Article type : Full Length

Accepted Article
Features, Treatment and Outcomes of Macrophage Activation Syndrome in Childhood-
onset Systemic Lupus Erythematosus

R. Ezequiel Borgia1 MD, Maya Gerstein1 MD, Deborah M. Levy1 MD, MS, FRCPC, Earl D.
Silverman1a MD, FRCPC, Linda T. Hiraki1a MD, FRCPC, MS, ScD
1
Division of Rheumatology, The Hospital for Sick Children and Research Institute, Hospital
for Sick Children; Department of Pediatrics, University of Toronto, Ontario, Canada.
a
Co-senior and principal investigators

Running title: Features, Treatment and Outcomes: MAS in cSLE

Keywords: Childhood-onset Systemic lupus erythematosus

Macrophage activation syndrome
Outcomes

Corresponding author:

Linda T. Hiraki, MD, FRCPC, ScD

Clinician Scientist, Division of Rheumatology
Scientist Track, Research Institute
The Hospital for Sick Children
PGCRL, 686 Bay Street | Toronto ON M5G 0A4
Email: linda.hiraki@sickkids.ca

Financial Support:
Dr. Hiraki: Fellowship Award, Canadian Institute of Health Research (CIHR)

Disclosures:
The authors have no disclosures or conflicts of interest to declare.

ABSTRACT

Objective: To describe the features and treatment of macrophage activation syndrome

(MAS) in a childhood-onset systemic lupus erythematosus (cSLE) single centre cohort, and

compare the cSLE manifestations and outcomes between those with and without MAS.

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1002/art.40417
This article is protected by copyright. All rights reserved.
 Methods: We included all cSLE patients followed at SickKids Hospital from 2002-12, and

identified those also diagnosed with MAS. Demographic, clinical and laboratory features of
Accepted Article
MAS and SLE, medication use, hospital and PICU admissions as well as damage indices and

mortality were extracted from the Lupus database. Student’s t-tests and Fisher’s exact tests

were used to compare continuous and categorical variables respectively. We calculated

incidence-rate ratios (IRR) of hospital and PICU admissions comparing MAS with non-MAS

patients, using Poisson models. Kaplan-Meier survival analysis was used to examine the time

to disease damage accrual.

Results: Of the 403 cSLE patients, 38 (9%) had MAS. The majority (68%) had concomitant

MAS and SLE diagnoses. Fever was the most common MAS clinical feature. The frequency

of renal and CNS disease, hospital admissions, the average daily dose of steroids and time to

disease damage were similar between those with and without MAS. We observed a higher

mortality rate among those with MAS (5%) compared to those without MAS (0.2%) (p=

0.02). Conclusions: MAS was most likely to develop concomitantly with cSLE diagnosis.

The majority of the MAS patients were successfully treated with corticosteroids with no

MAS relapses. Although the numbers were small, there was a higher risk of death associated

with MAS compared to those without MAS.

INTRODUCTION
Macrophage activation syndrome (MAS) is a potentially life-threatening complication

of systemic lupus erythematosus (SLE) characterized by excessive activation and

proliferation of T lymphocytes and macrophages and a consequent massive production of

cytokines or “cytokine storm” 1-4. MAS is considered a secondary or acquired form of

hemophagocytic lymphohistiocytosis (HLH) and is usually associated with infection,

rheumatic disease or malignancy 5. Primary or familial HLH is caused by mutations in genes

This article is protected by copyright. All rights reserved.

 involved in the granule-dependent cytolytic secretory pathway. Despite the inciting cause,

primary and secondary HLH share similar clinical and biochemical features 5.
Accepted Article
MAS was initially described in association with systemic juvenile idiopathic arthritis

(sJIA) 6, however, has been increasingly recognized as a complication of SLE 3,5,7. There are

only a few studies examining the clinical and laboratory features of MAS in childhood-onset

SLE (cSLE) and most of the available data are based on cross-sectional studies and case

reports 3,8-12. As a result the true prevalence of MAS in cSLE is unknown. MAS is life-

threatening, with mortality rates ranging from 8-22% in pediatric autoimmune diseases

generally 11,13 and 10-22% in MAS complicating cSLE specifically 3,8,14. Yet there are limited

available data on long-term outcomes, including rates of recurrence of MAS in cSLE 3,8,14.

Moreover, it remains unclear whether cSLE complicated by MAS has a distinctive disease

course in terms of SLE organ involvement and damage accrual in long-term follow-up when

compared to cSLE without MAS.

The aims of this study were to: 1) Describe the clinical and laboratory characteristics,

outcomes and treatment for MAS in a large cSLE cohort from a single pediatric tertiary care

centre; and 2) Compare the clinical and laboratory SLE features and disease-associated

outcomes between those cSLE patients with and without MAS.

METHODS

Study population

We included all patients diagnosed and followed for cSLE at SickKids Hospital,

Toronto between January 2002 and December 2012 (n=403). All patients met the American

College of Rheumatology (ACR) and/or Systemic Lupus International Collaborating Clinics

(SLICC) classification criteria for SLE 15,16. Since there are no validated nor universally

accepted diagnostic criteria for MAS in SLE, the definition of MAS was based on the treating

This article is protected by copyright. All rights reserved.

 pediatric rheumatologist’s expert opinion at the time of the initial presentation. The first

pediatric rheumatologist (EDS) has 35 years of experience in caring for children with SLE
Accepted Article
and the second (DML) has more than 15 years experience. These diagnoses were

independently reviewed (MG) and any questionable diagnoses were brought forth to all

authors. There were 4 cases in which the diagnosis of MAS was disputed. After individual

case review, 2 were excluded as MAS cases. The final decision on MAS diagnosis and

subsequent inclusion of the MAS patients in the study was made upon agreement of all the

contributing authors of this study. Institutional Research Ethics Board (REB) approval was

obtained prior to initiation of the study (REB #1000035186).

Variables

Prospectively collected demographic, clinical and laboratory data on SLE and MAS

features were extracted from the SickKids Lupus database and supplemented by data from

the hospital medical records. The diagnosis of MAS and cSLE was considered as

“concomitant” if MAS was diagnosed within 7 days of cSLE diagnosis.

Demographic features included age at cSLE and MAS diagnoses and gender. The

following clinical MAS features 3,17 were extracted: fever, hepatosplenomegaly,

lymphadenopathy, clinical bleeding episodes (hemorrhages) and central nervous system

(CNS) involvement. CNS involvement secondary to MAS was defined as any evidence of

altered level of consciousness or seizures at the time of MAS presentation excluding

metabolic causes, infections and drugs. Since MAS with CNS involvement may overlap with

the clinical spectrum of neuropsychiatric lupus (NPSLE)21, the definition of CNS disease

secondary to MAS was based on a multidisciplinary team approach including pediatric

neurologists, neuroradiologists, oncologists and rheumatologists. Laboratory MAS features

extracted included: platelet count, hemoglobin, white blood cell count with differential,

This article is protected by copyright. All rights reserved.

 alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactate dehydrogenase

(LDH), ferritin, fibrinogen, triglyceride level, D-Dimers, partial thromboplastin time (PTT),
Accepted Article
serum sodium level, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR).

Additional laboratory features such as natural killer (NK) cell cytotoxic activity, soluble

interleukin-2 receptor (sIL-2R) levels, bone marrow aspirate/biopsy and infectious work-up

were also included when available. We also reviewed results of Sanger sequencing of exons 2

and 3 in the perforin gene (PRF1) 18 and of whole exome sequencing of known HLH

associated variants in genes (AP3B1, BLOC1S6, CD27, ITK, LYST, NLRC4, PRF1, RAB27A,

SH2D1A, SLC7A7, STX11, STXBP2, UNC13D, XIAP) when available. We applied the

preliminary diagnostic criteria for MAS proposed by Parodi et al 3 in our MAS cohort.

Medications prescribed for MAS treatment were reviewed and reported. Attribution of

calcineurin inhibitor therapy was to cSLE in those with concomitant membranous LN and

MAS. Otherwise, cacineurin inhibitor use was attributed to MAS therapy.

All available clinical and laboratory SLE features 15,16 during complete follow-up were

extracted. Patients with clinical evidence of lupus nephritis underwent kidney biopsy unless

contraindicated. Lupus nephritis was classified according to the International Society of

Nephrology/Renal Pathology Society (ISN/RPS) classification, revised in 2003 20. The

definition of CNS disease secondary to SLE was based on 1999 ACR nomenclature and case

definitions for NPSLE syndromes 21.

In order to assess SLE disease severity and long-term SLE outcomes in MAS and

non-MAS patients, the following variables were recorded: immunosuppressive drug use,

average daily dose of corticosteroids and number of pediatric intensive care unit (PICU)

admissions over follow-up. Hospital admissions with length of stay > 72 hours were

considered clinically relevant in order to assess and compare lupus disease severity between

MAS and non-MAS patients over the follow-up. However, those hospital admissions entirely

This article is protected by copyright. All rights reserved.

 for medical procedures (e.g. for kidney biopsy) were excluded since they were not considered

an accurate indicator of disease severity. All deaths during follow-up at SickKids were
Accepted Article
documented in both groups. The SLICC Damage Index (SLICC-DI), previously validated in

cSLE, was used to assess damage at 6 months from cSLE diagnosis and subsequently at each

visit in both groups 22,23. All variables were collected until the last lupus clinic visit at

SickKids.

Statistical analyses

Demographic data, clinical and laboratory features were analyzed using descriptive

statistics. Continuous and categorical variables were compared between those with and

without MAS, using Student’s t-test and Fisher’s exact test respectively. Incidence rate ratios

(IRR) were calculated using Poisson models to compare the rates of hospital and PICU

admissions between those with and without MAS. Kaplan-Meier survival analyses were used

to examine the rate of disease damage accrual over time in both cohorts. A p-value <0.05 was

considered statistically significant and a Bonferroni correction for multiple testing was used

when testing multiple independent associations. All statistical analyses were performed using

Stata: Release 14, (StataCorp LP, College Station, Texas).

RESULTS

Demographic Data

Of our cSLE cohort of 403 patients diagnosed and followed at SickKids Hospital, 38

(9%) had MAS. The majority of the MAS patients were female (79%), the mean age at SLE

diagnosis was 13.7 years (SD: 2.8 years) and length of follow-up was 3.5 years (SD: 1.6

years). We did not observe a difference in age of SLE diagnosis, nor in the duration of

follow-up between the MAS and non-MAS groups (Table 2, Figure 1). MAS developed

concomitantly with cSLE diagnosis in the majority of the patients (68%) and 29% were

diagnosed with MAS within 180 days of cSLE diagnosis. Only 11% developed MAS > 180

This article is protected by copyright. All rights reserved.

 days following cSLE diagnosis. In one patient, the diagnosis of MAS secondary to Kikuchi-

Fujimoto disease, preceded the cSLE diagnosis by 3 years. There was no statistically
Accepted Article
significant change in MAS annual incidence over the study period in our cSLE cohort (data

not shown).

Clinical and laboratory MAS features at presentation and initial treatment in the MAS

cohort

a) Clinical and laboratory features of MAS

All MAS patients had fever at presentation. The second most common manifestation

was generalized lymphadenopathy (24%) followed by CNS involvement secondary to MAS

(18%) (Table 1). Attribution of CNS manifestations to either MAS or cSLE was difficult at

times, but upon review, attribution was agreed upon by all authors. An example of MAS-

CNS involvement included focal seizures with residual hemiparesis and subsequent coma

with biochemical evidence of MAS. In another patient, one week following treatment for

MAS, she had onset of CNS lupus manifestations including visual hallucinations and

cognitive slowing. Due to the nature and timing of her symptoms and since other MAS

manifestations such as pancytopenia and diffuse lymphadenopathy improved, her CNS

manifestations were attributed to cSLE.

All MAS patients had ferritin levels above the laboratory reference range values.

Elevated LDH and AST levels were present in 97% of the patients (Table 1). NK cell

cytotoxic activity was found to be normal in all 3 tested, and sIL-2R levels was elevated in all

4 tested (median concentration 3239 U/ml; range: 1047-7012; normal range: 460-1580 U/ml).

Seven patients had PRF1 sequencing and 6 had whole exome sequencing (WES) of HLH

associated genes. The majority (11/13) did not carry variants associated with HLH, with the

remainder of those tested being heterozygous carriers of variants of uncertain significance in

LYST or RAB27A (MAFs of 0.001 to 0.015 depending on the ancestral population).

This article is protected by copyright. All rights reserved.

 There was evidence of hemophagocytosis in 32% of patients who underwent bone

marrow aspirate/biopsy (Table 1). A minority of patients (16%) had documented concomitant
Accepted Article
infections at the time of MAS presentation (1 group A streptococcal bacteremia, 1 HSV1

cutaneous infection, 1 acute epstein barr virus (EBV) infection, 1 E. Coli urinary tract

infection [UTI], 1 candida UTI, 1 disseminated tuberculosis infection) and one patient

received the meningococcal vaccination 2 weeks prior to MAS diagnosis. All cSLE patients

clinically diagnosed with MAS met the preliminary diagnostic criteria for MAS proposed by

Parodi et al 3 (Table 1).

b) MAS treatment

All MAS patients were treated with corticosteroids (Table 1), the majority (68%)

received intravenous (IV) high dose methylprednisolone followed by either oral prednisone

or lower dose IV methylprednisolone. Intravenous immunoglobulin (IVIG) was used in 22

(58%) patients. A third of patients received an oral calcineurin inhibitor and 13% received

etoposide. Two patients died during the acute phase of MAS. Both required anakinra and

plasmapheresis while one also received alemtuzumab and intrathecal methotrexate due to

severe, refractory CNS disease secondary to MAS (Table 1).

MAS outcome

The mean duration follow-up from the time of SLE diagnosis to last visit was 3.5

years (SD: 1.6) in MAS patients. All patients required hospital admission at MAS diagnosis

and 21% also required PICU admission. Of the 2 MAS patients who died during the acute

episode: one had CNS disease and disseminated tuberculosis and the other had CNS

involvement (brain biopsy with CD163+ macrophages, erythrophagocytes and

lymphophagocytes infiltrate).

Three of 5 patients with seizures had no further seizure recurrence after the MAS

episode resolved. The 2 patients who initially presented with isolated altered level of

This article is protected by copyright. All rights reserved.

 consciousness had normal brain MRI scans at presentation and completely recovered without

further CNS involvement. None of the MAS patients experienced a MAS recurrence during
Accepted Article
the follow-up at SickKids.

Comparison of SLE clinical and laboratory features and treatment between MAS and

non-MAS cohorts

The mean duration follow-up among cSLE patients without MAS was 3.5 years (SD:

1.6). Over follow-up period, a higher proportion of those with MAS had lymphopenia,

thrombocytopenia and positive anti-dsDNA antibodies when compared with the non-MAS

group (p < 0.01) (Table 2). The average daily dose of prednisone or prednisone equivalents

over the course of follow-up (including use for MAS treatment) was similar between MAS

and non-MAS cohorts (18.3 mg/day, SD: 7.3 vs 18.6 mg/day, SD: 18.7 respectively, p=

0.94), as was the proportion of immunosuppressive medication use over follow-up (Table 3).

There was a trend towards more azathioprine use in the non-MAS group compared to the

MAS group, but this was not statistically significant after Bonferroni correction for multiple

comparisons (Table 3).

Lupus outcomes in MAS and non-MAS cohorts

There was no difference in the rate of hospital and PICU admissions per year between

MAS and non-MAS patients during follow-up (IRR for hospital admissions in the MAS

group compared with non-MAS group: 1.11 [95% CI: 0.83 - 1.48] and IRR for PICU

admissions: 1.60 [95% CI: 0.74 - 3.18]). There was a trend toward a higher proportion of

PICU admissions in the MAS group (all related to acute MAS presentation) within the first

year of cSLE diagnosis when compared to non-MAS patients, however the difference was not

statistically significant (PICU admission in 23% MAS patients vs. 10 % of non-MAS

patients, p=0.05).

This article is protected by copyright. All rights reserved.

 There was no difference in the proportion of patients who sustained damage (SLICC ≥

1) during follow-up (p= 0.3) (Figure 2). Cataracts were the most common manifestation of
Accepted Article
damage at last clinic visit in both groups, followed by avascular necrosis (AVN), cognitive

impairment and osteoporosis with fracture or vertebral collapse. Although numbers were

small, there was a higher mortality rate in the MAS group (2 patients [5%]) when compared

the non-MAS cohort (1 patient [0.2%]; p= 0.02). All deaths in the MAS cohort occurred in

the acute period of the MAS presentation and the one death in the non-MAS patient occurred

9 years after SLE diagnosis due to a malignancy (Table 4).

DISCUSSION

MAS is an increasingly recognized, life-threatening complication of SLE, however

the natural history of MAS among patients with cSLE is unknown. In our population of over

400 cSLE patients, those who developed MAS were most likely to be diagnosed with MAS

concomitantly with cSLE, and did not experience relapses of MAS in follow-up. We

observed higher rates of lymphopenia, thrombocytopenia and positive anti-dsDNA antibodies

among those with MAS compared to those without MAS. There were no differences in the

frequency of other SLE clinical features nor in rates of disease damage at last follow-up.

Although our mortality numbers were small, we observed a higher mortality rate among those

with MAS compared to those without MAS, where deaths in the MAS group occurred in the

acute period of MAS disease.

Although the first case of MAS secondary to SLE was reported in 1984, it was not

until a 1991 report of 6 cases, that MAS was recognized as a complication of SLE 24,25. A

systematic review in 2014 found 133 cases of MAS secondary to aSLE reported in the

literature, making it the most common cause of MAS in adults with rheumatic diseases 5.

There has not been a similar review of MAS in pediatric rheumatology, however, most large

This article is protected by copyright. All rights reserved.

 series report that MAS is more common in patients with sJIA than with cSLE 8,26. The

prevalence of MAS in our cSLE cohort at 9% is approximately double the prevalence (4%)
Accepted Article
reported in reviews and large series examining MAS prevalence in aSLE 5,26,27. This

difference in prevalence may reflect diagnostic bias or a true difference in risk of MAS

between cSLE and aSLE.

The initial case series suggested that MAS usually occurred at the time of diagnosis of

aSLE 24, however subsequent reports in aSLE found that MAS frequently occurred at the time

of disease flare as well 28,29. We found that MAS was most likely to develop concomitantly or

within one month of SLE diagnosis which is consistent with the other cSLE series to report

on the timing of MAS relative to SLE diagnosis 3,14. Of note, one patient in our cohort

developed MAS 3 years prior to cSLE diagnosis and one of the patients who died had SLE

recognized only after death. SLE should be considered in the differential diagnosis of all

patients who present with features of MAS even in the absence of clinical findings suggestive

of SLE.

Fever was the only clinical MAS feature present in all MAS patients in our cohort, as

observed in prior studies of both aSLE and cSLE patients 3,7,9. Other clinical features were

much less frequently found in our MAS cohort, with generalized lymphadenopathy found in

24%, and CNS dysfunction and hepatomegaly were each found in 18% of the patients. In

contrast, others have reported higher frequencies of lymphadenopathy, hepatomegaly and

CNS dysfunction in the range of 40% to 50% 3,7,9. The most common laboratory features in

our MAS cohort were elevated AST, LDH and ferritin levels as well as leucopenia with rates

similar to previous studies 3,7.

This article is protected by copyright. All rights reserved.

 We observed that only one third of the MAS patients who underwent a bone marrow

aspirate/biopsy had evidence of hemophagocytosis. This rate is lower than rates in other
Accepted Article
series of adult patients, however, many of those adult series required the presence of

hemophagocytosis on bone marrow aspirate/biopsy or lymph node/liver biopsy to make the

diagnosis of MAS 1,27,30. We also compared the MAS clinical and laboratory features between

those with and without hemophagocytosis among those who underwent BMA (n=25), and

found no significant differences between the groups (data not shown). We suggest that the

absence of increased hemophagocytosis on bone marrow examination should not delay the

diagnosis of MAS and initiation of therapy, however, bone marrow examination may be

required to rule out other processes such as malignancy or infections (e.g. Leishmaniasis).

Although MAS has been reported to recur in patients with sJIA; recurrence rates are

rarely reported in cSLE. None of the patients in our cohort experienced a recurrence of MAS

during a mean follow-up of 3.5 years. Similarly, other reports in cSLE did not observe

recurrence of MAS (follow-up times not specified) 1,14. In contrast, 2 studies of aSLE have

reported MAS recurrence in 3/12 after mean of 7.1 years of follow-up, and in 4/14 aSLE

patients (follow-up time not specified) 1,30. Therefore although the numbers are small,

recurrence of MAS has not been reported in cSLE but may occur in up to 25% of cases in

aSLE 1,14,30,31.

We observed a mortality rate of 5% among those with MAS, which is lower than the

mortality rate reported in most MAS studies in cSLE and aSLE (up to 22%) 1,3,7,8,14,27,29. In our

cohort, 7 MAS patients had CNS manifestations attributed to MAS. Of those, 2 (3%) patients

died with severe CNS involvement and multi-organ failure (one patient also had concomitant

disseminated tuberculosis infection). In keeping with our findings, a previous study of 19

This article is protected by copyright. All rights reserved.

 cSLE patients with MAS suggested that CNS involvement was also associated with a higher

mortality rate with multiple organ failure or sepsis frequently as the terminal event 8.
Accepted Article
We did not find any significant differences in SLE manifestations between the MAS

and non-MAS groups at presentation nor within the first year of lupus diagnosis (data not

shown).. An earlier study of 38 cSLE patients with MAS, observed a higher frequency of

major organ involvement (lupus nephritis and CNS involvement), hematologic involvement,

arthritis, serositis and oral/nasal ulcers at the time of lupus diagnosis when compared to non-

MAS patients (n=387). 3. These differences between studies, may reflect differences in the

cSLE cohorts or applied MAS definitions. However, both our study and the Parodi cohort

reported higher rates of hematologic involvement in the MAS as compared with the non-

MAS cohort which may be the result of cytopenias secondary to MAS itself.

Following the acute illness which was associated with 2 deaths secondary to MAS, we

did not find any significant differences in the number of deaths or damage accrual between

the cohorts including overall SLICC damage score or any specific damage feature within the

score. MAS is a life-threatening complication of cSLE and it should be considered an

important cause of mortality in cSLE. However if the initial presentation does not result in

death, the long-term outcome seemed to be comparable to those without MAS, and treatment-

related damage was not increased in our MAS cohort.

We acknowledge some limitations of our study. There is currently a lack of validated

criteria for MAS in SLE. Hence, we identified those patients with MAS based on pediatric

rheumatologist expert opinion. However, the diagnosis of MAS was validated by consensus

of all the contributing authors. It is therefore possible but unlikely that we missed any cases.

Although all clinical and laboratory data were prospectively collected and entered into our

database, we retrospectively reviewed the completeness of data collection with respect to

This article is protected by copyright. All rights reserved.

 MAS features. Hence, some laboratory data were missing at the time of MAS diagnosis.

Although our follow-up extended a mean of 3.5 years, we were unable to obtain data on most
Accepted Article
patients beyond 18 years of age, into adulthood.

Macrophage activation syndrome is a potentially fatal complication of pediatric

rheumatic diseases. We observed that in our cSLE cohort, unlike aSLE, MAS was most

frequently seen at the time of cSLE diagnosis and did not recur in follow-up. We have

demonstrated for the first time that the lupus disease course and outcome did not differ

between cSLE patients complicated with MAS compared to those without MAS. Although a

bone marrow examination is frequently warranted in the setting of the MAS presentation, in

particular to rule-out other disease processes, absence of significant hemophagocytosis on

bone marrow examination is frequent. The clinical presentation with persistent fever,

leucopenia (usually associated with a decrease of a second lineage), elevated ferritin levels

and liver enzymes, should raise the suspicion of MAS in those with cSLE.

REFERENCES

1. Lambotte O, Khellaf M, Harmouche H, et al. Characteristics and long-term outcome

of 15 episodes of systemic lupus erythematosus-associated hemophagocytic syndrome.
Medicine 2006;85:169-82.
2. Larroche C, Mouthon L. Pathogenesis of hemophagocytic syndrome (HPS).
Autoimmunity reviews 2004;3:69-75.
3. Parodi A, Davi S, Pringe AB, et al. Macrophage activation syndrome in juvenile
systemic lupus erythematosus: a multinational multicenter study of thirty-eight patients.
Arthritis and rheumatism 2009;60:3388-99.
4. Grom AA, Mellins ED. Macrophage activation syndrome: advances towards
understanding pathogenesis. Current opinion in rheumatology 2010;22:561-6.
5. Ramos-Casals M, Brito-Zeron P, Lopez-Guillermo A, Khamashta MA, Bosch X.
Adult haemophagocytic syndrome. Lancet 2014;383:1503-16.
6. Silverman ED, Miller JJ, 3rd, Bernstein B, Shafai T. Consumption coagulopathy
associated with systemic juvenile rheumatoid arthritis. The Journal of pediatrics
1983;103:872-6.
7. Kumakura S, Murakawa Y. Clinical characteristics and treatment outcomes of
autoimmune-associated hemophagocytic syndrome in adults. Arthritis & rheumatology
2014;66:2297-307.

This article is protected by copyright. All rights reserved.

 8. Bennett TD, Fluchel M, Hersh AO, et al. Macrophage activation syndrome in children
with systemic lupus erythematosus and children with juvenile idiopathic arthritis. Arthritis
and rheumatism 2012;64:4135-42.
9. Gormezano NW, Otsuzi CI, Barros DL, et al. Macrophage activation syndrome: A
Accepted Article
severe and frequent manifestation of acute pancreatitis in 362 childhood-onset compared to
1830 adult-onset systemic lupus erythematosus patients. Seminars in arthritis and rheumatism
2016;45:706-10.
10. Lin CI, Yu HH, Lee JH, et al. Clinical analysis of macrophage activation syndrome in
pediatric patients with autoimmune diseases. Clinical rheumatology 2012;31:1223-30.
11. Stephan JL, Kone-Paut I, Galambrun C, Mouy R, Bader-Meunier B, Prieur AM.
Reactive haemophagocytic syndrome in children with inflammatory disorders. A
retrospective study of 24 patients. Rheumatology 2001;40:1285-92.
12. Stabile A, Bertoni B, Ansuini V, La Torraca I, Salli A, Rigante D. The clinical
spectrum and treatment options of macrophage activation syndrome in the pediatric age.
European review for medical and pharmacological sciences 2006;10:53-9.
13. Sawhney S, Woo P, Murray KJ. Macrophage activation syndrome: a potentially fatal
complication of rheumatic disorders. Archives of disease in childhood 2001;85:421-6.
14. Pringe A, Trail L, Ruperto N, et al. Macrophage activation syndrome in juvenile
systemic lupus erythematosus: an under-recognized complication? Lupus 2007;16:587-92.
15. Petri M, Orbai AM, Alarcon GS, et al. Derivation and validation of the Systemic
Lupus International Collaborating Clinics classification criteria for systemic lupus
erythematosus. Arthritis and rheumatism 2012;64:2677-86.
16. Tan EM, Cohen AS, Fries JF, et al. The 1982 revised criteria for the classification of
systemic lupus erythematosus. Arthritis and rheumatism 1982;25:1271-7.
17. Henter JI, Horne A, Arico M, et al. HLH-2004: Diagnostic and therapeutic guidelines
for hemophagocytic lymphohistiocytosis. Pediatric blood & cancer 2007;48:124-31.
18. Stepp SE, Dufourcq-Lagelouse R, Le Deist F, et al. Perforin gene defects in familial
hemophagocytic lymphohistiocytosis. Science 1999;286:1957-9.
19. Yamamoto K, Ishii E, Horiuchi H, et al. Mutations of syntaxin 11 and SNAP23 genes
as causes of familial hemophagocytic lymphohistiocytosis were not found in Japanese people.
Journal of human genetics 2005;50:600-3.
20. Weening JJ, D'Agati VD, Schwartz MM, et al. The classification of
glomerulonephritis in systemic lupus erythematosus revisited. Journal of the American
Society of Nephrology : JASN 2004;15:241-50.
21. The American College of Rheumatology nomenclature and case definitions for
neuropsychiatric lupus syndromes. Arthritis and rheumatism 1999;42:599-608.
22. Brunner HI, Silverman ED, To T, Bombardier C, Feldman BM. Risk factors for
damage in childhood-onset systemic lupus erythematosus: cumulative disease activity and
medication use predict disease damage. Arthritis and rheumatism 2002;46:436-44.
23. Gladman D, Ginzler E, Goldsmith C, et al. The development and initial validation of
the Systemic Lupus International Collaborating Clinics/American College of Rheumatology
damage index for systemic lupus erythematosus. Arthritis and rheumatism 1996;39:363-9.
24. Wong KF, Hui PK, Chan JK, Chan YW, Ha SY. The acute lupus hemophagocytic
syndrome. Annals of internal medicine 1991;114:387-90.
25. Sakurai T, Kono I, Kabashima T, Yamane K, Nagasawa T, Kashiwagi H.
Amegakaryocytic thrombocytopenia associated with systemic lupus erythematosus
successfully treated by a high-dose prednisolone therapy. Japanese journal of medicine
1984;23:135-8.

This article is protected by copyright. All rights reserved.

 26. Atteritano M, David A, Bagnato G, et al. Haemophagocytic syndrome in rheumatic
patients. A systematic review. European review for medical and pharmacological sciences
2012;16:1414-24.
27. Fukaya S, Yasuda S, Hashimoto T, et al. Clinical features of haemophagocytic
Accepted Article
syndrome in patients with systemic autoimmune diseases: analysis of 30 cases.
Rheumatology 2008;47:1686-91.
28. Papo T, Andre MH, Amoura Z, et al. The spectrum of reactive hemophagocytic
syndrome in systemic lupus erythematosus. The Journal of rheumatology 1999;26:927-30.
29. Kim JM, Kwok SK, Ju JH, Kim HY, Park SH. Reactive hemophagocytic syndrome in
adult Korean patients with systemic lupus erythematosus: a case-control study and literature
review. The Journal of rheumatology 2012;39:86-93.
30. Dhote R, Simon J, Papo T, et al. Reactive hemophagocytic syndrome in adult
systemic disease: report of twenty-six cases and literature review. Arthritis and rheumatism
2003;49:633-9.
31. Arnez MA, de Azevedo MN, Bica BE. Reactive haemophagocytic syndrome in a
systemic lupus erythematosus patient: case report. Revista brasileira de reumatologia
2012;52:790-5.
32. Hiraki LT, Benseler SM, Tyrrell PN, Hebert D, Harvey E, Silverman ED. Clinical and
laboratory characteristics and long-term outcome of pediatric systemic lupus erythematosus:
a longitudinal study. The Journal of pediatrics 2008;152:550-6.

This article is protected by copyright. All rights reserved.

 TABLES

Table 1. Frequency of clinical and laboratory MAS features and treatment

Accepted Article
Clinical features 1 (n = 38) Number (%)
Fever 1,2 38 (100)
Generalized lymphadenopathy 9 (24)
CNS dysfunction 1,3 7 (18)
Hepatomegaly 1 7 (18)
Hemorrhage 1,4 5 (13)
Splenomegaly 1 4 (10)
Abnormal
Median Number5
Laboratory features 5,6,7 (n when <38) SickKids
(IQR)7 (%)
reference values

<140 (boys)
Hemoglobin, g/L 94 (84-107) 37 (97)
<120 (girls)
9
White blood cell count cells x 10 /L 2.15 (1.6-2.9) <4 34 (89)
Neutrophil count, cells x 109/L 1.1 (0.7-1.7) <2 32 (84)
Platelet count, cells x 109/L 140 (107-166) < 150 23 (60)
Aspartate aminotransferase (AST),
123 (73-247) >31 37 (97)
units/L6
Lactate dehydrogenase (LDH), IU/L 6 2186 (1189-
>580 35 (97)
(n=36) 3092)
Alanine aminotransferase (ALT), units/L 83 (50-137) >40 33 (87)
Partial thromboplastin time (PTT), sec
35 (31-45) > 36 18 (54)
(n=33)
D-Dimer, ng/mL (n=35) 240 (4.7-1346) > 0.51 17 (48)
Fibrinogen, g/L (n=35) 2.8 (2.1-3.4) < 1.9 6 (2)
Erythrocyte sedimentation rate (ESR),
64 (32-103) >10 37 (97)
mm/hour
C-reactive protein (CRP), mg/L (n=24) 18.4 (1.9-48.5) > 1.0 21 (87)
2453 (1072-
Ferritin, µg/L 6 (n=36) >78.8 36 (100)
5516)
Triglycerides, mmol/L 6 (n=35) 2.4 (1.9-3.4) > 1.3 19 (54)
Sodium, mmol/L (n=37) 135 (134-139) < 135 15 (40)
Bone marrow aspirate/biopsy (n = 25) Number (%)
Hemophagocytosis 8 (32)
MAS Medication (n=38) Number (%)
Intravenous methylprednisolone 26 (68)
Intravenous Immunoglobulin (IVIG) 22 (58)
Calcineurin inhibitor 8 13 (34)

This article is protected by copyright. All rights reserved.

 Prednisone (oral) alone 7 (18)
Dexamethasone (oral or intravenous) 6 (16)
alone or in combination with other meds
Accepted Article
Etoposide 5 (13)
Anakinra 2 (5)
Intrathecal methotrexate 1 (3)
Alemtuzumab 1 (3)

1) Clinical MAS features at the time of MAS diagnosis. Fever, CNS dysfunction,
hepatomegaly, hemorrhage, and splenomegaly are also MAS clinical features proposed by
Parodi et al.3.
2) Temperature over 38 degrees Celsius (° C) (rectal), 37.7° C (oral) or 37.5° C (axillary or
otic).
3) Central nervous system (CNS) dysfunction: irritability, disorientation, lethargy, headache,
seizures or coma (excluding metabolic, infectious or drug causes).
4) Hemorrhage is defined at least one of the following: pulmonary hemorrhage, cerebral
hemorrhage, hematochezia, epistaxis and gum bleeding with heavy menstruation.
5) Proportion of MAS patients with abnormal SickKids laboratory reference values prior to
initiation of MAS treatment.
6) Proportion of MAS patients who met the MAS laboratory criteria proposed by Parodi et
al.3 at the time of MAS diagnosis and prior to MAS treatment. AST > 40 units/L: 37 (97%),
9
LDH > 567 IU/L: 35 (92%), white blood cell count 4.0 x 10 /L: 34 (94%), ferritin > 500
µg/L: 32 (88%), triglycerides > 2 mmol/L (or > 178 mg/dl): 25 (66%), platelet count 150
cells x 109/L: 23 (60%), hemoglobin 9 g/L: 14 (37%), fibrinogen 1.5 g/L: 3 (8%) MAS
patients.
7) The most abnormal laboratory value at MAS presentation and prior to MAS treatment are
shown in this table.
8) Tacrolimus (2 patients) or cyclosporine A (11 patients) for MAS treatment.

This article is protected by copyright. All rights reserved.

 Table 2. Demographics, clinical and laboratory cSLE features of MAS and non-MAS
patients during follow-up
Accepted Article
MAS non-MAS
Number (%) Number (%)
Demographics p- value
n = 38 n = 365
Female 30 (79) 302 (83) 0.51
Mean age at SLE diagnosis in years
13.7 (2.8) 13.2 (3.2) 0.35
(standard deviation)
Mean duration follow-up in years
3.5 (1.6) 4 (2.4) 0.21
(standard deviation)
SLE clinical features
Malar rash 25 (66) 288 (79) 0.10
Oral or nasal ulcers 15 (39) 131 (36) 0.72
Arthritis 22 (58) 258 (70) 0.14
Serositis 1 9 (24) 48 (13) 0.09
Myositis 1 (3) 17 (5) 1.00
Headaches 9 (24) 81 (22) 0.52
Lupus nephritis 18 (47) 115 (31) 0.07
Mesangial 3 (17) 6 (5) 0.042
Proliferative lupus nephritis 11 (61) 66 (57) 0.80
Membranous lupus nephritis 3 (17) 25 (22) 0.76
Mixed proliferative/membranous
1 (5) 18 (16) 0.47
lupus nephritis
CNS involvement 10 (26) 85 (23) 0.68
Psychosis 4 (40) 43 (50) 0.74
Cognitive dysfunction 4 (40) 32 (37) 1.00
Acute confusional state 2 (20) 10 (12) 0.60
SLE laboratory features
Hematologic involvement 34 (89) 282 (77) 0.09
Thrombocytopenia 19 (55) 95 (33) 0.0042
Lymphopenia 29 (85) 173 (61) 0.0012
Coombs positive hemolytic
17 (50) 96 (34) 0.022
anemia
Specific autoantibodies
Anti-dsDNA 33 (87) 202 (55) 0.00012
Anti-Sm 17 (45) 99 (27) 0.042
Anti-RNP 17 (45) 137 (37) 0.39
Anti-Ro 18 (47) 138 (38) 0.29
Anti-La 6 (16) 54 (15) 0.81
Lupus anticoagulant 3 (8) 43 (12) 0.60
Anti-cardiolipin 17 (45) 127 (35) 0.29

This article is protected by copyright. All rights reserved.

 1) Pericarditis and/or pleuritis.
2) Bonferroni corrected p-value for significance < 0.005 (corrected for number
of ACR SLE criteria) and < 0.007 (corrected for specific autoantibodies).
Accepted Article
Table 3. Immunosuppressive medication use for cSLE during disease follow-up
MAS non-MAS
Medication use for cSLE Number (%) Number (%)
1 p-value
treatment n = 38 n = 2971
Mycophenolate mofetil or
19 (50) 117 (39) 0.22
Mycophenolate sodium
Azathioprine 11 (29) 148 (49) 0.012
Intravenous cyclophosphamide 11 (29) 65 (22) 0.31
Methotrexate 3 (8) 49 (16) 0.23
3
Calcineurin inhibitor 3 (8) 21 (7) 0.74
4
IVIG 1 (3) 25 (8) 0.33
Rituximab 0 28 (9) 0.06

1) All MAS patients received either corticosteroids or other immunosuppressive drugs during
follow-up. 68/365 (18%) non-MAS patients did not receive any immunosuppressive drugs
(including corticosteroids) during follow-up.
2) p-value < 0.007 following Bonferroni correction for multiple medication.
3) Tacrolimus or cyclosporine use for cSLE treatment only (excluding use for MAS
treatment).
4) IVIG: Intravenous immunoglobulin excluding use for MAS treatment only.

Table 4. cSLE-related outcomes in MAS and non-MAS patients

MAS non-MAS
Number (%) Number (%)
p-value
n = 38 n = 365
Deaths 2 (5) 1 1 (0.3) 2 0.02
3
SLICC ≥ 1 at last visit 7 (18) 58 (16) 0.64
Cataract 6 (16) 27 (7) 0.1
Avascular necrosis 2 (5) 15 (4) 0.66
Cognitive impairment 1 (3) 10 (3) 1.0
4
Osteoporosis 0 10 (3) 0.60
2
Malignancy 0 1 (0.3) 1.0
1) Both deaths occurred during acute phase of MAS.
2) Death occurred 9 years later of secondary T –cell lymphoblastic leukemia following
glioblastoma diagnosed 5 years after SLE diagnosis.
3) Data on damage available in 353/365 non-MAS patients only.
4) Osteoporosis defined as bone density Z score less than or equal to −2 SD, adjusted for age,
gender, and bone age, as appropriate, in combination with a fracture or vertebral collapse.

This article is protected by copyright. All rights reserved.

 Figure 1. Age at cSLE diagnosis in MAS (n=38) and non-MAS (n=365) patients
Figure 1 Legend:
The x-axis shows age in years at cSLE diagnosis and the y-axis the proportion of patients
diagnosed at each age category, as a percentage of the total MAS (light grey) and non-MAS
Accepted Article
(dark grey) cohorts.

Figure 2. Kaplan-Meier damage-free survival comparing non-MAS and MAS patients

Figure 2 Legend:
The x-axis shows time in years and the y-axis the probability of damage free survival
comparing non-MAS cSLE patients (hatched line) and MAS cSLE patients (solid line) (p-
value = 0.3). Then number of patients at risk each year is reported below the x-axis.

This article is protected by copyright. All rights reserved.

Accepted Article

This article is protected by copyright. All rights reserved.