Use of Anakinra in a Case of Severe Dengue with Refractory Secondary Hemophagocytic Lymphohistiocytosis

Abstract

Abstract Background: Hemophagocytic lymphohistiocytosis (HLH) is a severe life-threatening systemic inflammatory syndrome which may be secondary to infections. It is a potential complication of severe dengue. We report a child with severe dengue with worsening clinical course due to secondary HLH. The refractory course responded to intravenous anakinra (an interleukin-1 blocker) as an add-on therapy. Clinical Description: An 11-year-old girl with dengue presented on the 7th day, with progressively worsening clinical condition, having developed multi-organ dysfunction syndrome. Management and Outcome: She required mechanical ventilation, hemodialysis, and extracorporeal hemoadsorption therapy. In view of secondary HLH, intravenous immunoglobulin and methylprednisolone were administered, but there was clinical worsening. Hence, anakinra was initiated and improvement was noted in the next 48 hours. The child was finally extubated on day 17 of illness and could be discharged. Conclusion: Secondary HLH should be considered early in severe dengue cases with cytopenias, hyperferritinemia, and multi-organ dysfunction and immunotherapy should be initiated without delay. Anakinra is a promising, efficient, therapeutic choice and may have a beneficial role and better prognosis if started early in rapidly worsening HLH.