Case report: a fatal combination of hemophagocytic lymphohistiocytosis with extensive pulmonary microvascular damage in
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CASE REPORT
Case report: a fatal combination of hemophagocytic lymphohistiocytosis with extensive pulmonary microvascular damage in COVID-19 pneumonia Jan H. von der Thüsen 1 & Jasper van Bommel 2 & Johan M. Kros 1 King H. Lam 1 & Willem A. Dik 3,4 & Jelle R. Miedema 5
&
Robert M. Verdijk 1
&
Boaz Lopuhaä 1 &
Received: 10 September 2020 / Accepted: 13 October 2020 # The Author(s) 2020
Abstract The clinical features of COVID-19 have a considerable range from a mild illness to severe disease. Underlying pathophysiological mechanisms of the rapidly progressive, and often fatal, pulmonary disease frequently observed in COVID-19 need to be elucidated, in order to develop new treatment strategies for different disease endotypes. Fatal cases can display features of a cytokine storm, which may be related to hemophagocytic lymphohistiocytosis. Also, a spectrum of vascular changes, including microvascular damage, is known to accompany severe COVID-19. In this paper, we describe the co-occurrence of hemophagocytic lymphohistiocytosis and extensive pulmonary microvascular damage with thrombosis and its sequelae in a patient with fatal COVID-19. We believe these response patterns may be linked by common mechanisms involving hypercytokinemia and require further investigation as a fatal constellation in COVID-19, to generate appropriate treatment in patients who display these combined features. Keywords COVID-19 . Pneumonia . Hyperinflammatory syndrome . Microvascular thrombosis . Hemophagocytic lymphohistiocytosis
Introduction The clinical features of a patient with COVID-19 range from a mild illness with slight complaints such as sore throat and headache to patients with a very severe illness who have acute hypoxemic respiratory failure and need to be admitted to an intensive care unit. Risk factors for severe and fatal disease
* Jan H. von der Thüsen [email protected] 1
Department of Pathology, Erasmus MC, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
2
Department of Intensive Care, Erasmus MC, Rotterdam, The Netherlands
3
Department of Medical Immunology, Laboratory Medical Immunology, Erasmus MC, Rotterdam, The Netherlands
4
Department of Internal Medicine, Section Clinical Immunology, Erasmus MC, Rotterdam, The Netherlands
5
Department of Pulmonology, Erasmus MC, Rotterdam, The Netherlands
include elevated serum levels of D-dimer, ferritin, and interleukin (IL)-6 [1]. In addition to a study demonstrating the effect of remdesivir on time to recovery in hospital, recent evidence in favor of corticosteroid treatment to modulate inflammation in hospitalized COVID-19 patients with respiratory support is mounting [2, 3]. However, the underlying pathophysiological mechanisms of the rapidly progressive, and often fatal, pulmonary disease frequently observed in COVID-19 need to be elucidated in order to develop new treatment strategies for different disease endotypes. Hypercytokinemia has been found to correlate with occurrence of hemophagocytosis, which has been observed as a secondary ph
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