Critical Care: Student/Resident Case Report Poster - Critical Care IV |

Hemophagocytic Lymphohistiocytosis in a Patient With Cytomegalovirus and Mycoplasma Pneumonia FREE TO VIEW

Sami Abuqayyas, MD; Shruti Gadre, MD; Pulkit Chaudhury, MD; Hariom Joshi, MD; Madhu Sasidhar, MD
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Cleveland Clinic Foundation, Cleveland, OH

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):436A. doi:10.1016/j.chest.2016.08.449
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care IV

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: HLH is a life threatening hematological disorder characterized by over activation of T lymphocytes and macrophages leading to uncontrolled over production of inflammatory cytokines with resultant multi organ inflammation. HLH can be acquired or familial; it has different etiologies, including but not limited to malignancies, autoimmune disorders as well as infections1

CASE PRESENTATION: We are presenting a case of a 19-year-old caucasian male who presented with a three-week history of fevers (40-40.5°C) accompanied by night sweats, chills and right upper quadrant pain. Initial workup revealed pancytopenia, abnormal liver function tests (LFTs) and hepatosplenomegaly. Treatment was initiated with broad-spectrum antibiotics and filgrastim. He developed increased work of breathing, tachycardia and hypotension necessitating admission to the ICU. CT chest demonstrated multifocal groundglass and centrilobular opacities with consolidation in the lower lobes. Further workup revealed CMV viremia and positive mycoplasma pneumonia antibodies (IgM: 3.87 OD ratio and IgG: 9.8 ISR). He had an elevated ferritin 23635 ng/ml, soluble interlukin-2 receptor 24060 pg/ml and mildly elevated ANA but no other rheumatologic, endocrine or oncologic abnormalities. A bone marrow biopsy showed scattered lymphohistiocytic clusters and hemophagocytosis. He received pulse dose methylprednisolone in addition to vancomycin, piperacillin-tazobactam and levofloxacin. Ganciclovir and abatacept were added for CMV viremia. Antibiotics were discontinued after resolution of fevers and normalization of LFTs and ferritin. He was discharged on ganciclovir 2.5mg/kg q12h with prednisone taper. At one month post discharge follow up visit, the patient was symptom free and had resolution of pancytopenia

DISCUSSION: Our patient met six of eight diagnostic criteria for HLH. Moreover, the resolution of his symptoms and normalization of his labs with the steroids, antibiotics and continued antiviral therapy supported our clinical diagnosis. Both, CMV and mycoplasma pneumonia have been reported in the literature as possible underlying etiologies for HLH2,3. To the best of our knowledge, finding both organisms in one case is rarely reported. The presumed mechanism for his multi organ inflammatory syndrome is the altered immune response induced by the overwhelming bacterial and viral infection he had had, mycoplasma pneumonia and CMV in our case

CONCLUSIONS: HLH is an uncommon hematological disorder with viral infections being the most commonly inciting factors. Having both CMV and mycoplasma pneumonia in one patient diagnosed with HLH is a rare event. We are presenting this case aiming to raise the awareness for this rare combination

Reference #1: Janka GE. Familial and acquired hemophagocytic lymphohistiocytosis. Annu Rev Med. 2012

Reference #2: Fisman DN. Hemophagocytic syndromes and infection. Emerg Infect Dis. 2000

Reference #3: Koike Y. Hemophagocytic Syndrome Associated with Mycoplasma pneumoniae Pneumonia. Case Rep Pediatr. 2013:586705

DISCLOSURE: The following authors have nothing to disclose: Sami Abuqayyas, Shruti Gadre, Pulkit Chaudhury, Hariom Joshi, Madhu Sasidhar

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