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Dr.P.Subramani
II year Postgraduate
SRMCDr.Latha RavichandranProfessorDepartment of pediatrics
Dr.Julius Xavier ScottProfessorDepartment of pediatric hematooncology
Sri Ramachandra University, Porur.
CASE HISTORY
— 3 months old, Girl infant
— History of hypopigmentation over the skin x 1 month
— Recurrent respiratory tract infection x 1 month
— Fever x 3 days
— Loose stools x 2 days
GENERAL EXAMINATION
— Febrile (Temp 100.3 F).— Vitals stable
— Anthropometry:— Normal
— Pallor present.— Blond hair
— Intermittent areas of skin hypopigmentation over face, trunk and limbs— Cervical and axillary lymph nodes palpable.
SYSTEMIC EXAMINATION— Spleen 3 cm below left costal margin.
Liver 1 cm below right costal margin.
Other systems- NAD.
PROBLEM LIST
Fever
Splenohepatomegaly
Hypopigmentation
Blond hair
Recurrent infections
DIFFERENTIAL DIAGNOSISDD RULED OUT
1. IEM Urine for metabolic screening :NEGATIVE
2. TORCH infection TORCH panel: NEGATIVE
3. Immunodeficiency Immunoglobulin Assay : NORMAL
Further workup was planned.
INVESTIGATIONS
INVESTIGATION REPORT
Hb 6.6g/dl
Total count 5900/cu.mm
Lymphocytes 81
MCV 75
Platelets 60,000
RFT/serumelectrolytes
Normal
LFT/coagulation profile
Normal
INVESTIGATION REPORT
Uric acid 2
LDH 735
DCT NEGATIVE
Serum ferritin 2734
Triglycerides 323mg/dl
CXR and XraySkull,USG abdomen
Normal
INVESTIGATIONSINVESTIGATION REPORT
Hb 6.6g/dl
Total count 5900/cu.mm
L 81
PCV 19.2
MCV 75
Platelet 60,000
BUN 15
S.Creatinine 0.5
Peripheral smear Microcytic,thromocytopenic
INVESTIGATION REPORT
Serum electrolytes NORMAL
Uric acid 2
PT/PTT/INR NORMAL
LDH 735
S.G.O.T 146
S.G.P.T 70
DCT NEGATIVE
TOTAL BILIRUBIN 0.87
CXR NAD
HLH CRITERIA OUR CASE— Fever
— Splenomegaly
— Cytopenia ( more than or 2 cell lineages)
— Hypertriglyceridemia/
Hypofibrinogenemia
— Hyperferritinemia
— Low/Absent NK cell activity
— Hemophagocytosis
— Elevated soluble CD25
— Fever
— Splenomegaly
— Bicytopenia
— Hypertriglyceridemia -323mg/dl
— Hyperferritinemia- 2734
HLH – ?Familial? Secondary to infection
SUSPICION OF HLH
HLHHypo
pigmentation
Blond hair
Recurrent infection
MISSING LINK
?
PERIPHERAL SMEARRBC:
•Microcytic hypochromic with anisocytosis
WBC:•Few reactive lymphocytes
•Few lymphocytes showing large abnormal granules
PLATELET COUNT:•Thrombocytopenia
HLH
Hypo
Pigment
\Blond hair
CHSAccelerated
phase
Recurrent infections
PS- Granules
BONE MARROW SKIN BIOPSY
1. Hemophagocyte2. Large Granules
1. Irregulary arranged large melanosomes.
MANAGEMENT— Control infection
— IV Piperacillin/Tazobactum, Amikacin
— Stepped up to Meropenem
— IV fluconzole
— To find the source of infection— Blood &Urine C/S- NO GROWTH
Further Treatment Plan….— Ophthalmology evaluation : Not suggestive of occular
albinism
— Parents were counselled about the prognosis
— Genetic counselling given.
— Planned to continue IV antibiotics for a week
— Dexamethasone + Etoposide and intravenous immunoglobulin thrice weekly (HLH 2004 PROTOCOL)
— Referral to transplant physician
— Parents were not willing for any further approach of treatment and wanted to continue with the conservative plan of management.
— Child succumbed to illness 2 days post discharge.
CHEDIAK HIGASHI SYNDROME— Rare autosomal recessive disorder characterized by Ø Recurrent pyogenic infections,
Ø Partial oculocutaneous albinism,
Ø Progressive neurologic abnormalities,
Ø Mild coagulation defects,
Ø A lymphoma-like accelerated phase
— Less than 500 cases have been reported worldwide.
— First case in India reported in 1982
— *Chediak-Higashi syndrome. Kaplan J, De Domenico I, Ward DM
— Curr Opin Hematol. 2008;15(1):22.
PATHOGENESIS• Mutation in the lysosomal trafficking
regulator (CHS1/LYST) gene at 1q42
• Abnormal organellar protein trafficking
• Aberrant fusion of vesicles
• Failure to transport lysosomes to the appropriate site of action
Altered lysosomes/granules are found in all cell types in CHS, and are the hallmark of the disease
*Identification and mutation analysis of the complete gene for Chediak-Higashi syndrome. Nagle DL, Karim MA, Woolf EA, Holmgren L. Nat Genet. 1996;14(3):307.
RECURRENT INFECTIONS
HYPOPIGMENTATION
MILD BLEEDING DIATHESIS
Defective neutrophilchemotaxis, degranulation
and bactericidal activity.
Giant granules – Interfere with the cells ability to traverse the narrow passages between endothelial cells into tissue.
Impaired NK cell function
Pathologic aggregation and uneven distribution of
melanosomes
Impaired Platelet Aggregation
CLINICAL MANIFESTATIONS
— Partial oculocutaneousalbinism
— Hepatosplenomegaly and lymphadenopathy.
— Gingivitis, oral ulcerations, and periodontal disease.
— Recurrent pyogenicinfections
— Mild coagulation defect
— Ocular manifestations include photophobia, decreased visual acuity, nystagmus, and strabismus.
About 10 percent of patients survive early childhood despite serious infections, but develop severe, debilitating neurologic
manifestations in adolescence and early adulthood
DIAGNOSIS— Peripheral blood smear for the classic large granules
in all nucleated giant cells.
— Examination of skin melanocytes reveals giant melanosomes.
— Genetic testing for mutations in the CHS1/LYST gene.
— Light microscopy of hair shafts shows small aggregates of clumped pigmentation that are irregularly distributed.
— CHS can be diagnosed prenatally by examining amniotic or chorionic villus cells for enlarged lysosomes.
ACCELERATED PHASE— Lymphohistiocytic infiltration of virtually all organ
systems .
— Even more profound immune deficiency.
— Patients present with fever, increased hepatosplenomegaly and lymphadenopathy, and worsened pancytopenia and bleeding.
— This phase occurs in more than 80 percent of patients and is usually lethal.
MANAGEMENT— Supportive
— High dose Ascorbic acid improves the clinical status in stable phase- Controversy.
— IV antibiotics for infections.
— CURATIVE THERAPY : Stem Cell Transplant
MANAGEMENTINITIAL 8 WEEKS CHEMOTHERAPY
•Etoposide•Dexamethasone
•IT Methotrexate
(after 2 weeks when progressive neurological symptoms)
FAMILIAL
PERSISTANTNon-Familial
RESOLVEDNon-Familial
Stop Therapy
Re activation
HSCT
Accelerated Phase : HLH 2004 protocol.
— Chediak Higashi Syndrome presenting in Accelerated phase— Tanzeel Imran, Lybna Zafar, Madeeha Rehan— Journal of college of Physicians and surgeons Pakistan 2012
— A 2 year old boy presented with high grade fever, cough, swelling of neck and abdominal distention. pallor, hepatosplenomegaly significant cervical lymphadenopathy,enlarged axillary and inguinal lymph nodes. He also had silver hair and partial cutaneous albinism since birth.
— Bone marrow aspirate also revealed prominent histiocytes and haemophagocytosis. On the basis of his clinical presentation, peripheral blood film and bone marrow aspirate findings, the diagnosis of Chediak-Higashi syndrome was established.
— Unfortunately patient expired after 24 days of hospital stay.
— Chédiak-higashi Syndrome: An Accelerated Phase With Hereditary Elliptocytosis
— Abu Sharif M. A. Islam, MD; Zakaria M. Hawsawi, MD;
— Annals of Saudi Medicine, Vol 21, Nos 3-4, 2001
— 2 year-old male, blond hair and patchy cutaneoushypopigmentation, H/O recurrent Respiratory tract infections. Blood reports revealed features of HLH.
— Peripheral smear, Bone marrow confirmed Chediak Higashi Syndrome.
— Bone marrow transplantation was performed. Boy clinically well.
— Chediak higashi can present with — Oculo Cutaneous albinism, — Splenomegaly, — Lymphadenopathy, — Fever and H/O recurrent infections.
— Carefully examined peripheral smear can clinch the diagnosis.
— Accelerated phase of CHS presents as HLH.
— Since the disease is usually lethal in the first decade, its early detection may facilitate early BMT, which is the only curative approach.
THANK YOU !!THANK YOU !!
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