title: Screening assays for primary haemophagocytic lymphohistiocytosis in children presenting with suspected macrophage activation syndrome.
abstract: BACKGROUND
  Primary haemophagocytic lymphohistiocytosis (HLH) screening assays are increasingly being performed in patients presenting with macrophage activation syndrome (MAS). The objective of this study was to describe their diagnostic and prognostic relevance in children who had presented to paediatric rheumatology and had undergone investigative work up for MAS.
  
  
  METHODS
  Data was obtained retrospectively from an existing protein screening assay database and patient records. Assays included: intracellular expression of perforin in CD56+ Natural Killer (NK) cells; CD107a Granule Release Assay (GRA) in response to PHA in NK cells, or anti-CD3 stimulation of CD8 lymphocytes; in males Signal Lymphocyte Activating Molecule Associated Protein (SAP), and X-linked Inhibitor of Apoptosis Protein (XIAP) expression. All assays, requested by paediatric rheumatology, of children who had undergone investigative work up for MAS over a 5-year period (2007-2011) were included.
  
  
  RESULTS
  Twenty-one patients (15 female), median age 6.5 years (range 0.6-16) with follow-up of 16 months (range 1-51), were retrospectively identified. At presentation, 3/21 (14 %) fulfilled HLH-2004 diagnostic criteria. At least one screening test result was available for all 21 patients; 7/21 (33 %) had at least one persistent screening test abnormality. Of this group 4/7 (57 %) died or required haematopoietic stem cell transplantation (HSCT), compared to 1/14 (7 %) with no screening test abnormality (p = 0.025). 3/21 (14 %) ultimately had a diagnosis of primary HLH (two confirmed genetically; XIAP, familial HLH type 3, and one confirmed clinically). Of the six patients with abnormal GRA 5/6 had negative routine genetic results.
  
  
  CONCLUSIONS
  Screening for primary HLH is warranted for children whose first rheumatological presentation is with MAS, since overall 14 % had an eventual diagnosis of primary HLH. A persistently abnormal GRA in patients presenting with MAS defines a high-risk group with poor outcome (mortality or HSCT), possibly due to as yet unidentified genetic cause.
authors.affiliation: Departments of Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK. marycruikshank@doctors.org.uk.
authors.forename: Mary
authors.initials: M
authors.lastname: Cruikshank
authors.affiliation: Departments of Haematology, Great Ormond Street Hospital NHS Foundation Trust, London, UK. aparan@doctors.org.uk.
authors.forename: Parameswaran
authors.initials: P
authors.lastname: Anoop
authors.affiliation: Departments of Bone Marrow Transplantation, Great Ormond Street Hospital NHS Foundation Trust, London, UK. Olga.Nikolajeva@gosh.nhs.uk.
authors.forename: Olga
authors.initials: O
authors.lastname: Nikolajeva
authors.affiliation: Departments of Haematology, Great Ormond Street Hospital NHS Foundation Trust, London, UK. Anupama.Rao@gosh.nhs.uk.
authors.forename: Anupama
authors.initials: A
authors.lastname: Rao
authors.affiliation: Departments of Bone Marrow Transplantation, Great Ormond Street Hospital NHS Foundation Trust, London, UK. kanchan.rao@gosh.nhs.uk.
authors.forename: Kanchan
authors.initials: K
authors.lastname: Rao
authors.affiliation: Departments of Immunology, Great Ormond Street Hospital NHS Foundation Trust, London, UK. Kimberly.Gilmour@gosh.nhs.uk.
authors.forename: Kimberly
authors.initials: K
authors.lastname: Gilmour
authors.affiliation: Departments of Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK. d.eleftheriou@ucl.ac.uk.|Institute of Child Health, University College London, London, UK. d.eleftheriou@ucl.ac.uk.|Arthritis Research UK Centre for Adolescent Rheumatology, London, UK. d.eleftheriou@ucl.ac.uk.
authors.forename: Despina
authors.initials: D
authors.lastname: Eleftheriou
authors.affiliation: Departments of Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK. p.brogan@ucl.ac.uk.|Institute of Child Health, University College London, London, UK. p.brogan@ucl.ac.uk.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Brogan