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Le Coz C, Trofa M, Butler DL, Yoon S, Tian T, Reid W, Cruz Cabrera E, Knox AVC, Khanna C, Sullivan KE, Heimall J, Takach P, Fadugba OO, Lawrence M, Jyonouchi S, Hakonarson H, Wells AD, Handler S, Zur KB, Pillai V, Gildersleeve JC, Romberg N. The common variable immunodeficiency IgM repertoire narrowly recognizes erythrocyte and platelet glycans. J Allergy Clin Immunol 2024; 154:778-791.e9. [PMID: 38692308 PMCID: PMC11380600 DOI: 10.1016/j.jaci.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 04/10/2024] [Accepted: 04/16/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Autoimmune cytopenias (AICs) regularly occur in profoundly IgG-deficient patients with common variable immunodeficiency (CVID). The isotypes, antigenic targets, and origin(s) of their disease-causing autoantibodies are unclear. OBJECTIVE We sought to determine reactivity, clonality, and provenance of AIC-associated IgM autoantibodies in patients with CVID. METHODS We used glycan arrays, patient erythrocytes, and platelets to determine targets of CVID IgM autoantibodies. Glycan-binding profiles were used to identify autoreactive clones across B-cell subsets, specifically circulating marginal zone (MZ) B cells, for sorting and IGH sequencing. The locations, transcriptomes, and responses of tonsillar MZ B cells to different TH- cell subsets were determined by confocal microscopy, RNA-sequencing, and cocultures, respectively. RESULTS Autoreactive IgM coated erythrocytes and platelets from many CVID patients with AICs (CVID+AIC). On glycan arrays, CVID+AIC plasma IgM narrowly recognized erythrocytic i antigens and platelet i-related antigens and failed to bind hundreds of pathogen- and tumor-associated carbohydrates. Polyclonal i antigen-recognizing B-cell receptors were highly enriched among CVID+AIC circulating MZ B cells. Within tonsillar tissues, MZ B cells secreted copious IgM when activated by the combination of IL-10 and IL-21 or when cultured with IL-10/IL-21-secreting FOXP3-CD25hi T follicular helper (Tfh) cells. In lymph nodes from immunocompetent controls, MZ B cells, plentiful FOXP3+ regulatory T cells, and rare FOXP3-CD25+ cells that represented likely CD25hi Tfh cells all localized outside of germinal centers. In CVID+AIC lymph nodes, cellular positions were similar but CD25hi Tfh cells greatly outnumbered regulatory cells. CONCLUSIONS Our findings indicate that glycan-reactive IgM autoantibodies produced outside of germinal centers may contribute to the autoimmune pathogenesis of CVID.
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Affiliation(s)
- Carole Le Coz
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa; Infinity, Toulouse Institute for Infectious and Inflammatory Diseases, University of Toulouse, CNRS, Inserm, Toulouse, France
| | - Melissa Trofa
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Dorothy L Butler
- Chemical Biology Laboratory, Center for Cancer Research, National Cancer Institute, Frederick, Md
| | - Samuel Yoon
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Tian Tian
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Whitney Reid
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Emylette Cruz Cabrera
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Ainsley V C Knox
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Caroline Khanna
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Kathleen E Sullivan
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine, Philadelphia, Pa; Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Jennifer Heimall
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine, Philadelphia, Pa
| | - Patricia Takach
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Perelman School of Medicine, Philadelphia, Pa
| | - Olajumoke O Fadugba
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Perelman School of Medicine, Philadelphia, Pa
| | - Monica Lawrence
- Division of Asthma, Allergy and Immunology, Department of Medicine, University of Virginia, Charlottesville, Va
| | - Soma Jyonouchi
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine, Philadelphia, Pa
| | - Hakon Hakonarson
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, Pa; Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Andrew D Wells
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Center for Spatial and Functional Genomics, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Steven Handler
- Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Karen B Zur
- Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Vinodh Pillai
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pa; Division of Hematopathology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Jeffrey C Gildersleeve
- Chemical Biology Laboratory, Center for Cancer Research, National Cancer Institute, Frederick, Md
| | - Neil Romberg
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine, Philadelphia, Pa; Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
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2
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Fattizzo B, Marchetti M, Michel M, Cantoni S, Frederiksen H, Giordano G, Glenthøj A, González-López TJ, Murakhovskaya I, Napolitano M, Mingot ME, Arguello M, Patriarca A, Raso S, Vianelli N, Barcellini W. Diagnosis and management of Evans syndrome in adults: first consensus recommendations. Lancet Haematol 2024; 11:e617-e628. [PMID: 38968944 DOI: 10.1016/s2352-3026(24)00144-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/13/2024] [Accepted: 05/09/2024] [Indexed: 07/07/2024]
Abstract
Evans syndrome is a rare disease marked by a severe clinical course, high relapse rate, infectious and thrombotic complications, and sometimes fatal outcome. Management is highly heterogeneous. There are several case reports but few large retrospective studies and no prospective or randomised trials. Here, we report the results of the first consensus-based expert recommendations aimed at harmonising the diagnosis and management of Evans syndrome in adults. After reviewing the literature, we used a fuzzy Delphi consensus method, with two rounds of a 42-item questionnaire that were scored by a panel of 13 international experts from five countries using a 7-point Likert scale. Panellists were selected by the core panel on the basis of their personal experience and previous publications on Evans syndrome and immune cytopenias; they met virtually throughout 2023. The panellists recommended extensive clinical and laboratory diagnostic tests, including bone marrow evaluation and CT scan, and an aggressive front-line therapy with prednisone (with or without intravenous immunoglobulins), with different treatment durations and tapering for immune thrombocytopenia and autoimmune haemolytic anaemias (AIHAs). Rituximab was strongly recommended as first-line treatment in cold-type AIHA and as second-line treatment in warm-type AIHA and patients with immune thrombocytopenia and antiphospholipid antibodies, previous thrombotic events, or associated lymphoproliferative diseases. However, rituximab was discouraged for patients with immunodeficiency or severe infections, with the same applying to splenectomy. Thrombopoietin receptor agonists were recommended for chronic immune thrombocytopenia and in the case of previous grade 4 infection. Fostamatinib was recommended as third-line or further-line treatment and suggested as second-line therapy for patients with previous thrombotic events. Immunosuppressive agents have been moved to third-line or further-line treatment. The panellists recommended the use of recombinant erythropoietin in AIHA in the case of inadequate reticulocyte counts, use of the complement inhibitor sutimlimab for relapsed cold AIHA, and the combination of rituximab plus bendamustine in Evans syndrome secondary to lymphoproliferative disorders. Finally, recommendations were given for supportive therapy, platelet or red blood cell transfusions, and thrombotic and antibiotic prophylaxis. These consensus-based recommendations should facilitate best practice for diagnosis and management of Evans syndrome in clinical practice.
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Affiliation(s)
- Bruno Fattizzo
- Hematology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Oncology and Hematology-Oncology, University of Milan, Milan, Italy.
| | - Monia Marchetti
- Ematologia, Azienda Ospedaliera di Alessandria, Alessandria, Italy
| | - Marc Michel
- Centre de Référence Maladies Rares sur les Cytopénies Auto-Immunes de l'Adulte, Centre Hospitalier Universitaire Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil Université Paris-Est Créteil, Paris, France
| | - Silvia Cantoni
- Dipartimento di Ematologia e Oncologia, Niguarda Cancer Center, Azienda Socio Sanitaria Territoriale Ospedale Niguarda, Milan, Italy
| | | | - Giulio Giordano
- Unità Operativa Complessa, Medicina Servizio e Ambulatorio di Ematologia Ospedale di Riferimento Regionale Antonio Cardarelli, Campobasso, Italy
| | - Andreas Glenthøj
- Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Irina Murakhovskaya
- Department of Hematology and Oncology, Albert Einstein College of Medicine, Montefiore Medical Center, New York, NY, USA
| | - Mariasanta Napolitano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Maria-Eva Mingot
- Servicio de Hematologia y Hemoterapia, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, Sevilla, Spain
| | - Maria Arguello
- Hospital Universitario Principe de Asturias, Madrid, Spain
| | - Andrea Patriarca
- Department of Translational Medicine, Azienda Ospedaliera-Universitaria Maggiore della Carità, University of Eastern Piedmont, Novara, Italy
| | - Simona Raso
- Department of Hematology and Rare Diseases, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Nicola Vianelli
- Institute of Hematology L e A Seragnoli, University of Bologna, Bologna, Italy
| | - Wilma Barcellini
- Hematology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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3
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Nam HJ, Kim SY, Byeon JY, Choi HJ. Extremely Rare Case of Successful Treatment of Foot Ulcer Associated with Evans' Syndrome and Buerger's Disease. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1147. [PMID: 39064576 PMCID: PMC11279098 DOI: 10.3390/medicina60071147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 07/09/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024]
Abstract
Evans Syndrome (ES) is a rare autoimmune disorder characterized by the simultaneous occurrence of immune thrombocytopenia (ITP) and autoimmune hemolytic anemia (AIHA). Thrombotic complications in ES patients are uncommon, particularly involving Buerger's Disease (BD). We report a case of a 49-year-old male with ES and a history of diabetes and heavy smoking, presenting with a necrotic wound on his right great toe. Diagnostic evaluations revealed severe stenosis and thrombosis in the lower limb arteries, diagnosed as BD. The patient underwent successful popliteal-tibioperoneal artery bypass surgery and the subsequent disarticulation and revision of the distal phalanx, followed by the application of an acellular dermal matrix (ADM) to promote healing. Post-surgery, the patient showed significant improvement in blood flow and complete epithelialization without complications. This case highlights the importance of a multidisciplinary approach to managing complex wounds in ES patients, suggesting potential treatment pathways for future cases involving BD.
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Affiliation(s)
- Ha-Jong Nam
- Department of Plastic and Reconstructive Surgery, Soonchunhyang University Gumi Hospital, Gumi 39371, Republic of Korea; (H.-J.N.); (S.-Y.K.)
| | - Se-Young Kim
- Department of Plastic and Reconstructive Surgery, Soonchunhyang University Gumi Hospital, Gumi 39371, Republic of Korea; (H.-J.N.); (S.-Y.K.)
| | - Je-Yeon Byeon
- Department of Plastic and Reconstructive Surgery, Soonchunhyang University Cheonan Hospital, Cheonan 31538, Republic of Korea;
| | - Hwan-Jun Choi
- Department of Plastic and Reconstructive Surgery, Soonchunhyang University Cheonan Hospital, Cheonan 31538, Republic of Korea;
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4
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van Wijk XMR, Sanchez Oviol Z, Winter WE, Harris NS, Marin MJ. An Introduction to the Complete Blood Count for Clinical Chemists: Platelets. J Appl Lab Med 2024; 9:833-847. [PMID: 38549553 DOI: 10.1093/jalm/jfae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/12/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND The most ordered laboratory test worldwide is the complete blood count (CBC). CONTENT In this primer, an introduction to platelet testing in the context of the CBC is provided with a discussion of the laboratory evaluation of platelet abnormalities including thrombocytopenia and thrombocytosis. SUMMARY As clinical chemists continue to be tasked to direct laboratories outside of the traditional clinical chemistry sections such as hematology, expertise must be developed. This primer is dedicated to that effort.
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Affiliation(s)
| | - Zaraith Sanchez Oviol
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL, United States
| | - William E Winter
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL, United States
| | - Neil S Harris
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL, United States
| | - Maximo J Marin
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL, United States
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5
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Fattizzo B, Carrai V, Crugnola M, Baldacci E, Bellini M, Bosi C, Buzzatti E, Caramazza D, Carli G, Carpenedo M, Clissa C, Danesin C, De Paolis MR, Giannotta JA, Innao V, Marchetti M, Markovic U, Morotti A, Napolitano M, Patriarca A, Pettine L, Poloni A, Rivolti E, Rossi E, Santeremo TM, Santoro C, Zannier ME, Zaja F, Cantoni S, Palandri F, De Stefano V. Evans syndrome: Disease awareness and clinical management in a nation-wide ITP-NET survey. Eur J Haematol 2024. [PMID: 39031658 DOI: 10.1111/ejh.14256] [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: 04/10/2024] [Revised: 05/24/2024] [Accepted: 06/04/2024] [Indexed: 07/22/2024]
Abstract
Evans syndrome (ES) is rare and mostly treated on a "case-by-case" basis and no guidelines are available. With the aim of assessing disease awareness and current management of adult ES, a structured survey was administered to 64 clinicians from 50 Italian participating centers. Clinicians had to be involved in the management of autoimmune cytopenias and were enrolled into the ITP-NET initiative. The survey included domains on epidemiology, diagnosis, and therapy of ES and was designed to capture current practice and suggested work-up and management. Thirty clinicians who had followed a median of 5 patients (1-45)/15 years responded. The combination of AIHA plus ITP was more common than the ITP/AIHA with neutropenia (p < .001) and 25% of patients had an associated condition, including lymphoproliferative syndromes, autoimmune diseases, or primary immunodeficiencies. The agreement of clinicians for each diagnostic test is depicted (i.e., 100% for blood count and DAT; only 40% for anti-platelets and anti-neutrophils; 77% for bone marrow evaluation). Most clinicians reported that ES requires a specific approach compared to isolated autoimmune cytopenias, due to either a more complex pathogenesis and a higher risk of relapse and thrombotic and infectious complications. The heterogeneity of treatment choices among different physicians suggests the need for broader harmonization.
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Affiliation(s)
- Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Valentina Carrai
- Hematology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Monica Crugnola
- Hematology Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Erminia Baldacci
- Hematology Unit, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Marta Bellini
- Hematology Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Costanza Bosi
- Hematology Unit, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - Elisa Buzzatti
- Hematology Unit, Department of Biomedicine and Prevention, University "Tor Vergata", Rome, Italy
| | - Domenica Caramazza
- Hematology Unit, Hospital "Ospedale di Circolo e Fondazione Macchi", Varese, Italy
| | - Giuseppe Carli
- Hematology Unit, Center for Hemorrhagic and Thrombotic Diseases (CMET), Ospedale San Bortolo, Vicenza, Italy
| | | | - Cristina Clissa
- Hematology Unit, Integrated University Hospital of Verona, Policlinico G.B. Rossi, Verona, Italy
| | | | | | - Juri Alessandro Giannotta
- Internal Medicine, Haemostasis and Thrombosis Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Vanessa Innao
- Hematology Unit, Ospedale Garibaldi-Nesima, ARNAS Garibaldi, Catania, Italy
| | - Monia Marchetti
- Hematology Unit, Azienda Ospedaliero-Universitaria di Alessandria, Alessandria, Italy
| | - Uros Markovic
- Hematology Unit, Azienda Ospedaliero-Universitaria G. Rodolico, San Marco-Catania, Italy
| | - Alessandro Morotti
- Internal Medicine Division-Hematology, Ospedale San Luigi Gonzaga, Orbassano, Turin, Italy
| | - Mariasanta Napolitano
- Hematology Unit with Transplant, Policlinico Universitario Paolo Giaccone, Palermo, Italy
| | - Andrea Patriarca
- Unit of Transplantation and Biocompatibility: Hematopoietic Stem Cell Biology and Transplantation, Ospedale Maggiore della Carità, Novara, Italy
| | - Loredana Pettine
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonella Poloni
- Hematology Clinic, Università Politecnica delle Marche-AOU delle Marche, Ancona, Italy
| | - Elena Rivolti
- Hematology Clinic, CORE Oncology and Hematology Center, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Elena Rossi
- Department of Radiological and Hematological Sciences, Policlinico Universitario Agostino Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Cristina Santoro
- Hematology Unit, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Maria Elena Zannier
- Hematology Clinic, Azienda Sanitaria Universitaria Friuli Centrale ASU FC, Udine, Italy
| | - Francesco Zaja
- DSM (University Clinical Department of Medical, Surgical and Health Sciences), University of Trieste, Trieste, Italy
| | - Silvia Cantoni
- Hematology Unit, Azienda Sanitaria Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Valerio De Stefano
- Department of Radiological and Hematological Sciences, Policlinico Universitario Agostino Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
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Matsuura Y, Tomita T, Kondo M, Mukai M, Kataoka H. Severe Thrombocytopenia Secondary to Systemic Lupus Erythematosus With Antiphospholipid Antibodies in a Middle-Aged Woman. Cureus 2024; 16:e62804. [PMID: 39040719 PMCID: PMC11260694 DOI: 10.7759/cureus.62804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 07/24/2024] Open
Abstract
Thrombocytopenia is a common hematological complication of systemic lupus erythematosus (SLE). However, severe thrombocytopenia is a relatively rare presentation, accounting for only 3-10% of cases. A 52-year-old woman was being treated with 4 mg/day of prednisolone for 12 years for SLE-induced autoimmune hemolytic anemia. She presented to her family physician with nasal bleeding and purpura, which required more than two hours to control. She had bruises on her legs and mild multiple arthralgia. The platelet count was 19,000/µL. She was suspected to have developed immune thrombocytopenia as an exacerbation of SLE. Thus, she was referred to our hospital. Laboratory examination revealed thrombocytopenia, hypocomplementemia, and a positive result for anti-cardiolipin (CL) and anti-β2-glycoprotein (GP) I IgG antibodies. The patient was diagnosed with thrombocytopenic purpura, complicated by SLE. Methylprednisolone pulse therapy, followed by 60 mg/day of prednisolone and 200/400 mg of hydroxychloroquine on alternate days, was initiated. The platelet count increased from 5,000/µl to 50,000/µl, and the immature platelet fraction (IPF) decreased from 14.9% to 6.3%. Anti-CL and anti-β2-GPI IgG antibodies were considered to be associated with thrombocytopenia and a risk of thrombotic events after normalization of her platelet counts. Therefore, aspirin therapy was initiated to prevent thrombosis. As an episode of acute thrombocytopenia occurred without other clinical findings indicating active SLE, it was important to determine the exact cause of thrombocytopenia in this situation. Immediate recovery of thrombocytopenia with high-dose prednisolone reduced the risk of bleeding that could have otherwise been fatal.
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Affiliation(s)
- Yuki Matsuura
- Rheumatology and Clinical Immunology, Sapporo City General Hospital, Sapporo, JPN
| | - Tomoko Tomita
- Rheumatology and Clinical Immunology, Sapporo City General Hospital, Sapporo, JPN
| | - Makoto Kondo
- Rheumatology and Clinical Immunology, Sapporo City General Hospital, Sapporo, JPN
| | - Masaya Mukai
- Rheumatology and Clinical Immunology, Sapporo City General Hospital, Sapporo, JPN
| | - Hiroshi Kataoka
- Rheumatology and Clinical Immunology, Sapporo City General Hospital, Sapporo, JPN
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7
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Abufaraj M, Ramadan R, Alkhatib A. Paraneoplastic Syndromes in Neuroendocrine Prostate Cancer: A Systematic Review. Curr Oncol 2024; 31:1618-1632. [PMID: 38534956 PMCID: PMC10969281 DOI: 10.3390/curroncol31030123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 02/24/2024] [Accepted: 02/26/2024] [Indexed: 05/26/2024] Open
Abstract
Neuroendocrine prostate cancer (NEPC) is a rare subtype of prostate cancer (PCa) that usually results in poor clinical outcomes and may be accompanied by paraneoplastic syndromes (PNS). NEPC is becoming more frequent. It can initially manifest as PNS, complicating diagnosis. Therefore, we reviewed the literature on the different PNS associated with NEPC. We systematically reviewed English-language articles from January 2017 to September 2023, identifying 17 studies meeting PRISMA guidelines for NEPC and associated PNS. A total of 17 articles were included in the review. Among these, Cushing's Syndrome (CS) due to ectopic Adrenocorticotropic hormone (ACTH) secretion was the most commonly reported PNS. Other PNS included syndrome of inappropriate Anti-Diuretic Hormone secretion (SIADH), Anti-Hu-mediated chronic intestinal pseudo-obstruction (CIPO), limbic encephalitis, Evans Syndrome, hypercalcemia, dermatomyositis, and polycythemia. Many patients had a history of prostate adenocarcinoma treated with androgen deprivation therapy (ADT) before neuroendocrine features developed. The mean age was 65.5 years, with a maximum survival of 9 months post-diagnosis. NEPC is becoming an increasingly more common subtype of PCa that can result in various PNS. This makes the diagnosis and treatment of NEPC challenging. Further research is crucial to understanding these syndromes and developing standardized, targeted treatments to improve patient survival.
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Affiliation(s)
- Mohammad Abufaraj
- Division of Urology, Department of Special Surgery, The University of Jordan, Amman 11942, Jordan
| | - Raghad Ramadan
- School of Medicine, The University of Jordan, Amman 11942, Jordan
| | - Amro Alkhatib
- School of Medicine, The University of Jordan, Amman 11942, Jordan
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8
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Ríos NR, Bransfield A, Joyce CM, Cahill MR, O’Shaughnessy M, Costelloe SJ. Challenges of providing biochemistry results in a patient with Evans syndrome. Biochem Med (Zagreb) 2024; 34:011001. [PMID: 38125617 PMCID: PMC10731728 DOI: 10.11613/bm.2024.011001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 10/09/2023] [Indexed: 12/23/2023] Open
Abstract
A case report of in vivo hemolysis in a female patient with Evans syndrome is described. The patient was admitted with anemia and jaundice and, during her 26-day hospital admission, had 83 samples taken for biochemistry analyses. The laboratory hemolytic index (HI) was frequently elevated due to persistent complement-mediated in vivo hemolysis despite multiple lines of therapy. Initially, the release of many biochemical parameters was blocked per the manufacturer´s recommendations and reported as "sample hemolyzed". The patient developed severe acute kidney injury, ultimately requiring dialysis. Automated and timely reporting of indicative creatinine and other biochemical results in the context of ongoing hemolysis, therefore, became essential to patient care. Following a review of literature from various sources, a laboratory algorithm was designed to ensure the timely release of numerical biochemical values, where possible, with appropriate interpretative comments appended. Biochemistry, hematology, and nephrology teams were in regular communication to ensure patient samples were rapidly identified, analyzed and validated according to the algorithm, informing timely, safe and appropriate patient care. Ultimately, the patient died due to multiple disease- and treatment-related complications. In conjunction with clinical users, laboratories should plan for situations, such as in vivo hemolysis, where significant unavoidable interferences in biochemistry methodologies may occur in an ongoing manner for certain patients. Reporting categorical or best-estimate biochemistry results in such cases can be safer for patients than failing to report any results. Interpretation of these results by clinical teams requires input from appropriately trained and qualified laboratory personnel.
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Affiliation(s)
- Natividad Rico Ríos
- Department of Clinical Biochemistry, Cork University Hospital, Cork, Republic of Ireland
| | - Alison Bransfield
- Department of Clinical Biochemistry, Cork University Hospital, Cork, Republic of Ireland
| | - Caroline M Joyce
- Department of Clinical Biochemistry, Cork University Hospital, Cork, Republic of Ireland
| | - Mary R Cahill
- Department of Clinical Haematology, Cork University Hospital, Cork, Republic of Ireland
| | | | - Seán J. Costelloe
- Department of Clinical Biochemistry, Cork University Hospital, Cork, Republic of Ireland
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9
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Wang C, Sun B, Wu K, Farmer JR, Ujhazi B, Geier CB, Gordon S, Westermann-Clark E, Savic S, Secord E, Sargur R, Chen K, Jin JJ, Dutmer CM, Kanariou MG, Adeli M, Palma P, Bonfim C, Lycopoulou E, Wolska-Kusnierz B, Dbaibo G, Bleesing J, Moshous D, Neven B, Schuetz C, Geha RS, Notarangelo LD, Miano M, Buchbinder DK, Csomos K, Wang W, Wang JY, Wang X, Walter JE. Clinical, immunological features, treatments, and outcomes of autoimmune hemolytic anemia in patients with RAG deficiency. Blood Adv 2024; 8:603-607. [PMID: 37883797 PMCID: PMC10837476 DOI: 10.1182/bloodadvances.2023011264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/05/2023] [Accepted: 09/28/2023] [Indexed: 10/28/2023] Open
Affiliation(s)
- Chen Wang
- Department of Internal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL
| | - Bijun Sun
- Department of Clinical Immunology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Kevin Wu
- Department of Pediatrics & Medicine, University of South Florida at Johns Hopkins All Children’s Hospital, St. Petersburg, FL
| | - Jocelyn R. Farmer
- Division of Allergy and Inflammation, Beth Israel Lahey Health, Harvard Medical School, Boston, MA
| | - Boglarka Ujhazi
- Department of Pediatric Allergy and Immunology, University of South Florida at Johns Hopkins All Children’s Hospital, St. Petersburg, FL
| | - Christoph B. Geier
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, University of Freiburg; Center for Chronic Immunodeficiency, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sumai Gordon
- Department of Pediatric Allergy and Immunology, University of South Florida at Johns Hopkins All Children’s Hospital, St. Petersburg, FL
| | - Emma Westermann-Clark
- Department of Pediatric Allergy and Immunology, University of South Florida at Johns Hopkins All Children’s Hospital, St. Petersburg, FL
| | - Sinisa Savic
- St James’s University Hospital, University of Leeds, Leeds, United Kingdom
| | - Elizabeth Secord
- Division of Allergy and Immunology, Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI
| | - Ravishankar Sargur
- Sheffield Teaching Hospitals Foundation NHS Trust, Sheffield, United Kingdom
| | - Karin Chen
- Division of Immunology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| | - Jay J. Jin
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Cullen M. Dutmer
- Section of Allergy & Immunology, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Maria G. Kanariou
- Department of Immunology and Histocompatibility, Aghia Sophia Children’s Hospital, Athens, Greece
| | - Mehdi Adeli
- Pediatric Allergy and Immunology, Sidra Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Paolo Palma
- Unit of Clinical Immunology and Vaccinology, Bambino Gesu` Children’s Hospital, Department of Systems Medicine, University of Rome ‘‘Tor Vergata,’’ Rome, Italy
| | - Carmem Bonfim
- Hospital Pequeno Príncipe/Instituto de Pesquisa Pelé Pequeno Príncipe/Faculdades Pequeno Príncipe, Curitiba, Paraná, Brazil
| | - Evangelia Lycopoulou
- 1st Department of Pediatrics, University of Athens, Aghia Sofia Children’s Hospital, Athens, Greece
| | | | - Ghassan Dbaibo
- Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
| | - Jack Bleesing
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cancer and Blood Diseases Institute, Cincinnati, OH
| | - Despina Moshous
- Department of Pediatric Immunology, Hematology and Rheumatology, Necker Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, CEREDIH, French National Reference Centre for Primary Immunodeficiencies, Paris, France
- Imagine Institute, INSERM UMR 1163, University Paris Cité, Paris, France
| | - Benedicte Neven
- Imagine Institute, INSERM UMR 1163, University Paris Cité, Paris, France
| | - Catharina Schuetz
- Department of Pediatrics and Adolescent Medicine, University Hospital Ulm, Ulm, Germany
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Raif S. Geha
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Luigi D. Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Maurizio Miano
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Krisztian Csomos
- Department of Pediatric Allergy and Immunology, University of South Florida at Johns Hopkins All Children’s Hospital, St. Petersburg, FL
| | - Wenjie Wang
- Department of Clinical Immunology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Ji-Yang Wang
- Department of Immunology, School of Basic Medical Sciences, Fudan University, Shanghai, China
- Shanghai Huashen Institute of Microbes and Infections, Shanghai, China
| | - Xiaochuan Wang
- Department of Clinical Immunology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Jolan E. Walter
- Department of Pediatric Allergy and Immunology, University of South Florida at Johns Hopkins All Children’s Hospital, St. Petersburg, FL
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10
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Kakita S, Matsuo T, Ohki M, Tsuchiyama A, Yasuda T, Nakanishi H, Mitsunari K, Ohba K, Imamura R. Evans syndrome during pembrolizumab therapy for upper urinary tract cancer. IJU Case Rep 2023; 6:298-301. [PMID: 37667757 PMCID: PMC10475338 DOI: 10.1002/iju5.12609] [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: 03/19/2023] [Accepted: 07/11/2023] [Indexed: 09/06/2023] Open
Abstract
Introduction Immune checkpoint inhibitors are available for the treatment of advanced urothelial carcinoma; however, serious adverse events occasionally occur. Here, we report a rare case of Evans syndrome attributed to the use of an immune checkpoint inhibitor. Case presentation A 56-year-old man was diagnosed with left renal pelvic cancer and underwent left laparoscopic radical nephroureterectomy. Eight months postoperatively, computed tomography revealed para-aortic lymph node metastasis. Despite receiving chemotherapy, the disease progressed, and pembrolizumab was initiated. After 26 months of pembrolizumab treatment, the patient developed fever and anemia. Hematologic examination confirmed the diagnosis of Evans syndrome. He was treated with blood transfusions and corticosteroids, and gradual symptom improvement was observed. Conclusion This report highlights the potential risk of Evans syndrome associated with immune checkpoint inhibitor treatment. Clinicians should be aware of this possibility and consider early intervention with corticosteroids.
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Affiliation(s)
- Shota Kakita
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Tomohiro Matsuo
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Masaharu Ohki
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Ayaka Tsuchiyama
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Takuji Yasuda
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Hiromi Nakanishi
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Kensuke Mitsunari
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Kojiro Ohba
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Ryoichi Imamura
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
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11
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Zhang X, Gao BX, Guo CY, Su T. A 71-year-old male with a life-threatening recurrence of hemolytic anemia, thrombocytopenia, and acute kidney injury after pembrolizumab therapy: a case report. BMC Geriatr 2023; 23:478. [PMID: 37553570 PMCID: PMC10410872 DOI: 10.1186/s12877-023-04181-w] [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: 09/04/2022] [Accepted: 07/17/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment. However, their use has been restricted in patients with preexisting autoimmune diseases due to concerns about increased risk of immune-related adverse events (irAEs). CASE PRESENTATION We present a case of a patient with stage IV lung adenocarcinoma and a history of complement-mediated autoimmune hemolytic anemia in remission. After receiving a single dose of pembrolizumab, the patient experienced life-threatening recurrent hemolytic anemia, de novo thrombocytopenia, diarrhea, myocarditis, and acute kidney injury. Laboratory tests confirmed the diagnosis of Evan's syndrome, with positive PAIgG and direct antiglobulin test. Treatment with intravenous methylprednisolone at a dose of 2 mg/kg resulted in a favorable response, with resolution of symptoms and rapid recovery of kidney function. The probable cause of pre-renal hypoperfusion (evidenced by a BUN-to-creatinine ratio of 48.1) leading to acute tubular injury was attributed to pembrolizumab-induced diarrhea. CONCLUSIONS This case illustrates a life-threatening recurrence of complement-mediated autoimmune hemolytic anemia induced by ICIs. Clinicians should carefully consider the expected efficacy and potential toxicity before initiating ICIs therapy in patients with preexisting autoimmune diseases. Additionally, the occurrence of acute kidney injury during ICIs therapy adds complexity and requires careful differential diagnosis.
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Affiliation(s)
- Xin Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, People's Republic of China
- Institute of Nephrology, Peking University, No.8 Xishuku Street, Beijing, Xicheng District, 100034, People's Republic of China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, 100034, People's Republic of China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
- Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases Chinese Academy of Medical Sciences, 100034, Beijing, PR China
| | - Bi-Xia Gao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, People's Republic of China
- Institute of Nephrology, Peking University, No.8 Xishuku Street, Beijing, Xicheng District, 100034, People's Republic of China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, 100034, People's Republic of China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
- Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases Chinese Academy of Medical Sciences, 100034, Beijing, PR China
| | - Cui-Yan Guo
- Department of Pulmonary and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China
| | - Tao Su
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, People's Republic of China.
- Institute of Nephrology, Peking University, No.8 Xishuku Street, Beijing, Xicheng District, 100034, People's Republic of China.
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, 100034, People's Republic of China.
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China.
- Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases Chinese Academy of Medical Sciences, 100034, Beijing, PR China.
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12
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Corredor-Orlandelli D, Arévalo-Romero A, Reyes C, Arango D. Massive Right Chylothorax Secondary to a Severe Systemic Lupus Erythematosus Flare With Secondary Evans Syndrome: A Case Report and Literature Review. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2023; 16:11795476231186735. [PMID: 37457318 PMCID: PMC10338652 DOI: 10.1177/11795476231186735] [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] [Received: 03/25/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023]
Abstract
This case report describes a 23-year-old male patient who presented with right chylothorax as the initial manifestation of a severe flare of systemic lupus erythematosus (SLE) and secondary Evans syndrome. Chylothorax and chylous ascites are rare features of SLE that can occur due to the accumulation of triglyceride-rich fluid in serous cavities. However, they have never been reported as the initial manifestation of a lupus flare. Evans syndrome is a rare disease characterized by autoimmune hemolytic anemia and immune thrombocytopenia, which can be secondary to SLE. The concomitant occurrence of both chylothorax and Evans syndrome in the setting of systemic lupus erythematosus has never been described, and the exact causative mechanisms of both entities are yet to be fully understood. In this report, we discuss our approach to this challenging case to broaden the understanding of the clinical manifestations of systemic lupus erythematosus. Our findings emphasize the importance of considering rare features of systemic lupus erythematosus and secondary diseases when evaluating patients with the disease.
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Affiliation(s)
- David Corredor-Orlandelli
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
- Medical Department, Fundación Clínica Abood-Shaio, Bogotá, Colombia
| | | | - Carlos Reyes
- Medical Department, Fundación Clínica Abood-Shaio, Bogotá, Colombia
- School of Medicine and Health Sciences, Universidad Militar, Bogotá, Colombia
| | - Dylan Arango
- Medical Department, Fundación Clínica Abood-Shaio, Bogotá, Colombia
- School of Medicine, Universidad del Bosque, Bogotá, Colombia
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13
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Irimia R, Barbu S, Popa C, Badelita S. Evans Syndrome as a Possible Complication of Brentuximab Vedotin Therapy for Peripheral T Cell Lymphoma. Hematol Rep 2023; 15:220-224. [PMID: 36975736 PMCID: PMC10048708 DOI: 10.3390/hematolrep15010023] [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: 08/01/2022] [Revised: 09/14/2022] [Accepted: 03/17/2023] [Indexed: 03/29/2023] Open
Abstract
Recently, Brentuximab Vedotin (BV) has emerged as an important therapy not only for Hodgkin's Lymphoma, but also for CD30-positive T cell lymphomas. Although anemia and thrombocytopenia are common myelosuppressive side effects, to our knowledge, this is the first described case of Evans Syndrome associated with BV therapy. We present the case of a 64-year-old female, diagnosed with relapsed Peripheral T Cell Lymphoma Not Otherwise Specified (PTCL-NOS), who, after receiving six cycles of BV, developed authentic severe autoimmune hemolytic anemia with strong positive direct anti-globulin (Coombs) test, simultaneously associated with severe immune thrombocytopenia. The patient was unresponsive to systemic corticotherapy, but fully recovered after a course of IV immunoglobulin.
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Affiliation(s)
- Ruxandra Irimia
- School of Medicine, "Carol Davila" University of Medicine and Pharmacy, 4192910 Bucharest, Romania
- Fundeni Clinical Institute, 4192910 Bucharest, Romania
| | - Sinziana Barbu
- School of Medicine, "Carol Davila" University of Medicine and Pharmacy, 4192910 Bucharest, Romania
- Fundeni Clinical Institute, 4192910 Bucharest, Romania
| | - Codruta Popa
- School of Medicine, "Carol Davila" University of Medicine and Pharmacy, 4192910 Bucharest, Romania
- Fundeni Clinical Institute, 4192910 Bucharest, Romania
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14
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Ahoussougbemey Mele A, Chew C, Ruiz Vega R, Mahmood R, AlRubaye R. Naproxen-Induced Evans Syndrome. Cureus 2023; 15:e34910. [PMID: 36938179 PMCID: PMC10016752 DOI: 10.7759/cureus.34910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 02/15/2023] Open
Abstract
Evans syndrome is an autoimmune disorder characterized by the simultaneous occurrence of autoimmune hemolytic anemia and immune thrombocytopenic purpura. It can further be classified as primary Evans syndrome when it occurs by itself, or secondary Evans syndrome when it is associated with other autoimmune and lymphoproliferative disorders. Corticosteroids and immunoglobulins are the first-line treatments for primary Evans syndrome, and subsequent options include other immunosuppressive medications. Medical literature provides little information about the triggers of primary Evans syndrome. Knowing such information, however, is essential to recognize, treat and prevent the recurrence of the disease effectively. We report a 68-year-old female who presented with shortness of breath, cough, bruises, scleral icterus, and dark urine after several days of naproxen therapy for pain. Further workup noted direct antiglobulin test positive for IgG, anemia, and thrombocytopenia. Imaging studies showed deep venous thrombosis. She was diagnosed with Evans syndrome and improved following prompt treatment with corticosteroids, anticoagulants, blood transfusion therapies, and discontinuation of naproxen. The prognosis of Evans syndrome is poor, variable, and characterized by relapses. Early diagnosis and treatment are therefore associated with better prognosis. This case is critical because it shines a light on one of the major causes of Evans syndrome, reports a practical approach to treating the condition, and paves the way for future research on Evans syndrome. This case is also the first reported naproxen-induced Evans syndrome in the world's literature.
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Affiliation(s)
| | - Christopher Chew
- Internal Medicine, Northeast Georgia Medical Center, Gainesville, USA
| | - Ruben Ruiz Vega
- Internal Medicine, Northeast Georgia Medical Center, Gainesville, USA
| | - Riaz Mahmood
- Internal Medicine, Northeast Georgia Medical Center, Gainesville, USA
| | - Riyadh AlRubaye
- Internal Medicine, Northeast Georgia Medical Center, Gainesville, USA
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15
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Muacevic A, Adler JR, Jacinto Correia C, Duro J, Aguiar P. Therapeutic Options in Refractory Evans Syndrome: A Case Report. Cureus 2022; 14:e32635. [PMID: 36654549 PMCID: PMC9842105 DOI: 10.7759/cureus.32635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2022] [Indexed: 12/23/2022] Open
Abstract
Evans syndrome is a rare autoimmune disease, characterized by at least two immune cytopenias, most frequently anemia and thrombocytopenia and rarely immune neutropenia. It has a variable clinical presentation and is rarely diagnosed in adults. It can be idiopathic or secondary to lymphoproliferative disease, infections, autoimmune diseases, drugs, and immunodeficiencies in about 50% of cases. It is characterized by a chronic, relapsing, potentially fatal course due to its hemorrhagic complications as well as complications associated with the long-term immunosuppressive treatment required to control the disease, such as infectious diseases, and cardiovascular and renal complications. Its prognosis depends on the underlying cause. Because of its rarity, the treatment is empirical, based mostly on case series and recommendations for the treatment of other immune cytopenias. The underlying disease and demographic characteristics also play an important role in choosing the treatment, which should be adapted individually to each patient. We present a case of an elderly patient with idiopathic autoimmune hemolytic anemia and thrombocytopenia, refractory to various treatment options.
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16
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Ng TYM, Teo WZY, Ng TYM, Teng GG. New-onset Evans syndrome in a patient with SLE post SARS-CoV2 mRNA vaccination. Ann Hematol 2022; 102:235-236. [PMID: 36369498 PMCID: PMC9652039 DOI: 10.1007/s00277-022-05034-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 11/04/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Timothy Y. M. Ng
- Chronic and Fast Programs, Alexandra Hospital, National University Hospital System, Singapore, Singapore
| | - Winnie Z. Y. Teo
- Chronic and Fast Programs, Alexandra Hospital, National University Hospital System, Singapore, Singapore ,Department of Haematology-Oncology, National University Cancer Institute Singapore (NCIS), National University Health System, Singapore, Singapore
| | - Terence Y. M. Ng
- Department of Emergency Medicine, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Gim Gee Teng
- Chronic and Fast Programs, Alexandra Hospital, National University Hospital System, Singapore, Singapore ,Division of Rheumatology, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore
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17
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Jiang E, Kim KH, Babigian A. Acute Isolated Thenar Compartment Syndrome in a Patient with Evans Syndrome: A Case Report. Clin Pract Cases Emerg Med 2022; 6:292-295. [PMID: 36427036 PMCID: PMC9697890 DOI: 10.5811/cpcem.2022.8.57193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/22/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Acute compartment syndrome of the hand is a rare medical emergency, most often associated with trauma or fracture. CASE REPORT Here, we describe a rare case of isolated thenar compartment syndrome of the hand in the absence of major trauma as the presenting symptom of pancytopenia due to Evans syndrome, an uncommon autoimmune hematologic disorder. CONCLUSION In cases of atraumatic compartment syndrome, it is critical to evaluate for underlying coagulopathy in patients presenting to the emergency department.
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Affiliation(s)
- Elisabeth Jiang
- University of Connecticut School of Medicine, Emergency Medicine Residency, Farmington, Connecticut
| | - Kevin H. Kim
- University of Connecticut School of Medicine, Hand Surgery Fellowship, Farmington, Connecticut
| | - Alan Babigian
- Hartford Hospital, Department of Surgery, Hartford, Connecticut
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18
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Mazharuddin AA, Rehmani A, Puthenparambil L, Alappatt JJ, Lee WH. Ophthalmic Manifestations as First Presenting Sign of Evans Syndrome. JOURNAL OF VITREORETINAL DISEASES 2022; 6:479-484. [PMID: 37009543 PMCID: PMC9954779 DOI: 10.1177/24741264211062931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose This work reports a case of Evans syndrome first presenting with ophthalmic signs. Methods A 27-year-old previously healthy man presented with headaches and bilateral blurred vision for 2 weeks. The visual acuity was 20/30-1 and 20/60-2 in the right eye and left eye, respectively. A fundus examination revealed Roth spots, diffuse multilayer retinal hemorrhages in the macula and periphery, and tortuous vessels in both eyes. Optical coherence tomography showed a disrupted foveal contour from intraretinal fluid and hemorrhage in both eyes. Fluorescein angiography demonstrated dilated and tortuous vessels with scattered blocking defects from hemorrhages. Results A workup revealed warm hemolytic anemia with severe thrombocytopenia consistent with the diagnosis of Evans syndrome. Conclusions Evans syndrome is a rare blood dyscrasia that can first present as subacute vision loss and should be added to the differential of diffuse bilateral retinal hemorrhages spanning a multitude of retinal layers.
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Affiliation(s)
| | - Ahmad Rehmani
- University of Texas Medical Branch,
Galveston, TX, USA
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19
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McCarthy MD, Fareeth AGM. Evans syndrome in a young man with rare autoimmune associations and transplanted liver. BMJ Case Rep 2022; 15:15/9/e251252. [PMID: 36171014 PMCID: PMC9528579 DOI: 10.1136/bcr-2022-251252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Evans syndrome is classically characterised by two or more cytopenias occurring either concomitantly or sequentially. Most commonly, these are autoimmune haemolytic anaemia and immune thrombocytopenia purpura. It is mostly associated with specific autoimmune conditions such as systemic lupus erythematosus and lymphoproliferative disorders. We present a case report of Evans syndrome in a young man with primary sclerosing cholangitis and Crohn’s disease, neither of which are classically associated with the condition. The case also further adds to the number of case reports of Evans syndrome occurring in patients following liver transplantation.
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MESH Headings
- Anemia, Hemolytic, Autoimmune/complications
- Anemia, Hemolytic, Autoimmune/diagnosis
- Humans
- Liver Transplantation/adverse effects
- Lupus Erythematosus, Systemic/complications
- Lupus Erythematosus, Systemic/diagnosis
- Male
- Purpura, Thrombocytopenic, Idiopathic/complications
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Thrombocytopenia/complications
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Affiliation(s)
| | - A G Mohamed Fareeth
- Acute Medicine, East Lancashire Hospitals NHS Trust, Blackburn, Lancashire, UK
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20
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Wang C, Walter JE. Autoantibodies in immunodeficiency syndromes: The Janus faces of immune dysregulation. Blood Rev 2022; 55:100948. [PMID: 35428517 PMCID: PMC11166480 DOI: 10.1016/j.blre.2022.100948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/23/2022] [Accepted: 03/13/2022] [Indexed: 11/02/2022]
Abstract
Immunodeficiency syndromes represent a diverse group of inherited and acquired disorders, characterized by a spectrum of clinical manifestations, including recurrent infections, autoimmunity, lymphoproliferation and malignancy. Autoantibodies against various self-antigens reflect the immune dysregulation underlying these disorders, and could contribute to certain clinical findings, such as susceptibility to opportunistic infections, cytopenia of different hematopoietic lineages, and organ-specific autoimmune diseases. The mechanism of autoantibody production in the context of immunodeficiency remains largely unknown but is likely shaped by both intrinsic genetic aberrations and extrinsic exposures to possible infectious agents. These autoantibodies if harbor neutralizing activities and reach certain levels in the circulation, could disrupt the biological functions of their targets, resulting in specific clinical manifestations. Herein, we reviewed the prevalence of autoantibodies against cytokines, hematopoietic cells and organ-specific antigens in immunodeficiency syndromes and examined their associations with certain clinical findings. Moreover, the potential mechanism of autoantibody production was also discussed. These may shed light on the development of mechanism-based therapies to reset the dysregulated immune system in immunodeficient patients.
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Affiliation(s)
- Chen Wang
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Jolan E Walter
- Division of Pediatric Allergy/Immunology, University of South Florida at Johns Hopkins All Children's Hospital, St Petersburg, FL, USA; Division of Pediatric Allergy and Immunology, Massachusetts General Hospital for Children, Boston, MA, USA.
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21
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Thrombopoietin receptor agonists in adult Evans syndrome: an international multicenter experience. Blood 2022; 140:789-792. [PMID: 35749688 PMCID: PMC9389636 DOI: 10.1182/blood.2022016818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/07/2022] [Indexed: 11/20/2022] Open
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22
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Fayed M, Jain S, Leonardi N, Younger J. Unexpected Thrombocytopenia in a Parturient With Evans Syndrome Complicated by COVID-19 Infection. Cureus 2022; 14:e27409. [PMID: 36051718 PMCID: PMC9419897 DOI: 10.7759/cureus.27409] [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: 07/28/2022] [Indexed: 11/06/2022] Open
Abstract
We report the case of a 23-year-old parturient who received epidural analgesia and was subsequently diagnosed with Evans syndrome (ES). The diagnosis was made after a complete blood count (CBC) resulted in severe anemia and a platelet count of less than 10K/µL. To further complicate this case, the patient developed post-delivery pleuritic chest pain and pulmonary emboli (PE), and a chest computed tomography (CT) scan showed bilateral ground-glass lung opacities. This prompted a COVID-19 testing and ultimately confirmed infection.
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Bestwick JP, Skelly BJ, Swann JW, Glanemann B, Bexfield N, Gkoka Z, Walker DJ, Silvestrini P, Adamantos S, Seth M, Warland J. Splenectomy in the management of primary immune-mediated hemolytic anemia and primary immune-mediated thrombocytopenia in dogs. J Vet Intern Med 2022; 36:1267-1280. [PMID: 35801263 PMCID: PMC9308443 DOI: 10.1111/jvim.16469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 05/27/2022] [Indexed: 11/27/2022] Open
Abstract
Background Current reports about the use of splenectomy for the management of immune‐mediated hemolytic anemia (IMHA) or immune‐mediated thrombocytopenia (ITP) or both in dogs are limited. Objectives To retrospectively describe the use of splenectomy as part of the management for IMHA, ITP, and concurrent IMHA and severe thrombocytopenia (CIST) in dogs. It was hypothesized that splenectomy would be beneficial in allowing for reduction of dose of immunosuppressive drugs or discontinuation in 1 or more of these groups. Animals Seventeen client‐owned dogs (7 with IMHA, 7 with ITP, and 3 with CIST) were identified across 7 UK‐based referral hospitals from a study period of 2005 to 2016. Methods Data were collected retrospectively via questionnaires and included information about diagnosis, management and treatment response before and after splenectomy. Based on clinical outcome, treatment with splenectomy as part of the management protocol was classified as either successful or unsuccessful. Results Six of 7 dogs with ITP were managed successfully with splenectomy as part of their management protocol (3 complete and 3 partial responses), although 1 subsequently developed suspected IMHA. Of the 7 dogs with IMHA, splenectomy was part of a successful management protocol in 4 dogs (2 complete and 2 partial responses). In the CIST group, 1 case (1/3) responded completely to management with splenectomy as part of the management protocol. Conclusions and Clinical Importance Splenectomy was considered successful and well tolerated in most cases of isolated ITP. Whether there is a benefit of splenectomy in cases of IMHA and CIST could not be determined in the current study.
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Affiliation(s)
- Jason P Bestwick
- Animal Health Trust, Newmarket, Suffolk, United Kingdom.,Department of Veterinary Medicine, Univeristy of Cambridge, Cambridge, United Kingdom
| | - Barbara J Skelly
- Queen's Veterinary School Hospital, University of Cambridge, Cambridge, United Kingdom
| | - James W Swann
- Department of Clinical Science and Services, The Royal Veterinary College, University of London, Hertfordshire, United Kingdom.,Columbia Stem Cell Initiative, Columbia University, New York, New York, USA
| | - Barbara Glanemann
- Department of Clinical Science and Services, The Royal Veterinary College, University of London, Hertfordshire, United Kingdom
| | - Nick Bexfield
- Queen's Veterinary School Hospital, University of Cambridge, Cambridge, United Kingdom.,Pride Veterinary Centre, Derbyshire, United Kingdom
| | - Zeta Gkoka
- Anderson Moores Veterinary Specialists, Winchester, United Kingdom
| | - David J Walker
- Anderson Moores Veterinary Specialists, Winchester, United Kingdom
| | - Paolo Silvestrini
- Small Animal Teaching Hospital, Institute of Veterinary Science, University of Liverpool, Neston, United Kingdom
| | - Sophie Adamantos
- Langford Vets/University of Bristol, Bristol, North Somerset, United Kingdom.,Paragon Veterinary Referrals, Wakefield, West Yorkshire, United Kingdom
| | - Mayank Seth
- Animal Health Trust, Newmarket, Suffolk, United Kingdom.,Dick White Referrals, Cambridge, United Kingdom
| | - James Warland
- Animal Health Trust, Newmarket, Suffolk, United Kingdom.,Southfields Veterinary Specialists, Part of Linnaeus Veterinary Limited, Laindon, Essex, United Kingdom.,Wellcome-MRC Cambridge Stem Cell Institute, Jeffrey Cheah Biomedical Centre, University of Cambridge, Cambridge, United Kingdom
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24
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De Felice M, Farina G, Bianco R, Monaco G, Iaccarino S. Evans Syndrome Presenting as an Atypical Complication of SARS-CoV-2 Vaccination. Cureus 2022; 14:e26602. [PMID: 35936148 PMCID: PMC9354064 DOI: 10.7759/cureus.26602] [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: 07/05/2022] [Indexed: 11/05/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has drastically affected our daily lives, causing millions of deaths worldwide. The early and late complications of this infection are being increasingly revealed on a regular basis; however, an important brake on the spread and especially the lethality of the disease has been guaranteed by the introduction of mRNA-based and viral vector-based COVID-19 Vaccines. Also, an increasing number of adverse effects of the vaccination have been reported to specific pharmacovigilance boards, most of them totally non-serious events that are resolved within one to three days after the administration of the vaccine. In this report, we present a case of Evans syndrome (ES) secondary to SARS-CoV-2 vaccination in an 85-year-old male patient. To the best of our knowledge, this is the first case of ES caused by the COVID-19 vaccination to be reported in the literature.
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25
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Abu Kar S, Kaur A. Evans Syndrome in the Context of Incomplete Systemic Lupus Erythematosus. Cureus 2022; 14:e25795. [PMID: 35836439 PMCID: PMC9273191 DOI: 10.7759/cureus.25795] [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: 06/09/2022] [Indexed: 11/18/2022] Open
Abstract
Evans syndrome is an autoimmune disorder characterized by the simultaneous or sequential occurrence of autoimmune hemolytic anemia and idiopathic thrombocytopenic purpura (ITP) with or without neutropenia. It can occur idiopathically or secondary to autoimmune or malignant processes. We are presenting a case of ITP with concurrent chronic hemolytic anemia and positive markers for systemic lupus erythematosus with no prior diagnosis of any rheumatological disorder.
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26
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Sidda A, Manu G, Abdallah M, Griswold D, Alsharedi M, Pacioles T. Paraneoplastic Evans Syndrome in a Patient With Prostate Cancer With Small Cell Transformation. Cureus 2022; 14:e24505. [PMID: 35651454 PMCID: PMC9135308 DOI: 10.7759/cureus.24505] [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: 04/13/2022] [Indexed: 11/08/2022] Open
Abstract
Paraneoplastic syndromes are defined as tumor‐associated indirect systemic effects. Prostate cancer-associated paraneoplastic syndromes typically have endocrine, neurologic, and dermatologic manifestations. Reports have suggested up to 70% of metastatic prostate cancers manifest as paraneoplastic entities. Although common in hematological malignancies, it is rare for prostate cancer and other solid tumors to be associated with immune-mediated cytopenias such as Evans syndrome. Based on our PubMed search for the keywords Evans syndrome and prostate cancer, only one other case has been reported in the literature with this association. We report the second such case in a 63-year-old male who initially presented with hemolytic anemia and thrombocytopenia. He was diagnosed with Evans syndrome with initial responses to both steroids and intravenous immunoglobulin. Extensive workup, including an eventual bone marrow biopsy, revealed metastatic prostate cancer with transformation to small cell neuroendocrine carcinoma.
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27
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Santacruz JC, Mantilla MJ, Rueda I, Pulido S, Rodriguez-Salas G, Londono J. A Practical Perspective of the Hematologic Manifestations of Systemic Lupus Erythematosus. Cureus 2022; 14:e22938. [PMID: 35399432 PMCID: PMC8986464 DOI: 10.7759/cureus.22938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 12/15/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic inflammatory disease with an unknown etiology that can affect any organ or system of the human body. Hematological, renal, or central nervous system manifestations in these patients result in great morbidity because high doses of glucocorticoids, cytotoxic medications, or biological drugs are required to control these manifestations. It is noteworthy that hematological involvement predominates during the first years of the disease and tends to last over time, with the premise that it may be the initial manifestation of the disease. Clear examples of this are the cases of hemolytic anemia and immune thrombocytopenia that can be initially classified as idiopathic or primary to be later classified as secondary when associated with infections, medications, neoplasms, or autoimmune diseases. The spectrum of hematologic manifestations in SLE is very broad, including lymphopenia, anemia, thrombocytopenia, or pancytopenia. In some cases, lymphadenopathy and splenomegaly are also identified. The vast majority of these manifestations denote high disease activity. However, many of these alterations have a multifactorial cause that must be taken into account to adopt a more complete therapeutic approach. The objective of this review is to characterize in detail the hematological manifestations of SLE to offer clinicians a practical vision of its diagnosis and treatment.
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28
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Michel M. Adult Evans' Syndrome. Hematol Oncol Clin North Am 2022; 36:381-392. [DOI: 10.1016/j.hoc.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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29
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Kumar D, Prince C, Bennett CM, Briones M, Lucas L, Russell A, Patel K, Chonat S, Graciaa S, Edington H, White MH, Kobrynski L, Abdalgani M, Parikh S, Chandra S, Bleesing J, Marsh R, Park S, Waller EK, Prahalad S, Chandrakasan S. T-follicular helper cell expansion and chronic T-cell activation are characteristic immune anomalies in Evans syndrome. Blood 2022; 139:369-383. [PMID: 34424963 PMCID: PMC8777200 DOI: 10.1182/blood.2021012924] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 08/02/2021] [Indexed: 11/20/2022] Open
Abstract
Pediatric Evans syndrome (pES) is increasingly identified as the presenting manifestation of several inborn errors of immunity. Despite an improved understanding of genetic defects in pES, the underlying immunobiology of pES is poorly defined, and characteristic diagnostic immune parameters are lacking. We describe the immune characteristics of 24 patients with pES and compared them with 22 patients with chronic immune thrombocytopenia (cITP) and 24 healthy controls (HCs). Compared with patients with cITP and HC, patients with pES had increased circulating T-follicular helper cells (cTfh), increased T-cell activation, and decreased naïve CD4+ T cells for age. Despite normal or high immunoglobulin G (IgG) in most pES at presentation, class-switched memory B cells were decreased. Within the cTfh subset, we noted features of postactivation exhaustion with upregulation of several canonical checkpoint inhibitors. T-cell receptor β chain (TCR-β) repertoire analysis of cTfh cells revealed increased oligoclonality in patients with pES compared with HCs. Among patients with pES, those without a known gene defect had a similar characteristic immune abnormality as patients with defined genetic defects. Similarly, patients with pES with normal IgG had similar T-cell abnormalities as patients with low IgG. Because genetic defects have been identified in less than half of patients with pES, our findings of similar immune abnormalities across all patients with pES help establish a common characteristic immunopathology in pES, irrespective of the underlying genetic etiology.
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MESH Headings
- Adolescent
- Adult
- Anemia, Hemolytic, Autoimmune/immunology
- Anemia, Hemolytic, Autoimmune/pathology
- Child
- Child, Preschool
- Female
- Humans
- Infant
- Lymphocyte Activation
- Male
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Purpura, Thrombocytopenic, Idiopathic/pathology
- T-Lymphocytes, Helper-Inducer/immunology
- T-Lymphocytes, Helper-Inducer/pathology
- Thrombocytopenia/immunology
- Thrombocytopenia/pathology
- Young Adult
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Affiliation(s)
- Deepak Kumar
- Aflac Cancer and Blood Disorder Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Chengyu Prince
- Aflac Cancer and Blood Disorder Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Carolyn M Bennett
- Aflac Cancer and Blood Disorder Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Michael Briones
- Aflac Cancer and Blood Disorder Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Laura Lucas
- Aflac Cancer and Blood Disorder Center, Children's Healthcare of Atlanta, Atlanta; GA
| | - Athena Russell
- Genetics and Molecular Biology Graduate Program, Laney Graduate School, Emory University, Atlanta, GA
| | - Kiran Patel
- Allergy/Immunology Section, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorder Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Sara Graciaa
- Aflac Cancer and Blood Disorder Center, Children's Healthcare of Atlanta, Atlanta; GA
| | - Holly Edington
- Aflac Cancer and Blood Disorder Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Michael H White
- Aflac Cancer and Blood Disorder Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Lisa Kobrynski
- Allergy/Immunology Section, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | | | - Suhag Parikh
- Aflac Cancer and Blood Disorder Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Sharat Chandra
- Division of Bone Marrow Transplantation and Immune Deficiency, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jack Bleesing
- Division of Bone Marrow Transplantation and Immune Deficiency, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Rebecca Marsh
- Division of Bone Marrow Transplantation and Immune Deficiency, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Sunita Park
- Department of Pathology, Children's Healthcare of Atlanta, Atlanta, GA
| | - Edmund K Waller
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA; and
| | - Sampath Prahalad
- Division of Pediatric Rheumatology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Shanmuganathan Chandrakasan
- Aflac Cancer and Blood Disorder Center, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
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30
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Gupta M, Lamba A, Gupta S, Rajesh R. Evans syndrome and Graves' Disease: An unusual presentation – A case report. APOLLO MEDICINE 2022. [DOI: 10.4103/am.am_79_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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31
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Patra P, Samal P, Bhola R, Pradhan S. An event of Evans even in HIV. Indian J Sex Transm Dis AIDS 2022; 43:64-66. [PMID: 35846539 PMCID: PMC9282701 DOI: 10.4103/ijstd.ijstd_113_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 05/05/2021] [Accepted: 05/05/2021] [Indexed: 11/28/2022] Open
Abstract
Autoimmune cytopenias may be the initial presentation in patients with HIV infection or can develop while on treatment with antiretroviral therapy (ART). These cytopenias usually resolve after initiation of ART. We report a rare case of HIV who presented with Evans syndrome on ART, being refractory to steroids and rituximab but with response to splenectomy.
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32
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Fattizzo B, Michel M, Giannotta JA, Hansen DL, Arguello M, Sutto E, Bianchetti N, Patriarca A, Cantoni S, Mingot-Castellano ME, McDonald V, Capecchi M, Zaninoni A, Consonni D, Vos JM, Vianelli N, Chen F, Glenthøj A, Frederiksen H, González-López TJ, Barcellini W. Evans syndrome in adults: an observational multicenter study. Blood Adv 2021; 5:5468-5478. [PMID: 34592758 PMCID: PMC8714709 DOI: 10.1182/bloodadvances.2021005610] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/10/2021] [Indexed: 11/20/2022] Open
Abstract
Evans syndrome (ES) is a rare condition, defined as the presence of 2 autoimmune cytopenias, most frequently autoimmune hemolytic anemia and immune thrombocytopenia (ITP) and rarely autoimmune neutropenia. ES can be classified as primary or secondary to various conditions, including lymphoproliferative disorders, other systemic autoimmune diseases, and primary immunodeficiencies, particularly in children. In adult ES, little is known about clinical features, disease associations, and outcomes. In this retrospective international study, we analyzed 116 adult patients followed at 13 European tertiary centers, focusing on treatment requirements, occurrence of complications, and death. ES was secondary to or associated with underlying conditions in 24 cases (21%), mainly other autoimmune diseases and hematologic neoplasms. Bleeding occurred in 42% of patients, mainly low grade and at ITP onset. Almost all patients received first-line treatment (steroids with or without intravenous immunoglobulin), and 23% needed early additional therapy for primary refractoriness. Additional therapy lines included rituximab, splenectomy, immunosuppressants, thrombopoietin receptor agonists, and others, with response rates >80%. However, a remarkable number of relapses occurred, requiring ≥3 therapy lines in 54% of cases. Infections and thrombotic complications occurred in 33% and 21% of patients, respectively, mainly grade ≥3, and correlated with the number of therapy lines. In addition to age, other factors negatively affecting survival were severe anemia at onset and occurrence of relapse, infection, and thrombosis. These data show that adult ES is often severe and marked by a relapsing clinical course and potentially fatal complications, pinpointing the need for high clinical awareness, prompt therapy, and anti-infectious/anti-thrombotic prophylaxis.
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Affiliation(s)
- Bruno Fattizzo
- Hematology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Marc Michel
- Centre de Référence Maladies Rares sur les Cytopénies Auto-Immunes de l’Adulte, Centre Hospitalier Universitaire Henri Mondor, Assistance Publique–Hôpitaux de Paris, Créteil Université Paris-Est Créteil, Paris, France
| | - Juri Alessandro Giannotta
- Hematology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Maria Arguello
- Hospital Universitario Principe de Asturias (Alcala de Henares), Madrid, Spain
| | - Emanuele Sutto
- Institute of Hematology “L. e A. Seragnoli”, University of Bologna, Bologna, Italy
| | | | - Andrea Patriarca
- Department of Translational Medicine, Azienda Ospedaliera-Universitaria “Maggiore della Carità”, University of Eastern Piedmont, Novara, Italy
| | - Silvia Cantoni
- Dipartimento di Ematologia e Oncologia, Niguarda Cancer Center, Azienda Socio Sanitaria Territoriale Ospedale Niguarda, Milan, Italy
| | | | - Vickie McDonald
- Clinical Haematology, Barts Health National Health Service Trust, Queen Mary University, London, United Kingdom
| | - Marco Capecchi
- Hematology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Zaninoni
- Hematology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Dario Consonni
- Epidemiology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Josephine Mathilde Vos
- Amsterdam University Medical Center, University of Amsterdam–Sanquin Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Nicola Vianelli
- Institute of Hematology “L. e A. Seragnoli”, University of Bologna, Bologna, Italy
| | - Frederick Chen
- Clinical Haematology, Barts Health National Health Service Trust, Queen Mary University, London, United Kingdom
| | - Andreas Glenthøj
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark; and
| | | | | | - Wilma Barcellini
- Hematology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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33
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Makharia A, Lakhotia M, Roy B. Primary Evans syndrome in an adult man. BMJ Case Rep 2021; 14:e243051. [PMID: 34887288 PMCID: PMC8663103 DOI: 10.1136/bcr-2021-243051] [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] [Accepted: 11/25/2021] [Indexed: 11/04/2022] Open
Abstract
Evans syndrome (ES) is a simultaneous or subsequent development of two haematological disorders, autoimmune haemolytic anaemia (AIHA) and immune thrombocytopenia (ITP). It can be primary (idiopathic) or secondary (associated with an underlying disease). Primary Evans is a diagnosis of exclusion and has a poorer prognosis than AIHA or ITP alone. We present a 55-year-old man who presented with weakness and lethargy and was diagnosed to be suffering from primary ES.
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Affiliation(s)
- Archita Makharia
- General Medicine, Dr Sampurnanand Medical College, Jodhpur, India
| | - Manoj Lakhotia
- General Medicine, Dr Sampurnanand Medical College, Jodhpur, India
| | - Brateen Roy
- General Medicine, Dr Sampurnanand Medical College, Jodhpur, India
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34
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Turgutkaya A, Bolaman AZ, Yavaşoğlu İ. COVID-19-associated Evans syndrome: A case report and review of the literature. Transfus Apher Sci 2021; 61:103339. [PMID: 34896007 PMCID: PMC8655821 DOI: 10.1016/j.transci.2021.103339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 11/16/2021] [Accepted: 12/03/2021] [Indexed: 11/29/2022]
Abstract
Evans syndrome is a rare condition characterized by simultaneous or sequential development of autoimmune hemolytic anemia and immune thrombocytopenia (and/or immune neutropenia). Coronavirus disease 2019 (COVID-19) may cause various hematologic conditions, such as coagulation abnormalities (e.g., bleeding or thrombosis) or cell count alterations (e.g., lymphopenia and neutrophilia). COVID-19 may also induce Evans syndrome via immune mechanisms. Here, we describe the case of a patient developing Evans syndrome shortly after COVID-19 infection. Immune thrombocytopenia and warm-type autoimmune hemolytic anemia developed simultaneously, and intravenous immunoglobulin and methylprednisolone were initially administered. Additionally, we intend to review all COVID-19-induced Evans syndrome cases currently present in the literature and emphasize the differences as well as the similarities regarding patient characteristics, relationship to COVID-19 infection, and treatment approach. Since autoimmune cytopenias are frequent in COVID-19 patients, clinicians should pay particular attention to profound and abrupt-onset cytopenias. In these circumstances, hemolysis markers such as lactate dehydrogenase, haptoglobulin, Coombs tests, etc. should be investigated, and the possibility of Evans syndrome should always be considered to ensure prompt and appropriate treatment. These factors are essential to ensure hematologic recovery and prevent complications such as thrombosis.
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Affiliation(s)
- Atakan Turgutkaya
- Adnan Menderes University Hematology Department, Aytepe Mevki, Efeler, PC: 09010, Aydın, Turkey.
| | - Ali Zahit Bolaman
- Adnan Menderes University Hematology Department, Aytepe Mevki, Efeler, PC: 09010, Aydın, Turkey.
| | - İrfan Yavaşoğlu
- Adnan Menderes University Hematology Department, Aytepe Mevki, Efeler, PC: 09010, Aydın, Turkey.
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35
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Ibn Idris Rodwan AA, Ahmed Elmansour OK, Ahmed AFE, Elagib EM, Ahmed Eltahir NI, Hassan A, El-Sadig SM, Mohammed AGAA, Awadalla HH, Mohammed AA, Adam Essa ME. A Rare Association of Thrombotic Thrombocytopenic Purpura with Systemic Lupus Erythematosus in a Sudanese Woman: Case Report. J Blood Med 2021; 12:945-949. [PMID: 34785968 PMCID: PMC8579963 DOI: 10.2147/jbm.s334689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/13/2021] [Indexed: 11/23/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is an uncommon life-threatening condition characterized by hemolytic disorders. The coexistence of systemic lupus erythematosus (SLE) with TTP is extremely rare, although Africans are at increased risk due to inherited risk factors. This report describes a rare clinical manifestation of TTP associated with SLE in a Sudanese patient. A 41-year-old Sudanese woman presented to the emergency department with symptoms and features that were suggestive of malaria, for which she had been treated accordingly. However, a few days later she complained of fever, and was found to have a body temperature of 39.5°C, jaundice, anemia, and thrombocytopenia. Soon after admission, she developed confusion and unrecordable blood pressure. After the patient had stabilized, clinical assessment, immune-system investigation (antinuclear antibody profile, complements, blood panel), and imaging revealed a diagnosis of TTP associated with SLE. The patient received imipenem 500 mg, five sessions of plasmapheresis (60 mL/kg), methylprednisolone 1 g pulse for 3 days, and rituximab 375 mg/week. Three weeks later, the patient was discharged after her condition had improved, and she is now on regular follow-up.
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Affiliation(s)
| | - Osama Khder Ahmed Elmansour
- Department of Rheumatology, Sudan Medical Specialization Council, Khartoum, Sudan.,Department of Rheumatology, Faculty of Medicine, Shendi University, Shendi, Sudan
| | - Amar F Eldow Ahmed
- Department of Internal Medicine, Wayne State University, Detroit, MI, USA
| | - Elnour Mohammed Elagib
- Department of Rheumatology, Sudan Medical Specialization Council, Khartoum, Sudan.,Department of Rheumatology, Omdurman Military Hospital, Khartoum, Sudan
| | - Noha Ibrahim Ahmed Eltahir
- Department of Rheumatology, Omdurman Military Hospital, Khartoum, Sudan.,Department of Medicine, Faculty of Medicine, Karary University, Khartoum, Sudan
| | - Abubaker Hassan
- Department of Clinical Medicine, Medical and Cancer Research Institute, Nyala, Sudan
| | - Sara M El-Sadig
- Department of Medicine, Faculty of Medicine, University of Khartoum, Khartoum, Sudan
| | | | - Huyam H Awadalla
- Department of Internal Medicine, Detroit Medical Centre, Detroit, MI, USA
| | | | - Mohammed Elmujtba Adam Essa
- Department of Clinical Medicine, Medical and Cancer Research Institute, Nyala, Sudan.,Faculty of Medicine, Al Fashir University, Al Fashir, Sudan
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36
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Jamil SB, Patoli I, Kazim M, Abbas SH, Ali Z. A Case of Evans Syndrome and Unstable Angina. J Med Cases 2021; 12:415-418. [PMID: 34691339 PMCID: PMC8510669 DOI: 10.14740/jmc3777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 09/11/2021] [Indexed: 11/26/2022] Open
Abstract
Evans syndrome (ES) is characterized by autoimmune hemolytic anemia (AIHA) and immune-mediated thrombocytopenia. It is more common in the pediatric population than in adults. ES has been reported to be associated with thrombotic events and rarely can lead to acute coronary syndrome (ACS). There have been only a few reported cases of ACS secondary to ES. We present an interesting case of ES with unstable angina (UA) which had a limited response to oral and intravenous (IV) steroids requiring rituximab. A 64-year-old male with past medical history significant for hypertension, hyperlipidemia, diabetes mellitus and coronary artery disease, presented to the emergency room complaining of a 2-week history of chest pain, shortness of breath and hematuria. Physical examination indicated splenomegaly but was otherwise unremarkable with no petechiae or rash. Labs showed hemoglobin of 9.6 g/dL, platelet count 58 × 103/µL, troponin < 0.03 ng/mL, lactic acid 2.5 mmol/L and with parameters indicative of hemolysis, evidenced by elevated lactate dehydrogenase, low haptoglobin and elevated bilirubin levels. Electrocardiography (EKG) demonstrated ST depression in leads I, aVL, V5 - V6 and T wave inversions in lead III and aVL, which were new compared to previous EKG. Peripheral blood smear indicated spherocytes. Direct antiglobulin test was positive for immunoglobulin G (IgG). Patient was admitted for ES and initially treated with oral prednisone 80 mg daily. He was also diagnosed with UA thought to be possibly secondary to ES. He then underwent cardiac stress test which showed mild reversible inferior apical ischemia. Cardiac catheterization revealed 95% stenosis of proximal left circumflex artery requiring single drug eluding stent placement and dual antiplatelet therapy. Patient continued to have anemia despite blood transfusions, although platelet count improved. Prednisone was transitioned to high-dose IV dexamethasone, and patient was also started on rituximab which resulted in stabilization of anemia. The presentation of ES with ACS is a rare occurrence. ACS can be challenging to manage as stent placement may be required followed by dual antiplatelet therapy. Treatment of ES involves steroids followed by rituximab, IV immunoglobulin (IVIG) or splenectomy for non-responsive cases. Early intervention and management can prevent mortality and morbidity.
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Affiliation(s)
- Saad Bin Jamil
- Department of Internal Medicine, St. Mary's Hospital, Waterbury, CT 06706, USA
| | - Iqra Patoli
- Department of Internal Medicine, St. Mary's Hospital, Waterbury, CT 06706, USA
| | - Mehrunissa Kazim
- Department of Internal Medicine, Holyoke Health Center, Holyoke, MA 01040, USA
| | - Syed Hassan Abbas
- Department of Internal Medicine, St. Mary's Hospital, Waterbury, CT 06706, USA
| | - Zain Ali
- Abington Memorial Hospital, Philadelphia, PA 19001, USA
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New-onset Evans syndrome associated with systemic lupus erythematosus after BNT162b2 mRNA COVID-19 vaccination. Int J Hematol 2021; 115:424-427. [PMID: 34687421 PMCID: PMC8536917 DOI: 10.1007/s12185-021-03243-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 10/15/2021] [Accepted: 10/17/2021] [Indexed: 12/13/2022]
Abstract
Evans syndrome presents as concurrent autoimmune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP). Systemic lupus erythematosus (SLE) is the most frequent autoimmune disorder associated with Evans syndrome. We herein report a case of new-onset Evans syndrome associated with SLE after BNT162b2 mRNA coronavirus disease 2019 (COVID-19) vaccination in a 53-year-old woman. Blood examination at diagnosis showed hemolytic anemia with a positive Coombs test and thrombocytopenia. Hypocomplementemia and the presence of lupus anticoagulant indicated a strong association with SLE. Prednisolone administration rapidly restored hemoglobin level and platelet count. This case suggests that mRNA COVID-19 vaccination may cause an autoimmune disorder. Physicians should be aware of this adverse reaction by mRNA COVID-19 vaccination and should consider the benefits and risks of vaccination for each recipient.
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MESH Headings
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/pathology
- Anemia, Hemolytic, Autoimmune/physiopathology
- Anemia, Hemolytic, Autoimmune/therapy
- Blood Transfusion
- Complement Inactivating Agents/therapeutic use
- Glucocorticoids/therapeutic use
- Hemoglobinuria, Paroxysmal/diagnosis
- Hemoglobinuria, Paroxysmal/pathology
- Hemoglobinuria, Paroxysmal/physiopathology
- Hemoglobinuria, Paroxysmal/therapy
- Humans
- Immunologic Factors/therapeutic use
- Rituximab/therapeutic use
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Affiliation(s)
- Sigbjørn Berentsen
- From the Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway (S.B.); and the Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.)
| | - Wilma Barcellini
- From the Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway (S.B.); and the Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan (W.B.)
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Rutherford M, Tran M, Salazar L, Iqbal F, Mazharuddin A, Camarena J. An Uncharacteristic Presentation of Evans Syndrome Following Treatment With Dupilumab. Cureus 2021; 13:e16658. [PMID: 34462689 PMCID: PMC8388236 DOI: 10.7759/cureus.16658] [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] [Accepted: 07/26/2021] [Indexed: 11/18/2022] Open
Abstract
Evans syndrome is a rare autoimmune disorder where patients develop autoimmune hemolytic anemia (AIHA), immune thrombocytopenia (ITP), and less commonly immune neutropenia. Patients typically present with fatigue, pallor, jaundice, petechiae, or epistaxis. A 27-year-old man with a history of atopic dermatitis for which he recently began treatment with dupilumab presented to the emergency department with a headache and blurry vision. Multiple Roth spots were seen on fundoscopic examination. Laboratory studies were consistent with warm AIHA, confirmed by a positive direct antiglobulin test (DAT), and severe thrombocytopenia. He was diagnosed with Evans syndrome. He was treated with corticosteroids, rituximab, and intravenous immunoglobulin (IVIG). His recovery was prolonged with the slow improvement of anemia and thrombocytopenia. This is an atypical presentation of Evans syndrome with isolated symptoms of new-onset blurry vision and headache along with the finding of Roth spots. Another interesting feature in the case is the recent use of dupilumab. Dupilumab is a monoclonal antibody that inhibits the T-helper cells type 2 (Th2) signaling pathway by blocking interleukin (IL)-4 and IL-13 binding. This alteration in the immune response could have a role in the development of Evans syndrome.
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Affiliation(s)
- Megan Rutherford
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, USA
| | - Minh Tran
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, USA
| | - Leonardo Salazar
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, USA
| | - Fatima Iqbal
- Department of Pathology and Laboratory Medicine, University of Texas Medical Branch, Galveston, USA
| | - Anam Mazharuddin
- Department of Ophthalmology and Visual Sciences, University of Texas Medical Branch, Galveston, USA
| | - Julieanna Camarena
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, USA
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Yang YC, Chen YY. Right heart thrombus-in-transit in a patient with Evans syndrome: A case report. Medicine (Baltimore) 2021; 100:e27009. [PMID: 34414994 PMCID: PMC8376335 DOI: 10.1097/md.0000000000027009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/05/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Right heart free-floating thrombus in the absence of structural heart disease or atrial fibrillation is rare. When it travels to the heart into the lung, called thrombus-in-transit, may cause cardiopulmonary collapse and sudden death. The clinical presentation varies from mild respiratory symptoms to sudden death; however, there are few clinical case reports of giant, free-floating thrombus in the right heart in an asymptomatic patient, and the optimal management options have not been established. PATIENT CONCERNS A 36-year-old Asian woman presented to the emergency department with complaints of worsening swelling of the left lower extremity over 12 hours. DIAGNOSIS Left leg deep vein thrombosis accompanied by an asymptomatic giant right atrial thrombus and pulmonary embolism with a rare autoimmune disease of Evans syndrome. INTERVENTIONS Emergent surgical thrombectomy under cardiopulmonary bypass for right atrial thrombus. OUTCOMES The postoperative course was uneventful, and she was discharged on the eighth postoperative day with normal heart function and mild tricuspid regurgitation. CONCLUSION An additional diagnostic workup in cases of deep vein thrombosis is necessary for the rapid diagnosis of right heart thrombus and pulmonary embolism without delay. This case report illustrates that early recognition of venous thromboembolism and emergent thrombectomy of right heart thrombus-in-transit is crucial to prevent mortality.
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Affiliation(s)
- Ya-Chen Yang
- Kaohsiung Chang Gung Memorial Hospital Education Department, Kaohsiung, Taiwan
| | - Yen-Yu Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Lafaurie M, Maquet J, Baricault B, Ekstrand C, Christiansen CF, Linder M, Bahmanyar S, Nørgaard M, Sailler L, Lapeyre-Mestre M, Sommet A, Moulis G. Risk factors of hospitalisation for thrombosis in adults with primary immune thrombocytopenia, including disease-specific treatments: a French nationwide cohort study. Br J Haematol 2021; 195:456-465. [PMID: 34386974 DOI: 10.1111/bjh.17709] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/30/2021] [Indexed: 12/12/2022]
Abstract
We aimed to assess the risk factors of venous thrombosis (VT) and arterial thrombosis (AT) in adults with primary immune thrombocytopenia (ITP), particularly in relation to treatments. The population comprised all incident primary ITP adults in France between 2009 and 2017 (FAITH cohort; NCT03429660) built in the national health database. Outcomes were the first hospitalisation for VT and AT. Multivariable Cox regression models included baseline risk factors, time-varying exposure to ITP drugs, splenectomy and to cardiovascular drugs. The cohort included 10 039 patients. A higher risk of hospitalisation for VT was observed with older age, history of VT, history of cancer, splenectomy [hazard ratio (HR) 3·23, 95% confidence interval (CI) 2·26-4·61], exposure to corticosteroids (HR 3·55, 95% CI 2·74-4·58), thrombopoietin-receptor agonists (TPO-RAs; HR 2·28, 95% CI 1·59-3·26) and intravenous immunoglobulin (IVIg; HR 2·10, 95% CI 1·43-3·06). A higher risk of hospitalisation for AT was observed with older age, male sex, a history of cardiovascular disease, splenectomy (HR 1·50, 95% CI 1·12-2·03), exposure to IVIg (HR 1·85, 95% CI 1·36-2·52) and TPO-RAs (HR 1·64, 95% CI 1·26-2·13). Rituximab was not associated with an increased risk. These findings help to estimate the risk of thrombosis in adult patients with ITP and to select treatment.
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Affiliation(s)
- Margaux Lafaurie
- Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France.,UMR 1027, INSERM, Toulouse University, Toulouse, France.,CIC 1436, Toulouse University Hospital, Toulouse, France
| | - Julien Maquet
- CIC 1436, Toulouse University Hospital, Toulouse, France.,Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
| | | | - Charlotta Ekstrand
- Centre for Pharmaco-Epidemiology, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | | | - Marie Linder
- Centre for Pharmaco-Epidemiology, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | - Shahram Bahmanyar
- Centre for Pharmaco-Epidemiology, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | - Mette Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Laurent Sailler
- CIC 1436, Toulouse University Hospital, Toulouse, France.,Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
| | - Maryse Lapeyre-Mestre
- Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France.,UMR 1027, INSERM, Toulouse University, Toulouse, France.,CIC 1436, Toulouse University Hospital, Toulouse, France
| | - Agnès Sommet
- Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France.,UMR 1027, INSERM, Toulouse University, Toulouse, France.,CIC 1436, Toulouse University Hospital, Toulouse, France
| | - Guillaume Moulis
- CIC 1436, Toulouse University Hospital, Toulouse, France.,Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
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Bilochvostenko MA, Ermens AAM, Fiets RB. Evans syndrome with auto-immune neutropenia. Int J Lab Hematol 2021; 44:61-62. [PMID: 34228400 DOI: 10.1111/ijlh.13650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/02/2021] [Accepted: 06/10/2021] [Indexed: 12/01/2022]
Affiliation(s)
| | - Anton A M Ermens
- Specialist Laboratory Medicine, Laboratory for ClinicalChemistry & Hematology, Amphia Hospital, Breda, Netherlands
| | - Roel B Fiets
- Department of internal medicine, Amphia Hospital, Breda, Netherlands
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43
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Rieger MJ, Stolz SM, Ludwig S, Benoit TM, Bissig M, Widmer CC, Schwotzer R, Müller AM, Nair G, Hegemann I, Manz MG, Schanz U. Daratumumab in rituximab-refractory autoimmune haemolytic anaemia. Br J Haematol 2021; 194:931-934. [PMID: 34180543 DOI: 10.1111/bjh.17655] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Max J Rieger
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Sebastian M Stolz
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Sabine Ludwig
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Tobias M Benoit
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Marina Bissig
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Corinne C Widmer
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Rahel Schwotzer
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Antonia M Müller
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Gayathri Nair
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Inga Hegemann
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Markus G Manz
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Urs Schanz
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
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44
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Egg D, Rump IC, Mitsuiki N, Rojas-Restrepo J, Maccari ME, Schwab C, Gabrysch A, Warnatz K, Goldacker S, Patiño V, Wolff D, Okada S, Hayakawa S, Shikama Y, Kanda K, Imai K, Sotomatsu M, Kuwashima M, Kamiya T, Morio T, Matsumoto K, Mori T, Yoshimoto Y, Dybedal I, Kanariou M, Kucuk ZY, Chapdelaine H, Petruzelkova L, Lorenz HM, Sullivan KE, Heimall J, Moutschen M, Litzman J, Recher M, Albert MH, Hauck F, Seneviratne S, Pachlopnik Schmid J, Kolios A, Unglik G, Klemann C, Snapper S, Giulino-Roth L, Svaton M, Platt CD, Hambleton S, Neth O, Gosse G, Reinsch S, Holzinger D, Kim YJ, Bakhtiar S, Atschekzei F, Schmidt R, Sogkas G, Chandrakasan S, Rae W, Derfalvi B, Marquart HV, Ozen A, Kiykim A, Karakoc-Aydiner E, Králíčková P, de Bree G, Kiritsi D, Seidel MG, Kobbe R, Dantzer J, Alsina L, Armangue T, Lougaris V, Agyeman P, Nyström S, Buchbinder D, Arkwright PD, Grimbacher B. Therapeutic options for CTLA-4 insufficiency. J Allergy Clin Immunol 2021; 149:736-746. [PMID: 34111452 DOI: 10.1016/j.jaci.2021.04.039] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/23/2021] [Accepted: 04/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Heterozygous germline mutations in cytotoxic T lymphocyte-associated antigen-4 (CTLA4) impair the immunomodulatory function of regulatory T cells. Affected individuals are prone to life-threatening autoimmune and lymphoproliferative complications. A number of therapeutic options are currently being used with variable effectiveness. OBJECTIVE Our aim was to characterize the responsiveness of patients with CTLA-4 insufficiency to specific therapies and provide recommendations for the diagnostic workup and therapy at an organ-specific level. METHODS Clinical features, laboratory findings, and response to treatment were reviewed retrospectively in an international cohort of 173 carriers of CTLA4 mutation. Patients were followed between 2014 and 2020 for a total of 2624 months from diagnosis. Clinical manifestations were grouped on the basis of organ-specific involvement. Medication use and response were recorded and evaluated. RESULTS Among the 173 CTLA4 mutation carriers, 123 (71%) had been treated for immune complications. Abatacept, rituximab, sirolimus, and corticosteroids ameliorated disease severity, especially in cases of cytopenias and lymphocytic organ infiltration of the gut, lungs, and central nervous system. Immunoglobulin replacement was effective in prevention of infection. Only 4 of 16 patients (25%) with cytopenia who underwent splenectomy had a sustained clinical response. Cure was achieved with stem cell transplantation in 13 of 18 patients (72%). As a result of the aforementioned methods, organ-specific treatment pathways were developed. CONCLUSION Systemic immunosuppressants and abatacept may provide partial control but require ongoing administration. Allogeneic hematopoietic stem cell transplantation offers a possible cure for patients with CTLA-4 insufficiency.
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Affiliation(s)
- David Egg
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany
| | - Ina Caroline Rump
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany
| | - Noriko Mitsuiki
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany
| | - Jessica Rojas-Restrepo
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany
| | - Maria-Elena Maccari
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany; Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany
| | - Charlotte Schwab
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany
| | - Annemarie Gabrysch
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany
| | - Klaus Warnatz
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany; Department of Rheumatology and Clinical Immunology, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany
| | - Sigune Goldacker
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany; Department of Rheumatology and Clinical Immunology, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany
| | | | - Daniel Wolff
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Satoshi Okada
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Seiichi Hayakawa
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Yoshiaki Shikama
- Division of Infection, Immunology and Infection, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Kenji Kanda
- Department of Pediatrics, Hikone Municipal Hospital, Shiga, Japan
| | - Kohsuke Imai
- Department of Community Pediatrics, Perinatal and Maternal Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Manabu Sotomatsu
- Department of Hematology/Oncology, Gunma Children's Medical Center, Shibukawa, Japan
| | - Makoto Kuwashima
- Department of Pediatrics, Kiryu Kosei General Hospital, Kiryū, Japan
| | - Takahiro Kamiya
- Department of Lifetime Clinical Immunology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomohiro Morio
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuaki Matsumoto
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takeshi Mori
- Department of Hematology and Oncology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Yuri Yoshimoto
- Department of Pediatrics, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Ingunn Dybedal
- Department of Hematology, Oslo University Hospital, Oslo, Norway
| | - Maria Kanariou
- Department of Immunology and Histocompatibility, Center for Primary Immunodeficiencies-Paediatric Immunology, Aghia Sophia Children's Hospital, Athens, Greece
| | - Zeynep Yesim Kucuk
- Division of Bone Marrow Transplantation and Immune Deficiency, Children's Hospital Medical Center, Cincinnati, Ohio
| | - Hugo Chapdelaine
- Division of Clinical Immunology, Montreal Clinical Research Institute, Montreal, Quebec, Canada
| | - Lenka Petruzelkova
- Department of Paediatrics, Motol University Hospital, Second Medical Faculty in Prague, Charles University, Prague, Czech Republic
| | - Hanns-Martin Lorenz
- Division of Rheumatology, Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Kathleen E Sullivan
- The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania
| | - Jennifer Heimall
- The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania
| | - Michel Moutschen
- Department of Infectious Diseases and General Internal Medicine, University Hospital of Liège
| | - Jiri Litzman
- Department of Clinical Immunology and Allergology, Medical Faculty, Masaryk University, Brno, Czech Republic; Department of Clinical Immunology and Allergology, St. Anne's University Hospital, Brno, Czech Republic
| | - Mike Recher
- Immunodeficiency Clinic, Medical Outpatient Unit and Immunodeficiency Lab, Department Biomedicine, University Hospital, Basel, Switzerland
| | - Michael H Albert
- Department of Pediatrics, Dr von Hauner Children's Hospital, University Hospital, Ludwig Maximilians Universität München, Munich, Germany
| | - Fabian Hauck
- Department of Pediatrics, Dr von Hauner Children's Hospital, University Hospital, Ludwig Maximilians Universität München, Munich, Germany
| | - Suranjith Seneviratne
- Institute of Immunology and Transplantation, Royal Free Hospital, University College London, London, United Kingdom
| | - Jana Pachlopnik Schmid
- Division of Immunology, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Antonios Kolios
- Department of Immunology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Gary Unglik
- Department of Clinical Immunology and Allergy, Royal Melbourne Hospital, Melbourne, Australia
| | - Christian Klemann
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany; Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany
| | - Scott Snapper
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Lisa Giulino-Roth
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Weill Cornell Medicine, New York, NY
| | - Michael Svaton
- Childhood Leukaemia Investigation Prague, Department of Paediatric Haematology and Oncology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Craig D Platt
- Division of Immunology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Sophie Hambleton
- Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, and Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, United Kingdom
| | - Olaf Neth
- Pediatric Infectious Diseases, Rheumatology and Immunology Unit, Hospital Virgen del Rocío/Instituto de Biomedicina de Sevilla, Sevilla, RECLIP, Spain
| | - Geraldine Gosse
- Montreal Clinical Research Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Steffen Reinsch
- Jena University Hospital, Pediatric Gastroenterology, Jena, Germany
| | - Dirk Holzinger
- Department of Pediatric Hematology-Oncology, University of Duisburg-Essen, Essen, Germany
| | - Yae-Jean Kim
- Division of Infectious Diseases and Immunodeficiency, Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shahrzad Bakhtiar
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Faranaz Atschekzei
- Department for Clinical Rheumatology and Immunology, Hannover Medical School, Hannover, Germany
| | - Reinhold Schmidt
- Department for Clinical Rheumatology and Immunology, Hannover Medical School, Hannover, Germany
| | - Georgios Sogkas
- Department for Clinical Rheumatology and Immunology, Hannover Medical School, Hannover, Germany
| | - Shanmuganathan Chandrakasan
- Division of Bone Marrow Transplant, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - William Rae
- Department of Immunology, University Hospital Southampton NHSFT, Southampton, United Kingdom; Southampton National Institute for Health Research Clinical Research Facility, University Hospital Southampton NHSFT, Southampton, United Kingdom
| | - Beata Derfalvi
- Division of Immunology, IWK Health Centre and Dalhousie University, Department of Pediatrics, Halifax, Nova Scotia, Canada
| | - Hanne Vibeke Marquart
- Department of Clinical Immunology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ahmet Ozen
- Marmara University School of Medicine, Division of Pediatric Allergy and Immunology, Istanbul, Turkey
| | - Ayca Kiykim
- Marmara University School of Medicine, Division of Pediatric Allergy and Immunology, Istanbul, Turkey
| | - Elif Karakoc-Aydiner
- Marmara University School of Medicine, Division of Pediatric Allergy and Immunology, Istanbul, Turkey
| | - Pavlína Králíčková
- Institute of Clinical Immunology and Allergy, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Godelieve de Bree
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Dimitra Kiritsi
- Department of Dermatology, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany
| | - Markus G Seidel
- Research Unit for Pediatric Hematology and Immunology, Division of Pediatric Hemato-Oncology, Department of Pediatric and Adolescent Medicine, Medical University Graz, Graz, Austria
| | - Robin Kobbe
- Division of Infectious Diseases, First Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jennifer Dantzer
- Division of Pediatric Allergy and Immunology, and Rheumatology, Department of Pediatrics, John Hopkins University School of Medicine, Baltimore, Md
| | - Laia Alsina
- Clinical Immunology and Primary Immunodeficiencies Unit, Pediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu and Institut de Recerca Sant Joan de Déu, Barcelona; Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Thais Armangue
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Vassilios Lougaris
- Pediatric Neuroimmunology Unit, Neurology Department, Sant Joan de Déu Children's Hospital, University of Barcelona, Barcelona, Spain
| | - Philipp Agyeman
- Pediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, Department of Clinical and Experimental Sciences, University of Brescia, ASST-Spedali Civili of Brescia, Brescia, Italy
| | - Sofia Nyström
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David Buchbinder
- Department of Clinical Immunology and Transfusion Medicine, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Peter D Arkwright
- Division of Pediatric Hematology, Children's Hospital of Orange County, Orange, Calif
| | - Bodo Grimbacher
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany; Department of Rheumatology and Clinical Immunology, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany; Institute of Immunology and Transplantation, Royal Free Hospital, University College London, London, United Kingdom; Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Royal Manchester Children's Hospital, Manchester, United Kingdom; German Center for Infection Research, Satellite Center Freiburg, Freiburg, Germany; Centre for Integrative Biological Signaling Studies, Albert Ludwig University of Freiburg, Freiburg, Germany; RESIST-Cluster of Excellence 2155 to Hannover Medical School, Satellite Center Freiburg, Freiburg, Germany.
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45
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Angelopoulos A, Kirkilesis G, Kakavia K, Papanikolaou P. Diagnosis of Evans syndrome. Pan Afr Med J 2021; 38:314. [PMID: 34285737 PMCID: PMC8265255 DOI: 10.11604/pamj.2021.38.314.22410] [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] [Received: 03/19/2020] [Accepted: 04/11/2020] [Indexed: 11/30/2022] Open
Abstract
This manuscript concerns the case of a patient hospitalized and diagnosed with Evans syndrome. She was hospitalized with signs of thrombocytopenia induced purpura, petechiae, ecchymosis and anemia. She was successfully treated with corticoids and blood transfusions. Our purpose is to explain her clinical presentation and the exams, we used in order to make the diagnosis of Evans syndrome, which requires great suspicion. Moreover, other diseases causing hemolytic anemia and thrombocytopenia must be excluded. We used laboratory tests (blood samples, Coombs examination and virologic test). Bone marrow examination took place twice. Evans syndrome is an autoimmune disease which is characterized by the coexistence of hemolytic anemia and immune-mediated thrombocytopenia. There is no typical clinical presentation. Its etiology is unknown and its therapy is generally poor. Diagnosis of Evans syndrome is very difficult and requires the exclusion of other diseases causing anemia and thrombocytopenia.
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Affiliation(s)
| | | | - Kiriaki Kakavia
- Department of Vascular Surgery, Laikon General Hospital, Athens, Greece
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46
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Grimes AB, Kim TO, Kirk SE, Flanagan J, Lambert MP, Grace RF, Despotovic JM. Refractory autoimmune cytopenias in pediatric Evans syndrome with underlying systemic immune dysregulation. Eur J Haematol 2021; 106:783-787. [PMID: 33570766 DOI: 10.1111/ejh.13600] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/10/2021] [Indexed: 01/03/2023]
Abstract
Evans syndrome is a rare but challenging disorder in children; and despite rapidly growing evidence for targetable systemic immune dysregulation driving these "idiopathic" autoimmune cytopenias, precision diagnosis and management remains sub-optimal among these patients. We analyzed retrospective clinical data for 60 pediatric ES patients followed at 3 large tertiary referral centers in the United States over a recent 6-year period and found that definable underlying systemic immune dysregulation was identified in only 42% of these patients throughout the course of clinical care. Median time from ES diagnosis to identification of the underlying systemic immune dysregulation disorder was 1.3 years (<1 month for rheumatologic disease, 2.3 years for CVID, 3.4 years for ALPS, and 7.4 years for monogenic disorders of immune regulation). Notably, a significantly higher percentage of patients in whom a definitive immune dysregulation disorder was ultimately identified required ≥3 cytopenia-directed therapies (92%) and also second- and third-line immunomodulatory agents (84%), vs those in whom no unifying immune dysregulation was diagnosed (65%, and 35%, respectively)-indicating that autoimmune cytopenias as a manifestation of systemic immune dysregulation are more treatment-refractory and severe. These data underline the importance of identifying the underlying systemic immune dysregulation and providing targeted therapy in pediatric ES.
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Affiliation(s)
- Amanda B Grimes
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Taylor O Kim
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Susan E Kirk
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Jonathan Flanagan
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Michele P Lambert
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rachael F Grace
- Harvard Medical School, Boston, MA, USA.,Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | - Jenny M Despotovic
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
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47
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Barcellini W, Fattizzo B. How I treat warm autoimmune hemolytic anemia. Blood 2021; 137:1283-1294. [PMID: 33512406 DOI: 10.1182/blood.2019003808] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 08/28/2020] [Indexed: 12/17/2022] Open
Abstract
Warm autoimmune hemolytic anemia (wAIHA) is caused by increased erythrocyte destruction by immunoglobulin G (IgG) autoantibodies, with or without complement activation. Antibody-dependent cell-mediated cytotoxicity by macrophages/activated lymphocytes occurs in the lymphoid organs and spleen (extravascular hemolysis). The ability of the bone marrow (BM) to compensate determines clinical severity. The different pathogenic mechanisms, their complex interplay, and changes over time may explain wAIHA's great clinical heterogeneity and unpredictable course. The disease may be primary, drug induced, or associated with lymphoproliferative neoplasms, autoimmune and infectious diseases, immunodeficiencies, solid tumors, or transplants. Therapeutic interventions include steroids, splenectomy, immunosuppressants, and rituximab; the latter is increasingly used in steroid-refractory cases based on evidence from the literature and a few prospective trials. We present 5 patient case studies highlighting important issues: (1) the diagnosis and proper use of steroid therapy, (2) the concerns about the choice between rituximab and splenectomy in second-line treatment, (3) the need of periodical re-evaluation of the disease to assess the possible evolution of relapsed/refractory cases in myelodysplastic and BM failure syndromes, and (4) the difficulties in managing cases of severe/acute disease that are at high risk of relapse. Incorporating novel targeted therapies into clinical practice will be an exciting challenge in the future.
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Affiliation(s)
- Wilma Barcellini
- Hematology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; and
| | - Bruno Fattizzo
- Hematology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; and
- Department of Oncology and Onco-hematology, University of Milan, Milan, Italy
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48
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Pincez T, Fernandes H, Leblanc T, Michel G, Barlogis V, Bertrand Y, Neven B, Chahla WA, Pasquet M, Guitton C, Marie-Cardine A, Pellier I, Armari-Alla C, Benadiba J, Blouin P, Jeziorski E, Millot F, Paillard C, Thomas C, Cheikh N, Bayart S, Fouyssac F, Piguet C, Deparis M, Briandet C, Dore E, Picard C, Rieux-Laucat F, Landman-Parker J, Leverger G, Aladjidi N. Long term follow-up of pediatric-onset Evans syndrome: broad immunopathological manifestations and high treatment burden. Haematologica 2021; 107:457-466. [PMID: 33440924 PMCID: PMC8804581 DOI: 10.3324/haematol.2020.271106] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Indexed: 11/12/2022] Open
Abstract
Pediatric-onset Evans syndrome (pES) is defined by both immune thrombocytopenic purpura (ITP) and autoimmune hemolytic anemia (AIHA) before the age of 18 years. There have been no comprehensive long-term studies of this rare disease, which can be associated to various immunopathological manifestations (IM). We report outcomes of the 151 patients with pES and more than 5 years of follow-up from the nationwide French prospective OBS’CEREVANCE cohort. Median age at final follow-up was 18.5 years (range, 6.8–50.0 years) and the median follow-up period was 11.3 years (range, 5.1–38.0 years). At 10 years, ITP and AIHA were in sustained complete remission in 54.5% and 78.4% of patients, respectively. The frequency and number of clinical and biological IM increased with age: at the age of 20 years, 74% had at least one clinical IM (cIM). A wide range of cIM occurred, mainly lymphoproliferation, dermatological, gastrointestinal/hepatic and pneumological IM. The number of cIM was associated with a subsequent increase in the number of second-line treatments received (other than steroids and immunoglobulins; hazard ratio 1.4, 95% Confidence Interval: 1.15–1.60, P=0.0002, Cox proportional hazards method). Survival at 15 years after diagnosis was 84%. Death occurred at a median age of 18 years (range, 1.7–31.5 years), and the most frequent cause was infection. The number of second-line treatments and severe/recurrent infections were independently associated with mortality. In conclusion, long-term outcomes of pES showed remission of cytopenias but frequent IM linked to high second-line treatment burden. Mortality was associated to drugs and/or underlying immunodeficiencies, and adolescents-young adults are a high-risk subgroup.
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Affiliation(s)
- Thomas Pincez
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux, France; Division of Pediatric Hematology-Oncology, Charles-Bruneau Cancer Center, Department of Pediatrics, Sainte-Justine University Hospital, Université de Montréal, Montréal, Québec
| | - Helder Fernandes
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux, France; Pediatric Oncology Hematology Unit, University Hospital, Plurithématique CIC (CICP), Centre d'Investigation Clinique (CIC) 1401, INSERM Bordeaux
| | - Thierry Leblanc
- Pediatric Hematology Unit, Robert Debré University Hospital, AP-HP, Paris
| | - Gérard Michel
- Department of Pediatric Hematology, La Timone Hospital, Marseille University Hospital, Marseille
| | - Vincent Barlogis
- Department of Pediatric Hematology, La Timone Hospital, Marseille University Hospital, Marseille
| | - Yves Bertrand
- Institute of Pediatric Hematology and Oncology, Lyon University Hospital, Lyon
| | - Bénédicte Neven
- Pediatric Immuno-Hematology and Rheumatology Department, Necker-Enfants Malades University Hospital, AP-HP, Paris, France; Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, Paris, France; Imagine Institute, UMR 1163 INSERM and Paris University, Paris
| | - Wadih Abou Chahla
- Department of Pediatric Hematology, Jeanne de Flandre Hospital, Lille University Hospital, Lille
| | - Marlène Pasquet
- Pediatric Oncology Immunology Hematology Unit, Children's University Hospital, Toulouse
| | - Corinne Guitton
- Department of Pediatrics, Bicêtre University Hospital, AP-HP, Le Kremlin-Bicêtre
| | - Aude Marie-Cardine
- Department of Pediatric Hematology and Oncology, Rouen University Hospital, Rouen
| | | | | | - Joy Benadiba
- Department of Hemato-Oncology Pediatric, Nice University Hospital, Nice
| | - Pascale Blouin
- Department of Pediatric Hematology-Oncology, Clocheville Hospital, Tours University Hospital, Tours
| | - Eric Jeziorski
- Pediatric Oncology Hematology Unit, Arnaud de Villeneuve University Hospital, Montpellier
| | - Frédéric Millot
- Department of Pediatric Hematology, Poitiers University Hospital, Poitiers
| | - Catherine Paillard
- Department of Pediatric Hematology and Oncology, Hautepierre University Hospital, Strasbourg
| | - Caroline Thomas
- Pediatric Hematology Unit, Nantes University Hospital, Nantes
| | - Nathalie Cheikh
- Department of Pediatric Hematology-Oncology, Besanc_on University Hospital, Besanc_on
| | - Sophie Bayart
- Pediatric Hematology Unit, Rennes University Hospital, Rennes
| | - Fanny Fouyssac
- Pediatric Hematology Unit, Nancy University Hospital, Nancy
| | - Christophe Piguet
- Pediatric Oncology Hematology Unit, Limoges University Hospital, Limoges
| | - Marianna Deparis
- Pediatric Oncology-Hematology Unit Department, Caen University Hospital, Caen
| | | | - Eric Dore
- Pediatric Unit, Clermont-Ferrand University Hospital, Clermont-Ferrand
| | - Capucine Picard
- Imagine Institute, UMR 1163 INSERM and Paris University, Paris, France; Study Center for Primary Immunodeficiencies, Necker-Enfants Malades University Hospital, AP-HP, Paris
| | - Frédéric Rieux-Laucat
- Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, Paris, France; Imagine Institute, UMR 1163 INSERM and Paris University, Paris
| | - Judith Landman-Parker
- Pediatric Oncology Immunology Hematology Unit, Armand-Trousseau University Hospital, AP-HP, Paris
| | - Guy Leverger
- Pediatric Oncology Immunology Hematology Unit, Armand-Trousseau University Hospital, AP-HP, Paris
| | - Nathalie Aladjidi
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux, France; Pediatric Oncology Hematology Unit, University Hospital, Plurithématique CIC (CICP), Centre d'Investigation Clinique (CIC) 1401, INSERM Bordeaux.
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49
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Djerrou Z, Chettoum A, Guedri K, Khatabi L, Boudjerda S, Djeffali R. Epidemiological profile, clinical, paraclinical, and evolutionary of adult autoimmune cytopenia cases in East of Algeria. JOURNAL OF APPLIED HEMATOLOGY 2021. [DOI: 10.4103/joah.joah_169_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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50
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Bashir BA, Othman SA, Malik AA. A rare haematological disorder in a Sudanese child: Evans syndrome, case report and literature review. Sudan J Paediatr 2021; 21:89-94. [PMID: 33879949 DOI: 10.24911/sjp.106-1583095341] [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: 11/11/2022]
Abstract
Evans syndrome is a condition in which autoimmune-mediated red blood cells and platelet destruction happens consecutively. It may be associated with a reduction in neutrophil count as a result of immune neutropenia. No sex preference is known and it presents in all ages and any ethnic cohort. Generally, this syndrome tends to be chronic and is characterised by remission and exacerbation. We document a case of the immune-mediated disease associated with Epstein-Barr virus infection in an 8-year-old boy from eastern Sudan who presented with both immune thrombocytopenia purpura and autoimmune haemolytic anaemia. Complete blood count and peripheral blood picture revealed features consistent with immune haemolytic anaemia (rouleaux formation and spherocytes) and thrombocytopenia. Direct anti-human globulin test and indirect anti-human globulin test were positive. Evans syndrome is a potentially life-threatening condition due to the concomitant existence with antiplatelet and anti-erythrocyte antibodies distinguished by a positive antiglobulin test and possibly linked to other autoimmune or lymphoproliferative diseases.
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Affiliation(s)
- Bashir Abdrhman Bashir
- Department of Hematology, Faculty of Medical Laboratory Sciences, Port Sudan Ahlia College, Port Sudan, Sudan
| | - Suhair A Othman
- Department of Pediatric, Faculty of Medicine, Red Sea University, Port Sudan, Sudan
| | - Amel Aziz Malik
- Department of Pediatric, Faculty of Medicine, Red Sea University, Port Sudan, Sudan
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