International Journal of

HEMATOLOGY
Review Article

Advances in the Management of Hemophagocytic

Lymphohistiocytosis
Shinsaku Imashuku
Kyoto City Institute of Health and Environmental Sciences, Kyoto, Japan
Received November 18, 1999; received in revised form December 6, 1999; accepted December 14, 1999

Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a prototype of the hemophagocytic syndrome and occurs most often in chil-
dren. Progress in cytokine research has now made it possible to show that HLH occurs as a consequence of uncontrolled, dys-
regulated cellular immune reactivity caused by a number of different underlying diseases. Three major risk groups of HLH can
be identified: (1) familial HLH (FHL), (2) Epstein-Barr virus–associated HLH (EBV-HLH), and (3) life-threatening infection-
associated or underlying disease–unknown HLH in infancy. Diagnostic criteria now exist that allow the differential diagnosis of
these groups, which is important because distinct therapeutic measures are advised for each group. FHL patients require imme-
diate application of immunochemotherapy with a core combination of corticosteroids and etoposide together with monitoring
of central nervous system disease by early and repeated magnetic resonance imaging of the brain, followed by timely stem cell
transplantation (SCT). EBV-HLH should also be treated with a combination of corticosteroids and etoposide. Aggressive or
relapsed cases should be treated with cyclosporin A and, if necessary, with more intensive chemotherapy, such as that used for
non-Hodgkin’s lymphoma. SCT may also be needed in these refractory cases. In cases of herpes simplex virus, adenovirus 7, and
other pathogen-undetermined HLH in early infancy, it is of great importance to administer appropriate antiviral or antibacter-
ial agents. The most important point to make regarding HLH treatment is that the underlying cause of HLH must be promptly
established to enable the rapid application of the appropriate therapy. Currently, 30% to 40% of HLH cases have a poor out-
come. It is necessary for hematologists to cooperate with specialists in other fields so that early diagnosis, which is critical for
improvements in outcome, can be made. Int J Hematol. 2000;72:1-11.
© 2000 The Japanese Society of Hematology

Key words: Hemophagocytic lymphohistiocytosis; hemophagocytic syndrome; cyclosporin A; Epstein-Barr virus; cytokine

1. Introduction
Hemophagocytic syndrome is associated with viral, bacte-
rial, and fungal infections, lymphomas or other malignant dis-
eases, autoimmune diseases, and metabolic diseases. Thus, the
diseases underlying this syndrome vary widely [1-5]. As
shown in Figure 1, the occurrence of hemophagocytosis can
thus be considered a disease marker akin to a float used in
line fishing: movement of the float may simply be due to the
biting of a small fish (benign reactive disease); on the other
hand, it may indicate the presence of a large, fierce fish (neo-
plastic malignant disease).
Correspondence and reprint requests: Shinsaku Imashuku, MD,
Kyoto City Institute of Health and Environmental Sciences,
1-2 Higashi-Takada-cho, Mibu, Nakagyo-ku, Kyoto 604-8845, Japan;
fax: 81-75-311-3232 (e-mail: shinim95@mbox.kyoto-inet.or.jp).
1
Patient age can help determine the underlying disorder that
leads to hemophagocytosis. Hemophagocytic lymphohistiocy-
tosis (HLH), a prototype of hemophagocytic syndrome, occurs
most often in childhood. There are familial (FHL) and nonfa-
milial forms of HLH [6], also classified as primary and sec-
ondary HLH, respectively [1,2]. HLH has been diagnosed not
only by hematologists but also by neonatologists, infectious
disease specialists, rheumatologists, oncologists, transplant spe-
cialists, and physicians in many other clinical fields. HLH com-
monly presents as persistent unexplained fever, cytopenia,
hepatic dysfunction, hepatosplenomegaly, hypofibrinogene-
mia, and/or hypertriglyceridemia, and as hemophagocytosis in
bone marrow, spleen, and lymph nodes [1-3]. HLH may be
caused by an immune dysfunction where hypercytokinemia,
produced by activated or clonally proliferating T cells or nat-
ural killer (NK) cells and activated macrophages, develops
into reactive hemophagocytosis. This review discusses the
recent changes made in the management of HLH patients due
to an improved understanding of the disease [7-9].
2 Imashuku / International Journal of Hematology 72 (2000) 1-11
Figure 1. The phenomenon of hemophagocytosis can be likened to a
float used in line fishing. Movement of the float could be due to either a
good small fish (benign reactive disease) or a large, fierce fish (neoplastic
malignant disease) biting the hook. IAHS indicates infection-associated
hemophagocytic syndrome; VAHS, virus-associated hemophagocytic
syndrome; MAHS, malignancy-associated hemophagocytic syndrome;
LAHS, lymphoma-associated hemophagocytic syndrome.
2. Identification of Three Major Risk Groups of HLH
Currently, pediatric HLH patients in Japan have an acute
death rate of 16% and a 3-year survival rate of about 60% [8].
As analyzed for patients registered in the international
HLH-94 protocol study in Japan, the causes of death in 31 fatal
cases of 109 HLH cases (Table 1) indicate that there are
3 major risk groups of childhood HLH (summarized in Table
2). The first group consists of FHL cases [10], and the second
group consists of severe and aggressive HLH ensuing from
Epstein-Barr virus infection (EBV-HLH). The third group is a
mixture of patients in early infancy with HLH associated with
either a life-threatening infection or an unknown underlying
disease. It is often difficult, however, to distinguish between
familial (primary) and nonfamilial (secondary) disease.
The time of death after disease onset varies in the
3 groups. Although death occurs late in FHL, in EBV-HLH
death can occur either early or late. Rapid deaths are caused
by opportunistic infections, whereas late deaths are the
result of a refractory disease associated with cytogenetic
abnormalities [11,12]. In the third HLH group, death is the
most rapid; therefore, early diagnosis of the underlying dis-
ease, followed by systemic care administering appropriate
antiviral or antibacterial agents, is essential for these
patients. For cases in which hematopoietic stem cell trans-
plantation (SCT) is the only measure leading to a cure
[10,13], delays in performing the transplantation is another
risk factor that can lead to a poor outcome.
2.1. Familial Hemophagocytic Lymphohistiocytosis
The first step in diagnosing FHL is to determine whether
there is a familial link. Genetic studies have suggested that
FHL is associated with genes on chromosomes 10q21-22
[14] or 9q21.3-22 [15]. Another study has shown that
whereas the SHP-1 (protein tyrosine phosphatase) gene is
intact, Tyk2/SHP-1 interaction is reduced in FHL cases [16].
At the time of this writing, 1 of the pathogenetic genes or
gene products associated with FHL has been identified
[14a]; however, the assessment of a familial connection still
depends on the analysis of family history and on the pres-
ence of characteristic clinical indicators such as low NK cell
activity [17].
In an analysis of 122 FHL cases, Arico et al [10] showed
that the estimated 5-year survival rate was only 10.1% for
patients treated with immunochemotherapy alone and 66.0%
for patients who had allogeneic bone marrow transplantations
(BMTs). In contrast, we found in a Japanese study of 82 cases
of pediatric HLH patients that the 4-year survival rate was
57.2% for familial inheritance-unknown (FIU) cases treated
with only immunochemotherapy (with the exception of 1 case
in which the patient also received BMT) [8]. The significant
difference in survival rates of FHL and FIU patients treated
with only immunochemotherapy indicates that allogeneic
SCTs and/or BMTs are indispensable in the treatment of
FHL patients [10,18] but not in the treatment of FIU
patients. In FHL cases, central nervous system (CNS) disease
frequently occurs [19]. This occurrence is a characteristic of
FHL and, unless a SCT or BMT is performed as soon as pos-
sible, such CNS lesions, which are refractory to systemic and
intrathecal chemo-immunosuppressive therapy, will progress
and result in neuro-developmental deterioration and fatal out-
come [20,21]. Therefore, the key to obtaining a better progno-
sis for FHL patients is the immediate application of intensive
immunochemotherapy together with monitoring of the CNS
by early and repeated brain magnetic resonance imaging
(MRI), followed by timely SCT or BMT.
2.2. Severe and Aggressive EBV-HLH
EBV-HLH has characteristic clinical features [22] and is
easy to diagnose because we can directly detect the presence
of EBV by molecular and serologic methods. Reports of fatal
EBV-HLH cases have been found in the literature [22-24].
We have previously estimated, based on our own experiences
and a survey of the literature, that mortality in EBV-HLH is
Table 1.
Number of Fatal Cases Among 109 Registered HLH Cases*
Disease n
FHL† 6
FHL highly suspected‡ 2
EBV-HLH§ 12
Underlying disease–unknown infantile HLH§,|| 8
Adenovirus 7/neonatal HSV-HLH§,¶ 3
*HLH indicates hemophagocytic lymphohistiocytosis; FHL, familial
HLH; EBV-HLH, Epstein-Barr virus–associated HLH; HSV-HLH, herpes
simplex virus HLH.
†Stem cell transplantation was not performed in 5 of the 6 cases.
‡Diagnosed from the central nervous system disease characteristic
of but not exclusive to FHL.
§No family history could be demonstrated.
||Disease onset at ages ranging from 1.5 months to 7 months; 5 of
the 8 patients died within 8 weeks of onset.
¶All patients died within 3 weeks of disease onset.
 Management of HLH 3

Table 2.
Treatment and Outcome of the 3 Major Risk Groups in HLH*
Major Risk Groups Initial Management (Response) Subsequent Course and Management Outcome (Mortality, %)
FHL Cs/VP-16 Progressive CNS disease and poor outcome No SCT (90)†
(good) if SCT is not promptly performed SCT (34)†
EBV-HLH ±PE/ET, Cs/VP-16 ± CsA If refractory, NHL-type or HD-type chemotherapy, 21/51 (41)‡
(good)§ and if necessary, SCT recommended
Life-threatening Antiviral agents None# Adenovirus 7 pneumonia (18)**
infantile HLH Cs/CsA(?)¶ ± VP-16 Neonatal HSV infection (57)††
(poor) Other infantile severe infection (variable)
*HLH indicates hemophagocytic lymphohistiocytosis; FHL, familial HLH; Cs, corticosteroid; VP-16, etoposide; CNS, central nervous system; SCT,
hematopoietic stem cell transplantation; EBV-HLH, Epstein-Barr virus HLH; PE/ET, plasma exchange/exchange transfusion; CsA, cyclosporin A; NHL,
non-Hodgkin’s lymphoma; HD, Hodgkin’s disease; HSV, herpes simplex virus.
†Arico et al [10].
§Poor outcome in refractory cases; however, well-planned systemic therapy ± SCT produced a better outcome [9].
‡Imashuku [22]. Poor outcome in neutropenic cases complicated by fungal or bacterial infections.
¶The effect of CsA has not been well evaluated.
#First-aid life saving is most important in this group.
**Takahashi et al [38].
††Jacobs [31].

around 41% (Table 2) [22]. This figure may, however, be
somewhat higher than the actual incidence because cases
with poor outcome rather than cases with good prognoses
tend to be preferentially reported in the literature.
We recently reported that the majority of patients with
EBV-HLH attain remission following treatment with the
combination of corticosteroids and etoposide (VP-16) [9].
However, the relapse rate after stopping treatment at 8 weeks
was approximately 30%. The majority of relapse cases can be
effectively treated with cyclosporin A (CsA), but some need
more intensive chemotherapy, such as that used for non-
Hodgkin’s lymphoma. In some relapse cases, SCTs or BMTs
must also be performed to further control the disease [9].
Although immunochemotherapy is generally effective, analy-
sis of the fatal cases in Table 1 and of the literature indicates
that some patients suffered from rapid infections of fulminant
neutropenia-associated bacteria or fungus [12,25,26] and died
owing to active disease (or later due to refractory disease).
2.3. Life-Threatening Infection-Associated or
Underlying Disease–Unknown Hemophagocytic
Lymphohistiocytosis in Infancy
or soon after can cause disseminated multiorgan disease with
fulminant liver failure and disseminated intravascular coagu-
lation as well as hemophagocytosis [28-34]. Consequently, we
believe that infantile HLH is most probably caused by severe
infectious diseases and that in most cases the presence of the
etiological pathogen(s) has simply not been determined or
detected premortem.
One pathogen that has recently been implicated in infan-
tile HLH is adenovirus 7. Infection of young children (about
40% under 1 year of age) with adenovirus 7 has increased
since 1995 in Japan and has recently been associated with
hemophagocytosis, a severe clinical course, and poor progno-
sis with a mortality rate of 18% (Table 2) [35-39]. Early and
accurate diagnostic measures and the prompt introduction of
the appropriate therapy are indispensable for HSV-, aden-
ovirus 7–, and other pathogen-associated HLH cases in early
infancy. The combination of corticosteroids and VP-16
appears to be ineffective in treating severely affected infan-
tile HLH patients; therefore, it is of great importance to
administer appropriate antibiotics/antiviral agents to the
patient and to test the effect of introducing, in a timely man-
ner, immunosuppressants such as CsA.

We have estimated that the rate of acute death (ie, within
2 months after onset of disease) in pediatric HLH cases is
16.0%. The majority of these deaths occur in infantile HLH
cases, and the remaining deaths are due to fatal EBV-HLH in
older children [8]. The exact cause of death in the majority of
infantile HLH cases remains to be determined. Some inborn
metabolic disease may be hidden. Although the prognosis is
good for secondary non–EBV-HLH in older children [24,27],
such non–EBV-HLH cases are often severe and fatal in early
infancy [28-31]. Severe life-threatening infections seem to be
rare in FHL, but it is possible that these are FHL cases that
neither demonstrate the clinical markers for FHL nor show a
family history of HLH. It is well known that severe viral (her-
pes simples virus [HSV]-1, HSV-2, coxsackie B, human her-
pesvirus [HHV]-6) or bacterial infections that occur at birth
2.4. Delays in Finding a Suitable Donor for Stem Cell
and Bone Marrow Transplantations
For FHL or refractory EBV-HLH cases, SCT or BMT
should be performed in a timely manner. As shown in
Table 1, we have had several patients who died because SCT
could not be performed because of the lack of suitable
donors. In practice, it takes longer than 6 months to find and
obtain HLA-matched marrow cells from an unrelated donor
using the Japan Marrow Donor Program. Cord blood, in con-
trast, is more readily available and has been successfully
employed by Tanaka et al [40] in the therapy of an FHL case.
Thus, for HLH cases that need SCTs quickly, cord blood may
constitute a better source of stem cells than bone marrow
when no HLA-matched sibling donor is available.
4 Imashuku / International Journal of Hematology 72 (2000) 1-11

Patients with FHL exhibit abnormalities in certain

immunologic functions (eg, persistently low or absent NK
cell activity), and this knowledge can be used for diagnosis
and to determine the underlying disease [17,42,43]; however,
in nonfamilial HLH, immunological functions appear com-
petent. The expansion of certain peripheral blood mononu-
clear cell (PBMC) subsets, characterized by particular cell
surface markers, can also be informative in the differential
diagnosis of HLH. When we performed a comparative study
of familial and FIU-HLH cases, we found that the CD3+,
CD3+HLA-DR+, and CD45RO+ cell subsets occurred signi-
ficantly more frequently in FHL than in FIU, although het-
erogeneity was noted [43]. Another study also showed that
EBV-HLH could be differentiated from non–EBV-HLH by

Figure 2. Typical images of large granular lymphocytes (LGLs),

promonocytoid cells, and hemophagocytes found in peripheral blood
or bone marrow smears from hemophagocytic lymphohistiocytosis
(HLH) patients. a. Blastic LGLs. b. Mature LGLs. c. Promonocytoid
cells. d. Hemophagocyte. (Original magnification ×500)

3. Biomarkers Useful for the Establishment of

Appropriate Treatment Strategies and as Prognostic
Indicators

3.1. Immune Cell Morphology, Function, and

Cell-Surface Markers

The diagnosis of HLH patients requires the careful

assessment of peripheral blood and bone marrow smears.
Characterizing lymphocyte as well as monocyte-macrophage
morphology helps to identify the underlying disorders. We
routinely classify the lymphocytes into small agranular lym-
phocytes, mature large granular lymphocytes (mature LGL),
and LGL with nucleoli and basophilic cytoplasm (blastic
LGL). The monocyte-macrophages are classified into mono-
cytes, promonocytoid/monoblastoid cells, and hemophago-
cytes (Figures 2 and 3). The presence of hemophagocytes is
critical for the diagnosis of HLH, but we found that for dif-
ferential diagnosis, studying the morphology of lymphocytes
is more important. Figure 3 illustrates this type of analysis of
bone marrow smears taken at disease onset. The patterns
designated as types A and C in Figure 3, characterized by
LGL proliferation, account for 36% and 10% of patients,
respectively. Thus, approximately 50% of pediatric HLH Figure 3. Distribution of large granular lymphocytes (LGLs),
cases are characterized by LGL proliferation. The pattern promonocytoid cells (promono), and hemophagocytes (hemophago) in
designated as type B in Figure 3, characterized by prolifera- the bone marrow of hemophagocytic lymphohistiocytosis (HLH)
tion of promonocytoid cells, constitutes 15.4% of HLH cases. patients, and patterns permitting the differential diagnosis of HLH sub-
Proliferation of mature or blastic LGL (types A and C) is a groups. Values in the ordinate indicate percentages in the myelogram.
characteristic in both FHL and EBV-HLH, whereas prolif- Type A: proliferation of blastic (major) and mature LGLs, a pattern typ-
eration of promonocytoid cells (type B) is associated with ically found in Epstein-Barr virus–associated HLH, accounting for 36%
HSV- or adenovirus-related HLH [41]. In the remaining of cases examined; type B: proliferation of promonocytoid cells, a pat-
43.6% of cases, bone marrow smears at disease onset showed tern associated with neonatal herpes simplex virus or adenovirus 7
the presence of hemophagocytes only and did not provide infection–associated cases, accounting for 15.4% of cases examined;
any additional clues regarding possible underlying diseases. type C: proliferation of mature (major) and blastic LGLs, a pattern typ-
Bone marrow smears can also help in the diagnosis of ically found in familial HLH, accounting for 10.0% of cases examined;
autoimmune (collagen) disease-related or lymphoma-associ- and type D: nonspecific pattern, accounting for the remaining 43.6%.
ated hemophagocytic syndrome. bl-LGL indicates blastic LGL.
 Management of HLH
Table 3.
Useful Biomarkers for the Establishment of Treatment Strategies and as Prognostic Indicators*
Study Material
Cell morphology PB (BM) smear
Marker/cell function PBMC (BMMC)
EBV genome/clonality PBMC (BMMC)
Cytokine/serology Sera
*PB indicates peripheral blood; BM, bone marrow; LGL, large granular lymphocyte; MC, mononuclear cells; NK, natural killer; EBV, Epstein-Barr
virus; PCR, polymerase chain reaction; TCR, T-cell receptor.
the significantly increased frequency of CD3+HLA-DR+
cells [24]. Furthermore, NK cell–type EBV-HLH (character-
ized by NK-cell proliferation), whose prognosis is worse than
T cell–type HLH (typified by T-cell proliferation), could be
detected by expansion of the CD3–CD56+ subset. An atypi-
cal CD3+CD4low cell population has been found in fatal EBV
infections, but the significance of this remains to be deter-
mined [44]. These data together suggest that assessment of
bone marrow lymphocyte and monocyte-macrophage cell
morphology, NK-cell activity, and PBMC subsets is useful for
the prompt differential diagnosis of HLH.
3.2. Measurements of EBV Involvement in HLH
More than half of the pediatric HLH cases in Japan
may be associated with EBV infection. EBV-HLH can be
suspected from LGL proliferation in peripheral blood
and/or bone marrow smears, from an increase in the
CD3+HLA-DR+ cell subset, or from an augmented T helper
(Th) 1 cytokine response, and diagnosed by detection of the
EBV genome by polymerase chain reaction (PCR), South-
ern blotting, or serology. EBV is associated with both famil-
ial and nonfamilial HLH [45,46]. EBV-HLH develops after
primary exposure to the virus, at virus reactivation, or at the
terminal stage of chronic active Epstein-Barr virus infection
(CAEBV). In CAEBV, it was recently found that clinical
pictures include severe mosquito bite hypersensitivity, NK-
cell leukemia, and hydroa vacciniforme–like eruptions [47].
EBV-HLH is a subtle disease with a clinical course ranging
from mild/self-limiting to severe/aggressive and fatal. The
prognosis of EBV-HLH that develops in the terminal phase
of CAEBV is particularly poor [48].
Improving the prognosis of these cases requires a better
understanding of how EBV virulence and host immunity can
lead to the development of HLH. To date, we know that the
majority of EBV-HLH cases are characterized by mono- or
oligoclonal proliferation of EBV-infected NK or T cells.
Further, hypercytokinemia and apoptosis via the Fas
(CD95)/Fas ligand system are commonly involved in aggres-
sive clinical courses in patients with EBV-HLH. In addition,
a genetic predisposition for severe fatal EBV infection has
been found in X-linked lymphoproliferative disease (XLP)
cases, where the SAP (DSHP/SH2DIA) gene was found to
5
Biomarkers
LGLs (mature, blastic)
Promonocytoid cells
Hemophagocytes
Marker (CD3+,CD56+,CD19+)
NK-cell activity
EBV genome by PCR, Southern blot
TCR rearrangement (β, γ, δ)
Cytogenetics
Cytokines
Serology
play a critical role [49-51]. However, whether there is a
genetic predisposition to severe disease in non-XLP or spo-
radic and fatal nonfamilial EBV infection–associated dis-
eases remains to be determined.
Novel techniques such as real-time PCR, which permits
the easy quantification of EBV genome copy numbers in
lymphocytes, serum, and plasma [52-55], make it possible to
determine whether the viral load of EBV also contributes
to disease severity. This quantitative method may also be
useful in monitoring patients’ clinical responses to therapy.
The proliferating cells incorporating the EBV genome
(T or NK or B cells) may be associated with the clinical fea-
tures and responses to therapy in EBV-related diseases
[56], and mutations in the EBV genome may contribute to
disease severity. EBVs with mutant LMP1 (latent membrane
protein 1) have been associated with various EBV-related
disorders including EBV-HLH [57-59]. Thus, delineation of
the risk factors for severe disease (eg, the genetic predispo-
sition of the host, the viral load, and viral mutations) may
permit us to subgroup EBV-HLH cases more precisely into
high- and low-risk categories.
3.3. Clonality of Immune Cell Proliferation in HLH
In recent years, concern has grown over the lethal potential
of clonal proliferation in virus-associated HLH, particularly
when EBV is involved [60-64]. NK- and T-cell clonal prolifer-
ation in HLH can be measured using a variety of biological
materials and methods such as karyotypic analysis, assessment
of T-cell receptor (TCR) rearrangements, and study of the ter-
minal repeats of the EBV genome [65] (Table 3). Ishii et al
[46] also developed a meticulous method of measuring pref-
erential variable region β (Vβ) usage by T cells to study the
degree of clonality in HLH. Although case reports of clonal
HLH have accumulated in recent years [60-64,66], the impact
of T- or NK-cell clonality on the outcome for patients with
HLH remains to be determined; thus, we recently studied this
issue using 3 of the techniques described earlier [11]. Of the 32
HLH cases studied, 22 were EBV-clonal, 15 were TCR-clonal,
and 7 were cytogenetically clonal. All 7 cases with cytogeneti-
cally abnormal clones were found to be fatal, with a 3-year
survival rate, by Kaplan-Meier analysis, of only 14%. In con-
trast, the 3-year survival rate of the 22 EBV-clonal HLH cases,
6 Imashuku / International Journal of Hematology 72 (2000) 1-11
Figure 4. Schematic illustration of how to utilize cytokine data to
determine the underlying disease after onset and for establishing a
future treatment plan. Note that the limit of 8 weeks (8W) needed for
treatment has been set by the international HLH-94 protocol. HLH
indicates hemophagocytic lymphohistiocytosis.
3 of whom also had cytogenetic abnormalities, was 64% and
the survival rate of the 15 TCR-clonal cases was 53%. Our
observation suggests that cytogenetically abnormal HLH
cases present an extremely high risk of fatality.
3.4. Serum Cytokines in HLH
HLH is associated with hypercytokinemia characterized
by a bias toward Th1 cytokines. This hypercytokinemia has
been demonstrated to cause the basic pathophysiology of
HLH [67-71]. Measuring the type and the degree of hyper-
cytokinemia might permit differential diagnosis and assess-
ment of risk factors [27,68,69]. We have found that the
serum of older children with EBV-HLH contains signifi-
cantly high levels of both a classic Th1 cytokine (inter-
feron-γ [IFN-γ]) and soluble interleukin-2 receptor (sIL-2R);
sIL-2R is released upon Th1 cell activation [24]. In the dis-
ease, EBV by itself and IFN-γ affect the survival of leuko-
cytes [72,73]. The serum of infantile HLH patients infected
with HSV or adenovirus has higher levels of IL-6 and/or
macrophage colony-stimulating factor, and there was only a
slight increase in sIL-2R levels in these patients [27,37]. In
fact, cytokine production may differ between neonatal and
adult lymphocytes [74]. These observations suggest that in
EBV-HLH, primarily T and/or NK cells are being activated,
whereas in infantile HSV, adenovirus-infected HLH mono-
cytes are the predominant cytokine producers. Although
cytokine data are not immediately available for the first
week of treatment, they have a retrospective value in that
they can help identify the underlying diseases and thus may
assist in determining future treatment policies (Figure 4). In
a current protocol for pediatric HLH [7], we provide physi-
cians with treatment suggestions based on the patient’s
cytokine data. If the cytokine data indicate a low risk, the
patient can be taken off treatment at or before 8 weeks of
treatment. However, more careful observation of the
patient is needed if there are extremely high levels of
serum cytokines such as sIL-2R (>10,000 U/mL) and IFN-γ
(>100 U/mL) at disease onset.
4. Treatment Strategies
Historically, patients with HLH have been treated with
corticosteroids, intravenous immunoglobulin (IVIg), VP-16,
or a combination of these drugs. However, it remains difficult
to determine exactly how each HLH case should be treated.
Not all pediatric patients whose clinical signs and symptoms
and laboratory data are compatible with the diagnosis of
HLH should have immediate immunochemotherapy. Symp-
tomatic therapy alone is successful in the majority of infec-
tion-associated HLH cases except for EBV-HLH [24] in
apparently immunocompetent older children. IVIg therapy
has been reported to be beneficial in some low-risk cases but
not in others [75-78], whereas VP-16 has been documented
to be effective for HLH in general [79].
We propose here a treatment strategy for the 3 high-risk
HLH groups as categorized in section 2. The same treat-
ment strategy is employed for FHL and EBV-HLH cases
(Table 2) because both exhibit LGL proliferation and are
believed to be clonal diseases [9,46]. In designing this strat-
egy, a treatment protocol (proposed by the Histiocyte Soci-
ety) consisting of VP-16, dexamethasone, and cyclosporine
followed by SCT or BMT, has been particularly helpful
[7,9]. As mentioned above, the establishment of more spe-
cific therapies for EBV-HLH must await future risk-based
subclassification of this group. The treatment strategy for
nonfamilial infantile HLH cases seems to be different from
that for FHL and EBV-HLH (Figure 5) because the clinical
course is so rapid and aggressive.
4.1. Treatment of FHL and EBV-HLH Cases
4.1.1. Correction of Basal Pathological Conditions
Therapeutic plasma exchange (PE) (plasmapheresis) or
exchange transfusion (ET), IVIg, and corticosteroids have
been the first-choice treatment regimens most commonly
Figure 5. Treatment plan for high-risk familial hemophagocytic lym-
phohistiocytosis (FHL) and Epstein-Barr virus–associated hemophago-
cytic lymphohistiocytosis (EBV-HLH) patients. Bone marrow trans-
plantation (BMT) or stem cell transplantation (SCT) is necessary in all
cases of primary HLH (FHL) and in refractory cases of secondary
HLH. PR/NR indicates partial remission/no remission; CR, complete
remission; Dexa, dexamethasone; VP-16, etoposide; CsA, cyclosporin A.
 Management of HLH
employed in severe HLH cases. In particular, PE or ET is
used to correct the tendency to bleed and to control hyper-
cytokinemia [80-82]. We believe that prompt continuous
infusion of CsA (3 mg/kg per day, for several days) may help
alleviate the cytokine storm in severely affected patients.
4.1.2. Core Combination of Corticosteroids and
Etoposide
Currently, the most common treatment for HLH is a
core combination of corticosteroids and VP-16, as sug-
gested in the international HLH-94 protocol [7,9]. This
therapy aims to eventually eradicate the proliferating
T and NK cells and activated macrophages and thus result
in a cure for EBV-HLH. We propose that initial therapy
should be maintained for 8 weeks (Figure 5). In a previous
treatment report on EBV-HLH, we found that 1 of 17 cases
responded successfully to a regimen in the absence of
VP-16 [9]. It may therefore be possible to design a proto-
col in the future that consists of immunosuppressive drugs
but lacks VP-16 and that can still lead to remission and
prevention of a fatal outcome in EBV-HLH.
4.1.3. CsA and Antithymocyte Globulin Therapy
CsA has been found to be effective in controlling various
cytokine-related pathological conditions [83-88]. CsA effi-
ciently and rapidly suppresses the cytokine storm caused by
dysregulated T cells and activated macrophages; thus, CsA is
a key drug in the acute phase as well as maintenance therapy
of the international HLH-94 protocol [7]. We have also
reported that introducing CsA treatment effectively sup-
ports neutrophil recovery during the acute phase of HLH in
severely neutropenic patients [89]. In addition, antithymo-
cyte globulin (ATG) therapy with or without corticosteroids
is another effective regimen for HLH [90,91]. Perel et al [90]
reported that ATG had a dramatic effect in a pediatric case
of refractory EBV-HLH in which the patient had been heav-
ily treated with chemotherapy.
4.1.4. Care of CNS Disease
Clinical neurological symptoms in HLH patients include
seizures, coma, brain stem symptoms, or ataxia. Although
routine cerebrospinal fluid cytology is commonly used for
the early diagnosis of CNS disease, brain MRI is a much
more sensitive method for the detection of presymptomatic
CNS lesions. CNS disease has been documented in FHL [19-
21,92-95] as well as in nonfamilial cases such as EBV-HLH
[96,97] and rotavirus infection–associated HLH [98]. Typical
neuropathological findings in FHL include lymphohistio-
cytic infiltration of the leptomenges and perivascular spaces.
Further, calcification and necrotic lesions particularly in the
putamen, internal capsule, thalamus, and dentate nucleus
have been described [99].
Once CNS disease develops, its management is trouble-
some. The outcome of patients treated by systemic and
intrathecal chemotherapy and/or immunosuppressive agents
has been reported to be poor [19]. However, in the same
study, 7 of 9 patients who were treated with BMT in the first
7
complete remission status of CNS and systemic disease sub-
sequently did well and showed normal neurological func-
tions and cognitive development. Shuper et al [95] also
reported an FHL patient who showed gradual neurodevel-
opmental normalization after BMT at 5 months of age.
These results indicate the potential for BMT to reverse neu-
rodevelopmental deterioration in HLH and also indicate the
importance of both early diagnosis of CNS disease and
prompt introduction of SCT or BMT.
4.1.5. Strategy for Refractory Disease
4.1.5.1. Intensive Chemotherapy
For cases not responding to the initial combination of cor-
ticosteroids and VP-16, the first choice of treatments is to add
CsA if it has not been administered previously. CsA has been
proven to be effective in both FHL and nonfamilial EBV-
HLH [9,91,100], as well as in LGL-proliferating diseases such
as LGL leukemia/lymphoma [84,101]. Other choices of ther-
apy for refractory cases are various multiagent chemothera-
pies, particularly a combination of ACOP (CHOP) (adri-
amycin or cyclophosphamide plus doxorubicin, vincristine,
and prednisone) used for non-Hodgkin’s lymphoma (NHL-
type chemotherapy), or a combination of ACOPP and
ABVD regimens (adriamycin, cyclophosphamide, vincristine,
prednisolone, and procarbazine, plus adriamycin, bleomycin,
vindesine, and dacarbazine) used for Hodgkin’s disease (HD-
type chemotherapy), or high-dose cytosine arabinoside, or
cyclophosphamide plus VP-16 [9,102,103]. A combination of
CsA with multiagent chemotherapy is considered to be the
most effective therapy and in some cases even good enough
for a cure without SCT; however, other cases eventually
require SCT or BMT. More recently, Obama et al [104]
reported that L-asparaginase induced complete remission in
EBV-positive, multidrug-resistant cutaneous T-cell lym-
phoma, suggesting that this drug may be useful in treating
refractory EBV-HLH.
4.1.5.2. Hematopoietic Stem Cell Transplantation
Myeloablative chemotherapy and subsequent SCT or
BMT are the most acceptable treatment regimens for FHL
and therapy-resistant nonfamilial HLH cases [13]. Familial
as well as nonfamilial HLH cases have been successfully
treated with SCT/BMT from various stem cell sources,
including allogeneic related or unrelated bone marrow
[13,105-107], peripheral blood stem cells (PBSCs) [108],
autologous PBSCs [109], haploidentical stem cells [110], and
cord blood [40,111]. Jabado et al [112] recently reported that
BMT was successful even when the donor was nonidentical
in HLA. As discussed above, however, cord blood seems to
be a safer and a more easily available alternative stem cell
source for emergency SCT, as reported by Tanaka et al [40].
A busulfan/VP-16/cyclophosphamide conditioning regimen
is commonly used for FHL-SCT, whereas for refractory
EBV-HLH cases, a regimen containing TBI has been
employed. We reviewed the FHL and nonfamilial Japanese
HLH cases treated with SCT or BMT and found that 12 of
the 17 recipients were currently alive and well [13].
8 Imashuku / International Journal of Hematology 72 (2000) 1-11
Table 4.
Treatment Strategies for High-Risk HLH Cases*
FHL and EBV-HLH
Correct basal pathological conditions
Immunochemotherapy
Plasma exchange and/or exchange transfusion, CsA
Combination of corticosteroids/VP-16 ± CsA
Care of opportunistic infectious complications due to neutropenia
Care of central nervous system disease
Strategy for refractory disease
Intensive chemotherapy
Stem cell transplantation
Life-threatening infantile HLH
Early diagnosis of triggering factor(s)†
Prompt introduction of anti-infectious agent(s)
Possible early CsA application with corticosteroids
*HLH indicates hemophagocytic lymphohistiocytosis; FHL, familial
HLH; EBV-HLH, Epstein-Barr virus HLH; CsA, cyclosporin A; VP-16,
etoposide; The international HLH-94 protocol initially consists of dex-
amethasone/VP-16 for induction (for 8 weeks), followed by dexam-
ethasone/VP-16/CsA for maintenance therapy in unresolved cases [7]
(see Figure 5).
†In the majority of infantile HLH cases, the exact cause has not been
clarified.
4.1.6. Treatment of High-Risk Infantile and Other
HLH Cases
For high-risk HLH in infancy, such as neonatal HSV-
associated or severe adenovirus 7 infection–associated cases,
development of better therapeutic measures is essential.
Refined treatments that contain CsA remain to be tested.
The high mortality of these cases may be reduced by early
and accurate diagnosis, by detection of multiorgan failure as
early as possible, and by the prompt introduction of anti-
infectious agents (summarized in Table 4). The application of
VP-16 in these cases seems to be questionable.
Autoimmune disease (collagen disease)–related hemo-
phagocytic syndrome (CAHS) is a category distinct from
HLH [4,113] and it occurs in, among other diseases, systemic
lupus erythematosus, juvenile rheumatoid arthritis, der-
matomyositis, and cytophagic histiocytic panniculitis (CHP)
[86,88,113-117]. Hemophagocytosis develops either at the
onset of an autoimmune disease or during disease treat-
ment. In the latter case, it is often difficult to determine
whether an intervening infection or insufficient control of
the disease is responsible. It is important to distinguish
CAHS from HLH cases. Once a diagnosis is established,
corticosteroids or CsA can be used. There is no need to
administer VP-16. For better control of the disease, we rec-
ommend a continuous infusion of CsA (3 mg/kg per day for
one week) followed by oral CsA (6 mg/kg per day) together
with corticosteroids and, if necessary, oral methotrexate
weekly or a nonsteroid anti-inflammatory drug.
5. Problems Regarding Therapy-Related Malignancy
Etoposide is one of the key drugs in the treatment of HLH
but it has also been linked with the development of therapy-
related secondary myeloid leukemia (t-AML). Sporadic
cases of t-AML have been documented to date [118-120], and
Kitazawa et al reported on a patient with EBV-HLH who
had been treated with the international HLH-94 protocol and
developed t-AML 3 years later (personal communication).
Careful follow-up of HLH patients treated with VP-16 is
required. It has also been reported that acute lymphoid
leukemia (ALL) and HLH can occur simultaneously [121]
and that ALL developed 6 months following the treatment of
HLH [122], suggesting some common pathogenetic mecha-
nisms in the development of lymphoid leukemia and HLH.
6. Conclusions
Over the past decade, a great deal of information regard-
ing the treatment of HLH has accumulated. It is now possi-
ble to determine whether the HLH patient falls into a high-
risk group and to know which therapy to apply. Pinpointing
the underlying disease is critical because different therapeu-
tic measures, such as immunochemotherapy or SCT/BMT,
are required for some risk groups but not for others. The
most important point to make here is that the most appro-
priate treatment strategy must be given to each HLH case
without delay. The rapid diagnosis required in these cases
will require close cooperation between hematologists and
physicians in other fields.
Acknowledgments
The author thanks the members of the Japan Society
of Pediatric Hematology who participated in the cooper-
ative study on HLH cases treated according to the inter-
national HLH-94 protocol. Yasuko Hashimoto is also
gratefully acknowledged for her assistance in the prepa-
ration of this review.
References
1. Henter J-I, Elinder G, Ost A. Diagnostic guidelines for hemo-
phagocytic lymphohistiocytosis. Semin Oncol. 1991;18:29-33.
2. Imashuku S. Differential diagnosis of hemophagocytic syndrome:
underlying disorders and selection of the most effective treatment.
Int J Hematol. 1997;66:135-151.
3. Tsuda H. Hemophagocytic syndrome (HPS) in children and
adults. Int J Hematol. 1997;65:215-226.
4. Kumakura S, Ishikura H, Umegae N, et al. Autoimmune-associated
hemophagocytic syndrome. Am J Med. 1997;102:113-115.
5. Duval M, Fenneteau O, Doireau V, et al. Intermittent hemophago-
cytic lymphohistiocytosis is a regular feature of lysinuric protein
intolerance. J Pediatr. 1999;134:236-239.
6. Ishii E, Ohga S, Tanimura M, et al. Clinical and epidemiological
studies of familial hemophagocytic lymphohistiocytosis in Japan.
Japan LCH Study Group. Med Pediatr Oncol. 1998;30:276-283.
7. Henter J-I, Arico M, Egeler RM, et al. HLH-94 a treatment proto-
col for hemophagocytic lymphohistiocytosis. Med Pediatr Oncol.
1997;28:342-347.
8. Imashuku S, Hibi S, Todo S. Hemophagocytic lymphohistiocytosis
in infancy and childhood. J Pediatr. 1997;130:352-357.
9. Imashuku S, Hibi S, Ohara T, et al. Effective control of Epstein-
Barr virus-related hemophagocytic lymphohistiocytosis with immuno-
chemotherapy. Blood. 1999;93:1869-1874.
10. Arico M, Janka G, Fischer A, et al. Hemophagocytic lymphohistio-
cytosis: diagnosis, treatment, and prognostic factors. Report of
122 children from the international registry. Leukemia. 1996;10:197-203.
 Management of HLH
11. Imashuku S, Hibi S, Tabata Y, et al. Outcome of clonal hemo-
phagocytic lymphohistiocytosis: analysis of 32 cases. Leuk Lym-
phoma. 2000;37:577-584.
12. Ito E, Kitazawa J, Arai K, et al. Fatal Epstein-Barr virus-associated
hemophagocytic lymphohistiocytosis with unique karyotype abnor-
mality. Int J Hematol. 2000;71:263-265.
13. Imashuku S, Hibi S, Todo S, et al. Allogeneic hematopoietic stem
cell transplantation for patients with hemophagocytic syndrome
(HPS) in Japan. Bone Marrow Transplant. 1999;23:569-572.
14. Dufourcq-Lagelouse R, Jabado N, Le Deist F, et al. Linkage of
familial hemophagocytic lymphohistiocytosis to 10q21-22 and evi-
dence for heterogeneity. Am J Hum Genet. 1999;64:172-179.
14a. Stepp SE, Dufourcq-Lagelouse R, Le Deist F, et al. Perforin gene
defects in familial hemophagocytic lymphohistiocytosis. Science.
1999; 286:1957-1959.
15. Ohadi M, Lalloz MR, Sham P, et al. Localization of a gene for famil-
ial hemophagocytic lymphohistiocytosis at chromosome 9q21.3-22
by homozygosity mapping. Am J Hum Genet. 1999;64:165-171.
16. Tabrizi M, Yang W, Jiao H, et al. Reduced Tyk2/SHP-1 interaction
and lack of SHP-1 mutation in a kindred of familial hemophago-
cytic lymphohistiocytosis. Leukemia. 1998;12:200-206.
17. Sullivan KE, Delaat CA, Douglas SD, et al. Defective natural killer
cell function in patients with hemophagocytic lymphohistiocytosis
and in first degree relatives. Pediatr Res. 1988;44:465-468.
18. Fiorillo A, Catera P, Guarino A, et al. Familial erythrophagocytic
lymphohistiocytosis: adverse prognostic significance of delayed
diagnosis. Haematologica. 1993;78:242-244.
19. Haddad E, Sulis ML, Jabado N, et al. Frequency and severity of
central nervous system lesions in hemophagocytic lymphohistiocy-
tosis. Blood. 1997;89:794-800.
20. Henter J-I, Nennesmo I. Neuropathologic findings and neurologic
symptoms in twenty-three children with hemophagocytic lympho-
histiocytosis. J Pediatr. 1997;130:358-365.
21. Hyakuna N, China K, Fukuyama S, et al. Magnetic resonance imag-
ing of the brain in a case of primary hemophagocytic lymphohisti-
ocytosis with central nervous system involvement. Int J Pediatr
Hematol Oncol. 1998;5:449-454.
22. Imashuku S. Treatment of Epstein-Barr virus (EBV)–associated
hemophagocytic syndrome [in Japanese]. Nihonijishinpo. 1998;
3885:37-45.
23. Okano M, Gross TG. Epstein-Barr virus–associated hemophago-
cytic syndrome and fatal infectious mononucleosis. Am J Hematol.
1996;53:111-115.
24. Imashuku S, Hibi S, Tabata Y, et al. Biomarker and morphological
characteristics of Epstein-Barr virus–related hemophagocytic lym-
phohistiocytosis. Med Pediatr Oncol. 1998;31:131-137.
25. Connolly AA, Rowe-Jones J, Leighton SE, et al. Pseudomonal
supraglottitis occurring in a patient with profound neutropenia
secondary to virus-associated haemophagocytic syndrome. J Laryn-
gol Otol. 1992;106:739-740.
26. Kinoshita Y, Hashida T, Otsuka T, et al. A case of Epstein-Barr
virus–associated hemophagocytic lymphohistiocytosis that died as
a result of sepsis of Candida albicans at 1 month after initial treat-
ment. Jpn J Pediatr Hematol. 1999;13:46-50.
27. Imashuku S, Hibi S, Fujiwara F, et al. Hyper-interleukin (IL)-6-
naemia in haemophagocytic lymphohistiocytosis. Br J Haematol.
1996;93:803-807.
28. Lau G. Acute fulminant, fatal coxsackie B virus infection: a report
of two cases. Ann Acad Med Singapore. 1994;23:917-920.
29. Portolani M, Cermelli C, Meacci M, et al. Primary infection by
HHV-6 variant B associated with a fatal case of hemophagocytic
syndrome. New Microbiol. 1997;20:7-11.
30. Barre V, Marret S, Mendel I, et al. Enterovirus-associated
haemophagocytic syndrome in a neonate. Acta Paediatr. 1998;87:
469-471.
31. Jacobs RF. Neonatal herpes simplex virus infections. Semin Peri-
natol. 1998;22:64-71.
32. Stephan F, Thioliere B, Verdy E, et al. Role of hemophagocytic his-
tiocytosis in the etiology of thrombocytopenia in patients with sep-
sis syndrome or septic shock. Clin Infect Dis. 1997;25:1159-1164.
9
33. Pearl PL, Abu-Farsakh H, Starke JR, et al. Neuropathology of two
fatal cases of measles in the 1988-1989 Houston epidemic. Pediatr
Neurol. 1990;6:126-130.
34. Pohl M, Niemeyer CM, Hentschel R, et al. Haemophagocytosis in
early congenital syphilis. Eur J Pediatr. 1999;158:553-555.
35. Yamadera S, Yamashita K, Akatsuka M, et al. Epidemiological
report. Trend of adenovirus type 7 infection, an emerging disease
in Japan [in Japanese]. Jpn J Med Sci Biol. 1998;51:43-51.
36. Tokoeda Y, Sekine Y, Takahashi H. A case of virus-associated
hemophagocytic syndrome with adenovirus type 7 isolated [in
Japanese]. Jpn J Pediatr. 1997;50:1119-1124.
37. Nishimura A, Li K, Nishimoto M, et al. Clinical studies on aden-
ovirus 7 pneumonia in Japan [in Japanese] [abstract]. J Jpn Pediatr
Soc. 1998;102:340.
38. Takahashi Y, Togashi T, Anakura M, et al. A questionnaire survey
of patients with adenovirus type 7-induced pneumonia in Hokkaido
[in Japanese]. J Jpn Pediatr Soc. 1999;103:672-678.
39. Takahashi Y,Okamura A, Yasojima K, et al. Serum cytokine levels
in patients with severe adenovirus 7 infection. J Jpn Pediatr Soc.
1998;102:916-917.
40. Tanaka Y, Hosoi G, Ishii T, et al. Successful engraftment of unre-
lated cord blood stem cells for familial erythrophagocytic lympho-
histiocytosis. Bone Marrow Transplant. 1998;22:511-513.
41. Imashuku S, Hibi S, Morinaga S, et al. Hemophagocytic lympho-
histiocytosis in association with granular lymphocyte proliferative
disorders in early childhood: characteristic bone marrow morphol-
ogy. Br J Haematol. 1997;96:708-714.
42. Egeler RM, Shapiro R, Loechelt B, et al. Characteristic immune
abnormalities in hemophagocytic lymphohistiocytosis. J Pediatr
Hematol Oncol. 1996;18:340-345.
43. Imashuku S, Hibi S, Sako M, et al. Heterogeneity of immune mark-
ers in hemophagocytic lymphohistiocytosis: comparative study of
9 familial and 14 familial inheritance-unproved cases. J Pediatr
Hematol Oncol. 1998;20:207-214.
44. Gruber R, Krauss-Etschmann S, Jager G, et al. Atypical CD3+
CD4low cell population in a boy with fatal EBV-infection. Int Arch
Allergy Immunol. 1999;118:74-78.
45. Cho HS, Park YN, Lyu CJ, et al. EBV–elicited familial hemo-
phagocytic lymphohistiocytosis. Yonsei Med J. 1997;38:245-248.
46. Ishii E, Kimura N, Kato K, et al. Clonal change of infiltrating T-cells
in children with familial hemophagocytic lymphohistiocytosis. Pos-
sible association with Epstein-Barr virus infection. Cancer. 1999;
85:1636-1643.
47. Tokura Y, Ishihara S, Ohshima K, et al. Severe mosquito bite
hypersensitivity, natural killer cell leukaemia, latent or chronic
active Epstein-Barr virus infection and hydroa vacciniforme-like
eruption. Br J Dermatol. 1998;138:904-927.
48. Ishihara S, Okada S, Wakiguchi H, et al. Clonal lymphoprolifera-
tion following chronic active Epstein-Barr virus infection and
hypersensitivity to mosquito bites. Am J Hematol. 1997;54:276-281.
49. Sayos J, Wu C, Morra M, et al. The X-linked lymphoproliferative
disease gene product SAP regulates signals induced through the
co-receptor SLAM. Nature. 1998;395:462-469.
50. Coffey AJ, Brooksbank RA, Brandau O, et al. Host response to
EBV infection in X-linked lymphoproliferative disease results
from mutations in an SH2-domain encoding gene. Nat Genet.
1998;20:129-135.
51. Nichols KE, Harkin DP, Levitz S, et al. Inactivating mutations in an
SH2 domain–encoding gene in X-linked lymphoproliferative syn-
drome. Proc Natl Acad Sci U S A. 1998;95:13765-13770.
52. Kimura H, Morita M, Yabuta Y, et al. Quantitative analysis of
Epstein-Barr virus load by using a real-time PCR assay. J Clin
Microbiol. 1999;37:132-136.
53. Kanegane H, Wakiguchi H, Kanegane C, et al. Increased cell-free
viral DNA in fatal cases of chronic active Epstein-Barr virus infec-
tion. Clin Infect Dis. 1999;28:906-909.
54. Lo YMD, Chan LYS, Lo K-W, et al. Quantitative analysis of cell-
free Epstein-Barr virus DNA in plasma of patients with nasopha-
ryngeal carcinoma. Cancer Res. 1999;59:1188-1191.
55. Fontan J, Bassignot A, Mougin C, et al. Detection of Epstein-Barr
10 Imashuku / International Journal of Hematology 72 (2000) 1-11
virus DNA in serum of transplanted patients: a new diagnostic
guide for lymphoproliferative diseases. Leukemia. 1998;12:772-775.
56. Kanegane H,Wado T, Nunogami K, et al. Chronic persistent Epstein-
Barr virus infection of natural killer cells and B cells associated with
granular lymphocytes expansion. Br J Haematol. 1996;95:116-122.
57. Berger C, McQuain C, Sullivan J, et al. The 30-bp deletion variant
of Epstein-Barr virus-encoded latent membrane protein-1 prevails
in acute infectious mononucleosis. J Infect Dis. 1997;176:1370-1373.
58. Knecht H, Berger C, Al-Homsi AS, et al. Epstein-Barr virus onco-
genesis. Crit Rev Oncol Hematol. 1997;26:117-135.
59. Tabata Y, Hibi S, Teramura T, et al. Molecular analysis of latent
membrane protein 1 in patients with Epstein-Barr virus-associated
hemophagocytic lymphohistiocytosis in Japan. Leuk Lymphoma.
2000;38:373-380.
60. Gaillard F, Mechinaud-LeCroix F, Papin S, et al. Primary Epstein-
Barr virus infection with clonal T-cell lymphoproliferation. Am J
Clin Pathol. 1992;98:324-333.
61. Kaneko Y, Maseki N, Sakurai M, et al. Clonal and non-clonal kary-
otypically abnormal cells in haemophagocytic lymphohistiocytosis.
Br J Haematol. 1995;90:48-55.
62. Dolezal MV, Kamel OW, van de Rijn M, et al. Virus-associated
hemophagocytic syndrome characterized by clonal Epstein-Barr
virus genome. Am J Clin Pathol. 1995;103:189-194.
63. Chen J-S, Tzeng C-C, Tsao C-J, et al. Clonal karyotype abnormali-
ties in EBV-associated hemophagocytic syndrome. Haematologica.
1997;82:572-576.
64. Bird G, Peel D, McCarthy K, et al. Epstein-Barr virus induced
virus-associated hemophagocytic syndrome and monoclonal TCR-
beta rearrangement: a case report. Hematol Oncol. 1997;15:47-52.
65. Raab-Traub N, Flynn K. The structure of the termini of the Epstein-
Barr virus as a marker of clonal cellular proliferation. Cell.
1986;47:883-889.
66. Owen G, Webb DKH. Evidence of clonality in a child with
haemophagocytic lymphohistiocytosis. Br J Haematol. 1995;89:
681-682.
67. Osugi Y, Hara J, Tagawa S, et al. Cytokine production regulating
Th1 and Th2 cytokines in hemophagocytic lymphohistiocytosis.
Blood. 1997;89:4100-4103.
68. Imashuku S, Hibi S, Sako M, et al. Soluble interleukin-2 receptor:
a useful prognostic factor for patients with hemophagocytic lym-
phohistiocytosis. Blood. 1995;86:4706-4707.
69. Imashuku S, Hibi S, Fujiwara F, et al. Haemophagocytic lympho-
histiocytosis, inferferon-gamma-naemia and Epstein-Barr virus
involvement. Br J Haematol. 1994;88:656-658.
70. Akashi H, Hayashi S, Gondo H, et al. Involvement of interferon-g
and macrophage colony-stimulating factor in pathogenesis of
haemophagocytic lymphohistiocytosis in adults. Br J Haematol.
1994;87:243-250.
71. Takada H, Ohga S, Mizuno Y, et al. Oversecretion of IL-18 in
hemophagocytic lymphohistiocytosis: a novel marker of disease
activity. Br J Haematol. 1999;106:182-189.
72. Larochelle B, Flamand L, Gourde P, et al. Epstein-Barr virus
infects and induces apoptosis in human neutrophils. Blood.
1998;92:291-299.
73. Mizuno S, Akashi K, Ohshima K, et al. Interferon-γ prevents apo-
ptosis in Epstein-Barr virus–infected natural killer cell leukemia in
an autocrine fashion. Blood. 1999;93:3494-3504.
74. Schultz C, Rott C, Richter N, et al. Intracytoplasmic detection of
cytokines in neonatal lymphocytes and monocytes by flow cytom-
etry. Blood. 1999;105:3566-3567.
75. Gill DS, Spencer A, Cobcroft RG. High-dose gamma-globulin
therapy in the reactive haemophagocytic syndrome. Br J Haema-
tol. 1994;88:204-206.
76. Goulder P, Seward D, Hatton C. Intravenous immunoglobulin in
virus associated haemophagocytic syndrome. Arch Dis Child.
1990;65:1275-1277.
77. Freeman B, Rathore MH, Salman E, et al. Intravenously adminis-
tered immune globulin for the treatment of infection-associated
haemophagocytic syndrome. J Pediatr. 1993;123:479-481.
78. Nagasawa M, Okawa H, Yata J. Deleterious effects of high dose
g-globulin therapy on patients with hemophagocytic syndrome. Int
J Hematol. 1994;60:91-93.
79. Ambruso DR, Hays T, Zwartjes WJ, et al. Successful treatment of
lymphohistiocytic reticulosis with phagocytosis with epipodophyl-
lotoxin VP 16-213. Cancer. 1980;45:2516-2520.
80. Kizaki Z, Fukumochi H, Sawai T, et al. Exchange transfusion and
combination chemotherapy in the treatment of 4 cases of child-
hood malignant histiocytosis. Rinsho Ketsueki. 1987;28:845-851.
81. Henter JI, Elinder G. Familial hemophagocytic lymphohistiocyto-
sis. Clinical review based on the findings in seven children. Acta
Paediatr Scand. 1991;80:269-277.
82. Matsumoto Y, Naniwa D, Banno S, et al. The efficacy of therapeu-
tic plasmapheresis for the treatment of fatal hemophagocytic syn-
drome: two case reports. Ther Apher. 1998;2:300-304.
83. Abella EM, Artrip J, Schultz K, et al. Treatment of familial ery-
throphagocytic lymphohistiocytosis with cyclosporine A. J Pediatr.
1997;130:467-470.
84. Gabor EP, Mishalani, S, Lee S. Rapid response to cyclosporine
therapy and sustained remission in large granular lymphocyte
leukemia. Blood. 1996;87:1199-1200.
85. Bible KC, Tefferi A. Cyclosporine A alleviates severe anaemia
associated with refractory large granular lymphocytic leukaemia
and chronic natural killer cell lymphocytosis. Br J Haematol.
1996;93:406-408.
86. Mouy R, Stephan J-L, Pillet P, et al. Efficacy of cyclosporine A in
the treatment of macrophage activation syndrome in juvenile
arthritis: report of five cases. J Pediatr. 1996;129:750-754.
87. Tsuda H. The use of cyclosporin-A in the treatment of virus-
associated hemophagocytic syndrome in adults. Leuk Lymphoma.
1997;28:73-82.
88. Ostrov BE, Athreya BH, Eichenfield AH, et al. Successful treat-
ment of severe cytophagic histiocytic panniculitis with cyclo-
sporine A. Semin Arthritis Rheum. 1996;25:404-413.
89. Imashuku S, Hibi S, Kuriyama K, et al. Management of severe neu-
tropenia with cyclosporin during initial treatment of Epstein-Barr
virus-related hemophagocytic lymphohistiocytosis (EBV-HLH).
Leuk Lymphoma. 2000;36:339-346.
90. Perel Y, Alos N, Ansoborlo S, et al. Dramatic efficacy of antithy-
mocyte globulins in childhood EBV-associated haemophagocytic
syndrome. Acta Paediatr. 1997;86:911.
91. Stephan JL, Donadieu J, Ledeist F, et al. Treatment of familial
hemophagocytic lymphohistiocytosis with antithymocyte globu-
lins, steroids, and cyclosporine A. Blood. 1993;820:2319-2323.
92. Park JK, Palexas GN, Streeten BW, et al. Ocular involvement in
familial erythrophagocytic lymphohistiocytosis. Graefes Arch Clin
Exp Ophthalmol. 1997;235:647-652.
93. Henter JI, Elinder G. Cerebromeningeal hemophagocytic lympho-
histiocytosis. Lancet. 1992;i:104-107.
94. Ruano M, Castillo M. Brain CT and MR imaging in familial hemo-
phagocytic lymphohistiocytosis. Am J Roentgenol. 1998;170:802.
95. Shuper A, Attias D, Kornreich L, et al. Familial hemophagocytic
lymphohistiocytosis: improved neurodevelopmental outcome after
bone marrow transplantation. J Pediatr. 1998;133:126-128.
96. Yamashita S, Murakami C, Izumi Y, et al. Severe chronic active
Epstein-Barr virus infection accompanied by virus-associated
hemophagocytic syndrome, cerebellar ataxia and encephalitis. Psy-
chiatry Clin Neurosci. 1998;52:449-452.
97. Iwai A, Iwai T, Suzuya H, et al. Development of a clonal and
Epstein-Barr virus (EBV)-positive CNS tumor at recurrence in a
case of hemophagocytic lymphohistiocytosis. Int J Pediatr Hema-
tol/Oncol. 1999;6:183-188.
98. Takahashi S, Oki J, Miyamoto A, et al. Encephalopathy associated
with haemophagocytic lymphohistiocytosis following rotavirus
infection. Eur J Pediatr. 1999;158:133-137.
99. Takano T, Becker LE. Intracerebral vascular occulusion in familial
erythrophagocytic lymphohistiocytosis: a case report of two sib-
lings. Acta Neuropathol. 1995;90:532-538.
100. Oyama Y, Amano T, Hirakawa S, et al. Haemophagocytic syn-
drome treated with cyclosporin A: T cell disorder? Br J Haematol.
1989;73:276-278.
 Management of HLH
101. Brinkman K, van Dongen JJ, van Lom K, et al. Induction of clini-
cal remission in T-large granular lymphocyte leukemia with
cyclosporin A, monitored by use of immunophenotyping with
V beta antibodies. Leukemia. 1998;12:150-154.
102. Imashuku S, Naya M, Yamori M, et al. Chemotherapy and allo-
geneic bone marrow transplantation for T-cell/NK-cell type EBV-
related lymphoproliferative disorders [in Japanese] [abstract]. Jpn
J Pediatr Oncol. 1996;33:369.
103. Inoue M, Nomura K, Yasui M, et al. Treatment strategy for hemo-
phagocytic syndrome in childhood-application of stem cell trans-
plantation. Meeting program of Fourteenth Annual Meeting of the
Histiocyte Society; 1998:40.
104. Obama K, Tara M, Niina K. L-asparaginase induced complete
remission in Epstein-Barr virus positive, multidrug resistant, cuta-
neous T-cell lymphoma. Int J Hematol. 1999;69:260-262.
105. Bolme P, Henter J-I, Winiarski J, et al. Allogeneic bone marrow
transplantation in hemophagocytic lymphohistiocytosis in Sweden.
Bone Marrow Transplant. 1995;15:331-335.
106. Baker KS, DeLaat CA, Steinbuch M, et al. Successful correction of
hemophagocytic lymphohistiocytosis with related or unrelated
bone marrow transplantation. Blood. 1997;89:3857-3863.
107. Durken M, Schneider EM, Blutters-Sawatzki R, et al. Treatment of
hemophagocytic lymphohistiocytosis, HLH, with bone marrow
transplantation. Klin Paediatr. 1998;210:180-184.
108. Chan KW, Mullen CA, Korbling M. Allogeneic peripheral blood
stem cell transplantation for active hemophagocytic lymphohistio-
cytosis. Bone Marrow Transplant. 1998;22:301-302.
109. Ohga S, Nomura A, Kai T, et al. Prolonged resolution of hemo-
phagocytic lymphohistiocytosis following myeloablasive chemo-
therapy and subsequent autologous peripheral blood stem cell
transplantation. Bone Marrow Transplant. 1997;19:633-635.
110. Collins P, Watts M, Brocklesby M, et al. Successful engraftment of
haploidentical stem cell transplant for familial haemophagocytic
lymphohistiocytosis using both bone marrow and peripheral blood
stem cells. Br J Haematol. 1997;96:644-646.
111. Schwinger W, Urban C, Lacvkner H, et al. Unrelated 5/6-locus
11
matched umbilical cord blood transplantation in a 23-month-old
child with hemophagocytic lymphohistiocytosis. Bone Marrow
Transplant. 1998;22:393-396.
112. Jabado N, de Graeff-Meeder ER, Cavazzana-Calvo M, et al. Treat-
ment of familial hemophagocytic lymphohistiocytosis with bone
marrow transplantation from HLA genetically nonidentical
donors. Blood. 1997;90:4743-4748.
113. Wong KF, Hui PK, Chan JKC, et al. The acute lupus hemophago-
cytic syndrome. Ann Intern Med. 1991;114:387-390.
114. Quesnel B, Catteau B, Aznar V, et al. Successful treatment of juve-
nile rheumatoid arthritis associated haemophagocytic syndrome
by cyclosporin A with transient exacerbation by conventional-dose
G-CSF. Br J Haematol. 1997;97:508-510.
115. Kumakura S, Ishikura H, Munemasa S, et al. Adult onset Still’s dis-
ease associated hemophagocytosis. J Rheumatol. 1997;24:1645-1648.
116. Yasuda S, Tsutsumi A, Nakabayashi T, et al. Haemophagocytic syn-
drome in a patient with dermatomyositis. Br J Rheumatol.
1998;37:1357-1358.
117. Papo T, Andre M-H, Amoura Z, et al. The spectrum of reactive
hemophagocytic syndrome in systemic lupus erythematosus.
J Rheumatol. 1999;26:927-930.
118. Henter J-I, Elinder G, Lubeck P-O, et al. Myelodysplastic syndrome
following epipodophyllotoxin therapy in familial hemophagocytic
lymphohistiocytosis. Pediatr Hematol Oncol. 1993;10:163-168.
119. Stein KV, Saylors RL, Sawyer JR, et al. Secondary acute myeloge-
nous leukemia following safe exposure to etoposide. J Clin Oncol.
1997;15:1583-1586.
120. Takahashi T, Yagasaki F, Endo K, et al. Therapy-related AML after
successful chemotherapy with low dose etoposide for virus-associ-
ated hemophagocytic syndrome. Int J Hematol. 1998;68:333-336.
121. Gale G, Chu JY, Salinas L, et al. Simultaneous presentation of
acute leukemia and hemophagocytic syndrome in three children.
J Pediatr Hematol Oncol. 1997;19:391-392.
122. Suzuki T, Mugishima H, Yamada A, et al. Development of acute
lymphoblastic leukemia following hemophagocytic lymphohistio-
cytosis: is it secondary leukemia? Int J Hematol. 1999;70:58-59.