title: Pregnancy-related hemophagocytic lymphohistiocytosis associated with cytomegalovirus infection: A diagnostic and therapeutic challenge.
abstract: OBJECTIVE
  Hemophagocytic lymphohistiocytosis (HLH) is a disorder characterized by uncontrolled mature histiocyte proliferation, hemophagocytosis, and hypercytokinemia. We describe a previously healthy pregnant patient who presented in the third trimester of pregnancy with HLH.
  
  
  METHODS
  A 35-year-old woman presented at 38 weeks' gestation with pyrexia, jaundice, severe anemia, elevated liver enzymes, and lactate dehydrogenase suggestive of HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome. Unfortunately, her condition deteriorated and she was ventilated in the intensive care unit despite delivery of the baby and administration of dexamethasone. She developed microangiopathic hemolytic anemia, thrombocytopenia, and renal impairment suggestive of thrombotic thrombocytopenic purpura/hemolytic uremic syndrome. However, she was refractory to plasma exchange, intravenous immunoglobulin, and broad-spectrum antibiotics. HLH was eventually diagnosed from biochemical and bone marrow findings. An extensive search for possible causes yielded negative results. She improved significantly with intravenous dexamethasone and cyclosporine A and was transferred out of the intensive care unit. Unfortunately, she developed cytomegalovirus disease 2 weeks later, which improved transiently with intravenous ganciclovir; later, however, she succumbed to multidrug-resistant nosocomial infections, rapidly progressive cytomegalovirus disease, and multiorgan failure.
  
  
  CONCLUSIONS
  This case highlights the challenges and difficulties involved in the diagnosis and management of pregnancy-related HLH. Immunosuppressive treatment for HLH can precipitate life-threatening opportunistic infections, which need to be promptly diagnosed and treated.
authors.affiliation: Hematology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, 56000 Kuala Lumpur, Malaysia.
authors.forename: Nor Rafeah
authors.initials: NR
authors.lastname: Tumian
authors.affiliation: Hematology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, 56000 Kuala Lumpur, Malaysia. Electronic address: chiehwong@ppukm.ukm.edu.my.
authors.forename: Chieh Lee
authors.initials: CL
authors.lastname: Wong
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000379:methods; D003131:Combined Modality Therapy; D016572:Cyclosporine / Q000008:administration & dosage; D003586:Cytomegalovirus Infections / Q000150:complications / Q000175:diagnosis* / Q000628:therapy*; D003907:Dexamethasone / Q000008:administration & dosage; D018450:Disease Progression; D018432:Drug Resistance, Multiple; D004359:Drug Therapy, Combination; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D007262:Infusions, Intravenous; D051359:Lymphohistiocytosis, Hemophagocytic / Q000150:complications / Q000175:diagnosis* / Q000628:therapy*; D009102:Multiple Organ Failure; D010951:Plasma Exchange / Q000379:methods; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000175:diagnosis* / Q000628:therapy*; D011263:Pregnancy Trimester, Third; D012720:Severity of Illness Index
chemical_list: D003907:Dexamethasone; D016572:Cyclosporine
keywords: cytomegalovirus infection; hemophagocytic lymphohistiocytosis; hemophagocytic syndrome; pregnancy