Hemophagocytic lymphohistiocytosis

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

1. Hemophagocytic lymphohistiocytosis By Jagjit Khosla By. Dr. JAGJIT KHOSLA

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

3. Hlh - definition 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. ETIOLOGY OF HLH By. Dr. JAGJIT KHOSLA

5. 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 . By. Dr. JAGJIT KHOSLA

6. PATHOPHYSIOLOGY By. Dr. JAGJIT KHOSLA

7. HLH - Pathophysiology 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. HLH - pathophysiology By. Dr. JAGJIT KHOSLA

9. HLH - pathophysiology Perforin Deficiency By. Dr. JAGJIT KHOSLA

10. HLH - pathophysiology By. Dr. JAGJIT KHOSLA

11. HLH - pathophysiology 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. HLH - pathophysiology 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. 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. By. Dr. JAGJIT KHOSLA

14. PRIMARY HLH By. Dr. JAGJIT KHOSLA

15. 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 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 PRIMARY HLH By. Dr. JAGJIT KHOSLA

17. 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. By. Dr. JAGJIT KHOSLA

18. SECONDARY HLH By. Dr. JAGJIT KHOSLA

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

20. Secondary HLH Infections 1 - 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. Secondary HLH 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. Secondary HLH Infections Autoimmune disorders Malignancy 1 2 3 Leukemias Lymphomas By. Dr. JAGJIT KHOSLA

23. Secondary HLH 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. CLINICAL FINDINGS By. Dr. JAGJIT KHOSLA

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

26. Hlh CLINICAL FINDINGS 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. INVESTIGATIONS By. Dr. JAGJIT KHOSLA

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

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

30. Hlh Laboratory values Source : Filipovich , Alexandra H. " Hemophagocytic lymphohistiocytosis and other hemophagocytic disorders."  Immunology and allergy clinics of North America 28.2 (2008): 293-313 . By. Dr. JAGJIT KHOSLA

31. 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 >500 μ g/L : Sensitivity 82%, Specificity 42% Ferritin >10,000 μ g/L : Sensitivity 90%, Specificity 96% By. Dr. JAGJIT KHOSLA

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

33. Hlh Laboratory values 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. 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 By. Dr. JAGJIT KHOSLA

35. DIAGNOSTIC CRITERIA By. Dr. JAGJIT KHOSLA

36. 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. By. Dr. JAGJIT KHOSLA

37. Hlh - Diagnostic criteria Fever Splenomegaly Cytopenia – two or more cell lines 1 2 3 Peak temperature >38.5 o C for 7 or more days Spleen palpated >3 cm below the left costal margin Hemoglobin <9.0 g/ dL , or Platelets <100,000/ μ L, or Absolute neutrophil count <1000/ μ L By. Dr. JAGJIT KHOSLA

38. Hlh - Diagnostic criteria 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. Hlh - Diagnostic criteria Low or absent NK cell activity Elevated S. Ferritin Elevated sCD 25 6 7 8 Serum ferritin >500 μ g/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 fulfilled or Adapted from Treatment Protocol of the 2nd International HLH Study, 2004 By. Dr. JAGJIT KHOSLA

41. TREATMENT By. Dr. JAGJIT KHOSLA

42. 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 By. Dr. JAGJIT KHOSLA

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

44. HLH treatment Immediate goals 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. HLH treatment Long-term goal 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/m 2 per day for first two weeks 5 mg/m 2 per day for week 3 and 4 2.5 mg/m 2 per day for week 5 and 6 1.25 mg/m 2 per day for week 7 Tapering to zero over the 8 th week Etoposide (VP-16) 150mg/m 2 i.v. twice weekly for first two weeks 150mg/m 2 i.v. once weekly for next 6 weeks Cyclosporine A Start with 6mg/Kg daily (2 divided doses) , aim at levels around 200 μ g/L (Trough level) Intrathecal Methotrexate 12mg once weekly for pt >3 yr old for four weeks (week 3 to week 6) HLH treatment By. Dr. JAGJIT KHOSLA

47. 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/m 2 for 3 days Etoposide 150 mg/m2 every second week Cyclosporine A – aim for blood levels around 200 μ g/L, Monitor GFR Allogenic Hematopoietic Stem Cell Transplantation By. Dr. JAGJIT KHOSLA

48. 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. By. Dr. JAGJIT KHOSLA

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50. By. Dr. JAGJIT KHOSLA