Tyrosine kinase inhibitor-induced immune hemolytic anemia; three different drugs in three separate cases

INTRODUCTION

Molecular multitargeted small tyrosine kinase inhibitory (TKI) agents such as axitinib, sunitinib and pazopanib are commonly used in several types of solid tumors. Anemia is not a rare effect of these drugs which may occur at all grades. However, drug-induced immune hemolytic anemia (IHA), a very rare condition is distinctive from other types of anemia with its specific mechanism and management strategy.

CASE REPORTS

We reported three different TKI-induced IHA cases that occurred due to axitinib, sunitinib, and pazopanib, respectively. The first two cases were diagnosed with renal cell carcinoma and the last one was diagnosed with soft tissue sarcoma. They all presented with the characteristic symptoms of anemia and hemolysis. All the cases were detected positive for the complement C3d direct antiglobulin (direct coombs) test.

MANAGEMENT AND OUTCOMES

Discontinuation of the causative drug and 1 mg/kg/day dose of corticosteroid treatment were able to control IHA in all three cases. Excluding the other factors of IHA and an evident laboratory and clinical benefit after withholding the TKI led to the diagnosis of TKI-related IHA in each case.

DISCUSSION

TKIs are relatively new in clinical practice and are being used for more indications and in more patients. To our knowledge#these three cases are unique in terms of axitinib#sunitinib#and pazopanib-related IHA.

How Should Complicated Cases of Thrombotic Thrombocytopenic Purpura With Positive Coombs Test Be Treated?

Thrombocytopenia with concomitant anemia is a serious condition with a high mortality risk. Destruction of platelets, i.e., thrombocytopenia, can be secondary to either auto-antibodies (immune-mediated) or mechanical destruction (non-immune-mediated). The Coombs test is a widespread tool to differentiate between the two categories, resulting in different specific treatment approaches for each diagnosis. A peripheral blood smear can also help make the diagnosis; for instance, in cases of mechanical destruction such as thrombotic thrombocytopenic purpura (TTP), the red blood cell (RBC) shape looks fragmented, forming schistocytes. In rare instances, TTP can present with both schistocytes and a positive Coombs test, challenging the diagnosis of TTP. TTP is a hematological emergency requiring appropriate anticipation and the initiation of treatment prior to the confirmatory ADAMTS-13 test results. Mild forms of TTP can be managed with glucocorticoids and therapeutic plasma exchange. Refractory cases need more aggressive additional treatment with caplacizumab and rituximab. Caplacizumab is an expensive medication that is usually reserved for use after confirmation of a TTP diagnosis. The advantage of caplacizumab lies in its targeted mechanism of action against the A1 domain of the von Willebrand multimers that are normally destructed by the ADAMTS-13 enzyme. Here, we present a young female patient with confirmed TTP, and the initial diagnosis was challenged by the presence of antibodies with the Coombs test. Very little research has studied this rare instance and the appropriate treatment. Our case will save many future lives, as clinicians should be more aggressive in treating refractory TTP with a positive Coombs test.

Rare Loxoscelism-Associated IgG Coombs-Positive Hemolytic Anemia Treated Successfully With Systemic Corticosteroids

Loxoscelism-associated hemolytic anemia is a rare but critical complication of brown recluse spider bites. It may lead to various systemic manifestations, including jaundice, dark urine, and anemia-related symptoms, in addition to general loxoscelism symptoms such as skin lesions, fever, myalgia, nausea, and vomiting. Prompt diagnosis is crucial and requires recognizing typical laboratory findings such as low hemoglobin, elevated lactate dehydrogenase, reduced haptoglobin levels, and possibly a positive direct antiglobulin test. There is no definitive guideline for the treatment of loxoscelism-associated hemolytic anemia. we report a case of a 32-year-old female who developed severe Coombs-positive autoimmune hemolytic anemia following a brown recluse spider bite, with an improvement in hemoglobin levels and hemolysis indices after the administration of systemic corticosteroids.

A Rare Case of Cold Agglutinin Syndrome Associated With Legionella Pneumonia

Cold agglutinin syndrome (CAS) is a rare subset of autoimmune hemolytic anemia (AIHA) and can be classified as either primary or secondary. Secondary cold agglutinin disease has been associated with both viral and bacterial pathogens with the most common bacterial pathogen being Mycoplasma pneumoniae. Legionella pneumonia is a well-known causative agent for community-acquired pneumonia that can lead to a severe disease requiring hospitalization that is rarely associated with AIHA. We highlight the importance of recognizing Legionella pneumonia as a causative pathogen for CAS.

Hemolytic Anemia in the Setting of Atypical Pneumonia: A Case of Cold Agglutinin Disease

Cold agglutinin hemolytic anemia (cAHA) is a rare autoimmune disorder characterized by the production of cold agglutinins. We present a case of secondary cAHA in a 23-year-old female with severe anemia and unexplained hemolysis. The patient exhibited findings indicative of hemolysis and a positive direct antiglobulin test (DAT) with complement alone. Additional investigations revealed incidental lung infiltrates, negative serology for infections and autoimmune diseases, and a low cold agglutinin titer. The patient showed a favorable response to doxycycline and supportive therapy, including multiple packed red blood cell transfusions. At the two-week follow-up, the patient had a stable hemoglobin level with no evidence of ongoing hemolysis. This case highlights the importance of considering secondary cAHA in patients with cold symptoms or unexplained hemolysis. Primary cAHA patients may require more aggressive treatment, including rituximab and sutilumab.

Attack of the Clones: A Patient With Untreated Aplastic Anemia Presenting With Classical Paroxysmal Nocturnal Hemoglobinuria

Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired X-linked, clonal hematopoietic stem cell disease. Patients with PNH may complain of vague symptomatology that contributes to the challenge of its diagnosis. This is especially true in the clinical context of a coinciding hematologic disorder. Aplastic anemia (AA) is an additional immune-mediated illness that results in the destruction of hematopoietic precursors and pancytopenia. The authors encourage screening for PNH clones in patients initially diagnosed with AA, treating underlying hematologic disease to prevent clonal expansion, and further research to investigate the effectiveness of eculizumab in an unusual "classical" PNH secondary to AA with hypercellular bone marrow.

Complement-mediated hemolysis persists year round in patients with cold agglutinin disease

BACKGROUND

Cold agglutinin disease (CAD) is a rare autoimmune hemolytic anemia mediated by immunoglobulin M autoantibodies that bind to the "I" antigen on erythrocytes. IgM binding results in either agglutination at ≤37°C, activation of the classical complement pathway, or both. Patients with CAD can have transient agglutination-mediated circulatory symptoms triggered by exposure to cold conditions. Separately, patients with CAD can experience complement-mediated symptoms such as anemia, hemolysis, and fatigue, but the effect of the season on these complement-mediated manifestations of CAD and clinical outcomes is not well understood.

METHODS

Using data from the Optum® de-identified Electronic Health Record dataset, we compared hemoglobin, markers of hemolysis (bilirubin and lactate dehydrogenase [LDH]), and healthcare resource utilization (HRU) between seasons for 594 patients (62% female; 66% aged ≥65 years) with CAD (defined as having CAD-related terms in their clinical notes on ≥3 separate occasions between December 2008 and May 2016). Laboratory parameters and HRU were compared between seasons using multivariate regression models.

RESULTS

Estimated median hemoglobin (9.87 g/dL in summer and 9.86 g/dL in winter; P = 0.944) and bilirubin (1.04 mg/dL in summer and 1.09 mg/dL in winter; P = 0.257) were similar in winter versus summer. While LDH was statistically significantly higher in winter compared with summer (P < 0.001), the estimated median value was above normal for both seasons (309 U/L in summer and 367 U/L in winter). HRU measures and transfusion and thromboembolism rates were similar across seasons.

CONCLUSIONS

Patients with CAD had evidence of persistent chronic hemolysis, HRU, and thromboembolism risk year round.

A Rare Case of Hydrochlorothiazide-Induced Hemolytic Anemia

Drug-induced immune hemolytic anemia is an exceedingly rare adverse drug event. Thiazide diuretics, commonly used in the treatment of primary hypertension, have been associated with this complication. In this case report, we present a 77-year-old male who developed acute hemolytic anemia two days after starting hydrochlorothiazide in the treatment of high blood pressure.

Diclofenac-Induced Immune Hemolytic Anemia: A Case Report and Review of Literature

Non-steroidal anti-inflammatory drugs are widely used for pain management. Most frequently, adverse reactions affect the gastrointestinal tract and hematological side effects usually relate to the gastrointestinal manifestations. Drug-induced immune hemolytic anemia is a rare and frequently underdiagnosed complication that is associated with poor outcomes including organ failure and even death.

A 76-year-old female patient was treated with intramuscular diclofenac, thiocolchicoside, and diazepam for low back pain. Five days following diclofenac exposure, the patient was admitted to the Emergency Department with complaints of asthenia, nausea, vomiting, and diarrhea. Hemolysis and a positive direct antiglobulin test were detected on laboratory testing. Further causes of hemolytic anemia were excluded and a diagnosis of diclofenac-induced immune hemolytic anemia was established. Glucocorticoid therapy initiated on admission and drug eviction led to complete recovery. Long-term follow-up showed no recurrence of anemia.

Here, we present the unusual case of a successful recovery of a 76-year-old patient with diclofenac-induced immune hemolytic anemia, a rare but immediate life-threatening condition of a frequently used drug in clinical practice.

Rifampin-Induced Acute Intravascular Hemolysis Leading to Heme Pigment-Related Kidney Injury

Rifampin-induced acute kidney injury is very rare. Most cases of acute renal injury from rifampin use are related to acute tubular necrosis and acute interstitial nephritis. In this case report, we detail a unique presentation of rifampin-associated acute intravascular hemolysis and subsequent tubular injury in a tuberculosis patient. The patient had presented to the hospital with acute kidney injury and oliguria from intravascular volume depletion secondary to intractable vomiting. The patient had stopped taking his antituberculosis medications two weeks before hospitalization. At the time of hospital admission, his antituberculosis regimen of rifampin and isoniazid was reinstituted. Within four days of initiation of rifampin, he developed acute hemolytic anemia. His kidney biopsy revealed hemoglobin pigment deposition in the kidney tubules. Rifampin was discontinued, and he received a total of eight hemodialysis treatments spanning over 17 days. Subsequently, after discontinuing rifampin, his anemia and oliguria resolved with renal function markedly improved to near normal baseline levels. This case report also offers a review of known mechanisms of rifampin-induced acute hemolysis and acute renal failure, along with a discussion of contemporary literature.

Ceftriaxone-Induced Immune Hemolytic Anemia

Ceftriaxone is a commonly used antibiotic in hospitals for the treatment of pneumonia, urinary tract infection, bacteremia, meningitis, skin, and soft tissue infection. It can be associated with common allergic reactions like skin rash, itching, and, rarely, angioedema. Ceftriaxone-induced immune hemolytic anemia (IHA) is a rare and potentially fatal complication if not identified and managed in time. We report a case of ceftriaxone-induced IHA in a young woman.

Hemolytic Anemia and Reactive Thrombocytosis Associated With Cefoperazone/Sulbactam

Background: Cefoperazone/sulbactam is a broad-spectrum antibacterial agent. Drug-induced immune hemolytic anemia is a rare but serious condition, and reactive thrombocytosis is caused by processes extrinsic to the megakaryocyte. Limited data are available for cefoperazone/sulbactam-associated hemolytic anemia and reactive thrombocytosis. Case presentation: We report the case of a 60-year-old woman undergoing surgical excision of the left atrial myxoma, who presented with hemolytic anemia and thrombocytosis following cefoperazone/sulbactam administration for lung infection. The duration of cefoperazone/sulbactam therapy was 8 days. Blood analysis showed markedly decreased hemoglobin, hematocrit, and red blood cell levels, with elevated lactate dehydrogenase, indirect bilirubin, platelets, and reticulocytes. Furthermore, the direct antiglobulin test was positive for anti-C3 and a diagnosis of hemolytic anemia and reactive thrombocytosis was made. Then, cefoperazone/sulbactam was discontinued and red blood cell transfusion was performed for 3 days. After 1 week, the patient's condition improved, and she was discharged. Conclusion: This is the first suspected case report of immune hemolytic anemia and reactive thrombocytosis related to cefoperazone/sulbactam. Caution should be taken for this reaction in patients undergoing cefoperazone/sulbactam therapy.

Ceftriaxone-induced hemolytic anemia in a child successfully managed with intravenous immunoglobulin

Drug-induced hemolytic anemia is an immune-mediated phenomenon that leads to the destruction of red blood cells. Here, we present a case of life-threatening ceftriaxone-induced hemolytic anemia (CIHA) in a previously healthy 3-year-old girl. We also reviewed the literature to summarize the clinical features and treatment of hemolytic anemia. Acute hemolysis is a rare side effect of ceftriaxone therapy associated with high mortality. Our patient had a sudden loss of consciousness with macroscopic hematuria and her hemoglobin dropped from 10.2 to 2.2 g/dl over 4 hours, indicating that the patient had life-threatening hemolysis after an intravascular dose of ceftriaxone who had previously been treated with ceftriaxone in intramuscular form for six days. CIHA is associated with a positive direct antiglobulin test, revealing the presence of IgG in all cases and C3d in most cases. Our patient's direct antiglobulin test was positive for IgG (3+) and for C3d (4+). The case was managed successfully with supportive measures and intravenous immunoglobulin therapy. Ceftriaxone is used very frequently in children; an early diagnosis and proper treatment of hemolytic anemia are essential to improve the patient outcome. The pathophysiological mechanism is the same as for non-drug autoimmune hemolytic anemia. However, there is still no consensus treatment for CIHA. Intravenous immunoglobulin can be used in clinical emergencies, such as our case, or in refractory cases.