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Loriamini M, Cserti-Gazdewich C, Branch DR. Autoimmune Hemolytic Anemias: Classifications, Pathophysiology, Diagnoses and Management. Int J Mol Sci 2024; 25:4296. [PMID: 38673882 PMCID: PMC11049952 DOI: 10.3390/ijms25084296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
Autoimmune hemolytic anemias (AIHAs) are conditions involving the production of antibodies against one's own red blood cells (RBCs). These can be primary with unknown cause or secondary (by association with diseases or infections). There are several different categories of AIHAs recognized according to their features in the direct antiglobulin test (DAT). (1) Warm-antibody AIHA (wAIHA) exhibits a pan-reactive IgG autoantibody recognizing a portion of band 3 (wherein the DAT may be positive with IgG, C3d or both). Treatment involves glucocorticoids and steroid-sparing agents and may consider IVIG or monoclonal antibodies to CD20, CD38 or C1q. (2) Cold-antibody AIHA due to IgMs range from cold agglutinin syndrome (CAS) to cold agglutin disease (CAD). These are typically specific to the Ii blood group system, with the former (CAS) being polyclonal and the latter (CAD) being a more severe and monoclonal entity. The DAT in either case is positive only with C3d. Foundationally, the patient is kept warm, though treatment for significant complement-related outcomes may, therefore, capitalize on monoclonal options against C1q or C5. (3) Mixed AIHA, also called combined cold and warm AIHA, has a DAT positive for both IgG and C3d, with treatment approaches inclusive of those appropriate for wAIHA and cold AIHA. (4) Paroxysmal cold hemoglobinuria (PCH), also termed Donath-Landsteiner test-positive AIHA, has a DAT positive only for C3d, driven upstream by a biphasic cold-reactive IgG antibody recruiting complement. Although usually self-remitting, management may consider monoclonal antibodies to C1q or C5. (5) Direct antiglobulin test-negative AIHA (DAT-neg AIHA), due to IgG antibody below detection thresholds in the DAT, or by non-detected IgM or IgA antibodies, is managed as wAIHA. (6) Drug-induced immune hemolytic anemia (DIIHA) appears as wAIHA with DAT IgG and/or C3d. Some cases may resolve after ceasing the instigating drug. (7) Passenger lymphocyte syndrome, found after transplantation, is caused by B-cells transferred from an antigen-negative donor whose antibodies react with a recipient who produces antigen-positive RBCs. This comprehensive review will discuss in detail each of these AIHAs and provide information on diagnosis, pathophysiology and treatment modalities.
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Affiliation(s)
- Melika Loriamini
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5B 1W8, Canada; (M.L.); (C.C.-G.)
- Centre for Innovation, Canadian Blood Services, Keenan Research Centre, Room 420, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Christine Cserti-Gazdewich
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5B 1W8, Canada; (M.L.); (C.C.-G.)
- Laboratory Medicine Program, Blood Transfusion Laboratory, University Health Network, Toronto, ON M5G 2C4, Canada
- Blood Disorders Program, Department of Medical Oncology and Hematology, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Donald R. Branch
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5B 1W8, Canada; (M.L.); (C.C.-G.)
- Centre for Innovation, Canadian Blood Services, Keenan Research Centre, Room 420, 30 Bond Street, Toronto, ON M5B 1W8, Canada
- Department of Medicine, University of Toronto, Toronto, ON M5B 1W8, Canada
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Ghazizadeh M, Moini M, Ghazizadeh M. Autoimmune hemolytic anemia due to mediastinal teratoma: A case report and review article. Clin Case Rep 2023; 11:e7908. [PMID: 37720713 PMCID: PMC10500046 DOI: 10.1002/ccr3.7908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/02/2023] [Accepted: 08/06/2023] [Indexed: 09/19/2023] Open
Abstract
Key Clinical Massage Autoimmune hemolytic anemia (AIHA) is a rare disease that is divided into primary and secondary types. In patients with AIHA we should consider mediastinal tumors as a serious cause. If such teratoma was found surgical removal of it is in order. Abstract Autoimmune hemolytic anemia (AIHA) is a rare disease that is divided into primary and secondary types. The secondary type usually appears as a complication to some diseases such as chronic inflammatory diseases, systemic lupus erythematosus (SLE), and malignancies. A 26 years-old female with a chief complaint of weakness, fatigue, and exertional dyspnea is diagnosed with AIHA. Initially, medical steroid treatment appeared to be successful and the anemia improved, however, by weaning steroid dosage the disease relapsed. Eventually, surgical resection of the mediastinal teratoma lead to the hemolysis being treated successfully. In patients with AIHA we should consider mediastinal tumors as a serious cause. If such teratoma was found surgical removal of it is in order.
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Affiliation(s)
- Maryam Ghazizadeh
- Department of Hematology—Oncology, Shahid Modarres HospitalShahid Beheshti University of Medical SciencesTehranIran
| | - Mohammad Moini
- School of MedicineTehran University of Medical SciencesTehranIran
| | - Matin Ghazizadeh
- Department of Otolaryngology, Head and Neck Surgery, Taleghani HospitalShahid Beheshti University of Medical SciencesTehranIran
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3
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Djerrou Z, Chettoum A, Guedri K, Khatabi L, Boudjerda S, Djeffali R. Epidemiological profile, clinical, paraclinical, and evolutionary of adult autoimmune cytopenia cases in East of Algeria. JOURNAL OF APPLIED HEMATOLOGY 2021. [DOI: 10.4103/joah.joah_169_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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4
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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] [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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Wan Azman WN, Omar J, Koon TS, Tuan Ismail TS. Hemolyzed Specimens: Major Challenge for Identifying and Rejecting Specimens in Clinical Laboratories. Oman Med J 2019; 34:94-98. [PMID: 30918601 PMCID: PMC6425048 DOI: 10.5001/omj.2019.19] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Pre-analytical quality in clinical chemistry testing is as important as analytical and post-analytical quality. The most prevalent pre-analytical interference and a major source of error producing unreliable laboratory test results is hemolysis of blood samples. In vitro hemolysis may be due to the blood withdrawal technique or sample handling whereas in vivo hemolysis can originate from acquired, hereditary, or iatrogenic conditions and is not technique dependent. Interpreting in vivo or in vitro hemolysis requires clinicians to supply reliable clinical history and findings. Even then, to reject or release the result with interpretation is still under debate. Thus, hemolyzed specimens are a serious pre-analytical problem calling for well-designed and strictly implemented laboratory guidelines. The aim of this non-systematic review (addressed to healthcare professionals) was to highlight the challenges in identifying and rejecting hemolysis specimens.
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Affiliation(s)
- Wan Norlina Wan Azman
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains, Kelantan, Malaysia
| | - Julia Omar
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains, Kelantan, Malaysia
| | - Tan Say Koon
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains, Kelantan, Malaysia
| | - Tuan Salwani Tuan Ismail
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains, Kelantan, Malaysia
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Ntanishyan KI, Sabirov KR, Shcherbakova OV, Vybornykh DE, Shupletsova IA, Tsvetaeva NV. [Autoimmune hemolytic anemia associated with mesenteric teratoma]. TERAPEVT ARKH 2017; 89:78-81. [PMID: 28252632 DOI: 10.17116/terarkh201789178-81] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The paper describes a case of autoimmune hemolytic anemia (AIHA) in a 27-year-old woman whose examination revealed mesenteric teratoma. AIHA was characterized by a hypertensive crisis and a temporary response to corticosteroid therapy that was complicated by the development of somatogenic psychosis and discontinued. A relapse of hemolysis developed 6 months later. The patient underwent laparoscopic splenectomy and removal of mesenteric root teratoma. Immediately after surgery, a hematological response was obtained as relief of hemolysis and restoration of a normal hemoglobin level. There is a sustained remission of AIHA for the next 16 months.
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Affiliation(s)
- K I Ntanishyan
- Hematology Research Center, Ministry of Health of Russia, Moscow, Russia
| | - K R Sabirov
- Hematology Research Center, Ministry of Health of Russia, Moscow, Russia
| | - O V Shcherbakova
- Hematology Research Center, Ministry of Health of Russia, Moscow, Russia
| | - D E Vybornykh
- Hematology Research Center, Ministry of Health of Russia, Moscow, Russia
| | - I A Shupletsova
- Hematology Research Center, Ministry of Health of Russia, Moscow, Russia
| | - N V Tsvetaeva
- Hematology Research Center, Ministry of Health of Russia, Moscow, Russia
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Chatterjee S, Bhardwaj N, Saxena RK. Identification of Stages of Erythroid Differentiation in Bone Marrow and Erythrocyte Subpopulations in Blood Circulation that Are Preferentially Lost in Autoimmune Hemolytic Anemia in Mouse. PLoS One 2016; 11:e0166878. [PMID: 27870894 PMCID: PMC5117735 DOI: 10.1371/journal.pone.0166878] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 11/04/2016] [Indexed: 01/13/2023] Open
Abstract
Repeated weekly injections of rat erythrocytes produced autoimmune hemolytic anemia (AIHA) in C57BL/6 mice after 5–6 weeks. Using the double in vivo biotinylation (DIB) technique, recently developed in our laboratory, turnover of erythrocyte cohorts of different age groups during AIHA was monitored. Results indicate a significant decline in the proportion of reticulocytes, young and intermediate age groups of erythrocytes, but a significant increase in the proportion of old erythrocytes in blood circulation. Binding of the autoantibody was relatively higher to the young erythrocytes and higher levels of intracellular reactive oxygen species (ROS) were also seen in these cells. Erythropoietic activity in the bone marrows and the spleen of AIHA induced mice was examined by monitoring the relative proportion of erythroid cells at various stages of differentiation in these organs. Cells at different stages of differentiation were enumerated flow cytometrically by double staining with anti-Ter119 and anti-transferrin receptor (CD71) monoclonal antibodies. Erythroid cells in bone marrow declined significantly in AIHA induced mice, erythroblast C being most affected (50% decline). Erythroblast C also recorded high intracellular ROS level along with increased levels of membrane-bound autoantibody. No such decline was observed in spleen. A model of AIHA has been proposed indicating that binding of autoantibodies may not be a sufficient condition for destruction of erythroid cells in bone marrow and in blood circulation. Last stage of erythropoietic differentiation in bone marrow and early stages of erythrocytes in blood circulation are specifically susceptible to removal in AIHA.
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Affiliation(s)
- Sreoshi Chatterjee
- School of Life Sciences, Jawaharlal Nehru University, New Delhi, India
- Faculty of Life Sciences and Biotechnology, South Asian University, New Delhi, India
| | - Nitin Bhardwaj
- Faculty of Life Sciences and Biotechnology, South Asian University, New Delhi, India
| | - Rajiv K. Saxena
- Faculty of Life Sciences and Biotechnology, South Asian University, New Delhi, India
- * E-mail:
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Hirano Y, Itonaga T, Yasudo H, Isojima T, Miura K, Harita Y, Sekiguchi M, Kato M, Takita J, Oka A. Systemic lupus erythematosus presenting with mixed-type fulminant autoimmune hemolytic anemia. Pediatr Int 2016; 58:527-530. [PMID: 26892457 DOI: 10.1111/ped.12849] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 10/07/2015] [Accepted: 11/04/2015] [Indexed: 11/30/2022]
Abstract
We report the case of a 9-year-old girl who presented with mixed-type fulminant autoimmune hemolytic anemia (AIHA) at the onset of systemic lupus erythematosus (SLE). On admission, laboratory investigations indicated very severe anemia (Hb, 2.7 g/dL) with reticulocytosis and positive direct/indirect Coombs tests. In addition, agglutinative reaction was clinically observed. Based on further examinations, the patient was diagnosed with AIHA complicated with SLE, and mixed-type AIHA was clinically identified. With oral prednisolone and methylprednisolone pulse therapy, the patient entered remission.
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Affiliation(s)
- Yoko Hirano
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takaaki Itonaga
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Yasudo
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Isojima
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kenichiro Miura
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yutaka Harita
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masahiro Sekiguchi
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Motohiro Kato
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junko Takita
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akira Oka
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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9
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Bass GF, Tuscano ET, Tuscano JM. Diagnosis and classification of autoimmune hemolytic anemia. Autoimmun Rev 2014; 13:560-4. [DOI: 10.1016/j.autrev.2013.11.010] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2013] [Indexed: 12/27/2022]
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10
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Lippi G, Plebani M, Di Somma S, Cervellin G. Hemolyzed specimens: a major challenge for emergency departments and clinical laboratories. Crit Rev Clin Lab Sci 2011; 48:143-53. [DOI: 10.3109/10408363.2011.600228] [Citation(s) in RCA: 120] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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11
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Lee JS, Cho D, Shin MG, Ryang DW. [Usefulness of NaCl/Enzyme Gel Test for the Identification of Unexpected Antibodies.]. Ann Lab Med 2007; 26:204-9. [PMID: 18156726 DOI: 10.3343/kjlm.2006.26.3.204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The microcolumn assay technique offers significant advances in identification of unexpected antibodies; however, some erythrocyte antibodies still remain unidentified. To see if NaCl/Enzyme test is useful for the identification of antibodies, we compared the LISS/Coombs and NaCl/Enzyme tests for identification rates, and investigated an association between the frequency of each antibody and a history of transfusion or gestation. METHODS From June 2004 to June 2005, antibody screening tests were carried out on 5,517 patients using the LISS/Coombs gel test (DiaMed AG, Switzerland). When antibodies were detected, antibody identification tests were carried out with the LISS/Coombs and NaCl/Enzyme gel tests (DiaMed AG) simultaneously. RESULTS Unexpected antibodies were detected in 79 patients (1.43%). These antibodies were identified in 39 (49.4%), 59 (74.7%), and 68 patients (86.1%) by the LISS/Coombs test, the NaCl/Enzyme test, and the two tests combined, respectively. With the addition of the NaCl/ Enzyme test, unexpected antibodies were further identified in 29 cases (anti-Lewis, 14; anti-Rhesus, 13; and anti-P1, 2). On the other hand, 9 cases (anti-M, 5; anti-Fy(b), 3; and anti-N, 1) were identified by the LISS/Coombs test only. Of the unexpected antibodies found in patients without a previous history of transfusion or gestation, anti-Lewis (50.0%, 10/20) was the most common, while in patients with the history anti-Rhesus (48.1%, 26/54) was the most frequent. CONCLUSIONS The NaCl/Enzyme combined with LISS/Coombs gel test was useful for the identification of unexpected antibodies, and antibodies found in patients without a previous history of transfusion or gestation were clinically less relevant than those found in patients with the history.
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Affiliation(s)
- Jin Sol Lee
- Department of Laboratory Medicine, Chonnam National University Medical School, Gwangju, Korea.
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12
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van Royen-Kerkhof A, Sanders EAM, Walraven V, Voorhorst-Ogink M, Saeland E, Teeling JL, Gerritsen A, van Dijk MA, Kuis W, Rijkers GT, Vitale L, Keler T, McKenzie SE, Leusen JHW, van de Winkel JGJ. A novel human CD32 mAb blocks experimental immune haemolytic anaemia in FcgammaRIIA transgenic mice. Br J Haematol 2005; 130:130-7. [PMID: 15982355 DOI: 10.1111/j.1365-2141.2005.05571.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A fully human IgG1 kappa antibody (MDE-8) was generated, which recognised Fc-gamma receptor IIa (FcgammaRIIa) molecules on CD32 transfectants, peripheral blood monocytes, polymorphonuclear cells and platelets. This antibody blocked FcgammaRIIa ligand-binding via its F(ab')(2) fragment. Overnight incubation of monocytes with F(ab')(2) fragments of MDE-8 leads to a c. 60% decrease in cell surface expression of FcgammaRIIa. MDE-8 whole antibody induced a concomitant c. 30% decrease of FcgammaRI on THP-1 cells and monocytes. In humans FcgammaRIIa plays an important role in the clearance of antibody-coated red blood cells in vivo. As an equivalent of FcgammaRIIa does not exist in mice, the in vivo effect of MDE-8 was studied in an FcgammaRIIa transgenic mouse model. In these mice, antibody-induced anaemia could readily be blocked by MDE-8. These data document a new human antibody that effectively blocks FcgammaRIIa, induces modulation of both FcgammaRIIa and FcgammaRI from phagocytic cells, and ameliorates antibody-induced anaemia in vivo.
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MESH Headings
- Anemia, Hemolytic, Autoimmune/genetics
- Anemia, Hemolytic, Autoimmune/immunology
- Anemia, Hemolytic, Autoimmune/prevention & control
- Animals
- Antibodies, Monoclonal/pharmacology
- Antigens, CD/genetics
- Antigens, CD/immunology
- Cells, Cultured
- Granulocytes/pathology
- Humans
- Mice
- Mice, Transgenic
- Models, Animal
- Phagocytosis
- Platelet Activation
- Receptors, IgG/genetics
- Receptors, IgG/immunology
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Affiliation(s)
- Annet van Royen-Kerkhof
- Immunotherapy Laboratory, Department of Immunology, University Medical Centre Utrecht, the Netherlands
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Tas S, Donmez AA, Kirali K, Alp MH, Yakut C. Aortic valve replacement for a patient with glucose-6-phosphate dehydrogenase deficiency and autoimmune hemolytic anemia. J Card Surg 2005; 20:380-1. [PMID: 15985145 DOI: 10.1111/j.1540-8191.2005.200475.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Autoimmune hemolytic anemia and deficiency of glucose-6-phosphate deyhdrogenase (G6PD) result in severe hemolysis with different mechanisms. In patients with both pathologies, the effects of cardiopulmonary bypass on red blood cells and thrombocytes demand special care before and after open heart surgery. We evaluated the preoperative management and postoperative care of a patient with severe aortic insufficiency associated with G6PD deficiency and autoimmune hemolytic anemia who underwent aortic valve replacement.
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Affiliation(s)
- Serpil Tas
- Cardiovascular Surgery Department of Kosuyolu Heart and Research Hospital, Istanbul, Turkey.
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Wikman A, Axdorph U, Gryfelt G, Gustafsson L, Björkholm M, Lundahl J. Characterization of red cell autoantibodies in consecutive DAT-positive patients with relation to in vivo haemolysis. Ann Hematol 2004; 84:150-8. [PMID: 15551098 DOI: 10.1007/s00277-004-0959-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2004] [Accepted: 09/20/2004] [Indexed: 10/26/2022]
Abstract
The clinical symptoms of patients with autoimmune haemolytic anaemia (AIHA) may range from no symptoms at all to severe haemolysis with life-threatening anaemia. The aim of the present study was to characterize the autoantibodies serologically and to evaluate their activity in vitro in monocyte monolayer assay (MMA) in consecutive direct antiglobulin test (DAT)-positive patients from a haematological department. We also aimed to evaluate the monocyte production of cytokines in vitro and relate all findings to in vivo haemolysis. Twenty-nine patients with positive DAT were included in the study and clinical characteristics were documented. The patients were divided into three groups based on laboratory parameters, severe haemolysis, moderate haemolysis and no sign of haemolysis. Severe haemolysis was related to a strongly positive DAT and positive results in MMA. When eluates were analysed in MMA, a positive result was associated with a higher concentration in the supernatants of interleukin (IL)-8 after 6 h incubation. We conclude that MMA activity and in vitro cytokine production may reflect the in vivo activity of autoantibodies. This may be of importance in understanding the mechanisms of haemolysis and in predicting the harmfulness of antibodies, especially when blood transfusions are needed.
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Affiliation(s)
- Agneta Wikman
- Division of Transfusion Medicine, Huddinge, Department of Laboratory Medicine, Karolinska University Hospital, 141 86 Stockholm, Sweden.
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Oh YR, Carr-Lopez SM, Probasco JM, Crawley PG. Levofloxacin-induced autoimmune hemolytic anemia. Ann Pharmacother 2003; 37:1010-3. [PMID: 12841809 DOI: 10.1345/aph.1c525] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To report a case of autoimmune hemolytic anemia (AIHA) secondary to levofloxacin. CASE SUMMARY An 82-year-old white man was treated with levofloxacin 500 mg/d for cellulitis. Three days following completion of levofloxacin therapy, the patient presented to the emergency department with severe jaundice, dizziness, and loss of vision. He received packed red blood cells (PRBCs) and was discharged home. Two days later at the follow-up visit, he was diagnosed with AIHA secondary to levofloxacin. The patient was hospitalized and treated with a tapering dose of prednisone and additional PRBC infusion. He was discharged from the hospital in stable condition after 3 days. Repeated hematologic laboratory studies following discharge demonstrated that the hemolytic anemia had resolved. DISCUSSION Hemolytic anemia due to levofloxacin is an extremely rare, but potentially fatal, adverse drug event. An objective causality assessment revealed that the adverse reaction was probable. To our knowledge, this is the first published case of levofloxacin-induced AIHA. However, there are published case reports of hemolytic anemia with other fluoroquinolones including ciprofloxacin (n = 12) and temafloxacin (n = 95). Temafloxacin was withdrawn from the market in 1992 due to this adverse effect. The mechanism by which levofloxacin triggers hemolytic anemia is unknown. We believe that an immune-mediated reaction is most likely. CONCLUSIONS Levofloxacin-induced AIHA is a rare but serious complication of therapy. Immediate discontinuation of the offending medication and treatment of the hemolytic anemia are essential. Until more information is available, levofloxacin should not be prescribed for patients with previous reactions to any fluoroquinolone.
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Affiliation(s)
- Young R Oh
- Department of Clinical Pharmacy Services, David Grant USAF Medical Center, Travis Air Force Base, CA, USA.
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Genty I, Michel M, Hermine O, Schaeffer A, Godeau B, Rochant H. [Characteristics of autoimmune hemolytic anemia in adults: retrospective analysis of 83 cases]. Rev Med Interne 2002; 23:901-9. [PMID: 12481390 DOI: 10.1016/s0248-8663(02)00688-4] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE To describe the main characteristics and outcome of adult's acquired immune hemolytic anemias (AIHA). To analyse the relevance of the complementary tests performed for the search of an underlying disease. METHODS Retrospective (1980-2000) monocentric study. INCLUSION CRITERIA age above 16, AIHA defined by an hemoglobin level below 12 g/dl in men and 11 g/dl in women, with hemolysis and/or a positive direct Coombs test and/or the presence of cold agglutinins (threshold 1/500) and/or in the absence of any other cause. RESULTS Eighty three patients included (56 women and 27 men), with a mean age of 56 years (+/- 22) at AIHA onset including: 72 patients (87%) with warm antibody AIHA and 11 (13%) with cold agglutinin disease. The mean follow-up was 48 months (median 22 months). Among the 72 patients with warm antibody AIHA, the specificity of autoantibodies was: IgG + complement (43%), IgG (32%) or complement alone (25%); cold agglutinins (titre from 1/60 to 1/512) were detected in 15 (20%) of the patients. Antinuclear antibodies were detected (threshold: 1/80) in 33% of the cases. Hypogammaglobulinemia on serum protein electrophoresis (SPE) was significantively associated with the presence of an underlying non-Hogkin lymphoma (NHL). The CT-scan of the the chest and abdomen which was performed in 50% of the patients, showed abnormalities other than a spleen enlargement in 25% of the cases. The medullar biopsy (MB) was abnormal in 7 of 26 cases (27%) but lead by itself to the diagnosis of NHL in a single case. Thrirty seven (51%) of warm antibody AIHA cases were finally considered to be "secondary" to an underlying disease namely: NHLs (n = 14), Hogkin's disease (n = 1) connective tissue disease (CTD) (n = 14), drug-induced AIHA (n = 3), miscellaneous (n = 5). In 6 out of 14 cases (43%) of NHL's associated AIHA, the onset of AIHA precedes the NHL from 22 to 66 months. The response rates to different therapeutic regimens did not significatively differ when "secondary" and "idiopathic" AIHA were compared. Overall, 13 patients (15.6%) died mainly from infectious complications (n = 5) or an underlying NHL (n = 5). CONCLUSIONS In more than half of the cases AIHA are associated with an underlying disease and AIHA may precede the onset of a NHL for a long period. In the absence of a clinically apparent underlying disorder, testing for the presence of antinuclear antibodies, a SPE and a CT-scan must be systematic. Conversely, if no abnormalities are found, the relevance of a systematic MB at AIHA onset seems very low.
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Affiliation(s)
- I Genty
- Service de médecine interne, hôpital Henri-Mondor, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France
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17
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Abstract
Treatment of autoimmune hemolytic anemias varies depending on whether the patient has autoimmune hemolytic anemia of warm antibody type, cold agglutinin syndrome, paroxysmal cold hemoglobinuria, or autoimmune hemolytic anemia secondary to an underlying disorder. Initial therapy for warm antibody autoimmune hemolytic anemia should be corticosteroids, such as prednisone at conventional doses of 1 to 1.5 mg/kg/d orally. Criteria must be established to determine whether the therapeutic response is adequate, because long-term therapy may lead to significant detrimental side effects. Splenectomy has the advantage over therapeutic options in that it has the potential for complete and long-term remission. The major adverse effect is the syndrome of overwhelming postsplenectomy infection. Other therapeutic options, which are less likely to have long-term benefit, are immunosuppressive drugs, danazol, intravenous immunoglobulin, and plasma exchange. Therapy of cold agglutinin syndrome often is unsatisfactory. All patients should avoid exposure to cold, and if additional therapy is necessary, the therapies used for warm antibody autoimmune hemolytic anemia may be tried with less likelihood of response. Paroxysmal cold hemoglobinuria requires aggressive supportive therapy, generally supplemented by corticosteroids. Hemolysis usually terminates spontaneously. Patients with secondary autoimmune hemolytic anemia may be treated similarly to those with idiopathic autoimmune hemolytic anemia, and additional therapy for the underlying disorder also may result in remission of the hemolysis.
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Affiliation(s)
- L D Petz
- StemCyte, Inc., Arcadia, California 91007, USA.
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18
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Stroncek DF, Carter LB, Procter JL, Dale JK, Straus SE. RBC autoantibodies in autoimmune lymphoproliferative syndrome. Transfusion 2001; 41:18-23. [PMID: 11161240 DOI: 10.1046/j.1537-2995.2001.41010018.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patients with autoimmune lymphoproliferative syndrome (ALPS) have an autosomal dominant genetic defect that affects lymphocyte apoptosis and is associated with chronic nonmalignant lymphadenopathy, splenomegaly, and autoimmunity, particularly affecting RBCs, WBCs, and platelets. STUDY DESIGN AND METHODS DATs were performed on 34 consecutive patients with ALPS and 37 of their clinically unaffected relatives. The effects of age, sex, race, and immunoglobulin levels on the incidence of autoantibodies and clinical hemolysis were assessed. RESULTS The DAT was positive in 21 (62%) of ALPS patients but in only 1 (3%) of their relatives (p = 0.001). The DAT reacted because of IgG alone in 43 percent, complement alone in 5 percent, and IgG plus complement in 19 percent; 33 percent of the patients' cells had a positive reaction with polyspecific reagent only. All 10 ALPS patients with a history of hemolytic anemia had a positive DAT. Sixty percent of them had only IgG on their cells, 30 percent had IgG and complement, and 10 percent reacted only with polyspecific reagent. Of the 11 patients with a positive DAT and no history of hemolytic anemia, IgG alone was present in 27 percent, complement alone in 9%, and IgG plus complement in 9 percent; 55 percent had positive DATs only with polyspecific reagent. Among ALPS patients, those with a positive DAT had greater quantities of cells with increased alpha and ss T-cell receptors that phenotyped as CD4-CD8- and higher IgG levels. CONCLUSIONS The DAT results in ALPS patients are most similar to those found in warm autoimmune hemolytic anemia. The DAT is useful to distinguish affected and unaffected persons within an ALPS family.
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Affiliation(s)
- D F Stroncek
- Department of Transfusion Medicine, Warren G. Magnuson Clinical Center, National Institute of Allergy and Infectious Diseases (NIAID), the National Institutes of Health, Bethesda, Maryland 20892-1184, USA.
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