Guidelines on the management of drug-induced immune and secondary autoimmune, haemolytic anaemia

Managing discordance between HbA1c and glucose management indicator

AIMS

The assessment of haemoglobin A1c (HbA1c) continues to play an essential role in diabetes care; however, major advances in new technologies widen the armament available to clinicians to further refine treatment for their patients. Whilst HbA1c remains a critical glycaemic marker, advances in technologies such as Continuous Glucose Monitoring (CGM) now offer real-time glucose monitoring, allowing a more instant assessment of glycaemic control. Discrepancies between laboratory-measured HbA1c and Glucose Management Indicator (GMI) values are a significant clinical issue. In this article, we present a checklist of potential sources of error for both GMI and HbA1c values and provide suggestions to mitigate these sources in order to continue to improve diabetes care.

METHODS

We identified key literature pertaining to GMI measurement, HbA1c measurement, and potential factors of discordance between the two. Using these sources, we explore the potential factors leading to discordance and how to mitigate these when found.

RESULTS

We have constructed a quick reference checklist covering the main sources of discordance between HbA1c and GMI, with accompanying narrative text for more detailed discussion. Discordance can arise due to various factors, including CGM accuracy, sensor calibration, red blood cell turnover and other physiological conditions.

CONCLUSIONS

GMI will likely continue to be used in the upcoming years by both persons with diabetes and their health care providers, and so it is important for users of CGM devices to be equipped with the knowledge to understand the potential causes of discordance between GMI and HbA1c values.

Establishment and application of a new method for the detection of drug antibodies by flow cytometry

BACKGROUND

The drug antibodies can seriously affect the efficacy of the drug and/or destroy red blood cells (RBCs). In severe cases, the drug antibodies may lead to hemolytic anemia, ineffective transfusion, and even life-threatening conditions. However, current methods for detecting drug-induced antibodies present several limitations: cumbersome operational workflows, time-consuming processes, suboptimal sensitivity for low-titer antibodies, and ease of disturbance by autoantibodies and erythrocyte alloantibodies. Therefore, there is an urgent need for a drug antibody detection method with operational simplicity, ultrahigh sensitivity, and interference resistance.

METHODS

Blood samples were collected from patients with drug-induced immune hemolytic anemia (DIIHA). Based on the established assay protocol, nine reaction systems were prepared and sequentially analyzed by flow cytometry. The results of flow cytometry were used to determine the presence or absence of drug antibodies, identify the specific type of drug antibody, and assess the antibody titer.

RESULTS

Different drug antibodies, including ceftriaxone, cefoperazone, and amoxicillin, were identified in all six patients with DIIHA. Upon discontinuation of the implicated antibiotics, the efficacy of blood transfusions in those six patients showed significant improvement.

CONCLUSIONS

This approach offers several advantages, including ease of operation, rapid detection time, high specificity and sensitivity, and excellent interference resistance. This new approach will be suitable for determining drug antibodies in clinical laboratories.

Case Report: Hemolytic anemia secondary to infliximab treatment in a patient with ulcerative colitis

Infliximab, a monoclonal antibody targeting tumor necrosis factor-alpha (TNF-α), is widely used in treating inflammatory bowel diseases (IBD), including ulcerative colitis (UC). While generally well-tolerated, infliximab is associated with rare but significant adverse effects, including autoimmune hemolytic anemia (AIHA). This report describes the case of a 54-year-old male diagnosed with UC, who developed hemolytic anemia secondary to infliximab therapy after 1 year of treatment. During the infusion preceding the onset of anemia, the patient experienced a severe infusion reaction characterized by urticaria, bronchospasm, chills, fever, and pulsating headache. Laboratory findings confirmed hemolytic anemia with a positive direct and negative indirect Coombs tests. The patient responded well to corticosteroid therapy (prednisone at 1 mg/kg/day for 30 days) and stopping anti-TNF-α, with hemoglobin levels improving from 7.2 g/dL at presentation to 14.6 g/dL after 1 month. AIHA should be considered an uncommon but serious complication of infliximab therapy, necessitating careful monitoring, especially in patients treated for gastrointestinal indications. This case underscores the importance of recognizing and managing infusion-related complications of biologic therapies.

Whole blood exchange ameliorates acute hemolytic anemia by reducing inflammation and oxidative stress in rats

Hemolytic anemia (HA) is characterized by massive destruction of red blood cells (RBCs) and insufficient oxygen supply, which can lead to shock, organ failure, even death. Recent studies have preliminarily demonstrated the therapeutic effectiveness of whole blood exchange (WBE) in the management of acute hemolytic anemia and exhibited potential for reducing the duration of corticosteroid treatment, while the underlying mechanism of WBE therapy was not investigated in preclinical study. Hence, we investigate the therapeutic mechanisms of WBE in HA through established continued WBE therapy in rats creatively. This study aims to examine the mechanism of WBE on phenylhydrazine hydrochloride-induced hemolytic anemia in SD rats to aid the development of therapeutics for drug-induced hemolytic anemia (DIHA). Research results demonstrated the efficacy of WBE therapy in reducing mortality and ameliorating anemia in DIHA, as evidenced by significant improvements in representative hematological parameters such as RBCs, hemoglobin, and lactate dehydrogenase levels. Additionally, WBE indicated the ability to suppress oxidative stress and inflammation, and it mitigated organ damage and biochemical function by stabilizing hepatic ferroportin levels and decreasing organ iron content. These results highlighted the effectiveness of WBE as an innovative treatment for HA, furnishing evidence to prioritize it over traditional blood transfusion for severe anemias.

Ceftriaxone-induced hemolytic anemia managed successfully in a 54-year-old woman: a case report and literature review

Ceftriaxone is widely used in clinical practice for its efficacy against infections. However, its increasing association with life-threatening immune hemolytic reactions urge clinicians to enhance recognition and maintain sharp vigilance. This report details a rare and severe case of ceftriaxone-induced hemolytic anemia (CIHA), hemodynamic instability and hemolytic crisis in a 54-year-old woman after intravenous infusion of ceftriaxone following a respiratory infection. Clinicians must promptly identify symptoms suggestive of CIHA, such as fatigue, pallor, nausea, vomiting, and trunk pain, and immediately discontinue ceftriaxone. Laboratory examination can also assist in confirming the diagnosis of CIHA. Effective management measures include rigorous monitoring of vital signs, circulatory support, respiratory support, timely blood transfusion, administration of steroid hormones, IVIG infusion as necessary, plasma exchange, and symptomatic treatment of possible complications. Even after the patient has achieved full recovery, careful consideration should be given to the choice of subsequent antibiotics to prevent recurrence of CIHA.

Management of hemolytic transfusion reactions in a patient with chronic myelomonocytic leukemia and rare antibodies: A case report

Delayed hemolytic transfusion reaction (DHTR) poses a significant challenge in patients receiving blood transfusions. This case report highlights the complexities of managing DHTR in a newly diagnosed chronic myelomonocytic leukemia (CMML) patient with clinically significant JKa and little c antibodies during induction chemotherapy. A 46-year-old woman with CMML-2 who presented for induction chemotherapy was found to have hemolytic anemia. Due to presence of JKa and little c antibodies, she required intensive monitoring and supportive care measures. The coexistence of JKa and little c antibodies complicates transfusion management and chemotherapy tolerance in CMML patients.

Hemolytic anemia after percutaneous coronary intervention (PCI): A case report

Background

In clinical practice, intravascular hemolysis is not common after interventional cardiovascular procedures. Although diagnostic and treatment techniques have developed, with the increasing importance placed on people's own health and the popularity of cardiovascular intervention, there have been occasional reports of hemolysis after different cardiovascular interventions, mainly including cardiac pacemaker implantation, atrial-fibrillation radiofrequency ablation, transcatheter aortic-valve implantation (TAVI), transcatheter mitral valve replacement (TMVR) and percutaneous repair of Gerbode defect and percutaneous coronary intervention (PCI) with Impella. However, so far, there have been no relevant reports on postoperative hemolysis after percutaneous coronary intervention (PCI).

Case report

This article reports a very rare case of a 42-year-old male who developed hemolysis after PCI. The patient had dark brown urine for two days. Blood test showed significant decreases in red blood cell (RBC) and hemoglobin (Hb). After blood transfusion of 2 units, dexamethasone treatment and repeat PCI, he gradually recovered with no symptoms of further episodes of hemolysis.

Conclusions

Due to the use of antiplatelet and anticoagulation drugs in PCI patients, gastrointestinal bleeding (GIB) is often believed to be the main cause of postoperative bleeding events. Identifying the etiology of anemia in patients after PCI is crucial for targeted treatment in the later stage. Based on the symptoms of dark brown urine and the levels of RBC, HB, reticulocyte and unconjugated bilirubin (UCB), we finally diagnosed the patient with hemolytic anemia (HA), rather than the traditional consciousness of GIB. This is an uncommon case of hemolysis after PCI. Although the association between PCI and HA is very rare, PCI is now a commonly used treatment for patients with acute coronary syndromes (ACS). Therefore, clinicians should recognize that in addition to GBI, HA may also occur after PCI. Early recognition of the cause of anemia and early treatment is one of the key steps to ensure the later life and health of PCI patients.

Transfusion support and pre-transfusion testing in autoimmune haemolytic anaemia

Autoimmune haemolytic anaemia (AIHA) is characterized by an increased destruction of red blood cells due to immune dysfunction and auto-antibody production. Clinical manifestations are mainly related to anaemia, which can become life-threatening in case of acute haemolysis. Aiming at counterbalancing severe anaemia, supportive treatments for these patients frequently include transfusions. Unfortunately, free serum auto-antibodies greatly interfere in pre-transfusion testing, and the identification of compatible red blood cell units for AIHA patients can be challenging or even impossible. Problems faced in pre-transfusion testing often lead to delay or abandonment of transfusions for AIHA patients. In this review, we discuss publications concerning global transfusion management in AIHA, with a focus on pre-transfusion testing, and practical clues to manage the selection of transfusion units for these patients. Depending on the degree of transfusion emergency, we propose an algorithm for the selection and laboratory testing of units to be transfused to AIHA patients.

Autoimmune Hemolytic Anemias: Challenges in Diagnosis and Therapy

Background

Autoimmune hemolytic anemia (AIHA) is a rare disease due to increased destruction of erythrocytes by autoantibodies, with or without complement activation.

Summary

AIHA is usually classified in warm AIHA (wAIHA) and cold agglutinin disease (CAD), based on isotype and thermal amplitude of the autoantibody. The direct antiglobulin test (DAT) or Coombs test is the cornerstone of AIHA diagnosis, as it is positive with anti-IgG in wAIHA, and with anti-C3d/IgM antisera plus high titer cold agglutinins in CAD. Therapy is quite different, as steroids and rituximab are effective in the former, but have a lower response rate and duration in the latter. Splenectomy, which is still a good option for young/fit wAIHA, is contraindicated in CAD, and classic immunosuppressants are moving to further lines. Several new drugs are increasingly used or are in trials for relapsed/refractory AIHAs, including B-cell (parsaclisib, ibrutinib, rilzabrutinib), and plasma cell target therapies (bortezomib, daratumumab), bispecific agents (ianalumab, obexelimab, povetacicept), neonatal Fc receptor blockers (nipocalimab), and complement inhibitors (sutimlimab, riliprubart, pegcetacoplan, iptacopan). Clinically, AIHAs are highly heterogeneous, from mild/compensated to life-threatening/fulminant, and may be primary or associated with infections, neoplasms, autoimmune diseases, transplants, immunodeficiencies, and drugs. Along with all these variables, there are rare forms like mixed (wAIHA plus CAD), atypical (IgA or warm IgM driven), and DAT negative, where the diagnosis and clinical management are particularly challenging.

Key Messages

This article covers the classic clinical features, diagnosis, and therapy of wAIHA and CAD, and focuses, with the support of clinical vignettes, on difficult diagnosis and refractory/relapsing cases requiring novel therapies.

[Delayed hypersensitivity reactions to drugs: Group Report of the Drug Allergy Committee of the Mexican College of Clinical Immunology and Allergy (CMICA).]

BACKGROUND

Adverse drug reactions are defined as unexpected reactions, either derived from the pharmacokinetics of the treatment (Type A) or as a host immune response (Type B), resulting in harmful or undesirable manifestations in the patient following the administration of pharmacological therapy. Type B reactions are less defined and are considered a result of hypersensitivity to pharmacological treatment, categorized as immediate (within 1 to 6 hours after exposure) and delayed or non-immediate (occurring 6 hours after exposure).

OBJECTIVE

A review to describe the immunological mechanisms of delayed hypersensitivity reactions to drugs.

METHODS

A search of major medical databases on delayed hypersensitivity reactions to drugs was conducted. The review was limited to articles published in the period between 2013 and 2023, taking into consideration articles written in English and Spanish.

RESULTS

The terms defining delayed hypersensitivity reactions to drugs, their classification, clinical manifestations, diagnosis, treatment algorithms, and prognosis.

CONCLUSIONS

Adverse drug reactions represent a challenge for the specialist physician, with a complex pathophysiology. A prompt diagnosis and treatment focused on the drug phenotype and its immunological expression are required to provide a multidisciplinary approach.

Penicillin Allergy: Mechanisms, Diagnosis, and Management

Allergy to penicillin can occur via any of the 4 types of Gel-Coombs hypersensitivity reactions, producing distinct clinical histories and physical examination findings. Treatments include penicillin discontinuation, and depending on the type of reaction, epinephrine, antihistamines, and/or glucocorticoids. Most beta-lactams may be safely used in penicillin-allergic patients, with the possible exception of first-generation and second-generation cephalosporins. Penicillin testing includes skin testing, patch testing, and graded challenge. The selection of the type of testing depends on the clinical setting, equipment availability, and type of hypersensitivity reaction. Desensitization may be used in some cases where treatment with penicillins is essential.

The evolving management algorithm for the patient with newly diagnosed cold agglutinin disease

INTRODUCTION

Cold agglutinin disease (CAD) is driven by IgM autoantibodies reactive at <37°C and able to fix complement. The activation of the classical complement pathway leads to C3-mediated extravascular hemolysis in the liver and to intravascular hemolytic crises in case of complement amplifying conditions. C3 positivity at direct Coombs test along with high titer agglutins are required for the diagnosis. Treatment is less standardized.

AREAS COVERED

This review recapitulates CAD diagnosis and then focus on the evolving management of the disease. Both current approach and novel targeted drugs are discussed. Literature search was conducted in PubMed and Scopus from 2000 to 2024 using 'CAD' and 'autoimmune hemolytic anemia' as keywords.

EXPERT OPINION

Rituximab represents the frontline approach in patients with symptomatic anemia or disabling cold-induced peripheral symptoms and is effective in 50-60% of cases. Refractory/relapsing patients are an unmet need and may now benefit from complement inhibitors, particularly the anti-C1s sutimlimab, effective in controlling hemolysis thus improving anemia in >80% of patients, but not active on cold-induced peripheral symptoms. Novel drugs include long-acting complement inhibitors, plasma cells, and B-cell targeting agents (proteasome inhibitors, anti-CD38, BTKi, PI3Ki, anti-BAFF). Combination therapy may be the future answer to CAD unmet needs.

Autoimmune Hemolytic Anemia Associated with Mature Ovarian Cystic Teratoma Containing Monoclonal Immunoglobulin G: A Case Report and Review of Literature

Background

Autoimmune hemolytic anemia (AIHA) associated with solid tumors such as mature cystic teratomas is rare and poorly understood. Here, we report a successfully treated case of secondary AIHA in a mature cystic teratoma containing antibodies against red blood cells. Case description. A 22-year-old woman was referred to our hospital with progressive anemia. Laboratory findings revealed hemolysis with a positive direct and indirect antiglobulin test. Imaging studies identified a left ovarian mass, suspected to be a mature cystic teratoma, which was later confirmed by histopathology after laparoscopic oophorocystectomy. The patient was treated with prednisolone, resulting in improved anemia. To examine the relationship between the tumor and AIHA, an indirect antiglobulin test was performed on the tumor contents. Stronger aggregations were observed at any concentration diluted by 10 times from 10 to 10,000 times of the tumor contents compared to the patient's serum. Additionally, immunofixation electrophoresis of the tumor contents revealed the presence of monoclonal immunoglobulin G-κ.

Conclusion

The presence of monoclonal IgG-κ in the tumor suggests intratumoral antibody production as a possible mechanism. Further research is necessary to elucidate the pathogenic relationship between such tumors and AIHA. The report also highlights the importance of considering secondary AIHA in patients with unexplained anemia and solid tumors.

Severe, Refractory Primary Warm Autoimmune Hemolytic Anemia Requiring 90 Erythrocyte Transfusions

A previously healthy 60-year-old man presented to the hospital with a hemoglobin of 3.5 g/dL. He was diagnosed with severe warm autoimmune hemolytic anemia (wAIHA) with reticulocytopenia on hospital day 1 that was not responsive to steroids, immune globulin, and rituximab. Over a 42-day hospital stay, the patient remained continuously transfusion-dependent with a ninety red cell unit requirement for his refractory disease. He was trialed on therapeutic plasma exchange before ultimately undergoing inpatient splenectomy that led to a response within hours. He remains in complete remission at six months of follow-up.

A Real-World Disproportionality Analysis of Drug-Induced Immune Hemolytic Anemia in the FDA Adverse Event Reporting System

BACKGROUND

Drug-induced immune hemolytic anemia (DIIHA) is a rare but potentially life-threatening pharmacogenic hematological adverse effect. Updating the risk of DIIHA among the currently available drugs based on spontaneously reported adverse event data is of great significance.

OBJECTIVE

This study aimed to identify the top 50 drugs associated with immune hemolytic anemia in adults as well as common drugs that could cause immune hemolytic anemia in children based on the United States Food and Drug Administration Adverse Event Reporting System (FAERS) database.

METHODS

We extracted adverse events (AE) in the FAERS database from Q1 2004 to Q3 2022 using Open vigil2.1. We use the high-level term "anaemias haemolytic immune" according to the Medical Dictionary for Regulatory Activities (MedDRA) Dictionary (version 24.0). The reported correlation between drugs and DIIHA risk was identified by reported odds ratio (ROR) and proportional reporting ratio (PRR).

RESULTS

There were 10500309 AEs in FAERS from 2004Q1 to 2022Q3, of which 2326 (0.02%) were DIIHA cases. The incidence of DIIHA is comparable between males and females. The most common drugs associated with DIIHA in adults and children are summarized according to the number of AE reports. The top 3 categories in terms of quantity of drugs are antineoplastic agents, immunosuppressants, and antibiotics for systemic use. The top 5 drugs in terms of ROR and PRR are alemtuzumab, daclizumab, fludarabine, busulfan, and bendamustine in adults, with entecavir, treosulfan, vinorelbine, pegademase, and alemtuzumab for children.

CONCLUSIONS

Our study identified the most common drugs that could induce DIIHA in adults and children, as well as the respective ROR and PRR value to discover new drug signals. This study provides references to clinicians for the management of rare DIIHA.

Ceftriaxone-induced severe hemolytic anemia, renal calculi, and cholecystolithiasis in a 3-year-old child: a case report and literature review

Ceftriaxone is widely used in pediatric outpatient care for its efficacy against respiratory and digestive system infections, yet its increasing association with severe immune hemolytic reactions requires heightened vigilance from pediatricians. This report details a rare and severe case of ceftriaxone-induced severe immune hemolytic anemia (IHA), hemolytic crisis, myocardial injury, liver injury, renal calculi, and cholecystolithiasis in a previously healthy 3-year-old child. The child, treated for bronchitis, experienced sudden pallor, limb stiffness, and altered consciousness following the fifth day of ceftriaxone infusion, with hemoglobin (Hb) levels precipitously dropping to 21 g/L. Immediate cessation of ceftriaxone and the administration of oxygen therapy, blood transfusion, intravenous immunoglobulin (IVIG), and corticosteroids led to a gradual recovery. Despite initial improvements, the patient's condition necessitated extensive hospital care due to complications including myocardial injury, liver injury, renal calculi, and cholecystolithiasis. After a 12-day hospital stay and a 3-month follow-up, the child showed complete normalization of Hb and liver function and resolution of calculi. In children, ceftriaxone infusion may trigger severe, potentially fatal, hemolytic reactions. Pediatricians must promptly recognize symptoms such as pallor, limb stiffness, and unresponsiveness, indicative of ceftriaxone-induced severe IHA, and immediately discontinue the drug. Effective management includes timely blood transfusion, respiratory support, IVIG administration, and corticosteroids when necessary, along with rigorous vital signs monitoring. Continued vigilance is imperative, even after cessation of ceftriaxone, to promptly address any residual adverse effects.

Iron metabolism abnormalities in autoimmune hemolytic anemia and Jianpishengxue keli can ameliorate hemolysis and improve iron metabolism in AIHA mouse models

OBJECTIVE

Autoimmune hemolytic anemia (AIHA) is rare heterogeneous disorder characterized by red blood cell (RBC) destruction via auto-antibodies, and after RBC is destroyed, proinflammatory danger-associated molecular patterns including extracellular hemoglobin, heme, and iron which causing cell injury. And oxidative stress represents one of the most significant effects of chronic hemolysis. Jianpishengxue keli can improve the symptoms of anemia patients with kidney disease and tumors and are beneficial in promoting recovery from chronic inflammation. Therefore, it is presumed that Jianpishengxue keli can improve the symptoms of AIHA. We aimed to investigate iron metabolism in AIHA and effects of Jianpishengxue keli on AIHA murine model.

METHODS

Nineteen hemolytic episode AIHA patients, 10 remission patients and 10 healthy controls (HCs) were enrolled in this study. Serum hepcidin, ferritin and other related indicators of iron metabolism were measured. Mouse models of AIHA were established and received high, medium, or low doses of Jianpishengxue keli by gavage daily for 14 and 28 days respectively. The level of RBCs, Hb, bilirubin, LDH, hepcidin, and the expression level of hepcidin mRNA, and hepatic ferroportin 1(FPN1) protein were evaluated.

RESULTS

Serum hepcidin in hemolytic episode AIHA patients and remission patients were significantly higher than that in HCs (p = 0.0083 and p = 0.0473, respectively). Serum ferritin in hemolytic AIHA patients was significantly higher than that in HCs (p = 0.008). Serum transferrin saturation levels are increased in patients with AIHA[ (57.21 ± 8.96) %]. EPO in hemolytic group was higher than that in healthy control (p＜0.05). In AIHA mouse models, IBIL decreased after 14 days of high dose drug intervention. After 28 days, TBIL and IBIL both significantly decreased in all dose groups and LDH significantly decreased in the medium-and high-dose groups. Body weight improved, and the level of RBCs, Hb and hepcidin in the high-dose group returned to normal. After 14 and 28 days of intervention, hepatic hepcidin mRNA in all dose group significantly decreased. Hepatic FPN1 protein which were significantly lower in the AIHA mouse models, increased in all dose groups after drug intervention for 28 days.

CONCLUSION

Iron metabolism abnormalities exists in AIHA patients and Jianpishengxue keli can ameliorate hemolysis and improve iron metabolism in AIHA mouse models.KEY MESSAGESIron metabolism abnormalities exists in hemolytic episode AIHA patients. Hepcidin and ferritin levels significantly elevated and also correlated with the severity of AIHA patients. Jianpishengxue keli can ameliorate hemolysis and prompt the recovery of AIHA.

[In macrohematuria, medication history also needs to be considered : Penicillin-induced immune hemolysis: a case report and review of literature]

BACKGROUND

Drug-mediated immune hemolysis is a rare but potentially life-threatening condition. Based on a case of penicillin-induced immune hemolysis, a structured literature review of case reports and studies on penicillin-mediated Drug-Induced Immune Hemolytic Anemia (DIIHA) was carried out.

CASE REPORT

A 28-year-old male patient presented to the emergency department with gross hematuria and non-specific abdominal complaints. The patient had a 10-day history of respiratory infection with bacterial tonsillitis, treated orally with penicillin V on an outpatient basis. Laboratory diagnostics detected pathologically altered direct and indirect hemolysis parameters. After stopping the medication, the patient's condition could be stabilized.

CONCLUSION

Diagnosis of penicillin-mediated immune hemolysis requires structured cooperation between clinic and laboratory, as clinical and serological findings may be highly variable with the risk of misdiagnosis. Due to the rarity of the disease, this case report is intended to raise awareness with respect to the triad of abrupt drop in hemoglobin levels in connection with drug therapy and in combination with a strongly positive direct Coombs test.

The Role of the Spleen and the Place of Splenectomy in Autoimmune Hemolytic Anemia-A Review of Current Knowledge

Autoimmune hemolytic anemia (AIHA) is a rare, very heterogeneous, and sometimes life-threatening acquired hematologic disease characterized by increased red blood cell (RBC) destruction by autoantibodies (autoAbs), either with or without complement involvement. Recent studies have shown that the involvement of T- and B-cell dysregulation and an imbalance of T-helper 2 (Th2) and Th17 phenotypes play major roles in the pathogenesis of AIHA. AIHA can be primary (idiopathic) but is more often secondary, triggered by infections or drug use or as a part of other diseases. As the location of origin of autoAbs and the location of autoAb-mediated RBC clearance, as well as the location of extramedullary hematopoiesis, the spleen is crucially involved in all the steps of AIHA pathobiology. Splenectomy, which was the established second-line therapeutic option in corticosteroid-resistant AIHA patients for decades, has become less common due to increasing knowledge of immunopathogenesis and the introduction of targeted therapy. This article provides a comprehensive overview of current knowledge regarding the place of the spleen in the immunological background of AIHA and the rapidly growing spectrum of novel therapeutic approaches. Furthermore, this review emphasizes the still-existing expediency of laparoscopic splenectomy with appropriate perioperative thromboprophylaxis and the prevention of infection as a safe and reliable therapeutic option in the context of the limited availability of rituximab and other novel therapies.

Vancomycin-Induced Hemolytic Anemia

Drug-induced hemolytic anemia is rare and can occur either by an immune-mediated mechanism or a non-immune-mediated mechanism. The drugs most frequently associated with immune-mediated hemolysis are penicillins and cephalosporins. It is usually difficult to distinguish drug-induced hemolysis from other more common causes of hemolysis; therefore, a high index of clinical suspicion is required to make the diagnosis. In this case report, we present a case of vancomycin-induced immune hemolytic anemia in a 75-year-old patient who developed hemolytic anemia after starting vancomycin for joint infection. Hematological parameters improved after the discontinuation of vancomycin. Mechanism and management of drug-induced immune hemolytic anemia are also reviewed in this report.

Mixed Warm and Cold Autoimmune Hemolytic Anemia With Concomitant Immune Thrombocytopenia Following Recent SARS-CoV-2 Infection and Ongoing Rhinovirus Infection

Mixed-type autoimmune hemolytic anemia (AIHA) is a term used to describe hemolysis occurring in the context of both warm and cold reactive autoantibodies to red blood cells. Immune thrombocytopenia (ITP) is an acquired form of thrombocytopenia potentially complicated by hemorrhage due to autoantibodies reactive with platelets and megakaryocytes. Diagnosis of ITP requires exclusion of other known causes of thrombocytopenia. AIHA and ITP may be primary disorders or associated with lymphoproliferative, autoimmune, or viral infections. Here, we report a rare case of simultaneous mixed-type autoimmune hemolytic anemia with immune thrombocytopenia following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection treated with Paxlovid followed by Rhinovirus infection.

The choice of new treatments in autoimmune hemolytic anemia: how to pick from the basket?

Autoimmune hemolytic anemia (AIHA) is defined by increased erythrocyte turnover mediated by autoimmune mechanisms. While corticosteroids remain first-line therapy in most cases of warm-antibody AIHA, cold agglutinin disease is treated by targeting the underlying clonal B-cell proliferation or the classical complement activation pathway. Several new established or investigational drugs and treatment regimens have appeared during the last 1-2 decades, resulting in an improvement of therapy options but also raising challenges on how to select the best treatment in individual patients. In severe warm-antibody AIHA, there is evidence for the upfront addition of rituximab to prednisolone in the first line. Novel agents targeting B-cells, extravascular hemolysis, or removing IgG will offer further options in the acute and relapsed/refractory settings. In cold agglutinin disease, the development of complement inhibitors and B-cell targeting agents makes it possible to individualize therapy, based on the disease profile and patient characteristics. For most AIHAs, the optimal treatment remains to be found, and there is still a need for more evidence-based therapies. Therefore, prospective clinical trials should be encouraged.

Evans Syndrome as a Possible Complication of Brentuximab Vedotin Therapy for Peripheral T Cell Lymphoma

Recently, Brentuximab Vedotin (BV) has emerged as an important therapy not only for Hodgkin's Lymphoma, but also for CD30-positive T cell lymphomas. Although anemia and thrombocytopenia are common myelosuppressive side effects, to our knowledge, this is the first described case of Evans Syndrome associated with BV therapy. We present the case of a 64-year-old female, diagnosed with relapsed Peripheral T Cell Lymphoma Not Otherwise Specified (PTCL-NOS), who, after receiving six cycles of BV, developed authentic severe autoimmune hemolytic anemia with strong positive direct anti-globulin (Coombs) test, simultaneously associated with severe immune thrombocytopenia. The patient was unresponsive to systemic corticotherapy, but fully recovered after a course of IV immunoglobulin.

Autoimmune Hemolytic Anemia Following Uncomplicated Spinal Surgery: A Report and Brief Review

This report and literature review describes a case of a Coombs test-positive warm antibody autoimmune hemolytic anemia (AIHA) in a patient following routine spinal surgery without complications. This is the first reported case of symptomatic direct Coombs test-positive warm antibody AIHA developing in a neurosurgical patient. The patient is a 73-year-old female with left radicular leg pain who developed warm antibody AIHA following standard uncomplicated spinal surgery. A positive direct Coombs test confirmed the diagnosis in combination with characteristic laboratory values. The patient did not have any significant predisposing risk factors. On postoperative day (POD) 23, she presented with fatigue and characteristic laboratory values of decreased hemoglobin, elevated bilirubin, lactate dehydrogenase, and decreased haptoglobin. Hematology initiated and monitored appropriate treatment and proposed that the working hematologic diagnosis is stress-induced AIHA secondary to recent spinal surgery. The patient recovered well from a neurosurgical perspective and reported no neurosurgical complaints during the last follow-up. A female presenting with left radicular leg pain developed symptomatic anemia following uncomplicated spinal surgery. A positive direct Coombs test in combination with characteristic laboratory values confirmed the diagnosis of warm antibody AIHA.

Penicillin Allergy

Allergy to penicillin can occur via any of the 4 types of Gel-Coombs hypersensitivity reactions, producing distinct clinical histories and physical examination findings. Treatments include penicillin discontinuation, and depending on the type of reaction, epinephrine, antihistamines, and/or glucocorticoids. Most beta-lactams may be safely used in penicillin-allergic patients, with the possible exception of first-generation and second-generation cephalosporins. Penicillin testing includes skin testing, patch testing, and graded challenge. The selection of the type of testing depends on the clinical setting, equipment availability, and type of hypersensitivity reaction. Desensitization may be used in some cases where treatment with penicillins is essential.

Case Report: Tuberculosis-Induced Autoimmune Hemolytic Anemia

Tuberculosis (TB) is an infectious disease that affects different organs, causing multiple complications, including hematological sequelae. One of the most common TB-hematological complications is anemia of chronic disease. Very rarely autoimmune hemolytic anemia (AIHA) has been reported as an uncommon manifestation of TB. In this case, we present a female who presented with refractory AIHA, which was attributed to disseminated TB. The patient responded well to steroids, anti-TB medications, and rituximab.

Furosemide-induced haemolytic anaemia in an extreme elderly patient

Furosemide, a loop diuretic, is commonly used to treat fluid overload symptoms and heart failure. Drug-induced immune haemolytic anaemia is an unusual drug-adverse event. Furosemide-induced haemolysis is even rarer. This case report presents a 91-year-old male who developed acute haemolytic anaemia 3 days after initiating furosemide to treat myocardial infarction complicated with acute decompensated heart failure. He had increased lactate dehydrogenase and unconjugated bilirubin with undetectable haptoglobin, which indicated the destruction of red blood cells. Other causes for haemolytic anaemia, including hereditary, microangiopathic haemolytic anaemia, and paroxysmal nocturnal haemoglobinuria, were also excluded. He improved with drug cessation and a short course of glucocorticoids. This report aims to raise awareness of this rare complication caused by commonly prescribed drugs. Despite a negative result of a direct antiglobulin test, physicians must remain suspicious of drug-induced immune haemolytic anaemia in unclear cases of haemolysis.

[Autoimmune haemolytic anaemia]

Autoimmune haemolytic anaemias (AIHA) are acquired haematological disorders caused by increased peripheral erythrocyte destruction mediated by autoantibodies against erythrocyte antigens. They classified according to aetiology into primary and secondary, and according to the type of antibody and reaction temperature into AIHA due to warm antibodies (w-AIHA) and AIHA due to cold antibodies (c-AIHA). The mainstay of management in w-AIHA remains glucocorticoid therapy, and the early addition of rituximab has shown good results in recent studies. Primary c-AIHA is mainly treated with rituximab, alone or in combination with chemotherapy. New drugs such as Syk inhibitors, anti-FcRn Ig and complement inhibitors are in advanced development and will expand the therapeutic arsenal, especially in refractory or relapsed cases.

Enterovirus 71-Induced Autoimmune Hemolytic Anemia in a Boy

Autoimmune hemolytic anemia (AIHA) can be induced by recent or concomitant infections. Many infectious agents are postulated to be associated with this condition. Treatment of infection induced AIHA still varies. This report describes a previously healthy Thai boy who developed AIHA associated with enterovirus-71 infection. He was successfully treated with oral prednisone.

A Repeat Case of Cefotetan-Induced Hemolytic Anemia in a Surgical Patient

Drug-induced hemolytic anemia is a rare hematologic condition in which the immune system creates antibodies against red blood cell antigens in response to a medication exposure. This condition is commonly triggered by antibiotics, nonsteroidal anti-inflammatory drugs, and certain chemotherapies. Here, we describe a patient who experienced a repeat episode of drug-induced hemolytic anemia related to prophylactic cefotetan given before surgery. This case is important for increasing awareness of cephalosporin-induced hemolytic anemia, illustrating the significance of early detection and treatment of the condition, and highlighting the need for careful review of medication history in the surgical setting.

Infrequent Thrombotic Complications in Japanese Patients with Warm Autoimmune Hemolytic Anemia

Objective Patients with autoimmune hemolytic anemia (AIHA) are considered to be at an increased risk of thrombosis, and prophylaxis for venous thromboembolism (VTE) is often recommended. However, the occurrence of thrombosis in Asian patients has not been specifically studied. Thrombotic complications and features of Japanese warm AIHA (WAIHA) patients were studied to see if Japanese patients were at an increased risk of thrombosis and should receive prophylaxis for VTE. Patients and Methods Forty-seven consecutive patients with warm WAIHA were retrospectively studied. Twenty-nine patients were diagnosed as primary cases and 18 as secondary cases, and 10 patients were diagnosed with Evans syndrome. Results No patient presented with thrombosis, and over a median observation period of 15 months, 3 patients had ischemic cerebral vascular accidents. However, all three of those patients had other known risks for thrombosis, with only one taking thrombotic prophylaxis. No venous thrombosis occurred in any patients during the follow-up period. There was no mortality associated with thrombosis. D-dimer levels were often elevated in patients with WAIHA, indicating that the coagulation was activated in a considerable number of patients, but not to such a level as to be associated with clinically overt thrombosis. Conclusion Thrombotic complications occur infrequently in Japanese WAIHA patients, and these individuals do not appear to be at a particularly increased risk of thrombosis because of WAIHA. The indication of VTE prophylaxis should be determined individually, considering other risks.

Practical therapy for primary autoimmune hemolytic anemia in adults

BACKGROUND AND AIM

Autoimmune hemolytic anemias (AIHA) constitute a rare and heterogeneous group of diseases whose therapy differs according to the type of antibody involved in the genesis of the disease and the existence or not of an identified cause. With the aim of providing a practical guide for the therapy of AIHA, we summarize the emergency therapy and general measures habitually used in all forms of AIHA, as well as the specific treatment of the most frequent primary forms of AIHA: primary warm AIHA and AIHA from cold agglutinin disease (AIHA from CAD). We discuss the dependence of the treatment of the secondary forms on their underlying causes and the changes in the treatment of the primary forms in recent years.

METHODS

We examined the options available for the treatment of primary warm AIHA and AIHA from CAD.

RESULTS

We found many differences and only one similarity in their treatment.

DISCUSSION

The differences, particularly due to the non-responsiveness of AIHA from CAD to many treatments useful for primary warm AIHA, such as steroids, splenectomy and immunosuppressive agents, must be considered in the face of each, single case of AIHA. Preliminary identification of the type of antibody involved in the genesis of the disease and careful exclusion of a secondary form are particularly important. Rituximab plays a central role in the treatment of primary warm AIHA and AIHA from CAD.

Anemia in the pediatric patient

The World Health Organization estimates that approximately a quarter of the world's population suffers from anemia, including almost half of preschool-age children. Globally, iron deficiency anemia is the most common cause of anemia. Other important causes of anemia in children are hemoglobinopathies, infection, and other chronic diseases. Anemia is associated with increased morbidity, including neurologic complications, increased risk of low birth weight, infection, and heart failure, as well as increased mortality. When approaching a child with anemia, detailed historical information, particularly diet, environmental exposures, and family history, often yield important clues to the diagnosis. Dysmorphic features on physical examination may indicate syndromic causes of anemia. Diagnostic testing involves a stepwise approach utilizing various laboratory techniques. The increasing availability of genetic testing is providing new mechanistic insights into inherited anemias and allowing diagnosis in many previously undiagnosed cases. Population-based approaches are being taken to address nutritional anemias. Novel pharmacologic agents and advances in gene therapy-based therapeutics have the potential to ameliorate anemia-associated disease and provide treatment strategies even in the most difficult and complex cases.

A case of immune complex type hemolytic anemia by initial micafungin administration

We report the first case of immune complex type hemolytic anemia by initial micafungin administration that was given as prophylaxis to a 42-year-old Japanese man receiving chemotherapy for primary amyloidosis. The few cases found in the literature were associated with secondary administration to cause immune hemolysis attacks. Despite its rarity, the present case calls for increased awareness of micafungin-induced hemolytic anemia upon initial administration.

Efficacy of Whole-Blood Exchange Transfusion in Refractory Severe Autoimmune Haemolytic Anaemia Secondary to Systemic Lupus Erythematosus: A Real-World Observational Retrospective Study

Background

Severe autoimmune haemolytic anaemia (AIHA) in systemic lupus erythematosus (SLE) patients could be life-threatening and formidable, especially in those nonresponsive to glucocorticoids (GCs) and immunosuppressants (ISAs). Whole-blood exchange transfusion (WBE), with plasma exchange and pathogenic cell removal as well as healthy red blood cell transfusion, could be beneficial. The objective of this study was to investigate the efficacy and safety of WBE in combination with GCs/ISAs.

Methods

In this retrospective study, the clinical data of 22 refractory severe SLE-AIHA inpatients between February 2016 and February 2021 were collected and analysed, among whom 14 patients had received WBE and were compared with those treated with typical second-line therapy of intravenous immunoglobulin and/or rituximab (IVIG/RTX).

Results

Among the 22 severe refractory SLE-AIHA patients, eight patients received IVIG and/or RTX without WBE (group 1, IVIG/RTX, n = 8), seven patients were given WBE without IVIG/RTX (group 2, WBE alone, n = 7), and seven patients who failed initial IVIG/RTX therapy were given sequential WBE therapy (group 3 IVIG/RTX→WBE, n = 7). Fourteen patients had accepted WBE treatment regardless of prior IVIG/RTX usage (group 2 + 3, WBE ± IVIG/RTX, n = 14). On days 1, 3, 5, and 7 after corresponding therapies, patients of groups 2, 3, and 2 + 3 showed significantly higher levels of haemoglobin (Hb) than patients of group 1. Compared with patients of group 1, patients of groups 2, 3, and 2 + 3 took less time to reach and maintain Hb ≥60 g/L from baseline. Groups 2 and 2 + 3 consumed a lower dose of GCs than group 1 to reach and maintain Hb ≥60 g/L from baseline. Group 1 experienced longer hospital stays than group 2, and group 3's cost of hospitalisation is more than groups 1 and 2. Hb_min <40 g/L may be a key indicative factor for initiating WBE remedy therapy as IVIG/RTX may not be effective enough in 48-72 h in those patients with refractory severe SLE-AIHA. No severe adverse effects were observed in the WBE group.

Conclusions

WBE could be a safe and beneficial alternative therapy for refractory severe SLE-AIHA.

Autoimmune hemolytic anemia: causes and consequences

INTRODUCTION

Autoimmune hemolytic anemia (AIHA) is classified according to the direct antiglobulin test (DAT) and thermal characteristics of the autoantibody into warm and cold forms, and in primary versus secondary depending on the presence of associated conditions.

AREAS COVERED

AIHA displays a multifactorial pathogenesis, including genetic (association with congenital conditions and certain mutations), environmental (drugs, infections, including SARS-CoV-2, pollution, etc.), and miscellaneous factors (solid/hematologic neoplasms, systemic autoimmune diseases, etc.) contributing to tolerance breakdown. Several mechanisms, such as autoantibody production, complement activation, monocyte/macrophage phagocytosis, and bone marrow compensation are implicated in extra-/intravascular hemolysis. Treatment should be differentiated and sequenced according to AIHA type (i.e. steroids followed by rituximab for warm, rituximab alone or in association with bendamustine or fludarabine for cold forms). Several new drugs targeting B-cells/plasma cells, complement, and phagocytosis are in clinical trials. Finally, thrombosis and infections may complicate disease course burdening quality of life and increasing mortality.

EXPERT OPINION

Beyond warm and cold AIHA, a gray-zone still exists including mixed and DAT negative forms representing an unmet need. AIHA management is rapidly changing through an increasing knowledge of the pathogenic mechanisms, the refinement of diagnostic tools, and the development of novel targeted and combination therapies.

How to approach haemolysis: Haemolytic anaemia for the general physician

Haemolytic anaemia can seem like a complicated topic. The constellation of reticulocytosis, increased lactate dehydrogenase levels, increased unconjugated bilirubin levels and decreased haptoglobin levels should prompt general physicians to consider haemolysis as a differential diagnosis. When further approaching haemolytic anaemia, subdividing patients into those who are 'direct antiglobulin test (DAT) positive' (immune) or 'DAT negative' (non-immune) is a simple and clinically relevant way to start to formulate a cause for the haemolytic anaemia. Immune causes of haemolytic anaemia include autoimmune haemolytic anaemia, drugs and delayed haemolytic transfusion reactions. Non-immune causes include the haemoglobinopathies (such as sickle cell disease) and microangiopathic haemolytic anaemias (such as disseminated intravascular coagulation). Early supportive care in haemolytic anaemia is important and may involve blood transfusions as well as interventions to slow the rate of haemolysis, such as steroids in autoimmune haemolytic anaemia. Complications of haemolysis include pigment gallstones, high-output cardiac failure and thromboembolism. Haemolytic anaemia should be referred to the haematologist for further investigation, however, the recognition and early management by the general physician is imperative in improving the patient's outcome.

Risk of a subsequent diagnosis of inflammatory bowel disease in subjects with ophthalmic disorders associated with inflammatory bowel disease: a retrospective cohort analysis of UK primary care data

OBJECTIVES

Ophthalmic conditions including anterior uveitis (AU), episcleritis and scleritis may occur in association with the inflammatory bowel diseases (IBD) as ophthalmic extraintestinal manifestations. The aim of this study was to assess the risk of a later IBD diagnosis in those presenting with IBD associated ocular inflammation (IAOI).

DESIGN

Retrospective cohort study.

SETTING

Primary care UK database.

PARTICIPANTS

38 805 subjects with an IAOI were identified (median age 51 (38-65), 57% women) and matched to 153 018 subjects without IAOI.

MEASURES

The risk of a subsequent diagnosis of IBD in subjects with IAOIs compared with age/sex matched subjects without IAOI. HRs were adjusted for age, sex, body mass index, deprivation, comorbidity, smoking, baseline axial arthropathy, diarrhoea, loperamide prescription, anaemia, lower gastrointestinal bleeding and abdominal pain.Logistic regression was used to produce a prediction model for a diagnosis of IBD within 3 years of an AU diagnosis.

RESULTS

213 (0.6%) subsequent IBD diagnoses (102 ulcerative colitis (UC) and 111 Crohn's disease (CD)) were recorded in those with IAOIs and 329 (0.2%) (215 UC and 114 CD) in those without. Median time to IBD diagnosis was 882 (IQR 365-2043) days in those with IAOI and 1403 (IQR 623-2516) in those without. The adjusted HR for a subsequent diagnosis of IBD was 2.25 (95% CI 1.89 to 2.68), p<0.001; for UC 1.65 (95% CI 1.30 to 2.09), p<0.001; and for CD 3.37 (95% CI 2.59 to 4.40), p<0.001 in subjects with IAOI compared with those without.Within 3 years of an AU diagnosis, 84 (0.5%) subjects had a recorded diagnosis of IBD. The prediction model performed well with a C-statistic of 0.75 (95% CI 0.69 to 0.80).

CONCLUSIONS

Subjects with IAOI have a twofold increased risk of a subsequent IBD diagnosis. Healthcare professionals should be alert for potential signs and symptoms of IBD in those presenting with ophthalmic conditions associated with IBD.

Immunotherapy-associated Autoimmune Hemolytic Anemia

Over the past decade, the role of immunotherapy treatment in cancer has expanded; specifically, indications for immune checkpoint inhibitors (ICI) have multiplied and are used as first-line therapy. ICIs include cytotoxic T-lymphocyte-associated protein 4 and programmed cell death protein 1 inhibitors, as monotherapies or in combination. Autoimmune hemolytic anemia (AIHA) has emerged as a rare yet serious immune-related adverse event in ICI use. This review describes diagnosis and management of immunotherapy related AIHA (ir-AIHA) including an algorithmic approach based on severity of anemia. Suggested mechanisms are discussed, guidance on ICI resumption provided and prognosis reviewed including risk of recurrence.

A Case of Idiopathic Cold Agglutinin Hemolytic Anemia Successfully Treated With Steroids

Cold agglutinin disease (CAD) is a type of hemolytic anemia in which cold agglutinins can cause agglutination of red blood cells in cold parts of the body and hemolytic anemia. Cold agglutinin-mediated hemolytic anemia can occur in the setting of an underlying viral infection, autoimmune disorder, or lymphoid malignancy, referred to as a secondary cold agglutinin syndrome, or without one of these underlying disorders, referred to as primary CAD (also known as idiopathic CAD). We present a case of a 71-year-old female with hemolytic anemia due to primary CAD. The secondary causes of CAD, including infections, autoimmune disorders, and malignancy, were ruled out. She was successfully treated with prednisone.

DAT negative warm autoimmune haemolytic anaemia secondary to a mature cystic teratoma refractory to immunosuppressive therapy

Mature cystic teratomas (MCTs) have a rare but recognised association with IgG-mediated autoimmune haemolytic anaemia (AIHA). We present the first case of an MCT associated with IgA-mediated AIHA. We discuss the diagnostic challenges of patients presenting with a direct antiglobulin test negative AIHA picture and the importance of reviewing these cases with the local transfusion laboratory. We also review the treatment options for MCT associated AIHA. In particular, we note they are typically resistant to immunosuppression and that surgical resection should be considered at an early stage. Although MCTs are a rare cause of AIHA, they can be treated easily and should be excluded in young women presenting with AIHA, especially if resistant to corticosteroids.