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Jaime-Pérez JC, Aguilar-Calderón PE, Salazar-Cavazos L, Gómez-Almaguer D. Evans syndrome: clinical perspectives, biological insights and treatment modalities. J Blood Med 2018; 9:171-184. [PMID: 30349415 PMCID: PMC6190623 DOI: 10.2147/jbm.s176144] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Evans syndrome (ES) is a rare and chronic autoimmune disease characterized by autoimmune hemolytic anemia and immune thrombocytopenic purpura with a positive direct anti-human globulin test. It is classified as primary and secondary, with the frequency in patients with autoimmune hemolytic anemia being 37%–73%. It predominates in children, mainly due to primary immunodeficiencies or autoimmune lymphoproliferative syndrome. ES during pregnancy is associated with high fetal morbidity, including severe hemolysis and intracranial bleeding with neurological sequelae and death. The clinical presentation can include fatigue, pallor, jaundice and mucosal bleeding, with remissions and exacerbations during the person’s lifetime, and acute manifestations as catastrophic bleeding and massive hemolysis. Recent molecular theories explaining the physiopathology of ES include deficiencies of CTLA-4, LRBA, TPP2 and a decreased CD4/CD8 ratio. As in other autoimmune cytopenias, there is no established evidence-based treatment and steroids are the first-line therapy, with intravenous immunoglobulin administered as a life-saving resource in cases of severe immune thrombocytopenic purpura manifestations. Second-line treatment for refractory ES includes rituximab, mofetil mycophenolate, cyclosporine, vincristine, azathioprine, sirolimus and thrombopoietin receptor agonists. In cases unresponsive to immunosuppressive agents, hematopoietic stem cell transplantation has been successful, although it is necessary to consider its potential serious adverse effects. In conclusion, ES is a disease with a heterogeneous course that remains challenging to patients and physicians, with prospective clinical trials needed to explore potential targeted therapy to achieve an improved long-term response or even a cure.
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Affiliation(s)
- José Carlos Jaime-Pérez
- Department of Hematology, Internal Medicine Division, Dr José E González University Hospital, School of Medicine of the Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,
| | - Patrizia Elva Aguilar-Calderón
- Department of Hematology, Internal Medicine Division, Dr José E González University Hospital, School of Medicine of the Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,
| | - Lorena Salazar-Cavazos
- Department of Hematology, Internal Medicine Division, Dr José E González University Hospital, School of Medicine of the Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,
| | - David Gómez-Almaguer
- Department of Hematology, Internal Medicine Division, Dr José E González University Hospital, School of Medicine of the Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México,
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Zhang L, Wu X, Wang L, Li J, Chen H, Zhao Y, Zheng W. Clinical Features of Systemic Lupus Erythematosus Patients Complicated With Evans Syndrome: A Case-Control, Single Center Study. Medicine (Baltimore) 2016; 95:e3279. [PMID: 27082565 PMCID: PMC4839809 DOI: 10.1097/md.0000000000003279] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of the study was to investigate the clinical features of systemic lupus erythematous (SLE) complicated with Evans syndrome (ES). We conducted a retrospective case-control study to compare the clinical and laboratory features of age- and gender-matched lupus patients with and without ES in 1:3 ratios. In 5724 hospitalized SLE patients, we identified 27 (0.47%, 22 women and 5 men, average age 34.2 years) SLE patients complicated with ES. Fifteen patients (55.6%) presented with hematologic abnormalities initially, including 6 (22.2%) cases of isolated ITP, 4 (14.8%) cases of isolated AIHA, and 5 (18.5%) cases of classical ES. The median intervals between hematological presentations the diagnosis of SLE was 36 months (range 0-252). ES developed after the SLE diagnosis in 4 patients (14.8%), and concomitantly with SLE diagnosis in 8 patients (29.6%). Systemic involvements are frequently observed in SLE patients with ES, including fever (55.6%), serositis (51.9%), hair loss (40.7%), lupus nephritis (37%), Raynaud phenomenon (33.3%), neuropsychiatric (33.3%) and pulmonary involvement (25.9%), and photosensitivity (25.9%). The incidence of photosensitivity, hypocomplementemia, elevated serum IgG level, and lupus nephritis in patients with ES or without ES was 25.9% vs 6.2% (P = 0.007), 88.9% vs 67.1% (P = 0.029), 48.1% vs 24.4% (P = 0.021), and 37% vs 64.2% (P = 0.013), respectively. Twenty-five (92.6%) patients achieved improvement following treatment of glucocorticoids and immunosuppressants as well as splenectomy, whereas 6 patients experienced the relapse and 1 patient died from renal failure during the follow-up. ES is a relatively rare complication of SLE. Photosensitivity, hypocomplementemia, and elevated serum IgG level were frequently observed in ES patients, but lupus nephritis was less observed. More than half of patients presented with hematological manifestation at onset, and progress to typical lupus over months to years. Therefore, monitoring with antoantibodies profile as well as nonhematological presentations are necessary for patients with ITP and (or) AIHA.
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MESH Headings
- Adult
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/epidemiology
- Anemia, Hemolytic, Autoimmune/etiology
- Anemia, Hemolytic, Autoimmune/immunology
- Anemia, Hemolytic, Autoimmune/physiopathology
- Case-Control Studies
- China/epidemiology
- Female
- Glucocorticoids/therapeutic use
- Humans
- Immunosuppressive Agents/therapeutic use
- Incidence
- Lupus Erythematosus, Systemic/blood
- Lupus Erythematosus, Systemic/complications
- Lupus Erythematosus, Systemic/diagnosis
- Lupus Erythematosus, Systemic/drug therapy
- Lupus Erythematosus, Systemic/epidemiology
- Lupus Erythematosus, Systemic/physiopathology
- Male
- Middle Aged
- Monitoring, Immunologic/methods
- Prognosis
- Retrospective Studies
- Thrombocytopenia/diagnosis
- Thrombocytopenia/drug therapy
- Thrombocytopenia/epidemiology
- Thrombocytopenia/etiology
- Thrombocytopenia/immunology
- Thrombocytopenia/physiopathology
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Affiliation(s)
- Lili Zhang
- From the Department of Rheumatology and Clinical Immunology (LZ, XW, JL, HC, YZ, WZ), Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing; and Department of Rheumatology (LW), Huaihe Hospital of Henan University, Henan, China
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Annaloro C, Onida F, Lambertenghi Deliliers G. Autologous hematopoietic stem cell transplantation in autoimmune diseases. Expert Rev Hematol 2011; 2:699-715. [PMID: 21082959 DOI: 10.1586/ehm.09.60] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The term 'autoimmune diseases' encompasses a spectrum of diseases whose clinical manifestations and, possibly, biological features vary widely. The results of conventional treatment are considered unsatisfactory in aggressive forms, with subsets of patients having short life expectancies. Relying on wide experimental evidence and more feeble clinical data, some research groups have used autologous hematopoietic stem cell transplantation (HSCT) in the most disabling autoimmune diseases with the aim of resetting the patient's immune system. Immunoablative conditioning regimens are preferred over their myeloablative counterparts, and some form of in vivo and/or ex vivo T-cell depletion is generally adopted. Despite 15 years' experience, published controlled clinical trials are still lacking, with the evidence so far available coming from pilot studies and registry surveys. In multiple sclerosis, clinical improvement, or at least lasting disease stabilization, can be achieved in the majority of the patients; nevertheless, the worst results are observed in patients with progressive disease, where no benefit can be expected from conventional therapy. Concerning rheumatologic diseases, wide experience has been acquired in systemic sclerosis, with long-term improvements in cutaneous disease being frequently reported, although visceral involvement remains unchanged at best. Autografting has proved to be barely effective in rheumatoid arthritis and quite toxic in juvenile idiopathic arthritis, whereas it leads to clinical remission and the reversal of visceral impairment in the majority of patients with systemic lupus erythematosus. A promising indication is Crohn's disease, in which long-term endoscopic remission is frequently observed. Growing experience with autologous HCST in autoimmune diseases has progressively reduced concerns about transplant-related mortality and secondary myelodysplasia/leukemia. Therefore, a sustained complete remission seems to be within the reach of autografting in some autoimmune diseases; in others, the indications, risks and benefits of autografting need to be better defined. Consequently, the search for new drugs should also be encouraged.
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Affiliation(s)
- Claudio Annaloro
- Bone Marrow Transplantation Center-Hematology I, Fondazione Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, University of Milan, Via Francesco Sforza 35, Milan, Italy
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Godeau B, Bierling P. [Treatment of idiopathic thrombocytopenic purpura in adults]. Presse Med 2008; 37:1292-8. [PMID: 18644317 DOI: 10.1016/j.lpm.2008.01.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2008] [Accepted: 01/07/2008] [Indexed: 11/30/2022] Open
Abstract
The lack of controlled studies of the treatment of idiopathic thrombocytopenic purpura (ITP), also known as immune thrombocytopenic purpura, means that no evidence-based recommendations are available. ITP is a benign disease and severe hemorrhages are rare. Oral prednisone remains the first-line treatment. In patients with very low platelet counts and significant bleeding, intravenous immunoglobulins and high-dose oral dexamethasone may be an alternative. A validated bleeding score would help physicians use these treatments more effectively. Splenectomy remains the best curative treatment for adults with chronic ITP and platelet counts <30 x 10(9)/L after failure of the first-line treatments. Rituximab is probably the single most effective agent, as well as the least toxic, when splenectomy fails: the short-term response rate is 50% and the sustained-response rate more than 30%. Cytotoxic or other immunosuppressive agents should be reserved for patients with severe disease refractory to both splenectomy and rituximab. Thrombopoietin receptor agonists are a class of new investigational drugs for which promising results have been reported, but more data regarding long-term safety are needed.
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Affiliation(s)
- Bertrand Godeau
- Centre de référence labellisé pour la prise en charge des cytopénies auto-immunes de l'adulte, Service de médecine interne, Assistance-Publique Hôpitaux de Paris APHP, Université Paris 12, Hôpital Henri Mondor, Créteil, France.
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Garcia-Chavez J, Majluf-Cruz A, Montiel-Cervantes L, Esparza MGR, Vela-Ojeda J. Rituximab therapy for chronic and refractory immune thrombocytopenic purpura: a long-term follow-up analysis. Ann Hematol 2007; 86:871-7. [PMID: 17874322 PMCID: PMC2040174 DOI: 10.1007/s00277-007-0317-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2007] [Accepted: 05/07/2007] [Indexed: 01/19/2023]
Abstract
The aim of this study was to evaluate the long-term response to rituximab in patients with chronic and refractory immune thrombocytopenic purpura (ITP). Adults with ITP fail to respond to conventional therapies in almost 30% of cases, developing a refractory disease. Rituximab has been successfully used in these patients. We used rituximab at 375 mg/m2, IV, weekly for a total of four doses in 18 adult patients. Complete remission (CR) was considered if the platelet count was >100 × 109/l, partial remission (PR) if platelets were >50 × 109/l, minimal response (MR) if the platelet count was >30 × 109/l and <50 × 109/l, and no response if platelet count remained unchanged. Response was classified as sustained (SR) when it was stable for a minimum of 6 months. Median age was 43.5 years (range, 17 to 70). Median platelet count at baseline was 12.5 × 109/l (range, 3.0 to 26.3). CR was achieved in five patients (28%), PR in five (28%), MR in four (22%), and two patients were classified as therapeutic failures (11%). Two additional patients were lost to follow-up. The median time between rituximab therapy and response was 14 weeks (range, 4 to 32). SR was achieved in 12 patients (67%). There were no severe adverse events during rituximab therapy. During follow-up (median, 26 months; range, 12 to 59), no other immunosuppressive drugs were used. In conclusion, rituximab therapy is effective and safe in adult patients with chronic and refractory ITP. Overall response rate achieved is high, long term, and with no risk of adverse events.
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Affiliation(s)
- Jaime Garcia-Chavez
- Departamento de Hematología, UMAE “Dr. Antonio Fraga Mouret”, Hospital de Especialidades CMN “La Raza”, Mexico City, Mexico
| | - Abraham Majluf-Cruz
- Unidad de Investigación Médica en Trombosis, Hemostasia y Aterogénesis, Hospital General Regional Gabriel Mancera, Instituto Mexicano del Seguro Social, Apartado postal 12-1100, Mexico City, México 12 DF Mexico
| | - Laura Montiel-Cervantes
- Departamento de Hematología, UMAE “Dr. Antonio Fraga Mouret”, Hospital de Especialidades CMN “La Raza”, Mexico City, Mexico
| | - Miriam García-Ruiz Esparza
- Departamento de Hematología, UMAE “Dr. Antonio Fraga Mouret”, Hospital de Especialidades CMN “La Raza”, Mexico City, Mexico
| | - Jorge Vela-Ojeda
- Departamento de Hematología, UMAE “Dr. Antonio Fraga Mouret”, Hospital de Especialidades CMN “La Raza”, Mexico City, Mexico
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Pinto A, Lindemeyer RG, Alawi F. Management of a young patient with combined autoimmunity: Evans syndrome: a case report. ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY, AND ENDODONTICS 2007; 103:505-11. [PMID: 17095266 DOI: 10.1016/j.tripleo.2006.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2006] [Revised: 07/19/2006] [Accepted: 07/25/2006] [Indexed: 05/12/2023]
Abstract
Management of patients with autoimmune disease can present a challenge for clinicians. Combinations of autoimmune disorders carry a worse prognosis and are often difficult to diagnose. Evans syndrome is a rare hematologic disorder characterized by the concurrent presentation of autoimmune hemolytic anemia and immune thrombocytopenic purpura. This paper reports the first case of the dental management of a young patient with Evans, discusses the current literature surrounding the differential diagnosis and treatment of Evans syndrome, and suggests a guide for the oral medicine, pediatric dentist, or hospital dental clinician when treating these patients.
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Affiliation(s)
- Andres Pinto
- Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, PA, USA.
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Lechner K, Weltermann A, Pabinger I. Autoimmunthrombozytopenie (AITP) des Erwachsenen: Klinik, Diagnose und Therapie. Wien Klin Wochenschr 2006; 118:255-64. [PMID: 16810482 DOI: 10.1007/s00508-006-0602-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The incidence of AITP is 20-30/million/year. The diagnosis is based on the finding of an isolated thrombocytopenia without other blood abnormalities and absence of a palpable spleen. Additional tests such as bone marrow examination, determination of platelet antibodies and of thrombopoetin are required only in special cases. The usual first line therapy in patients with bleeding tendency and a low platelet count is prednisolone at a dose of 1 mg/kg/day. Patients who have platelet counts of less than 20,000/microl 3-6 months after steroid therapy are candidates for splenectomy, in particular if more than 0.1 mg/kg/day prednisolone is required to keep the patient free of bleedings. Laparoscopic splenectomy has a low mortality (0.2%) and morbidity (10%). The risk of post-splenectomy overwhelming pneumococcal septicaemia can be minimized by preoperative vaccination. Older patients, who have low platelet counts after splenectomy, have a high bleeding risk. The most effective treatment options for these patients are cyclophosphamide, azathioprine and rituximab, but the choice of treatment should be carefully considered, since the risk of adverse effects may be greater than the risk of fatal bleeding.
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Affiliation(s)
- Klaus Lechner
- Abteilung Hämatologie/Hämostaseologie, Universitätsklinik für Innere Medizin I, Medizinische Universität Wien, Wien, Austria.
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Abstract
Evans syndrome is an uncommon condition defined by the combination (either simultaneously or sequentially) of immune thrombocytopenia (ITP) and autoimmune haemolytic anaemia (AIHA) with a positive direct antiglobulin test (DAT) in the absence of known underlying aetiology. This condition generally runs a chronic course and is characterised by frequent exacerbations and remissions. First-line therapy is usually corticosteroids and/or intravenous immunoglobulin, to which most patients respond; however, relapse is frequent. Options for second-line therapy include immunosuppressive drugs, especially ciclosporin or mycophenolate mofetil; vincristine; danazol or a combination of these agents. More recently a small number of patients have been treated with rituximab, which induces remission in the majority although such responses are often sustained for <12 months and the long-term effects in children are unclear. Splenectomy may also be considered although long-term remissions are less frequent than in uncomplicated ITP. For very severe and refractory cases stem cell transplantation (SCT) offers the only chance of long-term cure. The limited data available suggest that allogeneic SCT may be superior to autologous SCT but both carry risks of severe morbidity and of transplant-related mortality. Cure following reduced-intensity conditioning has now been reported and should be considered for younger patients in the context of controlled clinical trials.
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Affiliation(s)
- Alice Norton
- Paediatric Haematology, Department of Paediatrics, St Mary's Hospital, Paddington, London, UK
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