December 2007 Vol 8 After Meeting.indd ABSTRACT Hemophagocytic Lymphohistiocytosis (HLH) implies a benign generalized histiocytic proliferate with erythrophago- cytosis and it includes familial hemophagocytic lymphohistiocytosis and secondary hemophgocytosis. Spinal fluid changes like mild to moderate pleocytosis (most of the cells are lymphocytes and macrophages) and sometimes hemophagocytosis are seen in primary HLH but are not reported in secondary HLH. Here we report a case of a previously healthy 0 months old male infant who was diagnosed as familial HLH with evidence of CSF hemophagocytosis. He was started on the HLH 2004 treatment protocol with no improvement. A second bone marrow aspiration revealed leshmania donovani antibodies and he was started on anti-leishmania treat- ment with dramatic response.To the best of our knowledge, this is the first case of secondary HLH with evidence of hemophagocytosis in cerebrospinal fluid. Key words: Lymphohistiocytosis, hemophagocytic; Leishmaniasis; Cerebrospinal fluid; Case Report; Oman. Cerebrospinal Fluid Involvement in a Case of Visceral Leishmaniasis Associated with Hemophagocytic Lymphohistiocytosis Mahmoud Fathalla, Javad Hashim, Hussein Alkindy, *Yasser Wali SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL DECEMBER 2007 VOL 7, NO. 3, P. 253-256 SULTAN QABOOS UNIVERSITY© SUBMITTED - 17TH MARCH 2007 ACCEPTED - 19TH SEPTEMBER 2007 Department of Child Health, College of Medicine and Health Sciences, Sultan Qaboos University, P. O. Box 35, Al-Khod 123, Muscat, Sultanate of Oman *To whom correspondence should be addressed. Email: yawali@squ.edu.om C A S E R E P O R T خلاليا املرافقة الليشمانيا االحشائية في حالة النخاعي السائل تأثر رَيَّات الكُ ةُ مَ بَلْعَ مرض والي الكندي، ياسر جافاد هاشم، حسني اهللا، فتح محمود هذه اخلاليا وتقوم باألنسجة املناعية ة جَ ُنْسِ للخاليا امل حميد بتكاثر مرض يتميز البالزماوي هو يٌّ جِ ُنْسِ امل فاوِيٌّ اللِمْ رَيَّات الكُ ةُ مَ بَلْعَ مرض امللخص: إن اخلاليا الليمفاوية في ــر تكاث مثل النخاعي ــائل الس في تغيرات حتدث . ثانوي واألخر وراثي أحدهما نوعني املرض هذا ــمل ويش . ر ــاتِ احلُمْ رَيَّ الكُ ــام بالته مصاب أشهر ذكر عمره عشرة طفل التقرير نشرح حاله هذا وفي فقط. الوراثي النوع في املناعية اخلاليا في تكاثر وأيضا البلعمة عملية وأحيانا حتصل هناك أن تبني الثاني العظم نقي فحص في . حتسن 2004 دون عولج سنة . الشوكي رَيَّات في السائل الكُ ةُ مَ بَلْعَ عنده وكان ، املرض من الوراثي بالنوع من حالة أول أن هذه علمنا حد وعلى . كبير ــكل حتسن بش وقد األساس هذا على عولج ــائية). (الليشمانيا االحش ونُوفانِيَّة الدُّ ــمانِيَّةُ اللِّيشْ ــام أجس . الشوكي في السائل رَيَّات الكُ ةُ مَ بَلْعَ وجود مع البالزماوي يٌّ جِ ُنْسِ امل فاوِيٌّ اللِمْ رَيَّات الكُ ةُ مَ بَلْعَ مرض عمان. ، حالة تقرير سائل شوكي، بالزماوي، ثانوي، يٌّ جِ نْسِ مُ ْفاوِيٌّ ملِ رَيَّات، الكُ ةُ مَ الكلمات: بَلْعَ مفتاح HAEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS (HLH) includes familial haemophagocytosis (FHLH) and secondary haemophagocytic syndrome. Primary (Familial) HLH is an autosomal re- cessive disease. By homozygosity mapping, two loci for FHLH have been identified, one each at 9q213-22 FHLI and 10q21-22 (FHL2). The incidence of FHLH is ap- proximately one case per 50,000 live births. Males and females are affected at equal frequencies and 80% of cases present in the first year of life.1 In Oman, 27 cases have been diagnosed so far, most of them (24) familial; genetic study was done in 8 families.2, 3 The typical HLH is diagnosed on the basis of Hentel et al’s guidelines.1 Secondary HLH may occur at any age, commonly in association with immunosuppressive therapy, infection (usually viruses) and or malignancy. The central nerv- ous system (CNS) symptoms are usually linked to fa- milial HLH. This is a rare case of secondary HLH that M A H M O U D FAT H A L L A , J AVA D H A S H I M , H U S S E I N A L K I N D Y A N D YA S S E R WA L I 254 presented with CNS symptoms as well as evidence of CSF haemophagocytosis. C A S E R E P O R T A 10 month old Omani male infant, was referred to Sultan Qaboos University Hospital, (SQUH) Oman, from a peripheral Omani hospital as a suspected case of HLH. He was admitted to SQUH with a history of high grade fever associated with diarrhoea and vomit- ing for the previous two weeks. He was a product of a consanguineous marriage, with no past history of diseases or previous admissions to hospitals; however, there was the unexplained early infant death of one of his siblings in his family history. On examination, he was sick looking, febrile, pale and had tachycardia. There was splenomegaly of 10 cm below the left costal margin and a large liver of 7 cm. After his admission, he developed generalized convulsions that responded to IV Phenytonin treat- ment (loading followed by maintenance). His complete blood count showed evidence of pan- cytopenia with WBC 2.37x109/L; absolute neutrophil count was 0.36x109/L and platelets were14.1x109/L. Other laboratory investigations revealed: lactate de- hydrogenase 829; erythrocyte sedimentation rate 47; C-reactive protein 65; albumin 24; serum ferritin 4687 ng/ml that increased to 25973 µ/ml within few days. Serum triglycerides were 3.0 mmol/L and fibrinogen was 1.9 g/L. Prothrombin time was 14 seconds and activated partial thromboplastin time was 55 seconds. Renal and liver function tests were within normal lim- its and hepatitis and HIV serology tests were negative. The bone marrow aspiration (BMA) was completely normal. The cerebrospinal fluid showed evidence of haemophagocytosis, Genetic study for perforin, Munc and syntaxin II genes were done in the SQUH genetic laboratory and found to be negative. The results of these tests usually come after one month. A provi- sional diagnosis of primary (familial) HLH was estab- lished on the basis of the young age of presentation, the unexplained death of a 6 months old sibling and the severe clinical course. Subsequently, treatment with HLH 2004 Protocol was started for 2 weeks. The child’s fever continued to spike with no improvement. As per protocol, after 2 weeks, a second BMA was done and revealed leishma- nia donovani antibodies. The HLH 2004 protocol was stopped and IV Ambisome was started with no clini- cal improvement. Treatment was changed to Na-Sti- blogluconate (20mg/kg/day). He received a full course of 21 days and improved significantly with disappear- ance of the fever and organomegaly. The BMA showed no evidence of leishmania or haemophagocytosis. The patient was subsequently discharged home. At a follow up visit after 6 months, he maintained his general well being and was completely normal. D I S C U S S I O N HLH implies a benign, generalized histiocytic proliferation with erythrophagocytosis and it in- cludes FHLH and secondary haemophagocytic syndrome1, 2, 4 associated with viral infections, proto- zoal infections and malignancy. These disorders are indistinguishable pathologically and are character- ized as ‘reactive’ disorders of antigen-presenting and antigen-processing histiocytes. The hallmark of these disorders is marked haemophagocytosis in the lym- phoreticular system.5, 6 The symptoms are supposed to be due to hyperactivity of macrophages.1 The cause of the inappropriate immune activation in FHLH has been shown in some families to be due to the genetic encoding of perforin, Munc and syntoxin II.7, 8 The Figure 1: There was a family history of unexplained death of one of his siblings C E R E B R O S P I N A L F L U I D I N V O LV E M E N T I N A C A S E O F VI S C E R A L L E I S H M A N I A S I S A S S O C I AT E D W I T H H E M O P H A G O C Y T I C LY M P H O H I S T I O C Y T O S I S 255 typical HLH is diagnosed on the basis of Henter et al’s guidelines9: (a) Clinical criteria: fever and splenom- egaly (both to be present); (b) Laboratory criteria: cytopenias (affecting 2 of 3 lineages in the peripheral blood); haemoglobin (<9 g/L); platelets (<100 x 109/L); neutrophils (<1.0x109); hypertriglyceridemia and/or hypofibrinogenemia fasting triglycerides ≥2.0 mmol/L or ≥3 SD of the normal value for age; fibrinogen (≥1.5 g/L or ≥3 SD); (c) Histopathological criteria: haemo- phagocytosis in the bone marrow or spleen or lymph nodes, cerebrospinal fluid (CSF) and no evidence of malignancy. Neurological symptoms may complicate and sometimes dominate the clinical course of the familial cases. Hepatic abnormalities, including elevated se- rum transaminases or hyperbilirubinemia, appear to be related to the degree of liver involvement. Elevated ferritin, lactate and coagulation derangement are also common during active disease. 10 The haemophagocy- tosis mostly affects erythrocytes, but occasionally also platelets and leukocytes.11, 12 Infection by the protozoan pathogen leishmania is a public health problem in certain regions of Oman such as North Batinah.13 Although, there are a number of different species, all of which are transmitted by phlebotomine sand flies,12 there are only two primary types of clinical disease: cutaneous and visceral leish- mania (VL).14 Visceral leishmaniasis revealed by hae- mophagocytic syndrome (HS) is an extremely rare event that can cause considerable diagnostic difficulty. The first case of leishmaniasis revealed by a reactive HS was reported by Matzner et al and concerned a 22 year old adult.15 CNS involvement has been almost to- tally linked to primary FHLH. In a retrospective study on visceral leishmaniasis carried out on 33 Omani children from 1993 to 1999 at Sultan Qaboos Univer- sity Hospital, Oman,16 there was no haemophagocyto- sis. Two children had CNS involvement in the form of encephalopathy, but there was no haemophagocytosis in the CSF. In another study regarding the current status of HLH in infants and children from the Division of Pediatrics, Children’s Research Hospital, Kyoto, Japan,17 82 cases of pediatric HLH without familial inheritance were studied. There were CNS symptoms in 32.3 cases, but none of them had spinal fluid hae- mophagocytosis. All of the cases revealed lymphohis- tiocytosis with the presence of haemophagocytosis in bone marrow and reticuloendothelial cells.18 From the Indian subcontinent, there are reports of secondary HLH following malaria and leishmaniasis (also called ‘kala-azar’).19 In 14 cases of secondary HLH following malaria and kala-azar there were no features of CSF haemophagocytosis. This is probably the first case of secondary HLH that presented with CNS symptoms with evidence of CSF haemophagocytosis. R E F E R E N C E S 1. Henter JI. Biology and treatment of familial hemo- phagocytic lymphohistioctytosis. Importance of per- forin in lymphocyte-mediated cytotoxicity and trigger- ing of apoptosis. Med Pediatr Oncol. 2002; 38:305-309. 2. Al Lamki Z, Wali YA, Pathare A, Ericson K, Henter IJ. Clinical and genetic study of Hemophagocytic Lympho- histiocytosis (HLH) in Oman: Need for early treatment. Pediatr Hematol Oncol 2003; 20:603-609. 3. Muralitahran S, Al-Lamki Z, Dennison D, Christie BS, Wali YA, Zachariah M, et al. An Inframe Perforin gene deletion in familial hemophgocytic lymphocytosis is as- Figure 1: Cerebrospinal fluid showing histiocytes with evidence of hemophagocytosis. M A H M O U D FAT H A L L A , J AVA D H A S H I M , H U S S E I N A L K I N D Y A N D YA S S E R WA L I 256 sociated with Perforin expression. Am J Hematol 2005; 78:59-63. 4. Henter JI, Tondini C, Pritchard J. Histiocyte disorders. Crit Rev Oncol Hematol. 2004; 50:157-174. 5. Imashuku S, Hibi S, Todo S. Hemophagocytic lympho- histiocytosis in infancy and childhood. J Pediatr 1997; 130:352-358. 6. Ladisch S, HO W. Immunologic and clinical effects of repeated blood exchange in familial erythrophagocytic lymphohistiocytosis. Blood 1982; 60:814-820. 7. Stepp SE, Lagelouse RD, Le Deist F, Bhawan S, Certain S, Mathew PA, et al. Perforin gene defects in familial hemophagocytic lymphohistiocytosis. Science 1999; 286:1957-1959. 8. Zur Stadt U, Beutel K, Kolberg S, Schneppenheim R, Ka- bisch H, Janka G, et al. Mutation spectrum in children with primary hemophagocytic lymphohistiocytosis: Molecular and functional analyses of PRF1, UNC13D, STX11 and RAB27A. Hum Mutat 2006; 27:62-68. 9. Henter JI, Elinder G, Ost A. Diagnostic guidelines for hemophagocytic lymphohistiocytosis. The FHL Study Group of the Histiocyte Society. Semin Oncol 1991; 18:29-33. 10. Favara B. Hemophagocytic Lymphohistiocytosis: A Hemophagocytic syndrome. Semin Diagn Pathol 1992; 9:63-74. 11. Stephan JL. Histiocytoses. Eur J Pediatr 1995; 154:600- 609. 12. Sulivan JL, Woda BA. Lymphohistiocytic Disorders. In: Nathan DG, Oski FA, eds.: Hematology of infancy and childhood. 5th ed. Philadelphia: WB Saunders, 1998. p.1359-1380. 13. Elnour B, Akinbami FO, Shakeel A, Venugopalan P. Vis- ceral leishmaniasis in Omani children: a review. Ann Trop Pediatr 2001; 21:159-163. 14. Pearson RD, Sousa AQ. Clinical spectrum of leishma- niasis. Clin Infect Dis 1996; 2:11-13. 15. Kinmond S, Galea P, Simpson EM. Kala-azar in a Scot- tish child. Lancet 1989; 2:325. 16. Matzner Y, Behar A, Beeri E, Herskko C. Systemic leish- maniasis mimicking malignant histiocytosis. Cancer 1979; 43:398-402. 17. IB Elnour, FO Akinbami, Shakeel A. Visceral leishma- niasis in Omani children. Areview. Ann Trop Paediatr 2001; 21:159-163. 18 Imashuku S, Hibi S, Todo S. Hemophagocytic lympho- histiocytosis in infancy and childhood. J Pediatr 1997; 130:352-356. 19. Phawa R, Singh T, Khurana N. Hemophagocytic syn- drome in malaria and kala-azar. Indian J Pathol Micro- biol 2004; 47:348-350.