Tuberculosis-Associated Hemophagocytic Lymphohistiocytosis: Diagnostic Challenges and Determinants of Outcome

• Published in: Open forum infectious diseases Vol. 11; no. 4; p. ofad697
• Main Authors: Kurver, Lisa, Seers, Timothy, van Dorp, Suzanne, van Crevel, Reinout, Pollara, Gabriele, van Laarhoven, Arjan
• Format: Journal Article
• Language: English
• Published: US Oxford University Press 01.04.2024
• Subjects: Microbiology and Pathogenesis; mortality; hemophagocytic lymphohistiocytosis; bone marrow; tuberculosis; anergy
• ISSN: 2328-8957; 2328-8957
• DOI: 10.1093/ofid/ofad697

Abstract Background Tuberculosis (TB) can induce secondary hemophagocytic lymphohistiocytosis (HLH), a severe inflammatory syndrome with high mortality. We integrated all published reports of adult HIV-negative TB-associated HLH (TB-HLH) to define clinical characteristics, diagnostic strategies, and therapeutic approaches associated with improved survival. Methods PubMed, Embase, and Global Index Medicus were searched for eligible records. TB-HLH cases were categorized into (1) patients with a confirmed TB diagnosis receiving antituberculosis treatment while developing HLH and (2) patients presenting with HLH of unknown cause later diagnosed with TB. We used a logistic regression model to define clinical and diagnostic parameters associated with survival. Results We identified 115 individual cases, 45 (39.1%) from countries with low TB incidence (<10/100 000 per year). When compared with patients with HLH and known TB (n = 21), patients with HLH of unknown cause (n = 94) more often had extrapulmonary TB (66.7% vs 88.3%), while the opposite was true for pulmonary disease (91.5% vs 59.6%). Overall, Mycobacterium tuberculosis was identified in the bone marrow in 78.4% of patients for whom examination was reported (n = 74). Only 10.5% (4/38) of patients tested had a positive result upon a tuberculin skin test or interferon-γ release assay. In-hospital mortality was 28.1% (27/96) in those treated for TB and 100% (18/18) in those who did not receive antituberculosis treatment (P < .001). Conclusions Tuberculosis should be considered a cause of unexplained HLH. TB-HLH is likely underreported, and the diagnostic workup of patients with HLH should include bone marrow investigations for evidence of Mycobacerium tuberculosis. Prompt initiation of antituberculosis treatment likely improves survival in TB-HLH. Hemophagocytic lymphohistiocytosis is an underreported complication of tuberculosis, often manifesting as extrapulmonary or miliary disease. Tuberculin skin tests and interferon-γ release assays mostly show an anergic response. The threshold should be low for bone marrow investigation for evidence of Mycobacterium tuberculosis and for commencement of antituberculosis treatment.