Coombs-positive autoimmune hemolytic anemia in ulcerative colitis

Autoimmune Hemolytic Anemia in Inflammatory Bowel Disease-Report of a Case and Review of the Literature

A wide spectrum of extraintestinal manifestations (EIMs) can burden patients with inflammatory bowel disease (IBD). EIMs contribute fairly to morbidity and mortality rates in IBD patients. Moreover, EIMs in IBD patients are so frequent that some suggest that IBD should be approached as a systemic disorder. Anemia is very common in IBD patients. The two most common types of anemia in IBD, iron deficiency anemia and anemia of chronic disease, are extraintestinal complications. Autoimmune hemolytic anemia (AIHA) is a rare extraintestinal manifestation of IBD, more frequent in ulcerative colitis (UC) than in Crohn's disease (CD). In this case-based review of the literature, we present a 36-year-old female patient diagnosed with Crohn's disease (CD) and Coombs positive AIHA, complicated by pulmonary thromboembolism and successfully treated with anti-tumor necrosis factor (anti-TNF) therapy. The underlying pathophysiological mechanism of AIHA in IBD is unclear. Treatment options for AIHA in IBD patients before biologic therapy included corticosteroids alone or in combination with azathioprine (AZA), methotrexate, and surgical treatment (colectomy and/or splenectomy). Currently, biologic therapy is a promising therapeutic option, especially in corticosteroid refractory or corticosteroid-dependent IBD patients with AIHA.

Detection of Anti-Erythrocyte Antibodies in Dogs with Inflammatory Bowel Disease (IBD)

Several extra-intestinal manifestations, including immune-mediated cytopenias, are reported in human inflammatory bowel disease (IBD), whereas they are poorly documented in dogs. Hypothesizing that immune-mediated subclinical anemia can occur in canine IBD, the study aim was to evaluate the erythrogram and the presence of anti-RBC antibodies in dogs with IBD. IBD was diagnosed according to the following criteria: chronic gastrointestinal signs, ruling out of extra-intestinal diseases, no improvement with diet trial, histological evidence of inflammatory infiltration, and improvement after immunosuppressant therapy. Canine Chronic Enteropathy Clinical Activity Index (CCECAI) endoscopic and histopathological scores were assessed for each dog. Twenty-five dogs were enrolled, and each dog had a CBC evaluation prior to endoscopy. The CBC was performed using laser hematology analyzer and blood smears were carefully reviewed for the presence of nucleated RBC, anisocytosis, polychromasia, and Howell-Jolly bodies. IgG and IgM anti-RBC antibodies were evaluated with flow cytometry. A high frequency of positive cases for anti-RBC antibodies in dogs with IBD (17/25 dogs) was ascertained. Approximatively 50% of dogs showed some hematologic features of RBC regeneration in addition to hematologic findings consistent with chronic inflammation. Anti-RBC antibodies and signs of erythroid regeneration may suggest possible subclinical chronic immune-mediated hemolysis that can cause anemia in dogs with IBD, together with the chronic inflammation.

Association of Immune Thrombocytopenia and Inflammatory Bowel Disease in Children

Background: The association between inflammatory bowel disease (IBD) and immune thrombocytopenia (ITP) is still uncertain. In this multicenter retrospective study, the coexistence of both diseases was investigated in children diagnosed from 1 January 2000 to 31 December 2019. Methods: Clinical characteristics of both IBD and ITP, onset of disorders, and patient’s response to treatment were collected through a structured form sent to 55 Italian pediatric referring centers for hematological disorders. Result: Centers responded to the survey and reported the coexistence of IBD and ITP in 14 children. The first diagnosis was ITP in 57.1% and IBD in 35.7% of patients: it was simultaneous in 7.1%. IBD was classified as ulcerative colitis (57.1%), Crohn disease (35.7%), and unclassified (7.1%). No therapy for IBD other than steroids had any effect on ITP course. Colectomy resulted in recovery from ITP in 1 of the 2 patients surgically treated. ITP was always mild but turned to be chronic in half of patients. Conclusions: In all patients, ITP was mild without any evident impact on IBD severity, but the incidence of chronic ITP seems to be higher than what is usually observed in the pediatric age group. Colectomy had unpredictable effects on ITP.

Diagnosis and Management of Autoimmune Hemolytic Anemia in Patients with Liver and Bowel Disorders

Anemia is a common feature of liver and bowel diseases. Although the main causes of anemia in these conditions are represented by gastrointestinal bleeding and iron deficiency, autoimmune hemolytic anemia should be considered in the differential diagnosis. Due to the epidemiological association, autoimmune hemolytic anemia should particularly be suspected in patients affected by inflammatory and autoimmune diseases, such as autoimmune or acute viral hepatitis, primary biliary cholangitis, and inflammatory bowel disease. In the presence of biochemical indices of hemolysis, the direct antiglobulin test can detect the presence of warm or cold reacting antibodies, allowing for a prompt treatment. Drug-induced, immune-mediated hemolytic anemia should be ruled out. On the other hand, the choice of treatment should consider possible adverse events related to the underlying conditions. Given the adverse impact of anemia on clinical outcomes, maintaining a high clinical suspicion to reach a prompt diagnosis is the key to establishing an adequate treatment.

Mapping the relationships between inflammatory bowel disease and comorbid diagnoses to identify disease associations

BACKGROUND

Massive amounts of patient data are captured daily in electronic medical records (EMR). Utilizing the power of such large data may help identify disease associations and generate hypotheses that can lead to a better understanding of disease associations and mechanisms. We aimed to comprehensively identify and validate associations between inflammatory bowel disease (IBD) and concurrent comorbid diagnoses.

METHODS

We performed a cross-sectional study using EMR data collected between 1986 and 2009 at a large tertiary referral center to identify associations with a diagnosis of IBD. The resulting associations were externally validated using the Truven MarketScan database, a large nationwide dataset of private insurance claims.

RESULTS

A total of 6225 IBD patients and 31 125 non-IBD controls identified using EMR data were used to abstract 41 comorbid diagnoses associated with an IBD diagnosis. The strongest associations included Clostridiodes difficile infection, pyoderma gangrenosum, parametritis, pernicious anemia, erythema nodosum, and cytomegalovirus infection. Two IBD association clusters were found, including diagnoses of nerve conduction abnormalities and nonspecific inflammatory conditions of organs outside the gut. These associations were validated in a national cohort of 80 907 patients with IBD and 404 535 age- and sex-matched controls.

CONCLUSION

We leveraged a big data approach to identify several associations between IBD and concurrent comorbid diagnoses. EMR and big data provide the opportunity to explore disease associations with large sample sizes. Further studies are warranted to refine the characterization of these associations and evaluate their usefulness for increasing our understanding of disease associations and mechanisms.

Autoimmune cytopenias associated with inflammatory bowel diseases: Insights from a multicenter retrospective cohort

INTRODUCTION

Autoimmune cytopenias (AIC) including autoimmune hemolytic anemia (AIHA) and immunologic thrombocytopenia (ITP) are rare immunologic disorders, scarcely reported in inflammatory bowel diseases (IBD). We conducted a multicentric retrospective study, including a case-control analysis, that aimed to describe the characteristics and outcomes of patients affected by AIC and IBD.

METHOD

Forty cases were recruited from 4 IBD centers and 2 AIC tertiary centers. Controls were recruited from the MICISTA registry.

RESULTS

From the MICISTA registry, incidences were estimated at 4.1/100,000 patient-years and 12.5/100,000 patient-years after IBD diagnosis for AIHA and ITP, respectively. All AIHA patients (n=14) had colonic involvement (13/14 with UC), whereas CD (52%) and UC (48%) diagnoses were evenly distributed among ITP patients. Compared to control IBD patients, cases were characterized by a higher frequency of extra-intestinal manifestations (37.5% vs 17%, p<0.001) and by the presence of IBD severity's hallmark. AIHA and IBD ran mainly in parallel, and 12 out of 14 AIHA were warm AIHA. In isolated cases, rituximab and infliximab were efficient to treat IBD and AIC, respectively. IBD surgery may induce AIC remission in some cases.

CONCLUSION

Although low, incidence of AIC appears higher in IBD patients compared to the general population. The association seems to be mainly non-fortuitous, especially for colitis-associated AIHA.

Distinct roles of helper T-cell subsets in a systemic autoimmune disease

Imbalance of T-helper cell (Th) differentiation and subsequent cytokine dysregulation is implicated in inflammatory and autoimmune diseases. In particular, 2 cytokines produced by different Th cell populations, interferon-gamma (IFN-gamma) and interleukin-17 (IL-17), have been shown to play a critical role in autoimmunity. We have examined the roles of these cytokines in a mouse model of systemic autoimmunity resulting from the deletion of IL-2 in which autoimmune hemolytic anemia (AIHA) is a prominent feature. We demonstrate that, in IL-2-knockout (KO) BALB/c mice, elimination of the Th1 cytokine, IFN-gamma, delays the development of AIHA. Further, CD4(+) T cells from IL-2/IFN-gamma-KO mice produce elevated levels of IL-17 compared with wild-type (WT) and IL-2-KO, and these mice eventually develop intestinal inflammation. In contrast, elimination of the Th17 cytokine, IL-17, from IL-2-KO mice fails to suppress early acute AIHA development. These results suggest that in a systemic autoimmune disease with multiple manifestations, Th1 cells drive the early autoantibody response and IL-17-producing cells may be responsible for the more chronic tissue inflammation.

Coombs-positive autoimmune hemolytic anemia in Crohn's disease

BACKGROUND

Anemia often occurs in patients with inflammatory bowel diseases. However, hemolytic anemia is a rare complication and is associated with Coombs-positive autoimmune disorders. There are several reports of autoimmune hemolytic anemia in patients with ulcerative colitis, whereas there are only four reports of this complication in patients with Crohn's disease. We report a case of a severe course Coombs-positive hemolytic anemia in a patient with Crohn's disease, which was refractory to medical treatment but resolved after subtotal colectomy.

CASE REPORT

A 29-year-old patient was submitted to our clinic several times because of a severe course of inflammatory bowel disease and additionally a Coombs-positive autoimmune hemolytic anemia. Histology indicated severe Crohn's disease, but neither medical treatment with steroids, nor with methotrexate, cyclosporine or tumor necrosis factor-alpha antibody had been successful in resolving the intestinal inflammation and the hemolytic anemia. As colonoscopy revealed a pancolitis and dysplastic changes, even in the less inflamed areas of the colonic mucosa, subtotal colectomy was indicated. Half a year later we observed clinical and immunological signs of complete remission (no gastrointestinal symptoms, negative Coombs test).

CONCLUSION

Autoimmune hemolytic anemia is a rare complication of inflammatory bowel disease and has been almost exclusively described in ulcerative colitis. The etiology is not yet completely understood. Presumably, the colon displays a role in the production of anti-erythrocyte antibodies. The therapy of choice in Crohn's associated hemolytic anemia is thought to be medical treatment with corticoid steroids. Some authors additionally prefer immunmodulators. However, in the case presented, colectomy (without splenectomy) was necessary to resolve refractory hemolysis and the severe course of Crohn's disease.

Anemia hemolítica autoinmune asociada a colitis ulcerosa

The incidence of immunological disorders has been reported to be greater in patients with inflammatory bowel disease than among the general population. The association of ulcerative colitis (UC) and autoimmune hemolytic anemia (AIHA) was first described in the early 1950s but no more than 50 cases have been described in the international literature. Detailed description of the pathogenic mechanisms involved in this association is lacking. The clinical course of AIHA and treatment response in these patients seems to be independent of UC, sometimes requiring immunosuppressive treatment and even surgery. We present 2 cases of AIHA associated with UC with distinct response to conventional treatment. We also review the literature on the subject.

[26-year-old patient with ulcerative colitis and anemia]

A 26-year-old patient was admitted to the hospital because of severe anemia and exacerbation of ulcerative colitis. Laboratory tests revealed a hemolytic anemia and elevated parameters of acute phase reaction. Ten months ago an autoimmune hemolytic anemia was diagnosed. Three months before admission splenectomy was performed due to ongoing hemolytic exacerbations despite treatment with corticosteroids. Anemia is a common problem of inflammatory bowel disease. The association of autoimmune hemolytic anemia and ulcerative colitis presented in this case report is a rare complication of ulcerative colitis. The autoimmune hemolytic anemia is often refractory to corticosteroids. Immunosuppressive treatment with azathioprine induced a sustained remission in our patient, thereby a total colectomy could be avoided.

First two patients with ulcerative colitis who developed classical thrombotic thrombocytopenic purpura successfully treated with medical therapy and plasma exchange

The association of ulcerative colitis (UC) and thrombotic thrombocytopenic purpura (TTP) is rare. Only one prior patient with these two syndromes has been reported in the literature. In that case, splenectomy and proctectomy were performed to control the symptoms of TTP. We present two patients with UC who developed TTP and were successfully treated with multiple plasma exchanges (PEXs) in conjunction with medical therapy without the necessity for surgical intervention. Acquired TTP may be another extraintestinal autoimmune feature of UC. TTP in association with UC may be refractory to high-dose steroids and PEX, possibly requiring vincristine and splenectomy, as in the one previously reported case, to achieve remission.

Colitis ulcerosa asociada a púrpura trombocitopénica idiopática

Multiple hematological anomalies have been described in association with chronic inflammatory bowel disease. Idiopathic thrombocytopenic purpura is an autoimmune disease characterized by the presence of isolated thrombopenia with a normal or increased number of megakaryocytes in bone marrow and absence of splenomegaly. Several case reports of idiopathic thrombocytopenic purpura associated with chronic inflammatory bowel disease, mostly ulcerative colitis, have been published in the literature. The pathogenic mechanism through which these entities are associated is unknown. Several treatments have been used, varying from short courses of steroids to the use of immunosuppressive agents and splenectomy, depending on the severity of the symptoms. We describe the case of a woman with ulcerative colitis and idiopathic thrombocytopenic purpura, in which the latter first presented when the patient was undergoing treatment with corticosteroids and cyclosporin, one of the therapeutic options for controlling thrombopenic purpura. Platelet deficiency persisted despite treatment with azathioprine and colectomy, also described as a possible curative treatment.

Frequency of extraintestinal manifestations in patients with inflammatory bowel disease in Northwest Greece and review of the literature

BACKGROUND

Inflammatory bowel disease mainly affects the bowel but also has extraintestinal manifestations.

AIMS

To report the frequency of extraintestinal manifestations in patients with inflammatory bowel disease in Northwest Greece. PATIENTS; The data files of 256 inflammatory bowel disease patients (diagnosis between 1983-19971 were analysed.

METHODS

Retrospective investigation of patient files.

RESULTS

In patients with ulcerative colitis: 13.9% (30/215) had developed skin manifestations, 6% (13/215) had kidney stones, 1.39% (3/215) had iridocyclitis, 1.86% (4/215) had primary sclerosing cholangitis, 4.18% (9/215) had sacroiliitis, 8.31% (18/215) had peripheral arthalgias, 2.3% (5/215) had colitic arthritis and finally 1.39% (3/215) had deep vein thrombosis). In patients with Crohn's disease: 24.3% (9/37) had developed skin manifestations, 5.4% (2/37) had kidney stones, 2.7% (1/37) had iridocyclitis, 16.2% (6/37) had sacroiliitis, 8.1% (3/37) had peripheral arthralgias, 5.4% (2/37) had colitic arthritis and, finally, 8.1% (3/37) had deep vein thrombosis. Sacroiliitis (p = 0.01), deep vein thrombosis (p = 0.04) and erythmema nodosum (p = 0.01) were more common in patients with Crohn's disease.

CONCLUSIONS

Extraintestinal manifestations are not rare in patients with inflammatory bowel disease, especially in Crohn's disease patients, in our area, but have, generally, a mild profile.

Extraintestinal manifestations of inflammatory bowel disease

Numerous extraintestinal diseases have been associated with IBD. The role of the gastrointestinal tract in host response to the foreign antigens present in the gut makes the enteric immune system highly susceptible to any external perturbation to the system. Dysregulation of the enteric immune response results in pathology in various organs outside of the gut. The site-specific manifestations of this immune response are not understood fully. Better understanding of the pathogenesis of IBD and the complex interactions between the gut immune system and the extraintestinal systems would provide insights into the development of many of these extraintestinal manifestations. Much is unknown about the presence of cardiac, pulmonary, and hematologic diseases in patients with IBD. True association or coincidental presence of the diseases in these organ systems with IBD requires better delineation. An important consideration in all patients with IBD presenting with extraintestinal manifestations should be a careful search for medication-related complications.

Ulcerative colitis and thrombotic thrombocytopenic purpura

Inflammatory bowel disease is often associated with hematologic abnormalities such as anemia, leukocytosis, and thrombocytosis. We report for the first time an unusual case of ulcerative colitis complicated by thrombotic thrombocytopenic purpura. Severe lower gastrointestinal bleeding resolved with subtotal colectomy, but the thrombotic thrombocytopenic purpura proved unresponsive to medical treatment. Splenectomy and completion proctectomy were performed, ultimately resulting in a successful outcome.

Further evidence that exacerbation of ulcerative colitis causes the onset of immune thrombocytopenia: a clinical case

Ulcerative colitis associated with immune-mediated thrombocytopenia is rare. It has been suggested that antigenic mimicry between platelet surface antigen and bacterial glycoprotein plays a role in this association. We present a case in which exacerbation of UC sequentially induced development of ITP associated with elevation of PAIgG. In the case, two episodes of ITP occurred, with each preceded by exacerbation of UC. After remission of UC, ITP remitted and PAIgG simultaneously decreased. In the first episode, the onset of ITP was about 1 month after the exacerbation of UC. However, in the second episode, the onset of ITP was much faster, 11 days after that of UC, and the magnitude of elevation of PAIgG was much higher in the second episode. This may provide further evidence that ITP is causally associated with UC, and is the result of immunostimulation from luminal antigens and altered immunoregulation.

Possible causal association between ulcerative colitis and idiopathic thrombocytopenic purpura

A 24-year-old Japanese male having ulcerative colitis and idiopathic thrombocytopenic purpura is described. When the symptoms of ulcerative colitis were manifest during his clinical course, the platelet life-span was shortened and the platelet associated IgG level was increased. Thus, causal association between the two diseases may be suggested.

Coombs-positive autoimmune hemolytic anemia in ulcerative colitis--a report of two cases

Two cases of ulcerative colitis with a positive Coombs test are reported herein. In a 30 year old woman, hemolytic anemia was well controlled by excision of a rectal stump left over from a former operation. A 53 year old woman had a positive Coombs test without clinical hemolytic anemia 10 years after undergoing a total procto-colectomy with ileo-anal anastomosis. Thus we concluded that total procto-colectomy may be preventive, as well as therapeutic, for Coombs positive hemolytic anemia associated with ulcerative colitis.