Successful treatment with rituximab for autoimmune hemolytic anemia concomitant with proliferation of Epstein-Barr virus and monoclonal gammopathy in a post-nonmyeloablative stem cell transplant patient

Refractory autoimmune haemolytic anaemia following allogenic haematopoietic stem cell transplantation: successful treatment of rituximab

Objective

To investigate the effectiveness and safety of rituximab in treating autoimmune haemolytic anaemia (AIHA) after allogeneic haematopoietic stem cell transplantation (allo-HSCT).

Methods

Patients with refractory AIHA following allo-HSCT were treated once-weekly with rituximab 375 mg/m² for a total of four doses. In an animal study, recipient CB6F1 mice were conditioned with busulfan/fludarabine and transplanted with splenocytes and T-cell-depleted bone marrow from C57Bl/6 mice. In this animal model, anti-CD20 monoclonal antibody (mAb) was evaluated to see if it could prevent graft versus host disease (GVHD). GVHD was monitored by body weight loss, GVHD clinical scores and the survival of each group of mice. Histopathological analyses of the skin, intestine, liver and lung were used to analyse the severity of GVHD.

Results

After rituximab therapy, refractory AIHA was resolved in all four patients as shown by increased haemoglobin levels. B-cell proportions were reduced with a relative increase of the proportions of T-cells following rituximab treatment. None of the four patients experienced chronic GVHD. In the animal model, anti-CD20 mAb treatment reduced GVHD.

Conclusions

Rituximab therapy deserves consideration for the treatment of post-HSCT patients with refractory AIHA. Further studies are needed to define the therapeutic role of this anti-CD20 mAb.

Autoimmune haemolytic anaemia associated with Epstein Barr virus infection as a severe late complication after kidney transplantation and successful treatment with rituximab: case report

BACKGROUND

Autoimmune haemolytic anaemia (AIHA) is a rare complication following kidney transplantation and usually occurs early in its course. It is characterised by autoantibodies or alloantibodies directed against red blood cells (RBCs).

CASE PRESENTATION

We describe a 44 year old woman who presented 5 years after kidney transplantation with profound transfusion dependent warm AIHA. Investigations confirmed an IgG autoantibody against RBCs and high titre Epstein-Barr virus (EBV) viraemia. The patient was at higher risk for EBV disease being seronegative at the time of transplantation but had detectable EBV capsid IgG antibody at the time of presentation. The haemolysis was refractory to high dose steroid and intravenous immunoglobulin. There was a rapid and complete resolution of both the anaemia and the viraemia following rituximab therapy, with no adverse events. Twenty-six units of blood were required during the course of treatment.

CONCLUSIONS

To our knowledge this is the first reported case of EBV associated AIHA in a renal transplant recipient. It highlights a rare pathology associated with post-transplant EBV infection, of broad interest to transplant physicians, haematologists, and microbiologists, and the effective novel use of monoclonal anti-CD20 therapy.

Reversible cardiomyopathy due to secondary hemochromatosis with multitransfusions for severe aplastic anemia after successful non-myeloablative stem cell transplantation

A 30-year-old Japanese woman with acquired severe aplastic anemia (SAA), diagnosed 20 years ago, was referred to our institution for allogeneic stem cell transplantation (SCT). As an unusual case of long-standing SAA, the patient was complicated with moderate heart failure due to secondary hemochromatosis. After successful SCT using a non-myeloablative conditioning regimen, she needed no transfusion. Five years after SCT, echocardiography showed a dramatic improvement of her cardiac function. This case indicates that the cardiac function in secondary hemochromatosis could be reversed once iron overload from multitransfusions is stopped.

Acquired immune cytopenias post-cardiac transplantation respond to rituximab

Hematologic abnormalities following solid organ transplantation are infrequently autoimmune in origin. We present a series of autoimmune cytopenias developing as a late complication of pediatric cardiac transplantation. Autoimmune cytopenias represented include autoimmune hemolytic anemia, acquired Glanzmann thrombasthenia, and idiopathic thrombocytopenic purpura. Standard therapies were used in each patient without sustainable results. Eventually, each patient was treated with and responded to rituximab. In this report, we review these cases, propose potential mechanisms for development of autoimmune cytopenias, and discuss our experience with rituximab in managing refractory autoimmune cytopenias.

Exogenous administration of immunomodulatory therapies in hematopoietic cell transplantation: an infectious diseases perspective

PURPOSE OF REVIEW

In contrast to the recipient of a solid organ transplantation, the immunological competence of recipients of hematopoietic cell transplantation does not correlate well with the administration of non-corticosteroid immunosuppressive agents. This apparent paradox reflects the unique and dynamic conglomeration of factors that affect immune reconstitution after hematopoietic cell transplantation. The following is the second part of a review of the recent primary literature regarding exogenous immunomodulatory influences as they pertain to infections in the setting of hematopoietic cell transplantation.

RECENT FINDINGS

The main themes of published primary research from 2004 to the present include the influence of exogenously administered immunomodulatory agents on infectious complications after hematopoietic cell transplantation.

SUMMARY

The use of immunomodulatory agents such as monoclonal antibodies directed against lymphocyte antigens in the treatment of hematopoietic malignancy has greatly expanded during the past decade. Separate trials of the potential utility of these agents, particularly in the reduction of graft-versus-host disease, in the setting of hematopoietic cell transplantation have yielded encouraging results. Given the infancy of these new approaches, it is not possible to make definitive statements regarding the relative risk of serious infection with each therapy. It is clear that a reduction in regimen-related non-infectious complications or mortality does not necessarily ensure a reduction in clinically significant infections. Improvements in early diagnostic and therapeutic options for these infections now bring us to an era of understanding pathogens such as cytomegalovirus as probes of the functional reconstitution of immunity.

Rituximab in autoimmune diseases

Modern treatments of autoimmune diseases are based on immunological therapies. Rituximab induces a targeted B-cell depletion in the aim of eradicating autoreactive clones in various autoimmune disorders. Several studies are being undertaken and preliminary reports are very encouraging. The mechanism of action is not evident, but appears to be connected with the lowering of autoantibody levels, in the diseases where relevant antibody titres are relievable. Most of the patients treated were affected by idiopathic thrombocytopenic purpura (ITP) and autoimmune haemolytic anaemia, but also very rare diseases like acquired haemophilia are reported. Best results are described in autoimmune haemolytic anaemia, in many others there is clear evidence for efficacy; in all the diseases the number of complete or partial remission, though temporary, is much greater than 50%. Side effects are rarely reported, and immunosuppression is not a great problem. The persistence of clinical improvement for more than 1 year after B-lymphocyte repopulation supports the hypothesis of a stochastic generation of pathogenic B-cell subsets. Other studies and controlled trials are required to establish when and which patients are to be treated, and find the opportunity of the association of others drugs.