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Blumer V, Parsons JB, Anderson DR, Bloomfield GS, Ward C. Hemophagocytic Lymphohistiocytosis Associated With Endocarditis: A Case Years in the Making. Circulation 2022; 145:934-939. [PMID: 35312382 DOI: 10.1161/circulationaha.121.057951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Vanessa Blumer
- Division of Cardiology, Department of Medicine (V.B., G.S.B., C.W.), Duke University Medical Center, Durham, NC.,Duke Clinical Research Institute, Durham, NC (V.B., G.S.B.)
| | - Joshua B Parsons
- Division of Infectious Diseases, Department of Medicine (J.B.P.), Duke University Medical Center, Durham, NC
| | - D Ryan Anderson
- Division of Rheumatology, Department of Medicine (D.R.A.), Duke University Medical Center, Durham, NC
| | - Gerald S Bloomfield
- Division of Cardiology, Department of Medicine (V.B., G.S.B., C.W.), Duke University Medical Center, Durham, NC.,Duke Clinical Research Institute, Durham, NC (V.B., G.S.B.)
| | - Cary Ward
- Division of Cardiology, Department of Medicine (V.B., G.S.B., C.W.), Duke University Medical Center, Durham, NC
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Burak N, Jan N, Kessler J, Oei E, Patel P, Feldman S. Diagnosis of GATA2 Deficiency in a Young Woman with Hemophagocytic Lymphohistiocytosis Triggered by Acute Systemic Cytomegalovirus Infection. Am J Case Rep 2021; 22:e927087. [PMID: 33684095 PMCID: PMC7959100 DOI: 10.12659/ajcr.927087] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 01/28/2021] [Accepted: 12/20/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease characterized by an intense immunologic response that results in multiorgan dysfunction. It typically manifests as a result of a familial genetic immunodeficiency disorder or secondary to a trigger such as an infection, malignancy, or autoimmune disease. The major factors involved in the development of the disease are an individual's genetic propensity to develop HLH, such as rare associated mutations, or inflammatory processes that trigger the immune system to go haywire. CASE REPORT Before the COVID-19 pandemic, a 22-year-old woman with a history of congenital absence of the right kidney, right-sided hearing loss, and leukopenia presented with a 3-week history of generalized malaise, fever, chest pain, cough, and shortness of breath. She developed an acute systemic cytomegalovirus infection further complicated by HLH. Based on her history and clinical course, an underlying primary immunodeficiency was suspected. An immunodeficiency gene panel revealed a monoallelic mutation in GATA2, a gene that encodes zinc-transcription factors responsible for the regulation of hematopoiesis. CONCLUSIONS GATA2 deficiency encompasses a large variety of mutations in the GATA2 gene and leads to disorders associated with hematologic and immunologic manifestations of monocytopenia and B-, and natural killer-cell deficiency. Over time, affected individuals are at high risk of developing life-threatening infections and serious hematologic complications, such as myelodysplastic syndromes and/or leukemias. We aimed to illustrate the importance of identifying an underlying genetic disorder associated with secondary HLH to help guide acute and long-term management.
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Affiliation(s)
- Nicole Burak
- Department of Internal Medicine, Morristown Medical Center, Morristown, NJ, U.S.A
| | - Naveed Jan
- Department of Hematology/Oncology, Morristown Medical Center, Morristown, NJ, U.S.A
| | - Jason Kessler
- Department of Infectious Diseases, Morristown Medical Center, Morristown, NJ, U.S.A
| | - Erwin Oei
- Department of Pulmonary Critical Care, Morristown Medical Center, Morristown, NJ, U.S.A
| | - Priya Patel
- Department of Allergy and Immunology, University of Pennsylvania School of Medicine, Philadelphia, PA, U.S.A
| | - Scott Feldman
- Department of Allergy and Immunology, University of Pennsylvania School of Medicine, Philadelphia, PA, U.S.A
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Hindi Z, Gad A, Jarvis C, Zahoor T, Spellman C, Filleur S. Effect of Serum Deprivation Stress on Signal Induction Regulatory Protein-Alpha (SIRP-Alpha)-Mediated Erythrophagocytosis by Macrophages. Med Sci Monit Basic Res 2019; 25:100-106. [PMID: 30894504 PMCID: PMC6441304 DOI: 10.12659/msmbr.912946] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 02/11/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare syndrome that involves loss of macrophages' self-cells recognition resulting in auto-phagocytosis of erythrocytes, leukocytes, and platelets and leading to multi-system effects. The pathogenesis of HLH is unclear but can be explained by malfunction of the physiologic inhibitory pathway through interaction between macrophage SIRP-alpha and erythrocyte CD 47. The goal of the present study was to evaluate if erythrocytes phagocytosis occurs as a result of altered macrophage SIRP-alpha expression during inflammatory/stressful conditions as seen in HLH. MATERIAL AND METHODS RAW264.7 macrophages were cultured in serum-free media (SFM) and complete media (CM) to simulate stressful and physiologic conditions, respectively. CD47+ mouse erythrocytes were used to test interactions with macrophages at different stages. SIRP-alpha expressions and phagocytosis assays were measured and analyzed at different steps. The study was in vitro and used murine cells to simulate in vivo human interactions. RESULTS SIRP-alpha expressions and phagocytosis rates were higher in SFM compared to CM. Interestingly, after adding SIRP-alpha blocking antibodies (Ab), phagocytosis rates significantly decreased. CONCLUSIONS Serum deprivation and LPS/INF-Gamma induction resulted in increased SIRP-alpha expression and erythrophagocytosis. Using SIRP-alpha Ab during this condition decreased the rate of erythrophagocytosis, which indicates that SIRP-alpha receptor can have pro-phagocytic activity.
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Affiliation(s)
- Zakaria Hindi
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Odessa, TX, U.S.A
| | - AbdAllah Gad
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Odessa, TX, U.S.A
| | - Courtney Jarvis
- Department of Urology, Texas Tech University Health Sciences Center, Lubbock, TX, U.S.A
| | - Talal Zahoor
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Odessa, TX, U.S.A
| | - Craig Spellman
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Odessa, TX, U.S.A
| | - Stephanie Filleur
- Department of Urology, Texas Tech University Health Sciences Center, Lubbock, TX, U.S.A
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Yamashita S, Furukawa NE, Matsunaga T, Hirakawa Y, Tago M, Yamashita SI. Extremely High Serum Ferritin: An Instrumental Marker of Masquerading Adult-Onset Still's Disease with Hemophagocytic Syndrome. Am J Case Rep 2017; 18:1296-1301. [PMID: 29208852 PMCID: PMC5726146 DOI: 10.12659/ajcr.905684] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 08/02/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Adult-onset Still's disease (AOSD) is a rare multi-systemic inflammatory disorder of unknown etiology characterized by spiking fever, characteristic rash, and arthritis. It often associates with high serum ferritin levels. CASE REPORT An 88-year-old woman had fever of over 39°C without response to extended-spectrum antibiotics for 6 days. She had non-specific erythema with infiltration on her trunk. She had leukocytosis with neutrophilia of 80%, mild hepatic dysfunction, normal level of rheumatoid factor and antinuclear antibody, thrombocytopenia, elevated d-dimer and soluble interleukin2 receptor, extremely high serum ferritin (78 662 ng/mL), and splenomegaly. Although she had no arthritis or specific erythema, we made the diagnosis of AOSD according to Yamaguchi's criteria with disseminated intravascular coagulation (DIC) and hemophagocytic syndrome (HPS) after ruling out infections, malignancies, or other connective tissue diseases. Twelve percent of AOSD patients have HPS. The mean serum ferritin of AOSD with HPS was reported at 18 179 ng/mL, which supported the diagnosis of AOSD because only a few other diseases could show such extremely high serum ferritin. Although she was treated with prednisolone (30 mg/day), her condition deteriorated and her left pleural effusion increased. Therefore, methylprednisolone 500 mg/day for 3 days was started followed by prednisolone 30 mg/day and immunosuppressive agent (Cyclosporine 50 mg/day), which improved her general condition, elevated C-reactive protein levels, and extremely high serum ferritin levels. CONCLUSIONS We report the case of an elderly patient with severe AOSD, who developed HPS and DIC, whose extremely high serum ferritin level was useful in diagnosis.
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Zhou XH, Luo JM, Bin Q, Huang XH. [Expression of porforin and granzyme B in familial hemophagocytic lymphohistiocytosis]. Zhonghua Xue Ye Xue Za Zhi 2016; 37:227-32. [PMID: 27033761 PMCID: PMC7342954 DOI: 10.3760/cma.j.issn.0253-2727.2016.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To analyze the correlation between genetic variants of PRF1 and expression level of perforin and granzyme B protein, and further determine the relationship between PRF1 gene variants and cytotoxic T lymphocyte/natural killer (CTL/NK) cell function in famililal hemophagocytic lymphohistiocytosis (FHL2). METHODS Eight children of FHL2 (P1-P8) after treatment, as well as parents and siblings of P1-P5 were included, and thirty healthy children came for physical examination were designated as controls. PRF1, Unc13D, STX11, STXBP2, RAB27A, LYST, SH2D1A, BIRC4 exons were amplified by PCR and followed by direct sequencing. Bioinformatics analysis of mutant PRF1 was performed by ExPASy online system. Perforin and granzyme B expression on cytotoxic lymphocyte was detected by flow cytometry. RESULTS ① Three of eight FHL2 children harbored heterozygous missense of PRF1 exons: P1 had compound heterozygous missense mutations (R4C and R33H) and P2 had heterozygous mutations (V50L), P3 had heterozygous mutations (R489W), which confirmed the diagnosis of FHL2. The father (F1) and younger brother (B1) of P1 also had compound heterozygous missense mutation (R4C/R33H), the mother (M2) and younger brother (B2) of P2 had V50L mutation, the father (F3) of P3 had no R489W mutation and the mother of P3 did not participate in this research, so mutation of R4C/R33H of P1 inherited from paternal line, and V50L mutation of P2 came from maternal line, R489W mutation of P3 came from maternal line. ② Comparing to control group, perforin expression of CD8(+) T cells and natural killer (NK) cells of P1, F1, B1, P2, M2 and B2 decreased significantly, but there was no significant difference between two groups in terms of granzyme B expression. CONCLUSIONS R4C/R33H compound heterozygous mutation and V50L heterozygous mutation all cause lower expression of perforin on CTL/NK cells, and may be causative mutations for familial hemophagocytic lymphohistiocytosis.
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Affiliation(s)
- X H Zhou
- Department of Pediatrics, Guangxi Medical University First Affiliated Hospital, Nanning 530021, China
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Zeng X, Wei N, Wang Y, Wang J, Zhang J, Wu L, Huang W, Gao Z, Pei R, Chen J, Jin Z, Wang Z. [Treatment outcomes and prognostic analysis of 61 Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis]. Zhonghua Xue Ye Xue Za Zhi 2015; 36:507-10. [PMID: 26134018 PMCID: PMC7343070 DOI: 10.3760/cma.j.issn.0253-2727.2015.06.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To investigate the outcomes, survival status, and the prognostic factors of Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis (EBV-HLH) patients. METHODS A retrospective study was carried out to analyze the clinical data of 61 EBV-HLH cases, from January 2008 to July 2014. Prognostic factors were analyzed through COX model (single factor and multiple factors). RESULTS A total of 246 patients with HLH were diagnosed, among which 102 cases were with EBV infection (including 61 EBV-HLH, 36 lymphoma associated HLH, 5 primary HLH. Among the 61 cases, 40 were male and 21 were female, with a ration of 1.9:1. The median age was 28 years (range, 12-78). 1, 3, 6 and 12-month overall survival rates of 61 EBV-HLH were 65.6%, 47.5%, 32.4%, and 25.0%, respectively. The median follow-up time was 3 (0.5-28) months. 12 patients didn't use etoposide within 4 weeks after diagnosis, while HLH-94 protocol was used in 33 patients and HLH-2004 protocol was used in 16 patients. Response rates of theses three groups were 33.3%, 51.5%, and 43.8%, respectively (P=0.401). There was statistically difference between the group without etoposide and the HLH-94/ HLH-2004 group in the overall survival rate (P=0.033). Serum albumin level (P=0.033) and whether EBV could became negative (P=0.010) were independent predictors for EBV-HLH. CONCLUSION EBV-HLH patients have severe clinical feature and poor prognosis. Early application of immune chemotherapy based on etoposide can improve survival. Serum albumin level and whether EBV can become negative are independent prognostic factors for survival.
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Affiliation(s)
- Xiangzong Zeng
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Na Wei
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Yi'ni Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Jingshi Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Jia Zhang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Lin Wu
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Wenqiu Huang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Zhuo Gao
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Ruijun Pei
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Jianhang Chen
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Zhili Jin
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Zhao Wang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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Shin HJ, Chung JS, Lee JJ, Sohn SK, Choi YJ, Kim YK, Yang DH, Kim HJ, Kim JG, Joo YD, Lee WS, Sohn CH, Lee EY, Cho GJ. Treatment outcomes with CHOP chemotherapy in adult patients with hemophagocytic lymphohistiocytosis. J Korean Med Sci 2008; 23:439-44. [PMID: 18583880 PMCID: PMC2526520 DOI: 10.3346/jkms.2008.23.3.439] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The objective of the current study was to investigate the treatment outcomes for the use of cyclophosphamide, adriamycin, vincristine, and prednisolone (CHOP) chemotherapy in adult patients with hemophagocytic lymphohistiocytosis (HLH). Seventeen HLH patients older than 18 yr of age were treated with CHOP chemotherapy. A response evaluation was conducted for every two cycles of chemotherapy. With CHOP chemotherapy, complete response was achieved for 7/17 patients (41.2%), a partial response for 3/17 patients (17.6%), and the overall response rate was 58.8%. The median response duration (RD) was not reached and the 2-yr RD rate was 68.6%, with a median follow-up of 100 weeks. Median overall survival (OS) was 18 weeks (95% CI, 6-30 weeks) and the 2-yr OS rate was 43.9%. Reported grade 3 or 4 non-hematological toxicities were increased serum liver enzyme levels and stomatitis. Grade 3 or 4 hematological toxicities were leukopenia (50.8%), anemia (20%), and thrombocytopenia (33.9%). Neutropenic fever was observed in 21.6% of patients (14/65 cycles), and most of the cases were resolved with supportive care including treatment with broad-spectrum antibiotics. CHOP chemotherapy seems to be effective in adult HLH patients and the toxicities are manageable.
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Affiliation(s)
- Ho-Jin Shin
- Department of Hematology-Oncology, Pusan National University Medical School, Pusan National University Hospital, Busan, Korea
| | - Joo Seop Chung
- Department of Hematology-Oncology, Pusan National University Medical School, Pusan National University Hospital, Busan, Korea
| | - Je-Jung Lee
- Department of Hematology-Oncology, Chonnam National University Medical School, Gwangju; Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Sang Kyun Sohn
- Department of Hematology-Oncology, Kyungpook National University Hospital, Daegu, Korea
| | - Young Jin Choi
- Department of Hematology-Oncology, Pusan National University Medical School, Pusan National University Hospital, Busan, Korea
| | - Yeo-Kyeoung Kim
- Department of Hematology-Oncology, Chonnam National University Medical School, Gwangju; Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Deok-Hwan Yang
- Department of Hematology-Oncology, Chonnam National University Medical School, Gwangju; Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Hyeoung-Joon Kim
- Department of Hematology-Oncology, Chonnam National University Medical School, Gwangju; Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Jong Gwang Kim
- Department of Hematology-Oncology, Kyungpook National University Hospital, Daegu, Korea
| | - Young Don Joo
- Department of Hematology-Oncology, Inje University Busan Paik Hospital, Busan, Korea
| | - Won Sik Lee
- Department of Hematology-Oncology, Inje University Busan Paik Hospital, Busan, Korea
| | - Chang-Hak Sohn
- Department of Hematology-Oncology, Inje University Busan Paik Hospital, Busan, Korea
| | - Eun Yup Lee
- Department of Clinical Pathology, College of Medicine, Pusan National University, Busan, Korea
| | - Goon Jae Cho
- Department of Hematology-Oncology, Pusan National University Medical School, Pusan National University Hospital, Busan, Korea
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Abstract
This study is to identify the spectrum of Epstein-Barr virus (EBV)-positive lymphoproliferative diseases (LPD) and relationships between these diseases in Korea. The EBV status and clinicopathology of 764 patients, including acute EBV-associated hemophagocytic lymphohistiocytosis (EBV-HLH), chronic active EBV (CAEBV) infections, B-LPD arising in chronic latent EBV infection, T & natural killer (NK) cell non-Hodgkin's lymphomas (NHL), B-NHLs, and Hodgkin's lymphomas (HD), were analyzed. T or NK cell NHLs were the most common forms of EBV-positive NHLs (107/167, 64%); among these, nasal-type NK/T cell lymphomas were the most common (89/107, 83%). According to the age, Burkitt's lymphoma was the most common in early childhood; in teenagers, chronic (active) EBV infection-associated LPD was the most common type. The incidence of NK/T cell lymphoma began to increase from the twenties and formed the major type of EBV-associated tumor throughout life. Diffuse large B cell lymphoma formed the major type in the sixties and seventies. In conclusion, primary infections in early childhood are complicated by the development of CAEBV infections that are main predisposing factors for EBV-associated T or NK cell malignancies in young adults. In old patients, decreased immunity associated with old age and environmental cofactors may provoke the development of peripheral T cell lymphoma, unspecified, and diffuse large B cell lymphoma.
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Affiliation(s)
- Eun-Yoon Cho
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki-Hyun Kim
- Department of Division of Hematology-oncology of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won-Seog Kim
- Department of Division of Hematology-oncology of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keon Hee Yoo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong-Hoe Koo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young-Hyeh Ko
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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