Drug induced immune haemolytic anaemia in the Berlin Case-Control Surveillance Study

Intravascular hemolytic anemia in a patient with antibodies related to meropenem

A 76-year-old woman treated with meropenem developed intravascular hemolytic attacks. A direct antiglobulin test was positive for C3d and IgG, and drug-dependent antibody testing indicated that the antibodies were indeed drug-dependent and reacted with drug-treated RBCs and RBCs in the presence of the drug. To our knowledge, this is the first reported case in which the causative antibodies related to meropenem were identified. This case highlights the importance of maintaining a high level of suspicion for drug-induced immune hemolytic anemia in patients with explained hemolysis as well as conducting specialized serologic testing.

Ceftriaxone-induced hemolytic anemia: case report and review of literature

Ceftriaxone is a frequently used empiric antibiotic in children. Acute hemolysis is a rare side effect of ceftriaxone therapy associated with a high mortality rate. A 14-year-old boy suffering from Crohn disease developed bacterial pneumonia that was treated with ceftriaxone. We report successful management of ceftriaxone-induced hemolytic anemia (CIHA) in this patient and review the CIHA literature in pediatric patients. Early recognition of CIHA with prompt discontinuation of ceftriaxone therapy may have a beneficial role in reduction of high mortality seen in these patients.

Metamizole-induced agranulocytosis revisited: results from the prospective Berlin Case-Control Surveillance Study

PURPOSE

Treatment with metamizole (dipyrone) has steadily increased in Germany over the last decade. The consequences of this increase for metamizole-induced agranulocytosis (MIA) are unclear. The present study addressed this topic using data from the Berlin Case-Control Surveillance Study.

METHODS

Adult patients (≥18 years of age) with acute nonchemotherapy-induced agranulocytosis were identified by active surveillance in all 51 Berlin hospitals between 2000 and 2010. Cases related to metamizole were ascertained applying the drug causality criteria of the World Health Organization. The incidence rate of MIA was calculated and standardised by age and sex based on the German standard population in 2010.

RESULTS

Twenty-six MIA cases out of 88 (30 %) patients with validated agranulocytosis were ascertained. The incidence of MIA was 0.96 (95 % confidence interval (CI) 0.95-0.97) cases per million per year. The median age of MIA cases was 50 years (quartile (Q)1 31 years; Q3 68 years) and 19 (73 %) of them were women. In 17 (65 %) cases, neutrophil granulocytes dropped below the value of 0.1 × 10(9) cells/L with three patients suffering from sepsis. Headache and postoperative pain were the most frequent indications for metamizole in outpatients (n = 16) and inpatients (n = 10), respectively. The median treatment duration was 6 days (Q1 4 days; Q3 19 days).

CONCLUSIONS

MIA persists as a severe condition in current pharmacotherapy. The continuous increase of metamizole applications should be critically assessed, especially in regard to indications in the outpatient setting and with respect to metamizole treatment duration.

Severe delayed autoimmune haemolytic anaemia following artesunate administration in severe malaria: a case report

Background

Parenteral artesunate is recommended as first-line therapy for severe and complicated malaria. Although its efficacy has been proven, long-term safety profile is still under evaluation. Several cases of delayed haemolytic anaemia occurred after initial clinical improvement and resolution of parasitaemia in non-immune travellers and children living in endemic areas. Reports have generated concern that this phenomenon might be related to the treatment itself, either by direct toxicity or immune-related mechanism. This is a report of the first case of autoimmune haemolytic anaemia following treatment of severe malaria initially managed with parenteral artesunate with strong indication for drug-immune related mechanism.

Case

A 17-year old Ivoirian female travelling in France presented with fever, headache and abdominal pain seven days after her arrival. Physical examination was indicative of septic shock while blood analysis showed normal haemoglobin level, but profound thrombocytopaenia and hyperlactataemia. Blood smear analysis showed Plasmodium falciparum infection with a parasitaemia of 0.8%. Severe malaria was diagnosed according to the WHO criteria. The patient was initially managed with artemether/lumefantrine combination and then parenteral artesunate for 48 hours. Empiric antibiotic course was also initiated with ceftriaxone, metronidazole, gentamycin, and then piperacillin and ciprofloxacin. At day 14, haemoglobin dropped to 4.6 g/dL with biologic features indicative of haemolysis (LDH 658 U/L, haptoglobin <0.15 g/L). At that time, parasitaemia was negative and other infections or hereditary disorders were excluded, while Coombs’ direct antiglobulin test was positive for IgG and C3d. Antinuclear antibodies were absent. Further investigations evidenced drug-induced antibodies related to artesunate. It was concluded a drug-mediated autoimmune haemolytic anaemia. A corticosteroids regimen was initiated at 1 mg/kg/day. Outcome was favourable and corticosteroids were progressively tapered during two months. At present the patient’s condition remains stable without recurrence of haemolytic anaemia.

Conclusion

This is the first case of delayed haemolytic anaemia related to artesunate with a strong indication for drug-immune related mechanism. Further research is warranted to better characterize this plausible cause of post-treatment haemolysis following parenteral artesunate administration in severe malaria patients.

Electronic supplementary material

The online version of this article (doi:10.1186/1475-2875-13-398) contains supplementary material, which is available to authorized users.

Immune hemolytic anemia with drug-induced antibodies to carboplatin and vincristine in a pediatric patient with an optic pathway glioma

BACKGROUND

Drug-induced immune hemolytic anemia (DIIHA) is a rare, but important condition requiring specialized laboratory testing for diagnosis. We report a case of DIIHA with antibodies against carboplatin and vincristine (VCR) in a child with an optic pathway glioma. Platinum-based drugs are established to cause DIIHA; to our knowledge, this is the first report implicating VCR.

STUDY DESIGN AND METHODS

A 35-month-old girl with an optic pathway glioma developed hemolytic anemia while receiving carboplatin and VCR. Specialized blood bank testing was performed to determine the presence of drug-dependent antibodies and thus DIIHA.

RESULTS

Initial direct antiglobulin test (DAT) was negative. A repeat DAT 3 days later was positive, 3+ with polyspecific-antiglobulin sera, weak+ with anti-immunoglobulin (Ig)G, and 2+ with anti-C3d. An eluate from the DAT-positive red blood cells (RBCs) was nonreactive. The patient's serum reacted without specificity to all RBC tested using papain-IgG-antiglobulin test (AGT) and polyethylene glycol-IgG-AGT. No alloantibodies to common RBC antigens were detected. When the serum was evaluated for the presence of drug-specific antibody, reactivity was shown with VCR and carboplatin using the drug addition solution method, but only with carboplatin using the drug-coating method.

CONCLUSION

The patient developed hemolytic anemia during chemotherapy. Initial detection of a panagglutinin suggested a warm-type autoimmune process. However, since DIIHA could not be excluded, chemotherapy was discontinued and further work-up was initiated. The findings confirmed the presence of antibodies to carboplatin and VCR. This case highlights the importance for clinicians to maintain a high index of suspicion for DIIHA in patients with unexplained hemolysis and the importance of specialized serologic testing.

Reappraisal of the etiology of extracorpuscular non-autoimmune acquired hemolytic anemia in 2657 hospitalized patients with non-neoplastic disease

INTRODUCTION

Unlike autoimmune hemolytic anemia (AIHA), literature on the etiological study of non-autoimmune hemolytic anemia (non-AIHA) is scarce. The incidence and prevalence of non-AIHA in different geographic regions are largely unknown perhaps owing to the lack of perspective investigation and different profiles of etiologies from different geographic regions. We aimed to examine the real-world etiology or mechanisms of the non-hereditary non-AIHA from a nationwide population-based administrative claim database in Taiwan.

PATIENTS AND METHODS

The National Health Insurance Research Database of Taiwan was adopted for this research. The studied population was total inpatient claim records including both pediatric and adult patients, contributed by a population of 23 million insured individuals in Taiwan. From 2002 to 2008, we retrieved 3,903 patients having no pre-existing malignancy discharged after inpatient management for acquired hemolytic anemia, which was defined as coding in discharge diagnoses containing ICD-9-CM code 283. By contrast, ICD-9-CM code 282 and all of the sub-codes are for hereditary hemolytic anemias.

RESULTS

AIHA accounted for 32% of the total cases. Among 2,657 patients with non-AIHA, mechanical or microangiopathic mechanism accounted for 19% of cases; hemolytic-uremic syndrome (HUS) 4%, hemoglobinuria because of hemolysis from external causes such as paroxysmal nocturnal hemoglobinuria (PNH) and march hemoglobinuria 7%, and chronic idiopathic hemolytic anemia or other unspecified non-AIHA 69%. We looked further for specific etiology or mechanism for this group of patients with non-hereditary extrinsic non-AIHA (n = 2,657). The explanatory disease states or conditions were splenomegaly; alcohol use disorder (spur cell hemolysis); heart-valve prosthesis; malignant hypertension; disseminated intravascular coagulation; transfusion reaction; dengue fever-induced hemolytic anemia; direct parasitization; snake, lizard, or spider bite; and Wilson's disease with internal toxin mechanism. All these cases can explain up to 34.6% of all the non-hereditary extrinsic non-AIHA cases. Fragmentation hemolysis (HUS, heart-valve prosthesis, malignant hypertension, and disseminated intravascular coagulation) accounted for 7.4% of non-AIHA hospitalized patients with non-neoplastic disease.

CONCLUSIONS

This article is the first one to clearly demonstrate that the non-neoplastic-induced HUS requiring hospitalization cases in Taiwan, which has a population of over 23 million were 110 over a span of seven years, 16 cases per year. Although the etiologies of non-AIHA are well known and described in the literature, this work added the statistical percentages of the various etiologies of non-AIHA in Taiwan.

Flupirtine-induced liver injury--seven cases from the Berlin Case-control Surveillance Study and review of the German spontaneous adverse drug reaction reporting database

PURPOSE

The hepatotoxic potential of the analgesic flupirtine has attracted increased attention over the past years. Recently, risk minimisation measures such as maximum treatment duration of 2 weeks have been requested by the European Medicines Agency (EMA). This study was conducted to further elucidate the clinical pattern of flupirtine-induced liver injury (FILI).

METHODS

Seven FILI patients were ascertained in all Berlin hospitals in the Berlin Case-control Surveillance Study (FAKOS) between 2002 and 2011. Furthermore, we reviewed the severe cases of flupirtine-associated hepatotoxicity included in the adverse drug reaction database of the Federal Institute for Drugs and Medical Devices (BfArM) in Germany from between 1991 and 2012.

RESULTS

All seven FILI patients of FAKOS were hospitalised. Six of them were female, mean age was 58 [corrected] years, and the most common symptoms were fatigue and jaundice. Three patients developed acute liver failure (ALF). Discontinuation of flupirtine invariably led to clinical and laboratory improvement. Review of the BfArM cases (n = 248) showed female sex predominance and high prevalence of jaundice and ALF. Time to onset of symptoms was less than 2 weeks in 9 % of the patients with respective data.

CONCLUSIONS

Our results corroborate previous findings on FILI's clinical pattern and on its potentially severe course. Although the hepatotoxic risk might be higher after the first 2 weeks of treatment, earlier onset of severe FILI cannot be ruled out. Postauthorisation safety studies are needed to evaluate EMA's risk minimisation measures and to quantify flupirtine's risk according to its duration of use.

Drug-induced acute pancreatitis: results from the hospital-based Berlin case-control surveillance study of 102 cases

BACKGROUND

Drug toxicity is a well-known cause of acute pancreatitis (AP). Although many drugs have been associated with AP, the magnitude of the risk of most of them remains largely unknown.

AIM

To determine the pancreatotoxic risk of a wide range of drugs.

METHODS

The hospital-based Berlin case-control surveillance study, including all 51 Berlin hospitals in a hospital network, ascertained 102 cases with idiopathic AP (IAP) and 750 controls between 2002 and 2011. Patients with IAP were thoroughly validated using anamnestic, clinical or laboratory data. Drug exposure was obtained in a face-to-face interview. Possible drug aetiology was assessed in individual patients through a standardised causality assessment applying the criteria of the World Health Organization. Drug risks were further quantified [odds ratios (OR) with 95% confidence intervals (CI)] in a case-control design with unconditional logistic regression analysis.

RESULTS

The pancreatotoxic risk of several drugs, including azathioprine (OR 5.1; 95% CI 1.9-13.5), fenofibrate (OR 12.2; 95% CI 2.3-69.1), mesalazine (OR 3.3; 95% CI 1.1-9.5) or angiotensin-converting enzyme inhibitors, was corroborated by case-control analysis and causality assessment. Causality assessment suggested a pancreatotoxic potential, among others, for mercaptopurine or the seldom reported leflunomide, and alluded to a novel risk for tocilizumab. Case-control analysis showed an increased risk for two phytotherapeutics: harpagophytum and valerian radix.

CONCLUSIONS

Our study quantified the pancreatotoxic risk of different drugs and phytotherapeutics. The findings corroborate previous results from the literature but also indicate risks for substances not previously reported, highlighting the need for further controlled studies on pancreatic toxicity.

Puerarin-induced immune hemolytic anemia

Drug-induced immune hemolytic anemia (DIIHA) is a relatively uncommon condition characterized by a sudden drop in hemoglobin, putatively following exposure to drugs. Severe forms of hemolysis characterized by rapidly falling hemoglobin levels and hemoglobinuria are extremely rare. Here we report the case of a patient who exhibited severe DIIHA due to puerarin. Direct antiglobulin testing and drug-dependent antibody testing indicated that the antibodies were drug-dependent and reacted only with RBCs in the presence of the drug. Puerarin is the major isoflavonoid derived from the Chinese medical herb Radix puerariae, and has not yet been widely reported as associated with DIIHA. These results suggest that puerarin may be a cause of severe hemolysis and should be used with caution.

A perspective on the role of extracellular hemoglobin on the innate immune system

Host cell-derived danger-associated molecular patterns (DAMPs), such as the hemoglobin (Hb) can interact with the innate immune system either directly or through binding to pathogen-associated molecular patterns (PAMPs). Hemolysis occurs under various pathological conditions, leading to hemoglobinemia. In the extracellular environment, the Hb becomes a redox-reactive DAMP molecule. In severe hemolysis, the massive level of extracellular pro-oxidative Hb generates reactive oxygen species (ROS), which perturbs the innate immune homeostasis. The Hb also binds to PAMPs and triggers Toll-like receptor-mediated signal transduction. In this perspective, we review the roles of cell-free Hb in the innate immune system, focusing on the plausible interactions among Hb, pathogens, host cell components, and innate immune cells, all of which remain to be explored with experiential detail.

Hemolytic anemia in adults: main causes and diagnostic procedures

Hemolytic anemia is not an exceptional situation in adults. Although establishing the hemolytic mechanism of an anemia is usually rather easy, finding the etiology may be quite difficult as both hereditary (corpuscular) and acquired causes of hemolytic anemia may occur during adulthood. The diagnosis of hemolytic anemia, therefore, requires a multistep procedure taking into account both the patient's and family history, a careful analysis of the blood smear and a direct antiglobulin test. Based on these first data, the diagnostic procedure may then require more specific tests whose indications are discussed in this review.

Severe sustained cholestatic hepatitis following temozolomide in a patient with glioblastoma multiforme: case study and review of data from the FDA adverse event reporting system

Glioblastoma multiforme (GBM) is the most frequent malignant brain tumor in adults. Its established first-line adjuvant treatment is radiotherapy in combination with temozolomide (TZM). Hematotoxicity is listed as a frequent adverse drug reaction in the US prescribing information and hepatotoxicity has been reported infrequently in the postmarketing period. We here present the case of a patient diagnosed with GBM who developed severe sustained cholestatic hepatitis following treatment with TZM. The cholestasis was not reversible after withdrawal of TZM during 6 months before the patient's death. Another 2 published case reports of sustained cholestasis following TZM treatment were identified; however, the sustained nature of cholestasis was not emphasized in these reports. Sixteen cases of cholestatic hepatitis/cholestasis associated with TZM were identified in the FDA spontaneous reporting system between 2007 and 2010. Information on the course of the cholestasis in these cases could not be retrieved. In the literature there are other published reports of hepatotoxicity associated with TZM that have reported reversibility upon withdrawal of the drug. Thus, TZM appears to cause different types of hepatotoxicity. Particular attention should be paid to sustained cholestasis as a very serious type of TZM-associated liver toxicity.

Piperacillin-induced immune hemolysis presenting with tachycardia and cardiac arrest

A 20-year-old nonverbal patient with profound developmental disabilities was treated with intravenous piperacillin-tazobactam for respiratory infection. After 8 days, he became afebrile with normal pulmonary status, but his pulse remained inexplicably rapid (114/minute). Investigations revealed severe normochromic normocytic hemolytic anemia (hemoglobin: 40 g/L, reticulocytes: 9.4%, nucleated erythrocytes: 5%). While being hospitalized, patient experienced sudden cardiac arrest from which he was successfully resuscitated. He had no blood loss or intrinsic heart disease to explain the acute anemia or cardiac arrest. He had uneventfully received piperacillin-tazobactam on 7 occasions during the preceding 5 years for >50 days. Patient was treated with intravenous crystalloids, methylprednisolone and transfusion of 3 units of packed erythrocytes. Piperacillin-tazobactam was discontinued. A direct antiglobulin test was positive for immunoglobulin G and complement. Antibody to piperacillin was detected in patient's serum by the “immune-complex” method confirming “piperacillin-induced immune hemolytic anemia (PIHA)”. On discharge (day 15), patient's hemoglobin improved to 115 g/L (baseline: 131 g/L). Vigilant clinical and hematological monitoring for anemia is indicated in piperacillin-treated patients, particularly in those unable to verbalize their discomfort. Repeated piperacillin exposure may sensitize and predispose patients to PIHA.