Autoimmune Hemolytic Anemia

Hemolytic Anemia as a Provoking Factor for Recurrent Venous Thromboembolism: A Case Report

Warm antibody autoimmune hemolytic anemia (WAIHA) is a rare disease that leads to the destruction of red blood cells in the reticuloendothelial system through the mediation of agglutinins (immunoglobulin G (IgG) type in most cases) that attach to the erythrocyte wall at 37 °C. The association of WAIHA and venous thromboembolism (VTE) seems to be higher than other hemolytic disorders classically associated with VTE and there is a current investigation aimed at clarifying this association and establishing some criteria to use anticoagulant treatment in patients with WAIHA. Despite this, WAIHA is a rare cause for the development of recurrent VTE under secondary prophylactic anticoagulant treatment, with only a few cases described in the literature. We present the case of a patient who developed a recurrence of deep vein thrombosis during a WAIHA episode despite treatment with acenocoumarol and a review of the literature.

Development and exacerbation of autoimmune hemolytic anemia following COVID-19 vaccination: A systematic review

Autoimmune hemolytic anemia (AIHA) is caused by the production of autoantibodies against RBCs. COVID-19 vaccines can reduce the risk of severe disease, however, various adverse effects such as AIHA were observed following vaccination. This review aimed to assess the relationship of AIHA and COVID-19 vaccination using the PRISMA guidelines. Among 18 cases included in this review, new post-vaccination AIHA development was reported in 11 patients (7 women and 4 men) with a median age of 67.0 years. In 7 of 11 and 3 of 11 cases, the onset of symptoms occurred after first and second vaccine dose with median times of 7 and 14 days, respectively. In 1 of 11 cases, the AIHA occurred on Day 17 after booster vaccination. Ten of 11 and 1 of 11 AIHA patients received mRNA- and vector-based vaccine, respectively. After vaccination, 9 of 11, 1 of 11, and 1 of 11 AIHA patients developed warm IgG, cold IgM, and mixed autoantibodies against RBCs, respectively. Significant AIHA exacerbation was reported in seven patients (four women and three men) with a median age of 73.0 years. In 4 of 7 and 2 of 7 exacerbated AIHA cases, the onset of symptoms occurred after first and second vaccine dose with median times of 7 and 3 days, respectively. In 1 of 7 exacerbated AIHA cases, the onset of symptoms was observed on Day 2 after booster vaccination. All exacerbated AIHA cases received mRNA-based vaccines; 3 of 7 and 4 of 7 exacerbated AIHA cases developed IgG and IgM against RBCs, respectively. This review provides a comprehensive explanation regarding the AIHA development and exacerbation after COVID-19 vaccination.

Relapses are common in severe hematologic systemic lupus erythematosus and may be prevented by early institution of immunosuppressive agents: Α real-life single-center study

BACKGROUND

Hematologic manifestations are common in systemic lupus erythematosus (SLE), either at initial presentation or during the course of the disease, but data regarding their natural history are scarce.

OBJECTIVE

To describe the characteristics, treatments, and outcomes of severe hematological manifestations in a large cohort of lupus patients.

METHODS

Retrospective cohort study of patients in the "Attikon" lupus cohort who had a history of a severe hematologic manifestation, defined as autoimmune hemolytic anemia (AIHA) with hemoglobin < 8 g/dL, thrombocytopenia with platelet count < 30,000/mm³, Evans syndrome with hemoglobin < 8 g/dL, and/or platelet count < 30,000/mm³, neutropenia with < 500 neutrophils/mm³, thrombotic microangiopathy (TMA)/thrombotic thrombocytopenic purpura (TTP)-like syndrome, or macrophage activation syndrome (MAS). Demographic and clinical characteristics, treatments, and outcomes were recorded.

RESULTS

From over 300 patients with hematologic manifestations, 41 qualified as severe (70.7% women, mean [SD] age at SLE diagnosis 42.6 [18.0] years). Hematologic manifestations preceded SLE diagnosis in 13 patients (31.7%), was concomitant to SLE diagnosis in 16 patients (39%), and occurred during the course of the disease in 12 (29.3%) patients, with a mean (SD) disease duration of 8.7 (5.5) years. Thrombocytopenia was the most common severe hematological manifestation (56.1%), followed by AIHA (17.1%) and TTP-like syndrome (12.2%). For initial treatment, all patients were treated with glucocorticoids (GC), while rituximab and cyclophosphamide were the most frequently used immunosuppressive agents. Following initial treatment, relapse occurred in 22 patients (53.7%). Compared to patients that did not relapse, those that relapsed had less often received concomitant immunosuppressive agents following treatment of initial episode (n = 17/23, 73.9% vs 5/17, 29.4%, p = 0.005).

CONCLUSION

Severe hematologic disease in SLE has a high risk of relapse, which may be mitigated by the early institution of GC-sparing agents.

The contribution of the alternative pathway in complement activation on cell surfaces depends on the strength of classical pathway initiation

Objectives

The complement system is an important component of innate immunity. The alternative pathway (AP) amplification loop is considered an essential feed forward mechanism for complement activation. However, the role of the AP in classical pathway (CP) activation has only been studied in ELISA settings. Here, we investigated its contribution on physiologically relevant surfaces of human cells and bacterial pathogens and in antibody-mediated complement activation, including in autoimmune haemolytic anaemia (AIHA) setting with autoantibodies against red blood cells (RBCs).

Methods

We evaluated the contribution of the AP to complement responses initiated through the CP on human RBCs by serum of AIHA patients and recombinant antibodies. Moreover, we studied complement activation on Neisseria meningitidis and Escherichia coli. The effect of the AP was examined using either AP-depleted sera or antibodies against factor B and factor D.

Results

We show that the amplification loop is redundant when efficient CP activation takes place. This is independent of the presence of membrane-bound complement regulators. The role of the AP may become significant when insufficient CP complement activation occurs, but this depends on antibody levels and (sub)class. Our data indicate that therapeutic intervention in the amplification loop will most likely not be effective to treat antibody-mediated diseases.

Conclusion

The AP can be bypassed through efficient CP activation. The AP amplification loop has a role in complement activation during conditions of modest activation via the CP, when it can allow for efficient complement-mediated killing.

Monoclonal Antibody Engineering and Design to Modulate FcRn Activities: A Comprehensive Review

Understanding the biological mechanisms underlying the pH-dependent nature of FcRn binding, as well as the various factors influencing the affinity to FcRn, was concurrent with the arrival of the first recombinant IgG monoclonal antibodies (mAbs) and IgG Fc-fusion proteins in clinical practice. IgG Fc–FcRn became a central subject of interest for the development of these drugs for the comfort of patients and good clinical responses. In this review, we describe (i) mAb mutations close to and outside the FcRn binding site, increasing the affinity for FcRn at acidic pH and leading to enhanced mAb half-life and biodistribution, and (ii) mAb mutations increasing the affinity for FcRn at acidic and neutral pH, blocking FcRn binding and resulting, in vivo, in endogenous IgG degradation. Mutations modifying FcRn binding are discussed in association with pH-dependent modulation of antigen binding and (iii) anti-FcRn mAbs, two of the latest innovations in anti-FcRn mAbs leading to endogenous IgG depletion. We discuss the pharmacological effects, the biological consequences, and advantages of targeting IgG–FcRn interactions and their application in human therapeutics.

Hemolytic anemia in COVID-19

COVID-19 is a global pandemic triggered by the severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2). The SARS-CoV-2 entry point involves the interaction with angiotensin-converting enzyme 2 (ACE2) receptor, CD147, and erythrocyte Band3 protein. Hemolytic anemia has been linked to COVID-19 through induction of autoimmune hemolytic anemia (AIHA) caused by the formation of autoantibodies (auto-Abs) or directly through CD147 or erythrocyte Band3 protein-mediated erythrocyte injury. Here, we aim to provide a comprehensive view of the potential mechanisms contributing to hemolytic anemia during the SARS-CoV-2 infection. Taken together, data discussed here highlight that SARS-CoV-2 infection may lead to hemolytic anemia directly through cytopathic injury or indirectly through induction of auto-Abs. Thus, as SARS-CoV-2-induced hemolytic anemia is increasingly associated with COVID-19, early detection and management of this condition may prevent the poor prognostic outcomes in COVID-19 patients. Moreover, since hemolytic exacerbations may occur upon medicines for COVID-19 treatment and anti-SARS-CoV-2 vaccination, continued monitoring for complications is also required. Given that, intelligent nanosystems offer tools for broad-spectrum testing and early diagnosis of the infection, even at point-of-care sites.

A Rare Case of COVID-19 Associated With Autoimmune Hemolytic Anemia, Thrombocytopenia and Acute Kidney Injury

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has numerous effects on different systemic organs other than the lungs. In this case report, we look at the presentation of a young female who was diagnosed with autoimmune hemolytic anemia (AIHA), kidney injury and thrombocytopenia during coronavirus disease 2019 (COVID-19) infection. She recovered well without the need for steroids. As demonstrated by this case, COVID-19 infection can be associated with the development of AIHA. The purpose of this report is to indicate that COVID-19 can present unusually with different clinical manifestations enough to require hospitalization.

COVID-19 and Immune-Mediated RBC Destruction

OBJECTIVES

To summarize the epidemiologic, clinical, and laboratory characteristics of autoimmune hemolytic anemia (AIHA) secondary to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or vaccination.

METHODS

We conducted a systematic review using standardized keyword search to identify all reports of SARS-CoV-2 infection or vaccination and AIHA across PubMed, Web of Science, Scopus, and Google Scholar through September 24, 2021.

RESULTS

Fifty patients (mean [SD] age, 50.8 [21.6] years) diagnosed with coronavirus disease 2019 (COVID-19) and AIHA were identified. AIHA subtypes and number of patients were as follows: cold AIHA (n = 18), warm AIHA (n = 14), mixed-type AIHA (n = 3), direct antiglobulin test (DAT)-negative AIHA (n = 1), DAT-negative Evans syndrome (n = 1), Evans syndrome (n = 3), and subtype not reported (n = 10). Mean (SD) hemoglobin at AIHA diagnosis was 6.5 [2.8] g/dL (95% confidence interval, 5.7-7.3 g/dL). Median time from COVID-19 symptom onset to AIHA diagnosis was 7 days. In total, 19% (8/42) of patients with COVID-19-associated AIHA with reported outcomes were deceased. Four patients (mean [SD] age, 73.5 [16.9] years) developed AIHA following SARS-CoV-2 vaccination: Pfizer-BioNTech BNT162b2 vaccine (n = 2); Moderna mRNA-1273 vaccine (n = 1); undisclosed mRNA vaccine (n = 1). AIHA occurred after 1 dose in 3 patients (median, 5 days).

CONCLUSIONS

SARS-CoV-2 infection and vaccination are associated with multiple AIHA subtypes, beginning approximately 7 days after infectious symptoms and 5 days after vaccination.

Clinical and surgical outcomes of splenectomy for autoimmune hemolytic anemia

INTRODUCTION

We investigated short and long-term remission rates after splenectomy in patients with primary and secondary autoimmune hemolytic anemia (AIHA).

METHODS

All adults who underwent splenectomy for primary or secondary AIHA at a single center (2004-2018) were retrospectively reviewed. Short-term response was determined at 30-day postoperatively and long-term at one year. Complete response was defined as hemoglobin > 10 g/dL without hemolysis, transfusions, or need for additional medical therapy for > 6 months.

RESULTS

Short-term complete response was attained in 22 of 36 patients (61%), partial response in 3 (8%), no response in 11 (31%). The response rate at 1 year was complete in 14/36 (39%), partial in 14 (39%), and 8 non-response (22%). At last available follow-up (median 33.1 months (IQR 19-59), 16/37 patients had experienced a complete response (43%), 14 partial response (38%), 7 non-response (19%). 80% of partial responders with primary AIHA required maintenance therapy compared to 100% with secondary AIHA.

CONCLUSION

Splenectomy is associated with short- and long-term improvement in anemia and hemolysis in the majority of patients with AIHA. Immunosuppressants remain important supplemental therapy.

A Case of Autoimmune Hemolytic Anemia after the First Dose of COVID-19 mRNA-1273 Vaccine with Undetected Pernicious Anemia

By this time, multiple vaccines have been approved to limit the spread of SARS-CoV-2 worldwide. These include new-generation vaccines that contain mRNA of the target organism. Some common side effects were identified and reported during phase 3 clinical trials of vaccination, but more rare adverse events were reported in the literature. One such concern is autoimmune conditions that SARS-CoV-2 viral antigens could have possibly incited. We are presenting here a case of a young female with no known autoimmune diseases, diagnosed with autoimmune hemolytic anemia about a week after receiving her first dose of the COVID-19 mRNA vaccine. We discuss the possible culprit for precipitation of autoimmune hemolytic anemia after the SARS-CoV-2 mRNA vaccine, which encodes virus spike protein. This case highlights the importance of being vigilant for identifying rare adverse events that could appear during mass vaccination.

First Case of Autoimmune Hemolytic Anemia Associated With COVID-19 Infection in Sri Lanka: A Case Report

Autoimmune hemolytic anemia (AIHA) is a condition characterized by the increased destruction of red blood cells (RBCs) mediated by anti-erythrocyte autoantibodies with or without complement activation. Its clinical presentation is heterogeneous, ranging from asymptomatic to severe forms with fatal outcomes, and it can be either idiopathic or secondary to a coexisting disorder. In this report, we present a case of a patient who suffered from her first episode of acute and severe AIHA during Severe Acute Respiratory Syndrome Coronavirus - 2 (SARS-CoV-2) and responded well with the treatment.

Autoimmune Hemolytic Anemia: A Case Study Presentation

Autoimmune hemolytic anemia (AIHA) is a rare and potentially life-threatening condition. This article presents a case study of AIHA in a patient with a history of acute myelogenous leukemia in remission. Differentiating the cause and type of HA (extrinsic versus intrinsic) will be discussed, along with information on follow-up and refractory AIHA. Advanced practice RNs (APRNs) play an essential role in the early recognition of HA, as well as the diagnosis, referral, and management of the condition.

Warm and Cold Autoimmune Hemolytic Anemia in the Setting of COVID-19 Disease

Known associations with autoimmune hemolytic anemia (AIHA) include lymphoproliferative neoplasms, autoimmune conditions, and viral infections. There are a few case reports that implicate a potential relationship between COVID-19 and either warm or cold AIHA. We present the case of combined warm and cold AIHA in the setting of COVID-19. A 51-year-old male with no known past medical history presented with weakness and jaundice. Initial workup revealed white blood cells 41.4, hemoglobin 3.1, platelets 343, total bilirubin 5.3, direct bilirubin 1.6, and COVID-19 positive. Direct antiglobulin test (DAT) found IgG and C3 antibodies and pathology revealed cold agglutinins, consistent with both warm and cold AIHA. He received a total of five blood transfusions and was started on prednisone 1 mg/kg daily with a gradual taper over months. Hemolysis labs normalized within two weeks after discharge although antibodies remained positive 70 days after admission. Our patient presented with IgG and C3 antibodies as well as cold agglutinins, consistent with both warm and cold AIHA. To our knowledge, this is the first case of both warm and cold AIHA presenting simultaneously in COVID-19 infection. Unlike most cases in the existing literature, this patient had no history of underlying hematologic malignancy and both warm and cold AIHA.

Resolution of serologic problems due to cold agglutinin mediated autoimmune hemolytic anemia and its transfusion decision

Background

Autoimmune hemolytic anemia (AIHA) is a rare disease characterized by hemolysis caused by autoantibodies against erythrocyte surface antigen. These antibodies can be classified as warm, cold, or mixed types.

Methods

We report two cases of cold agglutinin disease (CAD), which were eventually diagnosed owing to blood group discrepancy. Resolution was achieved after washing the red blood cells (RBCs) with warm saline and absorbing the autoantibodies at 4°C with the washed RBCs. We also assessed the patient's condition and discussed the strategy of blood transfusion.

Results

The first case occurred after postoperative chemotherapy for rectal cancer, and the other manifested with anemia from the outset. Direct antiglobulin tests were positive and revealed autoantibodies against C3d only. Cold agglutinin titration was performed, and the titers of both were 1:1024. Eventually, the patient's condition stabilized without blood transfusion.

Conclusion

The serological discrepancies observed in the blood transfusion department can successfully guide blood transfusion decisions in cases of CAD.

A Case of COVID-19-Associated Autoimmune Hemolytic Anemia With Hyperferritinemia in an Immunocompetent Host

We report an interesting case of a middle-aged gentleman who presented with diabetic ketoacidosis (DKA) and tested polymerase chain reaction (PCR) positive for COVID-19 infection. His hospital stay was complicated by acute kidney injury, hematuria, and normocytic anemia. Initial chest x-ray demonstrated bibasilar opacities. D-dimer and C-reactive protein were elevated. During his hospital stay, his hemoglobin decreased from 13.4 g/dL to 9 g/dL, and further workup demonstrated ferritin of 49,081 ng/mL with lactate dehydrogenase of 1665 U/L. He was treated with prednisone and folic acid for autoimmune hemolytic anemia (AIHA). Ferritin was downtrended, and hemoglobin stabilized. As demonstrated by this case report and prior literature review, COVID-19 infection can be associated with AIHA.

Favism-induced methemoglobinemia in a G6PD deficient male with a subsequent hemolytic cascade, a therapeutic challenge: Case report and review of literature

The co-occurrence of acute hemolysis and methemoglobinemia secondary to favism in G6PD deficient individuals is rare. Identifying it promptly is of high clinical significance as treating methemoglobinemia (with methylene blue) can worsen hemolysis.

Macrophage metabolic adaptation to heme detoxification involves CO-dependent activation of the pentose phosphate pathway

Heme is an essential cofactor for numerous cellular functions, but release of free heme during hemolysis results in oxidative tissue damage, vascular dysfunction, and inflammation. Macrophages play a key protective role in heme clearance; however, the mechanisms that regulate metabolic adaptations that are required for effective heme degradation remain unclear. Here we demonstrate that heme loading drives a unique bioenergetic switch in macrophages, which involves a metabolic shift from oxidative phosphorylation toward glucose consumption. Metabolomic and transcriptional analysis of heme-loaded macrophages revealed that glucose is funneled into the pentose phosphate pathway (PPP), which is indispensable for efficient heme detoxification and is required to maintain redox homeostasis. We demonstrate that the metabolic shift to the PPP is controlled by heme oxygenase-dependent generation of carbon monoxide (CO). Finally, we show that PPP upregulation occurs in vivo in organ systems central to heme clearance and that PPP activity correlates with heme levels in mouse sickle cell disease (SCD). Together, our findings demonstrate that metabolic adaptation to heme detoxification in macrophages requires a shift to the PPP that is induced by heme-derived CO, suggesting pharmacologic targeting of macrophage metabolism as a novel therapeutic strategy to improve heme clearance in patients with hemolytic disorders.

COVID-19 associated with severe autoimmune hemolytic anemia

BACKGROUND

Autoimmune hemolytic anemia (AIHA) has many known disease associations, including autoimmune, lymphoproliferative, and certain infectious diseases, as well as various medications. Studies have found that severe cases of coronavirus disease 2019 (COVID-19) may be associated with coagulopathies; however, the potential association with AIHA is not clear.

CASE REPORT

A patient with no known risk factors or underlying predisposition for developing AIHA presented to a hospital with vague symptoms and profound anemia with a complicated blood bank evaluation. She was found to have COVID-19 and AIHA, for which extensive laboratory testing was performed, including direct antiglobulin tests, elution studies, and cold agglutinin titers, to identify the causative autoantibody. She required multiple blood transfusions and therapeutic interventions before clinical stabilization.

DISCUSSION

AIHA is a complex disease with a spectrum of presentations and clinical severity. Many diseases have been associated with a propensity for developing AIHA; however, there are few cases in the literature of patients with COVID-19 and AIHA. Most of the reports involve patients with other underlying conditions that are known to be associated with the development of AIHA. The presentation, clinical findings, and therapeutic interventions in a patient with severe AIHA, without other underlying conditions, in the setting of COVID-19 are discussed.

CONCLUSIONS

There are few reports of patients with concurrent COVID-19 and AIHA, and the association is not clear. Although COVID-19 has been shown to be associated with coagulopathies, more research is required to determine whether AIHA may also be a potential complication.

The JANUS of chronic inflammatory and autoimmune diseases onset during COVID-19 - A systematic review of the literature

The diverse clinical manifestations of COVID-19 is emerging as a hallmark of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection. While the initial target of SARS-CoV-2 is the respiratory tract, it is becoming increasingly clear that there is a complex interaction between the virus and the immune system ranging from mild to controlling responses to exuberant and dysfunctional multi-tissue directed autoimmune responses. The immune system plays a dual role in COVID-19, being implicated in both the anti-viral response and in the acute progression of the disease, with a dysregulated response represented by the marked cytokine release syndrome, macrophage activation, and systemic hyperinflammation. It has been speculated that these immunological changes may induce the loss of tolerance and/or trigger chronic inflammation. In particular, molecular mimicry, bystander activation and epitope spreading are well-established proposed mechanisms to explain this correlation with the likely contribution of HLA alleles. We performed a systematic literature review to evaluate the COVID-19-related autoimmune/rheumatic disorders reported between January and September 2020. In particular, we investigated the cases of incident hematological autoimmune manifestations, connective tissue diseases, antiphospholipid syndrome/antibodies, vasculitis, Kawasaki-like syndromes, acute arthritis, autoimmune-like skin lesions, and neurologic autoimmune conditions such as Guillain–Barré syndrome. We screened 6263 articles and report herein the findings of 382 select reports which allow us to conclude that there are 2 faces of the immune response against SARS-CoV-2, that include a benign virus controlling immune response and a many faceted range of dysregulated multi-tissue and organ directed autoimmune responses that provides a major challenge in the management of this viral disease. The number of cases for each disease varied significantly while there were no reported cases of adult onset Still disease, systemic sclerosis, or inflammatory myositis.

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The immune system plays a major role in the acute progression of COVID-19.

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SARS-CoV-2 infection shares features with autoimmune diseases.

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SARS-CoV-2 can induce Guillain-Barré syndrome, arthritis, chilblain-like lesions.

Autoimmune Hemolytic Anemia After Cyanocobalamin Replacement in a Patient With a Previous Diagnosis of Pernicious Anemia: A Case Report

Pernicious anemia (PA) is associated with other autoimmune diseases, such as hypothyroidism, type 1 diabetes mellitus (DM1), Addison's disease, and vitiligo. The association between PA and autoimmune hemolytic anemia (AIHA) is rare, with less than 30 cases reported in the literature. In this paper, we report a case of a patient with a confirmed diagnosis of PA, who, six months after starting treatment with cyanocobalamin, presented with severe hemolysis with a positive direct antiglobulin test (DAT) for warm antibodies; the patient responded well to glucocorticoid treatment. AIHA in PA patients can be triggered by cyanocobalamin replacement due to the expression of membrane antigens by mature red blood cells entering into the peripheral circulation. This association should be considered because these patients, in addition to cyanocobalamin replacement, will require immunosuppressive treatment, usually with glucocorticoids.

[Autoimmune hemolytic anemia: Case review]

INTRODUCTION

Autoimmune hemolytic anemia (AIHA) is a rare and generally self-limiting disease in children.

MATERIAL AND METHODS

A descriptive cross-sectional study was performed in children under 18 years diagnosed with AIHA from January/1997 to July/2019. Clinical variables were collected and AIHA was classified according to the direct antiglobulin test (DAT) in warm AIHA (IgG+/-C3d) and cold AIHA (C3d). Response to treatment and evolution were analyzed.

RESULTS

25 patients were included and 72% were males. The median age at diagnosis was 2 years (range 0.4 to 9). Fever (72%), pallor (68%), jaundice (64%), hepatosplenomegaly and coluria (48%) were the most common presenting symptoms. The median hemoglobin at diagnosis was 5.4 g/dl. DAT was positive in 96%, with detection of IgG antibodies in 76%. A single case presented negative DAT. 20% of the patients associated another cytopenia, one of which was subsequently diagnosed with common variable immunodeficiency. Concomitant viral infection was suspected or documented in 32%. Most of the cases were self-limiting and responded to corticosteroid treatment (72%). Those with partial response (24%), mainly those associated with other cytopenias, required other lines of treatment (rituximab, mycophenolate, immunoglobulins). Complications (32%) and relapses (26%) were detected only in warm AIHA.

CONCLUSIONS

Our case series confirms that AIHA is a very rare disease in childhood. Most cases evolve favorably, although up to a quarter of them require second lines of treatment and, in exceptional cases, they need very aggressive treatments. These latter cases generally correspond to patients who present more than one cytopenia in the course of the disease.

Acute peripheral pulmonary embolism attributed to autoimmune haemolytic anaemia: a case report

BACKGROUND

PE (pulmonary embolism) is a life-threatening complication rarely seen in the AIHA (autoimmune haemolytic anaemia) patients. Herein we reported a rare and serious AIHA-PE patient characterised by extensive peripheral pulmonary embolism on CTPA.

CASE PRESENTATION

A 59-year-old woman presented to our ED (emergency department) complaining of acute chest pain and dyspnea. During her presentation in ED she experienced a sudden syncope and soon developed CA (cardiac arrest). Laboratory studies showed a increase of CK-MB,troponin T,myoglobin and D-dimer. Computed tomography pulmonary angiography (CTPA) showed no large central or segment pulmonary emboli but increased RV (right ventricle)size,enlarged main pulmonary artery and invisible peripheral pulmonary artery. She was diagnosed with acute PE and alteplase was delivered intravenously. After thrombolytic therapy she remained hypotension and developed worsening anaemia. Detailed examination for anaemia revealed AIHA. She was discharged in a stable condition after 5 weeks with methylprednisolone and warfarin. Hb, D-dimer and transthoracic echocardiography showed complete recovery at 3-months follow up.

CONCLUSION

PE attributed to AIHA is characterized by subsegment and distal pulmonary artery embolism which is easily neglected but always life-threatening. This case also highlights the PE as a secondary diagnosis should be evaluated comprehensively in order to identify the underlying pathogenesis.

Autoimmune hemolytic anemia in hospitalized patients: 450 patients and their red blood cell transfusions

Autoimmune hemolytic anemia (AIHA) is a rare disease in which autoantibodies target red blood cells (RBCs), leading to anemia that ranges from no symptoms to severe life-threatening hemolysis. Little is known about the severity of anemia, blood transfusion efficiency and risk of transfusion-related reactions among hospitalized AIHA patients, especially in those with incompatible RBC transfusions.A retrospective study was conducted among hospitalized AIHA patients from January 2009 to December 2015 in a large tertiary care medical center in southwest China.A total of 450 AIHA hospitalized patients were recruited, of whom 97.3% had warm AIHA, 30.3% had primary AIHA, and 90.7% were treated with corticosteroids. On admission, approximately 3% of patients had an hemoglobin (Hb) <30 g/L, 34% had an Hb between 30 and 59.9 g/L, and 46% had an Hb ranging from 60 to 89.9 g/L. A total of 2509.5 U RBCs were transfused to AIHA patients, and 14 transfusion-related adverse reactions were recorded, without any hemolytic transfusion reactions. With an average transfusion trigger of 52.0 ± 9.3 g/L, 59.7% of the patients received RBCs, and 55.8% of the transfusions were viewed as effective. Least incompatible RBCs were given in 39% of the transfusions, but the transfusion efficiency did not significantly decrease with these incompatible blood transfusions (P = .253). Primary AIHA patients with a nadir Hb of approximately 40 to 50 g/L during their hospital stay had the highest rate of remission and did not require a different total number of RBC transfusions (P = .068) or length of hospitalization (P = .194) compared to other groups with nadir Hb values <30 g/L, ≥30 and <40 g/L, ≥50 and <60 g/L, and ≥60 g/L.One-third of AIHA patients suffered from severe anemia during hospitalization, and transfusions, even with incompatible RBCs, were safe and efficient. However, transfusion triggers between 40 and 50 g/L seemed to benefit the most patients by alleviating the RBC destruction caused by autoantibodies, and a restrictive transfusion strategy was beneficial in AIHA patients.

A Retrospective Study of the Combination of Rituximab, Cyclophosphamide and Dexamethasone for the Treatment of Relapsed/Refractory Warm Antibody Autoimmune Hemolytic Anemia

The combination of rituximab, cyclophosphamide, and dexamethasone (RCD) is highly effective in the treatment of warm autoimmune hemolytic anemia (WAIHA) associated with chronic lymphocytic leukemia (CLL). We treated a cohort of patients with relapsed/refractory WAIHA, without CLL, with RCD. The primary objective was to evaluate the overall response (OR) of RCD therapy. Complete response (CR) was defined as a hemoglobin (Hgb) ≥12 g/dL. Partial response (PR) was defined as Hgb 10-11.9 g/dL or ≥2 g/dL increase in Hgb. Sustained response was defined as Hgb ≥10 g/dL with no treatment changes. A total of 16 patients with relapsed/refractory WAIHA received RCD (7 primary WAIHA, 9 secondary WAIHA) for a median of 4 cycles (range: 2-6). The median pretreatment Hgb was 10.0 g/dL (range: 4.3-12.2). The median best Hgb achieved was 12.5 g/dL (range: 10.6-15.1) with a median of 2 cycles until best Hgb response. The OR was 94% (11 CR, 4 PR). Two immunocompromised patients were admitted for infections during RCD treatment. There were no deaths during the treatment or follow-up period. Following a response to RCD, 4 patients received noncorticosteroid immune modulation therapy and 4 patients continued on corticosteroid therapy. Seven patients received no additional treatment.

Anti tissue transglutaminase antibody in idiopathic autoimmune haemolytic anemia

BACKGROUND

In idiopathic autoimmune haemolytic anaemia (AIHA haemolytic antibodies are directed to every type of red cellsWestern blot studies have shown antibody positivity towards red cell anion channel complex which also includes band 4.2 a protein with similarities to tissue trans glutaminase.

OBJECTIVE

Evaluation of AIHA for anti tissue transglutaminase antibody (Anti tTG).

MATERIALS & METHODS

Twenty three AIHA patients were tested along with routine hamatogical work up, for a series of auto antibodies and red cell eluates and serum from the patents were tested against solubilised group O red cell ghosts on western blot. Other ancillary investigations were done to rule out complications and secondary causes of haemolysis.

RESULTS

11/23 patients (48%) were positive for anti tTG, Four, 3 and 8,7 patients were positive for anti thyroid, anti b2 glycoprotein, lupus anticoagulant and ANA respectively. One patient with anti tTG had biopsy proven celiac disease. Three patient developed DVT and all of them were lupus anticoagulant as well as b2 gp-1 antibody positive.17 had become Coombs test negative on treatment while 21/23 had positive western blot test.

DISCUSSION & CONCLUSION

There is strong association of anti tTG antibody with idiopathic AIHA. Aetiological association of this finding needs exploration.

Autoimmune haemolytic anaemia in pancreatic adenocarcinoma: a potential paraneoplastic presentation

While autoimmune haemolytic anaemia (AIHA) is a well-known paraneoplastic syndrome in haematological malignancies, it has been described far less in solid tumours. We hereby report the case of a 61-year-old male patient presenting AIHA related to pancreatic cancer. Investigations excluded infectious, autoimmune and toxic causes of AIHA. CT of the abdomen highlighted the presence of hypodense, infiltrating mass of the tail of the pancreas measuring 70×37×36 mm, compatible with pancreas neoplasm. Histological examination of two associated nodular lesions of the liver showed metastasis of pancreatic adenocarcinoma. The patient was started on corticosteroid without improvement of haemoglobin. Palliative chemotherapy was initiated; this led to significant improvement in haemoglobin comforting our diagnosis. This case illustrates the rare association between AIHA and pancreatic cancer. However, such association cannot be considered before excluding other, more frequent, aetiologies.

Refractory autoimmune haemolytic anaemia following allogenic haematopoietic stem cell transplantation: successful treatment of rituximab

Objective

To investigate the effectiveness and safety of rituximab in treating autoimmune haemolytic anaemia (AIHA) after allogeneic haematopoietic stem cell transplantation (allo-HSCT).

Methods

Patients with refractory AIHA following allo-HSCT were treated once-weekly with rituximab 375 mg/m² for a total of four doses. In an animal study, recipient CB6F1 mice were conditioned with busulfan/fludarabine and transplanted with splenocytes and T-cell-depleted bone marrow from C57Bl/6 mice. In this animal model, anti-CD20 monoclonal antibody (mAb) was evaluated to see if it could prevent graft versus host disease (GVHD). GVHD was monitored by body weight loss, GVHD clinical scores and the survival of each group of mice. Histopathological analyses of the skin, intestine, liver and lung were used to analyse the severity of GVHD.

Results

After rituximab therapy, refractory AIHA was resolved in all four patients as shown by increased haemoglobin levels. B-cell proportions were reduced with a relative increase of the proportions of T-cells following rituximab treatment. None of the four patients experienced chronic GVHD. In the animal model, anti-CD20 mAb treatment reduced GVHD.

Conclusions

Rituximab therapy deserves consideration for the treatment of post-HSCT patients with refractory AIHA. Further studies are needed to define the therapeutic role of this anti-CD20 mAb.

Cold agglutinin disease and its implications for dental treatment

Cold agglutinin disease (CAD) is a rare variant of autoimmune hemolytic anemia, characterized by the destruction of red blood cells by autoantibodies following exposure to cold temperatures. This case is of a 75-year-old male who presented to a dedicated hematology dental clinic. The dental management over a 3-year period is described, whereby the patient had extraction and periodontal disease management with considerations for medical, social and dental risk assessments and treatment modifications. The principles are applicable to patients with other hematological disorders.

Legionella-Induced Autoimmune Hemolytic Anemia: A Delayed and Unexpected Complication

Legionella pneumophilia is a multi-systemic disease primarily affecting the pulmonary, gastrointestinal, and to a lesser extent, renal systems. We present a case of Legionella pneumonia, which after resolution of respiratory compromise, was complicated by the development of autoimmune hemolytic anemia (AIHA) as determined by a positive Coombs test, and negative workup of other causes. Steroid immunosuppression was initiated, and red cell counts subsequently improved. While AIHA has only been anecdotally described in one prior case, the separation in time of the development and resolution of respiratory symptoms with the development of anemia most likely makes this an under-appreciated entity. An in vitro mechanism has been suggested; however in vivo causation has yet to be proven. Given the prolonged deleterious clinical consequences associated with the development of AIHA and the increase in recognition of Legionella outbreaks, greater recognition of this potential complication and research into the pathophysiology is warranted for the future.

Developments in anti-complement therapy; from disease to clinical trial

The complement system is well known for its role in innate immunity and in maintenance of tissue homeostasis, providing a first line of defence against infection and playing a key role in flagging apoptotic cells and debris for disposal. Unfortunately complement also contributes to pathogenesis of a number of diseases; in some cases driving pathology, and in others amplifying or exacerbating the inflammatory and damaging impact of non-complement disease triggers. The role of complement in pathogenesis of an expanding number of diseases has driven industry and academia alike to develop an impressive arsenal of anti-complement drugs which target different proteins and functions of the complement cascade. Evidence from genetic and biochemical analyses, combined with improved identification of complement biomarkers and supportive data from sophisticated animal models of disease, has driven a drug development landscape in which the indications selected for clinical trial cluster in three 'target' tissues: the kidney, eye and vasculature. While the disease triggers may differ, complement activation and amplification is a common feature in many diseases which affect these three tissues. An abundance of drugs are in clinical development, some show favourable progression whereas others experience significant challenges. However, these hurdles in themselves drive an ever-evolving portfolio of 'next-generation' drugs with improved pharmacokinetic and pharmacodynamics properties. In this review we discuss the indications which are in the drug development 'spotlight' and review the relevant indication validation criteria. We present current progress in clinical trials, highlighting successes and difficulties, and look forward to approval of a wide selection of drugs for use in man which give clinicians choice in mechanistic target, modality and route of delivery.

Successful treatment of acute-on-chronic liver failure and hemolytic anemia with hepato-protective drugs in combination with intravenous ozone without steroids: A case report

Both acute-on-chronic liver failure (ACLF) and autoimmune hemolytic anemia (AIHA) are common causes of jaundice. A co-occurrence of ACLF and AIHA is rare in clinical practice. This report describes a male elderly patient who developed persistently increased levels of total bilirubin and ascites after endoscopic retrograde cholangiopancreatography for the successful treatment of common bile duct stones. Eventually, he was diagnosed with ACLF and AIHA according to current diagnostic criteria. The patient was given conventional hepato-protective drugs, human albumin, and diuretics in combination with immune ozone without steroids, and he responded well. The therapeutic role of immune ozone in this case is also discussed. When immune ozone was given, total bilirubin gradually decreased; however, no change in total bilirubin was observed after immune ozone was stopped. Notably, when immune ozone was re-initiated, total bilirubin decreased again.

Features of peripheral CD8+CD57+ lymphocytes in patients with autoimmune hemolytic anemia

Autoimmune hemolytic anemia (AIHA) is an acquired condition characterized by the presence of autoantibodies recognizing erythrocyte-related antigens. Several components of the immune system are involved in disease pathogenesis. Among them, as for other autoimmune disorders, a role for specific CD8⁺CD57⁺ regulatory cells subset could be hypothesized. We evaluated this lymphocyte subset by flow cytometry in 18 AIHA patients randomly selected in a retrospective population of 29 cases. Secondary forms were observed in 65.5% of cases, whereas frequencies of warm, cold, mixed, and atypical forms were similar. Cold agglutinins and cryoglobulins tested positive in 44.8% and 10.3% of cases, respectively. These patients exhibited a higher frequency of peripheral vascular symptoms (odds ratio = 8.2, p = .04) and complement consumption (odds ratio = 7.2, p = .02). Frequency of CD8⁺CD57⁺ cells resulted significantly higher in AIHA patients than in control group (17.0 ± 15.8% vs 8.2 ± 5.0%, p = .04). Regardless of therapeutic schedule, patients with partial or no response to therapy (8/18) showed higher frequencies of CD8⁺CD57⁺ cells as compared with controls (23.6 ± 21.3% vs 8.9 ± 4.9%, p = .01), whereas 10/18 complete responders (CR) showed lower levels of CD8⁺CD57⁺ cells (11.7 ± 6.9%, p = .11). CR and controls showed similar values (p = .24). This study suggests that monitoring this lymphocyte subset before and after treatment administration might have a prognostic value. Moreover, CD8⁺CD57⁺ cells may represent a possible therapeutic target to restore the normal balance between lymphocyte populations.

Haemolysis index for the screening of intravascular haemolysis: a novel diagnostic opportunity?

The diagnostic approach to patients with intravascular haemolysis remains challenging, since no first-line laboratory test seems to be entirely suitable for the screening of this condition. Recent evidence shows that an enhanced cell-free haemoglobin (fHb) concentration in serum or plasma is a reliable marker of red blood cell injury, and may also predict clinical outcomes in patients with different forms of haemolytic anaemias. However, the routine use of the haemiglobincyanide assay, the current reference method for measuring fHb, seems unsuitable for a timely diagnosis of intravascular haemolysis, for many safety and practical reasons. The spectrophotometric assessment of fHb by means of the so-called haemolysis-index (H-index) has now become available in most clinical chemistry analysers. This measure allows an accurate, rapid and inexpensive assessment of fHb in a large number of serum or plasma samples, and its use has already proven to be useful for identifying some forms of haemolytic anaemias. Therefore, the aim of this article is to provide an update and a personal opinion about the potential clinical use of the H-index for screening patients with suspected intravascular haemolysis.

Tuberculosis induced autoimmune haemolytic anaemia: a systematic review to find out common clinical presentations, investigation findings and the treatment options

Background

Tuberculosis induced autoimmune haemolytic anaemia is a rare entity. The aim of this study was to explore its common presentations, investigation findings and treatment options through a systematic review of published reports.

Methods

PubMed, Trip, Google Scholar, Science Direct, Cochrane Library, Open-Grey, Grey literature report and the reference lists of the selected articles were searched for case reports in English on tuberculosis induced auto-immune haemolytic anaemia. PRISMA statement was used for systematic review. Quality assessment of the selected reports was done using the CARE guidelines.

Results

Twenty-one articles out of 135 search results were included. Thirty-three percent of patients were reported from India. More than half had fever and pallor. The mean haemoglobin was 5.77 g/dl (SD 2.2). Positive direct coombs test was seen in all patients. Pulmonary tuberculosis (43%) was most prevalent. Twenty-nine percent of patients needed a combination of anti-tuberculosis medicines, blood transfusion and steroids. Higher percentage of disseminated TB induced AIHA (67%) needed steroids in comparison to the other types of TB induced AIHA (13%).

Conclusions

Rarer complications of tuberculosis such as auto-immune haemolytic anaemia should be looked for especially in disease-endemic areas. Blood transfusion and steroids are additional treatment options along with the anti-tuberculosis medicines.

Electronic supplementary material

The online version of this article (10.1186/s13223-018-0236-y) contains supplementary material, which is available to authorized users.

Efficacy and safety of rituximab for systemic lupus erythematosus-associated immune cytopenias: A multicenter retrospective cohort study of 71 adults

The aim of the study was to assess the efficacy and safety of rituximab (RTX) for treating systemic lupus erythematosus (SLE)-associated immune cytopenias. This multicenter retrospective cohort study of adults from French referral centers and networks for adult immune cytopenias and SLE involved patients ≥18 years old with a definite diagnosis of SLE treated with RTX specifically for SLE-associated immune cytopenia from 2005 to 2015. Response assessment was based on standard definitions. In total, 71 patients, 61 women (85.9%), with median age 36 years [interquartile range 31-48], were included. The median duration of SLE at the time of the first RTX administration was 6.1 years [2.6-11.6] and the reason for using RTX was immune thrombocytopenia (ITP) for 44 patients (62.0%), autoimmune hemolytic anemia (AIHA) for 16 (22.5%), Evans syndrome for 10 (14.1%), and pure red cell aplasia for one patient. Before receiving RTX, patients had received a mean of 3.1 ± 1.3 treatments that included corticosteroids (100%), and hydroxychloroquine (88.5%). The overall initial response rate to RTX was 86% (91% with ITP, 87.5% with AIHA, and 60% with Evans syndrome), including 60.5% with complete response. Median follow-up after the first injection of RTX was 26.4 months [14.3-71.2]. Among 61 initial responders, relapse occurred in 24 (39.3%); for 18, RTX retreatment was successful in 16 (88.8%). Severe infections occurred after RTX in three patients, with no fatal outcome. No cases of RTX-induced neutropenia were observed. In conclusion, RTX seems effective and relatively safe for treating SLE-associated immune cytopenias.

Mechanisms of Complement-Mediated Damage in Hematological Disorders

The complement cascade is an ancient defense system that destroys and eliminates threats to normal homeostasis in the bloodstream and tissues. Although multiple controls keep complement in check to minimize innocent bystander injury to normal cells and tissues, defects in complement regulation due to mutations in, or autoantibodies to, complement control proteins underlie the pathogenesis of several hemolytic diseases including paroxysmal nocturnal hemoglobinuria, and atypical hemolytic uremic syndrome. In autoimmune hemolytic anemias complement plays an important role in erythrocyte destruction mediated by antierythrocyte antibodies. The pathogenic mechanisms of these hemolytic diseases are discussed, with an emphasis on pivotal steps in complement activation.

Consequences of dysregulated complement regulators on red blood cells

The complement system represents the first line of defense that is involved in the clearance of pathogens, dying cells and immune complexes via opsonization, induction of an inflammatory response and the formation of a lytic pore. Red blood cells (RBCs) are very important for the delivery of oxygen to tissues and are continuously in contact with complement proteins in the blood plasma. To prevent complement activation on RBCs, various complement regulatory proteins can be found in plasma and on the cell membrane. RBCs are special cells without a nucleus and having a slightly different make-up of complement regulators than nucleated cells, as membrane cofactor protein (MCP) is not expressed and complement receptor 1 (CR1) is highly expressed. Decreased expression and/or function of complement regulatory proteins may result in unwanted complement activation and accelerated removal of RBCs. This review describes complement regulation on RBCs and the consequences when this regulation is out of balance.

Human Immunodeficiency Virus Infection Increases the Risk of Incident Autoimmune Hemolytic Anemia: A Population-Based Cohort Study in Taiwan

Background

Currently, the association between human immunodeficiency virus (HIV) infection and subsequent development of autoimmune hemolytic anemia (AIHA) remains unclear. This nationwide population-based cohort study aimed to determine the association between incident AIHA and HIV infection in Taiwan.

Methods

During 2000-2012, we identified people aged ≧15 years living with HIV (PLWH) from the Taiwan Centers for Disease Control HIV Surveillance System. Individuals were considered to be infected with HIV on the basis of positive results of an HIV type 1 Western blot. Age- and sex-matched controls without HIV infection were selected from the Taiwan National Health Insurance Research Database for comparison. All patients were followed until 31 December 2012 and observed for occurrence of AIHA.

Results

Of 171468 subjects (19052 PLWH and 152416 controls), 30 (0.02%) had incident AIHA during a mean follow-up of 5.45 years, including 23 PLWH (0.12%) and 7 controls (0.01%). After adjustment for age, sex, and comorbidities, HIV infection was found to be an independent risk factor of incident AIHA (adjusted hazard ratio, 20.9; 95% confidence interval, 8.34-52.3). Moreover, PLWH who were receiving highly active antiretroviral therapy were more likely to develop AIHA than those who were not receiving these drugs (adjusted hazard ratio, 16.2; 95% confidence interval, 3.52-74.2).

Conclusions

Our study suggests that HIV infection is an independent risk factor for incident AIHA.

Iron overload in hematological disorders

While most common symptom of impairment of iron homeostasis is iron deficiency anemia, some hematological disorders are associated with iron overload (IO). These disorders are related mainly to chronic severe hemolytic anemia, where red blood cells (RBC) or their precursors are destroyed prematurely (hemolyzed), leading to anemia that cannot be compensated by increased production of new RBC. In such cases, IO is mainly due to repeated RBC transfusions and/or increased uptake of iron in the gastrointestinal tract. Normally, iron is present in the plasma and in the cells bound to compounds that render it redox inactive. Iron overload leaves a fraction of the iron free (labile iron pool) and redox active, leading to the generation of excess free radicals such as the reactive oxygen species. This condition upsets the cellular redox balance between oxidants and antioxidants, leading to oxidative stress. The free radicals bind to various cellular components, thereby becoming toxic to vital organs. Oxidative stress may also affect blood cells, such as RBC, platelets and neutrophils, exacerbating the anemia, and causing recurrent infections and thrombotic events, respectively. The toxic effect of IO can be decreased by treating the patients with iron chelators that enter cells, bind free iron and remove it from the body through the urine and feces. Iron toxicity may be also ameliorated by treatment with anti-oxidants that scavenge free radicals and/or correct their damage. The use of iron chelators is widely accepted when started in young patients with severe chronic anemia, but is still debatable as a therapeutic modality for older patients suffering from IO due to myelodysplastic syndromes. It should be noted that in addition to preventing iron toxicity, some compounds with iron chelator activity may also benefit other aspects of hematological disorders. These aspects include stimulation of platelet production, inhibition of leukemic cell proliferation and induction of their differentiation. Compounds with such multiple activities may prove beneficial for at least some patients with leukemia and myelodysplastic syndromes.