Thrombotic microangiopathy associated with alpha-interferon therapy for chronic myelocytic leukemia

Association of thrombotic microangiopathy with interferon therapy for hepatitis B: a case report

BACKGROUND

Thrombotic microangiopathy is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and organ injury. The pathological features include vascular damage that is manifested by arteriolar and capillary thrombosis with characteristic abnormalities in the endothelium and vessel wall. Thrombocytopenia is one of the common adverse effects of interferon therapy. However, a more serious but rare side effect is thrombotic microangiopathy.

CASE PRESENTATION

We report the case of a 36-year-old Asian male patient with clinical manifestations of hypertension, blurred vision, acute renal failure, thrombocytopenia, and thrombotic microangiopathy. Renal biopsy showed interstitial edema with fibrosis, arteriolar thickening with vitreous changes, and epithelial podocytes segmental fusion. Immunofluorescence microscopy showed C3(+), Ig A(+) deposition in the mesangial region, which was pathologically consistent with thrombotic microangiopathy renal injury and Ig A deposition. The patient had a history of hepatitis B virus infection for more than 5 years. Lamivudine was used in the past, but the injection of long-acting interferon combined with tenofovir alafenamide fumarate was used since 2018. The comprehensive clinical investigation and laboratory examination diagnosed the condition as thrombotic microangiopathy kidney injury caused by interferon. After stopping interferon in his treatment, the patient's renal function partially recovered after three consecutive therapeutic plasma exchange treatments and follow-up treatment without immunosuppressant. The renal function of the patient remained stable.

CONCLUSIONS

This report indicates that interferon can induce thrombotic microangiopathy with acute renal injury, which can progress to chronic renal insufficiency.

Interferon induced thrombotic microangiopathy (TMA): Analysis and concise review

Interferon (IFN) has been associated with development of thrombotic microangiopathy including thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). We reviewed literature from the earliest reported association in 1993, to July 2016 and found 68 cases. Analysis of this data shows: (1) Mean age at diagnosis was 47 years (95% CI, 44-50). (2) Majority of cases were seen where IFN was used for the treatment of chronic myelogenous leukemia (CML), multiple sclerosis (MS), chronic hepatitis C virus infection (HCV) and one case each for hairy cell leukemia (HCL) and Sezary syndrome. (3) There were no cases reported for polycythemia vera (PV) or lymphoma. (4) Sex distribution was nearly equivalent with the exception in patients with multiple sclerosis where there was female predominance (12 of 16 with reported data). (5) For pooled analysis, the average duration of treatment with IFN before TMA was diagnosed was 40.4 months. (6) Comparative analysis showed that patients with MS required the highest cumulative dose exposure before developing TMA (MS 68.6 months, CML 35.5 months, HCV 30.4 months). (7) Cases of confirmed TTP (where A disintegrin and Metalloprotease with thrombospondin type 1 motif 13: ADAMTS 13 level was measured) showed presence of an inhibitor. (8) In all cases of confirmed TTP, moderate to severe thrombocytopenia was a striking clinical feature at presentation while this was not a consistent finding in all other cases of TMA. (9) Outcome analysis revealed complete remission in 27 (40%), persistent chronic kidney disease (CKD) in 28 (42%) and fatality in 12 patients (18%). (10) Treatment with corticosteroids, plasma exchange and rituximab resulted in durable responses.

Antineoplastic agents and thrombotic microangiopathy

Thrombotic microangiopathy is an uncommon but reported adverse effect of a variety of antineoplastic drugs, including chemotherapy agents such as mitomycin C and gemcitabine, and newer targeted agents such as the vascular endothelial growth factor inhibitors. We present a review of thrombotic microangiopathy associated with antineoplastic agents and its implications in current cancer therapy.

Hepatitis C Virus Infection Associated With an Increased Risk of Deep Vein Thrombosis: A Population-Based Cohort Study

The association between the hepatitis C virus (HCV) infection and the risk of myocardial infarction (MI) and stroke has been previously investigated. However, the association between the HCV infection and the risk of venous thromboembolism (VTE) has not been extensively discussed. Using the Longitudinal Health Insurance Database 2000 (LHID2000), we selected 3686 patients with newly diagnosed HCV infection. We randomly selected 14,744 people with no HCV or hepatitis B virus (HBV) infection as comparison group and frequency matched them with patients with HCV infection according to their age, sex, and index year. The incidence density rates and hazard ratios (HRs) of deep vein thrombosis (DVT) and pulmonary embolism (PE) were calculated until the end of 2011. The mean follow-up duration of 5.14 years for the HCV cohort and 5.61 years for the non-HCV cohort, the overall incidence density rates of DVT were 7.92 and 3.51 per 10,000 person-years in the non-HCV group, and the HCV groups, respectively (crude HR = 2.25; 95% confidence interval [CI] = 1.21-4.21). After adjusted for age, sex, and comorbidities, the risk of DVT remained significantly higher in the HCV group than in the non-HCV group (adjusted HR = 1.96; 95% CI = 1.03-3.73). The overall incidence density rates of PE in the HCV and non-HCV groups were not significantly different (crude HR = 2.20; 95% CI = 0.94-5.14). HCV infection is associated with the risk of DVT in a long-term follow-up period.

Kaposiform (spindle cell) hemangioendotelioma in a child with an unusual presentation

We describe a male child with multifocal kaposiform hemangioendothelioma in the right and left cervical region with development of Kasabach-Merritt syndrome. Treatment with interferon-alpha resulted in a good but only temporary clinical response.He relapsed 3 times with regrowth of the right cervical tumor. Involvement of the liver is suspected, because normalization of the liver size followed after the treatment with interferon-alpha. The question remains whether the multiple osteolytic bone lesions also reflect kaposiform hemangioendothelioma localization.

A case of deep venous thrombosis associated with pegylated interferon alpha2b plus ribavirin treatment of chronic hepatitis C

We present a case of deep venous thrombosis (DVT) during pegylated interferon (peg-IFN)-alpha2b plus ribavirin treatment of chronic hepatitis C (CHC). A 67-year-old man, who had been under treatment for hypertension and diabetes mellitus, was admitted to our hospital for peg-IFN-alpha2b plus ribavirin treatment for CHC. His serum hepatitis C virus (HCV) RNA level became undetectable 1 week after the initiation of peg-IFN-alpha2b plus ribavirin treatment. He suffered from severe pain, flare, and edema in both of his lower legs 6 weeks after the initiation of peg-IFN-alpha2b plus ribavirin treatment. He was diagnosed as having DVT because of the presence of a thrombus in the right soleus vein by ultrasonography. Peg-IFN-alpha2b plus ribavirin treatment was discontinued because a causal relationship between DVT and peg-IFN-alpha2b plus ribavirin treatment was suspected. DVT was not observed and the symptoms in both of his legs were improved after the administration of warfarin potassium. Subsequently, DVT has not recurred, and he has remained HCV-RNA negative.

Thrombotic microangiopathy associated with alpha-interferon therapy for chronic myeloid leukaemia (Case Report)

The association of interferon (IFN) therapy with haemolytic uraemic syndrome in patients with chronic myeloid leukaemia (CML) has been reported infrequently. The pathogenesis of the renal lesion in such cases remains unclear. We report the case of a patient with chronic myeloid leukaemia who developed nephrotic syndrome and renal failure while being treated with hydroxyurea and IFN-alpha. Renal biopsy showed features of chronic thrombotic microangiopathy. The discontinuation of IFN-alpha, and a prompt institution of plasmapheresis and steroids resulted in improvement of the nephrotic syndrome and renal function. These findings suggest that long-term IFN-alpha therapy can induce thrombotic microangiopathy and haemolytic uraemic syndrome in patients with chronic myeloid leukaemia.

Vascular Toxicity of Antineoplastic Agents

Among the various deleterious effects of cancer chemotherapy, vascular toxicity is the least well recognized. This lack of recognition may be because the vasculotoxic phenomena are not unique to antineoplastic agents, can occur in patients without exposure to these agents, and the fact cancer itself may produce a hypercoagulable state. As a result, many vascular events either go unnoticed, are ignored, and/or are attributed to the underlying malignancy. Many antineoplastic therapies are associated with various vascular phenomena that range from simple phelibitis to lethal microangiopathy. Recognition of these events is important to minimize the morbidity and even prevent unnecessary deaths. Herein we review the vascular syndromes that have been reported in association with antineoplastic agents.

Interferon-induced sarcoidosis

Interferons (IFNs) are widely used for the treatment of various medical diseases. They have marked immunomodulatory effects, and many reports have been published associating IFN therapy with the induction of autoimmune phenomena and other disorders of immune regulation such as sarcoidosis. The clinical presentation of IFN-induced sarcoidosis (IIS) is insidious and can be confused with common constitutional side effects of these drugs. The age of onset of IIS is later than that of naturally occurring sarcoidosis. The most common organs involved are the lungs and skin. In the majority of cases, IIS follows a benign course. As we show in an illustrative case report, complete resolution after discontinuation of IFN therapy can be expected. This review summarises 65 cases of IIS reported in the literature and highlights the pathophysiology, clinical features, diagnostic modalities and therapeutic options for this increasingly recognised phenomenon.

Von Willebrand factor-cleaving protease activity remains at the intermediate level in thrombotic thrombocytopenic purpura

A 59-year-old woman, diagnosed with chronic myelogenous leukemia (chronic phase) and treated with interferon-alpha for 13 years, developed renal failure. Renal biopsy showed thrombotic thrombocytopenic purpura, but intensive therapy including plasma exchange and steroid administration was not effective. The activity of von Willebrand factor-cleaving protease was detectable at the intermediate level (15-46%) during the clinical course, suggesting that this case was not compatible with the previously reported pattern of idiopathic or drug-induced thrombotic thrombocytopenic purpura, but with the pattern associated with malignant disease or immunological disorders. Further studies to determine the effects of interferon-alpha on endothelial cells in chronic myelogenous leukemia patients are needed.

Drug-induced thrombotic thrombocytopenic purpura/hemolytic uremic syndrome: a concise review

An extensive variety of drugs have been associated with thrombotic thrombocytopenic purpura and hemolytic uremic syndrome (TTP/HUS). Although a direct causal effect has usually not been proven, the cumulative evidence linking several drugs with TTP/HUS is strong. This paper reviews several categories of drugs including antineoplastics, immunotherapeutics and anti-platelet agents that have been reported to induce TTP/HUS. The pathogenesis of drug-induced TTP/HUS and the effectiveness of treatment regimens are also reviewed. A consensus on diagnostic criteria to accurately and consistently diagnose drug-induced TTP is needed.

Acute leukemia: an association with atypical hemolytic uremic syndrome

A 5-year-old boy was admitted for anemia, thrombocytopenia, and azotemia. Bone marrow examination demonstrated only erythroid hyperplasia, and he was diagnosed with an atypical form of hemolytic uremic syndrome (HUS). He was treated with daily prednisolone, and hematological profiles and renal function normalized 1 month later. However, heavy proteinuria persisted, and renal biopsy findings were consistent with HUS. Four months later, pancytopenia developed with recurrence of azotemia, and a second bone marrow examination revealed acute lymphoblastic leukemia (ALL). The remission of proteinuria with no recurrences of HUS after antileukemic treatment suggests that the HUS was associated with the ALL.

Withdrawal of interferon-alpha results in prompt resolution of thrombocytopenia and hemolysis but not renal failure in hemolytic uremic syndrome caused by interferon-alpha

This case report describes 2 patients with chronic myeloid leukemia in whom hemolytic uremic syndrome developed while being treated with interferon-alpha and hydroxycarbamide. Hemolytic uremic syndrome was recognized by progressive renal dysfunction, thrombocytopenia, microangiopathic hemolytic anemia, and histologic features of thrombotic microangiopathy in the kidney. Although renal dysfunction progressed to dialysis-dependent renal failure in one patient despite treatment with prednisolone and plasmapheresis but not in other, withdrawal of the treatment resulted in a prompt resolution of thrombocytopenia and microangiopathic hemolytic anemia in both patients.

Vascular events associated with alpha interferon therapy

Alpha Interferon (IFN) is a biological agent used for the therapy of an increasing number of diseases, either as an established effective therapeutic tool or in the context of clinical trials. The use of IFN may be complicated by serious adverse reactions. We describe here the clinical course of a variety of vasculopathic complications in association with IFN-therapy in 12 patients with the diagnosis of chronic myeloid leukemia and 1 patient with malignant melanoma treated at our institute. Vascular manifestations in these patients include Raynaud's phenomena, digital ulcerations and gangrene, pulmonary vasculitis, pulmonary hypertension and thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (TTP/HUS). These reactions occurred after 3 months to 3 years of 3-10 million units (MU) daily IFN therapy. Concomitant administration of hydroxyurea (HU) was noted in 5 patients. Discontinuation of IFN and initiation of immunosuppressive therapy brought about a complete resolution or arrested progression of these reactions. IFN-therapy may be complicated by severe vasculopathic/vasospastic complications that usually improve after its discontinuation. Possible underlying mechanisms for these complications are discussed. The early diagnosis of these complications may be vital and IFN should be immediately discontinued when early signs of these complications become evident.

Cytokines in coagulation and thrombosis: a preclinical and clinical review

The cytokine network is a complex and dynamic system, involved in numerous biological responses in the human body. This review of the current literature describes the role of cytokines and their interaction with the coagulation system, specifically in the maintenance of the thrombo-hemorrhagic balance in vivo in human subjects and in animals. In general, cytokines are thrombogenic, but they are amenable to therapeutic manipulations and hence are a potentially attractive tool in the clinician's armamentarium. Studies of the effects of cytokines in vivo are difficult because cytokines act in a very finite microenvironment and, although their actions are significant, they are transient. Most of the available clinical data related to interactions between cytokines and the coagulation system focuses on the role of tumor necrosis factor-alpha and interleukin-1 in septicemia and septic shock. However, several other cytokines and related proteins, such as platelet activating factor and plasminogen activator inhibitor, are also known to influence coagulation and thrombosis. These factors interact closely with cytokines, and have been included in this review for a better understanding of their interactions with traditional cytokines. Studies that utilize cell culture systems do not accurately model the in vivo status of this complex system and, hence, this review has excluded such studies. The role of the cytokine network in coronary artery disease, angiogenesis, or neoplasia has been addressed elsewhere by other workers and is not discussed here. By emphasizing important in vivo interactions, the intention of this review is to serve as an impetus to further translational research, both clinical and in the laboratory.

Drug-induced thrombotic microangiopathy: incidence, prevention and management

The term thrombotic microangiopathy (TMA) describes syndromes characterised by microangiopathic haemolytic anaemia, thrombocytopenia and variable signs of organ damage due to platelet thrombi in the microcirculation. In children, infections with Shigella dysenteriae type 1 or particular strains of Escherichia coli are the most common cause of TMA; in adults, a variety of underlying causes have been identified, such as bacterial and viral infections, bone marrow and organ transplantation, pregnancy, immune disorders and certain drugs. Although drug-induced TMA is a rare condition, it causes significant morbidity and mortality. Antineoplastic therapy may induce TMA. Most of the cases reported are associated with mitomycin. TMA has also been associated with cyclosporin, tacrolimus, muromonab-CD3 (OKT3) and other drugs such as interferon, anti-aggregating agents (ticlopidine, clopidogrel) and quinine. The early diagnosis of drug-induced TMA may be vital. Strict monitoring of renal function, urine and blood abnormalities, and arterial pressure has to be performed in patients undergoing therapy with potentially toxic drugs. The drug must be discontinued immediately in the case of suspected TMA. Treatment modalities sometimes effective in other forms of TMA have been used empirically. Although plasma exchange therapy seems to be of value, the effectiveness of this approach has yet to be proved in multicentre, randomised clinical studies.

Retinal vein thrombosis associated with chronic hepatitis C: a case series and review of the literature

The role of procoagulant autoantibodies in hepatitis C virus (HCV) infection is unclear. Three individuals with HCV infection and a unique genetic hypercoagulable state developed retinal vein thrombosis (RVT) in association with interferon-alpha (IFN-alpha) therapy. It is probable that a combination of active HCV infection in a genetically susceptible individual receiving IFN-alpha accounted for the observed RVT.

Glomerular and extraglomerular immune complex deposits in a bone marrow transplant recipient

A 44-year-old man developed nephrotic syndrome 9 months after HLA-identical sibling bone marrow transplantation. Membranous changes consisted mainly of alterations of glomeruli, which were interpreted as chronic graft-versus-host disease (GVHD) caused by lodging of the circulating immune complex. In the tubules, a lumpy deposition of IgG and complement breakdown products was distributed along the tubular basement membrane, which coincided with the peculiar deposits ascertained by electron microscopy. These findings suggest that an extraglomerular reaction should be considered in evaluating renal involvement of GVHD.

Interferons and cerebral palsy

OBJECTIVE

To explore the association of neonatal interferons (IFNs) with spastic cerebral palsy (CP) and with other measured substances.

STUDY DESIGN

Assays of archived neonatal blood of 31 predominantly term children with CP and 65 children in a control group were obtained by recycling immunoaffinity chromatography with laser-enhanced fluorescence and chemiluminescence detection.

RESULTS

Fourteen of 31 children with spastic CP had concentrations of IFNs-alpha, beta, and gamma exceeding any control. Levels of interleukins-1, 6, 8, tumor necrosis factor-alpha, chemokines, colony stimulating factors, transforming growth factor-beta, complement components and regulators, certain neuropeptides, and thyroid hormones also differed from control levels in these 14 children. The 17 children with CP whose IFN concentrations were within the control range had levels of inflammatory cytokines higher than but near to control values; 13 of these 17 had values for coagulation factors that exceeded control values. Seven of 9 children with spastic diplegia had high IFNs, and 8 of 10 hemiplegic children had normal IFNs.

CONCLUSION

Neonatal IFNs exceeding control concentrations were associated with other biochemical and clinical indicators of inflammation and with spastic diplegia. In these children with CP, IFNs within the control range were associated with concentrations of other inflammatory markers that were near to control values and with spastic hemiplegia.

A new model of renal microvascular injury

The vascular endothelial injury with its consequent activation is actively involved in inflammation and promotion of a procoagulant state, which are likely to be of major importance in the pathogenesis of various disorders, including renal thrombotic microangiopathy. This study briefly reviews the consequences of glomerular endothelial cell injury or activation, as shown by recent experimental data.