Fatal immune hemolytic anemia and hepatic failure associated with a warm-reacting IgM autoantibody

Multiorgan failure in a fatal case of autoimmune hemolytic anemia

BACKGROUND

Autoimmune hemolytic anemia (AIHA) results in red blood cell destruction by auto-antibodies directed against surface antigens and is rarely fatal. Here we describe a case of AIHA, refractory to both standard and experimental therapies, complicated by multiorgan failure, and rapidly leading to death.

CASE REPORT AND RESULTS

A 65 year-old man who presented with progressive dyspnea and jaundice was found to have hemolytic anemia. Diagnostic work-up revealed a positive direct antiglobulin test and a strong pan-reactive antibody in the plasma reacting to a titer of 1:1024 with strongest reactivity at 37 °C Coombs' phase with reagent anti-IgG. The red cell eluate contained a pan-agglutinin. The patient received multiple lines of treatment including glucocorticoids, intravenous immunoglobulin, rituximab, eculizumab, splenectomy and etoposide. Despite these interventions, he continued to experience brisk hemolysis and remained transfusion dependent. Repeat testing on day 16 demonstrated persistent high titer IgG auto-antibodies, suggesting minimal suppressive effect of therapy. His course was complicated by acute renal and liver failure, venous thrombosis, and worsening coagulopathy, and he ultimately died from multiorgan failure on day 18.

CONCLUSION

Severe cases of AIHA can result in multiorgan failure and a fatal outcome. The rapid development of liver failure in this setting has been described in only few case reports to date, and represents an important complication for clinicians to be aware of when treating patients with AIHA.

Severe Autoimmune Hemolytic Anemia in an Infant Caused by Warm-reactive IGM and IGA Autoantibodies: A Case Report and Review of the Literature

Warm-reactive IgM autoimmune hemolytic anemia is uncommon and carries a poor prognosis in adults. There have been rare reports in children, generally associated with an underlying immunologic deficiency, and outcomes are quite variable. Warm IgM in combination with other antibodies has not been reported in children. We report the first case of severe, steroid-responsive autoimmune hemolytic anemia caused by both warm-reactive IgM and IgA autoantibodies in an otherwise healthy 3-month-old.

Lethal autoimmune hemagglutination due to an immunoglobulin A autoagglutinin with Band 3 specificity

BACKGROUND

We describe a patient with a high-titer warm immunoglobulin (Ig)A autoantibody resulting in death due to hemagglutination rather than to hemolysis.

CASE REPORT

A 47-year-old male patient presented with an intriguing pronounced vascular erythema of the skin. A livedo reticularis associated with cold agglutinin of high thermal amplitude was suspected. The patient's condition unexpectedly and abruptly deteriorated resulting in death 3 days after admission.

STUDY DESIGN AND METHODS

Conventional serologic procedures and immunochemical methods were used.

RESULTS

Serologic and immunochemical examinations revealed a warm IgA autoantibody of high titer with anti-Band 3 specificity. Although the patient presented with severe anemia, only mild signs of hemolysis were observed, with no evidence of complement activation. The autopsy revealed an enormous accumulation of agglutinated red blood cells in liver and spleen and a B-cell lymphoma and cerebral edema. Thus, the patient's death was largely caused by hypoxia related to hemagglutination rather than to hemolysis and/or anemia per se.

CONCLUSION

Strongly hemagglutinating antibodies may not only cause immune hemolysis but also hypoxia due to intravascular hemagglutination.

Antibody specific for the glycophorin A complex mediates intravenous immune globulin-resistant anemia in a murine model

BACKGROUND

Therapy for patients with autoimmune hemolytic anemia (AHA) remains a major challenge. Patients with glycophorin A (GPA)-specific immunoglobulin G antibodies can have severe hemolysis, which may occur by mechanisms independent from traditional macrophage-dependent Fcγ receptor (FcγR)-mediated extravascular hemolysis. As intravenous immune globulin (IVIG) is known to display its beneficial effects in FcγR-mediated cytopenias, and IVIG responses in AHA are inconsistent at best, we sought to gain insight into the mechanism of anemia by a GPA complex-specific monoclonal antibody (TER119) in a mouse model of immune hemolytic anemia and evaluate the therapeutic effect of IVIG.

STUDY DESIGN AND METHODS

The anemic effect of the TER119 antibody was studied in vitro by incubation of mouse RBC with the antibody and in vivo by infusing the antibody into normal mice versus mice genetically deficient for the Fc receptor γ chain (Fcγ), complement C3, mice naturally deficient in complement C5, and splenectomized mice. IVIG efficacy in anemia was determined by treating mice with an intensive IVIG dosing regimen.

RESULTS

The TER119-mediated anemia was independent of classical FcγR-, C3-, and C5-dependent mechanisms, but occurred by a mechanism consistent with RBC agglutination. In accordance with agglutination, the presence of the spleen accelerated the anemia observed but anemia could still occur in splenectomized mice. IVIG did not significantly affect the induction of anemia by TER119.

CONCLUSION

The mechanism of anemia induced by AHA-causing antibodies may be an important factor to consider in the response to therapy with IVIG.

Hepatic manifestations in hematological disorders

Liver involvement is often observed in several hematological disorders, resulting in abnormal liver function tests, abnormalities in liver imaging studies, or clinical symptoms presenting with hepatic manifestations. In hemolytic anemia, jaundice and hepatosplenomegaly are often seen mimicking liver diseases. In hematologic malignancies, malignant cells often infiltrate the liver and may demonstrate abnormal liver function test results accompanied by hepatosplenomegaly or formation of multiple nodules in the liver and/or spleen. These cases may further evolve into fulminant hepatic failure.

Severe autoimmune hemolytic anemia in a liver transplanted child

AIHA can complicate solid organ and bone marrow transplantation early after transplant. We describe the first case report of a 16-month-old boy with mixed type warm-acting IgM and warm IgG autoantibodies AIHA, occurring eight months after liver transplantation. This case describes the complexity of this very rare form of AIHA. It also illustrates the efficacy of rituximab in this indication, as well as the transfusion support with extremely rare blood, along with the importance of international collaboration to provide it. In this report, the etiologies of HA occurring in post-transplant pediatric patients are reviewed and the different treatment strategies are discussed.

Membrane autoantibodies in systemic lupus erythematosus: a case of autoimmune hemolytic anemia, antiphospholipid antibodies, and transient acquired activated protein C resistance

BACKGROUND

Warm autoimmune hemolytic anemia and antiphospholipid antibodies (which include lupus anticoagulants and anticardiolipin [ACL] antibodies) are associated, respectively, with approximately 10 and 40 percent of cases of systemic lupus erythematosus (SLE). This study reports a case of SLE presenting with an unusual constellation of findings that included an immunoglobulin M (IgM) cold autoantibody of high thermal amplitude, high-titer ACL antibodies, and transient acquired activated protein C resistance.

CASE REPORT

A previously untransfused, nulligravid 17-year-old woman without a significant medical history presented with signs and symptoms of SLE and an extravascular hemolytic anemia. Spontaneous agglutination was noted in blood samples collected for testing. Serologic testing revealed a normal-titer, high-thermal-amplitude IgM red blood cell (RBC) autoantibody but no additional RBC antibodies in the patient's plasma. Additional testing was significant for a high-titer ACL IgM and a positive test for activated protein C resistance (a screening test for the Factor [F]V Leiden mutation), which prompted initiation of prophylactic anticoagulation. Confirmatory DNA testing for FV Leiden, however, was negative. The patient's symptoms, anemia, RBC autoagglutinins, ACL antibodies, and activated protein C resistance all resolved after 6 weeks of immunosuppression.

CONCLUSION

This case illustrates the wide range of clinical and laboratory findings that autoantibodies against cellular membranes may produce. IgM autoagglutinins of high thermal amplitude associated with a significant extravascular hemolytic anemia may be a presenting feature of SLE. Concomitant antiphospholipid antibodies may interfere with partial thromboplastin time-based tests of hypercoagulability such as that for activated protein C resistance.

Recurrent acute renal failure complicating IgG warm-type autoimmune intravascular haemolysis

A 44-year-old woman experienced recurrent episodes of massive intravascular haemolysis complicated by acute oliguric renal failure over a period of 22 years. The haemolysis was induced by IgG warm type autoantibody and complement and responded to corticosteroid therapy. The renal failure was treated effectively by dialysis. To our knowledge, such a life long occurrence of recurrent intravascular haemolysis induced by IgG warm type autoantibodies together with renal failure has not been reported before.

Fatal warm autoimmune hemolytic anemia resulting from IgM autoagglutinins in an infant with severe combined immunodeficiency

Autoimmune diseases are rare in patients with severe combined immunodeficiency (SCID). The authors describe an 11-month-old infant girl with SCID with fatal warm autoimmune hemolytic anemia (AIHA) resulting from IgM autoagglutinins. Serologic evaluation revealed IgM autoantibodies that caused in vitro hemagglutination at 37 degrees C. The patient had clinical evidence of ongoing hemolysis and agglutination despite aggressive treatment. She had three strokes and died 6 weeks after unsuccessful bone marrow transplantation. Autoimmune disease is an unexpected complication of SCID. The presence of warm reactive IgM autoagglutinins in AIHA confers a dismal prognosis.

Fatal autoimmune hemolytic anemia in a child due to warm-reactive immunoglobulin M antibody

PURPOSE

Autoimmune hemolytic anemia (AIHA) due to warm-reactive immunoglobulin M (IgM) antibodies is rare in adults and has never been described in children. This report describes a pediatric patient with warm AIHA due to high-titer complete IgM antibody.

PATIENTS AND METHODS

A 9-year-old girl with a history of Evan's syndrome had severe anemia, fatigue, and skin mottling.

RESULTS

Serologic evaluation revealed a high-titer, high thermal amplitude (37 degrees C) complete IgM autoantibody. Despite aggressive management (including high dose corticosteroids, intravenous immune globulin, cyclophosphamide, mycophenolate mofetil, whole blood exchange transfusions, and cyclosporine A), the patient remained markedly anemic and developed multiorgan system failure related to diffuse in vivo hemagglutination. Her clinical course included cardiovascular collapse caused by agglutinated red blood cells in the right ventricle with outflow obstruction, cerebrovascular infarcts, hepatic failure, and infarction of her extremities. She ultimately died from disseminated Aspergillosis infection.

CONCLUSION

This rare form of AIHA is associated with a dismal prognosis. Early, aggressive treatment is advocated, although it remains to be seen whether the clinical course can be reversed and the outcome improved.

Severe autoimmune hemolytic anemia associated with IgM warm autoantibodies directed against determinants on or associated with glycophorin A

BACKGROUND AND OBJECTIVES

Autoimmune hemolytic anemiA (AIHA) is rarely caused by IgM warm autoantibodies, and is sometimes difficult to diagnose. We describe three patients with severe AIHA caused by IgM warm autoantibodies; in two of the three, the hemolysis was fatal.

MATERIALS AND METHODS

Conventional hematologic and serologic procedures were used.

RESULTS

The IgM autoantibodies in all three cases were directed against determinants on or associated with glycophorin A (Ena, Wrb, and Pr). The IgM autoantibodies and unusual serological characteristics, in that the agglutinins were detected or greatly enhanced only by the presence of albumin or a low pH, and/or the agglutinins reacted optimally at 20-30 degrees C.

CONCLUSIONS

IgM warm autoantibodies directed at determinants on or associated with glycophorin A appear to cause severe (often fatal) hemolytic anemia.

Successful response to alpha-interferon 2b in a refractory IgM autoagglutinin-mediated hemolytic anemia

We describe the beneficial effect of recombinant alpha 2b interferon in a woman with an idiopathic and refractory IgM-mediated autoimmune hemolytic anemia due to low-titer, high-thermal-amplitude cold agglutinins. The response was partial but sustained, 2 months after interruption of interferon, with hemoglobin concentrations ranging between 8.5 and 10 g/dl. In the literature, such rarely encountered hemolyzing warm-reacting agglutinins are described as causing severe hemolysis with a frequently fatal clinical outcome.