Interhospital Conference Ramathibodi hospital 20 March 2012 Physical

Interhospital Conference Ramathibodi hospital 20 March 2012

Physical Examination V/S: T 37. 8°C, PR 120 bpm, RR 40 bpm, BP 96/44 mm. Hg, BW 14 kg (P 50 -75 th), Ht 95 cm (P 50 -75 th), HC 49 cm (P 50 th) GA: a Thai girl, drowsiness, mild pallor, no jaundice, no dysmorphic feature, capillary refill 3 sec HEENT: bilateral cervical LN 0. 5 cm, no neck mass, pharynx and tonsil not injected

Physical Examination CVS: normal S 1 S 2, no murmur Lung: clear, no adventitious sound, no retraction Abdomen: soft, no distension, liver 3 cm below RCM, liver span 9 cm, spleen 4 cm below LCM Skin : no lesion

Physical Examination Nervous system : drowsiness, pupils 3 mm RTLBE, no stiffness of neck, full EOM by observe, no nystagmus, no facial palsy, corneal reflex positive, gag reflex negative, tongue and uvula in midline, spastic all extremities, motor power: Rt side gr I, Lt side gr II, DTR 3+, BKK: present both sides

Investigation 1 2 6 10 3 7 11 8 12 5 4 9 13 14

CBC • • Hb 9. 5 g/d. L Hct 28. 2% WBC 2, 930/cumm. PMN 40% Lymph 51% Mono 5% Atyp L 4% Plt 34, 000/cumm. • • RDW 16. 9% MCV 70. 5 f. L MCH 23. 7 pg MCHC 33. 7 g/d. L Anisocytosis 1+ Microcyte 1+ Hypochromia 1+

Coagulogram • • • a. PTT 27 sec PT 13 sec INR 1. 13 TT 11 sec Fibrinogen 248 mg/d. L

Blood chemistry • • • Na 129 mmol/L • BUN 10 mg/d. L K 3. 2 mmol/L • Cr 0. 51 mg/d. L Cl 94 mmol/L CO 2 23. 5 mmol/L Inorganic phosphate 3. 5 mg/d. L Calcium 7. 6 mg/d. L (correct 8. 8) • Mg 1. 8 mg/d. L

Liver function test • • • AST 25 U/L ALT 29 U/L GGT 20 U/L TP 62. 6 g/L Albumin 25. 6 g/L • ALP 63 U/L • TB 0. 2 mg/d. L • DB 0. 1 mg/d. L

CXR

Ferritin • Ferritin 2, 248 ng/m. L

Viral studies • EBV Ig. G : Positive • EBV Ig. M : Negative • EBV viral load < 100 copies

Bone marrow aspiration • Bone marrow aspiration – Hypercellularity 1+ – Adequate in number of megakaryocyte, erythroid, myeloid series – No blast – No abnormal cell – No hemophagocytic activity

Bone marrow biopsy – Active trilinear hematopoiesis with increase histiocytes with hemaphagocytosis activity – No immunophenotypic evidence of increased blasts or non. Hodgkin lymphoma – CD 68 -positive histiocytes are increased

Lipid profile • TG 328 mg/d. L • Chol 112 mg/d. L • LDL 38 mg/d. L

LDH • LDH 164 U/L

CSF profile • CSF – WBC 3 cell/cumm – RBC not seen – Monocyte 100% – Glucose 58 mg/d. L – Protein 93. 8 mg/d. L – Blood glucose 104 mg/d. L

Brain biopsy – Dense perivascular lymphohistiocytic infiltration with demyelination – CD 1 a : negative – CD 3, CD 4, CD 8, CD 20 : Positive – CD 68 : Positive in reactive histiocytic cell

Brain biopsy (1) Perivascular cuffs of mononuclear inflammatory cells

Brain biopsy (2) Microglial activation

Brain biopsy (3) Infiltrate of foamy histiocytes with reaction astrocytes

PRF 1 gene mutation analysis • PCR amplification and sequencing analysis of PRF 1 gene (exon 2 and 3) • Interpretation : – The mutation of PRF 1 exon 2 or 3 was not identified – The PRF 1 c. 822 C>T and c. 900 C>T which synonymous SNPs

UNC 13 D (Munc 13 -4) – Polymorphism or Mutation of UNC 13 D IVS 4 -1 or IVS 9 -1 was not identified – c. 756_757 ins. AC cause a shift in the reading frame UNC 13 D c. 756_757 ins. AC

Posttreatment Hb (g/d. L) Hct (%) WBC (cumm) Neutrophil (%) Platelets (cumm) 1 -week 1 -month 3 -month 9. 4 10. 9 12. 5 29 30. 9 37. 9 2410 9020 9190 21 13 51 118000 500000 257000

MRI post treatment 3 -month • MRI brain – Marked decrease white matter lesions which severe white matter volume loss with bilateral ventricles dilatation – Increase choline with decrease NAA at residual periventricular lesions without relative hyperperfusion • MRI whole spine – Remaining intramedullary lesions entire spinal cord but not enhancement – Clumping with faint enhancing cauda equina nerve root

Method • Single center (France) retrospective 1981 to 1993 • 34 patients (19 girls, 15 boys) with HLH – 25 patients with family history (consanguinity or siblings affected same syndrome – 9 patients without family history, no concomitant infectioninduced, recurrence of hemophagocytic syndrome • Evaluate : clinical, CSF, neuroradiolological studies E. Haddad, et al. blood. 1997 Feb; 89: 794 -800.

Results E. Haddad, et al. blood. 1997 Feb; 89: 794 -800.

• Meningitis – 20 -80 lymphocytes/µL with protein 50 -100 mg/d. L • 20 with meningitis (mean age 6. 9 months) • 9 with neurological symptoms (mean age 16 months) E. Haddad, et al. blood. 1997 Feb; 89: 794 -800.

• Brain imaging – 9/20 with meningitis • 4 had abnormal : 2 with pericerebral diffuse subdural dilataion, 2 with white matter lesions – 8/9 with neurological symptoms • Most frequent focal necrosis with parenchyma volume loss and white matter lesions E. Haddad, et al. blood. 1997 Feb; 89: 794 -800.

• 19 patients had severe CNS progression • 4 patients repeat imaging – 3 with severe brain atrophy – 1 with enhance cerebellar white matter and parenchyma loss E. Haddad, et al. blood. 1997 Feb; 89: 794 -800.

E. Haddad, et al. blood. 1997 Feb; 89: 794 -800.

• 7 alive with normal neurological examination, CSF, cognitive development • 3 cases perform MRI before and after BMT – 2 had normal MRI (pre/post BMT) – 1 had white matter lesion before BMT and remain 2 years after BMT E. Haddad, et al. blood. 1997 Feb; 89: 794 -800.

• • Large cohort of children (n = 193) Originated from 25 countries Median age at diagnosis 9 months 106 (55%) less than 1 year of age at diagnosis 43/192 (22%) (no data = 1) familial disease Consanguinity 37/186 (20%) cases (no data = 7) 11 patients studied specified viral infections at diagnosis A. Horne, et al. BJH. 2007 Dec; 140: 327– 335.

A. Horne, et al. BJH. 2007 Dec; 140: 327– 335.

Neurological symptoms and relation to abnormal CSF A. Horne, et al. BJH. 2007 Dec; 140: 327– 335.

CSF • 101 patients (52%) abnormal CSF – Elevated CSF protein 76/188 (40%) – Elevated cell counts in 79/189 42%)) • Abnormal CSF at onset had sequelae compared to 5/61 (8%) patients with normal CSF (P = 0. 024) A. Horne, et al. BJH. 2007 Dec; 140: 327– 335.

A. Horne, et al. BJH. 2007 Dec; 140: 327– 335.

Neuroradiology • Performed 115/193 patients (60%) • 35/115 patients (30%) reported abnormal – Generalized cerebral atrophy (n = 16) – White matter lesions and demyelination (n = 5) – Non-specific inflammatory changes (n = 4), – Intracerebral bleeding (n = 2) and brain edema (n = 1) – Cerebellar involvement (n=5) A. Horne, et al. BJH. 2007 Dec; 140: 327– 335.

Mortality and CNS involvement • 3 -year probability of was 56% – 67(61%) transplanted – 37 (34%) ‘off-therapy’ • 49 patients died before SCT – 18 of these (37%) CNS involvement – No neurological symptom but abnormal CSF (CNS group 3) A. Horne, et al. BJH. 2007 Dec; 140: 327– 335.

A. Horne, et al. BJH. 2007 Dec; 140: 327– 335.

Neurological symptoms at follow-up Transplanted patients • 102 patients undergone SCT, 67 (66%) were alive • Most common sequelae – Neurodevelopmental retardation (n = 7) – Epilepsy (n = 4) – ADHD (n = 2) – Hearing loss (n = 2) – minimal cerebral palsy and hemiplegia (n = 1 each) A. Horne, et al. BJH. 2007 Dec; 140: 327– 335.

• 92 patients with HLH January 2004 to August 2008 • 82 patients (89%) active viral infection – 69/82 patients (75%) EBV infection • 9 patients not find any underlying disease • None of the patients were offspring of consanguineous marriages or history of siblings affected by same syndrome – 82 were only child in the family S. Yang, et al. Pediatr Blood Cancer 2010; 54: 408– 415.

Methods • Prior to start therapy, all patients underwent – CSF cytology and biochemical assays – Brain CT and/or MRI examination • CSF analysis repeated weekly until normalize • CT or MRI examinations – Repeated at 8 -week intervals until treatment stopped – Completed therapy every 6 months for at least 1 year

RESULTS • 43 patients CNS involvement, either clinical, MRI/CT or CSF abnormalities • 36 (84%) patients had EBV-HLH • No underlying disease found in 5 patients S. Yang, et al. Pediatr Blood Cancer 2010; 54: 408– 415.

RESULTS • • 4 : S+R+C 4 : S+R 2 : S+C 6 : R+C 2: S 3: C 22 : R S, symptoms R, neuroradiology C, CSF S. Yang, et al. Pediatr Blood Cancer 2010; 54: 408– 415.

Neuroradiological Examinations • CT 46 patients, 8 showed abnormalities – Calcifications (n= , (2 atrophy (n= , (2 demyelination (n=, (2 edema (n= , (1 and hemorrhage (n=(1 • MRI 64 patients, 34 showed abnormalities – High signal intensity lesions on T 2 -weighted and FLAIR MRI images (n= , (29 atrophy (n= , (9 hemorrhage (n= , (5 cerebromalacia (n= , (4 and calcifications (n=(2 S. Yang, et al. Pediatr Blood Cancer 2010; 54: 408– 415.

Clinical Manifestations • 12 patients neurological symptoms at diagnosis • Eleven of these EBV-HLH • Seizures (n= , (10 hemiplegia (n= , (3 ataxia (n= , (3 coma (n= , (2 cranial nerve palsy (n=(2 • 8 pathological changes in CT/MRI images • 6 abnormal CSF S. Yang, et al. Pediatr Blood Cancer 2010; 54: 408– 415.

Cerebrospinal Fluid Tests • 15 patients (16%) CSF abnormalities at onset – 11 patients elevated spinal fluid protein – 10 patients elevated spinal fluid leukocyte counts S. Yang, et al. Pediatr Blood Cancer 2010; 54: 408– 415.

CNS Involvement After Start of Therapy • 12 patients with neurological symptoms had improved • 3 discontinued therapy due to progressive systemic symptoms • One patient, presenting with CNS dysfunction preceding systemic HLH disease, improved initially but repeated relapses and progressive CNS symptoms 6 months later • 15 patients with CSF abnormalities at diagnosis – Normal within 6 weeks of therapy S. Yang, et al. Pediatr Blood Cancer 2010; 54: 408– 415.

CNS Involvement After Start of Therapy • • • Neuroradiological abnormalities showed slow recovery rate, Neurological symptoms resolved quickly 36 patients with neuroradiological abnormalities 2 patients showed any improvement 15 patients lost to follow-up, 5 patients still undergoing treatment at the end of study S. Yang, et al. Pediatr Blood Cancer 2010; 54: 408– 415.

CNS Involvement After Start of Therapy • 16 patients followed post-therapy • 12 showed some improvement of imaging after 3– 12 months • 5 completely normal CT/MRI scans at follow-up • One progressive changes in the CT/MRI images and relapsed • 3 patients CT/MRI findings unchanged S. Yang, et al. Pediatr Blood Cancer 2010; 54: 408– 415.

CNS Involvement After Start of Therapy • 42 patients followed after discontinuation of therapy • 21/42 had at least one manifestation of CNS involvement at diagnosis • 10/42 recovered completely from CNS involvement • 3 patients not improve with radiological findings while CSF analysis and clinical examination normalized S. Yang, et al. Pediatr Blood Cancer 2010; 54: 408– 415.

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