Hemophagocytic lymphohistiocytosis

By. Dr. JAGJIT KHOSLA

HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS

By Jagjit Khosla


HLH - OVERVIEW

Definition Etiology Pathophysiology

Primary and Secondary HLH

Clinical FindingsInvestigations

Diagnostic criteria Treatment


HLH - DEFINITION

HemophagocytosisPhagocytosis by macrophages of erythrocytes, leukocytes, platelets, and their precursors in bone marrow and other tissues

Hemophagocytic LymphohistiocytosisUncommon, life-threatening hyperinflammatory syndrome caused by severe hypercytokinemia due to a highly stimulated but ineffective immune process


ETIOLOGY OF HLH


ETIOLOGY

Primary (Genetic)• Familial HLH

– Known gene defects• PFR1• UNC13D• STX11

– Unknown gene defects• Immune deficiency syndromes

– Chediak-Higashi syndromes– Griscelli Syndrome 2– X-linked Lymphoproliferative

syndromes

Secondary (Acquired)• Infections• Autoimmune • Malignant diseases• Immunosuppression /

Organ transplantation

Janka G. (2009). “Hemophagocytic lymphohistiocytosis: when the immune system runs amok” Klin Padiatr Sep;221(5):278-85.


PATHOPHYSIOLOGY


HLH - PATHOPHYSIOLOGY

YYAntigen Presenting Cell

MHC

Viral Antigen

TNF-αIFN-γ

CD4+ T-Cell

IL – 1, IL - 6, IL - 18

IL - 2

TCR


HLH - PATHOPHYSIOLOGYPerforin Deficiency



Source : “Verbsky, J. W., & Grossman, W. J. (2006). Hemophagocytic lymphohistiocytosis: diagnosis, pathophysiology, treatment, and future perspectives. Annals of medicine, 38(1), 20-31.”



Source : “Menasche, G., Feldmann, J., Fischer, A. and de Saint, B. G. (2005).Primary hemophagocytic syndromes point to a direct link between lymphocyte cytotoxicity and homeostasis. Immunol. Rev. 203, 165-179.”


PRIMARY HLH VS SECONDARY HLH

• No laboratory test or clinical presentation provides a means to distinguish between primary and secondary.

• Natural history are similar for both• Primary HLH restricted to young age (80% -

presents in <1 year old)• In adults, almost all cases are secondary.


PRIMARY HLH


PRIMARY HLH

• Restricted to babies and young children

• Incidence is 1.2/1,000,000 children per year

• Median survival <2 months if untreated

• Most primary HLH episodes are triggered by

an infection


FHL1 – gene not yet described (located at 9q21.3-22)

FHL2 – Perforin (PRF1, located at 10q21-22)

FHL3 – Munc 13-4 (UNC13D, located at 17q25)

FHL4 – Syntaxin 11 (STX11, located at 6q24)

FHL5 – Munc 18-2 (STXBP2, located at 19p13)

Griscelli Syndrome 2 - RAB27A

Chediak-Higashi Syndrome – LYST

X- Linked Proliferative Syndrome – SAP

PRIMARY HLH


PRIMARY HLH

Perforin (FHL2)

RAB27A (GS2)LYST (CHS)

Munc 13-4(FHL3)

Syntaxin 11 (FHL4)

Munc 18-2 (FHL5)Source : Menasche, G., Feldmann, J., Fischer, A. and de Saint, B. G. (2005). Primary hemophagocytic syndromes point to a direct link between lymphocyte cytotoxicity and homeostasis. Immunol. Rev. 203, 165-179.


SECONDARY HLH


SECONDARY HLH

InfectionsAutoimmune disordersMalignancy

Immunosuppression / Organ transplant

1234


SECONDARY HLH

Infections1- Viruses – Epstein-Barr Virus, Cytomegalovirus,

Parvovirus, Herpes simplex, Varicella-zoster, measles, HHV-8, HIV infection

- Bacteria – Brucella, Gram neg bacteria, Tuberculosis

- Parasites – Leishmaniasis

- Fungi


SECONDARY HLH

InfectionsAutoimmune disorders

12

Also known as Macrophage Activation Syndrome (MAS)- Lupus Erythematosus- Rheumatoid arthritis- Still’s disease- Polyarteritis nodosa- Mixed connective tissue disorders- Pulmonary sarcoidosis- Systemic Sclerosis- Sjogren’s syndrome


SECONDARY HLH


123

- Leukemias- Lymphomas


SECONDARY HLH


Immunosuppression / Organ transplant

1234

- Post-Chemotherapy- After Renal or liver transplant- Immunosuppressive treatment


CLINICAL FINDINGS


HLH CLINICAL FINDINGS

• Common findings– Prolonged fever– Hepatosplenomegaly– Neurologic symptoms – seizures, cranial nerve palsies

• Less common findings– Lymphadenopathy– Rash– Jaundice


HLH CLINICAL FINDINGS

Feve

r

Hepatomega

ly

Splenomega

ly

Neurologic Rash

Lymphad

enopathy

0102030405060708090

100 91% 90% 84%

47% 43% 42%

Source : “Henter JI et al Incidence in Sweden and clinical features of familial hemophagocytic lymphohistiocytosis. Acta Paediatr Scand 1991;80:428”


INVESTIGATIONS


HLH LABORATORY VALUES• Cytopenias– Anemia and thrombocytopenias are more common– Mechanism –• Suppression by TNF-α and INF-γ• Consumption by hemophagocytosis


HLH LABORATORY VALUES• Cytopenias • Tissue demonstration of Hemophagocytosis– Repeated attempts needed to identify characteristic

histology– Lymph node biopsy or bone marrow aspirates


HLH LABORATORY VALUES

Source : Filipovich, Alexandra H. "Hemophagocytic lymphohistiocytosis and other hemophagocytic disorders." Immunology and allergy clinics of North America28.2 (2008): 293-313.


HLH LABORATORY VALUES• Cytopenias • Tissue demonstration of Hemophagocytosis• Elevated Ferritin – Can increase over a range of several 10000 ug/L within

several hours in HLH – Mechanisms – multiple hypotheses

• Passive release due to cell damage • Increased secretion by macrophages and release during

erythrophagocytosis• Increased ferritin gene expression by TNF-α• Decreased clearing due to lower glycosylation

– Ferritin >500μg/L : Sensitivity 82%, Specificity 42%– Ferritin >10,000 μg/L : Sensitivity 90%, Specificity 96%


HLH LABORATORY VALUES• Cytopenias • Tissue demonstration of Hemophagocytosis• Elevated Ferritin • Elevated triglycerides– Mechanism - Increased TNF-α suppress activity of

lipoprotein lipase


HLH LABORATORY VALUES• Cytopenias • Tissue demonstration of Hemophagocytosis• Elevated Ferritin • Elevated triglycerides• Depressed Fibrinogen – Mechanism - Increased levels of Plasminogen activator

secreted by activated macrophages


HLH LABORATORY VALUES• Cytopenias • Tissue demonstration of Hemophagocytosis• Elevated Ferritin • Elevated triglycerides• Depressed Fibrinogen • Impaired NK Cell Activity• Elevated soluble IL-2 receptor (sCD 25)• Elevated LDH• Elevated liver enzymes and bilirubin


DIAGNOSTIC CRITERIA


HLH - DIAGNOSTIC CRITERIA

• In HLH-94, diagnosis was based on 5 five criteria.

• In HLH-2004, three additional criteria added, making it total 8 criteria.



Fever

Splenomegaly

Cytopenia – two or more cell lines

1

2

3

Peak temperature >38.5oC for 7 or more days

Spleen palpated >3 cm below the left costal margin

Hemoglobin <9.0 g/dL, orPlatelets <100,000/μL, orAbsolute neutrophil count <1000/μL



Hypertriglyceridemia / Hypofibrinogenemia

Hemophagocytosis

4

5

Fasting triglycerids >2.0 mmol/L, or >3 SD above the normal value for age, orFibrinogen <1.5 g/L, or >3 SD below the normal value for age

Demonstrated in bone marrow, spleen or lymph node, no evidence for malignancy



Low or absent NK cell activity

Elevated S. Ferritin

Elevated sCD 25

6

7

8

Serum ferritin >500 μg/L

Soluble CD 25 (sIL-2 receptor) >2400 U/mL


• If patient meets only 4 criteria and clinical suspicion for HLH is high, one must initiate appropriate treatment

HLH

Molecular diagnosis e.g PRF mutations,

SAP mutations5 out of 8 diagnostic

criteria fulfilledor

Adapted from Treatment Protocol of the 2nd International HLH Study, 2004


TREATMENT


HLH TREATMENT• Until 1994, HLH therapy ineffective with 90% fatalities• HLH-94

– First international study on HLH treatment– Included combination of chemotherapy, immunotherapy and

steroids as well as antibiotics and antiviral drugs followed by stem cell transplant

– Two phases – Initial phase (8 weeks), Continuation phase– Survival rate – 55% at median follow-up of 3.1 years

• HLH-2004– Cyclosporine A started at the onset of therapy instead at

week 9


HLH TREATMENT

Immediate goals

Long term goals


HLH TREATMENTIm

med

iate

goa

lsSuppress the severe inflammation• Steroids – Dexamethasone• Cyclosporine A • Intrathecal Methotrexate, hydrocortisone (patients with persistent

active CNS disease)

Kill the over-stimulated Antigen-Presenting Cells• Etoposide (VP-16)

Treat the triggering agent (infection, neoplasm etc.)• Antibiotics, Antivirals

Supportive therapy• Prophylactic Cotrimoxazole, oral anti-mycotic• Gastroprotection - Ranitidine


HLH TREATMENTLo

ng-te

rm g

oal

Replace the defective immune system• Allogenic Hematopoietic Stem Cell Transplantation• Best overall cure rate in HLH• Needed for• Patients with genetic mutations diagnosed or

family history• Patients who responded poorly with initial eight

weeks of chemotherapy• Patients with CNS disease

• Non-myeloablative or Reduced intensity transplantation - Use of fludarabine, melphalan and alemtuzumab (anti-CD52 antibody) before transplantation improves survival rates (Marsh et al)


Source : Henter, Jan Inge, AnnaCarin Horne, Maurizio Aricó, R. Maarten Egeler, Alexandra H. Filipovich, Shinsaku Imashuku, Stephan ‐Ladisch et al. "HLH 2004: Diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis." ‐ Pediatric blood & cancer 48, no. 2 (2006): 124-131.

Dexamethasone10 mg/m2 per day for first two weeks5 mg/m2 per day for week 3 and 42.5 mg/m2 per day for week 5 and 61.25 mg/m2 per day for week 7 Tapering to zero over the 8th week

Etoposide (VP-16)150mg/m2 i.v. twice weekly for first two weeks150mg/m2 i.v. once weekly for next 6 weeks

Cyclosporine AStart with 6mg/Kg daily (2 divided doses) , aim at levels around 200 μg/L (Trough level)

Intrathecal Methotrexate12mg once weekly for pt >3 yr old for four weeks (week 3 to week 6)

HLH TREATMENT


HLH TREATMENT

Source : Henter, Jan Inge, AnnaCarin Horne, Maurizio Aricó, R. Maarten Egeler, Alexandra H. Filipovich, Shinsaku Imashuku, Stephan ‐Ladisch et al. "HLH 2004: Diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis." ‐ Pediatric blood & cancer 48, no. 2 (2006): 124-131.

Dexamethasone pulse every second week, 10 mg/m2 for 3 daysEtoposide 150 mg/m2 every second weekCyclosporine A – aim for blood levels around 200 μg/L, Monitor GFRAllogenic Hematopoietic Stem Cell Transplantation


HLH TREATMENT• Other treatment approaches– Antithymocyte globulin– Iv IG– Rituximab (EBV associated HLH)– HIT-HLH trial – A combined use of ATG, Etoposide,

Intrathecal methotrexate and Hydrocortisone is currently under study.


REFERENCES• Al-Hashmi, I., J. Decoteau, et al. (2001). "Establishment of a cytokine-producing anaplastic large-cell lymphoma cell line containing the t(2;5) translocation: potential role of

cytokines in clinical manifestations." Leuk Lymphoma40(5-6): 599-611.• Allen, C. E., X. Yu, et al. (2008). "Highly elevated ferritin levels and the diagnosis of hemophagocytic lymphohistiocytosis." Pediatr Blood Cancer50(6): 1227-35.• Arceci, R. J. (2008). "When T cells and macrophages do not talk: the hemophagocytic syndromes." Curr Opin Hematol15(4): 359-67.• Emmenegger, U., D. J. Schaer, et al. (2005). "Haemophagocytic syndromes in adults: current concepts and challenges ahead." Swiss Med Wkly135(21-22): 299-314.• Harada, Y., S. Yamada, et al. (2000). "Ki-1 lymphoma with nodular involvement in liver and spleen: possible role of cytokines insystemic manifestation of fever and leukocytosis." Dig

Dis Sci45(11): 2240-6.• Henter, J. I., M. Arico, et al. (1997). "HLH-94: a treatment protocol for hemophagocytic lymphohistiocytosis. HLH study Group ofthe Histiocyte Society." Med Pediatr Oncol28(5):

342-7.• Henter, J. I., A. Horne, et al. (2007). "HLH-2004: Diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis." Pediatr Blood Cancer48(2): 124-31.• Horne, A., K. G. Ramme, et al. (2008). "Characterization of PRF1, STX11 and UNC13D genotype-phenotype correlations in familial hemophagocytic lymphohistiocytosis." Br J

Haematol143(1): 75-83.• Hot, A. and J. Ninet (2008). "Healing hemophagocytic syndrome in adults: the challenge continues." Clin Adv Hematol Oncol6(8): 591-3.• Imashuku, S., S. Hibi, et al. (1995). "Soluble interleukin-2 receptor: a useful prognostic factor for patients with hemophagocytic lymphohistiocytosis." Blood86(12): 4706-7.• Jacobsen, E. (2006). "Anaplastic large-cell lymphoma, T-/null-cell type." Oncologist11(7): 831-40.• Janik, J. E., J. C. Morris, et al. (2004). "Elevated serum-soluble interleukin-2 receptor levels in patients with anaplastic large cell lymphoma." Blood104(10): 3355-7.• Janka, G. (2009). "Hemophagocytic lymphohistiocytosis: when the immune system runs amok." Klin Padiatr221(5): 278-85.• Janka, G. E. (2007). "Familial and acquired hemophagocytic lymphohistiocytosis." Eur J Pediatr166(2): 95-109.• Janka, G. E. (2007). "Hemophagocytic syndromes." Blood Rev21(5): 245-53.• Kaito, K., M. Kobayashi, et al. (1997). "Prognostic factors of hemophagocytic syndrome in adults: analysis of 34 cases." Eur J Haematol59(4): 247-53.• Knovich, M. A., J. A. Storey, et al. (2009). "Ferritin for the clinician." Blood Rev23(3): 95-104.• Menasche, G., J. Feldmann, et al. (2005). "Primary hemophagocytic syndromes point to a direct link between lymphocyte cytotoxicity and homeostasis." Immunol Rev203: 165-79.• Mosunjac, M. B., J. B. Sundstrom, et al. (2008). "Unusual presentation of anaplastic large cell lymphoma with clinical coursemimicking fever of unknown origin and sepsis: autopsy

study of five cases." Croat Med J49(5): 660-8.• Shimada, A., M. Kato, et al. (2008). "Hemophagocytic lymphohistiocytosis associated with uncontrolled inflammatory cytokinemia and chemokinemia was caused by systemic

anaplastic large cell lymphoma: a case report and review of the literature." J Pediatr Hematol Oncol30(10): 785-7.• Siebert, S., N. Amos, et al. (2007). "Cytokine production by hepatic anaplastic large-cell lymphoma presenting as a rheumatic syndrome." Semin Arthritis Rheum37(1): 63-7.• Wang, Z., Y. Wang, et al. (2009). "Early diagnostic value of low percentage of glycosylated ferritin in secondary hemophagocyticlymphohistiocytosis." Int J Hematol.• Wong, K. F., J. K. Chan, et al. (1991). "Anaplastic large cell Ki-1 lymphoma involving bone marrow: marrow findings and association with reactive hemophagocytosis." Am J

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