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Alasmari BG, Mohammed SE, Ali M, Elzubair L, Altayeb OA, Alshehri KS, Alpakra M, Mohammed M, Alabbas A. Familial Hemophagocytic Lymphohistiocytosis (FHLH) Perforin Deficiency: A Case Study and Literature Review. Cureus 2024; 16:e55770. [PMID: 38586661 PMCID: PMC10999172 DOI: 10.7759/cureus.55770] [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: 03/08/2024] [Indexed: 04/09/2024] Open
Abstract
Hemophagocytic lymphohistocytosis (HLH) is a severe and fatal immunological disorder that is either primary (i.e., familial) or secondary (i.e., acquired). The primary type comprises autosomal recessive disorders with gene mutations related to natural killer cells and cytotoxic T-cells, whereas the secondary type is related to other pathological causes, such as Epstein-Barr virus, bacterial or fungal infection, autoimmune conditions or autoinflammatory diseases, metabolic disorders, and cancer. In this report, we discuss a 37-day-old male who was brought to the emergency room with fever, decreased activity, and hepatosplenomegaly, with a strong family history of unknown cause of death for three siblings who died at the ages of one to two months. A whole exome sequencing confirmed the clinical diagnosis of familial HLH due to mutation in the PRF1 gene. We note the special importance of genetic counselling and antenatal screening or early neonatal screening in families affected by HLH, as this case highlights the importance of early diagnosis and intervention of primary HLH.
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Affiliation(s)
- Badriah G Alasmari
- Pediatric Hematology and Oncology, Armed Forces Hospital Southern Region, Khamis Mushait, SAU
| | - Samah E Mohammed
- Pediatrics, Armed Forces Hospital Southern Region, Khamis Mushait, SAU
| | | | - Lina Elzubair
- Pathology, Armed Forces Hospital Southern Region, Khamis Mushait, SAU
| | - Osama A Altayeb
- Flowcytometry, Flow Cytometry Laboratory for Leukemia & Lymphoma Diagnosis, Khartoum, SDN
| | - Khalid S Alshehri
- Pediatric Intensive Care Unit, Armed Forces Hospital Southern Region, Khamis Mushait, SAU
| | - Mohammed Alpakra
- Pediatric Hematology and Oncology, Armed Forces Hospital Southern Region, Khamis Mushait, SAU
| | - Mohaned Mohammed
- Pediatrics, Armed Forces Hospital Southern Region, Khamis Mushait, SAU
| | - Ali Alabbas
- Pediatrics, Najran General Hospital, Najran, SAU
- Pediatrics, Armed Forces Hospital Southern Region, Khamis Mushait, SAU
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2
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Cay E, Sezer A, Karakulak V, Serbes M, Ozcan D, Bisgin A, Aygunes U, Sasmaz HI, Yucel SP, Toyran T, Altintas DU. Hemophagocytic lymphohistiocytosis in children with Griscelli syndrome type 2: genetics, laboratory findings and treatment. AMERICAN JOURNAL OF CLINICAL AND EXPERIMENTAL IMMUNOLOGY 2023; 12:140-152. [PMID: 38187365 PMCID: PMC10767195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 12/03/2023] [Indexed: 01/09/2024]
Abstract
Griscelli syndrome is a rare inherited autosomal recessive syndrome that causes immunodeficiency. Hemophagocytic lymphohistiocytosis (HLH), which is characterized by a high mortality rate, may develop because of Griscelli syndrome type 2 (GS2). We aimed to share our experience with the diagnosis and treatment methods of patients who developed HLH secondary to GS2. Patients with GS2 who were diagnosed and treated for HLH between 2017 and 2022 at the Cukurova University Division of Pediatric Allergy & Immunology and Division of Pediatric Hematology were included in the study. Microscopic examination of the hair shaft and next-generation sequencing for molecular genetic testing of RAB27A helped in the diagnosis of GS2. The first clinical presentation of 8 patients was HLH. One patient presented with CNS involvement and two patients presented with recurrent fever. Over 5 years, GS2 was diagnosed in 15 patients, of whom 11 (73.3%) developed HLH. The HLH-2004 protocol was used to treat these patients. Hematopoietic stem cell transplantation (HSCT) was performed in five patients who were matched with suitable donors. While all patients who underwent HSCT were alive, three patients who could not undergo HSCT because no donor could be found died. Deletion of CAAGC at nucleotides 514_518 in GS2 patients is associated with CNS involvement and a poor prognosis. HLH may be the first sign of presentation in patients with GS2. Although further research is needed, regardless of the conditioning regimen utilized, early HSCT remains the primary therapy option for preventing GS2-induced mortality in HLH.
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Affiliation(s)
- Ezgi Cay
- Department of Pediatrics, Faculty of Medicine, Balcali Hospital, Cukurova UniversityAdana, Turkey
| | - Ahmet Sezer
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Balcali Hospital, Cukurova UniversityAdana, Turkey
| | - Veysel Karakulak
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Balcali Hospital, Cukurova UniversityAdana, Turkey
| | - Mahir Serbes
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Balcali Hospital, Cukurova UniversityAdana, Turkey
| | - Dilek Ozcan
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Balcali Hospital, Cukurova UniversityAdana, Turkey
| | - Atil Bisgin
- Cukurova University, AGENTEM (Adana Genetic Diseases Diagnosis and Treatment Center)Adana, Turkey
- Department of Medical Genetics, Faculty of Medicine, Balcali Hospital, Cukurova UniversityAdana, Turkey
| | - Utku Aygunes
- Division of Pediatric Hematology, Oncology and BMT Unit, Acibadem Adana HospitalAdana, Turkey
| | - H Ilgen Sasmaz
- Division of Pediatric Hematology, Faculty of Medicine, Balcali Hospital, Cukurova UniversityAdana, Turkey
| | - Sevinc P Yucel
- Department of Biostatistics, Faculty of Medicine, Balcali Hospital, Cukurova UniversityAdana, Turkey
| | - Tugba Toyran
- Department of Pathology, Faculty of Medicine, Balcali Hospital, Cukurova UniversityAdana, Turkey
| | - Derya U Altintas
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Balcali Hospital, Cukurova UniversityAdana, Turkey
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Safavi M, Parvaneh N. Chediak Higashi Syndrome with Hemophagocytic Lymphohistiocytosis. Fetal Pediatr Pathol 2023; 42:259-262. [PMID: 35608383 DOI: 10.1080/15513815.2022.2077489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Chediak-Higashi syndrome (CHS) is caused by dysfunction of lysosomal trafficking and presents with hypopigmentation, bleeding tendencies, neurological symptoms, and NK cell dysfunction. Hemophagocytic lymphohistiocytosis (HLH) can complicate CHS due to the abnormal function of NK cells. CASE PRESENTATION This 1.5-year-old light-skinned gray-haired girl microscopically had abnormal hair pigment clumps and lilac inclusions in the myeloid series, characteristic of CHS. She presented with HLH, requiring treatment with etoposide and dexamethasone followed by cyclosporine and dexamethasone. CONCLUSION CHS is one of the underlying primary causes of HLH.
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Affiliation(s)
- Moeinadin Safavi
- Pathology Department, Children Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Parvaneh
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran
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4
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Jiang F, Liu Z, Guo Z, Xiao J, Wu N, Fan S, Yue Y, Chen J, Sun Y. Second Allogeneic Hematopoietic Stem Cell Transplantation for Hemophagocytic Syndrome with Engraftment Failure. Indian J Hematol Blood Transfus 2022. [DOI: 10.1007/s12288-022-01603-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
AbstractThis study aims to assess the efficacy of second allogeneic hemopoietic stem cell transplantation (allo-HSCT) for treating hemophagocytic syndrome with first engraftment failure. Among a total of 35 patients who underwent allo-HSCT between June 2015 and July 2021 for HLH, 10 patients who underwent a second HSCT following graft rejection were retrospectively analyzed. Various factors, such as the treatment course and outcome, the remission status, donor selection, and the conditioning regimen of patients before second allo-HSCT, were scrutinized for transplant-related complications and transplant-related mortality, as well as transplant outcomes. All the subjects have achieved complete donor engraftment, in which the neutrophils and platelets engraftment occurred in a median time of 12 d (range 10–19 d) and 24 d (range 11–97 d), respectively. Among the selected subjects, 20% of patients are diseased due to transplant-related thrombotic microangiopathy. Further, 90% of patients are diagnosed with aGVHD, in which 3 of them with grade I aGVHD, one patient with grade II aGVHD, two patients with grade III GVHD, and three patients with localized chronic GVHD. Moreover, 70% of patients showed signs of combined viral infections. Despite the complex symptoms, the overall survival rate is around 80%, with transplant-related mortality and the incidence of post-transplant GVHD of 20% and 60%, respectively. Together, our findings indicated that the second allo-HSCT showed great potential in treating hemophagocytic syndrome with engraftment failure.
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Li XY, Zhu SM, Li XY, Dong RS, Zhang AA, Li SJ, Geng YL. Reactive Hemophagocytic Lymphohistiocytosis Secondary to Ovarian Adenocarcinoma: A Rare Case Report. J Inflamm Res 2022; 15:5121-5128. [PMID: 36097636 PMCID: PMC9464022 DOI: 10.2147/jir.s376756] [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] [Received: 06/07/2022] [Accepted: 08/09/2022] [Indexed: 11/23/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH), a syndrome of immune hyperactivation and abnormal regulation that causes life-threatening inflammation, is mainly characterized by fever, hepatosplenomegaly, cytopenia, and other symptoms. Reactive HLH (rHLH) is typically secondary to immune deregulation caused by underlying rheumatologic, infectious, or malignant conditions. Malignancy-associated HLH (M-HLH) continues to be a critical health problem worldwide. Most malignancies associated with HLH are hematologic tumors, and M-HLH in non-hematologic tumors very rarely occurs. Case Report A 34-year-old Chinese woman had a history of persistent fever, acute dizziness, and bicytopenia. She was found to have developed bilateral ovarian cancer. Additional tests showed splenomegaly, hemophagocytes in the bone marrow, low natural killer activity, and hyperferritinemia, which met the diagnostic criteria put forth in the Histiocyte Society HLH-2004. The patient was treated with correcting anemia, increased platelets, and glucocorticoid therapy but showed no response. She progressively deteriorated and died 55 days later. Conclusion Hemophagocytic lymphohistiocytosis related to a solid tumor is extremely rare. To the best of the authors’ knowledge, the present case was the first to report rHLH secondary to ovarian adenocarcinoma. It is very significant for a better understanding of the disease mechanisms of HLH and should attract the attention of hematologists and other clinicians as the condition progresses and the cost of treating it increases.
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Affiliation(s)
- Xiao-Yan Li
- Department of Laboratory Medicine, Shanxi Province Fenyang Hospital, Fenyang, 032200, People's Republic of China
| | - Shu-Min Zhu
- Department of Laboratory Medicine, The First Hospital of Hebei Medical University, Shijiazhuang, 050031, People's Republic of China
| | - Xin-Yuan Li
- Department of Laboratory Medicine, The First Hospital of Hebei Medical University, Shijiazhuang, 050031, People's Republic of China
| | - Rui-Sheng Dong
- Department of Imaging Medicine, Shanxi Province Fenyang Hospital, Fenyang, 032200, People's Republic of China
| | - Ai-Ai Zhang
- Department of Laboratory Medicine, Shanxi Province Fenyang Hospital, Fenyang, 032200, People's Republic of China
| | - Shu-Jing Li
- Department of Radiology, The First Hospital of Hebei Medical University, Shijiazhuang, 050031, People's Republic of China
| | - Yu-Lan Geng
- Department of Laboratory Medicine, The First Hospital of Hebei Medical University, Shijiazhuang, 050031, People's Republic of China
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Conditioning regimens for inborn errors of immunity: current perspectives and future strategies. Int J Hematol 2022; 116:7-15. [PMID: 35675025 DOI: 10.1007/s12185-022-03389-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/11/2022] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
Abstract
Inborn errors of immunity (IEI) are caused by germline genetic mutations, resulting in defects of innate or acquired immunity. Hematopoietic cell transplantation (HCT) is indicated for curative therapy especially in patients with IEI who develop fatal opportunistic infections or severe manifestations of immune dysregulation. The first successful HCT for severe combined immunodeficiency (SCID) was reported in 1968. Since then, the indications for HCT have expanded from SCID to various non-SCID IEI. In general, HCT for IEI differs from that for other hematological malignancies in that the goal is not to eradicate certain immune cells but to achieve immune reconstitution. European Society for Blood and Marrow Transplantation/European Society for Immunodeficiencies guidelines recommend reduced-intensity conditioning to avoid treatment-related toxicity, and the optimal conditioning regimen should be considered for each IEI. We review conditioning regimens for some representative IEI disorders in Japanese and worldwide cohort studies, and future strategies for treating IEI.
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Masood A, Wahab A, Iqbal Q, Davis J, Ehsan H, Hashmi H. Efficacy and safety of allogeneic hematopoietic stem cell transplant in adults with hemophagocytic lymphohistiocytosis: a systematic review of literature. Bone Marrow Transplant 2022; 57:866-873. [PMID: 35411107 DOI: 10.1038/s41409-022-01668-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 11/09/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare but life-threatening disorder of the immune system. While familial HLH is usually seen in children, secondary HLH is more common in adults. Secondary HLH is associated with a wide variety of underlying conditions including infections, malignancy and autoimmune disorders. While HLH 94/04 protocol-based chemotherapy can be used for initial treatment, allogeneic hematopoietic stem cell transplant (allo-HSCT) remains the only potentially curative treatment modality for this disorder. In this systematic review, we analyzed available literature on the role of allo-HSCT in adolescent and adult patients using PubMed, Cochrane, Embase and ClinicalTrials.gov. A total of 11 retrospective studies evaluated the role of allo-HSCT for HLH. Allo-HSCT, when compared to non-HSCT approach, appears to be associated with reasonable efficacy and acceptable safety for adolescent and adult patients with HLH.
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Affiliation(s)
- Adeel Masood
- Internal Medicine - Tidal Health Peninsula Regional, 100 East Carroll Street, Salisbury, MD, 21801, USA.
| | - Ahsan Wahab
- Internal Medicine - Baptist Medical Center South/The University of Alabama at Birmingham, Montgomery, AL, 36116, USA
| | - Qamar Iqbal
- Internal Medicine - Tidal Health Peninsula Regional, 100 East Carroll Street, Salisbury, MD, 21801, USA
| | - James Davis
- Hematology/Oncology - Medical University of South Carolina, 171 Ashley Ave, Charleston, SC, 29425, USA
| | - Hamid Ehsan
- Hematology/Oncology Fellow - Levine Cancer Institute/Atrium Health, 1021 Morehead Medical Dr, Charlotte, NC, 28204, USA
| | - Hamza Hashmi
- Hematology/Oncology -Medical University of South Carolina. 171 Ashley Ave, Charleston, SC, 29425, USA
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8
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Posas-Mendoza TF, McLeod C, Davis W, Zakem J, Quinet R. Etiologies and management of haemophagocytic lymphohistiocytosis: is it time for an updated protocol and targeted treatments? Rheumatology (Oxford) 2021; 60:2927-2933. [PMID: 33313881 DOI: 10.1093/rheumatology/keaa741] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/07/2020] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE The objective of this study was to analyse the features, therapeutic approaches, and outcomes for adult patients with haemophagocytic lymphohistiocytosis (HLH) at a single centre. METHODS This study was a retrospective chart review of all patients >18 years of age diagnosed with HLH according to HLH-2004 or H-score criteria at Ochsner Medical Center-New Orleans between 2013 and 2019. RESULTS A total of 29 patients with HLH met inclusion criteria. A total of 7 patients had an underlying malignancy, 12 had an autoimmune disease, 2 were transplant patients, and 2 had a combination of malignancy, autoimmune disease, or immunodeficiency. A total of 6 patients developed HLH precipitated by infection alone. All 29 patients presented with fever. A total of 28 (97%) patients met H-score criteria, and only 20 (67%) met HLH-2004 criteria. Fifteen patients were treated with the HLH-2004 protocol. Of those treated with the HLH-2004 protocol, 73% (11/15) died, 8% (1/15) had recurrence of HLH, and 20% (3/15) had resolution of HLH. A total of 14 patients were treated with targeted therapy. Of those treated with targeted therapy, 93% (13/14) had resolution of HLH and 1 died. Targeted therapy included pulse steroids, tocilizumab, anakinra, IVIG, CSA, rituximab, and/or CYC in addition to antiviral or antibiotic therapy. CONCLUSION Our findings suggested that the rheumatologic patient population responded well to a targeted therapeutic approach and poorly to the HLH-2004 protocol. Whether the poor outcomes found with the use of the HLH-2004 protocol are secondary to the protocol itself or the aggressive nature of malignancy-associated HLH is unclear. Further studies are needed to develop tailored therapeutic regimens.
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Affiliation(s)
| | - Cara McLeod
- Department of Rheumatology, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - William Davis
- Department of Rheumatology, Ochsner Clinic Foundation, New Orleans, LA, USA.,The University of Queensland, Faculty of Medicine, Ochsner Clinical School, New Orleans, LA, USA
| | - Jerald Zakem
- Department of Rheumatology, Ochsner Clinic Foundation, New Orleans, LA, USA.,The University of Queensland, Faculty of Medicine, Ochsner Clinical School, New Orleans, LA, USA
| | - Robert Quinet
- Department of Rheumatology, Ochsner Clinic Foundation, New Orleans, LA, USA.,The University of Queensland, Faculty of Medicine, Ochsner Clinical School, New Orleans, LA, USA
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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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10
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Nixon A, Roddick E, Moore K, Wild D. A qualitative investigation into the impact of hemophagocytic lymphohistiocytosis on children and their caregivers. Orphanet J Rare Dis 2021; 16:205. [PMID: 33957935 PMCID: PMC8101208 DOI: 10.1186/s13023-021-01832-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/20/2021] [Indexed: 11/30/2022] Open
Abstract
Background Primary hemophagocytic lymphohistiocytosis (pHLH) is a rare and life-threatening disorder, which usually occurs during infancy or early childhood and is characterized by abnormal activation of the immune system. However, the burden of pHLH on children and their families has not been previously evaluated. This qualitative study investigated the impact of pHLH and its treatment on the physical, emotional, and social well-being of patients and caregivers in the USA and UK using interviews to provide a comprehensive insight from the perspective of the caregivers and young survivors. Results Twenty-one caregivers were enrolled (median [range] age, 41.1 [26–58] years) and represented 20 patients, four from the UK and 16 from the USA. At enrollment, 17 of the 20 patients were alive with a median [range] age of 12.75 [5–31] years at a mean [range] of 7.8 [0.6–11.6] years after diagnosis. In addition, four adult survivors (median [range] age, 23.3 [21–30] years) were also enrolled (total participants n = 25). From noticing initial symptoms to receiving a diagnosis, caregivers reported a mean (range) of 25.9 (0–258) months. pHLH and its treatment had a substantial and long-lasting impact on patients and caregivers, affecting their physical, emotional and social well-being, family relationships, friendships, and ability to work and study. Many of the experiences reported were negative, even after curative treatment, and some participants experienced long-lasting physical and emotional issues. The most noticeable impact of pHLH for patients was on their physical well-being, whereas for caregivers it was emotional well-being. Across all participants there was a sense of isolation due to the illness and its treatment, particularly regarding the patient being immunocompromised and the fear of infection. Areas having a major impact and considered in need of improvement included: delays in diagnosis, lack of patient-specific information on pHLH and a lack of support and understanding about the condition. Conclusions pHLH placed a substantial burden on patients and caregivers, which for some were long-lasting. This was compounded by the lack of awareness and understanding of pHLH by healthcare professionals, and a lack of accessible information for those affected by pHLH. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-01832-2.
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Affiliation(s)
- Annabel Nixon
- Chilli Consultancy, The Old Fire Station, 2 Salt Lane, Salisbury, SP1 1JS, UK.
| | - Elina Roddick
- Chilli Consultancy, The Old Fire Station, 2 Salt Lane, Salisbury, SP1 1JS, UK
| | - Karen Moore
- Chilli Consultancy, The Old Fire Station, 2 Salt Lane, Salisbury, SP1 1JS, UK
| | - Diane Wild
- Chilli Consultancy, The Old Fire Station, 2 Salt Lane, Salisbury, SP1 1JS, UK
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11
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Zając-Spychała O, Zaucha-Prażmo A, Zawitkowska J, Wachowiak J, Kowalczyk JR, Frączkiewicz J, Salamonowicz M, Kałwak K, Gorczyńska E, Chybicka A, Czyżewski K, Dziedzic M, Wysocki M, Zalas-Więcek P, Goździk J, Styczyński J. Infectious complications after hematopoietic stem cell transplantation for primary immunodeficiency in children: A multicenter nationwide study. Pediatr Allergy Immunol 2020; 31:537-543. [PMID: 32150770 DOI: 10.1111/pai.13239] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/24/2020] [Accepted: 02/25/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of this nationwide study was to evaluate the characteristics of bacterial infections (BI), invasive fungal disease (IFD), and viral infections (VI) in pediatric patients with PID after allogeneic hematopoietic stem cell transplantation (allo-HSCT). PATIENTS AND METHODS In total, 114 HSCT recipients were enrolled into the study. At least one infectious complication (IC) was diagnosed in 60 (52.6%) patients aged 0.1-17.7 years, that is, 59.5% with SCID and 49.4% with non-SCID. RESULTS Among 60 HSCT recipients diagnosed with at least one IC, 188 episodes of infectious complications (EIC) were recorded, that is, 46.8% of BI, 41.5% of VI, and 11.7% of proven/probable IFD. According to PID and HSCT donor type, the incidence of EIC was comparable (P = .679). The localization of infections differed significantly due to PID type (P = .002). After each HSCT donor type, the most common site of infection was GI. Overall, BI caused by Gram-positive strains (59.1%) were prevalent, especially Staphylococcaceae. The multidrug-resistant (MDR) pathogens were diagnosed in 52.3%, especially ESBL + Enterobacteriaceae. The profile of VI was comparable for SCID and non-SCID patients (P = .839). The incidence of IFD was comparable for each PID and HSCT donor type. Survival after infection was 91.5% and was comparable for PID and HSCT donor type. CONCLUSIONS The rate of patients diagnosed with IC among pediatric PID-HSCT recipients did not depend on PID type, but rather on HSCT donor type. The localization of IC depended on PID and HSCT donor type. Within bacterial infections, predominated Gram-positive strains and the MDR pathogens were responsible for more than half of EIC.
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Affiliation(s)
- Olga Zając-Spychała
- Department of Pediatric Oncology, Hematology and Transplantology, University of Medical Sciences, Poznan, Poland
| | - Agnieszka Zaucha-Prażmo
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, Medical University, Lublin, Poland
| | - Joanna Zawitkowska
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, Medical University, Lublin, Poland
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, University of Medical Sciences, Poznan, Poland
| | - Jerzy R Kowalczyk
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, Medical University, Lublin, Poland
| | - Jowita Frączkiewicz
- Department of Pediatric Stem Cell Transplantation, Hematology and Oncology, Medical University, Wroclaw, Poland
| | - Malgorzata Salamonowicz
- Department of Pediatric Stem Cell Transplantation, Hematology and Oncology, Medical University, Wroclaw, Poland
| | - Krzysztof Kałwak
- Department of Pediatric Stem Cell Transplantation, Hematology and Oncology, Medical University, Wroclaw, Poland
| | - Ewa Gorczyńska
- Department of Pediatric Stem Cell Transplantation, Hematology and Oncology, Medical University, Wroclaw, Poland
| | - Alicja Chybicka
- Department of Pediatric Stem Cell Transplantation, Hematology and Oncology, Medical University, Wroclaw, Poland
| | - Krzysztof Czyżewski
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Magdalena Dziedzic
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Mariusz Wysocki
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Patrycja Zalas-Więcek
- Department of Microbiology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | - Jolanta Goździk
- Stem Cell Transplant Center, Department of Clinical Immunology and Transplantology, Jagiellonian University Collegium Medicum, University Children's Hospital, Krakow, Poland
| | - Jan Styczyński
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
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12
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Yoon HS. A Recent Update on Histiocytic Disorder in Children: Focus on Diagnosis and Treatment. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2020. [DOI: 10.15264/cpho.2020.27.1.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Hoi Soo Yoon
- Department of Pediatrics, Kyung Hee University College of Medicine, Seoul, Korea
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13
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Han SP, Lin YF, Weng HY, Tsai SF, Fu LS. A Novel BTK Gene Mutation in a Child With Atypical X-Linked Agammaglobulinemia and Recurrent Hemophagocytosis: A Case Report. Front Immunol 2019; 10:1953. [PMID: 31481959 PMCID: PMC6711359 DOI: 10.3389/fimmu.2019.01953] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 08/02/2019] [Indexed: 01/08/2023] Open
Abstract
X-linked agammaglobulinemia (XLA), caused by a mutation in the Bruton's tyrosine kinase (BTK) gene, is rarely reported in patients with recurrent hemophagocytic lymphohistiocytosis (HLH). This mutation leads to significantly reduced numbers of circulatory B cells and serum immunoglobulins in patients. Therefore, they exhibit repetitive bacterial infections since infancy, and immunoglobulin (Ig) replacement therapy is the primary treatment. HLH is a life-threatening condition with manifestations of non-remitting fever, hepatosplenomegaly, cytopenias, coagulopathy, lipid disorder, and multiple organ failure. It is caused by the immune dysregulation between cytotoxic T cells, NK cells, and histiocytes. The treatment is based on HLH-2004 protocol including immunotherapy, chemotherapy, supportive therapy, and stem cell transplantation. However, as we know more about the classification and pathophysiology of HLH, the treatment is modified. T-cell-directed immunotherapy is effective in patients with primary HLH, and strong immunosuppression is contraindicated in patients with severe ongoing infections or some primary immunodeficiency diseases (PIDs). Here, we report the case of a 7-year-old boy who presented with ecthyma gangrenosum and several episodes of pyogenic infections during childhood. At the age of 5 years, he exhibited cyclic HLH every 2–3 months. The remission of HLH episodes finally achieved after he received monthly Ig replacement therapy (400 mg/kg) at the 4th HLH. However, transient elevation of IgM was incidentally discovered after 6 cycles of monthly Ig replacement therapy. IgM-secreting multiple myeloma, Waldenström's macroglobulinemia, and lymphoma were excluded. The IgM levels then declined and returned to the normal range within a year. The patient and his parents received whole-genome sequencing analysis. It revealed a novel hemizygous c.1632-1G>A mutation in the BTK gene and XLA was diagnosed. XLA exhibits a spectrum of clinical and immunological presentations in patients. The identification of the mutation in the BTK gene contribute to an accurate diagnosis. Ig replacement therapy is the primary treatment for HLH in patients with XLA.
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Affiliation(s)
- Shu-Ping Han
- Department of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yung-Feng Lin
- Institute of Molecular and Genomic Medicine, National Health Research Institutes, Zhunan, Taiwan
| | - Hui-Ying Weng
- Cancer Progression Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Feng Tsai
- Institute of Molecular and Genomic Medicine, National Health Research Institutes, Zhunan, Taiwan.,Institute of Genetics, National Yang-Ming University, Taipei, Taiwan
| | - Lin-Shien Fu
- Department of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Pediatrics, National Yang-Ming University, Taipei, Taiwan
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14
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Hall E, Shenoy S. Hematopoietic Stem Cell Transplantation: A Neonatal Perspective. Neoreviews 2019; 20:e336-e345. [PMID: 31261097 DOI: 10.1542/neo.20-6-e336] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is indicated in various nonmalignant disorders that arise from genetic, hematopoietic, and immune system defects. Many of the disorders described here have life-threatening consequences in the absence of HSCT, a curative intervention. However, timing and approach to HSCT vary by disorder and optimum results are achieved by performing transplantation before irreversible disease-related morbidity or infectious complications. This article details the principles of HSCT in the very young, lists indications, and explores the factors that contribute to successful outcomes based on transplantation and disease-related nuances. It provides an overview into the HSCT realm from a neonatologist's perspective, describes the current status of transplantation for relevant disorders of infancy, and provides a glimpse into future efforts at improving on current success.
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Affiliation(s)
- Erin Hall
- Department of Pediatrics, Division of Hematology/Oncology/Bone Marrow Transplantation, Children's Mercy Hospital, Kansas City, MO
| | - Shalini Shenoy
- Department of Pediatrics, Division of Hematology/Oncology/Bone Marrow Transplantation, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, MO
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15
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Jia C, Wang B, Zhu G, Zhang R, Wang K, Yan Y, Qin M. Haploidentical hematopoietic stem cell transplantation using reduced-intensity conditioning for pediatric patients with familial hemophagocytic lymphohistiocytosis. Pediatr Investig 2018; 2:216-221. [PMID: 32851268 PMCID: PMC7331449 DOI: 10.1002/ped4.12096] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 12/12/2018] [Indexed: 11/12/2022] Open
Abstract
IMPORTANCE Allogeneic hematopoietic stem cell transplantation (HSCT) is considered to be the only curative treatment for familial hemophagocytic lymphohistiocytosis (FHLH). Treatment of pediatric FHLH with reduced-intensity conditioning (RIC)-based haploidentical donor (HID) HSCT has been rarely reported. OBJECTIVE To investigate outcomes and adverse events in patients with FHLH who received HID-HSCT. METHODS We conducted a retrospective study of five patients, including three with mutations in PRF1 and two with XIAP deficiency. Four of the five donors were heterozygous for these mutations. The conditioning regimen included fludarabine, cyclophosphamide, and antithymocyte globulin, with or without low-dose irradiation. Unmanipulated mobilized bone marrow and peripheral blood stem cells were used as the grafts. RESULTS All five patients were successfully engrafted. Four patients survived, and one patient died. All exhibited complete response (CR) after HSCT. All of the patients who survived exhibited CR to FHLH without severe regimen-related complications at a median of 29.5 months (range: 23-34 months) after HSCT. Four of the five patients had mixed donor chimerism. Three patients had 17% to 87% mixed donor chimerism but remained free of disease. Four patients received donor lymphocyte infusion (DLI), which improved the level of mixed donor chimerism. One patient experienced a decrease in donor chimerism to 1% and relapsed; Four patients developed acute graft-versus-host disease (GvHD) (grade I or II), and one patient developed grade IV GvHD. INTERPRETATION HID-HSCT with RIC can be considered for treatment for patients with FHLH, but the conditions and DLI regimens need to be optimized for long-term use, and more prospective studies should be conducted.
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Affiliation(s)
- Chenguang Jia
- Beijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics, Ministry of Education; Key Laboratory of Major Diseases in Children, Ministry of EducationHematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Bin Wang
- Beijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics, Ministry of Education; Key Laboratory of Major Diseases in Children, Ministry of EducationHematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Guanghua Zhu
- Beijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics, Ministry of Education; Key Laboratory of Major Diseases in Children, Ministry of EducationHematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Rui Zhang
- Beijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics, Ministry of Education; Key Laboratory of Major Diseases in Children, Ministry of EducationHematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Kai Wang
- Beijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics, Ministry of Education; Key Laboratory of Major Diseases in Children, Ministry of EducationHematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Yan Yan
- Beijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics, Ministry of Education; Key Laboratory of Major Diseases in Children, Ministry of EducationHematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Maoquan Qin
- Beijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics, Ministry of Education; Key Laboratory of Major Diseases in Children, Ministry of EducationHematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
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16
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Furtado-Silva JM, Paviglianiti A, Ruggeri A, Boelens JJ, Veys P, Ahmari AA, Zecca M, Locatelli F, Michel G, Volt F, Kenzey C, Sedlacek P, Rao K, Lankester A, Gluckman E, Rocha V. Risk factors affecting outcome of unrelated cord blood transplantation for children with familial haemophagocytic lymphohistiocytosis. Br J Haematol 2018; 184:397-404. [PMID: 30460979 DOI: 10.1111/bjh.15642] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 08/24/2018] [Indexed: 11/27/2022]
Abstract
Allogeneic haematopoietic stem cell transplantation is still the only available curative option for Familial Haemophagocytic Lymphohistiocytosis (FHLH). Most studies report outcomes after bone marrow or peripheral blood stem cell transplantation. We analysed the outcomes of 118 children with FHLH undergoing single-unit umbilical cord blood transplantation performed from 1996 to 2014. Myeloablative conditioning regimen was given to 90% of the patients, and was mostly busulfan-based (n = 81, 76%), including anti-thymocyte globulin or alemtuzumab (n = 102, 86%). The cumulative incidence of Day 60 neutrophil engraftment was 85%; and that of non-relapse mortality and acute graft-versus-host disease (GvHD) was 21% and 33% at 100 days, respectively. The 6-year cumulative incidence of chronic GvHD was 17% and the 6-year probability of overall survival was 55%. In multivariate analysis, children receiving a graft with a total nucleated cell dose greater than 9·9 × 107 /kg had a better overall survival (hazard ratio [HR]: 0·49, 95% CI: 0·27-0·88, P = 0·02). Degree of human leucocyte antigen (HLA) matching was associated with improved disease-free survival (5/6 vs. 6/6 HR: 2·11, 95% confidence interval [CI]: 1·01-4·4, P = 0·05 and ≤4/6 vs. 6/6, HR: 2·82, CI: 1·27-6·23, P = 0·01). Umbilical cord blood transplantation with a high cell dose and good HLA match is a suitable alternative option to haematopoietic stem cell transplantation in children with FHLH who lack a HLA-matched donor.
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Affiliation(s)
| | - Annalisa Paviglianiti
- Eurocord, Hôpital Saint Louis, Paris, France.,Monacord, Centre Scientifique de Monaco, Monaco, Monaco
| | - Annalisa Ruggeri
- Eurocord, Hôpital Saint Louis, Paris, France.,Monacord, Centre Scientifique de Monaco, Monaco, Monaco.,Department of Paediatric Haematology and Oncology, Instituto di Ricovero e Cura a Carattere Scientifico (IRCCS) "Bambino Gesù" Children's Hospital, Rome, Italy.,Department of Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Jaap Jan Boelens
- Paediatric Blood and Marrow Transplantation Programme, Paediatric Blood and Marrow Transplantation Programme University Hospital Utrecht, Utrecht, The Netherlands
| | - Paul Veys
- Bone Marrow Transplant Department, Great Ormond Street Hospital NHS Trust, London, UK
| | - Ali Abdallah Ahmari
- Department of Paediatric Haematology and Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Marco Zecca
- Paediatric Haematology Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Franco Locatelli
- Department of Paediatric Haematology and Oncology, Instituto di Ricovero e Cura a Carattere Scientifico (IRCCS) "Bambino Gesù" Children's Hospital, Rome, Italy.,Department of Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Gerard Michel
- Department of Paediatric Haematology and Oncology, Hopital d'Enfants de la Timone, CHU, Marseille, France
| | - Fernanda Volt
- Eurocord, Hôpital Saint Louis, Paris, France.,Monacord, Centre Scientifique de Monaco, Monaco, Monaco
| | - Chantal Kenzey
- Eurocord, Hôpital Saint Louis, Paris, France.,Monacord, Centre Scientifique de Monaco, Monaco, Monaco
| | - Petr Sedlacek
- Department of Paediatric Haematology and Oncology, University Hospital Motol, Prague, Czech Republic
| | - Kanchan Rao
- Bone Marrow Transplant Department, Great Ormond Street Hospital NHS Trust, London, UK
| | - Arjan Lankester
- Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Eliane Gluckman
- Eurocord, Hôpital Saint Louis, Paris, France.,Monacord, Centre Scientifique de Monaco, Monaco, Monaco
| | - Vanderson Rocha
- Eurocord, Hôpital Saint Louis, Paris, France.,Monacord, Centre Scientifique de Monaco, Monaco, Monaco.,Haematology, Transfusion and Cell therapy service, Universidade de São Paulo, São Paulo, Brazil.,Haematology Unit, Churchill Hospital, University of Oxford, Oxford, UK
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17
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Haplo-identical Hematopoietic Stem Cell Transplant is a Possible Cure in a Patient with Relapsed Hemophagocytic Lymphohistiocytosis Syndrome. Indian J Hematol Blood Transfus 2018; 34:760-761. [PMID: 30369760 DOI: 10.1007/s12288-018-0948-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 03/08/2018] [Indexed: 10/17/2022] Open
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18
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Chang Y, Cui M, Fu X, Han L, Zhang L, Li L, Li X, Sun Z, Wu J, Zhang X, Li Z, Nan F, Yan J, Sheng G, Zhang M. Lymphoma associated hemophagocytic syndrome: A single-center retrospective study. Oncol Lett 2018; 16:1275-1284. [PMID: 30061947 DOI: 10.3892/ol.2018.8783] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 04/03/2018] [Indexed: 12/20/2022] Open
Abstract
To improve the understanding of lymphoma associated hemophagocytic syndrome (LAHS) and find an effective treatment for this fatal disease, 57 patients with LAHS were retrospectively reviewed. The most common histopathological type was extranodal natural killer (NK)/T-cell lymphoma, nasal type (ENKL) (45.61%). Patients with B-cell LAHS were significantly older (P<0.001), and exhibited a higher triglyceride level (P=0.012), lower serum ferritin level (P=0.014) and lower plasma Epstein-Barr virus DNA (P<0.001) compared with patients with T/NK-cell LAHS. The median survival time of all patients was 43 days, and patients with B-cell (n=14) and T/NK-cell (n=43) LAHS had a median survival time of 55 and 40 days, respectively (P=0.797). Compared with patients who were treated based on HLH-2004 protocols combined with multidrug chemotherapy, those without chemotherapy had a reduced prognosis (P=0.002). The patients that underwent hematopoietic stem cell transplantation (HSCT) following chemotherapy had a significantly improved overall survival (OS) compared with patients that did not undergo HSCT (P=0.001). Patients with B-cell LAHS treated with rituximab (P=0.015) and patients with ENKL treated with L-asparaginase/pegaspargase (L-asp/peg) (P=0.009) had an improved prognosis compared with patients not treated with these drugs. In the T/NK-cell LAHS group, patients treated with chemotherapy containing gemcitabine did not exhibit an improved OS compared with those not treated with gemcitabine (P=0.326). Furthermore, multivariate analysis demonstrated that long diagnosis time and poor performance status were independent prognosis factors for all patients with LAHS. The present study indicated that survival time does not differ between patients with B-cell LAHS and patients with T/NK-cell LAHS. Early diagnosis and appropriate immunochemotherapy plus HSCT are essential to achieve improved outcomes. The outcome of patients with B-cell LAHS may be significantly improved following treatment with rituximab. L-asp/peg-containing regimens are promising treatments for patients with NK/T-cell LAHS.
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Affiliation(s)
- Yu Chang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Meng Cui
- Department of Head and Neck and Thyroid, Henan Cancer Hospital Affiliated to Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Xiaorui Fu
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Lijuan Han
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Lei Zhang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Ling Li
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Xin Li
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Zhenchang Sun
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Jingjing Wu
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Xudong Zhang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Zhaoming Li
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Feifei Nan
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Jiaqin Yan
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Guangyao Sheng
- Department of Pediatrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Mingzhi Zhang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
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19
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Durable Chimerism and Long-Term Survival after Unrelated Umbilical Cord Blood Transplantation for Pediatric Hemophagocytic Lymphohistiocytosis: A Single-Center Experience. Biol Blood Marrow Transplant 2017. [PMID: 28647558 DOI: 10.1016/j.bbmt.2017.06.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disorder of immune dysregulation characterized by fever, hepatosplenomegaly, cytopenias, central nervous system disease, increased inflammatory markers, and hemophagocytosis. Currently, allogeneic hematopoietic stem cell transplantation is the only curative approach for patients with HLH, with reported survival ranging from 50% to 70% with myeloablative conditioning (MAC) regimens. However, donor availability and transplantation-related mortality associated with conventional MAC are major barriers to success. Unrelated umbilical cord blood transplantation (UCBT) provides a readily available alternative donor source for patients lacking matched related donors. Accordingly, we report the results of UCBT in 14 children treated between 1998 and 2016. All children received standard HLH chemotherapy before UCBT. The median age at diagnosis was 2.7 months (range, .8 to 10.4) and at transplantation was 7.5 months (range, 3.8 to 17). Ten patients received MAC with busulfan/cyclophosphamide/etoposide /antithymocyte globulin (ATG) (n = 5), busulfan/cyclophosphamide /ATG (n = 4), or busulfan /melphalan/ATG (n = 1). Four patients received reduced-toxicity conditioning (RTC) with alemtuzumab/fludarabine/melphalan/hydroxyurea ± thiotepa. Cord blood units were mismatched at either 1 (n = 9) or 2 (n = 5) loci and delivered a median total nucleated cell dose of 11.9 × 107/kg (range, 4.6 to 27.9) and CD34+ dose of 3.1 × 105/kg (range, 1.1 to 6.8). The cumulative incidence of neutrophil engraftment by day 42 was 78.6% (95% confidence interval [CI], 42.9% to 93.4%) with a median of 19 days (range, 13 to 27), and that for platelet (50,000) engraftment by day 100 was 64.3% (95% CI, 28.2% to 85.7%) with a median of 51 days (range, 31 to 94). Six patients developed either grade II (n = 5) or grade IV (n = 1) acute graft-versus-host disease (GVHD); no extensive chronic GVHD was seen. Ten patients (71.4%) are alive and well at a median of 11.2 years after transplantation (range, .85 to 18.25), 9 of whom maintain sustained full donor chimerism after a single UCBT, whereas 1 patient with autologous recovery after first UCBT with RTC has achieved full donor chimerism after a second UCBT with MAC. This series demonstrates that, in combination with standard HLH therapy, UCBT after MAC or RTC conditioning can provide long-term survival with durable complete donor chimerism comparable to that of conventional donors. UCBT should be considered for patients with HLH lacking a fully matched related or unrelated adult donor.
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20
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Affiliation(s)
- Sun Young Park
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu, Korea
| | - Jae Min Lee
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu, Korea
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21
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Similar but not the same: Differential diagnosis of HLH and sepsis. Crit Rev Oncol Hematol 2017; 114:1-12. [PMID: 28477737 DOI: 10.1016/j.critrevonc.2017.03.023] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 03/17/2017] [Accepted: 03/20/2017] [Indexed: 12/12/2022] Open
Abstract
Differential diagnosis of hemophagocytic lymphohistiocytosis (HLH; hemophagocytic syndrome) and sepsis is critically important because the life-saving aggressive immunosuppressive treatment, required in the effective HLH therapy, is absent in sepsis guidelines. Moreover, HLH may be complicated by sepsis. Hyperinflammation, present in both states, gives an overlapping clinical picture including fever and performance status deterioration. The aim of this review is to provide aid in this challenging diagnostic process. Analysis of clinical features and laboratory results in multiple groups of patients (both adult and pediatric) with either HLH or sepsis allows to propose criteria differentiating these two conditions. The diagnosis of HLH is supported by hyperferritinemia, splenomegaly, marked cytopenias, hypofibrinogenemia, low CRP, characteristic cytokine profile and, only in adults, hypertriglyceridemia. In the presence of these parameters (especially the most characteristic hyperferritinemia), the other HLH criteria should be assessed. Genetic analyses can reveal familial HLH. Hemophagocytosis is neither specific nor sensitive for HLH.
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22
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Weaver LK, Behrens EM. Weathering the storm: Improving therapeutic interventions for cytokine storm syndromes by targeting disease pathogenesis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017; 3:33-48. [PMID: 28944163 DOI: 10.1007/s40674-017-0059-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cytokine storm syndromes require rapid diagnosis and treatment to limit the morbidity and mortality caused by the hyperinflammatory state that characterizes these devastating conditions. Herein, we discuss the current knowledge that guides our therapeutic decision-making and personalization of treatment for patients with cytokine storm syndromes. Firstly, ICU-level supportive care is often required to stabilize patients with fulminant disease while additional diagnostic evaluations proceed to determine the underlying cause of cytokine storm. Pharmacologic interventions should be focused on removing the inciting trigger of inflammation and initiation of an individualized immunosuppressive regimen when immune activation is central to the underlying disease pathophysiology. Monitoring for a clinical response is required to ensure that changes in the therapeutic regimen can be made as clinically warranted. Escalation of immunosuppression may be required if patients respond poorly to the initial therapeutic interventions, while a slow wean of immunosuppression in patients who improve can limit medication-related toxicities. In certain scenarios, a decision must be made whether an individual patient requires hematopoietic cell transplantation to prevent recurrence of disease. Despite these interventions, significant morbidity and mortality remains for cytokine storm patients. Therefore, we use this review to propose a clinical schema to guide current and future attempts to design rational therapeutic interventions for patients suffering from these devastating conditions, which we believe speeds the diagnosis of disease, limits medication-related toxicities, and improves clinical outcomes by targeting the heterogeneous and dynamic mechanisms driving disease in each individual patient.
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Affiliation(s)
- Lehn K Weaver
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Edward M Behrens
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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23
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Kamoun F, Hsairi M, Grandin V, Ben Ameur S, De Saint Basile G, Hachicha M. Familial haemophagocytosis lymphohisticytosis type 3: A case report. Arch Pediatr 2016; 24:33-35. [PMID: 27914778 DOI: 10.1016/j.arcped.2016.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 06/24/2016] [Accepted: 10/26/2016] [Indexed: 11/16/2022]
Abstract
Familial hemophagocytic lymphohistiocytosis (FHL) is a rare autosomal recessive disorder of immune regulation. Here, we report on a fatal case of type 3 FHL (FHL3) in a 45-day-old boy. Clinically, the infant presented with fever and hepatosplenomegaly. Biology showed pancytopenia, elevated ferritin, and decreased fibrinogen. Images of hemophagocytosis were found at the bone morrow examination. The diagnosis of FHL type 3 was made by the identification of homozygous mutation in the Munc13-4 gene (UNC13D) located in exon 20: 1822 del 12bp (V608fs). This mutation was previously observed in a Tunisian and in Moroccan families.
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Affiliation(s)
- F Kamoun
- Pediatrics department, Hedi Chaker hospital, route El Ain Km 0,5, 3029 Sfax, Tunisia; Faculty of medicine of Sfax, route El Ain Km 0,5, 3029 Sfax, Tunisia.
| | - M Hsairi
- Pediatrics department, Hedi Chaker hospital, route El Ain Km 0,5, 3029 Sfax, Tunisia; Faculty of medicine of Sfax, route El Ain Km 0,5, 3029 Sfax, Tunisia
| | - V Grandin
- Centre d'études des déficits immunitaires, Assistance publique-Hôpitaux de Paris (AP-HP), hôpital Necker, 75015 Paris, France
| | - S Ben Ameur
- Pediatrics department, Hedi Chaker hospital, route El Ain Km 0,5, 3029 Sfax, Tunisia; Faculty of medicine of Sfax, route El Ain Km 0,5, 3029 Sfax, Tunisia
| | - G De Saint Basile
- Centre d'études des déficits immunitaires, Assistance publique-Hôpitaux de Paris (AP-HP), hôpital Necker, 75015 Paris, France; Inserm UMR1163, laboratory of normal and pathological homeostasis of the immune system, 75015 Paris, France; Paris Descartes university, Sorbonne Paris Cité, imagine institute, 75015 Paris, France
| | - M Hachicha
- Pediatrics department, Hedi Chaker hospital, route El Ain Km 0,5, 3029 Sfax, Tunisia; Faculty of medicine of Sfax, route El Ain Km 0,5, 3029 Sfax, Tunisia
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Ayala E, LaFave D, Nishihori T, Kharfan-Dabaja MA. Haploidentical transplantation as a promising therapy for relapsed hemophagocytic lymphohistiocytosis in an older adult patient. Hematol Oncol Stem Cell Ther 2016; 11:96-98. [PMID: 27352259 DOI: 10.1016/j.hemonc.2016.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 05/21/2016] [Indexed: 12/28/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare but severe and often overwhelming systemic hyper-inflammatory syndrome generally presenting with unexplained fevers, hepatosplenomegaly, and progressive multi-organ dysfunction. Treatment of HLH has two major goals: Halting the triggering event and controlling the overactive immune system. However, patients with primary or recurrent secondary HLH should subsequently undergo allogeneic HCT for long lasting disease remission. Hereby we present the case of a 69 years old man with recurrent HLH who underwent a reduced intensity conditioning of fludarabine, cyclophosphamide and low dose total body irradiation followed by a haploidentical marrow graft and post-transplantation cyclophosphamide (PTCy), tacrolimus and mycophenolate mofetil as GVHD prophylaxis. He achieved a durable remission of HLH symptoms despite persistent myeloid mixed chimerism. The use of haploidentical donors and PTCy as tolerance inducing regimen is feasible in HLH. The achievement of mixed donor chimerism may be enough to control the clinical manifestations and to cure HLH.
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Affiliation(s)
- Ernesto Ayala
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, FL, USA; Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
| | - Denise LaFave
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, FL, USA; Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Mohamed A Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, FL, USA; Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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