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Yang Y, Chen C, Zheng B, Fan L, Chen X, Hu M. Pure white cell aplasia before and after thymectomy in the rare conundrum of thymoma: A case report and review of the literature. Medicine (Baltimore) 2024; 103:e36920. [PMID: 38241556 PMCID: PMC10798751 DOI: 10.1097/md.0000000000036920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 12/20/2023] [Indexed: 01/21/2024] Open
Abstract
RATIONALE Pure white cell aplasia (PWCA) is a rare paraneoplastic syndrome that occurs in patients with thymomas. Currently, the pathogenesis and treatment of this disease remain in the exploratory stage. PATIENT CONCERNS We report a 68-year-old woman with thymoma experienced PWCA involvement as her first presentation. The patient had high fever and agranulocytosis at the onset of the disease. The white blood cell count in the complete blood count was 1.9 × 109/L with a neutrophil of 0.1 × 109/L. The bone marrow aspirates showed decreased granulocyte proliferation. Computed tomography showed a large mass in the anterior mediastinum. DIAGNOSES The final diagnosis of our patient was PWCA and thymoma. INTERVENTIONS She underwent a thymectomy and cyclosporine A administration during first remission. OUTCOMES Long-term remission was achieved following the readministration of cyclosporine A after the disease recurrence. LESSONS PWCA or agranulocytosis with thymoma has been confirmed to be an extremely rare disease. Thymomas with PWCA correlate with autoimmunity. From this case study and the literature review, we concluded that the pathogenesis of thymomas in PWCA is mainly related to the activation of autoreactive T cells. Thymectomy and the immunosuppressive drug, cyclosporine A, were chosen for treatment. The patient's granulocyte levels were unable to recover after surgery because of the inability to promptly clear activated T cells. After surgery, cyclosporine A continued to take for a long time. Thymectomy combined with prolonged cyclosporine A administration may be an effective method for treating this rare disease.
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Affiliation(s)
- Yang Yang
- Department of Hematology, the Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Chunmei Chen
- Department of Hematology, the Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Bingrong Zheng
- Department of Hematology, the Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Liping Fan
- Department of Hematology, the Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Xiajun Chen
- Department of Hematology, the Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Meiwei Hu
- Department of Hematology, the Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
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Lutz M, Neumann DT, Farfán López F, Pfeiffer T, Hirschbühl K. Pure White Cell Aplasia Associated With Long-Term Unprotected Exposure to High Concentrations of Benzalkonium Chloride and 2-Phenoxyethanol. Cureus 2023; 15:e49473. [PMID: 38152773 PMCID: PMC10751735 DOI: 10.7759/cureus.49473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2023] [Indexed: 12/29/2023] Open
Abstract
Pure white cell aplasia (PWCA) is a very rare hematological disorder with a nearly total absence of granulocytes and their precursor cells. While the disease is rarely diagnosed incidentally in otherwise asymptomatic individuals, most patients suffer from sometimes life-threatening infections. Due to its very low incidence, the precise pathomechanism of PWCA still needs to be elucidated. While most cases reported in the literature have been associated with an underlying thymic or autoimmune disease, some other factors including the intake of certain drugs such as antimicrobial agents or immune checkpoint inhibitors have been identified as potential triggers. Since PWCA is commonly refractory to treatment with granulocyte colony-stimulating factors (G-CSF), the main focus lies in identifying and eliminating the underlying trigger. Here, we report a unique case where the development of PWCA in a 56-year-old man with an upper respiratory tract infection has to be attributed to the long-term unprotected exposure to an industrial detergent containing high concentrations of the preservatives benzalkonium chloride (BAC) and 2-phenoxyethanol (2-PE). As a matter of fact, certain hematotoxic potential has been described in the literature for both BAC and 2-PE.
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Affiliation(s)
- Mathias Lutz
- Hematology and Oncology, University of Augsburg, Augsburg, DEU
| | | | | | - Tim Pfeiffer
- Hematology and Oncology, University of Augsburg, Augsburg, DEU
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Suzuki E, Oda R, Kanno T, Kimura S, Saito Y, Kanbayashi H, Matsuda S, Migita K. Pure White Cell Aplasia Complicated by Systemic Sclerosis with Accompanying Scleroderma Renal Crisis. Intern Med 2022; 61:1907-1912. [PMID: 34803102 PMCID: PMC9259819 DOI: 10.2169/internalmedicine.8436-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Pure white cell aplasia (PWCA) is a rare neutropenic disorder caused by absence of neutrophil-lineage cells. A 49-year-old man was diagnosed with scleroderma renal crisis 2 months prior to admission to Ohta-Nishinouchi Hospital after experiencing a fever and abdominal pain. Blood tests revealed severe neutropenia, and bone marrow aspirate showed the absence of neutrophil-lineage cells. He was diagnosed with PWCA. Steroids alone were not effective, but adding cyclosporine A and high-dose immunoglobulin recovered his neutropenia and improved his condition. Cyclosporine A and high-dose immunoglobulin are thus considered effective for treating PWCA in autoimmune diseases.
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Affiliation(s)
- Eiji Suzuki
- Department of Rheumatology, Ohta-Nishinouchi Hospital, Japan
| | - Ryoma Oda
- Department of Rheumatology, Ohta-Nishinouchi Hospital, Japan
| | - Takashi Kanno
- Department of Rheumatology, Ohta-Nishinouchi Hospital, Japan
| | - Satoru Kimura
- Department of Hematology, Ohta-Nishinouchi Hospital, Japan
| | - Yurie Saito
- Department of Hematology, Ohta-Nishinouchi Hospital, Japan
| | | | - Shin Matsuda
- Department of Hematology, Ohta-Nishinouchi Hospital, Japan
| | - Kiyoshi Migita
- Department of Rheumatology, Fukushima Medical University School of Medicine, Japan
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Céspedes López R, Amutio Díez E, Martín Martitegui X, Balerdi Malcorra A, Insunza Oleaga L, Arzuaga‐Méndez J, Moreno Gámiz M, Saiz Camín M, Aberasturi Plata Y, García‐Ruíz JC. Pure white cell aplasia an exceptional condition in the immunological conundrum of thymomas: Responses to immunosuppression and literature review. Clin Case Rep 2022; 10:e05742. [PMID: 35582161 PMCID: PMC9083807 DOI: 10.1002/ccr3.5742] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 02/25/2022] [Accepted: 03/22/2022] [Indexed: 12/05/2022] Open
Abstract
Thymomas are tumours frequently associated with autoimmune manifestations or immunodeficiencies like Good syndrome. In rare cases, pure white cells aplasia (PWCA) has been described in association with thymomas. PWCA is characterized by agranulocytosis of autoimmune background primary refractory to granulocyte colony-stimulating factor (G-CSF). It is necessary the use of immunosuppressor to allow granulocyte recovery. Without treatment, it could be fatal.
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5
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Youssef M, Stratton TW, Gallant RC, Young C, Li DY, Piran S. Pure White Cell Aplasia and Immune Thrombocytopenia after Thymoma Resection: A Case Report and Review of the Literature. Case Rep Hematol 2022; 2022:8271069. [PMID: 35360458 PMCID: PMC8964212 DOI: 10.1155/2022/8271069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 12/22/2021] [Accepted: 02/18/2022] [Indexed: 11/26/2022] Open
Abstract
We report a case of pure white cell aplasia (PWCA) postthymoma resection in a 74-year-old male presenting with a 2-week history of fevers, night sweats, and severe febrile neutropenia. His pure white cell aplasia was treated with intravenous immunoglobulin (IVIg), granulocyte colony-stimulating factor (G-CSF), prednisone, and cyclosporine with a mixed response. He also developed immune thrombocytopenia, which responded well to a short course of eltrombopag. With continued cyclosporine treatment, his platelet counts were stable after stopping eltrombopag. The patient's cyclosporine treatment was complicated by renal failure, resulting in cessation of cyclosporine. His PWCA and immune thrombocytopenia significantly worsened after stopping cyclosporine, and unfortunately, he died from multiorgan failure and sepsis.
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Affiliation(s)
| | - Tyler W. Stratton
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | | | - Christine Young
- Department of Pharmacy, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Daniel Y. Li
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Siavash Piran
- Department of Medicine, Division of Hematology, University of Toronto, Toronto, Canada
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A Rare Complication of Thymoma: Pure White Cell Aplasia in Good's Syndrome. Case Rep Hematol 2019; 2019:1024670. [PMID: 31737381 PMCID: PMC6815588 DOI: 10.1155/2019/1024670] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 09/09/2019] [Indexed: 01/01/2023] Open
Abstract
Pure white cell aplasia (PWCA) is a rare manifestation of thymoma. It is characterized by agranulocytosis with absent myeloid precursors in the bone marrow and normal hematopoiesis for other cell lines. Here we describe a 65-year-old female patient who presented with three days of fever and night sweat. Chest CT revealed an anterior mediastinal mass. A biopsy of the mass confirmed a diagnosis of thymoma mixed type A and B2. The patient developed a severe neutropenia, and her bone marrow revealed significantly decreased neutrophil-lineage cells, rare to absent B cells, and defective T cells, consistent with PWCA. Following thymectomy, a complete resolution of PWCA was achieved via multimodality therapy of intravenous immunoglobulins, granulocyte colony-stimulating factor, and immunosuppressant. This report highlights the care complexity regarding treatment choices and decision to perform thymectomy in patients presenting with PWCA.
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7
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Complete remission of pure white cell aplasia associated with thymoma after thymectomy and cyclosporine administration. Int J Hematol 2018; 109:346-350. [DOI: 10.1007/s12185-018-02573-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 12/04/2018] [Accepted: 12/04/2018] [Indexed: 10/27/2022]
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9
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Becker H, Auman K, Claus R, von Bubnoff N, Sachs UJ, Waller CF. Sunitinib in the Treatment of Thymoma and Associated Autoimmune Neutropenia. JCO Precis Oncol 2017; 1:1-7. [DOI: 10.1200/po.17.00095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Heiko Becker
- Heiko Becker, Konrad Auman, Rainer Claus, Nikolas von Bubnoff, and Cornelius F. Waller, University of Freiburg, Freiburg; and Ulrich J. Sachs, Justus Liebig University, Giessen, Germany
| | - Konrad Auman
- Heiko Becker, Konrad Auman, Rainer Claus, Nikolas von Bubnoff, and Cornelius F. Waller, University of Freiburg, Freiburg; and Ulrich J. Sachs, Justus Liebig University, Giessen, Germany
| | - Rainer Claus
- Heiko Becker, Konrad Auman, Rainer Claus, Nikolas von Bubnoff, and Cornelius F. Waller, University of Freiburg, Freiburg; and Ulrich J. Sachs, Justus Liebig University, Giessen, Germany
| | - Nikolas von Bubnoff
- Heiko Becker, Konrad Auman, Rainer Claus, Nikolas von Bubnoff, and Cornelius F. Waller, University of Freiburg, Freiburg; and Ulrich J. Sachs, Justus Liebig University, Giessen, Germany
| | - Ulrich J. Sachs
- Heiko Becker, Konrad Auman, Rainer Claus, Nikolas von Bubnoff, and Cornelius F. Waller, University of Freiburg, Freiburg; and Ulrich J. Sachs, Justus Liebig University, Giessen, Germany
| | - Cornelius F. Waller
- Heiko Becker, Konrad Auman, Rainer Claus, Nikolas von Bubnoff, and Cornelius F. Waller, University of Freiburg, Freiburg; and Ulrich J. Sachs, Justus Liebig University, Giessen, Germany
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10
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Koh S, Koh H, Kubo Y, Kuroda M, Nishimoto M, Yoshimura T, Nakashima Y, Nakane T, Nakamae H, Ohsawa M, Hino M. An Elderly Woman with Anti-neutrophil Antibody-positive Agranulocytosis Who Responded to High-dose Intravenous Methylprednisolone. Intern Med 2017; 56:2199-2203. [PMID: 28781303 PMCID: PMC5596284 DOI: 10.2169/internalmedicine.8268-16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Although anti-neutrophil antibodies (ANAs) often exist and immunoreaction may be involved in agranulocytosis, few reports have so far described ANA-positive cases of agranulocytosis with an unknown etiology. We herein describe the case of a 69-year-old woman who presented with ANA-positive agranulocytosis. In this case, both the withdrawal of the drugs that had possibly caused neutropenia and the use of granulocyte-colony stimulating factor (G-CSF) were ineffective treatment measures. Approximately 2 weeks after the discontinuation of the suspected drugs, we initiated corticosteroid pulse therapy; the neutrophil count recovered by day 19 of steroid therapy. High-dose methylprednisolone therapy should thus be considered for patients demonstrating ANA-positive agranulocytosis with an unknown etiology that is refractory to G-CSF treatment.
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Affiliation(s)
- Shiro Koh
- Hematology, Graduate School of Medicine, Osaka City University, Japan
| | - Hideo Koh
- Hematology, Graduate School of Medicine, Osaka City University, Japan
| | - Yuki Kubo
- Department of Diagnostic Pathology, Graduate School of Medicine, Osaka City University, Japan
| | - Maiko Kuroda
- Hematology, Graduate School of Medicine, Osaka City University, Japan
| | | | - Takuro Yoshimura
- Hematology, Graduate School of Medicine, Osaka City University, Japan
| | | | - Takahiko Nakane
- Hematology, Graduate School of Medicine, Osaka City University, Japan
| | - Hirohisa Nakamae
- Hematology, Graduate School of Medicine, Osaka City University, Japan
| | - Masahiko Ohsawa
- Department of Diagnostic Pathology, Graduate School of Medicine, Osaka City University, Japan
| | - Masayuki Hino
- Hematology, Graduate School of Medicine, Osaka City University, Japan
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11
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Pure White Cell Aplasia and Necrotizing Myositis. Case Rep Hematol 2016; 2016:4161679. [PMID: 27073704 PMCID: PMC4814688 DOI: 10.1155/2016/4161679] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 03/02/2016] [Indexed: 01/22/2023] Open
Abstract
Pure white cell aplasia (PWCA) is a rare hematologic disorder characterized by the absence of neutrophil lineages in the bone marrow with intact megakaryopoiesis and erythropoiesis. PWCA has been associated with autoimmune, drug-induced, and viral exposures. Here, we report a case of a 74-year-old female who presented with severe proximal weakness without pain and was found to have PWCA with nonspecific inflammatory necrotizing myositis and acute liver injury on biopsies. These findings were associated with a recent course of azithromycin and her daily use of a statin. Myositis improved on prednisone but PWCA persisted. With intravenous immunoglobulin and granulocyte-colony stimulating factor therapies, her symptoms and neutrophil counts improved and were sustained for months.
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12
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Kyritsi EMA, Yiakoumis X, Pangalis GA, Pontikoglou C, Pyrovolaki K, Kalpadakis C, Mavroudi I, Koutala H, Mastrodemou S, Vassilakopoulos TP, Vaiopoulos G, Diamanti-Kandarakis E, Papadaki HA, Angelopoulou MK. High Frequency of Thyroid Disorders in Patients Presenting With Neutropenia to an Outpatient Hematology Clinic STROBE-Compliant Article. Medicine (Baltimore) 2015; 94:e886. [PMID: 26061308 PMCID: PMC4616464 DOI: 10.1097/md.0000000000000886] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Granulopoiesis abnormalities have been described in association with thyroid disorders (TD). However, data regarding systematic evaluation of adult neutropenia and concurrent or prior TD are scarce. To investigate the frequency of TD among patients presenting with neutropenia, and the immunophenotypic and immunologic profile of neutropenic patients with concomitant thyroidopathy. Two hundred eighteen consecutive neutropenic patients were prospectively evaluated in our outpatient Hematology Clinic, with a detailed laboratory screen, including thyroid function tests, antineutrophil antibodies, blood lymphocytes immunophenotyping, and detection of T-cell clonality by PCR. Among 218 patients with neutropenia, 95 (43.6%) had TD, 65 chronic immunologic neutropenia, 20 clonal proliferation of T-large granular lymphocytes (T-LGL), 5 autoimmune disorders, and 33 other diagnoses. TD-patients had an increased frequency of recurrent infections compared with other patients (P = 0.045). The following correlations were found: negative correlation between FT3 and absolute neutrophil count (ANC) (r² = -0.274, P = 0.007), negative correlation between TPO-Abs/TG-Abs and C4 (r² = -0.16, P = 0.045; r² = -0.266, P = 0.001), and CD4⁺ counts were inversely correlated to T4 and positively to TSH (r² = -0.274, P = 0.024; r² = 0.16, P = 0.045). In addition, TD-patients had significantly higher percentages of CD4⁺ lymphocytes (P = 0.003). Among TD-patients, 23.4% had Hashimoto thyroiditis (HT), 4.1%, Graves disease (GD), 8.2% nontoxic multinodular goiter (NTMG), 5% subclinical hypothyroidism, and 2.8% had undergone total thyroidectomy associated with nodules (TTM). Thirteen TD-patients displayed T-LGL. Patients with autoimmune thyroidopathy had an increased frequency of concomitant autoimmune manifestations (P = 0.03). Significant differences between the different thyroidopathies included: HT-patients had higher percentages of B-lymphocytes, while the opposite was evident for the TTM-subgroup (P = 0.009, 0.02); GD-patients showed an increase of the proportion of NK cells and a decrease in the percentage of TCRγδ+ lymphocytes (P = 0.001, 0.045); and NTMG-patients had significantly higher ANC (P = 0.004) compared to other thyroidopathies. Antineutrophil antibodies were found in 37.2% of TD-patients tested. Anti-TPO titers were significantly higher in patients with positive antineutrophil antibodies (P = 0.04). The frequency of TD among neutropenic patients may be higher than previously reported. The existence of antineutrophil antibodies, as well as the different distribution of lymphocyte subsets among patients with different TD, suggests both humoral and cellular mechanisms in the pathophysiology of thyroid disease-associated neutropenia.
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Affiliation(s)
- Eleni Magdalini A Kyritsi
- From the Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens, University of Athens Medical School, "Aghia Sophia" Children's Hospital, (EMK); Hematology Clinic, Athens Medical Center, Psychiko Branch, Athens (XY, GAP); Department of Hematology, University of Crete School of Medicine, Heraklion, Crete (CP, KP, CK, IM, HK, SM, HAP); Department of Hematology and BMT, National and Kapodistrian University of Athens, Laikon General Hospital (TPV, MKA); First Department of Internal Medicine, National and Kapodistrian University of Athens, Laikon General Hospital (GV); and Third Department of Internal Medicine, Medical School, University of Athens, Sotiria General Hospital, Athens, Greece (ED-K)
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Keast T, Weeraman D, Mayhead P, Grace R, Mathe S. Pure white cell aplasia: report of first case associated with autoimmune hepatitis. Frontline Gastroenterol 2014; 5:287-290. [PMID: 28839785 PMCID: PMC5369740 DOI: 10.1136/flgastro-2013-100427] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 02/19/2014] [Accepted: 02/26/2014] [Indexed: 02/04/2023] Open
Abstract
Pure white cell aplasia (PWCA) is a rare, immune-mediated condition that causes a profound inhibition of myelopoiesis. It has been seen in association with other autoimmune conditions, thymomas, chronic lymphocytic leukaemia and as an adverse drug reaction. We report what we believe to be the first case of PWCA associated with autoimmune hepatitis. An 18-year-old woman presented with jaundice and was found to be suffering from acute hepatitis. Later she became neutropenic and lymphopenic. Liver biopsy was indicative of autoimmune hepatitis. This was later confirmed by autoantibody results. Bone marrow aspirate found an absence of all myeloid progenitor cells, highly suggestive of PWCA. The low white cell count only improved after immunosuppression with corticosteroids. Her condition remains stable 1 year later with azathioprine therapy.
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Affiliation(s)
- Thomas Keast
- Eastbourne District General Hospital, Eastbourne, UK
| | | | - Phil Mayhead
- Eastbourne District General Hospital, Eastbourne, UK
| | - Richard Grace
- Eastbourne District General Hospital, Eastbourne, UK
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14
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Abstract
Neutropenia is a common reason for hematology consultations in the inpatient and outpatient settings and is defined as an absolute neutrophil count less than 1500 cells/μL. Neutropenia varies in severity, with more profound neutropenia being associated with higher rates of infections and infection-related deaths. The causes for neutropenia are diverse and include congenital and acquired conditions (ie, autoimmune, drugs, infection, and malignancy). This article outlines the most common causes of neutropenia and discusses differential diagnoses, treatment modalities, and the mechanisms by which neutropenia occurs.
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Jethava Y, Alamelu J, Rangarajan S, Lang-Lazdunski L, van der Walt J, Fields P. Acquired Agranulocytosis and Factor XI Deficiency in Association With Thymoma. J Clin Oncol 2011; 29:e604-6. [DOI: 10.1200/jco.2010.34.3707] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | - Paul Fields
- Guy's and St Thomas' Hospital, London, United Kingdom
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16
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Coudurier M, Houot R, Geriniere L, Blandin S, Salles G, Lamy T, Souquet PJ. [Thymic tumours, autoimmune neutropaenia and autoimmune haemolytic anaemia]. Rev Mal Respir 2008; 25:605-9. [PMID: 18535529 DOI: 10.1016/s0761-8425(08)71619-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Although an association between thymic tumour and autoimmune disease (including autoimmune cytopenia) has been established, the association between thymic tumour and autoimmune neutropenia has rarely been reported, with only 13 cases described in the literature. OBSERVATION We report on a 30 year old man diagnosed with autoimmune neutropenia who had been treated for invasive thymic tumour one year previously. He successfully responded to cyclosporin and steroids therapy. A few months later, the patient presented with autoimmune haemolytic anaemia after prematurely halting his own immunosuppressive treatment. CONCLUSION This observation brings additional insights about the clinical features, biology and treatment of autoimmune neutropenia associated with thymic tumours and underlines the potential severity of such an association. Furthermore, the association of a thymic tumour with both autoimmune neutropaenia and autoimmune haemolytic anaemia has not been reported previously.
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Affiliation(s)
- M Coudurier
- Service de Pneumologie, Centre hospitalier, Lyon Sud, Hospices Civils de Lyon, Lyon, France.
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17
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Chakupurakal G, Murrin RJA, Neilson JR. Prolonged remission of pure white cell aplasia (PWCA), in a patient with CLL, induced by rituximab and maintained by continuous oral cyclosporin. Eur J Haematol 2007; 79:271-3. [PMID: 17655705 DOI: 10.1111/j.1600-0609.2007.00901.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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18
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Ströbel P, Murumägi A, Klein R, Luster M, Lahti M, Krohn K, Schalke B, Nix W, Gold R, Rieckmann P, Toyka K, Burek C, Rosenwald A, Müller-Hermelink HK, Pujoll-Borrell R, Meager A, Willcox N, Peterson P, Marx A. Deficiency of the autoimmune regulator AIRE in thymomas is insufficient to elicit autoimmune polyendocrinopathy syndrome type 1 (APS-1). J Pathol 2007; 211:563-571. [PMID: 17334980 DOI: 10.1002/path.2141] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2006] [Accepted: 12/21/2006] [Indexed: 01/12/2023]
Abstract
Thymomas are thymic epithelial neoplasms, associated with a variety of autoimmune disorders (especially myasthenia gravis), that apparently result from aberrant intra-tumourous thymopoiesis and export of inefficiently tolerized T-cells to the periphery. The autoimmune regulator (AIRE) drives the expression of self-antigens in the thymic medulla and plays an essential role in 'central' tolerance in both humans and mice. However, while inactivating AIRE mutations result in the 'autoimmune polyendocrinopathy syndrome type 1' (APS-1), its major features are not well reproduced in AIRE-knock-out mice. Therefore, alternative human disease scenarios with concomitant AIRE deficiency may be valuable tools to test conclusions drawn from mouse models. Here we show, in a large series, that approximately 95% of thymoma patients are 'chimeric'; expression of AIRE and major AIRE-related autoantigens (eg insulin) were undetectable in their tumours but maintained in their remnant thymic tissue and lymph nodes. Notably, despite the AIRE-deficient thymopoiesis in thymomas, disorders and autoantibodies typical of APS-1 were distinctly uncommon in these patients. The one striking similarity was in the recently observed neutralizing anti-type I interferon (IFN) antibodies, which are found at diagnosis in 100% of patients with APS-1 and in approximately 60% of patients with thymomas, as we show here. We conclude that APS-1 type autoantigens must be protected from autoimmunity by mechanisms that do not extend to the muscle autoantigens so frequently targeted in thymoma patients but so rarely recognized in APS-1. Thus our findings argue strongly for a tolerogenic function of AIRE beyond its role in negative T-cell selection in human thymopoiesis, and/or for specific autoimmunization against muscle in thymomas.
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Affiliation(s)
- P Ströbel
- Institute of Pathology, University Medical Centre Mannheim, University of Heidelberg, Germany
| | - A Murumägi
- Institute of Medical Technology, Tampere, Finland
| | - R Klein
- Department of Internal Medicine II, University of Tübingen, Germany
| | - M Luster
- Department of Nuclear Medicine, University of Würzburg, Germany
| | - M Lahti
- Institute of Medical Technology, Tampere, Finland
| | - K Krohn
- Institute of Medical Technology, Tampere, Finland
| | - B Schalke
- Department of Neurology, University of Regensburg, Germany
| | - W Nix
- Department of Neurology, University of Mainz, Germany
| | - R Gold
- Department of Neurology, University of Göttingen, Germany
| | - P Rieckmann
- Department of Neurology, University of Würzburg, Germany
| | - K Toyka
- Department of Neurology, University of Würzburg, Germany
| | - C Burek
- Institute of Pathology, University of Würzburg, Germany
| | - A Rosenwald
- Institute of Pathology, University of Würzburg, Germany
| | | | | | - A Meager
- Biotherapeutics, National Institute for Biological Standards and Control, South Mimms, UK
| | - N Willcox
- Neurosciences Group, Weatherall Institute of Molecular Medicine, University of Oxford, UK
| | - P Peterson
- Molecular Pathology, University of Tartu, Estonia
| | - A Marx
- Institute of Pathology, University Medical Centre Mannheim, University of Heidelberg, Germany
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19
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Tamura H, Okamoto M, Yamashita T, Sato C, Watanabe A, Kondo A, Tatsuguchi A, Tsuji T, Ogata K, Dan K. Pure white cell aplasia: report of the first case associated with primary biliary cirrhosis. Int J Hematol 2007; 85:97-100. [PMID: 17321984 DOI: 10.1532/ijh97.06018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Pure white cell aplasia (PWCA) is a rare hematologic disorder characterized by agranulocytosis, a lack of virtually all neutrophil-lineage cells (from neutrophils to myeloblasts) in the bone marrow, and normal erythropoiesis and megakaryocy-topoiesis. We report the first case of PWCA that developed in a patient with primary biliary cirrhosis (PBC). An 83-year-old woman, who had had an elevated serum alkaline phosphatase level and shown positivity for serum antimitochondrial antibodies for 10 years, was referred to us because of a perianal abscess. She had severe neutropenia, and her bone marrow showed typical findings of PWCA. Although methylprednisolone pulse therapy induced complete neutrophil recovery, this effect was transient. She died of infection, and the autopsy confirmed the diagnosis of PBC. In vitro investigations showed that factors inhibitory to normal CD34 cell-derived granulopoiesis were present in the patient's serum.
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Affiliation(s)
- Hideto Tamura
- Division of Hematology, Department of Medicine, Nippon Medical School, Tokyo, Japan
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20
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Current literature in diabetes. Diabetes Metab Res Rev 2003; 19:248-55. [PMID: 12789659 DOI: 10.1002/dmrr.348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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