Immune hemolytic anemia following administration of antithymocyte globulin

Antithymocyte globulin-induced hemolytic anemia and thrombocytopenia after kidney transplantation

Antithymocyte globulin is the most widely used lymphocyte-depleting treatment in kidney transplantation. In spite of the frequency of side effects, including anemia and thrombocytopenia, their pathophysiological mechanisms are not clearly established. Here, we report the case of a 21-year-old patient who had a first kidney transplantation and received induction immunosuppressive therapy by thymoglobulin. Immediately after kidney transplantation, he developed a severe hemolytic anemia and thrombocytopenia with a subsequent perirenal hematoma, which lead to a second surgical procedure and a transfer to the intensive care unit. Our patients' anemia and thrombocytopenia had heteroimmune characteristics, and thymoglobulin therapy was suspected to be the cause, via an interaction with a common Fc-receptor epitope in the different cell lines.

Development of a secondary autoimmune disorder after hematopoietic stem cell transplantation for autoimmune diseases: role of conditioning regimen used

Patients undergoing autologous hematopoietic stem cell transplantation (auto-HSCT) for autoimmune disease may have an added propensity to develop a second autoimmune disorder, given the genetic predisposition to autoimmunity. Therefore, we undertook a retrospective analysis of all patients who have undergone auto-HSCT for an autoimmune disease in our institution to determine the occurrence of a second autoimmune disorder and possible risk factors. In all, 155 patients underwent auto-HSCT for various autoimmune diseases; of those patients, 6 manifested a distinct secondary autoimmune disease at a median of 8.5 months (range, 2-30 months) after auto-HSCT. There were 2 patients with systemic lupus erythematosus, conditioned with a regimen containing antithymocyte globulin (ATG), who developed factor VIII inhibitors with severe bleeding. There were 4 patients (2 with multiple sclerosis, one each with lupus and systemic sclerosis) who received an alemtuzumab-containing conditioning regimen who developed autoimmune cytopenias. Among the 155 patients, the frequency of secondary autoimmune complications was 16.0% with alemtuzumab (4/25), 1.9% for ATG (2/102), and 0% for conditioning regimens without lympho-depleting antibodies (0/28)-a difference that was found to be significantly higher with alemtuzumab exposure (P = .011). In contrast, sex, type of ATG used, and CD34-selection of peripheral blood stem cells were not found to be significantly associated with development of a secondary autoimmune disorder.

Guillain Barré syndrome precipitated by the use of antilymphocyte globulin in the treatment of severe aplastic anaemia

This report describes the case of a 54 year old woman with very severe aplastic anaemia who was treated with antilymphocyte globulin (ALG) and developed Guillain Barré syndrome (GBS). No antecedent infective aetiology was identified. Although there are numerous reports of autoimmune disease after treatment with ALG in aplastic anaemia, and GBS after immunosuppressive treatment, there are none reporting GBS after the use of ALG for severe aplastic anaemia. The occurrence of autoimmune disease after immunosuppressive treatment, in particular ALG, is discussed, together with the possible mechanisms that result from T cell depression.

Drug-induced red cell dyscrasias

Major advances have been made in recent years in our understanding of the pathogenetic mechanisms of drug-induced blood dyscrasias, particularly those involving the red cell. Among the latter, hemolytic anemia is the most common. Drug-induced red cell destruction may occur on an immune basis or through disruption by the drug of red cell metabolism. The immunological basis of drug-induced hemolysis is reviewed with emphasis on the clinical and laboratory manifestations, differential diagnosis and the major mechanisms involved. Drug-induced oxidative hemolysis both in normal individuals and in those with certain enzymopathies, notably glucose-6-phosphate dehydrogenase deficiency, is summarized. Drugs may also produce red cell dyscrasias by acting on the immature erythroid compartment. Some of these inhibit erythroid growth by as yet poorly understood mechanisms. Others exert more specific metabolic effects in erythroid precursors. These include drugs which interfere with DNA synthesis causing megaloblastic erythropoiesis and those which disrupt mitochondrial function and the synthesis of heme manifested by sideroblastic erythropoiesis. A brief consideration of heme biosynthesis and the action of drugs which are associated with sideroblastic anemia, including the antituberculous agents, lead, alcohol and chloramphenicol is presented. Finally, where pertinent, an updated listing of drugs involved in red cell dyscrasias is included.