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Bianchi C, Margot H, Fernandes H, Pasquet M, Priqueler L, Roy-Peaud F, Bauduer F, Bayart S, Garnier N, Fain O, Van Gils J, Joly SB, Rialland F, Paillard C, Deparis M, Lambilliotte A, Leblanc T, Fahd M, Leverger G, Héritier S, Geneviève D, Rieux-Laucat F, Picard C, Neyraud C, Aladjidi N. Autoimmune cytopenia and Kabuki syndrome in paediatrics: Insights in 11 patients. Br J Haematol 2024. [PMID: 38432067 DOI: 10.1111/bjh.19387] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 02/16/2024] [Accepted: 02/24/2024] [Indexed: 03/05/2024]
Abstract
Kabuki syndrome (KS) is now listed in the Human Inborn Errors of Immunity (IEI) Classification. It is a rare disease caused by KMT2D and KDM6A variants, dominated by intellectual disability and characteristic facial features. Recurrently, pathogenic variants are identified in those genes in patients examined for autoimmune cytopenia (AIC), but interpretation remains challenging. This study aims to describe the genetic diagnosis and the clinical management of patients with paediatric-onset AIC and KS. Among 11 patients with AIC and KS, all had chronic immune thrombocytopenic purpura, and seven had Evans syndrome. All had other associated immunopathological manifestations, mainly symptomatic hypogammaglobinaemia. They had a median of 8 (5-10) KS-associated manifestations. Pathogenic variants were detected in KMT2D gene without clustering, during the immunological work-up of AIC in three cases, and the clinical strategy to validate them is emphasized. Eight patients received second-line treatments, mainly rituximab and mycophenolate mofetil. With a median follow-up of 17 (2-31) years, 8/10 alive patients still needed treatment for AIC. First-line paediatricians should be able to recognize and confirm KS in children with ITP or multiple AIC, to provide early appropriate clinical management and specific long-term follow-up. The epigenetic immune dysregulation in KS opens exciting new perspectives.
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Affiliation(s)
- Chloé Bianchi
- Pediatric Haemato-Immunology, CIC1401, INSERM CICP, National Reference Center for Autoimmune Cytopenias in Children (CEREVANCE), Bordeaux University Hospital, Bordeaux, France
| | - Henri Margot
- Department of Medical Genetics, MRGM INSERM U1211, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - Helder Fernandes
- Pediatric Haemato-Immunology, CIC1401, INSERM CICP, National Reference Center for Autoimmune Cytopenias in Children (CEREVANCE), Bordeaux University Hospital, Bordeaux, France
| | - Marlène Pasquet
- Pediatric Oncology Immunology Hematology Unit, Children's University Hospital, Toulouse, France
| | - Laurence Priqueler
- Department of Pediatrics, Mont de Marsan Hospital Center, Mont de Marsan, France
| | | | | | - Sophie Bayart
- Pediatric Hematology Unit, Rennes University Hospital, Rennes, France
| | - Nathalie Garnier
- Institute of Pediatric Hematology and Oncology, Hospices Civils de Lyon, Lyon, France
| | - Olivier Fain
- Sorbonne Université, Service de Médecine Interne, AP-HP Hôpital Saint Antoine, Paris, France
| | - Julien Van Gils
- Department of Medical Genetics, MRGM INSERM U1211, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | | | - Fanny Rialland
- Pediatric Oncology Immunology Hematology Unit, Nantes University Hospital, Nantes, France
| | - Catherine Paillard
- Department of Pediatric Hematology and Oncology, Hautepierre University Hospital, Strasbourg, France
| | - Marianna Deparis
- Pediatric Oncology-Hematology Unit, Caen University Hospital, Caen, France
| | - Anne Lambilliotte
- Department of Pediatric Hematology, Jeanne de Flandre Hospital, Lille University Hospital, Lille, France
| | - Thierry Leblanc
- Pediatric Hematology Unit, National Reference Center for Autoimmune Cytopenias in Children (CEREVANCE) Robert-Debré University Hospital, AP-HP, Paris, France
| | - Mony Fahd
- Pediatric Hematology Unit, National Reference Center for Autoimmune Cytopenias in Children (CEREVANCE) Robert-Debré University Hospital, AP-HP, Paris, France
| | - Guy Leverger
- Sorbonne University, AP-HP, National Reference Center for Autoimmune Cytopenias in Children (CEREVANCE) Armand Trousseau Hospital, Pediatric Hematology Oncology Unit, Paris, France
| | - Sébastien Héritier
- Sorbonne University, AP-HP, National Reference Center for Autoimmune Cytopenias in Children (CEREVANCE) Armand Trousseau Hospital, Pediatric Hematology Oncology Unit, Paris, France
| | - David Geneviève
- Department of Medical Genetics, Montpellier University Hospital, Montpellier University, INSERM U1183, Reference Center for Rare Disease Malformative Syndromes, Montpellier, France
| | - Frédéric Rieux-Laucat
- Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, IMAGINE Institute, Unité Mixte de recherche (UMR) 1163, INSERM, Paris, France
| | - Capucine Picard
- Study Center for Primary Immunodeficiencies, Necker Hospital for Sick Children, Assistance Publique-Hopitaux de Paris (AP-HP), Université de Paris cité, Paris, France
| | - Caroline Neyraud
- Pediatric Haemato-Immunology, CIC1401, INSERM CICP, National Reference Center for Autoimmune Cytopenias in Children (CEREVANCE), Bordeaux University Hospital, Bordeaux, France
| | - Nathalie Aladjidi
- Pediatric Haemato-Immunology, CIC1401, INSERM CICP, National Reference Center for Autoimmune Cytopenias in Children (CEREVANCE), Bordeaux University Hospital, Bordeaux, France
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Liu H, Ding K, Zhang W, Xing L, Wang Y, Wang H, Song J, Li L, Fu R. A pilot study of orelabrutinib treatment in three cases of refractory/relapsed autoimmune haemolytic anaemia/ Evans syndrome. Br J Haematol 2024; 204:1082-1085. [PMID: 37932927 DOI: 10.1111/bjh.19146] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 09/24/2023] [Accepted: 09/27/2023] [Indexed: 11/08/2023]
Abstract
Currently, there is no effective treatment for refractory/relapsed (R/R) autoimmune haemolytic anaemia (AIHA), associated with poor quality of life. Bruton tyrosine kinase inhibitors have begun to be used in some autoimmune diseases. We initiated the clinical trial of orelabrutinib treatment on R/R AIHA/Evans Syndrome, which is in progress. The preliminary results showed that nine of the 12 enrolled patients responded to orelabrutinib treatment. Here, we reported three cases who have completed the treatment and were followed up for 6 months, achieving complete or partial remission. Orelabrutinib is expected to become a new second-line treatment for R/R AIHA/Evans syndrome.
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Affiliation(s)
- Hui Liu
- Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Kai Ding
- Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Wei Zhang
- Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Limin Xing
- Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Yihao Wang
- Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Huaquan Wang
- Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Jia Song
- Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Lijuan Li
- Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Rong Fu
- Tianjin Medical University General Hospital, Tianjin, P.R. China
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Ríos NR, Bransfield A, Joyce CM, Cahill MR, O’Shaughnessy M, Costelloe SJ. Challenges of providing biochemistry results in a patient with Evans syndrome. Biochem Med (Zagreb) 2024; 34:011001. [PMID: 38125617 PMCID: PMC10731728 DOI: 10.11613/bm.2024.011001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 10/09/2023] [Indexed: 12/23/2023] Open
Abstract
A case report of in vivo hemolysis in a female patient with Evans syndrome is described. The patient was admitted with anemia and jaundice and, during her 26-day hospital admission, had 83 samples taken for biochemistry analyses. The laboratory hemolytic index (HI) was frequently elevated due to persistent complement-mediated in vivo hemolysis despite multiple lines of therapy. Initially, the release of many biochemical parameters was blocked per the manufacturer´s recommendations and reported as "sample hemolyzed". The patient developed severe acute kidney injury, ultimately requiring dialysis. Automated and timely reporting of indicative creatinine and other biochemical results in the context of ongoing hemolysis, therefore, became essential to patient care. Following a review of literature from various sources, a laboratory algorithm was designed to ensure the timely release of numerical biochemical values, where possible, with appropriate interpretative comments appended. Biochemistry, hematology, and nephrology teams were in regular communication to ensure patient samples were rapidly identified, analyzed and validated according to the algorithm, informing timely, safe and appropriate patient care. Ultimately, the patient died due to multiple disease- and treatment-related complications. In conjunction with clinical users, laboratories should plan for situations, such as in vivo hemolysis, where significant unavoidable interferences in biochemistry methodologies may occur in an ongoing manner for certain patients. Reporting categorical or best-estimate biochemistry results in such cases can be safer for patients than failing to report any results. Interpretation of these results by clinical teams requires input from appropriately trained and qualified laboratory personnel.
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Affiliation(s)
- Natividad Rico Ríos
- Department of Clinical Biochemistry, Cork University Hospital, Cork, Republic of Ireland
| | - Alison Bransfield
- Department of Clinical Biochemistry, Cork University Hospital, Cork, Republic of Ireland
| | - Caroline M Joyce
- Department of Clinical Biochemistry, Cork University Hospital, Cork, Republic of Ireland
| | - Mary R Cahill
- Department of Clinical Haematology, Cork University Hospital, Cork, Republic of Ireland
| | | | - Seán J. Costelloe
- Department of Clinical Biochemistry, Cork University Hospital, Cork, Republic of Ireland
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Li Y, Du J, Wu P, Zeng X. Susceptive piperacillin-tazobactam-induced Evans syndrome after radical resection of esophageal cancer: A rare case report. Asian J Surg 2023; 46:5879-5881. [PMID: 37659935 DOI: 10.1016/j.asjsur.2023.08.185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 08/25/2023] [Indexed: 09/04/2023] Open
Affiliation(s)
- Yan Li
- Department of Cardio-Thoracic Surgery, The Second Affiliated Hospital of Chengdu Medical College (China National Nuclear Corporation 416 Hospital), Chengdu, Sichuan, 610051, China.
| | - Juan Du
- Department of Nursing, The Second Affiliated Hospital of Chengdu Medical College (China National Nuclear Corporation 416 Hospital), Chengdu, Sichuan, 610051, China.
| | - Ping Wu
- Department of Cardio-Thoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan, 610017, China.
| | - Xingling Zeng
- Operating Room, The Second Affiliated Hospital of Chengdu Medical College (China National Nuclear Corporation 416 Hospital), Chengdu, Sichuan, 610051, China.
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Tezuka T, Shibata M, Hanaoka H, Izawa Y, Kikuchi T, Akino K, Ozawa Y, Saito M, Kaneko Y, Nakahara J, Takizawa T. Systemic lupus erythematosus mimicking retinal migraine: a case report. Cephalalgia 2023; 43:3331024231219477. [PMID: 38069834 DOI: 10.1177/03331024231219477] [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] [Indexed: 12/18/2023]
Abstract
BACKGROUND Retinal migraine is a diagnosis of exclusion and is characterized by repeated episodes of transient monocular blindness associated with migraine. We report a case of systemic lupus erythematosus with acute episodes mimicking retinal migraines. CASE REPORT A 46-year-old woman with a history of migraine with aura since her 20s and Evans syndrome presented with episodic transient monocular blindness. Retinal migraine was considered as the cause, and migraine prophylaxis initially reduced its frequency. After 5 months, the frequency increased, with chilblain-like lupus lesions on her extremities. Laboratory testing revealed lymphopenia and hypocomplementemia, fulfilling the diagnostic criteria for systemic lupus erythematosus, which may have caused Evans syndrome and transient monocular blindness, mimicking retinal migraines. After intravenous methylprednisolone and rituximab therapy, the transient monocular blindness episodes did not recur. CONCLUSION Given the clinical presentation, systemic lupus erythematosus should be considered as a cause of transient monocular blindness and should be distinguished from retinal migraine.
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Affiliation(s)
- Toshiki Tezuka
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Mamoru Shibata
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Hironari Hanaoka
- Department of Rheumatology, Keio University School of Medicine, Tokyo, Japan
| | - Yoshikane Izawa
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Taku Kikuchi
- Department of Hematology, Keio University School of Medicine, Tokyo, Japan
- Department of Hematology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Kunihiko Akino
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
| | - Yoko Ozawa
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
- Department of Clinical Regenerative Medicine, Fujita Medical Innovation Center Tokyo and Eye Center, Fujita Health University, Haneda Clinic, Tokyo, Japan
| | - Masataka Saito
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kaneko
- Department of Rheumatology, Keio University School of Medicine, Tokyo, Japan
| | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Tsubasa Takizawa
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
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Zhang Z, Hu Q, Yang C, Chen M, Han B. Sirolimus is effective for primary refractory/relapsed warm autoimmune haemolytic anaemia/ Evans syndrome: a retrospective single-center study. Ann Med 2023; 55:2282180. [PMID: 37967535 PMCID: PMC10653746 DOI: 10.1080/07853890.2023.2282180] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 10/31/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Some patients with warm autoimmune haemolytic anaemia (wAIHA) or Evans syndrome (ES) have no response to glucocorticoid or relapse. Recent studies found that sirolimus was effective in autoimmune cytopenia with a low relapse rate. METHODS Data from patients with refractory/relapsed wAIHA and ES in Peking Union Medical College Hospital from July 2016 to May 2022 who had been treated with sirolimus for at least 6 months and followed up for at least 12 months were collected retrospectively. Baseline and follow-up clinical data were recorded and the rate of complete response (CR), partial response (PR) at different time points, adverse events, relapse, outcomes, and factors that may affect the efficacy and relapse were analyzed. RESULTS There were 44 patients enrolled, with 9 (20.5%) males and a median age of 44 (range: 18-86) years. 37 (84.1%) patients were diagnosed as wAIHA, and 7 (15.9%) as ES. Patients were treated with sirolimus for a median of 23 (range: 6-80) months and followed up for a median of 25 (range: 12-80) months. 35 (79.5%) patients responded to sirolimus, and 25 (56.8%) patients achieved an optimal response of CR. Mucositis (11.4%), infection (9.1%), and alanine aminotransferase elevation (9.1%) were the most common adverse events. 5/35 patients (14.3%) relapsed at a median of 19 (range: 15-50) months. Patients with a higher sirolimus plasma trough concentration had a higher overall response (OR) and CR rate (p = 0.009, 0.011, respectively). At the time of enrolment, patients were divided into two subgroups that relapsed or refractory to glucocorticoid, and the former had poorer relapse-free survival (p = 0.032) than the other group. CONCLUSION Sirolimus is effective for patients with primary refractory/relapsed wAIHA and ES, with a low relapse rate and mild side effects. Patients with a higher sirolimus plasma trough concentration had a higher OR and CR rate, and patients who relapsed to glucocorticoid treatment had poorer relapse-free survival than those who were refractory.
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Affiliation(s)
- Zhuxin Zhang
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Qinglin Hu
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Chen Yang
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Miao Chen
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
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7
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Zhang L, Yu C, Ren C. Systemic lupus erythematosus combined with Evans syndrome and primary biliary cirrhosis: A rare case. Asian J Surg 2023; 46:4920-4921. [PMID: 37330298 DOI: 10.1016/j.asjsur.2023.05.172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 05/31/2023] [Indexed: 06/19/2023] Open
Affiliation(s)
- Lili Zhang
- Institute of Acupuncture and Moxibustion, Shandong University of Traditional Chinese Medicine, Jinan, China; College of Acupuncture and Massage, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China.
| | - Cheng Yu
- Department of Traditional Chinese Medicine Classics, Shandong University of Traditional Chinese Medicine Affiliated Hospital, Jinan, Shandong, China.
| | - Chengqiang Ren
- Department of Rheumatology, Qingdao Hospital of Traditional Chinese Medicine(Qingdao hiser Hospital), Qingdao, Shandong Province, China.
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Novak W, Berner J, Svaton M, Jimenez-Heredia R, Segarra-Roca A, Frohne A, Guiliani S, Rouhani D, Eder SK, Rottal A, Trapin D, Scheuchenstuhl A, Pickl WF, Simonitsch-Klupp I, Kager L, Boztug K. Evans syndrome caused by a deleterious mutation affecting the adaptor protein SASH3. Br J Haematol 2023; 203:678-683. [PMID: 37646304 DOI: 10.1111/bjh.19061] [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: 04/23/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 09/01/2023]
Abstract
Increasing evidence suggests multilineage cytopenias (also known as Evans syndrome) may be caused by inborn errors of immunity (IEI) with immune dysregulation. We studied a patient with autoimmune haemolytic anaemia and immune thrombocytopenia and identified a germline mutation in SASH3 (c.862C>T;p.Arg288Ter), indicating a recently identified IEI. Immunohistochemistry performed after clinically indicated splenectomy revealed severe hypoplasia/absence of germinal centres. The autoimmune phenotype was associated with an increased CD21low T-bet+ CD11c+ subset along with decreased regulatory T cells, impaired T-cell proliferation and T-cell exhaustion. The younger brother carries the same SASH3 mutation and shares immunophenotypic features but is currently clinical asymptomatic, indicating heterogeneity of SASH3 deficiency.
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Affiliation(s)
- Wolfgang Novak
- St. Anna Children's Hospital, Vienna, Austria
- Medical University of Vienna, Department of Pediatrics and Adolescent Medicine, Vienna, Austria
| | - Jakob Berner
- St. Anna Children's Hospital, Vienna, Austria
- Medical University of Vienna, Department of Pediatrics and Adolescent Medicine, Vienna, Austria
- St. Anna Children's Cancer Research Institute (CCRI), Vienna, Austria
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria
- Department of Dermatology, Venerology and Allergology, Klinik Landstrasse, Vienna, Austria
| | - Michael Svaton
- St. Anna Children's Cancer Research Institute (CCRI), Vienna, Austria
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Raul Jimenez-Heredia
- St. Anna Children's Hospital, Vienna, Austria
- Medical University of Vienna, Department of Pediatrics and Adolescent Medicine, Vienna, Austria
- St. Anna Children's Cancer Research Institute (CCRI), Vienna, Austria
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria
| | - Anna Segarra-Roca
- St. Anna Children's Cancer Research Institute (CCRI), Vienna, Austria
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria
| | - Alexandra Frohne
- St. Anna Children's Cancer Research Institute (CCRI), Vienna, Austria
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria
| | - Sarah Guiliani
- St. Anna Children's Cancer Research Institute (CCRI), Vienna, Austria
| | - David Rouhani
- St. Anna Children's Hospital, Vienna, Austria
- Medical University of Vienna, Department of Pediatrics and Adolescent Medicine, Vienna, Austria
| | - Sebastian K Eder
- St. Anna Children's Hospital, Vienna, Austria
- Medical University of Vienna, Department of Pediatrics and Adolescent Medicine, Vienna, Austria
- St. Anna Children's Cancer Research Institute (CCRI), Vienna, Austria
| | - Arno Rottal
- Medical University of Vienna, Center for Pathophysiology, Infectiology and Immunology, Institute of Immunology, Vienna, Austria
| | - Doris Trapin
- Medical University of Vienna, Center for Pathophysiology, Infectiology and Immunology, Institute of Immunology, Vienna, Austria
| | - Anja Scheuchenstuhl
- Medical University of Vienna, Center for Pathophysiology, Infectiology and Immunology, Institute of Immunology, Vienna, Austria
| | - Winfried F Pickl
- Medical University of Vienna, Center for Pathophysiology, Infectiology and Immunology, Institute of Immunology, Vienna, Austria
| | | | - Leo Kager
- St. Anna Children's Hospital, Vienna, Austria
- Medical University of Vienna, Department of Pediatrics and Adolescent Medicine, Vienna, Austria
- St. Anna Children's Cancer Research Institute (CCRI), Vienna, Austria
| | - Kaan Boztug
- St. Anna Children's Hospital, Vienna, Austria
- Medical University of Vienna, Department of Pediatrics and Adolescent Medicine, Vienna, Austria
- St. Anna Children's Cancer Research Institute (CCRI), Vienna, Austria
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
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9
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Berrueco R, González-Forster E, Deya-Martinez A, Solsona M, García-García A, Calzada-Hernández J, Yiyi L, Vlagea A, Ruiz-Llobet A, Alsina L. Mycophenolate mofetil for autoimmune cytopenias in children: high rates of response in inborn errors of immunity. Front Pediatr 2023; 11:1174671. [PMID: 37915985 PMCID: PMC10616248 DOI: 10.3389/fped.2023.1174671] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 09/25/2023] [Indexed: 11/03/2023] Open
Abstract
Second-line treatments of autoimmune cytopenias (AC) are not well-defined in children. Mycophenolate mofetil (MMF) is an immunosuppressant agent that has been demonstrated to be safe and effective in this setting. A retrospective observational study was conducted in 18 children with prolonged AC who received MMF, in order to describe clinical and biological markers of response. The overall response rate of MMF at 20-30 mg/kg per day was 73.3%. All patients with Evans syndrome (n = 9) achieved complete response. Among the patients with monolineage AC (n = 9), those with an underlying inborn errors of immunity (IEI), tended to respond better to MMF. No biological markers related to treatment response were found. Rather, lymphocyte subpopulations proved useful for patient selection as a marker suggestive of IEI along with immunoglobulin-level determination.
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Affiliation(s)
- Rubén Berrueco
- Pediatric Hematology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Institut de Recerca Sant Joan de Déu de Barcelona (IRSJD), Barcelona, Spain
- Instituto Nacional de Investigación Biomédica en Enfermedades Raras (CIBER ER), Instituto de Salud Carlos III, Madrid, Spain
| | - Elisa González-Forster
- Pediatric Hematology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Institut de Recerca Sant Joan de Déu de Barcelona (IRSJD), Barcelona, Spain
| | - Angela Deya-Martinez
- Institut de Recerca Sant Joan de Déu de Barcelona (IRSJD), Barcelona, Spain
- Clinical Immunology and Primary Immunodeficiencies Unit, Pediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic Barcelona, Barcelona, Spain
| | - María Solsona
- Pediatric Hematology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Institut de Recerca Sant Joan de Déu de Barcelona (IRSJD), Barcelona, Spain
| | - Ana García-García
- Institut de Recerca Sant Joan de Déu de Barcelona (IRSJD), Barcelona, Spain
- Clinical Immunology and Primary Immunodeficiencies Unit, Pediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic Barcelona, Barcelona, Spain
| | - Joan Calzada-Hernández
- Pediatric Rheumatology Unit, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Luo Yiyi
- Clinical Immunology and Primary Immunodeficiencies Unit, Pediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic Barcelona, Barcelona, Spain
| | - Alexandru Vlagea
- Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic Barcelona, Barcelona, Spain
- Immunology Department, Centre of Biomedical Diagnosis, Hospital Clínic, Barcelona, Spain
| | - Anna Ruiz-Llobet
- Pediatric Hematology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Institut de Recerca Sant Joan de Déu de Barcelona (IRSJD), Barcelona, Spain
- Instituto Nacional de Investigación Biomédica en Enfermedades Raras (CIBER ER), Instituto de Salud Carlos III, Madrid, Spain
| | - Laia Alsina
- Institut de Recerca Sant Joan de Déu de Barcelona (IRSJD), Barcelona, Spain
- Clinical Immunology and Primary Immunodeficiencies Unit, Pediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic Barcelona, Barcelona, Spain
- Department of Surgery and Surgical Specializations, Facultat de Medicina I Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
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10
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Venkatachari IV, Chougule A, Gowri V, Taur P, Bodhanwala M, Prabhu S, Madkaikar M, Desai M. Monogenic inborn errors of immunity in autoimmune disorders. Immunol Res 2023; 71:771-780. [PMID: 37199901 DOI: 10.1007/s12026-023-09391-3] [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: 03/01/2023] [Accepted: 05/03/2023] [Indexed: 05/19/2023]
Abstract
To estimate the prevalence of monogenic inborn errors of immunity in patients with autoimmune diseases (AID), the study included 56 subjects (male:female ratio: 1.07) with mean age of onset of autoimmunity 7 years (4 months-46 years). 21/56 had polyautoimmunity. 5/56 patients met the JMF criteria for PID. The different AID referred were hematological (42%) > gastrointestinal (GI) (16%) > skin (14%) > endocrine (10%) > rheumatological (8%) > renal (6%) > neurological (2%). 36/56 reported recurrent infections. 27/56 were on polyimmunotherapy. 18/52 (35%) had CD19 lymphopenia, 24/52 (46%) had CD4 lymphopenia, 11/52 (21%) had CD8 lymphopenia, and 14/48 (29%) had NK lymphopenia. 21/50 (42%) had hypogammaglobinemia; 3 of whom were given rituximab. 28/56 were found to have pathogenic variants among PIRD genes. These 28 patients had 42 AID among which hematological was most common (50%) > GI (14%) = skin (14%)> endocrine (9%) > rheumatological (7%) > renal and neurological (2%). Hematological AID was the most common AID (75%) in children with PIRD. Positive predictive value (PPV) of abnormal immunological tests was 50% and sensitivity of 70%. JMF criteria had specificity of 100% in identifying PIRD and sensitivity of 17%. Polyautoimmunity had a PPV of 35% and sensitivity of 40%. 11/28 of these children were offered transplant. 8/28 were started on sirolimus, 2/28 on abatacept, and 3/28 on baricitinib/ruxolitinib after diagnosis. In conclusion, 50% of children with AID have underlying PIRD. LRBA deficiency and STAT1 GOF were the most common PIRD. Age at presentation, number of autoimmunity, routine immunological tests, and JMF criteria are not predictive of underlying PIRD. Early diagnosis with exome sequencing alters the prognosis and opens new therapeutic avenue.
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Affiliation(s)
| | - Akshaya Chougule
- Department of Immunology, Bai Jerbai Wadia Hospital for Children, Acharya Dhonde Marg, Parel, Mumbai, 400012, India
| | - Vijaya Gowri
- Department of Immunology, Bai Jerbai Wadia Hospital for Children, Acharya Dhonde Marg, Parel, Mumbai, 400012, India
| | - Prasad Taur
- Department of Immunology, Bai Jerbai Wadia Hospital for Children, Acharya Dhonde Marg, Parel, Mumbai, 400012, India
| | - Minnie Bodhanwala
- Department of Immunology, Bai Jerbai Wadia Hospital for Children, Acharya Dhonde Marg, Parel, Mumbai, 400012, India
| | - Shakuntala Prabhu
- Department of Immunology, Bai Jerbai Wadia Hospital for Children, Acharya Dhonde Marg, Parel, Mumbai, 400012, India
| | - Manisha Madkaikar
- National Institute of Immunohematology, ICMR, KEM, Parel, Mumbai, India
| | - Mukesh Desai
- Department of Immunology, Bai Jerbai Wadia Hospital for Children, Acharya Dhonde Marg, Parel, Mumbai, 400012, India.
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11
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Aladjidi N, Pincez T, Rieux-Laucat F, Nugent D. Paediatric-onset Evans syndrome: Breaking away from refractory immune thrombocytopenia. Br J Haematol 2023; 203:28-35. [PMID: 37735545 DOI: 10.1111/bjh.19073] [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: 06/21/2023] [Accepted: 08/02/2023] [Indexed: 09/23/2023]
Abstract
Since its first description by Evans in 1951, this syndrome has been linked to chronic immune thrombocytopenia with the concurrent or delayed onset of autoimmune haemolytic anaemia or neutropenia. For decades, the evolution of Evans syndrome (ES) has carried a poor prognosis and often resulted in chronic steroid exposure, multiple immune suppressing medications directed against T or B lymphocytes, and splenectomy. This paper presents a new view of ES based on recent advances in genomics which begin to classify patients based on their underlying molecular variants in previously described primary immune disorders. This has opened up new avenues of targeted therapy or bone marrow transplant at rather than broad long-term immune suppression or splenectomy. Importantly, recent studies of the full lifespan of ES suggest that at least 80% of those paediatric patients will progress to various clinical or biological immunopathological manifestations with age despite the resolution of their cytopenias. Those patients merit long-term follow-up and monitoring in dedicated transition programs to improve outcome at the adult age.
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Affiliation(s)
- Nathalie Aladjidi
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux, France
- Pediatric Hemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
| | - Thomas Pincez
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux, France
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Charles-Bruneau Cancer Center, Sainte-Justine University Hospital, Université de Montréal, Québec, Montréal, Canada
| | - Frédéric Rieux-Laucat
- Université Paris Cité, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, Institut Imagine, INSERM UMR 1163, Paris, France
| | - Diane Nugent
- Division of Hematology, Childrens Hospital of ORange County (CHOC), University of California Irvine, Irvine, California, USA
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12
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Kakita S, Matsuo T, Ohki M, Tsuchiyama A, Yasuda T, Nakanishi H, Mitsunari K, Ohba K, Imamura R. Evans syndrome during pembrolizumab therapy for upper urinary tract cancer. IJU Case Rep 2023; 6:298-301. [PMID: 37667757 PMCID: PMC10475338 DOI: 10.1002/iju5.12609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 07/11/2023] [Indexed: 09/06/2023] Open
Abstract
Introduction Immune checkpoint inhibitors are available for the treatment of advanced urothelial carcinoma; however, serious adverse events occasionally occur. Here, we report a rare case of Evans syndrome attributed to the use of an immune checkpoint inhibitor. Case presentation A 56-year-old man was diagnosed with left renal pelvic cancer and underwent left laparoscopic radical nephroureterectomy. Eight months postoperatively, computed tomography revealed para-aortic lymph node metastasis. Despite receiving chemotherapy, the disease progressed, and pembrolizumab was initiated. After 26 months of pembrolizumab treatment, the patient developed fever and anemia. Hematologic examination confirmed the diagnosis of Evans syndrome. He was treated with blood transfusions and corticosteroids, and gradual symptom improvement was observed. Conclusion This report highlights the potential risk of Evans syndrome associated with immune checkpoint inhibitor treatment. Clinicians should be aware of this possibility and consider early intervention with corticosteroids.
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Affiliation(s)
- Shota Kakita
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Tomohiro Matsuo
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Masaharu Ohki
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Ayaka Tsuchiyama
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Takuji Yasuda
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Hiromi Nakanishi
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Kensuke Mitsunari
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Kojiro Ohba
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Ryoichi Imamura
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
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13
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LaBere B, Nguyen AA, Habiballah SB, Elkins M, Imperial J, Li B, Devana S, Timilsina S, Stubbs SB, Joerger J, Chou J, Platt CD. Clinical utility of measuring CD4 + T follicular cells in patients with immune dysregulation. J Autoimmun 2023; 140:103088. [PMID: 37549449 PMCID: PMC10839119 DOI: 10.1016/j.jaut.2023.103088] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/23/2023] [Accepted: 07/11/2023] [Indexed: 08/09/2023]
Abstract
Mechanistic studies of autoimmune disorders have identified circulating T follicular helper (cTfh) cells as drivers of autoimmunity. However, the quantification of cTfh cells is not yet used in clinical practice due to the lack of age-stratified normal ranges and the unknown sensitivity and specificity of this test for autoimmunity. We enrolled 238 healthy participants and 130 patients with common and rare disorders of autoimmunity or autoinflammation. Patients with infections, active malignancy, or any history of transplantation were excluded. In 238 healthy controls, median cTfh percentages (range 4.8%-6.2%) were comparable among age groups, sexes, races, and ethnicities, apart from a significantly lower percentages in children less than 1 year of age (median 2.1%, CI: 0.4%-6.8, p < 0.0001). Among 130 patients with over 40 immune regulatory disorders, a cTfh percentage exceeding 12% had 88% sensitivity and 94% specificity for differentiating disorders with adaptive immune cell dysregulation from those with predominantly innate cell defects. This threshold had a sensitivity of 86% and specificity of 100% for active autoimmunity and normalized with effective treatment. cTfh percentages exceeding 12% distinguish autoimmunity from autoinflammation, thereby differentiating two endotypes of immune dysregulation with overlapping symptoms and different therapies.
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Affiliation(s)
- Brenna LaBere
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alan A Nguyen
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Saddiq B Habiballah
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Megan Elkins
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Juliet Imperial
- Department of Laboratory Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Betty Li
- Department of Laboratory Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Suraj Timilsina
- Department of Laboratory Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Spencer B Stubbs
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jill Joerger
- Department of Laboratory Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Janet Chou
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Craig D Platt
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Laboratory Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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Corredor-Orlandelli D, Arévalo-Romero A, Reyes C, Arango D. Massive Right Chylothorax Secondary to a Severe Systemic Lupus Erythematosus Flare With Secondary Evans Syndrome: A Case Report and Literature Review. Clin Med Insights Case Rep 2023; 16:11795476231186735. [PMID: 37457318 PMCID: PMC10338652 DOI: 10.1177/11795476231186735] [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: 03/25/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023]
Abstract
This case report describes a 23-year-old male patient who presented with right chylothorax as the initial manifestation of a severe flare of systemic lupus erythematosus (SLE) and secondary Evans syndrome. Chylothorax and chylous ascites are rare features of SLE that can occur due to the accumulation of triglyceride-rich fluid in serous cavities. However, they have never been reported as the initial manifestation of a lupus flare. Evans syndrome is a rare disease characterized by autoimmune hemolytic anemia and immune thrombocytopenia, which can be secondary to SLE. The concomitant occurrence of both chylothorax and Evans syndrome in the setting of systemic lupus erythematosus has never been described, and the exact causative mechanisms of both entities are yet to be fully understood. In this report, we discuss our approach to this challenging case to broaden the understanding of the clinical manifestations of systemic lupus erythematosus. Our findings emphasize the importance of considering rare features of systemic lupus erythematosus and secondary diseases when evaluating patients with the disease.
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Affiliation(s)
- David Corredor-Orlandelli
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
- Medical Department, Fundación Clínica Abood-Shaio, Bogotá, Colombia
| | | | - Carlos Reyes
- Medical Department, Fundación Clínica Abood-Shaio, Bogotá, Colombia
- School of Medicine and Health Sciences, Universidad Militar, Bogotá, Colombia
| | - Dylan Arango
- Medical Department, Fundación Clínica Abood-Shaio, Bogotá, Colombia
- School of Medicine, Universidad del Bosque, Bogotá, Colombia
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15
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Cvetković M, Pantić N, Virijević M, Pravdić Z, Sabljić N, Mitrović M, Suvajdžić-Vuković N. Relapse of Evans syndrome following BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine: case report and literature review. J Infect Dev Ctries 2023; 17:800-804. [PMID: 37406068 DOI: 10.3855/jidc.17719] [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: 11/27/2022] [Accepted: 02/16/2023] [Indexed: 07/07/2023] Open
Abstract
INTRODUCTION Coronavirus disease 2019 (COVID-19) vaccines are considered to be safe. Only few cases of vaccine-induced immune thrombocytopenia or immune hemolysis have been reported so far. Evans syndrome (ES) is a very rare syndrome characterized mainly by warm autoimmune hemolytic anemia (wAIHA) and immune thrombocytopenia (ITP). CASE PRESENTATION We present a case of a 47-year-old male with a history of wAIHA, diagnosed in 1995 and successfully treated with glucocorticoids, with sustained remission. ITP was diagnosed in May 2016. Due to refractoriness to glucocorticoids, intravenous immunoglobulins (IVIGs), azathioprine and vinblastine, he was splenectomised in April 2017, resulting in complete remission. In May 2021, eight days after the second dose of BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine, he experienced mucocutaneous bleeding. Blood tests showed platelet count (PC) of 8×109/L, while his hemoglobin (Hb) was normal (153 g/L). He was treated with prednisone and azathioprine, without response. On day 28 after vaccine administration, weakness, jaundice and dark brown urine occurred. His laboratory tests: PC 27×109/L, Hb 45 g/L, reticulocytes 10.4%, total bilirubin 106.6 μmol/L, direct bilirubin 19.8 μmol/L, lactate dehydrogenase 633 U/L, haptoglobin ˂0.08 g/L, and positive Coombs test were consistent with ES relapse. After treatment with glucocorticoids, azathioprine and IVIGs, his blood count finally improved (PC 490×109/L, Hb 109 g/L) and remained stable on day 40 of hospitalization. CONCLUSIONS Although it is unclear whether the relationship between COVID-19 vaccination and relapse of ES in our patient is coincidental or causal, it highlights the need for monitoring of serious outcomes following vaccination.
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Affiliation(s)
- Mirjana Cvetković
- Clinic of Hematology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Nikola Pantić
- Clinic of Hematology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Marijana Virijević
- Clinic of Hematology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Zlatko Pravdić
- Clinic of Hematology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Nikica Sabljić
- Clinic of Hematology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Mirjana Mitrović
- Clinic of Hematology, University Clinical Center of Serbia, Belgrade, Serbia
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16
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Leonardi L, Testa A, Feleppa M, Paparella R, Conti F, Marzollo A, Spalice A, Giona F, Gnazzo M, Andreoli GM, Costantino F, Tarani L. Immune dysregulation in Kabuki syndrome: a case report of Evans syndrome and hypogammaglobulinemia. Front Pediatr 2023; 11:1087002. [PMID: 37360370 PMCID: PMC10288106 DOI: 10.3389/fped.2023.1087002] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 05/25/2023] [Indexed: 06/28/2023] Open
Abstract
Kabuki syndrome (KS) is a rare multisystemic disease due to mutations in the KMT2D or KDM6A genes, which act as epigenetic modulators of different processes, including immune response. The syndrome is characterized by anomalies in multiple organ systems, and it is associated with autoimmune and inflammatory disorders, and an underlying immunological phenotype characterized by immunodeficiency and immune dysregulation. Up to 17% of KS patients present with immune thrombocytopenia characterized by a severe, chronic or relapsing course, and often associated to other hematological autoimmune diseases including autoimmune hemolytic anemia, eventually resulting in Evans syndrome (ES). A 23-year-old woman, clinically diagnosed with KS and presenting from the age of 3 years with ES was referred to the Rare Diseases Centre of our Pediatric Department for corticosteroid-induced hyperglycemia. Several ES relapses and recurrent respiratory infections in the previous years were reported. Severe hypogammaglobulinemia, splenomegaly and signs of chronic lung inflammation were diagnosed only at the time of our observation. Supportive treatment with amoxicillin-clavulanate prophylaxis and recombinant human hyaluronidase-facilitated subcutaneous immunoglobulin replacement were immediately started. In KS patients, the failure of B-cell development and the lack of autoreactive immune cells suppression can lead to immunodeficiency and autoimmunity that may be undiagnosed for a long time. Our patient's case is paradigmatic since she presented with preventable morbidity and severe lung disease years after disease onset. This case emphasizes the importance of suspecting immune dysregulation in KS. Pathogenesis and immunological complications of KS are discussed. Moreover, the need to perform immunologic evaluations is highlighted both at the time of KS diagnosis and during disease follow-up, in order to allow proper treatment while intercepting avoidable morbidity in these patients.
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Affiliation(s)
- Lucia Leonardi
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Alessia Testa
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Mariavittoria Feleppa
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Roberto Paparella
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesca Conti
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Antonio Marzollo
- Pediatric Hematology, Oncology and Stem Cell Transplant Division, Padua University Hospital, Padua, Italy
| | - Alberto Spalice
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Fiorina Giona
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Maria Gnazzo
- Translational Cytogenomics Research Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Gian Marco Andreoli
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesco Costantino
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Luigi Tarani
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
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17
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Qin BE, Yuan D, Xu XF, Su Z, Gu M, Dai K, Peng FH, Jiang Y. Neurological worsening during treatment of HIV-negative cryptococcal meningitis in a patient with Evans syndrome. Future Microbiol 2023; 18:541-545. [PMID: 37314347 DOI: 10.2217/fmb-2022-0268] [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] [Indexed: 06/15/2023] Open
Abstract
A 49-year-old woman with a rare autoimmune hematological disease, Evans syndrome, was admitted to the authors' hospital with immune reconstitution inflammatory syndrome-like reconstitution syndrome after effective antifungal therapy for cryptococcal meningitis. She initially improved after receiving corticosteroid treatment; after prednisone was tapered, her clinical presentation and brain imaging deteriorated but finally improved with the addition of thalidomide. Immune reconstitution inflammatory syndrome-like reconstitution syndrome is a rare complication in cryptococcal meningitis patients receiving immunosuppressive therapy. Thalidomide can be given in addition to corticosteroid therapy to effectively control the paradoxical inflammatory response and improve clinical outcomes.
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Affiliation(s)
- Bang-E Qin
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, 600# Tianhe Road, Guangzhou, Guangdong, 510630, China
| | - Dasen Yuan
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, 600# Tianhe Road, Guangzhou, Guangdong, 510630, China
| | - Xiao-Feng Xu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, 600# Tianhe Road, Guangzhou, Guangdong, 510630, China
| | - Zhihui Su
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, 600# Tianhe Road, Guangzhou, Guangdong, 510630, China
| | - Meifeng Gu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, 600# Tianhe Road, Guangzhou, Guangdong, 510630, China
| | - Kai Dai
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, 600# Tianhe Road, Guangzhou, Guangdong, 510630, China
| | - Fu-Hua Peng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, 600# Tianhe Road, Guangzhou, Guangdong, 510630, China
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, 600# Tianhe Road, Guangzhou, Guangdong, 510630, China
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18
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Irimia R, Barbu S, Popa C, Badelita S. Evans Syndrome as a Possible Complication of Brentuximab Vedotin Therapy for Peripheral T Cell Lymphoma. Hematol Rep 2023; 15:220-224. [PMID: 36975736 PMCID: PMC10048708 DOI: 10.3390/hematolrep15010023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/14/2022] [Accepted: 03/17/2023] [Indexed: 03/29/2023] Open
Abstract
Recently, Brentuximab Vedotin (BV) has emerged as an important therapy not only for Hodgkin's Lymphoma, but also for CD30-positive T cell lymphomas. Although anemia and thrombocytopenia are common myelosuppressive side effects, to our knowledge, this is the first described case of Evans Syndrome associated with BV therapy. We present the case of a 64-year-old female, diagnosed with relapsed Peripheral T Cell Lymphoma Not Otherwise Specified (PTCL-NOS), who, after receiving six cycles of BV, developed authentic severe autoimmune hemolytic anemia with strong positive direct anti-globulin (Coombs) test, simultaneously associated with severe immune thrombocytopenia. The patient was unresponsive to systemic corticotherapy, but fully recovered after a course of IV immunoglobulin.
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Affiliation(s)
- Ruxandra Irimia
- School of Medicine, "Carol Davila" University of Medicine and Pharmacy, 4192910 Bucharest, Romania
- Fundeni Clinical Institute, 4192910 Bucharest, Romania
| | - Sinziana Barbu
- School of Medicine, "Carol Davila" University of Medicine and Pharmacy, 4192910 Bucharest, Romania
- Fundeni Clinical Institute, 4192910 Bucharest, Romania
| | - Codruta Popa
- School of Medicine, "Carol Davila" University of Medicine and Pharmacy, 4192910 Bucharest, Romania
- Fundeni Clinical Institute, 4192910 Bucharest, Romania
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19
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Motoyama R, Higuchi T, Hirahara S, Konda N, Yamada R, Watanabe K, Fujisaki M, Yamaguchi R, Katsumata Y, Kawaguchi Y, Harigai M. A case of systemic lupus erythematosus having concurrent Evans syndrome and acquired thrombotic thrombocytopenic purpura. Mod Rheumatol Case Rep 2023:7035350. [PMID: 36779528 DOI: 10.1093/mrcr/rxad011] [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: 12/22/2022] [Revised: 01/19/2023] [Accepted: 02/02/2023] [Indexed: 02/14/2023]
Abstract
An 18-year-old Japanese woman with systemic lupus erythematosus (SLE) experienced dyspnoea, headache, tinnitus, and purpura for two weeks and was admitted to our hospital. The patient had been diagnosed with SLE and secondary immune thrombocytopenia eight years before and treated with high-dose prednisolone (PSL) and mycophenolate mofetil. Since the blood test on admission showed haemolytic anaemia with a positive direct Coombs test and anti-glycoprotein IIb/IIIa antibodies, the patient was initially diagnosed with Evans syndrome (ES). The patient was treated with pulse intravenous methylprednisolone followed by 45 mg/day prednisolone; however, the patient's platelet count did not normalise. Based on a low level of a disintegrin-like metalloproteinase with thrombospondin type 1 motif 13 (ADAMTS-13) activity and a high level of ADAMTS-13 inhibitors, a diagnosis of acquired thrombotic thrombocytopenic purpura (TTP) was confirmed. After undergoing therapeutic plasma exchange for six consecutive days, the patient's platelet count recovered rapidly. Although concurrent acquired TTP and ES have not been reported previously, the findings from this case highlight the importance of measuring ADAMTS-13 activity and inhibitors to rule out acquired TTP, especially when ES is refractory to glucocorticoids.
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Affiliation(s)
- Ryo Motoyama
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Tomoaki Higuchi
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Division of Multidisciplinary Management of Rheumatic Diseases, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Shinya Hirahara
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Naoko Konda
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Risa Yamada
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Kotaro Watanabe
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Mayuko Fujisaki
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Rei Yamaguchi
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Yasuhiro Katsumata
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Yasushi Kawaguchi
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Masayoshi Harigai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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Mazharuddin AA, Rehmani A, Puthenparambil L, Alappatt JJ, Lee WH. Ophthalmic Manifestations as First Presenting Sign of Evans Syndrome. J Vitreoretin Dis 2022; 6:479-484. [PMID: 37009543 PMCID: PMC9954779 DOI: 10.1177/24741264211062931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose This work reports a case of Evans syndrome first presenting with ophthalmic signs. Methods A 27-year-old previously healthy man presented with headaches and bilateral blurred vision for 2 weeks. The visual acuity was 20/30-1 and 20/60-2 in the right eye and left eye, respectively. A fundus examination revealed Roth spots, diffuse multilayer retinal hemorrhages in the macula and periphery, and tortuous vessels in both eyes. Optical coherence tomography showed a disrupted foveal contour from intraretinal fluid and hemorrhage in both eyes. Fluorescein angiography demonstrated dilated and tortuous vessels with scattered blocking defects from hemorrhages. Results A workup revealed warm hemolytic anemia with severe thrombocytopenia consistent with the diagnosis of Evans syndrome. Conclusions Evans syndrome is a rare blood dyscrasia that can first present as subacute vision loss and should be added to the differential of diffuse bilateral retinal hemorrhages spanning a multitude of retinal layers.
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Affiliation(s)
| | - Ahmad Rehmani
- University of Texas Medical Branch,
Galveston, TX, USA
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21
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Higuchi T, Hoshi T, Toriyama M, Nakajima A, Haruki K. Infrequent Thrombotic Complications in Japanese Patients with Warm Autoimmune Hemolytic Anemia. Intern Med 2022; 62:1441-1447. [PMID: 36171129 DOI: 10.2169/internalmedicine.0541-22] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective Patients with autoimmune hemolytic anemia (AIHA) are considered to be at an increased risk of thrombosis, and prophylaxis for venous thromboembolism (VTE) is often recommended. However, the occurrence of thrombosis in Asian patients has not been specifically studied. Thrombotic complications and features of Japanese warm AIHA (WAIHA) patients were studied to see if Japanese patients were at an increased risk of thrombosis and should receive prophylaxis for VTE. Patients and Methods Forty-seven consecutive patients with warm WAIHA were retrospectively studied. Twenty-nine patients were diagnosed as primary cases and 18 as secondary cases, and 10 patients were diagnosed with Evans syndrome. Results No patient presented with thrombosis, and over a median observation period of 15 months, 3 patients had ischemic cerebral vascular accidents. However, all three of those patients had other known risks for thrombosis, with only one taking thrombotic prophylaxis. No venous thrombosis occurred in any patients during the follow-up period. There was no mortality associated with thrombosis. D-dimer levels were often elevated in patients with WAIHA, indicating that the coagulation was activated in a considerable number of patients, but not to such a level as to be associated with clinically overt thrombosis. Conclusion Thrombotic complications occur infrequently in Japanese WAIHA patients, and these individuals do not appear to be at a particularly increased risk of thrombosis because of WAIHA. The indication of VTE prophylaxis should be determined individually, considering other risks.
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Affiliation(s)
- Takakazu Higuchi
- Blood Transfusion Department, Dokkyo Medical University Saitama Medical Center, Japan
| | - Takao Hoshi
- Clinical Laboratory, Dokkyo Medical University Saitama Medical Center, Japan
| | - Mitsuru Toriyama
- Blood Transfusion Department, Dokkyo Medical University Saitama Medical Center, Japan
| | - Atsuko Nakajima
- Clinical Laboratory, Dokkyo Medical University Saitama Medical Center, Japan
| | - Kosuke Haruki
- Clinical Laboratory, Dokkyo Medical University Saitama Medical Center, Japan
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Pan XH, Xu JK, Pan L, Wang CH, Huang XQ, Qiu JK, Ji XB, Mao MJ. Concurrent severe pulmonary tuberculosis with Evans syndrome: a case report with literature review. BMC Infect Dis 2022; 22:533. [PMID: 35692044 PMCID: PMC9188905 DOI: 10.1186/s12879-022-07512-1] [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: 02/28/2022] [Accepted: 05/31/2022] [Indexed: 11/21/2022] Open
Abstract
Background Tuberculosis is a bacterial infection involving multiple organs and systems. Its hematological presentation mainly includes anemia and leukocytosis. Evans syndrome is a rare autoimmune disease characterized by autoimmune hemolytic anemia, immune thrombocytopenia, and neutropenia, with positive results for the direct Coombs test and platelet antibodies. The cooccurrence of tuberculosis and Evans syndrome is rarely reported. Case presentation A 69-year-old female presented with a fever and shortness of breath. Her chest computerized tomography scan showed extensive miliary nodules in the bilateral lung fields. She rapidly developed respiratory failure that required endotracheal intubation and mechanical ventilation. The acid-fast bacilli sputum smear results indicated a grade of 3+. Later on, blood testing revealed hemolytic anemia, a positive direct Coombs test result, and the presence of the platelet antibody IgG. This patient was diagnosed as having disseminated pulmonary tuberculosis and Evans syndrome. She successfully recovered after treatment with antituberculosis drugs and glucocorticoids. Conclusions Tuberculosis can occur together with Evans syndrome. Affected patients should receive both antituberculosis and immunosuppressive drugs.
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Affiliation(s)
- Xiao-Hong Pan
- Tuberculosis Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng East Road, Hangzhou, 310003, Zhejiang, China
| | - Jie-Kun Xu
- Tuberculosis Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng East Road, Hangzhou, 310003, Zhejiang, China
| | - Lei Pan
- Tuberculosis Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng East Road, Hangzhou, 310003, Zhejiang, China
| | - Cai-Hong Wang
- Tuberculosis Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng East Road, Hangzhou, 310003, Zhejiang, China
| | - Xiao-Qing Huang
- Tuberculosis Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng East Road, Hangzhou, 310003, Zhejiang, China
| | - Jun-Ke Qiu
- Tuberculosis Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng East Road, Hangzhou, 310003, Zhejiang, China
| | - Xiao-Bo Ji
- Tuberculosis Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng East Road, Hangzhou, 310003, Zhejiang, China
| | - Min-Jie Mao
- Tuberculosis Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng East Road, Hangzhou, 310003, Zhejiang, China.
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23
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Miano M, Guardo D, Grossi A, Palmisani E, Fioredda F, Terranova P, Cappelli E, Lupia M, Traverso M, Dell'Orso G, Corsolini F, Beccaria A, Lanciotti M, Ceccherini I, Dufour C. Underlying Inborn Errors of Immunity in Patients With Evans Syndrome and Multilineage Cytopenias: A Single-Centre Analysis. Front Immunol 2022; 13:869033. [PMID: 35655776 PMCID: PMC9152001 DOI: 10.3389/fimmu.2022.869033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 02/03/2022] [Accepted: 04/07/2022] [Indexed: 02/05/2023] Open
Abstract
Background Evans syndrome (ES) is a rare disorder classically defined as the simultaneous or sequential presence of autoimmune haemolytic anaemia and immune thrombocytopenia, but it has also been described as the presence of at least two autoimmune cytopenias. Recent reports have shown that ES is often a manifestation of an underlying inborn error of immunity (IEI) that can benefit from specific treatments. Aims The aim of this study is to investigate the clinical and immunological characteristics and the underlying genetic background of a single-centre cohort of patients with ES. Methods Data were obtained from a retrospective chart review of patients with a diagnosis of ES followed in our centre. Genetic studies were performed with NGS analysis of 315 genes related to both haematological and immunological disorders, in particular IEI. Results Between 1985 and 2020, 40 patients (23 men, 17 women) with a median age at onset of 6 years (range 0-16) were studied. ES was concomitant and sequential in 18 (45%) and 22 (55%) patients, respectively. Nine of the 40 (8%) patients had a positive family history of autoimmunity. Other abnormal immunological features and signs of lymphoproliferation were present in 24/40 (60%) and 27/40 (67%) of cases, respectively. Seventeen out of 40 (42%) children fit the ALPS diagnostic criteria. The remaining 21 (42%) and 2 (5%) were classified as having an ALPS-like and an idiopathic disease, respectively. Eighteen patients (45%) were found to have an underlying genetic defect on genes FAS, CASP10, TNFSF13B, LRBA, CTLA4, STAT3, IKBGK, CARD11, ADA2, and LIG4. No significant differences were noted between patients with or without variant and between subjects with classical ES and the ones with other forms of multilineage cytopenias. Conclusions This study shows that nearly half of patients with ES have a genetic background being in most cases secondary to IEI, and therefore, a molecular evaluation should be offered to all patients.
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Affiliation(s)
- Maurizio Miano
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Daniela Guardo
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Alice Grossi
- Unità Operativa Semplice DIpartimentale (UOSD) Genetics and Genomics of Rare Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Elena Palmisani
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Paola Terranova
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Enrico Cappelli
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Michela Lupia
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Monica Traverso
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, University of Genoa, Genoa, Italy
| | - Gianluca Dell'Orso
- Stem Cell Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Fabio Corsolini
- Laboratory of Molecular Genetics and Biobanks, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Beccaria
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Isabella Ceccherini
- Unità Operativa Semplice DIpartimentale (UOSD) Genetics and Genomics of Rare Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Carlo Dufour
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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24
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Fattizzo B, Cantoni S, Giannotta JA, Bandiera L, Zavaglia R, Bortolotti M, Barcellini W. Efficacy and safety of cyclosporine A treatment in autoimmune cytopenias: the experience of two Italian reference centers. Ther Adv Hematol 2022; 13:20406207221097780. [PMID: 35585968 PMCID: PMC9109490 DOI: 10.1177/20406207221097780] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 12/20/2021] [Accepted: 04/13/2022] [Indexed: 12/24/2022] Open
Abstract
Background: Immune thrombocytopenia (ITP) and autoimmune hemolytic anemia (AIHA) show
good responses to frontline steroids. About two-third of cases relapse and
require second-line treatment, including rituximab, mainly effective in
AIHA, and thrombopoietin-receptor agonists (TPO-RAs) in ITP, while the use
of splenectomy progressively decreased due to concerns for
infectious/thrombotic complications. For those failing second line,
immunosuppressants may be considered. Objectives: The aim of this study was to evaluate the efficacy of cyclosporine treatment
in patients with ITP and AIHA. Design: In this retrospective study, we evaluated the efficacy and safety of
cyclosporine A (CyA) in ITP (N = 29) and AIHA
(N = 10) patients followed at two reference centers in
Milan, Italy. Methods: Responses were classified as partial [Hb > 10 or at least 2 g/dl increase
from baseline, platelets (PLT) > 30 × 109/l with at least
doubling from baseline] and complete (Hb > 12 g/dl or
PLT > 100 × 109/l) and evaluated at 3, 6, and 12 months.
Treatment emergent adverse events were also registered. Results: The median time from diagnosis to CyA was 35 months (3–293), and patients had
required a median of 4 (1–8) previous therapy lines. Median duration of CyA
was 28 (2–140) months and responses were achieved in 86% of ITP and 50% of
AIHA subjects. Responders could reduce or discontinue concomitant treatment
and resolved PLT fluctuations on TPO-RA. CyA was generally well tolerated,
and only two serious infectious complications in elderly patients on
concomitant steroids suggesting caution in this patient population. Conclusion: CyA may be advisable in ITP, which is not well controlled under TPO-RA, and
in AIHA failing rituximab, particularly if ineligible in clinical trial.
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Affiliation(s)
- Bruno Fattizzo
- Hematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan, via F. Sforza 35, 20100 Milan, Italy
| | - Silvia Cantoni
- Hematology Unit, Hematology & Oncology Department, Niguarda Cancer Center, ASST Ospedale Niguarda, Milan, Italy
| | | | - Laura Bandiera
- Pathology Unit, Hematology & Oncology Department, Niguarda Cancer Center, ASST Ospedale Niguarda, Milan, Italy
| | - Rachele Zavaglia
- Department of Oncology and Hemato-Oncologyilan, University of Milan, Italy
| | - Marta Bortolotti
- Department of Oncology and Hemato-Oncologyilan, University of Milan, Italy
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan, Milan, Italy
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25
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Schiavo E, Martini B, Attardi E, Consonni F, Ciullini Mannurita S, Coniglio ML, Tellini M, Chiocca E, Fotzi I, Luti L, D'Alba I, Veltroni M, Favre C, Gambineri E. Autoimmune Cytopenias and Dysregulated Immunophenotype Act as Warning Signs of Inborn Errors of Immunity: Results From a Prospective Study. Front Immunol 2022; 12:790455. [PMID: 35058929 PMCID: PMC8765341 DOI: 10.3389/fimmu.2021.790455] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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: 10/06/2021] [Accepted: 11/22/2021] [Indexed: 12/19/2022] Open
Abstract
Inborn errors of immunity (IEI) are genetic disorders characterized by a wide spectrum of clinical manifestations, ranging from increased susceptibility to infections to significant immune dysregulation. Among these, primary immune regulatory disorders (PIRDs) are mainly presenting with autoimmune manifestations, and autoimmune cytopenias (AICs) can be the first clinical sign. Significantly, AICs in patients with IEI often fail to respond to first-line therapy. In pediatric patients, autoimmune cytopenias can be red flags for IEI. However, for these cases precise indicators or parameters useful to suspect and screen for a hidden congenital immune defect are lacking. Therefore, we focused on chronic/refractory AIC patients to perform an extensive clinical evaluation and multiparametric flow cytometry analysis to select patients in whom PIRD was strongly suspected as candidates for genetic analysis. Key IEI-associated alterations causative of STAT3 GOF disease, IKAROS haploinsufficiency, activated PI3Kδ syndrome (APDS), Kabuki syndrome and autoimmune lymphoproliferative syndrome (ALPS) were identified. In this scenario, a dysregulated immunophenotype acted as a potential screening tool for an early IEI diagnosis, pivotal for appropriate clinical management and for the identification of new therapeutic targets.
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Affiliation(s)
- Ebe Schiavo
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Beatrice Martini
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Enrico Attardi
- Division of Hematology, Careggi University Hospital, Florence, Italy
| | - Filippo Consonni
- Meyer University Children's Hospital, University of Florence, Florence, Italy
| | - Sara Ciullini Mannurita
- Centre of Excellence, Division of Pediatric Oncology/Hematology, Meyer University Children's Hospital, Florence, Italy
| | - Maria Luisa Coniglio
- Centre of Excellence, Division of Pediatric Oncology/Hematology, Meyer University Children's Hospital, Florence, Italy
| | - Marco Tellini
- Meyer University Children's Hospital, University of Florence, Florence, Italy
| | - Elena Chiocca
- Centre of Excellence, Division of Pediatric Oncology/Hematology, Meyer University Children's Hospital, Florence, Italy
| | - Ilaria Fotzi
- Centre of Excellence, Division of Pediatric Oncology/Hematology, Meyer University Children's Hospital, Florence, Italy
| | - Laura Luti
- Division of Pediatric Oncology/Hematology, University Hospital of Pisa, Pisa, Italy
| | - Irene D'Alba
- Division of Pediatric Oncology/Hematology, University Hospital of Ospedali Riuniti, Ancona, Italy
| | - Marinella Veltroni
- Centre of Excellence, Division of Pediatric Oncology/Hematology, Meyer University Children's Hospital, Florence, Italy
| | - Claudio Favre
- Centre of Excellence, Division of Pediatric Oncology/Hematology, Meyer University Children's Hospital, Florence, Italy
| | - Eleonora Gambineri
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy.,Centre of Excellence, Division of Pediatric Oncology/Hematology, Meyer University Children's Hospital, Florence, Italy
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Acharya A, Dash A, Otta S. A rare case of calvarial tuberculosis in post-COVID-19 scenario. Int J Mycobacteriol 2022; 11:123-125. [PMID: 35295036 DOI: 10.4103/ijmy.ijmy_180_21] [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] [Indexed: 06/14/2023] Open
Abstract
Isolated calvarial involvement with tuberculosis (TB) is a very rare entity, with the incidence of only 0.01% of all patients with mycobacterial infections. The factors attributable could be malnutrition, poor socioeconomic conditions, and immunodeficiency syndromes. We hereby present the case of a 35-year-old male who had recently recovered from coronavirus disease 2019 and a diagnosed case of Evan's syndrome with secondary hemophagocytic lymphohistiocytosis who presented with a scalp swelling on the right frontotemporal region. He presented to the emergency department with acute-onset generalized tonic - clonic seizures with high-grade fever. Clinically, the swelling appeared like a cystic swelling of the scalp. On evaluation, there was a collection present below the scalp communicating with the extradural space, involving the underlying skull bone. The patient was operated with drainage of the abscess plus excision of the pathological underlying skull bone. The pus revealed florid amount of acid-fast bacillus on Ziehl-Neelsen staining. The patient was started on four drugs Category 1 antitubercular regimen. The patient responded well to the combined surgical and medical treatment. It should be emphasized that TB can involve any part of the body. It should be kept as differential diagnosis of any chronic inflammatory lesion involving the bony skeleton, especially in endemic countries where combined surgical and medical treatment is usually sufficient to provide a cure.
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Affiliation(s)
- Abhijit Acharya
- Department of Neurosurgery, IMS and SUM Hospital, Bhubaneswar, Odisha, India
| | - Atmaranjan Dash
- Department of Neurosurgery, IMS and SUM Hospital, Bhubaneswar, Odisha, India
| | - Sarita Otta
- Department of Microbiology, SUM Hospital, Bhubaneswar, Odisha, India
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Santosa D, Sofro MAU, Farida, Nindita N, Pangarsa EA, Setiawan B, Rizky D, Suharti C. A full-term pregnant woman with secondary Evans syndrome caused by severe coronavirus disease 2019: a case report. J Med Case Rep 2021; 15:606. [PMID: 34903274 PMCID: PMC8667974 DOI: 10.1186/s13256-021-03205-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 08/30/2021] [Accepted: 11/16/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND In this report, we describe a very challenging case of a patient with secondary Evans syndrome caused by severe coronavirus disease 2019 infection in a pregnant full-term woman. CASE PRESENTATION A 29-year-old full-term pregnant Indonesian woman presented with gross hematuria, dry cough, fever, dyspnea, nausea, anosmia, and fatigue 5 days after confirmation of coronavirus disease 2019 infection. Laboratory examinations showed very severe thrombocytopenia, increased indirect bilirubin, and a positive direct Coombs' test. From peripheral blood, there was an increased number of spherocytes, which indicated an autoimmune hemolytic process. Antinuclear antibody and anti-double-stranded DNA test results were negative, and her virology serological markers are also negative for human immunodeficiency virus, cytomegalovirus, and hepatitis B and C. Despite aggressive treatment with platelet transfusion, high-dose steroid, and thrombopoietin receptor agonists, the platelet count did not recover, and a speculative cesarean delivery had to be done with a very low platelet count.
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Affiliation(s)
- Damai Santosa
- Department of Hematology Medical-Oncology, Dr. Kariadi General Hospital, Semarang, Indonesia
| | - Muchlis A U Sofro
- Department of Tropical-Infection, Dr. Kariadi General Hospital, Semarang, Indonesia
| | - Farida
- Department of Pulmonology, Dr. Kariadi General Hospital, Semarang, Indonesia
| | - Nurvita Nindita
- Department of Obstetrics and Gynecology, Dr. Kariadi General Hospital, Semarang, Indonesia
| | - Eko A Pangarsa
- Department of Hematology Medical-Oncology, Dr. Kariadi General Hospital, Semarang, Indonesia
| | - Budi Setiawan
- Department of Hematology Medical-Oncology, Dr. Kariadi General Hospital, Semarang, Indonesia
| | - Daniel Rizky
- Department of Hematology Medical-Oncology, Dr. Kariadi General Hospital, Semarang, Indonesia.
| | - Catharina Suharti
- Department of Hematology Medical-Oncology, Dr. Kariadi General Hospital, Semarang, Indonesia
- Faculty of Medicine, Diponegoro University, Semarang, Indonesia
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28
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Jamil SB, Patoli I, Kazim M, Abbas SH, Ali Z. A Case of Evans Syndrome and Unstable Angina. J Med Cases 2021; 12:415-418. [PMID: 34691339 PMCID: PMC8510669 DOI: 10.14740/jmc3777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 09/11/2021] [Indexed: 11/26/2022] Open
Abstract
Evans syndrome (ES) is characterized by autoimmune hemolytic anemia (AIHA) and immune-mediated thrombocytopenia. It is more common in the pediatric population than in adults. ES has been reported to be associated with thrombotic events and rarely can lead to acute coronary syndrome (ACS). There have been only a few reported cases of ACS secondary to ES. We present an interesting case of ES with unstable angina (UA) which had a limited response to oral and intravenous (IV) steroids requiring rituximab. A 64-year-old male with past medical history significant for hypertension, hyperlipidemia, diabetes mellitus and coronary artery disease, presented to the emergency room complaining of a 2-week history of chest pain, shortness of breath and hematuria. Physical examination indicated splenomegaly but was otherwise unremarkable with no petechiae or rash. Labs showed hemoglobin of 9.6 g/dL, platelet count 58 × 103/µL, troponin < 0.03 ng/mL, lactic acid 2.5 mmol/L and with parameters indicative of hemolysis, evidenced by elevated lactate dehydrogenase, low haptoglobin and elevated bilirubin levels. Electrocardiography (EKG) demonstrated ST depression in leads I, aVL, V5 - V6 and T wave inversions in lead III and aVL, which were new compared to previous EKG. Peripheral blood smear indicated spherocytes. Direct antiglobulin test was positive for immunoglobulin G (IgG). Patient was admitted for ES and initially treated with oral prednisone 80 mg daily. He was also diagnosed with UA thought to be possibly secondary to ES. He then underwent cardiac stress test which showed mild reversible inferior apical ischemia. Cardiac catheterization revealed 95% stenosis of proximal left circumflex artery requiring single drug eluding stent placement and dual antiplatelet therapy. Patient continued to have anemia despite blood transfusions, although platelet count improved. Prednisone was transitioned to high-dose IV dexamethasone, and patient was also started on rituximab which resulted in stabilization of anemia. The presentation of ES with ACS is a rare occurrence. ACS can be challenging to manage as stent placement may be required followed by dual antiplatelet therapy. Treatment of ES involves steroids followed by rituximab, IV immunoglobulin (IVIG) or splenectomy for non-responsive cases. Early intervention and management can prevent mortality and morbidity.
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Affiliation(s)
- Saad Bin Jamil
- Department of Internal Medicine, St. Mary's Hospital, Waterbury, CT 06706, USA
| | - Iqra Patoli
- Department of Internal Medicine, St. Mary's Hospital, Waterbury, CT 06706, USA
| | - Mehrunissa Kazim
- Department of Internal Medicine, Holyoke Health Center, Holyoke, MA 01040, USA
| | - Syed Hassan Abbas
- Department of Internal Medicine, St. Mary's Hospital, Waterbury, CT 06706, USA
| | - Zain Ali
- Abington Memorial Hospital, Philadelphia, PA 19001, USA
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29
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Hidaka D, Ogasawara R, Sugimura S, Fujii F, Kojima K, Nagai J, Ebata K, Okada K, Kobayashi N, Ogasawara M, Imamura M, Ota S. New-onset Evans syndrome associated with systemic lupus erythematosus after BNT162b2 mRNA COVID-19 vaccination. Int J Hematol 2021. [PMID: 34687421 DOI: 10.1007/s12185-021-03243-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 10/15/2021] [Accepted: 10/17/2021] [Indexed: 12/13/2022]
Abstract
Evans syndrome presents as concurrent autoimmune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP). Systemic lupus erythematosus (SLE) is the most frequent autoimmune disorder associated with Evans syndrome. We herein report a case of new-onset Evans syndrome associated with SLE after BNT162b2 mRNA coronavirus disease 2019 (COVID-19) vaccination in a 53-year-old woman. Blood examination at diagnosis showed hemolytic anemia with a positive Coombs test and thrombocytopenia. Hypocomplementemia and the presence of lupus anticoagulant indicated a strong association with SLE. Prednisolone administration rapidly restored hemoglobin level and platelet count. This case suggests that mRNA COVID-19 vaccination may cause an autoimmune disorder. Physicians should be aware of this adverse reaction by mRNA COVID-19 vaccination and should consider the benefits and risks of vaccination for each recipient.
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30
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Venkatachala RP, Sheela CN, Anandram S, Ross CR. Autoimmune Hemolytic Anaemias in Pregnancy: Experience in a Tertiary Care Hospital in South India. J Obstet Gynaecol India 2021; 71:379-385. [PMID: 34566296 DOI: 10.1007/s13224-021-01443-8] [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: 10/08/2020] [Accepted: 01/12/2021] [Indexed: 10/22/2022] Open
Abstract
Background Autoimmune hemolytic anaemia is very rare and there is limited data regarding their pregnancy outcomes. Hence we aimed to study the maternal and perinatal outcomes in pregnancies with autoimmune hemolytic anaemias (AIHA). Methods A retrospective descriptive study of pregnant women with AIHA, who delivered at SJMCH between January 2011 and January 2016 was carried out. Their antenatal and labour records were reviewed and demographic details noted.The primary outcome measures studied were-the prevalence of AIHA, gestational age at delivery, antepartum, intrapartum and postpartum complications, mode of delivery and requirement of transfusion of blood and blood products. The secondary outcome measures studied included neonatal outcomes such as low birth weight, intrauterine growth restriction and need for intensive care. The data is presented as descriptive statistics, including means and percentage. Results The prevalence of AIHA was (18/12,420) 0.14%. The mean gestational age at delivery was 34 weeks; 100%, 77% and 50% had antenatal, intra partum or postpartum complications, respectively. 44% had preeclampsia, 38% intrauterine growth restriction and 16% preterm labour. 83% required additional drugs for treatment of AIHA.72% had vaginal delivery; 28% had caesarean delivery; 33% were transfused antenatally and 22% postnatally; 50% of the babies were preterm and required intensive care, 66% had low birth weight. There was no maternal mortality. Conclusion Multidisciplinary approach, early diagnosis and detection of autoimmune hemolytic anaemia and complications, good antenatal care, judicious transfusions and delivery at tertiary care centre are the keys to successful outcomes.
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Affiliation(s)
- Rao Preethi Venkatachala
- Department of Obstetrics and Gynaecology, St Johns Medical College and Hospital, Bengaluru, Karnataka 560034 India
| | - C N Sheela
- Department of Obstetrics and Gynaecology, St Johns Medical College and Hospital, Bengaluru, Karnataka 560034 India
| | - Seetharam Anandram
- Department of Medicine (Division of Haematology), St Johns Medical College and Hospital, Bengaluru, Karnataka India
| | - Cecil R Ross
- Department of Medicine (Division of Haematology), St Johns Medical College and Hospital, Bengaluru, Karnataka India
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Shi YF, Shi XH, Zhang Y, Chen JX, Lai WX, Luo JM, Ba JH, Wang YH, Chen JN, Wu BQ. Disseminated Tuberculosis Associated Hemophagocytic Lymphohistiocytosis in a Pregnant Woman With Evans syndrome: A Case Report and Literature Review. Front Immunol 2021; 12:676132. [PMID: 34177917 PMCID: PMC8222916 DOI: 10.3389/fimmu.2021.676132] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 03/04/2021] [Accepted: 05/28/2021] [Indexed: 11/13/2022] Open
Abstract
Background Tuberculosis (TB) is a leading cause of morbidity and mortality in underdeveloped and developing countries. Disseminated TB may induce uncommon and potentially fatal secondary hemophagocytic lymphohistiocytosis (HLH). Timely treatment with anti-tuberculosis therapy (ATT) and downmodulation of the immune response is critical. However, corticosteroid treatment for TB-associated HLH remains controversial. Herein, we report a successful case of disseminated TB-associated HLH in a pregnant woman with Evans syndrome accompanied by a literature review. Case Presentation A 26-year-old pregnant woman with Evans syndrome was transferred to the Third Affiliated Hospital of Sun Yat-Sen University because of severe pneumonia. She presented with cough, fever, and aggravated dyspnea. Nested polymerase chain reaction for Mycobacterium tuberculosis (M. tuberculosis) complex in sputum was positive. Sputum smear sample for acid-fast bacilli was also positive. Metagenome next-generation sequencing (mNGS) of the bronchoalveolar lavage fluid identified 926 DNA sequence reads and 195 RNA sequence reads corresponding to M. tuberculosis complex, respectively. mNGS of blood identified 48 DNA sequence reads corresponding to M. tuberculosis. There was no sequence read corresponding to other potential pathogens. She was initially administered standard ATT together with a low dose of methylprednisolone (40 mg/day). However, her condition deteriorated rapidly with high fever, acute respiratory distress syndrome, pancytopenia, and hyperferritinemia. Bone marrow smears showed hemophagocytosis. And caseating tuberculous granulomas were found in the placenta. A diagnosis of disseminated TB-associated HLH was made. Along with the continuation of four drug ATT regimen, therapy with a higher dose of methylprednisolone (160 mg/day) combined with immunoglobulin and plasma exchange was managed. The patient’s condition improved, and she was discharged on day 19. Her condition was good at follow-up with the continuation of the ATT. Conclusions Clinicians encountering patients with suspected TB accompanied by unexplainable inflammation not responding to ATT should consider complications with HLH. Timely administration of ATT combined with corticosteroids may result in a favorable outcome.
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Affiliation(s)
- Yun-Feng Shi
- Medical Intensive Care Unit, Department of Respiratory and Critical Care Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Institute of Respiratory Diseases, Sun Yat-Sen University, Guangzhou, China
| | - Xiao-Han Shi
- Medical Intensive Care Unit, Department of Respiratory and Critical Care Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Institute of Respiratory Diseases, Sun Yat-Sen University, Guangzhou, China
| | - Yuan Zhang
- Department of Gynaecology and Obstetrics, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jun-Xian Chen
- Medical Intensive Care Unit, Department of Respiratory and Critical Care Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Institute of Respiratory Diseases, Sun Yat-Sen University, Guangzhou, China
| | - Wen-Xing Lai
- Department of Hematology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jin-Mei Luo
- Medical Intensive Care Unit, Department of Respiratory and Critical Care Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Institute of Respiratory Diseases, Sun Yat-Sen University, Guangzhou, China
| | - Jun-Hui Ba
- Medical Intensive Care Unit, Department of Respiratory and Critical Care Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Institute of Respiratory Diseases, Sun Yat-Sen University, Guangzhou, China
| | - Yan-Hong Wang
- Medical Intensive Care Unit, Department of Respiratory and Critical Care Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Institute of Respiratory Diseases, Sun Yat-Sen University, Guangzhou, China
| | - Jian-Ning Chen
- Department of Pathology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ben-Quan Wu
- Medical Intensive Care Unit, Department of Respiratory and Critical Care Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Institute of Respiratory Diseases, Sun Yat-Sen University, Guangzhou, China
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32
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Gyawali S, Joshi U, Kharel Z, Khanal S, Shrestha A. Tuberculosis with Evans syndrome: A case report. Clin Case Rep 2021; 9:e04113. [PMID: 34026153 PMCID: PMC8122135 DOI: 10.1002/ccr3.4113] [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: 01/02/2021] [Accepted: 03/16/2021] [Indexed: 11/20/2022] Open
Abstract
Evans syndrome and tuberculosis could be predisposing factors for one another, or there may be a common pathophysiological denominator for the co-occurrence. Further research is needed for a better understanding of pathophysiology and treatment.
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Affiliation(s)
- Sagar Gyawali
- Department of Internal MedicineInstitute of MedicineTribhuvan University Teaching HospitalKathmanduNepal
| | - Utsav Joshi
- Department of Internal MedicineRochester General HospitalRochesterNYUSA
| | - Zeni Kharel
- Department of Internal MedicineRochester General HospitalRochesterNYUSA
| | - Shambhu Khanal
- Department of Internal MedicineInstitute of MedicineTribhuvan University Teaching HospitalKathmanduNepal
| | - Anjan Shrestha
- Department of Internal MedicineInstitute of MedicineTribhuvan University Teaching HospitalKathmanduNepal
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33
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Westermann-Clark E, Meehan CA, Meyer AK, Dasso JF, Amre D, Ellison M, Patel B, Betensky M, Hauk CI, Mayer J, Metts J, Leiding JW, Sriaroon P, Kumar A, Ayala I, Walter JE. Primary Immunodeficiency in Children With Autoimmune Cytopenias: Retrospective 154-Patient Cohort. Front Immunol 2021; 12:649182. [PMID: 33968040 PMCID: PMC8100326 DOI: 10.3389/fimmu.2021.649182] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 01/04/2021] [Accepted: 03/01/2021] [Indexed: 11/13/2022] Open
Abstract
Background Primary immunodeficiency is common among patients with autoimmune cytopenia. Objective The purpose of this study is to retrospectively identify key clinical features and biomarkers of primary immunodeficiency (PID) in pediatric patients with autoimmune cytopenias (AIC) so as to facilitate early diagnosis and targeted therapy. Methods Electronic medical records at a pediatric tertiary care center were reviewed. We selected 154 patients with both AIC and PID (n=17), or AIC alone (n=137) for inclusion in two cohorts. Immunoglobulin levels, vaccine titers, lymphocyte subsets (T, B and NK cells), autoantibodies, clinical characteristics, and response to treatment were recorded. Results Clinical features associated with AIC-PID included splenomegaly, short stature, and recurrent or chronic infections. PID patients were more likely to have autoimmune hemolytic anemia (AIHA) or Evans syndrome than AIC-only patients. The AIC-PID group was also distinguished by low T cells (CD3 and CD8), low immunoglobulins (IgG and IgA), and higher prevalence of autoantibodies to red blood cells, platelets or neutrophils. AIC diagnosis preceded PID diagnosis by 3 years on average, except among those with partial DiGeorge syndrome. AIC-PID patients were more likely to fail first-line treatment. Conclusions AIC patients, especially those with Evans syndrome or AIHA, should be evaluated for PID. Lymphocyte subsets and immune globulins serve as a rapid screen for underlying PID. Early detection of patients with comorbid PID and AIC may improve treatment outcomes. Prospective studies are needed to confirm the diagnostic clues identified and to guide targeted therapy.
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Affiliation(s)
- Emma Westermann-Clark
- Division of Allergy and Immunology, Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL, United States.,Division of Allergy and Immunology, Department of Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Cristina Adelia Meehan
- Division of Allergy and Immunology, Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Anna K Meyer
- Division of Allergy and Immunology, Department of Pediatrics, National Jewish Health, Denver, CO, United States.,Graduate Medical Education, University of Colorado, Denver, CO, United States
| | - Joseph F Dasso
- Division of Allergy and Immunology, Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL, United States.,Department of Biology, University of Tampa, Tampa, FL, United States
| | - Devendra Amre
- Division of Allergy and Immunology, Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Maryssa Ellison
- Division of Allergy and Immunology, Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Bhumika Patel
- Division of Allergy and Immunology, Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Marisol Betensky
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St Petersburg, FL, United States.,Division of Hematology, Department of Pediatrics Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States
| | - Charles Isaac Hauk
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St Petersburg, FL, United States
| | - Jennifer Mayer
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St Petersburg, FL, United States
| | - Jonathan Metts
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St Petersburg, FL, United States
| | - Jennifer W Leiding
- Division of Allergy and Immunology, Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL, United States.,Division of Allergy/Immunology, Department of Pediatrics Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States
| | - Panida Sriaroon
- Division of Allergy and Immunology, Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL, United States.,Division of Allergy/Immunology, Department of Pediatrics Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States
| | - Ambuj Kumar
- Research Methodology and Biostatistics Core, Morssani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Irmel Ayala
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St Petersburg, FL, United States.,Division of Hematology, Department of Pediatrics Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States
| | - Jolan E Walter
- Division of Allergy and Immunology, Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL, United States.,Division of Allergy/Immunology, Department of Pediatrics Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States.,Division of Allergy and Immunology, Massachusetts General Hospital for Children, Boston, MA, United States
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34
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Matsuoka N, Watanabe H, Kurooka N, Kato S, Higashi C, Tanabe K, Kinomura M, Fujii N, Sada KE, Sugiyama H, Wada J. Acute Kidney Injury Caused by Evans Syndrome with Systemic Lupus Erythematosus and Systemic Sclerosis. Intern Med 2021; 60:1055-1060. [PMID: 33116016 PMCID: PMC8079912 DOI: 10.2169/internalmedicine.5976-20] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A 65-year-old woman with systemic sclerosis and systemic lupus erythematosus developed acute kidney injury (AKI), Coombs-positive autoimmune hemolytic anemia and autoimmune thrombocytopenia; therefore, she was diagnosed with Evans syndrome (ES). Intravascular hemolysis was suggested as the cause of AKI based on the presence of acute tubular injury and trace hemosiderin deposits on the renal biopsy. The renal function, hemolytic anemia and thrombocytopenia were restored by an increased dose of glucocorticoids, hemodialysis, and plasma exchange. Although ES with severe hemolytic anemia is very rare, it is important to detect possible renal dysfunction when encountering patients with severe hemolysis.
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Affiliation(s)
- Natsumi Matsuoka
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
| | - Haruki Watanabe
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
| | - Naoko Kurooka
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
| | - Sumari Kato
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
| | - Chika Higashi
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
| | - Katsuyuki Tanabe
- Division of Hemodialysis and Apheresis, Okayama University Hospital, Japan
| | - Masaru Kinomura
- Division of Hemodialysis and Apheresis, Okayama University Hospital, Japan
| | - Nobuharu Fujii
- Department of Transfusion Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
| | - Ken-Ei Sada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
| | - Hitoshi Sugiyama
- Department of Human Resource Development of Dialysis Therapy for Kidney Disease, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
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35
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Angelopoulos A, Kirkilesis G, Kakavia K, Papanikolaou P. Diagnosis of Evans syndrome. Pan Afr Med J 2021; 38:314. [PMID: 34285737 PMCID: PMC8265255 DOI: 10.11604/pamj.2021.38.314.22410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [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: 03/19/2020] [Accepted: 04/11/2020] [Indexed: 11/30/2022] Open
Abstract
This manuscript concerns the case of a patient hospitalized and diagnosed with Evans syndrome. She was hospitalized with signs of thrombocytopenia induced purpura, petechiae, ecchymosis and anemia. She was successfully treated with corticoids and blood transfusions. Our purpose is to explain her clinical presentation and the exams, we used in order to make the diagnosis of Evans syndrome, which requires great suspicion. Moreover, other diseases causing hemolytic anemia and thrombocytopenia must be excluded. We used laboratory tests (blood samples, Coombs examination and virologic test). Bone marrow examination took place twice. Evans syndrome is an autoimmune disease which is characterized by the coexistence of hemolytic anemia and immune-mediated thrombocytopenia. There is no typical clinical presentation. Its etiology is unknown and its therapy is generally poor. Diagnosis of Evans syndrome is very difficult and requires the exclusion of other diseases causing anemia and thrombocytopenia.
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Affiliation(s)
| | | | - Kiriaki Kakavia
- Department of Vascular Surgery, Laikon General Hospital, Athens, Greece
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36
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Wang M, Zhang Z, Yan J, Shi J, Liu S, Wan H. The Presence of Secondary Evans Syndrome in AIDS Patients with Talaromyces marneffei Infection. Infect Drug Resist 2021; 14:1265-1271. [PMID: 33824596 PMCID: PMC8018431 DOI: 10.2147/idr.s300082] [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: 01/08/2021] [Accepted: 03/04/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Talaromyces marneffei (T.M) is a common opportunistic fungus in human immunodeficiency virus (HIV) infection individual. Secondary Evans syndrome in AIDS patients with Talaromyces marneffei infection has not been reported before. Here, we described cases related to this comorbidity. Methods AIDS patients diagnosed with Talaromyces marneffei infection from 2016 to 2020 at Xixi Hospital of Hangzhou were included in this retrospective study. Results Total 76 AIDS patients with T.M infection were enrolled. The most common symptoms were fever and cough (70/76; 55/76, respectively). 53/76 (69.74%) patients got positive results of direct antiglobulin test. 14/76 AIDS-T.M patients combined with secondary Hemophagocytic lymphohistiocytosis (HLH). Five patients were diagnosed with AIDS-T.M associated Evans syndrome. There were severe inflammatory reaction, liver dysfunction, coagulation dysfunction and immunodeficiency status in AIDS-T.M patients with secondary Evans syndrome. All patients received antifungal therapy and three patients received corticosteroids for Evans syndrome treatment. One patient died due to sepsis. Conclusion AIDS-T.M patients with secondary Evans syndrome is extremely rare and we need to be alert to the occurrence of secondary Evans syndrome in AIDS-T.M patients. Clinicians should timely start effective antifungal treatments with suspicious T.M infection in AIDS patients.
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Affiliation(s)
- Mengyan Wang
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Hangzhou Sixth People's Hospital, Hangzhou, 310023, People's Republic of China
| | - Zhongdong Zhang
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Hangzhou Sixth People's Hospital, Hangzhou, 310023, People's Republic of China
| | - Jun Yan
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Hangzhou Sixth People's Hospital, Hangzhou, 310023, People's Republic of China
| | - Jinchuan Shi
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Hangzhou Sixth People's Hospital, Hangzhou, 310023, People's Republic of China
| | - Shourong Liu
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Hangzhou Sixth People's Hospital, Hangzhou, 310023, People's Republic of China
| | - Hu Wan
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Hangzhou Sixth People's Hospital, Hangzhou, 310023, People's Republic of China
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37
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Grimes AB, Kim TO, Kirk SE, Flanagan J, Lambert MP, Grace RF, Despotovic JM. Refractory autoimmune cytopenias in pediatric Evans syndrome with underlying systemic immune dysregulation. Eur J Haematol 2021; 106:783-787. [PMID: 33570766 DOI: 10.1111/ejh.13600] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 10/28/2020] [Accepted: 02/10/2021] [Indexed: 01/03/2023]
Abstract
Evans syndrome is a rare but challenging disorder in children; and despite rapidly growing evidence for targetable systemic immune dysregulation driving these "idiopathic" autoimmune cytopenias, precision diagnosis and management remains sub-optimal among these patients. We analyzed retrospective clinical data for 60 pediatric ES patients followed at 3 large tertiary referral centers in the United States over a recent 6-year period and found that definable underlying systemic immune dysregulation was identified in only 42% of these patients throughout the course of clinical care. Median time from ES diagnosis to identification of the underlying systemic immune dysregulation disorder was 1.3 years (<1 month for rheumatologic disease, 2.3 years for CVID, 3.4 years for ALPS, and 7.4 years for monogenic disorders of immune regulation). Notably, a significantly higher percentage of patients in whom a definitive immune dysregulation disorder was ultimately identified required ≥3 cytopenia-directed therapies (92%) and also second- and third-line immunomodulatory agents (84%), vs those in whom no unifying immune dysregulation was diagnosed (65%, and 35%, respectively)-indicating that autoimmune cytopenias as a manifestation of systemic immune dysregulation are more treatment-refractory and severe. These data underline the importance of identifying the underlying systemic immune dysregulation and providing targeted therapy in pediatric ES.
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Affiliation(s)
- Amanda B Grimes
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Taylor O Kim
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Susan E Kirk
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Jonathan Flanagan
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Michele P Lambert
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rachael F Grace
- Harvard Medical School, Boston, MA, USA.,Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | - Jenny M Despotovic
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
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38
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Diez-Feijóo R, Rodríguez-Sevilla JJ, Colomo L, Papaleo N, Maiques JM, Gimeno E, Andrade-Campos M, Abella E, Merchan BM, Calvo X, Jimenez C, Román-Bravo OD, Salar A, Sanchez-Gonzalez B. Massive intrasplenic arterial thrombosis in a patient with chronic ITP during the development of an Evans syndrome. Thromb Res 2021:S0049-3848(21)00076-1. [PMID: 33714615 DOI: 10.1016/j.thromres.2021.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 01/29/2021] [Accepted: 02/16/2021] [Indexed: 11/22/2022]
Abstract
Long-term safety and efficacy of eltrombopag in adults with persitent/chronic primary immune thrombocytopenia (ITP) evaluated in EXTEND study, showed a high response rate (80%) but, in the clinical safety study, it was observed that 6% of the patients presented venous and arterial thrombotic events. In addition, in the course of the disease, autoimmune hemolytic anemia (Evans syndrome, ES) may occur and could increase the risk of thrombosis. We report an interesting case of splenic rupture due to massive intrasplenic arterial thrombosis in the course of ES in a patient with chronic ITP treated with eltrombopag. The purpose of this case report is to highlight the potential increase in thrombotic risk that may involve the use of eltrombopag in hemolysis situations in patients with ITP.
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39
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Atallah I, Quinodoz M, Campos-Xavier B, Peter VG, Fouriki A, Bonvin C, Bottani A, Kumps C, Angelini F, Bellutti Enders F, Christen-Zaech S, Rizzi M, Renella R, Beck-Popovic M, Poloni C, Frossard V, Blouin JL, Rivolta C, Riccio O, Candotti F, Hofer M, Unger S, Superti-Furga A. Immune deficiency, autoimmune disease and intellectual disability: A pleiotropic disorder caused by biallelic variants in the TPP2 gene. Clin Genet 2021; 99:780-788. [PMID: 33586135 DOI: 10.1111/cge.13942] [Citation(s) in RCA: 3] [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: 01/20/2021] [Revised: 02/10/2021] [Accepted: 02/11/2021] [Indexed: 12/16/2022]
Abstract
Four individuals from two families presented with a multisystemic condition of suspected genetic origin that was diagnosed only after genome analysis. The main phenotypic features were immune system dysregulation (severe immunodeficiency with autoimmunity) and intellectual disability. The four individuals were found to be homozygous for a 4.4 Kb deletion removing exons 20-23 (NM_003291.4) of the TPP2 gene, predicting a frameshift with premature termination of the protein. The deletion was located on a shared chromosome 13 haplotype indicating a Swiss founder mutation. Tripeptidyl peptidase 2 (TPP2) is a protease involved in HLA/antigen complex processing and amino acid homeostasis. Biallelic variants in TPP2 have been described in 10 individuals with variable features including immune deficiency, autoimmune cytopenias, and intellectual disability or chronic sterile brain inflammation mimicking multiple sclerosis. Our observations further delineate this severe condition not yet included in the OMIM catalog. Timely recognition of TPP2 deficiency is crucial since (1) immune surveillance is needed and hematopoietic stem cell transplantation may be necessary, and (2) for provision of genetic counselling. Additionally, enzyme replacement therapy, as already established for TPP1 deficiency, might be an option in the future.
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Affiliation(s)
- Isis Atallah
- Division of Genetic Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Mathieu Quinodoz
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), Basel, Switzerland.,Department of Ophthalmology, University of Basel, Basel, Switzerland.,Department of Genetics and Genome Biology, University of Leicester, Leicester, UK
| | - Belinda Campos-Xavier
- Division of Genetic Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Virginie G Peter
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), Basel, Switzerland.,Department of Ophthalmology, University of Basel, Basel, Switzerland.,Department of Genetics and Genome Biology, University of Leicester, Leicester, UK
| | - Athina Fouriki
- Pediatric Immunology Unit, Division of Pediatrics, Lausanne University Hospital, Lausanne, Switzerland
| | - Christophe Bonvin
- Division of Neurology, Lausanne University Hospital, Lausanne, Switzerland
| | - Armand Bottani
- Division of Genetic Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Camille Kumps
- Division of Genetic Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Federica Angelini
- Pediatric Immunology Unit, Division of Pediatrics, Lausanne University Hospital, Lausanne, Switzerland
| | - Felicitas Bellutti Enders
- Pediatric Immunology Unit, Division of Pediatrics, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Mattia Rizzi
- Pediatric Hemato-Oncology Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - Raffaele Renella
- Pediatric Hemato-Oncology Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - Maja Beck-Popovic
- Pediatric Hemato-Oncology Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - Claudia Poloni
- Pediatric Neurology Unit, Sion Hospital, Sion, Switzerland
| | | | - Jean-Louis Blouin
- Division of Genetic Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Carlo Rivolta
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), Basel, Switzerland.,Department of Ophthalmology, University of Basel, Basel, Switzerland.,Department of Genetics and Genome Biology, University of Leicester, Leicester, UK
| | - Orbicia Riccio
- Division of Immunology and Allergy, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabio Candotti
- Division of Immunology and Allergy, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Michael Hofer
- Pediatric Immunology Unit, Division of Pediatrics, Lausanne University Hospital, Lausanne, Switzerland
| | - Sheila Unger
- Division of Genetic Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Andrea Superti-Furga
- Division of Genetic Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Bashir BA, Othman SA, Malik AA. A rare haematological disorder in a Sudanese child: Evans syndrome, case report and literature review. Sudan J Paediatr 2021; 21:89-94. [PMID: 33879949 DOI: 10.24911/sjp.106-1583095341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [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.
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Affiliation(s)
- Bashir Abdrhman Bashir
- Department of Hematology, Faculty of Medical Laboratory Sciences, Port Sudan Ahlia College, Port Sudan, Sudan
| | - Suhair A Othman
- Department of Pediatric, Faculty of Medicine, Red Sea University, Port Sudan, Sudan
| | - Amel Aziz Malik
- Department of Pediatric, Faculty of Medicine, Red Sea University, Port Sudan, Sudan
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Muñoz AM, Orozco Niño JA, Seehaus CM, Giménez Conca AD, Chuliber FA, Lo Giudice LF, Bendek GE. [ Evans syndrome and rheumatoid arthritis as autoimmune manifestations of large granular T-cell leukemia]. Medicina (B Aires) 2021; 81:1060-1064. [PMID: 34875608] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023] Open
Abstract
Large granular T-cell leukemia is a rare cytotoxic lymphocyte disorder. These cells play an integral role in the immune system and are divided into 2 lineages: CD3 T positive and natural killer. Its proliferation and uncontrolled cytotoxicity can generate autoimmunity or malignancy. Rheumatoid arthritis is the most common autoimmune disease in individuals with this type of leukemia, however, it has been associated with a wide spectrum of other autoimmune diseases and hematological conditions including hemolytic anemia, pure red blood cell aplasia, and neutropenia, leading to recurring bacterial infections. The following is a case of a 72-year-old female with a history of large granular T-cell leukemia and manifestations compatible with rheumatoid arthritis, which occurs with a severe Evans syndrome with a good initial and sustained response to gamma globulin, corticosteroid therapy, and rituximab.
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Affiliation(s)
- Agustín M Muñoz
- Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Argentina. E-mail:
| | - José A Orozco Niño
- Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Argentina
| | - Cristian M Seehaus
- Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Argentina
| | | | | | | | - Georgina E Bendek
- Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Argentina
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Beydoun SB, Persaud Y, Lafferty J, Callaghan MU, Savaşan S. Bortezomib treatment of steroid-refractory Evans syndrome in children. Pediatr Blood Cancer 2020; 67:e28725. [PMID: 32969165 DOI: 10.1002/pbc.28725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 12/13/2022]
Abstract
Treatment of refractory Evans syndrome (ES) remains a challenge in hematology practice. Due to rarity of this condition, evidence-based approaches are limited and often treatment choices stem from small case series or anecdotal experiences. There is mounting evidence that some patients have genetic defects that could be targeted with promising preliminary results. Here, we describe three very refractory pediatric ES cases treated on bortezomib without adverse effects. Two of the three patients had dramatic and long-lasting recovery that started following the initial doses of the drug. Clinical trials to assess the role of bortezomib in ES treatment are warranted.
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Affiliation(s)
- Serina B Beydoun
- Division of Hematology/Oncology, Children's Hospital of Michigan
| | - Yogindra Persaud
- Division of Hematology/Oncology, Children's Hospital of Michigan
| | | | - Michael U Callaghan
- Division of Hematology/Oncology, Children's Hospital of Michigan Department of Pediatrics, Barbara Ann Karmanos Cancer Center, Children's Hospital of Michigan, Central Michigan University College of Medicine
| | - Süreyya Savaşan
- Division of Hematology/Oncology, Children's Hospital of Michigan Department of Pediatrics, Barbara Ann Karmanos Cancer Center, Children's Hospital of Michigan, Central Michigan University College of Medicine
- Division of Hematology/Oncology, Pediatric Bone Marrow Transplant Program, Children's Hospital of Michigan Department of Pediatrics, Barbara Ann Karmanos Cancer Center, Children's Hospital of Michigan, Central Michigan University College of Medicine
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43
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Pinczés LI, Szabó R, Miltényi Z, Illés Á. The impact of autoimmune cytopenias on the clinical course and survival of Hodgkin lymphoma. Int J Hematol 2020; 113:175-182. [PMID: 33057959 DOI: 10.1007/s12185-020-03021-6] [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: 05/25/2020] [Revised: 09/01/2020] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
The characteristics of autoimmune cytopenias (AICP) associated with Hodgkin lymphoma (HL) are not thoroughly defined. We retrospectively assessed the clinical features of HL-associated AICPs in 563 HL patients diagnosed over a period of 28 years. We identified 8 cases of autoimmune hemolytic anemia (AIHA) and 8 cases of autoimmune thrombocytopenia among 14 patients altogether. Four (26%) AICPs were present at lymphoma diagnosis, while 11 (74%) cytopenias occurred during follow-up after first-line therapy. The overall incidence of HL-associated AICPs was 2.8%. Nine (75%) cytopenias responded to intravenous steroids. Seven (46%) AICPs led to the diagnosis of HL, indicated a relapse, or revealed secondary malignancies. AIHAs and AICPs altogether were more likely to develop in patients with advanced-stage HL (p = 0.010 and p < 0.004, respectively). HL patients experiencing AICPs had an increased short-term (1-year) mortality compared to the general HL population (p < 0.022). The 5-year OS of HL patients with concurrent AICPs at diagnosis was inferior compared to HL patients developing AICPs during follow-up (p = 0.005), and to HL patients without AICPs (p < 0.001). Patients with HL-associated AICPs appear to have a particular disease-related profile. The association of HL and AICPs may increase short-term mortality, while patients with concurrent AICPs at HL diagnosis have a dismal prognosis.
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Affiliation(s)
- László Imre Pinczés
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary. .,Doctoral School of Clinical Medicine, University of Debrecen, Debrecen, Hungary.
| | - Roxána Szabó
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zsófia Miltényi
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.,Doctoral School of Clinical Medicine, University of Debrecen, Debrecen, Hungary
| | - Árpád Illés
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.,Doctoral School of Clinical Medicine, University of Debrecen, Debrecen, Hungary
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Zhu F, Li Q, Pan H, Xiao Y, Liu T, Liu X, Li J, Wu G, Zhang L. Successful Treatment of Chidamide and Cyclosporine for Refractory/Relapsed Angioimmunoblastic T Cell Lymphoma With Evans Syndrome: A Case Report With Long-Term Follow-Up. Front Oncol 2020; 10:1725. [PMID: 32984055 PMCID: PMC7481371 DOI: 10.3389/fonc.2020.01725] [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: 05/03/2020] [Accepted: 08/03/2020] [Indexed: 11/13/2022] Open
Abstract
Background Refractory/relapsed angioimmunoblastic T cell lymphoma (AITL) with Evans syndrome is a very rare condition with a poor prognosis. There is no evidence-based treatment strategy for refractory/relapsed AITL with Evans syndrome. Case Presentation A 51-year-old female was admitted to our hospital with multiple enlarged bilateral cervical lymph nodes, more than 1 week-long chest distress, and night sweats in July 2014. An excision biopsy of the left cervical enlarged lymph node revealed AITL. However, the patient showed resistance to the first-line chemotherapy for AITL and was diagnosed with refractory AITL. Complete remission was achieved after the salvage treatment with the combination of chemotherapy, radiotherapy, and immunomodulatory agent lenalidomide. Unfortunately, 12 months later, the patient suffered from disease progression and was diagnosed as refractory/relapsed AITL with Evans syndrome according to the laboratory findings and imaging. With the diagnosis of refractory/relapsed AITL with Evans syndrome, the patient received the first-line treatment for Evans syndrome including prednisone and intravenous immunoglobulin. The response to the first-line treatment for Evans syndrome was poor. The combination regimen of chidamide (30 mg, po, biw) and cyclosporine were administrated considering the treatment targeting simultaneously both refractory/relapsed AITL and Evans syndrome. The efficacy evaluation was complete remission. The last follow-up of the patient was April 30th, 2020, and no evidence of disease progression was observed. The overall survival of the patient was more than 70 months. Conclusion The treatment for refractory/relapsed AITL combined with Evans syndrome remains challenging to patients and physicians. The combination of chidamide and cyclosporine may be an effective and tolerable regimen for the intractable AITL with Evans syndrome case and more observations are necessary to identify the efficacy and safety in the future.
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Affiliation(s)
- Fang Zhu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qiuhui Li
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huaxiong Pan
- Department of Pathology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yin Xiao
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tao Liu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinxiu Liu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Juan Li
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gang Wu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liling Zhang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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45
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Lee PY, Platt CD, Weeks S, Grace RF, Maher G, Gauthier K, Devana S, Vitali S, Randolph AG, McDonald DR, Geha RS, Chou J. Immune dysregulation and multisystem inflammatory syndrome in children (MIS-C) in individuals with haploinsufficiency of SOCS1. J Allergy Clin Immunol 2020; 146:1194-1200.e1. [PMID: 32853638 PMCID: PMC7445138 DOI: 10.1016/j.jaci.2020.07.033] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [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: 07/09/2020] [Revised: 07/28/2020] [Accepted: 07/29/2020] [Indexed: 12/29/2022]
Abstract
Background We studied 2 unrelated patients with immune thrombocytopenia and autoimmune hemolytic anemia in the setting of acute infections. One patient developed multisystem inflammatory syndrome in children in the setting of a severe acute respiratory syndrome coronavirus 2 infection. Objectives We sought to identify the mechanisms underlying the development of infection-driven autoimmune cytopenias. Methods Whole-exome sequencing was performed on both patients, and the impact of the identified variants was validated by functional assays using the patients’ PBMCs. Results Each patient was found to have a unique heterozygous truncation variant in suppressor of cytokine signaling 1 (SOCS1). SOCS1 is an essential negative regulator of type I and type II IFN signaling. The patients’ PBMCs showed increased levels of signal transducer and activator of transcription 1 phosphorylation and a transcriptional signature characterized by increased expression of type I and type II IFN-stimulated genes and proapoptotic genes. The enhanced IFN signature exhibited by the patients’ unstimulated PBMCs parallels the hyperinflammatory state associated with multisystem inflammatory syndrome in children, suggesting the contributions of SOCS1 in regulating the inflammatory response characteristic of multisystem inflammatory syndrome in children. Conclusions Heterozygous loss-of-function SOCS1 mutations are associated with enhanced IFN signaling and increased immune cell activation, thereby predisposing to infection-associated autoimmune cytopenias.
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Affiliation(s)
- Pui Y Lee
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Craig D Platt
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Sabrina Weeks
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Rachael F Grace
- Division of Hematology/Oncology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - George Maher
- Division of Pediatric Hematology/Oncology, Sanford Children's Hospital, Sioux Falls, SD
| | - Kasey Gauthier
- Division of Pediatric Hematology/Oncology, Sanford Children's Hospital, Sioux Falls, SD
| | - Sridevi Devana
- Department of Laboratory Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics Harvard Medical School, Boston, Mass
| | - Sally Vitali
- Boston Children's Hospital, Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, Mass
| | - Adrienne G Randolph
- Boston Children's Hospital, Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, Mass
| | - Douglas R McDonald
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Raif S Geha
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Janet Chou
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass.
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46
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Lian X, Liu C, Hou X, Zhang W, Hao J. Evans syndrome in a female with erythrophagocytosis by monocytes in peripheral blood smear. Int J Lab Hematol 2020; 42:e150-e151. [PMID: 32383790 DOI: 10.1111/ijlh.13206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 03/24/2020] [Accepted: 03/26/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Xiaoqiang Lian
- Department of Clinical Laboratory, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chen Liu
- Department of Clinical Laboratory, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xuening Hou
- Department of Clinical Laboratory, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wenchao Zhang
- Department of Clinical Laboratory, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jihong Hao
- Department of Clinical Laboratory, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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47
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Salehizadeh S, Naser Moghadasi A, Sahrain MA. The co-occurrence of multiple sclerosis and Evans syndrome: A case report. Caspian J Intern Med 2020; 11:343-345. [PMID: 32874446 PMCID: PMC7442462 DOI: 10.22088/cjim.11.3.343] [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] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 04/24/2019] [Accepted: 04/27/2019] [Indexed: 12/04/2022]
Abstract
BACKGROUND Evans syndrome is an uncommon autoimmune disorder manifested by fatigue, jaundice, pallor, purpura and petechiae. The main characteristics of this rare disease are simultaneous or sequential existence of positive anti-globulin test, immune thrombocytopenia (ITP) and autoimmune hemolytic anemia (AIHA). Evans syndrome as an autoimmune disorder can be associated with other diseases. The concomitancy of Evans syndrome and multiple sclerosis (MS) has not been reported so far. In this case study, a -21-year old male with concomitant Evans syndrome and MS has been reported. CASE PRESENTATION A 21-year-old male of Iranian origin and known case of Evans syndrome, was referred to our hospital for better evaluation. Evans syndrome was presented with acute jaundice, purpura, petechiae, and easy bruising when he was 9.He was under treatment of corticosteroid and cytotoxic agents, and presented with left lower extremity paresis for 5 months before admission to our hospital. According to neuroimaging and pathologic results, multiple sclerosis (MS) was diagnosed. Hence, we decided to treat the patient with rituximab. The patient has been stable without any further exacerbation or increase in disability progression after 2 years from diagnosis. CONCLUSION Evans syndrome can be associated with other autoimmune disorders. For our case, we have reported this association with MS.
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Affiliation(s)
- Saeideh Salehizadeh
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Abdorreza Naser Moghadasi
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Sahrain
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
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48
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Hamamoto H, Yoshimura K. Successful cardiac surgery in a patient with Evans syndrome. Interact Cardiovasc Thorac Surg 2020; 30:652-653. [PMID: 31860079 DOI: 10.1093/icvts/ivz300] [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: 08/14/2019] [Revised: 10/11/2019] [Accepted: 11/11/2019] [Indexed: 11/13/2022] Open
Abstract
Evans syndrome is a rare haematological disease that may cause several complications during heart surgery. Herein we documented heart valve surgery in a patient with Evans syndrome who was receiving monoclonal antibody therapy, and valve replacement was successfully performed via prophylactic measures against haemolysis.
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Affiliation(s)
| | - Kenshi Yoshimura
- Department of Cardiac Surgery, Almeida Memorial Hospital, Oita, Japan
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49
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Kutluǧ Ş, Boztuǧ K, Yıldıran A. Development of multiple gallstones in a child with lipopolysaccharide-responsive beige-like anchor protein mutation. Cent Eur J Immunol 2019; 44:332-5. [PMID: 31871423 DOI: 10.5114/ceji.2019.89613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 05/29/2017] [Indexed: 12/21/2022] Open
Abstract
A defect in the lipopolysaccharide-responsive beige-like anchor protein (LRBA) gene is a newly defined rare cause of primary immunodeficiency diseases, which manifests as immune dysregulation and humoral immune deficiency. LRBA deficiency is a combined immunodeficiency. A boy with LRBA deficiency is described in this report. He had been diagnosed with Evans syndrome in a haematology clinic. He was referred to an immunology and allergy clinic for frequent respiratory tract infections. He also had hepatosplenomegaly but no lymphadenopathy. Immunological evaluation revealed hypogammaglobulinaemia, increased double-negative T cells, decreased memory B cells and switched B cells, and an inverted CD4/CD8 ratio. LRBA deficiency was considered due to common variable immunodeficiency-autoimmune lymphoproliferative overlap syndrome. A homozygote mutation (c.1964C>T) in LRBA was found through exome sequencing. Gastrointestinal investigation was performed due to unexplained abdominal pain. It revealed atrophic gastritis, partial villous atrophy, and multiple gallstones. There was no chronic diarrhoea or failure to thrive. The abdominal pain disappeared after a cholecystectomy. Multiple gallstones have not been reported in other LRBA-deficient patients who also had autoimmune haemolytic anaemia. Multiple gallstones that require cholecystectomy can develop in LRBA-deficient patients during adolescence.
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50
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Caré W, Arnautou P, Segot A, de Charry F, Foissaud V, Bugier S, Cournac JM, Konopacki J, Malfuson JV. [Autoimmune hemolytic anemia and immune thrombocytopenia associated with Hodgkin disease: Retrospective monocentric study]. Rev Med Interne 2019; 40:785-790. [PMID: 31668883 DOI: 10.1016/j.revmed.2019.03.328] [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: 10/12/2018] [Revised: 03/11/2019] [Accepted: 03/21/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Hodgkin's lymphoma (HL) is less common than non-Hodgkin lymphoma and is rarely associated with autoimmune cytopenia. METHOD We report a consecutive, monocentric and retrospective series of HL patients diagnosed with concomitant or subsequent autoimmune cytopenia over a period of 8 years. RESULTS We report 4 out of 84 HL patients (4.8%) diagnosed with autoimmune cytopenia (4 immune thrombocytopenia including 2 Evans' syndromes). They were 4 males (average age 24 years for the 3 youngest, and one over 60 years old). Autoimmune cytopenia revealed lymphoma in 2 patients and occurred after HL treatment in the two other patients (5 and 36 months from the end of chemotherapy) without HL relapse. All cytopenias were resistant to conventional treatments (glucocorticoids, intravenous immune globulin, rituximab) and sensitive to chemotherapy when indicated for HL treatment. CONCLUSION In our series, the predominance of males, a higher frequency of immune thrombocytopenia than autoimmune hemolytic anemia, the resistance to usual treatments and the efficacy of specific chemotherapy were consistent with the literature. Unexpectedly, patients were young and with nodular sclerosis morphology (vs. mixed cellularity) in 3 of 4 cases.
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Affiliation(s)
- W Caré
- Service d'hématologie, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France; Service de médecine interne, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France.
| | - P Arnautou
- Service d'hématologie, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - A Segot
- Service d'hématologie, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - F de Charry
- Service d'hématologie, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - V Foissaud
- Laboratoire de biologie médicale, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - S Bugier
- Laboratoire de biologie médicale, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - J-M Cournac
- Service de médecine interne, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - J Konopacki
- Service d'hématologie, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - J-V Malfuson
- Service d'hématologie, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France; École du Val-de-Grâce, 1, place Alphonse-Laveran, 75005 Paris, France
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