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Zhang C, Charland D, O'Hearn K, Steele M, Klaassen RJ, Speckert M. Childhood autoimmune hemolytic anemia: A scoping review. Eur J Haematol 2024; 113:273-282. [PMID: 38894537 DOI: 10.1111/ejh.14253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/24/2024] [Accepted: 06/04/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND AND OBJECTIVE Autoimmune hemolytic anemia (AIHA) is a rare but important cause of morbidity in pediatric hematology patients. Given its rarity, there is little high-quality evidence on which to base the investigation and management of pediatric AIHA. This scoping review aims to summarize the current evidence and highlight key gaps to inform future studies. METHODS This review searched MEDLINE and the Cochrane CENTRAL Trials Register from 2000 to November 03, 2023. Experimental and observational studies reporting AIHA diagnostic criteria, laboratory workup, or treatment/management in populations with at least 20% of patients ≤18 years were included. RESULTS Forty-three studies were included, with no randomized controlled trials identified. AIHA diagnostic criteria, diagnostic tests, and treatments were highly variable. First-line treatment approaches include corticosteroids, intravenous immunoglobulin, or both. Approaches to AIHA resistance to first-line therapy were widely variable between studies, but most commonly included rituximab and/or cyclosporine. CONCLUSIONS We identify a heterogenous group of observational studies into this complex, immune-mediated disorder. Standardized definitions and classifications are needed to guide collaborative efforts needed to study this rare disease. The work done by the CEREVANCE group provides an important paradigm for future studies.
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Affiliation(s)
- Caseng Zhang
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Danielle Charland
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Katie O'Hearn
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - MacGregor Steele
- Department of Pediatrics, Section of Pediatric Hematology, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Robert J Klaassen
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
- Division of Hematology Oncology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Matthew Speckert
- Division of Hematology Oncology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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2
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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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Kar S, Kumar CGD, Kar R, Basavarajegowda A. Autoimmune Hemolytic Anemia in Children: Clinical Profile and Outcome. Indian J Pediatr 2024; 91:143-148. [PMID: 36787020 DOI: 10.1007/s12098-022-04469-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 11/18/2022] [Indexed: 02/15/2023]
Abstract
OBJECTIVE To discover the common triggers for AIHA in children, their clinical profile, treatment response, and outcome. METHODS This was an ambispective descriptive study conducted between 2013 and 2020. Children aged 1 mo to 14 y with hemolytic anemia and a positive direct antiglobulin test (DAT) were included. Children with a positive DAT but without any clinicolaboratory evidence of hemolysis were excluded. Data were collected from a structured pro forma with particulars comprising clinicolaboratory profile, treatment administered, and disease outcome. RESULTS A total of 46 children (aged between 1 mo and 14 y) were enrolled in the study. The mean age of onset was 8.7 (± 4.34) y, and 24 (52.8%) were males. Secondary causes were observed in 29 (63%) cases, while the primary cause was found in 17 (37%). Systemic lupus erythematosus (SLE) was the common trigger in 13 (45%) cases, followed by malignancy in 4 (14%) cases. Pallor (98%), hepatomegaly (72%), and splenomegaly (48%) were the most commonly observed clinical signs. The mixed immunophenotype was observed in 27 (59%) cases, followed by warm type in 12 (26%) and cold agglutinin type in 7 (15%) cases. All children received glucocorticoid therapy, and mycophenolate mofetil was commonly used as second-line therapy in 15 (33%) cases. 13 cases (71%) of primary AIHA and only 4 (14%) cases of secondary anemia achieved complete remission. Overall, 7 children (15%) died, all belonging to secondary AIHA. CONCLUSION Secondary AIHA was more common than primary in the present study, and SLE was the standard trigger. Primary AIHA carries a better prognosis than secondary.
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Affiliation(s)
- Shrutiprajna Kar
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
| | - C G Delhi Kumar
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India.
| | - Rakhee Kar
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Abhishekh Basavarajegowda
- Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Jain R, Bansal D. Autoimmune Hemolytic Anemia, Inborn Errors of Immunity and Genetics: An Evolving Arena. Indian J Pediatr 2024; 91:115-116. [PMID: 38157115 DOI: 10.1007/s12098-023-05011-y] [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] [Received: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Richa Jain
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepak Bansal
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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5
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Romano S, Pepe G, Fotzi I, Casini T, Chiocca E, Trapani S. Autoimmune Hemolytic Anemia (AIHA) Secondary to Cytomegalovirus (CMV) Infection in a 2-Month-Old Infant: A Case Report. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1895. [PMID: 38136097 PMCID: PMC10741631 DOI: 10.3390/children10121895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 11/27/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023]
Abstract
Autoimmune hemolytic anemia (AIHA) is a rare hematologic disorder in the pediatric population and most cases are associated with microbiological infection. The pathological process is not completely clear, but some evidence suggests immunological dysregulation triggered by bacterial or viral infections. Based on the thermal range of the pathogenic antibody, AIHA can be divided into warm (WAIHA) and cold (CAIHA) groups. Cytomegalovirus (CMV) is one of the most common viruses reported as a trigger of AIHA. We present an unusual case of AIHA in a 2-month-old infant positive for both the direct antiglobulin test (C3 complement fraction) and CMV-Polymerase chain reaction in blood samples. In this case, the dating of the infection was uncertain, making it impossible to discriminate between congenital flare-up or a primary acute episode, emphasizing the importance of CMV prenatal testing as a screening measure. We adopted multiple therapeutic strategies including steroids (methylprednisolone and prednisone), Intravenous Immunoglobulin, antivirals (ganciclovir and valganciclovir), and red blood cell transfusion.
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Affiliation(s)
- Stefano Romano
- Department of Health Science, University of Florence, 50134 Florence, Italy;
| | - Giuseppe Pepe
- Department of Health Science, University of Florence, 50134 Florence, Italy;
| | - Ilaria Fotzi
- Centre of Excellence, Division of Pediatric Oncology/Hematology, Meyer Children’s Hospital IRCCS, 50134 Florence, Italy; (I.F.); (T.C.); (E.C.)
| | - Tommaso Casini
- Centre of Excellence, Division of Pediatric Oncology/Hematology, Meyer Children’s Hospital IRCCS, 50134 Florence, Italy; (I.F.); (T.C.); (E.C.)
| | - Elena Chiocca
- Centre of Excellence, Division of Pediatric Oncology/Hematology, Meyer Children’s Hospital IRCCS, 50134 Florence, Italy; (I.F.); (T.C.); (E.C.)
| | - Sandra Trapani
- Department of Health Science, University of Florence, 50134 Florence, Italy;
- Pediatric Unit, Meyer Children’s Hospital IRCCS, 50134 Florence, Italy
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Hanna M, Carcao M. Rare case of refractory mixed autoimmune hemolytic anemia in a 6-year-old child: a case report. J Med Case Rep 2023; 17:418. [PMID: 37794483 PMCID: PMC10552242 DOI: 10.1186/s13256-023-04154-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 08/30/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Mixed autoimmune hemolytic anemia (AIHA) shows combined clinical and laboratory characteristics of warm and cold AIHA. It is relatively uncommon in children. Consequently, knowledge about mixed AIHA prevalence, clinical presentation, treatment options, and prognosis in children is limited to very few case reports. CASE PRESENTATION We describe a six-year-old Asian girl presenting with profound anemia, blood group typing discrepancy and crossmatch incompatibility, post upper respiratory tract infection. Detection of red cell warm and cold reactive autoantibodies, led to the diagnosis of mixed AIHA. Autoantibodies with laboratory evidence of hemolysis persisted despite high dose steroid therapy. Due to the inability to wean further, the patient was subsequently commenced on mycophenolate mofetil to which she seems to be responding. CONCLUSIONS Mixed AIHA may be notoriously difficult to diagnose and treat. Detailed clinical and laboratory work-up is essential to establish the diagnosis. To the best of our knowledge, this is the first case report of mixed AIHA following upper respiratory tract infection. Awareness of this occurrence is important, as similar to warm AIHA, mixed AIHA should be treated immediately by early initiation of steroid therapy. In addition, prompt supportive care as well as long-term clinical follow-up are required to improve outcomes of these cases.
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Affiliation(s)
- Mirette Hanna
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.
- Division of Hematopathology, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.
| | - Manuel Carcao
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
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Hogan KO, Oroszi G. Paroxysmal cold hemoglobinuria: A diagnostic dilemma in a paediatric patient. Transfus Med 2023; 33:416-419. [PMID: 37574257 DOI: 10.1111/tme.12991] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 07/24/2023] [Accepted: 08/01/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Autoimmune hemolytic anaemia is rare in the paediatric population. Differentiation of the underlying aetiology is complicated by heterogeneity in diagnostic criteria and testing strategies. Paroxysmal cold hemoglobinuria (PCH) is an uncommon form of paediatric autoimmune hemolytic anaemia. Identification of the causative biphasic hemolysin requires clinical recognition and access to the Donath-Landsteiner (DL) test. CASE PRESENTATION We report a young paediatric patient with no significant past medical history who presented with severe anaemia, jaundice, and dark urine following a respiratory illness. Initial laboratory evaluation showed a haemoglobin of 3.6 g/dL with plasma free haemoglobin 170 mg/dL (reference range <5 mg/dL), 3+ hemoglobinuria (reference range = 0), and direct antiglobulin testing (DAT) positive for complement component 3 (C3) only. Haemoglobin continued to decline following RBC transfusions using a blood warmer for presumed cold agglutinin syndrome. Subsequent testing at the reference laboratory revealed a DAT positive for C3 and immunoglobulin isotype G (IgG) and an eluate pan-agglutinin most consistent with a warm autoantibody, but the patient's anaemia was non-responsive to glucocorticoids and blood warmer cessation. However, a maximum cold agglutinin titre of 4 and absent thermal amplitude substantially weakened the evidence for the clinical significance of the cold autoantibodies. Consultation with the institutional transfusion medicine specialist prompted collection for the DL test, which demonstrated a definitive biphasic hemolysin consistent with PCH. DISCUSSION Conflicting clinical and immunohematologic evidence can obscure the aetiology of autoimmune hemolysis, including concurrent warm and/or cold autoantibodies. Clinical correlation, consultation with the institutional transfusion service, and access to specialised testing are essential to establish the correct diagnosis.
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Affiliation(s)
- Keenan O Hogan
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Gabor Oroszi
- Department of Pathology and Laboratory Medicine, Children's Mercy Hospital, Kansas City, Missouri, USA
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Abdel-Salam A, Bassiouni ST, Goher AM, Shafie ES. Autoimmune Hemolytic Anemia in the Pediatric Age Group: The Egyptian Experience. Ann Hematol 2023:10.1007/s00277-023-05230-5. [PMID: 37093240 DOI: 10.1007/s00277-023-05230-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 04/11/2023] [Indexed: 04/25/2023]
Abstract
Autoimmune hemolytic anemia (AIHA) is a common disease entity among adults; however, it is rare among the pediatric age group. Evidence is scarce regarding pediatric AIHA in the literature. The objective of this study is to assess the frequency of AIHA and describe the clinical and laboratory characteristics and treatment outcomes of a cohort of children with AIHA in Egypt. A retrospective study was conducted on 50 children with AIHA who were registered and followed up at the New Children's Hospital in Cairo, Egypt, between January 2010 and January 2021. The study group comprised 60% females and 40% males. Their median age was 8.25 years. All patients showed low hemoglobin levels with a mean of 5.40 ± 1.34 g/dl and a median reticulocyte count of 10 (IQR: 8-15). Twelve (24%) patients were diagnosed with Evans syndrome, and a positive Coombs test was detected in 46 patients (92%). The frequency of primary AIHA was 40%, whereas it was 60% for secondary AIHA. The first line of therapy for acute attacks was high-dose IV steroids which responded well in 38 (76%) patients. Secondary AIHA was more common among our children (60%). AIHA is more prevalent in females (60%). The clinical and laboratory characteristics matched previous reports.
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Affiliation(s)
- Amina Abdel-Salam
- Deparment of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sherifa Tarek Bassiouni
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alaa Magdi Goher
- Deparment of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Eman Shafik Shafie
- Deparment of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt.
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9
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Sekhar Das S, Chaudhuri K, Mukherjee S. Clinical and immunohematological characterization of autoimmune hemolytic anemia in children. Transfus Apher Sci 2023:103703. [PMID: 36934038 DOI: 10.1016/j.transci.2023.103703] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/17/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023]
Abstract
Autoimmune Hemolytic Anemia (AIHA) in childhood is uncommon and estimated to be three per million annually under 18 years of age. Detailed immunohematological and clinical characterizations are essential for correct diagnosis of the disease and its management. In this study we described AIHA in children with regards to patient demography, underlying etiology, disease classification, antibody characterization, clinical features, degree of in vivo hemolysis and transfusion management. The prospective observational study was conducted over a period of 6 years and included 29 children with newly diagnosed AIHA. Patient details were obtained from the hospital information system and patient treatment file. The median age of the children was 12 years with a female preponderance. Secondary AIHA was observed in 62.1% patients. The mean hemoglobin and reticulocyte were 7.1 gm/dL and 8.8 percentages respectively. The median polyspecific direct antiglobulin test (DAT) grading was 3+. Red cell bound multiple autoantibodies were found in 27.6% children. Free serum autoantibodies were present in 62.1% patients. Twenty six of the 42 units transfused were "best match" or "least incompatible". Follow-up of 21 children showed clinical and laboratory improvement with DAT still positive at the end of 9 months. AIHA in childhood requires advanced and efficient clinical, immunohematological and transfusion support. Detailed characterization of AIHA is important, as they determine degree of in vivo hemolysis, disease severity, serological incompatibility and necessity of blood transfusion. Although blood transfusion in AIHA is a challenge but it should not be withheld in critically ill patients.
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Affiliation(s)
- Sudipta Sekhar Das
- Department of Transfusion Medicine, Apollo Multispeciality Hospitals, Kolkata 700054, India.
| | | | - Sourav Mukherjee
- Department of Transfusion Medicine, Apollo Multispeciality Hospitals, Kolkata 700054, India
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Pattanakitsakul P, Sirachainan N, Tassaneetrithep B, Priengprom T, Kijporka P, Apiwattanakul N. Enterovirus 71-Induced Autoimmune Hemolytic Anemia in a Boy. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2022; 15:11795476221132283. [PMID: 36277905 PMCID: PMC9580087 DOI: 10.1177/11795476221132283] [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: 03/23/2022] [Accepted: 09/23/2022] [Indexed: 11/07/2022]
Abstract
Autoimmune hemolytic anemia (AIHA) can be induced by recent or concomitant infections. Many infectious agents are postulated to be associated with this condition. Treatment of infection induced AIHA still varies. This report describes a previously healthy Thai boy who developed AIHA associated with enterovirus-71 infection. He was successfully treated with oral prednisone.
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Affiliation(s)
- Ploy Pattanakitsakul
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nongnuch Sirachainan
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Boonrat Tassaneetrithep
- Center of Research Excellence in Immunoregulation, Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thongkoon Priengprom
- Center of Research Excellence in Immunoregulation, Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pimpun Kijporka
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nopporn Apiwattanakul
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand,Nopporn Apiwattanakul, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, 270 Rama VI Road, Ratchathewi District, Bangkok 10400, Thailand.
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11
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Sahoo D, Anuragaa S. Serological characteristics and immunohematological difficulties in autoimmune hemolytic anemia patients: A retrospective analytical study from South India. Asian J Transfus Sci 2022. [DOI: 10.4103/ajts.ajts_163_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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12
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Das SS, Chakrapani A, Bhattacharya S, Biswas RN, Safi M. Immunohematological and Clinical Characterization of Complement and Non-Complement Associated Warm Autoimmune Haemolytic Anemia and Risk Factors Predicting their Occurrences. Indian J Hematol Blood Transfus 2021; 37:623-631. [PMID: 34744345 DOI: 10.1007/s12288-021-01402-3] [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: 09/29/2020] [Accepted: 01/10/2021] [Indexed: 12/17/2022] Open
Abstract
Antigen - antibody complexes on heavily coated red cells in Warm autoimmune haemolytic anemia (WAIHA) often activates the complement pathway and red cells bound C3 complement component are encountered in complement associated WAIHA (CWAIHA). Patients belonging to CWAIHA and non-complement associated WAIHA (NCWAIHA) may demographically, clinically and immunohematologically behave differently therefore we planned to study the clinical and immunohematological characteristics of CWAIHA and NCWAIHA with emphasis to various potential factors associated with CWAIHA. The prospective study included 229 patients of WAIHA. Complete DAT evaluation was performed in all these patients. Details of patients and their hematological and biochemical parameters were obtained from patient file and Hospital Information System. In vivo hemolysis was documented as per the criteria established by previous workers. Statistical analysis was done using SPSS statistical package. Of the total 229 patients of WAIHA, 83 (36.2%) belonged to the complement associated WAIHA group. A total of 146 (63.8%) patients were females of which 43 (29.4%) had CWAIHA. The median age of WAIHA patients was 37 years. A total of 46 (56.1%) patients above age 40 years suffered from CWAIHA. Where secondary WAIHA was found in 121 (52.8%) patients; more than half (61.4%) with CWAIHA had underlying aetiology. Over 95% of patients in both categories presented with weakness and pallor. Strong DAT (> 2 +) was observed in 86.7% of CWAIHA patients. Factors like gender, age, aetiology and DAT IgG dilution were independent risk factors for CWAIHA. DAT remained positive even at the end of 10 months of successful treatment. We conclude that detailed characterization of WAIHA with particular emphasis to complement and non-complement associated WAIHA is essential to evaluate the disease characters, immunological behaviours, prognosis and therapeutic management. Moreover an understanding of the risk factors of CWAIHA will help physicians / hematologists and immunohematologists to manage WAIHA more prudently and solicitously.
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Affiliation(s)
- Sudipta Sekhar Das
- Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, 700054 India
| | - Anupam Chakrapani
- Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, 700054 India
| | - Soumya Bhattacharya
- Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, 700054 India
| | - Rathindra Nath Biswas
- Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, 700054 India
| | - Mahammad Safi
- Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, 700054 India
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ÖZCAN A, CANSEVER M, YILMAZ E, ÜNAL E, KARAKÜKÇÜ M, PATIROĞLU T. The spectrum of underlying diseases in children with autoimmune hemolytic anemia. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2021. [DOI: 10.32322/jhsm.985008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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14
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Walker SC, Ransom M, Sood S, Andrews J, Smith CM. Respiratory failure and shock in an infant with severe anemia. Clin Case Rep 2021; 9:e04852. [PMID: 34584715 PMCID: PMC8455968 DOI: 10.1002/ccr3.4852] [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: 06/09/2021] [Revised: 08/17/2021] [Accepted: 09/06/2021] [Indexed: 11/29/2022] Open
Abstract
Patients with severe anemia can present with non-specific symptoms, including shock and respiratory distress. Ensuring a rapid, targeted workup is initiated and providing prompt transfusions as necessary are critical for both diagnostic success and clinical improvement.
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Affiliation(s)
- Shannon C. Walker
- Division of Pediatric Hematology/OncologyDepartment of PediatricsVanderbilt University Medical CenterNashvilleTennesseeUSA
- Division of Transfusion MedicineDepartment of Pathology, Microbiology, and ImmunologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Meaghan Ransom
- Division of NeonatologyDepartment of PediatricsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Shawn Sood
- Division of Pediatric Critical Care MedicineDepartment of PediatricsUniversity of Kansas Medical CenterKansas CityMissouriUSA
| | - Jennifer Andrews
- Division of Pediatric Hematology/OncologyDepartment of PediatricsVanderbilt University Medical CenterNashvilleTennesseeUSA
- Division of Transfusion MedicineDepartment of Pathology, Microbiology, and ImmunologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Christine M. Smith
- Division of Pediatric Hematology/OncologyDepartment of PediatricsVanderbilt University Medical CenterNashvilleTennesseeUSA
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15
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Abstract
Objective To analyze clinical and laboratory parameters, and treatment outcomes of children with autoimmune hemolytic anemia (AIHA). Methods Retrospective analysis of 50 children aged 0–18 years. Monospecific direct antiglobulin test (DAT) and investigations for secondary causes were performed. Disease status was categorized based on Cerevance criteria. Results Median (range) age at diagnosis was 36 (1.5–204) months. AIHA was categorized as cold (IgM+,C3+/cold agglutinin+) (35%), warm (IgG+ with/without C3+) (28%), mixed (IgG+, IgM+, C3+) (15%) and paroxysmal cold hemoglobinuria (4%). Primary AIHA accounted for 64% cases. Treatment modalities included steroid (66%), intravenous immunoglobulin (IVIg) (4%), steroid+IVIg (4%), and steroid+rituximab (4%). Treatment duration was longer for secondary AIHA than primary (11 vs 6.6 months, P<0.02) and in patients needing polytherapy than steroids only (13.3 vs 7.5 months, P<0.006). During median (range) follow-up period of 73 (1–150) months, 29 (58%) remained in continuous complete remission, 16 (32%) remained in complete remission. Conclusion Infants with AIHA have a more severe presentation. Monospecific DAT and a thorough search for an underlying cause help optimize therapy in most patients of AIHA.
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Moon GS, Choi YU, Shim H, Jang JY. Autoimmune Hemolytic Anemia Combined with Sepsis After Abdominal Trauma Surgery. JOURNAL OF ACUTE CARE SURGERY 2021. [DOI: 10.17479/jacs.2021.11.2.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Intra-abdominal infection is a common, serious complication in patients undergoing emergency abdominal surgery following blunt abdominal trauma. Infectious conditions increase the incidence of autoimmune hemolytic anemia (AIHA), but reports of AIHA occurring after abdominal trauma surgery are rare. Therefore, we report a case of sepsis due to fasciitis and AIHA after abdominal trauma surgery which was successfully managed following the appropriate treatment of both conditions.
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Sánchez MN, Zubicaray J, Sebastián E, Gálvez E, Sevilla J. Autoimmune hemolytic anemia: Case review. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2021. [DOI: 10.1016/j.anpede.2020.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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18
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Tranekær S, Hansen DL, Frederiksen H. Epidemiology of Secondary Warm Autoimmune Haemolytic Anaemia-A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10061244. [PMID: 33802848 PMCID: PMC8002719 DOI: 10.3390/jcm10061244] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/09/2021] [Accepted: 03/14/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Warm autoimmune haemolytic anaemia (wAIHA) is a haemolytic disorder, most commonly seen among adults and is classified as either primary or secondary to an underlying disease. We describe the age and sex distribution and the proportion of secondary wAIHA. Method: We retrieved 2635 published articles, screened abstracts and titles, and identified 27 articles eligible for full-text review. From these studies, we extracted data regarding number of patients, sex distribution, age at diagnosis, number of patients with secondary wAIHA, and whether the patients were diagnosed through local or referral centres. All data were weighted according to the number of included patients in each study. Results: 27 studies including a total of 4311 patients with wAIHA, of which 66% were females, were included. The median age at diagnosis was 68.7 years, however, wAIHA affected all ages. The mean proportion of secondary wAIHA was 49%, most frequently secondary to systemic lupus erythematosus. The proportions of secondary wAIHA reported from primary vs. referral centres were 35% vs. 59%, respectively. Conclusion: This review consolidates previously reported gender distribution. The higher proportion of secondary wAIHA in referral centres suggests that the most severely affected patients are disproportionally more frequent in such facilities.
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Affiliation(s)
- Stinne Tranekær
- Haematological Research Unit, Department of Clinical Research, University of Southern, 5230 Odense M, Denmark; (S.T.); (D.L.H.)
- Department of Haematology, Odense University Hospital, 5000 Odense C, Denmark
| | - Dennis Lund Hansen
- Haematological Research Unit, Department of Clinical Research, University of Southern, 5230 Odense M, Denmark; (S.T.); (D.L.H.)
- Department of Haematology, Odense University Hospital, 5000 Odense C, Denmark
| | - Henrik Frederiksen
- Haematological Research Unit, Department of Clinical Research, University of Southern, 5230 Odense M, Denmark; (S.T.); (D.L.H.)
- Department of Haematology, Odense University Hospital, 5000 Odense C, Denmark
- Correspondence:
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Autoimmune Hemolytic Anemia in the Pediatric Setting. J Clin Med 2021; 10:jcm10020216. [PMID: 33435309 PMCID: PMC7828053 DOI: 10.3390/jcm10020216] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 12/21/2022] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is a rare disease in children, presenting with variable severity. Most commonly, warm-reactive IgG antibodies bind erythrocytes at 37 °C and induce opsonization and phagocytosis mainly by the splenic macrophages, causing warm AIHA (w-AIHA). Post-infectious cold-reactive antibodies can also lead to hemolysis following the patient’s exposure to cold temperatures, causing cold agglutinin syndrome (CAS) due to IgM autoantibodies, or paroxysmal cold hemoglobinuria (PCH) due to atypical IgG autoantibodies which bind their target RBC antigen and fix complement at 4 °C. Cold-reactive antibodies mainly induce intravascular hemolysis after complement activation. Direct antiglobulin test (DAT) is the gold standard for AIHA diagnosis; however, DAT negative results are seen in up to 11% of warm AIHA, highlighting the need to pursue further evaluation in cases with a phenotype compatible with immune-mediated hemolytic anemia despite negative DAT. Prompt supportive care, initiation of treatment with steroids for w-AIHA, and transfusion if necessary for symptomatic or fast-evolving anemia is crucial for a positive outcome. w-AIHA in children is often secondary to underlying immune dysregulation syndromes and thus, screening for such disorders is recommended at presentation, before initiating treatment with immunosuppressants, to determine prognosis and optimize long-term management potentially with novel targeted medications.
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Prakash A, Paul V, Ittoop A. Autoimmune hemolytic anemia in children: Clinical profile and outcomes. JOURNAL OF APPLIED HEMATOLOGY 2021. [DOI: 10.4103/joah.joah_235_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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21
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Sánchez N, Zubicaray J, Sebastián E, Gálvez E, Sevilla J. [Autoimmune hemolytic anemia: Case review]. An Pediatr (Barc) 2020; 94:206-212. [PMID: 32972857 DOI: 10.1016/j.anpedi.2020.07.012] [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: 04/28/2020] [Revised: 07/12/2020] [Accepted: 07/22/2020] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Autoimmune hemolytic anemia (AIHA) is a rare and generally self-limiting disease in children. MATERIAL AND METHODS A descriptive cross-sectional study was performed in children under 18 years diagnosed with AIHA from January/1997 to July/2019. Clinical variables were collected and AIHA was classified according to the direct antiglobulin test (DAT) in warm AIHA (IgG+/-C3d) and cold AIHA (C3d). Response to treatment and evolution were analyzed. RESULTS 25 patients were included and 72% were males. The median age at diagnosis was 2 years (range 0.4 to 9). Fever (72%), pallor (68%), jaundice (64%), hepatosplenomegaly and coluria (48%) were the most common presenting symptoms. The median hemoglobin at diagnosis was 5.4 g/dl. DAT was positive in 96%, with detection of IgG antibodies in 76%. A single case presented negative DAT. 20% of the patients associated another cytopenia, one of which was subsequently diagnosed with common variable immunodeficiency. Concomitant viral infection was suspected or documented in 32%. Most of the cases were self-limiting and responded to corticosteroid treatment (72%). Those with partial response (24%), mainly those associated with other cytopenias, required other lines of treatment (rituximab, mycophenolate, immunoglobulins). Complications (32%) and relapses (26%) were detected only in warm AIHA. CONCLUSIONS Our case series confirms that AIHA is a very rare disease in childhood. Most cases evolve favorably, although up to a quarter of them require second lines of treatment and, in exceptional cases, they need very aggressive treatments. These latter cases generally correspond to patients who present more than one cytopenia in the course of the disease.
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Affiliation(s)
- Nazaret Sánchez
- Servicio de Pediatría, Hospital Clínico Universitario de Valladolid, Valladolid, España.
| | - Josune Zubicaray
- Servicio de Hematología y Hemoterapia, Hematología y Oncología Pediátricas, Hospital Infantil Universitario Niño Jesús, Fundación para la Investigación Biomédica del Hospital Infantil Universitario Niño Jesús, Madrid, España
| | - Elena Sebastián
- Servicio de Hematología y Hemoterapia, Hematología y Oncología Pediátricas, Hospital Infantil Universitario Niño Jesús, Fundación para la Investigación Biomédica del Hospital Infantil Universitario Niño Jesús, Madrid, España
| | - Eva Gálvez
- Servicio de Hematología y Hemoterapia, Hematología y Oncología Pediátricas, Hospital Infantil Universitario Niño Jesús, Fundación para la Investigación Biomédica del Hospital Infantil Universitario Niño Jesús, Madrid, España
| | - Julián Sevilla
- Servicio de Hematología y Hemoterapia, Hematología y Oncología Pediátricas, Hospital Infantil Universitario Niño Jesús, Fundación para la Investigación Biomédica del Hospital Infantil Universitario Niño Jesús, Madrid, España
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22
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Defining autoimmune hemolytic anemia: a systematic review of the terminology used for diagnosis and treatment. Blood Adv 2020; 3:1897-1906. [PMID: 31235526 DOI: 10.1182/bloodadvances.2019000036] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/21/2019] [Indexed: 12/11/2022] Open
Abstract
The terminology applied to autoimmune hemolytic anemia (AIHA) seems inconsistent. We aimed to evaluate the consistency of definitions used for diagnosis and treatment. In this systematic review of literature from January 2006 to December 2015, we assessed heterogeneity in the definition of AIHA and its subtypes, refractory disease, disease phase, severity, criteria for treatment response, and response durability. A Medline search for anemia, hemolytic, autoimmune was supplemented with keyword searches. Main exclusions were conference abstracts, animal and non-English studies, and studies with <10 cases. Of 1371 articles retrieved, 1209 were excluded based on titles and abstracts. Two authors independently reviewed 10% and 16% of abstracts and full papers, respectively. After full-paper review, 84 studies were included. AIHA was most frequently (32 [52%] of 61) defined as hemolytic anemia with positive direct antiglobulin test (DAT) and exclusion of alternatives, but 10 of 32 also recognized DAT-negative AIHA. A lower threshold for diagnosis of DAT-negative AIHA was observed in literature on chronic lymphocytic leukemia. Definitions of anemia, hemolysis, and exclusion criteria showed substantial variation. Definitions of primary/secondary cold agglutinin disease/syndrome were not consistent. Forty-three studies provided criteria for treatment response, and other than studies from 1 center, these were almost entirely unique. Other criteria were rarely defined. Only 7, 0, 3, 2, 2, and 3 studies offered definitions of warm AIHA, paroxysmal cold hemoglobinuria, mixed AIHA, AIHA severity, disease phase, and refractory AIHA, respectively. Marked heterogeneity in the time period sampled indicates the need to standardize AIHA terminology.
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Weli M, Ben Hlima A, Belhadj R, Maalej B, Elleuch A, Mekki N, Gargouri L, Kamoun T, Barbouche MR, Mahfoudh A. Diagnosis and management of autoimmune hemolytic anemia in children. Transfus Clin Biol 2020; 27:61-64. [PMID: 32280062 DOI: 10.1016/j.tracli.2020.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 03/18/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIM The aim of this study is to evaluate the clinical, biological and hematological profiles of autoimmune hemolytic anemia (AIHA) in children and to specify its etiologies, therapeutic modalities, and treatment responses. METHODS This is a 14-year retrospective study of AIHA cases collected at the department of pediatric emergency and reanimation of Hedi Chaker University Hospital in Sfax. We included patients under 14 years old with clinical and biological features of hemolysis and a positive direct antiglobulin test (DAT). The selected patients' demographic characteristics, physical signs, laboratory findings, and treatment responses were recorded. RESULTS Thirteen cases of AIHA were collected, including 8 girls and 5 boys. The median age at diagnosis was 4 years and 6 months (range: 8 months to 13 years). Consanguinity was reported in 6 cases and 4 patients had a previous infection history. The onset of AIHA was progressive in 9 cases, marked by an anemic syndrome and hemolysis symptoms in 6 and 8 cases, respectively. The clinical triad (pallor, jaundice and splenomegaly) was found in only 4 cases. At the time of diagnosis, the median hemoglobin (Hb) level was 6g/dL (range: 4.2 to 9.2g/dL), anemia was non-regenerative in 2 patients. Thrombocytopenia and neutropenia were noted in 5 and 1 patient, respectively. Peripheral smear examination showed spherocytosis in 2 cases. All the patients had a positive DAT. Of these, 10 were positive with IgG and 3 with both IgG and C3d. AIHA was secondary to other conditions in 9 patients: infection (3 cases), autoimmune disease (4 cases), and immunodeficiency (2 cases). All the patients received first-line corticosteroid therapy but only 8 of them required blood transfusions due to severe anemia. Complete remission was obtained in 7 cases. Corticosteroid resistance and dependence were noted in 1 and 2 cases, respectively. During evolution, additional therapy was indicated in 4 patients and it included cyclosporine A, azathioprine, and mycophenolate mofetil (MMF). After a median follow-up of 4.5 years, the cure rate was 80% and only 1 patient (a boy) died due to his underlying pathology. CONCLUSION Our study highlights the rarity, severity, and heterogeneity of etiological contexts of AIHA in children. The therapeutic difficulties justify specific expertise in pediatric hematology.
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Affiliation(s)
- M Weli
- Department of pediatric emergency and reanimation, Hedi Chaker university hospital of Sfax, Sfax, Tunisia; Faculty of medicine, university of Sfax, Sfax, Tunisia
| | - A Ben Hlima
- Department of pediatric emergency and reanimation, Hedi Chaker university hospital of Sfax, Sfax, Tunisia; Faculty of medicine, university of Sfax, Sfax, Tunisia
| | - R Belhadj
- Department of pediatrics, Hedi Cheker university hospital of Sfax, Sfax, Tunisia; Faculty of medicine, university of Sfax, Sfax, Tunisia.
| | - B Maalej
- Department of pediatric emergency and reanimation, Hedi Chaker university hospital of Sfax, Sfax, Tunisia; Faculty of medicine, university of Sfax, Sfax, Tunisia
| | - A Elleuch
- Department of pediatric emergency and reanimation, Hedi Chaker university hospital of Sfax, Sfax, Tunisia; Faculty of medicine, university of Sfax, Sfax, Tunisia
| | - N Mekki
- Laboratory of transmission, control and immunobiology of infections (LR11IPT02), Tunis, Tunisia
| | - L Gargouri
- Department of pediatric emergency and reanimation, Hedi Chaker university hospital of Sfax, Sfax, Tunisia; Faculty of medicine, university of Sfax, Sfax, Tunisia
| | - T Kamoun
- Department of pediatrics, Hedi Cheker university hospital of Sfax, Sfax, Tunisia; Faculty of medicine, university of Sfax, Sfax, Tunisia
| | - M-R Barbouche
- Laboratory of transmission, control and immunobiology of infections (LR11IPT02), Tunis, Tunisia
| | - A Mahfoudh
- Department of pediatric emergency and reanimation, Hedi Chaker university hospital of Sfax, Sfax, Tunisia; Faculty of medicine, university of Sfax, Sfax, Tunisia
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Diagnosis and treatment of autoimmune hemolytic anemia in adults: Recommendations from the First International Consensus Meeting. Blood Rev 2019; 41:100648. [PMID: 31839434 DOI: 10.1016/j.blre.2019.100648] [Citation(s) in RCA: 245] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 11/21/2019] [Accepted: 11/25/2019] [Indexed: 12/15/2022]
Abstract
Autoimmune hemolytic anemias (AIHAs) are rare and heterogeneous disorders characterized by the destruction of red blood cells through warm or cold antibodies. There is currently no licensed treatment for AIHA. Due to the paucity of clinical trials, recommendations on diagnosis and therapy have often been based on expert opinions and some national guidelines. Here we report the recommendations of the First International Consensus Group, who met with the aim to review currently available data and to provide standardized diagnostic criteria and therapeutic approaches as well as an overview of novel therapies. Exact diagnostic workup is important because symptoms, course of disease, and therapeutic management relate to the type of antibody involved. Monospecific direct antiglobulin test is considered mandatory in the diagnostic workup, and any causes of secondary AIHA have to be diagnosed. Corticosteroids remain first-line therapy for warm-AIHA, while the addition of rituximab should be considered early in severe cases and if no prompt response to steroids is achieved. Rituximab with or without bendamustine should be used in the first line for patients with cold agglutinin disease requiring therapy. We identified a need to establish an international AIHA network. Future recommendations should be based on prospective clinical trials whenever possible.
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Verma G, Nayak L, Banerjee A, Nayak B. Premacular haemorrhage in a child with Evans syndrome. BMJ Case Rep 2019; 12:12/3/bcr-2019-229636. [PMID: 30898948 DOI: 10.1136/bcr-2019-229636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Gargi Verma
- Ophthalmology, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Orissa, India
| | - Lipika Nayak
- Institute of Medical Sciences and SUM Hospital, Siksha O Anusandhan University, Bhubaneswar, Orissa, India
| | - Aparajita Banerjee
- Ophthalmology, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Orissa, India
| | - Bhagabat Nayak
- Ophthalmology, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Orissa, India
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26
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Barcellini W, Fattizzo B, Zaninoni A. Current and emerging treatment options for autoimmune hemolytic anemia. Expert Rev Clin Immunol 2018; 14:857-872. [PMID: 30204521 DOI: 10.1080/1744666x.2018.1521722] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [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 a heterogeneous disease mainly due to autoantibody-mediated destruction of erythrocytes but also involves complement activation, dysregulation of cellular and innate immunity, and defective bone marrow compensatory response. Several drugs targeting these mechanisms are under development in addition to standard therapies. Areas covered: The following targeted therapies are illustrated: drugs acting on CD20 (rituximab, alone or in association with bendamustine and fludarabine) and CD52 (alemtuzumab), B cell receptor and proteasome inhibitors (ibrutinib, bortezomib), complement inhibitors (eculizumab, BIVV009, APL-2), and other drugs targeting T lymphocytes (subcutaneous IL-2, belimumab, and mTOR inhibitors), IgG driven extravascular hemolysis (fostamatinib), and bone marrow activity (luspatercept). Expert opinion: Although AIHA is considered benign and often easy to treat, chronic/refractory cases represent a challenge even for experts in the field. Bone marrow biopsy is fundamental to assess one of the main mechanisms contributing to AIHA severity, i.e. inadequate compensation, along with lymphoid infiltrate, the presence of fibrosis or dyserythropoiesis. The latter may give hints for targeted therapies (either B or T cell directed) and for new immunomodulatory drugs. Future studies on the genomic landscape in AIHA will further help in designing the best choice, sequence and/or combination of targeted therapies.
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Affiliation(s)
- Wilma Barcellini
- a UOC Ematologia, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico , Milano , Italy
| | - Bruno Fattizzo
- a UOC Ematologia, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico , Milano , Italy
| | - Anna Zaninoni
- a UOC Ematologia, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico , Milano , Italy
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27
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Clinical features and treatment of primary autoimmune hemolytic anemia in childhood. Transfus Apher Sci 2018; 57:665-668. [DOI: 10.1016/j.transci.2018.07.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 07/26/2018] [Accepted: 07/27/2018] [Indexed: 11/17/2022]
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28
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Anti-CD20 Treatment of Autoimmune Hemolytic Anemia Refractory to Corticosteroids and Azathioprine: A Pediatric Case Report and Mini Review. Case Rep Hematol 2018; 2018:8471073. [PMID: 30225153 PMCID: PMC6129358 DOI: 10.1155/2018/8471073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 07/30/2018] [Indexed: 12/18/2022] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is a relatively uncommon hematological entity in children and sometimes is characterized by a severe course requiring more than one line course therapy. Treatment decisions depend on the severity and chronicity of the anemia and the characteristics of the autoantibodies. Immunosuppression with corticosteroids is the first-line treatment, especially in warm-reactive AIHA. Refractory cases are treated with immunosuppressive drugs, cytotoxic agents, androgens, or splenectomy, with various side effects and questionable efficacy. Another second-line option is rituximab, an anti-CD20 monoclonal antibody, which has been used as an off-label agent with encouraging results from small limited studies or case reports. Herein, we add our experience on the safety and clinical efficacy of rituximab by presenting the case of a boy with warm-type AIHA resistant to corticosteroids and azathioprine, successfully treated with rituximab. We also offer a review of the relevant literature.
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29
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Khalifeh HK, Mourad YM, Chamoun CT. Infantile Cytomegalovirus-Associated Severe Warm Autoimmune Hemolytic Anemia: A Case Report. CHILDREN-BASEL 2017; 4:children4110094. [PMID: 29099741 PMCID: PMC5704128 DOI: 10.3390/children4110094] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/01/2017] [Accepted: 11/01/2017] [Indexed: 11/18/2022]
Abstract
Autoimmune hemolytic anemia is a rare hematologic entity in children. Etiologies are mainly viruses or bacteria. We describe here a case of severe warm autoimmune hemolytic anemia (IgG- and C3d-positive direct antiglobulin test) in an immunocompetent 6-month-old infant with acute Cytomegalovirus infection that responded well to corticotherapy and intraveneous immunoglobulins without using blood component transfusion. This case demonstrates the importance of recognizing CMV in infantile Autoimmune Hemolytic Anemia, especially because hemolysis can be severe and lethal.
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Affiliation(s)
- Hassan K Khalifeh
- Department of Pediatric Hematology Oncology, Zahraa University Hospital, Beirut 1131, Lebanon.
| | - Youmna M Mourad
- Department of Pediatric Hematology Oncology, Zahraa University Hospital, Beirut 1131, Lebanon.
| | - Cynthia T Chamoun
- Department of Pediatric Hematology Oncology, Zahraa University Hospital, Beirut 1131, Lebanon.
- Department of Pediatric Hematology Oncology, Faculty of Medical Sciences, Lebanese University, Beirut 1131, Lebanon.
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30
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SIC-reg.org: Managementleitfaden und Registerstudie für schwere Immunzytopenien. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-017-0325-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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31
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Singh A, Mandal A, Patel A, Mishra S. Autoimmune Haemolytic Anaemia-A Spectrum of Presentation in Children. J Clin Diagn Res 2017; 11:SR01-SR02. [PMID: 29207801 DOI: 10.7860/jcdr/2017/27895.10646] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 05/29/2017] [Indexed: 11/24/2022]
Abstract
Autoimmune Haemolytic Anaemias (AIHAs) are rare in children. They can be either a primary disease or secondary to/triggered by a host of other clinical conditions. We present five interesting cases of paediatric AIHA associated with infections (viral, bacterial and atypical) and autoimmune diseases {Systemic Lupus Erythematosus (SLE) and Autoimmune Hepatitis (AIH)}. The H1N1 influenza associated AIHA responded to oseltamivir and Intravenous Immunoglobulin (IvIg) while the cases secondary to Mycoplasma pneumoniae and pneumococcal bacteraemia required only treatment of the primary infection. AIHA with SLE responded well to corticosteroid therapy but the patient with AIH and AIHA succumbed to severe liver failure. Rest of the four cases with good response to therapy did not have any recurrence/relapse of AIHA during their follow up periods.
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Affiliation(s)
- Amitabh Singh
- Assistant Professor, Department of Paediatrics, Chacha Nehru Bal Chikitsalaya, New Delhi, India
| | - Anirban Mandal
- Attending Consultant, Department of Paediatrics, Sitaram Bhartia Institute of Science and Research, New Delhi, India
| | - Ankita Patel
- Senior Resident, Department of Paediatrics, Chacha Nehru Bal Chikitsalaya, New Delhi, India
| | - Sataroopa Mishra
- Senior Resident, Department of Paediatrics, Chacha Nehru Bal Chikitsalaya, New Delhi, India
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Ladogana S, Maruzzi M, Samperi P, Perrotta S, Del Vecchio GC, Notarangelo LD, Farruggia P, Verzegnassi F, Masera N, Saracco P, Fasoli S, Miano M, Girelli G, Barcellini W, Zanella A, Russo G. Diagnosis and management of newly diagnosed childhood autoimmune haemolytic anaemia. Recommendations from the Red Cell Study Group of the Paediatric Haemato-Oncology Italian Association. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2017; 15:259-267. [PMID: 28151390 PMCID: PMC5448833 DOI: 10.2450/2016.0072-16] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 11/09/2016] [Indexed: 01/20/2023]
Abstract
Autoimmune haemolytic anaemia is an uncommon disorder to which paediatric haematology centres take a variety of diagnostic and therapeutic approaches. The Red Cell Working Group of the Italian Association of Paediatric Onco-haematology (Associazione Italiana di Ematologia ed Oncologia Pediatrica, AIEOP) developed this document in order to collate expert opinions on the management of newly diagnosed childhood autoimmune haemolytic anaemia.The diagnostic process includes the direct and indirect antiglobulin tests; recommendations are given regarding further diagnostic tests, specifically in the cases that the direct and indirect antiglobulin tests are negative. Clear-cut definitions of clinical response are stated. Specific recommendations for treatment include: dosage of steroid therapy and tapering modality for warm autoimmune haemolytic anaemia; the choice of rituximab as first-line therapy for the rare primary transfusion-dependent cold autoimmune haemolytic anaemia; the indications for supportive therapy; the need for switching to second-line therapy. Each statement is provided with a score expressing the level of appropriateness and the agreement among participants.
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Affiliation(s)
- Saverio Ladogana
- Paediatric Onco-haematology Unit, “Casa Sollievo della Sofferenza” Hospital, IRCCS, San Giovanni Rotondo, Italy
| | - Matteo Maruzzi
- Paediatric Onco-haematology Unit, “Casa Sollievo della Sofferenza” Hospital, IRCCS, San Giovanni Rotondo, Italy
| | - Piera Samperi
- Paediatric Onco-haematology Unit, Azienda Policlinico “Vittorio Emanuele”, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Silverio Perrotta
- Department of Women, Children and General and Specialized Surgery, Second University of Naples, Naples, Italy
| | | | - Lucia D. Notarangelo
- Paediatric Onco-haematology Unit, Children’s Hospital, Spedali Civili, Brescia, Italy
| | - Piero Farruggia
- Paediatric Onco-haematology Unit, Civico Hospital, Palermo, Italy
| | | | - Nicoletta Masera
- Paediatric Department, University of Milano-Bicocca, “San Gerardo” Hospital, Monza, Italy
| | - Paola Saracco
- Paediatric and Adolescent Science Department, University of Turin, Turin, Italy
| | - Silvia Fasoli
- Paediatric Unit, “Carlo Poma” Hospital, Mantua, Italy
| | - Maurizio Miano
- Clinical and Experimental Haematology Unit, “G. Gaslini” Children’s Hospital, Genoa, Italy
| | - Gabriella Girelli
- Immunohaematology and Transfusion Medicine Unit, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Wilma Barcellini
- Onco-haematology, Physiopathology of Anaemia Unit, IRCCS Ca’ Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Zanella
- Onco-haematology, Physiopathology of Anaemia Unit, IRCCS Ca’ Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanna Russo
- Paediatric Onco-haematology Unit, Azienda Policlinico “Vittorio Emanuele”, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
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Hill QA, Stamps R, Massey E, Grainger JD, Provan D, Hill A. The diagnosis and management of primary autoimmune haemolytic anaemia. Br J Haematol 2016; 176:395-411. [PMID: 28005293 DOI: 10.1111/bjh.14478] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Quentin A Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | | | | | - John D Grainger
- Royal Manchester Children's Hospital, University of Manchester, Manchester, UK
| | - Drew Provan
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Anita Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
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Autoimmune Haemolytic Anaemia in a Child Due to Chickenpox. Indian J Hematol Blood Transfus 2016; 32:522-524. [DOI: 10.1007/s12288-016-0693-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 06/04/2016] [Indexed: 11/25/2022] Open
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Prabhu R, Bhaskaran R, Shenoy V, G R, Sidharthan N. Clinical characteristics and treatment outcomes of primary autoimmune hemolytic anemia: a single center study from South India. Blood Res 2016; 51:88-94. [PMID: 27382552 PMCID: PMC4931942 DOI: 10.5045/br.2016.51.2.88] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 05/11/2016] [Accepted: 05/24/2016] [Indexed: 11/25/2022] Open
Abstract
Background Autoimmune hemolytic anemia (AIHA) is a less recognized, potentially fatal condition. There is a scarcity of data on clinicoserological characteristics and response to therapy concerning this disease from South India. Methods Data for 33 patients with primary AIHA recorded from July 2009 to June 2015 were retrospectively analyzed for clinical presentation, response to frontline therapy, durability of response, time to next treatment (TTNT), and response to second-line agents. Results The median follow-up period was 50 months. Among 33 patients, 48% of the cases were warm autoimmune hemolytic anemia (WAIHA), 46% were cold agglutinin disease (CAD), and 6% were atypical. Three-fourth of patients had severe anemia (<8 g/dL hemoglobin [Hb]) at onset; younger patients (age <40 yr) had more severe anemia. All of the patients who required treatment received oral prednisolone at 1.5 mg/kg/d as a frontline therapy, and the response rate was 90% (62% complete response [CR] and 28% partial response [PR]). The overall response to corticosteroids in WAIHA and CAD was 87% and 92%, respectively. The median corticosteroid duration was 14 months, and 50% of the patients required second-line agents. Fourteen patients received azathioprine as a second-line agent, and 11 of these patients responded well, with half of them not requiring a third agent. Four patients developed severe infections (pneumonia, sepsis, and soft tissue abscess) and two had life-threatening venous thrombosis. One case of death was recorded. Conclusion AIHA is a heterogeneous disease that requires care by physicians experienced in treating these patients.
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Affiliation(s)
- Raghuveer Prabhu
- Department of Medical Oncology and Hematology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Kochi, India
| | - Renjitha Bhaskaran
- Department of Medical Oncology and Hematology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Kochi, India
| | - Veena Shenoy
- Department of Medical Oncology and Hematology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Kochi, India
| | - Rema G
- Department of Medical Oncology and Hematology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Kochi, India
| | - Neeraj Sidharthan
- Department of Medical Oncology and Hematology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Kochi, India
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Abstract
We studied 35 pediatric patients with autoimmune hemolytic anemia seen at Mayo Clinic from 1994 to 2014. The median age was 10.0 years and 65.7% were males. Most had warm antibodies (80.0%) and some secondary to viral (14.3%) or autoimmune disorders (31.4%). Seven (20.0%) patients presented with Evans syndrome, 3 of whom also had common variable immunodeficiency. The median hemoglobin at diagnosis was 6.1 g/dL and 62.8% patients required red cell transfusions. The severity of anemia was worse among children below 10 years (median 5.5 vs. 7.0 g/dL, P=0.01). Steroid was the initial treatment for 88.5% patients, with overall response rate of 82.7% (68.5% complete, 14.2% partial) and median response duration of 10.7 months (range, 0.2 to 129.7+ mo). After median follow-up of 26.6 months, 8 (22.8%) patients relapsed. Salvage treatments included splenectomy, intravenous immunoglobulin, rituximab, and mycophenolate mofetil. Infectious complications occurred in 9 (25.7%) patients and 1 patient died of cytomegalovirus infection. Four patients had cold agglutinin disease and 3 (75.0%) responded to steroids. Autoimmune hemolytic anemia is a rare disorder in pediatric population and most respond well to steroids regardless of the type of antibody. Infectious complications are common and screening for immunodeficiency is recommended among those with Evans syndrome.
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Fan J, He H, Zhao W, Wang Y, Lu J, Li J, Li J, Xiao P, Lu Y, Chai Y, Hu S. Clinical Features and Treatment Outcomes of Childhood Autoimmune Hemolytic Anemia: A Retrospective Analysis of 68 Cases. J Pediatr Hematol Oncol 2016; 38:e50-5. [PMID: 26630535 DOI: 10.1097/mph.0000000000000476] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Autoimmune hemolytic anemia (AIHA) is a rare disease in children, and its clinical severity varies. To better understand disease manifestation and treatment outcome, we analyzed 68 children diagnosed as AIHA for clinical characteristics, laboratory findings, and treatment outcomes. Data show that primary AIHA accounted for 39.7% of all patients, whereas secondary AIHA accounted for 60.3%. Among them, Evans syndrome (ES) accounted for 20 cases (29.4%). Average hemoglobin was lower in the 1-year or below age group than in the above 1-year age group, combined-antibody group than single-antibody group, and IgM-contained group than non-IgM-contained group (P<0.05 for all). The duration of therapy in the ES group was longer than that in the AIHA-only group (P<0.05). During the follow-up period, 29 cases (29/45, 64.4%) remained in continuous remission. In total, 35.6% of patients relapsed after first complete remission and 56.3% of them still showed good response to glucocorticoid after relapse. There was no difference in the duration of therapy or relapse rate between the intravenous immunoglobulin (IVIG)-treatment group and the non-IVIG-treatment group. In conclusion, the severity of anemia correlates with age and serologic types of direct antiglobulin test. Glucocorticoid is efficacious for AIHA regardless of whether it is a first attack or relapse in this cohort of young patients. ES needs longer treatment duration. IVIG does not improve the outcome of AIHA.
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Affiliation(s)
- Junjie Fan
- Children's Hospital of Soochow University, Soochow, China
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38
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Affiliation(s)
- Maurizio Miano
- Clinical and Experimental Haematology Unit; Department of Haematology/Oncology; IRCCS Istituto Giannina Gaslini; Genoa Italy
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39
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Abstract
Autoimmune hemolytic anemia (AIHA) is a relatively uncommon disorder caused by autoantibodies directed against self red blood cells. It can be idiopathic or secondary, and classified as warm, cold (cold hemagglutinin disease (CAD) and paroxysmal cold hemoglobinuria) or mixed, according to the thermal range of the autoantibody. AIHA may develop gradually, or have a fulminant onset with life-threatening anemia. The treatment of AIHA is still not evidence-based. The first-line therapy for warm AIHA are corticosteroids, which are effective in 70-85% of patients and should be slowly tapered over a time period of 6-12 months. For refractory/relapsed cases, the current sequence of second-line therapy is splenectomy (effective approx. in 2 out of 3 cases but with a presumed cure rate of up to 20%), rituximab (effective in approx. 80-90% of cases), and thereafter any of the immunosuppressive drugs (azathioprine, cyclophosphamide, cyclosporin, mycophenolate mofetil). Additional therapies are intravenous immunoglobulins, danazol, plasma-exchange, and alemtuzumab and high-dose cyclophosphamide as last resort option. As the experience with rituximab evolves, it is likely that this drug will be located at an earlier point in therapy of warm AIHA, before more toxic immunosuppressants, and in place of splenectomy in some cases. In CAD, rituximab is now recommended as first-line treatment.
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Affiliation(s)
- Alberto Zanella
- U.O. Ematologia, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Wilma Barcellini
- U.O. Ematologia, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
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40
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Clinical heterogeneity and predictors of outcome in primary autoimmune hemolytic anemia: a GIMEMA study of 308 patients. Blood 2014; 124:2930-6. [PMID: 25232059 DOI: 10.1182/blood-2014-06-583021] [Citation(s) in RCA: 218] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The clinical outcome, response to treatment, and occurrence of acute complications were retrospectively investigated in 308 primary autoimmune hemolytic anemia (AIHA) cases and correlated with serological characteristics and severity of anemia at onset. Patients had been followed up for a median of 33 months (range 12-372); 60% were warm AIHA, 27% cold hemagglutinin disease, 8% mixed, and 5% atypical (mostly direct antiglobulin test negative). The latter 2 categories more frequently showed a severe onset (hemoglobin [Hb] levels ≤6 g/dL) along with reticulocytopenia. The majority of warm AIHA patients received first-line steroid therapy only, whereas patients with mixed and atypical forms were more frequently treated with 2 or more therapy lines, including splenectomy, immunosuppressants, and rituximab. The cumulative incidence of relapse was increased in more severe cases (hazard ratio 3.08; 95% confidence interval, 1.44-6.57 for Hb ≤6 g/dL; P < .001). Thrombotic events were associated with Hb levels ≤6 g/dL at onset, intravascular hemolysis, and previous splenectomy. Predictors of a fatal outcome were severe infections, particularly in splenectomized cases, acute renal failure, Evans syndrome, and multitreatment (4 or more lines). The identification of severe and potentially fatal AIHA in a largely heterogeneous disease requires particular experienced attention by clinicians.
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Losa Frías V, García Sánchez A, Ortiz Valentín I, González Vicent M, Velasco Arribas M, Madero López L, Sevilla Navarro J. Rituximab en el tratamiento de citopenias autoinmunitarias refractarias a tratamientos convencionales. An Pediatr (Barc) 2013; 78:398-404. [DOI: 10.1016/j.anpedi.2012.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Revised: 11/03/2012] [Accepted: 11/05/2012] [Indexed: 01/19/2023] Open
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Sobota A, Neufeld EJ. Recognition and Management of Immune Thrombocytopenic Purpura and Autoimmune Hemolytic Anemia in the Emergency Department. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2011. [DOI: 10.1016/j.cpem.2011.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Aladjidi N, Leverger G, Leblanc T, Picat MQ, Michel G, Bertrand Y, Bader-Meunier B, Robert A, Nelken B, Gandemer V, Savel H, Stephan JL, Fouyssac F, Jeanpetit J, Thomas C, Rohrlich P, Baruchel A, Fischer A, Chêne G, Perel Y. New insights into childhood autoimmune hemolytic anemia: a French national observational study of 265 children. Haematologica 2011; 96:655-63. [PMID: 21228033 DOI: 10.3324/haematol.2010.036053] [Citation(s) in RCA: 146] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Autoimmune hemolytic anemia is a rare condition in children. Little is known about its initial presentation and the subsequent progression of the disease. DESIGN AND METHODS Since 2004, a national observational study has been aiming to thoroughly describe cases and identify prognostic factors. Patients from all French hematologic pediatric units have been included if they had a hemoglobin concentration less than 11 g/dL, a positive direct antiglobulin test and hemolysis. Evans' syndrome was defined by the association of autoimmune hemolytic anemia and immunological thrombocytopenic purpura. Data from patients' medical records were registered from birth to last follow-up. Autoimmune hemolytic anemia was classified as primary or secondary. Remission criteria, qualifying the status of anemia at last follow-up, were used with the aim of identifying a subgroup with a favorable prognosis in continuous complete remission. RESULTS The first 265 patients had a median age of 3.8 years at diagnosis. In 74% of cases the direct antiglobulin test was IgG/IgG+C3d. Consanguinity was reported in 8% of cases and first degree familial immunological diseases in 15% of cases. Evans' syndrome was diagnosed in 37% of cases. Autoimmune hemolytic anemia was post-infectious in 10%, immunological in 53% and primary in 37% of cases. After a median follow-up of 3 years, 4% of children had died, 28% were still treatment-dependent and 39% were in continuous complete remission. In multivariate analysis, IgG and IgG+C3d direct antiglobulin tests were associated with a lower rate of survival with continuous complete remission (adjusted hazard ratio, 0.43; 95% confidence interval, 0.21-0.86). CONCLUSIONS This nationwide French cohort is the largest reported study of childhood autoimmune hemolytic anemia. The rarity of this condition is confirmed. Subgroups with genetic predisposition and underlying immune disorders were identified.
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Affiliation(s)
- Nathalie Aladjidi
- Pediatric Hematology Unit, Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE) Hôpital des Enfants, Hôpital Pellegrin, CHU Bordeaux, Place Amelie Raba Leon, 33 000 Bordeaux, France.
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Haller W, Hind J, Height S, Mitry R, Dhawan A. Successful treatment of mixed-type autoimmune hemolytic anemia with rituximab in a child following liver transplantation. Pediatr Transplant 2010; 14:E20-5. [PMID: 19254271 DOI: 10.1111/j.1399-3046.2009.01128.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Development of a severe form of mixed-type AIHA after orthotopic liver transplantation is a rare, but a life-threatening event. We report a case of mixed-type AIHA that developed in a child after hepatocyte and living-related orthotopic liver transplantation for factor VII deficiency.
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Affiliation(s)
- Wolfram Haller
- Paediatric Liver Centre, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK.
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45
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Abstract
Autoantibodies against red blood cell antigens are considered the diagnostic hallmark of AIHA: Direct antiglobulin test (DAT) completed by cytofluorometry and specific diagnostic monoclonal antibodies (mAbs) allow for a better understanding of autoimmune hemolytic anemia (AIHA) triggers. Once B-cell tolerance checkpoints are bypassed, the patient loses self-tolerance, if the AIHA is not also caused by an possible variety of secondary pathogenic events such as viral, neoplastic and underlying autoimmune entities, such as SLE or post-transplantation drawbacks; treatment of underlying diseases in secondary AIHA guides ways to curative AIHA treatment. The acute phase of AIHA, often lethal in former times, if readily diagnosed, must be treated using plasma exchange, extracorporeal immunoadsorption and/or RBC transfusion with donor RBCs devoid of the auto-antibody target antigen. Genotyping blood groups (www.bloodgen.com) and narrowing down the blood type subspecificities with diagnostic mAbs help to define the triggering autoantigen and to select well compatible donor RBC concentrates, which thus escape recognition by the autoantibodies.
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Affiliation(s)
- Jean-Francois Lambert
- Service of Hematology, University Hospitals of Canton Vaud (CHUV), Lausanne, Switzerland
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