Professor Soltanzadeh

پروفسور محمد حسین سلطان زاده

      استاد دانشگاه علوم پزشکی شهید بهشتی
     متخصص کودکان ونوزادان
        طی دوره بالینی عفونی از میوکلینیک آمریکا
دبیر برگزاری کنفرانس های ماهیانه گروه اطفال
دانشگاه علوم پزشکی شهید بهشتی

خانم دکتر مژگان هاشمیه
فوق تخصص خون انکولوژی

خانم دکتر آزاده کیومرثی

رزیدنت اطفال بیمارستان مفید

آقای دکتر امیرحسین حسینی

رزیدنت اطفال بیمارستان شهدا

خانم دکتر مژگان هاشمیه

Hemophagocytic lymphohistocytosis (HLH) is a potentially life threatening condition occurring as a:

familial disease (FHLH) or

secondary to marked immunological activation during viral, bacterial and parasitic infections, malignancies, rheumatologic conditions or immune deficiencies with cytotoxic T and/or NK-cell dysfunction .

Although FHLH is an autosomal recessive disease that affect immune regulation, sporadic cases with no obvious family inheritance occur.

All organ systems might be affected in HLH.

Eventually multiple organ dysfunction syndrome (MODS) develops and death occurs.

Clinical presentation of HLH might be confused with :

sepsis

metabolic disorders,

immune deficiency syndrome

&BCGeosis.

The diagnosis of HLH can be established if 1of either 2 below is fulfilled

A) A molecular diagnosis consistent with HLH

B) Diagnostic criteria for HLH fulfilled five of eight criteria below

1- Splenomegaly

2- Cytopenia (affecting >2 of 3lineages in the peripheral blood)

3- Hypertriglyceridemia and / or hypofibrinogenemia: fasting TG >265 mg/dl fibrinogen <1.5 gr/dl

4- Hemophagocytosis in bone marrow or spleen or lymph nodes with out evidence of malignancy

5- Low or absent natural killer cell activity

6- Ferritin > 500 µg /l

7- Soluble CD25 (IL2 receptor) > 2400/ml

8-fever

Five of the eight criteria for FHLH in our patient

1-Fever

2-Hepatosplenomegaly

3- Bicytopenia with a total white count at 6.1× 103 / µl , and 14% PMN (absolute neutrophil count :714), Hb: 8.7 gr/dl and platelet count:55×103/µl

4-Ferritin: 1135 µg /l (normal range: 25-200 µg /l)

5- TG: 794 mg/dl (normal range <110 mg/dl), fibrinogen was less than 2 g/dl (normal range: 2.5-4 g/dl).

Considering the positive familial history of death in her sibling with similar presentation and familial relationship of parents , FHLH was the first suspected diagnosis1,

Some metabolic diseases like lysinuric protein intolerance 1,9 have a similar clinical presentation with HLH .

Therefore we checked our patient metabolic profile including serum levels of lactate, ammonia, pyruvate also chromatography of amino acid and sugar in blood and urine.

All the results were normal so metabolic disorder was ruled out .

Because of worsening of clinical condition in our patient and her sibling after BCG injection, another differential diagnosis was immune deficiency syndromes .

we performed bone marrow flow cytometry immunophenotype analysis. The results were not specific and did not support this diagnosis.

Considering some reports of association between tuberculosis and final diagnosis of secondary HLH , PCR and culture of CSF, liver biopsy, BM aspiration and ascitis fluid were performed.

No evidences of TB were found.

The clinical findings in children with infection associated HLH are similar to those in FHLH .

The most common agent causing this syndrome is viruses, predominantly the herpes group viruses including EBV, HSV, and CMV .

A search for these etiologic agents were performed in our patient .She was found to be negative for EBV, HIV, CMV and rubella virus.

A distinctive diagnosis of FHLH can be made if there are genetic defects involving the perforin gene on chromosome 9q21.3 locus (FHLH type 1 ),10q 21-22mutations (FHLH type 2).

Perforin acts by perforatings the cytolytic target cell membrane in turn initiate the apoptotic cell death pathway 1,9.

The other genetic defects are inactivating the MUNC 13-4 gene which is essential for cytolytic granule fusion at chromosome 17q 25 (FHLH type 3) and mutations in syntaxin 11 gene which is located on chromosome 6q24.

Hemophagocytosis might be found in the first bone marrow aspiration of a FHLH patient but the absence of it will not rule out the diagnosis.

In previous literature some cases of FHLH without hemophagocytosis has been reported.

In our case, the bone marrow aspiration was performed two times and liver biopsy one time that did not revealed any site of hemophagocytosis.

خانم دکتر آزاده کیومرثی

آقای دکتر امیرحسین حسینی

A 52 day old girl with high grade fever & poor feeding who expired in hospital on 2nd week of admission

History

lHx.

l52 d/o girl with fever & poor feeding since 1week prior to admission.

lPt. was on Ampicillin, ceftriaxone, gentamicin 1week prior to addmission

lReffered due to Bicytopenia

lPMH.

l3rd sibling , GA= 38wk, elective C/S ,G3P3L2A0D1,

lB.wt=3500g, HC=35, Lt=50 cm

lNICU admission for 7 days due to pneumnia

lVaccination history is complete

lFamily hx.

Parents are relatives

l1st sibling is 9 y/o girl and in good health condition

l2nd sibling expired on 2mo of age due to fever, splenomegaly &pancytopenia (after vaccination)

Physical examination

lOn admission; ill, pale & irritable

lv/s: T=38 c /RR=48/ PR= 120bpm/BP=90/50 mmHg/ O2 Sat. without O2=88-98%

l wt= 5400g, HC=38cm, Lt.=53cm

lAnt. Fontanel= 1.5*1.5 cm----

l Post. Fontanel= tip of finger

lA firm LN (1*1cm), mobile, non tender, in Rt. axilla

lLung: clear (bilat.) with mild IC retraction

lHeart: nl

lAbdomen: distended, spleen can be palpated in umbilical area, liver span=8cm.

lMuscle tone is nl

lGood eye contact

lOther examinations are nl

Hospital course

lPt. treated with vancomycin +meropenem

l4 days later pt’s respiratory distress & abdominal distension exacerbated

lAbdominal sonography:

hepatomegaly (98mm), splenomegaly (99mm),free fluid in abdomen, Pleural effusion in Rt. hemithorax without LAP.

Lab. data

lWBC=6100/micl (P=14%, L=83%), Hb=8.7gr/dl, Hct=25.6%, Plt=55000/micl, MCV=77.2fl , RBC= 3660000/micl,

Retic= 1%

lESR= 12 CRP=+1

lAST=108 u/l ALT=70u/l LDH=950IU/l, Alb=3.1g/dl

lBUN=10mg/dl, Cr=0.5mg/dl, UA=6mg/dl, BS=70gr/dl,

lPT=12s, PTT=47s

lTG= 240 mg/dl

lFibrinogen level: nl

lFerritin :nl

lABG: PH=7.46, Pco2=33.6, Po2=58.3, HCO3=24.2

lNa=137meq/l, K=4.1meq/l,

lU/A: nl U/C :neg.

lB/C: neg S/E: nl

lAcitic fluid:

glu.=67mg/dl, pro.=3.6g/dl, WBC=250 (P=20%,MN=80%)

RBC=5200, LDH=643

lCXR: bilat. Perihilar haziness

lPBS:hypochromia, anisocytosis, leukopenia, partial lymphocytosis, thrombocytosis

lBMA (2 times with 10 days interval):

60% cellularity with maturation arrest at myeloid series without evidence of hemophagocytosis. No blast, no erythrophagocyte

lBM immuno-phenotyping:

60% lymphoid immune-population of total cells, half of them are mature T-cells with reverse CD4/CD8 ratio, B-precursors expressing CD19, HLA-DR & variable expression of CD20

lMetabolic profile (Before pc transfusion): including lactate, ammonia, pyrovate & chromatography of A.A. & sugar in blood & urine were Nl

lToRCH study: nl

lCMV, HSV, EBV, HCV, HIV : neg

lPCR, smear & culture of ascitic fluid, CSF & BM were neg. about acid fast bacilli

lLiver Bx: chronic active hepatitis

lBone survey: Nl

Lab. data on 10th day of admission

lTG=794 mg/dl (nl<110)

lFerritin =1135 micgr/dl (nl. 25-200)

lFibrinogen level: <2 gr/dl (nl.2.5-4)

On 14th day

lCardiopulmonary arrest

lCPCR was not successful

lNo permission for autopsy

lLast lab. Data:

CBC: WBC=6100 (P=18%,L=80%) plt=33000, Hb.=9.5

ABG: PH=7.57, pco2=32.4, Hco3=29.7 Sat. O2=87.7%

Problem list

A 52 d/o girl, term, with fever, poor feeding (since 7 days prior to admission), irritability, abdominal distension, who had the following data,problems, and Para clinic points:

l Fever + poor feeding

lparents are relatives

lPositive family history of a similar death in previous sibling

lNo skin lesion, no congenital deformity

lHepatosplenomegaly + ascetic fluid

lBicytopenia

lHypertrigeliceridemia

lhypofibrinogenemia

l high ferritin level

lBM immuno-phenotyping: Reverse CD4/CD8 ratio

lMetabolic profile : nl

lABG: nl

lNl. Blood Sugar /NL. biochemistry

lNl. U/A,

l mildly elevated liver enzymes

lToRCH study: nl

lCMV, HSV, EBV, HCV, HIV : neg.

lBMA: without evidence of hemophagocytosis. No blast, no erythrophagocyte

lPCR, smear & culture of ascitic fluid, CSF & BM were neg. about acid fast bacilli

Hepatosplenomegaly

lstorage diseases:

lGaucher disease

lneonatal iron storage disease

l Secondary or metastatic processes

Lymphoma, Leukemia,

Langerhans cell Histiocytosis (bone survey—skin manifestation)

lHemoglobinopathies:thalassemia major

lCastlemann ‘s disease

lHyperreactive malaria splenomegaly

lInfections:

lGram neg. bacteria (Salmonella)

l Kala Azar (lymphopenia)

lMiliary TB, Malaria

lCongenital cytomegalovirus (CMV)

lHepatitis B, and C

lEpstein-Barr virus (EBV)

lViral hemophagocytic syndromes: CMV, EBV, HHV-6

lHuman immunodeficiency virus (HIV)

lALPS

(Autoimmune lymphoproliferative syndrome)

hemolysis

skin manifestation

lHLH

(hemophagocyticlymphohistiocytosis)

Bicytopenia

lConstitutional (Inherited)

lVIRUSES

CMV, EBV, Hepatitis B Hepatitis C

non-B, non-C (seronegative hepatitis)

HIV

lMARROW REPLACEMENT

Leukemia , Myelodysplasia, Myelofibrosis

lHLH

HYPERTRIGLYCERIDEMIA

l Hemophagocytic lymphohistiocytosis (HLH)

l AIDS

lprotease inhibitions

lAcquired Immunodeficiency Syndrome

(Human Immunodeficiency Virus)

lVertical transmission of HIV:

lintrauterine

l intrapartum

lbreast-feeding

l3 distinct patterns of disease were described in children

l1. rapid disease course

l2. slow progression of disease

l3. long-term survivors

lApproximately 15–25% of HIV-infected newborns in developed countries present with a rapid disease course, with onset of AIDS and symptoms during the 1st few months of life and, if untreated, a median survival time of 6–9 mo

lIn most infants, physical examination at birth is normal

l Initial symptoms may be

-subtle, such as lymphadenopathy andhepatosplenomegaly,

-nonspecific, such as FTT, chronic or recurrent diarrhea, interstitial pneumonia, or oral thrush, and may be distinguishable only by their persistence.

Diagnosis

lAll infants born to HIV-infected mothers test antibody-positive at birth because of passive transfer of maternal HIV antibody across the placenta during gestation

lDefinitive diagnosis in most infected infants by 1–6 mo of age:

lViral diagnostic assays, such as HIV DNA or RNA PCR, HIV culture, or HIV p24 antigen immune-dissociated p24 (ICD-p24), are considerably more useful in young infants

lInfants born to HIV-infected mothers should be prescribed zidovudine (ZDV) prophylaxis.

Treatment

lThe currently available therapy does not eradicate the virus and cure the patient

lIt only suppresses the virus for extended periods of time and changes the course of the disease to a chronic process

(HLH)
Hemophagocytic lymphohistiocytosis

Diagnostic Criteria for HLH:

lFever >38.5°C and lasting ≥7 days

lSplenomegaly >3 cm

lTWO OF THE FOLLOWING HEMATOLOGIC ABNORMALITIES:

Anemia (<9 g/dL hemoglobin)

Thrombocytopenia (<100,000 cells/L)

Neutropenia (<1000 neutrophils/L)

lONE OF THE FOLLOWING ABNORMALITIES:

Hypertriglyceridemia >2.0 nmol/L

Hypofibrinogenemia <150 mg/dL

land

lHemophagocytosis in bone marrow, spleen, or lymph node

lNo evidence of marrow hyperplasia or malignant neoplasia

lHLH may be present in the absence of genetic mutations of the perforin or Munc 13–4 genes and the presence of 5 of the following:

lfever,

lsplenomegaly,

lcytopenia of 2 cell lines,

lhypertriglyceridemia or hypofibrinogenemia,

lhyperferritinemia,

l elevated SCD25 (interleukin-2 receptor),

lreduced or absent NK cells,

land bone marrow, cerebrospinal fluid or lymph node evidence of hemophagocytosis

Minor criteria

l1. hyperferritinemia (>500 micgr/dl)

l2. elevated SCD25 (interleukin-2 receptor) >2400 u/ml

l3. reduced or absent NK cells

@ 2 of these criteria can be substituted for 1 major criteria

lFamilial: (FHLH)

lSecondary:

Infectious agents: viruses (e.g., CMV,EBV, parvovirus B19, HHV6), fungi, parasite, protozoa, and bacteria (Gram neg. ,TB)

HAART

Kawasaki disease

X-linked lymphoproliferative disorders

Recipients of liver & kidney Transplantation

EBV associated limphoproliferativedisorders

lPresentation with fever, maculopapular and/or petechial rash, weight loss, and irritability

lFHLH also is characterized by severe immunodeficiency.

lChildren with FHLH always are <4 yr of age, whereas children with secondary HLH may present at an older age.

lPhysical examination :

hepatosplenomegaly,

lymphadenopathy,

respiratory distress,

and symptoms of CNS involvement

laboratory findings

lAssociated laboratory findings in both forms of HLH include:

hyperlipidemia,

hypofibrinogenemia,

elevated levels of hepatic enzymes,

extremely elevated levels of circulating soluble interleukin-2 receptors released by the activated lymphocytes,

very high levels of serum ferritin (often >10,000),

and cytopenias (especially pancytopenia from hemophagocytosis in the marrow)

lgenetic markers for FHLH can complement a positive family history for other affected children

lTreatment of the underlying infection, coupled with supportive care, is critical

limmunosuppressive treatment :

etoposide, corticosteroids, and intrathecalmethotrexate

lSome recommend antithymocyte globulin and cyclosporine for maintenance therapy

lEven with chemotherapy, FHLH remains ultimately fatal, often after a relapse of the disease.

lAllogeneic stem cell transplantation is effective in curing approximately 60% of patients with FHLH

lIn contrast, in secondary HLH, when an infection can be documented and effectively treated, the prognosis is good without any other specific treatment

lWhen a treatable infection cannot be documented, the prognosis may be as poor as that of FHLH, and an identical chemotherapeutic approach, including etoposide, is recommended