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Zhai C, Jin X, You L, Yan N, Dong J, Qiao S, Zhong Y, Zheng Y, Pan H. Hemophagocytic lymphohistiocytosis following pembrolizumab and bevacizumab combination therapy for cervical cancer: a case report and systematic review. BMC Geriatr 2024; 24:32. [PMID: 38191289 PMCID: PMC10773023 DOI: 10.1186/s12877-023-04625-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 12/18/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Programmed cell death protein 1 (PD-1) checkpoint inhibitors such as pembrolizumab are novel therapeutics used to treat various advanced malignancies. Immune-related adverse events are common, among the most serious of these toxicities is hemophagocytic lymphohistiocytosis (HLH), which is a life-threatening disorder of unbridled immune activation but has not been properly established. METHODS We have procured the first case of hemophagocytic lymphohistiocytosis as an aftermath of treatment with pembrolizumab from the Sir Run Run Shaw Hospital, Zhejiang University, China. In a pursuit to enhance the understanding of this condition, a comprehensive systematic review was performed encompassing all reported instances of ICI-associated Hemophagocytic lymphohistiocytosis within the realms of PubMed and Embase databases. RESULTS We detail the recovery of a cervical cancer patient with a history of psoriasis who developed HLH after combined pembrolizumab and bevacizumab treatment. Remarkably, tumor lesions exhibited substantial and sustained regression. From an analysis of 52 identified Immune Checkpoint Inhibitor (ICI)-related HLH cases, we discovered that HLH often occurred within the first two treatment cycles and approximately 20% of these patients had a history of autoimmune-related diseases. Despite a 15% mortality rate, the majority of patients experienced positive outcomes. Notably, in instances of recovery from HLH, 80% showed positive tumor outcomes. Even after discontinuation of ICI treatment, tumor control persisted in some cases. CONCLUSION We identified the first case of HLH caused by ICI treatment in cervical cancer and summarized the possible occurrence factors of these cases, the treatment outcomes of HLH, and the impact on tumor outcomes.
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Affiliation(s)
- Chongya Zhai
- Department of Medical Oncology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310000, Zhejiang Province, People's Republic of China
| | - Xuanhong Jin
- Department of Medical Oncology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310000, Zhejiang Province, People's Republic of China
| | - Liangkun You
- Department of Medical Oncology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310000, Zhejiang Province, People's Republic of China
| | - Na Yan
- Key Laboratory of Digital Technology in Medical Diagnostics of Zhejiang Province, Dian Diagnostics Group Co.,Ltd, Hangzhou, China
| | - Jie Dong
- Department of Medical Oncology, Shaoxing Campus, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Shaoxing, China
| | - Sai Qiao
- Key Laboratory of Precision Medicine in Diagnosis and Monitoring Research of Zhejiang Province, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yuhong Zhong
- Key Laboratory of Precision Medicine in Diagnosis and Monitoring Research of Zhejiang Province, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yu Zheng
- Department of Medical Oncology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310000, Zhejiang Province, People's Republic of China.
| | - Hongming Pan
- Department of Medical Oncology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310000, Zhejiang Province, People's Republic of China.
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Le Goubey JB, Sassier M, Nakouri I, De Pontville M, Césaire L, Aide N, Kottler D. Recurrent hemophagocytic lymphohistiocytosis in advanced melanoma treated with two different BRAF/MEK-inhibitor regimens. Melanoma Res 2023; 33:159-61. [PMID: 36815470 DOI: 10.1097/CMR.0000000000000872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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Tejedor I, Tedbirt B, Carvalho P, Duval-Modeste AB, Joly P, Hébert V. Successful use of rituximab for refractory hemophagocytic lymphohistiocytosis in a melanoma patient treated with targeted therapy. Melanoma Res 2022; 32:485-487. [PMID: 36125885 DOI: 10.1097/cmr.0000000000000845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease characterized by aberrant immune hyperactivation of T CD8 lymphocytes and macrophages driven by cytokine dysfunction. We report a 64-year-old man, with advanced BRAF-mutant melanoma treated by combined targeted therapies who had a recalcitrant and cortico-dependent Epstein-Barr virus (EBV)-induced HLH. One rituximab cycle led to a rapid and prolonged HLH remission which allowed to switch the targeted therapy for immunotherapy rituximab thus makes it possible to limit the use of corticosteroids, which limits the effectiveness of immunotherapy. The patient finally died of a cerebral tumoral progression 2 years later. Despite secondary hypogammaglobulinemia, we did not observe any severe infections during this period. This case suggests that rituximab can be a valuable option for EBV-induced HLH to avoid the T-suppressive effects of high-dose of corticosteroids in immunotherapy-treated patients.
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Affiliation(s)
- Ines Tejedor
- Department of Dermatology, Rouen University Hospital, Rouen, France
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Rubio-Perez J, Rodríguez-Perez ÁR, Díaz-Blázquez M, Moreno-García V, Dómine-Gómez M. Treatment-related hemophagocytic lymphohistiocytosis due to atezolizumab: a case report and review of the literature. J Med Case Rep 2022; 16:365. [PMID: 36195892 PMCID: PMC9531226 DOI: 10.1186/s13256-022-03585-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/21/2022] [Indexed: 11/15/2022] Open
Abstract
Background Immune checkpoint inhibitors avoid inhibition of T-cell responses, upregulating antitumor immune response. Moreover, a dysregulation with hyperactive immune response can be caused, some of them underdiagnosed. Hemophagocytic lymphohistiocytosis is a rare and often fatal syndrome of uncontrolled and ineffective hyperinflammatory response that triggers an inflammatory cascade that can lead in many cases to death. Case presentation We report the case of a 67-year-old Caucasian man with stage IV lung adenocarcinoma who developed hemophagocytic lymphohistiocytosis after initiation of atezolizumab, an antagonist of programmed death-ligand 1. Even with early diagnosis and proper treatment, death occurs in approximately half of all cases reported. Conclusion Key markers are needed to better identify patients at risk of developing severe immune-related adverse events. In addition to key markers, a higher degree of suspicion and early intervention are needed to improve outcomes in acquired hemophagocytic lymphohistiocytosis, especially with the increasingly and expanding use of immune activation.
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Affiliation(s)
- Jaime Rubio-Perez
- Medical Oncology Department, University Hospital Fundacion Jimenez Diaz, Instituto de investigación sanitaria FJD, Madrid, Spain.
| | - Ángel Ricardo Rodríguez-Perez
- Medical Oncology Department, University Hospital Fundacion Jimenez Diaz, Instituto de investigación sanitaria FJD, Madrid, Spain.
| | - María Díaz-Blázquez
- Anatomic Pathology Unit Department, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - Victor Moreno-García
- Medical Oncology Department, University Hospital Fundacion Jimenez Diaz, Instituto de investigación sanitaria FJD, Madrid, Spain.,START Madrid-FJD, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - Manuel Dómine-Gómez
- Medical Oncology Department, University Hospital Fundacion Jimenez Diaz, Instituto de investigación sanitaria FJD, Madrid, Spain
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5
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Masood A, Wahab A, Clifford T, Weaver EJ, Ehsan H, El Ayass W. Secondary hemophagocytic lymphohistiocytosis due to nivolumab/ipilimumab in a renal cell cancer patient-A case report. Clin Case Rep 2021; 9:e05184. [PMID: 34917381 PMCID: PMC8645178 DOI: 10.1002/ccr3.5184] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 11/06/2021] [Accepted: 11/14/2021] [Indexed: 12/24/2022] Open
Abstract
Secondary immune-related hemophagocytic lymphohistiocytosis is a rare but life-threatening complication of immune checkpoint inhibitors. HLH-2004 and HLH-1994 guidelines originally developed for primary HLH are the only available guidelines. It has proven to have a good prognosis if diagnosed promptly with discontinuation of immunotherapy and treated with corticosteroid monotherapy.
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Affiliation(s)
- Adeel Masood
- Masters of Public Health in Epidemiology at the University of Alabama at BirminghamAlabamaUSA
- Tidal Health Peninsula RegionalSalisburyMarylandUSA
| | - Ahsan Wahab
- Baptist Medical Center SouthUniversity of Alabama at BirminghamMontgomeryAlabamaUSA
| | | | | | - Hamid Ehsan
- Levine Cancer Institute/Atrium HealthCharlotteNorth CarolinaUSA
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Maloney NJ, Rana J, Yang JJ, Zaba LC, Kwong BY. Clinical features of drug-induced hypersensitivity syndrome to BRAF inhibitors with and without previous immune checkpoint inhibition: a review. Support Care Cancer 2021; 30:2839-2851. [PMID: 34546454 DOI: 10.1007/s00520-021-06543-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 09/04/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Cutaneous reactions to BRAF inhibitors are common, but severe reactions resembling or consistent with drug-induced hypersensitivity syndrome (DIHS)/drug reaction with eosinophilia and systemic symptoms (DRESS) are relatively rare. Several reports suggest that cutaneous reactions including DRESS/DIHS to BRAF inhibitors are more frequent and severe in the setting of previous immune checkpoint inhibition (ICI). METHODS To characterize existing literature on these reports, we queried the PubMed/MEDLINE database for cases of DIHS/DRESS to BRAF inhibitors. RESULTS We identified 23 cases of DIHS to BRAF inhibitors following checkpoint inhibition and 14 cases without prior checkpoint inhibitor therapy. In both cohorts, DIHS occurred relatively early, with median time to onset from drug exposure of 8-10 days. Patients who received prior ICI were less likely to have peripheral eosinophilia (26% vs 71%), atypical lymphocytes (9% vs 50%), renal involvement (61% vs 79%), hepatic involvement (52% vs 86%), and lymphadenopathy (9% vs 43%) compared to patients who did not receive prior ICI. Thrombocytopenia was more common with prior ICI (17% vs 7%). Only patients who received prior ICI experienced hypotension (26%) during the course of their DIHS. All cases of BRAF-induced DIHS generally improved on systemic steroids/supportive care, and no cases of death were identified. CONCLUSION Dermatologists should consider a diagnosis of DIHS following BRAF inhibitor initiation, particularly in the setting of past checkpoint inhibition, with atypical features including relatively rapid onset and steroid responsiveness, lack of peripheral eosinophilia, lymphocytosis, or lymphadenopathy, and increased risk of thrombocytopenia and hypotension.
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Affiliation(s)
- Nolan J Maloney
- Department of Dermatology, Stanford University Medical Center and Cancer Institute, 780 Welch Road, CJ220F, Palo Alto, CA, 94304-5779, USA
| | - Jasmine Rana
- Department of Dermatology, Stanford University Medical Center and Cancer Institute, 780 Welch Road, CJ220F, Palo Alto, CA, 94304-5779, USA
| | - Jason J Yang
- Division of Dermatology, Department of Medicine, David Geffen School of Medicine At UCLA, Los Angeles, CA, USA
| | - Lisa C Zaba
- Department of Dermatology, Stanford University Medical Center and Cancer Institute, 780 Welch Road, CJ220F, Palo Alto, CA, 94304-5779, USA
| | - Bernice Y Kwong
- Department of Dermatology, Stanford University Medical Center and Cancer Institute, 780 Welch Road, CJ220F, Palo Alto, CA, 94304-5779, USA.
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Samaran Q, Belakebi D, Theret S, Becquart O, Girard C, Du Thanh A, Guillot B, Lesage C, Dereure O. Hemophagocytic lymphohistiocytosis in advanced melanoma treated with dabrafenib and trametinib combination: two cases. Melanoma Res 2020; 30:519-23. [PMID: 32784332 DOI: 10.1097/CMR.0000000000000690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) has been only rarely reported in patients with BRAF-mutated advanced melanoma treated with targeted therapies and never with first-line dabrafenib/trametinib combination thus far. Two patients treated with first-line dabrafenib and trametinib combination therapy for metastatic melanoma presented with sudden occurrence of fever, cytopenia, rhabdomyolysis, hepatic cytolysis, hypertriglyceridemia and very high ferritin levels after few weeks of treatment, associated with concomitant epstein-barr virus (EBV) reactivation in one patient. In both cases, drug-induced HLH was primarily considered owing to a high H-score and the absence of other etiology. Patients rapidly improved after treatment discontinuation associated with oral steroids in one patient and did not relapse after subsequent treatment resumption with a concurrent anti-BRAF/anti-MEK combination. In metastatic melanoma HLH may occur either spontaneously in the absence of any treatment as a paraneoplastic condition, related to an intercurrent infection or drug-induced mainly with various immunotherapy or with dabrafenib and trametinib following immunotherapy. However, such observations are scarce and these are the first cases of HLH occurring during first-line treatment with dabrafenib and trametinib in advanced melanoma to our knowledge. Pathomechanisms remain to be elucidated since triggering factors may encompass the treatment itself but also other significant actors including viral reactivation along with the underlying disease. The liability of treatment should be considered in cases of HLH occurring in patients with advanced melanoma successfully treated with a combined targeted therapy. A rechallenge with a concurrent anti-BRAF/anti-MEK can be proposed in this setting.
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Ghous G, Shoukat HMH, Tarar ZI, Zafar MU, McGreevy JW. Encephalitis Associated With Hemophagocytic Lymphohistiocytosis Secondary to Immune Checkpoint Inhibitors: An Unfamiliar Spin-Off. Cureus 2021; 13:e16079. [PMID: 34345559 PMCID: PMC8324828 DOI: 10.7759/cureus.16079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2021] [Indexed: 11/09/2022] Open
Abstract
Checkpoint inhibitors (CPI) have become mainstream in standard therapy in various tumors, especially in malignant melanoma. Despite their widespread beneficial effects, these inhibitors are also notorious for immune-related adverse events (irAEs). Hemophagocytic lymphohistiocytosis (HLH) is an aggressive and life-threatening syndrome of excessive immune activation. We report a case of a 33-year-old male having a history of metastatic melanoma on immunotherapy (status post two cycles of ipilimumab/nivolumab) admitted for persistent fever and elevated liver enzymes. Additional work showed anemia, thrombocytopenia, hypertriglyceridemia, and hyperferritinemia which meet the diagnostic criteria of histiocyte society HLH-2004. The patient was effectively treated with oral prednisone. Moreover, further complications encompassed slurred speech, word-finding difficulties, ataxia, and lower extremity hyperreflexia concerning for autoimmune encephalitis. He was treated with high-dose IV methylprednisolone (1 gram/day for 3 days) with improvement in symptoms. Autoimmune encephalitis associated with HLH can be fatal - high-dose IV methylprednisolone should be considered, but this avenue still needs to be explored.
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Affiliation(s)
- Ghulam Ghous
- Internal Medicine, University of Missouri Columbia, Columbia, USA
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9
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Zhou YS, Cui YC, Yin MJ, Xie QW, Shen ZL, Shi HX, Ye YJ, Liang B. Gastric cancer complicated with hemophagocytic lymphohistiocytosis: case report and a brief review. J Gastrointest Oncol 2021; 12:892-899. [PMID: 34012677 DOI: 10.21037/jgo-20-432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) comprises a group of severe immune function disorders that can lead to immune-mediated organ damage. There are two subtypes of HLH: primary and secondary. Secondary HLH is associated with infectious, oncologic, chemotherapeutic, and other underlying causes, and studies on HLH triggered by tumors have mainly focused on hematological malignancies. Secondary HLH in patients with solid tumors is rare. Here, we present two cases of gastric cancer complicated with HLH. The patient 1 was diagnosed as gastric cancer at stage I and got intractable fever after a distal subtotal gastrectomy without any evidence of infections or other complications. The patient 2 suffered from unresectable gastric adenocarcinoma and got fever, hemorrhagic rashes, and petechiae in mouth after six cycles of neoadjuvant chemotherapy. After detailed and comprehensive examinations, HLH was diagnosed in the two patients according to 2004 HLH diagnostic criteria, and the patients received treatment including immunosuppressive agents immediately. After therapy, the two patients showed partial remission, but both eventually died due to HLH relapse or progression of the primary tumor. The treatment regimen for HLH is intricate, and only a few relevant studies have focused on the treatment of cancer patients with HLH. The high mortality associated with this disease calls for more attention and additional research to improve the prognosis for these patients.
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Affiliation(s)
- Yu-Shi Zhou
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, China
| | - Yan-Cheng Cui
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, China
| | - Mu-Jun Yin
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, China
| | - Qi-Wei Xie
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, China
| | - Zhan-Long Shen
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, China
| | - Hong-Xia Shi
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Ying-Jiang Ye
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, China
| | - Bin Liang
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, China
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Dudda M, Mann C, Heinz J, Schmidgen I, Weid F, Kühn M, Saloga J, Grabbe S, Loquai C. Hemophagocytic lymphohistiocytosis of a melanoma patient under BRAF/MEK-inhibitor therapy following anti-PD1 inhibitor treatment: a case report and review to the literature. Melanoma Res 2021; 31:81-84. [PMID: 33234845 DOI: 10.1097/cmr.0000000000000703] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare but life-threatening condition. HLH in infants and young children is usually inherited, which is then classified as primary HLH. Secondary HLH, in contrast, is caused by many different conditions such as infections, cancer or medication and affects mostly adults. HLH is a hyperinflammatory condition, which may mimic an acute septic shock. We report on a 68-year-old patient with malignant melanoma with lymph node metastases. Due to the lymphogenic progression, treatment was switched from nivolumab to dabrafenib and trametinib. Twenty-one days after initiation of BRAF/MEK inhibitor therapy, the patient presented to our emergency department with clinical signs of infection such as fever and fatigue. Laboratory tests showed excessive inflammation levels without identifying an underlying pathogen. Two days later, the patient developed an increasing pancytopenia. After extending the diagnosis, we found very high ferritin levels, hypertriglyceridemia, hypofibrinogenemia and a soluble CD25 receptor. Based on the laboratory results, prolonged fever and splenomegaly, we were able to diagnose HLH as the underlying condition. We immediately initiated treatment with intravenous prednisone, which remarkably improved the clinical symptoms. After full recovery, we reinitiated anti-tumor treatment with vemurafenib and cobimetinib, which was tolerated without side effects. Due to the relatively nonspecific nature of the clinical signs and symptoms and the significant overlap with other diseases such as sepsis, the diagnosis of HLH is often delayed. This explains, in part, the high morbidity and mortality rate. Our case shows that early treatment with steroids is effective. However, much work remains in order to raise awareness and improve the understanding of the pathophysiology of this condition.
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Affiliation(s)
| | | | | | | | | | - M Kühn
- Internal Medicine, University Medical Center Mainz, Germany
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Yang JJ, Lei DK, Ravi V, Maloney NJ, Crew A, Worswick S. Overlap between hemophagocytic lymphohistiocytosis and drug reaction and eosinophilia with systemic symptoms: a review. Int J Dermatol 2020; 60:925-932. [PMID: 32964443 DOI: 10.1111/ijd.15196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/21/2020] [Accepted: 08/26/2020] [Indexed: 12/17/2022]
Abstract
Drug reaction and eosinophilia with systemic symptoms (DRESS), also known as drug-induced hypersensitivity syndrome (DIHS), shares features with hemophagocytic lymphohistiocytosis (HLH), most notably fever, rash, and internal organ involvement. However, there is increasing recognition of drug-induced (secondary) HLH and biopsy-proven hemophagocytosis in DRESS, suggesting that HLH and DRESS not only overlap but also may be diseases on the same spectrum of immune dysfunction. To characterize existing literature on HLH/DRESS overlap, we queried the PubMed/MEDLINE database for 23 cases of HLH-DRESS codiagnosis. Average time-to-onset of rash after exposure to inciting drug was 2.7 weeks. Fourteen cases (61%) clinically worsened despite initial therapy, prompting a workup with diagnosis of HLH on average 2.3 weeks after diagnosing DRESS. Nine cases met HLH diagnostic criteria and had a RegiSCAR score ≥4. Nine cases met one set of criteria with a presentation suggestive of the other. Five cases met neither criteria. A patient presenting with fever, generalized rash, bicytopenia, and internal organ involvement after drug exposure was most predictive of meeting diagnostic criteria for both HLH and DRESS. Treatment was highly variable, although most initiated systemic corticosteroids with/without IVIG, plasmapheresis, or etoposide. Patients with poor outcomes in this review were treated using steroid monotherapy and had viral reactivation. Dermatologists should consider the possibility of HLH in any patient presenting with fever, rash, internal organ involvement, and cytopenia. Additional studies will be necessary to further characterize HLH and DRESS overlap and determine optimal management.
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Affiliation(s)
- Jason J Yang
- Division of Dermatology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Donald K Lei
- Department of Dermatology, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Vignesh Ravi
- Department of Dermatology, Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA
| | - Nolan J Maloney
- Division of Dermatology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ashley Crew
- Department of Dermatology, Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA
| | - Scott Worswick
- Department of Dermatology, Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA
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Noseda R, Bertoli R, Müller L, Ceschi A. Haemophagocytic lymphohistiocytosis in patients treated with immune checkpoint inhibitors: analysis of WHO global database of individual case safety reports. J Immunother Cancer 2019; 7:117. [PMID: 31046841 PMCID: PMC6498487 DOI: 10.1186/s40425-019-0598-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 04/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibitor (ICI) use in clinical practice has unravelled a spectrum of immune-related adverse events (irAEs) due to immune system hyper-activation. ICI-related haemophagocytic lymphohistiocytosis (HLH) has been recently outlined in single case reports, raising a concern about the need of increasing our knowledge on this rare yet life threatening ICI haematological toxicity. METHODS To determine ICI-related HLH clinical, haematological, and coagulation features, its timing and outcome, concurrent irAEs and concomitant infections, we performed a retrospective observational cross-sectional study and queried VigiBase, the WHO global database of suspected adverse drug reactions (ADRs), on September 30th, 2018. We retrieved the individual case safety reports reporting HLH in association with ipilimumab, nivolumab, pembrolizumab, atezolizumab, avelumab or durvalumab, gathered in the database starting from the ICIs' approval dates by the US Food and Drug Administration. The main outcome measures were co-suspected drugs, concurrent irAEs, HLH clinical, haematological and coagulation features, concomitant infections, HLH median time to onset and outcome. RESULTS Among 49'883 ICI-related ADRs collated in VigiBase as of September 30th, 2018, HLH was reported in 38 cases of which 34 (90%) mentioned ICIs as the solely suspected drugs. ICI-related HLH showed clinical, haematological and coagulation features similar to those of HLH with different etiology. Concurrent irAEs occurred in 5 (13%) patients and 6 (16%) reported concomitant viral infections. 31 (82%) cases defined ICI-related HLH outcome, which resolved in 19 (61%) cases. HLH developed a median of 6.7 weeks after initiation of ICI treatment (IQR 2.9-15.4, n = 18, 47%). CONCLUSIONS By evaluating the largest cohort of ICI-related HLH cases, we observed that ICI-related HLH arises with a delayed timing with respect to initiation of ICI treatment, and usually presents without other irAEs and concomitant infections. Keeping in mind these findings, clinicians should consider ICIs' involvement in the onset of HLH whenever they diagnose a disease of this group of syndromes in cancer patients treated with ICIs.
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Affiliation(s)
- Roberta Noseda
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Via Tesserete 46, 6903, Lugano, Switzerland.
| | - Raffaela Bertoli
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Via Tesserete 46, 6903, Lugano, Switzerland
| | - Laura Müller
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Via Tesserete 46, 6903, Lugano, Switzerland
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Via Tesserete 46, 6903, Lugano, Switzerland.,Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
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Saab KR, Mooradian M, Wang DY, Chon J, Xia CY, Bialczak A, Abbate KT, Menzies AM, Johnson DB, Sullivan RJ, Shoushtari AN. Tolerance and efficacy of BRAF plus MEK inhibition in patients with melanoma who previously have received programmed cell death protein 1-based therapy. Cancer 2019; 125:884-891. [PMID: 30521084 PMCID: PMC8074192 DOI: 10.1002/cncr.31889] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 10/19/2018] [Accepted: 11/06/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Combined BRAF and MEK inhibition (BRAF-MEK) is a standard therapy for patients with BRAF V600-mutant melanoma, but to the authors' knowledge, the tolerance, adverse event (AE) profile, and efficacy have not been well defined in the post-programmed cell death protein 1 (PD-1) setting. METHODS Patients with BRAF V600-mutant melanoma who received combined BRAF-MEK after prior PD-1-based therapy were assembled from 4 tertiary care centers in the United States and Australia. Dose modification was defined as a treatment break, dose reduction, or intermittent dosing. Rates of hospitalization and discontinuation due to AEs were collected, and overall survival (OS) was calculated using Kaplan-Meier methods from the time of the initiation of BRAF-MEK therapy. RESULTS A total of 78 patients were identified as having received a BRAF-MEK regimen at a median of 34 days after the last dose of PD-1-based therapy. The majority of patients (86%) received the combination of dabrafenib and trametinib. Approximately 80% of patients had American Joint Committee on Cancer M1c or M1d disease. Sixty-five regimens (83%) had ≥1 dose modification. The median time to the first dose modification was 14 days; 86% occurred within 90 days and 71% involved pyrexia. Dose modifications were more common in patients receiving BRAF-MEK <90 days after the last dose of PD-1 and who were not receiving steroids. Of the dose modifications, 25 (31%) led to an AE-related hospitalization. Among 55 BRAF-naive patients, the median time receiving BRAF-MEK therapy was 5.8 months and the median OS was 15.6 months. CONCLUSIONS The majority of patients receiving BRAF-MEK inhibition after PD-1 therapy require dose interruptions, and a significant minority require hospitalization for AEs. In this higher risk population, the median time receiving therapy and OS may be inferior to those presented in published phase 3 trials.
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Affiliation(s)
- Karim R. Saab
- Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Meghan Mooradian
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - Daniel Y. Wang
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeewon Chon
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cathy Y. Xia
- Melanoma Institute Australia, Sydney, New South Wales, Australia
| | | | | | - Alexander M. Menzies
- Melanoma Institute Australia, Sydney, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
| | | | - Ryan J. Sullivan
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - Alexander N. Shoushtari
- Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
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14
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Al-Samkari H, Snyder GD, Nikiforow S, Tolaney SM, Freedman RA, Losman JA. Haemophagocytic lymphohistiocytosis complicating pembrolizumab treatment for metastatic breast cancer in a patient with the PRF1A91V gene polymorphism. J Med Genet 2018; 56:39-42. [PMID: 30287596 DOI: 10.1136/jmedgenet-2018-105485] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 06/12/2018] [Accepted: 09/18/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Immune checkpoint inhibitor therapy is a modern breakthrough in medical oncology, but it can precipitate inflammatory and autoimmune adverse effects. Among the most serious of these toxicities is haemophagocytic lymphohistiocytosis (HLH), a life-threatening disorder of unbridled immune activation that results in injury to multiple organ systems. OBJECTIVE Description of a case of pembrolizumab-associated HLH in a patient with a proposed underlying genetic risk factor for its occurrence. METHODS AND RESULTS We describe a patient with aggressive metastatic breast cancer who developed HLH while undergoing experimental treatment with pembrolizumab, resulting in critical illness and multiorgan system failure. Pembrolizumab discontinuation and high-dose corticosteroids were effective in managing HLH. Subsequent next-generation sequencing of 15 genes associated with HLH revealed a germline polymorphism in perforin-1 (PRF1), PRFA91V, that may have predisposed the patient to develop HLH. The patient has had no evidence of malignancy for 2 years following recovery despite receiving no further cancer-directed treatment. CONCLUSIONS HLH is a rare but serious complication of immune checkpoint blockade. Patients with underlying hypomorphic alleles in PRF1 may be predisposed to develop this toxicity. Further studies are necessary to confirm a possible link between perforin gene mutations and immune checkpoint blockade-associated HLH.
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Affiliation(s)
- Hanny Al-Samkari
- Center for Hematology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory D Snyder
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah Nikiforow
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Sara M Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Julie-Aurore Losman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA.,Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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