Pure white-cell aplasia. Antibody-mediated autoimmune inhibition of granulopoiesis

[Pure white cell aplasia combined with thymoma and lung cancer: a case report and literature review]

Pure white cell aplasia (PWCA) is a rare hematologic disorder. In this case study, a 67-year-old man presented with severe neutropenia along with thymoma and lung cancer. A comprehensive diagnostic approach was done which included routine blood test, bone marrow cytology, bone marrow pathology, flow cytometry, and thymic pathology. Other potential causes, such as pure red blood cell aplasia and myelodysplastic syndrome, were ruled out. The final diagnosis was determined to be thymoma-related PWCA. Continuous treatment with human granulocyte colony-stimulating factor (G-CSF) was ineffective for treating PWCA in this patient. The patient's white blood cell and neutrophil count increased following treatment with cyclosporine and subsequently returned to normal levels by the 8th day after thymectomy. A recurrence of PWCA was identified 40 days after the operation and coincided with COVID-19 infection. The patient eventually succumbed to a severe infection. Therefore, in cases of severe neutropenia with an unclear etiology, prompt evaluation of mediastinal and bone marrow status is imperative.

Pure White Cell Aplasia Associated With Long-Term Unprotected Exposure to High Concentrations of Benzalkonium Chloride and 2-Phenoxyethanol

Pure white cell aplasia (PWCA) is a very rare hematological disorder with a nearly total absence of granulocytes and their precursor cells. While the disease is rarely diagnosed incidentally in otherwise asymptomatic individuals, most patients suffer from sometimes life-threatening infections. Due to its very low incidence, the precise pathomechanism of PWCA still needs to be elucidated. While most cases reported in the literature have been associated with an underlying thymic or autoimmune disease, some other factors including the intake of certain drugs such as antimicrobial agents or immune checkpoint inhibitors have been identified as potential triggers. Since PWCA is commonly refractory to treatment with granulocyte colony-stimulating factors (G-CSF), the main focus lies in identifying and eliminating the underlying trigger. Here, we report a unique case where the development of PWCA in a 56-year-old man with an upper respiratory tract infection has to be attributed to the long-term unprotected exposure to an industrial detergent containing high concentrations of the preservatives benzalkonium chloride (BAC) and 2-phenoxyethanol (2-PE). As a matter of fact, certain hematotoxic potential has been described in the literature for both BAC and 2-PE.

Pure White Cell Aplasia Complicated by Systemic Sclerosis with Accompanying Scleroderma Renal Crisis

Pure white cell aplasia (PWCA) is a rare neutropenic disorder caused by absence of neutrophil-lineage cells. A 49-year-old man was diagnosed with scleroderma renal crisis 2 months prior to admission to Ohta-Nishinouchi Hospital after experiencing a fever and abdominal pain. Blood tests revealed severe neutropenia, and bone marrow aspirate showed the absence of neutrophil-lineage cells. He was diagnosed with PWCA. Steroids alone were not effective, but adding cyclosporine A and high-dose immunoglobulin recovered his neutropenia and improved his condition. Cyclosporine A and high-dose immunoglobulin are thus considered effective for treating PWCA in autoimmune diseases.

Pure white cell aplasia an exceptional condition in the immunological conundrum of thymomas: Responses to immunosuppression and literature review

Thymomas are tumours frequently associated with autoimmune manifestations or immunodeficiencies like Good syndrome. In rare cases, pure white cells aplasia (PWCA) has been described in association with thymomas. PWCA is characterized by agranulocytosis of autoimmune background primary refractory to granulocyte colony-stimulating factor (G-CSF). It is necessary the use of immunosuppressor to allow granulocyte recovery. Without treatment, it could be fatal.

Pure White Cell Aplasia and Necrotizing Myositis

Pure white cell aplasia (PWCA) is a rare hematologic disorder characterized by the absence of neutrophil lineages in the bone marrow with intact megakaryopoiesis and erythropoiesis. PWCA has been associated with autoimmune, drug-induced, and viral exposures. Here, we report a case of a 74-year-old female who presented with severe proximal weakness without pain and was found to have PWCA with nonspecific inflammatory necrotizing myositis and acute liver injury on biopsies. These findings were associated with a recent course of azithromycin and her daily use of a statin. Myositis improved on prednisone but PWCA persisted. With intravenous immunoglobulin and granulocyte-colony stimulating factor therapies, her symptoms and neutrophil counts improved and were sustained for months.

Severe chronic primary neutropenia in adults: report on a series of 108 patients

Severe CPN in adults is a benign entity without secondary myeloid malignancies. Neutrophil count at diagnosis is the only predictive factor of severe infections.

Pure white cell aplasia: report of first case associated with autoimmune hepatitis

Pure white cell aplasia (PWCA) is a rare, immune-mediated condition that causes a profound inhibition of myelopoiesis. It has been seen in association with other autoimmune conditions, thymomas, chronic lymphocytic leukaemia and as an adverse drug reaction. We report what we believe to be the first case of PWCA associated with autoimmune hepatitis. An 18-year-old woman presented with jaundice and was found to be suffering from acute hepatitis. Later she became neutropenic and lymphopenic. Liver biopsy was indicative of autoimmune hepatitis. This was later confirmed by autoantibody results. Bone marrow aspirate found an absence of all myeloid progenitor cells, highly suggestive of PWCA. The low white cell count only improved after immunosuppression with corticosteroids. Her condition remains stable 1 year later with azathioprine therapy.

Diagnostic criteria for autoimmune neutropenia

Autoimmune neutropenia denotes that the number of circulating polymorphonuclear neutrophils is below 1.5×10(9)/L. This encompasses a wide range of disorders from primary conditions to complications of systemic autoimmune diseases or hematological neoplasms. Antineutrophil autoantibodies are particularly difficult to detect, and their amount does not correlate with the degree of neutropenia. Granulocyte colony-stimulating factor is the first-line therapy, but should be restricted to patients with total absence of neutrophils and/or severe infections.

Why is my patient neutropenic?

Neutropenia is a common reason for hematology consultations in the inpatient and outpatient settings and is defined as an absolute neutrophil count less than 1500 cells/μL. Neutropenia varies in severity, with more profound neutropenia being associated with higher rates of infections and infection-related deaths. The causes for neutropenia are diverse and include congenital and acquired conditions (ie, autoimmune, drugs, infection, and malignancy). This article outlines the most common causes of neutropenia and discusses differential diagnoses, treatment modalities, and the mechanisms by which neutropenia occurs.

Pure white cell aplasia: report of the first case associated with primary biliary cirrhosis

Pure white cell aplasia (PWCA) is a rare hematologic disorder characterized by agranulocytosis, a lack of virtually all neutrophil-lineage cells (from neutrophils to myeloblasts) in the bone marrow, and normal erythropoiesis and megakaryocy-topoiesis. We report the first case of PWCA that developed in a patient with primary biliary cirrhosis (PBC). An 83-year-old woman, who had had an elevated serum alkaline phosphatase level and shown positivity for serum antimitochondrial antibodies for 10 years, was referred to us because of a perianal abscess. She had severe neutropenia, and her bone marrow showed typical findings of PWCA. Although methylprednisolone pulse therapy induced complete neutrophil recovery, this effect was transient. She died of infection, and the autopsy confirmed the diagnosis of PBC. In vitro investigations showed that factors inhibitory to normal CD34 cell-derived granulopoiesis were present in the patient's serum.

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

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

Complete remission of pure white cell aplasia associated with thymoma, autoimmune thyroiditis and type 1 diabetes

Pure white cell aplasia (PWCA) is a rare disorder of unknown origin, often associated with thymoma, characterized by selective neutropenia or pure agranulocytosis, and absence of granulocyte precursors in the bone marrow, but with normal erythroblasts and megakaryocytes. We report a case of PWCA associated with thymoma. Unusual findings in this case report included simultaneous presence of autoimmune thyroiditis, type 1 diabetes, anti-striated muscle antibodies, and the presence in the peripheral blood of CD8+ T cells that expressed a homogeneous naive phenotype. Neutrophil count became normal on immunosuppressive therapy after thymectomy.

Idiopathic, immune, infectious, and idiosyncratic neutropenias

In idiopathic and immune neutropenias the susceptibility to infectious agents is highly variable, but the reason why some patients exhibit no undue susceptibility whereas others contract life-threatening infections is poorly understood. An important factor is the efficacy of delivery of neutrophils to the tissues. Recent investigations of the mechanisms for mild to moderate chronic neutropenias have shown the significance of interactions between myelopoiesis and the immune system, as for example, in relation to immunoglobulin aberrations and the cytokine network. Antibody-mediated neutropenias (alloimmune, autoimmune) are now well-characterized diseases. If infections occur, apart from antibiotics, granulocyte colony-stimulating factor (G-CSF) is the treatment of choice, while intravenous or monoclonal immunoglobulins and cyclosporine are reserved for refractory cases.

Diagnosis and management of chronic neutropenia during childhood

The approach to the diagnostic evaluation of a patient with neutropenia can be guided largely by clinical history and physical examination and does not always require an extensive laboratory evaluation. Based on the history and bone marrow morphology, most children with chronic neutropenia can be classified and managed. Most patients with chronic neutropenia are free of infections and are able to maintain a normal lifestyle with no or minimal medical intervention. On the other hand, for patients with recurrent or severe infections, careful follow-up and institution of treatment are mandatory. The Food and Drug Administration has approved the use of rhG-CSF in patients with chronic neutropenia. As mentioned previously, the use of colony-stimulating factors has dramatically improved the outcome for many patients with the more severe neutropenia; however, this cytokine is expensive, so treatment should be reserved for more severely affected patients and not given just because the ANC is low. Although concerns exist regarding leukemogenic effects or eventual loss of the progenitor cell compartment driven by the continuous stimulation of rhG-CSF, at this moment, the long-term data available suggest that the chronic administration of rhG-CSF is safe.

Acquired immune deficiency syndrome caused by hyperimmunity

Normal immunocytes including T and B cells are equilibrated by a reciprocal attacking mechanism called a network. Continuous disequilibrium of this network results in general immunodeficiency with oligo- and polyclonal hyperimmunity, for example, T-cell activation due to spontaneous reticuloendotheliosis, paraneoplastic autoimmune syndromes, and human immunodeficiency virus infection. In these disorders, reciprocal self-reactivity, including autologous graft-versus-host reaction, plays a role in the immunodeficiency. A priori self-targeting immunity is a key mechanism to explain autoimmunity in the acquired immunodeficiency syndrome. In the treatment of the immunodeficiency due to hyperimmunity, I propose immunological suppression by agents and reconstitution of the network by bone-marrow transplantation.

The effect of thymectomy on myasthenia gravis, thrombocytopenia, and granulocytopenia associated with thymoma: report of a case

We report the case of a 47-year-old woman with thymoma who developed myasthenia gravis, thrombocytopenia, and granulocytopenia, simultaneously, the concurrent association of these four disorders being extremely rare. Thymectomy was performed, and, during the post-thymectomy course, there were surprising findings concerning the recovery of not only the myasthenia gravis but also of the hematologic disorders. Immediately after thymectomy, the myasthenic symptoms completely disappeared, and the granulocyte and platelet counts recovered to within the normal range within a few days. The laboratory data revealed no difference between pre- and post-thymectomy in the release of cytokines (tumor necrosis factor; TNF, interleukin; IL-2, and IL-6), anti-acetylcholine receptor antibody, or platelet-associated IgG. On the other hand, the serum level of anti-neutrophil cytoplasmic antibody (p-ANCA), against the myeloperoxidase of the granulocytes was dramatically decreased, after thymectomy, showing a significant correlation with the granulocyte count. According to our survey of the literature, this is the first report to show that the removal of a thymoma led to the dramatic resolution not only of myasthenia gravis but also of other associated diseases. It is possible that p-ANCA may be regulated by thymoma, thus causing severe granulocytopenia.

Autoimmune neutropenia successfully treated with cyclosporine

A case history is presented concerning a 59-year-old female patient with chronic autoimmune neutropenia complicated by recurrent skin infections, mucositis, and conjunctivitis. For subjective reasons she refused treatment with prednisone, but eventually cyclosporine led to an important clinical improvement and an increase of the peripheral granulocyte count. Treatment modalities of autoimmune neutropenia are briefly discussed.

Treatment of chronic neutropenia with chloramphenicol

We describe a patient with chronic congenital idiopathic neutropenia whose neutropenia resolved on four occasions during chloramphenicol therapy. This is the second report of chloramphenicol-responsive chronic neutropenia. Chloramphenicol, in addition to its antimicrobial action, has immune-modulating activity, which may explain the reversal of neutropenia.

[Immuno-allergic thrombopenias and leukopenias induced by drugs]

Certain types of cytopenia are due to the destruction of blood cells by an antibody, active only in conjunction with a drug which has previously provoked sensitivity in patients when administered in standard doses. Drug-induced thrombocytopenia and leucopenia of allergic origin are relatively rare. They produce characteristic symptoms, i.e. brutal onset and acute development of the disease; healing takes place when the drug in question is withdrawn. Haematological diseases of drug-related aetiology are being brought to light by serological methods which detect the specific antibody for the drug responsible for the accident. The physiopathological mechanism is still not clearly elucidated.

The role of antilymphocyte globulin in the treatment of chronic acquired bone marrow failure

Antilymphocyte globulin is an immunoglobulin preparation prepared from heterologous serum after the animal (horse or rabbit) has been immunised with human lymphocytes, obtained from the thymus (antithymocyte globulin, ATG) or thoracic duct (antilymphocyte globulin, ALG). The rationale for the use of ALG in the treatment of chronic acquired marrow failure is based on its immunosuppressive activity and the fact that a proportion of cases of bone marrow failure, whether affecting single or multiple haemopoietic cell lines are due to immune-mediated suppression of haemopoiesis. In addition, in vitro studies have shown that ALG also has an immunostimulatory effect on lymphokine and haemopoietic growth factor production, and may therefore directly stimulate haemopoietic progenitor cells. ALG has been used for the treatment of aplastic anaemia and acquired chronic marrow failure affecting single cell lines namely pure red cell aplasia (PRCA), amegakaryocytic thrombocytopenia and chronic neutropenia due to immune inhibition of granulopoiesis ('acquired white cell aplasia'). ALG is used for treatment of non-severe aplastic anaemia (NSAA) and in those cases of severe aplastic anaemia (SAA) where allogeneic transplantation is not possible or is not indicated. Treatment with ALG results in 75% long term survival for NSAA and 40-50% for SAA although there is a very severe subgroup of SAA defined by peripheral blood neutrophils of less than 0.2 x 10(9)/l who rarely benefit from ALG therapy. For those patients who do not respond a second course of ALG can be given later using ALG from a different animal source.(ABSTRACT TRUNCATED AT 250 WORDS)

'Auto'-immune neutropenia after allogeneic bone marrow transplantation unresponsive to conventional immunosuppression but resolving promptly after splenectomy

A 32-year-old male presented with isolated neutropenia 6 months after allogeneic bone marrow transplantation for CML from his HLA-matched brother. The presence of granulocyte-specific IgM and IgG antibodies in the patient's serum indicated an immune-mediated basis for the neutropenia. A variety of manoeuvres to suppress antibody production or to reduce peripheral destruction, including high-dose intravenous immunoglobulins 400 mg/kg (total 24 g) on 5 consecutive days, prednisolone 80 mg for 10 d and plasmapheresis on 3 consecutive d, failed to raise the neutrophil count. Splenectomy, however, resulted in a prompt and sustained rise of neutrophils to normal values.

Human T cell leukemia virus-I-associated T-suppressor cell inhibition of erythropoiesis in a patient with pure red cell aplasia and chronic T gamma-lymphoproliferative disease

Human retroviruses have recently been linked with T cell lymphoproliferative disorders and with the acquired immune deficiency syndrome. We investigated the mechanisms for acquired pure red cell aplasia and cutaneous anergy in a patient with the chronic T gamma-lymphoproliferative disease (T gamma-LPD) syndrome. Patient marrow erythroid progenitors (BFU-E) were 17 +/- 9% of control and were selectively increased to 88-102% of control after marrow T cell depletion. Patient Leu 2+ suppressor T cells spontaneously produced high titers of human gamma-interferon and resulted in a concentration-dependent selective inhibition (74-91%) of BFU-E when co-cultured with autologous or allogeneic marrow. Conditioned media (CM) derived from patient Leu 2+ T cells similarly inhibited growth of autologous or allogeneic marrow BFU-E. The inhibitory factor derived from patient CM was acid-labile (pH 2) and sensitive to trypsin; prior treatment of patient T cells with anti-HLA-DR monoclonal antibody plus complement abrogated the suppressive effect of T cell-derived CM. Patient peripheral blood mononuclear cells (PBMC) were unable to support growth of cultured interleukin 2 (IL 2)-dependent T cells, but responded to exogenous IL 2 in vitro with a 16-21-fold augmentation, relative to control, in mitogen-induced proliferation. Antibodies to HTLV-I core proteins p19 and p24 but not to HTLV-III proteins were detected in patient serum by Western blotting; patient cultured PBMC stained (7-11%) with antibodies to p19 and p24. Patient cultured PBMC demonstrated integrated HTLV-I genomic sequences by the Southern technique and expressed both specific HTLV-I genomic sequences by RNA dot blot plus reverse transcriptase activity. Utilizing a cloned DNA probe for the beta chain of the T cell receptor gene, patient PMBC demonstrated gene rearrangements providing presumptive evidence for clonality. The presence in serum of HTLV-I p19 and p24 antibodies, the expression of p19 and p24 core antigens on patient mononuclear cells, the evidence of HTLV-I proviral integration sequences and the expression of HTLV-I genomic sequences in patient cells, indicates infection with HTLV-I and raises the possibility of an etiologic link between human retrovirus infection and some instances of large granular lymphocytic leukemia (T gamma-LPD).

Antithymocyte globulin therapy for pure white cell aplasia

Severe neutropenia due to selective loss from the bone marrow of cells of the entire neutrophil maturation sequence developed in a patient with Goodpasture's Syndrome and was associated with serious infections complicating continuous ambulatory peritoneal dialysis. Involvement of T-lymphocytes in the process affecting the neutrophil series was implicated by the relation between recovery from neutropenia and treatment with antithymocyte globulin (ATG). Azathioprine and corticosteroid administration failed to sustain recovery from neutropenia induced by ATG. It is concluded that ATG can provide a nonmyelotoxic form of therapy for pure white cell aplasia whose effectiveness is independent of responsiveness to other immunosuppressive agents.

Simultaneous transient erythroblastopenia and agranulocytosis: IgG-mediated inhibition of erythrogranulopoiesis

We report a case of simultaneous transient erythroblastopenia and agranulocytosis recovering spontaneously. In vitro study using autologous bone marrow cells after recovery demonstrated IgG-mediated inhibition of both erythropoiesis and granulopoiesis but not megakaryopoiesis. The inhibitory activity disappeared shortly after remission. These findings suggest that IgG-mediated inhibition of hematopoiesis may be pathogenetic for transient bone marrow failure of the patient.

Efficacy of danazol in pure red cell aplasia

Twenty-one unselected patients with refractory chronic anemias of various etiologies were treated with danazol, a synthetic attenuated androgen. All had previously failed treatment with hematinics, androgens, corticosteroids, high-dose intravenous immunoglobulin, antithymocyte globulin, cytotoxic immunosuppressive agents, and/or plasmapheresis. Three patients with pure red cell aplasia and one with aplastic anemia responded. No responses were observed in 11 patients with myelodysplastic syndromes, two patients with myelofibrosis, and two with paroxysmal nocturnal hemoglobinuria. Remission in pure red cell aplasia was maintained with danazol alone in one patient and required combined low-dose prednisone in two. Objective responses occurred in 2 to 3 weeks and therapy generally was well tolerated. To date, one patient with pure red cell aplasia remains in complete remission at 9 months on low-dose danazol alone. We conclude that danazol alone or combined with prednisone may induce and maintain remission in severe refractory pure red cell aplasia and possibly other chronic cytopenias characterized by immunologic marrow suppression. Further trials of danazol in treating these disorders are indicated.

K-cell lymphocytosis/neutropenia syndrome: the neutropenia is not caused by autoimmunity

The role of humoral immune mechanisms in the pathogenesis of the neutropenia in five patients with chronic killer (K)-cell lymphocytosis was studied. For the detection of neutrophil antibodies in the patient's blood, immunofluorescence, cytotoxicity and agglutination tests and a sensitive antibody-dependent cellular cytotoxicity (ADCC) assay were applied. An assay for bone-marrow colony growth (CFU-GM, BFU-E) inhibition was applied as well. A C1q-binding test was used to detect immune complexes. The lymphocytes of all five patients had the capacity to lyse alloantibody sensitized neutrophils. Neutrophil-bound IgG was found only in one patient. Two patients had neutrophil-reactive antibodies in their serum; in one patient these antibodies were only detectable in the ADCC using the patient's serum to sensitize target cells. However, these antibodies reacted also with lymphocytes, were absorbable with platelets and thus probably were HLA antibodies. The serum of one of these two patients showed complement-dependent CFU-GM and BFU-E inhibition, but the observed inhibition was probably also due to the anti-HLA antibodies present in his serum, as the inhibiting effect disappeared after absorption of the serum with platelets. The serum of only one patient contained low amounts of immune complexes, as measured in the C1q-binding test. Our data suggest that humoral autoimmune mechanisms, such as autoantibodies against neutrophils or neutrophil precursors or circulating immune complexes, do not seem to play an important role in the K-cell lymphocytosis/neutropenia syndrome. The possible role of the expanded K-cell population, and its humoral products (tumour necrosis factor, interferons), in the syndrome is discussed.

Chronic idiopathic and secondary neutropenia: clinical and serological investigations

Clinical data on 49 patients with chronic idiopathic neutropenia (CIN) and 42 patients with neutropenia secondary to a well-defined immunological disorder (SN) were collected and related to serological parameters. In 47% of the patients with CIN and 53% of those with SN, a positive direct immunofluorescence test was obtained with granulocytes from the patients. In the sera from the patients in the two groups, antibodies against donor granulocytes were detected by the indirect immunofluorescence test, the leucoagglutination test and/or the granulocytotoxicity test in 15%, 19% and 15%, respectively. The results of the above tests could not be correlated with any clinical or haematological parameter. Immune complexes in the serum were detected by the 125I-Clq-binding test in 29% of patients with CIN and in 58% of those with SN. The presence of serum immune complexes correlated well with the existence of a low neutrophil count, but not with the presence of recurrent infections, with bone-marrow abnormalities, or with positive reactions in other serological tests. The sera of eight out of 14 patients with CIN and seven out of 12 patients with SN had inhibitory activity for myeloid colony formation in vitro (CFU-GM). This CFU-GM inhibitory activity was correlated with the presence of recurrent infections and with hypoplasia of the myeloid compartment of the bone marrow, but not with positive reactions in other tests. We conclude that the 125I-Clq-binding test probably detects circulating immune complexes that induce a shift neutropenia, whereas serum activity inhibitory for CFU-GM possibly relates to clinically more serious forms of neutropenia. The significance of neutrophil-bound Ig and granulocyte-reactive antibodies in the serum is not clear.