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Casanova JL, Peel J, Donadieu J, Neehus AL, Puel A, Bastard P. The ouroboros of autoimmunity. Nat Immunol 2024; 25:743-754. [PMID: 38698239 DOI: 10.1038/s41590-024-01815-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/13/2024] [Indexed: 05/05/2024]
Abstract
Human autoimmunity against elements conferring protective immunity can be symbolized by the 'ouroboros', a snake eating its own tail. Underlying infection is autoimmunity against three immunological targets: neutrophils, complement and cytokines. Autoantibodies against neutrophils can cause peripheral neutropenia underlying mild pyogenic bacterial infections. The pathogenic contribution of autoantibodies against molecules of the complement system is often unclear, but autoantibodies specific for C3 convertase can enhance its activity, lowering complement levels and underlying severe bacterial infections. Autoantibodies neutralizing granulocyte-macrophage colony-stimulating factor impair alveolar macrophages, thereby underlying pulmonary proteinosis and airborne infections, type I interferon viral diseases, type II interferon intra-macrophagic infections, interleukin-6 pyogenic bacterial diseases and interleukin-17A/F mucocutaneous candidiasis. Each of these five cytokine autoantibodies underlies a specific range of infectious diseases, phenocopying infections that occur in patients with the corresponding inborn errors. In this Review, we analyze this ouroboros of immunity against immunity and posit that it should be considered as a factor in patients with unexplained infection.
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Affiliation(s)
- Jean-Laurent Casanova
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, New York, NY, USA.
- Howard Hughes Medical Institute, New York, NY, USA.
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM, Necker Hospital for Sick Children, Paris, France.
- Paris Cité University, Imagine Institute, Paris, France.
- Pediatric Hematology-Immunology and Rheumatology Unit, Necker Hospital for Sick Children, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.
| | - Jessica Peel
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, New York, NY, USA
| | - Jean Donadieu
- Trousseau Hospital for Sick Children, Centre de référence des neutropénies chroniques, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Anna-Lena Neehus
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM, Necker Hospital for Sick Children, Paris, France
- Paris Cité University, Imagine Institute, Paris, France
| | - Anne Puel
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, New York, NY, USA
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM, Necker Hospital for Sick Children, Paris, France
- Paris Cité University, Imagine Institute, Paris, France
| | - Paul Bastard
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, New York, NY, USA
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM, Necker Hospital for Sick Children, Paris, France
- Paris Cité University, Imagine Institute, Paris, France
- Pediatric Hematology-Immunology and Rheumatology Unit, Necker Hospital for Sick Children, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
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2
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Ríos NR, Bransfield A, Joyce CM, Cahill MR, O’Shaughnessy M, Costelloe SJ. Challenges of providing biochemistry results in a patient with Evans syndrome. Biochem Med (Zagreb) 2024; 34:011001. [PMID: 38125617 PMCID: PMC10731728 DOI: 10.11613/bm.2024.011001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 10/09/2023] [Indexed: 12/23/2023] Open
Abstract
A case report of in vivo hemolysis in a female patient with Evans syndrome is described. The patient was admitted with anemia and jaundice and, during her 26-day hospital admission, had 83 samples taken for biochemistry analyses. The laboratory hemolytic index (HI) was frequently elevated due to persistent complement-mediated in vivo hemolysis despite multiple lines of therapy. Initially, the release of many biochemical parameters was blocked per the manufacturer´s recommendations and reported as "sample hemolyzed". The patient developed severe acute kidney injury, ultimately requiring dialysis. Automated and timely reporting of indicative creatinine and other biochemical results in the context of ongoing hemolysis, therefore, became essential to patient care. Following a review of literature from various sources, a laboratory algorithm was designed to ensure the timely release of numerical biochemical values, where possible, with appropriate interpretative comments appended. Biochemistry, hematology, and nephrology teams were in regular communication to ensure patient samples were rapidly identified, analyzed and validated according to the algorithm, informing timely, safe and appropriate patient care. Ultimately, the patient died due to multiple disease- and treatment-related complications. In conjunction with clinical users, laboratories should plan for situations, such as in vivo hemolysis, where significant unavoidable interferences in biochemistry methodologies may occur in an ongoing manner for certain patients. Reporting categorical or best-estimate biochemistry results in such cases can be safer for patients than failing to report any results. Interpretation of these results by clinical teams requires input from appropriately trained and qualified laboratory personnel.
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Affiliation(s)
- Natividad Rico Ríos
- Department of Clinical Biochemistry, Cork University Hospital, Cork, Republic of Ireland
| | - Alison Bransfield
- Department of Clinical Biochemistry, Cork University Hospital, Cork, Republic of Ireland
| | - Caroline M Joyce
- Department of Clinical Biochemistry, Cork University Hospital, Cork, Republic of Ireland
| | - Mary R Cahill
- Department of Clinical Haematology, Cork University Hospital, Cork, Republic of Ireland
| | | | - Seán J. Costelloe
- Department of Clinical Biochemistry, Cork University Hospital, Cork, Republic of Ireland
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3
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Waldron C, Goshua G. Splenectomy reappraised: Bridging the gap in immune cytopenia treatment paradigms. J Intern Med 2024; 295:120-122. [PMID: 38044059 DOI: 10.1111/joim.13756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Affiliation(s)
| | - George Goshua
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
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Fernandes YR, Morais KB, Campos AC, Machado RS. Primary Squamous Cell Carcinoma of the Stomach: A Case Report. Cureus 2024; 16:e54188. [PMID: 38496204 PMCID: PMC10941998 DOI: 10.7759/cureus.54188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2024] [Indexed: 03/19/2024] Open
Abstract
Gastric squamous cell carcinoma (SCC) is a rare and puzzling entity that challenges conventional paradigms of gastric malignancies, especially in young adults. This case report presents a 22-year-old male with invasive SCC of the stomach, emphasizing the rarity of such occurrences and their diagnostic challenges. The literature review underscores the scarcity of information on gastric SCC, necessitating a critical examination of its clinical implications, etiological factors, and optimal management. The patient's complex medical history, diagnostic journey, and treatment course are detailed, highlighting the importance of multidisciplinary collaboration and advanced diagnostic techniques. Immunohistochemistry is a crucial tool for precise tumor characterization, and the absence of established risk factors emphasizes the enigmatic nature of gastric SCC. This case report contributes to the understanding of gastric SCC, prompting further research into its unique features, etiology, and therapeutic strategies in the context of gastric cancer.
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Affiliation(s)
- Ygor R Fernandes
- Center of Digestive Endoscopy of University of São Paulo, Universidade Federal de São Paulo/Escola Paulista de Medicina/Hospital São Paulo, São Paulo, BRA
| | - Ketlin B Morais
- Center of Digestive Endoscopy, Federal University of São Paulo, São Paulo, BRA
| | - Ana Carolina Campos
- Center of Digestive Endoscopy, Hospital São Paulo/Federal University of São Paulo, São Paulo, BRA
| | - Rodrigo S Machado
- Division of Pediatric Gastroenterology, Department of Pediatrics, Center of Digestive Endoscopy, Hospital São Paulo/Federal University of São Paulo, São Paulo, BRA
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Tezuka T, Shibata M, Hanaoka H, Izawa Y, Kikuchi T, Akino K, Ozawa Y, Saito M, Kaneko Y, Nakahara J, Takizawa T. Systemic lupus erythematosus mimicking retinal migraine: a case report. Cephalalgia 2023; 43:3331024231219477. [PMID: 38069834 DOI: 10.1177/03331024231219477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND Retinal migraine is a diagnosis of exclusion and is characterized by repeated episodes of transient monocular blindness associated with migraine. We report a case of systemic lupus erythematosus with acute episodes mimicking retinal migraines. CASE REPORT A 46-year-old woman with a history of migraine with aura since her 20s and Evans syndrome presented with episodic transient monocular blindness. Retinal migraine was considered as the cause, and migraine prophylaxis initially reduced its frequency. After 5 months, the frequency increased, with chilblain-like lupus lesions on her extremities. Laboratory testing revealed lymphopenia and hypocomplementemia, fulfilling the diagnostic criteria for systemic lupus erythematosus, which may have caused Evans syndrome and transient monocular blindness, mimicking retinal migraines. After intravenous methylprednisolone and rituximab therapy, the transient monocular blindness episodes did not recur. CONCLUSION Given the clinical presentation, systemic lupus erythematosus should be considered as a cause of transient monocular blindness and should be distinguished from retinal migraine.
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Affiliation(s)
- Toshiki Tezuka
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Mamoru Shibata
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Hironari Hanaoka
- Department of Rheumatology, Keio University School of Medicine, Tokyo, Japan
| | - Yoshikane Izawa
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Taku Kikuchi
- Department of Hematology, Keio University School of Medicine, Tokyo, Japan
- Department of Hematology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Kunihiko Akino
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
| | - Yoko Ozawa
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
- Department of Clinical Regenerative Medicine, Fujita Medical Innovation Center Tokyo and Eye Center, Fujita Health University, Haneda Clinic, Tokyo, Japan
| | - Masataka Saito
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kaneko
- Department of Rheumatology, Keio University School of Medicine, Tokyo, Japan
| | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Tsubasa Takizawa
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
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Zhang Z, Hu Q, Yang C, Chen M, Han B. Sirolimus is effective for primary refractory/relapsed warm autoimmune haemolytic anaemia/Evans syndrome: a retrospective single-center study. Ann Med 2023; 55:2282180. [PMID: 37967535 PMCID: PMC10653746 DOI: 10.1080/07853890.2023.2282180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 10/31/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Some patients with warm autoimmune haemolytic anaemia (wAIHA) or Evans syndrome (ES) have no response to glucocorticoid or relapse. Recent studies found that sirolimus was effective in autoimmune cytopenia with a low relapse rate. METHODS Data from patients with refractory/relapsed wAIHA and ES in Peking Union Medical College Hospital from July 2016 to May 2022 who had been treated with sirolimus for at least 6 months and followed up for at least 12 months were collected retrospectively. Baseline and follow-up clinical data were recorded and the rate of complete response (CR), partial response (PR) at different time points, adverse events, relapse, outcomes, and factors that may affect the efficacy and relapse were analyzed. RESULTS There were 44 patients enrolled, with 9 (20.5%) males and a median age of 44 (range: 18-86) years. 37 (84.1%) patients were diagnosed as wAIHA, and 7 (15.9%) as ES. Patients were treated with sirolimus for a median of 23 (range: 6-80) months and followed up for a median of 25 (range: 12-80) months. 35 (79.5%) patients responded to sirolimus, and 25 (56.8%) patients achieved an optimal response of CR. Mucositis (11.4%), infection (9.1%), and alanine aminotransferase elevation (9.1%) were the most common adverse events. 5/35 patients (14.3%) relapsed at a median of 19 (range: 15-50) months. Patients with a higher sirolimus plasma trough concentration had a higher overall response (OR) and CR rate (p = 0.009, 0.011, respectively). At the time of enrolment, patients were divided into two subgroups that relapsed or refractory to glucocorticoid, and the former had poorer relapse-free survival (p = 0.032) than the other group. CONCLUSION Sirolimus is effective for patients with primary refractory/relapsed wAIHA and ES, with a low relapse rate and mild side effects. Patients with a higher sirolimus plasma trough concentration had a higher OR and CR rate, and patients who relapsed to glucocorticoid treatment had poorer relapse-free survival than those who were refractory.
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Affiliation(s)
- Zhuxin Zhang
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Qinglin Hu
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Chen Yang
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Miao Chen
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
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Shi ML, Guan EQ, Zhang RY. Advances in the diagnosis and treatment of Evans syndrome in children. Asian J Surg 2023; 46:4823-4825. [PMID: 37316342 DOI: 10.1016/j.asjsur.2023.05.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 05/25/2023] [Indexed: 06/16/2023] Open
Affiliation(s)
- Meng-Li Shi
- Department of Pediatrics, Affiliated Hospital of Weifang Medical University, School of Clinical Medicine, Weifang Medical University, Weifang, 261053, China
| | - En-Qin Guan
- Department of Pediatrics, Qingdao Hospital, University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao, 266011, China
| | - Rui-Yun Zhang
- Department of Pediatrics, Qingdao Hospital, University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao, 266011, China.
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Cvetković Z, Pantić N, Cvetković M, Virijević M, Sabljić N, Marinković G, Milosavljević V, Pravdić Z, Suvajdžić-Vuković N, Mitrović M. The Role of the Spleen and the Place of Splenectomy in Autoimmune Hemolytic Anemia-A Review of Current Knowledge. Diagnostics (Basel) 2023; 13:2891. [PMID: 37761258 PMCID: PMC10527817 DOI: 10.3390/diagnostics13182891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
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.
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Affiliation(s)
- Zorica Cvetković
- Department of Hematology, University Hospital Medical Center Zemun, 11080 Belgrade, Serbia
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
| | - Nikola Pantić
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Mirjana Cvetković
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Marijana Virijević
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nikica Sabljić
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Gligorije Marinković
- Department of Hematology, University Hospital Medical Center Zemun, 11080 Belgrade, Serbia
| | - Vladimir Milosavljević
- Department for HPB Surgery, University Hospital Medical Center Bežanijska Kosa, 11070 Belgrade, Serbia
| | - Zlatko Pravdić
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nada Suvajdžić-Vuković
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Mirjana Mitrović
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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Kakita S, Matsuo T, Ohki M, Tsuchiyama A, Yasuda T, Nakanishi H, Mitsunari K, Ohba K, Imamura R. Evans syndrome during pembrolizumab therapy for upper urinary tract cancer. IJU Case Rep 2023; 6:298-301. [PMID: 37667757 PMCID: PMC10475338 DOI: 10.1002/iju5.12609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 07/11/2023] [Indexed: 09/06/2023] Open
Abstract
Introduction Immune checkpoint inhibitors are available for the treatment of advanced urothelial carcinoma; however, serious adverse events occasionally occur. Here, we report a rare case of Evans syndrome attributed to the use of an immune checkpoint inhibitor. Case presentation A 56-year-old man was diagnosed with left renal pelvic cancer and underwent left laparoscopic radical nephroureterectomy. Eight months postoperatively, computed tomography revealed para-aortic lymph node metastasis. Despite receiving chemotherapy, the disease progressed, and pembrolizumab was initiated. After 26 months of pembrolizumab treatment, the patient developed fever and anemia. Hematologic examination confirmed the diagnosis of Evans syndrome. He was treated with blood transfusions and corticosteroids, and gradual symptom improvement was observed. Conclusion This report highlights the potential risk of Evans syndrome associated with immune checkpoint inhibitor treatment. Clinicians should be aware of this possibility and consider early intervention with corticosteroids.
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Affiliation(s)
- Shota Kakita
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Tomohiro Matsuo
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Masaharu Ohki
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Ayaka Tsuchiyama
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Takuji Yasuda
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Hiromi Nakanishi
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Kensuke Mitsunari
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Kojiro Ohba
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Ryoichi Imamura
- Department of UrologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
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Bogucki J, Tuszyńska-Bogucka W. ' Be the Match'. Predictors of Decisions Concerning Registration as a Potential Bone Marrow Donor-A Psycho-Socio-Demographic Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5993. [PMID: 37297597 PMCID: PMC10252417 DOI: 10.3390/ijerph20115993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/12/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023]
Abstract
(1) Background: The study was aimed at a better understanding of the factors determining making a decision to become a potential bone marrow donor, in a Polish research sample; (2) Methods: The data was collected using a self-report questionnaire among persons who voluntarily participated in the study concerning donation, conducted on a sample of the Polish population via Internet. The study included 533 respondents (345 females and 188 males), aged 18-49. Relationships between the decision about registration as potential bone marrow donor and psycho-socio-demographic factors were estimated using the machine learning methods (binary logistic regression and classification & regression tree); (3) Results. The applied methods coherently emphasized the crucial role of personal experiences in making the decision about willingness for potential donation, f.e. familiarity with the potential donor. They also indicated religious issues and negative health state assessment as main decision-making destimulators; (4) Conclusions. The results of the study may contribute to an increase in the effectiveness of recruitment actions by more precise personalization of popularizing-recruitment actions addressed to the potential donors. It was found that selected machine learning methods are interesting set of analyses, increasing the prognostic accuracy and quality of the proposed model.
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Affiliation(s)
- Jacek Bogucki
- Department of Organic Chemistry, Faculty of Pharmacy, Medical University of Lublin, 20-059 Lublin, Poland
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Hoffman TW, Leavis HL, Smits BM, van der Veken LT, van Kessel DA. Prolonged Disease Course of COVID-19 in a Patient with CTLA-4 Haploinsufficiency. Case Reports Immunol 2023; 2023:3977739. [PMID: 37260564 PMCID: PMC10228224 DOI: 10.1155/2023/3977739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 04/23/2023] [Accepted: 05/05/2023] [Indexed: 06/02/2023] Open
Abstract
Patients with primary immunodeficiencies are especially vulnerable to developing severe coronavirus disease 2019 (COVID-19) after infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Cytotoxic T lymphocyte antigen-4 (CTLA-4) is an important regulator of immune responses, and patients who suffer from CTLA4 haploinsufficiency have hyperactivation of effector T cells and infiltration of various organs. Overexpression of CTLA4 has been associated with a more severe disease course in patients with COVID-19, but there have only been a few reports on the disease course of COVID-19 in patients with CTLA4 haploinsufficiency. We report on a 33-year-old female with a history of immune thrombocytopenia, autoimmune haemolytic anaemia, granulomatous-lymphocytic interstitial lung disease, and common variable immunodeficiency who developed COVID-19. She was admitted and discharged from the hospital several times in the months thereafter and remained symptomatic and had a positive SARS-CoV-2 PCR for up to 137 days after the first symptoms. No SARS-CoV-2 antibodies were identified in the patients' serum. The disease was finally controlled after repeated infusions of convalescent plasma and treatment of concurrent bacterial and fungal infections. Genetic analysis revealed a likely pathogenic variant in CTLA4, and CTLA4 expression on regulatory T-cells was low. This case illustrates that patients with primary immunodeficiencies who have a protracted disease course of COVID-19 could benefit from convalescent plasma therapy.
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Affiliation(s)
- T. W. Hoffman
- Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, Netherlands
| | - H. L. Leavis
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, Netherlands
| | - B. M. Smits
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, Netherlands
| | - L. T. van der Veken
- Department of Genetics, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, Netherlands
| | - D. A. van Kessel
- Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, Netherlands
- Department of Pulmonology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, Netherlands
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12
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Abdel-Salam A, Bassiouni ST, Goher AM, Shafie ES. Autoimmune Hemolytic Anemia in the Pediatric Age Group: The Egyptian Experience. Ann Hematol 2023:10.1007/s00277-023-05230-5. [PMID: 37093240 DOI: 10.1007/s00277-023-05230-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 04/11/2023] [Indexed: 04/25/2023]
Abstract
Autoimmune hemolytic anemia (AIHA) is a common disease entity among adults; however, it is rare among the pediatric age group. Evidence is scarce regarding pediatric AIHA in the literature. The objective of this study is to assess the frequency of AIHA and describe the clinical and laboratory characteristics and treatment outcomes of a cohort of children with AIHA in Egypt. A retrospective study was conducted on 50 children with AIHA who were registered and followed up at the New Children's Hospital in Cairo, Egypt, between January 2010 and January 2021. The study group comprised 60% females and 40% males. Their median age was 8.25 years. All patients showed low hemoglobin levels with a mean of 5.40 ± 1.34 g/dl and a median reticulocyte count of 10 (IQR: 8-15). Twelve (24%) patients were diagnosed with Evans syndrome, and a positive Coombs test was detected in 46 patients (92%). The frequency of primary AIHA was 40%, whereas it was 60% for secondary AIHA. The first line of therapy for acute attacks was high-dose IV steroids which responded well in 38 (76%) patients. Secondary AIHA was more common among our children (60%). AIHA is more prevalent in females (60%). The clinical and laboratory characteristics matched previous reports.
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Affiliation(s)
- Amina Abdel-Salam
- Deparment of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sherifa Tarek Bassiouni
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alaa Magdi Goher
- Deparment of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Eman Shafik Shafie
- Deparment of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt.
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13
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Irimia R, Barbu S, Popa C, Badelita S. Evans Syndrome as a Possible Complication of Brentuximab Vedotin Therapy for Peripheral T Cell Lymphoma. Hematol Rep 2023; 15:220-224. [PMID: 36975736 PMCID: PMC10048708 DOI: 10.3390/hematolrep15010023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/14/2022] [Accepted: 03/17/2023] [Indexed: 03/29/2023] Open
Abstract
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.
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Affiliation(s)
- Ruxandra Irimia
- School of Medicine, "Carol Davila" University of Medicine and Pharmacy, 4192910 Bucharest, Romania
- Fundeni Clinical Institute, 4192910 Bucharest, Romania
| | - Sinziana Barbu
- School of Medicine, "Carol Davila" University of Medicine and Pharmacy, 4192910 Bucharest, Romania
- Fundeni Clinical Institute, 4192910 Bucharest, Romania
| | - Codruta Popa
- School of Medicine, "Carol Davila" University of Medicine and Pharmacy, 4192910 Bucharest, Romania
- Fundeni Clinical Institute, 4192910 Bucharest, Romania
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14
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Liu J, Zhang Y, Li Z, Li J, Zhang L, Song Y, Lyu Z, Wang C, Gou L, Quan M, Xiao J, Song H. The effect of antinuclear antibody titre and its variation on outcomes in children with primary immune thrombocytopenia. Br J Haematol 2023. [PMID: 36929463 DOI: 10.1111/bjh.18732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 03/18/2023]
Abstract
Antinuclear antibody (ANA) can be positive in children with primary immune thrombocytopenia (ITP), but the effect of ANA titre and its variation on outcomes of children with primary ITP remains unclear. Here, we conducted a single-centre retrospective cohort study of children with primary ITP at the Peking Union Medical College Hospital in China. A total of 324 children with primary ITP included in this study were followed for a median time of 25 months. In this cohort, 39.2% had an ANA titre of 1:160 or higher. Results from a generalized estimating equation model revealed that patients with higher ANA titres had lower platelet counts at onset but a higher recovery rate of subsequent platelet counts. Results from Cox regression models adjusted for potential confounders revealed that patients with ANA titres of 1:160 or more were more likely to develop to autoimmune disease (AID) than those without, and the risk of AID development increased with the rise of ANA titres (p value for trend less than 0.001). These data highlight the predictive value of ANA titre for platelet counts and the risk of AID development in children with primary ITP.
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Affiliation(s)
- Jing Liu
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuelun Zhang
- Medical Research Center, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhuo Li
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Ji Li
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Lejia Zhang
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuqing Song
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Zichao Lyu
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Changyan Wang
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Lijuan Gou
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Meiying Quan
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Juan Xiao
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Hongmei Song
- Department of Pediatrics, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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15
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El Hasbani G, Saliba AN, Uthman I, Taher AT. Hematological manifestations of antiphospholipid syndrome: Going beyond thrombosis. Blood Rev 2023; 58:101015. [PMID: 36175215 DOI: 10.1016/j.blre.2022.101015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 11/30/2022]
Abstract
Thrombotic complications are a hallmark of antiphospholipid syndrome (APS). These vascular - arterial, venous, and/or small vessel - complications are well described and known to hematologists and healthcare providers caring for patients with this disease. In this review, we shed light on other hematological manifestations of the disease, including bleeding, thrombocytopenia, autoimmune hemolytic anemia, and thrombotic microangiopathy syndromes. While these manifestations are not bona fide clinical criteria for the diagnosis of APS, they frequently interact and contribute to the complexity of clinical management of APS.
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Affiliation(s)
- Georges El Hasbani
- Department of Internal Medicine, Hartford Healthcare, St. Vincent's Medical Center, Bridgeport, CT 06606, USA
| | - Antoine N Saliba
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Imad Uthman
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon..
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16
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Evans' syndrome induced by atezolizumab plus bevacizumab combination therapy in advanced hepatocellular carcinoma. Clin J Gastroenterol 2023; 16:402-406. [PMID: 36746879 DOI: 10.1007/s12328-023-01767-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/30/2023] [Indexed: 02/08/2023]
Abstract
An 86-year-old man presented with recurrence of hepatocellular carcinoma (HCC) after surgery. Atezolizumab plus bevacizumab was initiated. After the third course of atezolizumab plus bevacizumab therapy, petechial purpura appeared on the extremities and trunk. Laboratory tests revealed isolated severe thrombocytopenia without evidence of combined coagulopathy. He was diagnosed with immune thrombocytopenic purpura (ITP), and high-dose immunoglobulin and Helicobacter pylori eradication therapies were administered. Improvement in thrombocytopenia was observed; however, 20 days after the onset of ITP, laboratory data revealed hemolytic anemia. Both direct and indirect Coombs tests were positive, and he was diagnosed with Evan's syndrome complicated by ITP and autoimmune hemolytic anemia (AIHA) induced by immune-related adverse events (irAEs). After treatment with prednisolone, the hemoglobin level increased, and hemolytic findings improved on blood tests. We encountered a rare case of Evans' syndrome due to atezolizumab plus bevacizumab therapy for HCC. In atezolizumab plus bevacizumab therapy, hematologic toxicities are not rare adverse events and attention is required.
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17
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Muacevic A, Adler JR, Jacinto Correia C, Duro J, Aguiar P. Therapeutic Options in Refractory Evans Syndrome: A Case Report. Cureus 2022; 14:e32635. [PMID: 36654549 PMCID: PMC9842105 DOI: 10.7759/cureus.32635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2022] [Indexed: 12/23/2022] Open
Abstract
Evans syndrome is a rare autoimmune disease, characterized by at least two immune cytopenias, most frequently anemia and thrombocytopenia and rarely immune neutropenia. It has a variable clinical presentation and is rarely diagnosed in adults. It can be idiopathic or secondary to lymphoproliferative disease, infections, autoimmune diseases, drugs, and immunodeficiencies in about 50% of cases. It is characterized by a chronic, relapsing, potentially fatal course due to its hemorrhagic complications as well as complications associated with the long-term immunosuppressive treatment required to control the disease, such as infectious diseases, and cardiovascular and renal complications. Its prognosis depends on the underlying cause. Because of its rarity, the treatment is empirical, based mostly on case series and recommendations for the treatment of other immune cytopenias. The underlying disease and demographic characteristics also play an important role in choosing the treatment, which should be adapted individually to each patient. We present a case of an elderly patient with idiopathic autoimmune hemolytic anemia and thrombocytopenia, refractory to various treatment options.
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18
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Ng TYM, Teo WZY, Ng TYM, Teng GG. New-onset Evans syndrome in a patient with SLE post SARS-CoV2 mRNA vaccination. Ann Hematol 2022; 102:235-236. [PMID: 36369498 PMCID: PMC9652039 DOI: 10.1007/s00277-022-05034-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 11/04/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Timothy Y. M. Ng
- Chronic and Fast Programs, Alexandra Hospital, National University Hospital System, Singapore, Singapore
| | - Winnie Z. Y. Teo
- Chronic and Fast Programs, Alexandra Hospital, National University Hospital System, Singapore, Singapore ,Department of Haematology-Oncology, National University Cancer Institute Singapore (NCIS), National University Health System, Singapore, Singapore
| | - Terence Y. M. Ng
- Department of Emergency Medicine, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Gim Gee Teng
- Chronic and Fast Programs, Alexandra Hospital, National University Hospital System, Singapore, Singapore ,Division of Rheumatology, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore
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19
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Jiang E, Kim KH, Babigian A. Acute Isolated Thenar Compartment Syndrome in a Patient with Evans Syndrome: A Case Report. Clin Pract Cases Emerg Med 2022; 6:292-295. [PMID: 36427036 PMCID: PMC9697890 DOI: 10.5811/cpcem.2022.8.57193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/22/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Acute compartment syndrome of the hand is a rare medical emergency, most often associated with trauma or fracture. CASE REPORT Here, we describe a rare case of isolated thenar compartment syndrome of the hand in the absence of major trauma as the presenting symptom of pancytopenia due to Evans syndrome, an uncommon autoimmune hematologic disorder. CONCLUSION In cases of atraumatic compartment syndrome, it is critical to evaluate for underlying coagulopathy in patients presenting to the emergency department.
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Affiliation(s)
- Elisabeth Jiang
- University of Connecticut School of Medicine, Emergency Medicine Residency, Farmington, Connecticut
| | - Kevin H. Kim
- University of Connecticut School of Medicine, Hand Surgery Fellowship, Farmington, Connecticut
| | - Alan Babigian
- Hartford Hospital, Department of Surgery, Hartford, Connecticut
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20
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Barcellini W, Fattizzo B. Diagnosis and Management of Autoimmune Hemolytic Anemias. J Clin Med 2022; 11:6029. [PMID: 36294350 PMCID: PMC9604556 DOI: 10.3390/jcm11206029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 10/11/2022] [Indexed: 10/29/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is usually categorized, as other immune-mediated cytopenias, in so-called benign hematology, and it is consequently managed in various settings, namely, internal medicine, transfusion centers, hematology and, more rarely, onco-hematology departments [...].
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Affiliation(s)
- Wilma Barcellini
- Haematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20100 Milan, Italy
| | - Bruno Fattizzo
- Haematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20100 Milan, Italy
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Via Festa del Perdono 7, 20122 Milan, Italy
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21
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Jackson D, Di Bella A. Concurrent hypoadrenocorticism, immune‐mediated thrombocytopenia and immune‐mediated haemolytic anaemia in a Jack Russell Terrier dog. VETERINARY RECORD CASE REPORTS 2022. [DOI: 10.1002/vrc2.491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- David Jackson
- Southern Counties Veterinary Specialists Ringwood UK
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22
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Zhang R, Chen M, Yang C, Han B. Efficacy and steroid-sparing effect of tacrolimus in patients with autoimmune cytopenia. Ann Hematol 2022; 101:2421-2431. [PMID: 36066607 DOI: 10.1007/s00277-022-04967-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 08/21/2022] [Indexed: 01/19/2023]
Abstract
The aim of this study was to evaluate the efficacy, safety, and steroid-sparing effect of tacrolimus in patients with autoimmune cytopenia, including immune thrombocytopenia (ITP), autoimmune hemolytic anemia (AIHA), and Evans syndrome (ES). Patients in the tacrolimus group were treated with tacrolimus in combination with steroids, and the control group received only steroids. Of the 318 patients finally enrolled, 87 (27.4%) were males, with a median age of 45 (14-90) years. The tacrolimus group comprised 144 patients, including 120 ITP, 19 AIHA, and 5 ES patients, and the control group comprised 174 patients, including 141 ITP, 25 AIHA, and 8 ES patients. The optimal ORR of the tacrolimus group was comparable to that of the control group, and the optimal CRR was higher (p < 0.05). Patients receiving tacrolimus had a decreased relapse rate and prolonged relapse-free survival (p < 0.05) compared with the controls for both the whole cohort and the ITP and AIHA subgroups. Compared with the control group, the tacrolimus group had a lower cumulative steroid dosage and earlier discontinuation of steroids (p < 0.05), which resulted in a decreased incidence of steroid-related adverse events (p < 0.05) although the total side effects were similar between the two groups. Similar drug expenses were observed between the tacrolimus and control groups at the 18-month follow-up. In conclusion, the early addition of tacrolimus had a similar ORR, better CRR, lower relapse rate, and prolonged relapse-free survival compared to steroids alone, with reduced steroid-related adverse events.
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Affiliation(s)
- Ruoxi Zhang
- Department of Hematology, Chinese Academy of Medical Sciences, Peking Union Medical College, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Miao Chen
- Department of Hematology, Chinese Academy of Medical Sciences, Peking Union Medical College, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Chen Yang
- Department of Hematology, Chinese Academy of Medical Sciences, Peking Union Medical College, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Bing Han
- Department of Hematology, Chinese Academy of Medical Sciences, Peking Union Medical College, Peking Union Medical College Hospital, Beijing, 100730, China.
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23
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McCarthy MD, Fareeth AGM. Evans syndrome in a young man with rare autoimmune associations and transplanted liver. BMJ Case Rep 2022; 15:15/9/e251252. [PMID: 36171014 PMCID: PMC9528579 DOI: 10.1136/bcr-2022-251252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Evans syndrome is classically characterised by two or more cytopenias occurring either concomitantly or sequentially. Most commonly, these are autoimmune haemolytic anaemia and immune thrombocytopenia purpura. It is mostly associated with specific autoimmune conditions such as systemic lupus erythematosus and lymphoproliferative disorders. We present a case report of Evans syndrome in a young man with primary sclerosing cholangitis and Crohn’s disease, neither of which are classically associated with the condition. The case also further adds to the number of case reports of Evans syndrome occurring in patients following liver transplantation.
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MESH Headings
- Anemia, Hemolytic, Autoimmune/complications
- Anemia, Hemolytic, Autoimmune/diagnosis
- Humans
- Liver Transplantation/adverse effects
- Lupus Erythematosus, Systemic/complications
- Lupus Erythematosus, Systemic/diagnosis
- Male
- Purpura, Thrombocytopenic, Idiopathic/complications
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Thrombocytopenia/complications
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Affiliation(s)
| | - A G Mohamed Fareeth
- Acute Medicine, East Lancashire Hospitals NHS Trust, Blackburn, Lancashire, UK
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24
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De Felice M, Farina G, Bianco R, Monaco G, Iaccarino S. Evans Syndrome Presenting as an Atypical Complication of SARS-CoV-2 Vaccination. Cureus 2022; 14:e26602. [PMID: 35936148 PMCID: PMC9354064 DOI: 10.7759/cureus.26602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 11/05/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has drastically affected our daily lives, causing millions of deaths worldwide. The early and late complications of this infection are being increasingly revealed on a regular basis; however, an important brake on the spread and especially the lethality of the disease has been guaranteed by the introduction of mRNA-based and viral vector-based COVID-19 Vaccines. Also, an increasing number of adverse effects of the vaccination have been reported to specific pharmacovigilance boards, most of them totally non-serious events that are resolved within one to three days after the administration of the vaccine. In this report, we present a case of Evans syndrome (ES) secondary to SARS-CoV-2 vaccination in an 85-year-old male patient. To the best of our knowledge, this is the first case of ES caused by the COVID-19 vaccination to be reported in the literature.
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25
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Mingot-Castellano ME, Butta N, Canaro M, del Carmen Gómez del Castillo Solano M, Sánchez-González B, Jiménez-Bárcenas R, Pascual-Izquierdo C, Caballero-Navarro G, Entrena Ureña L, José González-López T. COVID-19 Vaccines and Autoimmune Hematologic Disorders. Vaccines (Basel) 2022; 10:vaccines10060961. [PMID: 35746569 PMCID: PMC9231220 DOI: 10.3390/vaccines10060961] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 06/12/2022] [Accepted: 06/15/2022] [Indexed: 02/06/2023] Open
Abstract
Worldwide vaccination against SARS-CoV-2 has allowed the detection of hematologic autoimmune complications. Adverse events (AEs) of this nature had been previously observed in association with other vaccines. The underlying mechanisms are not totally understood, although mimicry between viral and self-antigens plays a relevant role. It is important to remark that, although the incidence of these AEs is extremely low, their evolution may lead to life-threatening scenarios if treatment is not readily initiated. Hematologic autoimmune AEs have been associated with both mRNA and adenoviral vector-based SARS-CoV-2 vaccines. The main reported entities are secondary immune thrombocytopenia, immune thrombotic thrombocytopenic purpura, autoimmune hemolytic anemia, Evans syndrome, and a newly described disorder, so-called vaccine-induced immune thrombotic thrombocytopenia (VITT). The hallmark of VITT is the presence of anti-platelet factor 4 autoantibodies able to trigger platelet activation. Patients with VITT present with thrombocytopenia and may develop thrombosis in unusual locations such as cerebral beds. The management of hematologic autoimmune AEs does not differ significantly from that of these disorders in a non-vaccine context, thus addressing autoantibody production and bleeding/thromboembolic risk. This means that clinicians must be aware of their distinctive signs in order to diagnose them and initiate treatment as soon as possible.
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Affiliation(s)
- María Eva Mingot-Castellano
- Hematology Department, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS/CSIC), 41013 Sevilla, Spain
- Correspondence:
| | - Nora Butta
- Hospital Universitario La Paz-IdiPAZ, 28046 Madrid, Spain;
| | - Mariana Canaro
- Hematology Department, Hospital Universitario Son Espases, 07210 Palma, Spain;
| | | | | | | | - Cristina Pascual-Izquierdo
- Department of Hematology, Gregorio Marañón General University Hospital (HGUGM) Madrid, Instituto de Investigación Gregorio Marañón, 28009 Madrid, Spain;
| | | | - Laura Entrena Ureña
- Hematology Department, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain;
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26
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Pan XH, Xu JK, Pan L, Wang CH, Huang XQ, Qiu JK, Ji XB, Mao MJ. Concurrent severe pulmonary tuberculosis with Evans syndrome: a case report with literature review. BMC Infect Dis 2022; 22:533. [PMID: 35692044 PMCID: PMC9188905 DOI: 10.1186/s12879-022-07512-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/31/2022] [Indexed: 11/21/2022] Open
Abstract
Background Tuberculosis is a bacterial infection involving multiple organs and systems. Its hematological presentation mainly includes anemia and leukocytosis. Evans syndrome is a rare autoimmune disease characterized by autoimmune hemolytic anemia, immune thrombocytopenia, and neutropenia, with positive results for the direct Coombs test and platelet antibodies. The cooccurrence of tuberculosis and Evans syndrome is rarely reported. Case presentation A 69-year-old female presented with a fever and shortness of breath. Her chest computerized tomography scan showed extensive miliary nodules in the bilateral lung fields. She rapidly developed respiratory failure that required endotracheal intubation and mechanical ventilation. The acid-fast bacilli sputum smear results indicated a grade of 3+. Later on, blood testing revealed hemolytic anemia, a positive direct Coombs test result, and the presence of the platelet antibody IgG. This patient was diagnosed as having disseminated pulmonary tuberculosis and Evans syndrome. She successfully recovered after treatment with antituberculosis drugs and glucocorticoids. Conclusions Tuberculosis can occur together with Evans syndrome. Affected patients should receive both antituberculosis and immunosuppressive drugs.
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Affiliation(s)
- Xiao-Hong Pan
- Tuberculosis Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng East Road, Hangzhou, 310003, Zhejiang, China
| | - Jie-Kun Xu
- Tuberculosis Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng East Road, Hangzhou, 310003, Zhejiang, China
| | - Lei Pan
- Tuberculosis Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng East Road, Hangzhou, 310003, Zhejiang, China
| | - Cai-Hong Wang
- Tuberculosis Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng East Road, Hangzhou, 310003, Zhejiang, China
| | - Xiao-Qing Huang
- Tuberculosis Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng East Road, Hangzhou, 310003, Zhejiang, China
| | - Jun-Ke Qiu
- Tuberculosis Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng East Road, Hangzhou, 310003, Zhejiang, China
| | - Xiao-Bo Ji
- Tuberculosis Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng East Road, Hangzhou, 310003, Zhejiang, China
| | - Min-Jie Mao
- Tuberculosis Care Unit, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, No. 208 Huancheng East Road, Hangzhou, 310003, Zhejiang, China.
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27
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Abu Kar S, Kaur A. Evans Syndrome in the Context of Incomplete Systemic Lupus Erythematosus. Cureus 2022; 14:e25795. [PMID: 35836439 PMCID: PMC9273191 DOI: 10.7759/cureus.25795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2022] [Indexed: 11/18/2022] Open
Abstract
Evans syndrome is an autoimmune disorder characterized by the simultaneous or sequential occurrence of autoimmune hemolytic anemia and idiopathic thrombocytopenic purpura (ITP) with or without neutropenia. It can occur idiopathically or secondary to autoimmune or malignant processes. We are presenting a case of ITP with concurrent chronic hemolytic anemia and positive markers for systemic lupus erythematosus with no prior diagnosis of any rheumatological disorder.
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28
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Mohammadien HA, Abudab LH, Ahmad AM. Evan syndrome as initial presentation of COVID-19 infection. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2022. [PMCID: PMC9066390 DOI: 10.1186/s43168-022-00125-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Background Evans’ syndrome (ES) is a rare and chronic autoimmune disease characterized by the concomitant or sequential association of auto-immune hemolytic anemia (AIHA) with immune thrombocytopenia (ITP), and less frequently autoimmune neutropenia with a positive direct anti-human globulin test. ES represents up to 7% of AIHA and around 2% of ITP. Studies have found that coronavirus disease 2019 (COVID-19) may be associated with various hematological complications, i.e., coagulopathies; however, finding of Evans syndrome is a novel case. Case report A 54-year-old diabetic man complaining of fever (high grade), arthralgia and myalgia, fatigue, and dark color of urine. He was admitted to isolation sector at Sohag General Hospital on day 6 because of fever with cough, dyspnea, and progressive fatigue, and at admission, he was tachypneic, tachycardiac, jaundiced, febrile (38 °C), and hypoxemic (O2 saturations on room air was 80%). Laboratory studies showed hemoglobin (Hb) 5.43 g/dL, high reticulocyte (12.5%), ↓ed platelet count (54 × 103/μl), hyperbilirubinemia and elevated C-reactive protein (CRP), D-dimer, ferritin, and lactate dehydrogenase. Markers of autoimmune diseases and screening for malignant diseases were negative. HRCT chest showed bilateral small-sized peripheral ground glass opacities in both lungs, with positive reverse transcriptase-polymerase chain reaction (RT-PCR) for SARS-CoV-2 RNA in the nasopharyngeal swab. Direct Coombs test was positive for immunoglobulin (IgG) and C3d. Evans syndrome secondary to COVID-19 was diagnosed and treatment with packed red cell (PRC) transfusions, favipiravir, dexamethasone, prednisone, ceftriaxone, enoxaparin, oral hypoglycemic, and oxygen using face mask, and then Hb value increased to 10.3 g/dL and he was discharged home without any complications. Conclusion There are few reports of patients with concurrent COVID-19 and Evans syndrome. So, SARS-CoV-2 infection should be considered in any patient presenting with new-onset ES of unclear etiology.
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Su K, Cheng H, Jia Z, Yuan Y, Yang H, Gao Q, Jiang Z, Wen H, Jiang J. Predictors of refractory risk in systemic lupus erythematosus-related thrombocytopenia: a dual-centre retrospective study. Lupus Sci Med 2022; 9:9/1/e000677. [PMID: 35606019 PMCID: PMC9125766 DOI: 10.1136/lupus-2022-000677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 05/09/2022] [Indexed: 11/17/2022]
Abstract
Objectives Based on clinical and laboratory indicators, this study aimed to establish a multiparametric nomogram to assess the risk of refractory cases of SLE-related thrombocytopenia (SLE-related TP) before systematic treatment. Methods From June 2012 to July 2021, a dual-centre retrospective cohort study of prospectively collected data of patients with SLE-related TP was conducted. The cohort data were divided into a developing set, internal validation set and external validation set. Refractory thrombocytopenia (RTP) was defined as failed to prednisone at 1 mg/kg per day with a platelet count cannot achieve or maintain higher than 50×109/L. In the developing set, a nomogram were established to predict RTP risk based on clinical characteristics and laboratory indicators by multivariable logistic regression, and its performance was assessed by receiver operating characteristic (ROC) curves, calibration curves, decision curve analysis (DCA) and clinical impact curve (CIC). Results A total of 1778 patients with SLE were included, and 413 eligible patients were involved in the final analysis with 121 RTPs. The RTP risk assessment (RRA) model was composed of five significant risk variables: pregnancy, severity of TP, complement 3, anticardiolipin antibody-immunoglobulin G and autoimmune haemolytic anaemia. In three datasets, the AUCs were 0.887 (95% CI 0.830 to 0.945), 0.880 (95% CI 0.785 to 0.975) and 0.871 (95% CI 0.793 to 0.949), respectively. The calibration curve, DCA and CIC all showed good performance of the RRA model. Conclusion The RRA model demonstrated good capability for assessing the refractory risk in SLE-related TP, which may be helpful for early identification and intervention.
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Affiliation(s)
- Kaisheng Su
- Department of Clinical Epidemiology, The First Hospital of Jilin University, Changchun, China.,Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin, China
| | - Hao Cheng
- Department of Rheumatology, Shanxi Medical University Second Affiliated Hospital, Taiyuan, Shanxi, China
| | - Zhifang Jia
- Department of Clinical Epidemiology, The First Hospital of Jilin University, Changchun, China
| | - Yi Yuan
- Department of Rheumatology, The First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Huidan Yang
- Department of Rheumatology, Shanxi Medical University Second Affiliated Hospital, Taiyuan, Shanxi, China
| | - Qi Gao
- Department of Rheumatology, The First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Zhenyu Jiang
- Department of Rheumatology, The First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Hongyan Wen
- Department of Rheumatology, Shanxi Medical University Second Affiliated Hospital, Taiyuan, Shanxi, China
| | - Jing Jiang
- Department of Clinical Epidemiology, The First Hospital of Jilin University, Changchun, China .,Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin, China
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Porpaczy E, Jäger U. How I manage autoimmune cytopenias in patients with lymphoid cancer. Blood 2022; 139:1479-1488. [PMID: 34517415 PMCID: PMC11017954 DOI: 10.1182/blood.2019003686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 04/29/2021] [Indexed: 11/20/2022] Open
Abstract
Autoimmune conditions can occur in a temporary relationship with any malignant lymphoma. In many instances, treatment at diagnosis is not required, but symptomatic autoimmune conditions represent an indication for treatment, particularly in chronic lymphoproliferative diseases. Treatment is selected depending on the predominant condition: autoimmune disease (immunosuppression) or lymphoma (antilymphoma therapy). Steroids and anti-CD20 antibodies are effective against both conditions and may suppress the autoimmune complication for a prolonged period. The efficacy of B-cell receptor inhibitors has provided us with novel insights into the pathophysiology of antibody-producing B cells. Screening for underlying autoimmune conditions is part of the lymphoma workup, because other drugs, such as immunomodulators and checkpoint inhibitors, should be avoided or used with caution. In this article, we discuss diagnostic challenges and treatment approaches for different situations involving lymphomas and autoimmune cytopenias.
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Affiliation(s)
- Edit Porpaczy
- Department of Medicine I, Division of Hematology and Hemostaseology
| | - Ulrich Jäger
- Department of Medicine I, Division of Hematology and Hemostaseology
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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31
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Blanco BP, Garanito MP. Pediatric Evans Syndrome: A 20-year experience from a tertiary center in Brazil. Hematol Transfus Cell Ther 2022:S2531-1379(22)00032-3. [DOI: 10.1016/j.htct.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 01/06/2022] [Accepted: 01/28/2022] [Indexed: 10/19/2022] Open
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32
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Gupta M, Lamba A, Gupta S, Rajesh R. Evans syndrome and Graves' Disease: An unusual presentation – A case report. APOLLO MEDICINE 2022. [DOI: 10.4103/am.am_79_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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33
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Belloumi N, Bougacha M, Bachouch I, Habouria C, Chermiti F, Fenniche S. Alveolar hemorrhage linked to Evans syndrome. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2022. [DOI: 10.4103/ecdt.ecdt_73_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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34
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Makharia A, Lakhotia M, Roy B. Primary Evans syndrome in an adult man. BMJ Case Rep 2021; 14:e243051. [PMID: 34887288 PMCID: PMC8663103 DOI: 10.1136/bcr-2021-243051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2021] [Indexed: 11/04/2022] Open
Abstract
Evans syndrome (ES) is a simultaneous or subsequent development of two haematological disorders, autoimmune haemolytic anaemia (AIHA) and immune thrombocytopenia (ITP). It can be primary (idiopathic) or secondary (associated with an underlying disease). Primary Evans is a diagnosis of exclusion and has a poorer prognosis than AIHA or ITP alone. We present a 55-year-old man who presented with weakness and lethargy and was diagnosed to be suffering from primary ES.
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Affiliation(s)
- Archita Makharia
- General Medicine, Dr Sampurnanand Medical College, Jodhpur, India
| | - Manoj Lakhotia
- General Medicine, Dr Sampurnanand Medical College, Jodhpur, India
| | - Brateen Roy
- General Medicine, Dr Sampurnanand Medical College, Jodhpur, India
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35
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Beryl S, Ross BJ, Tergestina M, Kumar M. Severe neonatal autoimmune thrombocytopenia secondary to maternal Evans syndrome. BMJ Case Rep 2021; 14:e245695. [PMID: 34857590 PMCID: PMC8640653 DOI: 10.1136/bcr-2021-245695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 11/04/2022] Open
Abstract
Evans syndrome is a rare and chronic autoimmune disease seen in both paediatric and adult age groups. We present a case of severe thrombocytopenia in a neonate born to a mother with Evans syndrome who showed no response to intravenous immunoglobulin therapy initially and improved after treatment with methylprednisolone.
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MESH Headings
- Adult
- Anemia, Hemolytic, Autoimmune/complications
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/drug therapy
- Child
- Humans
- Immunoglobulins, Intravenous/therapeutic use
- Infant, Newborn
- Purpura, Thrombocytopenic, Idiopathic/complications
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Thrombocytopenia
- Thrombocytopenia, Neonatal Alloimmune
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Affiliation(s)
- Shafini Beryl
- Department of Neonatology, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
| | - Benjamin Jeyanth Ross
- Department of Neonatology, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
| | - Mintoo Tergestina
- Department of Neonatology, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
| | - Manish Kumar
- Department of Neonatology, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
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36
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Carsetti R, Corrente F, Capponi C, Mirabella M, Cascioli S, Palomba P, Bertaina V, Pagliara D, Colucci M, Piano Mortari E. Comprehensive phenotyping of human peripheral blood B lymphocytes in pathological conditions. Cytometry A 2021; 101:140-149. [PMID: 34851033 PMCID: PMC9299869 DOI: 10.1002/cyto.a.24518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 10/14/2021] [Accepted: 11/11/2021] [Indexed: 12/13/2022]
Abstract
Several diseases are associated with alterations of the B-cell compartment. Knowing how to correctly identify by flow cytometry the distribution of B-cell populations in the peripheral blood is important to help in the early diagnosis. In the accompanying article we describe how to identify the different B-cell subsets in the peripheral blood of healthy donors. Here we show a few examples of diseases that cause dysregulation of the B-cell compartment.
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Affiliation(s)
- Rita Carsetti
- Diagnostic Immunology Research Unit, Multimodal Medicine Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,Microbiology and Diagnostic Immunology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesco Corrente
- Microbiology and Diagnostic Immunology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Claudia Capponi
- Microbiology and Diagnostic Immunology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Mattia Mirabella
- Microbiology and Diagnostic Immunology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Simona Cascioli
- Research Laboratories, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Patrizia Palomba
- Microbiology and Diagnostic Immunology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Valentina Bertaina
- Department of Pediatric Hematology/Oncology and Cell Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Daria Pagliara
- Department of Pediatric Hematology/Oncology and Cell Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Manuela Colucci
- Renal Diseases Research Unit, Genetic and Rare Diseases Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Eva Piano Mortari
- Diagnostic Immunology Research Unit, Multimodal Medicine Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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37
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Jamil SB, Patoli I, Kazim M, Abbas SH, Ali Z. A Case of Evans Syndrome and Unstable Angina. J Med Cases 2021; 12:415-418. [PMID: 34691339 PMCID: PMC8510669 DOI: 10.14740/jmc3777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 09/11/2021] [Indexed: 11/26/2022] Open
Abstract
Evans syndrome (ES) is characterized by autoimmune hemolytic anemia (AIHA) and immune-mediated thrombocytopenia. It is more common in the pediatric population than in adults. ES has been reported to be associated with thrombotic events and rarely can lead to acute coronary syndrome (ACS). There have been only a few reported cases of ACS secondary to ES. We present an interesting case of ES with unstable angina (UA) which had a limited response to oral and intravenous (IV) steroids requiring rituximab. A 64-year-old male with past medical history significant for hypertension, hyperlipidemia, diabetes mellitus and coronary artery disease, presented to the emergency room complaining of a 2-week history of chest pain, shortness of breath and hematuria. Physical examination indicated splenomegaly but was otherwise unremarkable with no petechiae or rash. Labs showed hemoglobin of 9.6 g/dL, platelet count 58 × 103/µL, troponin < 0.03 ng/mL, lactic acid 2.5 mmol/L and with parameters indicative of hemolysis, evidenced by elevated lactate dehydrogenase, low haptoglobin and elevated bilirubin levels. Electrocardiography (EKG) demonstrated ST depression in leads I, aVL, V5 - V6 and T wave inversions in lead III and aVL, which were new compared to previous EKG. Peripheral blood smear indicated spherocytes. Direct antiglobulin test was positive for immunoglobulin G (IgG). Patient was admitted for ES and initially treated with oral prednisone 80 mg daily. He was also diagnosed with UA thought to be possibly secondary to ES. He then underwent cardiac stress test which showed mild reversible inferior apical ischemia. Cardiac catheterization revealed 95% stenosis of proximal left circumflex artery requiring single drug eluding stent placement and dual antiplatelet therapy. Patient continued to have anemia despite blood transfusions, although platelet count improved. Prednisone was transitioned to high-dose IV dexamethasone, and patient was also started on rituximab which resulted in stabilization of anemia. The presentation of ES with ACS is a rare occurrence. ACS can be challenging to manage as stent placement may be required followed by dual antiplatelet therapy. Treatment of ES involves steroids followed by rituximab, IV immunoglobulin (IVIG) or splenectomy for non-responsive cases. Early intervention and management can prevent mortality and morbidity.
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Affiliation(s)
- Saad Bin Jamil
- Department of Internal Medicine, St. Mary's Hospital, Waterbury, CT 06706, USA
| | - Iqra Patoli
- Department of Internal Medicine, St. Mary's Hospital, Waterbury, CT 06706, USA
| | - Mehrunissa Kazim
- Department of Internal Medicine, Holyoke Health Center, Holyoke, MA 01040, USA
| | - Syed Hassan Abbas
- Department of Internal Medicine, St. Mary's Hospital, Waterbury, CT 06706, USA
| | - Zain Ali
- Abington Memorial Hospital, Philadelphia, PA 19001, USA
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38
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Evans syndrome in adults: an observational multicentre study. Blood Adv 2021; 5:5468-5478. [PMID: 34592758 PMCID: PMC8714709 DOI: 10.1182/bloodadvances.2021005610] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/10/2021] [Indexed: 11/20/2022] Open
Abstract
Adult ES is a rare, often severe, and potentially fatal condition. ES is marked by frequent relapses, high therapy burden, and increased risk of infection/thrombosis, significantly affecting survival.
Evans syndrome (ES) is a rare condition, defined as the presence of 2 autoimmune cytopenias, most frequently autoimmune hemolytic anemia and immune thrombocytopenia (ITP) and rarely autoimmune neutropenia. ES can be classified as primary or secondary to various conditions, including lymphoproliferative disorders, other systemic autoimmune diseases, and primary immunodeficiencies, particularly in children. In adult ES, little is known about clinical features, disease associations, and outcomes. In this retrospective international study, we analyzed 116 adult patients followed at 13 European tertiary centers, focusing on treatment requirements, occurrence of complications, and death. ES was secondary to or associated with underlying conditions in 24 cases (21%), mainly other autoimmune diseases and hematologic neoplasms. Bleeding occurred in 42% of patients, mainly low grade and at ITP onset. Almost all patients received first-line treatment (steroids with or without intravenous immunoglobulin), and 23% needed early additional therapy for primary refractoriness. Additional therapy lines included rituximab, splenectomy, immunosuppressants, thrombopoietin receptor agonists, and others, with response rates >80%. However, a remarkable number of relapses occurred, requiring ≥3 therapy lines in 54% of cases. Infections and thrombotic complications occurred in 33% and 21% of patients, respectively, mainly grade ≥3, and correlated with the number of therapy lines. In addition to age, other factors negatively affecting survival were severe anemia at onset and occurrence of relapse, infection, and thrombosis. These data show that adult ES is often severe and marked by a relapsing clinical course and potentially fatal complications, pinpointing the need for high clinical awareness, prompt therapy, and anti-infectious/anti-thrombotic prophylaxis.
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39
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Lafaurie M, Maquet J, Baricault B, Ekstrand C, Christiansen CF, Linder M, Bahmanyar S, Nørgaard M, Sailler L, Lapeyre-Mestre M, Sommet A, Moulis G. Risk factors of hospitalisation for thrombosis in adults with primary immune thrombocytopenia, including disease-specific treatments: a French nationwide cohort study. Br J Haematol 2021; 195:456-465. [PMID: 34386974 DOI: 10.1111/bjh.17709] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/30/2021] [Indexed: 12/12/2022]
Abstract
We aimed to assess the risk factors of venous thrombosis (VT) and arterial thrombosis (AT) in adults with primary immune thrombocytopenia (ITP), particularly in relation to treatments. The population comprised all incident primary ITP adults in France between 2009 and 2017 (FAITH cohort; NCT03429660) built in the national health database. Outcomes were the first hospitalisation for VT and AT. Multivariable Cox regression models included baseline risk factors, time-varying exposure to ITP drugs, splenectomy and to cardiovascular drugs. The cohort included 10 039 patients. A higher risk of hospitalisation for VT was observed with older age, history of VT, history of cancer, splenectomy [hazard ratio (HR) 3·23, 95% confidence interval (CI) 2·26-4·61], exposure to corticosteroids (HR 3·55, 95% CI 2·74-4·58), thrombopoietin-receptor agonists (TPO-RAs; HR 2·28, 95% CI 1·59-3·26) and intravenous immunoglobulin (IVIg; HR 2·10, 95% CI 1·43-3·06). A higher risk of hospitalisation for AT was observed with older age, male sex, a history of cardiovascular disease, splenectomy (HR 1·50, 95% CI 1·12-2·03), exposure to IVIg (HR 1·85, 95% CI 1·36-2·52) and TPO-RAs (HR 1·64, 95% CI 1·26-2·13). Rituximab was not associated with an increased risk. These findings help to estimate the risk of thrombosis in adult patients with ITP and to select treatment.
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Affiliation(s)
- Margaux Lafaurie
- Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France.,UMR 1027, INSERM, Toulouse University, Toulouse, France.,CIC 1436, Toulouse University Hospital, Toulouse, France
| | - Julien Maquet
- CIC 1436, Toulouse University Hospital, Toulouse, France.,Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
| | | | - Charlotta Ekstrand
- Centre for Pharmaco-Epidemiology, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | | | - Marie Linder
- Centre for Pharmaco-Epidemiology, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | - Shahram Bahmanyar
- Centre for Pharmaco-Epidemiology, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | - Mette Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Laurent Sailler
- CIC 1436, Toulouse University Hospital, Toulouse, France.,Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
| | - Maryse Lapeyre-Mestre
- Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France.,UMR 1027, INSERM, Toulouse University, Toulouse, France.,CIC 1436, Toulouse University Hospital, Toulouse, France
| | - Agnès Sommet
- Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France.,UMR 1027, INSERM, Toulouse University, Toulouse, France.,CIC 1436, Toulouse University Hospital, Toulouse, France
| | - Guillaume Moulis
- CIC 1436, Toulouse University Hospital, Toulouse, France.,Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
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Shi YF, Shi XH, Zhang Y, Chen JX, Lai WX, Luo JM, Ba JH, Wang YH, Chen JN, Wu BQ. Disseminated Tuberculosis Associated Hemophagocytic Lymphohistiocytosis in a Pregnant Woman With Evans syndrome: A Case Report and Literature Review. Front Immunol 2021; 12:676132. [PMID: 34177917 PMCID: PMC8222916 DOI: 10.3389/fimmu.2021.676132] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/28/2021] [Indexed: 11/13/2022] Open
Abstract
Background Tuberculosis (TB) is a leading cause of morbidity and mortality in underdeveloped and developing countries. Disseminated TB may induce uncommon and potentially fatal secondary hemophagocytic lymphohistiocytosis (HLH). Timely treatment with anti-tuberculosis therapy (ATT) and downmodulation of the immune response is critical. However, corticosteroid treatment for TB-associated HLH remains controversial. Herein, we report a successful case of disseminated TB-associated HLH in a pregnant woman with Evans syndrome accompanied by a literature review. Case Presentation A 26-year-old pregnant woman with Evans syndrome was transferred to the Third Affiliated Hospital of Sun Yat-Sen University because of severe pneumonia. She presented with cough, fever, and aggravated dyspnea. Nested polymerase chain reaction for Mycobacterium tuberculosis (M. tuberculosis) complex in sputum was positive. Sputum smear sample for acid-fast bacilli was also positive. Metagenome next-generation sequencing (mNGS) of the bronchoalveolar lavage fluid identified 926 DNA sequence reads and 195 RNA sequence reads corresponding to M. tuberculosis complex, respectively. mNGS of blood identified 48 DNA sequence reads corresponding to M. tuberculosis. There was no sequence read corresponding to other potential pathogens. She was initially administered standard ATT together with a low dose of methylprednisolone (40 mg/day). However, her condition deteriorated rapidly with high fever, acute respiratory distress syndrome, pancytopenia, and hyperferritinemia. Bone marrow smears showed hemophagocytosis. And caseating tuberculous granulomas were found in the placenta. A diagnosis of disseminated TB-associated HLH was made. Along with the continuation of four drug ATT regimen, therapy with a higher dose of methylprednisolone (160 mg/day) combined with immunoglobulin and plasma exchange was managed. The patient’s condition improved, and she was discharged on day 19. Her condition was good at follow-up with the continuation of the ATT. Conclusions Clinicians encountering patients with suspected TB accompanied by unexplainable inflammation not responding to ATT should consider complications with HLH. Timely administration of ATT combined with corticosteroids may result in a favorable outcome.
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Affiliation(s)
- Yun-Feng Shi
- Medical Intensive Care Unit, Department of Respiratory and Critical Care Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Institute of Respiratory Diseases, Sun Yat-Sen University, Guangzhou, China
| | - Xiao-Han Shi
- Medical Intensive Care Unit, Department of Respiratory and Critical Care Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Institute of Respiratory Diseases, Sun Yat-Sen University, Guangzhou, China
| | - Yuan Zhang
- Department of Gynaecology and Obstetrics, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jun-Xian Chen
- Medical Intensive Care Unit, Department of Respiratory and Critical Care Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Institute of Respiratory Diseases, Sun Yat-Sen University, Guangzhou, China
| | - Wen-Xing Lai
- Department of Hematology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jin-Mei Luo
- Medical Intensive Care Unit, Department of Respiratory and Critical Care Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Institute of Respiratory Diseases, Sun Yat-Sen University, Guangzhou, China
| | - Jun-Hui Ba
- Medical Intensive Care Unit, Department of Respiratory and Critical Care Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Institute of Respiratory Diseases, Sun Yat-Sen University, Guangzhou, China
| | - Yan-Hong Wang
- Medical Intensive Care Unit, Department of Respiratory and Critical Care Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Institute of Respiratory Diseases, Sun Yat-Sen University, Guangzhou, China
| | - Jian-Ning Chen
- Department of Pathology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ben-Quan Wu
- Medical Intensive Care Unit, Department of Respiratory and Critical Care Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,Institute of Respiratory Diseases, Sun Yat-Sen University, Guangzhou, China
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41
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Leonhardt LP, Pervez A, Calvo A. Evans Syndrome in a Jehovah's Witness. Cureus 2021; 13:e15508. [PMID: 34277157 PMCID: PMC8269972 DOI: 10.7759/cureus.15508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2021] [Indexed: 11/05/2022] Open
Abstract
Evans syndrome (ES) is a rare hematologic disorder characterized by the development of autoimmune hemolytic anemia (AIHA), idiopathic thrombocytopenia, and occasionally immune-mediated neutropenia. Jehovah's Witnesses (JW) often decline blood product transfusion on the grounds of a scriptural stand based on biblical texts. The acute management of ES often consists of blood product transfusion in addition to high-dose steroids and intravenous immunoglobulin. We describe the case of a JW female presenting with new-onset, acutely worsening AIHA and thrombocytopenia with concern for hemodynamic compromise who was successfully treated with erythropoietin-stimulating agents, parenteral iron, folic acid, and high-dose steroids.
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Affiliation(s)
| | - Aamir Pervez
- Internal Medicine, Kettering Medical Center, Dayton, USA
| | - Alejandro Calvo
- Hematology and Medical Oncology, Kettering Medical Center, Dayton, USA
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42
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Manzo ML, Galati C, Gallo C, Santangelo G, Marino A, Guccione F, Pitino R, Raieli V. ADEM post-Sars-CoV-2 infection in a pediatric patient with Fisher-Evans syndrome. Neurol Sci 2021; 42:4293-4296. [PMID: 33982145 PMCID: PMC8115868 DOI: 10.1007/s10072-021-05311-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 05/05/2021] [Indexed: 11/22/2022]
Abstract
Introduction Sars-CoV-2 is a single-strained RNA virus belonging to Coronaviridae’s family. In pediatric age, the majority of patients is asymptomatic; however, several neurological manifestations associated with Sars-CoV-2 infection have been detected in a percentage of cases ranging from 17.3 to 36.4%. Acute disseminated encephalomyelitis (ADEM) has been recently included among the potential complications of Sars-Cov2 infection. The available data regarding pediatric patient show only one case. Case report We present a case regarding a 6-year-old patient suffering from Fisher-Evans syndrome who was given sirolimus and thalidomide therapy. After 10 days since the first positive nasopharyngeal swab for Sars-CoV-2, in which he had no symptoms, he presented an episode of generalized tonic-clonic seizure with spontaneous resolution. The patient underwent MRI which showed the typical picture of acute disseminated encephalomyelitis. His clinical course was favorable, with a good response to cortisone therapy and a progressive improvement of the neuroradiological and electroencephalographic picture. Conclusions According to our knowledge, this is the second case of an acute disseminated encephalomyelitis following SARS-CoV-2 infection in a pediatric patient, characterized by monosymptomatic onset, in which the immunosuppressive therapy practiced for the Fisher-Evans syndrome has probably contributed to a favorable evolution of ADEM, in contrast to other case described in the literature.
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Affiliation(s)
- Maria Laura Manzo
- Child Neuropsychiatry School, University of Palermo, Piazzale delle Cliniche, 90100, Palermo, Italy.
| | - Cristina Galati
- Child Neuropsychiatry School, University of Palermo, Piazzale delle Cliniche, 90100, Palermo, Italy
| | - Cristina Gallo
- U.O.C Neuroradiology ARNAS Civico, Piazzale Nicola Leotta 4, 90100, Palermo, Italy
| | - Giuseppe Santangelo
- Child Neuropsychiatry Unit, ISMEP-P.O. Cristina-ARNAS Civico, Via Dei Benedettini 1, 90100, Palermo, Italy
| | - Antonio Marino
- Child Neuropsychiatry School, University of Palermo, Piazzale delle Cliniche, 90100, Palermo, Italy
| | - Fulvio Guccione
- Child Neuropsychiatry School, University of Palermo, Piazzale delle Cliniche, 90100, Palermo, Italy
| | - Renata Pitino
- Child Neuropsychiatry Unit, ISMEP-P.O. Cristina-ARNAS Civico, Via Dei Benedettini 1, 90100, Palermo, Italy
| | - Vincenzo Raieli
- Child Neuropsychiatry Unit, ISMEP-P.O. Cristina-ARNAS Civico, Via Dei Benedettini 1, 90100, Palermo, Italy
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Wang M, Zhang Z, Yan J, Shi J, Liu S, Wan H. The Presence of Secondary Evans Syndrome in AIDS Patients with Talaromyces marneffei Infection. Infect Drug Resist 2021; 14:1265-1271. [PMID: 33824596 PMCID: PMC8018431 DOI: 10.2147/idr.s300082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/04/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Talaromyces marneffei (T.M) is a common opportunistic fungus in human immunodeficiency virus (HIV) infection individual. Secondary Evans syndrome in AIDS patients with Talaromyces marneffei infection has not been reported before. Here, we described cases related to this comorbidity. Methods AIDS patients diagnosed with Talaromyces marneffei infection from 2016 to 2020 at Xixi Hospital of Hangzhou were included in this retrospective study. Results Total 76 AIDS patients with T.M infection were enrolled. The most common symptoms were fever and cough (70/76; 55/76, respectively). 53/76 (69.74%) patients got positive results of direct antiglobulin test. 14/76 AIDS-T.M patients combined with secondary Hemophagocytic lymphohistiocytosis (HLH). Five patients were diagnosed with AIDS-T.M associated Evans syndrome. There were severe inflammatory reaction, liver dysfunction, coagulation dysfunction and immunodeficiency status in AIDS-T.M patients with secondary Evans syndrome. All patients received antifungal therapy and three patients received corticosteroids for Evans syndrome treatment. One patient died due to sepsis. Conclusion AIDS-T.M patients with secondary Evans syndrome is extremely rare and we need to be alert to the occurrence of secondary Evans syndrome in AIDS-T.M patients. Clinicians should timely start effective antifungal treatments with suspicious T.M infection in AIDS patients.
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Affiliation(s)
- Mengyan Wang
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Hangzhou Sixth People's Hospital, Hangzhou, 310023, People's Republic of China
| | - Zhongdong Zhang
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Hangzhou Sixth People's Hospital, Hangzhou, 310023, People's Republic of China
| | - Jun Yan
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Hangzhou Sixth People's Hospital, Hangzhou, 310023, People's Republic of China
| | - Jinchuan Shi
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Hangzhou Sixth People's Hospital, Hangzhou, 310023, People's Republic of China
| | - Shourong Liu
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Hangzhou Sixth People's Hospital, Hangzhou, 310023, People's Republic of China
| | - Hu Wan
- Department II of Infectious Diseases, Xixi Hospital of Hangzhou, Hangzhou Sixth People's Hospital, Hangzhou, 310023, People's Republic of China
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Autoimmune Hemolytic Anemia and Immune Thrombocytopenia: A Unique Presentation of Kawasaki Disease. Case Rep Rheumatol 2021; 2021:6640006. [PMID: 33728087 PMCID: PMC7936906 DOI: 10.1155/2021/6640006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 02/03/2021] [Accepted: 02/17/2021] [Indexed: 11/30/2022] Open
Abstract
Kawasaki disease is an acute multisystem vasculitis characterized by involvement of medium-sized vessels that mostly affects children under the age of 5 years. The presentation is typically preceded by five or more days of fever with additional clinical findings including rash, peripheral edema, mucositis, conjunctival changes, and unilateral cervical lymphadenopathy. The most feared complication of Kawasaki disease is development of coronary artery aneurysms. Common laboratory abnormalities include normocytic anemia, thrombocytosis, leukocytosis, and elevated inflammatory markers. Immune-mediated cytopenias such as autoimmune hemolytic anemia and thrombocytopenia are rarely seen at presentation in Kawasaki disease. We describe a unique case of a child presenting with autoimmune hemolytic anemia, who sequentially developed immune thrombocytopenia concerning for Evans' syndrome and eventually diagnosed with Kawasaki Disease with coronary artery dilatation. Characteristic clinical findings including extremity edema, cracked lips, and rash developed later in the course. Our patient was treated with IVIG and steroids with significant clinical improvement and complete resolution of cytopenias and coronary aneurysms on long term follow up. Timely administration of IVIG prevents and minimizes the risk of long term cardiac consequences. Hence a high index of suspicion should be maintained for this relatively common pediatric illness, even in absence of more commonly seen laboratory findings.
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