1
|
Yucel OK, Alemdar MS, Akkaya B, Kocak H, Suleymanlar G, Yilmaz VT. Tacrolimus-Associated Pure Red Cell Aplasia in a Patient With Renal Transplant. EXP CLIN TRANSPLANT 2022; 20:1131-1133. [PMID: 33272158 DOI: 10.6002/ect.2020.0290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pure red cell aplasia is a relatively rare disease characterized by suppression or absence of erythroid precursors while other cell lineages are normal in the bone marrow. The disease could be secondary to other diseases or an adverse side effect of certain drugs. Tacrolimus is widely used as an immunosuppressive agent in solid-organ transplant without significant myelosuppressive effects. However, several tacrolimus-related pure red cell aplasia cases have been reported to date. Here, we report a case of a renal transplant recipient who developed tacrolimus-associated pure red cell aplasia in the posttransplant period and recovered dramatically after switching from tacrolimus to cyclosporine. Early diagnosis of pure red cell aplasia, which generally requires multiple blood transfusions, is very important because an increased number of blood transfusions can cause immunogenic effects and increased risk for allograft survival. Tacrolimus is a prominent drug for immunosuppression and is suspected to cause pure red cell aplasia during the posttransplant period; therefore, clinicians should consider a switch from tacrolimus to another immunosuppressive agent.
Collapse
Affiliation(s)
- Orhan Kemal Yucel
- From the Department of Hematology and Stem Cell Transplantation, Akdeniz University School of Medicine, Antalya, Turkey
| | | | | | | | | | | |
Collapse
|
2
|
Gurnari C, Maciejewski JP. How I manage acquired pure red cell aplasia in adults. Blood 2021; 137:2001-2009. [PMID: 33657207 PMCID: PMC8057257 DOI: 10.1182/blood.2021010898] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 02/18/2021] [Indexed: 12/19/2022] Open
Abstract
Pure red cell aplasia (PRCA) is a rare hematological disorder with multiple etiologies. The multifaceted nature of this disease is emphasized by the variety of concomitant clinical features. Classic idiopathic presentation aside, prompt recognition of pathogenetic clues is important because of their diagnostic and therapeutic implications. As a consequence, treatment of PRCA is diverse and strictly dependent on the presented clinical scenario. Here, we propose a series of clinical vignettes that showcase instructive representative situations derived from our routine clinical practice. Using these illustrative clinical cases, we review the diagnostic workup needed for a precise diagnosis and the currently available therapeutic options, discussing their applications in regard to the various PRCA-associated conditions and individual patients' characteristics. Finally, we propose a treatment algorithm that may offer guidance for personalized therapeutic recommendations.
Collapse
Affiliation(s)
- Carmelo Gurnari
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH; and
- Department of Biomedicine and Prevention, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, Rome, Italy
| | - Jaroslaw P Maciejewski
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH; and
| |
Collapse
|
3
|
Huang Y, Jiang X, Han B. Effective treatment of refractory acquired pure red blood cell aplasia with eltrombopag and sirolimus: a case report. Ther Adv Hematol 2020; 11:2040620720940144. [PMID: 32733663 PMCID: PMC7372523 DOI: 10.1177/2040620720940144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/11/2020] [Indexed: 12/17/2022] Open
Abstract
Acquired pure red cell aplasia (aPRCA) is a kind of anemia characterized
by severe reticulocytopenia and reduced bone marrow erythroblastic
cells. For patients who are refractory to the first-line therapy
(cyclosporin A with/without glucocorticoids), second-line therapy is
considered less effective. We report on a patient with primary aPRCA
who was refractory to cyclosporin A, glucocorticoids, and several
second-line regimens. The patient was treated with sirolimus for
10 months with no improvement in hemoglobin but complete response was
achieved after adding eltrombopag at a dosage of 25 mg/day.
Eltrombopag was well tolerated with no evidence of clonal evolution at
the end of follow up. This case provided a new attempt at treating
patients with refractory/relapse aPRCA with eltrombopag, probably in
combination with sirolimus.
Collapse
Affiliation(s)
- Yuzhou Huang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xianyong Jiang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuaifuyuan No. 1, Dongcheng District, Beijing 100730, China
| |
Collapse
|
4
|
[How I diagnose and treat pure red cell aplasia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:5-9. [PMID: 32023747 PMCID: PMC7357908 DOI: 10.3760/cma.j.issn.0253-2727.2020.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
5
|
Zhao J, Bhatnagar V, Ding L, Atay SM, David EA, McFadden PM, Stamnes S, Lechtholz-Zey E, Wightman SC, Detterbeck FC, Kim AW. A systematic review of paraneoplastic syndromes associated with thymoma: Treatment modalities, recurrence, and outcomes in resected cases. J Thorac Cardiovasc Surg 2019; 160:306-314.e14. [PMID: 31982129 DOI: 10.1016/j.jtcvs.2019.11.052] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 11/05/2019] [Accepted: 11/06/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Paraneoplastic syndromes associated with thymomas remain incompletely understood. The objective was to examine the association between surgically resected thymomas and paraneoplastic syndromes over the past half century. METHODS A primary PubMed/MEDLINE search was used to identify published articles describing paraneoplastic syndromes associated with thymomas from 1960 to 2019. A secondary search identified additional articles referenced in the articles found in the primary search. Kaplan-Meier and log-rank test were used for time-to-event data analyses. RESULTS From 407 articles describing 507 patients, 123 different paraneoplastic syndromes were associated with thymoma. The 5 most common paraneoplastic syndromes were myasthenia gravis, pure red cell aplasia, lichen planus, Good syndrome, and limbic encephalitis. Complete or partial resolution of paraneoplastic syndrome symptoms after surgery was noted in 76% of patients, of whom 21% had a relapse or new paraneoplastic syndrome onset after surgery. The most common adjunctive therapy associated with resolution of paraneoplastic syndrome was corticosteroids (30%). For all patients after surgery, thymoma recurrence was observed in 17% of cases, whereas recurrence of paraneoplastic syndrome was observed in 34% of cases, and both were observed in approximately 11% of cases. The 5- and 10-year overall survivals were 78% and 66%, respectively. Improved overall survival was associated with patients who had total resolution from paraneoplastic syndrome. CONCLUSIONS A comprehensive assessment of publications over the past half century suggests that a multimodal treatment approach that includes surgical resection of thymomas is able to achieve paraneoplastic syndrome resolution in a majority of patients. Onset of new paraneoplastic syndromes after surgery is associated with the recurrence of the first paraneoplastic syndrome, and resolution of paraneoplastic syndrome is associated with improved overall survival.
Collapse
Affiliation(s)
- Jasmine Zhao
- Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Vikrant Bhatnagar
- Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio
| | - Li Ding
- Division of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Scott M Atay
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Elizabeth A David
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - P Michael McFadden
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Stephanie Stamnes
- Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | | | - Sean C Wightman
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | | | - Anthony W Kim
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif.
| |
Collapse
|
6
|
Balasubramanian SK, Sadaps M, Thota S, Aly M, Przychodzen BP, Hirsch CM, Visconte V, Radivoyevitch T, Maciejewski JP. Rational management approach to pure red cell aplasia. Haematologica 2017; 103:221-230. [PMID: 29217782 PMCID: PMC5792266 DOI: 10.3324/haematol.2017.175810] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 12/06/2017] [Indexed: 11/09/2022] Open
Abstract
Pure red cell aplasia is an orphan disease, and as such lacks rationally established standard therapies. Most cases are idiopathic; a subset is antibody-mediated. There is overlap between idiopathic cases and those with T-cell large granular lymphocytic leukemia, hypogammaglobulinemia, and low-grade lymphomas. In each of the aforementioned, the pathogenetic mechanisms may involve autoreactive cytotoxic responses. We selected 62 uniformly diagnosed pure red cell aplasia patients and analyzed their pathophysiologic features and responsiveness to rationally applied first-line and salvage therapies in order to propose diagnostic and therapeutic algorithms that may be helpful in guiding the management of prospective patients, 52% of whom were idiopathic, while the others involved large granular lymphocytic leukemia, thymoma, and B-cell dyscrasia. T-cell-mediated responses ranged between a continuum from polyclonal to monoclonal (as seen in large granular lymphocytic leukemia). During a median observation period of 40 months, patients received a median of two different therapies to achieve remission. Frequently used therapy included calcineurin-inhibitors with a steroid taper yielding a first-line overall response rate of 76% (53/70). Oral cyclophosphamide showed activity, albeit lower than that produced by cyclosporine. Intravenous immunoglobulins were effective both in parvovirus patients and in hypogammaglobulinemia cases. In salvage settings, alemtuzumab is active, particularly in large granular lymphocytic leukemia-associated cases. Other potentially useful salvage options include rituximab, anti-thymocyte globulin and bortezomib. The workup of acquired pure red cell aplasia should include investigations of common pathological associations. Most effective therapies are directed against T-cell-mediated immunity, and therapeutic choices need to account for associated conditions that may help in choosing alternative salvage agents, such as intravenous immunoglobulin, alemtuzumab and bortezomib.
Collapse
Affiliation(s)
- Suresh Kumar Balasubramanian
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, OH, USA
| | - Meena Sadaps
- Department of Internal Medicine, Taussig Cancer Institute, Cleveland Clinic, OH, USA
| | - Swapna Thota
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, OH, USA
| | - Mai Aly
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, OH, USA
| | - Bartlomiej P Przychodzen
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, OH, USA
| | - Cassandra M Hirsch
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, OH, USA
| | - Valeria Visconte
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, OH, USA
| | - Tomas Radivoyevitch
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, OH, USA
| | - Jaroslaw P Maciejewski
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, OH, USA
| |
Collapse
|
7
|
Abstract
Pure red cell aplasia (PRCA) is a syndrome defined by a normocytic normochromic anemia with severe reticulocytopenia and marked reduction or absence of erythroid precursors from the bone marrow. Diamond-Blackfan anemia is a congenital form of PRCA. Acquired PRCA may be either a primary disorder or secondary to some other disorder or agent. Primary acquired PRCA is an autoimmune disorder that is frequently antibody-mediated. Myelodysplastic syndromes may also present with the morphologic appearance of PRCA. Secondary acquired PRCA may be associated with collagen vascular/autoimmune disorders such as systemic lupus erythematosus; lymphoproliferative disorders such as chronic lymphocytic leukemia or large granular lymphocyte leukemia; infections, particularly B19 parvovirus; thymoma and other solid tumors; or a variety of other disorders, drugs, or toxic agents. The therapeutic approach to PRCA typically involves immunosuppression, but specific pathogenic subtypes are associated with specific therapeutic approaches. Cyclosporine A, with or without concurrent corticosteroids, appears to be the single most effective immunosuppressive agent.
Collapse
|
8
|
Abstract
Pure red cell aplasia (PRCA) is a syndrome defined by a normocytic normochromic anemia with severe reticulocytopenia and marked reduction or absence of erythroid precursors from the bone marrow. Diamond-Blackfan anemia is a congenital form of PRCA. Acquired PRCA may be either a primary disorder or secondary to some other disorder or agent. Primary acquired PRCA is an autoimmune disorder that is frequently antibody-mediated. Myelodysplastic syndromes may also present with the morphologic appearance of PRCA. Secondary acquired PRCA may be associated with collagen vascular/autoimmune disorders such as systemic lupus erythematosus; lymphoproliferative disorders such as chronic lymphocytic leukemia or large granular lymphocyte leukemia; infections, particularly B19 parvovirus; thymoma and other solid tumors; or a variety of other disorders, drugs, or toxic agents. The therapeutic approach to PRCA typically involves immunosuppression, but specific pathogenic subtypes are associated with specific therapeutic approaches. Cyclosporine A, with or without concurrent corticosteroids, appears to be the single most effective immunosuppressive agent.
Collapse
MESH Headings
- Adrenal Cortex Hormones/therapeutic use
- Anemia, Diamond-Blackfan/drug therapy
- Anemia, Diamond-Blackfan/immunology
- Anemia, Diamond-Blackfan/pathology
- Autoimmune Diseases/drug therapy
- Autoimmune Diseases/immunology
- Autoimmune Diseases/pathology
- Cyclosporine/therapeutic use
- Humans
- Immunosuppressive Agents/therapeutic use
- Leukemia, Large Granular Lymphocytic/drug therapy
- Leukemia, Large Granular Lymphocytic/immunology
- Leukemia, Large Granular Lymphocytic/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Myelodysplastic Syndromes/drug therapy
- Myelodysplastic Syndromes/etiology
- Myelodysplastic Syndromes/immunology
- Myelodysplastic Syndromes/pathology
- Parvoviridae Infections/drug therapy
- Parvoviridae Infections/immunology
- Parvoviridae Infections/pathology
- Parvovirus B19, Human/immunology
- Thymoma/drug therapy
- Thymoma/immunology
- Thymoma/pathology
- Vasculitis/drug therapy
- Vasculitis/immunology
- Vasculitis/pathology
Collapse
Affiliation(s)
- Robert T Means
- Office of the Dean, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN
| |
Collapse
|
9
|
Pure red cell aplasia induced by anti-erythropoietin antibodies, well-controlled with tacrolimus. Int J Hematol 2016; 104:502-5. [DOI: 10.1007/s12185-016-2047-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 06/16/2016] [Accepted: 06/16/2016] [Indexed: 10/21/2022]
|
10
|
Yildirim R, Bilen Y, Keles M, Uyanik A, Gokbulut P, Aydinli B. Treatment of pure red-cell aplasia with cyclosporine in a renal transplant patient. EXP CLIN TRANSPLANT 2012; 11:63-5. [PMID: 22891934 DOI: 10.6002/ect.2012.0066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Acquired pure red-cell aplasia is a rare disorder that can be either idiopathic or associated with certain autoimmune diseases, pregnancy, lymphoproliferative disorders, nutritional deficiencies, or medicines. We present a deceased-donor renal transplant patient who developed pure red-cell aplasia associated with mycophenolate mofetil or tacrolimus and was treated with cyclosporine. A 20-year-old woman was transplanted from a deceased donor 1 month earlier and presented to us with symptoms of fatigue, prostration, and palpitation. The results of a laboratory examination revealed anemia. A diagnostic work-up resulted in a diagnosis of pure red-cell aplasia. Mycophenolate mofetil was discontinued. Tacrolimus also was replaced with cyclosporine 2 months after mycophenolate mofetil was halted because of a lack of improvement in anemia. Three months later, her anemia improved with cyclosporine. Starting cyclosporine instead of tacrolimus or mycophenolate mofetil showed good improvement in our patient within 6 months of therapy.
Collapse
Affiliation(s)
- Rahsan Yildirim
- Department of Hematology, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | | | | | | | | | | |
Collapse
|
11
|
Ectopic thymoma with pure red cell aplasia--ambiguity with indolence. Int J Surg 2008; 6:e12-4. [PMID: 19059124 DOI: 10.1016/j.ijsu.2006.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2006] [Accepted: 09/09/2006] [Indexed: 11/23/2022]
Abstract
Two cases of thymomas with pure red cell aplasia (PRCA) are presented, highlighting variability in their anatomic location, ambiguity in presentation, indolence of course and unpredictability of response to treatment. Multi-modality approach is necessary for both diagnosis and management of this combination. Duration and side effects of treatment determine the overall prognosis.
Collapse
|
12
|
Fukushima K, Sato T, Mitsuhashi S, Gono T, Kaneko K, Yazaki M, Mastuda M, Ikeda SI. Pure red cell aplasia developing after treatment of pleural recurrence of thymoma, successfully treated with cyclosporin A but not with tacrolimus. Intern Med 2006; 45:485-6. [PMID: 16679708 DOI: 10.2169/internalmedicine.45.1587] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Kazuhiro Fukushima
- Department of Internal Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto
| | | | | | | | | | | | | | | |
Collapse
|