Hemophagocytic syndrome and the influenza virus (H3N2)

Martín Asenjo, M.; Martín Guerra, J.M.; Prieto de Paula, J.M.

doi:10.1016/j.rceng.2019.09.004

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Martín Asenjo, J.M. Martín Guerra, J.M. Prieto de Paula" "autores" => array:3 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Martín Asenjo" "email" => array:1 [ 0 => "miguel.martin.asenjo@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.M." "apellidos" => "Martín Guerra" ] 2 => array:2 [ "nombre" => "J.M." "apellidos" => "Prieto de Paula" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Interna, Hospital clínico Universitario de Valladolid, Valladolid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome hemofagocítico y virus de la influenza (H3N2)" ] ] "textoCompleto" => "Reading the study by Rodríguez Vidigal et al.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> that examined the presence of hemophagocytic syndrome (HPS) in 6 patients and its relationship with certain infections has promoted us to present a new case of HPS caused, in this case, by the influenza virus.Infections are known to be the most common processes associated with HPS. However, although the influenza virus has been reported as one of the causes of HPS, there are very few reviews in the literature on the topic (Medline and PubMed searches; key words: Haemophagocytic syndrome, Hemophagocytic lymphohistiocytosis and Influenza virus).A 68-year-old man with a history of chronic ischemic heart disease was admitted for deterioration of his general condition, headaches, febricula and sweats, all of which started 3 weeks earlier. The physical examination revealed hepatosplenomegaly and tenderness in the paraumbilical region. The laboratory tests revealed the presence of leukopenia (3190/mm3), thrombocytopenia (74,000/mm3), hypertriglyceridemia (274 mg/dL), cytolysis with cholestasis (aspartate transaminase, 459 U/L; alanine aminotransferase, 339 U/L; gamma-glutamyl transferase, 182 U/L; and alkaline phosphatase, 207 U/l), lactate dehydrogenase level of 1258 U/L and hyperferritinemia (>1000 ng/mL). The prothrombin rate was 72 %, and the dimer D level was 16,040 ng/mL. The interleukin-2 receptor level was 1416 U/mL. The abdominal ultrasound confirmed hepatosplenomegaly, while the serology for cytomegalovirus, Epstein-Barr virus, toxoplasma, Borrelia, syphilis, legionella, herpes simplex, Coxiella burnetii and human immunodeficiency virus was negative. The polymerase chain reaction for respiratory viruses was positive for the influenza A virus (H3N2). The bone marrow biopsy did not reveal the presence of hemophagocytosis. Treatment was started with oseltamivir, with progressive resolution of the symptoms and complete normalization of the laboratory tests in several weeks.According to the guidelines of the International Histiocyte Society, diagnosing HPS requires the presence of at least 5 of the following criteria: fever, splenomegaly, cytopenias (affecting 2 or 3 peripheral blood lines), hypertriglyceridemia and/or hypofibrinogenemia, hemophagocytosis in the bone marrow, lymph nodes or spleen, low levels or absence of NK cells, ferritin level >500 μg/L and high interleukin-2 levels.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Our patient met 6 of these criteria.Several studies have demonstrated the association between influenza A virus (H1N1) and HPS. Most of these patients have underlying comorbidities such as obesity, hypertension, diabetes, chronic obstructive pulmonary disease and neoplasia.<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a> However, there are few cases of HPS related to the H3N2 virus, despite being the most common subtype of the influenza virus infection.<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a> Unlike the published cases, our patient did not require treatment with glucocorticoids or other vital support measures.We believe, as does Rodríguez Vidigal et al.,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> that infection-associated HPS is more frequent than is published in the literature. Therefore, the etiological study of HPS and the search for infections by Leishmania spp., to which the authors allude, should include other more common pathogens in our setting, such as the influenza A virus." 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Vol. 220. Issue 3.

Pages 209-210 (April 2020)

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