09 November 2021
: Case report 
Prompt Recognition of Hemophagocytic Lymphohistiocytosis in an Afebrile Patient with Lupus and Staphylococcus aureus Bacteremia
Challenging differential diagnosis, Management of emergency care, Rare coexistence of disease or pathology
Joshua Hardage1ADEF, Natalie B. Otto1ADEF, Joanne Skaggs
12E*, Stephen Travis13ADEF
DOI: 10.12659/AJCR.934092
Am J Case Rep 2021; 22:e934092
Table 1. Clinical course and laboratory findings.
| Intervention | Day 1 | Day 2 | Day 3 | Day 5 | Reference |
|---|---|---|---|---|---|
| Methylprednisolone Blood cultures drawn Piperacillin/tazobactam started | Plasmapheresis Blood culture grew MSSA | HLH suspected Plasmapheresis Anakinra started Antibiotics deescalated to cefazolin | Bone Marrow Biopsy Hydroxychloroquine started | ||
| WBC, K/mm | 1.56 | 1.53 | 1.04 | 1.37 | |
| RBC, M/mm | 4.43 | 3.34 | 3.56 | 3.21 | |
| Hgb, g/dL | 12.3 | 9.5 | 10.1 | 10.5 | |
| Reticulocyte count | 0.2% | ||||
| Plt, K/mm | 77 | 51 | 48 | 78 | |
| BUN, mg/dL | 122 | 101 | 91 | 66 | |
| Cr, mg/dL | 8.26 | 4.72 | 2.47 | 1.82 | |
| Na, mEq/L | 133 | ||||
| Anion gap | 17 | ||||
| AST, U/L | 406 | 266 | 140 | 212 | |
| ALT, U/L | 128 | 91 | 63 | 89 | |
| Lipase, U/L | 323 | ||||
| C3, mg/dL | 38 | ||||
| C4, mg/dL | 9.4 | ||||
| ESR, mm/hr | 34 | 78 | 24 | ||
| dsDNA ab, IU/mL | 119 | 90 | |||
| ANA | 1: 3240 | ||||
| LDH, U/L | 1900 | ||||
| Haptoglobin, mg/dL | 2 | ||||
| D-dimer, ng/dL | 47 582 | ||||
| Fibrinogen, mg/dL | 199 | ||||
| Ferritin, ng/dL | >16 500 | 9023 | |||
| Triglycerides, mg/dL | 399 | ||||
| Urine protein, mg/dL | 175 | ||||
| Urine Na, mEq/L | 13 | ||||
| Urine Cr, mg/dL | 272 | ||||
| * Baseline Cr 0.94 in 2018. Highlighted are notable trends and values that increased our patient’s HScore. | |||||
| Intervention | Day 7 | Day 8 | Day 10 | Day 16 | Reference |
| Renal biopsy | Solumedrol started | Etoposide and tocilizumab started | Day of discharge | ||
| WBC, K/mm | 1.20 | 0.95 | 2.33 | 1.32 | |
| RBC, M/mm | 3.28 | 2.94 | 3.00 | 2.75 | |
| Hgb, g/dL | 8.8 | 8.9 | 8.3 | 7.6 | |
| Reticulocyte count | |||||
| Plt, K/mm | 84 | 87 | 76 | 45 | |
| BUN, mg/dL | 42 | 36 | 32 | 21 | |
| Cr, mg/dL | 1.05 | 0.97 | 1.03 | 0.82 | |
| Na, mEq/L | |||||
| Anion gap | |||||
| AST, U/L | 203 | 173 | 110 | 51 | |
| ALT, U/L | 118 | 90 | 46 | 32 | |
| Lipase, U/L | |||||
| C3, mg/dL | |||||
| C4, mg/dL | |||||
| ESR, mm/hr | 30 | ||||
| dsDNA ab, IU/mL | |||||
| ANA | |||||
| LDH, U/L | |||||
| Haptoglobin, mg/dL | |||||
| D-dimer, ng/dL | |||||
| Fibrinogen, mg/dL | |||||
| Ferritin, ng/dL | 9430 | 11295 | >16 500 | 3307 | |
| Triglycerides, mg/dL | |||||
| Urine protein, mg/dL | |||||
| Urine Na, mEq/L | |||||
| Urine Cr, mg/dL | |||||
| * Baseline Cr 0.94 in 2018. Highlighted are notable trends and values that increased our patient’s HScore. | |||||