another day, another fever

The UC San Diego AntiViral Research Center sponsors weekly presentations by infectious disease clinicians, physicians and researchers. The goal of these presentations is to provide the most current research, clinical practices and trends in HIV, HBV, HCV, TB and other infectious diseases of global significance. The slides from the AIDS Clinical Rounds presentation that you are about to view are intended for the educational purposes of our audience. They may not be used for other purposes without the presenter’s express permission.

AIDS CLINICAL ROUNDS

Another Day, Another Fever Gigi Blanchard, MD July 11,2014

HPI • 59yo with AIDS (CD4 = 14/14% and VL <20) and

NHL presented to the ED with acute onset AMS, fever and SOB

• NHL dx’d ’06 complicated by relapse 3/13 • Chemo 4/13 • Relapse with CNS involvement 7/13 • Autologous SCT at Sloan-Kettering ~ 10/13

• Complicated by CMV colitis • Transfusion dependent since SCT

• Plts q 3weeks; PRBC monthly; GCSF prn • Relapse 1/14 to skull – s/p XRT

HPI • Recently treated for pna before driving from AZ

to San Diego for vacation • Chest CT in April in AZ: RUL and LLL infiltrates

c/w atypical pna • Levofloxacin for 2 weeks • Repeat CT showed improvement

• On the night of arrival in SD, fell out of bed and was altered in the AM

• Presented for eval of acute onset AMS, fever and SOB

ROS • GEN: fever x 1 day; No NS or weight loss • HEENT: No HA; no sinus pain/drainage; no visual sx; no

odynophagia or dysphagia • HEME: no epistaxis; no oral bleeding; + easy bruising • PULM: + SOB; No cough • CV: No chest pain, orthopnea or PND; + pedal edema • GI: No abd pain; no N/V/D; no blood in stools or melena • GU: no dysuria or discharge; no hematuria; no frequency

or urgency • Neuro: Neuropathy to mid-shin • Musculoskeletal: no joint or muscle pain • Skin: No rash

PMHx & FHx • AIDS - Atripla • NHL • Hepatitis B

• Entecavir added when in NY • Adrenal Insuff • CMV colitis • Anemia and thrombocytopenia • Peripheral Neuropathy • GERD • Fhx: Non-contributory

• Meds prior to admission: • Atripla • Entecavir • Valganciclovir 900mg qday • Fluconazole 100mg qday • Hydrocortisone 40mg bid • Atovaquone • Omeprazole • Pregabalin • GCSF • Megace • Morphine

• NKDA

Shx • Tob: 1PPD; min etoh; no drugs; married • Travel Hx: Had worked for an airline

• Every country in South America x Paraguay, Throughout Mexico 18months ago

• Europe • Hong Kong 2-3 years ago • Bangkok, Thailand and Cambodia 3 years ago • Egypt • Australia and New Guinea 3.5 years ago

ED Course • Became hypotensive and obtunded -> intubated • Tm 100; T low 96.4 • Labs:

• Cr = 1.15 GFR >60 • AST/ALT = 19/15; Albumin = 3.1 • WBC = 1.0 S 8%, B 8% ANC = 160 • H/H = 10.3/31.8; Plt = 37

• CXR: bibasilar infiltrates/trace effusions

ICU Course • Started on azithro, pip/tazo, vancomycin, Septra

and fluconazole • Continued on valganciclovir 900mg daily • Head CT: Sinusitis but o/w nl • Chest CT:

• Multifocal pneumonia • Severe centrilobular and paraseptal emphysema

• Bronch: • Diffusely inflamed airways • Moderate amount of thin, purulent secretions

Hospital Course • Sputum/saliva

• Enterobacter cloacae – moderate • MSSA – heavy • Strep Pna – heavy

• Bronch cx grew yeast, not cryptococcus • 1 colony of MSSA • AFB smear and cx negative at 10days • Cytology negative for PCP

Hospital Course cont’d • Azithromycin and SMX/TMP d/c’d • Weaned off pressors by day 6 • Extubated day 7 • Afebrile for days 2-4 days • Then daily fevers

• 100.4-102.2 • CBC improved briefly; no longer neutropenic • Called out to floor team ~ 36 hours • Resp failure – re-intubated

PE • T 99.5 BP 64-123/45-67 P 90-127 RR 13-37 • GEN: intubated and sedated; anasarcic • HEENT: limited exam but no obvious thrush • CV: RR no M • PULM: CTA B/L anteriorly • ABD: soft, NT, ND, NABS; no HSM • SKIN: petechiae; violaceous plaque/nodule on R

5th toe c/w KS • Neuro: unable to assess

Labs • CBC

• WBC = 1.5, S 68%, B 20% ANC = 1.3 • H/H = 6.8/20.5 (retic 1.8%) Plt = 7

• Chemistries essentially unremarkable • Nl renal function; Nl AG

• AST/ALT = 86/54 • AlkΦ = 770 GGT = 1086 (nl <60) • T/Dbili = 1.3/0.9 • LDH = 888 (nl 135-225)

Labs • INR = 1.4 PTT = 31.9 • Fibrinogen = 596 -> 452 -> 273 (nl 200 - 450) • D-dimer = 8614 • PPP - negative • Ferritin = 8508 • Haptoglobin = 332 (nl up to 200) • CRP = 16.6

Micro/Serology • Blood cx negative 5/22, 5/27, 5/29/5/30 • AFB blood and sputum cx negative • Fungal blood cx not done • Urine cx negative • CMV PCR negative • Cryptococcal Antigen negative • Cocci ID/CF neg • Quantiferon negative

What is the cause of his fever and pancytopenia? • Lymphoma – another recurrence • Castleman’s Disease • Fungal infection – histoplasmosis? Penicillium? • Drug Fever • Malaria, Leishmaniasis or some other exotic

infection • Other

What to do next? • H/O is concerned about HLH

• Fever and pancytopenia • Elevated TG • Elevated ferritin

• BMbx performed and results pending • They recommend etoposide and steroids

• High mortality if not treated promptly

• Do you agree?

Do you agree with treating him for HLH?

• No – He’s got plenty of reasons to be febrile &

pancytopenic with elevated ferritin

• Yes – He meets criteria and he’s got little to lose

• What’s HLH?

Ferritin • Storage protein for iron (4000 atoms of iron) • Produced in hepatocytes and in any cell that

stores iron (macrophages and hepatocytes) • Serum ferritin mirrors tissue stores in normal

conditions • Acute Phase Reactant

• Cytokines (IL-1, IL-6) increase production of ferritin -> increased storage of iron • Hides it from invaders • Low serum iron in chronic inflammation

Elevated Ferritin Ddx • Iron Overload

• Hereditary hemochromatosis • Transfusions

• Inflammation • Rheumatologic diseases - Still’s disease; SLE

• Malignancy • Infections – Histoplasmosis & TB • Liver disease

• Chronic viral hepatitis • Alcoholic liver disease & Non-alcoholic steatohepatitis

(NASH) • HLH

Hemophagocytic LymphoHistiocytosis (HLH) • AKA Macrophage Activation Syndrome in ass’n

with rheumatologic diseases • Hemophagocytosis: the pathologic finding of

activated macrophages (MΦ) engulfing RBC, WBCs, platelets and their precursors

• A syndrome of extreme inflammation and tissue destruction d/t pathologic immune activation

• The excessive inflammation is thought to be caused by a lack of normal down regulation of activated MΦ d/t defective CTL/NK cells

HLH - Intro • First described in 1939 as histiocytic medullary

reticulosis • aka Viral Ass’d Hemophagocytic Syndrome • Most frequently affects infants 0-18 mo • Can affect anyone of any age • Familial and sporadic forms • Infection is a common trigger of both forms • Aggressive and life-threatening • Prompt initiation of treatment is essential for

survival

Immunology Review

Immunology review: The Macrophage • Monocytes are made in the bone marrow • Within 24hours, enter tissues • Differentiate from circulating peripheral-blood

mononuclear cells (PBMCs) to specific type of mononuclear phagocytic cell or macrophage w/in the tissue

• Lives w/in the tissues for days to months

Immunology Review

Macrophage Functions • Phagocytosis/Janitor – engulf and digest

senescent cells & remove cellular debris • Clear 200 billion RBCs/day • Recycle ~ 3kg of iron per year • Synthesize ferritin

• Innate Immunity/1st Responder • Phagocytosis – engulf and digest pathogens and

cancer cells • Antigen Presentation Cells • Secrete cytokines that stimulate lymphocytes &

other immune cells to respond to pathogens

Macrophage Functions • Immune regulation – dampen the immune

response and limit inflammation • Down regulates production of pro-inflammatory

cytokine IL-12 • Makes anti-inflammatory cytokine IL-10

• Wound-healing • makes precursors of collagen – contribute to the

production of the extracellular matrix • Stimulates fibroblast proliferation and survival

Cytokines & Chemokines • Cytokine: any small protein made by a cell that

affects the behavior of other cells. They act via specific cytokine receptors on the cells they affect.

• Interleukin: cytokine made by lymphocyte • Chemokine: A type of cytokine that attracts

WBCs to sites of infection. Small chemoattractant protein that stimulates the migration and activation of cells, especially phagocytic cells and lymphocytes.

Cytokines & their actions Cytokine Produced by

Local Effects Systemic Effects

IL-1 MΦ

Activates lymphocytes, Local tissue destruction

Fever Production of IL-6

IFN-γ T-cells NK cells

Macrophage activation

TNF-α MΦ

Increases vascular permeability Increased entry of IgG ,complement &

cells to tissues Increased fluid drainage to lymph nodes

Increases NK cells’ killing 20-100 fold

Fever Shock

IL-6

MΦ T-cells

Lymphocyte activation Increased antibody production

Fever Induces acute-phase protein production

IL-12 MΦ

Activates NK cells to secrete IFN-γ/TNF-α Induces differentiation of T cells

IL-18 MΦ

Activates NK cells to secrete IFN-γ/TNF-α Induces CTL to secrete IFN-γ

Immunology Review – NK cells • Natural Killer cells 10-15% of lymphocytes • Lymphocytes that originate in the BM and develop

outside the thymus • First line of defense b/c they can destroy another cell

w/o prior sensitization (Innate immunity) • They are activated by IFN and macrophage-derived

cytokines • Produce IFN-γ which primes MΦ to secrete pro-

inflammatory cytokines • NK eliminate damaged, stressed or infected host

cells such as MΦ, typically in response to viral infection or malignancy

Immunology Review - CTL • Cytotoxic T lymphocytes are activated T cells that

lyse autologous cells such as macrophages bearing foreign antigens

• Adaptive Immune Response • IL-2 is necessary for the growth, proliferation and

differentiation of T-cells to b/c effector cells • Antigen binding to T-cell stimulates secretion of

IL2 and expression of IL2 receptors

IL-2 (aka T-cell growth factor) & IL-2 receptor (CD25) • T cells produce IL-2 to make themselves

proliferate and differentiate • The IL-2 receptor has 3 chains: α, β, γ • Resting T cells – IL2 receptor has only β & γ

chains • binds IL-2 w/ moderate affinity

• Activated T cells also produce α chain of IL-2 receptor (aka CD25)

• Add’n of α-chain creates receptor bind with much higher affinity • 1 T cell can give rise to 1000s in 2-3 days

NK and CTLs • NK and CTLs normally eliminate MΦ • NK/CTLs create a pore in the MΦ membrane

using a protein called perforin • Deliver cytotoxic granules into the MΦ • Granules contain proteases such as granzyme B

that can initiate cell death, often through apoptosis

HLH - Pathogenesis • NK & CTLs become unable to create a hole in

the target cell and/or unable to deliver cytotoxic molecules

• Familial forms of HLH involve genetic defects in the perforin gene which encodes a membranolytic protein • Other mutations involve granule exocytosis

• Priming for exocytosis • Membrane fusion of cytolytic granules

HLH Pathophysiology • Defective triggering of apoptosis of MΦ and

reduced T-cell and NK cytotoxicity • Failure to control infections with intracellular

pathogens • Prolonged antigen presentation to CD8+ • Excessive activation of T cells, which leads to

increased cytokine secretion and hyperactivation of MΦ • Increased cytokines induce end-organ

dysfunction and immune dysregulation

HLH Pathophysiology • Activated histiocytes infiltrate organs • Hemophagocytosis and infiltration with cytokine

storm result in: • Organomegaly, • Multi-organ dysfunction, • Life-threatening cytopenias

• Cause of HLH in adult/acquired forms is unknown

• Unidentified genetic predisposition?

IL-18 & CD25 • Both correlate significantly with disease activity • IL-18 (made by MΦ) induces CTL to secrete IFN-γ • IFN-γ mediates macrophage activation • MΦ excessively phagocytose erythrocytes,

leukocytes, platelets and their pre-cursors in the RES - hemophagocytosis

• IL-18 has been shown to modulate the synthesis of ferritin by monocytes/MΦ in vitro

• CD25 – IL-2 receptor α chain that puts CTL into overdrive

Bone marrow aspirate Histiocytes

Erythroid precursors (nucleated RBCs)

Dysplastic erythroid precursor

(trilobed nucleus)

Degenerated cells (artifact)

Myeloid precursors

Nucleus of histiocyte

Clinical Presentation • Fever • Resp problems (ARDS) including need for

ventilation • Severe hypotension – requiring pressors • Hepatomegaly & Splenomegaly • Neuro findings:

• Seizures • AMS c/w encephalitis • Demyelinating peripheral neuropathy d/t diffuse MΦ

infiltration of the nerve sheath • Skin: rash, petechiae, purpura, edema,erythroderma

Lab findings in HLH • Anemia & Thrombocytopenia • Very high serum ferritin • High LFTs: AST, ALT, GGT, LDH and bilirubin

• GGT is especially sensitive d/t biliary tract infiltration by lymphocytes and MΦ

• Increased TGs • D/t cytokine inhibition of lipoprotein lipase • May not be elevated until the liver has been

affected for some time • Elevated d-dimer

Diagnostic Criteria (5 out of 8) • Fever ≥ 38.5 (101.3) • Splenomegaly • Cytopenias (need 2 out of 3)

• Hgb < 9; Plt <100, ANC <1000 • Hypertriglyceridemia &/or Hypofibrinogenemia

• Fasting TG > 265 Fibrinogen < 150 • Hemophagocytosis in BM, spleen, LN or liver • Low or absent NK-cell activity • Elevated soluble CD25 • Ferritin > 500 ng/mL (3000 is better value)

Making the Diagnosis • Extremely difficult! • Rare • Variable presentation • Non-specific findings

• Hemophagocytosis is neither specific or sensitive • May be absent early in the disease (up to 20%)

• Counter-intuitive dx of immune activation • Expect rising white count, plts & fibrinogen

HLH - Triggers • Viral illness

• Herpes viruses • HSV, VZV (HHV3), EBV (HHV4), CMV (HHV5), HHV8

• EBV Latent membrane protein-1 activates and stimulates MΦ to phagocytose hematopoietic cells

• EBV+/T-lymphoma cells secrete high levels of TNF-α, IFN-γ, and IL-1

• Parvovirus • HIV • Measles • H1N1 influenza

HLH - Triggers • Bacteria (salmonella typhi) • Parasites

• Toxoplasmosis • Leishmaniasis

• Fungi • TB

HLH - triggers • Autoimmune disease

• Juvenile idiopathic arthritis (Still’s disease) • SLE, RA, PAN, Sarcoidosis

• Malignancies, most commonly lymphoid cancers • Lymphomas • Leukemias • Myeloid malignancies • Solid tumors

• ½ of adult HLH is ass’d with cancer • Those with malignancy still had acute infectious

trigger

HLH – Malignancy triggers • HLH can precede the diagnosis or occur after the

diagnosis • Can also occur during chemo • Usually T/NK cell lymphomas and leukemias • May be d/t release of TNF-α, IFN-γ and CD25

from neoplastic cells, causing MΦ activation

HLH and HIV • Has been reported at all stages of HIV

• Case reports in acute seroconversion illness • CD4 median ~ 250 (range 63-500) • 100% survival • D/t cytokine alteration ass’d with viremia?

• Usually advanced AIDS • 20% survival • Triggered by OI

• HLH IRIS • Subclinical HLH in HIV pts?

• Autopsy study from 1985 of 56 AIDS pts • 20% had e/o hemophagocytosis

HLH and HIV Triggers • Herpes viruses are most common trigger in HIV

• EBV ass’n most common • HHV8 – cases had high viral loads of HHV8

• 4/5 had cutaneous KS • 3 cases reported of Castleman’s disease

• CMV • AFB: MAI, TB, M kansasii • Histoplasmosis, Penicillium marneffi,

Cryptococcus, and Candidal fungemia • Pneumocystis, Toxo

Labs to get for HLH • CBC with diff • PT/PTT, INR = 1.4 • Fibrinogen • D-dimer • Ferritin • LFTs: AST,ALT, GGT, T Bili albumin, LDH • Serum Triglycerides • Soluble IL-2 receptor (CD25)

More Labs to Get • Blood, urine and sputum cx • Fungal and AFB cx • EBV serology and viral load • CMV serology and viral load • HHV-8 viral load • Adenovirus and parvovirus • Cryptococcal antigen • Toxo serology

Even more studies • CT of Chest/Abdomen/Pelvis • Lymph node biopsy • Bone Marrow Bx

Treatment of HLH • HLH-94: International treatment protocol by the

Histiocyte Society in 1994 • 8 week induction with dexamethasone, etoposide

and intrathecal methotrexate for pts with CNS disease or CSF abnormalities

• At the end of 8 weeks, weaned off if possible • If not, continued until stem cell transplant

• HLH 2004 • Added cyclosporine to etoposide and

dexamethasone

Treatment of HLH today • HLH-2004 protocol

• Etoposide, cyclosporine and dexamethasone • IVIG – 0.5g/kg/day for 2 days • Anakinra (Kineret) – IL-1 R inhibitor • Treat the trigger • Consider HAART if not already on it • Case reports of TNF-α blockade with inflixamab

in refractory cases • Splenectomy • Stem cell transplant in genetic HLH

Back to the Case • Treated with IVIG (1gm/kg) x 2 days • Histo urinary antigen negative • HHV8 virus not detected • EBV PCR + (Quantitative not done) • IL-2 receptor (CD25) = 1721 pg/ml (nl < 1033)

6/1 6/2 6/3 6/4 6/5 6/6 6/7

Ferritin 8508 4723 5387 3769 2578

IVIG IVIG

Tmax 99.5 101.2 100.2 99.9 100.6 101.3 102.4

Abd CT

BMbx • Hypercellular marrow with dysplastic erythroid

precursors • Occasional hemophagocytosis • B-cell lymphoma • Focal non-caseating granulomas with no fungal

or mycobacteria identified

Bone marrow aspirate Histiocytes

Erythroid precursors (nucleated RBCs)

Dysplastic erythroid precursor

(trilobed nucleus)

Degenerated cells (artifact)

Myeloid precursors

Nucleus of histiocyte

Dysplastic erythroid precursor

(nuclear bleb)

Anucleated red blood cells

Hemosiderin granules

Diagnostic Criteria (5 out of 8) • Fever ≥ 38.5 (101.3) • Splenomegaly • Cytopenias (need 2 out of 3)

• Hgb < 9; Plt <100, ANC <1000 • Hypertriglyceridemia &/or Hypofibrinogenemia

• Fasting TG > 265 Fibrinogen < 150 • Hemophagocytosis in BM, spleen, LN or liver • Low or absent NK-cell activity • Elevated soluble CD25 • Ferritin > 500 ng/mL (3000 is better value)

What’s your diagnosis?

Take Home Points • Consider HLH in pts with SIRS/Sepsis who are not

responding to broad spectrum antibiotics (check ferritin)

• Consider HLH if ferritin is elevated • If you have a pt with HLH, check an HIV test!

JP

JP 1 year later

JP 1 year later

Thank you