle Children's Therapeutics, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Annie Luong
- Cancer and Blood Disease Institute, Children's Hospital of Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ashley L Wilson
- Seattle Children's Therapeutics, Seattle Children's Research Institute, Seattle, Washington, USA.
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Wan Mohd Zohdi WA, Ismail AZ, Yusof N, Ithnin A, Shuib S, Masir N, Palaniappan S, Tumian NR. Rare but Potentially Fatal Presentations of Diffuse Large B-cell Lymphoma: Leukemic Phase or Hemophagocytic Syndrome in Bone Marrow. CLINICAL PATHOLOGY (THOUSAND OAKS, VENTURA COUNTY, CALIF.) 2022; 15:2632010X211070774. [PMID: 35036912 PMCID: PMC8753065 DOI: 10.1177/2632010x211070774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/14/2021] [Indexed: 11/17/2022]
Abstract
Diffuse large B-cell lymphoma (DLBCL) is a type of non-Hodgkin Lymphoma commonly presenting as a solid tumor either by nodal or extra-nodal manifestations. Here we describe two atypical presentations of lymphoma, finally resulting in the diagnosis of DLBCL. Case 1: A 53-year-old man with a previous history of nasopharyngeal carcinoma presented with a two-week history of B-symptoms and hyperleukocytosis. Peripheral blood film showed 78% abnormal mononuclear cells. Immunohistochemical stain showing Ki-67 of 90%, negative c-myc, BCL2 and BCL6, and negative c-MYC with fluorescence in-situ hybridization studies on the trephine biopsy, concluded the diagnosis of CD5+ DLBCL of ABC subtype. He received intravenous cyclophosphamide and oral prednisolone for cytoreduction, followed by 6 cycles of chemo-immunotherapy. However, he succumbed due to severe sepsis after the completion of therapy. Case 2: A 56-year-old lady who was initially investigated for pyrexia of unknown origin was noted to have hemophagocytosis upon bone marrow aspirate examination. The bone marrow trephine biopsy revealed some atypical clusters of B-cells positive for CD20 which was inconclusive. PET-CT scan noted an enlarged hypermetabolic spleen without lymphadenopathy. Splenic biopsy with immunohistochemical studies revealed DLBCL of ABC subtype. The diagnosis was consistent with primary splenic DLBCL. She became unwell post splenic biopsy and was admitted to the intensive care unit where she passed away 2 weeks later from Candida and Sternotrophomonas septicemia. These cases highlight the atypical presentations of a common subtype of NHL in our center. Arriving at the definitive diagnosis can be difficult especially when patients are acutely ill, hampering the necessary invasive procedures for diagnosis. The outcomes of both cases are briefly discussed hoping to spread awareness among clinicians on the rare and acutely critical presentations of DLBCL.
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Affiliation(s)
| | - Ahmad Zulhimi Ismail
- Department of Pathology, Universiti Kebangsaan Malaysia (UKM) Medical Centre, Kuala Lumpur, Malaysia
| | - Nurasyikin Yusof
- Department of Pathology, Universiti Kebangsaan Malaysia (UKM) Medical Centre, Kuala Lumpur, Malaysia
| | - Azlin Ithnin
- Department of Pathology, Universiti Kebangsaan Malaysia (UKM) Medical Centre, Kuala Lumpur, Malaysia
| | - Salwati Shuib
- Department of Pathology, Universiti Kebangsaan Malaysia (UKM) Medical Centre, Kuala Lumpur, Malaysia
| | - Noraidah Masir
- Department of Pathology, Universiti Kebangsaan Malaysia (UKM) Medical Centre, Kuala Lumpur, Malaysia
| | - Sivakumar Palaniappan
- Department of Medicine, Universiti Kebangsaan Malaysia (UKM) Medical Centre, Kuala Lumpur, Malaysia
| | - Nor Rafeah Tumian
- Department of Medicine, Universiti Kebangsaan Malaysia (UKM) Medical Centre, Kuala Lumpur, Malaysia
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12
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Takushi SE, Paik NY, Fedanov A, Prince C, Doering CB, Spencer HT, Chandrakasan S. Lentiviral Gene Therapy for Familial Hemophagocytic Lymphohistiocytosis Type 3, Caused by UNC13D Genetic Defects. Hum Gene Ther 2021; 31:626-638. [PMID: 32253931 DOI: 10.1089/hum.2019.329] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Familial hemophagocytic lymphohistiocytosis type 3 (FHL3) is a rare disease caused by mutations to the UNC13D gene and the subsequent absence or decreased activity of the Munc13-4 protein. Munc13-4 is essential for the exocytosis of perforin and granzyme containing granules from cytotoxic cells. Without it, these cells are able to recognize an immunological insult but are unable to execute their cytotoxic functions. The result is a hyperinflammatory state that, if left untreated, is fatal. At present, the only curative treatment is hematopoietic stem cell transplantation (HSCT), but eligibility and response to this treatment are largely dependent on the ability to control inflammation before HSCT. In this study, we describe an optimized lentiviral vector that can restore Munc13-4 expression and degranulation capacity in both transduced FHL3 patient T cells and transduced hematopoietic stem cells from the FHL3 (Jinx) disease model.
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Affiliation(s)
- Sarah E Takushi
- Department of Immunology and Molecular Pathogenesis, Graduate Division of Biological and Biomedical Sciences, Laney Graduate School, Emory University, Atlanta, Georgia, USA.,Cell and Gene Therapy Program, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Na Yoon Paik
- Cell and Gene Therapy Program, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Andrew Fedanov
- Cell and Gene Therapy Program, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Chengyu Prince
- Cell and Gene Therapy Program, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Christopher B Doering
- Cell and Gene Therapy Program, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Pediatrics, Emory University, Atlanta, Georgia, USA.,Department of Molecular and Systems Pharmacology, Graduate Division of Biological and Biomedical Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - H Trent Spencer
- Cell and Gene Therapy Program, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Pediatrics, Emory University, Atlanta, Georgia, USA.,Department of Molecular and Systems Pharmacology, Graduate Division of Biological and Biomedical Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Shanmuganathan Chandrakasan
- Cell and Gene Therapy Program, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Pediatrics, Emory University, Atlanta, Georgia, USA.,Bone Marrow Transplant Program, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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13
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Miao L, Zhang Z, Ren Z, Li Y. Reactions Related to CAR-T Cell Therapy. Front Immunol 2021; 12:663201. [PMID: 33995389 PMCID: PMC8113953 DOI: 10.3389/fimmu.2021.663201] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/13/2021] [Indexed: 12/11/2022] Open
Abstract
The application of chimeric antigen receptor (CAR) T-cell therapy as a tumor immunotherapy has received great interest in recent years. This therapeutic approach has been used to treat hematological malignancies solid tumors. However, it is associated with adverse reactions such as, cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), off-target effects, anaphylaxis, infections associated with CAR-T-cell infusion (CTI), tumor lysis syndrome (TLS), B-cell dysplasia, hemophagocytic lymphohistiocytosis (HLH)/macrophage activation syndrome (MAS) and coagulation disorders. These adverse reactions can be life-threatening, and thus they should be identified early and treated effectively. In this paper, we review the adverse reactions associated with CAR-T cells, the mechanisms driving such adverse reactions, and strategies to subvert them. This review will provide important reference data to guide clinical application of CAR-T cell therapy.
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Affiliation(s)
- Lele Miao
- Department of General Surgery, Second Hospital of Lanzhou University, Lanzhou, China.,Key Laboratory of the Digestive System Tumors of Gansu Province, Second Hospital of Lanzhou University, Lanzhou, China
| | - Zhengchao Zhang
- Department of General Surgery, Second Hospital of Lanzhou University, Lanzhou, China.,Key Laboratory of the Digestive System Tumors of Gansu Province, Second Hospital of Lanzhou University, Lanzhou, China
| | - Zhijian Ren
- Department of General Surgery, Second Hospital of Lanzhou University, Lanzhou, China.,Key Laboratory of the Digestive System Tumors of Gansu Province, Second Hospital of Lanzhou University, Lanzhou, China
| | - Yumin Li
- Department of General Surgery, Second Hospital of Lanzhou University, Lanzhou, China.,Key Laboratory of the Digestive System Tumors of Gansu Province, Second Hospital of Lanzhou University, Lanzhou, China
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14
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Nanno S, Koh H, Okamura H, Nishimoto M, Nakashima Y, Ohsawa M, Hino M, Nakamae H. Acute fibrinous and organizing pneumonia following hemophagocytic syndrome in two adult patients with hematological malignancies. J Clin Exp Hematop 2021; 61:93-96. [PMID: 33883345 PMCID: PMC8265494 DOI: 10.3960/jslrt.20042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Acute fibrinous and organizing pneumonia (AFOP) is a rare acute lung injury featuring pathological intra-alveolar fibrin balls and organizing pneumonia without hyaline membranes or eosinophils. AFOP forms acute and subacute patterns; the former often has a poor prognosis, whereas the latter has better survival. Secondary hemophagocytic syndrome (HPS) is a cytokine-related and potentially lethal disorder induced by various diseases, and pulmonary involvement in HPS is not rare. However, to our knowledge, no report has addressed the association between secondary HPS and AFOP development. We report two cases of subacute AFOP following HPS in hematological malignancies.
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Affiliation(s)
- Satoru Nanno
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Hideo Koh
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Hiroshi Okamura
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Mitsutaka Nishimoto
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Yasuhiro Nakashima
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Masahiko Ohsawa
- Diagnostic pathology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Masayuki Hino
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Hirohisa Nakamae
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
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15
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Chu R, van Eeden C, Suresh S, Sligl WI, Osman M, Cohen Tervaert JW. Do COVID-19 Infections Result in a Different Form of Secondary Hemophagocytic Lymphohistiocytosis. Int J Mol Sci 2021; 22:2967. [PMID: 33803997 PMCID: PMC8001312 DOI: 10.3390/ijms22062967] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/12/2021] [Accepted: 03/10/2021] [Indexed: 12/15/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has resulted in significant morbidity and mortality across the world, with no current effective treatments available. Recent studies suggest the possibility of a cytokine storm associated with severe COVID-19, similar to the biochemical profile seen in hemophagocytic lymphohistiocytosis (HLH), raising the question of possible benefits that could be derived from targeted immunosuppression in severe COVID-19 patients. We reviewed the literature regarding the diagnosis and features of HLH, particularly secondary HLH, and aimed to identify gaps in the literature to truly clarify the existence of a COVID-19 associated HLH. Diagnostic criteria such as HScore or HLH-2004 may have suboptimal performance in identifying COVID-19 HLH-like presentations, and criteria such as soluble CD163, NK cell activity, or other novel biomarkers may be more useful in identifying this entity.
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Affiliation(s)
- Raymond Chu
- Division of Rheumatology, Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON K1H 7W9, Canada;
| | - Charmaine van Eeden
- Division of Rheumatology, Department of Medicine, University of Alberta Hospital, University of Alberta, Edmonton, AB T6G 2R3, Canada; (C.v.E.); (M.O.)
| | - Sneha Suresh
- Division of IHOPE, Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, AB T6G 1C9, Canada;
| | - Wendy I. Sligl
- Department of Critical Care Medicine and Division of Infectious Diseases, Department of Medicine, University of Alberta Hospital, University of Alberta, Edmonton, AB T6G 2B7, Canada;
| | - Mohammed Osman
- Division of Rheumatology, Department of Medicine, University of Alberta Hospital, University of Alberta, Edmonton, AB T6G 2R3, Canada; (C.v.E.); (M.O.)
| | - Jan Willem Cohen Tervaert
- Division of Rheumatology, Department of Medicine, University of Alberta Hospital, University of Alberta, Edmonton, AB T6G 2R3, Canada; (C.v.E.); (M.O.)
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16
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McGonagle D, Ramanan AV, Bridgewood C. Immune cartography of macrophage activation syndrome in the COVID-19 era. Nat Rev Rheumatol 2021; 17:145-157. [PMID: 33547426 PMCID: PMC7863615 DOI: 10.1038/s41584-020-00571-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2020] [Indexed: 02/06/2023]
Abstract
A hyperinflammatory 'cytokine storm' state termed macrophage activation syndrome (MAS), culminating from a complex interplay of genetics, immunodeficiency, infectious triggers and dominant innate immune effector responses, can develop across disparate entities including systemic juvenile idiopathic arthritis (sJIA) and its counterpart adult-onset Still disease (AOSD), connective tissue diseases, sepsis, infection, cancers and cancer immunotherapy. Classifying MAS using the immunological disease continuum model, with strict boundaries that define the limits of innate and adaptive immunity, at one boundary is MAS with loss of immune function, as occurs in the 'perforinopathies' and some cases of sJIA-AOSD. Conversely, at the other boundary, immune hypersensitivity with gain of immune function in MHC class II-associated sJIA-AOSD and with chimeric antigen receptor (CAR) T cell therapy also triggers MAS. This provides a benchmark for evaluating severe inflammation in some patients with COVID-19 pneumonia, which cripples primary type I interferon immunity and usually culminates in a lung-centric 'second wave' cytokine-driven alveolitis with associated immunothrombosis; this phenomenon is generally distinct from MAS but can share features with the proposed 'loss of immune function' MAS variant. This loss and gain of function MAS model offers immune cartography for a novel mechanistic classification of MAS with therapeutic implications.
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Affiliation(s)
- Dennis McGonagle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.
- National Institute for Health Research (NIHR), Leeds Biomedical Research Centre (BRC), Leeds Teaching Hospitals, Leeds, UK.
| | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust & Translational Health Sciences, University of Bristol, Bristol, UK
| | - Charlie Bridgewood
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
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17
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Ricard JA, Charles R, Tommee CG, Yohe S, Bell WR, Flanagan ME. Epstein Virus Barr-Positive Diffuse Large B-Cell Lymphoma Associated with Hemophagocytic Lymphohistiocytosis. J Neuropathol Exp Neurol 2021; 79:915-920. [PMID: 32647871 DOI: 10.1093/jnen/nlaa061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 08/25/2019] [Accepted: 06/04/2020] [Indexed: 11/15/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and often fatal disease if not diagnosed and treated promptly. HLH can be due to genetic factors or infections, malignancies and collagen-associated vascular diseases. Malignancy-associated HLH is not only more common in the setting of T/NK-cell lymphomas, but may also rarely be seen in the setting of B-cell lymphoma. Here, we describe a unique case of a patient who initially was diagnosed with HLH secondary to Epstein Barr virus (EBV) infection and subsequently developed EBV-positive diffuse large B-cell lymphoma affecting the brain. This case highlights the spectrum of findings associated with EBV infections and the challenges in diagnosing underlying diseases associated with HLH.
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Affiliation(s)
- Jocelyn A Ricard
- From the Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - River Charles
- From the Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Carolina Gil Tommee
- From the Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Sophia Yohe
- From the Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - W Robert Bell
- From the Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Margaret E Flanagan
- From the Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
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18
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Fattizzo B, Ferraresi M, Giannotta JA, Barcellini W. Secondary Hemophagocytic Lymphohistiocytosis and Autoimmune Cytopenias: Case Description and Review of the Literature. J Clin Med 2021; 10:870. [PMID: 33672504 PMCID: PMC7923749 DOI: 10.3390/jcm10040870] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/12/2021] [Accepted: 02/15/2021] [Indexed: 12/25/2022] Open
Abstract
Hemophagocytic lymphohistocytosis (HLH) is a rare hyperinflammatory condition which may be primary or secondary to many diseases, including hematologic malignancies. Due to its life-threatening evolution, a timely diagnosis is paramount but challenging, since it relies on non-specific clinical and laboratory criteria. The latter are often altered in other diseases, including autoimmune cytopenias (AIC), which in turn can be secondary to infections, systemic autoimmune or lymphoproliferative disorders. In the present article, we describe two patients presenting at the emergency department with acute AICs subsequently diagnosed as HLH with underlying diffuse large B cell lymphoma. We discuss the diagnostic challenges in the differential diagnosis of acute cytopenias in the internal medicine setting, providing a literature review of secondary HLH and AIC.
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Affiliation(s)
- Bruno Fattizzo
- Oncohematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (J.A.G.); (W.B.)
- Department of Oncology and Oncohematology, University of Milan, 20122 Milan, Italy
| | - Marta Ferraresi
- Department of Internal Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
- Department of Internal Medicine, University of Milan, 20122 Milan, Italy
| | - Juri Alessandro Giannotta
- Oncohematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (J.A.G.); (W.B.)
| | - Wilma Barcellini
- Oncohematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (J.A.G.); (W.B.)
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19
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Flores Chang BS, Arias Morales CE, Flores Chang MM, Vigoda I. Secondary Hemophagocytic Lymphohistiocytosis in a Young Hispanic Adult. Cureus 2021; 13:e13084. [PMID: 33680624 DOI: 10.7759/cureus.13084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a disease caused by a severe immune system reaction that involves an overwhelming inflammatory response with overproduction of cytokines and hemophagocytosis. HLH is classified as primary HLH or familial HLH (PHLH or FHLH) and secondary HLH. PHLH is due to mutations in several genes that regulate immune cells, while secondary HLH is triggered by a severe illness (viral infections or malignancies) that induce an excessive immune response that is difficult to control. We present a case of a young Hispanic adult female with a medical history of diabetes mellitus type 1 and hepatitis E that was diagnosed with HLH secondary to lymphoma caused by Epstein Barr virus infection. The patient was started on broad-spectrum antibiotics and steroid therapy; however, the patient succumbed to the disease. HLH is associated with high mortality, mainly because it is not a very common entity and patients usually present critically ill and deteriorate very fast. Immunosuppression and treatment of the underlying disorder is the target of the treatment of HLH, however, the prognosis remains poor.
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Affiliation(s)
- Bessy S Flores Chang
- Medicine/Nephrology, St. Barnabas Hospital Health System, Bronx, USA.,Medicine, City University of New York School of Medicine, New York, USA
| | - Carlos E Arias Morales
- Medicine, St. Barnabas Hospital Health System, Bronx, USA.,Medicine, City University of New York School of Medicine, New York, USA
| | - Marjorie M Flores Chang
- Medicine, St. Barnabas Hospital Health System, Bronx, USA.,Medicine, City University of New York School of Medicine, New York, USA
| | - Ivette Vigoda
- Hematology-Oncology, St. Barnabas Hospital Health System, Bronx, USA.,Medicine, City University of New York School of Medicine, New York, USA
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20
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Zheng XQ, Zhu HY, Wang JY, Fan L, Xu W, Li J. [Research progress of lymphoma associated hemophagocytic syndrome]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 41:788-792. [PMID: 33113618 PMCID: PMC7595859 DOI: 10.3760/cma.j.issn.0253-2727.2020.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- X Q Zheng
- Department of Hematology, Key Laboratory of Hematology of Nanjing Medical University, Jiangsu Province Hospital/The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - H Y Zhu
- Department of Hematology, Key Laboratory of Hematology of Nanjing Medical University, Jiangsu Province Hospital/The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China; Pukou CLL Center, Pukou Division of Jiangsu Province Hospital, Nanjing 211800, China
| | | | | | | | - Jianyong Li
- Department of Hematology, Key Laboratory of Hematology of Nanjing Medical University, Jiangsu Province Hospital/The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China; Pukou CLL Center, Pukou Division of Jiangsu Province Hospital, Nanjing 211800, China
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21
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Angelova P, Brock R, Negoescu AT, Schmitt LM, Meißner J, Dietrich S, Müller-Tidow C, Novotny JP. A Severe Case of Anaplastic Large Cell Lymphoma in a Previously Healthy Woman: Diagnostic and Therapeutic Challenges. Prague Med Rep 2020; 121:262-266. [PMID: 33270014 DOI: 10.14712/23362936.2020.23] [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: 10/22/2022] Open
Abstract
Anaplastic large cell lymphomas are an aggressive subtype of peripheral T-cell lymphomas that can manifest with a variety of symptoms. Our case highlights the importance of prompt tissue sampling, especially if an associated hemophagocytic lymphohistiocytosis is detected and no clinical improvement is observed upon glucocorticoid treatment.
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Affiliation(s)
- Petya Angelova
- Heidelberg Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Robert Brock
- Heidelberg Medical Faculty, Heidelberg University, Heidelberg, Germany
| | | | - Lara-Marie Schmitt
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Julia Meißner
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Sascha Dietrich
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Carsten Müller-Tidow
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Jan Philipp Novotny
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany.
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22
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Lovetrue B. The AI-discovered aetiology of COVID-19 and rationale of the irinotecan+ etoposide combination therapy for critically ill COVID-19 patients. Med Hypotheses 2020; 144:110180. [PMID: 33254502 PMCID: PMC7428675 DOI: 10.1016/j.mehy.2020.110180] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/21/2020] [Indexed: 02/06/2023]
Abstract
We present the AI-discovered aetiology of COVID-19, based on a precise disease model of COVID-19 built under five weeks that best matches the epidemiological characteristics, transmission dynamics, clinical features, and biological properties of COVID-19 and consistently explains the rapidly expanding COVID-19 literature. We present that SARS-CoV-2 implements a unique unbiased survival strategy of balancing viral replication with viral spread by increasing its dependence on (i) ACE2-expressing cells for viral entry and spread, (ii) PI3K signaling in ACE2-expressing cells for viral replication and egress, and (iii) viral- non-structural-and-accessory-protein-dependent immunomodulation to balance viral spread and viral replication. We further propose the combination of irinotecan (an in-market topoisomerase I inhibitor) and etoposide (an in-market topoisomerase II inhibitor) could potentially be an exceptionally effective treatment to protect critically ill patients from death caused by COVID-19-specific cytokine storms triggered by sepsis, ARDS, and other fatal comorbidities.
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Affiliation(s)
- Bragi Lovetrue
- Demiurge Technologies AG, Baarerstrasse 14, ZUG, 6300 Zug, Switzerland.
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23
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Mendes FR, Sobral KM, Culler HF, Couto SCF, Pereira J, Rocha V, Martinez GA, Lage LADPC. Acquired hemophagocytic lymphohistiocytosis as initial manifestation of multiple myeloma: A case report and literature review. Medicine (Baltimore) 2020; 99:e22299. [PMID: 32991435 PMCID: PMC7523830 DOI: 10.1097/md.0000000000022299] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a condition characterized by a hyperinflammatory state and persistent macrophage activation, resulting in reactive phagocytosis of the hematopoietic elements. In children, it is usually a hereditary disorder, while in adults it is usually acquired secondary to viral infections, collagenoses, or tumors. Although accounting for 10% of hematologic malignancies, HLH is rarely associated with multiple myeloma (MM) and other plasmacytic dyscrasias. PATIENT CONCERNS A 64-year-old Brazilian man seeked medical care with a 3-month history of intermittent fever, weight loss, night sweats, and progressive anemic symptoms. DIAGNOSIS Total blood count showed severe bicytopenia (normocytic-normochromic anemia and thrombocytopenia), biochemical exams showed elevation of creatinine, as well as monoclonal peak in serum protein electrophoresis, high IgA dosage, and serum immunofixation with IgA kappa paraprotein. Bone marrow biopsy showed 30% of monoclonal and phenotypically anomalous plasmocytes, confirming the diagnosis of MM. Diagnosis of HLH was established by the presence of clinical and laboratory criteria: fever, splenomegaly, cytopenias, hypofibrinogenemia, hyperferritinemia, elevation of triglycerides, and several figures of erythrophagocytosis in bone marrow aspirate. INTERVENTIONS The patient experienced pulse therapy with methylprednisolone for hemophagocytic lymphohistiocytosis, followed by initial therapy for multiple myeloma with cyclophosphamide and dexamethasone. OUTCOMES Once the diagnosis of MM and secondary hemophagocytic syndrome was established, the patient had a rapid clinical deterioration despite the established therapeutic measures, evolving with cardiovascular failure, acute liver failure, acute disseminated intravascular coagulation, worsening renal dysfunction requiring dialysis support, respiratory dysfunction, and lowering of consciousness, characterizing rapid multiple organ dysfunction, ultimately leading to the death of the patient. INNOVATION Here, we aimed to describe the sixth reported case of HLH associated with MM, according to cases cataloged in the PubMed database, and the first case evaluated by 18-fluordeoxyglucose positron emission tomography (18-FDG-PETCT). CONCLUSION Our case report seeks to provide support for a better clinical and laboratory characterization of this rare paraneoplastic entity associated with MM, and aims to call the attention of hematologists and intensivists to this condition that falls within the scope of the differential diagnosis of rapid onset multiple organ failure in patients with plasmacytic neoplasms.
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Affiliation(s)
- Fernanda Rodrigues Mendes
- Department of Hematology, Hemotherapy and Cell Therapy, Medicine School, Sao Paulo University (FMUSP)
| | - Karine Marques Sobral
- Department of Hematology, Hemotherapy and Cell Therapy, Medicine School, Sao Paulo University (FMUSP)
| | - Hebert Fabricio Culler
- Department of Hematology, Hemotherapy and Cell Therapy, Medicine School, Sao Paulo University (FMUSP)
| | | | - Juliana Pereira
- Department of Hematology, Hemotherapy and Cell Therapy, Medicine School, Sao Paulo University (FMUSP)
| | - Vanderson Rocha
- Department of Hematology, Hemotherapy and Cell Therapy, Medicine School, Sao Paulo University (FMUSP)
- Fundação Pró-Sangue – Hemocentro de São Paulo, São Paulo, Brazil
- Hematology & Hemotherapy, Churchill Hospital, Oxford University, Oxford, UK
| | - Gracia Aparecida Martinez
- Department of Hematology, Hemotherapy and Cell Therapy, Medicine School, Sao Paulo University (FMUSP)
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24
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Brambilla B, Barbosa AM, Scholze CDS, Riva F, Freitas L, Balbinot RA, Balbinot S, Soldera J. Hemophagocytic Lymphohistiocytosis and Inflammatory Bowel Disease: Case Report and Systematic Review. Inflamm Intest Dis 2020; 5:49-58. [PMID: 32596254 DOI: 10.1159/000506514] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 02/13/2020] [Indexed: 12/23/2022] Open
Abstract
Aim To report a case of a female patient with hemophagocytic lymphohistiocytosis (HLH) and to systematically review the available cases of the association between HLH and inflammatory bowel disease (IBD). Methods In accordance to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, retrieval of studies was based on Medical Subject Headings and Health Sciences Descriptors, which were combined using Boolean operators. Searches were run on the electronic databases Scopus, Web of Science, MEDLINE (PubMed), Biblioteca Regional de Medicina, Latin American and Caribbean Health Sciences Literature, Cochrane Library for Systematic Reviews and Opengrey.eu. Languages were restricted to English, Spanish and Portuguese. There was no date of publication restrictions. The reference lists of the studies retrieved were searched manually. Results The search strategy retrieved 223 references. In the final analysis, 28 references were included, with the report of 35 cases. The most common clinical finding was fever, 57% of patients had a cytomegalovirus infection and 30 patients were on thiopurines previously to HLH diagnosis. Most patients were treated with steroids and antiviral therapy. All-cause mortality was 22%. Conclusion These findings suggest that there might be a connection of HLH to IBD, opportunistic viral infections and the use of thiopurines. Due to the severity of such disease, the clinical suspicion is paramount to early diagnosis and therapy.
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Affiliation(s)
- Bárbara Brambilla
- Faculty of Medicine, Universidade de Caxias do Sul, Caxias do Sul, Brazil
| | | | | | - Floriano Riva
- Pathologist, CPM Laboratório de Caxias do Sul, Caxias do Sul, Brazil
| | - Lislene Freitas
- Clinical Gastroenterology, Universidade de Caxias do Sul, Caxias do Sul, Brazil
| | | | - Silvana Balbinot
- Clinical Gastroenterology, Universidade de Caxias do Sul, Caxias do Sul, Brazil
| | - Jonathan Soldera
- Clinical Gastroenterology, Universidade de Caxias do Sul, Caxias do Sul, Brazil
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25
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Carter SJ, Tattersall RS, Ramanan AV. Macrophage activation syndrome in adults: recent advances in pathophysiology, diagnosis and treatment. Rheumatology (Oxford) 2019; 58:5-17. [PMID: 29481673 DOI: 10.1093/rheumatology/key006] [Citation(s) in RCA: 146] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Indexed: 01/27/2023] Open
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome, which if not promptly treated, can lead rapidly to critical illness and death. HLH is termed macrophage activation syndrome (MAS) when associated with rheumatic disease (where it is best characterized in systemic JIA) and secondary HLH (sHLH) when associated with other triggers including malignancy and infection. MAS/sHLH is rare and coupled with its mimicry of other conditions, is underrecognized. These inherent challenges can lead to diagnostic and management challenges in multiple medical specialties including haematology, infectious diseases, critical care and rheumatology. In this review we highlight the pathogenesis of MAS/sHLH including its underlying triggers, key clinical features and diagnostic challenges, prognostic factors and current treatments in adults.
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Affiliation(s)
- Stuart J Carter
- Rheumatology Department, Sheffield Children's Hospital, Sheffield, UK
| | - Rachel S Tattersall
- Rheumatology Department, Sheffield Children's Hospital, Sheffield, UK.,Paediatric and Adolescent Rheumatology, Sheffield Children's Hospital, Sheffield, UK
| | - Athimalaipet V Ramanan
- Paediatric Rheumatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.,Bristol Medical School, University of Bristol, Bristol, UK
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Pasvolsky O, Zoref-Lorenz A, Abadi U, Geiger KR, Hayman L, Vaxman I, Raanani P, Leader A. Hemophagocytic lymphohistiocytosis as a harbinger of aggressive lymphoma: a case series. Int J Hematol 2019; 109:553-562. [PMID: 30850926 DOI: 10.1007/s12185-019-02623-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 12/23/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare hyperinflammatory syndrome, which can manifest either secondary to a variety of underlying causes, or due to a primary genetic defect. Malignancy is the most common underlying disease in adults with HLH, with lymphomas being the most common malignancy. Lymphoma-associated hemophagocytic syndrome (LAHS) typically follows a rapidly progressive clinical course and is associated with poor prognosis. We herein present four patients with HLH associated with aggressive lymphoma. At initial presentation, the underlying etiology of the HLH was unclear. Two patients were eventually diagnosed with anaplastic large cell lymphoma, while the other two had diffuse large B cell lymphoma. Two of the patients experienced rapid clinical deterioration, one at diagnosis and the other at relapse, and both died prior to diagnosis of lymphoma despite HLH-directed therapy. These cases highlight the need for intensive management in adults with HLH without a clear etiology, especially in cases when lymphoma-associated HLH is suspected. We describe the current pitfalls in diagnosis and treatment of LAHS and discuss possible ways to improve patient management.
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Affiliation(s)
- Oren Pasvolsky
- Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Beilinson Hospital, 49100, Petah Tikva, Israel. .,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Adi Zoref-Lorenz
- Department of Internal Medicine B, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Abadi
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Karyn Revital Geiger
- Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Beilinson Hospital, 49100, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lucille Hayman
- Department of Pathology, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Iuliana Vaxman
- Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Beilinson Hospital, 49100, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pia Raanani
- Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Beilinson Hospital, 49100, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avi Leader
- Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Beilinson Hospital, 49100, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Akiyoshi M, Hisasue M, Neo S, Akiyoshi M, Goto-Koshino Y. A case of hemophagocytic syndrome progressing into large granular lymphoma in a dog. Vet Clin Pathol 2019; 48:71-77. [PMID: 30811622 DOI: 10.1111/vcp.12704] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/02/2018] [Accepted: 07/31/2018] [Indexed: 12/27/2022]
Abstract
A 12-year-old castrated male mixed breed dog was presented with anorexia, lethargy, intermittent vomiting, diarrhea, and weight loss. Clinicopathologic and imaging abnormalities included pancytopenia, icterus, and splenomegaly with multiple minute hypoechogenic nodules. Bone marrow (BM) smears revealed 2.5% hemophagocytic macrophages. In addition, an increased number of small to intermediate lymphocytes (16.3%) and plasma cells (3.2%) were recognized in the BM smears. More than 80% of the lymphocytes contained multiple small intracytoplasmic magenta granules. Histopathologic findings of the spleen revealed hemophagocytosis. Large granular lymphocytes (LGLs) were not found on the liver cytology or splenic histopathology at this time. PCR for antigen receptor rearrangement (PARR) analysis showed a clonal reaction in the T-cell receptor ɤ (TCRɤ) gene in the BM sample. The dog was diagnosed with hemophagocytic syndrome (HPS). The dog was maintained in good condition with immunosuppressive therapy. However, the dog developed hepatic LGL lymphoma 7 months later. At this time, PARR analysis showed a clonal TCRɤ gene rearrangement in the hepatic LGL lymphoma samples. The BM and liver sample clonal rearrangements showed 100% homology, indicating that the small to intermediate granular lymphocytes in the BM at the HPS stage had progressed to hepatic LGL lymphoma. To our knowledge, this is the first report of canine secondary HPS caused by the occurrence of a BM LGL lymphoma clone that progressed to hepatic LGL lymphoma.
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Affiliation(s)
- Makoto Akiyoshi
- Laboratory of Small Animal Internal Medicine, School of Veterinary Medicine, Azabu University, Sagamihara City, Japan.,Akiyoshi Animal Clinic, Yamato City, Japan
| | - Masaharu Hisasue
- Laboratory of Small Animal Internal Medicine, School of Veterinary Medicine, Azabu University, Sagamihara City, Japan
| | - Sakurako Neo
- Laboratory of Small Animal Internal Medicine, School of Veterinary Medicine, Azabu University, Sagamihara City, Japan
| | | | - Yuko Goto-Koshino
- Department of Veterinary Internal Medicine, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Bunkyo-Ku, Japan
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28
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Karras A. Atteinte rénale du syndrome d’activation macrophagique. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Le syndrome d’activation macrophagique (SAM) ou syndrome hémophagocytaire est une pathologie compliquant soit certains déficits immunitaires d’origine génétique, soit certaines maladies hématologiques (essentiellement des lymphomes non hodgkiniens), infectieuses (herpèsvirus, bactéries, parasites) ou auto-immunes (lupus, maladie de Still). Il se caractérise par une suractivation aiguë du système immunitaire et plus particulièrement des lymphocytes T cytotoxiques et des cellules histiocytaires/macrophagiques, déclenchant une production massive de cytokines pro-inflammatoires avec fièvre, pancytopénie, organomégalie, altérations du bilan hépatique et de la coagulation. Une défaillance multiviscérale est fréquente, nécessitant la prise en charge en réanimation et mettant souvent en jeu le pronostic vital, avec une mortalité qui reste dans certains cas à près de 50 %. Le SAM implique souvent le rein, par le biais d’une nécrose tubulaire aiguë, d’une néphropathie interstitielle inflammatoire ou d’une glomérulopathie sévère, responsable de syndrome néphrotique. La mise en évidence de ce syndrome n’est pas toujours facile chez un patient avec un tableau de sepsis ou de choc septique, mais elle peut guider la prise en charge thérapeutique, notamment l’initiation d’un traitement par chimiothérapie ou immunosuppresseurs, selon l’étiologie identifiée.
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