Hemophagocytic lymphohistiocytosis - definition, etiology, pathophysiology, primary and secondary HLH, clinical findings, investigations, diagnostic criteria, treatment

1. By Jagjit Khosla
By. Dr. JAGJIT KHOSLA

2. Definition Etiology Pathophysiology
Primary and
Secondary HLH
Clinical
Findings
Investigations
Diagnostic
criteria
Treatment
By. Dr. JAGJIT KHOSLA

3. Hemophagocytosis
Phagocytosis by macrophages of erythrocytes,
leukocytes, platelets, and their precursors in
bone marrow and other tissues
Hemophagocytic Lymphohistiocytosis
Uncommon, life-threatening hyperinflammatory syndrome caused by severe
hypercytokinemia due to a highly stimulated but ineffective immune process
By. Dr. JAGJIT KHOSLA

4. By. Dr. JAGJIT KHOSLA

5. 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.
By. Dr. JAGJIT KHOSLA

6. By. Dr. JAGJIT KHOSLA

7. Y
Y
Antigen Presenting Cell
MHC
Viral Antigen
TNF-α
IFN-γ
CD4+ T-Cell
IL – 1, IL - 6, IL - 18
IL - 2
TCR
By. Dr. JAGJIT KHOSLA

8. By. Dr. JAGJIT KHOSLA

9. Perforin Deficiency
By. Dr. JAGJIT KHOSLA

10. By. Dr. JAGJIT KHOSLA

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

12. 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.”
By. Dr. JAGJIT KHOSLA

13. • 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.
By. Dr. JAGJIT KHOSLA

14. By. Dr. JAGJIT KHOSLA

15. • 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
By. Dr. JAGJIT KHOSLA

16. 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
By. Dr. JAGJIT KHOSLA

17. 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.
By. Dr. JAGJIT KHOSLA

18. By. Dr. JAGJIT KHOSLA

19. Infections
Autoimmune disorders
Malignancy
Immunosuppression /
Organ transplant
1
2
3
4
By. Dr. JAGJIT KHOSLA

20. 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
By. Dr. JAGJIT KHOSLA

21. Infections
Autoimmune disorders
1
2
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
By. Dr. JAGJIT KHOSLA

22. Infections
Autoimmune disorders
Malignancy
1
2
3
- Leukemias
- Lymphomas
By. Dr. JAGJIT KHOSLA

23. Infections
Autoimmune disorders
Malignancy
Immunosuppression /
Organ transplant
1
2
3
4
- Post-Chemotherapy
- After Renal or liver transplant
- Immunosuppressive treatment
By. Dr. JAGJIT KHOSLA

24. By. Dr. JAGJIT KHOSLA

25. • Common findings
– Prolonged fever
– Hepatosplenomegaly
– Neurologic symptoms – seizures, cranial nerve
palsies
• Less common findings
– Lymphadenopathy
– Rash
– Jaundice
By. Dr. JAGJIT KHOSLA

26. 0
10
20
30
40
50
60
70
80
90
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”By. Dr. JAGJIT KHOSLA

27. By. Dr. JAGJIT KHOSLA

28. • Cytopenias
– Anemia and thrombocytopenias are more common
– Mechanism –
• Suppression by TNF-α and INF-γ
• Consumption by hemophagocytosis
By. Dr. JAGJIT KHOSLA

29. • Cytopenias
• Tissue demonstration of Hemophagocytosis
– Repeated attempts needed to identify characteristic
histology
– Lymph node biopsy or bone marrow aspirates
By. Dr. JAGJIT KHOSLA

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

31. • 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%
By. Dr. JAGJIT KHOSLA

32. • Cytopenias
• Tissue demonstration of Hemophagocytosis
• Elevated Ferritin
• Elevated triglycerides
– Mechanism - Increased TNF-α suppress activity of
lipoprotein lipase
By. Dr. JAGJIT KHOSLA

33. • Cytopenias
• Tissue demonstration of Hemophagocytosis
• Elevated Ferritin
• Elevated triglycerides
• Depressed Fibrinogen
– Mechanism - Increased levels of Plasminogen activator
secreted by activated macrophages
By. Dr. JAGJIT KHOSLA

34. • 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
By. Dr. JAGJIT KHOSLA

35. By. Dr. JAGJIT KHOSLA

36. • In HLH-94, diagnosis was based on 5 five
criteria.
• In HLH-2004, three additional criteria added,
making it total 8 criteria.
By. Dr. JAGJIT KHOSLA

37. 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, or
Platelets <100,000/μL, or
Absolute neutrophil count <1000/μL
By. Dr. JAGJIT KHOSLA

38. Hypertriglyceridemia /
Hypofibrinogenemia
Hemophagocytosis
4
5
Fasting triglycerids >2.0 mmol/L, or >3 SD above the normal value for
age, or
Fibrinogen <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
By. Dr. JAGJIT KHOSLA

39. 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
By. Dr. JAGJIT KHOSLA

40. • 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 mutations
5 out of 8 diagnostic
criteria fulfilledor
Adapted from Treatment Protocol of the 2nd International HLH Study, 2004By. Dr. JAGJIT KHOSLA

41. By. Dr. JAGJIT KHOSLA

42. • 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
By. Dr. JAGJIT KHOSLA

43. Immediate goals
Long term goals
By. Dr. JAGJIT KHOSLA

44. Immediategoals
Suppress 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
By. Dr. JAGJIT KHOSLA

45. Long-termgoal
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)
By. Dr. JAGJIT KHOSLA

46. 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
10 mg/m2 per day for first two weeks
5 mg/m2 per day for week 3 and 4
2.5 mg/m2 per day for week 5 and 6
1.25 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 weeks
150mg/m2 i.v. once weekly for next 6 weeks
Cyclosporine A
Start with 6mg/Kg daily (2 divided doses) , aim at
levels around 200 μg/L (Trough level)
Intrathecal Methotrexate
12mg once weekly for pt >3 yr old for four weeks
(week 3 to week 6)
By. Dr. JAGJIT KHOSLA

47. 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 days
Etoposide 150 mg/m2 every second week
Cyclosporine A – aim for blood levels around 200 μg/L, Monitor GFR
Allogenic Hematopoietic Stem Cell Transplantation
By. Dr. JAGJIT KHOSLA

48. • 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.
By. Dr. JAGJIT KHOSLA

49. • 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
Hematol37(2): 112-9.
By. Dr. JAGJIT KHOSLA

50. By. Dr. JAGJIT KHOSLA