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Caravaggi E, Serana F, Carini M, Ferrari F, Tregambe D, Micheletti M, Martellosio G, Brugnoni D, Bresciani R, Biasiotto G. Diagnostic accuracy of bone marrow blood evaluation in haemophagocytic lymphohistiocytosis paediatric patients. Ann Clin Biochem 2025; 62:91-100. [PMID: 39415315 DOI: 10.1177/00045632241295694] [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] [Indexed: 10/18/2024]
Abstract
IntroductionHaemophagocytic lymphohistiocytosis (HLH) is a rare and serious immunological syndrome that involves a strong activation of cytotoxic T lymphocytes and macrophages. HLH determines a cytokine-mediated tissue injury with a contemporary multi-organ failure and a high fatality rate.Material and methodsA retrospective study was performed considering the medical records of paediatric patients who underwent a bone marrow aspirate for suspect HLH. The biomarkers evaluated were among those included in the HLH-2004. Lactate dehydrogenase (LD) was also evaluated. Haemophagocytosis was evaluated in bone marrow blood smear slides.ResultsEnrolled were 11 patients included in the HLH group and 8 patients as controls. Haemoglobin and fibrinogen resulted lower in HLH patients than in controls, while blood triglycerides, serum ferritin and LD resulted increased. Blood triglycerides and fibrinogen discriminated HLH cases perfectly, with a sensitivity and specificity of 100%. Ferritin had a sensitivity of 100% and a specificity of 83% (cut off ≥3,721 µg/L) and LD of 73% and of 100% (the cut off ≥1,903 U/L). Haemoglobin was found to have a sensitivity of 75% and a specificity of 100% (cut off ≤ 96 g/L). Total haemophagocytes cell counts were not different between patients and controls. Only the increased number of phagocytized nucleated red blood cells (NRBC) was found to be significantly increased in the patients. Erythrocytes phagocytosis (≥4/1,000 cells) only tended towards significance.ConclusionsThe blood biomarkers showed better diagnostic performance than the morphological evaluation. Among the different cell lineages engulfed by haemophagocytes, the best diagnostic performance was obtained by phagocytosed mature erythrocytes and immature nucleated erythrocytes.
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Affiliation(s)
- Elisa Caravaggi
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
- Highly Specialized Laboratory, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Federico Serana
- Clinical Chemistry Laboratory, Diagnostic Department, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Mattia Carini
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
- Highly Specialized Laboratory, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Fabiana Ferrari
- Pediatrics, Mother's and Baby's Health Department, Poliambulanza Foundation Hospital Institute, Brescia, Italy
| | - Daniela Tregambe
- Clinical Chemistry Laboratory, Diagnostic Department, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Moira Micheletti
- Clinical Chemistry Laboratory, Diagnostic Department, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Giovanni Martellosio
- Clinical Chemistry Laboratory, Diagnostic Department, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Duilio Brugnoni
- Clinical Chemistry Laboratory, Diagnostic Department, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Roberto Bresciani
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
- Highly Specialized Laboratory, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Giorgio Biasiotto
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
- Highly Specialized Laboratory, ASST Spedali Civili di Brescia, Brescia, Italy
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Luo N, Yang G, Li B, Zhang P, Ma J, Chen Y, Du Z, Huang P. Clinical characteristics and prognostic analysis of pediatric hemophagocytic lymphohistiocytosis using lasso-logistic regression. Ann Hematol 2024:10.1007/s00277-024-06061-8. [PMID: 39470776 DOI: 10.1007/s00277-024-06061-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 10/19/2024] [Indexed: 11/01/2024]
Abstract
This study aims to evaluate and predict mortality risks among pediatric patients with hemophagocytic lymphohistiocytosis (HLH). We conducted a retrospective analysis of pediatric patients with HLH diagnosed at the Affiliated Hospital of Zunyi Medical University between January 2012 and April 2023. Patients were divided into a death group and a survival group based on their outcomes. Risk factors for mortality were analyzed using a lasso-logistic regression model. This study included 142 pediatric patients with HLH, with a median age of 40.5 (14.75-84) months, of whom 78 (54.93%) were male. The overall mortality rate was 34.51%. Through lasso-logistic regression analysis, five independent prognostic factors were identified: concurrent central nervous system involvement, multiple organ dysfunction syndrome involving three or more organs, platelet count ≤ 42.5 × 109/L, activated partial thromboplastin time ≥ 54.05 s, and the utilization of blood purification in conjunction with the HLH-94/2004 treatment protocol. The predictive value of the lasso-logistic regression model is better than that of the traditional logistic regression model (AUC: 0.906 vs 0.811, P = 0.001). Subsequently, a lasso-logistic regression-based predictive model incorporating these identified risk factors was developed. Our lasso-logistic regression-based prediction model may help to identify high-risk patients with HLH early, thereby enabling the timely initiation of appropriate treatment interventions.
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Affiliation(s)
- Nandu Luo
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Guizhou Children's Hospital, Zunyi, China
| | - Guangli Yang
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Guizhou Children's Hospital, Zunyi, China
| | - Baoli Li
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Guizhou Children's Hospital, Zunyi, China
| | - Pingping Zhang
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Guizhou Children's Hospital, Zunyi, China
| | - Jinhua Ma
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Guizhou Children's Hospital, Zunyi, China
| | - Yan Chen
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Guizhou Children's Hospital, Zunyi, China
| | - Zuochen Du
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, China.
- Guizhou Children's Hospital, Zunyi, China.
| | - Pei Huang
- Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, China.
- Guizhou Children's Hospital, Zunyi, China.
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3
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Hira B, Siddique AW, Ahmed S, Latif A, Manzoor R, Ghafoor T, Arshed A. Outcome and Prognostic Factors of Hemophagocytic Lymphohistiocytosis in Children: Experience From a Low- and Middle-Income Country. Cureus 2024; 16:e62494. [PMID: 39022463 PMCID: PMC11253576 DOI: 10.7759/cureus.62494] [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: 06/16/2024] [Indexed: 07/20/2024] Open
Abstract
Objective Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition especially in low- and middle-income countries (LMICs). This study was done to evaluate the outcome and prognostic factors of HLH in patients presenting to our center. Methods The study was carried out at the Paediatric Oncology Department of Combined Military Hospital (CMH) in Rawalpindi, Pakistan. All cases of HLH, from one month to 15 years of age enrolled between January 1, 2013 to June 30, 2023, were included. IBM SPSS Statistics for Windows, version 25.0 (released 2017, IBM Corp., Armonk, NY) was used for statistical analysis, and t-test and chi-square tests were used for comparison between continuous and categorical variables. Frequencies and percentages were calculated for categorical variables. Results Out of 115 patients, seven (6%) abandoned the treatment. The data of 108 cases, including 58 males (53.7%), were analyzed. The mean age at diagnosis was 31.5 ± 39.03 months. The mean time to reach a pediatric oncologist was 30.20 ± 22.15 days. Fever and pallor were common symptoms occurring in 107 (99.1%) and 98 (90.7%) cases, respectively. Jaundice was present in 44 (40.7%), visceromegaly in 64 (59.3%), and bruising/bleeding in 16 cases (14.8%). Twenty-six (24.1%) patients underwent hematopoietic stem cell transplant (HSCT), out of which 17 (65.4%) children were cured. Overall survival at two years, five years, and 10 years was 38%, 37%, and 36.1%, respectively. Disease-free survival at two years, five years, and 10 years was 33.3%, 32.4%, and 31.5%, respectively. Conclusion HLH leads to high mortality due to delayed or misdiagnosis in LMICs. Early diagnosis and early referral to a pediatric oncologist is the detrimental factor in survival for HLH. HSCT is the treatment of choice for primary, refractory, or relapse cases.
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Affiliation(s)
- Benish Hira
- Department of Paediatric Oncology, Combined Military Hospital, Rawalpindi, PAK
| | | | - Shakeel Ahmed
- Department of Paediatric Oncology, Combined Military Hospital, Rawalpindi, PAK
| | - Ayesha Latif
- Department of Paediatric Oncology, Combined Military Hospital, Rawalpindi, PAK
| | - Rabiha Manzoor
- Department of Paediatric Oncology, Combined Military Hospital, Rawalpindi, PAK
| | - Tariq Ghafoor
- Armed Forces Bone Marrow Transplant Centre, Department of Paediatrics, Combined Military Hospital, Rawalpindi, PAK
| | - Awais Arshed
- Department of Paediatric Oncology, Combined Military Hospital, Rawalpindi, PAK
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Yoshinari H, Kawahara Y, Niijima H, Oh Y, Morimoto A. High Plasma Presepsin Levels in Children With Hemophagocytic Lymphohistiocytosis. J Pediatr Hematol Oncol 2024; 46:e103-e106. [PMID: 37910819 DOI: 10.1097/mph.0000000000002779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 10/06/2023] [Indexed: 11/03/2023]
Abstract
Presepsin is reported as a novel diagnostic and prognostic biomarker for sepsis, and its optimal cutoff value is reported to be 600 to 650 pg/mL. Three children were diagnosed with hemophagocytic lymphohistiocytosis (HLH). The cause of HLH was unknown in cases 1 and 2, while Epstein-Barr virus infection was the cause in case 3. The plasma presepsin levels at the diagnosis were 1020, 1080, and 3160 pg/mL in cases 1, 2, and 3, respectively. In case 1, the plasma level of presepsin decreased to 164 pg/mL on day 19 of her sickness, when symptoms improved. Follow-up plasma presepsin levels were missing for cases 2 and 3. No microbiological pathogens were detected in the blood cultures of any of the patients. Our cases suggest that plasma presepsin levels can be elevated in childhood HLH.
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Affiliation(s)
- Hiroki Yoshinari
- Department of Pediatrics, Jichi Medical University School of Medicine, Shimotsuke, Japan
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Verkamp B, Zoref-Lorenz A, Francisco B, Kieser P, Mack J, Blackledge T, Brik Simon D, Yacobovich J, Jordan MB. Early response markers predict survival after etoposide-based therapy of hemophagocytic lymphohistiocytosis. Blood Adv 2023; 7:7258-7269. [PMID: 37903321 PMCID: PMC10698531 DOI: 10.1182/bloodadvances.2023010546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 09/29/2023] [Accepted: 10/01/2023] [Indexed: 11/01/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome that is most commonly treated with etoposide and dexamethasone. This standard of care therapy has improved survival, but ∼15% of patients still die in the first months after diagnosis, and poor responses prompting salvage therapy are frequent. Thus, identifying patients at risk promptly is likely to improve outcomes. We conducted a multi-institutional, retrospective study of pediatric and young adults treated per HLH-94 or HLH-2004 from 2010 to 2019 to identify patients at risk for early mortality. Biweekly data during the first 100 days of treatment were analyzed using receiver operating curves to define optimal prognostic indicators and their thresholds. The primary end point was survival to bone marrow transplant (BMT) or ∼1 year if no BMT was pursued. Eighty-nine patients met the study inclusion criteria. Pre-BMT mortality was 13% (n = 12), and overall mortality was 27% (n = 24). Laboratory markers measured on day 7 of therapy more efficiently predicted outcomes than did either pretreatment or later assessments. The most potent day 7 unfavorable marker was improvement in soluble CD25 (sCD25) of less than 25% from pretherapy levels. Absolute sCD25 level, platelet count, absolute lymphocyte count, and blood urea nitrogen were also discriminatory markers (area under the curve ≥ 0.7). The presence of ≥3 of these unfavorable markers was strongly associated with pre-BMT mortality (accuracy, 0.93). Thus, serial monitoring of sCD25 and assessment of other early (day 7) response markers optimally predicts prognosis with etoposide-based therapy and may indicate the need for earlier use of alternative, response-adapted therapeutic strategies for HLH.
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Affiliation(s)
- Bethany Verkamp
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Adi Zoref-Lorenz
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Brenton Francisco
- Department of Pediatrics, Mount Sinai Kravis Children’s Hospital, New York, NY
| | - Pearce Kieser
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Joana Mack
- Division of Hematology and Oncology, Arkansas Children’s Hospital, Little Rock, AR
| | - Tucker Blackledge
- Division of Hematology and Oncology, Arkansas Children’s Hospital, Little Rock, AR
| | - Dafna Brik Simon
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Hematology Oncology, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel
| | - Joanne Yacobovich
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Hematology Oncology, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel
| | - Michael B. Jordan
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Division of Bone Marrow Transplantation and Immune Deficiency, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
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Abdelhay A, Mahmoud AA, Al Ali O, Hashem A, Orakzai A, Jamshed S. Epidemiology, characteristics, and outcomes of adult haemophagocytic lymphohistiocytosis in the USA, 2006-19: a national, retrospective cohort study. EClinicalMedicine 2023; 62:102143. [PMID: 37599909 PMCID: PMC10432999 DOI: 10.1016/j.eclinm.2023.102143] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023] Open
Abstract
Background Haemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening syndrome characterized by an excessive inflammatory response. Limited data exist on adult HLH. Methods In this national, retrospective cohort study, we analysed data from the US National Inpatient Sample database collected between October 1, 2006 and December 31, 2019. Using the International Classification of Diseases (ICD) codes, we identified all adult patients who were admitted non-electively with the diagnosis of HLH. We described demographic characteristics, triggers, and associated conditions. Trends of diagnosis, treatment, and in-hospital mortality were analysed using joinpoint models. In-hospital mortality rates were compared using multivariable logistic regression models that adjusted for demographic characteristics and associated conditions. Finally, we described resource utilization outcomes including cost of hospitalization and length of stay. Findings We identified 16,136 non-elective adult HLH admissions. The population pyramid showed a bimodal distribution, with peaks in young adults (16-30 years) and older adults (56-70 years). Joinpoint regression analysis revealed a significant increase in HLH incidence per 100,000 admissions over the study period (Average Annual Percent Change [APC] = 25.3%, p < 0.0001), and no significant change in rates of in-hospital mortality (slope = -0.01; p = 0.95) or administration of in-hospital HLH treatment (slope = 0.46, p = 0.20). The most common associated conditions were malignancy (4953 admissions [30.7%]), infections (3913 admissions [24.3%]), autoimmune conditions (3362 admissions [20.8%]), organ transplant status (639 admissions [4%]), and congenital immunodeficiency syndromes (399 admissions [2.5%]). In-hospital mortality was higher in older adults and males. Furthermore, Congenital immunodeficiency syndromes had the worst in-hospital mortality rate (mortality rate 31.1%, adjusted OR 2.36 [1.56-3.59]), followed by malignancies (mortality rate 28.4%, adjusted OR 1.80 [1.46-2.22]), infections (mortality rate 21.4%, adjusted OR 1.33 [1.10-1.62]), other/no trigger (mortality rate 13.6%, adjusted OR 0.73 [0.58-0.92]), autoimmune (mortality rate 13%, adjusted OR 0.72 [0.57-0.92]), and post-organ transplant status (mortality rate 14.1%, adjusted OR 0.64 [0.43-0.97]). The overall mean length of stay was 14.3 ± 13.9 days, and the mean cost of hospitalization was $54,900 ± 59,800. Interpretation We provide insight into the burden of adult HLH in the USA. The incidence has been increasing and the outcomes remain dismal. This signifies the growing need for the development of updated diagnosis and treatment protocols that are specific to adult HLH. Funding None.
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Affiliation(s)
- Ali Abdelhay
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Amir A. Mahmoud
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Omar Al Ali
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Anas Hashem
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Abdullah Orakzai
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Saad Jamshed
- Division of Hematology and Oncology, Rochester Regional Health, Rochester, NY, USA
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Jiang JG, Liu CJ, Yeh CM, Yang CF, Liu YC, Wang HY, Ko PS, Chen PM, Yu YB, Gau JP, Tsai CK. Prognostic factors in patients with bone marrow hemophagocytosis and its association with hematologic malignancies. Hematol Oncol 2023; 41:167-177. [PMID: 36305496 DOI: 10.1002/hon.3097] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 10/17/2022] [Accepted: 10/22/2022] [Indexed: 02/03/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a heterogeneous group of hyperinflammatory statuses that are difficult to diagnose and can be life-threatening. Bone marrow (BM) hemophagocytosis is one of the diagnostic criteria according to HLH 2004 diagnostic criteria and HS score. Limited studies have focused on the prognostic factors of BM hemophagocytosis and its association with hematologic malignancies. We aimed to analyze the clinical significance of BM hemophagocytosis. Patients with BM hemophagocytosis, either by cytology or pathology, were enrolled at Taipei Veterans General Hospital from January 2002 to July 2021. Relevant clinical and laboratory data were extracted from medical records. Of 119 patients with BM hemophagocytosis, 57 were diagnosed with hematologic malignancies. The median age of the patients was 58, ranging from 21 to 90. Splenomegaly (adjusted odds ratio [aOR] 2.96; 95% confidence interval [CI] 1.13-7.79) was a risk factor for hematologic malignancies, while autoimmune disease (aOR 0.07; 95% CI 0.01-0.39) and increased D-dimer (aOR 0.25; 95% CI 0.07-0.92) were protective factors. Risk factors for mortality in patients with BM hemophagocytosis were hematologic malignancies (adjusted hazard ratio [aHR] 2.34; 95% CI 1.24-4.44), Eastern Cooperative Oncology Group score ≥3 (aHR 2.42; 95% CI 1.20-4.89) and thrombocytopenia (aHR 3.09; 95% CI 1.04-9.16). In conclusion, among patients with BM hemophagocytosis, splenomegaly was a predictor of hematologic malignancies. Patients with hematologic malignancies, poor performance status, or thrombocytopenia had a higher mortality risk. Further validation studies are warranted.
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Affiliation(s)
- Jing-Gu Jiang
- Department of Medicine, Division of Hematology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, Division of Hematology and Oncology, Far Eastern Memorial Hospital, Taipei, Taiwan
| | - Chia-Jen Liu
- Department of Medicine, Division of Hematology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chiu-Mei Yeh
- Department of Medicine, Division of Hematology, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Fen Yang
- Pathology and Laboratory Medicine Department, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yao-Chung Liu
- Department of Medicine, Division of Hematology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hao-Yuan Wang
- Department of Medicine, Division of Hematology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Po-Shen Ko
- Department of Medicine, Division of Hematology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Biochemistry and Molecular Biology, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Po-Min Chen
- Department of Medicine, Division of Hematology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yuan-Bin Yu
- Department of Medicine, Division of Hematology and Oncology, Far Eastern Memorial Hospital, Taipei, Taiwan
| | - Jyh-Pyng Gau
- Department of Medicine, Division of Hematology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chun-Kuang Tsai
- Department of Medicine, Division of Hematology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Alsohime F, Temsah MH, Alotaibi RM, Alhalabi RM, AlEnezy S, Yousef AA, Alzaydi AM, Inany HS, Al-Eyadhy A, Almazyad M, Alharbi A, Alsoqati AA, Andijani A, Abu Ghazal M, El Masri K, Doussouki M, Butt RF, Alshehri S, Alsatrawi M, Macarambon J, Hasan GM, Alsultan A. Presentations and outcomes of familial hemophagocytic lymphohistiocytosis in the pediatric intensive care units (PICUs). Front Pediatr 2023; 11:1152409. [PMID: 37144147 PMCID: PMC10151775 DOI: 10.3389/fped.2023.1152409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 03/30/2023] [Indexed: 05/06/2023] Open
Abstract
Objectives We aimed to describe Familial Hemophagocytic Lymphohistiocytosis (F-HLH) patients' clinical features, intensive care courses, and outcomes. Methods Multi-center retrospective cohort study of pediatric patients diagnosed with F-HLH from 2015 to 2020 in five tertiary centers in Saudi Arabia. Patients were classified as F-HLH based on their genetic confirmation of known mutation or on their clinical criteria, which include a constellation of abnormalities, early disease onset, recurrent HLH in the absence of other causes, or a family history of HLH. Results Fifty-eight patients (28 male, 30 female), with a mean age of 21.0 ± 33.9 months, were included. The most common principal diagnosis was hematological or immune dysfunction (39.7%), followed by cardiovascular dysfunction in 13 (22.4%) patients. Fever was the most common clinical presentation in 27.6%, followed by convulsions (13.8%) and bleeding (13.8%). There were 20 patients (34.5%) who had splenomegaly, and more than 70% of patients had hyperferritinemia >500 mg/dl, hypertriglyceridemia >150 mg/dl and hemophagocytosis in bone marrow biopsy. Compared to deceased patients 18 (31%), survivors had significantly lower PT (p = 041), bilirubin level of <34.2 mmol/L (p = 0.042), higher serum triglyceride level (p = 0.036), and lesser bleeding within the initial 6 h of admission (p = 0.004). Risk factors for mortality included requirements of higher levels of hemodynamic (61.1% vs. 17.5%, p = 0.001) and respiratory (88.9% vs. 37.5%, p < 0.001) support, and positive fungal cultures (p = 0.046). Conclusions Familial HLH still represents a challenge in the pediatric critical care setting. Earlier diagnosis and prompt initiation of appropriate treatment could improve F-HLH survival.
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Affiliation(s)
- Fahad Alsohime
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Pediatric Intensive Care Unit, Department of Pediatrics, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Mohamad-Hani Temsah
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Pediatric Intensive Care Unit, Department of Pediatrics, King Saud University Medical City, Riyadh, Saudi Arabia
- Prince Abdullah bin Khaled Coeliac Disease Research Chair, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Correspondence: Mohamad-Hani Temsah
| | - Rawan M. Alotaibi
- College of Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Reham M. Alhalabi
- College of Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Sarah AlEnezy
- College of Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Aly Abdelrahman Yousef
- Division of Pediatric Critical Care, Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
- Department of Pediatrics, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Abdullah Mohammed Alzaydi
- Division of Pediatric Critical Care, Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Hussam Sameer Inany
- Division of Pediatric Critical Care, Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Ayman Al-Eyadhy
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Pediatric Intensive Care Unit, Department of Pediatrics, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Mohammed Almazyad
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Pediatric Intensive Care Unit, Department of Pediatrics, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Ali Alharbi
- Pediatric Critical Care Division, Specialized Children Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdulaziz Abdullah Alsoqati
- Pediatric Critical Care Division, Specialized Children Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdurahman Andijani
- Pediatric Critical Care Division, Specialized Children Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Mohammed Abu Ghazal
- Pediatric Critical Care Division, Specialized Children Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Kamal El Masri
- Pediatric Intensive Care Unit, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Maher Doussouki
- Pediatric Hematology & Oncology Department, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Raheel Farooq Butt
- Pediatric Critical Care Division, King Saud Medical City, Riyadh, Saudi Arabia
| | - Saleh Alshehri
- Pediatric Critical Care Division, King Saud Medical City, Riyadh, Saudi Arabia
| | - Mohammed Alsatrawi
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Pediatric Intensive Care Unit, Department of Pediatrics, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Jaramia Macarambon
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Gamal M. Hasan
- Pediatric Department, Assiut Faculty of Medicine, Assiut University, Assiut, Egypt
- Pediatric Department, Pediatric Intensive Care Unit, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Abdulrahman Alsultan
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Oncology Center, King Saud University Medical City, Riyadh, Saudi Arabia
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Li X, Yan H, Xiao Z, Luo T, Xie L, Yang Y, Gong L, Tang Z, Huang J, Zhang X, Zheng M, Yao Z, Zang P, Zhu D, Lu X. Development of a screening score for Hemophagocytic Lymphohistiocytosis among pediatric patients with acute infection of Epstein-Barr virus. Front Immunol 2022; 13:981251. [PMID: 36172365 PMCID: PMC9510983 DOI: 10.3389/fimmu.2022.981251] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/24/2022] [Indexed: 11/17/2022] Open
Abstract
Background and aims Deciding when to suspect hemophagocytic lymphohistiocytosis (HLH) and perform diagnostic tests in patients with acute infection of Epstein-Barr virus (EBV) is challenging, given the high prevalence of EBV infection, the life-threatening risk of EBV-HLH, the relatively low incidence of EBV-HLH, and the wide spectrum of disease presentations. The aim of this study was to develop an EBV-HLH screening model for pediatric patients diagnosed with acute infection of EBV. Methods An inpatient cohort with 3183 pediatric patients who were diagnosed with active infection of EBV was used to construct and validate the EBV-HLH screening score model. The model parameters were selected from common laboratory parameters using the method of Akaike Information Criterion-optimal selection through cross-validation under logistic regression. Performance of the score was evaluated and compared with the performance of screening methods using the number of cytopenias lineages. Results The EBV-HLH screening score has five parameters, including hemoglobin, platelet, neutrophil, albumin, and lactate dehydrogenase. Using a cut-of value of 29, the scoring model had a sensitivity of 89.2% and a specificity of 89.5% in the validation set. The false negative rate, false positive rate, positive predictive value, and negative predictive value in the validation set was 10.8%, 10.5%, 26.8%, and 99.5%, respectively, similar to that of the training set. Conclusions With five common laboratory parameters, the EBV-HLH score provides a simple tool to assist the identification of EBV patients who require further evaluation of HLH. Further studies are needed to evaluate the generalizability of the score and optimize the diagnose process for EBV-HLH.
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Affiliation(s)
- Xun Li
- Pediatrics Research Institute of Hunan Province and Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Haipeng Yan
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
| | - Zhenghui Xiao
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
| | - Ting Luo
- Pediatrics Research Institute of Hunan Province and Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Longlong Xie
- Pediatrics Research Institute of Hunan Province and Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Yufan Yang
- Pediatrics Research Institute of Hunan Province and Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
| | - Ling Gong
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
| | - Zhexuan Tang
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
| | - Jiaotian Huang
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
| | - Xinping Zhang
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
| | - Mincui Zheng
- Department of Pediatric Hematology, Hunan Children’s Hospital, Changsha, China
| | - Zhenya Yao
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
| | - Ping Zang
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
| | - Desheng Zhu
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
| | - Xiulan Lu
- Hunan Provincial Key Laboratory of Emergency Medicine for Children, Hunan Children's Hospital, Changsha, China
- Department of Pediatric Intensive Care Unit (PICU), Hunan Children’s Hospital, Changsha, China
- *Correspondence: Xiulan Lu,
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Li X, Yan H, Luo T, Xiao Z, Gong L, Huang J, Zhang X, Zheng M, Yao Z, Zang P, Zhu D, Lu X. Fulfillment status of hypertriglyceridemia and hypofibrinogenemia in children with hemophagocytic lymphohistiocytosis and risks of multiple organ dysfunction syndrome and early mortality. Orphanet J Rare Dis 2022; 17:161. [PMID: 35410268 PMCID: PMC8996201 DOI: 10.1186/s13023-022-02315-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 03/29/2022] [Indexed: 12/26/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disorder. How to stratify high risk patients is one of the current challenges for the treatment of HLH. HLH patients usually fulfill multiple but not all eight diagnostic criteria. Different combinations of the fulfilled criteria may naturally cluster into previously undescribed subsets or phenotypes that may have different pathophysiology and demonstrate different risks for a poor outcome. The objectives of this study were to identify HLH subgroups according to the fulfillment of diagnostic criteria and evaluate the risk of multiple organ dysfunction syndrome (MODS) and 30-day mortality for subgroups. We retrospectively collect medical records of patients with discharge diagnosis of HLH between June 2015 and October 2018 from a tertiary children’s hospital in China. Latent class analysis was used to identify class defining variables from HLH diagnostic items, and subgroups were defined according to different combinations of the class defining variables. Results Triglyceride and fibrinogen were identified as the class defining variables. When evaluated in combinations, patients with hypertriglyceridemia and normal fibrinogen levels during hospitalization had the lowest risks for MODS (27.8%, OR = 1) and 30-day mortality (18.8%, OR = 1), and patients with normal triglyceride and hypofibrinogenemia had the highest risks for MODS (86.2%, OR = 16.24, P = 0.0002) and 30-day mortality (57.1%, OR = 5.78, P = 0.0187). The fulfillment status of hypertriglyceridemia and hypofibrinogenemia within 72 h of hospital admission was also associated with the risk of adverse outcomes. Conclusions The fulfillment status of hypertriglyceridemia and hypofibrinogenemia were associated with the risks of MODS and 30-day mortality among pediatric HLH patients. Further studies are needed to validate this association and investigate its clinical utility in the severity evaluation for HLH. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02315-8.
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Harnchoowong S, Soponkanaporn S, Vilaiyuk S, Lerkvaleekul B, Pakakasama S. Central nervous system involvement and thrombocytopenia as predictors of mortality in children with hemophagocytic lymphohistiocytosis. Front Pediatr 2022; 10:941318. [PMID: 36147804 PMCID: PMC9485874 DOI: 10.3389/fped.2022.941318] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/18/2022] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a potentially life-threatening condition. This study aimed to evaluate treatment outcomes and identify prognostic-related factors in Thai children with HLH. MATERIALS AND METHODS We retrospectively reviewed the medical records of 76 pediatric patients with HLH who were treated at Ramathibodi Hospital between January 2004 and December 2019. Treatment outcomes were defined as early mortality (death within 30 days after diagnosis) and early treatment response (resolution of all clinical features and normalization of at least one HLH-related laboratory parameter within 4 weeks). RESULTS The overall mortality rate was 38% (29/76), with an early mortality rate of 45% (13/29). Malignancy-associated HLH had the highest mortality rate (88%), followed by primary HLH (56%). The predictors of early mortality were central nervous system (CNS) involvement [OR 13 (95%CI 2-83), p = 0.007] and platelet counts <44 × 106/mm3 [OR 8 (95%CI 1.3-49), p = 0.024]. The predictors of early treatment response were no CNS involvement [OR 6.6 (95%CI 1.5-28.8), p = 0.011], platelet counts more than 44 × 106/mm3 [OR 8 (95%CI 2.1-30.9), p = 0.003], and total bilirubin levels <1.8 mg/dL [OR 4 (95%CI 1.1-14.8), p = 0.036]. In the mixed-model analysis, platelet counts in non-survivors increased significantly less than those in survivors, with a mean difference in platelet changes between the two groups of 94.6 × 106/mm3 (p = 0.003). CONCLUSION The independent predictors of early mortality in children with HLH were CNS involvement and low baseline platelet counts. A slow rate of platelet increases during the first week after diagnosis was also associated with mortality.
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Affiliation(s)
- Saralee Harnchoowong
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sirisucha Soponkanaporn
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Soamarat Vilaiyuk
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Butsabong Lerkvaleekul
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Samart Pakakasama
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Zhou YH, Han XR, Xia FQ, Poonit ND, Liu L. Clinical Features and Prognostic Factors of Early Outcome in Pediatric Hemophagocytic Lymphohistiocytosis: A Retrospective Analysis of 227 Cases. J Pediatr Hematol Oncol 2022; 44:e217-e222. [PMID: 34986134 PMCID: PMC8728756 DOI: 10.1097/mph.0000000000002283] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 06/16/2021] [Indexed: 11/26/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare but life-threatening clinical syndrome in children, and the knowledge of it is still limited. Two hundred twenty-seven children with HLH in our hospital were retrospectively analyzed from January 2001 to December 2018. The age of the patients on admission ranged from 1 day to 14 years old. The 3 most common clinical manifestations include fever (98.7%), hepatomegaly (95.6%), and splenomegaly (92.1%). The decrease of high-density lipoprotein cholesterol (99.1%) is very common in children with HLH. Albumin<25 g/L, activated partial thromboplastin time >65 s, and lactose dehydrogenase >1000 U/L were independent risk factors for poor early prognosis in children with HLH, and their odds ratio values were 2.515, 3.094, and 2.378, respectively, while age >28 months was identified as a protective factor (odds ratio=0.295). Of the 227 children, 67 (29.52%) died within 30 days of onset. The mortality rate in 2013 to 2018 was significantly lower than that in 2001 to 2012 (16.35% vs. 40.65%, P=0.000). The shortening of the time from onset to admission and the reduction of time from admission to definite diagnosis could be some of the reasons for the decrease of HLH mortality in 2013 to 2018 (P<0.05, respectively). Our study suggests that early identification of risk factors for HLH, timely diagnosis and treatment are important measures to improve the short-term prognosis of HLH in children.
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Affiliation(s)
- Yong-Hai Zhou
- Department of Neonatology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an
- Department of Pediatrics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xin-Ru Han
- Department of Pediatrics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Fang-Qing Xia
- Department of Pediatrics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Neha-Devi Poonit
- Department of Pediatrics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Li Liu
- Department of Neonatology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an
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Yu TY, Lu MY, Lin KH, Chang HH, Chou SW, Lin DT, Jou ST, Yang YL. Outcomes and prognostic factors associated with 180-day mortality in Taiwanese pediatric patients with Hemophagocytic Lymphohistiocytosis. J Formos Med Assoc 2020; 120:1061-1068. [PMID: 33218852 DOI: 10.1016/j.jfma.2020.10.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 10/21/2020] [Accepted: 10/26/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND/PURPOSE Hemophagocytic lymphohistiocytosis (HLH), a rarely occurring syndrome with various triggers, is associated with early mortality. Owing to a lack of sufficient corresponding data in Taiwan, this study aimed to identify the outcome and potential factors associated with 180-day mortality in pediatric HLH. METHODS This retrospective study analyzed clinical and laboratory data on pediatric patients diagnosed with HLH at our institute (1995-2019). Logistic regression analysis was conducted to determine the associations between various factors and 180-day mortality. RESULTS Overall, 48 patients had HLH; their median age at diagnosis was 5 years (interquartile range: 2-11 years). Clinical presentations and laboratory parameters required for diagnosis included fever (98%), splenomegaly (79%), hyperferritinemia (98%), hemophagocytosis (94%), thrombocytopenia (90%), anemia (63%), hypertriglyceridemia (68%), and neutropenia (57%). The 5-year overall survival (OS) rate was 49%. Of 22 patients who had died at the last follow-up, 15 (68%) died within 180 days after diagnosis. In the multivariate analysis, hemoglobin (odds ratio [OR]: 0.564, p = 0.024) and triglyceride (OR: 1.004, p = 0.049) were significantly associated with 180-day mortality. Higher triglyceride levels at diagnosis were related to significantly lower 180-day OS rates (52.9% vs. 86.1%, p = 0.018). CONCLUSION The overall outcome in our cohort was similar to that reported in some of the largest international cohorts. Hypertriglyceridemia and anemia may be indicative of poor prognoses in pediatric HLH patients independently and may be used to guide treatment strategy formulations for better outcomes.
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Affiliation(s)
- Teng-Yang Yu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Meng-Yao Lu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Kai-Hsin Lin
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsiu-Hao Chang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Shu-Wei Chou
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Dong-Tsamn Lin
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shiann-Tarng Jou
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan.
| | - Yung-Li Yang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Laboratory Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Li X, Yan H, Zhang X, Huang J, Xiang ST, Yao Z, Zang P, Zhu D, Xiao Z, Lu X. Clinical profiles and risk factors of 7-day and 30-day mortality among 160 pediatric patients with hemophagocytic lymphohistiocytosis. Orphanet J Rare Dis 2020; 15:229. [PMID: 32867836 PMCID: PMC7456759 DOI: 10.1186/s13023-020-01515-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 08/19/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a relatively rare and life-threatening disorder. Early mortality remains significantly high among patients with HLH. Our aim was to investigate clinical features and risk factors associated with 7-day and 30-day mortality among pediatric HLH patients. We retrospectively collected medical records of patients with discharge diagnosis of HLH between August 2014 and October 2018 from a tertiary children's hospital in China. The main outcome measures were the 7-day and 30-day outcome after hospital admission. The associations between symptoms, concomitant diagnoses, laboratory test results, and the risk of 7-day and 30-day mortality were examined. RESULTS Among 160 pediatric HLH patients, 18 (11.3%) patients were deceased within 7 days after admission, and 46 (28.8%) patients were deceased within 30 days. The identified strong risk factors (OR > 10 and p < 0.05) for 30-day mortality were myocardial damage, severe pneumonia, respiratory failure, coagulopathy, gastrointestinal disorder, and multiple organ dysfunction syndrome (MODS). Factors strongly associated with 7-day mortality were sepsis, myocardial damage, shock, and respiratory failure. All patients deceased within 7 days developed hepatic dysfunction, coagulopathy, and MODS. CONCLUSIONS The identified risk factors could help to stratify patients with high risk of early death, and need to be considered in the development of treatment protocols. As early mortality of HLH remains high, studies are needed to investigate how to initiate adequate HLH-directed treatment strategies for patients at higher risk of early death.
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Affiliation(s)
- Xun Li
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, University of South China, Changsha, China
| | - Haipeng Yan
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Xinping Zhang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Jiaotian Huang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Shi-Ting Xiang
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, University of South China, Changsha, China
| | - Zhenya Yao
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Ping Zang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Desheng Zhu
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Zhenghui Xiao
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China.
| | - Xiulan Lu
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China.
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Abstract
Hemophagocytic lymphohistiocytosis (HLH) is characterized by uncontrolled and excessive immune responses with high mortality. We aimed to define mortality-related parameters in HLH secondary to primary immunodeficiency (PID). A total of 28 patients with HLH between the years 2013 and 2017 were enrolled in the study. The patients were evaluated in 2 groups including PID with hypopigmentation (n=7) (Chédiak-Higashi syndrome [CHS] and Griscelli syndrome type 2 [GS2]) and other PIDs (n=21). The median age of the study population was 23 (4.3 to 117.0) months at the time of the diagnosis of HLH. Central nervous system involvement was recorded in 7 (GS2/CHS patients [n=4], other PIDs [n=3], P=0.026), and death was observed in 9 patients (GS2/CHS patients [n=1], other PIDs [n=8], P=0.371). Five patients (3 GS2/CHS and 2 other PID patients) underwent hematopoietic stem cell transplantation. Low serum albumin level was the only variable associated with the mortality and albumin levels less than the cut-off value of 3.07 g/dL increased mortality 5.8 times in patients with HLH secondary to PID. We presented a single-center experience consisting of patients with HLH secondary to PID with a mortality rate of 32.1%. Hypoalbuminemia was the only risk factor to increase the overall mortality rate of HLH.
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Chen TY, Hsu MH, Kuo HC, Sheen JM, Cheng MC, Lin YJ. Outcome analysis of pediatric hemophagocytic lymphohistiocytosis. J Formos Med Assoc 2020; 120:172-179. [PMID: 32307323 DOI: 10.1016/j.jfma.2020.03.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 02/18/2020] [Accepted: 03/29/2020] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease associated with rapid clinical deterioration and the need for intensive care; therefore, it is essential to identify clinical parameters related to mortality and establish prognostic factors correlated with unfavorable outcome in high risk patients whose treatment may fail. METHODS Between January 2004 and December 2018, a total of 51 pediatric patients (less than 18 years old) who fulfilled the diagnostic criteria of HLH-2004 with documented results of bone marrow investigations at Kaohsiung Chang Gung Memorial Hospital were enrolled. The treatment protocol was based on hemophagocytic lymphohistiocytosis-94 (HLH-94) and HLH-2004. We retrospectively reviewed electronic medical records (EMR) including clinical features, length of intensive care unit (ICU) stay, serological tests, microscopic reports of bone marrow examination, and ultrasound examination reports at diagnosis to identify prognostic factors. The patients were divided into four groups based on etiology; these included infection associated hemophagocytic syndrome (IAHS), macrophage activation syndrome (MAS), malignancy associated hemophagocytic lymphohistiocytosis (MA-HLH), and idiopathic hemophagocytic lymphohistiocytosis (IHLH) to identify differences among the groups. RESULTS Out of 51 patients enrolled, 27 patients had IAHS, 12 MAS, 8 MA-HLH, and 4 IHLH. The median age at diagnosis was 7 years. The overall mortality rate was 15.7% (there was no mortality in the MA-HLH group); the mean length of ICU stay was 6 ± 20.8 days. Longer activated partial thromboplastin time (aPTT) (p = 0.007), lower sodium concentration (p = 0.0007), and higher creatinine (p = 0.032) and aspartate aminotransferase (AST) (p = 0.017) were significantly related to mortality. Multivariate Cox regression analysis demonstrated that aPTT (p = 0.045, HR = 1.03, 95% CI = 1.0-1.1) was an independent risk factor for mortality. The receiver operating characteristic (ROC) curve showed that aPTT longer than 44.35 s was the cutoff value predicting mortality, with a sensitivity and specificity of 72% and 66.7%, respectively. CONCLUSION MA-HLH had the lowest mortality rate, as most children died from the underlying malignant disease and not from HLH. Impaired liver and renal functions were related to mortality. Prolonged aPTT > 44.35 s is a strong predictive factor for mortality.
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Affiliation(s)
- Tsung-Yen Chen
- Division of Critical Care, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC; Department of Pediatrics, E-Da Hospital, I-Shou university, Kaohsiung, Taiwan, ROC
| | - Mei-Hsin Hsu
- Division of Critical Care, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC; Division of Neurology, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Hsuan-Chang Kuo
- Division of Critical Care, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC; Division of Cardiology, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC; Adjunct Lecturers, Department of Nursing, Meiho University, Taiwan, ROC
| | - Jiunn-Ming Sheen
- Division of Hematology, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Ming-Chou Cheng
- Division of Critical Care, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Ying-Jui Lin
- Division of Critical Care, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC; Division of Cardiology, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC.
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Li X, Yan H, Zhang X, Huang J, Xiang ST, Yao Z, Zang P, Zhu D, Xiao Z, Lu X. Elevated serum myoglobin levels at hospital admission and the risk of early death among patients with hemophagocytic lymphohistiocytosis: evidence from 155 pediatric patients. Ann Hematol 2020; 99:963-971. [PMID: 32221652 DOI: 10.1007/s00277-020-03980-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 03/01/2020] [Indexed: 12/20/2022]
Abstract
Patients with hemophagocytic lymphohistiocytosis (HLH) have high risk of early mortality. The purpose of this study was to test the hypothesis that the elevated level of serum myoglobin among patients with HLH is associated with disease severity and increased risk of mortality. We retrospectively investigated the serum myoglobin levels from 155 pediatric patients diagnosed with HLH in the Hunan Children's Hospital, China. The levels of myoglobin and creatine kinase at hospital admission among non-survivors and survivors were compared. The myoglobin level was dichotomized for the estimation of hazard ratio (HR) for mortality. Patients who died within 7 and 30 days of hospitalization had significantly higher myoglobin levels than did survivors (p < 0.05). The myoglobin level was negatively associated with the days of survival among non-survivors (Spearman correlation coefficient = - 0.29, p = 0.04). An elevated myoglobin level (> 90 ng/mL) was significantly associated with increased mortality (unadjusted HR = 2.66, 95%CI: 1.41, 5.00, p = 0.0024) and persisted after adjusting for age, Epstein-Barr virus infection, admission department, acute kidney injury, myocardial damage, and shock. In conclusion, an elevated serum myoglobin level was associated with increased risk of early death among pediatric patients with HLH, suggesting the potential of myoglobin to be used as a reference indicator for monitoring and managing of HLH.
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Affiliation(s)
- Xun Li
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, University of South China, Changsha, China
| | - Haipeng Yan
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Xinping Zhang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Jiaotian Huang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Shi-Ting Xiang
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, University of South China, Changsha, China
| | - Zhenya Yao
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Ping Zang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Desheng Zhu
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Zhenghui Xiao
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China.
| | - Xiulan Lu
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China.
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Zhao Y, Lu D, Ma S, Li L, Zhu J, Zhou D, Zheng Y, Yang X, Zhu L, Zhu M, Xie M, Sun J, Ye X, Xie W. Risk factors of early death in adult patients with secondary hemophagocytic lymphohistiocytosis: a single-institution study of 171 Chinese patients. ACTA ACUST UNITED AC 2020; 24:606-612. [PMID: 31474196 DOI: 10.1080/16078454.2019.1660458] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Adult secondary hemophagocytic lymphohistiocytosis (HLH) is a potentially life-threatening syndrome characterized by excessive activation of mononuclear-phagocytic system resulting in hyperinflammatory response. To date, the factors influencing early death of HLH are still not fully elucidated. Patients and Methods: We did a retrospective study of 171 adult patients with newly diagnosed HLH at our institution from January 2012 to April 2018. All patients' clinical features, laboratory findings, treatments and prognosis were reviewed. Results: The median age was 49 years (range, 18-88 years), and 110 (64.3%) were male. The major underlying trigger of HLH was malignancy (88/171, 51.5%), especially non-Hodgkin lymphoma. In a multivariate analysis, age ≥54 years (P = 0.002), platelet ≤39.5 × 109/L (P = 0.028), activated partial thromboplastin time (APTT) ≥54 sec (P = 0.048), triglyceride ≥3.23 mmol/L (P < 0.001), lactate dehydrogenase (LDH) ≥1300 U/L (P = 0.012) and malignancy (P = 0.001) were significantly associated with early death in HLH. Then, patients were classified into four groups according to the number of risk factors at the time of diagnosis: low risk (zero, one or two risk factors), low intermediate risk (three risk factors), high intermediate risk (four risk factors) and high risk (at least five risk factors), with the 30-day overall survival (OS) of 92.4%, 58.8%, 30.0% and 4.8%, respectively (P < 0.001). Conclusions: Patients with old age, thrombocytopenia, prolonged APTT, hypertriglyceridemia, elevated LDH and malignancy had inferior survival. It is important to identify those patients at risk of early death, which may guide treatment and reduce mortality.
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Affiliation(s)
- Yanchun Zhao
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Danlei Lu
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Shanshan Ma
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Li Li
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Jingjing Zhu
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - De Zhou
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Yanlong Zheng
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Xiudi Yang
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Lixia Zhu
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Mingyu Zhu
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Mixue Xie
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Jianai Sun
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Xiujin Ye
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
| | - Wanzhuo Xie
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , People's Republic of China
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Etiologies and Clinical Outcomes of Patients With Secondary Hemophagocytic Lymphohistiocytosis at a Tertiary PICU. Pediatr Crit Care Med 2019; 20:e311-e318. [PMID: 31149968 DOI: 10.1097/pcc.0000000000001980] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess the etiologies and outcomes of patients with secondary hemophagocytic lymphohistiocytosis in the PICU. DESIGN Prospective observational cohort study. SETTING A single PICU at a pediatric tertiary hospital in Hanoi, Vietnam. PATIENTS Pediatric patients meeting the criteria for secondary hemophagocytic lymphohistiocytosis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Between June 2017 and May 2018, 25 consecutive patients with a mean (SD) age of 23.3 months (21.6 mo) were included. Collected variables included etiologies of hemophagocytic lymphohistiocytosis and clinical and laboratory findings at admission. The Pediatric Index of Mortality 2 score at admission was calculated. Outcomes were death and multiple organ dysfunction. The severity of multiple organ dysfunction was assessed by the Pediatric Logistic Organ Dysfunction 2 score. The mean (SD) Pediatric Index of Mortality 2 predicted mortality rate was 5.6% (7.6%). Cytomegalovirus and Epstein-Barr virus coinfections (60%) were the most common suspected etiology of hemophagocytic lymphohistiocytosis. Other etiologies included Epstein-Barr virus sole infections (20%), cytomegalovirus sole infections (16%), and one unknown cause (4%). Multiple organ dysfunction (excluding hematologic failure) was found in 22 patients (88%) with death occurring in 14 patients (56%). The mean (SD) Pediatric Logistic Organ Dysfunction 2 predicted mortality rate among patients with multiple organ dysfunction was 11.9% (11.2%). Despite having lower Pediatric Index of Mortality 2 predicted mortality rates at admission, Epstein-Barr virus-cytomegalovirus coinfection cases with multiple organ dysfunction had slightly greater Pediatric Logistic Organ Dysfunction 2 predicted mortality rates than Epstein-Barr virus sole infection cases with multiple organ dysfunction: 12.2% (10.5%) versus 11.3% (11.0%). However, these rates were lower than cytomegalovirus sole infection cases with multiple organ dysfunction (14.4% [16.3%]). Area under the curve values for Pediatric Index of Mortality 2 and Pediatric Logistic Organ Dysfunction 2 were 0.74 (95% CI, 0.52-0.95) and 0.78 (95% CI, 0.52-1.00), respectively, suggesting that both scales were fair to good at predicting mortality. CONCLUSIONS Viral infections, particularly Epstein-Barr virus-cytomegalovirus coinfections, were a common cause of secondary hemophagocytic lymphohistiocytosis. The implication of these coinfections on the clinical course of hemophagocytic lymphohistiocytosis needs to be delineated.
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Tang YM, Luo Z. Prognostic factors of early death in children with hemophagocytic lymphohistiocytosis. Cytokine 2018; 110:481-482. [DOI: 10.1016/j.cyto.2017.09.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 09/21/2017] [Indexed: 12/29/2022]
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Buda P, Gietka P, Książyk JB, Machaczka M. The influence of various therapeutic regimens on early clinical and laboratory response and outcome of children with secondary hemophagocytic lymphohistiocytosis. Arch Med Sci 2018; 14:138-150. [PMID: 29379544 PMCID: PMC5778409 DOI: 10.5114/aoms.2015.56325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 11/15/2015] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Secondary hemophagocytic lymphohistiocytosis (sHLH) is a life-threatening syndrome of severe hyperinflammation which is often triggered by infection or autoimmune disease (macrophage activation syndrome - MAS). The aim of our study was to assess the frequency of sHLH/MAS in children treated in our institution and to compare the effectiveness of various therapeutic interventions. MATERIAL AND METHODS Between 2005 and 2013, 24 children (age: 1-17 years) were consecutively treated for sHLH/MAS. Therapy was based on glucocorticoids (GCs) in high or standard doses (hd-GCs or sd-GCs), intravenous immunoglobulin (IVIG), and cyclosporin A (CyA). A comparison of selected laboratory and clinical parameters during the first 72 h of treatment and after a week from the last intervention applied in the first 72 h after diagnosis was performed retrospectively. RESULTS The majority of patients (14/24, 58%) suffered from sHLH/MAS in the course of an autoimmune disease (12 patients diagnosed with a systemic form of juvenile idiopathic arthritis). We found with a confidence level of 95% that the application of hd-GCs in the first 24 h caused rapid alleviation of fever, reduction of hepatosplenomegaly, and an increase in thrombocytes and s-fibrinogen concentrations. The use of combination therapy with hd-GCs, IVIG, and CyA in the first 72 h caused a faster increase in s-fibrinogen. All patients survived and were alive at the follow-up of 1-8 years. CONCLUSIONS The results indicate that treatment of sHLH/MAS based on hd-GCs, CyA and IVIG is an effective therapy in children.
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Affiliation(s)
- Piotr Buda
- Department of Pediatrics, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Piotr Gietka
- Eleonore Reicher’s Rheumatology Institute, Warsaw, Poland
| | - Janusz B. Książyk
- Department of Pediatrics, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Maciej Machaczka
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
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Prognostic factors of early death in children with hemophagocytic lymphohistiocytosis. Cytokine 2017; 97:80-85. [PMID: 28582648 DOI: 10.1016/j.cyto.2017.03.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 03/10/2017] [Accepted: 03/31/2017] [Indexed: 11/20/2022]
Abstract
Hemophagocytic lymphohistiocytosis is a rapidly progressing and fatal disease. Early identification of early death for HLH patients based on the laboratory findings at the time of diagnosis could improve the overall survival. A retrospective study was performed on 95 Chinese pediatric patients with HLH. Patients' data including clinical features and laboratory findings at diagnosis were collected. In a multivariate Cox proportional hazard regression model analysis, albumin≤27.75g/L (hazard ratio (HR)=11.82, 95% confidence interval (CI) 2.58-54.23; P=0.001), LDH≥3707.5 U/L (HR=4.15, 95%CI 1.43-12.01; P=0.009), and IL-10≥456pg/ml (HR=12.39, 95%CI 1.59-96.79; P=0.016) at diagnosis were independent prognostic factors of early death. The risk of early death was 33-fold increase in patients with three risk factors (HR=33.33; 95%CI 8.40-125.00; P<0.001), and 12-fold increase in patients with two risk factors (HR=12.80; 95%CI 2.34-69.80; P=0.002) when compared to it in patients with zero to one risk factor. Our results reveal that HLH patients with the risk of early death can be identified by laboratory findings at diagnosis, which may help guide the treatment decision making for this disease.
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Guo Y, Bai Y, Gu L. Clinical features and prognostic factors of adult secondary hemophagocytic syndrome: Analysis of 47 cases. Medicine (Baltimore) 2017; 96:e6935. [PMID: 28562543 PMCID: PMC5459708 DOI: 10.1097/md.0000000000006935] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
This study aimed to investigate the relationship between clinical features and prognosis of adult secondary hemophagocytic syndrome (HPS).A retrospective analysis was conducted on the pathogenesis, clinical manifestations, laboratory examinations, treatment options, and prognosis of 47 patients with adult secondary HPS diagnosed from January 2013 to December 2015.The average age at disease onset was (46.26 ± 18.98) years with a male:female ratio of 1:1.14. Thirteen patients died, with the highest mortality rate in patients with HPS underlying blood system malignancy (33.33%, 2/6). The mortality rate in patients with HPS underlying autoimmune disorders was the lowest (18.75%, 3/16). The Kaplan-Meier analysis indicated that signs of hemorrhage, pulmonary and nervous system involvement, serous effusion, and decrease in the blood platelet count were associated with death. The Cox regression analysis revealed that signs of hemorrhage, pulmonary involvement, serous effusion, and nervous system involvement were independent risk factors of patient death.Adult secondary HPS has multiple etiologies and diversified clinical features. The risk of death increases in patients with signs of hemorrhage, serous effusion, pulmonary involvement, and nervous system involvement.
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Affiliation(s)
- Yiqun Guo
- Department of Infectious Diseases and Clinical Microbiology
| | - Yu Bai
- Department of Internal medicine, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Li Gu
- Department of Infectious Diseases and Clinical Microbiology
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Horne A, Wickström R, Jordan MB, Yeh EA, Naqvi A, Henter JI, Janka G. How to Treat Involvement of the Central Nervous System in Hemophagocytic Lymphohistiocytosis? Curr Treat Options Neurol 2017; 19:3. [PMID: 28155064 PMCID: PMC5290057 DOI: 10.1007/s11940-017-0439-4] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OPINION STATEMENT Central nervous system (CNS)-hemophagocytic lymphohistiocytosis (HLH) is not a disease in itself, but it is part of a systemic immune response. The vast majority of patients with CNS-HLH also have systemic HLH and a large number of patients with primary and secondary HLH have CNS involvement. Reactivations within the CNS are frequent during the course of HLH treatment and may occur concomitant with or independent of systemic relapses. It is also important to consider primary HLH as an underlying cause of "unknown CNS inflammation" as these patients may present with only CNS disease. To initiate proper treatment, a correct diagnosis must be made. A careful review of the patient's history and a thorough neurological examination are essential. In addition to the blood tests required to make a diagnosis of HLH, a lumbar puncture with cerebrospinal fluid (CSF) analysis and magnetic resonance imaging (MRI) should always be done in all cases regardless of the presence or absence of neurological signs or symptom. Treatment options for CNS-HLH include, but are not limited to, those commonly used in systemic HLH, including corticosteroids, etoposide, cyclosporine A, alemtuzumab, and ATG. In addition, intrathecal treatment with methotrexate and corticosteroids has become a standard care and is likely to be beneficial. Therapy must be initiated without inappropriate delay to prevent late effects in HLH. An interesting novel approach is an anti-IFN-gamma antibody (NI-0501), which is currently being tested. Hematopoietic stem cell transplantation (HSCT) also represents an important CNS-HLH treatment; patients with primary HLH may benefit from immediate HSCT even if there is active disease at time of transplantation, though care should be taken to monitor CNS inflammation through HSCT and treat if needed. Since CNS-HLH is a condition leading to the most severe late effects of HLH, early expert consultation is recommended.
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Affiliation(s)
- AnnaCarin Horne
- Department of Women's and Children's Health, Karolinska Institute, Division of Pediatrics Karolinska University Hospital, Stockholm, Sweden.
| | - Ronny Wickström
- Department of Women's and Children's Health, Karolinska Institute, Division of Pediatrics Karolinska University Hospital, Stockholm, Sweden
| | - Michael B Jordan
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Ahmed Naqvi
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Jan-Inge Henter
- Department of Women's and Children's Health, Karolinska Institute, Division of Pediatrics Karolinska University Hospital, Stockholm, Sweden
| | - Gritta Janka
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
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Saikia UN, Gupta A, Vignesh P, Suri D, Singh MP. Hemophagocytic Lymphohistiocytosis in a Young Child. Indian Pediatr 2016; 53:505-11. [PMID: 27376605 DOI: 10.1007/s13312-016-0880-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a multisystem disorder mediated by cytokine storm and is characterized by fever, pancytopenia and organomegaly coupled with laboratory features like hyperferritinemia, hypertriglyceridemia, hypofibrinogenemia and transaminitis. Etiology can be genetic or acquired such as infections, malignancy and autoimmune disorders. Diagnosis, identification of underlying etiology and management of HLH remain tough clinical puzzles to sort out for the managing physician. We report a clinico-pathological conference of a three-year-old boy who had such a presentation and succumbed during the hospital stay.
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Affiliation(s)
- Uma Nahar Saikia
- Departments of Pediatrics, *Histopathology and #Virology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Correspondence to: Dr Anju Gupta, Additional Professor, Department of Pediatrics Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Prognostic Factors and Long-Term Outcome in 52 Turkish Children With Hemophagocytic Lymphohistiocytosis. Pediatr Crit Care Med 2015; 16:e165-73. [PMID: 25901543 DOI: 10.1097/pcc.0000000000000449] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Hemophagocytic lymphohistiocytosis is a syndrome of pathologic immune activation that shares similar clinical and laboratory phenotypes with severe sepsis. Recent studies led to better recognition of hemophagocytic lymphohistiocytosis by clinicians, but no consensus exists on the criteria for high-risk patients. DESIGN We retrospectively reviewed the medical records of patients diagnosed with hemophagocytic lymphohistiocytosis to analyze the risk factors associated with poor outcome. SETTING Pediatric intensive care and hematology units of three tertiary hospitals in Turkey. PARTICIPANTS Fifty-two children with hemophagocytic lymphohistiocytosis. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS There were a total of 52 children meeting the diagnostic criteria of Histiocytic Society. Of them, 28 (54%) had a primary hemophagocytic lymphohistiocytosis. Mutation studies were performed in 18 of 28 patients (65%). Fourteen of them had PRF1, STX11, STXBP2, and UNC13D mutations, and four had Rab27a and LYST mutations. The remaining 24 patients (46%) were defined as having secondary hemophagocytic lymphohistiocytosis. Twenty-one of them had infection-associated hemophagocytic lymphohistiocytosis, and three had lysinuric protein intolerance. The mortality rate was significantly higher in primary hemophagocytic lymphohistiocytosis (64%) than in secondary hemophagocytic lymphohistiocytosis (16%) (p < 0.05). There were no significant differences for survival rate between hemophagocytic lymphohistiocytosis 94 (44%) and hemophagocytic lymphohistiocytosis 2004 (64%) protocols (p > 0.05). Age below 2 years, hyperferritinemia, thrombocytopenia, high disseminated intravascular coagulation score at diagnosis, and no clinical response at 2 weeks of treatment were independent prognostic factors for poor prognosis. CONCLUSIONS Our data suggest that disseminated intravascular coagulation score greater than or equal to 5 can be used in the definition of high-risk patients. Early recognition of poor risk factors has important prognostic and therapeutic implications.
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Ozen S, Dai A, Coskun E, Oztuzcu S, Ergun S, Aktekin E, Yavuz S, Bay A. Importance of hyperbilirubinemia in differentiation of primary and secondary hemophagocytic lymphohistiocytosis in pediatric cases. Mediterr J Hematol Infect Dis 2014; 6:e2014067. [PMID: 25408853 PMCID: PMC4235485 DOI: 10.4084/mjhid.2014.067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 10/03/2014] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyper-inflammatory disease. It is difficult to differentiate between primary and secondary HLH based on clinical findings at the onset of disease. We aimed to find parameters that can help to differentiate primary and secondary HLH at initial diagnosis especially for physicians working in developing countries. PATIENT AND METHOD We retrospectively analyzed data of 38 HLH patients who were admitted to the Pediatric Hematology Department of Gaziantep University between January 2009 and December 2013. RESULTS Of 38 patients, 20 were defined as primary, and 18 were secondary HLH. The average age of primary and secondary HLH patients was 31±9 and 81±14 months, respectively (p=0.03). We found consanguinity rates significantly higher in primary HLH patients compared to secondary HLH patients (p=0.03). We found that total and direct bilirubin levels significantly increased in primary HLH patients compared to secondary HLH patients (p=0.006, p=0.044). Also, CRP levels were found markedly increased in secondary HLH patients compared to primary ones (p=0.017). CONCLUSION We showed that cholestasis and hyperbilirubinemia findings of HLH patients at the initial diagnosis should be considered in favor of primary HLH, and an increased level of CRP should be considered in favor of secondary HLH.
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Affiliation(s)
- Seval Ozen
- Gaziantep University Department of Pediatrics, Gaziantep, Turkey
| | - Alper Dai
- Gaziantep University Department of Pediatrics, Gaziantep, Turkey
| | - Enes Coskun
- Gaziantep University Department of Pediatrics, Gaziantep, Turkey
| | - Serdar Oztuzcu
- Gaziantep University Department of Medical Biology, Gaziantep, Turkey
| | - Sercan Ergun
- Gaziantep University Department of Medical Biology, Gaziantep, Turkey
| | - Elif Aktekin
- Gaziantep University Department of Pediatrics, Gaziantep, Turkey
| | - Sibel Yavuz
- Gaziantep University Department of Pediatrics, Gaziantep, Turkey
| | - Ali Bay
- Gaziantep University Department of Pediatrics, Gaziantep, Turkey
- Gaziantep University Division of Pediatric Hematology Gaziantep, Turkey
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