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Liu L, Hu C, Chen Z, Zhu S, Zhu L. Co-Occurring Thrombotic Thrombocytopenic Purpura and Autoimmune Hemolytic Anemia in a Child Carrying the Pathogenic SHOC2 c.4A>G (p.Ser2Gly) Variant. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e942377. [PMID: 38019730 PMCID: PMC10697549 DOI: 10.12659/ajcr.942377] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/21/2023] [Accepted: 11/11/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND RASopathies involve mutations in genes that encode proteins participating in the RAS-mitogen-activated protein kinase pathway and are a collection of multisystem disorders that clinically overlap. Variants in the SHOC2 gene have been reported in Noonan-like syndrome, which include distinct facial features, short stature, congenital cardiac defects, developmental delays, bleeding disorders, and loose anagen hair. This report is of a 7-year-old girl with the c.4A>G (p.Ser2Gly) variant of the SHOC2 gene, consistent with Noonan-like syndrome, with loose anagen hair, presenting with thrombotic thrombocytopenic purpura and autoimmune hemolytic anemia. CASE REPORT The child had a medical history of 7 hospitalizations at our institution. At the age of 2 months, she underwent surgical correction for ventricular and atrial septal defects. At the age of 2 years, tonsil and adenoid removal surgery was performed, followed by surgery for otitis media at age 5 years. At 7 years, she was hospitalized for the simultaneous occurrence of thrombotic thrombocytopenic purpura and autoimmune hemolytic anemia. The patient displayed short stature and mild intellectual disability. Notable facial features included sparse hair, mild frontal bossing, and low-set ears. Antinuclear antibody levels demonstrated a significant gradual shift. Through trio whole-exome sequencing, a c.4A>G (p.Ser2Gly) variation in the SHOC2 gene was identified. CONCLUSIONS Given the clinical information and genetic testing results, the patient's condition appeared to closely be a type of RASopathy. This report has highlighted the importance of physical, developmental, and genetic testing in children presenting with dysmorphism, developmental delay, and hematological abnormalities.
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Affiliation(s)
- Lijun Liu
- Department of Pediatric Intensive Care Unit, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, PR China
| | - Chanchan Hu
- Department of Pediatric Intensive Care Unit, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, PR China
| | - Zhenjie Chen
- Department of Pediatric Intensive Care Unit, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, PR China
| | - Shuzhen Zhu
- Department of Emergency, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, PR China
| | - Lvchang Zhu
- Department of Pediatric Intensive Care Unit, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, PR China
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Cavallaro F, Barcellini W, Fattizzo B. Antibody based therapeutics for autoimmune hemolytic anemia. Expert Opin Biol Ther 2023; 23:1227-1237. [PMID: 37874225 DOI: 10.1080/14712598.2023.2274912] [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: 07/11/2023] [Accepted: 10/20/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Autoimmune hemolytic anemia (AIHA) treatment has been revolutionized by the introduction of target therapies, mainly monoclonal antibodies (MoAbs). AREAS COVERED The anti-CD20 rituximab, which targets Ab production by B-cells, induces 80% of response in warm-type AIHA (wAIHA) and 50-60% in cold agglutinin disease (CAD). Other B-cell targeting MoAbs including ianalumab, povetacicept, and obexelimab are under active study. The anti-CD38 MoAb daratumumab has been used in several reports to target long-lived plasma-cells responsible for AIHA relapse, being effective even in multi-refractory cases. Anti-complement MoAbs will soon change the treatment paradigm in CAD; the anti-C1s sutimlimab rapidly increased Hb in more than 80% of the cases. Finally, MoAbs inhibiting the neonatal Fc receptor (FcRn), such as nipocalimab, can reduce the half-life of the pathogenic autoAbs, representing a promising treatment for wAIHA. EXPERT OPINION MoAbs offer the potential to improve efficacy by reducing toxicity. However, there is a huge need for clinical trials exploring response duration rather than short-term efficacy. Complement inhibitors and anti-FcRns do not abrogate autoAb production and are being developed as long-term therapies. Thus, the combination of B-cell/plasma cell targeting drugs deserves to be explored. On the other hand, their rapid efficacy should be exploited for the acute AIHA phase.
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Affiliation(s)
- Francesca Cavallaro
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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Marinho A, Delgado Alves J, Fortuna J, Faria R, Almeida I, Alves G, Araújo Correia J, Campar A, Brandão M, Crespo J, Marado D, Matos-Costa J, Oliveira S, Salvador F, Santos L, Silva F, Fernandes M, Vasconcelos C. Biological therapy in systemic lupus erythematosus, antiphospholipid syndrome, and Sjögren's syndrome: evidence- and practice-based guidance. Front Immunol 2023; 14:1117699. [PMID: 37138867 PMCID: PMC10150407 DOI: 10.3389/fimmu.2023.1117699] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 03/13/2023] [Indexed: 05/05/2023] Open
Abstract
Systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), and Sjögren's syndrome (SS) are heterogeneous autoimmune diseases. Severe manifestations and refractory/intolerance to conventional immunosuppressants demand other options, namely biological drugs, and small molecules. We aimed to define evidence and practice-based guidance for the off-label use of biologics in SLE, APS, and SS. Recommendations were made by an independent expert panel, following a comprehensive literature review and two consensus rounds. The panel included 17 internal medicine experts with recognized practice in autoimmune disease management. The literature review was systematic from 2014 until 2019 and later updated by cross-reference checking and experts' input until 2021. Preliminary recommendations were drafted by working groups for each disease. A revision meeting with all experts anticipated the consensus meeting held in June 2021. All experts voted (agree, disagree, neither agree nor disagree) during two rounds, and recommendations with at least 75% agreement were approved. A total of 32 final recommendations (20 for SLE treatment, 5 for APS, and 7 for SS) were approved by the experts. These recommendations consider organ involvement, manifestations, severity, and response to previous treatments. In these three autoimmune diseases, most recommendations refer to rituximab, which aligns with the higher number of studies and clinical experience with this biological agent. Belimumab sequential treatment after rituximab may also be used in severe cases of SLE and SS. Second-line therapy with baricitinib, bortezomib, eculizumab, secukinumab, or tocilizumab can be considered in SLE-specific manifestations. These evidence and practice-based recommendations may support treatment decision and, ultimately, improve the outcome of patients living with SLE, APS, or SS.
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Affiliation(s)
- António Marinho
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - José Delgado Alves
- Systemic Autoimmune Diseases Unit, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
- Immune Response and Vascular Disease Unit - iNOVA4Health, NOVA Medical School, Lisboa, Portugal
| | - Jorge Fortuna
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Raquel Faria
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Isabel Almeida
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Glória Alves
- Serviço de Medicina Interna, Hospital da Senhora da Oliveira - Centro Hospitalar Alto Ave, Guimarães, Portugal
| | - João Araújo Correia
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
- Serviço de Medicina Interna, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Ana Campar
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Mariana Brandão
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Jorge Crespo
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Daniela Marado
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - João Matos-Costa
- Serviço de Medicina Interna, Hospital Distrital de Santarém, Santarém, Portugal
| | - Susana Oliveira
- Systemic Autoimmune Diseases Unit, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Fernando Salvador
- Unidade de Doenças Autoimunes, Serviço de Medicina Interna, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Lelita Santos
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
- Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
- Linha de Investigação Clínica e Interdisciplinar em Meio Ambiente, Genética e Oncobiologia (CIMAGO), Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | - Fátima Silva
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Milene Fernandes
- Real-World Evidence & Late Phase, CTI Clinical Trial & Consulting Services Unipessoal Lda, Lisboa, Portugal
| | - Carlos Vasconcelos
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
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Tomasello R, Giordano G, Romano F, Vaccarino F, Siragusa S, Lucchesi A, Napolitano M. Immune Thrombocytopenia in Antiphospholipid Syndrome: Is It Primary or Secondary? Biomedicines 2021; 9:biomedicines9091170. [PMID: 34572358 PMCID: PMC8472578 DOI: 10.3390/biomedicines9091170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 08/31/2021] [Accepted: 09/03/2021] [Indexed: 02/05/2023] Open
Abstract
Antiphospholipid syndrome (APS) is frequently associated with thrombocytopenia, in most cases mild and in the absence of major bleedings. In some patients with a confirmed APS diagnosis, secondary immune thrombocytopenia (ITP) may lead to severe thrombocytopenia with consequent major bleeding. At the same time, the presence of antiphospholipid antibodies (aPL) in patients with a diagnosis of primary ITP has been reported in several studies, although with some specific characteristics especially related to the variety of antigenic targets. Even though it does not enter the APS defining criteria, thrombocytopenia should be regarded as a warning sign of a “high risk” APS and thus thoroughly evaluated. The presence of aPL in patients with ITP should be assessed as well to stratify the risk of paradoxical thrombosis. In detail, besides the high hemorrhagic risk in secondary thrombocytopenia, patients with a co-diagnosis of APS or only antibodies are also at risk of arterial and venous thrombosis. In this narrative review, we discuss the correlation between APS and ITP, the mechanisms behind the above-reported entities, in order to support clinicians to define the most appropriate treatment strategy in these patients, especially when anticoagulant or antiplatelet agents may be needed.
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Affiliation(s)
- Riccardo Tomasello
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90141 Palermo, Italy; (R.T.); (F.R.); (F.V.); (S.S.)
| | - Giulio Giordano
- Division of Internal Medicine, Hematology Service, Regional Hospital “A. Cardarelli”, 86100 Campobasso, Italy;
| | - Francesco Romano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90141 Palermo, Italy; (R.T.); (F.R.); (F.V.); (S.S.)
| | - Federica Vaccarino
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90141 Palermo, Italy; (R.T.); (F.R.); (F.V.); (S.S.)
| | - Sergio Siragusa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90141 Palermo, Italy; (R.T.); (F.R.); (F.V.); (S.S.)
| | - Alessandro Lucchesi
- Haematology Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori “Dino Amadori” (IRST), 47104 Meldola, Italy;
| | - Mariasanta Napolitano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90141 Palermo, Italy; (R.T.); (F.R.); (F.V.); (S.S.)
- Correspondence: ; Tel.: +39-0916554519; Fax: +39-0916554503
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Michalak SS, Olewicz-Gawlik A, Rupa-Matysek J, Wolny-Rokicka E, Nowakowska E, Gil L. Autoimmune hemolytic anemia: current knowledge and perspectives. Immun Ageing 2020; 17:38. [PMID: 33292368 PMCID: PMC7677104 DOI: 10.1186/s12979-020-00208-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 11/10/2020] [Indexed: 02/07/2023]
Abstract
Autoimmune hemolytic anemia (AIHA) is an acquired, heterogeneous group of diseases which includes warm AIHA, cold agglutinin disease (CAD), mixed AIHA, paroxysmal cold hemoglobinuria and atypical AIHA. Currently CAD is defined as a chronic, clonal lymphoproliferative disorder, while the presence of cold agglutinins underlying other diseases is known as cold agglutinin syndrome. AIHA is mediated by autoantibodies directed against red blood cells (RBCs) causing premature erythrocyte destruction. The pathogenesis of AIHA is complex and still not fully understood. Recent studies indicate the involvement of T and B cell dysregulation, reduced CD4+ and CD25+ Tregs, increased clonal expansions of CD8 + T cells, imbalance of Th17/Tregs and Tfh/Tfr, and impaired lymphocyte apoptosis. Changes in some RBC membrane structures, under the influence of mechanical stimuli or oxidative stress, may promote autohemolysis. The clinical presentation and treatment of AIHA are influenced by many factors, including the type of AIHA, degree of hemolysis, underlying diseases, presence of concomitant comorbidities, bone marrow compensatory abilities and the presence of fibrosis and dyserthropoiesis. The main treatment for AIHA is based on the inhibition of autoantibody production by mono- or combination therapy using GKS and/or rituximab and, rarely, immunosuppressive drugs or immunomodulators. Reduction of erythrocyte destruction via splenectomy is currently the third line of treatment for warm AIHA. Supportive treatment including vitamin supplementation, recombinant erythropoietin, thrombosis prophylaxis and the prevention and treatment of infections is essential. New groups of drugs that inhibit immune responses at various levels are being developed intensively, including inhibition of antibody-mediated RBCs phagocytosis, inhibition of B cell and plasma cell frequency and activity, inhibition of IgG recycling, immunomodulation of T lymphocytes function, and complement cascade inhibition. Recent studies have brought about changes in classification and progress in understanding the pathogenesis and treatment of AIHA, although there are still many issues to be resolved, particularly concerning the impact of age-associated changes to immunity.
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Affiliation(s)
- Sylwia Sulimiera Michalak
- Department of Pharmacology and Toxicology Institute of Health Sciences, Collegium Medicum, University of Zielona Gora, Zielona Góra, Poland.
| | - Anna Olewicz-Gawlik
- Department of Anatomy and Histology Institute of Health Sciences, Collegium Medicum, University of Zielona Gora, Zielona Góra, Poland
- Department of Infectious Diseases, Hepatology and Acquired Immune Deficiencies, Poznan University of Medical Sciences, Poznan, Poland
- Department of Immunology, Poznan University of Medical Sciences, Poznan, Poland
| | - Joanna Rupa-Matysek
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
| | - Edyta Wolny-Rokicka
- Department of Radiotherapy, Multidisciplinary Hospital, Gorzów Wielkopolski, Poland
| | - Elżbieta Nowakowska
- Department of Pharmacology and Toxicology Institute of Health Sciences, Collegium Medicum, University of Zielona Gora, Zielona Góra, Poland
| | - Lidia Gil
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
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