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Letter to the Editor
Hemophagocytic lymphohistiocytosis secondary to X-linked lymphoproliferative syndrome type 2
Linfohistiocitosis hemofagocítica secundaria a síndrome linfoproliferativo ligado al cromosoma X tipo 2
Pedro Laguna del Estal
Corresponding author
pedro.laguna@salud.madrid.org

Corresponding author.
, Amy Galán Gómez, Sonia García Prieto
Servicio de Medicina Interna, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hemophagocytic lymphohistiocytosis<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> &#40;HLH&#41; is a syndrome characterized by uncontrolled hyperactivation of the immune system&#46; It presents with fever&#44; hepatosplenomegaly&#44; lymphadenopathy&#44; cytopenia&#44; and characteristic laboratory &#40;hyperferritinemia&#44; hypertriglyceridemia&#44; hypofibrinogenemia&#41;&#44; immunological &#40;reduced NK activity&#44; elevated CD25s&#41; and pathological &#40;hemophagocytosis in bone marrow or spleen&#41; abnormalities&#59; these clinical&#8211;biological data are used as diagnostic criteria&#46; HLH can be sporadic or hereditary&#46; In a recent series&#44; 44&#37; were hereditary&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Of these&#44; 76&#37; were due to mutations in familial HLH &#40;FHL&#41; genes&#59; 16&#37; resulted from mutations causing immunodeficiency&#44; such as Griscelli syndrome&#44; Ch&#233;diak&#8211;Higashi syndrome&#44; X-linked lymphoproliferative syndrome type 1 &#40;SLX-1&#41; and type 2 &#40;SLX-2&#41;&#59; and 8&#37; showed no genetic alterations&#46; We report a case of HLH associated with SLX-2 &#40;OMIM &#35;300635&#41;&#44; the first in Spain&#44; diagnosed in adulthood&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 35 year-old male with repeated episodes of fever and splenomegaly &#40;the first at 3 months of age&#41; with no aetiological diagnosis&#46; Admitted for fever of 39&#160;&#176;C&#44; vomiting and diarrhoea&#46; On examination&#44; splenomegaly was observed&#46; Laboratory tests on admission highlighted the following&#58; 760&#160;neutrophils&#47;mm<span class="elsevierStyleSup">3</span>&#44; 56&#44;000&#160;platelets&#47;mm<span class="elsevierStyleSup">3</span>&#44; ALT 392&#160;U&#47;L&#44; AST 284&#160;U&#47;L&#44; LDH 1742&#160;U&#47;L&#44; ferritin 17&#44;030&#160;ng&#47;mL&#44; triglycerides 392&#160;mg&#47;dL&#59; IgG&#44; IgA&#44; IgM and IgD values were normal&#46; Stool microbiological studies&#44; blood cultures&#44; serology&#44; and PCR for EBV and CMV were negative&#46; A computed tomography scan revealed hepatosplenomegaly and retroperitoneal and mesenteric lymphadenopathy&#46; Symptomatology subsided without specific treatment and the patient was discharged&#46; At a 3 month check-up he was asymptomatic&#44; with normal blood tests and an ultrasound splenomegaly of 14&#160;cm&#46; Hereditary HLH was studied &#40;FHL types 2&#8211;5&#44; Griscelli syndrome&#44; SLX-1&#44; and SLX-2&#41;&#46; A hemizygous mutation consisting of a transition from a C to a T &#40;c&#46;664C&#62; T&#41; was detected in the BIRC4 gene&#44; which at the level of the X-linked apoptosis inhibitor protein &#40;XIAP&#41; produces the change of an arginine from position 222 to a premature stop codon &#40;p&#46;R222&#42;&#41;&#44; a causative mutation of SLX-2&#46; The mutation was also detected in the mother&#44; who had never had any symptoms&#44; but not in her only female sibling&#46; At 16 months he was admitted with similar clinical features&#59; hemophagocytosis was not observed in the bone marrow aspirate&#46; He received immunoglobulin treatment &#40;0&#46;5&#160;mg&#47;kg&#41; and dexamethasone &#40;40&#160;mg&#47;day&#47;5 days&#44; 20&#160;mg&#47;day&#47;4 days&#41;&#44; with good response&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Initially described in 2006&#44; the SLX-2 has an incidence of 1&#47;10<span class="elsevierStyleSup">6</span> males and causes 2&#37; of hereditary HLH&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Aguilar and Latour<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> analysed 100 cases reported up to 2015&#46; The most common clinical manifestations were&#58; splenomegaly associated with fever and cytopenia &#40;57&#37;&#41;&#59; HLH &#40;54&#37;&#41;&#44; triggered by EBV in 66&#37; of cases&#59; inflammatory bowel disease &#40;26&#37;&#41;&#44; similar to Crohn&#8217;s disease&#59; hypogammaglobulinemia &#40;16&#37;&#41;&#59; other inflammatory manifestations<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> &#40;7&#37;&#41;&#44; including arthritis&#44; skin abscesses&#44; erythema nodosum&#44; uveitis&#44; and nephritis&#46; Each of the above phenotypes can occur in isolation in patients&#44; although they usually present at least 2 phenotypes&#44; which may not coincide temporally&#46; Affected members of the same family may have significant differences in phenotype &#40;HLH vs&#46; Crohn&#8217;s disease&#41; and severity &#40;asymptomatic vs&#46; fatal&#41; of the disease&#46; Women can transmit the disease to their male children but remain asymptomatic as a consequence of the random inactivation of one of the alleles of the BIRC4 gene&#46; However&#44; exceptionally&#44; women with SLX-2 symptoms due to a biased inactivation of the healthy gene have been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The diagnosis can only be confirmed by genetic study&#44; detecting some of the described pathogenic genetic alterations in the BIRC4 gene&#46; Flow cytometry can also be used to determine the absence of XIAP activity in peripheral blood mononuclear cells&#44; but this technique may give false negatives in patients with mutations that allow residual expression of the protein&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Treatment will be adjusted to the clinical phenotype&#58; HLH&#44; Crohn&#8217;s disease&#44; hypogammaglobulinemia&#44; etc&#46; The only curative treatment is hematopoietic stem cell transplantation&#44; but it should be reserved for the most severe cases that do not respond to conventional treatment&#44; since the procedure is associated with high mortality &#40;63&#37;&#41;&#44; especially in cases with active HLH at the time of transplant and if reduced intensity conditioning regimens are not used&#46; In 2015&#44; 22 of the 100 cases reported died<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#58; 4 from HLH&#44; 4 from Crohn&#8217;s disease&#44; one from pneumonia&#44; one from liver failure&#44; and 12 during transplantation&#59; exceptionally&#44; some patients remained asymptomatic &#40;identified in the familial study&#41;&#46; Such extreme variety in the course of the disease&#44; together with the different phenotypic expression by which it can manifest itself&#44; means that treatment must be individualised&#46;</p></span>"
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