Lymphohistiocytosis (Hemophagocytic Lymphohistiocytosis) Clinical Presentation

Updated: Oct 18, 2017
  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Max J Coppes, MD, PhD, MBA  more...
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Presentation

History

The diagnostic criteria set forth by the Histiocyte Society for inclusion in the International Registry for Hemophagocytic Lymphohistiocytosis (HLH) is as follows. [25] All 5 criteria must be met to establish a diagnosis of hemophagocytic lymphohistiocytosis:

  • Fever - Seven or more days of a temperature as high as 38.5°C (101.3°F)
  • Splenomegaly - A palpable spleen greater than 3 cm below the costal margin
  • Cytopenia - Counts below the specified range in at least 2 of the following cell lineages:
  • Hypofibrinogenemia or hypertriglyceridemia - (1) Fibrinogen less than 1.5 g/L or levels greater than 3 standard deviations below the age adjusted reference range value or (2) fasting triglycerides greater than 2 mmol/L or levels greater than 3 standard deviations above the age-adjusted reference range value
  • Hemophagocytosis - Must have tissue demonstration from lymph node, spleen, or bone marrow without evidence of malignancy
  • Rash - Skin findings in more than half of patients; [1] scaly and waxy lesions; rashes on the scalp and behind the ear
  • Other - Swollen or hemorrhagic gums that can result in tooth loss; feeding problems (especially prominent in infants); abdominal pain, vomiting, diarrhea, and weight loss
  • Hemophagocytic lymphohistiocytosis was noted in a boy with Chédiak-Higashi syndrome. [26]
    • In a sampling from Brazil, 90% of the those with hemophagocytic lymphohistiocytosis had fever and thrombocytopenia, although in adults, hepatomegaly, splenomegaly and jaundice were less common in children, and serous cavity effusion more frequent. [19]
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Physical

See the list below:

  • Clinical findings, including evidence of infection due to decreased immunity and white cell killing defects, easy bruisability, and pallor, are related to pancytopenia secondary to bone marrow infiltration or splenic sequestration.
  • Evidence of a coagulopathy with an increased activated partial thromboplastin time (aPTT) is present.
  • Jaundice is often present due to hyperbilirubinemia.
  • As many as 65% of patients have a nonspecific rash that is often vaguely termed maculopapular although it has also been described as ranging from erythroderma to generalized purpuric macules and papules to morbilliform eruptions. [1]
  • One Swedish study described nearly 75% of patients having some form of CNS involvement, with half showing neurologic symptoms including seizures, ataxia, hemiplegia, mental status changes, or simply irritability. [27]
  • Because of the predilection of the disease for certain tissues, lymphadenopathy is commonly found on physical examination.
  • Other common constitutional findings such as malaise, anorexia with or without weight loss, and failure to thrive can occur. [25]
  • The skin can be involved in various ways; this is clinically best characterized as erythroderma, generalized purpuric macules and papules, or morbilliform eruptions.
  • Hemophagocytic lymphohistiocytosis may be complicated by central nervous system involvement. [28]
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Causes

See the list below:

  • See Pathophysiology.
  • Epstein-Barr virus infection is most common one linked with hemophagocytic lymphohistiocytosis. [15]
  • Hemophagocytic lymphohistiocytosis may be a complication of dengue, although this association is unusual. [29, 30]
  • Scrub typhus may also be linked. [31]
  • The tick-borne parasitic infection babesiosis can have findings ranging from mild anemia to hemophagocytic lymphohistiocytosis. [32]
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