CLINICAL AND VACCINE IMMUNOLOGY, Apr. 2011, p. 609–614
Copyright © 2011, American Society for Microbiology. All Rights Reserved.
Vol. 18, No. 4
Serum Neopterin Levels as a Diagnostic Marker of Hemophagocytic
Maria F. Ibarra,1,2Marisa Klein-Gitelman,1,2Elaine Morgan,2,3Maria Proytcheva,2,4Christine Sullivan,5†
Gabrielle Morgan,6Lauren M. Pachman,1,2,6and Maurice R. G. O’Gorman2,7*
Division of Rheumatology, Children’s Memorial Hospital, Chicago, Illinois1; Department of Pediatrics, Feinberg School of Medicine,
Northwestern University, Chicago, Illinois2; Division of Hematology, Oncology and Stem Cell Transplant, Children’s Memorial Hospital,
Chicago, Illinois3; Hematology Laboratories, Children’s Memorial Hospital, Chicago, Illinois4; The Mary Ann and
J. Milburn Smith Child Health Research Program, Children’s Memorial Research Center, Chicago, Illinois5;
Clinical Immunology, Children’s Memorial Research Center, Chicago, Illinois6; and Pathology and
Laboratory Medicine, Children’s Memorial Hospital, Chicago, Illinois7
Received 29 July 2010/Returned for modification 12 September 2010/Accepted 13 January 2011
The objective of this study was to retrospectively evaluate the utility of serum neopterin as a diagnostic
marker of hemophagocytic lymphohistiocytosis (HLH). The medical records of patients diagnosed with HLH
(familial and secondary) between January 2000 and May 2009 were reviewed retrospectively, and clinical and
laboratory information related to HLH criteria, in addition to neopterin levels, was recorded. A group of 50
patients with active juvenile dermatomyositis (JDM) (who routinely have neopterin levels assessed) served as
controls for the assessment of the accuracy, sensitivity, and specificity of neopterin as a diagnostic test for
HLH. The Pearson correlation was used to measure the association between serum neopterin levels and
established HLH-related laboratory data. Serum neopterin levels were measured using a competitive enzyme
immunoassay. During the time frame of the study, 3 patients with familial HLH and 18 patients with secondary
HLH were identified as having had serum neopterin measured (all HLH patients were grouped together). The
mean neopterin levels were 84.9 nmol/liter (standard deviation [SD], 83.4 nmol/liter) for patients with HLH
and 21.5 nmol/liter (SD, 10.13 nmol/liter) for patients with JDM. A cutoff value of 38.9 nmol/liter was 70%
sensitive and 95% specific for HLH. For HLH patients, neopterin levels correlated significantly with ferritin
levels (r ? 0.76, P ? 0.0007). In comparison to the level in a control group of JDM patients, elevated serum
neopterin was a sensitive and specific marker for HLH. Serum neopterin has value as a diagnostic marker of
HLH, and prospective studies are under way to further evaluate its role as a marker for early diagnosis and
management of patients.
Hemophagocytic lymphohistiocytosis syndrome (HLH) is a
rare clinical condition characterized by prolonged fevers in
association with hepatosplenomegaly, cytopenias, coagulopa-
thy, and central nervous system (CNS) manifestations. HLH
results from a pathological activation of macrophages leading
to hyperproduction of cytokines, such as gamma interferon
(IFN-?) and tumor necrosis factor alpha (TNF-?) (9), that is
believed to be the cause of many of the clinical symptoms.
HLH is currently classified into a familial form, affecting pri-
marily infants and young children, and a secondary form, which
usually occurs in older children. The secondary form of HLH
is associated with autoimmune disorders, infections, and ma-
lignancies. Macrophage activation syndrome (MAS) is a term
that has been used by rheumatologists and refers to the sec-
ondary form of HLH seen in the context of rheumatic disor-
ders (13). Familial HLH is an invariably fatal disease curable
only with bone marrow transplant. MAS or the secondary form
of HLH also has a relatively high mortality rate (8 to 22%)
even if treated appropriately (16).
The current diagnostic and therapeutic guidelines were
line Protocol (HLH-2004) (8). These diagnostic criteria, sum-
marized in Table 1, do not distinguish between familial or
secondary HLH. The diagnosis requires that five of the follow-
ing eight criteria are met: fever, splenomegaly, cytopenias,
hypertriglyceridemia and/or hypofibrinogenemia, hemophago-
cytosis in bone marrow, spleen, or lymph nodes with no evi-
dence of malignancy, low or absent natural killer (NK) cell
activity, hyperferritinemia, and elevated soluble CD25 (i.e.,
soluble interleukin 2 receptor alpha [sIL-2R?]) (8). Other
findings, such as liver dysfunction with elevated serum
transaminases, coagulopathy, and neurological symptoms, are
often seen in patients with HLH (2–4) but are not included in
the current HLH-2004 diagnostic guidelines (6, 8).
Familial HLH is inherited in an autosomal recessive pattern.
Three genes have been found to underlie more than 50% of
the familial HLH cases worldwide: PRF1, encoding perforin, a
major cytotoxic protein; UNC13D, encoding the MUNC 13-4
protein, which is involved in the exocytosis of perforin-bearing
cytotoxic granules; and STX11, encoding the protein t-SNARE
syntaxin 11 involved in vesicular transport (6, 12). HLH has
been associated with other autosomal recessive immunodefi-
ciencies, including Chediak-Higashi syndrome caused by mu-
* Corresponding author. Mailing address: Children’s Memorial
Hospital, Diagnostic Immunology Laboratory, 2300 Children’s Plaza,
Box 50b, Chicago, IL 60614. Phone: (773) 880-3070. Fax: (773) 880-
4687. E-mail: email@example.com.
† Present address: Healthcare Analytics, CVS Caremark, North-
?Published ahead of print on 26 January 2011.
2. Bohan, A., and J. B. Peter. 1975. Polymyositis and dermatomyositis. N. Engl.
J. Med. 292:344–403.
3. Castillo, L., and J. Carcillo. 2009. Secondary hemophagocytic lymphohistio-
cytosis and severe sepsis/systemic inflammatory response syndrome/multior-
gan dysfunction syndrome/macrophage activation syndrome share common
intermediate phenotypes on a spectrum of inflammation. Pediatr. Crit. Care
4. De Benedetti, F., M. De Amici, L. Aramini, N. Ruperto, and A. Martini. 1993.
Correlation of serum neopterin concentrations with disease activity in juve-
nile dermatomyositis. Arch. Dis. Child. 2:232–235.
5. Enders, A., et al. 2006. Lethal hemophagocytic lymphohistiocytosis in Her-
mansky-Pudlak syndrome type II. Blood 108:81–87.
6. Filipovich, A. H. 2006. Hemophagocytic lymphohistiocytosis and related
disorders. Curr. Opin. Allergy Clin. Immunol. 6:410–415.
7. Gulcan, E. M., I. Tirit, A. Anil, E. Adal, and G. Ozbay. 2008. Serum neop-
terin levels in children with hepatitis-B-related chronic liver disease and its
relationship to disease severity. World J. Gastroenterol. 14(44):6840–6843.
8. Henter, J.-I., et al. 2007. HLH-2004: diagnostic and therapeutic guide-
lines for hemophagocytic lymphohistiocytosis. Pediatr. Blood Cancer
9. Humber, C., et al. 1984. Immune response-associated production of neop-
terin. Release from macrophages primarily under control of interferon-
gamma. J. Exp. Med. 160:310–316.
10. Imashuku, S., et al. 2002. Low natural killer activity and central nervous
system disease as a high-risk prognostic indicator for young patients with
hemophagocytic lymphohistiocytosis (HLH). Cancer 94:3023–3031.
11. Imashuku, S., et al. 2001. Requirement for etoposide in the treatment of
Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis. J. Clin.
12. Janka, G. E. 2007. Familial and acquired hemophagocytic lymphohystiocy-
tosis. Eur. J. Pediat. 166:95–109.
13. Kelly, A., and A. V. Ramanan. 2007. Recognition and management of mac-
rophage activation syndrome in juvenile arthritis. Curr. Opin. Rheumatol.
14. Mildvan, D., et al. 2005. Serum neopterin, an immune activation marker,
independently predicts disease progression in advanced HIV-1 infection.
Clin. Infect. Dis. 40:476–479.
15. Prat, C., et al. 2008. Evaluation of procalcitonin, neopterin, C-reactive pro-
tein, IL-6 and IL-8 as a diagnostic marker of infection in patients with febrile
neutropenia. Leuk. Lymphoma 49:1752–1761.
16. Sawhney, S., P. Woo, and K. J. Murray. 2001. Macrophage activation syn-
drome: a potentially fatal complication of rheumatic disorders. Arch. Dis.
17. Shimizu, M., et al. 14 May 2010, posting date. Distinct cytokine profiles of
systemic-onset juvenile idiopathic arthritis-associated macrophage activation
syndrome with particular emphasis on the role of interleukin-18 in its patho-
genesis. Rheumatology. doi:10.1093/rheumatology/keq133.
18. Sucher, R., et al. 2010. Neopterin, a prognostic marker in human malignan-
cies. Cancer Lett. 287:13–22.
19. Sumegi, J., J. Johnson, A. Filipovich, K. Zhan, and R. Marsh. 27 February
2004, posting date. Lymphoproliferative disease, X-linked. GeneReviews.
20. Tatzber, F., et al. 1991. Elevated serum neopterin levels in atherosclerosis.
614IBARRA ET AL.CLIN. VACCINE IMMUNOL.