1
|
Abstract
OBJECTIVE To discover the common triggers for AIHA in children, their clinical profile, treatment response, and outcome. METHODS This was an ambispective descriptive study conducted between 2013 and 2020. Children aged 1 mo to 14 y with hemolytic anemia and a positive direct antiglobulin test (DAT) were included. Children with a positive DAT but without any clinicolaboratory evidence of hemolysis were excluded. Data were collected from a structured pro forma with particulars comprising clinicolaboratory profile, treatment administered, and disease outcome. RESULTS A total of 46 children (aged between 1 mo and 14 y) were enrolled in the study. The mean age of onset was 8.7 (± 4.34) y, and 24 (52.8%) were males. Secondary causes were observed in 29 (63%) cases, while the primary cause was found in 17 (37%). Systemic lupus erythematosus (SLE) was the common trigger in 13 (45%) cases, followed by malignancy in 4 (14%) cases. Pallor (98%), hepatomegaly (72%), and splenomegaly (48%) were the most commonly observed clinical signs. The mixed immunophenotype was observed in 27 (59%) cases, followed by warm type in 12 (26%) and cold agglutinin type in 7 (15%) cases. All children received glucocorticoid therapy, and mycophenolate mofetil was commonly used as second-line therapy in 15 (33%) cases. 13 cases (71%) of primary AIHA and only 4 (14%) cases of secondary anemia achieved complete remission. Overall, 7 children (15%) died, all belonging to secondary AIHA. CONCLUSION Secondary AIHA was more common than primary in the present study, and SLE was the standard trigger. Primary AIHA carries a better prognosis than secondary.
Collapse
Affiliation(s)
- Shrutiprajna Kar
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
| | - C G Delhi Kumar
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India.
| | - Rakhee Kar
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Abhishekh Basavarajegowda
- Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| |
Collapse
|
2
|
Arora H, Trivedi S, Jain P, Singhal U, Kaur A, Raina A. Collage of cases and brief review of the laboratory diagnosis and molecular testing in autoimmune haemolytic anaemia. J Family Med Prim Care 2024; 13:409-416. [PMID: 38605807 PMCID: PMC11006078 DOI: 10.4103/jfmpc.jfmpc_2131_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 04/10/2023] [Accepted: 04/17/2023] [Indexed: 04/13/2024] Open
Abstract
Autoimmune haemolytic anaemia (AIHA) is an acquired heterogenous clinical entity with variable presentations like acute haemolysis or mild, chronic haemolysis compounded with acute exacerbation in winters or fatal uncompensated haemolysis. A step-wise approach to the diagnosis and characterisation of AIHA should be undertaken, firstly the diagnosis of haemolysis followed by the establishment of immune nature with the aid of direct agglutination tests (DAT). Simultaneously the other causes of immune haemolysis need to be excluded too. In light of advancements in diagnostics, a wide array of investigations can be used like absolute reticulocyte count, bone marrow responsiveness index to establish the evidence of haemolysis, sensitive gel technology, enhanced DAT assays, e.g., modified DAT with low ionic strength saline solution (LISS) at 4°C, DAT assays utilizing reagents such as anti-IgA and anti-IgM and DAT by flowcytometry, to detect RBC bound autoantibodies (Abs) and monospecific DAT to establish immune causes of haemolysis and characterisation of the autoantibodies. The compensatory role of bone marrow and synchronous pathologies like clonal lymphoproliferation, dyserythropoiesis, fibrosis are important factors in the evolution of the disease and aid in the customisation of treatment modalities. The laboratory work up should aim to diagnose underlying diseases like chronic lymphoproliferative disorders, autoimmune disorders and infectious diseases. Also, tests like autoimmune lymphoproliferative syndromes (ALPS) screening panel and Next-generation sequencing (NGS) panel for RBC membrane disorders, RBC enzymopathies, and congenital dyserythropoietic aneamia have found their place. It is incumbent upon the clinicians to use the all-available diagnostic modalities for the accurate diagnosis, prognostication and customisation of the therapy.
Collapse
Affiliation(s)
- Harkiran Arora
- Department of Blood Bank and Transfusion Medicinet Attending Consultant, FMRI, Gurgaon, Haryana, India
| | - Shalini Trivedi
- Department of Pathology, E.S.I.C. Hospital and Dental College, Rohini, Sector-15A, New Delhi, India
| | - Pooja Jain
- Department of Pathology, E.S.I.C. Hospital and Dental College, Rohini, Sector-15A, New Delhi, India
| | - Udita Singhal
- Department of Pathology, E.S.I.C. Hospital and Dental College, Rohini, Sector-15A, New Delhi, India
| | - Arunpreet Kaur
- Department of Blood Bank and Transfusion Medicine, AIIMS, Raebarelli, Uttar Pradesh, India
| | - Aditi Raina
- Department of Pathology, Saraswati Institute of Medical Sciences, Hapur, Uttar Pradesh, India
| |
Collapse
|
3
|
Ilonze J, Kannan Loganathan P, Kumar R, Elliot C. Does strengths of a positive direct antiglobulin test predicts the need for phototherapy and duration of phototherapy? - a single center, retrospective study. J Matern Fetal Neonatal Med 2023; 36:2227910. [PMID: 38092424 DOI: 10.1080/14767058.2023.2227910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/16/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND Use of Direct Antiglobulin test (DAT) in management of neonatal hyperbilirubinemia is conflicting. OBJECTIVE whether strength of positive DAT predicts the need for phototherapy, duration of phototherapy and need for major interventions. METHODS We retrospectively collected data on all DAT positive neonates with birth gestational age ≥32 weeks over six years (2014-2019). Data regarding blood group, DAT and clinical details were obtained from a hospital database. We also collected data on serial hemoglobin and other relevant laboratory parameters. We also collected data on infants receiving major interventions such as exchange transfusion, in-utero transfusion, immunoglobulins, and postnatal transfusion for the duration of the study period. All of these infants were electronically followed up for a period of 6 weeks. This study was approved by institutional audit authority. All the statistics were performed using SPSS software. RESULTS Out of 1285 DAT tests performed, only 91 infants were positive (7%), and 78 DAT positive infants were available for analysis. There were 54 infants with DAT (1+), 15 infants with DAT (2+), 7 infants with DAT (3+) and 2 infants with DAT (4+). There was no significant statistical difference in terms of need for phototherapy, duration of phototherapy, need for major interventions and hemoglobin levels at different time points between the groups (DAT 1+ Vs DAT ≥2+; DAT ≤2+ Vs DAT >2). A Total of 10 infants received major intervention, with one infant receiving all three interventions (DAT 3+ with significant maternal antibodies), 2 additional infants (both DAT1+) received exchange transfusion, 6 additional infants received immunoglobulin (2 infants: DAT 2+; 4 infants: DAT 1+) and one additional infant (DAT 1+) with significant maternal antibodies received a postnatal transfusion. CONCLUSION Strength of a DAT did not predict the need for phototherapy, duration of phototherapy, and the need for major hemolysis related intervention in the first 6 weeks of life.
Collapse
Affiliation(s)
- Jennifer Ilonze
- Neonatal Unit, James Cook University Hospital, Middlesbrough, UK
| | - Prakash Kannan Loganathan
- Neonatal Unit, James Cook University Hospital, Middlesbrough, UK
- Clinical Academic office, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Department of Physics, University of Durham, Durham, UK
| | - Rohit Kumar
- Neonatal Unit, James Cook University Hospital, Middlesbrough, UK
| | - Chris Elliot
- Transfusion, South Tees Pathology, James Cook University Hospital, Middlesbrough, UK
| |
Collapse
|
4
|
Duan L, Chen P, Tu N, Hu H. Clinical value of combination detection of direct antiglobulin test and serum albumin globulin ratio in severe hyperbilirubinemia caused by ABO hemolytic disease of the newborn. J Matern Fetal Neonatal Med 2023; 36:2228965. [PMID: 37369373 DOI: 10.1080/14767058.2023.2228965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 04/11/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023]
Abstract
Background To explore of a combination of antiglobulin test(DAT) and albumin globulin ratio(AGR) could predict the severity of ABO hemolytic disease of the newborn(ABO-HDN).Methods The measurement of DAT, AGR and combination detection of DAT and AGR was done to predict severe ABO-HDN hyperbilirubinemia in 270 full-term infants based on whether the infants received transfusions of blood components. The infants were divided into three groups according to the results of DAT and ARG and compared the differences of phototherapy day and hospitalization day of the three groups.Results Of the 270 cases enrolled in this study, 69 infants were DAT positive. Peak total bilirubin, AGR, and positive DAT were independently associated with the need for blood components transfusion. ROC curve analysis for blood components transfusion showed that DAT cutoff value >± with a sensitivity of 39.4% and a specificity of 83.9%, AGR cutoff value <2.05 with a sensitivity of 54.1% and a specificity of 85.7%, and combination detection of DAT and ARG with a sensitivity of 62.1% and a specificity of 91.2%. The AUCs for DAT, AGR, and combination detection of DAT and AGR were .621, .740, and .750 respectively. The phototherapy day and hospitalization day were significantly longer in group of AGR <2.05 and DAT >± than that of a group of AGR <2.05 and group of DAT >±.Conclusions DAT and ARG could be early predictors for the severity ABO-HDN hyperbilirubinemia and combination detection of DAT and AGR could further increase its predictive value.
Collapse
Affiliation(s)
- Ling Duan
- Department of Blood Transfusion, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei, China
| | - Ping Chen
- Department of Blood Transfusion, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei, China
| | - Na Tu
- Department of Clinical Laboratory, Wuhan Prevention and Treatment Center for Occupational Diseases, Wuhan, Hubei, China
| | - Hongbing Hu
- Department of Blood Transfusion, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei, China
| |
Collapse
|
5
|
Paccoud O, Chamillard X, Kendjo E, Vinatier I, Surgers L, Magne D, Wyplosz B, Angoulvant A, Bouchaud O, Izri A, Matheron S, Houzé S, Thellier M, Ndour AP, Buffet P, Caumes E, Jauréguiberry S. Favorable outcome without corticosteroids during post-artesunate delayed hemolysis with positive direct antiglobulin test in severe imported Plasmodium falciparum malaria, France. Int J Infect Dis 2023; 137:144-148. [PMID: 37926196 DOI: 10.1016/j.ijid.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/25/2023] [Accepted: 10/21/2023] [Indexed: 11/07/2023] Open
Abstract
OBJECTIVES Positive direct antiglobulin tests (DATs) have been reported in cases of post-artesunate delayed hemolysis (PADH), but the causal role of auto-immune hemolysis remains unclear. We aimed to analyze a cohort of patients with PADH and DAT during severe malaria. METHODS We describe PADH and DAT results in a 7-year multi-center retrospective cohort of patients receiving artesunate for severe imported malaria. RESULTS Of 337 patients treated with artesunate, 46 (13.6%) had at least one DAT result within 30 days of treatment initiation, and 25/46 (54.3%) had at least one positive DAT. Among 40 patients with available data, 17 (42.5%) experienced PADH. Patient characteristics were similar for patients with a positive or negative DAT, and DAT positivity was not associated with PADH occurrence (P = 0.36). Among patients, 5/13 (38.5%) with a positive DAT after day 7 experienced PADH, compared to 10/13 (76.9%) of those with a negative DAT after day 7 (P = 0.11). Overall, 41% of patients required blood transfusions, and outcome was favorable without corticosteroids, even in cases of PADH. CONCLUSIONS DAT does not appear to be a marker of PADH, but rather an indirect marker of an immune-mediated mechanism. DAT positivity should not lead to the administration of systemic corticosteroids during PADH.
Collapse
Affiliation(s)
- Olivier Paccoud
- Sorbonne Université, Assistance Publique des Hôpitaux de Paris (AP-HP), Service des Maladies Infectieuses et Tropicales, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Xavier Chamillard
- Etablissement Français du Sang (EFS) Ile-de-France, Laboratoire de Biologie Médicale de l'EFS Ile-de-France, Paris, France
| | - Eric Kendjo
- Centre National de Référence du Paludisme (NRC-M), Paris, France
| | - Isabelle Vinatier
- Etablissement Français du Sang (EFS) Ile-de-France, Laboratoire de Biologie Médicale de l'EFS Ile-de-France, Paris, France
| | - Laure Surgers
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, Paris, France; Sorbonne Université, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service des Maladies Infectieuses et Tropicales, Paris, France
| | - Denis Magne
- Sorbonne Université, Assistance Publique des Hôpitaux de Paris (AP-HP), Laboratoire de Mycologie et Parasitologie, Hôpital Saint-Antoine, Paris, France
| | - Benjamin Wyplosz
- Université de Paris Saclay, Assistance Publique des Hôpitaux de Paris (AP-HP), Service des Maladies Infectieuses et Tropicales, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
| | - Adéla Angoulvant
- Université de Paris Saclay, Assistance Publique des Hôpitaux de Paris (AP-HP), Laboratoire de Mycologie et Parasitologie, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
| | - Olivier Bouchaud
- Université Sorbonne Paris Nord, Assistance Publique des Hôpitaux de Paris (AP-HP), Service des Maladies Infectieuses et Tropicales, Hôpital Avicenne, Bobigny, France; Société Française de Médecine des Voyages
| | - Arezki Izri
- Université Sorbonne Paris Nord, Assistance Publique des Hôpitaux de Paris (AP-HP), Laboratoire de Mycologie et Parasitologie, Hôpital Avicenne, Bobigny, France
| | - Sophie Matheron
- Université de Paris, Assistance Publique des Hôpitaux de Paris (AP-HP), Service des Maladies Infectieuses et Tropicales, Hôpital Bichat Claude Bernard, Paris, France
| | - Sandrine Houzé
- Université de Paris, IRD, MERIT, Paris, France; Université de Paris, Assistance Publique des Hôpitaux de Paris (AP-HP), Laboratoire de Mycologie et Parasitologie, Hôpital Bichat Claude Bernard, Paris, France
| | - Marc Thellier
- Centre National de Référence du Paludisme (NRC-M), Paris, France; Sorbonne Université, Assistance Publique des Hôpitaux de Paris (AP-HP), Laboratoire de Mycologie et Parasitologie, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Alioune P Ndour
- Université de Paris, INSERM, Biologie Intégrée du Globule Rouge, Laboratoire d'excellence GR-Ex, France
| | - Pierre Buffet
- Université de Paris, INSERM, Biologie Intégrée du Globule Rouge, Laboratoire d'excellence GR-Ex, France
| | - Eric Caumes
- Sorbonne Université, Assistance Publique des Hôpitaux de Paris (AP-HP), Service des Maladies Infectieuses et Tropicales, Hôpital de la Pitié-Salpêtrière, Paris, France; Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, Paris, France; Société Française de Médecine des Voyages
| | - Stéphane Jauréguiberry
- Centre National de Référence du Paludisme (NRC-M), Paris, France; Université de Paris Saclay, Assistance Publique des Hôpitaux de Paris (AP-HP), Service des Maladies Infectieuses et Tropicales, Hôpital de Bicêtre, Le Kremlin Bicêtre, France; Société Française de Médecine des Voyages; Université de Paris Saclay, INSERM, Centre de Recherche en Epidémiologie et Santé des Populations, Villejuif, France.
| |
Collapse
|
6
|
Sekhar Das S, Chaudhuri K, Mukherjee S. Clinical and immunohematological characterization of autoimmune hemolytic anemia in children. Transfus Apher Sci 2023:103703. [PMID: 36934038 DOI: 10.1016/j.transci.2023.103703] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/17/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023]
Abstract
Autoimmune Hemolytic Anemia (AIHA) in childhood is uncommon and estimated to be three per million annually under 18 years of age. Detailed immunohematological and clinical characterizations are essential for correct diagnosis of the disease and its management. In this study we described AIHA in children with regards to patient demography, underlying etiology, disease classification, antibody characterization, clinical features, degree of in vivo hemolysis and transfusion management. The prospective observational study was conducted over a period of 6 years and included 29 children with newly diagnosed AIHA. Patient details were obtained from the hospital information system and patient treatment file. The median age of the children was 12 years with a female preponderance. Secondary AIHA was observed in 62.1% patients. The mean hemoglobin and reticulocyte were 7.1 gm/dL and 8.8 percentages respectively. The median polyspecific direct antiglobulin test (DAT) grading was 3+. Red cell bound multiple autoantibodies were found in 27.6% children. Free serum autoantibodies were present in 62.1% patients. Twenty six of the 42 units transfused were "best match" or "least incompatible". Follow-up of 21 children showed clinical and laboratory improvement with DAT still positive at the end of 9 months. AIHA in childhood requires advanced and efficient clinical, immunohematological and transfusion support. Detailed characterization of AIHA is important, as they determine degree of in vivo hemolysis, disease severity, serological incompatibility and necessity of blood transfusion. Although blood transfusion in AIHA is a challenge but it should not be withheld in critically ill patients.
Collapse
Affiliation(s)
- Sudipta Sekhar Das
- Department of Transfusion Medicine, Apollo Multispeciality Hospitals, Kolkata 700054, India.
| | | | - Sourav Mukherjee
- Department of Transfusion Medicine, Apollo Multispeciality Hospitals, Kolkata 700054, India
| |
Collapse
|
7
|
Singh L, Prinja N, Jain A, Sharma RR, Marwaha N. Impact of buffy coat reduction on the severity of febrile nonhemolytic transfusion reactions with red cell components. Asian J Transfus Sci 2023; 17:69-73. [PMID: 37188007 PMCID: PMC10180807 DOI: 10.4103/ajts.ajts_90_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/21/2022] [Accepted: 09/11/2022] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Febrile nonhemolytic transfusion reactions (FNHTRs) are the most common adverse reaction reported under the Haemovigilance Programme of India, and the use of leukodepleted blood products is recommended. The severity of the reaction may affect the morbidity associated with the reaction. This study aims to calculate the incidence of various transfusion reactions in our blood center and to evaluate the impact of buffy coat reduction on the severity of febrile reaction and other hospital resource-consuming activities. MATERIALS AND METHODS It was an observational retrospective study in which all reported FNHTRs were evaluated during the period July 1, 2018-July 31, 2019. Patient demographic details, component transfused, and clinical presentation were analyzed to identify factors affecting the severity of FNHTRs. RESULTS The incidence of transfusion reaction in our study period was 0.11%. Out of total 76 reactions reported, 34 (44.7%) were febrile reactions. Other reactions included allergic reactions (36.8%), pulmonary reactions (9.2%), transfusion-associated hypotension (3.9%), and others (2.7%). The incidence of FNHTR in buffy coat-depleted packed red blood cells (PRBCs) and PRBCs is 0.03% and 0.05%, respectively. FNHTRs are seen more in females with prior history of transfusion (87.5%) as compared to males (66.67%) (P = 0.046). We also found that FNHTRs are less severe with buffy coat-depleted PRBC transfusion than PRBC transfusion as mean ± standard deviation temperature rise was less in buffy coat-depleted PRBC (1.3 ± 0.8) than PRBC (1.74 ± 1.129). The febrile response to buffy coat-depleted PRBC transfusion occurred at higher volume (145 ml) transfusion than PRBC transfusion (87.2 ml), and it was statistically significant (P = 0.047). CONCLUSION AND SUMMARY Leukoreduction remains the main modality to prevent FNHTR, but in developing countries like India, the use of buffy coat-depleted PRBC over PRBC can reduce the incidence and severity of FNHTR.
Collapse
Affiliation(s)
| | - Nippun Prinja
- Department of Transfusion Medicine, PGIMER, Chandigarh, India
| | - Ashish Jain
- Department of Transfusion Medicine, PGIMER, Chandigarh, India
| | | | - Neelam Marwaha
- Department of Transfusion Medicine, PGIMER, Chandigarh, India
| |
Collapse
|
8
|
Rikitake J, Kakiuchi S, Takagi I, Kagebayashi M, Tomida K, Yoshida T, Hara S, Iwata N, Kamesaki T. [Autoimmune hemolytic anemia complicated with acute kidney injury and tubulopathy due to hemoglobin casts]. Rinsho Ketsueki 2023; 64:91-96. [PMID: 36990738 DOI: 10.11406/rinketsu.64.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
A 62-year-old male patient was admitted for close monitoring of anemia (hemoglobin level, 8.2 g/dl). Hemolytic anemia was observed; however, the direct antiglobulin test (DAT) result (standard tube method) was negative. Nevertheless, autoimmune hemolytic anemia (AIHA) was still suspected; therefore, a DAT (Colum method) and quantifying levels of red-blood-cell bound immunoglobulin G were performed, resulting in a definite diagnosis of warm AIHA. The patient also had an acute kidney injury (AKI) from the time of admission, which was poorly improved by supplemental fluids therapy alone. Therefore, renal biopsy was performed. Renal biopsy revealed acute tubular injury due to hemoglobin columns, and a diagnosed AKI caused by hemolysis due to AIHA. Following the definitive diagnosis of AIHA, the patient was treated with prednisolone, and after approximately 2 weeks, the anemia and nephropathy completely improved, which is maintained to this day. We report this case as a rare case of AKI induced by hemolysis of AIHA and a successful case of renal salvage by early administration of steroid.
Collapse
Affiliation(s)
| | | | - Ikumi Takagi
- Department of Hematology, Yodogawa Christian Hospital
| | | | - Kodo Tomida
- Department of Nephrology, Yodogawa Christian Hospital
| | | | - Shigeo Hara
- Department of Pathology, Kobe City Medical Center General Hospital
| | - Nobuko Iwata
- Department of Hematology, Yodogawa Christian Hospital
| | - Toyomi Kamesaki
- Division of Support in Community Medicine, Jichi Medical University
| |
Collapse
|
9
|
Matsuura H, Fujii S, Matsui Y, Sugiura Y, Akiyama H, Miura Y. An association between a positive direct antiglobulin test and HLA-DR12 in COVID-19. Ann Hematol 2022; 101:1959-1969. [PMID: 35833981 PMCID: PMC9281373 DOI: 10.1007/s00277-022-04921-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/28/2022] [Indexed: 12/02/2022]
Abstract
SARS-CoV-2 infection has been reported to be associated with a positive direct antiglobulin test (DAT). In this study, an analysis of 40 consecutive coronavirus disease 2019 (COVID-19) cases from December 2020 to September 2021 in Japan revealed that patients of 70 years and over were predisposed to a positive DAT. DAT positivity was related to a decrease in the hemoglobin level. Anemia in DAT-positive COVID-19 patients was attributed to hemolysis, which was corroborated by high reticulocyte counts and an increase in the red blood cell distribution width. Human leukocyte antigen (HLA)-DRB1*12:01 and DRB1*12:02 were exclusively found in DAT-positive COVID-19 patients. In silico assays for the Spike protein of SARS-CoV-2 predicted several common core peptides that met the criteria for a B cell epitope and strong binding to both HLA-DRB1*12:01 and DRB1*12:02. Among these peptides, the amino acids sequence TSNFR, which is found within the S1 subunit of SARS-CoV-2 Spike protein, is shared by human blood group antigen Rhesus (Rh) CE polypeptides. In vitro analysis showed that the expression of HLA-DR in CD4+ T cells and CD8+ T cells from a DAT-positive patient was increased after pulsation with TSNFR-sequence-containing peptides. In summary, positive DAT is related to enhanced anemia and to HLA-DR12 in the Japanese population. A peptide sequence within SARS-CoV-2 Spike protein may act as an epitope for IgG binding to RBCs in DAT-positive COVID-19 patients.
Collapse
Affiliation(s)
- Hideaki Matsuura
- Department of Blood Transfusion, Fujita Health University Hospital, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan.,Department of Cellular and Molecular Biology, Fujita Health University School of Medical Sciences, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Sumie Fujii
- Department of Transfusion Medicine and Cell Therapy, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Yusuke Matsui
- Gladstone Institute of Virology and Immunology, University of California, San Francisco, San Francisco, CA, USA
| | - Yukari Sugiura
- Department of Blood Transfusion, Fujita Health University Hospital, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Hidehiko Akiyama
- Department of Cellular and Molecular Biology, Fujita Health University School of Medical Sciences, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Yasuo Miura
- Department of Blood Transfusion, Fujita Health University Hospital, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan. .,Department of Transfusion Medicine and Cell Therapy, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan.
| |
Collapse
|
10
|
Das SS, Mukherjee S. Influence of immunohematological markers on severity of in vivo hemolysis in human warm autoimmune haemolytic anemia. Transfus Apher Sci 2022; 61:103492. [PMID: 35773127 DOI: 10.1016/j.transci.2022.103492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/13/2022] [Accepted: 06/16/2022] [Indexed: 10/17/2022]
Abstract
Autoantibody production in autoimmune haemolytic anemia (AIHA) is the result of the loss of self-immunological tolerance of the host. Here we investigated the various immunohematological markers that may influence the severity of in vivo hemolysis in warm AIHA (WAIHA). Complete direct antiglobulin test (DAT) evaluation and immunohematological characterization were performed in 247 patients of WAIHA following departmental protocols. Clinical and laboratory details of patients were obtained from patient file. The median age of WAIHA patients was 47 years with a female preponderance. Lymphoproliferative diseases were the major underlying causes of secondary WAIHA. The mean haemoglobin (Hb) and reticulocyte count (Retic) were 6.43 gm/dL and 7.58% respectively. Single autoantibody bound to red cells was investigated in 151 patients. The main IgG subclass was IgG1. Multiple autoantibodies like IgG+ C, IgG+IgA and IgG+IgA+C were found in 87 (35.2%) patients. Free autoantibodies were observed in 112 patients with a median indirect antiglobulin test (IAT) reactivity of 2+. Derangement of haematological and biochemical values was statistically significant with increase in DAT reactivity, presence of multiple autoantibodies on red cells, coating of red cells by IgG3 or multiple IgG subclass, higher DAT dilution and increasing IAT reactivity. We conclude that several important but simple immunohematological parameters may influence the degree of in vivo hemolysis in WAIHA. Since a set of common haematological and biochemical test determines the severity of in vivo hemolysis therefore a comprehensive clinical and immunohematological evaluation is advisable for a correct diagnostic and therapeutic workup of WAIHA.
Collapse
Affiliation(s)
- Sudipta Sekhar Das
- Department of Transfusion Medicine, Apollo Multispeciality Hospitals, Kolkata 700054, India.
| | - Sourav Mukherjee
- Department of Transfusion Medicine, Apollo Multispeciality Hospitals, Kolkata 700054, India
| |
Collapse
|
11
|
Zhou Y, Ding YL, Zhang LJ, Peng M, Huang J. Direct antiglobulin test-negative autoimmune hemolytic anemia in a patient with β-thalassemia minor during pregnancy: A case report. World J Clin Cases 2022; 10:1388-1393. [PMID: 35211574 PMCID: PMC8855192 DOI: 10.12998/wjcc.v10.i4.1388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 11/27/2021] [Accepted: 12/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Severe refractory anemia during pregnancy can cause serious maternal and fetal complications. If the cause cannot be identified in time and accurately, blind symptomatic support treatment may cause serious economic burden. Thalassemia minor pregnancy is commonly considered uneventful, and the condition of anemia rarely progresses during pregnancy. Autoimmune hemolytic anemia (AIHA) is rare during pregnancy with no exact incidence available.
CASE SUMMARY We report the case of a 30-year-old β-thalassemia minor multiparous patient experiencing severe refractory anemia throughout pregnancy. We monitored the patient closely, carried out a full differential diagnosis, made a diagnosis of direct antiglobulin test-negative AIHA, and treated her with prednisone and intravenous immunoglobulin. The patient gave birth to a healthy full-term baby.
CONCLUSION Coombs-negative AIHA should be suspected in cases of severe hemolytic anemia in pregnant patients with and without other hematological diseases.
Collapse
Affiliation(s)
- Yang Zhou
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Yi-Ling Ding
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Li-Juan Zhang
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Mei Peng
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
| | - Jian Huang
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
| |
Collapse
|
12
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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.
| |
Collapse
|
13
|
Das SS, Chakrapani A, Bhattacharya S, Biswas RN, Safi M. Immunohematological and Clinical Characterization of Complement and Non-Complement Associated Warm Autoimmune Haemolytic Anemia and Risk Factors Predicting their Occurrences. Indian J Hematol Blood Transfus 2021; 37:623-631. [PMID: 34744345 DOI: 10.1007/s12288-021-01402-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/10/2021] [Indexed: 12/17/2022] Open
Abstract
Antigen - antibody complexes on heavily coated red cells in Warm autoimmune haemolytic anemia (WAIHA) often activates the complement pathway and red cells bound C3 complement component are encountered in complement associated WAIHA (CWAIHA). Patients belonging to CWAIHA and non-complement associated WAIHA (NCWAIHA) may demographically, clinically and immunohematologically behave differently therefore we planned to study the clinical and immunohematological characteristics of CWAIHA and NCWAIHA with emphasis to various potential factors associated with CWAIHA. The prospective study included 229 patients of WAIHA. Complete DAT evaluation was performed in all these patients. Details of patients and their hematological and biochemical parameters were obtained from patient file and Hospital Information System. In vivo hemolysis was documented as per the criteria established by previous workers. Statistical analysis was done using SPSS statistical package. Of the total 229 patients of WAIHA, 83 (36.2%) belonged to the complement associated WAIHA group. A total of 146 (63.8%) patients were females of which 43 (29.4%) had CWAIHA. The median age of WAIHA patients was 37 years. A total of 46 (56.1%) patients above age 40 years suffered from CWAIHA. Where secondary WAIHA was found in 121 (52.8%) patients; more than half (61.4%) with CWAIHA had underlying aetiology. Over 95% of patients in both categories presented with weakness and pallor. Strong DAT (> 2 +) was observed in 86.7% of CWAIHA patients. Factors like gender, age, aetiology and DAT IgG dilution were independent risk factors for CWAIHA. DAT remained positive even at the end of 10 months of successful treatment. We conclude that detailed characterization of WAIHA with particular emphasis to complement and non-complement associated WAIHA is essential to evaluate the disease characters, immunological behaviours, prognosis and therapeutic management. Moreover an understanding of the risk factors of CWAIHA will help physicians / hematologists and immunohematologists to manage WAIHA more prudently and solicitously.
Collapse
Affiliation(s)
- Sudipta Sekhar Das
- Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, 700054 India
| | - Anupam Chakrapani
- Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, 700054 India
| | - Soumya Bhattacharya
- Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, 700054 India
| | - Rathindra Nath Biswas
- Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, 700054 India
| | - Mahammad Safi
- Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, 700054 India
| |
Collapse
|
14
|
Shi L, Qin W, Mei C, Xu W, Deng Y, Yin W, Zhou R, Fan X, Li R, Peng F, Huang Z, Li N. Low hemoglobin levels are associated with direct antiglobulin test positivity in patients with acute-on-chronic liver failure. Transfus Apher Sci 2021; 60:103201. [PMID: 34238707 DOI: 10.1016/j.transci.2021.103201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 06/16/2021] [Accepted: 06/27/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Multiple factors contribute to anemia in patients with Hepatitis B virus (HBV)related acute-on-chronic liver failure (ACLF); however, the mechanism is unclear. The purpose of this study was to evaluate the clinical significance of the direct antiglobulin test (DAT) in patients with HBV related ACLF. METHODS DAT was used to detect immunoglobulins and/or complement proteins on the surface of erythrocytes. RESULTS We recruited 78 HBV-associated ACLF patients, 30 chronic hepatitis B(CHB)patients and 40 healthy people between October 2015 and May 2016. In HBV related ACLF patients, the hemoglobin concentration, number of erythrocytes, and hematocrit value were significantly lower, while the erythrocyte distribution width was significantly higher, compared to patients with CHB and healthy controls (HCs) (P < 0.001). The rates of DAT positivity in HBV related ACLF patients, CHB patients, and HCs were 62.8 %, 13.3 %, and 0%, respectively. DAT-positive ACLF patients exhibited lower Hb levels, older average age, as well as higher total bilirubin, alanine aminotransferase, and complement component 3 levels compared to DAT-negative patients. CONCLUSIONS HBV related ACLF patients showed significant alterations in erythrocyte parameters, possibly reflecting disease development and severity. The high presence of erythrocyte autoantibodies suggested that immunologic clearance of erythrocytes contributed to multifactorial anemia in HBV related ACLF patients.
Collapse
Affiliation(s)
- Linxi Shi
- Department of Blood Transfusion, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, 87 Xiangya Road, Changsha, Hunan Province, 410008, China
| | - Wanyuan Qin
- Department of Blood Transfusion, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, 87 Xiangya Road, Changsha, Hunan Province, 410008, China; Department of Laboratory Medicine, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530021, China
| | - Cheng Mei
- Department of Blood Transfusion, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, 87 Xiangya Road, Changsha, Hunan Province, 410008, China
| | - Wei Xu
- Department of Blood Transfusion, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, 87 Xiangya Road, Changsha, Hunan Province, 410008, China
| | - Ying Deng
- Ningxiang People's Hospital Affiliated to Hunan University of Traditional Chinese Medicine, Ningxiang, Hunan Province, China
| | - Wenyu Yin
- Department of Blood Transfusion, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, 87 Xiangya Road, Changsha, Hunan Province, 410008, China
| | - Rongrong Zhou
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Key Laboratory of Viral Hepatitis, Hunan Province, 87 Xiangya Road, Changsha, 410008, China
| | - Xuegong Fan
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Key Laboratory of Viral Hepatitis, Hunan Province, 87 Xiangya Road, Changsha, 410008, China
| | - Ruixuan Li
- Department of Cardiology, The First Hospital Affiliated to Hunan Normal University, Changsha, Hunan Province, China
| | - Fang Peng
- Key Laboratory of Cancer Proteomics of Chinese Ministry of Health, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Zebing Huang
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Key Laboratory of Viral Hepatitis, Hunan Province, 87 Xiangya Road, Changsha, 410008, China.
| | - Ning Li
- Department of Blood Transfusion, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, 87 Xiangya Road, Changsha, Hunan Province, 410008, China.
| |
Collapse
|
15
|
Abstract
About 5-10% of patients with autoimmune hemolytic anemia (AIHA) and a negative result on the direct antiglobulin test (DAT) are difficult to diagnose. Most of these patients with AIHA have red blood cell-associated IgG levels below the cut-off value of DAT. Comprehensive diagnosis and classification of DAT-negative AIHA can be made with additional tests of low-affinity IgG and IgA/IgM autoantibodies. However, 17% of patients with DAT-negative AIHA show negative results on all these tests and are diagnosed with "clinically diagnosed DAT-negative AIHA," after excluding other hemolytic anemias and responsiveness to steroids. This percentage can be reduced to 4% if tests are conducted during pretreatment stage. Patients with "clinically diagnosed DAT-negative AIHA" show relatively worse prognosis than patients with low-affinity IgG, and tend to receive treatment in the later stages of the disease. When treating a patient with DAT-negative hemolysis, DAT-negative AIHA should be considered and tested in reference laboratories, especially at pretreatment stage.
Collapse
|
16
|
Cabo J, Brochier A, Saussoy P, van Dievoet MA, Capirchio L, Delire B, Deneys V. Positive direct antiglobulin test in COVID-19 patients: Decision-making process. Transfus Clin Biol 2021; 28:414-419. [PMID: 34111506 PMCID: PMC8183097 DOI: 10.1016/j.tracli.2021.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/19/2021] [Accepted: 05/27/2021] [Indexed: 01/04/2023]
Abstract
In this unprecedented crisis of severe acute respiratory syndrome coronavirus 2 and its associated coronavirus disease 2019 (COVID-19), polymerase chain reaction and then serological testing platforms have been massively developed to face the important screening demand. Polymerase chain reaction and serological testing platforms are not the only actors impacted by the crisis, transfusion services are facing important difficulties. A positive direct antiglobulin test is frequently observed for patients encountering COVID-19. Patients with severe symptoms may develop anaemia and become good candidates for blood transfusions. The interpretation of a positive direct antiglobulin test for patients recently transfused and suffering from COVID-19 is complex. The differentiation between COVID-19 induced antibodies and possible associated transfusion alloantibodies is therefore crucial. In this context, the elution technique incorporated in an appropriate decision-making process plays its full role. This intricate topic is presented through a case report followed by literature review and finally decision-making process for COVID-19 patients necessitating red blood cells administration.
Collapse
Affiliation(s)
- J Cabo
- Clinical Biology Department, Cliniques Universitaires St Luc, Université catholique de Louvain, Banque de sang, Avenue Hippocrate 10, 1200 Woluwe-Saint-Lambert, Brussels, Belgium.
| | - A Brochier
- Clinical Biology Department, Cliniques Universitaires St Luc, Université catholique de Louvain, Banque de sang, Avenue Hippocrate 10, 1200 Woluwe-Saint-Lambert, Brussels, Belgium.
| | - P Saussoy
- Clinical Biology Department, Cliniques Universitaires St Luc, Université catholique de Louvain, Banque de sang, Avenue Hippocrate 10, 1200 Woluwe-Saint-Lambert, Brussels, Belgium.
| | - M-A van Dievoet
- Clinical Biology Department, Cliniques Universitaires St Luc, Université catholique de Louvain, Banque de sang, Avenue Hippocrate 10, 1200 Woluwe-Saint-Lambert, Brussels, Belgium.
| | - L Capirchio
- Gastroenterology department, Cliniques Universitaires St Luc, Université catholique de Louvain, Avenue Hippocrate 10, 1200 Woluwe-Saint-Lambert, Brussels, Belgium.
| | - B Delire
- Gastroenterology department, Cliniques Universitaires St Luc, Université catholique de Louvain, Avenue Hippocrate 10, 1200 Woluwe-Saint-Lambert, Brussels, Belgium.
| | - V Deneys
- Clinical Biology Department, Cliniques Universitaires St Luc, Université catholique de Louvain, Banque de sang, Avenue Hippocrate 10, 1200 Woluwe-Saint-Lambert, Brussels, Belgium.
| |
Collapse
|
17
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
18
|
Kasinathan G, Sathar J. Mixed-type autoimmune hemolytic anaemia presenting as multiple thromboses: A case report. Ann Med Surg (Lond) 2020; 60:323-326. [PMID: 33204423 PMCID: PMC7653202 DOI: 10.1016/j.amsu.2020.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/01/2020] [Accepted: 11/01/2020] [Indexed: 11/13/2022] Open
Abstract
Autoimmune hemolytic anaemia (AIHA) is a heterogenous disorder characterised by the presence of IgG or IgM pathological autoantibodies that target antigens of erythrocytes resulting in active hemolysis. Case presentation: A 40-year-old gentleman presented to a medical centre with chest pain and right sided hemiparesis for a week. He was pale and jaundiced. The power of the right upper and lower limbs was 3/5. His spleen was palpable. His complete blood count revealed macrocytic anaemia of 7.6 g/dL. The brain Magnetic Resonance Imaging (MRI) showed left fronto-parietal infarction. The right cardiac and left carotid angiogram revealed thromboses involving the right coronary and left internal carotid artery respectively. At the cardiology department, he was transfused with two units of red blood cells without his anemia being investigated and a stent was deployed to the left internal carotid artery. He was referred to the hematology department in which his peripheral blood smear revealed hemolysis and his direct antiglobulin test was positive. He responded to a course of steroids and direct oral anticoagulation and is in complete remission for the past 18 months. Conclusion: It is always imperative to investigate the cause of anaemia and consider hemolysis in a patient presenting with multiple unexplained thromboses.
Collapse
Affiliation(s)
- Ganesh Kasinathan
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Jameela Sathar
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| |
Collapse
|
19
|
Sánchez N, Zubicaray J, Sebastián E, Gálvez E, Sevilla J. [Autoimmune hemolytic anemia: Case review]. An Pediatr (Barc) 2020; 94:206-212. [PMID: 32972857 DOI: 10.1016/j.anpedi.2020.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/12/2020] [Accepted: 07/22/2020] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Autoimmune hemolytic anemia (AIHA) is a rare and generally self-limiting disease in children. MATERIAL AND METHODS A descriptive cross-sectional study was performed in children under 18 years diagnosed with AIHA from January/1997 to July/2019. Clinical variables were collected and AIHA was classified according to the direct antiglobulin test (DAT) in warm AIHA (IgG+/-C3d) and cold AIHA (C3d). Response to treatment and evolution were analyzed. RESULTS 25 patients were included and 72% were males. The median age at diagnosis was 2 years (range 0.4 to 9). Fever (72%), pallor (68%), jaundice (64%), hepatosplenomegaly and coluria (48%) were the most common presenting symptoms. The median hemoglobin at diagnosis was 5.4 g/dl. DAT was positive in 96%, with detection of IgG antibodies in 76%. A single case presented negative DAT. 20% of the patients associated another cytopenia, one of which was subsequently diagnosed with common variable immunodeficiency. Concomitant viral infection was suspected or documented in 32%. Most of the cases were self-limiting and responded to corticosteroid treatment (72%). Those with partial response (24%), mainly those associated with other cytopenias, required other lines of treatment (rituximab, mycophenolate, immunoglobulins). Complications (32%) and relapses (26%) were detected only in warm AIHA. CONCLUSIONS Our case series confirms that AIHA is a very rare disease in childhood. Most cases evolve favorably, although up to a quarter of them require second lines of treatment and, in exceptional cases, they need very aggressive treatments. These latter cases generally correspond to patients who present more than one cytopenia in the course of the disease.
Collapse
Affiliation(s)
- Nazaret Sánchez
- Servicio de Pediatría, Hospital Clínico Universitario de Valladolid, Valladolid, España.
| | - Josune Zubicaray
- Servicio de Hematología y Hemoterapia, Hematología y Oncología Pediátricas, Hospital Infantil Universitario Niño Jesús, Fundación para la Investigación Biomédica del Hospital Infantil Universitario Niño Jesús, Madrid, España
| | - Elena Sebastián
- Servicio de Hematología y Hemoterapia, Hematología y Oncología Pediátricas, Hospital Infantil Universitario Niño Jesús, Fundación para la Investigación Biomédica del Hospital Infantil Universitario Niño Jesús, Madrid, España
| | - Eva Gálvez
- Servicio de Hematología y Hemoterapia, Hematología y Oncología Pediátricas, Hospital Infantil Universitario Niño Jesús, Fundación para la Investigación Biomédica del Hospital Infantil Universitario Niño Jesús, Madrid, España
| | - Julián Sevilla
- Servicio de Hematología y Hemoterapia, Hematología y Oncología Pediátricas, Hospital Infantil Universitario Niño Jesús, Fundación para la Investigación Biomédica del Hospital Infantil Universitario Niño Jesús, Madrid, España
| |
Collapse
|
20
|
Ray GK, Mishra D, Jena RK, Mahapatra S, Palai S, Parida AA. Clinical Profile and Severity of Hemolysis in Adult Patients of Primary Autoimmune Hemolytic Anemia and Their Response to Steroid: A Prospective Cohort Study from Single Institution. Indian J Hematol Blood Transfus 2020; 37:119-125. [PMID: 33707844 DOI: 10.1007/s12288-020-01326-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/29/2020] [Indexed: 11/29/2022] Open
Abstract
Autoimmune hemolytic anaemia (AIHA) has traditionally been classified based on the temperature sensitivity of the autoagglutinins as warm (WAIHA), cold (CAIHA) and mixed type. Autoagglutinin may be of IgG or IgM type. The present prospective study was conducted to evaluate the profile of clinical picture, severity of haemolysis, treatment response of steroid. This study on patients of adult primary AIHA was conducted by taking complete history followed by detail physical examination. Laboratory investigations were performed to establish haemolytic anaemia and to assess severity of haemolysis. Immunehematological work up including blood grouping, direct antiglobulin test (DAT), IAT, antibody screening, adsorption elution was performed to diagnose type of AIHA. All cases were followed up to assess the response to prednisolone. All the data were collected and analysed by SPSS 19. Out of 62 primary AIHA cases, female were affected more than male (41:21). WAIHA is most common type (42, 67.8%) followed by mixed (20.9%) and cold AIHA (11.3%). Severity of haemolysis showed significant correlation with the DAT strength and not with type of AIHA. (P < 0.05) On oral prednisolone, 22 cases attended complete remission, while relapse, drug dependency and partial remission was achieved in 13, 9, 3 cases respectively. Severity of haemolysis in AIHA is directly related with DAT strength. WAIHA is most common type and can be managed with oral prednisolone (cr 45.2%), without red cell transfusion in most of cases. Mixed type AIHA cases were presented mostly with severe haemolysis, with minimum therapeutic response to prednisolone and maximum relapse/drug dependency.
Collapse
Affiliation(s)
- Gopal Krushna Ray
- Department of Transfusion Medicine, Sriram Chandra Bhanja Medical College and Hospital, Cuttack, Odisha India
| | - Debasish Mishra
- Department of Transfusion Medicine, Sriram Chandra Bhanja Medical College and Hospital, Cuttack, Odisha India
| | - Rabindra Kumar Jena
- Department of Clinical Hematology, Sriram Chandra Bhanja Medical College and Hospital, Cuttack, Odisha India
| | - Smita Mahapatra
- Department of Transfusion Medicine, Sriram Chandra Bhanja Medical College and Hospital, Cuttack, Odisha India
| | - Sabita Palai
- Department of Transfusion Medicine, Sriram Chandra Bhanja Medical College and Hospital, Cuttack, Odisha India
| | - Ansuman Abhishek Parida
- Department of Pharmacology, Sriram Chandra Bhanja Medical College and Hospital, Cuttack, Odisha India
| |
Collapse
|
21
|
Puri V, Chhikara A, Sharma G, Sehgal S, Sharma S. Critical evaluation of donor direct antiglobulin test positivity: Implications in cross-matching and lessons learnt. Asian J Transfus Sci 2019; 13:70-72. [PMID: 31360017 PMCID: PMC6580823 DOI: 10.4103/ajts.ajts_125_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Direct Antiglobulin Test is a method of demonstrating the presence of antibody/ complement bound to red cell membrane by using AHG to form a visible agglutination reaction. DAT positivity is seen in immune mediated haemolytic anaemias, however rarely non immune mediate haemolytic anaemias also show DAT positivity. DAT positivity predictive of 83% of autoimmune haemolytic anaemia and 1.4% cases without haemolytic anaemia. Screening of blood donors for DAT is usually not recommended traditionally by any guidelines. However DAT positivity is reported in 0.008% of donors. On extensive search of literature we could find only very few studies on DAT positivity in donors. We report two cases of DAT positive donors with no clinical or laboratory evidence of hemolysis.
Collapse
Affiliation(s)
- Vandana Puri
- Department of Pathology, Lady Hardinge Medical College, New Delhi, India
| | - Aruna Chhikara
- Department of Pathology, Lady Hardinge Medical College, New Delhi, India
| | - Geetika Sharma
- Department of Pathology, Lady Hardinge Medical College, New Delhi, India
| | - Shivali Sehgal
- Department of Pathology, Lady Hardinge Medical College, New Delhi, India
| | - Sunita Sharma
- Department of Pathology, Lady Hardinge Medical College, New Delhi, India
| |
Collapse
|
22
|
Khaled MB, Ouederni M, Sahli N, Dhouib N, Abdelaziz AB, Rekaya S, Kouki R, Kaabi H, Slama H, Mellouli F, Bejaoui M. Predictors of autoimmune hemolytic anemia in beta-thalassemia patients with underlying red blood cells autoantibodies. Blood Cells Mol Dis 2019; 79:102342. [PMID: 31302454 DOI: 10.1016/j.bcmd.2019.102342] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 06/28/2019] [Indexed: 01/19/2023]
Abstract
In beta-thalassemia patients, erythrocyte autoantibodies can remain silent or lead to Autoimmune Hemolytic Anemia (AIHA).The aim of this study was to identify predictors of AIHA in beta-thalassemia patients with positive Direct Antiglobulin Test (DAT), in Tunisia. This longitudinal prognosis study was carried out on beta-thalassemia patients with a positive confirmed DAT. Predictors of AIHA were identified the Kaplan-Meier method. A Cox model analysis was used to identify independent predictors. Among 385 beta thalassemia patients, 87 developed positive DAT (22.6%). Autoimmune hemolytic anemia was occurred in 25 patients. Multivariate analysis showed that AIHA was independently associated with beta-thalassemia intermedia and similar family history of AIHA. Splenectomy in patients with positive DAT was independently associated with an increased risk of AIHA (HR = 6.175, CI: 2.049-18.612, p < 0.001). The risk of developing AIHA was higher during the first 72 transfusions. Autoimmune hemolytic anemia was significantly associated with polyspecific DAT (anti-complement and anti-IgG), blood group AB and prior alloimmunization. Whereas transfusion by phenotypic and leukoreduced blood was a protective factor. In summary, splenectomy after autoimmunization, prior alloimmunization, DAT specificity (IgG with complement), thalassemia intermedia, AB blood group and family history of AIHA were strongly associated with AIHA. Leukoreduced blood transfusion had a proven preventive role.
Collapse
Affiliation(s)
- Monia Ben Khaled
- Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia; Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center Tunis, Tunis, Tunisia.
| | - Monia Ouederni
- Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia; Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center Tunis, Tunis, Tunisia
| | - Nessrine Sahli
- Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia; Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center Tunis, Tunis, Tunisia
| | - Nawel Dhouib
- Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center Tunis, Tunis, Tunisia
| | | | - Samia Rekaya
- Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia; Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center Tunis, Tunis, Tunisia
| | - Ridha Kouki
- Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia; Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center Tunis, Tunis, Tunisia
| | - Houda Kaabi
- National Center of Blood Transfusion, Tunis, Tunisia
| | - Hmida Slama
- National Center of Blood Transfusion, Tunis, Tunisia
| | - Fethi Mellouli
- Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia; Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center Tunis, Tunis, Tunisia
| | - Mohamed Bejaoui
- Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia; Pediatric Immuno-Hematology Unit, Bone Marrow Transplantation Center Tunis, Tunis, Tunisia
| |
Collapse
|
23
|
Camprubí D, Pereira A, Rodriguez-Valero N, Almuedo A, Varo R, Casals-Pascual C, Bassat Q, Malvy D, Muñoz J. Positive direct antiglobulin test in post-artesunate delayed haemolysis: more than a coincidence? Malar J 2019; 18:123. [PMID: 30961636 PMCID: PMC6454619 DOI: 10.1186/s12936-019-2762-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 04/02/2019] [Indexed: 11/10/2022] Open
Abstract
Background Delayed haemolysis is a frequent adverse event after treatment with artesunate (AS). Removing once-infected “pitted” erythrocytes by the spleen is the most accepted mechanism of haemolysis in these cases. However, an increasing number of cases with positive direct antiglobulin test (DAT) haemolysis after AS have been reported. Methods All malaria cases seen at Hospital Clinic of Barcelona between 2015 and 2017 were retrospectively reviewed. Clinical, parasitological and laboratory data from patients treated with intravenous artesunate—specifically looking for delayed haemolysis and DAT—was collected. Results Among the 36 severe malaria patients treated with artesunate at the hospital, 10 (27.8%) developed post-artesunate delayed haemolysis. Out of these, DAT was performed in six, being positive in four of them (at least 40%). DAT was positive only for complement—without IgG—suggesting drug-dependent immune-haemolytic anaemia of the immune-complex type. Three of the four patients were treated with corticosteroids and two also received blood transfusion, with a complete recovery. Conclusions Drug-induced auto-immune phenomena in post-artesunate delayed haemolysis may be underreported and must be considered. The role of corticosteroids should be reassessed.
Collapse
Affiliation(s)
- Daniel Camprubí
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.
| | - Arturo Pereira
- Hematology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Alex Almuedo
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.,Internal Medicine Department, Hospital General de Granollers, Barcelona, Spain
| | - Rosauro Varo
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | | | - Quique Bassat
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.,ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain.,Centro de Investigaçao em Saúde de Manhiça (CISM), Maputo, Mozambique.,Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain
| | - Denis Malvy
- Travel Clinics and Tropical Diseases Unit, University Hospital Center of Bordeaux, Bordeaux, France
| | - Jose Muñoz
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| |
Collapse
|
24
|
|
25
|
Bahri T, de Bruyn K, Leys R, Weerkamp F. Fatal Acute Hemolytic Transfusion Reaction due to Anti-Wr a. Transfus Med Hemother 2018; 45:438-441. [PMID: 30574061 DOI: 10.1159/000488863] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 03/27/2018] [Indexed: 11/19/2022] Open
Abstract
Background The Wra blood group antigen is a low-frequency antigen. Antibody screening sets used in pretransfusion laboratory investigations usually do not contain a Wr(a+) cell. If subsequent cross-matching is performed without indirect antiglobulin test (IAT), Wra antibodies reacting with donor red blood cells (RBCs) will be missed. For reasonable economic and time-saving arguments the risk of missing the detection of a potential clinically relevant antibody is worldwide accepted. Case Report A 66-year-old women with a negative antibody screen rapidly deteriorated after she received two units of RBCs for symptomatic anemia after hip surgery. Diagnosis of a transfusion reaction was obscured by pre-existing and nonspecific symptoms. Laboratory investigation indicated acute hemolysis. Cross-matching in IAT was positive for the first unit, and an extended antibody identification panel showed reactivity with Wr(a+) cells. The patient did not respond to supportive therapy and died within 48 h after the start of transfusion. Conclusion This dramatic case provides further evidence on the clinical relevance of Wra blood group antibodies. In addition, it underlines the clinical importance of risk awareness in the blood transfusion chain and the possible complexity in relation to patient monitoring in daily transfusion practice.
Collapse
Affiliation(s)
- Tanaz Bahri
- Department of Hematology, Maasstad Hospital, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Kim de Bruyn
- Laboratory of Clinical Chemistry, Hematology and Transfusion Medicine, Maasstad Hospital, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Rineke Leys
- Department of Hematology, Maasstad Hospital, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Floor Weerkamp
- Laboratory of Clinical Chemistry, Hematology and Transfusion Medicine, Maasstad Hospital, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
26
|
Kamesaki T, Kajii E. A Comprehensive Diagnostic Algorithm for Direct Antiglobulin Test-Negative Autoimmune Hemolytic Anemia Reveals the Relative Ratio of Three Mechanisms in a Single Laboratory. Acta Haematol 2018; 140:10-17. [PMID: 30007985 DOI: 10.1159/000488753] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 03/24/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Direct antiglobulin test (DAT)-negative warm autoimmune hemolytic anemia (AIHA) is mainly caused by three mechanisms: red blood cell (RBC)-bound immunoglobulin (Ig)G below the detection limit of routine DAT; RBC-bound IgA or IgM; or low-affinity autoantibodies. Although most cases of DAT-negative AIHA are thought to be caused by RBC-bound IgG, and combinatory serological analyses are recommended, the relative ratios of each mechanism have not been clarified. METHODS Two groups of patients with undiagnosed hemolytic anemia and negative conventional tube method-DAT (TM-DAT) were investigated using anti-IgA and anti-IgM sera, or column agglutination method-DAT (CM-DAT), respectively, in addition to radioimmunological quantitation of RBC-bound IgG. RESULTS Three of 73 patients with DAT-negative AIHA showed positive RBC-bound IgA and normal amounts of RBC-bound IgG. Another group of 3 patients were RBC-bound IgM-positive, but only one of these showed normal amounts of RBC-bound IgG. In another group of patients with DAT-negative AIHA, 4 of the 20 showed positive CM-DAT and negative CM-DAT after washing RBCs. Three of these patients had normal amounts of RBC-bound IgG. Five patients with positive CM-DAT both before and after washing RBCs had high amounts of RBC-bound IgG. CONCLUSION Relative ratios of patients with DAT-negative AIHA resulting from RBC-bound IgG, RBC-bound IgA, RBC-bound IgM, and low-affinity IgG were estimated as 80, 4, 1 and 15%, respectively. A new classification and diagnostic algorithm for DAT-negative AIHA were proposed.
Collapse
|
27
|
Kumawat V, Kulkarni K, Goyal M, Lokadas V. ABO Hemolytic Disease of Fetus and Newborn; Still a Diagnostic Dilemma: A Case Report. Indian J Hematol Blood Transfus 2018; 34:183-4. [PMID: 29398829 DOI: 10.1007/s12288-017-0792-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 02/18/2017] [Indexed: 10/20/2022] Open
|
28
|
de Bruijn S, Philipse E, Couttenye MM, Bracke B, Ysebaert D, Michielsen P, Francque S, Vanwolleghem T, Verlinden A. Passenger Lymphocyte Syndrome (PLS): A Single-center Retrospective Analysis of Minor ABO-incompatible Liver Transplants. J Clin Transl Hepatol 2017; 5:9-15. [PMID: 28507920 PMCID: PMC5411361 DOI: 10.14218/jcth.2016.00072] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 02/05/2017] [Accepted: 02/22/2017] [Indexed: 12/04/2022] Open
Abstract
Background and Aims: Due to the shortage of donor livers, minor ABO-incompatible liver transplantations are commonly performed. Together with the allograft, immunocompetent B-lymphocytes, called passenger lymphocytes, are transplanted. In case of minor ABO-incompatibility, these passenger lymphocytes produce antibodies directed towards the recipient's red blood cells, which causes immune-mediated hemolysis, also known as the passenger lymphocyte syndrome (PLS). Although this is a self-limiting disorder, serious complications can occur, including graft failure. Retrospectively, we evaluated the role of PLS in minor ABO-incompatible liver transplantations performed at our center. Methods: A retrospective analysis was conducted for all minor ABO-incompatible liver transplantations performed at the Antwerp University Hospital between 2003 and 2015. All patient files were inspected for clinical and laboratory findings. In cases of PLS diagnosis, the applied treatment was also studied. Results: In total, 10 patients underwent a minor ABO-incompatible liver transplantation and 4 showed signs of PLS. All 4 PLS patients were treated with different therapeutic strategy, corresponding to the severity of hemolysis. In all 4 cases, PLS resolved following treatment. Conclusion: When performing minor ABO-incompatible liver transplantations, knowledge of PLS is elemental. Next to a high index of clinical suspicion, we suggest routine screening for markers of hemolysis, with emphasis on haptoglobin level and direct antiglobulin test, weekly in the first 4 weeks post-transplantation as well as in case of a sudden hemoglobin drop within the first 3 months after transplantation. Peri- and postoperative transfusion support using donor-compatible blood has been suggested to prevent the occurrence or limit the extent of hemolysis.
Collapse
Affiliation(s)
- Sévérine de Bruijn
- Departments of Hematology, Antwerp University Hospital, Edegem, Belgium
- *Correspondence to: Sévérine de Bruijn, Department of Hematology, Antwerp University Hospital, Wilrijkstraat 10, 2650 Edegem, Belgium. Tel: +32-494-40-39-62, Fax: +32-3821-42-86, E-mail:
| | - Ester Philipse
- Departments of Nephrology, Antwerp University Hospital, Edegem, Belgium
| | | | - Bart Bracke
- Departments of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Dirk Ysebaert
- Departments of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Peter Michielsen
- Departments of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium
| | - Sven Francque
- Departments of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium
| | - Thomas Vanwolleghem
- Departments of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium
| | - Anke Verlinden
- Departments of Hematology, Antwerp University Hospital, Edegem, Belgium
| |
Collapse
|
29
|
Alonso HC, Manuel AAV, Amir CGC, Sergio RR, Allan P, Xavier LK, Juventina TAE. Warm autoimmune hemolytic anemia: experience from a single referral center in Mexico City. Blood Res 2017; 52:44-49. [PMID: 28401101 PMCID: PMC5383587 DOI: 10.5045/br.2017.52.1.44] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 10/31/2016] [Accepted: 01/17/2017] [Indexed: 11/17/2022] Open
Abstract
Background Autoimmune hemolytic anemia (AIHA) is characterized by an autoimmune-mediated destruction of red blood cells. Warm AIHA (wAIHA) represents 60% of AIHA cases and is associated with the positive detection of IgG and C3d in the direct antiglobulin test (DAT). This study aimed to assess the clinical and laboratorial differences between primary and secondary wAIHA patients from a referral center in Mexico City. Methods All patients diagnosed with wAIHA in our institution from January 1992 to December 2015 were included and received corticosteroids as the first-line treatment. We analyzed the response to the first-line treatment, relapse-free survival, and time to splenectomy. Results Eighty-nine patients were included. Secondary wAIHA represented 55.1% of the cases. At diagnosis, secondary wAIHA patients showed a DAT mixed pattern more frequently than primary wAIHA patients (36.7 vs. 17.5%, P<0.001). In the survival analysis, patients with secondary wAIHA had a lower time to response (18 vs. 37 days, P=0.05), median disease-free survival (28.51 vs. 50.95 weeks, P=0.018), and time to splenectomy (43.5 vs. 61 wks, P=0.029) than those with primary wAIHA. Due to economic constraints, rituximab was considered as the third-line treatment in only two patients. Conclusion Secondary wAIHA may benefit from a longer low-dose steroid maintenance period mainly due to its shorter time to relapse and time to splenectomy than primary wAIHA.
Collapse
Affiliation(s)
- Hernandez-Company Alonso
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Anguiano-Alvarez Victor Manuel
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Rodriguez-Rodriguez Sergio
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Pomerantz Allan
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Lopez-Karpovitch Xavier
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Tuna-Aguilar Elena Juventina
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| |
Collapse
|
30
|
Sudulagunta SR, Kumbhat M, Sodalagunta MB, Settikere Nataraju A, Bangalore Raja SK, Thejaswi KC, Deepak R, Mohammed AH, Sunny SP, Visweswar A, Suvarna M, Nanjappa R. Warm Autoimmune Hemolytic Anemia: Clinical Profile and Management. J Hematol 2017; 6:12-20. [PMID: 32300386 PMCID: PMC7155818 DOI: 10.14740/jh303w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2017] [Indexed: 12/20/2022] Open
Abstract
Background Autoimmune hemolytic anemia (AIHA) is a rare autoimmune disease in which autoantibodies target red blood cells leading to marked decrease in their lifespan. The classification of AIHA is based on the immunochemical properties of the RBC autoantibody. Warm antibody AIHA (wAIHA) accounts for 75-80% of all adult AIHA cases. The treatment of wAIHA is mainly corticosteroids. Our retrospective study aimed to study the clinical profile and management of wAIHA. Methods Data of 75 patients admitted with wAIHA or presented to outpatient department (previous medical records) with wAIHA between January 2003 and January 2016 were analyzed. Results In our study, females constituted 12 and 26 patients of primary and secondary wAIHA, while males constituted 17 and 20 patients of primary and secondary wAIHA, respectively. Mean hemoglobin level at AIHA onset was found to be 7.1 ± 1.7 g/dL in primary wAIHA group and 6.3 ± 1.2 g/dL in secondary wAIHA group, which is statistically significant. Splenectomy was used as mode of treatment in one (3.4%) patient of primary wAIHA group and 15 (32.60%) patients of secondary wAIHA group, which is statistically significant. Mean age of wAIHA onset was 69.7 ± 21.5 years in wAIHA group secondary to lymphoma and 54.3 ± 25.7 years in other wAIHA group, which is statistically significant. Conclusion The most common causes of secondary wAIHA are B-cell lymphoma, systemic lupus erythematosus, rheumatoid arthritis, chronic lymphocytic leukemia (CLL), common variable immune deficiency, renal cell carcinoma and secondary to drug usage (alpha methyldopa and carbamazepine), respectively. Reducing the cumulative dose of corticosteroids with second line treatment whenever possible and therefore reducing the risk of sepsis, specifically in older patients with comorbidities will reduce morbidity and mortality.
Collapse
Affiliation(s)
| | - Monica Kumbhat
- Department of Pathology, Sri Ramachandra Medical College, Chennai, India
| | | | | | | | | | - Raj Deepak
- Department of General Medicine, Dr.B.R.Ambedkar Medical College, Bangalore, India
| | | | - Sony P Sunny
- Department of General Medicine, Dr.B.R.Ambedkar Medical College, Bangalore, India
| | - Amulya Visweswar
- Department of General Medicine, Dr.B.R.Ambedkar Medical College, Bangalore, India
| | - Mikita Suvarna
- Department of General Medicine, Dr.B.R.Ambedkar Medical College, Bangalore, India
| | - Rashmi Nanjappa
- Department of General Medicine, Dr.B.R.Ambedkar Medical College, Bangalore, India
| |
Collapse
|
31
|
Kaur D, Bains L, Kandwal M, Parmar I. Erythrocyte Alloimmunization and Autoimmunization among Blood Donors and Recipients visiting a Tertiary Care Hospital. J Clin Diagn Res 2017; 11:EC12-EC15. [PMID: 28511387 DOI: 10.7860/jcdr/2017/22904.9401] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 11/28/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The ultimate aim of pretransfusion testing is the acceptable survival of donor red cells in recipient's body and antibody detection plays a critical role in achieving the same. The cornerstone of antibody detection method is detecting an unexpected antibody as against the expected antibodies of ABO blood group system. Autoantibodies can also interfere with the detection of clinically significant alloantibodies. AIM To study the frequency of alloantibodies and autoantibodies in the healthy blood donors and patient population visiting our hospital. MATERIALS AND METHODS The Column Agglutination Technology (CAT) was used for ABO RhD blood grouping, Direct Antiglobulin Test (DAT), Autocontrol (AC), Indirect Antiglobulin Test (IAT) and red cell antibody screening and the unexpected reactions in any of these tests were recorded for further evaluation. Ethylene Diamine Tetra Acetic Acid (EDTA) blood samples were used for all these tests for both blood donors and admitted patients. The CAT was exercised for the blood grouping (using ABD-Reverse Diluent cassettes) and antibody screening (using 0.8% Surgiscreen, Ortho Clinical Diagnostics Limited, USA and Low Ionic Strength Saline Ortho BLISS with AHG cassettes) on the automated immunohaematology platform ORTHO AutoVue® Innova system (Ortho Clinical Diagnostics Limited, USA). RESULTS Among all blood donors (n=6350), seven (0.11%) donors had showed unexpected reaction. Of these, four had positive antibody screen (three having naturally occuring antibodies 2=anti-M, 1=anti-Lea and 1=inconclusive) and the other three had positive DAT. Of all the patient samples (n=6136) screened for irregular red cell antibodies, four (0.06%) patients were found to have unexpected reaction revealing one (0.02%) with anti-M antibody and the other three (0.05%) had autoantibodies in their serum. CONCLUSION The combined prevalence for both blood donor and recipient population (n=12,486) was found to be 0.11% at our center. The alloimmunisation among patient population was found to be lower than many other studies worldwide as our hospital does not cater to multitransfused or transfusion dependant patients with haematological disorders and majorly elective surgery patients with no history of previous blood transfusions visit our hospital.
Collapse
Affiliation(s)
- Daljit Kaur
- Consultant, Department of Transfusion Medicine, Max Superspeciality Hospital, Dehradun, Uttarakhand, India
| | - Lovenish Bains
- Assistant Professor, Department of General Surgery, Maulana Azad Medical College and Associated Hospital, Delhi, India
| | - Manoj Kandwal
- Technical Supervisor, Department of Transfusion Medicine, Max Superspeciality Hospital, Dehradun, Uttarakhand, India
| | - Indu Parmar
- Senior Scientific Officer, Department of Transfusion Medicine, Max Superspeciality Hospital, Dehradun, Uttarakhand, India
| |
Collapse
|
32
|
Sankaralingam P, Jain A, Bagga R, Kumar P, Marwaha N. Red cell alloimmunization in RhD positive pregnant women and neonatal outcome. Transfus Apher Sci 2016; 55:153-8. [PMID: 27324408 DOI: 10.1016/j.transci.2016.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 03/31/2016] [Accepted: 06/08/2016] [Indexed: 11/25/2022]
Abstract
The frequency of red blood cell (RBC) alloimmunization in RhD positive pregnant women is not known in our population. We planned to determine its frequency and correlation with neonatal outcome. We included 1000 RhD positive pregnant women: 500 had 'normal pregnancy' (Group I) and another 500 had 'high risk pregnancy' (Group II). ABO and extended Rh phenotyping were done by tube technique, antibody screening and identification by gel technique. For alloimmunized women, the paternal and neonatal ABO and extended Rh typing were done. Neonatal direct antiglobulin test (DAT) was also done and their clinical outcome observed. The frequency of RBC alloimmunization was 0.7% (7/1000) and all these women were from group II (p = 0.015). The alloantibodies were anti-E (85.7%), anti-c (71.4%), anti-Cw (14.3%) and anti-S (14.3%). Also, 6 women had history of transfusion (p < 0.01). Of the 7 neonates born to alloimmunized mothers, 4 (57.14%) had a positive DAT. The mean duration of phototherapy was higher in the DAT positive neonates (p < 0.01) and 2 (50%) required exchange transfusion. Thus, the frequency of alloimmunization was 0.7% in RhD positive pregnant women. High risk pregnancies and antenatal patients having a history of blood transfusion should be considered for regular antibody screening.
Collapse
Affiliation(s)
- Prabakaran Sankaralingam
- Department of Transfusion Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Ashish Jain
- Department of Transfusion Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India.
| | - Rashmi Bagga
- Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Praveen Kumar
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Neelam Marwaha
- Department of Transfusion Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| |
Collapse
|
33
|
Swann JW, Szladovits B, Glanemann B. Demographic Characteristics, Survival and Prognostic Factors for Mortality in Cats with Primary Immune-Mediated Hemolytic Anemia. J Vet Intern Med 2016; 30:147-56. [PMID: 26645865 PMCID: PMC4913623 DOI: 10.1111/jvim.13658] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 08/30/2015] [Accepted: 10/05/2015] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Immune-mediated hemolytic anemia (IMHA) is uncommon in cats, but may result in severe disease. Demographic predispositions for development of the disease and prognostic factors for mortality have not been investigated previously. HYPOTHESIS/OBJECTIVES To explore possible demographic predispositions for development of primary IMHA in cats and to investigate possible prognostic factors for mortality. ANIMALS 107 client-owned cats with IMHA, of which 72 had primary IMHA and 35 had secondary IMHA, and 9,194 control cats. METHODS Data were collected retrospectively from records of cats with IMHA, defined by the presence of anemia and concurrent autoagglutination, ghost cells without oxidative damage on fresh blood smear, positive titer in a direct antiglobulin test, or evidence of phagocytosis of erythroid precursors in bone marrow. Odds ratios were calculated to assess the risk of development of primary IMHA in different demographic groups and Cox proportional hazards analysis was conducted to evaluate prognostic factors. RESULTS No sex or breed predisposition was identified for the development of primary IMHA in comparison to the control cats, but cats in the age range 2.1-5.9 years were predisposed. Higher total bilirubin concentration and age were significant negative prognostic factors and higher lymphocyte numbers and serum globulin concentration were positive prognostic factors in a multivariable model. CONCLUSIONS AND CLINICAL IMPORTANCE Young adult cats were more likely to develop primary IMHA than other groups, but no apparent male predisposition was identified in this study, contrary to previous reports. Several prognostic factors were identified, which may be helpful in guiding clinical practice in the future.
Collapse
Affiliation(s)
- J W Swann
- Department of Clinical Science and Services, Royal Veterinary College, University of London, London, UK
| | - B Szladovits
- Department of Pathology and Pathogen Biology, Royal Veterinary College, University of London, London, UK
| | - B Glanemann
- Department of Clinical Science and Services, Royal Veterinary College, University of London, London, UK
| |
Collapse
|
34
|
Abstract
Autoimmune hemolytic anemia is characterized by shortened red blood cell survival and a positive Coombs test. The responsible autoantibodies may be either warm reactive or cold reactive. The rate of hemolysis and the severity of the anemia may vary from mild to severe and life-threatening. Diagnosis is made in the laboratory by the findings of anemia, reticulocytosis, a positive Coombs test, and specific serologic tests. The prognosis is generally good but renal failure and death sometimes occur, especially in cases mediated by drugs.
Collapse
Affiliation(s)
- Charles H Packman
- Department of Hematology, Levine Cancer Institute, University of North Carolina School of Medicine, Carolinas Healthcare System, Charlotte, NC, USA
| |
Collapse
|
35
|
Abstract
Warm autoimmune hemolytic anemia (AIHA) is defined as the destruction of circulating red blood cells (RBCs) in the setting of anti-RBC autoantibodies that optimally react at 37°C. The pathophysiology of disease involves phagocytosis of autoantibody-coated RBCs in the spleen and complement-mediated hemolysis. Thus far, treatment is aimed at decreasing autoantibody production with immunosuppression or reducing phagocytosis of affected cells in the spleen. The role of complement inhibitors in warm AIHA has not been explored. This article addresses the diagnosis, etiology, and treatment of warm AIHA and highlights the role of complement in disease pathology.
Collapse
Affiliation(s)
- Rakhi Naik
- Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, 1830 East Monument Street, Baltimore, MD 21230, USA.
| |
Collapse
|
36
|
Caviezel LL, Raj K, Giger U. Comparison of 4 direct Coombs' test methods with polyclonal antiglobulins in anemic and nonanemic dogs for in-clinic or laboratory use. J Vet Intern Med 2014; 28:583-91. [PMID: 24433319 PMCID: PMC4004353 DOI: 10.1111/jvim.12292] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 10/15/2013] [Accepted: 11/26/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Difficulties with the direct antiglobulin test (DAT) and its apparent lack of sensitivity and specificity for immune-mediated hemolytic anemia (IMHA) in dogs have raised skepticism regarding its diagnostic value. OBJECTIVE To compare different DATs and other hematologic parameters in dogs. ANIMALS Anticoagulated blood samples from 59 nonanemic and 46 anemic dogs (± IMHA) from a research colony and veterinary clinics. METHODS Prospective observational study: Immunochromatographic strip, gel microcolumn, and capillary techniques were compared with standard microtiter DAT using 2 polyvalent antiglobulins. Spherocytosis, autoagglutination, osmotic fragility, and clinical data were assessed. RESULTS Blood samples from all 59 nonanemic dogs were DAT-. Among 46 anemic dogs, 33 were suspected of IMHA, but only 20 were DAT+. Old and new DAT methods yielded comparable and consistent results even after storage of chilled blood samples for 1 week. Spherocytosis and autoagglutination (that did not persist after washing) were noted in 15 and 16 DAT+ dogs, respectively. The other 26 anemic dogs, including 21 previously transfused dogs and 4 with autoagglutination, tested DAT- by the other methods. Osmotic fragility was increased in 70% (19/27) of anemic and all 15 DAT+ dogs tested. Limited follow-up testing revealed DAT+ results for 3-70 days. CONCLUSIONS AND CLINICAL IMPORTANCE The novel strip and capillary DAT methods are promising adjunct in-clinic tools. Despite prior immunosuppressive treatment and presence of autoagglutination, the DAT was positive in anemic dogs with IMHA. Transfusion did not cause false DAT+ results. Our results support DAT as a cornerstone in the diagnosis of canine IMHA.
Collapse
Affiliation(s)
- L L Caviezel
- Section of Medical Genetics, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | |
Collapse
|