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Sakamoto AS, Sequeira FS, Blanco BP, Garanito MP. Pediatric autoimmune hemolytic anemia: A single-center retrospective study. Hematol Transfus Cell Ther 2024:S2531-1379(24)00016-6. [PMID: 38402032 DOI: 10.1016/j.htct.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 11/11/2023] [Accepted: 12/27/2023] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND Autoimmune hemolytic anemia (AIHA) is a rare, life-threatening disease in pediatrics. This article describes the clinical features, diagnostic workup, treatment and outcome in patients with AIHA. METHOD Medical charts of under 18-year-old patients with AIHA treated at a tertiary Brazilian institution from 2006 to 2021 were retrospectively reviewed. Data analysis was primarily descriptive, using medians, interquartile ranges, and categorical variables presented as absolute frequencies. MAIN RESULTS Twenty-four patients (14 female, 10 male) were evaluated in this study. The median age at diagnosis was 5.99 years (range: 0.25-17.1 years) and the median hemoglobin level was 4.85 g/dL (range: 4.17-5.57 g/dL). Most had warm antibodies (83.3 %). Twelve patients (50 %) had known underlining diseases, four (16.6 %) presented with AIHA concomitant with acute infectious diseases and three (12.5 %) had an undetermined post-vaccine association. Steroids and intravenous immunoglobulin were first-line therapy in 23 cases. Seven patients (29.1 %) required second and third-line treatments (rituximab, cyclophosphamide and splenectomy). The median follow-up period was 4.4 years (range: 1.0-6.7 years). Thirteen patients (54.1 %) were discharged, five cases (20.8 %) were lost to follow-up and no patient died. The median age for the six remaining patients was 11.53 years (8.5-14.7) with all of them having complete responses with no further therapies. CONCLUSION Most cases of AIHA are secondary to an underlying systemic disease or have a possible correlation with infections/vaccines and respond to steroids. The second and third-line therapies for refractory and relapse cases remain a dilemma. A prospective, multicenter study is essential to address the best therapeutic combinations.
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Yu WM, Patel HN. Autoimmune Hemolytic Anemia Following Uncomplicated Spinal Surgery: A Report and Brief Review. Cureus 2023; 15:e35591. [PMID: 37007336 PMCID: PMC10063239 DOI: 10.7759/cureus.35591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 02/27/2023] [Indexed: 03/04/2023] Open
Abstract
This report and literature review describes a case of a Coombs test-positive warm antibody autoimmune hemolytic anemia (AIHA) in a patient following routine spinal surgery without complications. This is the first reported case of symptomatic direct Coombs test-positive warm antibody AIHA developing in a neurosurgical patient. The patient is a 73-year-old female with left radicular leg pain who developed warm antibody AIHA following standard uncomplicated spinal surgery. A positive direct Coombs test confirmed the diagnosis in combination with characteristic laboratory values. The patient did not have any significant predisposing risk factors. On postoperative day (POD) 23, she presented with fatigue and characteristic laboratory values of decreased hemoglobin, elevated bilirubin, lactate dehydrogenase, and decreased haptoglobin. Hematology initiated and monitored appropriate treatment and proposed that the working hematologic diagnosis is stress-induced AIHA secondary to recent spinal surgery. The patient recovered well from a neurosurgical perspective and reported no neurosurgical complaints during the last follow-up. A female presenting with left radicular leg pain developed symptomatic anemia following uncomplicated spinal surgery. A positive direct Coombs test in combination with characteristic laboratory values confirmed the diagnosis of warm antibody AIHA.
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Tambunan BA, Ugrasena IDG, Aryati. Role of Hemin in the Immune Response of T Follicular Helper Lymphocytes Expressing T-Cell Immunoreceptor with Immunoglobulin and Immunoreceptor Tyrosine-Based Inhibitory Domains, Programmed Cell Death-1, and Interleukin-21 in Allo-Auto Positive and Negative Thalassemia. J Blood Med 2023; 14:7-17. [PMID: 36660451 PMCID: PMC9844107 DOI: 10.2147/jbm.s393134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 01/06/2023] [Indexed: 01/13/2023] Open
Abstract
Introduction Repeated transfusions in thalassemia patients can cause several complications, including alloimmunization and autoimmunization. Purpose This study compares the immune response of T follicular helper (Tfh) lymphocytes expressing T-cell immunoreceptor with immunoglobulin and immunoreceptor tyrosine-based inhibitory domains (TIGIT), programmed cell death-1 (PD-1), and interleukin-21 (IL-21) between patients with allo-auto positive and negative thalassemia before and after hemin administration. Materials and Methods This study used a quasi-experimental pre- and post-test design and was performed between April and November 2021 at the Dr. Soetomo General Academic Hospital in Surabaya, Indonesia. It enrolled 29 patients with allo-auto positive thalassemia and 28 with allo-auto negative, and 9 mL of whole blood (WB) was drawn from each patient. Hemin solution (20 µM) was added to 5 mL of WB, incubated for two hours, processed into peripheral blood mononuclear cells (PBMCs) in RPMI media, and cultured with 5% CO2 for three days. The 4 mL WB sample was also processed into PBMCs. PBMC cells cultured and without cultured were examined by flow cytometry using a BD FACSCalibur after surface and intracellular staining. Differences in Tfh cells expressing TIGIT, PD-1, and IL-21 between thalassemia groups before and after hemin administration were compared using independent t-tests or Mann-Whitney U-tests (p < 0.05). Results Tfh cell expression did not differ between groups before hemin administration and increased after hemin administration. The increase in Tfh cell expression was higher in the allo-auto positive group. TIGIT and PD-1 expression in Tfh cells did not differ between groups, but TIGIT decreased after hemin administration in contrast to PD-1 result. IL-21 expression in Tfh cells did not differ between groups and did not change after hemin administration. Conclusion Hemin affected the expression of Tfh cells in both group thalassemia, but there was no difference of Tfh cell expression between the groups.
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Affiliation(s)
- Betty Agustina Tambunan
- Doctoral Program of Medical Science, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia,Department of Clinical Pathology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia,Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - I Dewa Gede Ugrasena
- Dr. Soetomo General Academic Hospital, Surabaya, Indonesia,Department of Pediatrics, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Aryati
- Department of Clinical Pathology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia,Dr. Soetomo General Academic Hospital, Surabaya, Indonesia,Correspondence: Aryati, Department of Clinical Pathology, Faculty of Medicine, Universitas Airlangga, St. Mayjen. Prof. Dr. Moestopo 47, Surabaya, East Java, 60132, Indonesia, Tel +6281230570493; +62-031-5020251, Email
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Tambunan BA, Ugrasena IDG, Aryati A. Impact of Hemin on Interleukin-21 Levels and Plasma Cells in Transfusion-Dependent Thalassemia with Positive and Negative Allo-Autoantibody. Int J Gen Med 2023; 16:47-56. [PMID: 36636711 PMCID: PMC9830417 DOI: 10.2147/ijgm.s397317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 12/22/2022] [Indexed: 01/06/2023] Open
Abstract
Introduction Antibody formation in transfusion-dependent thalassemia is associated with chronic hemolysis and repeated transfusions. Hemolysis produces heme, which mediates B-cell differentiation into plasma cells and produces antibodies influenced by interleukin-21 (IL-21). Objective This study aimed to compare IL-21 levels, plasma cell percentage, and red blood cell antibodies between positive and negative allo-autoantibody thalassemia before and after hemin administration. Materials and Methods This research employed a quasi-experimental nonequivalent control group pre-test and post-test design performed from April to November 2021 at Soetomo Academic Hospital in Surabaya, Indonesia. Heparinized blood samples of 5 mL and 4 mL and EDTA blood samples of 3 mL were taken from positive (29 patients) and negative (28 patients) allo-autoantibody thalassemia participants. Hemin 20 µM was added to 5 mL of heparinized blood, incubated for 2 hours, prepared into peripheral blood mononuclear cells (PBMCs), and cultured for 3 days. The percentage of plasma cells (CD38+CD184+) of cultured and uncultured PBMCs was measured by BD FACSCalibur Flow Cytometer. IL-21 levels of plasma and supernatants were measured with Sandwich Enzyme-Linked Immunosorbent Assay by Elabscience. Red blood cell antibodies were detected by QWALYS 3 E.M. Technology. Autoantibodies were determined by the Grifols gel tube method. Results IL-21 levels were significantly different in the positive and negative allo-autoantibody thalassemia groups after hemin administration. The percentage of plasma cells in the positive allo-autoantibody group increased significantly after the administration of hemin. The percentage of plasma cells between thalassemia groups was not significantly different before the hemin administration but increased significantly after it. Red blood cell antibodies after the administration of hemin were significantly different in the negative allo-autoantibody group but not significantly different in the positive allo-autoantibody group. Conclusion Hemin administration affected IL-21 levels, plasma cell percentage, and antibody formation in positive and negative allo-auto antibody thalassemia.
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Affiliation(s)
- Betty Agustina Tambunan
- Doctoral Program of Medical Science, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia,Department of Clinical Pathology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia,Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - I Dewa Gede Ugrasena
- Dr. Soetomo General Academic Hospital, Surabaya, Indonesia,Department of Pediatrics, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Aryati Aryati
- Department of Clinical Pathology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia,Dr. Soetomo General Academic Hospital, Surabaya, Indonesia,Correspondence: Aryati Aryati, Email
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Prevalence of the Direct Antiglobulin Test and Its Clinical Impact on Multiply Transfused Thalassemia Patients: A Prospective Study Conducted at a Tertiary Care Center in Northern India. Lab Med 2022:6887105. [DOI: 10.1093/labmed/lmac140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Abstract
Objective
This study was conducted to estimate prevalence of direct antiglobulin test (DAT) positivity and its impact on transfusion support in patients with thalassemia.
Methods
The DAT testing was performed for patients with β-thalassemia who received transfusion from November 2021 to March 2022. Elution was done for DAT-positive samples.
Results
Of 180 patients, 21 (11.6%) were DAT positive. Immunoglobulin G (IgG) was present in 4 (19%) and IgG+C3d was present in 8 (38%). Only complement was present in 9 (42.8%) patients. The IgG-reactive DATs were associated with pan-reactive eluate. Patients who were DAT-positive had significantly higher levels of serum bilirubin, ferritin, and IgG than those who were DAT-negative.
Conclusion
Autoantibody formation in multiply transfused thalassemia patients is common and merits equal attention as alloimmunization. It is particularly important as DAT-positive red blood cells may undergo clinically significant hemolysis, which may increase the transfusion requirements with associated sequalae such as increased serum ferritin and splenomegaly.
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Ferreira de Matos C, Comont T, Castex MP, Lafaurie M, Walter O, Moulis G, Dion J, Cougoul P. Risk of vaso-occlusive episodes in patients with sickle cell disease exposed to systemic corticosteroids: a comprehensive review. Expert Rev Hematol 2022; 15:1045-1054. [PMID: 36412212 DOI: 10.1080/17474086.2022.2149488] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Sickle cell disease (SCD) is the most frequent inherited disorder in the world. It is caused by a single amino acid mutation on the beta-globin chain, which lead to red blood cell deformation, haemolysis, and chronic inflammation. Clinical consequences are vaso-occlusives crisis, acute chest syndrome, thrombosis, infection, and chronic endothelial injury. AREAS COVERED Corticosteroids are an old therapeutic class, that are inexpensive and widely available, which can be administered in different forms. Their adverse effects are numerous and well-known. This class could appear to be useful in SCD treatment due to its anti-inflammatory effect. Moreover, corticosteroids remain an essential therapeutic class for many indications, besides SCD. Although specific adverse effects of corticosteroids have been suspected in SCD patients for decades, recent papers has reported strong evidence of specific and severe adverse effects in this population. Based on a literature review, we will discuss pathophysiological considerations, consequences, and practical use of corticosteroids in SCD. EXPERT OPINION High corticosteroid doses, for any indication , induce vaso-occlusive crises, acute chest syndrome, and re-hospitalization in patients with SCD. There is no evidence of any benefits of corticosteroid use in the SCD acute events. Prevention by hydroxyurea and/or red blood cell transfusion or exchange should be discussed when corticosteroid use is indispensable.
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Affiliation(s)
| | - Thibault Comont
- Internal Medicine Department, Toulouse University Hospital, Toulouse, France
| | - Marie-Pierre Castex
- Pediatric Oncology Immunology Hematology Unit, Children's University Hospital - Toulouse University Hospital, Toulouse, France
| | - Margaux Lafaurie
- CIC 1436, Team Pharmacologie en Population, Cohortes, Biobanques (PEPSS), Toulouse, France.,Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France
| | - Ondine Walter
- Internal Medicine Department, Toulouse University Hospital, Toulouse, France.,CIC 1436, Team Pharmacologie en Population, Cohortes, Biobanques (PEPSS), Toulouse, France
| | - Guillaume Moulis
- Internal Medicine Department, Toulouse University Hospital, Toulouse, France.,CIC 1436, Team Pharmacologie en Population, Cohortes, Biobanques (PEPSS), Toulouse, France
| | - Jérémie Dion
- Internal Medicine Department, Toulouse University Hospital, Toulouse, France
| | - Pierre Cougoul
- Internal Medicine Department, Toulouse University Hospital, Toulouse, France
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Teawtrakul N, Songdej D, Hantaweepant C, Tantiworawit A, Lauhasurayotin S, Torcharus K, Sripornsawan P, Sutcharitchan P, Surapolchai P, Komvilaisak P, Saengboon S, Pongtanakul B, Charoenkwan P. Red blood cell alloimmunization and other transfusion-related complications in patients with transfusion-dependent thalassemia: A multi-center study in Thailand. Transfusion 2022; 62:2039-2047. [PMID: 35986658 PMCID: PMC9560980 DOI: 10.1111/trf.17068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/07/2022] [Accepted: 07/18/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Thalassemia is a common genetic disease in Southeast Asia. Red blood cell (RBC) transfusion is an essential treatment for severe forms of thalassemia. We performed a study to demonstrate RBC alloimmunization and other transfusion-related complications in patients with transfusion-dependent thalassemia (TDT). STUDY DESIGN AND METHODS A multi-center web-based registry of TDT was conducted in eight medical centers across Thailand. Thalassemia information, transfusion therapy, and transfusion-related complications were collected. Factors associated with each complication were demonstrated using the logistic regression analysis. RESULTS Of 1000 patients recruited for the study, 449 were males (44.9%). The mean age was 23.9 ± 15.4 years. The majority of patients, 738 (73.8%) had hemoglobin E/beta-thalassemia. In the study, 421 transfusion-related complications were reported from 357 patients (35.7%). Alloimmunization was the most common complication which was found in 156 patients (15.6%) with 284 positive antibody tests. The most frequent antibodies against RBC were anti-E (80/284, 28.2%) followed by anti-Mia (45/284, 15.8%) and anti-c (32/284, 11.3%). Age ≥3 years at initial blood transfusion, splenomegaly, higher frequencies, and volumes of transfusion were significant factors associated with alloimmunization. None of the patients had to terminate blood transfusion due to multiple alloantibodies. Other commonly seen complications were allergic reactions (130, 13.0%), autoimmune hemolytic anemia (70, 7.0%) and febrile non-hemolytic transfusion reaction (54, 5.4%). CONCLUSIONS Transfusion-related complications, especially alloimmunization, were common among Thai patients with TDT. Extended RBC antigen-matching for the Rh system and Mia should be implemented to prevent the development of alloantibodies in multi-transfused patients.
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Affiliation(s)
- Nattiya Teawtrakul
- Division of Hematology, Department of Internal Medicine, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Duantida Songdej
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chattree Hantaweepant
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Adisak Tantiworawit
- Division of Hematology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
- Thalassemia and Hematology Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Supanun Lauhasurayotin
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kitti Torcharus
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Pornpun Sripornsawan
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkla, Thailand
| | - Pranee Sutcharitchan
- Division of Hematology, Department of Internal Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Pacharapan Surapolchai
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Patcharee Komvilaisak
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Supawee Saengboon
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Bunchoo Pongtanakul
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pimlak Charoenkwan
- Thalassemia and Hematology Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Zhou Y, Ding YL, Zhang LJ, Peng M, Huang J. Direct antiglobulin test-negative autoimmune hemolytic anemia in a patient with β-thalassemia minor during pregnancy: A case report. World J Clin Cases 2022; 10:1388-1393. [PMID: 35211574 PMCID: PMC8855192 DOI: 10.12998/wjcc.v10.i4.1388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 11/27/2021] [Accepted: 12/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Severe refractory anemia during pregnancy can cause serious maternal and fetal complications. If the cause cannot be identified in time and accurately, blind symptomatic support treatment may cause serious economic burden. Thalassemia minor pregnancy is commonly considered uneventful, and the condition of anemia rarely progresses during pregnancy. Autoimmune hemolytic anemia (AIHA) is rare during pregnancy with no exact incidence available.
CASE SUMMARY We report the case of a 30-year-old β-thalassemia minor multiparous patient experiencing severe refractory anemia throughout pregnancy. We monitored the patient closely, carried out a full differential diagnosis, made a diagnosis of direct antiglobulin test-negative AIHA, and treated her with prednisone and intravenous immunoglobulin. The patient gave birth to a healthy full-term baby.
CONCLUSION Coombs-negative AIHA should be suspected in cases of severe hemolytic anemia in pregnant patients with and without other hematological diseases.
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Affiliation(s)
- Yang Zhou
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Yi-Ling Ding
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Li-Juan Zhang
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Mei Peng
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Jian Huang
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
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William V, Rusmawatiningtyas D, Makrufardi F, Widjajanto PH. Comprehensive management of refractory autoimmune hemolytic anemia in pediatric beta-thalassemia major patient: A case report. Ann Med Surg (Lond) 2021; 70:102853. [PMID: 34691416 PMCID: PMC8519758 DOI: 10.1016/j.amsu.2021.102853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 11/08/2022] Open
Abstract
Introduction and importance: Autoimmune hemolytic anemia (AIHA) is characterized by the production of antibodies against the red blood cells (RBCs) leading to increased hemolysis. Incidence of AIHA in patients with beta-thalassemia major is 5 of 100 thalassemia patients. Case presentation A 15-year-old female patient with refractory AIHA and thalassemia was unresponsive to steroid therapy. In this report, she was treated with cyclosporine and prednisone in addition to leucodepleted packed red cell (PRC). She was successfully got remission during one-year monitoring. Clinical discussion Cyclosporine is an immunosuppressive agent that interferes with T-cells activation by inhibiting transcription of cytokines, such as interleukin 2 and interferon-ɣ. Cyclosporine and steroid have synergic effects to prevent antibody production. Nephrotoxicity is one of the most concerning effect in cyclosporine usage, but it rarely develops using doses lower than 5 mg/kgBW/day. In limited resources blood bank with ABO and Rh crossmatch only, leucodepleted PRC transfusion could be an effective way to prevent antibody formation to minor blood group. Conclusion Cyclosporine and steroid could be considered for management in refractory AIHA with thalassemia patients. Non-pharmacological therapy such as leucodepleted PRC transfusion and limited donor transfusion could be considered. Cyclosporine and steroid may be of benefit in patients with refractory AIHA and beta thalassemia major. Leukodepleted PRC transfusion showed protective effect for antibody formation. Limited donor transfusion could be beneficial in recurrent transfusion patient.
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Affiliation(s)
- Vincencius William
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
| | - Desy Rusmawatiningtyas
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
| | - Firdian Makrufardi
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
| | - Pudjo Hagung Widjajanto
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
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Confounding factors in the diagnosis and clinical course of rare congenital hemolytic anemias. Orphanet J Rare Dis 2021; 16:415. [PMID: 34627331 PMCID: PMC8501562 DOI: 10.1186/s13023-021-02036-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/19/2021] [Indexed: 01/19/2023] Open
Abstract
Congenital hemolytic anemias (CHAs) comprise defects of the erythrocyte membrane proteins and of red blood cell enzymes metabolism, along with alterations of erythropoiesis. These rare and heterogeneous conditions may generate several difficulties from the diagnostic point of view. Membrane defects include hereditary spherocytosis and elliptocytosis, and the group of hereditary stomatocytosis; glucose-6-phosphate dehydrogenase and pyruvate kinase, are the most common enzyme deficiencies. Among ultra-rare forms, it is worth reminding other enzyme defects (glucosephosphate isomerase, phosphofructokinase, adenylate kinase, triosephosphate isomerase, phosphoglycerate kinase, hexokinase, and pyrimidine 5′-nucleotidase), and congenital dyserythropoietic anemias. Family history, clinical findings (anemia, hemolysis, splenomegaly, gallstones, and iron overload), red cells morphology, and biochemical tests are well recognized diagnostic tools. Molecular findings are increasingly used, particularly in recessive and de novo cases, and may be fundamental in unraveling the diagnosis. Notably, several confounders may further challenge the diagnostic workup, including concomitant blood loss, nutrients deficiency, alterations of hemolytic markers due to other causes (alloimmunization, infectious agents, rare metabolic disorders), coexistence of other hemolytic disorders (autoimmune hemolytic anemia, paroxysmal nocturnal hemoglobinuria, etc.). Additional factors to be considered are the possible association with bone marrow, renal or hepatic diseases, other causes of iron overload (hereditary hemochromatosis, hemoglobinopathies, metabolic diseases), and the presence of extra-hematological signs/symptoms. In this review we provide some instructive clinical vignettes that highlight the difficulties and confounders encountered in the diagnosis and clinical management of CHAs.
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Thalassemia and autoimmune diseases: Absence of evidence or evidence of absence? Blood Rev 2021; 52:100874. [PMID: 34404565 DOI: 10.1016/j.blre.2021.100874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 01/19/2023]
Abstract
The thalassemias are a group of inherited disorders of hemoglobin synthesis that continue to pause a global public health concern. The complex molecular and pathogenetic pathways involved in disease process lead to an array of comorbidities that require lifelong management. The disease and its treatment can also lead to alterations in immune function and a link to various autoimmune diseases has been frequently suggested. However, most data stem from single case reports and small studies that do not allow proper assessment of causal associations. Still, the high morbidity in thalassemia makes patients vulnerable to the added burden of coexisting autoimmune diseases, and special management considerations in this patient population are warranted. In this review, we explore insights and data from the literature on various autoimmune disease that have been observed in patients with thalassemia. The role of the thalassemia carrier state in modifying outcomes of patients with autoimmune diseases is also discussed.
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Autoimmune Hemolytic Anemia as a Complication of Congenital Anemias. A Case Series and Review of the Literature. J Clin Med 2021; 10:jcm10153439. [PMID: 34362222 PMCID: PMC8347040 DOI: 10.3390/jcm10153439] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 07/28/2021] [Indexed: 01/19/2023] Open
Abstract
Congenital anemias may be complicated by immune-mediated hemolytic crisis. Alloantibodies are usually seen in chronically transfused patients, and autoantibodies have also been described, although they are rarely associated with overt autoimmune hemolytic anemia (AIHA), a serious and potentially life-threatening complication. Given the lack of data on the AIHA diagnosis and management in congenital anemias, we retrospectively evaluated all clinically relevant AIHA cases occurring at a referral center for AIHA, hemoglobinopathies, and chronic hemolytic anemias, focusing on clinical management and outcome. In our cohort, AIHA had a prevalence of 1% (14/1410 patients). The majority were warm AIHA. Possible triggers were recent transfusion, infection, pregnancy, and surgery. All the patients received steroid therapy as the first line, and about 25% required further treatment, including rituximab, azathioprine, intravenous immunoglobulins, and cyclophosphamide. Transfusion support was required in 57% of the patients with non-transfusion-dependent anemia, and recombinant human erythropoietin was safely administered in one third of the patients. AIHA in congenital anemias may be challenging both from a diagnostic and a therapeutic point of view. A proper evaluation of hemolytic markers, bone marrow compensation, and assessment of the direct antiglobulin test is mandatory.
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Barcellini W, Giannotta J, Fattizzo B. Autoimmune hemolytic anemia in adults: primary risk factors and diagnostic procedures. Expert Rev Hematol 2020; 13:585-597. [PMID: 32274943 DOI: 10.1080/17474086.2020.1754791] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Autoimmune hemolytic anemia (AIHA) is due to autoantibodies against erythrocytes that may arise either because of primary tolerance breakage or along with several associated conditions, including genetic predispositions, congenital syndromes, environmental triggers, autoimmune diseases, immunodeficiencies, and neoplasms. AREAS COVERED This review evaluated the risk of AIHA development in associated conditions and summarized disease-intrinsic risk factors for relapse and outcome. Diagnostic procedures were analyzed to properly identify primary and secondary forms. A Medline including clinical trials, meta-analyses, guidelines, consensus, and case reports, published in the last 30 years were performed. EXPERT OPINION The several associated conditions listed above constitute a risk for AIHA development and should be considered since disease course and therapy may be different. Particularly, AIHA developing after transplant or novel checkpoint inhibitors is an emerging complex entity whose proper therapy is still an unmet need. Concerning intrinsic risk factors, the severity of anemia at onset correlated with the recurrence of relapses, refractoriness, and fatal outcome. This finding reflects the presence of several mechanisms involved in AIHA, i.e. highly pathogenic antibodies, complement activation, and failure of marrow compensation. With the advent of novel target therapies (complement and various tyrosine kinase inhibitors), a risk-adapted therapy for AIHA is becoming fundamental.
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Affiliation(s)
- Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy
| | - Juri Giannotta
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy.,Università degli Studi di Milano , Milan, Italy
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy.,Università degli Studi di Milano , Milan, Italy
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