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Jaime-Pérez JC, Aguilar-Calderón PE, Salazar-Cavazos L, Gómez-Almaguer D. Evans syndrome: clinical perspectives, biological insights and treatment modalities. J Blood Med 2018; 9:171-184. [PMID: 30349415 PMCID: PMC6190623 DOI: 10.2147/jbm.s176144] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Evans syndrome (ES) is a rare and chronic autoimmune disease characterized by autoimmune hemolytic anemia and immune thrombocytopenic purpura with a positive direct anti-human globulin test. It is classified as primary and secondary, with the frequency in patients with autoimmune hemolytic anemia being 37%–73%. It predominates in children, mainly due to primary immunodeficiencies or autoimmune lymphoproliferative syndrome. ES during pregnancy is associated with high fetal morbidity, including severe hemolysis and intracranial bleeding with neurological sequelae and death. The clinical presentation can include fatigue, pallor, jaundice and mucosal bleeding, with remissions and exacerbations during the person’s lifetime, and acute manifestations as catastrophic bleeding and massive hemolysis. Recent molecular theories explaining the physiopathology of ES include deficiencies of CTLA-4, LRBA, TPP2 and a decreased CD4/CD8 ratio. As in other autoimmune cytopenias, there is no established evidence-based treatment and steroids are the first-line therapy, with intravenous immunoglobulin administered as a life-saving resource in cases of severe immune thrombocytopenic purpura manifestations. Second-line treatment for refractory ES includes rituximab, mofetil mycophenolate, cyclosporine, vincristine, azathioprine, sirolimus and thrombopoietin receptor agonists. In cases unresponsive to immunosuppressive agents, hematopoietic stem cell transplantation has been successful, although it is necessary to consider its potential serious adverse effects. In conclusion, ES is a disease with a heterogeneous course that remains challenging to patients and physicians, with prospective clinical trials needed to explore potential targeted therapy to achieve an improved long-term response or even a cure.
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Affiliation(s)
- José Carlos Jaime-Pérez
- Department of Hematology, Internal Medicine Division, Dr José E González University Hospital, School of Medicine of the Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,
| | - Patrizia Elva Aguilar-Calderón
- Department of Hematology, Internal Medicine Division, Dr José E González University Hospital, School of Medicine of the Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,
| | - Lorena Salazar-Cavazos
- Department of Hematology, Internal Medicine Division, Dr José E González University Hospital, School of Medicine of the Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,
| | - David Gómez-Almaguer
- Department of Hematology, Internal Medicine Division, Dr José E González University Hospital, School of Medicine of the Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,
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2
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Abstract
Primary Evans syndrome (ES) is defined by the concurrent or sequential occurrence of immune thrombocytopenia and autoimmune hemolytic anemia in the absence of an underlying etiology. The syndrome is characterized by a chronic, relapsing, and potentially fatal course requiring long-term immunosuppressive therapy. Treatment of ES is hardly evidence-based. Corticosteroids are the mainstay of therapy. Rituximab has emerged as the most widely used second-line treatment, as it can safely achieve high response rates and postpone splenectomy. An increasing number of new genetic defects involving critical pathways of immune regulation identify specific disorders, which explain cases of ES previously reported as "idiopathic".
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3
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Abstract
Evans syndrome is an underdiagnosed condition consisting of simultaneous or sequential combination of autoimmune hemolytic anemia and immune-mediated thrombocytopenia. We report a case of severe Evans syndrome presenting as altered mental status, a rare presenting sign of the disease. This case highlights the difficulty in diagnosing Evans syndrome and provides a review of the literature and management strategies for treating the disorder.
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4
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Damlaj M, Séguin C. Refractory autoimmune hemolytic anemia in a patient with DiGeorge syndrome treated successfully with plasma exchange: a case report and review of the literature. Int J Hematol 2014; 100:494-7. [DOI: 10.1007/s12185-014-1648-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 07/17/2014] [Accepted: 07/18/2014] [Indexed: 10/25/2022]
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5
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Li Y, Pankaj P, Wang X, Wang Y, Peng B. Splenectomy in the management of Evans syndrome in adults: Long-term follow up of 32 patients. SURGICAL PRACTICE 2014. [DOI: 10.1111/1744-1633.12043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Yongbin Li
- Department of Hepatopancreatobiliary Surgery; West China Hospital; Sichuan University; Chengdu China
| | - Prasoon Pankaj
- Department of Hepatopancreatobiliary Surgery; West China Hospital; Sichuan University; Chengdu China
| | - Xin Wang
- Department of Hepatopancreatobiliary Surgery; West China Hospital; Sichuan University; Chengdu China
| | - Yichao Wang
- Department of Hepatopancreatobiliary Surgery; West China Hospital; Sichuan University; Chengdu China
| | - Bing Peng
- Department of Hepatopancreatobiliary Surgery; West China Hospital; Sichuan University; Chengdu China
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Simon OJ, Kuhlmann T, Bittner S, Müller-Tidow C, Weigt J, Wiendl H, Meuth SG. Evans syndrome associated with sterile inflammation of the central nervous system: a case report. J Med Case Rep 2013; 7:262. [PMID: 24299473 PMCID: PMC3879039 DOI: 10.1186/1752-1947-7-262] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Accepted: 10/14/2013] [Indexed: 12/05/2022] Open
Abstract
Introduction Evans syndrome is a rare hematological disease commonly defined as Coombs-positive hemolytic anemia and immune thrombocytopenia. Pathophysiology of this disease involves decreased cluster of differentiation (CD)4+ T-helper cell counts, increased CD8+ T-suppressor cell counts, a decreased CD4/CD8 ratio, and reduced serum immunoglobulin G, M and A levels - indicating a complex immune dysregulation. Association with other autoimmune diseases has been described although involvement of the central nervous system has not been reported so far. Case presentation We here present a case of a 28-year-old woman of Turkish origin with progressive, disseminated, partly mass-forming lymphoplasmacellular infiltration (CD3+ and CD138+ cells) of the brain in association with Evans syndrome. No other central nervous system disorder could be identified on neuropathological evaluation. Although treatment with rituximab was effective to normalize erythrocyte and thrombocyte levels in her peripheral blood, it failed to dampen the inflammation in her central nervous system or prevent clinical progression. Initiation of treatment with cyclophosphamide resulted in stabilization of her central nervous system inflammation and the disease course. Conclusions The complex immune dysregulation resulting in the antibody-mediated pathologies that can be regarded as the cause of both lymphoplasmacellular encephalitis and Evans syndrome renders this association to be of clinical relevance for both neurologists and hematologists. Our experience also sheds light on the effectiveness of different treatments for both disorders and we advise clinicians to take a closer look when encountering a combination of peripheral blood diseases with affection of the central nervous system.
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Affiliation(s)
| | | | | | | | | | | | - Sven G Meuth
- Department of Neurology, University of Muenster, Muenster, Germany.
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7
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Wright DE, Rosovsky RP, Platt MY. Case records of the Massachusetts General Hospital. Case 36-2013. A 38-year-old woman with anemia and thrombocytopenia. N Engl J Med 2013; 369:2032-43. [PMID: 24256382 DOI: 10.1056/nejmcpc1215972] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
MESH Headings
- Adult
- Anemia/etiology
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/etiology
- Anemia, Hemolytic, Autoimmune/therapy
- Antibodies, Antinuclear/blood
- Bone Marrow/pathology
- Coombs Test
- Diagnosis, Differential
- Fatigue/etiology
- Female
- Glucocorticoids/therapeutic use
- Humans
- Lupus Erythematosus, Systemic/complications
- Lupus Erythematosus, Systemic/diagnosis
- Splenectomy
- Syndrome
- Thrombocytopenia/etiology
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8
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Transient effect of anti-CD20 therapy in a child with 22q11.2 deletion syndrome and severe steroid refractory cytopenias: a case report. J Pediatr Hematol Oncol 2013; 35:311-4. [PMID: 23612383 DOI: 10.1097/mph.0b013e31828be602] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
We report on the development of steroid-refractory recurrent cytopenias in a child with 22q11.2 deletion syndrome. His first hematological complication was autoimmune hemolytic anemia at 3 months of age. Thereafter, he developed severe autoimmune cytopenias of all 3 hematological lineages with poor response to steroids and intravenous immunoglobulin. At the age of 2½ years, a course of anti-CD20 therapy (Rituximab) was given with transient hematological recovery. Because of persistent symptoms, bone marrow transplantation from a matched unrelated donor was performed. Although the data in the use of anti-CD20 therapy in children with 22q11.2 deletion syndrome and autoimmune cytopenias are limited, our experience suggests its potential benefit.
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9
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Stiakaki E, Perdikogianni C, Thomou C, Markaki EA, Katzilakis N, Tsirigotaki M, Kalmanti M. Idiopathic thrombocytopenic purpura in childhood: twenty years of experience in a single center. Pediatr Int 2012; 54:524-7. [PMID: 22647082 DOI: 10.1111/j.1442-200x.2012.03606.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder with a variable clinical course. METHODS A retrospective analysis was carried out of ITP patients presenting to a pediatric hematology-oncology department during a period of 20 years, with a focus on treatment and outcome. RESULTS One hundred and twenty-four cases were recorded (mean patient age, 8.4 years). Forty-nine children (39.5%) had platelet counts <10,000/µL at diagnosis. No episode of severe bleeding was observed. Peak incidence was observed during spring and summer. Respiratory infections proceeded in 58% of cases. Treatment consisted of i.v. immunoglobulin (IVIG) in 93 children at four dosing schedules. Sixteen children received corticosteroids, 10 children received anti-D immunoglobulin and 14 received no treatment. Recovery was observed in 67% of children on IVIG and in 50% on anti-D globulin. Eight patients did not respond initially and received corticosteroids. Three children with refractory thrombocytopenia received anti-CD20 (rituximab). Fourteen children (11%) had persistent/chronic disease. In 10 of them recovery was observed in 13 months-8 years. Splenectomy was performed in six children with resistant/chronic disease. CONCLUSION ITP has a benign course in the majority of cases. Anti-D globulin can effectively be used as an alternative first-line treatment. Rituximab can successfully be used in refractory cases, while splenectomy has currently limited indications.
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Affiliation(s)
- Eftichia Stiakaki
- Department of Pediatric Hematology-Oncology, University of Crete, Heraklion, Crete, Greece
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10
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Atay D, Oztürk G, Anak S, Devecioğlu O, Unüvar A, Karakaş Z, Ağaoğlu L. Rituximab therapy for refractory autoimmune thrombocytopenia in patients with systemic lupus erythematosus. Turk J Haematol 2012; 29:92-3. [PMID: 24744634 PMCID: PMC3986779 DOI: 10.5505/tjh.2012.26539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 09/19/2011] [Indexed: 01/19/2023] Open
Affiliation(s)
- Didem Atay
- Okmeydani Education and Research Hospital, Department of Pediatric Hematology and Oncology, İstanbul, Turkey
| | - Gülyüz Oztürk
- Istanbul University, Istanbul School of Medicine, Department of Pediatric Hematology, Oncology, BMT, İstanbul, Turkey
| | - Sema Anak
- Istanbul University, Istanbul School of Medicine, Department of Pediatric Hematology, Oncology, BMT, İstanbul, Turkey
| | - Omer Devecioğlu
- Istanbul University, Istanbul School of Medicine, Department of Pediatric Hematology, Oncology, BMT, İstanbul, Turkey
| | - Ayşegül Unüvar
- Istanbul University, Istanbul School of Medicine, Department of Pediatric Hematology, Oncology, BMT, İstanbul, Turkey
| | - Zeynep Karakaş
- Istanbul University, Istanbul School of Medicine, Department of Pediatric Hematology, Oncology, BMT, İstanbul, Turkey
| | - Leyla Ağaoğlu
- Istanbul University, Istanbul School of Medicine, Department of Pediatric Hematology, Oncology, BMT, İstanbul, Turkey
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11
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Oh HJ, Yun MJ, Lee ST, Lee SJ, Oh SY, Sohn I. Evans syndrome following long-standing Hashimoto's thyroiditis and successful treatment with rituximab. THE KOREAN JOURNAL OF HEMATOLOGY 2011; 46:279-82. [PMID: 22259635 PMCID: PMC3259521 DOI: 10.5045/kjh.2011.46.4.279] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 07/26/2011] [Accepted: 11/14/2011] [Indexed: 12/03/2022]
Abstract
We report a case of a 51-year-old woman with Evans syndrome (autoimmune hemolytic anemia and primary immune thrombocytopenia) and hypothyroidism. She was previously diagnosed with Hashimoto's thyroiditis in 1994 (age, 35) and autoimmune hemolytic anemia (AIHA) 3 years ago. She was treated with oral prednisolone. After a period, in which the anemia waxed and waned, there was an abrupt development of thrombocytopenia (nadir 15×109/L) that coincided with the tapering off of prednisolone after 3 years of administration. Because her thrombocytopenia was refractory to prednisolone, we administered rituximab (375 mg/m2 weekly) for 4 weeks. Two weeks after the completion of the rituximab treatment, her platelet count was up to 92×109/L. No intermittent peaking of thyroid stimulating hormone occurred after rituximab treatment was initiated. Evans syndrome and autoimmune thyroiditis might share common pathophysiological mechanisms. This notion supports the use of rituximab in a patient suffering from these disorders.
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Affiliation(s)
- Hye Jin Oh
- Department of Internal Medicine, Seoul Medical Center, Seoul, Korea
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12
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Gonzalez-Nieto JA, Martin-Suarez I, Quattrino S, Ortiz-Lopez E, Muñoz-Beamud FR, Colchero-Fernández J, Alcoucer-Diaz MR. The efficacy of romiplostim in the treatment of severe thrombocytopenia associated to Evans syndrome refractory to rituximab. Lupus 2011; 20:1321-3. [PMID: 21719526 DOI: 10.1177/0961203311404913] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We present a case of a man diagnosed with systemic lupus erythematosus, associated antiphospholipid syndrome and Evans syndrome, who developed a severe thrombocytopenia refractory to treatment with first-line drugs, cyclophosphamide and rituximab, and who responded to romiplostim with a normalization of the platelet recount, which later enabled a therapeutic splenectomy to be performed.
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MESH Headings
- Adult
- Anemia, Hemolytic, Autoimmune/blood
- Anemia, Hemolytic, Autoimmune/complications
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/surgery
- Antibodies, Monoclonal, Murine-Derived/therapeutic use
- Antiphospholipid Syndrome/complications
- Antiphospholipid Syndrome/drug therapy
- Cyclophosphamide/therapeutic use
- Humans
- Lupus Erythematosus, Systemic/complications
- Lupus Erythematosus, Systemic/drug therapy
- Male
- Platelet Count
- Receptors, Fc/therapeutic use
- Recombinant Fusion Proteins/therapeutic use
- Rituximab
- Splenectomy
- Thrombocytopenia/blood
- Thrombocytopenia/complications
- Thrombocytopenia/drug therapy
- Thrombocytopenia/etiology
- Thrombocytopenia/surgery
- Thrombopoietin/therapeutic use
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Affiliation(s)
- J A Gonzalez-Nieto
- Autoimmune Diseases Unit, Internal Medicine Department, Juan Ramón Jimenez Hospital, Huelva, Spain
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13
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Ryeon lee S, Lee SY, Nam MH, Park Y, Jong park S, Jung sung H, Won choi C, Soo kim B. Successful control of steroid-intolerant Evans' syndrome associated with allogeneic peripheral blood hematopoietic stem cell transplant by rituximab. Leuk Lymphoma 2011; 52:528-30. [DOI: 10.3109/10428194.2010.538940] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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14
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Tratamiento con rituximab para la trombocitopenia secundaria a lupus eritematoso sistémico. ACTA ACUST UNITED AC 2010; 6:82-5. [DOI: 10.1016/j.reuma.2009.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2009] [Revised: 04/01/2009] [Accepted: 04/16/2009] [Indexed: 11/23/2022]
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15
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Abstract
Immune thrombocytopenia (ITP) is mediated by platelet autoantibodies that accelerate platelet destruction and inhibit their production. Most cases are considered idiopathic, whereas others are secondary to coexisting conditions. Insights from secondary forms suggest that the proclivity to develop platelet-reactive antibodies arises through diverse mechanisms. Variability in natural history and response to therapy suggests that primary ITP is also heterogeneous. Certain cases may be secondary to persistent, sometimes inapparent, infections, accompanied by coexisting antibodies that influence outcome. Alternatively, underlying immune deficiencies may emerge. In addition, environmental and genetic factors may impact platelet turnover, propensity to bleed, and response to ITP-directed therapy. We review the pathophysiology of several common secondary forms of ITP. We suggest that primary ITP is also best thought of as an autoimmune syndrome. Better understanding of pathogenesis and tolerance checkpoint defects leading to autoantibody formation may facilitate patient-specific approaches to diagnosis and management.
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16
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Rückert A, Glimm H, Lübbert M, Grüllich C. Successful treatment of life-threatening Evans syndrome due to antiphospholipid antibody syndrome by rituximab-based regimen: a case with long-term follow-up. Lupus 2008; 17:757-60. [PMID: 18625656 DOI: 10.1177/0961203307087876] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
An association of antiphospholipid antibody syndrome with antibodies directed against either phospholipids or plasma proteins strongly suggest that B-cell dysfunction may be involved in its pathogenesis. Antiphospholipid antibody syndrome with autoimmune cytopenias shows a poor response rate to conventional treatment with anticoagulants, glucocorticosteroids, immunosuppressive agents, intravenous immunoglobulin or plasmapheresis. We report a case of life-threatening antiphospholipid antibody syndrome with Evans syndrome receiving successful multimodal treatment including anti-CD20 monoclonal antibody rituximab with long-term follow-up.
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Affiliation(s)
- A Rückert
- Department of Internal Medicine, Haematology and Oncology, Albert-Ludwigs University Freiburg, Hugstetter Strasse 55, Freiburg, Germany
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17
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Kittaka K, Dobashi H, Baba N, Iseki K, Kameda T, Susaki K, Kitanaka A, Kubota Y, Ishida T. A case of Evans syndrome combined with systemic lupus erythematosus successfully treated with rituximab. Scand J Rheumatol 2008; 37:390-3. [PMID: 18609263 DOI: 10.1080/03009740802068599] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Evans syndrome is a rare autoimmune disorder with unknown aetiology. Although corticosteroids and/or intravenous immunoglobulin (IVIG) are commonly used in its treatment, no standard strategy has been established. We report here a 44-year-old male with refractory Evans syndrome combined with systemic lupus erythematosus (SLE) who responded well to rituximab. He was admitted to our hospital with severe bleeding caused by worsening of Evans syndrome. Despite treatment with a high-dose corticosteroid and IVIG, his thrombocytopaenia and haemolytic anaemia did not improve. We started rituximab at a dose of 375 mg/m(2) once a week for a total of two doses. There was significant improvement in his thrombocytopaenia and anaemia 1 month after administration of rituximab. Although the total immunoglobulin G (IgG) level did not change, the titres of platelet-associated IgG (PA-IgG) and of an indirect antiglobulin test (IAT) decreased under the treatment with rituximab. It is suggested that rituximab would be a powerful candidate in the treatment of refractory Evans syndrome by depleting abnormal clone-producing autoantibody.
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Affiliation(s)
- K Kittaka
- Division of Endocrinology and Metabolism, Haematology, Rheumatology and Respiratory Medicine, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
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18
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Aleem A. Rituximab therapy in a patient with autoimmune hemolytic anemia and immune thrombocytopenia associated with chronic lymphocytic leukemia. Ann Saudi Med 2008; 28:382-5. [PMID: 18779631 PMCID: PMC6074481 DOI: 10.5144/0256-4947.2008.382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Aamer Aleem
- Department of Medicine, Division of Hematology/Oncology, College of Medicine & King Khalid University Hospital, Riyadh, Saudi Arabia.
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19
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Consolidation treatment with rituximab induces complete and persistent remission of mixed type Evans syndrome. Blood Coagul Fibrinolysis 2008; 19:315-8. [PMID: 18469554 DOI: 10.1097/mbc.0b013e3282f9ae12] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We describe a 58-year-old woman affected by immune thrombocytopenic purpura (ITP) since 1999, well controlled by low doses of steroid for 4 years, who experienced a relapse with severe mixed type Evans syndrome in March 2006. After an initial response to high doses of steroid, severe anaemia recurred 2 months later, this time resistant to second-line therapy with intravenous immunoglobulins (IVIG) and cyclophosphamide. So in May, we started the treatment with anti-CD20 monoclonal antibody rituximab with the dose of 375 mg/m2 once weekly for a total of four doses. We obtained a full normalization of haemoglobin concentration, but the disease haemolytic parameters persisted. Therefore, we decided to treat the patient with two monthly courses of rituximab, and a gradual normalization of haptoglobin and lactate dehydrogenase (LDH) plasma levels was finally achieved, with a sustained response up to date, lasting more than 12 months. We conclude that rituximab treatment is effective in refractory patients with mixed type Evans syndrome, and consolidation therapy should be considered to prolong beneficial effects achieved during the induction.
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20
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Arkfeld DG. The potential utility of B cell-directed biologic therapy in autoimmune diseases. Rheumatol Int 2008; 28:205-15. [PMID: 17957371 PMCID: PMC2134974 DOI: 10.1007/s00296-007-0471-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Accepted: 09/28/2007] [Indexed: 12/28/2022]
Abstract
Increasing awareness of the importance of aberrant B cell regulation in autoimmunity has driven the clinical development of novel B cell-directed biologic therapies with the potential to treat a range of autoimmune disorders. The first of these drugs-rituximab, a chimeric monoclonal antibody against the B cell-specific surface marker CD20-was recently approved for treating rheumatoid arthritis in patients with an inadequate response to other biologic therapies. The aim of this review is to discuss the potential use of rituximab in the management of other autoimmune disorders. Results from early phase clinical trials indicate that rituximab may provide clinical benefit in systemic lupus erythematosus, Sjögren's syndrome, vasculitis, and thrombocytopenic purpura. Numerous case reports and several small pilot studies have also been published reporting the use of rituximab in conditions such as myositis, antiphospholipid syndrome, Still's disease, and multiple sclerosis. In general, the results from these preliminary studies encourage further testing of rituximab therapy in formalized clinical trials. Based on results published to date, it is concluded that rituximab, together with other B cell-directed therapies currently under clinical development, is likely to provide an important new treatment option for a number of these difficult-to-treat autoimmune disorders.
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Affiliation(s)
- D G Arkfeld
- Division of Rheumatology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA.
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21
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Silvana B, Antonella LM, Basilia P, Trombetta D, Saija A, Salpietro C. Rituximab for the treatment of post-bone marrow transplantation refractory hemolytic anemia in a child with Omenn's syndrome. Pediatr Transplant 2007; 11:552-6. [PMID: 17631027 DOI: 10.1111/j.1399-3046.2007.00678.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Omenn's syndrome is a rare severe combined immunodeficiency that kills affected subjects before the end of the first year of life unless patients are treated with bone marrow transplantation (BMT). Unfortunately, post-BMT patients may develop autoimmune diseases, such as autoimmune hemolytic anemia (AIHA), which sometimes fails to respond to standard therapies. Rituximab is a chimeric, human, immunoglobulin G1/k monoclonal antibody specific for the CD20 antigen expressed on the surface of B lymphocytes. Rituximab is currently only labeled for treatment of B-cell lymphoproliferative disorders, such as B-cell non-Hodgkin's lymphoma and follicular lymphoma; however, it is also employed in the treatment of a variety of disorders mediated by auto-antibodies, such as AIHA and transplant-related autoimmune disorders. Herein, we describe the case of a 23-month-old male child with Omenn's syndrome, who had undergone BMT and was successfully treated with rituximab (375 mg/m(2) intravenously, weekly for three times) for refractory post-BMT hemolytic anemia. Our findings evidence that rituximab should be considered for treatment of post-BMT AIHA refractory to traditional therapy also in children with primary immunodeficiencies; furthermore, rituximab might represent a means to obtain remissions without the toxic effects associated with corticosteroid and immunosuppressive agents.
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Affiliation(s)
- Briuglia Silvana
- Paediatric Therapy, Operative Unit of Genetic and Immunology Paediatrics, University of Messina, Contrada Annunziata, 98168 Messina, Italy
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22
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Schweizer C, Reu FJ, Ho AD, Hensel M. Low rate of long-lasting remissions after successful treatment of immune thrombocytopenic purpura with rituximab. Ann Hematol 2007; 86:711-7. [PMID: 17622529 DOI: 10.1007/s00277-007-0335-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2006] [Accepted: 03/19/2007] [Indexed: 01/20/2023]
Abstract
Idiopathic thrombocytopenic purpura (ITP), also known as immune thrombocytopenic purpura, is thought to be caused primarily by the production of autoantibodies directed against platelet surface glycoproteins. Treatment of an acute ITP episode can be difficult, and relapses are common. Recent studies have shown that the anti-CD20 antibody rituximab is effective in the treatment of relapsed and refractory patients. We report the results of a retrospective analysis of rituximab treatment in 14 patients with immune thrombocytopenic purpura. Nine of these patients had a refractory disease, and five patients had a relapse of the thrombocytopenia. The median time since last treatment was 10 days (range 1-470 days). All patients were previously treated with one to seven different regimens, and four had undergone splenectomy. Rituximab was administered at the standard dose of 375 mg/m(2) once per week with a median of 4 infusions (range 2-4). The overall response rate was 64%; 7 of 14 patients (50%) achieved a complete remission (platelet levels > 100 x 10(9)/l), 2 of 14 patients (14%) had a partial remission (platelets > 50 x 10(9)/l), and 5 patients did not respond. The median time to response was 2 weeks (range 1-4) after the first infusion. Responding patients stayed in remission for a median period of 8 weeks (range 10 days-36 months). Three patients (21%) remained in remission after 26 to 156 weeks of follow-up. All of the four splenectomized patients achieved a complete remission after rituximab therapy, and two of them are still in remission after 26 and 156 weeks observation. Our data confirm that rituximab is well tolerated and effective in refractory and relapsed immune thrombocytopenias; however, response duration was short, and only about one fifth of our patients enjoyed a long-lasting remission.
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MESH Headings
- Acute Disease
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal, Murine-Derived
- Autoantibodies/immunology
- Female
- Follow-Up Studies
- Humans
- Immunologic Factors/administration & dosage
- Male
- Middle Aged
- Platelet Count
- Platelet Membrane Glycoproteins/immunology
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Remission Induction
- Retrospective Studies
- Rituximab
- Splenectomy
- Time Factors
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Affiliation(s)
- Christof Schweizer
- Department of Internal Medicine V, Haematology, Oncology and Rheumatology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
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Pinto A, Lindemeyer RG, Alawi F. Management of a young patient with combined autoimmunity: Evans syndrome: a case report. ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY, AND ENDODONTICS 2007; 103:505-11. [PMID: 17095266 DOI: 10.1016/j.tripleo.2006.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2006] [Revised: 07/19/2006] [Accepted: 07/25/2006] [Indexed: 05/12/2023]
Abstract
Management of patients with autoimmune disease can present a challenge for clinicians. Combinations of autoimmune disorders carry a worse prognosis and are often difficult to diagnose. Evans syndrome is a rare hematologic disorder characterized by the concurrent presentation of autoimmune hemolytic anemia and immune thrombocytopenic purpura. This paper reports the first case of the dental management of a young patient with Evans, discusses the current literature surrounding the differential diagnosis and treatment of Evans syndrome, and suggests a guide for the oral medicine, pediatric dentist, or hospital dental clinician when treating these patients.
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Affiliation(s)
- Andres Pinto
- Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, PA, USA.
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24
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Abstract
Primary biliary cirrhosis associated with autoimmune haemolytic anaemia and thrombocytopaenia has rarely been reported in adults. We are presenting an 83-year-old woman with primary biliary cirrhosis who was also diagnosed with autoimmune haemolytic anaemia and idiopathic thrombocytopaenic purpura.
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MESH Headings
- Aged, 80 and over
- Anemia, Hemolytic, Autoimmune/complications
- Anemia, Hemolytic, Autoimmune/diagnosis
- Female
- Humans
- Liver Cirrhosis, Biliary/complications
- Liver Cirrhosis, Biliary/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/complications
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Syndrome
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Affiliation(s)
- A Azad
- Department of General Medicine, The Northern Hospital, Epping, Vic., Australia.
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25
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AZAD A, BERERA V, JAYARAJAN J, LIM K. Evans syndrome and primary biliary cirrhosis. Int J Lab Hematol 2006. [DOI: 10.1111/j.1365-2257.2006.00831.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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26
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Klepfish A, Rachmilevitch E, Schattner A. Parvovirus B19 reactivation presenting as neutropenia after rituximab treatment. Eur J Intern Med 2006; 17:505-7. [PMID: 17098597 DOI: 10.1016/j.ejim.2006.05.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2006] [Revised: 04/23/2006] [Accepted: 05/11/2006] [Indexed: 01/13/2023]
Abstract
A patient with primary biliary cirrhosis and associated refractory immune thrombocytopenic purpura was treated with 4 weekly courses of rituximab, a monoclonal antibody targeting B-cell surface antigen CD20. Her thrombocyte count and even cholestatic liver function tests improved. However, 17 weeks after rituximab treatment, she developed severe neutropenia (absolute neutrophil count 0.23x10(3)/mul) and recurrent thrombocytopenia with abnormal bone marrow of all three lineages. Although delayed-onset neutropenia has been reported after rituximab, reactivated viral infections have also been encountered. Parvovirus B19 was suspected and confirmed as the cause of neutropenia in our patient. The patient was supported by GCSF treatment and recovered uneventfully after several weeks. Neutropenia after rituximab can also be the predominant manifestation of reactivated parvovirus B19 infection and have a favorable prognosis.
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Affiliation(s)
- A Klepfish
- Hematology Institute, Wolfson Medical Centre, Tel Aviv and Sackler Medical School, Jerusalem, Israel
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27
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Miale TD, Wong JYC, Ahmed I, Wagman LD. Multimodal management, including precisely targeted irradiation, in a severe refractory case of Evans syndrome. Pediatr Blood Cancer 2006; 47:726-8. [PMID: 16933267 DOI: 10.1002/pbc.20976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A challenging case of acute autoimmune thrombocytopenia (ITP) which evolved into a chronic refractory case of Evans syndrome over a period of more than 23 years is presented and may illustrate current therapeutic dilemmas now perplexing patients and clinicians. Newer modalities are being developed and their eventual role in the scheme of clinical management remains to be established. While this development unfolds, highly targeted radiotherapy was applied in this case to reduce platelet uptake by a refractory recurrent splenule with the goal of stabilizing the platelet count until promising investigational thrombopoietic agents or other newer, less toxic therapies might become available for wider application.
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MESH Headings
- Adult
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/radiotherapy
- Anemia, Hemolytic, Autoimmune/surgery
- Disease Management
- Female
- Humans
- Platelet Count
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/radiotherapy
- Purpura, Thrombocytopenic, Idiopathic/surgery
- Radiotherapy/instrumentation
- Radiotherapy/methods
- Recurrence
- Severity of Illness Index
- Splenectomy
- Syndrome
- Thrombocytopenia/drug therapy
- Thrombocytopenia/surgery
- Treatment Outcome
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Affiliation(s)
- Thomas D Miale
- Pediatric Hematology-Oncology Section, Fort Sanders Regional Medical Center, Knoxville, Tennessee 37950-0642, USA.
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28
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Abstract
Evans syndrome is an uncommon condition defined by the combination (either simultaneously or sequentially) of immune thrombocytopenia (ITP) and autoimmune haemolytic anaemia (AIHA) with a positive direct antiglobulin test (DAT) in the absence of known underlying aetiology. This condition generally runs a chronic course and is characterised by frequent exacerbations and remissions. First-line therapy is usually corticosteroids and/or intravenous immunoglobulin, to which most patients respond; however, relapse is frequent. Options for second-line therapy include immunosuppressive drugs, especially ciclosporin or mycophenolate mofetil; vincristine; danazol or a combination of these agents. More recently a small number of patients have been treated with rituximab, which induces remission in the majority although such responses are often sustained for <12 months and the long-term effects in children are unclear. Splenectomy may also be considered although long-term remissions are less frequent than in uncomplicated ITP. For very severe and refractory cases stem cell transplantation (SCT) offers the only chance of long-term cure. The limited data available suggest that allogeneic SCT may be superior to autologous SCT but both carry risks of severe morbidity and of transplant-related mortality. Cure following reduced-intensity conditioning has now been reported and should be considered for younger patients in the context of controlled clinical trials.
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Affiliation(s)
- Alice Norton
- Paediatric Haematology, Department of Paediatrics, St Mary's Hospital, Paddington, London, UK
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29
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Abstract
Abstract
Autoimmune hemolytic anemia (AIHA) is most often idiopathic. However, in recent years, AIHA has been noted with increased incidence in patients receiving purine nucleoside analogues for hematologic malignancies; it has also been described as a complication of blood transfusion in patients who have also had alloimmunization. As the technology of hematopoietic stem cell transplantation has become more widespread, immune hemolysis in the recipients of ABO-mismatched products has become better recognized. The syndrome is caused by passenger lymphocytes transferred from the donor, and although transient, can be quite severe. A similar syndrome has been observed in recipients of solid organ transplants when there is ABO-incompatibility between donor and recipient.
Venous thromboembolism is a little-recognized, though likely common, complication of autoimmune hemolytic anemia (AIHA), and may in some instances be related to coexistent antiphospholipid antibodies. While AIHA is a well-documented complication of malignant lymphoproliferative disorders, lymphoproliferative disorders may also paradoxically appear as a consequence of AIHA.
A number of newer options are available for treatment of AIHA in patients refractory to corticosteroids and splenectomy. Newer immunosuppressives such as mycophenolate may have a role in such cases. Considerable experience has been accumulating in the last few years with monoclonal antibody therapy, specifically rituximab, in difficult AIHA cases; it appears to be a safe and effective option.
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Affiliation(s)
- Philip C Hoffman
- University of Chicago, 5841 S Maryland Ave, MC2115, Chicago, IL 60637, USA.
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30
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Teachey DT, Felix CA. Development of cold agglutinin autoimmune hemolytic anemia during treatment for pediatric acute lymphoblastic leukemia. J Pediatr Hematol Oncol 2005; 27:397-9. [PMID: 16012332 DOI: 10.1097/01.mph.0000174031.63108.eb] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Autoimmune hemolytic anemia (AIHA) is a potentially fatal complication of many lymphoid malignancies. Those most often associated with AIHA include chronic lymphocytic leukemia, B-cell lymphomas, and Burkitt-type acute lymphoblastic leukemia (ALL) and are clonal populations of mature B cells. There have been no reports of patients with B-cell precursor ALL who developed AIHA while undergoing chemotherapy, but AIHA has been reported in a few patients with ALL after hematopoietic stem cell transplant. The authors describe a child with B-cell precursor ALL who developed cold agglutinin AIHA during maintenance treatment while in remission after infection with influenza B.
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Affiliation(s)
- David T Teachey
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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