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Muradashvili T, Liu Y, VanOudenhove J, Gu SX, Krause DS, Montanari F, Carlino MJ, Mancuso R, Stempel JM, Halene S, Zeidan AM, Podoltsev NA, Neparidze N. Aplastic anemia in association with multiple myeloma: clinical and pathophysiological insights. Leuk Lymphoma 2024:1-8. [PMID: 39225418 DOI: 10.1080/10428194.2024.2393260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 07/31/2024] [Accepted: 08/12/2024] [Indexed: 09/04/2024]
Abstract
We investigated immune cytopenia in multiple myeloma (MM) patients with concurrent acquired aplastic anemia (AA), focusing on three clinical cases treated with plasma cell-directed therapy. All three patients achieved partial response in MM and one patient experienced complete resolution of AA. Two patients had partial improvement in transfusion requirement but continued to suffer from severe AA, leading to immunosuppressive therapy (IST) with improvement of transfusion requirement in both patients. In vitro serum testing of these patients demonstrated platelet mitochondrial dysfunction and platelet apoptosis but did not show sera-specific inhibition of erythroid colony formation in progenitor cells. The levels of IL8 and IL15 were elevated in MM patients with AA, implicating their potential roles in this co-occurrence. Response to IST points to the possibility of myeloma-dysregulated immune system leading to autoreactive T-cell destruction of hematopoietic stem and progenitor cells, offering insights for developing new treatment for cytopenia in MM.
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Affiliation(s)
| | - Yuxin Liu
- Section of Hematology, Department of Internal Medicine, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jennifer VanOudenhove
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Sean X Gu
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Diane S Krause
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Pathology, Yale School of Medicine, New Haven, USA
- Yale Stem Cell Center, New Haven, CT, USA
| | - Francesca Montanari
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Maximillian J Carlino
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
- Yale Stem Cell Center, New Haven, CT, USA
| | - Rubia Mancuso
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
- Yale Stem Cell Center, New Haven, CT, USA
| | - Jessica M Stempel
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Stephanie Halene
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Nikolai A Podoltsev
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Natalia Neparidze
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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Mehdipour Dalivand M, Woddor N, Makuria A, Aggarwal A, Nava VE. IgA plasma cell myeloma presenting as cold agglutinin-induced haemolytic transfusion reaction. BMJ Case Rep 2024; 17:e251638. [PMID: 38423573 PMCID: PMC10910471 DOI: 10.1136/bcr-2022-251638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
Cold agglutinins produced in the setting of B cell neoplasms, such as lymphoplasmacytic lymphoma and plasma cell myeloma, can mediate autoimmune haemolytic anemia. Transfusion of these patients can exacerbate cold agglutinin-mediated haemolysis. Moreover, the workup for these reactions represents a diagnostic challenge due in part to false negative direct antiglobulin tests (DATs). Here, we report an anaemic patient who after a red blood cell (RBC) transfusion performed without blood warming, experienced a DAT-negative haemolytic transfusion reaction, and was later diagnosed with IgA-multiple myeloma, which showed an uncommon granular pattern by CD138 immunohistochemistry. Extensive workup excluded other diagnostic possibilities, including the presence of Donath-Landsteiner antibodies and cryoglobulins. Successful treatment with CyBorD (cyclophosphamide, bortezomib and dexamethasone) achieved complete remission, and additional RBC transfusions using warmers were completed uneventfully.
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Affiliation(s)
- Maryam Mehdipour Dalivand
- Pathology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Navitha Woddor
- Pathology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Addisalem Makuria
- Department of Pathology, Brody School of Medicine, Greenville, NC, USA
| | - Anita Aggarwal
- Hematology and Oncology, DC VA Medical Center, Washington, District of Columbia, USA
| | - Victor Eduardo Nava
- Department of the Pathology, George Washington University Medical Faculty Associates, Washington, District of Columbia, USA
- Washington DC VA Medical Center, Washington, District of Columbia, USA
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3
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Rassner M, Jung J, Schneider J, Wäsch R, Engelhardt M. Dapsone-Induced Hemolytic Anemia in Multiple Myeloma: Case Report of Various Differential Diagnoses. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e821-e825. [PMID: 32753123 DOI: 10.1016/j.clml.2020.06.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/22/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Michael Rassner
- Department of Medicine I (Hematology, Oncology, and Stem Cell Transplantation), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Jung
- Department of Medicine I (Hematology, Oncology, and Stem Cell Transplantation), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johanna Schneider
- Department of Medicine IV, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ralph Wäsch
- Department of Medicine I (Hematology, Oncology, and Stem Cell Transplantation), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Monika Engelhardt
- Department of Medicine I (Hematology, Oncology, and Stem Cell Transplantation), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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Khan MS, Kasmani R, Khan G, Changal K, Singh H. A Case of Multiple Myeloma Presenting with Gastrointestinal Bleeding and Evans Syndrome. Cureus 2019; 11:e5969. [PMID: 31777698 PMCID: PMC6867356 DOI: 10.7759/cureus.5969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Autoimmune events are rare in multiple myeloma (MM). Herein, we report a rare case of a patient presenting with recurrent gastrointestinal (GI) bleeding of unknown origin, also having pancytopenia eventually diagnosed as MM with Evans syndrome. This is an uncommon disorder presenting as autoimmune hemolytic anemia (AIHA) with immune thrombocytopenia purpura (ITP). A 56-year-old African American male presenting with recurrent GI bleeds and pancytopenia of unknown origin developed acute colonic diverticulitis on recurrent admissions, and sigmoid colectomy with primary anastomosis was performed. Flow cytometry with serum protein electrophoresis eventually revealed IgG MM with elevated Kappa/Lambda ratio. Bone marrow biopsy revealed 80% to 90% Kappa clonal plasma cells confirming MM. Direct antiglobulin test (DAT) was positive with pancytopenia. The patient initially showed a good response to chemotherapy with thrombocytopenia improving with intravenous (I/V) dexamethasone. DAT done after completion of initial chemotherapy was negative. However, his disease relapsed after three months with pancytopenia and DAT becoming positive again. The patient was restarted on chemotherapy for debulking, which resulted in a negative DAT again after two months, but pancytopenia did not improve. The patient eventually passed away due to subarachnoid hemorrhage. We highlight only this fourth reported case because of its unique presentation. In elderly patients with unknown cause of GI bleeding with pancytopenia, blood dyscrasias, especially MM, should be considered. Autoimmune workup if positive might warrant the use of steroids for pancytopenia, which can improve thrombocytopenia in MM with Evans syndrome but not anemia.
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Affiliation(s)
- Muhammad S Khan
- Internal Medicine, Mercy St. Vincent Medical Center, Toledo, USA
| | - Rahil Kasmani
- Nephrology, Mercy St. Vincent Medical Centre, Toledo, USA
| | - Ghazal Khan
- Internal Medicine, University of Missouri, Kansas City, USA
| | - Khalid Changal
- Cardiology, University of Toledo Medical Centre, Toledo, USA
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Karapetians A, Bajaj T, Valdes A, Heidari A. A Rare Case of Multiple Myeloma Presenting as Evan's Syndrome. J Investig Med High Impact Case Rep 2019; 7:2324709619852760. [PMID: 31195829 PMCID: PMC6573156 DOI: 10.1177/2324709619852760] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Multiple myeloma is defined as the neoplastic proliferation of plasma cells resulting in a monoclonal gammopathy. The classic presentation of a patient is someone who presents with bone pain, osteopenia, or new onset fractures. We present a case of multiple myeloma presenting as Evan’s syndrome (ES). Evan’s syndrome is autoimmune hemolytic anaemia with autoimmune thrombocytopenia. A 44-year-old female was referred from her primary physician to the hospital as laboratory testing revealed haemoglobin of 5 gm/dL. The patient reported a two-month history of fatigue and a sixty-pound weight loss. Laboratory results demonstrated autoimmune hemolytic anaemia, C3 positivity, elevated immunoglobulin (Ig)G, elevated lactate dehydrogenase (LDH), low haptoglobin, elevated reticulocyte count, elevated RDW-CV (red blood cell distribution width-corpuscular volume), positive direct Coombs test, thrombocytopenia, and proteinuria, all of which led to an underlying ES. The patient was started on intravenous steroids followed by oral steroids. A flow cytometry, serum protein electrophoresis, and cytogenetics were obtained. A bone marrow biopsy revealed multiple myeloma and she was started on Bortezomib treatment. We present the fifth reported case of Evan’s syndrome and multiple myeloma.
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Affiliation(s)
| | | | - Amanda Valdes
- 1 UCLA-Kern Medical, Bakersfield, CA, USA.,2 Ross University, Miramar, FL, USA
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Al-Ammari M, Adam S. Concomitant multiple myeloma, gastric adenocarcinoma and Evan's syndrome in a patient presenting with anaemia. BMJ Case Rep 2016; 2016:bcr-2016-217697. [PMID: 27979847 DOI: 10.1136/bcr-2016-217697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
An association between multiple myeloma (MM) and solid tumours has been previously described.1 Furthermore, autoimmune disorders can precede plasma cell dyscrasias, and the pathogenesis of MM maybe linked to chronic immune stimulation. 2 We describe a case of concomitant MM and gastric adenocarcinoma preceded by Evan's syndrome. A previously healthy woman presented to the emergency room with symptomatic anaemia. Her initial workup was compatible with autoimmune haemolytic anaemia and monoclonal gammopathy of undetermined significance. On progression of the anaemia and development of thrombocytopenia, she was diagnosed with Evan's syndrome. Two months later, she presented with severe back pain and her MRI revealed L4-5 vertebral collapse. The clinical picture was compatible with MM. Occult blood was repeatedly positive in stools, and she underwent oesophagogastroduodenoscopy and was found to have gastric adenocarcinoma. The patient refused surgical resection of the adenocarcinoma and refused active treatment for MM.
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Affiliation(s)
- Maged Al-Ammari
- Department of Medicine, Dr Soliman Fakeeh Hospital, Jeddah, Makkah, Saudi Arabia
| | - Soheir Adam
- Department of Internal Medicine, Division of Hematology, Duke University, Durham, North Carolina, USA.,Department of Hematology, King Abdulaziz University, Jeddah, Makkah, Saudi Arabia
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Bechir A, Haifa R, Nesrine BS, Emna B, Senda M, Asma A, Amina BB, Mrabet S, Yosra BY, Mondher K, Abderrahim K. Multiple myeloma associated with an Evan's syndrome. Pan Afr Med J 2016; 25:127. [PMID: 28292089 PMCID: PMC5325491 DOI: 10.11604/pamj.2016.25.127.10750] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 10/17/2016] [Indexed: 01/31/2023] Open
Abstract
Auto-immun events are rare in multiple myeloma (MM). Here, we report one MM case complicated by Evans syndrome (Autoimmun hemolytic anemia (AIHA) associated with thrombocytopenia). A 52-year-old man was admitted in nephrology department with severe anemia, renal insufficiency and hypergamma globulinemia. Laboratory exams showed acute hemolysis due to an IgG warm autoantibody. Serum electrophoresis revealed the presence of a monoclonal IgG protein and urinary M protein was 2g/day. A whole body CT-Scan showed osteolytic lesions of vertebral body of C5, D4, L3, L4 and the left iliac wing. The diagnosis of multiple myeloma and Evan's syndrome was made, we underwent chemotherapy by BTD (bortezomib-thalidomide-dexamethasone) and continuous corticosteroid therapy but unfortunately the patient died secondary of a Lactic acidosis. The relationship between MM and hemolysis remain unclear.
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Affiliation(s)
- Achour Bechir
- Department of Hematology, Farhat Hached Hospital, Sousse Tunisia
| | - Regaieg Haifa
- Department of Hematology, Farhat Hached Hospital, Sousse Tunisia
| | | | - Bouslema Emna
- Department of Hematology, Farhat Hached Hospital, Sousse Tunisia
| | - Mejdoub Senda
- Department of Radiology, Farhat Hached Hospital, Sousse Tunisia
| | - Achour Asma
- Department of Radiology, Farhat Hached Hospital, Sousse Tunisia
| | | | - Senda Mrabet
- Departement of Nephrology, Sahloul Hospital, Sousse Tunisia
| | | | - Kortas Mondher
- Laboratory of biologic Hematology, Farhat Hached Hospital, Sousse Tunisia
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Shimanovsky A, Alvarez Argote J, Murali S, Dasanu CA. Autoimmune manifestations in patients with multiple myeloma and monoclonal gammopathy of undetermined significance. BBA CLINICAL 2016; 6:12-8. [PMID: 27331023 PMCID: PMC4900299 DOI: 10.1016/j.bbacli.2016.05.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 05/15/2016] [Accepted: 05/23/2016] [Indexed: 12/20/2022]
Abstract
Background Multiple myeloma (MM) and its precursor, monoclonal gammopathy of undetermined significance (MGUS), have been linked with several autoimmune conditions in the medical literature. Yet, significance of these associations is not well understood. Methods Herein, we provide a comprehensive literature review on autoimmune disorders identified in patients with MM and MGUS. Most relevant papers were identified via searching the PubMed/Medline and EMBASE databases for articles published from inception until May 1, 2016. Findings Scientific literature on autoimmune conditions in patients with MM and MGUS consists of several case series and a multitude of case reports. Our analysis suggests an increased prevalence of autoimmune conditions in patients with MM and monoclonal gammopathy of undetermined significance (MGUS), including various autoimmune hematologic and rheumatologic conditions among other entities. Conversely, persons with various autoimmune conditions tend to have a higher prevalence of MGUS and MM than the general population. Conclusions Future research is required to explore further the link between MGUS/MM and autoimmune disorders. Inflammation in the setting of autoimmunity may serve as a trigger for MGUS and MM. In addition, a common genetic susceptibility for developing both an autoimmune disease and MM/MGUS might also exist. Autoimmune hematologic and rheumatologic diseases may pose important clinical problems for the MM patients. Therefore, a catalogue of these problems is important so that physicians are able to consider, identify and address them promptly. A comprehensive review linking MM and MGUS with autoimmune disorders There is increased prevalence of autoimmune conditions in patients with MM and MGUS Most autoimmune disorders precede the development of plasma cell dyscrasias
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Affiliation(s)
- Alexei Shimanovsky
- Department of Hematology and Oncology, University of Connecticut Health Science Center, Farmington, CT, USA
| | - Juliana Alvarez Argote
- Department of Medicine, University of Connecticut Health Science Center, Farmington, CT, USA
| | - Shruti Murali
- Department of Medicine, University of Connecticut Health Science Center, Farmington, CT, USA
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Kashyap R, Singh A, Kumar P. Prevalence of autoimmune hemolytic anemia in multiple myeloma: A prospective study. Asia Pac J Clin Oncol 2014; 12:e319-22. [PMID: 25244430 DOI: 10.1111/ajco.12230] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2014] [Indexed: 11/27/2022]
Abstract
AIM Autoimmune hemolytic anemia (AIHA) is frequently associated with B-cell lymphoproliferative disorders, and patients rarely develop overt clinical manifestations of AIHA. AIHA is rare in patients with multiple myeloma (MM). We conducted a prospective study to detect the presence of AIHA in MM patients and its impact on clinical presentation and outcome of the disease. METHODS Sixty-six patients were diagnosed to have MM. Seventeen of these patients who had severe anemia (hemoglobin < 6 g/dL) requiring frequent blood transfusions with or without features of hemolysis were screened for AIHA by performing direct and indirect antiglobulin (Coombs') test. RESULTS Seven (10.6%) of these 17 patients were found to be complicated with AIHA and carried autoantibodies in their sera. Five patients had de novo MM and two had relapsed MM. Six patients (85.7%) had stage IIIA disease and one (14.3%) had stage IIIB disease. The IgG subclass of the antibody binding to red cell membrane was compared with that of M-protein and these findings showed full correlation in all the seven patients. All of these patients were positive for subtypes of IgG and one patient had simultaneous positivity for IgA and IgG2, with presence of cold antibodies in the serum. Patients with primary disease showed remission of AIHA with therapy, whereas both the patients with relapsed disease showed no response to treatment and remained positive for antiglobulin test. CONCLUSION AIHA should be suspected in MM patients with severe anemia requiring frequent blood transfusions.
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Affiliation(s)
- Rajesh Kashyap
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Abhay Singh
- Department of Transfusion Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Pradeep Kumar
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Multiple myeloma presenting with autoimmune hemolytic anemia. Indian J Hematol Blood Transfus 2013; 30:38-9. [PMID: 25332530 DOI: 10.1007/s12288-013-0232-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 01/21/2013] [Indexed: 10/27/2022] Open
Abstract
Autoimmune hemolysis is rare in multiple myeloma. We describe a rare case of multiple myeloma who presented with autoimmune hemolytic anemia at initial presentation.
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Baek SW, Lee MW, Ryu HW, Lee KS, Song IC, Lee HJ, Yun HJ, Kim S, Jo DY. Clinical features and outcomes of autoimmune hemolytic anemia: a retrospective analysis of 32 cases. THE KOREAN JOURNAL OF HEMATOLOGY 2011; 46:111-7. [PMID: 21747883 PMCID: PMC3128891 DOI: 10.5045/kjh.2011.46.2.111] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Revised: 06/13/2011] [Accepted: 06/13/2011] [Indexed: 11/25/2022]
Abstract
Background There has been no report on the clinical features or natural history of autoimmune hemolytic anemia (AIHA) in the Korean adult population. This study retrospectively analyzed the clinical characteristics and long-term outcomes of AIHA in the Korean adults. Methods Patients newly diagnosed with AIHA between January 1994 and December 2010 at Chungnam National University Hospital were enrolled. Patient characteristics at diagnosis, response to treatment, and the natural course of the disease were documented. Results Thirty-two patients (31 females and 1 male) with a median age of 48 years (range, 17-86) were enrolled. Of these, 21.9% were initially diagnosed with secondary AIHA. Thirteen patients (40.6%) were initially diagnosed with Evans' syndrome. Of the 29 patients who were placed on therapy, 27 (93.1%) showed a partial response or better. Nevertheless, 1 year after initiating treatment, 80% of the patients were still treatment-dependent. During follow-up (median length 14 months; range, 0.5-238), 14 of 25 patients (56.0%) who were initially diagnosed with primary warm antibody AIHA were found to have systemic lupus erythematosus (SLE). Median time to conversion to SLE was 8.0 months (95% CI, 4.3-11.7), and the probabilities of conversion at 12 and 24 months were 63% and 91%, respectively. Younger age (<60 years) and a positive fluorescent anti-nuclear antibody test were associated with a higher probability of SLE conversion (P=0.01 and P<0.001, respectively). Conclusion Primary AIHA is rare. Regular, vigilant testing for SLE is required in patients initially diagnosed with AIHA.
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Affiliation(s)
- Seung-Woo Baek
- Department of Internal Medicine, School of Medicine, Chungnam National University, Daejeon, Korea
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