Aplastic anemia presenting as hemophagocytic lymphohistiocytosis/ Hemofagositik lenfohistositoz olarak baslayan aplastik anemi.
Two unusual cases of hemophagocytic lymphohistiocytosis (HLH)
complicating aplastic anemia (AA) are described. Each patient had a
history of preexisting acute hepatitis of unknown cause at the time of
HLH diagnosis and infection-associated secondary HLH. They developed
high fever and pancytopenia. Hemophagocytes were seen in the bone
marrow. With steroid (in combination with etoposide and CyA in 1
patient), high fever disappeared and the patients' liver function
gradually recovered. As severe pancytopenia persisted, bone marrow
became acellular and AA was diagnosed. Since HLH is known to be able to
cause an aplastic bone marrow if untreated for a prolonged time, it is
therefore in line that hepatitis-associated AA may also be associated
Aplastic anemia-associated HLH has been reported rarely, and problems in the diagnostic procedure are discussed. (Turk J Hematol 2010; 27: 38-42)
Key words: Hemophagocytosis, aplastic anemia, hepatitis
Bu makalede hemofagositik sendrom (HLH) tanisi alip daha sonra aplastik anemi (AA) gelisen 2 hasta sunulmustur. Her 2 hastada da HLH tanisindan once etyolojisi net olarak konulmamis akut hepatit oykusu vardi ve bu enfeksiyon nedeni ile HLH'leri enfeksiyon iliskili HLH olarak degerlendirilmisti. Iki olguda da ates ve pansitopeni vardi. Hemofagositoz iki olguda da kemik iligi aspirasyon materyalinde gosterilmisti. Bir olguda steroid digerinde steroide ek olarak etoposid ve siklosporin (CyA) ile yuksek ates ve karaciger fonksiyonlarinda duzelme saptanmaya baslanmisti. Tedaviye ragmen agir sitopeninin devam etmesi uzerine kemik iliginin tekrar degerlendirilmesi sonucunda hastalara aplastik anemi tanisi konuldu. Hemofagositik sendrom uzun sureli tedavi edilmediginde kemik iliginde aplaziye neden olabilir, bu nedenle hepatite bagli gelisen aplastik anemilerin gelisim surecinde HLH' da olabilir. (Turk J Hematol 2010; 27: 38-42)
Anahtar kelimeler: Hemofagositoz, aplastik anemi, hepatit
|Article Type:||Clinical report|
Aplastic anemia (Drug therapy)
Aplastic anemia (Research)
Immunosuppressive agents (Usage)
Immunosuppressive agents (Health aspects)
|Publication:||Name: Turkish Journal of Hematology Publisher: Aves Yayincilik Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Aves Yayincilik ISSN: 1300-7777|
|Issue:||Date: March, 2010|
|Topic:||Event Code: 310 Science & research|
|Product:||SIC Code: 2834 Pharmaceutical preparations|
|Geographic:||Geographic Scope: Turkey Geographic Code: 7TURK Turkey|
Differential diagnosis of hemophagocytic lymphohistiocytosis (HLH) and aplastic anemia (AA) is very confusing for a clinician who must initiate life-saving therapy with immunosuppressive/immunomodulatory agents in time [1-3]. Brown et al.  reported that post-hepatitis AA typically occurs in young, previously healthy males with self-limited but severe liver inflammation with very high serum aminotransferase and bilirubin levels; profound pancytopenia follows several weeks later.
We present herein our experience with two adolescent boys ages 11 and 12 years who both presented with hyperbilirubinemia and secondary HLH resulting in AA. Both diseases may have some similar immune-mediated conditions involving the activation of T lymphocytes. Moreover, immunosuppressive therapy with antithymocyte globulin (ATG) and cyclosporine (CyA) is very effective for AA, while intensive immunosuppressive therapy with ATG and CyA might be a useful strategy for steroid-resistant HLH .
Aplastic anemia is an immune-mediated disease that is associated with increased apoptosis of bone marrow stem cells. The increase in apoptosis is due to various cytokines that inhibit hematopoiesis, produced by activated T-cells. As is well known, HLH is characterized by a systemic activation of macrophages/histiocytes, which are induced to undergo phagocytosis of hematopoietic elements. This hyperinflammatory condition is associated with genetic inheritance, infection, malignancy, and immune deficiencies. The cardinal symptoms are prolonged fever, cytopenias, hepatosplenomegaly, and hemo-phagocytosis by activated, morphologically benign macrophages. Biochemical markers include elevated ferritin and triglycerides and low fibrinogen. Impaired function of natural killer (NK) and cytotoxic T-cells is characteristic. Two forms of HLH, primary (genetic) and secondary (acquired), have been reported. Secondary HLH has been reported in association with a variety of conditions . Children with HLH have a higher probability of malignancy, suggesting a possible predisposing role. However, there are only rare reports of an association between AA and HLH.
Generally, the diagnosis of HLH is difficult unless there is suspicion. HLH initially may masquerade as a normal infection since all symptoms may be common.
Written informed consent was obtained from all patients.
Case 1: A 12-year-old boy was followed with hepatitis in a local health center for 40 days. Serologic tests for Epstein-Barr virus (EBV), cytomegalovirus (CMV), herpes simplex virus (HSV)-I, HSV-II, hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis A virus (HAV), and parvovirus B-19 were either negative or consistent with prior exposure. As liver enzymes remained elevated (AST 1975 U/L, ALT 2950 U/L) and total bilirubin increased to 4.73 mg/dl, with international normalized ratio (INR) of 4.67, he was referred to our hospital. Persistent pancytopenia was noticed, and he was consulted to the hematology ward after 25 days. The patient met the diagnostic criteria of HLH described by the Histiocyte Society . Bone marrow aspiration was performed and showed an increased number of histiocytes with hemophagocytosis. As he was suspected to have infection-associated secondary HLH, steroid therapy was started (dexamethasone 10 mg/[m.sup.2] in the beginning and tapered after 2 weeks, planned for a total period of 8 weeks). After steroid, the long-lasting fever disappeared in 2 days and there was an unexpected rapid resolution of hepatosplenomegaly (each 2 cm below the costal margin). Although the clinical manifestations, which were attributed to hypercyto-kinemia, were controlled with steroid, the pancytopenia persisted even after etoposide was added to the HLH regimen after a 4-week period. Bone marrow biopsy performed after 6 weeks of HLH treatment due to no response of cytopenia revealed AA. He was lost 25 days after ATG treatment due to aspergillus in the lung and pseudomonas bacteremia.
Case 2: An 11-year-old boy was followed with persistent hepatitis in a local health center for 2 months until gastrointestinal bleeding was detected. Viral documentation was normal. Liver enzymes remained elevated (AST 2930 U/L, ALT 3460 U/L), INR increased to 6.3, and he was referred to our hospital. Pancytopenia and fever were noticed and he was consulted to the hematology ward after 15 days. The liver biopsy performed before hematology consultation revealed infection. The patient was diagnosed as secondary HLH after an increased number of histiocytes with hemophagocytosis were noticed in the bone marrow aspiration, supported by decreased fibrinogen and increased ferritin, which until the HLH diagnosis were thought to be due to numerous transfusions. He was given dexameth-asone at a dose of 10 mg/[m.sup.2]. Fever and splenomegaly disappeared in the first week, but pancytopenia resulting in near-fatal infection persisted. Granulocyte colony-stimulating factor (G-CSF) was added to steroid treatment due to no hematological relief, and bone marrow biopsy was done. His parents refused any treatment for AA and the patient died due to uncontrolled bleeding and sepsis.
Both of the presented patients had no family history suggestive of familial HLH. The patients died before any mutational analysis or NK cell function studies could be performed. The diagnosis of secondary HLH, therefore, is based on fulfillment of a minimum of five clinical criteria . Gupta et al.  mentioned in their commentary that despite the availability of genetic and immunological tests in the diagnosis of HLH, there is a lack of a confirmatory diagnostic test for acute situations. There are also no clear-cut definitions for HLH bone marrow infiltration. Three smears with at least 2 histiocytes demonstrating hemophagocytosis on each are suggested for HLH diagnosis, which were detected in both of our patients . No fatty infiltration was detected during HLH diagnosis. Bone marrow examination showed normal maturation of the three series without dysplastic features or any blast. The most prominent feature was an increase in hemophagocytosing histiocytes. Based on these findings, the patients were diagnosed as HLH and not AA. Then, after 15-21 days of HLH treatment, the bone marrow became severely hypoplastic. However, the hemophagocytic features that were apparent before the HLH regimen had disappeared in both patients.
Both patients were diagnosed as having severe bone marrow failure after HLH that was similar to severe AA. Severe pancytopenia with fatty infiltration of the bone marrow is characteristic of AA, but high fever or liver dysfunction is not common if there is no coexisting infection.
Hemophagocytic lymphohistiocytosis and AA represent distinct disease entities, but they have some pathologically similar aspects with activation of T lymphocytes. As mentioned in the literature, HLH can be diagnosed before or after AA [8-10]. In our patients, post-hepatitis AA, or HLH associated with an undiagnosed viral infection in a patient with AA, or a coexistence of HLH and AA could be considered in the differ- ential diagnosis. However, no fatty change of the marrow was found in the beginning, and its cellularity was not severely depressed at the time of admission, while hemophagocytic histiocytes were prominent.
These findings were characteristic of HLH rather than AA. The diagnosis of AA is often difficult because of the presence of local hemapoietically active spots that can lead to an erroneous assessment before fatty bone marrow. Thus, marrow examinations need to be repeated if pancyto-penia persists. The histiocyte count is sometimes increased in AA just like plasma cells, but this is a relative increase and is not associated with hemophagocytosis. Ost et al.  reported that the cellularity of the marrow was decreased in some patients and this tissue was severely hypoplastic, even in some children who had not been treated with cyto-static drugs. They also reported that the histological pattern in HLH resembles that of chronic persistent hepatitis. In other words, there is a potential link between AA, HLH and hepatitis-associated AA .
Hyperbilirubinemia usually coexists with pancytopenia in HLH, while bone marrow failure secondary to acute hepatitis generally occurs after the hepatitis has resolved if the diagnosis is AA. Immunosuppressive therapy with ATG and CyA, which is a common treatment strategy for severe AA, is sometimes used successfully for HLH, especially for steroid-refractory HLH [5,12].
Impaired function of NK cells and cytotoxic T-cells is characteristic for both genetic and acquired forms of HLH. Frequent triggers are infectious agents, mostly viruses of the herpes group [13,14]. HLH has been identified to be related with genes encoding perforin (PRF1/FHL2), Munc 13-4 (UNC13D/FHL3), and syntaxin-11 (STX11/FHL4). In order to show the relation of AA and HLH, Solomou et al.  studied perforin levels in patients with AA. They found that in AA disease with hematopoietic stem cells, which were destructed by activated T-cells and Th1 cytokines, perforin protein levels were very low or absent, and perforin granules were completely diminished . NK cells are the predominant perforin-containing cell type. As a result, NK cell cytotoxicity in these patients was significantly decreased . In one of the HLH subgroups with normal perforin levels, syntaxin-deficient patients, it was shown very recently that their NK cells failed to degranulate when they encountered susceptible target cells [16,17].
Patients with HLH, however, cannot control the hyperin-flammatory response which, if untreated, is fatal. Awareness of the clinical symptoms and of the diagnostic criteria of HLH is important to start life-saving therapy with immunosuppressive/ immunomodulatory agents in time. Therefore, we suggest that patients with hepatitis who develop pancytopenia and high liver enzymes that remain elevated for longer than expected should be examined with bone marrow aspiration and biopsy for demonstration of hemophagocytosis or for bone marrow failure resulting in AA.
Conflict of interest
No author of this paper has a conflict of interest, including specific financial interests, relationships, and/or affiliations relevant to the subject matter or materials included in this manuscript.
Received: August 14, 2008 Accepted: April 8, 2009
Gelis tarihi: 14 Agustos 2008 Kabul tarihi: 8 Nisan 2009
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Department of Pediatric Hematology-Oncology, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
Address for Correspondence: Assoc. Prof. Tiraje Celkan, Konaklar mah. Sebboy sok. Armakent sitesi B2/8 4. Levent/ 80620 Istanbul, Turkiye Phone: +90 212 283 69 22 Office: +90 212 414 30 00 / 21956 E-mail: firstname.lastname@example.org
Table 1. Findings of patients (ND: not done) Case 1 Clinical findings Fever + Hepatomegaly 2 cm Splenomegaly 2 cm Infection + Jaundice + Bleeding Laboratory findings Hemoglobin gr/dl At the beginning of complainment 9.6 At the admission our hospital 5.6 At the diagnosis of HLH 3.6 At the diagnosis of AA 3.7 WBC [mm.sup.3] At the beginning of complainment 12.600 At the admission our hospital 5400 At the diagnosis of HLH 3000 At the diagnosis of AA 2200 Platelet [mm.sup.3] At the beginning of complainment 178.000 At the admission our hospital 98.000 At the diagnosis of HLH 6000 At the diagnosis of AA 9000 Reticulocyte <0.1 AST iu/L At the beginning of complainment 1108 At the admission our hospital 1975 At the diagnosis of HLH 46 At the diagnosis of AA 44 ALT iu/L At the beginning of complainment 1963 At the admission our hospital 2950 At the diagnosis of HLH 27 At the diagnosis of AA 660 bilirubin At the beginning of complainment 4.8 At the admission our hospital 1.35 Triglyceride mg/dL At the diagnosis of HLH 456 At the diagnosis of AA 115 Fibrinogen g/dL At the admission our hospital ND At the diagnosis of HLH 80 At the diagnosis of AA 170 Bone marrow aspiration At the diagnosis of HLH hemophagocytic features At the diagnosis of AA Bone marrow failure, hypoplasia Bone marow biopsy At the diagnosis of AA devoid of hematopoietic elements, fat and reticulum cells Case 2 Clinical findings Fever + Hepatomegaly 1.5 cm Splenomegaly 2 cm Infection + Jaundice + Bleeding Laboratory findings Hemoglobin gr/dl At the beginning of complainment 10.8 At the admission our hospital 6.8 At the diagnosis of HLH 8.7( With transfusions) At the diagnosis of AA 7.5 WBC [mm.sup.3] At the beginning of complainment 17.000 At the admission our hospital 6700 At the diagnosis of HLH 1400 At the diagnosis of AA 1100 Platelet [mm.sup.3] At the beginning of complainment 186.000 At the admission our hospital 79.000 At the diagnosis of HLH 8000 At the diagnosis of AA 4000 Reticulocyte AST iu/L At the beginning of complainment 2089 At the admission our hospital 1790 At the diagnosis of HLH 47 At the diagnosis of AA ALT iu/L At the beginning of complainment 2298 At the admission our hospital 1810 At the diagnosis of HLH 45 At the diagnosis of AA 43 bilirubin At the beginning of complainment Not known At the admission our hospital 1.77 Triglyceride mg/dL At the diagnosis of HLH 780 At the diagnosis of AA ND Fibrinogen g/dL At the admission our hospital 180 At the diagnosis of HLH 56 At the diagnosis of AA ND Bone marrow aspiration At the diagnosis of HLH hemophagocytic features At the diagnosis of AA Hypoplasia Bone marow biopsy At the diagnosis of AA Diminished hematopoietic elements, increased showing largely fatty tissue and reticulum cells
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