A 53-year-old male presented with a 1-month history of hyperpyrexia. The clinical manifestations revealed hemophagocytic lymphohistiocytosis (HLH). Although a lymph node biopsy could not be obtained, a bone marrow biopsy revealed the activated B-cell subtype of diffuse large B-cell lymphoma (DLBCL). After being treated with HLH-1994 (dexamethasone and etoposide), a rituximab-containing chemotherapy and target agents involving bortezomib, the patient achieved remission. To understand the molecular profile of patient, next-generation sequencing and MYD88 L265P mutation examinations were performed, and the patient was determined to be positive for the MYD88 L265P mutation. Reports of DLBCL with plasmacytic differentiation and a MYD88 innate immune signal transduction adaptor L265P mutation concurrent with HLH are rare. Early recognition, precise diagnosis and timely therapy are pivotal in improving patient prognosis. Furthermore, molecular profiling enables researchers to develop potential therapies aimed at the activated NF-κB and endoplasmic reticulum stress signaling pathways. The present study highlights this pathogenesis and provides suggestions for further individualized therapeutics.
Hemophagocytic lymphohistiocytosis (HLH) is a fatal and hyperinflammatory disorder associated with excessive activation of cytotoxic T cells, natural killer (NK) cells and macrophages. Failure to control the immune response leads to marked elevation of cytokines, inducing systemic inflammatory symptoms and signs (
Diffuse large B-cell lymphoma (DLBCL) accounts for 30–35% of newly diagnosed B-cell lymphomas (
As B-cell lymphoma with HLH is seldom reported, to the best of our knowledge, this is the first report of a case of HLH as a prelude to activated B-cell-like DLBCL (ABC DLBCL), which was accompanied by plasmacytic differentiation and a MYD88 innate immune signal transduction adaptor L265P (MYD88 L265P) mutation. It was assumed that the mutation of MYD88 L265P and plasmacytic differentiation resulted in activation of the endoplasmic reticulum (ER) stress and NF-κB signaling pathways. Understanding the pathogenesis enables researchers to develop novel intervention strategies for patients with activated NF-κB and ER stress signaling pathways, proposing a safe and feasible way to enhance outcomes in this subset of patients.
A 53-year-old male was admitted to Xiangya Hospital (Central South University, Changsha, China) with a 1-month history of hyperpyrexia in June 2018. Upon admission, the vital signs included a temperature of 37.5°C, a heart rate of 96 beats/min, a blood pressure of 110/50 mmHg, and a respiratory rate of 20 breaths/min. Physical examination revealed an anemic appearance but no palpable lymphadenopathy. An initial workup showed acute inflammatory deterioration [C reactive protein, 69.3 mg/l (normal, 0–8 mg/dl); procalcitonin, 0.88 ng/ml (normal, 0–0.1 ng/ml); anemia [hemoglobin level, 5.4 g/dl (normal, 13–17.5 g/dl)], thrombocytopenia [platelet level, 25×103/µl (normal, 100–300×103/µl)], hypertriglyceridemia [triglyceride level, 3.47 mmol/l (normal, 0–1.7 mmol/l)] and increased ferritin [>2,530 µg/l (normal, 16–400 µg/l)]. Moreover, the patient had elevated immunoglobulin levels [IgM, 5,010 mg/l (normal, 400–2,800 mg/l)]. Simultaneously, both serum and urine electrophoresis detected IgM κ chains. B-mode ultrasound imaging of the superficial lymph nodes showed multiple lymph nodes on both sides of the cervical region, axillary fossa and groin, but none were larger than 13×4 mm. A computed tomography (CT) scan revealed multiple mesentery lymph nodes and splenomegaly. Notably, bone marrow aspiration showed hemophagocytosis (data not shown).
According to HLH-2004, a diagnosis of secondary HLH could be made as the patient had 5 out of 8 parameters (bicytopenia, splenomegaly, hypertriglyceridemia, hyperferritinemia and hemophagocytosis) (
Although R-CHOP is the frontline standard of care for DLBCL, among patients with RR DLBCL, less favorable outcomes have prompted efforts to improve first-line approaches. EPOCH-R, a 96-h continuous infusion regimen of R-CHOP that incorporates a dynamic dose adjustment, has shown excellent efficacy in Bcl-2-positive DLBCL (
Since the collection of stem cells from the bone marrow failed, ibrutinib or lenalidomide administration was recommended. The patient selected lenalidomide (25 mg daily) for maintenance treatment. The last PET/CT performed in February 2019 showed that glucose metabolism, which was originally increased in multiple bone parenchyma, the spleen and both adrenal glands, was generally ameliorated, which indicated complete remission (CR) of the lymphoma (
The plain and contrast-enhanced CT scans of the chest, abdomen and pelvis were made with the Aquilion ONE 320-detector row CT scanner (Canon Medical Systems Corporation). The CT parameters were as follows: 120 kV, automatic mAsec, 1.0-mm thickness, 1.0-mm intervals and a matrix of 256×256. The PET/CT scans were performed on a GE Discovery 690 PET/CT scanner (GE Healthcare).
Interphase FISH analysis was performed according to the standards of the International System for Human Cytogenetic Nomenclature 2016 (
The flow cytometry analysis was performed in the laboratory of the Department of Hematology, Xiangya Hospital, using bone marrow aspirate specimens. A total of 3 ml EDTA-anti-coagulated bone marrow samples were collected and kept on ice (4°C). Samples (1.5 ml) were added into a conical centrifuge tube with 10 ml erythrocyte-lysing solution (cat. no. 348202; BD Biosciences). Next, the sample was incubated in the dark at 4°C for 5 min. After lysis procession, the cells were preserved using cell preservation medium [composed of 500 ml RPMI1640, 25 ml 5% FBS (cat. no. 164210-500; Procell Life Science & Technology Co., Ltd.) and 5 ml Penicillin-Streptomycin solution (cat. no. DXT-0503; ScienCell Research Laboratories, Inc.)]. The cells were counted after infiltration. The cell suspension concentration was adjusted to 3.0×106/ml. A total of 100 µl cell suspension was added to each tube, and then the fluorochrome-combined antibodies were added to cell suspension for incubation at 4°C for 30 min. During cell washing, the cells were centrifuged at 400 × g for 5 min at 4°C and resuspended in cold PBS three times. Finally, the cells were preserved with incubation in the dark at 4°C to acquire data as soon as possible. The fluorochrome-combined monoclonal antibodies were as follows: Anti-CD7 (FITC-A), anti-CD56 (PE-A), anti-CD8 (PE-Cy7-A), anti-CD3 (APC-A), anti-CD4 (APC-Cy7-A), anti-CD45 (PerCP-A/APC-Cy7-A), anti-CD19 (PE-Cy7-A), anti-CD20 (APC-Cy7-A), anti-CD38 (APC-A), anti-CD34 (APC-A), anti-CD5 (PE-A/PerCP-A), anti-CD10 (FITC-A), sκ (FITC-A) and sλ (PE-A). All of the fluorochromes and antibodies were acquired from Becton-Dickinson and Company. Flow cytometry was performed by FACSCanto II (BD Biosciences) and data were analyzed with FACSDiva software (v7.0; BD Biosciences).
The blood routine was analyzed by a Coulter LH 750 automatic blood cell analyzer. The biochemical tests including hepatorenal function and ferritin analysis, were performed on Beckman Coulter AU680 automatic biochemical analyzer (Beckman Coulter, Inc.). All of the examinations were conducted and analyzed by the Clinical Laboratory of Xiangya Hospital.
The bone marrow specimens collected from the patient were fixed in 10% neutral formalin solution for further pathological and immunohistochemistry (IHC) analysis, as well as H&E staining, by Kindstar Global Company. The NGS of fusion genes and gene mutations, FISH probes (bcl-2, bcl-6 and myc rearrangements) and Ig gene rearrangements (PCR) were performed by Kindstar Global Company. The MYD88 L265P mutation examination was performed by Kindstar Global Company using allele-specific PCR.
A comprehensive literature search was performed using the databases of PubMed (
Studies were included if they met the following criteria: i) Refer to secondary HLH in critically ill patients; ii) concern patients with a diagnosis of histologically confirmed DLBCL; iii) provide relevant information on clinical course, treatments and outcomes; iv) are written in English; and v) contain one or multiple clinical case reports or letters. Other recognized LBCL variants, such as intravascular lymphoma, T-cell/histiocyte-rich LBCL, primary diffuse LBCL of the central nervous system (CNS) and Epstein-Barr virus-positive DLBCL were excluded due to possible different pathophysiologies. Reviewers resolved all discrepancies by discussion during the study identification process.
Among the malignancies associated with HLH, lymphoma is the most common underlying condition. It was established that patients with lymphoma who developed HLH exhibited immune activation due to lymphoma cells or inhibitory immune function failure from the disease or treatment-induced bone marrow dysfunction (
The current case presents several intriguing findings. First, the most plausible diagnosis was DLBCL with plasmacytic differentiation. From the imaging results, lymphoma was identified. However, surgeons found that neither the adrenal gland nor the palpable lymph nodes were palpable for excision biopsy. Finally, the diagnosis of ABC DLBCL was established through a bone biopsy. A previous study revealed that different diagnoses can be made by examining lymph node biopsies and other sites of involvement, and the diagnosis concordance rate between bone marrow and lymph nodes was 84.85% (
The second item of note in the present study was that it was hypothesized that the NF-κB signaling pathway was activated. In HLH, disruption of granule-mediated cytotoxicity impairs apoptosis in target cells and causes uncontrolled activation of T cells, which release proinflammatory cytokines (
Third, ER signaling pathway activation was mediated by lymphoma cells with plasmacytic differentiation. ER stress is obligatory in the modification and trafficking of proteins (
The effects of MYD88 on the NF-κB and ER signaling pathways are presented in
In response to many paraproteins, ER stress induces the UPR, which includes three pathways, the PERK-eIF2α-ATF4, IRE1-XBP1 and the ATF6 axes, which contributes to avoiding fatal ER stress through the activation of the ER chaperon and ER-associated degradation (
It is generally agreed that ABC DLBCL presents with significantly inferior progression-free survival (PFS) and overall survival (OS) times compared with germinal center B-cell (GCB) DLBCL (
Lymphoma cells in ABC tumors take advantage of BCR expression, which associates with increased tyrosine phosphorylation levels of CD79 complexes and induces sustained BCR signaling that is activated through the NF-κB pathway to sustain neoplastic proliferation (
Lenalidomide can impact NF-κB signaling and type I interferon to improve the efficacy of ABC DLBCL. In the first phase III trial (REMARC study) comparison of lenalidomide with placebo in patients with DLBCL treated with R-CHOP, the 2-year PFS rate improved from 75 to 80% in the lenalidomide group. It is noteworthy that the patients were 60 to 80 years old, and further clinical trials need to define the effect of this agent on other age groups (
BTZ, a proteasome inhibitor, could prevent the degradation of proapoptotic proteins in HLH and increase the protein load within the cell, consistently stimulating ER stress, and finally inducing apoptosis in cells. Furthermore, BTZ inhibited the activation of the 26S proteasome complex, blocking the degradation of IκBα. Consequently, NF-κB was unable to mediate transcription, and signaling activity was suppressed. BTZ is now widely used in the treatment of MM as an initial therapy (
In summary, the current study presented the case of a patient with HLH triggered by ABC DLBCL exhibiting plasmacytic differentiation and the MYD88 L265P mutation. Prompt recognition of HLH and an accurate diagnosis of underlying disease are obligatory and vital. Treatments not only control cytokine release but also target the underlying disorder and significantly affect the prognosis of patients. Therefore, a reliable diagnosis of lymphoma and precision therapy pointing to gene aberrations need to be examined in further research. As suggested by the present case, the application of B+R-CHOP may be successful in the treatment of the subtype of ABC DLBCL characterized by NF-κB and ER stress pathway activity.
Not applicable.
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
YC contributed to the analysis and interpretation of the data, as well as the drafting of the manuscript. LZ and HZ contributed to data analysis and manuscript preparation. GF contributed to the conception of the manuscript. XZ helped perform the analysis, with constructive discussions. All authors read and approved the final version of the manuscript. LZ and GF confirm the authenticity of all the raw data.
The patient provided written informed consent for the present study.
The patient provided written informed consent for the publication of all the data and associated images.
The authors declare that they have no competing interests.
PET-CT at diagnosis of lymphoma and at completion of 4 cycles of chemotherapy. (A) Initial PET-CT revealed increased glucose metabolism of multiple bone parenchyma suggesting lymphoma infiltration (red arrows). (B) PET-CT scans performed after 4 cycles of chemotherapy were negative for residual disease. PET-CT, positron emission tomography-computed tomography.
Pathological findings of bone marrow biopsy are diffuse large B-cell lymphoma. (A) Hematoxylin and eosin staining patterns revealing diffuse, pleomorphic, medium to large tumor cell infiltration (magnification, ×400). Immunohistochemical staining patterns showing tumor cells positive for (B) CD20, (C) paired box 5, (D) Bcl-6, (E) multiple myeloma ongogene 1, (F) Bcl-2, (G) c-myc, and (H) Ki67 (magnification, ×400).
Flow cytometry analysis of the bone marrow. (A) The large cells were positive for CD45 (purple cell cluster of ~3.1%). (B) There were 3.1% CD19-positive cells (bottle green cell cluster). (C) 3.1% of cells were positive for CD19 and CD20 (bottle green/purple cell cluster). (D) Cells positive for CD20 (purple cell cluster of ~3.1%) and negative for CD38. (E) The cells were positive for sκ (purple cell cluster ~91%) and negative for sλ. (F) The mature B cells were negative for both CD5 and CD10. Dark grey, impurities; light green, lymphoid cells; light grey, immature cells; blue, neutrophils; orange, monocytes; pink, karyocytes; bottle green, CD19-positive cells; purple, CD45/CD20 and sκ-positive cells
Images of FISH results. The FISH detection results showed that chromosomal translocations of (A) t(14;16)(q32;q23), (B) t(4;14)(q16;q32) and (C) t(11;14)(q13;q32) were negative for this patient (magnification, ×100). Positive control images of corresponding translocations are on the right side of each figure (magnification, ×400). FISH, fluorescence
Chemotherapy timeline. EPOCH-R, etoposide, vincristine, epirubicin, cyclophosphamide, prednisone and rituximab; HD-MTX + VR-CAPE, methotrexate, rituximab, bortezomib, cyclophosphamide, doxorubicin hydrochloride liposome, dexamethasone and etoposide; R+CP, rituximab, cyclophosphamide and dexamethasone; R+ECHOP, etoposide, vincristine, epirubicin, cyclophosphamide, dexamethasone and rituximab.
Proposed model indicating the effects of MYD88 innate immune signal transduction adaptor on the NF-κB and endoplasmatic reticulum stress signaling pathways. ERAD, endoplasmic reticulum-associated protein degradation.
Clinical features of patients with DLBCL and HLH.
First author, year | Country | Age, years | Sex | Symptoms and signs | Laboratory examination | Subtype of DLBCL | Clinical stage | International Prognostic Index | Treatment | Treatment response | Outcome from remission until publication follow-up | (Refs.) |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Malkan |
Turkey | 32 | Male | Vomiting, nausea and diarrhea, anuria, fever and hepatosplenomegaly | Pancytopenia, hypertriglyceridemia, elevated transaminases and CRP, high level of LDH and fer-ritin, hypercalcemia, hemophagocytosis | NA | NA | NA | HLH-2004, R-EPOCH | CR | Survival | ( |
Desai |
USA | 73 | Female | Fever, splenomegaly | Cytopenia, hypertriglyceridemia, hyperferritinemia, hemophagocytosis | NA | IV | NA | HLH-1994, R-CHOP | ND | Death | ( |
Tang |
China | 64 | Female | Upper abdominal pain and continuous high-grade fever | Anemia, elevated CRP and procalcitonin, liver dysfunction, lymphadenopathy | GC | NA | NA | R-CHOP | ND | Death | ( |
Wu |
China | 66 | Male | Continuous high-grade fever with no obvious cause | Bicytopenia, increased level of ferritin, sIL-2R and triglycerides, hemophagocytosis, lymphadenopathy, splenomegaly | nGC | III B | High risk | R+ECHOP, intrathecal chemotherapy (methotrexate, cytarabine, dexamethasone) | CR | Survival | ( |
Kim |
Korea | 57 | Male | Fever, weight loss | Bicytopenia, increased levels of ferritin, soluble CD25, LDH and β2-microglobulin, splenomegaly, hyperdiploidy and complex abnormalities, clonal rearrangement of the IGH gene | NA | NA | NA | R-CHOP | CR | Survival | ( |
Patel |
USA | 57 | Male | Weakness, fatigue, confusion, dizziness and mild jaundice | Bicytopenia, elevated creatinine, LDH, ferritin, triglycerides, liver dysfunction, coagulopathy, splenomegaly, lymphadenopathy | NA | NA | NA | Dexamethasone, ifosfamide, carboplatin and etoposide | ND | Death | ( |
Patel |
USA | 70 | Female | Left facial weakness, fatigue, night sweats, fever, decreased appetite and weight loss | Pancytopenia, elevated LDH, ferritin, coagulopathy, hypertriglyceridemia, sCD-25 | NA | IV B | NA | R-CHOP | ND | Survival | ( |
Entezari |
USA | 66 | Male | Fevers and altered mental status without focal neurological deficits | Bicytopenia, splenomegaly elevated LDH, serum ferritin, fibrinogen, triglyceride and sCD25, low NK cell levels, hemophagocytosis | nGC | NA | NA | High-dose dexamethasone, cyclosporine, R-CHOP | ND | Survival | ( |
Li |
China | 48 | Male | High-grade fever, cough, weight loss, hepatosplenomegaly, lymphadenopathy | Pancytopenia, liver dysfunction, elevation of triglyceride, LDH and serum ferritin, hemophagocytosis LDH, serum ferritin | GC | IV B | High risk | High-dose methylprednisolone, cyclophosphamide, vincristine, doxorubicin and etoposide, R+ECHOP | At first CR, relapsed after 8 cycles of chemotherapy | Survival | ( |
Kuo |
China (Taiwan) | 51 | Female | Intermit-tent fever | Anemia, elevated CRP, hemophagocytosis | NA | NA | NA | E-POCH | ND | Survival | ( |
Wang |
China | 46 | Male | Persistent fever, vibration white fingers, discontinuous arthralgia, jaundice, abdominal distention, anorexia, hepatosplenomegaly, scrotal edema and loss of body weight | Pancytopenia, coagulopathy, splenohepatomegaly, hemophagocytosis | NA | I B | NA | HLH-2004, R-CHOP | ND | Survival | ( |
Davidson-Moncada |
Greek | 74 | Male | Increasing abdominal pain, nausea, vomiting, splenomegaly, lymphadenopathy | Anemia, liver dysfunction, coagulopathy, lymphadenopathy, elevated fibrinogen levels, serum ferritin and LDH, hemophagocytosis | NA | NA | NA | High-dose corticosteroids with rituximab, cyclophosphamide | ND | Death | ( |
Sano |
Japan | 63 | Male | Fever and upper abdominal discomfort, hepatosplenomegaly | Pancytopenia, liver dysfunction, elevation of LDH, serum ferritin, sIL-2R, CRP, lymphadenopathy; | NA | IV | High risk | High-dose methylprednisolone, R-CHOP | CR | Survival | ( |
NA, information not available; CRP, C reactive protein; LDH, lactate dehydrogenase; Ig, immunoglobulin; sCD25, soluble CD25; sIL-2R, soluble interleukin-2 receptor; GC, germinal center; nGC, non-germinal center; CR, complete remission; ND, not determined; DLBCL, diffuse large B-cell lymphoma; HLH, hemophagocytic lymphohistiocytosis; R-CHOP, rituximab plus cyclophosphamide, doxorubicin, vincristine and prednisone; R-EPOCH, etoposide, vincristine, epirubicin, cyclophosphamide, prednisone and rituximab; R+ECHOP, etoposide, vincristine, epirubicin, cyclophosphamide, dexamethasone and rituximab.