Original article / research
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2022 |
Month :
July
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Volume :
11 |
Issue :
3 |
Page :
PO70 - PO74 |
Full Version
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Hemophagocytic Lymphohistiocytosis: New Insights into Diagnosis
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Pragyan Lisha Panda, Priyadarshini Biswal, Subhasis Mishra, Pranati Mohanty
1. Assistant Professor, Department of Pathology, SCB Medical College, Bhubaneswar, Odisha, India.
2. Assistant Professor, Department of Pathology, SCB Medical College, Bhubaneswar, Odisha, India.
3. Assistant Professor, Department of Pathology, SCB Medical College, Bhubaneswar, Odisha, India.
4. Associate Professor, Department of Pathology, SCB Medical College, Bhubaneswar, Odisha, India.
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Correspondence
Address :
Pragyan Lisha Panda, Priyadarshini Biswal, Subhasis Mishra, Pranati Mohanty,
Dr. Pranati Mohanty,
Associate Professor, Department of Pathology, SCB Medical College, Bhubaneswar, Odisha, India.
E-mail: drpranati05@gmail.co
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| | | ABSTRACT |  | : Introduction: Haemophagocytic lymphohistiocytosis (HLH) or haemophagocytic syndrome is a very fatal and an underdiagnosed disease which involves a pathway of hypercytokinemia, that results in Multiorgan Dysfunction Syndrome (MODS) and poor survival. Although an early diagnosis is important to decrease mortality, the definitive diagnosis is an enigma due to the absence of confirmatory gold standard tests. Since the range of laboratory assays involved in the diagnosis of HLH is wide, practicing pathologists should be familiar with the disease so, that they can appropriately flag results and convey them to the clinicians.
Aim: To diagnose Haemophagocytic lymphohistiocytosis and find its advantage over the criteria used in 2004.
Materials and Methods: The cross-sectional study was accomplished in the Pathology Department of Sriram Chandra Bhanja Medical College and Hospital Cuttack, Odisha, India over a period of 5 years and 4 months in which 26 cases were evaluated. A complete clinical history, haematological, biochemical work-up and H-scoring by Fardet L et al., in 2014 was done to dwell into the depths of aetiology of HLH. Univariate statistical analysis was done to understand the basic statistics of the data in term of frequency and percentage.
Results: Total of 26 patients were diagnosed and the age ranges from 47 days to 65 years; two were infants. The average age of the patients was 28 years. The H-score was more accurate than the previous (2004) criteria to diagnose HLH. The diagnostic sensitivity improved by 7.7% by using H-score. The underlying aetiology was found to be infective, autoimmune and malignancies in our cases.
Conclusion: H-score, a new scoring system proposed helps to diagnose HLH in a robust and efficient way for early diagnosis and treatment.
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| Keywords
: Ferritin, Fever, H-Score, Pancytopenia, Splenomegaly |
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| DOI and Others
: DOI: 10.7860/NJLM/2022/53580.2654
Date of Submission: Dec 26, 2021
Date of Peer Review: Jan 29, 2022
Date of Acceptance: Apr 01, 2022
Date of Publishing: Jul 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? No
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHO |
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INTRODUCTION |
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Haemophagocytic lymphohistiocytosis (HLH) is a life-threatening haematologic disease of uninhibited activation of immune cells causing extensive inflammation and tissue damage resulting in multiorgan dysfunction and failure. It is thought to be caused by the upregulation of activated macrophages and lymphocytes, possibly by failure of natural killer cells and/or cytotoxic T-cells to kill these activated macrophages (1),(2). The syndrome was first described in 1939 by Scott Robin and Smith as poorly controlled histiocyte proliferation and named as ‘Histiocytic medullary reticulocytosis.’ HLH can be primary (familial) or secondary (acquired). HLH is sporadic about 75% of time and remaining cases are familial. Primary HLH is due to gene mutations or associated with immunodeficiency syndrome like Chediak Higashi syndrome, Griscelli syndrome. Secondary HLH patients have a clear trigger for development of HLH. They are either due to underlying infections or malignancies like lymphomas, medications that suppress the immune system, autoimmune diseases and/or metabolic diseases (3),(4) but genetic mutation is absent unlike primary HLH. There can also be an overlap between these two designations as any factor that triggers secondary HLH can precipitate the condition in those with a known genetic mutation. Familial Haemophagocytic Lymphohistiocytosis (FHLH) is relatively rare.The incidence of familial HLH in children in India has been reported as 1.2 per million (5) but that of infection associated HLH is still uncertain.
Untreated HLH has a very high mortality rate. Immediate treatment is critical, but the greatest barrier to a successful outcome is often a delay in diagnosis as HLH is a rare syndrome. Variable clinical presentation, and lack of specificity of the clinical and laboratory findings add to the delay. Immunochemotherapy followed by allogenic bone marrow transplantation results in long-term survival in these patients (6). As this form of treatment is currently available to limited population in India (7), early diagnosis of HLH is important so that appropriate treatment can be rendered. The aim of the present study is to diagnose HLH using H-score proposed by Fardet L et al., (8) and find its advantage over the previous HLH 2004 guidelines.
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Material and Methods |
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The present cross-sectional study was carried out in the Pathology Department of Sriram Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India between June 2015 and October 2020 extending over a period of 5 years and 4 months. Ethical clearance was obtained from the Institutional Ethics Committee (No.742).
Inclusion and Exclusion criteria: A total of 93 cases with high index of clinical suspicion of HLH were evaluated, out of which 26 cases were confirmed to be HLH. These 26 cases were included in the final analysis. Patients admitted in Intensive Care Unit (ICU) were excluded from the study.
Procedure
A total of 26 cases were evaluated. On presentation, a complete history was taken including past history, relevant drug history and physical examination was done for recording the positive findings. Routine complete blood count was done followed by peripheral smear examination. All necessary investigations like serum triglyceride level, fibrinogen level, liver function tests, ferritin level, viral serology and further case specific investigations were carried out for a diagnostic workup. Patients provided written informed consent prior to the bone marrow aspiration. Care was taken to carry out the procedure under sterile conditions. The bone marrow aspirate smears were stained with Leishman stain after drying. Special stains like Myeloperoxidase and Perl’s iron were done wherever necessary to reach a diagnosis. Bone marrow biopsy was done wherever indicated and cores were collected in formalin vial, imprints of the core was taken. Cases were diagnosed by two experienced pathologists of the Department of Pathology, SCB Medical College, Cuttack who were blinded to avoid observation bias. The diagnostic criteria proposed by Fardet L et al., (2014) was followed to score the findings and to stamp the case as HLH. Nine parameters were taken to calculate H-score (Table/Fig 1). Cut-off value to diagnose HLH was 169. Univariate statistical analysis was done. Due to unavailability of genetic molecular tests or flow cytometry for perforin protein on routine basis, these tests were not done.
STATISTICAL ANALYSIS
Post the data collection, pre-processing was done on the dataset and tabulated. Univariate analysis was done on the dataset to understand the basic statistics of the data in term of frequency and percentage.
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Results |
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Total 26 patients were diagnosed as HLH over a period of 5 years and 4 months. The age of patients ranged from 47 days to 65 years; two were infants. The average age of the patients was 28 years. Parental consanguinity was present in four of the patients: two had affected siblings and one had a history of sibling death due to pyrexia of unknown origin. Male to female ratio was 9:4. The most common presenting symptom was fever in 92.3% cases followed by splenomegaly in 38.5% cases.The other clinical findings according to their decreasing order of frequency were hepatomegaly, joint pain, lymphadenopathy, abdominal pain, rash, pedal oedema and seizures. Both splenomegaly and hepatomegaly were seen in three cases (Table/Fig 2).
Total 23 patients (88.5%) had elevated levels of Serum Glutamic Oxaloacetic Transaminase (SGOT) (≥30). Serum ferritin >2000 ng/mL was seen in 50% cases; hypertriglyceridemia (>132.7 mg/dl) was seen in 80.8% and 73.1% patients had fibrinogen level ≤250 mg/dL (Table/Fig 3). Pancytopenia was noted in 23.07% cases (Table/Fig 4), bicytopenia in 46.1% cases and unicytopenia in 11.53% cases (2 case of Microcytichypochromic anemia are also to be included, total 3 case). Total 73.1% of the patients had haemoglobin <9.2 gm/dL; 73.1% patients had total leucocyte count <5000/cubic mm and 38.5% had total platelet count <110,000/cubic mm (Table/Fig 5). Peripheral smear revealed neutrophilic leucocytosis in 15.4% patients, monocytosis in 3.8% and thrombocytosis in 3.8% of patients. Myeloid leukemoid reaction was seen in a single case and sickle cells were seen in a 15-year-old female. A 10-year-old child who presented with fever and splenomegaly showed the presence of gametocytes of Plasmodium falciparum in peripheral smear following which immunochromatographic test was done and found positive. Schistocytes were seen in 11.5% cases and bone marrow haemophagocytosis was seen in 92.3% cases (Table/Fig 6)a-d. One case had increased number of reticulum cells but haemophagocytosis was not evident within the reticulum cell.
Patients were extensively investigated to find out the underlying cause of HLH. Bone marrow samples were sent for culture to rule out fungal and tubercular aetiology. Cartridge-based Nucleic Acid Amplification Test (CBNAAT) on Fine Needle Aspirates (FNA) and blood samples were done to exclude tuberculosis. Tests like blood culture, NS-1 antigen and IgM antibodies for dengue, Widal, malaria parasite by smear and antigen test, Weil-Felix, Brucella serology, Leptospira serology, HIV/Enzyme-Linked Immunosorbent Assay (ELISA), Hepatitis B surface Antigen (HBsAg), Hepatitis C Virus (HCV) antibody, antinuclear antibody tests were done in all patients. Viral serology was sent wherever anticipated.
Underlying aetiology was detected after extensive investigations in 15 cases. Three cases were EBV positive, one was HSV positive and one was positive for Parvovirus (Table/Fig 7). A single patient was HIV positive. FNA of cervical lymph node of a patient with lymphadenopathy showed granulomatous lymphadenitis following which a biopsy of the same node was processed which showed features of Hodgkin's lymphoma (Table/Fig 8). He had developed HLH over a setting of Evans syndrome. Direct Coombs test was positive. A sickle cell anaemia patient was found to have Non Hodgkin's lymphoma on lymph node biopsy. He was positive for Parvovirus also. High performance liquid chromatography of a 7-year-old child showed a beta thalassemia picture and he was antistreptolysin O positive. Apart from malignancies and infective causes, seven cases had autoimmune aetiology; two cases of SLE and three cases of Still’s disease, one of mixed connective tissue disease with interstitial lung disease and one of systemic sclerosis.The diagnostic accuracy of H-score was 100%. Using 2004 criteria, 92.3% cases were diagnosed as HLH while H-score showed a sensitivity of 100% proving to be a better diagnostic method. The two cases which were undiagnosed by 2004 criteria and diagnosed as HLH by H-score responded well to steroids.
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Discussion |
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Haemophagocytic lymphohistiocytosis (HLH) is a syndrome which poses major diagnostic and therapeutic challenges. The clinical features of secondary HLH mimic sepsis with multiorgan dysfunction syndrome, scrub typhus and severe malaria, visceral leishmaniasis, disseminated tuberculosis, leptospirosis, autoimmune disease in adults, haematological malignancy like leukaemia and lymphoma (9). HLH is under reported in India especially in adolescents and adult population. The relative unawareness of this condition results in a high threshold of suspicion for the same. The biggest barrier in the workup of HLH patients is the unavailability of diagnostic facilities. In such a scenario, the diagnosis of HLH is a team work needing communication between pathologists and clinicians so as to carry out all necessary investigations to arrive at a diagnosis as early as possible. HLH should always be kept in mind as a differential diagnosis in any patients presenting with pancytopenia and febrile illness and H-scoring is to be done. H-score proposed by Fardet L et al., incorporates relatively simpler laboratory parameters to arrive at a diagnosis of HLH.
The serum ferritin level of all the patients was greater than 500 mcg/L.Two patients diagnosed with HIV, Non hodgkin’s lymphoma had serum ferritin levels of 24560 ng/mL and 37700 ng/mL respectively. One patient had extreme elevation of serum ferritin (72,000 ng/mL) at presentation which led to suspicion for HLH. Ferritin levels >10,000 mcg/L were found to be highly sensitive and specific for diagnosis of HLH (10). In a 2015 study conducted by Otrock ZK et and Eby CS 73 patients, greater than 85% of the patients displayed fever, cytopenias and elevated ferritin levels (11). Serum ferritin rise is due to inhibitory cytokines IL-1? elevation. Hypertriglyceridemia was present in 81% of our patients. 64%-70% of paediatric patients with HLH reported elevated triglyceride levels (12).
Hypertriglyceridemia is due to lipoprotein lipase inhibition by Tumor Necrosis factor-? (TNF-?). Bone marrow evidence of haemophagocytosis was present in 92% cases. One patient had no evidence of haemophagocytosis but showed only increase in number of reticulum cells. Presence of bone marrow haemophagocytosis can be seen in various infections without full clinical syndrome. Hence it is not a diagnostic marker. In HLH, the incidence of haemophagocytosis on bone marrow examination ranges from 25-100% (13).
The most common trigger for HLH is viral infection, most commonly EBV (14). Viruses associated with our cases were EBV, HSV, HIV and Parvovirus. Viruses are believed to have triggered HLH.Haematological malignancies can be a secondary cause of HLH. In this study, two patients had Hodgkin's and Non hodgkin's lymphoma. A multicentre study by Parodi A et al., demonstrated autoimmune aetiology like we reported in seven cases (15).
Without treatment, FHL has a median survival of about two months (16),(17). Survival in our patients was 52% at a median follow-up of 5 years. The survival was prolonged by the combined use of steroids and epipodophyllotoxins. Recently, effective cure has been achieved by immunotherapy with cyclosporin and antithymocyte globulin (18). A major therapeutic breakthrough was achieved with allogenic Bone Marrow Transplantation (BMT) (19). Chemotherapy followed by BMT is the current recommendation for treatment purpose (20). The prognosis is better in sporadic HLH. Infection associated haemophagocytic syndrome caused by bacterial infection has a high recovery rate. However, the outcome of EBV associated HLH is poor (21).
Limitation(s)
The underlying aetiology could not be revealed in all cases as patients were lost to follow-up.
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Conclusion |
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Haemophagocytic lymphohistiocytosis (HLH) is an underdiagnosed and rare disease. Because of the high mortality rate, a timely diagnosis is very crucial. Infections and malignancies are the major precipitating factors in HLH. So in a patient with fever and cytopenias, HLH should be suspected as a culprit and H-scoring should be done since early diagnosis and treatment can save patients life. H-scoring needs laboratory tests which are comparatively affordable and available than the tests used in HLH criteria 2004. So it is critical to create a multicenter database where the information about HLH cases can be maintained and tracked. Even if a diagnostic dilemma is created due to the initial clinical findings mimicking other disorders, a comprehensive investigation and a close follow-up could address this problem.
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