Autoimmune haemolytic anaemia with monoclonal IgM (kappa) anti-P cold autohaemolysins

Clinical and serological characterization of cold agglutinin syndrome in a Tertiary Care Hospital in Eastern India

Background and Aim:

Cold agglutinin syndrome (CAS) primary or secondary represents approximately 16-32% of autoimmune hemolytic anemia cases. Most patients present with mild, chronic hemolytic anemia with exacerbation of the condition in the cold environment. Red cell transfusions are only indicated when there is a life-threatening anemia causing crisis. We studied the clinical and serological characterization of CAS with the aim that the information gained from this study would help in proper diagnosis and management of these patients.

Materials and Methods:

The prospective study included nine patients who were admitted with severe anemia. Detailed work-up were conducted to establish the diagnosis, severity of in vivo hemolysis and transfusion management.

Results:

All patients presented with pallor, weakness, fatigue and painful fingers and toes with exacerbation of symptoms in winter months. Secondary CAS was observed in three patients suffering from malignant lymphoma. Red cells of all patients were coated with complements (C3) more specifically C3d. In one patient suffering from malignant lymphoma, the cold autoagglutinin titer was as high as 4096. Autoantibody in seven patients was specific to “I” antigen and one to “i” antigen.

Conclusions:

We conclude that detailed clinical and serological characterization is needed to diagnose and manage CAS. Whereas avoidance of cold exposure is the primary therapy, but no critical patient should be denied blood transfusion due to serological complications. All transfusion services should follow the correct protocol to maximize blood safety in CAS.

The Clinical Pictures of Autoimmune Hemolytic Anemia

Autoimmune hemolytic anemia is characterized by shortened red blood cell survival and a positive Coombs test. The responsible autoantibodies may be either warm reactive or cold reactive. The rate of hemolysis and the severity of the anemia may vary from mild to severe and life-threatening. Diagnosis is made in the laboratory by the findings of anemia, reticulocytosis, a positive Coombs test, and specific serologic tests. The prognosis is generally good but renal failure and death sometimes occur, especially in cases mediated by drugs.

Autoimmune hemolytic anemia: From lab to bedside

Autoimmune hemolytic anemia (AIHA) is not an uncommon clinical disorder and requires advanced, efficient immunohematological and transfusion support. Many AIHA patients have underlying disorder and therefore, it is incumbent upon the clinician to investigate these patients in detail, as the underlying condition can be of a serious nature such as lymphoproliferative disorder or connective tissue disorder. Despite advances in transfusion medicine, simple immunohematological test such as direct antiglobulin test (DAT) still remains the diagnostic hallmark of AIHA. The sensitive gel technology has enabled the immunohematologist not only to diagnose serologically such patients, but also to characterize red cell bound autoantibodies with regard to their class, subclass and titer in a rapid and simplified way. Detailed characterization of autoantibodies is important, as there is a relationship between in vivo hemolysis and strength of DAT; red cell bound multiple immunoglobulins, immunoglobulin G subclass and titer. Transfusing AIHA patient is a challenge to the immunohematologist as it is encountered with difficulties in ABO grouping and cross matching requiring specialized serological tests such as alloadsorption or autoadsorption. At times, it may be almost impossible to find a fully matched unit to transfuse these patients. However, transfusion should not be withheld in a critically ill patient even in the absence of compatible blood. The “best match” or “least incompatible units” can be transfused to such patients under close supervision without any serious side-effects. All blood banks should have the facilities to perform the necessary investigations required to issue “best match” packed red blood cells in AIHA. Specialized techniques such as elution and adsorption, which at times are helpful in enhancing blood safety in AIHA should be established in all transfusion services.

Autoimmune hemolytic anemia

Red blood cell (RBC) autoantibodies are a relatively uncommon cause of anemia. However, autoimmune hemolytic anemia (AIHA) must be considered in the differential diagnosis of hemolytic anemias, especially if the patient has a concomitant lymphoproliferative disorder, autoimmune disease, or viral or mycoplasmal infection. Classifications of AIHA include warm AIHA, cold agglutinin syndrome, paroxysmal cold hemoglobinuria, mixed-type AIHA, and drug-induced AIHA. Characteristics of the autoantibodies are responsible for the various clinical entities. As a result, diagnosis is based on the clinical presentation and a serologic work-up. For each classification of AIHA, this review discusses the demographics, etiology, clinical presentation, laboratory evaluation, and treatment options.

Hemolytic disorders associated with cancer

Three principal environmental causes of hemolytic anemia in malignancy have been identified: (1) hemolysis mediated by auto-antibodies to red cells; (2) hemolysis due to microangiopathic disorders; and (3) chemotherapy-induced red cell destruction. These three environmental stressors occur rarely in cancer patients, and they form the subject of this review.

Mucosa-associated lymphoid tissue lymphoma of the lung with cold-reacting autoantibody-mediated hemolytic anemia

Mucosa-associated lymphoid tissue lymphoma (MALT-oma) of the lung is a rare low-grade B cell lymphoma arising from bronchus-associated lymphoid tissue. This report concerns a 39-year-old woman with bilateral diffuse alveolar consolidations and cold-reacting autoantibody-mediated hemolytic anemia. Open-lung biopsy showed angulated lymphoid cells with lymphoepithelial lesions. Immunocytochemistry revealed that the lymphoid cells were positive for CD19, CD20, and IgM (lambda), which was consistent with immunophenotype of MALToma. The serum immunoelectrophoresis demonstrated IgM (lambda) monoclonal gammopathy. The association of cold-reacting auto-antibody-mediated hemolytic anemia with MALToma, to our knowledge, has never been reported before in the English language.

Cold agglutination

Autoantibodies against red cells optimally reacting at 0 degree C, ie, CA, are normally found with low titers in the serum of human adults. High-titer CA may be induced by certain infectious agents, including M pneumoniae, EBV, CMV, and rubella virus, or may develop on the basis of chronic (malignant) B cell lymphoproliferation. The main clinical manifestation of cold agglutination is AIHA. Antigens and antibodies of cold agglutination are the best characterized reaction partners of a human autoimmune process. CA may recognize I and i antigens, which are lipid- and protein-linked branched and linear N-acetyl-lactosamine chains, respectively. They are precursors of the ABH blood group antigens and are converted into H by fucosylation. An alternative substitution by sialylation creates Gd, Fl, and probably Vo/Li antigens. CA with anti-Pr and anti-Sa specificities recognize 0-glycans with immunodominant sialyl groups on glycophorins. Several Pr subspecificities can be identified by chemically modified sialyl groups on glycophorins. Because CA in chronic lymphoproliferation are monoclonal antibodies, structure-specificity-interrelations of the antibodies could be identified by primary structure analyses of the N-terminal variable regions of H and L chains and by studies on CA idiotypes. Interrelations between distinct CA specificities and particular infectious agents could explain cold agglutination as a response to receptors for the agents or to the binding sites of antibodies against the agents. Interrelations also existing between certain CA isotypes (Ig classes and L chain types) and CA specificities could be a basis for the elucidation of the enigmatic etiology of chronic (malignant) monoclonal cold agglutination.

Evans' syndrome as a presenting manifestation of atypical paroxysmal cold hemoglobinuria

Paroxysmal cold hemoglobinuria is a rare and potentially life-threatening acquired hemolytic anemia occurring either as an acute transient anemia following several different viral syndromes, or in a chronic idiopathic form. Episodic hemolysis in paroxysmal cold hemoglobinuria is usually associated with a biphasic (Donath-Landsteiner) IgG cold-reactive complement-fixing autohemolysin with anti-P specificity. Paroxysmal cold hemoglobinuria has not previously been associated with malignancy nor has it been clearly shown to be steroid-responsive. This report describes a patient with steroid-responsive autoimmune hemolytic anemia and immune thrombocytopenia (Evans' syndrome) associated with oat cell carcinoma of the lung and a unique biphasic anti-IgM autohemolysin. This case extends the spectrum of biphasic antibody-mediated immune cytopenias and widens both the clinical and the serologic definition of paroxysmal cold hemoglobinuria.

A human monoclonal IgM kappa cold agglutinin recognizing oligosaccharides with immunodominant sialyl groups preferentially at the blood group M-specific peptide backbone of glycophorins: anti-PrM

A kappa-monotypic IgM high titer cold agglutinin reacting like anti-Pr at low, like anti-M at higher temperatures, is described. It recognizes tetra- and/or trisaccharides with immunodominant sialyl groups on glycophorins A, B, C like anti-Pr. Its affinity to the oligosaccharides is, however, approximately 10-fold increased when they are attached to the M-specific peptide backbone of glycophorin A. The antibody, termed anti-PrM, occurred in a blood group MN patient with chronic cold agglutinin disease and caused autoimmune hemolytic anemia.

A murine monoclonal IgM antibody specific for blood group P antigen (globoside)

A murine monoclonal IgM erythrocyte antibody appeared to have anti-P (anti-globoside) specificity. The antibody was a relatively weak cold agglutinin, but a strong haemolysin and its reactivity with red cells was markedly enhanced by enzyme treatment. This antibody was used to study the cell and tissue distribution of globoside. Globoside was not only detectable on red cells and erythroblasts, but also on endothelial cells and on subsets of platelets, megakaryocytes and fibroblasts. It was not detectable on granulocytes, monocytes and most peripheral blood lymphocytes. Neither was it present on erythroblast precursors (CFU-E, BFU-E), pro-erythroblasts or on the cells of the pro-erythroblastic cell lines K562 and HEL. However, K562 cells expressed globoside when induced to mature into erythroblasts by sodium butyrate. Cells of patients with various leukaemias were also tested. A significant number of positively reacting cells was frequently (six out of 18) seen in cases with a CML blast crisis (CML-BC) and rarely in AML (four out of 37 cases). In CML-BC the P-positive cells were probably erythroblasts and/or megakaryoblasts. Thus, globoside appeared to be an interesting marker in CML-BC of the erythroblastic or mixed erythroblastic-megakaryoblastic type.

Two human IgM myeloma proteins with unusual specificities for streptococcal carbohydrate-associated epitopes

Five hundred and fifty human sera from patients with IgM myeloma or Waldenström's macroglobulinaemia were screened by a solid-phase enzyme-linked immunoassay for binding to the carbohydrate of group A streptococci (A-CHO). Two of them (AC8 and AC179) contained immunoglobulin, which bound specifically to A-CHO even at serum dilutions of 1:10(7). Using synthetic oligosaccharides coupled to protein for inhibition studies, the fine specificities of AC8 and AC179 were determined. AC179 is directed to alpha-linked rhamnose oligosaccharides. AC8 appears to be specific for N-acetyl-D-glucosamine (GlcNAc) side chains beta(1----2)-linked to rhamnose, whereas GlcNAc side chains in A-CHO are reported to be beta(1----3)-linked to the rhamnose backbone. Naturally occurring anti-A-CHO antibodies consist mainly of low-affinity antibodies to such beta(1----3)-linked GlcNAc. In contrast, both myeloma antibodies show more than 10 times higher relative affinities to A-CHO than antibodies prepared from normal human serum (anti-GlcNAc and anti-A-CHO, respectively) by selection for high affinity in the elution procedure. AC179 induced complement activation in the presence of A-CHO.