Neonatal hemophagocytic lymphohistiocytosis: A meta-analysis of 205 cases

Lincoln A Kranz; Wyatt S Hahn; Whitney S Thompson; Roland Hentz; Nathan L Kobrinsky; Paul Galardy; Jacob R Greenmyer

doi:10.1002/pbc.30894

Neonatal hemophagocytic lymphohistiocytosis: A meta-analysis of 205 cases

Pediatr Blood Cancer. 2024 Apr;71(4):e30894. doi: 10.1002/pbc.30894. Epub 2024 Jan 31.

Authors

Lincoln A Kranz¹, Wyatt S Hahn¹, Whitney S Thompson², Roland Hentz³, Nathan L Kobrinsky⁴, Paul Galardy⁵, Jacob R Greenmyer⁶

Affiliations

¹ University of North Dakota School of Medicine, Grand Forks, North Dakota, USA.
² Mayo Clinic, Neonatal and Perinatal Medicine, Clinical Genomics, Center for Individualized Medicine, Rochester, Minnesota, USA.
³ Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA.
⁴ Hematology, Essentia Health, Fargo, North Dakota, USA.
⁵ Pediatric Hematology and Oncology, Mayo Clinic, Rochester, Minnesota, USA.
⁶ Pediatric Hematology and Oncology, Hospice and Palliative Medicine, Mayo Clinic, Rochester, Minnesota, USA.

PMID: 38296838
DOI: 10.1002/pbc.30894

Abstract

Background: Neonatal hemophagocytic lymphohistiocytosis (nHLH), defined as HLH that presents in the first month of life, is clinically devastating. There have been few large descriptive studies of nHLH.

Objectives: The objective of this study was to perform a meta-analysis of published cases of nHLH.

Methods: A comprehensive literature database search was performed. Cases of HLH were eligible for inclusion if clinical analysis was performed at age ≤30 days. Up to 70 variables were extracted from each case.

Results: A total of 544 studies were assessed for eligibility, and 205 cases of nHLH from 142 articles were included. The median age of symptom onset was day of life 3 (interquartile range [IQR]: 0-11, n = 141). Median age at diagnosis was day of life 15 (IQR: 6-27, n = 87). Causes of HLH included familial HLH (48%, n = 99/205), infection (26%, n = 53/205), unknown (17%, n = 35/205), macrophage activation syndrome/rheumatologic (2.9%, n = 4/205), primary immune deficiency (2.0%, n = 5/205), inborn errors of metabolism (2.4%, n = 5/205), and malignancy (2.0%, n = 4/205). Fever was absent in 19% (n = 28/147) of all neonates and 39% (n = 15/38) of preterm neonates. Bicytopenia was absent in 26% (n = 47/183) of patients. Central nervous system (CNS) manifestations were reported in 63% of cases (n = 64/102). Liver injury (68%, n = 91/134) and/or liver failure (24%, n = 32/134) were common. Flow cytometry was performed in 22% (n = 45/205) of cases. Many patients (63%, n = 121/193) died within the period of reporting. Discernable values for HLH diagnostic criteria were reported between 30% and 83% of the time.

Conclusions: Evaluation of nHLH requires rapid testing for a wide range of differential diagnoses. HLH diagnostic criteria such as fever and bicytopenia may not occur as frequently in the neonatal population as in older pediatric populations. Neurologic and hepatic manifestations frequently occur in the neonatal population. Current reports of nHLH suggest a high mortality rate. Future publications containing data on nHLH should improve reporting quality by reporting all clinically relevant data.

Keywords: HLH; hemophagocytic lymphohistiocytosis; macrophage activation syndrome; meta-analysis; neonatal; neonate.

Publication types

Meta-Analysis

MeSH terms

Databases, Factual
Diagnosis, Differential
Fever / diagnosis
Humans
Infant, Newborn
Lymphohistiocytosis, Hemophagocytic* / diagnosis
Lymphohistiocytosis, Hemophagocytic* / epidemiology
Lymphohistiocytosis, Hemophagocytic* / etiology
Macrophage Activation Syndrome*