Lymphoproliferative disease with IgM lambda monoclonal protein and autoimmune hemolytic anemia. A report of four cases and a review of the literature

Hemolytic disorders associated with cancer

Three principal environmental causes of hemolytic anemia in malignancy have been identified: (1) hemolysis mediated by auto-antibodies to red cells; (2) hemolysis due to microangiopathic disorders; and (3) chemotherapy-induced red cell destruction. These three environmental stressors occur rarely in cancer patients, and they form the subject of this review.

[Two-dimensional electrophoretic study of monoclonal gammopathies and cold agglutinins associated with a chronic hemolytic anemia]

Two-dimensional gel electrophoresis (2-DGE) associated with a very sensitive silver staining is one of the most powerful technique available for protein analysis. Proteins are separated in the first dimension by isoelectric focusing in a pH gradient, and in the second dimension by polyacrylamide gel electrophoresis. Proteins are thus separated according to their charge and to their size. The high resolution of 2-DGE allows the analysis of complex mixture of proteins with a great reproducibility. More than hundred different proteins can be individualized after 2-DGE of plasma or serum samples. Using this technique, we analysed samples obtained from normal donors and from patients with different gammopathies. Our results confirm that the heavy chains of immunoglobulins are easily detected and that the alpha, gamma and mu chains are clearly differentiated from one another. The typical polyclonal heavy and light chains appear as indiscrete spots after staining of the gels. On the contrary, the monoclonal chains appear as discrete spots. Monoclonal heavy chains have a restricted charge heterogeneity. We also analysed cold agglutinins, partially purified from plasma of three patients showing evidence of chronic hemolysis, a positive direct antiglobulin test of the complement type and anti-I autoantibodies. The 2-DGE have clearly demonstrated that these cold agglutinins were monoclonal IgM, when these later were not detectable by immunofixation electrophoresis. We think that the 2-DGE is a very usefull specialized aid to the analysis of such particular immunohematological problems.

Cold agglutination

Autoantibodies against red cells optimally reacting at 0 degree C, ie, CA, are normally found with low titers in the serum of human adults. High-titer CA may be induced by certain infectious agents, including M pneumoniae, EBV, CMV, and rubella virus, or may develop on the basis of chronic (malignant) B cell lymphoproliferation. The main clinical manifestation of cold agglutination is AIHA. Antigens and antibodies of cold agglutination are the best characterized reaction partners of a human autoimmune process. CA may recognize I and i antigens, which are lipid- and protein-linked branched and linear N-acetyl-lactosamine chains, respectively. They are precursors of the ABH blood group antigens and are converted into H by fucosylation. An alternative substitution by sialylation creates Gd, Fl, and probably Vo/Li antigens. CA with anti-Pr and anti-Sa specificities recognize 0-glycans with immunodominant sialyl groups on glycophorins. Several Pr subspecificities can be identified by chemically modified sialyl groups on glycophorins. Because CA in chronic lymphoproliferation are monoclonal antibodies, structure-specificity-interrelations of the antibodies could be identified by primary structure analyses of the N-terminal variable regions of H and L chains and by studies on CA idiotypes. Interrelations between distinct CA specificities and particular infectious agents could explain cold agglutination as a response to receptors for the agents or to the binding sites of antibodies against the agents. Interrelations also existing between certain CA isotypes (Ig classes and L chain types) and CA specificities could be a basis for the elucidation of the enigmatic etiology of chronic (malignant) monoclonal cold agglutination.

Monoclonal gammopathies in Japanese patients with Sjögren's syndrome

We report 10 Japanese patients with Sjögren's syndrome (SS) who developed monoclonal gammopathies (MG). One was of the IgG class, five of IgA, three of IgM, and one of IgG/IgM. The monoclonality of 7 of 10 M proteins was studied using antiidiotypic (Id) antibodies against M proteins. Four (three IgA and one IgM) of 10 M proteins had rheumatoid factor (RF) activity. Hemagglutination inhibition tests and enzyme-linked immunosorbent assays (ELISA) showed that the RF activity was inhibited by anti-Id antibodies in all four monoclonal RFs. In two patients examined, many cells infiltrating into the salivary glands were stained with anti-Id antibodies. Our review of 19 Japanese SS patients with MG revealed that the non-IgM class predominated (13/19). This contrasts with 19 reported non-Japanese SS patients, among whom 14 were IgM. In both Japanese and non-Japanese patients there was a higher incidence of MG in primary than in secondary SS. The difference in the dominant heavy-chain class may reflect a difference in the genetic factors affecting B cell differentiation in immunologically disordered states.

B-lymphoproliferative disorders: a proposed unified pathogenetic pathway

The clinical features of lymphoproliferative diseases associated with paraproteinemia are briefly reviewed and correlated with current immunologic concepts in an effort to clarify the pathophysiology of B-lymphocyte disorders. B-lymphocyte maturation proceeds in a predictable manner from the Pre-B cell to the formation of idiotype specific plasma cells and memory B-lymphocytes. The immunoglobulin isotype produced by the mature plasma cell is determined by a site specific process of gene switching which proceeds from mu to alpha production. Lymphoproliferative diseases are the result of disordered B cell maturation and their clinical features can be explained by identifying the locus of the maturational defect.

B-cell neoplasms with homogeneous cold-reacting antibodies (cold agglutinins)

Among 78 patients with persistent cold agglutinins, 31 had lymphoma, 13 had macroglobulinemia of Waldenstrom, six had chronic lymphocytic leukemia and 28 had chronic cold agglutinin disease. The average age was over 60 years. Patients wit chronic cold agglutinin disease had more hemolytic crises, bleeding and Raynaud's phenomena, and less frequently lymphadenopathy or hepatosplenomegaly. The frequency of anemia, positive Coombs test results, cryoglobulinemia and Bence Jones proteinuria was similar in the various groups. Survival time from diagnosis was on average two years in lymphoma, two and a half years in Waldenstrom's macroglobulinemia, more than six years in chronic lymphocytic leukemia and more than five years in chronic cold agglutinin disease. Anti-I were common in chronic cold agglutinin disease (74 percent) and rare in other groups (32 to 33 percent). Anti-I and other cold agglutinins were rare in chronic cold agglutinin disease and common in lymphoma and Waldenstrom's macroglobulinemia. In chronic cold agglutinin disease, and in Waldenstrom's macroglobulinemia, cold agglutinins usually had K light chains--92 percent and 71 percent, respectively--whereas in lymphoma, 71 percent of cold agglutinins had lambda light chains. The type of light chains related to the specifically of cold agglutinins: 58 percent of IgM/K were anti-I, 75 percent of IgM/lambda had other specificities. Cold agglutinins were cytotoxic to autologous and allogeneic cells were killed implying that the former may be precoated in vivo with the antibodies. In conclusion, conditions with persistent cold agglutinins are a spectrum that varies from "benign" autoimmune-like chronic cold agglutinin disease to malignant lymphoma. Marked differences in the light chain type of cold agglutinins, specificity toward membranous antigens and severity of clinical manifestations were noted in benign and malignant varieties.

Autoimmune haemolytic anaemia with monoclonal IgM (kappa) anti-P cold autohaemolysins

A patient is described with immunoblastic non-Hodgkin's lymphoma and autoimmune haemolytic anaemia of the cold autoantibody type. The autoantibodies were monoclonal IgM-kappa cold haemagglutinins/haemolysins with blood-group specificity, anti-P. Red-cell autoantibodies directed against blood-group-P antigen have until now only been detected, as polyclonal IgG antibodies, in paroxysmal nocturnal haemoglobinuria.

Monoclonal immunoglobulins with affinity for platelets and their relationship to malignant lymphoma

Monoclonal immunoglobulins with affinity for platelets were detected in the blood of seven patients. Two of these had thrombocytopenia and non-Hodgkin's lymphoma (NHL). One patient had thrombocytopenia and possibly incipient NHL. The other four patients had pseudothrombocytopenia at the time of diagnosis but one of them developed NHL six years later. It is suggested that these monoclonal immunoglobulins may in some cases be associated with malignant lymphoma and that subjects presenting with these immunoglobulins should have a long term follow-up in order to elucidate the question whether or not lymphoma will develop.

Macroglobulinemia Waldenström complicated by autoimmune hemolytic anemia, meningeal sign and femoral lysis

A necropsied case of macroglobulinemia Waldenström with unusual complications was presented; the patient was found to have autoimmune hemolytic anemia, first. During the course of its treatment, he developed monoclonal immunoglobulin M in serum together with lytic osseous lesion in both femurs, and died of meningeal involvement by tumor cells. Clinically, he had hepatosplenomegaly and generalized lymphadenopathy. The macroglobulin was kappa type of light chain, ultracentrifugation showed sharp spike of 21S in 18.6%, and myelogram revealed increased lymphocytoid series of 29.6%. It was proved that autoantibody causing autoimmune hemolytic anemia was composed of IgG and macroglobulin itself had no activity as an anti-red cell antibody. An emphasis was made that autoimmune hemolytic anemia followed by macroglobulinemia is based on the state of immunodeficiency of this patient.

Cold agglutinin disease. Report of a case

Cold agglutinin disease is an autoimmune hemolytic anemia with varying causes. Two major types are recognized, with different clinical manifestations. Cold agglutinins are circulating antibodies capable of erythrocyte agglutination. However, the reaction is readily reversible. Treatment of the disease is variable. A case is presented to illustrate that minor oral surgical procedures are feasible, provided the proper precautions are taken.