Accepted Manuscript

Hemophagocytic lymphohistiocytosis with high serum levels of

IL-18 and predominant lymphocyte activation in a neonate born
to a mother with adult-onset Still's disease

Megumi Hashimoto, Shohei Ogata, Ayano Yamaguchi, Kota

Kawada, Manabu Kenmochi, Takasuke Ebato, Keiko Nomoto,
Yuki Bando, Saeko Shimodera, Hirofumi Shibata, Shintaro Ono,
Manabu Nakayama, Takahiro Yasumi, Masahiro Ishii

PII: S1521-6616(17)30135-3
DOI: doi: 10.1016/j.clim.2017.04.007
Reference: YCLIM 7835
To appear in: Clinical Immunology
Received date: 24 February 2017
Revised date: 28 March 2017
Accepted date: 24 April 2017

Please cite this article as: Megumi Hashimoto, Shohei Ogata, Ayano Yamaguchi, Kota
Kawada, Manabu Kenmochi, Takasuke Ebato, Keiko Nomoto, Yuki Bando, Saeko
Shimodera, Hirofumi Shibata, Shintaro Ono, Manabu Nakayama, Takahiro Yasumi,
Masahiro Ishii , Hemophagocytic lymphohistiocytosis with high serum levels of IL-18
and predominant lymphocyte activation in a neonate born to a mother with adult-onset
Still's disease. The address for the corresponding author was captured as affiliation for all
authors. Please check if appropriate. Yclim(2017), doi: 10.1016/j.clim.2017.04.007

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 ACCEPTED MANUSCRIPT

Hemophagocytic lymphohistiocytosis with high serum levels of IL-18 and predominant

lymphocyte activation in a neonate born to a mother with adult-onset Still’s disease

Megumi Hashimoto1 †, Shohei Ogata1 †, Ayano Yamaguchi1 , Kota Kawada1 , Manabu Kenmochi1 ,
Takasuke Ebato1 , Keiko Nomoto1 , Yuki Bando2 , Saeko Shimodera3 , Hirofumi Shibata3 , Shintaro
Ono4, 5 , Manabu Nakayama6 , Takahiro Yasumi3 *, and Masahiro Ishii1

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†These authors contributed equally to this work.

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1 2
Department of Pediatrics, Kitasato University School of Medicine, Sagamihara, Japan; Department
of Pediatrics, Kitasato Medical Center Hospital, Kitamoto, Japan; 3 Department of Pediatrics, Kyoto

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University Graduate School of Medicine, Kyoto, Japan; Department of Pediatrics and
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Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan; Laboratory for
Integrative Genomics, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan;
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Department of Technology Development, Kazusa DNA Research Institute, Kisarazu, Japan
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*Correspondence:
Takahiro Yasumi
Department of Pediatrics, Kyoto University Graduate School of Medicine
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54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan

Phone: +81-75-751-3291 Fax: +81-75-752-2361
E-mail: yasumi@kuhp.kyoto-u.ac.jp
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Key words:
Interleukin-18; Natural killer cell dysfunction; Lymphocyte activation; Hemophagocytic
lymphohistiocytosis; Adult-onset Still’s disease

Abbreviations:
HLH, hemophagocytic lymphohistiocytosis; CTL, cytotoxic T lymphocytes; FHL, familial HLH;

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MAS, macrophage activation syndrome; AOSD, adult-onset Still’s disease; sJIA, systemic-onset
juvenile idiopathic arthritis; NK, natural killer; IL, interleukin; sIL2R, soluble IL-2 receptor; CsA,

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cyclosporine A; Ig, immunoglobulin.

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To the Editor

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening syndrome of immune

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dysregulation resulting from the uncontrolled activation of cytotoxic T lymphocytes (CTLs) and

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macrophages. It is classified as primary or secondary based on the underlying etiology. Familial

HLH (FHL) is the major form of primary HLH; a prototypic secondary HLH is referred to as

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macrophage activation syndrome (MAS), which often complicates adult-onset Still’s disease

(AOSD) and systemic-onset juvenile idiopathic arthritis (sJIA) [1]. FHL is caused by an impairment
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in the cytolytic function of CTLs and natural killer (NK) cells. In FHL patients, impaired clearance

of antigens and defective suppression of antigen presentation results in hyper-activation of CTLs and
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excessive production of inflammatory cytokines such as interferon-. This leads to secondary

activation of macrophages, which then produce additional inflammatory cytokines, resulting in

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hyper-inflammatory HLH [1]. AOSD and sJIA are auto-inflammatory in nature and are associated

with underlying macrophage activation [2, 3]. A marked increase in serum interleukin (IL)-18 and
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NK cell dysfunction are characteristic findings [4, 5]. Although not supported by direct evidence, it
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is thought that IL-18 produced by activated macrophages induces NK cell dysfunction and promotes
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hyper-activation of CTLs, leading to MAS.

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We recently reported that combined measurement of the lymphocyte percentage within the

peripheral blood leucocyte population and the soluble IL-2 receptor (sIL2R)/ferritin ratio effectively

discriminates FHL from sJIA-MAS during the early course of the disease [6]. A predominance of

lymphocytes within the peripheral blood leukocyte population and a high sIL2R/ferritin ratio in FHL

patients reflects primary activation of lymphocytes. By contrast, sJIA-MAS is characterized by low

lymphocyte percentage within the peripheral blood leucocyte population and a low sIL2R/ferritin

ratio [6]. This is thought to reflect primary activation of macrophages. Here, we report a neonatal
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case of HLH with a high level of serum IL-18 and a profile similar to that of FHL who was born to a

mother with AOSD.

A 27-year-old woman developed AOSD at 18 weeks of gestation and received steroid

therapy. However, she became resistant to steroids and so cyclosporine A (CsA) was added from 26

weeks of gestation. Her condition stabilized thereafter. Her disease course was not complicated by

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HLH. A female infant was delivered vaginally at 34 weeks of gestation due to threatened preterm

labour. At birth, the infant displayed mild tachypnea and hepatosplenomegaly. There was no

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evidence of oculo-cutaneous albinism. Laboratory examination revealed the following: pancytopenia
9 9 9

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(WBC, 3.8 ×10 /L; neutrophils, 1.35 ×10 /L; lymphocytes, 1.68 ×10 /L; haemoglobin, 134 g/L;
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platelets, 33 ×10 /L), elevated liver enzymes (AST, 282U/L; ALT, 101U/L; γGTP, 1,082U/L; LDH,
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988U/L), low fibrinogen (83 mg/dL), and high ferritin (1,701 μg/L) and sIL2R (4,560 U/mL) levels.

NK cell activity was within the normal range (36%) at birth. Bone marrow aspiration was not
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performed. Immunoglobulin (Ig) M levels was elevated (116 mg/dL) but no evidence of infection

was identified including hepatitis B virus, hepatitis C virus, herpes simplex virus, cytomegalovirus,

or Epstein-Barr virus. Although infant’s condition did not fulfil the HLH-2004 diagnostic criteria,
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HLH was strongly suspected. Therefore, the baby received dexamethasone and Cs A. The patient’s

status and laboratory parameters gradually improved and her clinical course was uneventful
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thereafter. She was discharged without sequelae. Perforin expression by NK cells and Munc13-4,

Syntaxin 11, and Munc18-2 expression by platelets was normal. Analysis of the PRF1, UNC13D,
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STX11, STXBP2, SH2D1A, BIRC4, MVK, and NLRC4 genes revealed no pathogenic mutation.
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IL-18 was markedly elevated, and sIL2R and ferritin levels were moderately elevated, in

the mother’s serum at the time of AOSD onset (Table). Although the levels in the mother returned to

near-normal at the time of delivery, they were signific antly increased in the infant. Importantly, the

sIL2R/ferritin ratio in the infant’s was high at birth and there were more lymphocytes than

neutrophils; the sIL2R/ferritin ratio remained high throughout the infant’s disease course. These data

suggest that lymphocyte activation predominated over that of macrophages (pathology similar to that

observed in cases of FHL).

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To the best of our knowledge, only one case of neonatal HLH associated with maternal

AOSD has been reported [7]. In this case, incidental findings included hepatosplenomegaly and

thrombocytopenia on Day 7 after birth; however, there was no diagnosis of HLH and several index

parameters were evaluated only after Day 15, when the clinical condition of the patient had

deteriorated. By contrast, we took prompt evaluation of HLH in our patient, which allowed precise

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observation of disease pathology during the early phase.

Shimizu, et al. reported that IL-18 can be transferred from the mother to the infant and can

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reach a significantly high levels [8]. This can cause transient NK cell dysfunction, which may

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predispose the infant to MAS/HLH [8]. Although NK activity in the infant was normal at the time of

birth, it was low (13 %) when re-evaluated at 1 month of age (Table). Because NK activity in FHL
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patients is normal sometimes, particularly at the time of disease onset [9], it is possible that some

factors associated with, or produced by, activated lymphocytes augment the activity of NK cells in
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the infant at the time of birth. It is generally accepted that a trigger (e.g., infection) is required to first

activate CTLs, and that high levels of IL-18 and NK cell dysfunction somehow promote aberrant

activation of CTLs to induce MAS in AOSD/sJIA [10]. Because IgM levels at the time of birth were
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elevated, we speculate that an intrauterine infection triggered the CTL activation, which was then

augmented by high serum levels of IL-18 (along with NK cell dysfunction) resulting in FHL-like
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pathology.

In conclusion, we present a case of neonatal HLH with pathology similar to that of FHL
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occurring in an infant born to a mother with AOSD. This case suggests that elevated serum IL-18
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can promote aberrant CTL activation in the absence of overt macrophage activation. Therefore,

physicians should be aware that an infant born to mother with AOSD is at a risk of developing HLH,

even if the mother’s disease is well controlled at the time of delivery.

Conflict-of-interest disclosure:
The authors declare no competing financial interests.

Consent for publication:

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Consent to publish was obtained from the patient’s parents.

Funding:
This work was partially supported by JSPS KAKENHI Grant Number 26461582.

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Mother Mother

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Baby Baby Baby
(at time of (at time of
(Day 0) (Day 30) (Day 142)
AOSD onset) delivery)
IL-18 (pg/mL)

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171,000 2,614 177,427 3,133 203
[NA]
sIL2R (U/mL)
1,880 ND 4,560 3,460 1,482
[145–519]

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Ferritin (μg/L)
637 15 1,701 110 18
[5–152]
NK activity (%)
ND ND 36 13 ND
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[18–40]
Lymphocyte (%) 4.5 24.7 44.2 19.9 44.3
Table. Index HLH parameters of the mother and baby
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Numbers in square brackets indicate normal reference ranges.

AOSD, Adult-onset Still’s disease; IL, interleukin; sIL2R, soluble IL-2 receptor; NA, not available;
ND, not determined.
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