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Rare Presentation of Atypical Hemolytic Uremic Syndrome in a Child With Acute Lymphocytic Leukemia and Pancreatitis. J Pediatr Hematol Oncol 2022; 44:412-414. [PMID: 35180765 DOI: 10.1097/mph.0000000000002409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/20/2021] [Indexed: 11/25/2022]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is associated with significant mortality and morbidity, including acute renal injury, anemia and thrombocytopenia. Rare cases of aHUS in a child with acute leukemia before diagnosis or during chemotherapy have been reported. We report a pediatric case of B-cell acute lymphoblastic leukemia complicated by pancreatitis with concomitant aHUS following induction chemotherapy.
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Lee FSW, Lee CY, Hung GY, Tseng MH, Wang HH, Yen HJ. Recurrent microangiopathic hemolysis after recovery from complement-mediated hemolytic uremia syndrome during chemotherapy for a CFH-mutated patient with T-lymphoblastic lymphoma. Int J Hematol 2022; 116:812-818. [PMID: 35790695 DOI: 10.1007/s12185-022-03409-6] [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] [Received: 01/15/2022] [Revised: 06/13/2022] [Accepted: 06/13/2022] [Indexed: 11/25/2022]
Abstract
Complement-mediated hemolytic uremic syndrome (CM-HUS) following chemotherapy for pediatric acute lymphoid neoplasms has rarely been reported. We report the case of an 8-year-old boy with T-lymphoblastic lymphoma (T-LBL) who developed CM-HUS with complement factor H (CFH) mutations (S1191L, V1197A) during induction therapy. Safe administration of chemotherapy after CM-HUS recovery was challenging. By closely monitoring hemolytic and renal parameters during the 2-year treatment period, we observed four episodes of microangiopathic hemolytic anemia (MAHA) with hypocomplementemia and low haptoglobin but no renal dysfunction or thrombocytopenia. Here, we describe the MAHA and CM-HUS episodes in the hopes of elucidating the complex pathophysiology of disorders associated with CFH mutation.
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Affiliation(s)
- Fu-Shiuan Whitney Lee
- Department of Pediatrics, Taipei Veterans General Hospital, and National Yang Ming Chiao Tung University School of Medicine, Peitou District, NO. 201, Shih-Pai Rd Sec 2, Taipei, 112, Taiwan, ROC
| | - Chih-Ying Lee
- Department of Pediatrics, Taipei Veterans General Hospital, and National Yang Ming Chiao Tung University School of Medicine, Peitou District, NO. 201, Shih-Pai Rd Sec 2, Taipei, 112, Taiwan, ROC
- Department of Life Science, National Taiwan Normal University, Taipei, Taiwan, ROC
| | - Giun-Yi Hung
- Department of Pediatrics, Taipei Veterans General Hospital, and National Yang Ming Chiao Tung University School of Medicine, Peitou District, NO. 201, Shih-Pai Rd Sec 2, Taipei, 112, Taiwan, ROC
- Department of Life Science, National Taiwan Normal University, Taipei, Taiwan, ROC
| | - Min-Hua Tseng
- Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Hsin-Hui Wang
- Department of Pediatrics, Taipei Veterans General Hospital, and National Yang Ming Chiao Tung University School of Medicine, Peitou District, NO. 201, Shih-Pai Rd Sec 2, Taipei, 112, Taiwan, ROC
| | - Hsiu-Ju Yen
- Department of Pediatrics, Taipei Veterans General Hospital, and National Yang Ming Chiao Tung University School of Medicine, Peitou District, NO. 201, Shih-Pai Rd Sec 2, Taipei, 112, Taiwan, ROC.
- Department of Life Science, National Taiwan Normal University, Taipei, Taiwan, ROC.
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Turudic D, Milosevic D, Bilic K, Prohászka Z, Bilic E. A Limited Course of Eculizumab in a Child with the Atypical Hemolytic Uremic Syndrome and Pre-B Acute Lymphoblastic Leukemia on Maintenance Therapy: Case Report and Literature Review. J Clin Med 2022; 11:jcm11102779. [PMID: 35628906 PMCID: PMC9142928 DOI: 10.3390/jcm11102779] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/25/2022] [Accepted: 05/10/2022] [Indexed: 02/06/2023] Open
Abstract
Acute lymphoblastic leukemia (ALL) is considered a possible risk for the occurrence of thrombotic microangiopathies. We present a girl with pre-B ALL successfully treated according to the BFM ALL IC-2009 protocol on maintenance therapy followed by aHUS occurrence. This is the seventh case of HUS/aHUS on ALL maintenance therapy and the first with clearly documented eculizumab use in the early stage of aHUS/secondary TMA. Standard and additional parameters were used in aHUS monitoring alongside the reticulocyte production index adjusted for age (RPI/A) and the aspartate aminotransferase-to-platelet ratio index (APRI) as markers of hemolysis and rapid response following treatment. RPI/A and APRI are markers of bone marrow response to anemia serving as red blood cell vs. platelet recovery markers. Together they mark the exact recovery point of thrombotic microangiopathy and serve as a prognostic marker of eculizumab treatment success. During the 8-month treatment and 6-month follow-up, no recurrence of hemolysis, ALL relapse, or renal damage were observed. A systematic review of the literature revealed 14/312 articles; five children had aHUS before the onset of ALL, and two children had both diseases concurrently. At least 3/7 patients are attributed to aHUS, of whom 2/7 have renal damage. Potential undiagnosed/unpublished cases may be assumed.
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Affiliation(s)
- Daniel Turudic
- Department of Pediatric Hematology and Oncology, University Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, Croatia; (D.T.); (E.B.)
| | - Danko Milosevic
- School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia;
- Department of Pediatrics, General Hospital Zabok and Hospital of Croatian Veterans, Bracak 8, 49210 Bracak, Croatia
- Correspondence:
| | - Katarina Bilic
- School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia;
| | - Zoltán Prohászka
- Department of Internal Medicine and Haematology, Semmelweis University, 1085 Budapest, Hungary;
- Research Group for Immunology and Haematology, Semmelweis University, 1085 Budapest, Hungary
| | - Ernest Bilic
- Department of Pediatric Hematology and Oncology, University Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, Croatia; (D.T.); (E.B.)
- School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia;
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Ahlawat P, Gupta M, Upadhyay P, Gupta S, Kaur A. Gemcitabine-Induced Hemolytic Uremic Syndrome in Lung Cancer: A Case Report. Cureus 2022; 14:e20926. [PMID: 35145816 PMCID: PMC8812056 DOI: 10.7759/cureus.20926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 11/20/2022] Open
Abstract
Gemcitabine is a broad-spectrum anti-metabolite drug that is widely used in the therapy of numerous advanced cancers such as pancreatic, breast, ovary, lung, and bladder cancer. Gemcitabine has been reported to cause hemolytic uremic syndrome (HUS), but the underlying mechanism is not elucidated. The outcome of gemcitabine-induced HUS is often poor and associated with high mortality. We present a case report of a patient who was on chemotherapy for lung cancer and presented with the concerns of decreased urine output and shortness of breath. He was investigated and found to have HUS. He was managed with plasmapheresis, which resulted in partial recovery. This case report describes HUS caused by gemcitabine in patients with lung carcinoma and the management implemented and also aims to highlight the importance of early and timely recognition and treatment to improve clinical outcomes in these patients.
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Mantri S, Kendre G, Patil V, S C, Hilalpure S, Goyanka S, Toshniwal A, Jijina F. A case of atypical HUS during maintenance phase of acute lymphoblastic leukemia: A stitch in time saves nine. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2019. [DOI: 10.1016/j.phoj.2019.08.179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Recurrent Atypical Hemolytic Uremic Syndrome in Children With Acute Lymphoblastic Leukemia Undergoing Maintenance Chemotherapy. J Pediatr Hematol Oncol 2018; 40:560-562. [PMID: 28991131 DOI: 10.1097/mph.0000000000000987] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Chemotherapy-associated myelosuppression and renal dysfunction is not uncommon during childhood acute lymphoblastic leukemia (ALL) therapy. Here we report 2 cases of atypical hemolytic uremic syndrome (aHUS) presenting with pancytopenia and renal dysfunction that developed during maintenance chemotherapy characterized by hypocomplementemia. Both cases experienced recurrence after resolution of the initial aHUS episode upon resumption of chemotherapy, raising a possible contributory role for chemotherapy in the disease pathogenesis.
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Iardino A, Bunin V, Truong LD, Preti HA. Complement activation: an atypical presentation of an atypical syndrome. BMJ Case Rep 2017; 2017:bcr-2017-221798. [PMID: 29084740 DOI: 10.1136/bcr-2017-221798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 42-year-old Hispanic female and long-distance runner was seen for evaluation of fatigue. Her physical examination showed petechiae and ecchymoses in upper extremities, abdominal distension and bilateral ankle oedema. Laboratory workup revealed anaemia, thrombocytopenia, hypoalbuminemia and proteinuria of 1.4 g/24 hours. No schistocytes were found on peripheral blood smear. CT of her abdomen revealed diffuse small lymphadenopathy and hepatomegaly. Bone marrow biopsy demonstrated normal trilineage hematopoiesis with no hemophagocytosis. The patient was started on oral prednisone with no improvement and was subsequently admitted to the hospital for pulsed steroids, intravenous immunoglobulin and rituximab. Her proteinuria became nephrotic range, and a renal biopsy revealed features of thrombotic microangiopathy limited to the glomerular capillaries. ADAMTS13 was low which is >10% of normal, and a diagnosis of atypical haemolytic-uraemic syndrome (aHUS) was made. Eculizumab was started with prompt response. Whole exome sequencing demonstrated mutation in SPTA1, which has been associated with red blood cell membrane diseases but has not been described in patients with aHUS.
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Affiliation(s)
- Alfredo Iardino
- Internal Medicine, Texas Tech University at the Permian Basin, Odessa, Texas, USA
| | - Viviane Bunin
- Rheumatology, Houston Methodist Hospital, Houston, Texas, USA
| | - Luan D Truong
- Department of Pathology, Houston Methodist Hospital, Houston, Texas, USA
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Nanjappa S, Singh V, Uttamchandani S, Pabbathi S. Thrombotic Microangiopathy in a Patient Treated With Gemcitabine. Cancer Control 2017; 24:54-56. [PMID: 28178713 DOI: 10.1177/107327481702400108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Thrombotic microangiopathy syndromes consist of a collection of disorders with a varied etiology that share common clinical and pathological features. Although thrombotic microangiopathy is rare, it is associated with significant morbidity and mortality. Without early recognition and intervention, the prognosis of the disease is poor. This report illustrates the case of a 56-year-old man with advanced-stage metastatic pancreatic cancer who presented with hemolytic uremic syndrome associated with gemcitabine use. His condition was managed with eculizumab, a monoclonal antibody, although he was dependent on dialysis. This report reflects the importance of considering thrombotic microangiopathy syndromes in the differential diagnosis, because many malignancies and use of chemotherapeutic agents can trigger hemolytic uremic syndrome.
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Affiliation(s)
- Sowmya Nanjappa
- Department of Internal Hospital Medicine, Moffitt Cancer Center and University of South Florida Morsani College of Medicine, Tampa, FL.
| | | | | | - Smitha Pabbathi
- Department of Internal Hospital Medicine, Moffitt Cancer Center, Tampa, FL
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Clarke RT, Mitchell C. Haemolytic uraemic syndrome in a patient with acute lymphoblastic leukaemia. Pediatr Blood Cancer 2010; 55:1402-5. [PMID: 20734402 DOI: 10.1002/pbc.22707] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We describe a patient diagnosed with haemolytic uraemic syndrome (HUS) during long-term maintenance therapy for childhood acute lymphoblastic leukaemia (ALL). He rapidly developed renal failure, hypertension and profound thrombocytopenia. Despite suffering a large intracerebral haemorrhage, he made a full recovery without residual neurological or renal deficit. His case raises the question of whether ALL or its treatments predispose an individual to developing HUS.
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Affiliation(s)
- Rachel T Clarke
- Department of Paediatric Haematology/Oncology, John Radcliffe Hospital, Oxford, UK.
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Sinha R, AlAbbas A, Dionne JM, Hurley RM. Simultaneous occurrence of atypical hemolytic uremic syndrome and acute lymphoblastic leukemia: a case report and literature review. Pediatr Nephrol 2008; 23:835-9. [PMID: 18188608 DOI: 10.1007/s00467-007-0703-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2007] [Revised: 10/12/2007] [Accepted: 11/02/2007] [Indexed: 10/22/2022]
Abstract
A 3.5-year-old girl with fever had a pancytopenic blood smear that also showed schistocytes and blast cells. Bone marrow examination resulted in a diagnosis of acute lymphoblastic leukemia (ALL). Although creatinine on admission was normal, she had mild hematuria and moderate proteinuria. Chemotherapy was started, but she was initially given only steroids (dexamethasone) due to high liver enzymes. Her renal parameters worsened, and her creatinine doubled. She also developed nephrotic-range proteinuria and hypertension. Renal biopsy showed thrombotic microangiopathy that was clinically consistent with hemolytic uremic syndrome (HUS). Some reports of HUS preceding ALL do exist. However, to the best of our knowledge, this is the first case that describes ALL and HUS presenting simultaneously.
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Affiliation(s)
- Rajiv Sinha
- Department of Pediatrics, Division of Nephrology, British Columbia's Children's Hospital, 4480 Oak Street, Vancouver, BC, Canada.
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Abstract
PURPOSE OF REVIEW The hemolytic uremic syndrome (HUS) is the most common cause of acute renal failure in infants and young children, and is a substantial cause of acute mortality and chronic morbidity. It is therefore relevant and appropriate that pediatricians remain familiar with the various subsets of the disease including its classification, management, and outcome. RECENT FINDINGS This review will focus on recent information relative to epidemiology, pathogenesis, treatment, and outcome. It will include some of the newer associations between HUS and a variety of infections, including, but not limited to E. coli 0157:H7 (Shiga toxin-mediated) HUS, as well as the ever-increasing number of associations between HUS and a variety of drugs. It will review some of the newer therapies for the more common subsets, but will acknowledge that choosing evidence-based therapies is often limited by our incomplete understanding of the various pathogenic cascades, and that with the possible exception of Shiga toxin-mediated HUS(D+HUS), long-term outcome information is often limited by small numbers and limited follow-up. SUMMARY This review should provide a framework for making the proper diagnosis, implementing appropriate treatment, and advising the family about anticipated outcome.
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Affiliation(s)
- Richard Siegler
- Department of Pediatrics, Division of Nephrology, University of Utah School of Medicine, East Salt Lake City, Utah, USA.
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