Corticosteroid-responsive pure red cell aplasia in rheumatoid arthritis and its association with pregnancy: a case report

A pregnant woman with thymoma-associated pure red cell aplasia

Background

Pure red cell aplasia (PRCA) is a hematological disorder characterized by anemia with severe reticulocytopenia caused by a marked reduction in erythroid precursors in the bone marrow. PRCA is known to be associated with pregnancy, but thymoma-associated PRCA during pregnancy is very rare, and its successful management has not been reported.

Case presentation

A 37-year-old primiparous woman with severe anemia was referred to our center at 27 weeks’ gestation. She was diagnosed with PRCA based on bone aspiration findings at 33 weeks’ gestation. Magnetic resonance imaging (MRI) revealed an anterior mediastinal mass 4 cm in size suspected of being thymoma. She was therefore diagnosed with thymoma-associated PRCA during pregnancy. Surgery for thymoma was planned after delivery, since the imaging findings were suggestive of early-stage thymoma (Masaoka stage I or II). With transfusion of a total 3,360 ml of red blood cells (RBCs) during pregnancy, the patient gave birth to a baby girl weighing 2,548 g at 40 weeks’ gestation. The baby showed transient congenital cutaneous candidiasis. The placental pathology revealed subamniotic inflammation with a fungal structure. Treatment with topical anti-fungal cream immediately ameliorated the baby’s skin lesion. Maternal anemia did not improve after delivery; however, the thymoma did not increase in size. At five months after delivery, the mother underwent thymectomy with oral cyclosporine A. A pathological examination revealed Masaoka stage II-a thymoma. She completely had recovered from anemia at six months after surgery. Cyclosporine A treatment was discontinued three years after surgery. Remission has been sustained for four years since surgery.

Conclusions

A very rare case of thymoma-associated PRCA during pregnancy was diagnosed without any subjective symptoms and was expectantly managed, resulting in a good prognosis. Although bone marrow aspiration during pregnancy is an invasive test, it is important to confirm the diagnosis. Conservative management with blood transfusion was possible for early-stage thymoma-associated PRCA during pregnancy. Active surveys, including MRI, for PRCA during pregnancy led to the detection of thymoma at an early stage and the achievement of a preferable pregnancy outcome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05145-5.

Pure red cell aplasia secondary to rheumatoid arthritis: a case report

BACKGROUND

Rheumatoid arthritis is a common autoimmune disease with many extra-articular manifestations. Pure red cell aplasia is a rare manifestation of rheumatoid arthritis and is sparsely documented in the literature, with a variable clinical outcome following immunosuppressive therapy.

CASE PRESENTATION

A 63-year-old Sinhalese female presented with transfusion-dependent anemia associated with deforming inflammatory arthritis. She also had leukopenia, right subclavian venous thrombosis, and generalized lymphadenopathy. The diagnosis of rheumatoid arthritis following initial clinical workup and additional blood and bone marrow investigations revealed pure red cell aplasia as a secondary manifestation of rheumatoid arthritis after excluding other secondary causes, such as infections, thymoma, thrombophilic conditions, and hematological malignancy. She responded well to oral prednisolone, cyclosporine A, and hydroxychloroquine, and she attained complete recovery in 2 months.

CONCLUSION

Pure red cell aplasia is a disabling illness that may lead to transfusion-dependent anemia, which may occur due to rare extrapulmonary manifestation of rheumatoid arthritis. The diagnosis of pure red cell aplasia secondary to rheumatoid arthritis may be challenging where hematological investigations, including bone marrow biopsy, will aid in the diagnosis, and early diagnosis and treatment will bring about a better outcome.

Pure red-cell aplasia secondary to pregnancy, characterization of a syndrome

The aim of this study was to characterize the syndrome of pure red-cell aplasia (PRCA) secondary to pregnancy. All published cases of PRCA induced by pregnancy were reviewed. Additionally, we reported a patient who developed PRCA on three occasions; two were triggered by pregnancy and one after medroxyprogesterone administration. Ten patients with 13 pregnancy-induced PRCA episodes were reported. The PRCA occurred at any gestational age. All patients received blood transfusions, and six of them were treated corticosteroids. The PRCA resolved in all subjects postpartum. Five women had subsequent pregnancies; three were complicated by PRCA, one was normal, and one had spontaneous abortion without PRCA. One subject developed a PRCA after long-term exposure to medroxyprogesterone. Infant blood values were normal in the nine reported cases. Pregnancy-induced PRCA is a self-limited syndrome with a high risk for relapse during subsequent pregnancies. It can be managed by blood transfusions. Progestins might cause PRCA in these women.

Pregnancy complicated with pure red cell aplasia: a case report

A 31-year-old Japanese pregnant woman had no remarkable previous medical and family histories except for artificial abortion in 1993. A full-term normal infant was subsequently delivered in 1998. In this pregnancy, she began to experience general fatigability with a hemoglobin concentration of 8.5 g/dl at 19 weeks of gestation. Although she had been treated with intravenous iron, the hemoglobin decreased to 6.0 g/dl. She was referred to our hospital at 34 weeks of gestation. The laboratory data were as follows on this admission; hemoglobin 5.1 g/dl, RBC 128 x 10(4)/l, reticulocytes 1.1%, WBC 7.1 x 10(9)/l, platelet count 229 x 10(9)/l, folic acid 5.6 ng/ml, serum vitamin B12 200 pg/ml, ferritin 184 ng/ml, parvovirus B19 (-). A bone marrow aspiration revealed normal granulopoiesis and megakaryocytes, but almost complete absence of erythropoietic precursors. A diagnosis of pure red cell aplasia was made due to these findings. Treatment with prednisone (50 mg/day) and blood transfusion was started before delivery. She was delivered transvaginally at 37 weeks of gestation. The neonate was a normal female infant without anemia (hemoglobin 17.9 g/dl) and the 1 minute Apgar score was 8. Her hemoglobin level rose to 12.1 g/dl spontaneously two weeks after delivery.

Pure red cell aplasia in a man with RA

A 65 year-old man with long-standing rheumatoid arthritis (RA) developed pure red cell aplasia (PRCA), which was apparently not caused by drugs or viral infections. The condition responded favorably to danazol in combination with sulfasalazine. This was probably the 2nd case of RA with PRCA in a male patient.