Hemophagocytic Lymphohistiocytosis: an Unusual Complication of Orientia tsutsugamushi Disease (Scrub Typhus)

Background Hemophagocytic lymphohistiocytosis (HLH) is an uncommon, potentially fatal, hyperinflammatory syndrome that may rarely complicate the clinical course of Orientia tsutsugamushi disease (scrub typhus). Methods Here we describe the clinicopathological features, laboratory parameters, management, and outcome of three adult patients (1 female, 2 males) with scrub typhus associated HLH from a tertiary center. A brief and concise review of international literature on the topic was also added. Results All three patients satisfied the HLH-2004 diagnostic criteria; one had multi-organ dysfunction with very high ferritin level (>30,000 ng/ml), and all had a dramatic recovery following doxycyclin therapy. Literature review from January 1990 to March 2014 revealed that scrub typhus associated HLH were reported in 21 patients, mostly from the scrub endemic countries of the world. These included 11 females and 10 males with a mean age of 35 years (range; 8 months to 81 years). Fifteen of 17 patients (where data were available) had a favorable outcome following early serological diagnosis and initiation of definitive antibiotic therapy with (N=6) or without (N=9) immunosuppressive/immunomodulator therapy. Mutation analysis for primary HLH was performed in one patient only, and HLH-2004 protocol was used in two patients. Conclusion We suggest that HLH should be considered in severe cases of scrub typhus especially if associated with cytopenia (s), liver dysfunction, and coagulation abnormalities. Further studies are required to understand whether an immunosuppressive and/or immunomodulator therapy could be beneficial in those patients who remain unresponsive to definitive antibiotic therapy.

Introduction.Hemophagocytic lymphohistiocytosis (HLH) is a syndrome, often fatal, of exacerbated but ineffective inflammatory response, characterized by excessive macrophage and T-cell activation as well as impairment of the ability of natural killer (NK) cell and cytotoxic T lymphocytes to kill the target cells.This results in uncontrolled histiocytic phagocytosis of mature blood elements and their precursors throughout the reticuloendothelial organs; and associated cytokinemediated multiorgan dysfunction. 1,2Primary or familial HLH appears to have a genetic basis, whereas secondary or acquired HLH may be associated with infections (commonly Epstein Barr Virus, bacteria, Rickettsia, etc), hematological malignancies (mostly T/NK cell leukemias/lymphomas), rheumatological/autoimmune disorders (so-called macrophage activation syndrome), etc. [3][4][5] The diagnosis is established by fulfilling one of the following HLH-2004 criteria: i) positive family history or molecular diagnosis consistent with HLH (mutations of PRF, SAP, or MUNC13-4 genes), ii) any five out of the following eight criteria: prolonged fever, unexplained progressive cytopenias involving at least 2 cell lines (hemoglobin ≤ 90 g/L, platelet count ≤ 100 x 10 9 /L, absolute neutrophil count < 1 x 10 9 /L), splenomegaly, hyperferritinemia (≥ 500ng/mL), fasting hypertriglyceridemia (≥ 265 mg/dL) or hypofibrinogenemia (≤ 1.5 g/L), histiocytic hemophagocytosis in bone marrow, liver, spleen, or lymph nodes without evidence of malignancy, low or absent NK cell cytotoxicity, and elevated soluble CD25 levels (≥ 2400 IU/mL of interleukin-2Rα chain). 6n this manuscript, we describe three adult patients with scrub typhus associated HLH from a tertiary care center in South India.We also present a brief concise review of international literature regarding scrub typhus associated HLH in relation to the clinicopathological characteristics, immunopathology, and therapeutic outcome.

Material and Methods.
Present case descriptions: The clinicopathological features, laboratory data, and therapeutic outcome of all three patients (1 female, aged 19 years; and 2 males, aged 64, 45 years) are presented in Table 1.All the three required admission into intensive care unit.They had prolonged fever (that ranged from 10 days to 2 months duration) and generalized signs, and symptoms suggestive of systemic inflammatory response syndrome (SIRS), which were presumptively managed as sepsis.All three developed tachypnea, bilateral coarse crepitations and hypoxemia.Clinical, laboratory, and radiological features were consistent with acute respiratory distress syndrome (ARDS), which required ventilator support.In addition, two of the patients (cases 1 & 2) also developed acute kidney injury; all three had jaundice with elevated liver transaminases with deranged coagulation parameters in the form of prolonged prothrombin time (PT) and/or activated partial thromboplastin time (APTT); and one patient (case 1) progressed to disseminated intravascular coagulation (DIC) [increased fibrin degradation product, D-dimer + (qualitative)], possibly secondary to severe sepsis.Physical examination revealed conjunctival pallor and hepatosplenomegaly in all; whereas lymphadenopathy (cervical and axillary) and an eschar (over left groin) were noted in one patient (case 3).
Microbiological and serological work-up was negative for HIV, hepatitis B and C viruses, dengue, malaria, leptospira, brucella, and Epstein-Barr virus.Microbial cultures of blood, urine, sputum, bronchoalveolar lavage fluid, and bone marrow aspirate were sterile.A diagnosis of scrub typhus was confirmed by presence of IgM antibody against Orientia tsutsugamushi (O.tsutsugamushi) by ELISA.All underwent single bone marrow procedure due to persistent bi/pancytopenia, fever, and organomegaly; that revealed histiocytic hemophagocytosis (marked in case 1, mild in cases 2 & 3).The assessment of histiocytic hemophagocytosis on bone marrow aspirate smears was done as per the method devised by Ho et al (low/mild; 1-5 hemophagocytic cells per entire slide, moderate; 6-10 hemophagocytic cell per entire slide; and > 10 hemophagocytic cell per entire slide). 7urthermore, all three had hyperferritinemia (>1000 ng/mL) [a "sky high" level of >30,000 ng/mL in case 1] and elevated lactate dehydrogenase (>500 IU/L); and two (cases 1 & 2) had hypertriglyceridemia (>265 mg/dL), hypoalbuminemia (<2.5 g/dL), and hyponatremia (≤ 125 meq/L).All patients fulfilled five of six HLH-2004 diagnostic criteria, as NK cell activity and soluble CD25 levels were not tested due to lack of facility, and none of the patients were subjected to genetic testing for the diagnosis of primary HLH.
All 3 patients were empirically treated with broadspectrum intravenous antibiotics and supportive measures.Following confirmation of scrub typhus by IgM ELISA, oral doxycyclin (100 mg twice daily) was started.Furthermore, case 1 was started on intravenous corticosteroids and vasopressor drugs.Over a period of one week, the patients responded positively to the treatment, with abatement of fever, resolution of acute kidney injury, and hepatic dysfunction with correction of coagulopathy.Considering the very high ferritin level and clinical scenario in case 1, hematologist's opinion was sought for commencing HLH-2004 protocol.After resolution of multi-organ dysfunction (MOD), etoposide was added to the ongoing regimen and was later withdrawn after full recovery of clinical and hematological parameters.At present this patient is under regular follow-up without any medications.The other two patients did not receive any specific immunosuppressive therapy for HLH and improved following treatment with oral doxycyclin.ytosis/ macrophage activation syndrome and scrub typhus/Orientia tsutsugamushi/tsutsugamushi disease/Rickettsial disease; and references of all articles were cross-checked for relevant articles.][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25] Cascio et al, in 2011, reported a case of HLH (negative for perforin 1, MUNC 13-4, SYNTAXIN 11 mutations) in a 5 year old Italian male child secondary to Rickettsia conorii (Mediterranean Spotted Fever, MSF); and reviewed another 16 cases of rickettsia associated HLH till that year [7 due to scrub typhus, 5 due to MSF, and 4 due to human monocytic ehrlichiosis (HME)]. 5In 4 of 21 cases of scrub typhus (2 from Taiwan, two from Japan), complete articles were not fully accessible for study. 19,22,25Clinical and laboratory data available have been put in a tabular format (Table 2).

Review of International
Result and Discussion.Scrub typhus, also known as tsutsugamushi disease, is a chigger-borne zoonosis which is of great public health importance in tropical Asia and the islands of the Western Pacific Ocean.This infection or its etiologic agent (O.tsutsugamushi) has been documented within an endemic triangle with apices in the Primorje region of the Russian Far East, northern Australia, and Afghanistan. 26Scrub typhus is an acute febrile illness which results from the bite of infected larval form of mite, called chigger, in endemic areas.Following an incubation period of 7 to 10 days, the nonspecific prodrome of pyrexia, skin rash, myalgia, gastrointestinal disturbances, and lymphadenopathy starts.Although not consistently seen, the most pathognomonic sign of scrub typhus is an eschar that develops at the site of mite bite.During human infection, O. tsutsugamushi, being a rickettsial organism, selectively targets the vascular endothelial cells of the small to medium-sized blood vessels.However, it can also invade underlying tissues such as smooth muscle cells, perivascular macrophages, and monocytes.
Consequently, widespread vasculitis/perivasculitis is the hallmark pathophysiologic mechanism implicated in multiorgan dysfunction syndrome (MODS) in patients with severe infections. 5,26he main pathophysiologic characteristic of HLH is exacerbated but deregulated Th 1 cell-mediated immune response against an intracellular pathogen, macrophage hyperactivity, widespread hemophagocytosis, and hypercytokinemia leading to multi-organ dysfunction.This results due to impaired or suppressed function of cytotoxic T cells and NK cells to effectively clear the antigenic stimulus and thus turn off the inflammatory response. 1The severity of rickettsial diseases varies with the causative organism and the host.Some rickettsial species such as Rickettsia rickettsii, Rickettsia prowazekii, and O. tsutsugamushi often cause more severe disease.Host factors like old age, alcoholism, diabetes mellitus, liver and respiratory diseases, and glucose-6-phosphate dehydrogenase deficiency have been associated with more severe disease. 5Experimental studies have shown that human cells are capable of controlling rickettsial infections intracellularly, by one or combination of three mechanisms involving nitric oxide synthesis, hydrogen peroxide production, and tryptophan degradation.These mechanisms involve a complex interaction of CD4 + and CD8 + T lymphocytes, macrophages, NK cells, B lymphocytes, antibodies, and cytokines.Inflammatory responses of humans appear to coincide with the disease severity in scrub typhus, and the cytotoxic T-cell mediated macrophage over activity may induce hemophagocytosis in susceptible individuals. 27This hypothesis has been further substantiated by the observation of increased serum levels of IFN-γ, M-CSF and TNF-α in patient with scrub typhus in several studies. 28 concise review on clinicopathological characteristics of all reported cases of scrub typhus associated HLH till March 2014 is presented in Table 2.][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25] These included 11 females and 10 males, with a mean age of 35 years (range; 8 months to 81 years); and none of these cases had obvious underlying co-morbidities.All patients, 18/18, in whom data were available, presented with acute febrile illness (mean duration; 10 days, range: 4 to 24 days): similarly all cases reported (14/14) had hepatosplenomegaly with or without regional lymphadenopathy.A characteristic eschar was signaled in 9/18 (50%) patients and seven of 18 (39%) had ARDS, 3 (16.7%)had neurological manifestations, 2 (11%) had acute renal failure, 2 (11%) had DIC with MODS, 2 (11%) had at onset acute hepatic failure.One had co-existent leptospirosis, 8 and one had myocarditis, interstitial pneumonia, and reactivation of EBV infection. 13Eleven of 18 patients (61%), in whom data were available, had bicytopenia; 4/18 (22%) had pancytopenia, and 6/13 (37.5%) had coagulation abnormalities.Histiocytic hemophagocytosis was reported in bone marrow of all 16 examined patients (100%).Hemophagocytosis was of mild to moderate intensity in 14 (87.5%)patients whereas appeared marked in only two patients.This was reflected by modest elevation of serum ferritin level (N=13/21) (mean; 3320 ng/ml, range; 1415-15,000 ng/ml).Molecular analysis for primary HLH such as mutation of perforin and SYNTAXIN gene was performed in one patient (8 month male child) only. 11A recent study on pediatric HLH patients (N=38; 20 primary HLH, 18 secondary HLH) reported that hyperbilirubinemia with cholestasis was highly suggestive of primary HLH; whereas high C-reactive protein levels was more in favor of a secondary HLH.The other parameters such as ferritin, triglyceride, PT, APTT were not statistically Puducherry, India , 2013 different between the two groups. 29All the 3 patients in our series satisfied the HLH-2004 criteria and had hyperbilirubinemia (marked in case 1) with biochemical evidence of cholestasis (direct bilirubin fraction greater than indirect), two had raised transaminases and all three had coagulation abnormality in the form of prolonged PT, APTT, or both (Table 1).One patient (case 1) had "sky high" ferritin levels (>30,000 ng/ml), high procalcitonin levels suggestive of sepsis, and evidence of marked degree of histiocytic hemophagocytosis in bone marrow.During the clinical course, she progressed to DIC with hypofibrinogenemia leading to MODS.
Serological diagnosis of scrub typhus is usually possible after 5 to 10 days following onset of symptoms.Conventionally, Weil-Felix test based on heterophile antigen of Proteus Vulgaris (OX-2, and OX-19) and Proteus mirabilis (OX-K) has been used widely.An agglutinating titer of >320 with OX-K is suggestive of scrub typhus. 30However, several Indian studies have shown a lower cut-off titer at ≥ 80 to indicate a possible infection with O. tsutsugamushi, thus making the test even more non-specific. 31,32Poor sensitivity and specificity of Weil-Felix is well established.Recently, IgM ELISA and IgM Capture ELISA techniques have shown better predictive value as diagnostic tests in scrub typhus.PCR-based tests have overcome the drawbacks of serological tests, in early detection using specific primers; 33 and multiplex PCR has further improved diagnostic criteria in endemic areas. 34In all the reported cases of scrub typhus associated HLH, the diagnosis of rickettsial disease was serologically confirmed.The following serological methods were used for the diagnosis: Weil-Felix (N=5), IgM ELISA (N=6), IgM antibodies by indirect haemagglutination (IHA) (N=1), antibody titres by immunofluorescence (N=3), IgM antibody by immunochromatography (N=1), and IgM anti O. tsutsugamushi Gilliam antibody (N=1).
Scrub typhus responds more readily to antibiotics than other rickettsial diseases, with most patients becoming afebrile within 24 to 36 hours after beginning antibiotic therapy.A recent study by Japanese group had shown that age was an independent risk factor for mortality; furthermore patients with ≥ 2 days delay in treatment with tetracyclines had a significantly higher risk of complications compared to those without delay. 35In another study from South Korea, factors such as old age, presence of comorbidities, and high serum osteopontin (>100ng/ml) were important risk factors of disease severity; though delay in treatment and strain type (Boryong, Taguchi, or Kanda/Kawasaki) did not contribute to disease severity. 36Therapeutic and follow-up data were available In 17 patients with scrub typhus associated HLH, ten of them received oral antibiotics in the form of doxycyclin and/or clarithromycin/minocyclin; six patients received immunotherapy in addition to oral antibiotic therapy (two of them used HLH-2004), 12,13 and one patient refused any definitive therapy. 15arring two patients (one with residual neurological impairment, 12 and other with fatal outcome, 15 all 15 had a dramatic recovery from their illness without any residual impairment. Though the HLH protocol has been well established in the management of primary HLH, its utility in the setting of secondary HLH has been controversial. 2 High ferritin level has been reported to be a diagnostic and prognostic marker in patients with HLH, and a rapid rate of fall of ferritin levels following therapy initiation associated with decreased mortality. 37owever, Park et al. in their cohort of 23 patients with secondary HLH found that high fibrinogen at the time of diagnosis, not the rate of decline in ferritin, was associated with prolonged survival.Furthermore, in patients with severe disease and/or associated sepsis or multiple organ failure at the time of diagnosis, it may be difficult to use cytotoxic agents such as etoposide.In such circumstances, immunosuppression with corticosteroids and/or cyclosporine remains the foundation of early management as it can control systemic inflammation. 38In view of the limited number of cases of HLH at our institute; etoposide has not been widely used; hence limiting our experience.A very high ferritin (>30, 000 ng/ml), in conjunction with other criteria, was highly characteristic of HLH in one of our patients (case 1).During the course of her illness, she developed MODS secondary to sepsis and DIC (prolonged PT, aPTT, and increased fibrin degradation product) (Table 1).She was managed initially with vasopressor drugs, high-dose corticosteroids, and intravenous broad-spectrum antibiotics.Doxycyclin was added following the serological diagnosis of scrub typhus.Once her clinical conditions improved, etoposide was added in consultation with hematologist; however, it was later withdrawn after restoration of normal hematological parameters.
Summary.HLH though rare, should be considered in severe cases of scrub typhus especially if associated with cytopenias, liver dysfunction, and coagulation abnormalities.Furthermore, wherever possible, a diagnosis of primary HLH should always be excluded in these cases by appropriate mutation analysis studies.As observed in our three patients and supported by available literature, early diagnosis and initiation of definitive antibiotic therapy may completely reverse the clinical course of the disease.Further studies are needed to understand whether an immunosuppressive and/or immunomodulator therapy such as treatment with corticosteroids, etoposide or cyclosporine could be beneficial in those cases which do not respond promptly to tetracycline therapy.
Literature.A systematic search of HLH that complicated the course of scrub typhus over last 24 years (January 1990 to March 2014) was done by the search engine of PubMed, PubMed Central, Medline, and Directory of Open Access Journal databases.The following terminologies were used in the data search; hemophagocytic lymphohistiocytosis/hemophagocytosis/erythrophagoc 6able1.Clinicopathological characteristics and outcome data of 3 adult patients with scrub typhus associated hemophagocytic lymphohistiocytosis (HLH) diagnosed as per HLH-2004 criteria.6 OutcomeAlive, on follow-up, 12 months Cured and discharged Cured and discharged Abbreviations: MODS; multiorgan dysfunction syndrome, +; present, WNL; within normal limits, TB/DB; total bilirubin/direct bilirubin, -; not present, FDP; fibrin degradation product, IV; intravenous.