Hemolytic Anemia of Malignancy: A Case Study Involving Signet Ring Cell Metastatic Breast Cancer with Severe Microangiopathic Hemolytic Anemia

Prevalence and risk factors of preoperative anemia in patients undergoing elective orthopedic procedures in Northwest Ethiopia: a multicenter prospective observational cohort study

BACKGROUND

Preoperative anemia is a common hematologic problem in major orthopedic surgery in developing countries. It is a condition in which the number and size of red blood cells are insufficient to meet the body's physiologic needs, consequently impairing the capacity of the blood to transport oxygen to the body. Preoperative anemia is common in elective orthopedic surgical patients and is an independent risk factor for perioperative morbidity and mortality. This study aimed to assess preoperative anemia prevalence and risk factors in patients undergoing elective orthopedic procedures.

METHOD

A multicenter prospective observational cohort study was conducted from June 01 to August 30, 2022. A systematic random sampling technique was used to select the study unit. Data were collected using a structured questionnaire. Descriptive statistics were expressed in percentages and presented with tables and figures. Binary logistic regression was used to see the association between independent and dependent variables. A P-value < 0.05 was considered statistically significant.

RESULT

Preoperative anemia's prevalence and risk factors in patients undergoing elective orthopedic procedures was 24.1[95%CI= (18.2-30.6)]. Multivariable logistic analyses showed that low monthly income level [AOR:5,95%CI:(1.36-7.98)], patient with cancer [AOR:3.4,95%CI:(3.7-8.84)], patient with malaria infectious [AOR: 3.2,95%CI:( 1.13-8.91)], patient with anti-retroviral therapy [AOR: 5.2,95%CI:( 1.8-11.04)], and previous history of surgery [AOR:1,95%CI(1.43-2.4)], were factors significantly associated with preoperative anemia.

CONCLUSION

The prevalence of preoperative anemia among adult patients who underwent elective orthopedics procedures was high. Low Monthly income, patients with cancer, patient with malaria infection, and patients with anti-retroviral therapy, previous histories of surgery were found significantly associated with preoperative anemia. So, we recommend to health professional's early identification, diagnosis and treatment of preoperative anemia should be done to reduce the risks of anemia and related adverse outcomes.

Prevalence and factors associated with preoperative anemia among adult patients scheduled for major elective surgery at University hospital in Northwest Ethiopia; a cross-sectional study

BACKGROUND

Anemia is the most common hematological finding in surgical patients. One-third of surgical patients were anemic during preoperative assessment. The presence of preoperative anemia was found to be related with increased morbidity, mortality, length of hospital stay, intensive care unit admissions and postoperative infections.

OBJECTIVE

To determine the prevalence and factors associated with preoperative anemia among adult patients scheduled for major elective surgery at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2020.

METHODS

After obtaining an ethical approval, hospital-based cross-sectional quantitative study was conducted from June to August 2020 in University of Gondar Hospital. Full blood count within two weeks of preoperative period was considered valid if there were no any factors that affect the hematologic system Descriptive statistics, cross-tabulations and binary logistic regression analysis were performed to identify factors associated withpreoperative anemia. The strength of the association was presented using AOR with 95% confidence interval and p-value < 0.05 was considered as statistically significant.

RESULT

A total of 185 patients enrolled with 100% response rate. We observed preoperative anemia in 36.8% patients. The multi-variable binary logistic analysis showed that ASA II and III [AOR: 3.8, CI: 1.6-9.2], recent prior surgery [AOR: 3.3, CI: 1.3-8.5], history of malignancy [AOR: 9.4, CI: 2.0-43.4], orthopedic procedure [AOR: 11.2, CI: 4.0-31.6] and gynecologic procedure [AOR: 5.2, CI: 1.7-14.5] were significantly associated with preoperative anemia.

CONCLUSION

The prevalence of preoperative anemia was high and ASA ≥2, recent prior surgery, history of malignancy, orthopedic surgery and gynecologic procedure were significantly associated with preoperative anemia. We recommend to clinicians to aim prevention, early detection and treatment of preoperative anemia among adult patients scheduled for major elective surgery to reduce risk of anemia and related adverse outcomes.

How I treat microangiopathic hemolytic anemia in patients with cancer

Microangiopathic hemolytic anemia (MAHA) with thrombocytopenia, suggests a thrombotic microangiopathy (TMA), linked with thrombus formation affecting small or larger vessels. In cancer patients, it may be directly related to the underlying malignancy (initial presentation or progressive disease), to its treatment, or a separate incidental diagnosis. It is vital to differentiate incidental thrombotic thrombocytopenia purpura or atypical hemolytic uremic syndrome in cancer patients presenting with a TMA, as they have different treatment strategies, and prompt initiation of treatment impacts outcome. In the oncology patient, widespread microvascular metastases or extensive bone marrow involvement can cause MAHA and thrombocytopenia. A disseminated intravascular coagulation (DIC) picture may be precipitated by sepsis or driven by the cancer itself. Cancer therapies may cause a TMA, either dose-dependent toxicity, or an idiosyncratic immune-mediated reaction due to drug-dependent antibodies. Many causes of TMA seen in the oncology patient do not respond to plasma exchange and, where feasible, treatment of the underlying malignancy is important in controlling both cancer-TMA or DIC driven disease. Drug-induced TMA should be considered and any putative causal agent stopped. We will discuss the differential diagnosis and treatment of MAHA in patients with cancer using clinical cases to highlight management principles.

Thrombotic Microangiopathy: A Rare Breast Cancer-associated Complication Treated Successfully With Doxorubicin and Cyclophosphamide

BACKGROUND

Thrombotic microangiopathy (TMA) is a clinical syndrome consisting of hemolytic anemia, thrombocytopenia, and presence of schistocytes on peripheral blood smear secondary to disorders of systemic microvascular thrombosis. Malignancy-associated TMA is a rare entity and shares clinical features with that of HUS and TTP usually seen in patients with metastatic cancer, tumor cell infiltration of the bone marrow and/or response to cancer-directed therapy.

CASE REPORT

We present a rare case of TMA secondary to breast cancer without evidence of bone marrow infiltration responsive to doxorubicin and cyclophosphamide treatment, after failed plasmapheresis with prednisone and later, eculizumab.

CONCLUSION

Despite being a rare manifestation of metastatic carcinoma, early identification and treatment are essential to improving survival.

Post-partum occurrence of Wunderlich syndrome and microangiopathic haemolytic anaemia (MAHA): a case report

This is a case of a 27-year-old primigravida with monochorionic diamniotic twin gestation who was admitted to the hospital for induction of labour. Her postpartum course was complicated by microangiopathic haemolytic anemia (MAHA). The etiology for the MAHA was initially thought to be secondary to pre-eclampsia and vitamin B12/folate deficiency. However, she had persistent anemia and further workup demonstrated that she had a left renal cell carcinoma (RCC) with perinephric haemorrhage consistent with Wunderlich syndrome. This case was intriguing because of its unusual presentation and the several diagnostic and therapeutic challenges along the way. Abbreviations: MAHA: microangiopathic haemolytic anaemia; RCC: renal cell carcinoma; BP: blood pressure; WS: Wunderlich syndrome; CT: computed tomography; LFTs: liver function tests; LDH: lactate dehydrogenase; HELLP: haemolysis elevated liver enzymes, low platelets; DIC: disseminated intravascular coagulation; PLASMIC: score for TTP - includes platelet count <30 x 109/L, evidence of haemolysis (reticulocyte count >2.5%, haptoglobin undetectable, or indirect bilirubin >2mg/dL), active cancer, history of solid organ transplant, mean corpuscular volume (MCV) <90fL, INR <1.5, creatinine <2mg/dL. Each item is sored as being present (YES) or not (NO). Absence of active cancer and solid organ transplant gets scored with a point each. The total points are added up to categorize the severity and risk of TTP. Low risk <4, Intermediate 5, high risk >6; TTP: thrombotic thrombocytopenic purpura; APLA- anti-phophospholipid antibody; BMI: body mass index; TMAs: thrombotic microangiopathies; HUS: haemolytic uremic syndrome; vWF: von Willebrand factor.

Case Report: Microangiopathic Hemolytic Anemia With Normal ADAMTS13 Activity

Thrombotic microangiopathies (TMAs) include a heterogeneous group of diseases characterized by abnormalities in the vessel walls of arterioles and capillaries resulting in microvascular thrombosis that typically presents with a microangiopathic hemolytic anemia (MAHA) and severe thrombocytopenia. We describe here the case of an 82-year-old woman, who came to our attention for a clinical condition consistent with thrombotic microangiopathy. Even if initially highly suggestive for a thrombotic thrombocytopenic purpura (TTP), the elevated ADAMTS13 activity together with the alteration of the main coagulation parameters (D-dimer elevation, fibrinogen consumption, slightly prolonged prothrombin time), induced us to consider several other diseases in the differential diagnostic process. The case evolved toward a suspected overlapped secondary hemophagocytic syndrome, though the hyperferritinemia was finally interpreted within the frame of a cytokine storm. After a complex diagnostic workup, the clinical and biochemical parameters guided us toward the diagnosis of a cancer-related microangiopathic hemolytic anemia (CR-MAHA) secondary to a relapsing breast cancer with multiple metastatic localizations. Prednisone 1 mg/kg body weight was started, and several units of fresh frozen plasma were infused, obtaining a good control of the hemolysis. No specific oncological therapies were, however, possible, due to the older age and the critically compromised general condition of the patient; therefore, after clinical stabilization, the patient was discharged for treatment in a palliative care Hospital.