Gigi Blanchard, MD, from UC San Diego Owen Clinic, presents "Another Day, Another Fever" at AIDS Clinical Rounds

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AIDS CLINICAL ROUNDS

2. Another Day,
Another Fever
Gigi Blanchard, MD
July 11,2014

3. HPI
• 59yo with AIDS (CD4 = 14/14% and VL <20) and
NHL presented to the ED with acute onset AMS,
fever and SOB
• NHL dx’d ’06 complicated by relapse 3/13
• Chemo 4/13
• Relapse with CNS involvement 7/13
• Autologous SCT at Sloan-Kettering ~ 10/13
• Complicated by CMV colitis
• Transfusion dependent since SCT
• Plts q 3weeks; PRBC monthly; GCSF prn
• Relapse 1/14 to skull – s/p XRT

4. HPI
• Recently treated for pna before driving from AZ
to San Diego for vacation
• Chest CT in April in AZ: RUL and LLL infiltrates
c/w atypical pna
• Levofloxacin for 2 weeks
• Repeat CT showed improvement
• On the night of arrival in SD, fell out of bed and
was altered in the AM
• Presented for eval of acute onset AMS, fever and
SOB

5. ROS
• GEN: fever x 1 day; No NS or weight loss
• HEENT: No HA; no sinus pain/drainage; no visual sx; no
odynophagia or dysphagia
• HEME: no epistaxis; no oral bleeding; + easy bruising
• PULM: + SOB; No cough
• CV: No chest pain, orthopnea or PND; + pedal edema
• GI: No abd pain; no N/V/D; no blood in stools or melena
• GU: no dysuria or discharge; no hematuria; no frequency
or urgency
• Neuro: Neuropathy to mid-shin
• Musculoskeletal: no joint or muscle pain
• Skin: No rash

6. PMHx & FHx
• AIDS - Atripla
• NHL
• Hepatitis B
• Entecavir added when in NY
• Adrenal Insuff
• CMV colitis
• Anemia and thrombocytopenia
• Peripheral Neuropathy
• GERD
• Fhx: Non-contributory

7. • Meds prior to admission:
• Atripla
• Entecavir
• Valganciclovir 900mg qday
• Fluconazole 100mg qday
• Hydrocortisone 40mg bid
• Atovaquone
• Omeprazole
• Pregabalin
• GCSF
• Megace
• Morphine
• NKDA

8. Shx
• Tob: 1PPD; min etoh; no drugs; married
• Travel Hx: Had worked for an airline
• Every country in South America x Paraguay,
Throughout Mexico 18months ago
• Europe
• Hong Kong 2-3 years ago
• Bangkok, Thailand and Cambodia 3 years ago
• Egypt
• Australia and New Guinea 3.5 years ago

9. ED Course
• Became hypotensive and obtunded -> intubated
• Tm 100; T low 96.4
• Labs:
• Cr = 1.15 GFR >60
• AST/ALT = 19/15; Albumin = 3.1
• WBC = 1.0 S 8%, B 8% ANC = 160
• H/H = 10.3/31.8; Plt = 37
• CXR: bibasilar infiltrates/trace effusions

11. ICU Course
• Started on azithro, pip/tazo, vancomycin, Septra
and fluconazole
• Continued on valganciclovir 900mg daily
• Head CT: Sinusitis but o/w nl
• Chest CT:
• Multifocal pneumonia
• Severe centrilobular and paraseptal emphysema
• Bronch:
• Diffusely inflamed airways
• Moderate amount of thin, purulent secretions

13. Hospital Course
• Sputum/saliva
• Enterobacter cloacae – moderate
• MSSA – heavy
• Strep Pna – heavy
• Bronch cx grew yeast, not cryptococcus
• 1 colony of MSSA
• AFB smear and cx negative at 10days
• Cytology negative for PCP

14. Hospital Course cont’d
• Azithromycin and SMX/TMP d/c’d
• Weaned off pressors by day 6
• Extubated day 7
• Afebrile for days 2-4 days
• Then daily fevers
• 100.4-102.2
• CBC improved briefly; no longer neutropenic
• Called out to floor team ~ 36 hours
• Resp failure – re-intubated

15. PE
• T 99.5 BP 64-123/45-67 P 90-127 RR 13-37
• GEN: intubated and sedated; anasarcic
• HEENT: limited exam but no obvious thrush
• CV: RR no M
• PULM: CTA B/L anteriorly
• ABD: soft, NT, ND, NABS; no HSM
• SKIN: petechiae; violaceous plaque/nodule on R
5th toe c/w KS
• Neuro: unable to assess

16. Labs
• CBC
• WBC = 1.5, S 68%, B 20% ANC = 1.3
• H/H = 6.8/20.5 (retic 1.8%) Plt = 7
• Chemistries essentially unremarkable
• Nl renal function; Nl AG
• AST/ALT = 86/54
• AlkΦ = 770 GGT = 1086 (nl <60)
• T/Dbili = 1.3/0.9
• LDH = 888 (nl 135-225)

17. Labs
• INR = 1.4 PTT = 31.9
• Fibrinogen = 596 -> 452 -> 273 (nl 200 - 450)
• D-dimer = 8614
• PPP - negative
• Ferritin = 8508
• Haptoglobin = 332 (nl up to 200)
• CRP = 16.6

18. Micro/Serology
• Blood cx negative 5/22, 5/27, 5/29/5/30
• AFB blood and sputum cx negative
• Fungal blood cx not done
• Urine cx negative
• CMV PCR negative
• Cryptococcal Antigen negative
• Cocci ID/CF neg
• Quantiferon negative

19. What is the cause of his fever
and pancytopenia?
• Lymphoma – another recurrence
• Castleman’s Disease
• Fungal infection – histoplasmosis? Penicillium?
• Drug Fever
• Malaria, Leishmaniasis or some other exotic
infection
• Other

20. What to do next?
• H/O is concerned about HLH
• Fever and pancytopenia
• Elevated TG
• Elevated ferritin
• BMbx performed and results pending
• They recommend etoposide and steroids
• High mortality if not treated promptly
• Do you agree?

21. Do you agree with treating him
for HLH?
• No – He’s got plenty of reasons to be febrile &
pancytopenic with elevated ferritin
• Yes – He meets criteria and he’s got little to lose
• What’s HLH?

22. Ferritin
• Storage protein for iron (4000 atoms of iron)
• Produced in hepatocytes and in any cell that
stores iron (macrophages and hepatocytes)
• Serum ferritin mirrors tissue stores in normal
conditions
• Acute Phase Reactant
• Cytokines (IL-1, IL-6) increase production of
ferritin -> increased storage of iron
• Hides it from invaders
• Low serum iron in chronic inflammation

23. Elevated Ferritin Ddx
• Iron Overload
• Hereditary hemochromatosis
• Transfusions
• Inflammation
• Rheumatologic diseases - Still’s disease; SLE
• Malignancy
• Infections – Histoplasmosis & TB
• Liver disease
• Chronic viral hepatitis
• Alcoholic liver disease & Non-alcoholic steatohepatitis
(NASH)
• HLH

24. Hemophagocytic
LymphoHistiocytosis (HLH)
• AKA Macrophage Activation Syndrome in ass’n
with rheumatologic diseases
• Hemophagocytosis: the pathologic finding of
activated macrophages (MΦ) engulfing RBC,
WBCs, platelets and their precursors
• A syndrome of extreme inflammation and tissue
destruction d/t pathologic immune activation
• The excessive inflammation is thought to be
caused by a lack of normal down regulation of
activated MΦ d/t defective CTL/NK cells

25. HLH - Intro
• First described in 1939 as histiocytic medullary
reticulosis
• aka Viral Ass’d Hemophagocytic Syndrome
• Most frequently affects infants 0-18 mo
• Can affect anyone of any age
• Familial and sporadic forms
• Infection is a common trigger of both forms
• Aggressive and life-threatening
• Prompt initiation of treatment is essential for
survival

26. Immunology Review

28. Immunology review:
The Macrophage
• Monocytes are made in the bone marrow
• Within 24hours, enter tissues
• Differentiate from circulating peripheral-blood
mononuclear cells (PBMCs) to specific type of
mononuclear phagocytic cell or macrophage
w/in the tissue
• Lives w/in the tissues for days to months

29. Immunology Review

30. Macrophage Functions
• Phagocytosis/Janitor – engulf and digest
senescent cells & remove cellular debris
• Clear 200 billion RBCs/day
• Recycle ~ 3kg of iron per year
• Synthesize ferritin
• Innate Immunity/1st Responder
• Phagocytosis – engulf and digest pathogens and
cancer cells
• Antigen Presentation Cells
• Secrete cytokines that stimulate lymphocytes &
other immune cells to respond to pathogens

31. Macrophage Functions
• Immune regulation – dampen the immune
response and limit inflammation
• Down regulates production of pro-inflammatory
cytokine IL-12
• Makes anti-inflammatory cytokine IL-10
• Wound-healing
• makes precursors of collagen – contribute to the
production of the extracellular matrix
• Stimulates fibroblast proliferation and survival

32. Cytokines & Chemokines
• Cytokine: any small protein made by a cell that
affects the behavior of other cells. They act via
specific cytokine receptors on the cells they
affect.
• Interleukin: cytokine made by lymphocyte
• Chemokine: A type of cytokine that attracts
WBCs to sites of infection. Small
chemoattractant protein that stimulates the
migration and activation of cells, especially
phagocytic cells and lymphocytes.

33. Cytokines & their actions
Cytokine Produced
by
Local Effects Systemic Effects
IL-1
MΦ
Activates lymphocytes,
Local tissue destruction
Fever
Production of IL-6
IFN-γ T-cells
NK cells
Macrophage activation
TNF-α
MΦ
Increases vascular permeability
Increased entry of IgG ,complement &
cells to tissues
Increased fluid drainage to lymph nodes
Increases NK cells’ killing 20-100 fold
Fever
Shock
IL-6
MΦ
T-cells
Lymphocyte activation
Increased antibody production
Fever
Induces acute-phase
protein production
IL-12 MΦ Activates NK cells to secrete IFN-γ/TNF-α
Induces differentiation of T cells
IL-18 MΦ Activates NK cells to secrete IFN-γ/TNF-α
Induces CTL to secrete IFN-γ

38. Immunology Review – NK cells
• Natural Killer cells 10-15% of lymphocytes
• Lymphocytes that originate in the BM and develop
outside the thymus
• First line of defense b/c they can destroy another cell
w/o prior sensitization (Innate immunity)
• They are activated by IFN and macrophage-derived
cytokines
• Produce IFN-γ which primes MΦ to secrete pro-
inflammatory cytokines
• NK eliminate damaged, stressed or infected host
cells such as MΦ, typically in response to viral
infection or malignancy

41. Immunology Review - CTL
• Cytotoxic T lymphocytes are activated T cells that
lyse autologous cells such as macrophages
bearing foreign antigens
• Adaptive Immune Response
• IL-2 is necessary for the growth, proliferation and
differentiation of T-cells to b/c effector cells
• Antigen binding to T-cell stimulates secretion of
IL2 and expression of IL2 receptors

42. IL-2 (aka T-cell growth factor)
& IL-2 receptor (CD25)
• T cells produce IL-2 to make themselves
proliferate and differentiate
• The IL-2 receptor has 3 chains: α, β, γ
• Resting T cells – IL2 receptor has only β & γ
chains
• binds IL-2 w/ moderate affinity
• Activated T cells also produce α chain of IL-2
receptor (aka CD25)
• Add’n of α-chain creates receptor bind with
much higher affinity
• 1 T cell can give rise to 1000s in 2-3 days

44. NK and CTLs
• NK and CTLs normally eliminate MΦ
• NK/CTLs create a pore in the MΦ membrane
using a protein called perforin
• Deliver cytotoxic granules into the MΦ
• Granules contain proteases such as granzyme B
that can initiate cell death, often through
apoptosis

45. HLH - Pathogenesis
• NK & CTLs become unable to create a hole in
the target cell and/or unable to deliver cytotoxic
molecules
• Familial forms of HLH involve genetic defects in
the perforin gene which encodes a
membranolytic protein
• Other mutations involve granule exocytosis
• Priming for exocytosis
• Membrane fusion of cytolytic granules

46. HLH Pathophysiology
• Defective triggering of apoptosis of MΦ and
reduced T-cell and NK cytotoxicity
• Failure to control infections with intracellular
pathogens
• Prolonged antigen presentation to CD8+
• Excessive activation of T cells, which leads to
increased cytokine secretion and
hyperactivation of MΦ
• Increased cytokines induce end-organ
dysfunction and immune dysregulation

47. HLH Pathophysiology
• Activated histiocytes infiltrate organs
• Hemophagocytosis and infiltration with cytokine
storm result in:
• Organomegaly,
• Multi-organ dysfunction,
• Life-threatening cytopenias
• Cause of HLH in adult/acquired forms is
unknown
• Unidentified genetic predisposition?

48. IL-18 & CD25
• Both correlate significantly with disease activity
• IL-18 (made by MΦ) induces CTL to secrete IFN-γ
• IFN-γ mediates macrophage activation
• MΦ excessively phagocytose erythrocytes,
leukocytes, platelets and their pre-cursors in the
RES - hemophagocytosis
• IL-18 has been shown to modulate the synthesis
of ferritin by monocytes/MΦ in vitro
• CD25 – IL-2 receptor α chain that puts CTL into
overdrive

50. Bone marrow
aspirate Histiocytes
Erythroid precursors
(nucleated RBCs)
Dysplastic erythroid
precursor
(trilobed nucleus)
Degenerated cells
(artifact)
Myeloid precursors
Nucleus of histiocyte

51. Clinical Presentation
• Fever
• Resp problems (ARDS) including need for
ventilation
• Severe hypotension – requiring pressors
• Hepatomegaly & Splenomegaly
• Neuro findings:
• Seizures
• AMS c/w encephalitis
• Demyelinating peripheral neuropathy d/t diffuse MΦ
infiltration of the nerve sheath
• Skin: rash, petechiae, purpura, edema,erythroderma

52. Lab findings in HLH
• Anemia & Thrombocytopenia
• Very high serum ferritin
• High LFTs: AST, ALT, GGT, LDH and bilirubin
• GGT is especially sensitive d/t biliary tract
infiltration by lymphocytes and MΦ
• Increased TGs
• D/t cytokine inhibition of lipoprotein lipase
• May not be elevated until the liver has been
affected for some time
• Elevated d-dimer

53. Diagnostic Criteria (5 out of 8)
• Fever ≥ 38.5 (101.3)
• Splenomegaly
• Cytopenias (need 2 out of 3)
• Hgb < 9; Plt <100, ANC <1000
• Hypertriglyceridemia &/or Hypofibrinogenemia
• Fasting TG > 265 Fibrinogen < 150
• Hemophagocytosis in BM, spleen, LN or liver
• Low or absent NK-cell activity
• Elevated soluble CD25
• Ferritin > 500 ng/mL (3000 is better value)

54. Making the Diagnosis
• Extremely difficult!
• Rare
• Variable presentation
• Non-specific findings
• Hemophagocytosis is neither specific or sensitive
• May be absent early in the disease (up to 20%)
• Counter-intuitive dx of immune activation
• Expect rising white count, plts & fibrinogen

55. HLH - Triggers
• Viral illness
• Herpes viruses
• HSV, VZV (HHV3), EBV (HHV4), CMV (HHV5), HHV8
• EBV Latent membrane protein-1 activates and
stimulates MΦ to phagocytose hematopoietic
cells
• EBV+/T-lymphoma cells secrete high levels of
TNF-α, IFN-γ, and IL-1
• Parvovirus
• HIV
• Measles
• H1N1 influenza

56. HLH - Triggers
• Bacteria (salmonella typhi)
• Parasites
• Toxoplasmosis
• Leishmaniasis
• Fungi
• TB

57. HLH - triggers
• Autoimmune disease
• Juvenile idiopathic arthritis (Still’s disease)
• SLE, RA, PAN, Sarcoidosis
• Malignancies, most commonly lymphoid cancers
• Lymphomas
• Leukemias
• Myeloid malignancies
• Solid tumors
• ½ of adult HLH is ass’d with cancer
• Those with malignancy still had acute infectious
trigger

58. HLH – Malignancy triggers
• HLH can precede the diagnosis or occur after the
diagnosis
• Can also occur during chemo
• Usually T/NK cell lymphomas and leukemias
• May be d/t release of TNF-α, IFN-γ and CD25
from neoplastic cells, causing MΦ activation

59. HLH and HIV
• Has been reported at all stages of HIV
• Case reports in acute seroconversion illness
• CD4 median ~ 250 (range 63-500)
• 100% survival
• D/t cytokine alteration ass’d with viremia?
• Usually advanced AIDS
• 20% survival
• Triggered by OI
• HLH IRIS
• Subclinical HLH in HIV pts?
• Autopsy study from 1985 of 56 AIDS pts
• 20% had e/o hemophagocytosis

60. HLH and HIV Triggers
• Herpes viruses are most common trigger in HIV
• EBV ass’n most common
• HHV8 – cases had high viral loads of HHV8
• 4/5 had cutaneous KS
• 3 cases reported of Castleman’s disease
• CMV
• AFB: MAI, TB, M kansasii
• Histoplasmosis, Penicillium marneffi,
Cryptococcus, and Candidal fungemia
• Pneumocystis, Toxo

61. Labs to get for HLH
• CBC with diff
• PT/PTT, INR = 1.4
• Fibrinogen
• D-dimer
• Ferritin
• LFTs: AST,ALT, GGT, T Bili albumin, LDH
• Serum Triglycerides
• Soluble IL-2 receptor (CD25)

62. More Labs to Get
• Blood, urine and sputum cx
• Fungal and AFB cx
• EBV serology and viral load
• CMV serology and viral load
• HHV-8 viral load
• Adenovirus and parvovirus
• Cryptococcal antigen
• Toxo serology

63. Even more studies
• CT of Chest/Abdomen/Pelvis
• Lymph node biopsy
• Bone Marrow Bx

64. Treatment of HLH
• HLH-94: International treatment protocol by the
Histiocyte Society in 1994
• 8 week induction with dexamethasone, etoposide
and intrathecal methotrexate for pts with CNS
disease or CSF abnormalities
• At the end of 8 weeks, weaned off if possible
• If not, continued until stem cell transplant
• HLH 2004
• Added cyclosporine to etoposide and
dexamethasone

65. Treatment of HLH today
• HLH-2004 protocol
• Etoposide, cyclosporine and dexamethasone
• IVIG – 0.5g/kg/day for 2 days
• Anakinra (Kineret) – IL-1 R inhibitor
• Treat the trigger
• Consider HAART if not already on it
• Case reports of TNF-α blockade with inflixamab
in refractory cases
• Splenectomy
• Stem cell transplant in genetic HLH

66. Back to the Case
• Treated with IVIG (1gm/kg) x 2 days
• Histo urinary antigen negative
• HHV8 virus not detected
• EBV PCR + (Quantitative not done)
• IL-2 receptor (CD25) = 1721 pg/ml (nl < 1033)
6/1 6/2 6/3 6/4 6/5 6/6 6/7
Ferritin 8508 4723 5387 3769 2578
IVIG IVIG
Tmax 99.5 101.2 100.2 99.9 100.6 101.3 102.4

67. Abd CT

68. BMbx
• Hypercellular marrow with dysplastic erythroid
precursors
• Occasional hemophagocytosis
• B-cell lymphoma
• Focal non-caseating granulomas with no fungal
or mycobacteria identified

70. Bone marrow
aspirate Histiocytes
Erythroid precursors
(nucleated RBCs)
Dysplastic erythroid
precursor
(trilobed nucleus)
Degenerated cells
(artifact)
Myeloid precursors
Nucleus of histiocyte

72. Dysplastic erythroid
precursor
(nuclear bleb)
Anucleated
red blood cells
Hemosiderin granules

73. Diagnostic Criteria (5 out of 8)
• Fever ≥ 38.5 (101.3)
• Splenomegaly
• Cytopenias (need 2 out of 3)
• Hgb < 9; Plt <100, ANC <1000
• Hypertriglyceridemia &/or Hypofibrinogenemia
• Fasting TG > 265 Fibrinogen < 150
• Hemophagocytosis in BM, spleen, LN or liver
• Low or absent NK-cell activity
• Elevated soluble CD25
• Ferritin > 500 ng/mL (3000 is better value)

74. What’s your diagnosis?

75. Take Home Points
• Consider HLH in pts with SIRS/Sepsis who are not
responding to broad spectrum antibiotics (check
ferritin)
• Consider HLH if ferritin is elevated
• If you have a pt with HLH, check an HIV test!

76. JP

78. JP 1 year later

79. JP 1 year later

80. Thank you