Drug-induced immune hemolytic anemia: detection of new signals and risk assessment in a nationwide cohort study

Immunotherapy-associated autoimmune hemolytic anemia induced by anti-PD-1 therapy in esophageal cancer: A case report and literature review

RATIONALE

Numerous immune checkpoint inhibitors have been approved for clinical use in metastatic advanced esophageal cancer. While immunotherapy brings therapeutic benefits, immune-related adverse events (irAEs) should nevertheless not be overlooked. This paper reports on the first documented case of Autoimmune hemolytic anemia (AIHA) caused by anti-programmed cell death protein-1 therapy in esophageal squamous cancer.

PATIENT CONCERNS

An 84-year-old female patient with metastatic squamous esophageal cancer developed chest tightness, generalized weakness, and a yellowing of the skin after 2 cycles of sintilimab treatment.

DIAGNOSES

Initial examination revealed severe anemia with elevated levels of bilirubin, reticulocytes, lactate dehydrogenase, decreased levels of haptoglobin, and a positive direct antihuman globulin test. The patient was diagnosed with immunotherapy-associated AIHA.

INTERVENTIONS

The patient was promptly treated with corticosteroids and human immunoglobulin, supportive transfusion with washed erythrocytes.

OUTCOMES

Her AIHA was controlled after treatment. Subsequent immunotherapy was not continued, and there was no recurrence of AIHA.

LESSONS

We have identified a rare case of serious adverse reaction caused by anti-PD-1 therapy. We summarize the clinical presentations, diagnosis, and treatment of this case of immunotherapy-related AIHA and discuss the pathogenesis and therapeutic advances in immunotherapy-related AIHA, as well as sintilimab-induced irAEs, in detail. These findings underscore the importance of the early detection, diagnosis, and treatment of these rare and potentially fatal irAEs.

Ceftriaxone-induced immune hemolytic anemia: a case report

Background

Drug-induced immune hemolytic anemia (DIIHA) is a rare but serious disease associated with various antibiotics, which is often misdiagnosed. DIIHA often leads to adverse outcomes, including organ failure and even death. Ceftriaxone is one of the most common drugs that cause DIIHA. This study reports a case of ceftriaxone-induced DIIHA.

Case description

A 5-year-old patient diagnosed with community-acquired pneumonia developed a rash on the 5th day of anti-infective treatment with cefazoxime and azithromycin, followed by a rapid decline in hemoglobin levels and the presence of hemoglobin in the urine (hemoglobinuria). Laboratory analysis showed a positive Coombs' test for the patient. The rash and hematuria subsided after cefazoxime and azithromycin were stopped and symptomatic treatment such as methylprednisolone intravenous infusion, sodium bicarbonate-alkalized urine, enoxaparin sodium anticoagulation, and antiallergic therapy. 5 days later, the child was treated with ceftriaxone for anti-infective therapy because the pneumonia was not healed. During the treatment, the patient suddenly developed itching all over the body, pale face, slightly fast breathing, vomiting, abdominal pain, and low back pain. Immediate cessation of ceftriaxone sodium infusion, continuous nasal catheter oxygen inhalation, normal saline dilatation, and meprednisolone anti-inflammatory and symptomatic treatment of cetirizine were performed. On the evening of the same day, the patient presented with symptoms of wine-colored urine. Laboratory analysis indicated severe anemia and persistent hemolysis, which was considered to autoimmune hemolytic anemia caused by ceftriaxone. After three transfusions and plasma exchange, the patient improved and was discharged from the hospital. One month later, there were no obvious abnormalities in urine analysis, blood routine analysis, reticulocyte analysis, and liver function test.

Conclusion

Understanding the patient's medical history can provide critical information for the diagnosis of DIIHA, and effective management of DIIHA includes immediate discontinuation of suspected drugs, transfusion support, plasma exchange, and symptomatic medication.

Management of haemolysis-induced hyperkalaemia in an extremely low birthweight infant exposed to maternal sulfasalazine

Sulfasalazine is a non-specific immunomodulator with haemolytic anaemia as a known side effect that crosses the placenta. We present a preterm neonate with cardiac arrhythmia secondary to hyperkalaemia in the setting of maternal sulfasalazine therapy. A preterm infant was born to a mother taking hydroxychloroquine, sulfasalazine, aspirin and enoxaparin throughout pregnancy. Ventricular tachycardia developed at 24 hours of life with a serum potassium of 7.2 mmol/L and hyperkalaemia medication treatment resulted in the resolution of the arrhythmia. At 42 hours of life, arrhythmia reoccurred with a serum potassium of 8.8 mmol/L. Treatment for hyperkalaemia was initiated without a return to normal sinus rhythm, thus rectal sodium polystyrene sulfonate was administered and electrocardiogram (EKG) normalised. This is the first reported case of hyperkalaemia in a neonate associated with maternal sulfasalazine use. Healthcare professionals should be aware of potential electrolyte alterations with sulfasalazine use during pregnancy.

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.

Autoimmune haemolytic anaemias

Adult autoimmune haemolytic anaemias (AIHAs) include different subtypes of a rare autoimmune disease in which autoantibodies targeting autoantigens expressed on the membrane of autologous red blood cells (RBCs) are produced, leading to their accelerated destruction. In the presence of haemolytic anaemia, the direct antiglobulin test is the cornerstone of AIHA diagnosis. AIHAs are classified according to the isotype and the thermal optimum of the autoantibody into warm (wAIHAs), cold and mixed AIHAs. wAIHAs, the most frequent type of AIHAs, are associated with underlying conditions in ~50% of cases. In wAIHA, IgG autoantibody reacts with autologous RBCs at 37 °C, leading to antibody-dependent cell-mediated cytotoxicity and increased phagocytosis of RBCs in the spleen. Cold AIHAs include cold agglutinin disease (CAD) and cold agglutinin syndrome (CAS) when there is an underlying condition. CAD and cold agglutinin syndrome are IgM cold antibody-driven AIHAs characterized by classical complement pathway-mediated haemolysis. The management of wAIHAs has long been based around corticosteroids and splenectomy and on symptomatic measures and non-specific cytotoxic agents for CAD. Rituximab and the development of complement inhibitors, such as the anti-C1s antibody sutimlimab, have changed the therapeutic landscape of AIHAs, and new promising targeted therapies are under investigation.

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.