ULCERATIVE COLITIS WITH ANTI-ERYTHROCYTE ANTIBODIES

Coombs-positive autoimmune hemolytic anemia in Crohn's disease

BACKGROUND

Anemia often occurs in patients with inflammatory bowel diseases. However, hemolytic anemia is a rare complication and is associated with Coombs-positive autoimmune disorders. There are several reports of autoimmune hemolytic anemia in patients with ulcerative colitis, whereas there are only four reports of this complication in patients with Crohn's disease. We report a case of a severe course Coombs-positive hemolytic anemia in a patient with Crohn's disease, which was refractory to medical treatment but resolved after subtotal colectomy.

CASE REPORT

A 29-year-old patient was submitted to our clinic several times because of a severe course of inflammatory bowel disease and additionally a Coombs-positive autoimmune hemolytic anemia. Histology indicated severe Crohn's disease, but neither medical treatment with steroids, nor with methotrexate, cyclosporine or tumor necrosis factor-alpha antibody had been successful in resolving the intestinal inflammation and the hemolytic anemia. As colonoscopy revealed a pancolitis and dysplastic changes, even in the less inflamed areas of the colonic mucosa, subtotal colectomy was indicated. Half a year later we observed clinical and immunological signs of complete remission (no gastrointestinal symptoms, negative Coombs test).

CONCLUSION

Autoimmune hemolytic anemia is a rare complication of inflammatory bowel disease and has been almost exclusively described in ulcerative colitis. The etiology is not yet completely understood. Presumably, the colon displays a role in the production of anti-erythrocyte antibodies. The therapy of choice in Crohn's associated hemolytic anemia is thought to be medical treatment with corticoid steroids. Some authors additionally prefer immunmodulators. However, in the case presented, colectomy (without splenectomy) was necessary to resolve refractory hemolysis and the severe course of Crohn's disease.

Coombs-positive autoimmune hemolytic anemia in ulcerative colitis

Coombs-positive autoimmune hemolytic anemia is a rare complication of ulcerative colitis, occurring in fewer than 1% of cases. We have found eight patients with autoimmune hemolytic anemia in a series of 1150 hospitalized patients with ulcerative colitis (0.7%). There was a marked preponderance of female patients F:M = 7:1, in accord with previous reports. The hemolytic anemia appeared at a mean of 10 years after the onset of colitis, apparently independent of the age of the patient. Although seven of the eight patients had active colitis at the time of diagnosis of anemia, there was no consistent relationship to the extent of the bowel disease. Seven of the eight patients survived. One patient showed a partial response to steroid therapy, two responded to splenectomy, but four required both colectomy and splenectomy. Steroids should be the first line of therapy followed by splenectomy, if necessary. For those patients who have severe colitis, which in itself would merit surgery, a total proctocolectomy combined with splenectomy seems advisable.

Autoimmune hemolytic anemia associated with ulcerative colitis

Three patients are reported in whom autoimmune hemolytic anemia developed during the course of ulcerative colitis. A review of the literature yielded 11 additional cases, and the clinical, immunologic, and therapeutic characteristics are summarized. The results of steroid therapy and splenectomy are similar to those for idiopathic autoimmune hemolytic anemia. The cause and effect relationship between these two diseases is not clear, but colectomy appears to produce remission in hemolysis when the latter is refractory to both steroids and splenectomy.

Auto-immune reactions in ulcerative colitis

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