Autoimmunity in Waldenström's macroglobulinaemia

First Report of Severe Autoimmune Hemolytic Anemia During Eltrombopag Therapy in Waldenström Macroglobulinemia-Associated Thrombocytopenia

Autoimmune thrombocytopenia (ITP) and autoimmune hemolytic anemia (AIHA) can be observed in Waldenström macroglobulinemia (WM). The autoimmune disorders are primarily mediated by autoimmune monoclonal gammopathy, but drug-induced hemolysis should also be considered. Herein, we presented the case of a 63-year-old female WM patient complicated with ITP, who was admitted to our department with a complaint of abdominal pain. After first half of bortezomib/dexamethasone/rituximab (BRD) chemotherapy, her platelet level recovered, but subsequently decreased to extremely low level (around 1–2×10⁹/L), and the patient suffered from platelet transfusion refractoriness. During the management of refractory thrombocytopenia, the patient developed severe hemolytic anemia, and further tests confirmed warm AIHA. FcγRIIα polymorphism test showed that the patient had FcγRIIα-131RH, which implied that the AIHA may not be WM-related. Given the effects of ibrutinib in controlling WM, secondary AITP and AIHA, ibrutinib single treatment was started, which quickly corrected the thrombocytopenia within five days, but not hemolysis. With a relatively safe platelet level, eltrombopag was stopped, and the hemolysis relieved three days after eltrombopag withdrawal. This is the first report on eltrombopag-induced AIHA in the management of WM-associated ITP.

[Secondary ITP in adults]

Secondary forms of immune thrombocytopenia (ITP) represent approximately 20% of all ITP cases in adulthood and this rate increases with age. Since some causes may influence both the prognosis and outcome but also the management of ITP, a minimal workup must be performed at ITP diagnosis to look for an associated or underlying cause. Among adults, B-cell lymphomas and mainly chronic lymphocytic leukemia, systemic auto-immune diseases such as systemic lupus or primary immunodeficiencies mainly represented by common variable immunodeficiency are the most frequent causes of secondary ITP. Whereas first-line therapy used for secondary ITP is usually similar to the one commonly used in primary ITP and relies mostly on corticosteroids±intravenous immunoglobulin according to the severity of bleeding, second and third-line treatments must take into account the type and degree of activity of the underlying disease.

Multiple cystic lung lesions and autoimmune thrombocytopaenia developing after chemotherapy for pulmonary indolent B-cell lymphoma with plasmacytic differentiation

Among lung malignancies, primary pulmonary lymphoma is rare and many of them are indolent B-cell lymphomas. We describe a case of primary pulmonary indolent B-cell lymphoma with plasmacytic differentiation, which exacerbated with the manifestation of macroglobulinaemia and was successfully treated using chemotherapy. The patient subsequently developed pulmonary cysts and thrombocytopaenia due to autoimmune pathology and was successfully treated using prednisolone. This case suggests that in indolent B-cell lymphoma with plasmacytic differentiation, immunoglobulin M level should be carefully followed even if it is within the normal range at lymphoma onset. Additionally, new cystic pulmonary infiltrates that develop during the post-treatment follow-up of an indolent pulmonary B-cell lymphoma may indicate pulmonary lymphoma recurrence, but there is also a possibility of an immunological complication.

Isolated optic nerve, chiasm, and tract involvement in Bing-Neel Syndrome

Central nervous system infiltration of Waldenström's macroglobulinemia is referred to as Bing-Neel Syndrome. We describe 2 patients whose clinical presentation was due to isolated involvement of the anterior visual pathways. The mechanism of visual failure in Bing-Neel Syndrome may involve both infiltrative and autoimmune processes.

Immune thrombocytopenia in lymphoproliferative disorders

Lymphoproliferative disorders are recognized as a common cause of secondary immune thrombocytopenia (ITP). The mechanisms involved in the pathogenesis of ITP associated with lymphoproliferative disorders are heterogeneous and often linked to the presence and activity of the malignant clone. A better understanding of the responsible mechanisms leading to ITP in each disease may allow for targeted treatment decisions, avoiding unwarranted immunosuppression and bleeding complications.

Waldenstrom's Macroglobulinemia Presenting as Goodpasture's Syndrome

We report a case of Waldenstrom's macroglobulinemia (WM) presenting as classic Goodpasture's syndrome. Thrombocytopenia, an additional autoimmune phenomenon, further complicated the clinical course. Renal disease is well recognized in Waldenstrom's macroglobulinemia and other B-cell dyscrasias. Similarly, a wide spectrum of autoimmune-mediated conditions has been reported in association with paraproteinemia. However, rapidly progressive glomerulonephritis in association with antiglomerular basement membrane antibodies has never been reported as either an autoimmune or a renal manifestation of WM. This article reviews the current understanding of renal pathology and autoimmune phenomenon associated with WM.

Autoimmune hemolytic anemias, Evans' syndromes, and pure red cell aplasia in non-Hodgkin lymphomas

We analyzed 108 cases of non-CLL non-Hodgkin lymphoma (NHL) associated with autoimmune hemolytic anemia (AIHA) (+/- pure red cell aplasia (PRCA)) or Evans' syndrome. The analysis was based on cases reported in the literature, which were retrieved by means of Pubmed and Medline searches and of an original series of 121 patients with NHL as well as reference lists of papers in the field. The number of cases in various NHL subtypes was small (n = 6-25). Nevertheless, interesting and sometimes unexpected differences in sex prevalence, temporal relationship between onset of lymphoma and AIHA, stage of lymphoma, relative frequency of warm antibody-AIHA (WA-AIHA) and cold antibody (CA-AIHA), association with PRCA and response of AIHA to treatments were noted for various lymphoma entities. WA-AIHA was more frequent in B-cell lymphomas, while CA-AIHA and PRCA predominantly occurred in T-cell lymphomas. Anti-lymphoma treatment seemed to be more effective against AIHA than conventional therapy with steroids or immunoglobulin. Although generated by a literature survey, this compilation of data indicates a complex relation of lymphoma and AIHA and warrants more attention and specific studies.

Amyloidosis, Evans syndrome and management options of lymphoplasmacytic lymphoma

A 77-year-old man presented with Evans syndrome (ES), hard palate thickening, gastrointestinal (GI) hemorrhage, acute myocardial infarction (AMI) and pleural and pericardial effusions. The patient responded well to emergent ES treatment with high-dose steroids and intravenous immunoglobulin. Investigation revealed lymphoplasmacytic lymphoma (LPL) as well as amyloidosis in the hard palate, lymph nodes, and pericardium. Considering his age, non-myelosuppressive agents were administered, with the exception of dose-reduced cyclophosphamide. The patient developed neutropenic fever, atrial fibrillation and subsequently died. This report describes the first LPL patient with ES. LPL is generally an indolent disease. However, as in our patient, it can be life threatening because of its complications. ES contributed to his GI hemorrhage, severe anemia, and thus AMI at the time of presentation. Probable cardiac amyloidosis played a role in the latter phase (i.e. cardiac arrhythmia and hypotension during sepsis). Although rare, the presence of ES and amyloidosis should be investigated diligently in elderly LPL patients. Instead of aggressive myelosuppressive chemotherapy agents, targeted therapies might be considered in these fragile patients.

[Shouldn't the Achilles' heel be on the foot - regarding a clinical case]

Clinical suspicion is the bedrock of a thorough clinical work-up, and a review of the clinical files with no definitive diagnosis is a must. Such a review can uncover rare diagnoses, such as Waldenstrom's macroglobulinaemia, a proliferative B-cell disease characterised by medular infiltration and monoclonocal IgM production. 1% of these are biclonal. We present a case of a 74 year old patient diagnosed in October 2004 with acute cholecystitis. Surgical evaluation revealed bilateral pleural effusion with an inconclusive aetiology. Patient underwent a right pleurodesis in May 2005 and the aetiology remained inconclusive. The third evaluation, in July 2005, led to a final diagnosis of Waldenstrom's macroglobulinaemia.

IgM-enriched human intravenous immunoglobulin suppresses T lymphocyte functions in vitro and delays the activation of T lymphocytes in hu-SCID mice

Previous studies of an experimental human immunoglobulin preparation for intravenous use, containing normal pooled IgM (IVIgM), have shown its beneficial therapeutic effect in experimental autoimmune diseases. The mechanisms of its immunomodulatory activity remain however, poorly understood. In the experiments reported here, IVIgM inhibited the proliferation of various autonomously growing human lymphoid cell lines in vitro, as well as of MLR- and of PHA-stimulated human T-lymphocytes. These effects of IVIgM were observed at non-apoptotic concentrations and were stronger on a molar basis than those of normal pooled IgG for intravenous use (IVIg). Both preparations, when administered to SCID mice, repopulated with human peripheral blood mononuclear cells, delayed the expression of the early activation marker CD69 on both human CD4+ and CD8+ T-lymphocytes, activated by the mouse antigenic environment. The data obtained show that normal pooled human IgM exerts a powerful antiproliferative effect on T-cells that is qualitatively similar but quantitatively superior to that of therapeutic IVIg. Our results suggest that infusions with IVIgM might have a significant beneficial immunomodulating activity in patients with selected autoimmune diseases.