Abstract
BackgroundPrimary haemophagocytic lymphohistiocytosis (HLH) screening assays are increasingly being performed in patients presenting with macrophage activation syndrome (MAS). The objective of this study was to describe their diagnostic and prognostic relevance in children who had presented to paediatric rheumatology and had undergone investigative work up for MAS.MethodsData was obtained retrospectively from an existing protein screening assay database and patient records. Assays included: intracellular expression of perforin in CD56+ Natural Killer (NK) cells; CD107a Granule Release Assay (GRA) in response to PHA in NK cells, or anti-CD3 stimulation of CD8 lymphocytes; in males Signal Lymphocyte Activating Molecule Associated Protein (SAP), and X-linked Inhibitor of Apoptosis Protein (XIAP) expression. All assays, requested by paediatric rheumatology, of children who had undergone investigative work up for MAS over a 5-year period (2007–2011) were included.ResultsTwenty-one patients (15 female), median age 6.5 years (range 0.6–16) with follow-up of 16 months (range 1–51), were retrospectively identified. At presentation, 3/21 (14 %) fulfilled HLH-2004 diagnostic criteria. At least one screening test result was available for all 21 patients; 7/21 (33 %) had at least one persistent screening test abnormality. Of this group 4/7 (57 %) died or required haematopoietic stem cell transplantation (HSCT), compared to 1/14 (7 %) with no screening test abnormality (p = 0.025). 3/21 (14 %) ultimately had a diagnosis of primary HLH (two confirmed genetically; XIAP, familial HLH type 3, and one confirmed clinically). Of the six patients with abnormal GRA 5/6 had negative routine genetic results.ConclusionsScreening for primary HLH is warranted for children whose first rheumatological presentation is with MAS, since overall 14 % had an eventual diagnosis of primary HLH. A persistently abnormal GRA in patients presenting with MAS defines a high-risk group with poor outcome (mortality or HSCT), possibly due to as yet unidentified genetic cause.Electronic supplementary materialThe online version of this article (doi:10.1186/s12969-015-0043-7) contains supplementary material, which is available to authorized users.
Highlights
Primary haemophagocytic lymphohistiocytosis (HLH) screening assays are increasingly being performed in patients presenting with macrophage activation syndrome (MAS)
Screening assays Standard operating procedures for the granule release assay and detection of perforin, X-linked Inhibitor of Apoptosis Protein (XIAP) and Signal Lymphocyte Activating Molecule Associated Protein (SAP) are included as a supplement [Additional file 1]
As primary HLH and MAS overlap clinically, we suggest that rapid screening for primary HLH in these patients is warranted; clinicians could consider these investigations for children with MAS even with an established underlying rheumatological disorder, for those cases not responding to high-dose corticosteroids and ciclosporin
Summary
Primary haemophagocytic lymphohistiocytosis (HLH) screening assays are increasingly being performed in patients presenting with macrophage activation syndrome (MAS). HLH is classified into primary (genetic/familial) or secondary forms [2]. There is an increasing understanding of the genetic and molecular basis of many primary forms of HLH, summarised in Fig. 1 [3,4,5,6,7,8,9,10]. When HLH is secondary to these latter rheumatological conditions, it is usually referred to as macrophage activation syndrome (MAS) [12]. This can be a severe and potentially fatal complication if not recognised early and treated aggressively
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