Published online Nov 30, 2018. doi: 10.5492/wjccm.v7.i6.73
Peer-review started: August 7, 2018
First decision: October 8, 2018
Revised: October 21, 2018
Accepted: November 7, 2018
Article in press: November 7, 2018
Published online: November 30, 2018
To study the management, complications and outcomes of adult patients admitted with hemophagocytic lymphohistiocytosis (HLH) in the intensive care unit (ICU).
We performed a retrospective observational study of adult patients with the diagnosis of “HLH” admitted to the two academic medical ICUs of Baylor College of Medicine between 01/01/2013 to 06/30/2017. HLH was diagnosed using the HLH-2004 criteria proposed by the Histiocyte Society.
Sixteen adult cases of HLH were admitted to the medical ICUs over 4 years. Median age of presentation was 49 years and 10 (63%) were males. Median Sequential Organ Failure Assessment (SOFA) score at the time of ICU admission was 10. Median ICU length of stay (LOS) was 11.5 d and median hospital LOS was 29 d. Septic shock and acute respiratory failure accounted for majority of diagnoses necessitating ICU admission. Septic shock was the most common ICU complication seen in (88%) patients, followed by acute kidney injury (81%) and acute respiratory failure requiring mechanical ventilation (75%). Nine patients (56%) developed disseminated intravascular coagulation and eight (50%) had acute liver failure. 10 episodes of clinically significant bleeding were observed. Multi system organ failure was the most common cause of death seen in 12 (75%) patients. The 30 d mortality was 37% (6 cases) and 90 d mortality was 81% (13 cases). There was no difference in mortality based on age (above or less than 50 years), SOFA score on ICU admission (more than or less than 10), immunosuppression, time to diagnose HLH or direct ICU admission versus floor transfer.
HLH is a devastating disease associated with poor outcomes in ICU. Intensivists need to have a high degree of clinical suspicion for HLH in patients with septic shock/multi system organ failure and progressive bi/pancytopenia who are not responding to standard management in ICU.
Core tip: Hemophagocytic lymphohistiocytosis is a serious disorder in intensive care unit (ICU) with high morbidity and mortality. Septic shock, acute kidney injury and respiratory failure are the most common manifestations in ICU. We observed high incidence of bleeding complications and bloodstream infections. High index of suspicion is necessary for ICU patients with severe septic shock and multi organ failure who do not respond to standard treatment.