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Wang P, Zhou R, Xue F, Zhou H, Bai J, Wang X, Ma Y, Song Z, Chen Y, Liu X, Fu R, Sun T, Ju M, Dai X, Dong H, Yang R, Liu W, Zhang L. Single-dose rituximab plus glucocorticoid versus cyclophosphamide plus glucocorticoid in patients with newly diagnosed acquired hemophilia A: A multicenter, open-label, randomized noninferiority trial. Am J Hematol 2024; 99:28-37. [PMID: 37851608 DOI: 10.1002/ajh.27128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/26/2023] [Indexed: 10/20/2023]
Abstract
Acquired hemophilia A (AHA) is a rare but serious bleeding disorder. Randomized controlled trial (RCT) comparing the efficacy of immunosuppression therapy for AHA lacks. We conducted the first multicenter RCT aiming to establish whether the single-dose rituximab combination regimen was noninferior to the cyclophosphamide combination regimen. From 2017 to 2022, 63 patients with newly diagnosed AHA from five centers were randomly assigned 1:1 to receive glucocorticoid (methylprednisolone 0.8 mg/kg per day for the first 3 weeks and then tapered) plus single-dose rituximab (375 mg/m2 ; n = 31) or plus cyclophosphamide (2 mg/kg per day until inhibitor becomes negative, for a maximum of 5 weeks; n = 32). The primary outcome was complete remission (CR, defined as FVIII activity ≥50 IU/dL, FVIII inhibitor undetectable, immunosuppression tapered and no bleeding for 24 h without bypassing agents) rate measured within 8 weeks. The noninferiority margin was an absolute difference of 20%. Twenty-four (77.4%) patients in the rituximab group and 22 (68.8%) patients in the cyclophosphamide group achieved CR, which showed the noninferiority of the single-dose rituximab-based regimen (absolute difference = -8.67%, lower limit of the 95% confidence interval = -13.11%; Pnoninferiority = 0.005). No difference was found in the incidence of treatment-related adverse events. Single-dose rituximab plus glucocorticoid regimen showed similar efficacy and safety, without a reported risk of secondary malignancies or reproductive toxicity seen in cyclophosphamide, it might be recommended as a first-line therapy for AHA, especially in China where there is a young age trend in AHA patients. This trial was registered at ClinicalTrials.gov as #NCT03384277.
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Affiliation(s)
- PanJing Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Rongfu Zhou
- Department of Hematology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Feng Xue
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Hu Zhou
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, China
| | - Jie Bai
- Department of Hematology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Xianghua Wang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yueshen Ma
- Office of Biostatistics, Center for Information and Resources of State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Zhen Song
- Center for Information and Resources of State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Yunfei Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Xiaofan Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Rongfeng Fu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Ting Sun
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Mankai Ju
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Xinyue Dai
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Huan Dong
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Wei Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
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Nardella J, Comitangelo D, Marino R, Malcangi G, Barratta MD, Sabba C, Perrone A. Acquired Hemophilia A After SARS-CoV-2 Infection: A Case Report. J Med Cases 2022; 13:197-201. [PMID: 35655623 PMCID: PMC9119369 DOI: 10.14740/jmc3921] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/14/2022] [Indexed: 11/17/2022] Open
Abstract
Acquired hemophilia A is a rare autoimmune coagulation disorder associated to the development of neutralizing antibodies directed towards coagulation factor VIII, known as factor VIII inhibitors, in subjects with previous normal clotting system homeostasis and personal and family history negative for bleeding episodes. This condition, although variable in severity and clinical presentation, may lead to severe and life-threatening hemorrhages which can be either spontaneous or associated with traumatic events and invasive procedures. Here we report the case of a 53-year-old woman who was admitted to our Internal Medicine Unit "Cesare Frugoni", Policlinico di Bari, in July 2021, and diagnosed with acquired hemophilia A. We aim to raise awareness about this rare condition, its clinical presentation and therapeutic management options in order to obtain a quick diagnosis and an effective therapeutic intervention.
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Affiliation(s)
- Jennifer Nardella
- DIM - Interdisciplinary Department of Medicine, Internal Medicine Unit “Cesare Frugoni”, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
| | - Domenico Comitangelo
- DIM - Interdisciplinary Department of Medicine, Internal Medicine Unit “Cesare Frugoni”, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
| | - Renato Marino
- Hemophilia and Transfusion Center, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
| | - Giuseppe Malcangi
- Hemophilia and Transfusion Center, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
| | - Marco Damiano Barratta
- DIM - Interdisciplinary Department of Medicine, Internal Medicine Unit “Cesare Frugoni”, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
| | - Carlo Sabba
- DIM - Interdisciplinary Department of Medicine, Internal Medicine Unit “Cesare Frugoni”, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
| | - Antonio Perrone
- DIM - Interdisciplinary Department of Medicine, Internal Medicine Unit “Cesare Frugoni”, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
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3
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Hunt S, Robertson J, Conn J, Casey J, Royle J, Collins J, Hourigan M, Richmond J, Yang Wang T, Mills A, Mason J. A low-dose rituximab regimen for first-line treatment of acquired haemophilia A. Eur J Haematol 2021; 108:28-33. [PMID: 34528303 DOI: 10.1111/ejh.13708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 09/02/2021] [Accepted: 09/06/2021] [Indexed: 01/31/2023]
Abstract
A low-dose rituximab regimen for first-line treatment of acquired haemophilia A. INTRODUCTION Acquired haemophilia A (AHA) is a rare disease caused by the development of autoantibodies against FVIII. Diagnosis involves confirmation of FVIII deficiency and the presence of an inhibitor via the Bethesda assay. Severe bleeding is often managed with bypassing agents such as recombinant factor VII. This is then followed by eradication of the inhibitor with immunosuppression which typically includes a corticosteroid backbone. AIM Review the current management and outcomes of AHA in Queensland, Australia. Determine the incidence, demographics and clinical characteristics of AHA patients. METHODS Retrospective case series of AHA diagnosed between May 2014 and August 2018. Data were derived from the Australian Bleeding Disorders Registry and state-wide pathology database. Data collection proforma was completed by the treating haematologist and reviewed/compiled centrally. RESULTS 24 patients were identified (incidence 1 in 1.27 million). The median age was 76.5 years. Median follow-up was 20 months. Index bleed was atraumatic and skin/soft tissue in the majority of patients. Recombinant FVIIa was the most commonly used haemostatic therapy and effective in 85% of patients. Immunosuppression and steroid usage were uniform. Upfront second agent was used in 75% of patients and was most commonly rituximab. 87.5% of patients achieved a complete remission in a median time of 48 days. Low-dose rituximab was frequently used and equally as efficacious as standard dose. CONCLUSION Immunosuppression with combination therapy, notably rituximab, appears to be non-inferior and has a favourable side effect profile.
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Affiliation(s)
- Stewart Hunt
- Queensland Haemophilia Centre, Cancer Care Services, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Jeremy Robertson
- Department of Haematology and Haemophilia, Queensland Children's Hospital, South Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Herston, QLD, Australia
| | - Jason Conn
- Department of Haematology, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - John Casey
- Department of Haematology, The Townsville Hospital, Douglas, QLD, Australia
| | - Jane Royle
- Department of Haematology, The Townsville Hospital, Douglas, QLD, Australia
| | - Joel Collins
- Department of Haematology, Toowoomba Hospital, South Toowoomba, QLD, Australia
| | - Matthew Hourigan
- Department of Haematology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Joshua Richmond
- Department of Haematology, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Tzu Yang Wang
- Department of Haematology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Anthony Mills
- Department of Haematology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Jane Mason
- Queensland Haemophilia Centre, Cancer Care Services, Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,Faculty of Medicine, University of Queensland, Herston, QLD, Australia
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Tiede A, Collins P, Knoebl P, Teitel J, Kessler C, Shima M, Di Minno G, d'Oiron R, Salaj P, Jiménez-Yuste V, Huth-Kühne A, Giangrande P. International recommendations on the diagnosis and treatment of acquired hemophilia A. Haematologica 2020; 105:1791-1801. [PMID: 32381574 PMCID: PMC7327664 DOI: 10.3324/haematol.2019.230771] [Citation(s) in RCA: 163] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 04/07/2020] [Indexed: 12/18/2022] Open
Abstract
Acquired hemophilia A (AHA), a rare bleeding disorder caused by neutralizing autoantibodies against coagulation factor VIII (FVIII), occurs in both men and women without a previous history of bleeding. Patients typically present with an isolated prolonged activated partial thromboplastin time due to FVIII deficiency. Neutralizing antibodies (inhibitors) are detected using the Nijmegen-modified Bethesda assay. Approximately 10% of patients do not present with bleeding and, therefore, a prolonged activated partial thromboplastin time should never be ignored prior to invasive procedures. Control of acute bleeding and prevention of injuries that may provoke bleeding are top priorities in patients with AHA. We recommend treatment with bypassing agents, including recombinant activated factor VII, activated prothrombin complex concentrate, or recombinant porcine FVIII in bleeding patients. Autoantibody eradication can be achieved with immunosuppressive therapy, including corticosteroids, cyclophosphamide and rituximab, or combinations thereof. The median time to remission is 5 weeks, with considerable interindividual variation. FVIII activity at presentation, inhibitor titer and autoantibody isotype are prognostic markers for remission and survival. Comparative clinical studies to support treatment recommendations for AHA do not exist; therefore, we provide practical consensus guidance based on recent registry findings and the authors' clinical experience in treating patients with AHA.
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Affiliation(s)
- Andreas Tiede
- Hannover Medical School, Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover, Germany
| | - Peter Collins
- Arthur Bloom Haemophilia Centre, University Hospital of Wales School of Medicine, Cardiff University, Cardiff, UK
| | - Paul Knoebl
- Department of Medicine 1, Division of Hematology and Hemostasis, Medical University of Vienna, Vienna, Austria
| | - Jerome Teitel
- Division of Hematology and Oncology, St. Michael's Hospital, Toronto, and Department of Medicine, University of Toronto, Toronto, Canada
| | - Craig Kessler
- Georgetown University Hospital, Lombardi Cancer Center, Division of Hematology/Oncology, Washington, DC, USA
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Nara, Japan
| | - Giovanni Di Minno
- Regional Reference Center for Coagulation Disorders, Federico II University Hospital, Naples, Italy
| | - Roseline d'Oiron
- Centre de Référence de l'Hémophilie et des Maladies Hémorragiques Constitutionnelles Rares, Hôpitaux Universitaires Paris Sud, Hôpital Bicêtre APHP, Le Kremlin-Bicêtre, France
| | - Peter Salaj
- Institute of Hematology and Blood Transfusion, Prague, Czech Republic
| | - Victor Jiménez-Yuste
- Hematology Department, La Paz University Hospital, Autonoma University, Madrid, Spain
| | - Angela Huth-Kühne
- SRH Kurpfalzkrankenhaus Heidelberg GmbH and Hemophilia Center, Heidelberg, Germany
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Ghozlani I, Mounach A, Ghazi M, Kherrab A, Niamane R. Targeting Acquired Hemophilia A with Rheumatoid Arthritis by a Rituximab Shot: A Case Report and Review of the Literature. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:582-588. [PMID: 29780157 PMCID: PMC5993004 DOI: 10.12659/ajcr.908854] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Patient: Male, 66 Final Diagnosis: Acquired hemophilia A Symptoms: Polyarticular flare Medication: — Clinical Procedure: — Specialty: Rheumatology
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Affiliation(s)
- Imad Ghozlani
- Department of Rheumatology, 1st Military Medical-Surgical Center, Agadir, Morocco.,Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakesh, Morocco
| | - Aziza Mounach
- Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakesh, Morocco.,Department of Rheumatology, Military Hospital Mohammed V, Rabat, Morocco
| | - Mirieme Ghazi
- Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakesh, Morocco.,Department of Rheumatology, Military Hospital Avicenne, Marrakesh, Morocco
| | - Anass Kherrab
- Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakesh, Morocco.,Department of Rheumatology, Military Hospital Avicenne, Marrakesh, Morocco
| | - Radouane Niamane
- Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakesh, Morocco.,Department of Rheumatology, Military Hospital Avicenne, Marrakesh, Morocco
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Ohkawara H, Furukawa M, Ikeda K, Shichishima-Nakamura A, Fukatsu M, Sano T, Ueda K, Kimura S, Kanai R, Oka Y, Murakami F, Suzuki O, Hashimoto Y, Ogawa K, Ikezoe T. Steroid-resistant autoimmune myelofibrosis in a patient with autoimmune hepatitis and Evans syndrome complicated with increased expression of TGF-β in the bone marrow: a case report. Int J Hematol 2017; 106:718-724. [PMID: 28584963 DOI: 10.1007/s12185-017-2268-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 05/24/2017] [Accepted: 05/24/2017] [Indexed: 10/19/2022]
Abstract
We here report a 47-year-old female with autoimmune myelofibrosis (AIMF) associated with liver damage caused by autoimmune hepatitis and Evans syndrome. Bone marrow biopsy revealed hypocellular marrow with grade 2 reticulin fibrosis and increased levels of B lymphocytes (CD20+), T lymphocytes (CD3+, CD8+), and plasma cells (CD138+). Immunohistochemical analysis revealed increased expression of transforming growth factor-β (TGF-β) in infiltrating lymphocytes and macrophages in the bone marrow. She was initially treated with oral prednisolone (PSL) for 2 months, which had a limited effect. However, after treatment with rituximab, the patient's pancytopenia showed improvement, allowing us to rapidly reduce the PSL dosage. The present case suggests the possibility that increased expression of TGF-β in infiltrating lymphocytes and macrophages of bone marrow may contribute to the pathogenesis of AIMF. Prednisolone combined with rituximab may thus be an effective option for steroid-refractory cases.
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Affiliation(s)
- Hiroshi Ohkawara
- Department of Hematology, Fukushima Medical University, 1 Hikariga-oka, Fukushima, Fukushima, 960-1295, Japan.
| | - Miki Furukawa
- Department of Hematology, Fukushima Medical University, 1 Hikariga-oka, Fukushima, Fukushima, 960-1295, Japan
| | - Kazuhiko Ikeda
- Department of Hematology, Fukushima Medical University, 1 Hikariga-oka, Fukushima, Fukushima, 960-1295, Japan.,Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University, Fukushima, Japan
| | - Akiko Shichishima-Nakamura
- Department of Hematology, Fukushima Medical University, 1 Hikariga-oka, Fukushima, Fukushima, 960-1295, Japan
| | - Masahiko Fukatsu
- Department of Hematology, Fukushima Medical University, 1 Hikariga-oka, Fukushima, Fukushima, 960-1295, Japan
| | - Takahiro Sano
- Department of Hematology, Fukushima Medical University, 1 Hikariga-oka, Fukushima, Fukushima, 960-1295, Japan
| | - Koki Ueda
- Department of Hematology, Fukushima Medical University, 1 Hikariga-oka, Fukushima, Fukushima, 960-1295, Japan
| | - Satoshi Kimura
- Department of Hematology, Fukushima Medical University, 1 Hikariga-oka, Fukushima, Fukushima, 960-1295, Japan
| | - Risa Kanai
- Department of Diagnostic Pathology, Fukushima Medical University, Fukushima, Japan
| | - Yuka Oka
- Department of Diagnostic Pathology, Fukushima Medical University, Fukushima, Japan
| | - Fumi Murakami
- Department of Diagnostic Pathology, Fukushima Medical University, Fukushima, Japan
| | - Osamu Suzuki
- Department of Diagnostic Pathology, Fukushima Medical University, Fukushima, Japan
| | - Yuko Hashimoto
- Department of Diagnostic Pathology, Fukushima Medical University, Fukushima, Japan
| | - Kazuei Ogawa
- Department of Hematology, Fukushima Medical University, 1 Hikariga-oka, Fukushima, Fukushima, 960-1295, Japan
| | - Takayuki Ikezoe
- Department of Hematology, Fukushima Medical University, 1 Hikariga-oka, Fukushima, Fukushima, 960-1295, Japan
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