Medical ProgressHemophagocytic Lymphohistiocytosis: Advances in Pathophysiology, Diagnosis, and Treatment
Section snippets
Subtypes of HLH
Granule-mediated cytotoxic T lymphocyte (CTL) function is essential for the control of infection, as well as regulation and termination of the immune response. Mutations in genes that encode proteins critical to the lymphocyte granule-mediated cytotoxic pathway lead to FHLH.6 Based on genetic etiology, FHLH has been subcategorized into 5 subtypes, FHLH-1 to FHLH-5.7 The mutation in FHLH-1 remains unidentified, but the defect has been mapped to chromosome 9q21.3. FHLH-2 is due to mutations in
Pathophysiology
In the normal physiological context, granule-mediated cytotoxic function of natural killer (NK) cells and CTLs is required for clearance of viral infection as well as regulation and termination of the inflammatory response.19 Thus, defects in NK cell and CTL granule-mediated cytotoxicity result in ineffective clearance of infection and defective suppression of antigen presentation, leading to persistent antigen exposure and prolonged cytotoxic T-cell activation.19 Until recently, the
Clinical Presentation
FHLH was once thought to affect predominantly infants and young children. However, recent reports suggest that it can affect all age groups, from preterm neonates25 to elderly adults.26 With increasing awareness, HLH is likely to be diagnosed more often in infants. However, its occurrence in neonates and adults is still underrecognized.25, 27 HLH in neonates merits special mention because the disorder can be easily missed and mismanaged as sepsis. Fever, a frequent symptom in children with HLH,
Genetics
With the identification of defects in PRF1, UNC13D, STX11, and STXBP2 genes in FHLH, a genetic diagnosis can be made in up to 40%-80% of patients with HLH.35, 36 Defects in UNC13D are the predominant defects identified in Caucasians in the US.36 In African-American patients, PRF1 defects are by far the most common.36 Studies in patients with defects in PRF1,37 UNC13D,38 and STXBP232 have shown broad phenotype–genotype correlations based on the functionality of the protein expressed. Generally,
Diagnosis
The Histiocyte Society HLH 2004 protocol establishes both clinical and laboratory diagnostic criteria for the diagnosis of HLH29 (Table II). These published criteria pertain especially to the diagnosis of FHLH. For early diagnosis of secondary HLH (especially MAS), decreasing leukocyte and platelets counts may be more relevant than absolute cytopenias. Although analysis of bone marrow aspirate is commonly used for diagnosing HLH, it has a sensitivity of only ∼60%.42 Undue emphasis on a lack of
Treatment
Significant advances have been made in the management of HLH over the last 2 decades. Current management of HLH involves a 2-pronged approach comprising a short-term strategy aimed at controlling the hyperinflammatory state and a long-term strategy aimed at definitively correcting the underlying genetic defect by allogeneic HCT. Management of the hyperinflammatory state focuses on 3 main areas: controlling or eliminating the infectious trigger, stopping T-cell proliferation and activation, and
Summary
HLH is a potentially fatal disorder of immune regulation. Depending on the severity of the underlying genetic defect, it can present across all age groups. Both pediatricians and subspecialists need to be aware of the atypical presentations of HLH. Colitis, bleeding tendency, and hypogammaglobulinemia are not uncommon in HLH. When evaluating patients with HLH, secondary HLH/MAS from underlying infections, rheumatologic disease, or malignant neoplasms should be considered as well. Many rapid
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The authors declare no conflicts of interest.