Evans' syndrome as a presenting manifestation of atypical paroxysmal cold hemoglobinuria

Cold antibody autoimmune hemolytic anemias

The cold antibody autoimmune hemolytic anemias (AIHAs) are primarily comprised of cold agglutinin syndrome (CAS) and paroxysmal cold hemoglobinuria (PCH) but, in addition, there are unusual instances in which patients satisfy the serologic criteria of both warm antibody AIHA and CAS ("mixed AIHA"). CAS characteristically occurs in middle-aged or elderly persons, often with signs and symptoms exacerbated by cold. The responsible antibody is of the IgM immunoglobulin class, is maximally reactive in the cold but with reactivity up to at least 30 degrees C. Therapy is often ineffective, but newer agents such as rituximab have been beneficial in some patients. PCH occurs primarily in children, often after an upper respiratory infection. The causative antibody is of the IgG immunoglobulin class and is a biphasic hemolysin that is demonstrated by incubation in the cold followed by incubation at 37 degrees C in the presence of complement. Acute attacks are frequently severe but the illness characteristically resolves spontaneously within a few days to several weeks after onset and rarely recurs. Treatment consists of supportive care, with transfusions frequently being needed.

Physiological response to water immersion: a method for sport recovery?

Recovery from exercise can be an important factor in performance during repeated bouts of exercise. In a tournament situation, where athletes may compete numerous times over a few days, enhancing recovery may provide a competitive advantage. One method that is gaining popularity as a means to enhance post-game or post-training recovery is immersion in water. Much of the literature on the ability of water immersion as a means to improve athletic recovery appears to be based on anecdotal information, with limited research on actual performance change. Water immersion may cause physiological changes within the body that could improve recovery from exercise. These physiological changes include intracellular-intravascular fluid shifts, reduction of muscle oedema and increased cardiac output (without increasing energy expenditure), which increases blood flow and possible nutrient and waste transportation through the body. Also, there may be a psychological benefit to athletes with a reduced cessation of fatigue during immersion. Water temperature alters the physiological response to immersion and cool to thermoneutral temperatures may provide the best range for recovery. Further performance-orientated research is required to determine whether water immersion is beneficial to athletes.

Recurrent paroxysmal cold haemoglobinuria in a 3-year-old child: a case report

We present the case of a 3-year-old girl who presented on two separate occasions, eight months apart, with typical features of paroxysmal cold haemoglobinuria (PCH). On each occasion, she suffered malaise and fever with dark urine following an upper respiratory tract infection. She developed severe anaemia and required transfusion of red cells on both occasions, although each time she made a quick recovery. She was found to be direct antiglobulin test-positive with anti-C3d, and agglutination was observed on the blood film. A biphasic Donath-Landsteiner antibody was demonstrated. The specificity of the antibody was not identified, although it was not anti-P. As far as we are aware, recurrence of acute PCH in a child has not been previously reported in the literature.

Erythrocyte autoantibodies, autoimmune haemolysis, and carcinoma

AIMS

To examine a large series of patients in whom both red cell autoantibodies and carcinoma are present; and to determine whether this rare occurrence is a true association or a chance event.

METHODS

The laboratory records of 160 patients (76 men, 84 women; mean age 68 years) with erythrocyte autoantibodies and confirmed carcinoma were examined for site of tumour origin and clinical and immunohematological findings. To test whether the concomitant occurrence of autoantibodies and carcinoma was fortuitous, data on total population and carcinoma incidence were included in a chi 2 analysis.

RESULTS

The association was significant (chi 2 = 97.5, p < 0.0005); erythrocyte autoantibodies and carcinoma were found together 12-13 times more often than expected from their relative frequencies. Autoantibodies occurred with a variety of carcinomas, particularly those of breast, lung, colon, rectum, and prostate; this largely reflected tumour incidence. Adenocarcinoma, squamous, anaplastic, and transitional cell types were all represented. Warm, cold, and mixed autoantibodies were not associated with particular tumour sites or histology. Eighty six patients had haemolysis of varying severity, 37 had metastatic disease, and 28 died within a few months of presentation.

CONCLUSIONS

The presence of erythrocyte autoantibodies and carcinoma in the same patient is a true association and probably reflects a fundamental disturbance in immune homeostasis. It tends to occur with a large tumour mass and metastatic disease, and generally indicates a poor prognosis.

Acute paroxysmal cold hemoglobinuria

Over eighty years have passed since Donath and Landsteiner identified the syndrome of PCH and reported an in vitro test for its diagnosis. The accuracy of their observations, and the usefulness of the DL procedure has persisted. PCH has been investigated over the years providing further information regarding antibody specificity and serological characteristics. However, the etiology of the syndrome remains to be elucidated. PCH, which was once thought to be rare and associated primarily with congenital syphilis, is not encountered as one of the most common causes of acute transient hemolytic anemia in young children.