Haemolytic anaemia to the alpha-interferon treatment: a proposed mechanism

Autoimmune Hemolytic Anemia in Chronic Myeloid Leukemia

Background

Autoimmune hemolytic anemia (AIHA) might be associated with underlying hematological malignancies such as chronic lymphocytic leukemia. However, the association between AIHA and chronic myelogenous leukemia is extremely unusual.

Summary

We reviewed case reports and series of 54 patients with chronic myeloid leukemia (CML) who developed autoimmune hemolysis between 1952 and 2018. Almost all the patients were in the chronic phase and were classified into transplant and non-transplant groups. The onset of autoimmune hemolysis was earlier in the transplant group and required second- and third-line therapy to control it. The etiology of hemolysis is poorly understood but attributed in the transplant group to immune reconstitution, viral infections, or CML relapse. On the other hand, it is thought to be related in the non-transplant group to CML medications, especially interferon.

Key Messages

Although AIHA is uncommon in chronic myelogenous leukemia patients, it should be in the differential diagnosis list for those who develop a sudden drop in hemoglobin without a bleeding source.

Risk of immune thrombocytopenic purpura and autoimmune hemolytic anemia among 120 908 US veterans with hepatitis C virus infection

BACKGROUND

There is emerging evidence that hepatitis C virus (HCV) infection play a role in the etiology of immune thrombocytopenia purpura (ITP) and autoimmune hemolytic anemia (AIHA), both of which are severe autoimmune cytopenias.

METHODS

To determine if HCV infection increases the risk for ITP and AIHA, we calculated the incidence rates of ITP and AIHA among 120 691 HCV-infected and 454 905 matched HCV-uninfected US veterans who received diagnoses during the period 1997 to 2004. After excluding individuals with a prior diagnosis of a lymphoproliferative disease, human immunodeficiency virus, or cirrhosis, we fitted Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) as measures of risks.

RESULTS

We found 296 ITP and 90 AIHA cases. Among HCV-infected vs HCV-uninfected persons, the overall incidence rates of ITP were 30.2 and 18.5 per 100 000 person-years, and for AIHA they were 11.4 and 5.0 per 100 000 person-years, respectively. Hepatitis C virus was associated with elevated risks for ITP (HR, 1.8; 95% CI, 1.4-2.3) and AIHA (HR, 2.8; 95% CI, 1.8-4.2). The ITP incidence was increased among both untreated and treated HCV-infected persons (HR, 1.7; 95%, CI, 1.3-2.2 and HR, 2.4; 95% CI, 1.5-3.7, respectively), whereas AIHA incidence was elevated only among treated HCV-infected persons (HR, 11.6; 95% CI, 7.0-19.3).

CONCLUSIONS

Individuals infected with HCV are at an increased risk for ITP, whereas the development of AIHA seems to be associated with HCV treatment. It may be beneficial to test individuals newly diagnosed as having ITP for HCV infection.

Autoimmune hemolytic anemia in HCV/HIV coinfected patients during treatment with pegylated alpha-2a interferon plus ribavirin

Two cases of autoimmune hemolytic anemia that occurred during the treatment of chronic hepatitis C with pegylated alpha-2a interferon and ribavirin, in HIV coinfected patients, are presented and described. The late occurrence (after six months of therapy) of this severe hemolytic anemia leads to the recommendation that hemoglobin levels should be monitored throughout the treatment period, even among patients who presented stable hemoglobin levels in the preceding months.

An unusual case of autoimmune hemolytic anemia in treatment naïve hepatitis C virus infection

Hepatitis C virus (HCV) infection is emerging as a common and insidiously progressive liver condition. In more than one third of the cases, extrahepatic manifestations are seen in the course of the disease. Over the past decade, authors have reported membranous nephropathy, cutaneous vasculitis, idiopathic thrombocytopenic purpura, porphyria cutanea tarda and diabetes mellitus, among other extrahepatic manifestations of HCV infection. Recently, there have been a growing number of reports relating HCV infection to autoimmune cytopenias. Here, we report an unusual case of Coombs'-negative autoimmune hemolytic anemia (AHA) with severe autoimmune leukopenia and neutropenia, occurring simultaneously, in a patient with untreated hepatitis C infection. Mild cytopenias during chronic hepatitis C have been reported widely in the medical literature; however, severe cytopenias are seldom described and are usually seen only after or simultaneously with therapy.

Tolerability of treatments for viral hepatitis

Interferon-alpha is the most widely used antiviral drug in chronic hepatitis B and C. Tolerability is usually good and serious adverse effects are rare. Most of the adverse effects are mild or transient and do not necessitate drug withdrawal. More than 90% of patients who are given interferon-alpha achieve 6 months to 1 year of treatment without serious adverse effects. The serious adverse effects usually occur in predisposed patients with pre-existing organ dysfunction. Nevertheless, careful selection of patients for therapy and observation during therapy are recommended. Nucleoside analogues are promising drugs in the treatment of chronic hepatitis B through inhibition of viral DNA polymerase. Lamivudine has been licensed for use in this indication. Its tolerability is excellent even when used for periods of 1 year or more. The main concern is the relatively high incidence of viral resistance resulting in breakthrough during or relapse after therapy. In the treatment of chronic hepatitis C, ribavirin, in combination with interferon-alpha is currently the reference therapy. The main adverse effect is haemolytic anaemia, which necessitates careful monitoring and adjustment of dosage in many cases. Recently, large trials showed the better efficacy of pegylated interferons as compared with standard interferon. The combination of pegylated interferon with ribavirin is under evaluation.

Chronic hepatitis C virus infection associated with primary warm-type autoimmune hemolytic anemia

Autoimmune hematologic abnormalities are not well recognized in chronic hepatitis C virus infection. We demonstrate an unusual association between primary autoimmune hemolytic anemia and chronic hepatitis C virus infection. A 69-year-old woman who had a history of hepatitis C virus-related liver cirrhosis was found to have deteriorating anemia with reticulocytosis when admitted to the hospital. Laboratory work revealed both positive direct and indirect Coombs' tests, and warm-type immunoglobulin G against surface antigens of red blood cells. After prednisolone therapy, her anemia improved dramatically. To our knowledge, this is the first reported case of chronic hepatitis C virus infection linked with autoimmune hemolytic anemia in its natural course, not related to prior interferon treatment. Our report suggests that isolated autoimmune hemolytic anemia may be one of the unusual hematologic manifestations of chronic hepatitis C virus infection.

Autoimmunity induced by interferon-alpha therapy for chronic viral hepatitis

Type I interferons, which are mostly alpha-interferons (either as single agents or in combination with antiviral drugs), are currently the standard therapy for chronic viral hepatitis B, B/D, and C. Side-effects are not uncommon and include exacerbation of pre-existing autoimmune disorders or the de novo induction of autoimmunity. These adverse effects are attributed to the immunomodulatory properties of type I interferons, and should be distinguished from autoimmunity associated with chronic viral hepatitis in which interferon treatment may indeed be beneficial. The major autoimmune side-effects of interferon therapy for chronic viral hepatitis are thyroid or liver disease. Therefore, screening for thyroid antibodies and auto-antibodies indicative of autoimmune hepatitis both before, during, and after interferon therapy is strongly recommended. The presence of high concentrations of thyroid auto-antibodies or antibodies associated with autoimmune hepatitis can be contraindicative to interferon therapy. However, treatment is not contraindicated in viral hepatitis (in particular chronic hepatitis C) associated with autoimmune phenomena--including low-titer thyroid antibodies or other non-organ specific auto-antibodies. If interferon-induced autoimmunity occurs, the necessity of therapy has to be balanced carefully against the risks of autoimmune disease. Further research is needed to identify the factors which determine susceptibility to interferon-associated autoimmunity in individual patients.