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Chatzikalil E, Kattamis A, Diamantopoulos P, Solomou EE. New-onset aplastic anemia after SARS-CoV-2 vaccination. Int J Hematol 2023; 118:667-681. [PMID: 37768509 DOI: 10.1007/s12185-023-03666-z] [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: 03/24/2023] [Revised: 09/02/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023]
Abstract
Aplastic anemia (AA) is a rare autoimmune disease. Drugs, viruses, and radiation are among the most common etiologic factors, and most cases have immune pathophysiology. SARS-CoV-2 vaccines have been linked with rare side effects, including cases of acquired aplastic anemia. Here we review all the reported cases of new-onset AA after SARS-CoV-2 vaccination, and discuss their clinical characteristics and management. 18 patients in these case reports had a median age of 58 years. The time from vaccination to onset of aplastic anemia ranged from 1 day to 7 months, with a median of 2.5 weeks. Seventeen patients were diagnosed with severe or very severe aplastic anemia post-vaccination and all patients received standard treatments for acquired aplastic anemia. Seventeen patients achieved a complete or partial response and only 1 patient died. Aplastic anemia can be considered a very rare SARS-CoV-2 vaccine-related adverse event, although a causative relationship has not been proven. Reporting cases of such uncommon post-vaccination events could help clinicians to consider aplastic anemia when pancytopenia is observed after vaccination. The benefits of SARS-Cov-2 vaccination are established, and reports of rare events serve only to increase awareness in daily clinical practice.
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Affiliation(s)
- Elena Chatzikalil
- Department of Pediatrics, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Antonis Kattamis
- Department of Pediatrics, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Panagiotis Diamantopoulos
- First Department of Internal Medicine, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Elena E Solomou
- Internal Medicine-Hematology, University of Patras Medical School, 26500, Rion, Greece.
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2
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Argüello Marina M, López Rubio M, Castilla García L. [Autoimmune haemolytic anaemia]. Med Clin (Barc) 2023; 160:30-38. [PMID: 36334945 DOI: 10.1016/j.medcli.2022.07.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 12/29/2022]
Abstract
Autoimmune haemolytic anaemias (AIHA) are acquired haematological disorders caused by increased peripheral erythrocyte destruction mediated by autoantibodies against erythrocyte antigens. They classified according to aetiology into primary and secondary, and according to the type of antibody and reaction temperature into AIHA due to warm antibodies (w-AIHA) and AIHA due to cold antibodies (c-AIHA). The mainstay of management in w-AIHA remains glucocorticoid therapy, and the early addition of rituximab has shown good results in recent studies. Primary c-AIHA is mainly treated with rituximab, alone or in combination with chemotherapy. New drugs such as Syk inhibitors, anti-FcRn Ig and complement inhibitors are in advanced development and will expand the therapeutic arsenal, especially in refractory or relapsed cases.
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Affiliation(s)
- María Argüello Marina
- Servicio de Hematología y Hemoterapia, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España.
| | - Montserrat López Rubio
- Servicio de Hematología y Hemoterapia, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España
| | - Lucía Castilla García
- Servicio de Hematología y Hemoterapia, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España
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3
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Jacobs JW, Booth GS, Guarente J, Schlafer D, Zheng L, Adkins BD. Autoimmune haemolytic anaemia and immune thrombocytopenia following SARS-CoV-2 and non-SARS-CoV-2 vaccination: 32 Years of passive surveillance data. Br J Haematol 2022; 201:227-233. [PMID: 36564040 PMCID: PMC9880651 DOI: 10.1111/bjh.18627] [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: 10/13/2022] [Revised: 12/11/2022] [Accepted: 12/14/2022] [Indexed: 12/25/2022]
Abstract
Autoimmune haemolytic anaemia (AIHA) and immune thrombocytopenia (ITP) are two uncommon haematologic autoimmune conditions that can rarely arise secondary to vaccination. Prior studies using the US Centers for Disease Control's (CDC) Vaccine Adverse Event Reporting System (VAERS) have demonstrated this infrequency, but contemporary data as well as comparison with current information regarding SARS-CoV-2 vaccination has not been assessed. In this study, we reviewed VAERS database reports from 1990 to 2022 to characterize the incidence and clinical and laboratory findings of non-SARS-CoV-2-associated AIHA and ITP and SARS-CoV-2 vaccine-associated AIHA and ITP. We discovered a total of 863 AIHA and ITP reports following vaccination with 15 non-SARS-CoV-2 and four SARS-CoV-2 vaccines submitted to the CDC VAERS database. AIHA and ITP reporting was low for both groups, with a large proportion excluded due to a lack of clinical details. ITP was reported the most frequently in both groups and was significantly more common with measles-mumps-rubella (MMR) vaccination (p < 0.001) in the non-SARS-CoV-2 group. AIHA and ITP cases were higher in the SARS-CoV-2 vaccine group, though ultimately still very infrequent. Autoimmune haematologic disease is vanishingly rare after immunization and rates are lower than in the general population according to passive reporting.
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Affiliation(s)
- Jeremy W. Jacobs
- Department of Laboratory Medicine, Yale School of MedicineNew HavenConnecticutUSA
| | - Garrett S. Booth
- Department of Pathology, Microbiology and ImmunologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Juliana Guarente
- Department of Pathology, Anatomy, and Cell BiologyThomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA
| | - Danielle Schlafer
- Department of Pharmaceutical Services, Emory HealthcareAtlantaGeorgiaUSA
| | - Leon Zheng
- Division of Transfusion Medicine, Harvard Medical SchoolBostonMassachusettsUSA
| | - Brian D. Adkins
- Division of Transfusion Medicine and Hemostasis, Department of PathologyUniversity of Texas SouthwesternDallasTexasUSA
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4
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COVID-19 in Patients with Hematologic Diseases. Biomedicines 2022; 10:biomedicines10123069. [PMID: 36551825 PMCID: PMC9775038 DOI: 10.3390/biomedicines10123069] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/22/2022] [Accepted: 11/25/2022] [Indexed: 12/02/2022] Open
Abstract
The COVID-19 outbreak had a strong impact on people's lives all over the world. Patients with hematologic diseases have been heavily affected by the pandemic, because their immune system may be compromised due to anti-cancer or immunosuppressive therapies and because diagnosis and treatment of their baseline conditions were delayed during lockdowns. Hematologic malignancies emerged very soon as risk factors for severe COVID-19 infection, increasing the mortality rate. SARS-CoV2 can also induce or exacerbate immune-mediated cytopenias, such as autoimmune hemolytic anemias, complement-mediated anemias, and immune thrombocytopenia. Active immunization with vaccines has been shown to be the best prophylaxis of severe COVID-19 in hematologic patients. However, the immune response to vaccines may be significantly impaired, especially in those receiving anti-CD20 monoclonal antibodies or immunosuppressive agents. Recently, antiviral drugs and monoclonal antibodies have become available for pre-exposure and post-exposure prevention of severe COVID-19. As adverse events after vaccines are extremely rare, the cost-benefit ratio is largely in favor of vaccination, even in patients who might be non-responders; in the hematological setting, all patients should be considered at high risk of developing complications due to SARS-CoV2 infection and should be offered all the therapies aimed to prevent them.
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5
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Kocivnik N, Velnar T. A Review Pertaining to SARS-CoV-2 and Autoimmune Diseases: What Is the Connection? LIFE (BASEL, SWITZERLAND) 2022; 12:life12111918. [PMID: 36431053 PMCID: PMC9698792 DOI: 10.3390/life12111918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/11/2022] [Accepted: 11/15/2022] [Indexed: 11/19/2022]
Abstract
Coronavirus disease 2019 (COVID-19) is an infectious viral disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). It is known that infection with SARS-CoV-2 can lead to various autoimmune and autoinflammatory diseases. There are few reports in the literature on the association between SARS-CoV-2 and autoimmune diseases, and the number of reports has been increasing since 2020. Autoimmune diseases and SARS-CoV-2 infections are intertwined in several ways. Both conditions lead to immune-mediated tissue damage, the immune response is accompanied by the increased secretion of inflammatory cytokines and both conditions can be treated using immunomodulatory drugs. Patients with certain autoimmune diseases, such as systemic lupus erythematosus, rheumatoid arthritis, type 1 diabetes, cardiac sarcoidosis, idiopathic pulmonary fibrosis, autoimmune hepatitis, multiple sclerosis and others, are more susceptible to SARS-CoV-2 infection, either because of the active autoimmune disease or because of the medications used to treat it. Conversely, SARS-CoV-2 infection can also cause certain autoimmune diseases. In this paper, we describe the development of autoimmune diseases after COVID-19 and the recovery from COVID-19 in people with autoimmune diseases.
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Affiliation(s)
- Nina Kocivnik
- Faculty of Pharmacy, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Tomaz Velnar
- Department of Neurosurgery, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
- Correspondence:
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6
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Wang X, Laczko D, Caponetti GC, Rabatin S, Babushok DV. Severe aplastic anaemia after serial vaccinations for SARS‐CoV‐2, pneumococcus and seasonal influenza. EJHAEM 2022; 3:983-988. [PMID: 35941884 PMCID: PMC9348402 DOI: 10.1002/jha2.443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/23/2022] [Accepted: 04/04/2022] [Indexed: 01/03/2023]
Abstract
We present a 67‐year‐old woman who developed progressive pancytopenia over 10 months, concomitant with administration of severe adult respiratory syndrome coronavirus‐2 (SARS‐CoV‐2), pneumococcal and influenza vaccines. She developed mild leukopenia ∼2 weeks after the SARS‐CoV‐2 mRNA vaccine sequence, with progressive symptoms after subsequent vaccines, eventually developing severe aplastic anaemia (SAA). While there have been several reports of vaccine‐related SAA, at time of submission, our case is the first reported to develop after the Moderna mRNA SARS‐CoV‐2 vaccine, as well as the first to document the gradual development of SAA over the course of many vaccine exposures. Physicians should be cognizant of vaccine‐associated SAA, considering current widespread coronavirus disease 2019 vaccination efforts.
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Affiliation(s)
- Xiao Wang
- Division of Hematology and Oncology Department of Medicine Hospital of the University of Pennsylvania Philadelphia Pennsylvania USA
| | - Dorottya Laczko
- Department of Pathology and Laboratory Medicine Hospital of the University of Pennsylvania Philadelphia Pennsylvania USA
| | - Gabriel C. Caponetti
- Department of Pathology and Laboratory Medicine Hospital of the University of Pennsylvania Philadelphia Pennsylvania USA
| | - Susan Rabatin
- Division of Hematology and Oncology Department of Medicine Hospital of the University of Pennsylvania Philadelphia Pennsylvania USA
| | - Daria V. Babushok
- Division of Hematology and Oncology Department of Medicine Hospital of the University of Pennsylvania Philadelphia Pennsylvania USA
- Comprehensive Bone Marrow Failure Center Children's Hospital of Philadelphia Philadelphia Pennsylvania USA
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Abstract
INTRODUCTION Autoimmune hemolytic anemia (AIHA) is classified according to the direct antiglobulin test (DAT) and thermal characteristics of the autoantibody into warm and cold forms, and in primary versus secondary depending on the presence of associated conditions. AREAS COVERED AIHA displays a multifactorial pathogenesis, including genetic (association with congenital conditions and certain mutations), environmental (drugs, infections, including SARS-CoV-2, pollution, etc.), and miscellaneous factors (solid/hematologic neoplasms, systemic autoimmune diseases, etc.) contributing to tolerance breakdown. Several mechanisms, such as autoantibody production, complement activation, monocyte/macrophage phagocytosis, and bone marrow compensation are implicated in extra-/intravascular hemolysis. Treatment should be differentiated and sequenced according to AIHA type (i.e. steroids followed by rituximab for warm, rituximab alone or in association with bendamustine or fludarabine for cold forms). Several new drugs targeting B-cells/plasma cells, complement, and phagocytosis are in clinical trials. Finally, thrombosis and infections may complicate disease course burdening quality of life and increasing mortality. EXPERT OPINION Beyond warm and cold AIHA, a gray-zone still exists including mixed and DAT negative forms representing an unmet need. AIHA management is rapidly changing through an increasing knowledge of the pathogenic mechanisms, the refinement of diagnostic tools, and the development of novel targeted and combination therapies.
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Affiliation(s)
- B Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - W Barcellini
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Ghimire A, Platnich J, Chauhan U. Warm Autoimmune Hemolytic Anemia and Pure Red Cell Aplasia during a Severe COVID-19 B.1.1.7 Infection. Infect Dis Rep 2022; 14:413-419. [PMID: 35735754 PMCID: PMC9223138 DOI: 10.3390/idr14030044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 05/24/2022] [Accepted: 05/30/2022] [Indexed: 11/23/2022] Open
Abstract
Warm autoimmune hemolytic anemia (AIHA) is a rare complication of COVID-19 infection. We report a case of warm AIHA in a patient with COVID-19 pneumonia treated with methylprednisolone and several red blood cell transfusions. Despite treatment of the warm AIHA, the patient’s reticulocyte count remained low, and his biochemical markers were suggestive of pure red cell aplasia, which was later attributed to a concurrent parvovirus B19 infection. This case highlights an unusual situation of two separate hematological processes caused by two separate and simultaneous viral infections.
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Affiliation(s)
- Anukul Ghimire
- Department of Medicine, University of Alberta, Edmonton, AB T6G 2G3, Canada;
- Correspondence:
| | - Jaye Platnich
- Department of Medicine, University of Alberta, Edmonton, AB T6G 2G3, Canada;
| | - Utkarsh Chauhan
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2R7, Canada;
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Fattizzo B, Bortolotti M, Giannotta JA, Consonni D, Cantoni S, Barcellini W. Seroconversion to mRNA SARS-CoV-2 vaccines in patients with autoimmune cytopenias and bone marrow failures. Sci Rep 2022; 12:7743. [PMID: 35546175 PMCID: PMC9093558 DOI: 10.1038/s41598-022-11857-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 04/28/2022] [Indexed: 12/17/2022] Open
Abstract
Data concerning the efficacy of SARS-CoV-2 vaccines in patients with non-oncological hematologic conditions are lacking. These include autoimmune cytopenias (autoimmune hemolytic anemia AIHA, immune thrombocytopenia ITP, and autoimmune neutropenia), and bone marrow failure syndromes (aplastic anemia, low risk myelodysplastic syndromes, and paroxysmal nocturnal hemoglobinuria). These conditions may relapse/reactivate after COVID-19 infection and vaccine. Moreover, they are mainly handled with immunosuppressive drugs that may hamper the response to vaccine. In this study, we prospectively evaluated the rate of seroconversion after mRNA SARS-CoV-2 vaccines in patients with autoimmune cytopenias or bone marrow failure syndrome after 2 ± 1 months from the last vaccine dose. Overall, 149 patients were tested and 135 (91%) seroconverted. The highest proportion of non-responders was observed in Evans syndrome (association of ITP and AIHA) and warm AIHA patients (p = 0.001), in those with lower levels of baseline serum IgG (p = 0.008), and in patients on active therapy with steroids (p = 0.03) who also had lower anti-Spike titers. The latter were inversely related with age, and a positively with lymphocyte counts. Additionally, patients who had received rituximab within 12 months from vaccination showed higher rates of non-response (p = 0.03) as compared to those treated before. Contrarily, cyclosporine alone, complement inhibitors, and bone marrow stimulating agents had no detrimental effect on seroconversion. These data suggest maintaining high vigilance and adherence to preventive/protective measures in this population since a proportion of cases may not respond or exhibit low anti-Spike titers.
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Affiliation(s)
- Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via Francesco Sforza 35, 20100, Milan, Italy.
- Department of Oncology and Oncohematology, University of Milan, Milan, Italy.
| | - Marta Bortolotti
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via Francesco Sforza 35, 20100, Milan, Italy
- Department of Oncology and Oncohematology, University of Milan, Milan, Italy
| | - Juri Alessandro Giannotta
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via Francesco Sforza 35, 20100, Milan, Italy
| | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Cantoni
- Dipartimento di Ematologia e Oncologia, Niguarda Cancer Center, ASST Ospedale Niguarda, Milan, Italy
| | - Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via Francesco Sforza 35, 20100, Milan, Italy
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10
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Mohammadien HA, Abudab LH, Ahmad AM. Evan syndrome as initial presentation of COVID-19 infection. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2022. [PMCID: PMC9066390 DOI: 10.1186/s43168-022-00125-x] [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] [Indexed: 08/30/2023] Open
Abstract
Background Evans’ syndrome (ES) is a rare and chronic autoimmune disease characterized by the concomitant or sequential association of auto-immune hemolytic anemia (AIHA) with immune thrombocytopenia (ITP), and less frequently autoimmune neutropenia with a positive direct anti-human globulin test. ES represents up to 7% of AIHA and around 2% of ITP. Studies have found that coronavirus disease 2019 (COVID-19) may be associated with various hematological complications, i.e., coagulopathies; however, finding of Evans syndrome is a novel case. Case report A 54-year-old diabetic man complaining of fever (high grade), arthralgia and myalgia, fatigue, and dark color of urine. He was admitted to isolation sector at Sohag General Hospital on day 6 because of fever with cough, dyspnea, and progressive fatigue, and at admission, he was tachypneic, tachycardiac, jaundiced, febrile (38 °C), and hypoxemic (O2 saturations on room air was 80%). Laboratory studies showed hemoglobin (Hb) 5.43 g/dL, high reticulocyte (12.5%), ↓ed platelet count (54 × 103/μl), hyperbilirubinemia and elevated C-reactive protein (CRP), D-dimer, ferritin, and lactate dehydrogenase. Markers of autoimmune diseases and screening for malignant diseases were negative. HRCT chest showed bilateral small-sized peripheral ground glass opacities in both lungs, with positive reverse transcriptase-polymerase chain reaction (RT-PCR) for SARS-CoV-2 RNA in the nasopharyngeal swab. Direct Coombs test was positive for immunoglobulin (IgG) and C3d. Evans syndrome secondary to COVID-19 was diagnosed and treatment with packed red cell (PRC) transfusions, favipiravir, dexamethasone, prednisone, ceftriaxone, enoxaparin, oral hypoglycemic, and oxygen using face mask, and then Hb value increased to 10.3 g/dL and he was discharged home without any complications. Conclusion There are few reports of patients with concurrent COVID-19 and Evans syndrome. So, SARS-CoV-2 infection should be considered in any patient presenting with new-onset ES of unclear etiology.
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Fattizzo B. Evans syndrome in the SARS-CoV-2 era: "springing up like mushrooms". BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2022; 20:89-93. [PMID: 34967726 PMCID: PMC8971015 DOI: 10.2450/2021.0224-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Bruno Fattizzo
- Haematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
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12
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13
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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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14
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Fattizzo B, Pasquale R, Bellani V, Barcellini W, Kulasekararaj AG. Complement Mediated Hemolytic Anemias in the COVID-19 Era: Case Series and Review of the Literature. Front Immunol 2021; 12:791429. [PMID: 34899761 PMCID: PMC8655106 DOI: 10.3389/fimmu.2021.791429] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 10/29/2021] [Indexed: 12/11/2022] Open
Abstract
The complex pathophysiologic interplay between SARS-CoV-2 infection and complement activation is the subject of active investigation. It is clinically mirrored by the occurrence of exacerbations of complement mediated diseases during COVID-19 infection. These include complement-mediated hemolytic anemias such as paroxysmal nocturnal hemoglobinuria (PNH), autoimmune hemolytic anemia (AIHA), particularly cold agglutinin disease (CAD), and hemolytic uremic syndrome (HUS). All these conditions may benefit from complement inhibitors that are also under study for COVID-19 disease. Hemolytic exacerbations in these conditions may occur upon several triggers including infections and vaccines and may require transfusions, treatment with complement inhibitors and/or immunosuppressors (i.e., steroids and rituximab for AIHA), and result in thrombotic complications. In this manuscript we describe four patients (2 with PNH and 2 with CAD) who experienced hemolytic flares after either COVID-19 infection or SARS-Cov2 vaccine and provide a review of the most recent literature. We report that most episodes occurred within the first 10 days after COVID-19 infection/vaccination and suggest laboratory monitoring (Hb and LDH levels) in that period. Moreover, in our experience and in the literature, hemolytic exacerbations occurring during COVID-19 infection were more severe, required greater therapeutic intervention, and carried more complications including fatalities, as compared to those developing after SARS-CoV-2 vaccine, suggesting the importance of vaccinating this patient population. Patient education remains pivotal to promptly recognize signs/symptoms of hemolytic flares and to refer to medical attention. Treatment choice should be based on the severity of the hemolytic exacerbation as well as of that of COVID-19 infection. Therapies include transfusions, complement inhibitor initiation/additional dose in the case of PNH, steroids/rituximab in patients with CAD and warm type AIHA, plasma exchange, hemodialysis and complement inhibitor in the case of atypical HUS. Finally, anti-thrombotic prophylaxis should be always considered in these settings, provided safe platelet counts.
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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
| | - Raffaella Pasquale
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Valentina Bellani
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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15
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Cecchi N, Giannotta JA, Barcellini W, Fattizzo B. A case of severe aplastic anaemia after SARS-CoV-2 vaccination. Br J Haematol 2021; 196:1334-1336. [PMID: 34783367 PMCID: PMC8652946 DOI: 10.1111/bjh.17947] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/23/2021] [Accepted: 10/26/2021] [Indexed: 12/23/2022]
Affiliation(s)
- Nicola Cecchi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Oncology and Onco-hematology, University of Milan, Milan, Italy
| | | | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Fattizzo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Oncology and Onco-hematology, University of Milan, Milan, Italy
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16
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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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17
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Fattizzo B, Giannotta JA, Cecchi N, Barcellini W. SARS-CoV-2 vaccination induces breakthrough hemolysis in paroxysmal nocturnal hemoglobinuria on complement inhibitor. Am J Hematol 2021; 96:E344-E346. [PMID: 34057236 PMCID: PMC8212106 DOI: 10.1002/ajh.26262] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 05/25/2021] [Accepted: 05/27/2021] [Indexed: 01/30/2023]
Affiliation(s)
- Bruno Fattizzo
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
- Department of Oncology and Oncohematology University of Milan Milan Italy
| | | | - Nicola Cecchi
- Department of Oncology and Oncohematology University of Milan Milan Italy
| | - Wilma Barcellini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
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18
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Pérez‐Lamas L, Moreno‐Jiménez G, Tenorio‐Núñez MC, Velázquez‐Kennedy K, Jiménez‐Chillón C, Astibia‐Mahillo B, Núñez‐Torrón C, García‐Gutiérrez V, Jiménez‐Martín A, Vallés‐Carboneras A, López‐Jiménez JF. Hemolytic crisis due to Covid-19 vaccination in a woman with cold agglutinin disease. Am J Hematol 2021; 96:E288-E291. [PMID: 33939851 PMCID: PMC8212117 DOI: 10.1002/ajh.26214] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 12/17/2022]
Affiliation(s)
- Lucía Pérez‐Lamas
- Department of Hematology Ramón y Cajal University Hospital – IRYCIS Madrid Spain
| | - Gemma Moreno‐Jiménez
- Department of Hematology Ramón y Cajal University Hospital – IRYCIS Madrid Spain
| | | | | | | | | | - Claudia Núñez‐Torrón
- Department of Hematology Ramón y Cajal University Hospital – IRYCIS Madrid Spain
| | | | - Ana Jiménez‐Martín
- Department of Hematology Ramón y Cajal University Hospital – IRYCIS Madrid Spain
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19
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Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with a variety of clinical manifestations related to viral tissue damage, as well as a virally induced immune response. Hyperstimulation of the immune system can serve as a trigger for autoimmunity. Several immune-mediated manifestations have been described in the course of SARS-CoV-2 infection. Immune thrombocytopenic purpura (ITP) and autoimmune hemolytic anemia (AIHA) are the most common hematologic autoimmune disorders seen in the course of SARS-CoV-2 infection. Vaccine-induced thrombocytopenia is a unique autoimmune hematologic cytopenia associated with SARS-CoV-2 vaccination. This paper will review the current literature on the association of SARS-CoV-2 infection and vaccination with autoimmune cytopenias and the clinical course of autoimmune cytopenias in patients with COVID-19.
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20
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Multiple drugs. REACTIONS WEEKLY 2021. [PMCID: PMC7954690 DOI: 10.1007/s40278-021-92459-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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