Hemophagocytic Lymphohistiocytosis (HLH)

Nancy Berliner, M.D.

H. Franklin Bunn Professor of Medicine
Chief, Division of Hematology
Brigham and Women’s Hospital
 Case

39 y/o female home maker, wife and mother of three with no

significant past medical history

• 12/12/04 – fevers, chills, rigors

• WBC 3.9, Hct 34.8, plt 148
• Fevers resolved after a 10 day course of doxycycline

• 1/05—recurrent fevers
• CBC and chemistries - normal
• Bone marrow biopsy: normocellular w/small, poorly formed granulomas

• 2/12/05 – presented to New Milford Hospital with fever and back pain
• ROS – fevers, chills, rigors, back pain, generalized fatigue
 Case

Past medical history: C-section x 3

Outpatient medications: None

Family history: Hypertension

Social history:
• Home maker
• Denies tobacco, alcohol or illicit drug use
• No HIV risk factors
• Married, living with her husband and 3 children in a rural section of New
Milford, CT
• Well water
• Tick bite 3 years ago without consequence
• Vacations yearly on Block Island
 Case

Transferred to YNHH on vancomycin, ceftazadime, doxycycline

• WBC 0.9 with 18 segs, 42 bands, 26 lymphocytes, 9

monocytes, 5 metamyelocytes, 1 nucleated RBC
• Hct 22.8 with reticulocyte count of 2.3%, platelets 73
• Na+ 134, K+ 3.4 Cl- 102, HCO3- 25, BUN 12, Cr 0.8
• total bili 0.58, ALT 55, AST 128, AP 97, alb 3.2, TP 5.5, LDH
1350
• INR 1.47, PTT 30.5, D-dimer >1.0, FSP >40, fibrinogen 176
• Iron 50, IBC 245, % iron saturation 20, ferritin 1460
• CRP 5.3
 Hemophagocytic Syndrome

• Related to impaired cytolytic activity of T cells and NK cells

• Uncontrolled T-cell activation with activation of
macrophages and increased secretion of multiple
cytokines, including IFNg, IL-12, and IL-18
• Results in proliferation and activation of benign
macrophages, and is associated with phagocytosis of
hematopoietic elements throughout the RE system
• Familial HLH is associated with identified defects in
cytotoxic T cells and NK cells
• Mechanism of acquired forms of HLH is unknown
 CTL Killing of Target Cells

• Perforin resides within the

Figure 12-10
granules of NK cells and CTLs
• Granules released into the
“immunological synapse”
between a CTL and target cell
• The granule membrane fuses
Copyright © 2005 Elsevier Inc. (USA) All rights reserved. with the cell membrane, and
releases granule contents
• Perforin makes “pores” in the
target cell membrane.
• Allows entry of granzymes,
important mediators of apoptosis
• Results in killing of the target
cell.
 HLH: Diagnostic Criteria
Molecular Diagnosis consistent with HLH
OR
Clinical and laboratory criteria (5/8)
• Fever
• Splenomegaly
• Cytopenia
• Hypertriglyceridemia and/or hypofibrinogenemia
• Fasting triglycerides > 3mmol/l
• Fibrinogen < 1.5 g/l
• Ferritin > 500
• sCD25 > 2400U/ml
• Decreased or absent NK-cell activity
• Hemophagocytosis in bone marrow, CSF, or nodes

These criteria are entirely based on PEDIATRIC patients

 Hemophagocytic Lymphohistiocytosis (HLH)

Genetic HLH
• Familial HLH
• Known gene defects (perforin, munc 13-4, syntaxin 11)
• Unknown gene defects
• Immune deficiency syndromes
• Chediak-Higashi syndrome
• Griscelli syndrome
• X-linked lymphoproliferative syndrome
Acquired HLH
• Infection associated hemophagocytic syndrome
• Autoimmune disease (macrophage activation syndrome)
• Malignancy (T cell lymphoma)
• Drug hypersensitivity reaction (?)
 Genetic Defects in fHLH

DISEASE GENE FUNCTION

FHLH-1 UNKNOWN UNKNOWN
FHLH-2 PRF-1 INDUCTION OF APOPTOSIS
FHLH-3 MUNC13-4 VESICLE PRIMING
FHLH-4 STX11 VESICLE TRANSPORT; t-SNARE
GS-2 RAB27A VESICLE TRANSPORT; SMALL
GTPase
CHS-1 LYST VESICLE TRANSPORT
XLP SH2D1a LYMPHOCYTE SIGNAL
TRANSDUCTION
 Causes/Triggers of Acquired HLH

• Infection
• Malignancy
• Systemic Autoimmune Disease
(Macrophage Activation Syndrome)
• Drugs
• Idiopathic
 Infection-Associated HLH
• Infection is an important trigger of all forms of HLH, found
in over half of all reported cases, genetic or acquired
• Associated with many pathogens, including viral (EBV,
CMV, HHV-6, parvovirus B19), bacterial (M. tuberculosis,
Salmonella, Leishmania), fungal, and parasitic infections
• EBV is the leading organism causing HLH
• Important trigger in both genetic and acquired HLH
• Evidence for direct upregulation of TNF and IFNg expression in
infected T cells but not in infected B cells.
• EBV-associated HLH is associated with T cell lymphoma, and
not with underlying EBV-related B cell malignancies
…many acute viral infections cause
hemophagocytosis…not all hemophagocytosis is HLH
 Multifactorial Pathogenesis of HLH
Primary HLH: Secondary HLH:
FHL, XLP, CHS VAHS, MAHS, MAS
10 20
Infants Older children
Spontaneous (?) Clear triggers
Recurrent (if untreated) Minimal recurrence risk (?
Fixed NK defect (?) No fixed NK defect (?)
secondary XLP
Normal MAHS R-HLH HLH: VAHS CHS FHL
Intrinsic Defect of
Immune Regulation

Immune Stimuli

Avian Flu.(H5N1) EBV CMV Rhinovirus ?

Hem. Fevers with thanks to Michael Jordan
Adult HLH: A newly recognized epidemic?

• In the last 15-20 years, there has been an explosion of

reports and studies of adult HLH
• Apparent increase in HLH in adults is unexplained
• Newly-prevalent vs newly-recognized
• Either way, is an increasingly common diagnosis
• Despite this, the diagnosis continues to be driven by
criteria developed in the pediatric population
• Criteria for diagnosis in adults need to be reassessed
Clinical Characteristics: Pediatric vs Adult HLH

Pediatric HLH Adult-onset HLH

Clinical Presentation
Age (median, range) 8 mos (0-15 yrs) 49 years (41-67)
76% < 2 years Case reports > 70 years
Fever * ++++ (~100% ) ++++ (~100%)
Splenomegaly * +++ +++ (50-83%)
Hepatomegaly ++++ (95%) +++ (18-67%)
Neurological symptoms ++ (33%) + (9-25%)
Laboratory characteristics: Pediatric vs Adult HLH
Pediatric HLH Adult-onset HLH
Cytopenias of >2 lines * ++++ (~100% ) ++++ (>85%)
Hypertriglyceridemia* +++ +++ (45-85%)
Hypofibrinogenemia * +++ ++ (36-70%)
Ferritin
>500 ng/mL * ++++ (~100%) ++++ (85-100%)
>10,000 ng/mL ++++ (90%) ++ (43%)
Soluble IL-2 receptor
>2400 U/mL * ++++ (~100%) ++++ (~100%)
>5,000 U/mL ++++ (93%) ++++ (90%)
sIL-2R/ferritin ratio NR +++ (81%),
>2.0 Specificity 85%16
Hypoalbuminemia +++ (69%) ++++ (90-95%)
Abnormal renal function +/- (9%) ++ (16-52%)
Abnormal LFTs +++ (76%) +++ (71-100%)
CSF pleocytosis ++ (40%) Infrequently reported
Hemophagocytosis * ++++ (92%) ++++ (62-95%)
Low/absent NK cell activity* NK degranulation <5% - ++ (36-67%)
Sens 96%, Spec 88%29 (sent on <15% of patients)
 DDX: Marked Hyperferritinemia

• Still’s Disease
• Acute and chronic inflammation
• Autoimmune disease
• Chronic renal failure
• Hemolysis
• Infection
• Acute or Chronic Liver Disease
• Hemophagocytosis
Ferritin >10K: sensitive and specific for pediatric HLH

Ferritin values among 330 hospitalized children with ferritin levels >500.
Ferritin >10K is sensitive and specific for HLH.
Allen, CE. Ped Blood Cancer 2008
 …but much less specific in adults

Patients in the Partners RPDR

FERRITIN # of PATIENTS
>10,000 822
>20,000 340
>30,000 201
>40,000 147
>50,000 111

Of the patients with ferritin> 50,000, HLH in ~15 (including MAS)

Schram and Berliner, Blood 2015, 125:1548

 DDx: Elevated sIL-2R

• IL-2Ra (CD25) widely expressed in T cells, B cells, monocytes,

eosinophils, and NK cells
• Cleaved by macrophage MMP9 to release sIL-2R
• Marker of immune activation in a wide variety of
inflammatory disorders:
– Autoimmune Disease
– Infections (especially HIV, TB)
– Allograft Rejection
– T cell malignancy
– Other NHL
– Cirrhosis
– Renal failure
– Hemophagocytosis
sIL-2R in diagnosis of Lymphoma-associated HLH

Tabata and Tabata, Ann Hematol 2012; 91:63

sIL-2R in diagnosis of Lymphoma-associated HLH

Tsuji et al: Ann Hematol 2014; 93:821

 Survey of HLH in Japan
• Survey of 292 Japanese institutions
• 799 patients seen in 216 Japanese centers between 2001 and 2005
• Requested information was provided on 567 patients
• 74 because they couldn’t be classified

277 132

Ishii, E. Int J Hem 2007

 Other surveys of adult HLH
• 103 adult HLH patients from single hospital in China:
– 48% hematologic malignancy
– 14% autoimmune disease
– 23% infectious disease
– 23% unknown
Li et al, Medicine 2014; 93: 100
• 73 adult HLH patients from WUSL, St Louis
– 40% infectious disease
– 29% hematologic maliginancies
– 7% autoimmune disease
– 18% unknown
Otrock and Eby AmJHematol 2015; 90:220
• 68 patients in Partners hospitals, Boston
– 49% malignancy
– 33% infectious
– 28% autoimmune disease
– 15% unknown
Schram et al, BrJHaematol 2015; in press

• 62 patients at Mayo Clinic

– 62% malignancy
– 34% infectious
– 8% autoimmune disease
– 6% unknown
Parikh et al, Mayo Clinic Proc 2014; 89:484
 Mutations in fHLH genes in adult HLH

Study of 1531 patients with HLH

175 adults over age 18
15% had hypomorphic alleles of FHLH genes

Zhang et al; Blood. 2011;118:

5794
 Significance of fHLH mutations in adult HLH

• Unknown
• Many mutations may be polymorphisms, although modeling suggests
that at least some are deleterious
• For example, A91V PRF1 is present in 4-7% of the population
• A91V PRF may be associated with decreased perforin expression
• Associated with other defects in patients with documented fHLH
• Likely predisposing alleles, though the presence in many asymptomatic
individuals suggest the associated risk may be low

Longitudinal studies with routine testing of adult patients with HLH in

association with better recognition of the syndrome should elucidate
the importance in idiopathic HLH
 Significance of fHLH mutations in adult HLH

Case:
50 year old man with HLH of unknown etiology
Presented with multi-system failure
Responded to etoposide and steroids
Genetic testing: Prf A91V mutation (heterozygous)
Evaluation for stem cell transplant:
Only potential fully matched donors: two brothers, both matches, both
carrying the same perforin mutation
NK function normal; decreased perforin secretion

Underwent MRD allogeneic transplant from brother

 HLH: Therapy

Suppression of hyperinflammation
• Steroids
• Cyclosporin A
• IV Ig
• TNF inhibitors--no data
Cytotoxic therapy
• Etoposide is treatment of choice in EBV-related HLH
• Also used in genetic HLH, especially as precursor to SCT
Stem cell transplantation
• Treatment of choice for genetic HLH
• Role in acquired HLH is less clear
 HLH: Prognosis
HLH94 (Blood 100: 2367, 2002)
• 113 children up to age 15
• Treated with dexamethasone, CSA, and etoposide
• Familial HLH treated with subsequent transplant
• Survival at 3 years:
• Proven familial cases: 51%; All cases: 55%
24 pediatric patients with MAS (Rheum 40: 1285, 2001)
• Treated steroids, CSA A
• 22/24 survived
EBV-HLH (Blood 93: 1869, 1999)
• 17 pediatric patients, using HLH94 protocol
• Survival: 100%

Survival in adults is not well defined, since cases

are sporadic and not treated in series.
Treatment/outcome of secondary HLH

EBV-HLH: IVIgG, steroid, etoposide, +/- rituximab

MAS: IVIgG, CSA, anti-TNF, cyclophosphamide, MTX
Malignancy: cancer-directed therapy

Ishii, E. Int J Hem 2007

Treatment/outcome of adult HLH

Schram et al, BrJHaematol 2015; in press

 Case
Hospital course:
• YNHH for 10 days, with fever daily
• Seen by infectious disease, rheumatology, and hematology services
• Antibiotics were discontinued on hospital day 7
• Treated with IVIg 2g/kg on hospital day 14, with resolution of fever
• Discharged to home on hospital day 16 (2/27/05)
• WBC 0.8 (ANC 450), Hct 26.6, platelets 83

Outpatient course:
• 3/9: afebrile, spleen non-palpable, WBC 2.8, Hct 34.5, platelets 169
• 3/15: IVIg
• 3/22: WBC 2.7, Hct 36.8, platelets 145, ferritin 121, normal LFTs
• 4/19: fever 101, palpable spleen, WBC 1.6, Hct 32.7, platelets 93,
AST 156, ALT 61, ferritin 961
• Started on prednisone and cyclosporine
• 4/26: afebrile, spleen non-palpable, WBC 3.9, Hct 35.9, platelets 146
 Case

Subsequent Course:
• Relapse. Kidney biopsy of large lesions
• 2 unit retroperitoneal bleed
• Pathology: hemophagocytosis. No evidence of lymphoma
• Treated with HLH protocol
• Dramatic response
• Normal blood counts
• CT scan reverted to normal
• 6 weeks later:
• Relapsed with widespread adenopathy, fever, kidney lesions
• Begun on CAMPATH with excellent response
• Underwent MMUD
 Salvage Therapy for Adult HLH
1) Alemtuzumab (anti-CD52):
– Retrospective study of 22 pts (all ages) receiving alemtuzumab after prior
induction therapy
– 77% of pts made it to SCT
– Long term probability of survival estimated at 64%
Marsh RA et al, Pediatr Blood Cancer, 2013

2) DEP regimen:
– Multi-center, prospective study of
Doxil/Etoposide/Methylpred for
adult refractory HLH
– 29 lymphoma, 22 EBV, 4 FHLH, 8
unknown
– CR in 27%, PR in 49%
– 29/48 with CR/PR survived to chemo
or SCT

Wang Y et al, Blood, 2015

 Novel HLH Therapies: IFNg inhibition

Emapalumab (NI-0501) = fully human, high affinity anti-IFNg

mAb that binds and neutralizes human IFNg
• Open-label Phase 2 in US/Europe
• N=27 children with confirmed or suspected fHLH
• Overall Response: 63% (7 CR, 8 PR, 2 improved)
• All responding patients went on to transplant, so durability of
response not assessable.
• On basis of these data (which had not been published),
emapalumab was approved in December 2018 by FDA for
treatment of pediatric AND ADULT patients with fHLH
• Since published in the NEJM—and EMA declined to approve
the drug based on the opinion that data were inadequate
 Novel HLH Therapies: JAK inhibitors

Rationale: Uncontrolled activation T- cells and macrophages

results in massive cytokine release that damages tissues
– INFg, IL-2, IL-6 and IL-10 are released in these settings
– Janus kinases (JAK) can transduce signals upon binding
of various cytokines to their receptors
– JAK inhibition is beneficial in other inflammatory
conditions
– Has been demonstrated to prevent and treat HLH in
two mouse models of HLH
– Small case series show efficacy in refractory HLH
– Currently in early clinical trials
 HSCT for HLH in Children
• Only curative therapy • First large cohort in children per
• Indicated for patients HLH-94 protocol
with: - 249 children; 124 underwent HSCT
– FHLH - Mostly MAC with CBV +/- ATG
– Relapsed/refractory - 5 yr OS after HSCT was 66%
disease - If CR at HSCT, 5 yr OS 72%
– Persistent disease - Best outcomes if matched
– CNS involvement related/unrelated donors vs haplo
or mismatched

Overall TRM was 23% (14% died during

induction) with 29/43 deaths before D100

Trottestam H et al, Blood, 2011

RIC for HSCT for HLH

• 34 patients with HLH and 12

patients with
immunodeficiency
• 1 year OS 80%; 18 months 67%
• 20 required DLI or 2nd
transplant

Impact of RIC:
• Markedly lower transplant
related early mortality
• Increased loss of chimerism
requiring DLI or 2nd transplant

Allen et al, Blood 2018 132:1438-1451

 Adult HLH: Allogeneic Transplant

21 patients: no relapse without lymphoma relapse

 Principles of Therapy for HLH
Underlying Trigger for
Adult HLH

Rheumatologic Malignancy Infection Idiopathic

Disorder

Immunosuppression Disease-specific therapy, HLH-94 protocol with replacement of cyclosporine with

(Steroids, disease- with inclusion of Antimicrobial therapy tacrolimus and intrathecal chemotherapy only with
specific therapy) etoposide if appropriate evidence of CNS involvement

If refractory If EBV+ or refractory

HLH-94 protocol with replacement of cyclosporine with

tacrolimus and intrathecal chemotherapy only with If refractory, or
evidence of CNS involvement relapsed

If refractory or
relapsed
Allogeneic Hematopoietic
Stem Cell Transplantation

(1) Combination of immunosuppressive and cytotoxic therapy to

control hyperinflammatory state, plus
(2) disease-specific therapy, followed by
(3) Allo-SCT for familial or recurrent HLH
Schram, Berliner, Blood, 2015
Al-Samkari, Berliner. Annu Rev Pathol. 2018
 HLH: Take-home points
HLH is related to impaired cytolytic activity of T cells and NK cells
In HLH, uncontrolled T-cell activation with increased inflammatory
cytokines, including IFNg, activates macrophages
• Activated macrophages phagocytose hematopoietic elements
• Hemophagocytosis is not an obligatory finding and treatment
should not be delayed if it is absent
HLH can be inherited or acquired. Adult HLH is always acquired but
has links to fHLH
Adult HLH is associated with malignancy in about 50% of patients
Infections are an important trigger of HLH in both familial and
secondary cases.
Mechanism(s) of acquired forms of HLH are unknown; may reflect
an interplay among genetic, immunologic, and infectious factors.
Increasingly diagnosed…is it becoming more common?
 REVIEW SLIDE 1: HLH in children vs
HLH in children: adults
– Over half are associated with homozygous null mutations in genes critical for NK and
cytotoxic T cell function, usually diagnosed in the first year of life
– The remainder are associated with infection or autoimmune disease-almost never
with malignancy
– Primary HLH is almost uniformly lethal without stem cell transplantation
HLH in adults:
– Over half are associated with lymphoma
– The remainder are associated with infection or autoimmune disease; about 20-25%
have unknown trigger
– Role of transplant is still being established, but it is recommended for recurrent or
relapsed disease, EBV-related disease, and severe disease
 REVIEW SLIDE 2: HLH Treatment
Treatment in adults uses the same HLH94 protocol used in children:
– High dose steroids, etoposide
– Children get CNS prophylaxis; adults have less CNS disease and are treated only if they have neurologic signs
– Novel therapies: emapalumab—only data are in children and all responders had transplant; JAK2 inhibition
under study, successful in small case series
Hematopoietic Stem Cell Transplant
– Recommended for all children with primary HLH
– Recommended for all adults with relapse, severe disease, EBV-related HLH
– All age groups must have disease control to undergo transplant or they develop overwhelming GVHD
– Reduced intensity conditioning yields better results, as does pre-transplant alemtuzumab