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Weerasinghe S, Karunathilake P, Ralapanawa U, Jayalath T, Abeygunawardena S, Rathnayaka M. Pure red cell aplasia secondary to rheumatoid arthritis: a case report. J Med Case Rep 2021; 15:578. [PMID: 34872595 PMCID: PMC8647461 DOI: 10.1186/s13256-021-03141-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/04/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Rheumatoid arthritis is a common autoimmune disease with many extra-articular manifestations. Pure red cell aplasia is a rare manifestation of rheumatoid arthritis and is sparsely documented in the literature, with a variable clinical outcome following immunosuppressive therapy. CASE PRESENTATION A 63-year-old Sinhalese female presented with transfusion-dependent anemia associated with deforming inflammatory arthritis. She also had leukopenia, right subclavian venous thrombosis, and generalized lymphadenopathy. The diagnosis of rheumatoid arthritis following initial clinical workup and additional blood and bone marrow investigations revealed pure red cell aplasia as a secondary manifestation of rheumatoid arthritis after excluding other secondary causes, such as infections, thymoma, thrombophilic conditions, and hematological malignancy. She responded well to oral prednisolone, cyclosporine A, and hydroxychloroquine, and she attained complete recovery in 2 months. CONCLUSION Pure red cell aplasia is a disabling illness that may lead to transfusion-dependent anemia, which may occur due to rare extrapulmonary manifestation of rheumatoid arthritis. The diagnosis of pure red cell aplasia secondary to rheumatoid arthritis may be challenging where hematological investigations, including bone marrow biopsy, will aid in the diagnosis, and early diagnosis and treatment will bring about a better outcome.
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Affiliation(s)
| | | | - Udaya Ralapanawa
- Department of Medicine, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka
| | - Thilak Jayalath
- Department of Medicine, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka
| | | | - Manel Rathnayaka
- Department of Pathology, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka
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Tanna S, Ustun C. Immunosuppressive treatment in patient with pure red cell aplasia associated with chronic myelomonocytic leukemia: harm or benefit? Int J Hematol 2009; 90:597-600. [PMID: 19760482 DOI: 10.1007/s12185-009-0423-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Revised: 08/27/2009] [Accepted: 09/02/2009] [Indexed: 11/24/2022]
Abstract
Acquired pure red cell aplasia (PRCA) can be primary or secondary to other diseases. PRCA association with chronic myelomonocytic leukemia (CMML) is very rarely reported. Although treatment is directed to underlying cause in secondary PRCA treatment, optimal treatment in patients with CMML and PRCA is unknown, because only four case reports are available. In addition, the effect of hypomethylating agents can be detrimental due to myelosuppression, at least in the early phase of treatment. Bone marrow examination of a 66-year-old woman with severe anemia revealed PRCA and was suspicious for CMML. There was no HLA-matched sibling for bone marrow transplantation. The patient received immunosuppressive therapy with steroids and cyclosporine with temporary response in anemia; however, progressed to acute leukemia over 8 months and died. Immunosuppressive therapy in patients with CMML and PRCA should be cautiously used because it may accelerate acute leukemia transformation.
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Affiliation(s)
- Saloni Tanna
- Section of Hematology/Oncology, Department of Medicine, Medical College of Georgia, 1120 15th Street, BAA-5407, Augusta, GA, 30912, USA
| | - Celalettin Ustun
- Section of Hematology/Oncology, Department of Medicine, Medical College of Georgia, 1120 15th Street, BAA-5407, Augusta, GA, 30912, USA.
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Abramson JS, Kotton CN, Elias N, Sahani DV, Hasserjian RP. Case records of the Massachusetts General Hospital. Case 8-2008. A 33-year-old man with fever, abdominal pain, and pancytopenia after renal transplantation. N Engl J Med 2008; 358:1176-87. [PMID: 18337607 DOI: 10.1056/nejmcpc0800380] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Sloand EM, Rezvani K. The Role of the Immune System in Myelodysplasia: Implications for Therapy. Semin Hematol 2008; 45:39-48. [DOI: 10.1053/j.seminhematol.2007.11.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Thompson CA, Steensma DP. Pure red cell aplasia associated with thymoma: clinical insights from a 50-year single-institution experience. Br J Haematol 2006; 135:405-7. [PMID: 17032177 DOI: 10.1111/j.1365-2141.2006.06295.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Acquired pure red cell aplasia (PRCA) is a rare disorder of erythropoiesis that can develop in association with a thymoma. Optimal management of this subgroup is unclear, and there have been few series reporting long-term clinical outcomes. Here, we report features of 13 patients treated for PRCA associated with thymoma over 50 years at our institution. Surgical resection of the thymoma was insufficient for normalisation of erythropoiesis in all cases. T-cell gene rearrangement studies did not routinely demonstrate a clonal process, and ciclosporin and anti-thymocyte globulin were effective adjuvant treatments. However, treatment-related morbidity was high, with frequent infectious complications.
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Affiliation(s)
- Carrie A Thompson
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Mittal S, Milner BJ, Johnston PW, Culligan DJ. A case of hepatosplenic gamma-delta T-cell lymphoma with a transient response to fludarabine and alemtuzumab. Eur J Haematol 2006; 76:531-4. [PMID: 16548918 DOI: 10.1111/j.1600-0609.2006.00646.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Hepatosplenic gamma-delta T-cell lymphoma is a rare, usually fatal lymphoma and available literature on management is sparse. Allografting is probably the only curative option. We describe a further case with a dramatic, though transient response to Fludarabine and Alemtuzumab combination, following a failure of conventional chemotherapy. Given the dreadful prognosis with conventional chemotherapy, it is a regimen worth pursuing as a disease reduction strategy prior to allograft where appropriate.
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MESH Headings
- Adolescent
- Alemtuzumab
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal, Humanized
- Antibodies, Neoplasm/administration & dosage
- Antibodies, Neoplasm/adverse effects
- Antimetabolites, Antineoplastic/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Cisplatin
- Combined Modality Therapy
- Crohn Disease/complications
- Cytarabine
- Epirubicin/administration & dosage
- Epstein-Barr Virus Infections/complications
- Etoposide/administration & dosage
- Fatal Outcome
- Gene Rearrangement, delta-Chain T-Cell Antigen Receptor
- Gene Rearrangement, gamma-Chain T-Cell Antigen Receptor
- Hematopoietic Stem Cell Transplantation
- Humans
- Ifosfamide/administration & dosage
- Immunosuppressive Agents/adverse effects
- Liver/pathology
- Lymphoma, T-Cell, Peripheral/complications
- Lymphoma, T-Cell, Peripheral/drug therapy
- Lymphoma, T-Cell, Peripheral/surgery
- Lymphoproliferative Disorders/etiology
- Male
- Methylprednisolone
- Pentostatin/therapeutic use
- Receptors, Antigen, T-Cell, gamma-delta/analysis
- Remission Induction
- Spleen/pathology
- Transplantation, Homologous
- Vidarabine/administration & dosage
- Vidarabine/adverse effects
- Vidarabine/analogs & derivatives
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Affiliation(s)
- S Mittal
- Department of Clinical Haematology, Aberdeen Royal Infirmary, Aberdeen, UK.
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Ogata M, Ohtsuka E, Imamura T, Ikewaki J, Ogata Y, Kohno K, Nakayama T, Ono K, Saburi Y, Kikuchi H, Nasu M. Response to cyclosporine therapy in patients with myelodysplastic syndrome: a clinical study of 12 cases and literature review. Int J Hematol 2004; 80:35-42. [PMID: 15293566 DOI: 10.1532/ijh97.04051] [Citation(s) in RCA: 8] [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
Cyclosporine (CyA) was administered to 12 patients with myelodysplastic syndrome (MDS), and a response (major erythroid response, according to International Working Group criteria) was observed in 7 patients (58.3%). The median duration of response was 18 months (range, 3-22 months). Two patients are still responding and continuing to take CyA. Three patients stopped because of malignancy complications. To identify variables associated with responsiveness to CyA therapy, we analyzed the treatments of 72 MDS patients, comprising the 12 new patients and 60 patients previously described in the literature. Responses were observed in 44 of the 72 patients (61.1%). Univariate analyses revealed that higher daily dose of CyA (P for trend test, .007) and shorter disease duration (median, 5 months versus 17.5 months, P = .04) were factors significantly associated with response. No significant associations were observed between response and bone marrow features such as erythroid hypoplasia or hypoplastic marrow. Multivariate analysis also demonstrated that high CyA dose (>5 mg/kg per day) was significantly associated with response (P = .02). The present study showed that CyA therapy is useful for MDS patients with any marrow cellularity. Shorter disease duration is a pretreatment variable correlated with response, and a higher CyA dose results in a higher response rate.
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Affiliation(s)
- Masao Ogata
- Second Department of Internal Medicine, Faculty of Medicine, Oita University Hasama-machi, Oita, Japan.
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Djaldetti M, Blay A, Bergman M, Salman H, Bessler H. Pure red cell aplasia--a rare disease with multiple causes. Biomed Pharmacother 2004; 57:326-32. [PMID: 14568226 DOI: 10.1016/j.biopha.2003.08.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Pure red cell aplasia (PRCA) is a relatively rare disease although multiple factors are implied in the pathogenesis of its development. A slow progressive normocytic-normochromic anemia and reticulocytopenia, without leukopenia and thrombocytopenia in a patient who, except pallor, does not show abnormal findings on physical examination, should arise the suspicion that he has PRCA. Search for underlying diseases or infections and intake of drugs may help for the establishment of the diagnosis of acquired PRCA. Lack of erythroblasts in the bone marrow with normal development of the other hemopoietic series, as well as high level of serum erythropoietin are important clues for the diagnosis. Elimination of potentially causative factors, administration of immunosuppressive agents and/or recombinant erythropoietin, preferably epoetin beta, may induce remission and complete recovery.
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Affiliation(s)
- M Djaldetti
- Research Laboratory Unit, Rabin Medical Center, Golda Campus, 7, Keren Kayemet Street, Petah Tiqva, The Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel.
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Abstract
The myelodysplastic syndromes (MDS) comprise a heterogeneous group of clonal hematopoietic stem cell disorders, while, immunological abnormalities are frequently observed in patients with MDS. Several reports revealed that about 10% of MDS patients have clinical autoimmune disorders like skin vasculitis, rheumatic disease, or autoimmune hemolytic anemia. Furthermore, serological immunological abnormalities like hyper- or hypogammaglobulinemia, positivities of antinuclear antibody, positivities of direct Coombs test, or inverted CD4/8 ratios were found in 18-65% of patients with MDS. Recently immunosuppressive therapies including prednisolone, antithymocyte globulin, and cyclosporin A (CsA) are used to treat cytopenia in some patients with MDS. We examined the efficacy of CsA in 50 patients with MDS. Hematologic improvement was observed in 30 (60%) patients especially for erythroid lineage. There were significantly more responders with good karyotype or DRB1*1501 than with intermediate/poor karyotypes or with other HLA types. MDS with erythroid hypoplasia is a rare form of MDS, and has not yet been clearly defined. We reported four patients with MDS with erythroid hypoplasia who had morphological evidence of myelodysplasia and low percentage of erythroid precursors. Rearrangements of the TCR-beta and -gamma genes were seen in these patients using Southern blot and PCR analysis. Also they had skewed TCR usages using TCR repertoire analysis. Their anemia drastically improved with CsA therapy. We have to establish the clinical usefulness of immunosuppressive therapy in MDS patients and simple tools for revealing T-cell mediated myelosuppression in the individual patients for decision-making.
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Affiliation(s)
- Takashi Shimamoto
- First Department of Internal Medicine, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-ku Tokyo 160-0023, Japan.
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Shimamoto T, Ohyashiki K. Myelodysplastic syndrome with erythroid hypoplasia is a new clinical entity responsive to cyclosporin A therapy. Leuk Lymphoma 2002; 43:1895-6. [PMID: 12685853 DOI: 10.1080/1042819021000006349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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