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Patient (2 year old fetus) presents after 3 weeks of fever and weight loss and exhibits pallor, hepatomegaly, splenomegaly, and pancytopenia (low WBC, RBC, and platelets) These findings are consistent with hemophagocytic lymphohistiocytosis (HLH), which is confirmed by the bone marrow aspiration, demonstrating hemophagocytes. Hemophagocytes are macrophages that have engulfed red blood cells (RBCs) and lymphocytes. HLH involves the abnormal activation and proliferation of lymphohistiocytes, leading to hemophagocytosis and the upregulation of proinflammatory cytokines. The immune system becomes overstimulated and can begin attacking native cells in the bone marrow.

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