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Yui JC, Brodsky RA. Updates in the Management of Warm Autoimmune Hemolytic Anemia. Hematol Oncol Clin North Am 2022; 36:325-339. [DOI: 10.1016/j.hoc.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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52
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Denny N, Gordon E, Atoyebi O. DAT negative warm autoimmune haemolytic anaemia secondary to a mature cystic teratoma refractory to immunosuppressive therapy. BMJ Case Rep 2022; 15:e243017. [PMID: 35232728 PMCID: PMC8889156 DOI: 10.1136/bcr-2021-243017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 11/04/2022] Open
Abstract
Mature cystic teratomas (MCTs) have a rare but recognised association with IgG-mediated autoimmune haemolytic anaemia (AIHA). We present the first case of an MCT associated with IgA-mediated AIHA. We discuss the diagnostic challenges of patients presenting with a direct antiglobulin test negative AIHA picture and the importance of reviewing these cases with the local transfusion laboratory. We also review the treatment options for MCT associated AIHA. In particular, we note they are typically resistant to immunosuppression and that surgical resection should be considered at an early stage. Although MCTs are a rare cause of AIHA, they can be treated easily and should be excluded in young women presenting with AIHA, especially if resistant to corticosteroids.
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Affiliation(s)
- Nicholas Denny
- Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Elizabeth Gordon
- Haematology, Oxford University Hospitals NHS Foundation Trust, Banbury, UK
| | - Oyewale Atoyebi
- Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Yao M, Zhang J, Li Y, Lv L, Jia L, Yang C, Huang Y, Liu H, Wang J, Chen M, Zhang H. Combination of low-dose rituximab, bortezomib and dexamethasone for the treatment of autoimmune hemolytic anemia. Medicine (Baltimore) 2022; 101:e28679. [PMID: 35089216 PMCID: PMC8797600 DOI: 10.1097/md.0000000000028679] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 12/31/2021] [Indexed: 01/05/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) therapy may be associated with severe complications such as diabetes, hypertension, obesity, osteoporosis, peptic ulcers, infection, and some other diseases. To reduce those effects, we used low-dose rituximab, bortezomib and dexamethasone (LowR-BD regimen) to treat AIHA. The purpose of this study was to evaluate the efficacy and safety of this regimen.Seven patients with warm AIHA (wAIHA) admitted from March 2020 to October 2020 were treated with LowR-BD regimen: Rituximab 100 mg by intravenous infusion on day 1 combined with bortezomib 1.3 mg/m2 by subcutaneous injection on day 2 plus dexamethasone 20 mg by intravenous infusion on days 2, 3. Clinical efficacy and safety were assessed at the regular reexamination of relevant indicators and follow-up.After 4 cycles of the LowR-BD regimen, the overall response rate (ORR) was 85.71% with a complete response (CR) of 28.57% and a partial response (PR) of 57.14%. After a median follow-up of 12 (range 7-13) months, 5 patients achieved CR and 2 patients had PR status, including 1 patient who did not respond to LowR-BD treatment and reached CR after using methylprednisolone combined with cyclophosphamide. One patient relapsed and achieved PR after retreatment of 2 cycles LowR-BD regimen. The patients tolerated the treatment well and did not complain of apparently adverse reactions except a patient with Sjogren's syndrome and bronchiectasis who developed a severe infection during treatment.Low-dose rituximab combined with bortezomib and dexamethasone is effective and relatively safe in patients with wAIHA.
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Affiliation(s)
- Mingkang Yao
- Department of Clinical Medicine, Jining Medical University, Jining, Shandong Province, China
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, Shandong Province, China
- Institute of Blood and Marrow Transplantation, Jining Medical University, Jining, Shandong Province, China
| | - Jingjing Zhang
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, Shandong Province, China
- Institute of Blood and Marrow Transplantation, Jining Medical University, Jining, Shandong Province, China
| | - Ying Li
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, Shandong Province, China
- Institute of Blood and Marrow Transplantation, Jining Medical University, Jining, Shandong Province, China
| | - Linlin Lv
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, Shandong Province, China
- Institute of Blood and Marrow Transplantation, Jining Medical University, Jining, Shandong Province, China
| | - Lu Jia
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, Shandong Province, China
- Institute of Blood and Marrow Transplantation, Jining Medical University, Jining, Shandong Province, China
| | - Chunyan Yang
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, Shandong Province, China
- Institute of Blood and Marrow Transplantation, Jining Medical University, Jining, Shandong Province, China
| | - Yu Huang
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, Shandong Province, China
- Institute of Blood and Marrow Transplantation, Jining Medical University, Jining, Shandong Province, China
| | - Haihui Liu
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, Shandong Province, China
- Institute of Blood and Marrow Transplantation, Jining Medical University, Jining, Shandong Province, China
| | - Jian Wang
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, Shandong Province, China
- Institute of Blood and Marrow Transplantation, Jining Medical University, Jining, Shandong Province, China
| | - Mingtai Chen
- Institute of Blood and Marrow Transplantation, Jining Medical University, Jining, Shandong Province, China
- Medical Research Center, Affiliated Hospital of Jining Medical University, Jining, Shandong Province, China
| | - Hao Zhang
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, Shandong Province, China
- Institute of Blood and Marrow Transplantation, Jining Medical University, Jining, Shandong Province, China
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Garg M, Agarwal S, Altohami M. A single dose of eculizumab terminated life-threatening haemolysis in idiopathic IgM-mediated warm autoimmune haemolytic anaemia: A case report. Br J Haematol 2022; 197:e28-e31. [PMID: 34993954 DOI: 10.1111/bjh.18011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 12/07/2021] [Accepted: 12/08/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Mamta Garg
- Department of Haematology, University Hospitals of Leicester, Leicester, UK
| | - Siddharth Agarwal
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Mohammed Altohami
- Department of Haematology, University Hospitals of Leicester, Leicester, UK
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Li J, An X, Xu X, Xiao L, Wang Y, Zhu Y, Huang L, Zhang K, Yao X, Yi W, Qin J, Yu J. Type O blood, the MCHC, and the reticulocyte count impact the early recurrence of primary warm-antibody autoimmune hemolytic anemia in children: A retrospective cohort analysis. Front Pediatr 2022; 10:881064. [PMID: 36299697 PMCID: PMC9591122 DOI: 10.3389/fped.2022.881064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 08/10/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Primary warm-antibody autoimmune hemolytic anemia (w-AIHA) is prone to recurrence in children. In this study, we aimed to identify risk indicators for the early recurrence of primary w-AIHA and construct an effective recurrence risk assessment model. METHODS This was a retrospective cohort study. The clinical data of patients hospitalized with primary w-AIHA in the Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, between 1 January 2018 and 30 September 2021, were collected at the initial diagnosis. Univariate and multivariate logistic regression analyses were used to determine risk indicators for the early recurrence of primary w-AIHA in children, and ROC curve and Kaplan-Meier survival analyses were used for verification. Finally, a risk assessment model for early recurrence in children with primary w-AIHA was constructed using Cox regression and visualized using a nomogram. The model was also verified internally and externally. RESULTS This study included 62 children with primary w-AIHA. Of which, 18 experienced recurrence 1 year after the initial diagnosis. The univariate and multivariate logistic regression analyses showed that type O blood and the reticulocyte count (Ret) were risk indicators for the early recurrence of pediatric primary w-AIHA (P = 0.009, 0.047, respectively). The mean corpuscular hemoglobin concentration (MCHC) is a protective factor (P = 0.040). According to the ROC curve and Kaplan-Meier survival analyses, children with primary w-AIHA whose blood type was O or had an MCHC of <313.5 pg/fL or a Ret of ≥0.161×1012/L had a higher risk of early recurrence (HR = 2.640, 4.430 and 4.450, respectively, and P = 0.040, 0.015 and 0.018, respectively). The blood types (O), MCHCs, and Rets of 56 patients were incorporated into the Cox regression model, and the recurrence risk assessment model for children with primary w-AIHA was successfully constructed and visualized using a nomogram. The calibration curves and decision-curve analysis (DCA) suggested that the risk model has clinical applicability and effectiveness. CONCLUSION Children with type O blood and an MCHC value of <313.5 pg/fL or a Ret value of ≥0.161×1012/L have a higher risk of early recurrence. The risk assessment model for the early recurrence of pediatric primary w-AIHA constructed in this study has good clinical applicability and effectiveness.
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Affiliation(s)
- Jiacheng Li
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Xizhou An
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Ximing Xu
- Big Data Center for Children's Medical Care, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Li Xiao
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Big Data Center for Children's Medical Care, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Wang
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Yao Zhu
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Lan Huang
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Kainan Zhang
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Xinyuan Yao
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Weijia Yi
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Jiebin Qin
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Jie Yu
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
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The Role of a Routine Bone Marrow Biopsy in Autoimmune Hemolytic Anemia for the Detection of an Underlying Lymphoproliferative Disorder. Hemasphere 2021; 6:e674. [PMID: 34938958 PMCID: PMC8687727 DOI: 10.1097/hs9.0000000000000674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/22/2021] [Indexed: 12/02/2022] Open
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Arora S, Dua S, Radhakrishnan N, Singh S, Madan J, Nath D. Autoimmune hemolytic anemia in children: Clinical presentation and treatment outcome. Asian J Transfus Sci 2021; 15:160-165. [PMID: 34908748 PMCID: PMC8628237 DOI: 10.4103/ajts.ajts_31_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 12/06/2020] [Accepted: 01/10/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Autoimmune hemolytic anemias (AIHA) are characterized by the destruction of red cells following the production of autoantibodies directed against them. Although AIHA in children is usually self-limiting, many still succumb to the illness due to delay in the diagnosis and treatment. AIHA in children may be secondary to autoimmune diseases, drugs, or immune deficiencies. Early diagnosis and appropriate immunohematological evaluation can aid in the diagnosis and treatment. OBJECTIVE To analyze the evaluation, treatment, and outcome of AIHA in children. METHODS Prospective data of patients aged 0-18 years diagnosed with AIHA between June 2017 and May 2019 were collected. INTERVENTION Prednisolone was the first-line agent in all; second-line agents included cyclosporine and rituximab. Red cell transfusion was given in those with severe anemia with cardiac decompensation. RESULTS Eleven patients were diagnosed during the study period. Hemoglobin ranged from 1.2 to 9 g/dl. The initial presentation was severe anemia in 8 children and moderate anemia with thrombocytopenia in 3. The trigger was infection in 5. Polyspecific direct coomb's test (DCT) was positive in 10 patients. 2/10 polyspecific DCT-positive cases on further evaluation had immunoglobulin G (IgG) and C3d positivity, whereas rest 8 had only IgG. One infant was diagnosed with DCT-negative immunoglobulin A-mediated AIHA. 4/11 attained remission following the short course of prednisolone. Cyclosporine was used as the second-line agent in 2 and rituximab was used in 3. Seven children are in sustained remission and off medication. One died within 12 h of diagnosis. CONCLUSION AIHA is not an uncommon problem in children and can vary in its clinical severity. Early and correct diagnosis helps in deciding appropriate treatment.
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Affiliation(s)
- Satyam Arora
- Department of Transfusion Medicine and Blood Bank, Super Speciality Pediatric Hospital and Postgraduate Teaching Institute, Noida, Delhi NCR, India
| | - Seema Dua
- Department of Transfusion Medicine and Blood Bank, Super Speciality Pediatric Hospital and Postgraduate Teaching Institute, Noida, Delhi NCR, India
| | - Nita Radhakrishnan
- Department of Pediatric Hematology Oncology, Super Speciality Pediatric Hospital and Postgraduate Teaching Institute, Noida, Delhi NCR, India
| | - Savitri Singh
- Department of Pathology, Super Speciality Pediatric Hospital and Postgraduate Teaching Institute, Noida, Delhi NCR, India
| | - Jyotsna Madan
- Department of Pathology, Super Speciality Pediatric Hospital and Postgraduate Teaching Institute, Noida, Delhi NCR, India
| | - Devajit Nath
- Department of Pathology, Super Speciality Pediatric Hospital and Postgraduate Teaching Institute, Noida, Delhi NCR, India
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Patriquin CJ, Pavenski K. O, wind, if winter comes … will symptoms be far behind?: Exploring the seasonality (or lack thereof) and management of cold agglutinin disease. Transfusion 2021; 62:2-10. [PMID: 34893982 DOI: 10.1111/trf.16765] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 12/04/2021] [Indexed: 12/18/2022]
Affiliation(s)
- Christopher J Patriquin
- Division of Medical Oncology & Hematology, University Health Network, Toronto General Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Katerina Pavenski
- Departments of Medicine & Laboratory Medicine, St. Michael's Hospital, Toronto, Canada.,Departments of Medicine & Laboratory Medicine, University of Toronto, Toronto, Canada
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Abdallah GEM, Abbas WA, Elbeih EAS, Abdelmenam E, Mohammed Saleh MF. Systemic corticosteroids in the treatment of warm autoimmune hemolytic anemia: A clinical setting perspective. Blood Cells Mol Dis 2021; 92:102621. [PMID: 34808491 DOI: 10.1016/j.bcmd.2021.102621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/14/2021] [Accepted: 10/16/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION There are unmet answers about the effect of the different forms of corticosteroids in the treatment of the warm autoimmune hemolytic anemia (WAIHA). We aimed to describe the initial response rate and the safety profile of different regimens and forms of parenteral corticosteroids versus the solo oral prednisolone as first-line strategies for newly diagnosed adult WAIHA. METHODS We recruited 156 patients who treated with either oral prednisolone 1 mg/kg daily for 3 weeks or intravenous corticosteroids like dexamethasone 40 mg daily for 4 days, Methylprednisolone 1 g/day for 3 days, or Methylprednisolone 1 g/day for 5 days then followed by oral prednisolone 1 mg/kg/day for 3 weeks. Full clinical and laboratory evaluations were done every 3 days for 3 weeks. RESULTS The primary outcome was the rate of response at the end of the third-week post treatment. The rate of response was more in the group started the treatment intravenously (81.6% versus 41.7% and p = 0.0001). Multivariate cox regression analysis proved the predictivity of intravenous corticosteroid therapy for initial response. CONCLUSION The safety profile of the different forms and regimens of corticosteroids were comparable. Therefore, parenteral regimens can be used as a rescue treatment in severe cases of WAIHA.
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Affiliation(s)
- Ghada E M Abdallah
- Clinical Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt.
| | - Wael A Abbas
- Department of Internal Medicine, Faculty of Medicine, Assiut University Assiut, Egypt
| | - Esam A S Elbeih
- Clinical Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ehab Abdelmenam
- Clinical Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mostafa F Mohammed Saleh
- Clinical Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
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Autoimmune Hemolytic Anemia in Chronic Lymphocytic Leukemia: A Comprehensive Review. Cancers (Basel) 2021; 13:cancers13225804. [PMID: 34830959 PMCID: PMC8616265 DOI: 10.3390/cancers13225804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/06/2021] [Accepted: 11/11/2021] [Indexed: 12/19/2022] Open
Abstract
Simple Summary This review analyzes the occurrence, clinical characteristics, and prognostic impact and treatment of autoimmune hemolytic anemia (AIHA) in chronic lymphocytic leukemia (CLL). Autoimmune hemolytic anemia is observed in about 10% of CLL. Pathogenesis is multifactorial involving humoral, cellular, and innate immunity, so the different mechanisms are well described in this review which also focuses on drugs associated to CLL-AIHA and on difficulties to diagnose it. There is a comprehensive revision of the main published casistics and then of the treatments; in particular the paper analyzes the main chemo-immunotherapeutic agents used in this setting. Since the therapy depends on the presence and severity of clinical symptoms, disease status, and comorbidities, treatment is nowadays more individualized in CLL and also in CLL-AIHA. Patients not responding to corticosteroids and rituximab are treated with CLL-specific drugs as per current guidelines according to age and comorbidities and new targeted agents against BCR and BCL-2 which can be given orally and have few side effects, are very effective both in progressive CLL and in situations such as AIHA. Abstract Chronic lymphocytic leukemia (CLL) patients have a greater predisposition to develop autoimmune complications. The most common of them is autoimmune hemolytic anemia (AIHA) with a frequency of 7–10% of cases. Pathogenesis is multifactorial involving humoral, cellular, and innate immunity. CLL B-cells have damaged apoptosis, produce less immunoglobulins, and could be responsible for antigen presentation and releasing inflammatory cytokines. CLL B-cells can act similar to antigen-presenting cells activating self-reactive T helper cells and may induce T-cell subsets imbalance, favoring autoreactive B-cells which produce anti-red blood cells autoantibodies. Treatment is individualized and it depends on the presence and severity of clinical symptoms, disease status, and comorbidities. Corticosteroids are the standardized first-line treatment; second-line treatment comprises rituximab. Patients not responding to corticosteroids and rituximab should be treated with CLL-specific drugs as per current guidelines according to age and comorbidities. New targeted drugs (BTK inhibitors and anti BCL2) are recently used after or together with steroids to manage AIHA. In the case of cold agglutinin disease, rituximab is preferred, because steroids are ineffective. Management must combine supportive therapies, including vitamins; antibiotics and heparin prophylaxis are indicated in order to minimize infectious and thrombotic risk.
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William V, Rusmawatiningtyas D, Makrufardi F, Widjajanto PH. Comprehensive management of refractory autoimmune hemolytic anemia in pediatric beta-thalassemia major patient: A case report. Ann Med Surg (Lond) 2021; 70:102853. [PMID: 34691416 PMCID: PMC8519758 DOI: 10.1016/j.amsu.2021.102853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 11/08/2022] Open
Abstract
Introduction and importance: Autoimmune hemolytic anemia (AIHA) is characterized by the production of antibodies against the red blood cells (RBCs) leading to increased hemolysis. Incidence of AIHA in patients with beta-thalassemia major is 5 of 100 thalassemia patients. Case presentation A 15-year-old female patient with refractory AIHA and thalassemia was unresponsive to steroid therapy. In this report, she was treated with cyclosporine and prednisone in addition to leucodepleted packed red cell (PRC). She was successfully got remission during one-year monitoring. Clinical discussion Cyclosporine is an immunosuppressive agent that interferes with T-cells activation by inhibiting transcription of cytokines, such as interleukin 2 and interferon-ɣ. Cyclosporine and steroid have synergic effects to prevent antibody production. Nephrotoxicity is one of the most concerning effect in cyclosporine usage, but it rarely develops using doses lower than 5 mg/kgBW/day. In limited resources blood bank with ABO and Rh crossmatch only, leucodepleted PRC transfusion could be an effective way to prevent antibody formation to minor blood group. Conclusion Cyclosporine and steroid could be considered for management in refractory AIHA with thalassemia patients. Non-pharmacological therapy such as leucodepleted PRC transfusion and limited donor transfusion could be considered. Cyclosporine and steroid may be of benefit in patients with refractory AIHA and beta thalassemia major. Leukodepleted PRC transfusion showed protective effect for antibody formation. Limited donor transfusion could be beneficial in recurrent transfusion patient.
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Affiliation(s)
- Vincencius William
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
| | - Desy Rusmawatiningtyas
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
| | - Firdian Makrufardi
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
| | - Pudjo Hagung Widjajanto
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
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Wu Y, Liao L, Lin F. The diagnostic protocol for hereditary spherocytosis-2021 update. J Clin Lab Anal 2021; 35:e24034. [PMID: 34689357 PMCID: PMC8649336 DOI: 10.1002/jcla.24034] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 08/26/2021] [Accepted: 09/18/2021] [Indexed: 01/12/2023] Open
Abstract
Background Hereditary spherocytosis (HS), a commonly encountered hereditary hemolytic disease, is mostly inherited in an autosomal dominant manner. The clinical manifestations in patients with HS show obvious heterogeneity. Moreover, the sensitivity or specificity of some HS diagnostic tests are not ideal and may easily result in misdiagnosis or missed diagnosis in some patients. The objective of this study was to propose a simple and practical diagnostic protocol, which can contribute to the diagnosis of HS and its differential diagnosis with different types of hemolytic anemia such as thalassemia (THAL), autoimmune hemolytic anemia (AIHA), and glucose‐6‐phosphate dehydrogenase (G6PD) deficiency, thus, to provide an alternative simple and reliable method for better clinical diagnosis of HS. Methods Through combing our research with existing experimental technologies and studies, we propose a simple and practical protocol for HS diagnosis, which will help clinicians to improve HS diagnosis. Results Compared with the existing HS diagnostic protocols, the HS diagnostic protocol we proposed is simpler. In this new protocol, some experimental tests with ideal diagnostic efficiency are added, such as mean reticulocyte volume (MRV), mean sphered cell volume (MSCV), mean corpuscular volume (MCV), in combination with the observation of clinical manifestations, family investigation, routine tests for hemolytic anemia, genetic testing, and other screening tests. Conclusion The HS diagnostic protocol we proposed could improve the clinical practice and efficiency of HS diagnosis.
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Affiliation(s)
- Yangyang Wu
- Department of Clinical Laboratory, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lin Liao
- Department of Clinical Laboratory, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Faquan Lin
- Department of Clinical Laboratory, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Kamesaki T. Diagnostic algorithm for classification and characterization of direct antiglobulin test-negative autoimmune hemolytic anemia with 1-year clinical follow-up. Transfusion 2021; 62:205-216. [PMID: 34668206 DOI: 10.1111/trf.16709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 09/30/2021] [Accepted: 10/03/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Approximately 5%-10% of autoimmune hemolytic anemia (AIHA) cases are negative for direct antiglobulin test (DAT). We previously reported a classification system for untreated patients with DAT-negative AIHA by quantifying levels of red blood cell (RBC)-bound IgG. This study investigated the clinical utility of a novel diagnostic algorithm with a comprehensive classification system and characterized each subgroup in DAT-negative AIHA. STUDY DESIGN AND METHODS We assessed 637 patients with undiagnosed hemolytic anemia using our diagnostic algorithm and classification system, which was based on RBC-bound IgG levels and results of column method-DAT before and after washing RBCs. RESULTS Patients were diagnosed with DAT-negative AIHA with 97% sensitivity and 84% specificity when the laboratory tests were performed before treatment and classified into the following six categories: tube DAT-negative, low-affinity IgG, double DAT-negative, IgA- or IgM-positive, low-affinity IgM, and s/o non-AIHA. The first three types were major conditions and accounted for 76% of DAT-negative AIHA cases. Based on multivariate analyses of idiopathic DAT-negative AIHA (n = 71), platelet count and albumin concentration were significant factors for survival at 1-year follow-up. The low-affinity IgG group showed the highest platelet count and albumin levels, better response to steroids, and higher 1-year survival rate than those in other groups. DISCUSSION Our classification included DAT-negative, IgA-driven, and warm-IgM AIHA categories, which were atypical forms of AIHA with the severe onset and increased risk of relapse. When treating a patient with DAT-negative hemolysis, atypical AIHA should be considered and tested in reference laboratories, especially before treatment.
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Affiliation(s)
- Toyomi Kamesaki
- Division of Support in Community Medicine, Center for Community Medicine, Jichi Medical University, Tochigi, Japan
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Idalan N, Zeitz JO, Weber CN, Müller E, Giger U. Comparative study of immunohematological tests with canine blood samples submitted for a direct antiglobulin (Coombs') test. Canine Med Genet 2021; 8:10. [PMID: 34645506 PMCID: PMC8515749 DOI: 10.1186/s40575-021-00107-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 08/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A 2019 ACVIM consensus statement on diagnostics for immune-mediated hemolytic anemia (IMHA) in dogs made testing recommendations. As data on the performance of immunohematological tests was lacking, we undertook a comparative analysis. MATERIAL AND METHODS Anticoagulated blood samples from 126 dogs suspected of having IMHA submitted to a diagnostic veterinary laboratory for a routine direct antiglobulin test (DAT) and from 28 healthy control dogs were evaluated for spherocytosis and autoagglutination before and after three saline washes. Samples were also subjected to different DATs: a gel minitube and an immunochromatographic strip kit used in clinics; neutral gel column cards, microtiter plates (at 4°, 22°, and 37°C), capillary tubes, and flow cytometry used in laboratories. RESULTS Samples from healthy dogs yielded negative results with all immunodiagnostic tests. Among the 126 samples submitted for DAT 67 were positive by a DAT utilizing microtiter plates with goat anti-dog antiglobulin DAT at 22°C. Notably, DAT results were comparable and consistent across all evaluated methods regardless of antiglobulin and temperature used. DAT+ dogs were more severely anemic and more likely to have erythroid regeneration compared to DAT- dogs. Macroscopic agglutination in tubes or on slides was observed in 48 samples after 1:1 and 1:4 blood to saline dilution, but only persisted in four samples after washing. Among the DAT+ samples, 57% had agglutination, 87% had spherocytosis, and 45% had both. There was good correlation between spherocytosis and DAT results from the six DAT techniques, but the correlation with autoagglutination was only fair. Clinical follow-up was available for 42 dogs. Of the sample from 12 DAT+ dogs collected during treatment, 10 remained DAT+ when tested 1-24 weeks after initial assessment. CONCLUSIONS Based upon this comparative prospective survey, all in-clinic and laboratory DAT techniques produced similar results when performed by trained personnel and can therefore be recommended for detection of antibody-coated erythrocytes and immunohematological diagnosis. In addition, use of these tests for monitoring response of IMHA dogs to treatment might be valuable.
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Affiliation(s)
- Nadine Idalan
- Vetsuisse Faculty, University of Zürich, Winterthurerstrasse 260, 8057, Zürich, Switzerland
- Laboklin GmbH&Co.KG, Steubenstrasse 4, 97688, Bad Kissingen, Germany
| | - Johanna O Zeitz
- Laboklin GmbH&Co.KG, Steubenstrasse 4, 97688, Bad Kissingen, Germany
| | - Corinna N Weber
- Laboklin GmbH&Co.KG, Steubenstrasse 4, 97688, Bad Kissingen, Germany
| | - Elisabeth Müller
- Laboklin GmbH&Co.KG, Steubenstrasse 4, 97688, Bad Kissingen, Germany
| | - Urs Giger
- Vetsuisse Faculty, University of Zürich, Winterthurerstrasse 260, 8057, Zürich, Switzerland.
- Section of Medical Genetics, University of Pennsylvania, 3900 Delancey St, Philadelphia, PA, 19104, USA.
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MESH Headings
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/pathology
- Anemia, Hemolytic, Autoimmune/physiopathology
- Anemia, Hemolytic, Autoimmune/therapy
- Blood Transfusion
- Complement Inactivating Agents/therapeutic use
- Glucocorticoids/therapeutic use
- Hemoglobinuria, Paroxysmal/diagnosis
- Hemoglobinuria, Paroxysmal/pathology
- Hemoglobinuria, Paroxysmal/physiopathology
- Hemoglobinuria, Paroxysmal/therapy
- Humans
- Immunologic Factors/therapeutic use
- Rituximab/therapeutic use
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Affiliation(s)
- Sigbjørn Berentsen
- From the Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway (S.B.); and the Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.)
| | - Wilma Barcellini
- From the Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway (S.B.); and the Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.)
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Venkatachala RP, Sheela CN, Anandram S, Ross CR. Autoimmune Hemolytic Anaemias in Pregnancy: Experience in a Tertiary Care Hospital in South India. J Obstet Gynaecol India 2021; 71:379-385. [PMID: 34566296 DOI: 10.1007/s13224-021-01443-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 01/12/2021] [Indexed: 10/22/2022] Open
Abstract
Background Autoimmune hemolytic anaemia is very rare and there is limited data regarding their pregnancy outcomes. Hence we aimed to study the maternal and perinatal outcomes in pregnancies with autoimmune hemolytic anaemias (AIHA). Methods A retrospective descriptive study of pregnant women with AIHA, who delivered at SJMCH between January 2011 and January 2016 was carried out. Their antenatal and labour records were reviewed and demographic details noted.The primary outcome measures studied were-the prevalence of AIHA, gestational age at delivery, antepartum, intrapartum and postpartum complications, mode of delivery and requirement of transfusion of blood and blood products. The secondary outcome measures studied included neonatal outcomes such as low birth weight, intrauterine growth restriction and need for intensive care. The data is presented as descriptive statistics, including means and percentage. Results The prevalence of AIHA was (18/12,420) 0.14%. The mean gestational age at delivery was 34 weeks; 100%, 77% and 50% had antenatal, intra partum or postpartum complications, respectively. 44% had preeclampsia, 38% intrauterine growth restriction and 16% preterm labour. 83% required additional drugs for treatment of AIHA.72% had vaginal delivery; 28% had caesarean delivery; 33% were transfused antenatally and 22% postnatally; 50% of the babies were preterm and required intensive care, 66% had low birth weight. There was no maternal mortality. Conclusion Multidisciplinary approach, early diagnosis and detection of autoimmune hemolytic anaemia and complications, good antenatal care, judicious transfusions and delivery at tertiary care centre are the keys to successful outcomes.
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Affiliation(s)
- Rao Preethi Venkatachala
- Department of Obstetrics and Gynaecology, St Johns Medical College and Hospital, Bengaluru, Karnataka 560034 India
| | - C N Sheela
- Department of Obstetrics and Gynaecology, St Johns Medical College and Hospital, Bengaluru, Karnataka 560034 India
| | - Seetharam Anandram
- Department of Medicine (Division of Haematology), St Johns Medical College and Hospital, Bengaluru, Karnataka India
| | - Cecil R Ross
- Department of Medicine (Division of Haematology), St Johns Medical College and Hospital, Bengaluru, Karnataka India
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Abstract
The last decades have seen great progress in the treatment of cold agglutinin disease (CAD). Comparative trials are lacking, and recommendations must be based mainly on nonrandomized trials and will be influenced by personal experience. Herein, current treatment options are reviewed and linked to 3 cases, each addressing specific aspects of therapy. Two major steps in CAD pathogenesis are identified, clonal B-cell lymphoproliferation and complement-mediated hemolysis, each of which constitutes a target of therapy. Although drug treatment is not always indicated, patients with symptomatic anemia or other bothersome symptoms should be treated. The importance of avoiding ineffective therapies is underscored. Corticosteroids should not be used to treat CAD. Studies on safety and efficacy of relevant drugs and combinations are briefly described. The author recommends that B cell-directed approaches remain the first choice in most patients requiring treatment. The 4-cycle bendamustine plus rituximab combination is highly efficacious and sufficiently safe and induces durable responses in most patients, but the time to response can be many months. Rituximab monotherapy should be preferred in frail patients. The complement C1s inhibitor sutimlimab is an emerging option in the second line and may also find its place in the first line in specific situations.
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68
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Ma C, Feng Y, Yang L, Wang S, Sun X, Tai S, Guan X, Wang D, Yu Y. In vitro Immunomodulatory Effects of Human Umbilical Cord-Derived Mesenchymal Stem Cells on Peripheral Blood Cells from Warm Autoimmune Hemolytic Anemia Patients. Acta Haematol 2021; 145:63-71. [PMID: 34284381 DOI: 10.1159/000506759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 02/24/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Autoimmune hemolytic anemia is a potentially lethal disease characterized by autoimmune hemolysis. Although human umbilical cord-derived mesenchymal stem cells (hUC-MSCs) have been reported as a promising therapy, there is limited evidence regarding warm autoimmune hemolytic anemia (wAIHA) patients. This study aimed to investigate the potential therapeutic effects of hUC-MSCs via immune regulation in wAIHA patients. METHODS Peripheral blood mononuclear cells (PBMCs) from 10 wAIHA patients and 8 healthy controls were isolated from peripheral blood and cultured for 3 days with or without the presence of hUC-MSCs; PBMCs were co-cultured with hUC-MSCs using Transwell assays. The supernatant cytokine levels were measured after culture through AimPlex Multiple Immunoassays for Flow, including IL-2, IL-4, IL-10, IFN-γ, TNF-α, and IL-17A. The percentages of regulatory T cells, regulatory B cells, and Th1/Th2 in PBMCs were also assessed before and after culturing. RESULTS In the wAIHA group, hUC-MSCs could upregulate the Treg and Breg proportions after culturing for 3 days, and the Treg and Breg percentages increased after co-culturing with hUC-MSCs in the wAIHA group compared with PBMC cultured alone for 3 days (8.29 ± 8.59 vs. 6.82 ± 1.32, 3.82 ± 1.87 vs. 1.75 ± 1.20, respectively). Compared with the PBMC wAIHA group, the levels of TNF-α (2.13 ± 2.07 vs. 16.20 ± 21.13 pg/mL, p = 0.019) and IL-10 (10.51 ± 18.42 vs. 37.78 ± 44.20 pg/mL, p = 0.012) were significantly elevated in the PBMC + hUC-MSCs wAIHA group. CONCLUSION The hUC-MSCs contributed to the increasing proportion of regulatory cell populations in PBMCs of wAIHA patients, thereby potentially regulating autoimmune response; thus, hUC-MSCs may be a promising approach for wAIHA treatment.
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Affiliation(s)
- Chunya Ma
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yannan Feng
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Lu Yang
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Shufang Wang
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiaolin Sun
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Shengfei Tai
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiaozhen Guan
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Deqing Wang
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yang Yu
- Department of Blood Transfusion, First Medical Center of Chinese PLA General Hospital, Beijing, China
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Gabelli M, Ademokun C, Cooper N, Amrolia PI. Pathogenesis, risk factors and therapeutic options for autoimmune haemolytic anaemia in the post-transplant setting. Br J Haematol 2021; 196:45-62. [PMID: 34195990 DOI: 10.1111/bjh.17648] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/26/2021] [Indexed: 11/27/2022]
Abstract
Autoimmune haemolytic anaemia (AIHA) is a rare complication of allogeneic haematopoietic stem cell transplantation (HSCT), observed with an incidence of 1-5%. Paediatric age, diagnosis of non-malignant disease, lympho-depleting agents in the conditioning regimen, use of unrelated donor, graft versus host disease and infections have been associated with a higher risk of AIHA post HSCT. Post-HSCT AIHA is associated with high mortality and morbidity, and it is often very difficult to treat. Steroids and rituximab are used with a response rate around 30-50%. These and other therapeutic strategies are mainly derived from data on primary AIHA, although response rates in post-HSCT AIHA have been generally lower. Here we review the currently available data on risk factors and therapeutic options. There is a need for prospective studies in post-HSCT AIHA to guide clinicians in managing these complex patients.
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Affiliation(s)
- Maria Gabelli
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital, London, UK
| | - Christine Ademokun
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Nichola Cooper
- Department of Immunology and Inflammation, Imperial College, London, UK
| | - Persis I Amrolia
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital, London, UK
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Huda Z, Jahangir A, Sahra S, Rafay Khan Niazi M, Anwar S, Glaser A, Jahangir A. A Case of COVID-19-Associated Autoimmune Hemolytic Anemia With Hyperferritinemia in an Immunocompetent Host. Cureus 2021; 13:e16078. [PMID: 34345558 PMCID: PMC8324606 DOI: 10.7759/cureus.16078] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2021] [Indexed: 01/02/2023] Open
Abstract
We report an interesting case of a middle-aged gentleman who presented with diabetic ketoacidosis (DKA) and tested polymerase chain reaction (PCR) positive for COVID-19 infection. His hospital stay was complicated by acute kidney injury, hematuria, and normocytic anemia. Initial chest x-ray demonstrated bibasilar opacities. D-dimer and C-reactive protein were elevated. During his hospital stay, his hemoglobin decreased from 13.4 g/dL to 9 g/dL, and further workup demonstrated ferritin of 49,081 ng/mL with lactate dehydrogenase of 1665 U/L. He was treated with prednisone and folic acid for autoimmune hemolytic anemia (AIHA). Ferritin was downtrended, and hemoglobin stabilized. As demonstrated by this case report and prior literature review, COVID-19 infection can be associated with AIHA.
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Affiliation(s)
- Zoha Huda
- Medicine, The City University of New York (CUNY) School of Medicine, New York, USA
| | - Abdullah Jahangir
- Internal Medicine, Staten Island University Hospital, Northwell Health, New York, USA
| | - Syeda Sahra
- Internal Medicine, Northwell Health, New York, USA
| | | | - Shamsuddin Anwar
- Internal Medicine, Staten Island University Hospital, Northwell Health, New York, USA
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71
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Rieger MJ, Stolz SM, Ludwig S, Benoit TM, Bissig M, Widmer CC, Schwotzer R, Müller AM, Nair G, Hegemann I, Manz MG, Schanz U. Daratumumab in rituximab-refractory autoimmune haemolytic anaemia. Br J Haematol 2021; 194:931-934. [PMID: 34180543 DOI: 10.1111/bjh.17655] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Max J Rieger
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Sebastian M Stolz
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Sabine Ludwig
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Tobias M Benoit
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Marina Bissig
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Corinne C Widmer
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Rahel Schwotzer
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Antonia M Müller
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Gayathri Nair
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Inga Hegemann
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Markus G Manz
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Urs Schanz
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
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Fang S, Yang F. Recurrent infection-induced autoimmune haemolytic anaemia complicated by pulmonary embolism: a case report and literature review. Clin Med (Lond) 2021; 21:e306-e308. [PMID: 34001586 DOI: 10.7861/clinmed.2021-0112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A 73-year-old woman presented with progressive dyspnoea up to type 1 respiratory failure. Laboratory values showed leucocytosis, reduced haemoglobin to 71 g/L, elevated indirect serum bilirubin and lactic dehydrogenase. Computed tomography pulmonary angiography (CTPA) revealed peripheral pulmonary embolism (PE). Echocardiography showed enlarged right ventricle, elevated estimated pulmonary arterial systolic pressure (57.2 mmHg) and normal left ventricular ejection fraction. The patient was diagnosed with autoimmune haemolytic anaemia (AIHA), which was induced by recurrent infections without standard treatment in the past year. AIHA is the cause of PE due to the absence of common predisposing factors and other thrombophilia. The patient became better after administration of glucocorticoids, intravenous immunoglobulin and rivaroxaban.
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Affiliation(s)
- Shu Fang
- Peking University First Hospital, Beijing, China
| | - Fan Yang
- Peking University First Hospital, Beijing, China
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73
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Nasse SA. Autoimmune haemolytic anaemia: emergency blood transfusion. BMJ Case Rep 2021; 14:14/5/e242378. [PMID: 34011642 DOI: 10.1136/bcr-2021-242378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 50-year-old woman, with a background of autoimmune haemolytic anaemia, presented to the emergency department with lethargy and shortness of breath. Investigations revealed a haemoglobin level of 50 g/L. High dose steroids were administered and blood transfusion prescribed. However, the blood transfusion was delayed due to a positive antibody screen and concerns regarding administering blood when the patient was pyrexic. The delay resulted in a significant deterioration in the patient's clinical state with her haemoglobin level falling to 26 g/L 24 hours later. She was urgently transfused with blood and made a full recovery. This report analyses the delays for transfusion and how these could have been minimised. First, guidelines advise that emergency blood should be considered in life-threatening circumstances. Second, fever is not always a contraindication for transfusion, particularly in an emergency setting.
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The Role of Novel Agents in Treating CLL-Associated Autoimmune Hemolytic Anemia. J Clin Med 2021; 10:jcm10102064. [PMID: 34065833 PMCID: PMC8151128 DOI: 10.3390/jcm10102064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/04/2021] [Accepted: 05/11/2021] [Indexed: 12/14/2022] Open
Abstract
Autoimmune cytopenias (AICs) have been reported as a common complication in chronic lymphocytic leukemia (CLL) with autoimmune hemolytic anemia (AIHA), accounting for most cases. According to iwCLL guidelines, AICs poorly responsive to corticosteroids are considered indication for CLL-directed treatment. Chemo-immunotherapy has classically been employed, with variable results, and little data are available on novel agents, the current backbone of CLL therapy. The use of idelalisib in the setting of AICs is controversial and recent recommendations suggest avoiding idelalisib in this setting. Ibrutinib, through ITK-driven Th1 polarization of cell-mediated immune response, is known to produce an immunological rebalancing in CLL, which stands as a fascinating rationale for its use to treat autoimmunity. Although treatment-emergent AIHA has rarely been reported, ibrutinib has shown rapid and durable responses when used to treat AIHA arising in CLL. There is poor evidence regarding the role of BCL-2 inhibitors in CLL-associated AICs and the use of venetoclax in such cases is debated. Furthermore, their frequent use in combination with anti-CD20 agents might represent a confounding factor in evaluating their efficacy. In conclusions, because of their ability to mitigate an immunological dysregulation that is (at least partly) responsible for autoimmunity in CLL, to date BTK-inhibitors stand out as the most suitable choice when treatment of autoimmune cytopenias is required.
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75
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Sun P, Jeffery U. Response to letter regarding "Effect of dilution of canine blood samples on the specificity of saline agglutination tests for immune-mediated hemolysis". J Vet Intern Med 2021; 35:1216-1217. [PMID: 33951243 PMCID: PMC8163140 DOI: 10.1111/jvim.16129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 04/05/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Prudence Sun
- College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Unity Jeffery
- Department of Veterinary Pathobiology, Texas A&M University, College Station, Texas, USA
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Capecchi M, Ciavarella A, Artoni A, Abbattista M, Martinelli I. Thrombotic Complications in Patients with Immune-Mediated Hemolysis. J Clin Med 2021; 10:1764. [PMID: 33919638 PMCID: PMC8073900 DOI: 10.3390/jcm10081764] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/10/2021] [Accepted: 04/15/2021] [Indexed: 12/11/2022] Open
Abstract
Autoimmune hemolytic anemias are rare and heterogeneous disorders characterized by hemolysis, which is a well-recognized risk factor for thrombosis. The most common immune-mediated anemias are represented by autoimmune hemolytic anemia and paroxysmal nocturnal hemoglobinuria, both associated with a high rate of thrombosis. Multiple pathophysiological mechanisms for thrombosis have been proposed, involving hemolysis itself and additional effects of the immune system. Despite the increasing awareness of the thrombotic risk in these conditions, evidence-based guidance on prevention and management of thrombotic events is lacking. We herein report available evidence on epidemiological data on thrombosis and thrombophilia in immune-mediated hemolysis, together with possible underlying pathophysiological mechanisms. In addition, we summarize current recommendations for treatment of thrombosis in immune-mediated hemolysis. In particular, we address the issue of thrombotic complications treatment and prophylaxis by proposing a therapeutic algorithm, focusing on specific situations such as splenectomy and pregnancy.
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Affiliation(s)
- Marco Capecchi
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, 20133 Milan, Italy;
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (A.A.); (M.A.); (I.M.)
| | - Alessandro Ciavarella
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, 20133 Milan, Italy;
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (A.A.); (M.A.); (I.M.)
| | - Andrea Artoni
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (A.A.); (M.A.); (I.M.)
| | - Maria Abbattista
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (A.A.); (M.A.); (I.M.)
| | - Ida Martinelli
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (A.A.); (M.A.); (I.M.)
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Barcellini W, Fattizzo B. How I treat warm autoimmune hemolytic anemia. Blood 2021; 137:1283-1294. [PMID: 33512406 DOI: 10.1182/blood.2019003808] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 08/28/2020] [Indexed: 12/17/2022] Open
Abstract
Warm autoimmune hemolytic anemia (wAIHA) is caused by increased erythrocyte destruction by immunoglobulin G (IgG) autoantibodies, with or without complement activation. Antibody-dependent cell-mediated cytotoxicity by macrophages/activated lymphocytes occurs in the lymphoid organs and spleen (extravascular hemolysis). The ability of the bone marrow (BM) to compensate determines clinical severity. The different pathogenic mechanisms, their complex interplay, and changes over time may explain wAIHA's great clinical heterogeneity and unpredictable course. The disease may be primary, drug induced, or associated with lymphoproliferative neoplasms, autoimmune and infectious diseases, immunodeficiencies, solid tumors, or transplants. Therapeutic interventions include steroids, splenectomy, immunosuppressants, and rituximab; the latter is increasingly used in steroid-refractory cases based on evidence from the literature and a few prospective trials. We present 5 patient case studies highlighting important issues: (1) the diagnosis and proper use of steroid therapy, (2) the concerns about the choice between rituximab and splenectomy in second-line treatment, (3) the need of periodical re-evaluation of the disease to assess the possible evolution of relapsed/refractory cases in myelodysplastic and BM failure syndromes, and (4) the difficulties in managing cases of severe/acute disease that are at high risk of relapse. Incorporating novel targeted therapies into clinical practice will be an exciting challenge in the future.
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Affiliation(s)
- Wilma Barcellini
- Hematology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; and
| | - Bruno Fattizzo
- Hematology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; and
- Department of Oncology and Onco-hematology, University of Milan, Milan, Italy
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Immune cytopenia after allogeneic haematopoietic stem-cell transplantation: challenges, approaches, and future directions. LANCET HAEMATOLOGY 2021; 8:e229-e239. [PMID: 33636143 DOI: 10.1016/s2352-3026(20)30404-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/24/2020] [Accepted: 11/30/2020] [Indexed: 12/20/2022]
Abstract
Immune-mediated cytopenia after allogeneic haematopoietic stem-cell transplantation is rare. The pathophysiology of immune-mediated anaemia, thrombocytopenia, and neutropenia, which occur alone or in combination with other cytopenias, is unclear and most probably a consequence of immune dysregulation. Risk factors for this complication have been identified in retrospective studies but these should be interpreted with caution and should not be generalised to this heterogeneous patient population. Diagnosis is challenging, requires awareness of such complications, and has to be differentiated from a multitude of other, and sometimes overlapping, possible complications. The clinical course of immune-mediated cytopenia is highly variable. Treatment requires an interdisciplinary approach and ranges from observation to symptomatic measures and directed therapies. Intensive immunosuppression is associated with an increased risk of infections and relapse, and current treatments are based on approaches in patients who have not undergone transplantation. Plasma cell-directed therapies, immunomodulation, and receptor-stimulating agents can be used to treat immune-mediated cytopenia.
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79
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Cold agglutinin disease revisited: a multinational, observational study of 232 patients. Blood 2021; 136:480-488. [PMID: 32374875 DOI: 10.1182/blood.2020005674] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/16/2020] [Indexed: 12/26/2022] Open
Abstract
We retrospectively studied 232 patients with cold agglutinin disease (CAD) at 24 centers in 5 countries. In Norway and a northern region of Italy, the study was close to being population-based. For the first time, we demonstrate fourfold differences between cold and warmer climates regarding prevalence (20 vs 5 cases/million) and incidence (1.9 vs 0.48 cases/million per year). Mean baseline hemoglobin level was 9.3 g/dL, but 27% had hemoglobin <8 g/dL. Identification of typical features of CAD-associated lymphoproliferative disorder in the bone marrow was greatly increased by centralized biopsy assessment. CAD seems to be associated with a slightly increased risk of venous thrombosis. This work includes a follow-up study of therapies, focusing on the long-term outcomes of the rituximab plus bendamustine and rituximab plus fludarabine regimens. Rituximab plus bendamustine therapy resulted in responses in 35 (78%) of 45 patients; 24 (53%) achieved complete response. Interestingly, these rates were still higher than observed in the original (2017) prospective trial, and we also found a shift toward deeper responses with time. This is explained by the prolonged time to response seen in many patients, probably related to long-lived plasma cells. In patients responding to rituximab-bendamustine, median response duration was not reached after 88 months, and estimated 5-year sustained remission was 77%. The regimen appeared safe regarding late-occurring malignancies. Rituximab plus fludarabine therapy seems to carry a higher risk of long-term adverse effects.
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80
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Brand A, De Angelis V, Vuk T, Garraud O, Lozano M, Politis D. Review of indications for immunoglobulin (IG) use: Narrowing the gap between supply and demand. Transfus Clin Biol 2021; 28:96-122. [DOI: 10.1016/j.tracli.2020.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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81
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Cytomegalovirus reactivation in patients under immunosuppressive treatment for autoimmune haemolytic anaemia. Ann Hematol 2021; 101:227-228. [PMID: 33469687 DOI: 10.1007/s00277-021-04416-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/06/2021] [Indexed: 10/22/2022]
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82
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Solari D, Alberio L, Ribi C, Grandoni F, Stalder G. Autoimmune Hemolytic Anemia and Pulmonary Embolism: An Association to Consider. TH OPEN 2021; 5:e8-e13. [PMID: 33469565 PMCID: PMC7811891 DOI: 10.1055/s-0040-1721733] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 11/05/2020] [Indexed: 11/08/2022] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is increasingly recognized as a strong risk factor for venous thrombosis. However, there are currently no guidelines on thromboembolism prevention and management during AIHA. Here, we describe the case of a patient with AIHA and pulmonary embolism and resume the current knowledge on epidemiology, risk factors, treatment, and pathophysiology of thrombosis during AIHA, as well as new therapeutic perspectives to prevent thrombus formation during AIHA.
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Affiliation(s)
- Daria Solari
- Division and Central Laboratory of Hematology, Department of Oncology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Lorenzo Alberio
- Division and Central Laboratory of Hematology, Department of Oncology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Camillo Ribi
- Division of Immunology and Allergy, Department of Medicine, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Francesco Grandoni
- Division and Central Laboratory of Hematology, Department of Oncology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Gregoire Stalder
- Division and Central Laboratory of Hematology, Department of Oncology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
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83
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Autoimmune Hemolytic Anemia in the Pediatric Setting. J Clin Med 2021; 10:jcm10020216. [PMID: 33435309 PMCID: PMC7828053 DOI: 10.3390/jcm10020216] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 12/21/2022] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is a rare disease in children, presenting with variable severity. Most commonly, warm-reactive IgG antibodies bind erythrocytes at 37 °C and induce opsonization and phagocytosis mainly by the splenic macrophages, causing warm AIHA (w-AIHA). Post-infectious cold-reactive antibodies can also lead to hemolysis following the patient’s exposure to cold temperatures, causing cold agglutinin syndrome (CAS) due to IgM autoantibodies, or paroxysmal cold hemoglobinuria (PCH) due to atypical IgG autoantibodies which bind their target RBC antigen and fix complement at 4 °C. Cold-reactive antibodies mainly induce intravascular hemolysis after complement activation. Direct antiglobulin test (DAT) is the gold standard for AIHA diagnosis; however, DAT negative results are seen in up to 11% of warm AIHA, highlighting the need to pursue further evaluation in cases with a phenotype compatible with immune-mediated hemolytic anemia despite negative DAT. Prompt supportive care, initiation of treatment with steroids for w-AIHA, and transfusion if necessary for symptomatic or fast-evolving anemia is crucial for a positive outcome. w-AIHA in children is often secondary to underlying immune dysregulation syndromes and thus, screening for such disorders is recommended at presentation, before initiating treatment with immunosuppressants, to determine prognosis and optimize long-term management potentially with novel targeted medications.
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84
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Rituximab Use in Warm and Cold Autoimmune Hemolytic Anemia. J Clin Med 2020; 9:jcm9124034. [PMID: 33322221 PMCID: PMC7763062 DOI: 10.3390/jcm9124034] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/06/2020] [Accepted: 12/09/2020] [Indexed: 01/22/2023] Open
Abstract
Autoimmune hemolytic anemia is a rare condition characterized by destruction of red blood cells with and without involvement of complement. It is associated with significant morbidity and mortality. In warm autoimmune hemolytic anemia, less than 50% of patients remain in long-term remission following initial steroid therapy and subsequent therapies are required. Cold agglutinin disease is a clonal hematologic disorder that requires therapy in the majority of patients and responds poorly to steroids and alkylators. Rituximab has a favorable toxicity profile and has demonstrated efficacy in autoimmune hemolytic anemia in first-line as well as relapsed settings. Rituximab is the preferred therapy for steroid refractory warm autoimmune hemolytic anemia (wAIHA) and as part of the first- and second-line treatment of cold agglutinin disease. This article reviews the mechanism of action of rituximab and the current literature on its role in the management of primary and secondary warm autoimmune hemolytic anemia and cold agglutinin disease.
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85
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Abstract
A man in his early 50s presented with jaundice, mild shortness of breath on exertion and dark urine. He had had coryzal symptoms 2 weeks prior to admission. Medical history included obstructive sleep apnoea and hypertension. His initial blood tests showed a mild hyperbilirubinaemia and acute kidney injury stage 1. Chest X-ray and CT pulmonary angiogram were negative for features suggestive of COVID-19. He later developed a drop in haemoglobin and repeat bloods showed markedly raised lactate dehydrogenase and positive direct antiglobulin test. These results were felt to be consistent with a haemolytic anaemia. A nasopharyngeal swab came back positive for COVID-19. We suspect the cause of his symptoms was an autoimmune haemolytic anaemia secondary to COVID-19 which has recently been described in European cohorts.
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Affiliation(s)
- Memoona Jawed
- Queen's Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK
- Acute Medicine, Queen's Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Elizabeth Hart
- Acute Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Malik Saeed
- Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
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86
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de Araújo CDSR, Machado BA, Fior T, Mattiello JM, Meinhart M, Bortolotti P, Brittes LLH, Pasqualotti A, Castilho L. Association of positive direct antiglobulin test (DAT) with nonreactive eluate and drug-induced immune hemolytic anemia (DIHA). Transfus Apher Sci 2020; 60:103015. [PMID: 33277206 DOI: 10.1016/j.transci.2020.103015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVES Drug-induced immune hemolytic anemia is a rare condition that occurs primarily because of drug-induced antibodies, either dependent or independent and positive direct antiglobulin test. Our aim was to evaluate the association of positive DAT with nonreactive eluate and DIHA. MATERIALS AND METHODS From 2014-2018, we evaluated 159 patients who presented positive DAT with a nonreactive eluate. Laboratory and clinical analyses were performed including HIV, HBV and HCV testing. All patients were exposed to the following drugs: Dipyrone in 63.5 %, Furosemide in 28.9 %, Metoclopramide in 34.6 % and Ondansetron in 41.5 %. RESULTS Results of DAT showed IgG in 125 (78.4 %) patients and C3d in 24 (15.1 %) with reactions varying from 1+ to 4+. HIV test was positive in 10 (16.1 %) patients, HBV was positive in 3 (4.7 %) and HCV was positive in, 1 (1.5 %). There was no clinical significance when the parameters of hemoglobin, hematocrit, reticulocytes and LDH were evaluated, only a slight increase in bilirubin, especially, in patients with positive DAT reacting 3+/4+ due to IgG and C3d sensitization. Clinical evaluations showed that all patients were asymptomatic. CONCLUSIONS The association of drugs with positive DAT can be a challenge to transfusion services and immunohematology reference laboratories. There was no evidence of any case of severe hemolysis with clinical repercussion through the clinical and laboratory findings analyzed with the drugs associated with positive DAT. Dipyrone and Furosemide have already been associated with DIHA but there are no studies reporting the association of Metoclopramide and Ondansetron with DIHA.
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Affiliation(s)
- Cristiane da Silva Rodrigues de Araújo
- Faculdade de Medicina, Universidade de Passo Fundo, Passo Fundo, RS, Brazil; Serviço de Hemoterapia do Hospital São Vicente de Paulo, Passo Fundo, RS, Brazil.
| | | | - Tamaris Fior
- Acadêmicos de medicina da Faculdade de medicina, Universidade de Passo Fundo, Passo Fundo, RS, Brazil
| | - Júlia Mognon Mattiello
- Acadêmicos de medicina da Faculdade de medicina, Universidade de Passo Fundo, Passo Fundo, RS, Brazil
| | - Mosseli Meinhart
- Acadêmicos de medicina da Faculdade de medicina, Universidade de Passo Fundo, Passo Fundo, RS, Brazil
| | - Pillar Bortolotti
- Acadêmicos de medicina da Faculdade de medicina, Universidade de Passo Fundo, Passo Fundo, RS, Brazil
| | | | - Adriano Pasqualotti
- Programa de Pós-Graduação em Envelhecimento Humano, Universidade de Passo Fundo, Passo Fundo, RS, Brazil
| | - Lilian Castilho
- Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
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87
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Aveiro M, Ferreira G, Matias C, Oliveira A, Rodrigues T. Hard-To-Treat Idiopathic Refractory Autoimmune Haemolytic Anaemia with Reticulocytopenia. Eur J Case Rep Intern Med 2020; 7:002112. [PMID: 33457372 PMCID: PMC7806294 DOI: 10.12890/2020_002112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/10/2020] [Indexed: 11/05/2022] Open
Abstract
Autoimmune haemolytic anaemia (AIHA) is an uncommon condition characterized by increased destruction of erythrocytes associated with reticulocytosis in the great majority of cases. We present the case of a 68-year-old woman with jaundice and malaise. Investigation revealed AIHA with reticulocytopenia. The patient failed to respond to prednisolone or to rituximab. Azathioprine and epoetin beta were subsequently started, the prednisolone dose was increased, and the patient began to respond after 1 month. In AIHA, reticulocytopenia is a very rare presentation and a sign of great severity and poor outcome. The scarcity of therapeutic options in refractory cases poses a major challenge for physicians. LEARNING POINTS Autoimmune haemolytic anaemia is a rare disorder characterized by decompensated acquired haemolysis caused by the host's immune system acting against its own red cell antigens.Concomitant presentation with reticulocytopenia is very rare and a sign of great severity and poor outcome.Treatment options in refractory cases still greatly rely on individual experience and expert opinion.
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Affiliation(s)
- Marcelo Aveiro
- Internal Medicine Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Gisela Ferreira
- Haematology Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Carla Matias
- Internal Medicine Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Ana Oliveira
- Internal Medicine Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Tatiana Rodrigues
- Internal Medicine Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
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88
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Evans' Syndrome: From Diagnosis to Treatment. J Clin Med 2020; 9:jcm9123851. [PMID: 33260979 PMCID: PMC7759819 DOI: 10.3390/jcm9123851] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 11/21/2020] [Accepted: 11/25/2020] [Indexed: 12/13/2022] Open
Abstract
Evans' syndrome (ES) is defined as the concomitant or sequential association of warm auto-immune haemolytic anaemia (AIHA) with immune thrombocytopenia (ITP), and less frequently autoimmune neutropenia. ES is a rare situation that represents up to 7% of AIHA and around 2% of ITP. When AIHA and ITP occurred concomitantly, the diagnosis procedure must rule out differential diagnoses such as thrombotic microangiopathies, anaemia due to bleedings complicating ITP, vitamin deficiencies, myelodysplastic syndromes, paroxysmal nocturnal haemoglobinuria, or specific conditions like HELLP when occurring during pregnancy. As for isolated auto-immune cytopenia (AIC), the determination of the primary or secondary nature of ES is important. Indeed, the association of ES with other diseases such as haematological malignancies, systemic lupus erythematosus, infections, or primary immune deficiencies can interfere with its management or alter its prognosis. Due to the rarity of the disease, the treatment of ES is mostly extrapolated from what is recommended for isolated AIC and mostly relies on corticosteroids, rituximab, splenectomy, and supportive therapies. The place for thrombopoietin receptor agonists, erythropoietin, immunosuppressants, haematopoietic cell transplantation, and thromboprophylaxis is also discussed in this review. Despite continuous progress in the management of AIC and a gradual increase in ES survival, the mortality due to ES remains higher than the ones of isolated AIC, supporting the need for an improvement in ES management.
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89
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New Insights in Autoimmune Hemolytic Anemia: From Pathogenesis to Therapy Stage 1. J Clin Med 2020; 9:jcm9123859. [PMID: 33261023 PMCID: PMC7759854 DOI: 10.3390/jcm9123859] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 12/15/2022] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is a highly heterogeneous disease due to increased destruction of autologous erythrocytes by autoantibodies with or without complement involvement. Other pathogenic mechanisms include hyper-activation of cellular immune effectors, cytokine dysregulation, and ineffective marrow compensation. AIHAs may be primary or associated with lymphoproliferative and autoimmune diseases, infections, immunodeficiencies, solid tumors, transplants, and drugs. The direct antiglobulin test is the cornerstone of diagnosis, allowing the distinction into warm forms (wAIHA), cold agglutinin disease (CAD), and other more rare forms. The immunologic mechanisms responsible for erythrocyte destruction in the various AIHAs are different and therefore therapy is quite dissimilar. In wAIHA, steroids represent first line therapy, followed by rituximab and splenectomy. Conventional immunosuppressive drugs (azathioprine, cyclophosphamide, cyclosporine) are now considered the third line. In CAD, steroids are useful only at high/unacceptable doses and splenectomy is uneffective. Rituximab is advised in first line therapy, followed by rituximab plus bendamustine and bortezomib. Several new drugs are under development including B-cell directed therapies (ibrutinib, venetoclax, parsaclisib) and inhibitors of complement (sutimlimab, pegcetacoplan), spleen tyrosine kinases (fostamatinib), or neonatal Fc receptor. Here, a comprehensive review of the main clinical characteristics, diagnosis, and pathogenic mechanisms of AIHA are provided, along with classic and new therapeutic approaches.
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90
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Hill QA, Horan M, Charlton A, Bullock T, Massey E, Hill A, Allard S, Stanworth SJ. Developing the evidence base for the management of autoimmune haemolytic anaemia (AIHA): the UK experience. Br J Haematol 2020; 192:e54-e57. [PMID: 33216965 DOI: 10.1111/bjh.17217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/12/2020] [Indexed: 11/30/2022]
Affiliation(s)
| | | | | | | | | | | | | | - Simon J Stanworth
- NHS Blood and Transplant, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine and Oxford BRC Haematology Theme, University of Oxford, Oxford, UK
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91
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Michalak SS, Olewicz-Gawlik A, Rupa-Matysek J, Wolny-Rokicka E, Nowakowska E, Gil L. Autoimmune hemolytic anemia: current knowledge and perspectives. Immun Ageing 2020; 17:38. [PMID: 33292368 PMCID: PMC7677104 DOI: 10.1186/s12979-020-00208-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 11/10/2020] [Indexed: 02/07/2023]
Abstract
Autoimmune hemolytic anemia (AIHA) is an acquired, heterogeneous group of diseases which includes warm AIHA, cold agglutinin disease (CAD), mixed AIHA, paroxysmal cold hemoglobinuria and atypical AIHA. Currently CAD is defined as a chronic, clonal lymphoproliferative disorder, while the presence of cold agglutinins underlying other diseases is known as cold agglutinin syndrome. AIHA is mediated by autoantibodies directed against red blood cells (RBCs) causing premature erythrocyte destruction. The pathogenesis of AIHA is complex and still not fully understood. Recent studies indicate the involvement of T and B cell dysregulation, reduced CD4+ and CD25+ Tregs, increased clonal expansions of CD8 + T cells, imbalance of Th17/Tregs and Tfh/Tfr, and impaired lymphocyte apoptosis. Changes in some RBC membrane structures, under the influence of mechanical stimuli or oxidative stress, may promote autohemolysis. The clinical presentation and treatment of AIHA are influenced by many factors, including the type of AIHA, degree of hemolysis, underlying diseases, presence of concomitant comorbidities, bone marrow compensatory abilities and the presence of fibrosis and dyserthropoiesis. The main treatment for AIHA is based on the inhibition of autoantibody production by mono- or combination therapy using GKS and/or rituximab and, rarely, immunosuppressive drugs or immunomodulators. Reduction of erythrocyte destruction via splenectomy is currently the third line of treatment for warm AIHA. Supportive treatment including vitamin supplementation, recombinant erythropoietin, thrombosis prophylaxis and the prevention and treatment of infections is essential. New groups of drugs that inhibit immune responses at various levels are being developed intensively, including inhibition of antibody-mediated RBCs phagocytosis, inhibition of B cell and plasma cell frequency and activity, inhibition of IgG recycling, immunomodulation of T lymphocytes function, and complement cascade inhibition. Recent studies have brought about changes in classification and progress in understanding the pathogenesis and treatment of AIHA, although there are still many issues to be resolved, particularly concerning the impact of age-associated changes to immunity.
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Affiliation(s)
- Sylwia Sulimiera Michalak
- Department of Pharmacology and Toxicology Institute of Health Sciences, Collegium Medicum, University of Zielona Gora, Zielona Góra, Poland.
| | - Anna Olewicz-Gawlik
- Department of Anatomy and Histology Institute of Health Sciences, Collegium Medicum, University of Zielona Gora, Zielona Góra, Poland
- Department of Infectious Diseases, Hepatology and Acquired Immune Deficiencies, Poznan University of Medical Sciences, Poznan, Poland
- Department of Immunology, Poznan University of Medical Sciences, Poznan, Poland
| | - Joanna Rupa-Matysek
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
| | - Edyta Wolny-Rokicka
- Department of Radiotherapy, Multidisciplinary Hospital, Gorzów Wielkopolski, Poland
| | - Elżbieta Nowakowska
- Department of Pharmacology and Toxicology Institute of Health Sciences, Collegium Medicum, University of Zielona Gora, Zielona Góra, Poland
| | - Lidia Gil
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
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Coombs-negative haemolytic anaemia in pregnancy: A case report. Case Rep Womens Health 2020; 29:e00272. [PMID: 33294391 PMCID: PMC7695940 DOI: 10.1016/j.crwh.2020.e00272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 11/11/2020] [Accepted: 11/16/2020] [Indexed: 11/23/2022] Open
Abstract
We present a rare case of Coombs-negative autoimmune haemolytic anaemia in a multiparous woman in secondary care. There were no known underlying medical or obstetric risk factors for haemolytic anaemia. Following extensive investigation and a therapeutic trial of oral corticosteroids, a diagnosis was made. Autoimmune haemolytic anaemia is potentially fatal, and prompt diagnosis with haematology input is essential to ensure maternal and fetal safety in pregnancy and the puerperium. With only a small number of cases of Coombs-negative autoimmune haemolytic anaemia reported in the literature, we present this rare case for discussion. We highlight the importance of thorough investigation of refractory anaemia in pregnancy and consider the associated challenges. Anaemia is pregnancy is common. Refractory anaemia should be thoroughly investigated, it can be associated with increased maternal morbidity and mortality. Coombs negative anaemia in pregnancy is rare We report a case report of Coombs negative anaemia in pregnancy, with no significant underlying medical or family history.
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93
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Mejia Buritica L, Zapata Alvarez J, Vergara Quintero L, Villegas Molina JP, Torres Hernandez JD. Autoimmune Hemolytic Anemia After Cyanocobalamin Replacement in a Patient With a Previous Diagnosis of Pernicious Anemia: A Case Report. Cureus 2020; 12:e10797. [PMID: 33163301 PMCID: PMC7641469 DOI: 10.7759/cureus.10797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Pernicious anemia (PA) is associated with other autoimmune diseases, such as hypothyroidism, type 1 diabetes mellitus (DM1), Addison's disease, and vitiligo. The association between PA and autoimmune hemolytic anemia (AIHA) is rare, with less than 30 cases reported in the literature. In this paper, we report a case of a patient with a confirmed diagnosis of PA, who, six months after starting treatment with cyanocobalamin, presented with severe hemolysis with a positive direct antiglobulin test (DAT) for warm antibodies; the patient responded well to glucocorticoid treatment. AIHA in PA patients can be triggered by cyanocobalamin replacement due to the expression of membrane antigens by mature red blood cells entering into the peripheral circulation. This association should be considered because these patients, in addition to cyanocobalamin replacement, will require immunosuppressive treatment, usually with glucocorticoids.
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94
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Merashli M, Arcaro A, Graf M, Gentile F, Ames PRJ. Autoimmune haemolytic anaemia and antiphospholipid antibodies in paediatrics: a systematic review and meta-analysis. Clin Rheumatol 2020; 40:1967-1973. [PMID: 33006737 DOI: 10.1007/s10067-020-05436-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/28/2020] [Accepted: 09/29/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION/OBJECTIVE The relationship between autoimmune haemolytic anaemia (AIHA) and antiphospholipid antibodies (aPL) has never been addressed via a meta-analysis in the paediatric age group. We evaluated the link between AIHA and aPL in childhood systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS). METHODS EMBASE and PubMed were screened from inception to May 2020 and Peto's odds ratio for rare events was employed for the between group comparisons. RESULTS The meta-analysis included 11 articles for a total of 575 children: the pooled prevalence of AIHA was greater in (1) IgG aCL-positive than IgG aCL-negative children (39.7% vs 20.9%, p = 0.005); (2) in APS-positive than APS-negative SLE children (36.8% vs 13.2%, p = 0.01); and (3) in SLE-related APS than in primary APS children (53% vs 16.2%, p = 0.008). CONCLUSIONS The pooled prevalence of AIHA is greatest in SLE with aPL/APS, low-moderate in SLE without aPL/APS, and lowest in primary APS. Key Points • Antiphospholipid antibodies strongly relate to autoimmune haemolytic anaemia. • Autoimmune haemolytic anaemia is more common in systemic lupus erythematosus with antiphospholipid antibodies.
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Affiliation(s)
- Mira Merashli
- Department of Rheumatology, American University of Beirut, Beirut, Lebanon
| | - Alessia Arcaro
- Department of Medicine & Health Sciences 'V.Tiberio', Universita' del Molise, Campobasso, Italy
| | - Maria Graf
- Department of Laboratory and Transfusion Medicine, Federico II University Hospital, Naples, Italy
| | - Fabrizio Gentile
- Department of Medicine & Health Sciences 'V.Tiberio', Universita' del Molise, Campobasso, Italy
| | - Paul R J Ames
- Immune Response & Vascular Disease Unit, Nova University, Lisbon, Portugal.
- Dumfries and Galloway Royal Infirmary, Dumfries, UK.
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Jia MN, Qiu Y, Wu YY, Cai H, Zhou DB, Cao XX, Li J. Rituximab-containing therapy for cold agglutinin disease: a retrospective study of 16 patients. Sci Rep 2020; 10:12694. [PMID: 32728060 PMCID: PMC7391738 DOI: 10.1038/s41598-020-69465-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/13/2020] [Indexed: 12/03/2022] Open
Abstract
Cold agglutinin disease (CAD) is a rare form of autoimmune haemolytic anaemia, and because of its rareness, there is no standard treatment for CAD patients. We retrospectively analysed the response to rituximab-containing therapy in CAD patients at our hospital. All patients received rituximab-containing therapy for at least 1 month. A total of 16 patients (11 males and 5 females) were included. The median age at the onset of the disease was 63.5 years (range 41–79). Most patients had manifestations including anaemia (81.3%) or cold-induced circulatory symptoms (75.0%). The median haemoglobin level was 72 g/L (range 29–101), and the median cold agglutinin titre was 1,024 (range 64–2,048). Thirteen of 16 patients (81%) responded to the therapy. Responders achieved a median increase in haemoglobin levels of 45 g/L. Grade 3–4 neutropenia occurred in 3 patients (19%), but only 1 (6%) of them experienced infection. Anaphylaxis related to rituximab occurred in 1 patient. During follow-up, five patients experienced relapse, and two patients died. The estimated median progression-free survival was 36 months, and median overall survival was not yet reached. In conclusion, A rituximab-based therapy in accordance with individual patient characteristics may be a reasonable choice for CAD patients.
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Affiliation(s)
- Ming-Nan Jia
- Department of Haematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Yu Qiu
- Department of Haematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Yan-Yan Wu
- Department of Haematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Hao Cai
- Department of Haematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Dao-Bin Zhou
- Department of Haematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Xin-Xin Cao
- Department of Haematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| | - Jian Li
- Department of Haematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
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96
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Abstract
Cold agglutinin disease (CAD) is an uncommon form of cold autoimmune hemolytic anemia (AIHA). It should be considered in the differential diagnosis of elderly patients with unexplained chronic anemia presenting with or without cold-induced symptoms in the extremities, such as the fingers, ears, and nose. CAD is a complement-mediated process which leads to intravascular and extravascular hemolysis. A stepwise approach to laboratory testing can help confirm the diagnosis. Nearly all cold agglutinins are positive for the C3d direct antiglobulin test (DAT). A negative C3d DAT should prompt investigation of a possible warm AIHA. Ninety percent of cold agglutinins are of the IgM immunoglobulin class and should have a titer of 1:64 or higher at 4°C. Distinction from a warm AIHA is important, as therapy differs for the two entities. Corticosteroids are not effective at treating CAD and should not be used as therapy in these patients. Approximately 45–60% of patients with CAD respond to rituximab monotherapy. Combination therapy of rituximab and fludarabine has been shown to be effective in up to 76% of patients; however, patients experience more mild side effects with this treatment. New anti-complement drugs, such as eculizumab and sutimlimab, are currently in phase-3 trials to determine their efficacy and safety in patients with CAD.
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Affiliation(s)
- Amy P Gabbard
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Garrett S Booth
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
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97
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Kamesaki T, Nishimura JI, Wada H, Yu E, Tsao E, Morales J, Kanakura Y. Demographic characteristics, thromboembolism risk, and treatment patterns for patients with cold agglutinin disease in Japan. Int J Hematol 2020; 112:307-315. [DOI: 10.1007/s12185-020-02899-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/30/2020] [Accepted: 05/29/2020] [Indexed: 12/30/2022]
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98
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Defining autoimmune hemolytic anemia: a systematic review of the terminology used for diagnosis and treatment. Blood Adv 2020; 3:1897-1906. [PMID: 31235526 DOI: 10.1182/bloodadvances.2019000036] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/21/2019] [Indexed: 12/11/2022] Open
Abstract
The terminology applied to autoimmune hemolytic anemia (AIHA) seems inconsistent. We aimed to evaluate the consistency of definitions used for diagnosis and treatment. In this systematic review of literature from January 2006 to December 2015, we assessed heterogeneity in the definition of AIHA and its subtypes, refractory disease, disease phase, severity, criteria for treatment response, and response durability. A Medline search for anemia, hemolytic, autoimmune was supplemented with keyword searches. Main exclusions were conference abstracts, animal and non-English studies, and studies with <10 cases. Of 1371 articles retrieved, 1209 were excluded based on titles and abstracts. Two authors independently reviewed 10% and 16% of abstracts and full papers, respectively. After full-paper review, 84 studies were included. AIHA was most frequently (32 [52%] of 61) defined as hemolytic anemia with positive direct antiglobulin test (DAT) and exclusion of alternatives, but 10 of 32 also recognized DAT-negative AIHA. A lower threshold for diagnosis of DAT-negative AIHA was observed in literature on chronic lymphocytic leukemia. Definitions of anemia, hemolysis, and exclusion criteria showed substantial variation. Definitions of primary/secondary cold agglutinin disease/syndrome were not consistent. Forty-three studies provided criteria for treatment response, and other than studies from 1 center, these were almost entirely unique. Other criteria were rarely defined. Only 7, 0, 3, 2, 2, and 3 studies offered definitions of warm AIHA, paroxysmal cold hemoglobinuria, mixed AIHA, AIHA severity, disease phase, and refractory AIHA, respectively. Marked heterogeneity in the time period sampled indicates the need to standardize AIHA terminology.
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99
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Antiphospholipid Antibodies and Autoimmune Haemolytic Anaemia: A Systematic Review and Meta-Analysis. Int J Mol Sci 2020; 21:ijms21114120. [PMID: 32527000 PMCID: PMC7313475 DOI: 10.3390/ijms21114120] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 02/02/2023] Open
Abstract
The relationship between antiphospholipid antibodies (aPL) and autoimmune haemolytic anaemia (AIHA) has never been systematically addressed. The aim of this study is to assess the link between aPL and AIHA in adult systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS). This study performed an EMBASE/PubMed search from inception to June 2019 and meta-analysis using Peto’s odds ratios. The pooled prevalence (PP) of IgG/IgM anticardiolipin (aCL) and lupus anticoagulant (LA) was greater in AIHA +ve than AIHA −ve patients (34.7% vs. 27.6%, p = 0.03; 33.3% vs. 21.8%, p < 0.0001; 20.9% vs. 8.3%, p = 0.01). The PP of AIHA was greater in: (1) IgG and IgM aCL +ve than −ve patients (21.8% vs. 11.1%, p = 0.001 and 18.7% vs. 6.3%, p < 0.0001), (2) in SLE related APS than in primary APS patients (22.8% vs. 3.9% p < 0.0001), (3) in APS +ve than APS −ve SLE patients (23.2% vs. 8.4%, p = 0.01), and (4) in thrombotic APS than non-thrombotic APS/SLE patients (26.8% vs. 10%, p = 0.03). The PP of IgG/IgM aCL and LA was greater in DAT +ve than DAT −ve patients (42.4% vs. 12.8%, p < 0.0001; 26.2% vs. 12.8%, p = 0.03 and 29.2% vs. 15.7%, p = 0.004 respectively). It was found that AIHA prevalence is maximal in SLE with aPL/APS, low-moderate in SLE without aPL and minimal in PAPS. Moreover, AIHA is rightly included among the classification criteria for SLE but not for APS/aPL. The significance of an isolated DAT positivity remains unclear in this setting
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100
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Fang LW, Pan H, Shi J. [Ibrutinib treatment for 2 cases of relapsed/refractory autoimmune hemolytic anemia: a pilot study]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:412-416. [PMID: 32536139 PMCID: PMC7342072 DOI: 10.3760/cma.j.issn.0253-2727.2020.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Indexed: 11/20/2022]
Abstract
Objective: To explore the efficacy and safety of ibrutinib treatment for relapsed/refractory (R/R) primary autoimmune hemolytic anemia (AIHA) . Methods: Two cases of primary AIHA with relapse events were refractory to glucocorticoid, anti-CD20 monoclonal antibody, immunosuppressive drugs, and splenectomy (case 1 only) . Ibrutinib treatment was administered at an initial dose of 280 mg/d (420 mg/d for case 1 from the 3rd to 8th week) . Results: Both patients achieved transfusion independence and HGB>20 g/L above baseline after 2 weeks (partial response) . For case 1, HGB concentration restored to 113 g/L but with incomplete hemolysis recovery after 10 weeks; HGB reached the level of 118 g/L, also with incomplete hemolysis recovery, after 6 weeks in case 2. They all acquired complete response with incomplete hemolysis recovery (CRi) . The responses sustained 14 weeks and 10 weeks after follow-up at 16 weeks and 12 weeks, respectively. During the treatment, hematologic and nonhematologic toxicity is mild and acceptable. Conclusion: Ibrutinib alone is effective for the 2 R/R primary AIHA cases. We need further clinical trial to identify its efficacy and safety.
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Affiliation(s)
- L W Fang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Scienes and Peking Union Medical College, Tianjin 300020, China
| | - H Pan
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Scienes and Peking Union Medical College, Tianjin 300020, China
| | - J Shi
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Scienes and Peking Union Medical College, Tianjin 300020, China
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