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  Table of Contents    
Year : 2012  |  Volume : 55  |  Issue : 1  |  Page : 124-125
Hemophagocytic syndrome associated with concomitant Klebsiella and Parvovirus B-19 infection

Consultant and senior resident, Department of Pathology, Deen Dayal Upadhyay Hospital, Delhi, India

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Date of Web Publication11-Apr-2012

How to cite this article:
Sood N, Yadav P. Hemophagocytic syndrome associated with concomitant Klebsiella and Parvovirus B-19 infection. Indian J Pathol Microbiol 2012;55:124-5

How to cite this URL:
Sood N, Yadav P. Hemophagocytic syndrome associated with concomitant Klebsiella and Parvovirus B-19 infection. Indian J Pathol Microbiol [serial online] 2012 [cited 2019 Dec 13];55:124-5. Available from: http://www.ijpmonline.org/text.asp?2012/55/1/124/94886


This is in reference to the case report "Hemophagocytic Syndrome associated with Plasmodium falciparum infection" published in July-Sep 2011 issue of this journal. [1] We also wish to report a case of concomitant Klebsiella and Parvovirus B-19 infection leading to hemophagocytic syndrome in a 16-year-old boy.

A 16-year-old boy, resident of Delhi, presented to the casualty with a history of high grade fever associated with chills, headache, and altered sensorium for one week duration. On clinical examination, the patient was afebrile, conscious, but disoriented. He had neck rigidity with multiple petechiae on the lower limbs and hepatosplenomegaly. Provisional clinical diagnosis of febrile encephalopathy was made. Investigations revealed pancytopenia with normocytic normochromic red blood cell picture (hemoglobin 6.3 g%, total leukocyte count 0.89 ×10 3 /μl - polymorphs 70%, lymphocytes 25%, monocytes 05%, and platelet count 18,000/mm 3 ). Blood culture was positive for Klebsiella pneumoniae, sensitive to chloramphenicol, imipenem, tazobactum and meropenem.

Cerebospinal fluid (CSF) analysis did not show any pleocytosis. Renal function test, liver function test, and urine examination was within normal limits. Rapid Malarial Antigen test, Human Immunodeficiency Virus (HIV) serology, Widal test, acid fast bacilli (AFB) culture, and antinuclear antigen (ANA) were negative. Ultrasound abdomen showed hepatomegaly (15.7 cm) and splenomegaly (15 cm). Contrast enhanced computed tomography head was unremarkable.

Bone marrow aspiration, two days after admission, showed erythroid hyperplasia with an M:E ratio of 1:2. Erythroid cells were predominantly normoblastic with few megaloblastoid forms. In addition, there was marked proliferation of histiocytes, many of which showed hemophagocytic activity. Histiocytes with engulfed polymorphs, lymphocytes, RBCs as well as platelets were identified as observed by others too [Figure 1]. Many of these cells also had peripheral rim of vacuolization, which has not been described by others [Figure 2]. No hemoparasites were seen. Based on the clinical and hematological findings, a provisional diagnosis of hemophagocytic syndrome was considered. Viral serology for Dengue, Epstein-Barr virus (EBV), cytomegalovirus (CMV), and adenovirus were negative, but was positive for Parvovirus B-19. Serum triglyceride levels were raised (270 mg%). Serum ferritin levels and coagulation profile were normal. The final diagnosis was that of hemophagocytic syndrome secondary to Klebsiella and Parvovirus B-19 infection based on the criteria (5/8) laid down by histiocytic Society for diagnosis of Hemophagocytic syndrome. [2] The patient was put on antibiotic treatment comprising of amikacin, ofloxacin, and metronidazole for three weeks and showed remarkable recovery, suggesting the primary etiological role of Klebsiella infection in the present case. Follow-up bone marrow examination and peripheral smear were unremarkable.
Figure 1: Microphotograph showing mononuclear histiocyte with engulfed lymphocyte (thin arrow), ingested RBC (thick arrow), and with engulfed platelet (arrowhead) (Wright Giemsa, ×1000)

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Figure 2: Microphotograph showing monohistiocyte having peripheral rim of vacuolization (Wright Giemsa, ×1000)

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Infection-associated hemophagocytic syndrome (IAHS) was originally described by Risdall [3] in 1979, in viral disease. It occurs most commonly in association with herpes group viruses, in particular CMV and EBV. Others, including herpes simplex, herpes zoster, adenovirus, and parvovirus and HIV have also been implicated. [4] Since the initial description, IAHS has also been documented in patients with bacterial, parasitic, or fungal infections. Klebsiella infection has been observed in a few studies. [5],[6] The role of pro-inflammatory cytokines such as interferon gamma, interleukin (IL)-12, IL-18, tumor necrosis factor α, IL-1β, and IL-6 has been suggested in the pathogenesis of hemophagocytic syndrome. IAHS associated with pathogens other than EBV, is associated with recovery in 60%-70% with supportive care and treatment of the underlying infection, as seen in the present case.

   References Top

1.Vinoth PN, Thomas KA, Selvan SM, Renjitha Suman DF, Scott JX. Hemophagocytic Syndrome associated with Plasmodium falciparum infection. Indian J Pathol Microbiol 2011;54:594-6.  Back to cited text no. 1
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2.Henter JI, Horne A, Arico M, Egeler RM, Filipovich AH, Imashuku S, et al. HLH-2004: Diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer 2007;48:124-31.  Back to cited text no. 2
3.Risdall RJ, McKenna RW, Nesbit ME. Virus associated haemophagocytic syndrome. Cancer 1979;44:993-1102.  Back to cited text no. 3
4.Boruchoff SE, Woda BA, Pihan GA. Parvovirus-B19-associated hemophagocytic syndrome. Arch Intern Med 1990;150:897.  Back to cited text no. 4
5.Risdall RJ, Brunning RD, Hemandez Z, Gordon DH. Bacteria-associated hemophagocytic syndrome. Cancer1984;54:2968-72.  Back to cited text no. 5
6.Potter MN, Foot AB, Oakhill A. Influenza A and the virus associated haemophagocytic syndrome: Cluster of three cases in children with acute leukaemia. J Clin Pathol 1991;44:297-9.  Back to cited text no. 6

Correspondence Address:
Neelam Sood
B/3/337 GF, Paschim Vihar - 110 063, Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0377-4929.94886

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  [Figure 1], [Figure 2]

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