title: Hemophagocytic lymphohistiocytosis responding to withdrawal of gluten: a case report.
abstract: BACKGROUND
  This is the first documented case of a patient with hemophagocytic lymphohistiocytosis in association with coeliac disease. There was complete clinical and biochemical remission of hemophagocytic lymphohistiocytosis following the introduction of a gluten-free diet.
  
  
  METHODS
  A 7-year-old white girl presented with fevers and maculopapular rash with a recent history of tonsillitis. Blood tests revealed thrombocytopenia (64×109/L), anemia (80 g/L), hypofibrinogenemia (1 g/L), and hyperferritinemia (71,378 μg/L). A bone marrow revealed evidence of hemophagocytosis, but the results of tests for the genetic or familial-associated hemophagocytic lymphohistiocytosis syndromes were negative. The results of screening tests for known secondary causes were negative. She was diagnosed as having hemophagocytic lymphohistiocytosis and following treatment with the hemophagocytic lymphohistiocytosis-2004 protocol these symptoms, in addition to the biochemical and hematological markers, completely resolved. She presented again 10 months later with fever, rash, and biochemical abnormalities suggestive of hemophagocytic lymphohistiocytosis. Her tissue transglutaminase was markedly raised and the results of blood tests revealed a genetic susceptibly to coeliac disease in the form of HLA-DQ2 positivity. She commenced a gluten-free diet and there was complete symptomatic and biochemical response without any further chemotherapy. She had further episodic rashes, each associated with the accidental intake of gluten.
  
  
  CONCLUSIONS
  This is to the best of our knowledge the first documented case of hemophagocytic lymphohistiocytosis in association with coeliac disease. No other secondary cause found; she initially responded to chemoimmunotherapy specific for hemophagocytic lymphohistiocytosis but relapsed within a few months of cessation of treatment and then achieved complete remission on gluten withdrawal alone.
authors.affiliation: St Helier's Hospital, Wrythe Lane, Carshalton, Surrey, SM5 1AA, UK. nickfordham@doctors.org.uk.
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Fordham
authors.affiliation: Hillingdon Hospital, Pield Heath Road, Uxbridge, UB8 3NN, UK.
authors.forename: Richa
authors.initials: R
authors.lastname: Ajitsaria
authors.affiliation: St Mary's Hospital, Praed Street, London, W2 1NY, UK.
authors.forename: Leena
authors.initials: L
authors.lastname: Karnik
authors.affiliation: Imperial College London, London, SW7 2AZ, UK.
authors.forename: Subarna
authors.initials: S
authors.lastname: Chakravorty
keywords: Coeliac disease; Gluten; HLH; Hemophagocytosis