Severe autoimmune hemolytic anemia following immunotherapy with checkpoint inhibitors in two patients with metastatic melanoma: a case report

Introduction

Over the past decade, immune checkpoint inhibitors such as antibodies against cytotoxicity T-lymphocyte-associated protein 4 (CTLA-4) and programmed cell death protein 1 (PD-1) have become an important armamentarium against a broad spectrum of malignancies. However, these specific inhibitors can cause adverse autoimmune reactions by impairing self-tolerance. Hematologic side effects of immune checkpoint inhibitors, including autoimmune hemolytic anemia (AIHA), are rare but can be life-threatening.

Case report

Herein, we report two patients on immune checkpoint inhibitors for metastatic melanoma who developed AIHA with symptoms of dyspnea and fatigue. In the first patient, symptoms alleviated after discontinuation of combined anti CTLA-4 and anti-PD-1 therapy, initiation of corticosteroids and application of a single red blood cell transfusion. Due to subsequent progress of melanoma, combinational anti-PD-1 and tyrosine kinase inhibitor therapy was initiated based on multidisciplinary tumor board decision. After two months, she again developed the described hematological and clinical signs of AIHA leading to cessation of anti-PD-1 therapy and initiation of corticosteroids, which again resulted in an alleviation of her symptoms. Due to further progression, the patient received dacarbazine for several months before she decided to stop any therapy other than palliative supportive care. In the second patient, discontinuation of anti-PD-1 therapy and initiation of corticosteroids entailed a complete alleviation of his symptoms. After refusing chemotherapy due to subsequent melanoma progression, he received radiotherapy of bone metastases and is currently enrolled in a clinical trial. The patient did not develop AIHA ever since.

Conclusion

Hematologic immune-related adverse events due to treatment with immune checkpoint inhibitors are rare but can have life-threatening consequences. If dyspnea and other clinical symptoms are present, AIHA should be considered as a potential cause and treated promptly in a multidisciplinary setting. An expanded comprehension of risk factors and pathogenesis of AIHA is needed to identify high-risk patients beforehand, leading to more effective predictive and reactive treatment approaches.

Alectinib-induced Hemolytic Anemia with Positive Direct Antiglobulin Test in a Patient with Lung Adenocarcinoma: A Possible Drug-drug Interaction Effect

Recent studies have reported that direct antiglobulin test (DAT) results were negative in cases of alectinib-induced hemolytic anemia with abnormal red blood cell (RBC) morphology. We herein report the case of a 72-year-old female patient who was diagnosed with alectinib-induced hemolytic anemia who - in contrast to previous reports - showed a positive DAT result. After discontinuing famotidine and alectinib, the DAT results turned negative; however, when alectinib was resumed, hemolysis recurred. Although alectinib-induced hemolytic anemia has been previously thought to be associated with abnormal morphological changes of the RBCs, we suggest that alectinib-induced anemia may manifest as DAT-positive immune hemolytic anemia because of a complementary effect with other drugs.

Fostamatinib for warm antibody autoimmune hemolytic anemia: Phase 3, randomized, double-blind, placebo-controlled, global study (FORWARD)

Warm antibody autoimmune hemolytic anemia (wAIHA) is characterized by hemolysis and symptomatic anemia with no approved treatment options. Fostamatinib is an oral spleen tyrosine kinase inhibitor approved in the US and Europe for treatment of adults with chronic immune thrombocytopenia. In this phase 3 study, patients with an insufficient response to ≥1 prior wAIHA treatment were randomized to fostamatinib or placebo. The primary endpoint was the proportion of patients to achieve a durable hemoglobin (Hgb) response (Hgb ≥10 g/dL and increase from baseline of ≥2 g/dL on 3 consecutive visits) during the 24-week treatment period. Ninety patients were randomized, 45 to each arm. Of the fostamatinib-treated patients, 35.6% achieved a durable Hgb response versus 26.7% on placebo (p = .398). A post hoc analysis revealed a large placebo response in Eastern European patients. Significantly more patients on fostamatinib from North America, Australia and Western Europe exhibited a durable Hgb response compared to placebo (36% vs. 10.7%, p = .030). After censoring for Hgb values impacted by steroid rescue received during screening and excluding 2 placebo patients found to likely not have wAIHA, a reanalysis demonstrated a difference in durable Hgb response between fostamatinib and placebo (15/45 [33.3%] vs. 6/43 [14.0%], p = .0395). At least 1 AE was reported in 42 (93.3%) and 40 (88.9%) patients receiving fostamatinib and placebo, respectively. The most common AEs in the fostamatinib group were diarrhea (26.7%), hypertension (24.4%), and fatigue (15.6%). In this study, fostamatinib demonstrated a clinically meaningful benefit for patients in Western regions, and no new safety signals were identified.

Sirolimus is effective for primary refractory/relapsed warm autoimmune haemolytic anaemia/Evans syndrome: a retrospective single-center study

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.

A 71-year-old male with a life-threatening recurrence of hemolytic anemia, thrombocytopenia, and acute kidney injury after pembrolizumab therapy: a case report

BACKGROUND

Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment. However, their use has been restricted in patients with preexisting autoimmune diseases due to concerns about increased risk of immune-related adverse events (irAEs).

CASE PRESENTATION

We present a case of a patient with stage IV lung adenocarcinoma and a history of complement-mediated autoimmune hemolytic anemia in remission. After receiving a single dose of pembrolizumab, the patient experienced life-threatening recurrent hemolytic anemia, de novo thrombocytopenia, diarrhea, myocarditis, and acute kidney injury. Laboratory tests confirmed the diagnosis of Evan's syndrome, with positive PAIgG and direct antiglobulin test. Treatment with intravenous methylprednisolone at a dose of 2 mg/kg resulted in a favorable response, with resolution of symptoms and rapid recovery of kidney function. The probable cause of pre-renal hypoperfusion (evidenced by a BUN-to-creatinine ratio of 48.1) leading to acute tubular injury was attributed to pembrolizumab-induced diarrhea.

CONCLUSIONS

This case illustrates a life-threatening recurrence of complement-mediated autoimmune hemolytic anemia induced by ICIs. Clinicians should carefully consider the expected efficacy and potential toxicity before initiating ICIs therapy in patients with preexisting autoimmune diseases. Additionally, the occurrence of acute kidney injury during ICIs therapy adds complexity and requires careful differential diagnosis.

Auto-immune hemolytic anemia and hemophagocytic lymphohistiocytosis as immune-related adverse event in patients with metastatic melanoma and concurrent chronic lymphocytic leukemia: a case series and literature review

Auto-immune hemolytic anemia (AIHA) and hemophagocytic lymphohistiocytosis (HLH) are both rare immune-related adverse events (irAEs) following treatment with immune checkpoint inhibitors. Consensus treatment guidelines are currently lacking. Patients with a solid malignancy and a concurrent lymphoproliferative disorder, such as chronic lymphocytic leukemia (CLL), might be more prone to develop hematological irAEs. We report the case history of two patients, diagnosed with CLL, who during treatment for metastatic melanoma with nivolumab, a PD-1 immune checkpoint blocking mAb, developed AIHA and HLH in combination with AIHA. Furthermore, we provide a review of the literature on published cases of immune-related AIHA and HLH and their correlation with CLL.

Delayed autoimmune haemolytic anaemia after artesunate therapy for severe malaria

We report the case of a 51-year-old man with severe malaria, who developed delayed autoimmune haemolytic anaemia following artesunate therapy. Delayed autoimmune haemolytic anaemia following artesunate therapy has been previously described. Its diagnosis can be challenging in the setting of possible dengue coinfection. Clinicians should be vigilant of this potential side effect of artesunate therapy, especially in patients who later develop signs and symptoms of haemolytic anaemia.

Possible autoimmune hemolytic anemia induced by secukinumab: a case report

Secukinumab, an anti-IL-17 monoclonal antibody, has been used to treat psoriasis and psoriatic arthritis since 2015. Several adverse events were reported, such as diarrhea, upper respiratory tract infection, middle ear infection, and neutropenia. Here we report a probable case of autoimmune hemolytic anemia in a 39 years old male with psoriasis and psoriatic arthritis treated with secukinumab. Hemolytic anemia detected after first maintenance dose after completion of induction dose of secukinumab. The patient also had other comorbids, soft tissue infection that also predisposed to autoimmune hemolytic anemia, but secukinumab is still a possible etiology for drug-induced autoimmune hemolytic anemia based on Naranjo´s score. The patient decided to continue secukinumab treatment, interestingly hemoglobin levels improved.

Pembrolizumab-induced autoimmune haemolytic anemia in a patient with chronic lymphocytic leukaemia successfully treated with ibrutinib

We present a unique case of a patient with a long-standing history of indolent chronic lymphocytic leukaemia (CLL) who suddenly developed autoimmune haemolytic anaemia after starting immune checkpoint inhibitor therapy for bladder cancer. He had no clear indication to start CLL-directed treatment based on current clinical practice guidelines; however, targeted treatment of CLL with ibrutinib proved to be effective in treating the haemolytic anaemia.

Diagnosis and management of cold agglutinin disease associated with low-grade B-cell lymphoma in a patient receiving pembrolizumab for lung cancer

A 65-year-old with non-small cell lung cancer developed autoimmune haemolytic anaemia while receiving pembrolizumab containing chemoimmunotherapy. Initially thought to be due to pembrolizumab induced haemolysis, he was treated with steroids, and pembrolizumab was held. Haemolysis was refractory to steroids and blood was observed to agglutinate in cold room temperatures. Cold agglutinins in high titre and monoclonal serum IgM kappa protein were detected. Bone marrow biopsy showed marginal zone lymphoma confirming low grade B-cell lymphoma causing cold agglutinin disease. B-cell depletion by rituximab stopped haemolysis, and pembrolizumab was safely continued for lung cancer.

Pembrolizumab-associated autoimmune haemolytic anaemia

Treatment paradigms have recently changed with the introduction of immunotherapy; autoimmune toxicities that can arise are frequently very different from the more familiar chemotherapy toxicities. We present a clinical case of autoimmune haemolytic anaemia (AIHA) secondary to pembrolizumab occurring in a 73-year-old male patient being treated for lung adenocarcinoma, who had received 13 cycles of pembrolizumab. Treatment was immediately stopped and he was treated with high dose steroids to which he responded both clinically and biochemically. There have been prior reports of immunotherapy-associated AIHA with the use of cytotoxic T-lymphocyte-associated antigen-4 inhibitors, such as ipilimumab, but very few reports of programmed death-1 (PD-1)/programmed death-ligand 1 (PDL-1) inhibitor associated AIHA. We highlight a rare case of AIHA as an adverse effect of pembrolizumab, a PD-1 inhibitor. Although unusual, it is important to be vigilant for haematological immune-related adverse events.

A case of chronic lymphocytic leukemia complicated by autoimmune hemolytic anemia due to ibrutinib treatment

Ibrutinib (IBR) covalently binds to the active site of Bruton's tyrosine kinase (BTK) and is used for the treatment of relapsed/refractory chronic lymphocytic leukemia (CLL). Approximately 5-10% of CLL is complicated by autoimmune cytopenia (AIC), such as autoimmune hemolytic anemia (AIHA). Several cases of AIC have reportedly demonstrated improvement during IBR treatment. However, in our case, the patient developed AIHA during oral IBR treatment. As AIHA is exacerbated by the increased number of CLL cells in the peripheral blood, it may have developed because of disease progression rather than IBR use. This phenomenon may also be attributed to the production of autoantibodies due to increased number of CD5+ B cells. In this case, withdrawal of IBR and administration of rituximab improved hemolysis. If AIHA develops during treatment, its etiology must be examined to confirm the effects of treatment.

An Autoimmune Haemolytic Anaemia Secondary to Ipilimumab Treatment

BACKGROUND

Melanoma is one of the fastest growing neoplasms worldwide. Treatment of metastatic disease has swiftly shifted in the last decade from generally ineffective chemotherapy regimens to highly effective targeted treatments or immunotherapy, with a range of side effects that differ completely from those of previous treatments for this disease.

CASE

We present a case of a 71-year-old man with diagnosis metastatic melanoma. This patient was treated with anti-CTLA-4 antibody ipilimumab. Despite minor skin toxicity, the regimen was well tolerated until he developed hemolytic anemia, an autoimmune side effect of ipilimumab. The treatment was withdrawn and steroids were administered until the issue was resolved.

CONCLUSION

Immunotherapy has become the standard of care for many tumors, and its side effects are completely different from those of chemotherapy, meaning that oncologists must be aware of this to avoid a potentially life-threatening situation and arrive at an early diagnosis and implement prompt treatment.Key words: anemia - autoimmune event - anti-CTLA-4.

Autoimmune hemolytic anemia during adalimumab treatment for plaque psoriasis

Adalimumab is commonly used to treat autoimmune diseases with few reported hematological adverse reactions. We herein describe the case of an 85-year-old Japanese man with plaque psoriasis who developed autoimmune hemolytic anemia (AIHA) after 3 years of adalimumab treatment. The patient suddenly developed hematuria and dyspnea on exertion while receiving adalimumab treatment. Laboratory data showed low hemoglobin levels and slightly increased reticulocyte counts, while direct and indirect antiglobulin tests were positive. The patient was diagnosed with AIHA which resolved after replacing the adalimumab treatment with prednisolone therapy. The findings from this case indicate that AIHA may be caused by long-term adalimumab treatment.

Interferon-α induced psoriatic arthritis and autoimmune hemolytic anemia during chronic hepatitis C treatment

Chronic hepatitis C (CHC) can occur simultaneously with a myriad of rheumatic diseases or can induce autoimmunity. Inflammatory arthropathy is the main extra-hepatic manifestation of infection by virus C. In addition, the treatment for CHC with INF-α and ribavirin is also able to cause some immune-mediated events. The present case report describes an unusual case of psoriatic arthritis (PsA) and autoimmune hemolytic anemia (AIHA) during therapy for CHC.

Drug-induced immune hemolytic anemia: the last 30 years of changes

Drug-induced immune hemolytic anemia (DIIHA) is a rare condition that occurs primarily as a result of drug-induced antibodies, either drug-dependent or drug-independent. Drug- dependent antibodies can be detected by testing drug-treated red blood cells (RBCs) or untreated RBCs in the presence of a solution of drug. Drug-independent antibodies react with untreated RBCs (no drug added) and cannot be distinguished from warm autoantibodies. Many changes have occurred during the last 30 years, such as which drugs most commonly cause DIIHA, the optimal testing methods for identifying them, and the theories behind the mechanisms by which they react. This article reviews the major changes in DIIHA since the early 1980s involving the immune complex mechanism, cephalosporins, nonimmunologic protein adsorption, and penicillins. Because serologic results associated with DIIHA can mimic those expected with autoimmune hemolytic anemia or hemolytic transfusion reactions, DIIHA may go undetected in some cases.

Drugs that have been shown to cause drug-induced immune hemolytic anemia or positive direct antiglobulin tests: some interesting findings since 2007

This review updates new findings in drug-induced immune- hemolytic anemia (DIIHA) since the 2007 review in Immunohematology by these authors. Twelve additional drugs have been added to the three tables listing drugs associated with drug-dependent antibodies, drugs associated with drug-independent antibodies, and drugs associated with nonimmunologic protein adsorption. Other updated findings include (1) piperacillin is currently the most commonly encountered cause of DIIHA, (2) new data on blood group specificity of drug-dependent antibodies, (3) drug-dependent antibodies detected in healthy donors, (4) DIIHA associated with transplantation, and(5) DIIHA associated with chemotherapeutic drugs.

How we investigate drug-induced immune hemolytic anemia

Drugs are a rare cause of immune hemolytic anemia, but an investigation for a drug antibody may be warranted if a patient has definitive evidence of immune hemolysis, other more common causes of hemolysis have been excluded, and there is a good temporal relationship between the administration of a drug and the hemolytic event. Drug antibodies are either drug-dependent (require drug to be in the test system) or drug-independent (reactive without drug present in the test). Drug-dependent antibodies are investigated by testing drug-treated red blood cells (RBCs) or by testing RBCs in the presence of a solution of drug. Drug-independent antibodies are serologically indistinct from idiopathic warm autoantibodies and cannot be defined or excluded by serologic testing. Nonimmunologic protein adsorption, caused by some drugs, is independent of antibody production but may also cause immune hemolytic anemia. Serologic methods for testing for drug antibodies are presented, and observations from more than 30 years of this laboratory's experience are discussed.

Diagnostic pitfalls of drug-induced immune hemolytic anemia

Immune hemolytic anemia (IHA) is a rare complication of drug administration. However, its true incidence remains obscure, as there are a number of factors that may lead to misdiagnosis. The clinical and serologic pictures are variable, and there is a great deal of unawareness that certain drugs can cause IHA. Furthermore, serologic results can be easily misinterpreted, resulting in a wrong diagnosis.

Cefpodoxime proxetil-related hemolysis and acute interstitial nephritis

OBJECTIVE

We report a case of acute interstitial nephritis (AIN) and immune hemolytic anemia (IHA) associated with cefpodoxime therapy.

CASE SUMMARY

A patient with a recent history of cefpodoxime proxetil treatment presented with elevated serum creatinine, oliguria, nausea, vomiting, and dyspnea. Evidence of renal failure, abnormal urinalysis, and renal biopsy with inflammatory infiltrate in the interstitium confirmed a diagnosis of AIN. The patient subsequently developed IHA, which was confirmed by peripheral blood smear results and positive Coombs' test. The patient recovered after dialysis therapy and 2 days of intravenous methylprednisolone (500mg/day) followed by oral prednisolone (60 mg/day), which was rapidly tapered and stopped within 3 weeks.

CONCLUSIONS

To our knowledge, cefpodoxime-induced AIN and IHA are unprecedented. Physicians should be aware that drug-induced AIN and hemolysis can be associated with cefpodoxime proxetil.

Severe immune haemolytic anaemia due to ceftriaxone in a patient with congenital nephrotic syndrome

AIM

To describe the first case of ceftriaxone-related haemolysis in a patient with congenital nephrotic syndrome (CNS).

BACKGROUND

Severe haemolysis caused by an immune reaction to ceftriaxone has mostly been described in patients with underlying haematological or immune dysfunction.

CASE REPORT

The authors present a 20-month-old boy with CNS of the Finnish type with several previous severe infections treated with ceftriaxone, admitted for suspected sepsis. Following ceftriaxone administration he developed shock secondary to an acute haemolytic reaction, with severe anaemia. Hypersensitivity to ceftriaxone was documented through positive agglutination tests.

CONCLUSION

Onset of haemolysis following ceftriaxone administration, particularly in a patient previously exposed to the drug, must raise the suspicion of a possible immune reaction.

[Recurrent autoimmune hemolytic anemia induced by XELOX chemotherapy for colon cancer]

We describe a 54-year old woman with oxaliplatin-induced autoimmune hemolytic anemia and review the clinical features of similar published cases. The present patient had metastatic colon cancer and was admitted to our hospital with a floating sensation and general malaise on day 4 after undergoing the last of 4 cycles of a 7th round of chemotherapy with XELOX. Laboratory data revealed 4.6g/dl hemoglobin and 8.77 mg/dl creatinine. Direct and indirect Coombs tests of a blood sample for blood transfusion were both positive. We diagnosed immune hemolysis with acute renal failure based on the clinical course and blood samples showing haptoglobin <10mg/dl. We treated her with hemodialysis, plasmapheresis and immune suppression with prednisolone, which improved the anemia and renal failure.

[Autoimmune hemolytic anemia in a case of chronic hepatitis type C 56 weeks after initiation of second line treatment with pegylated interferon alpha2b/ribavirin combination therapy]

A 49-year-old man with chronic type C hepatitis had agreed to undergo pegylated interferon alpha2b/ribavirin (RBV) combination therapy during 48 weeks, but his hepatitis relapsed. Despite of second line treatment with the same combination, 56 weeks later, his hemoglobin decreased and the dose of RBV was decreased. He was then admitted to our hospital because of increasing anemia and this combination therapy was stopped. The results of blood chemistry and immunological examination revealed he had contracted autoimmune hemolytic anemia (AIHA). In cases of deterioration of anemia during this combination, we must discuss about not only RBV-induced hemolytic anemia but also AIHA.

Autoimmune hemolytic anemia associated with a formulation of traditional Chinese medicines

PURPOSE

A case of autoimmune hemolytic anemia (AIHA) after treatment with a Chinese herbal preparation is reported.

SUMMARY

A 29-year-old woman was admitted to the hospital with the primary complaints of jaundice, tea-colored urine, and fatigue lasting 10 days. Thirteen days prior, she went to a local private clinic seeking treatment for mild stomach pain and general malaise and was given weidean tablets. She took four tablets of weidean, a Chinese herbal preparation, orally three times daily for 2 days. After 2 days, she experienced fatigue, dizziness, and chest distress and subsequently discontinued treatment. Upon examination, she exhibited mild scleral and mucosal icterus. Her conjunctivas were pale, and her skin was slightly jaundiced. Preliminary laboratory tests found a low hemoglobin level and an elevated reticulocyte count. Biochemical tests showed an elevated total serum bilirubin concentration with indirect hyperbilirubinemia. Coombs' test results were positive for immunoglobulin G but negative for C3. All other test results were normal. The patient was diagnosed with AIHA secondary to weidean use, and she was treated promptly with oral prednisone, i.v. cimetidine, and oral sodium bicarbonate tablets. Seven days later, she showed clinical improvement. Her hemoglobin level rapidly increased to above 100 g/L, with a corresponding decrease in her reticulocyte count and serum bilirubin value over the next 8 days. She was discharged 15 days after admission and was asymptomatic at a three-week follow-up visit.

CONCLUSION

Weidean, a formulation of Chinese medicinal herbs and other constituents, was associated with AIHA in a woman taking the remedy for gastritis.

Methyldopa-induced autoimmune haemolytic anaemia revisited

Drug-induced haemolytic anaemia is a commonly encountered clinical situation. Methyldopa-induced haemolytic anaemia, once the most common cause of drug induced haemolysis, is now rarely seen due to decline in its use. We report a case of methyldopa induced immune haemolytic anaemia in a young woman where the diagnosis was initially missed. The major mechanisms of drug induced immune haemolysis and unique characteristics of methyldopa induced haemolysis are also outlined.

[A squamous cell lung cancer patient who developed immune hemolytic anemia after gemcitabine and docetaxel administration]

A 76-year-old man with squamous cell lung cancer underwent right lower lobectomy in November, 2005. He was diagnosed with pT2N0M0, stage I B, and tegafur/uracil (UFT) was administered. On July, 2007, right hilar lymphadenopathy was detected and considered to be a recurrence. UFT was discontinued, and gemcitabine (GEM) and docetaxel (DOC) combination chemotherapy was initiated on August 21. He began to complain of fatigue, palpitation and dizziness since the fifth day of the administration, and anemia (hemoglobin: Hb 8.7 g/dL) was detected on the fifteenth day. On the twenty-second day of the administration, he was admitted to our hospital because of aggravation of anemia (Hb 6.5 g/dL). His anemia was diagnosed as immune hemolytic anemia based on the laboratory findings including a positive Coombs' test. He showed improvement with prednisolone therapy. The anemia was considered to be drug-induced. This case was extremely rare, and there are no reports on immune hemolytic anemia related to GEM and/or DOC.

Chronic lymphocytic leukemia-associated autoimmune hemolytic anemia

The clinical course of patients with B-cell chronic lymphocytic leukemia (CLL) is often made complicated by autoimmune phenomena which mainly target the blood cells. Among them, the autoimmune hemolytic anemia (AIHA) is the most common form. On the other hand, it is believed that CLL is the most common of the known causes of AIHA. The source of any putative autoantibody (bystander nonmalignant cells or tumor cells) is not clear yet. Recently, it has been hypothesized that leukemic B-cells may also act as professional antigen presenting cells (APCs). With respect to the management of CLL-associated AIHA, steroids still represent the first-line treatment option. Intravenous immunoglobulin, immunosuppressive drugs, and splenectomy are also frequently used for steroid-refractory forms. Furthermore, although the case series is still too small, encouraging data is now supporting the use of monoclonal antibodies, in particular anti-CD20 rituximab, in managing this often life-threatening autoimmune complication of CLL.

Hematological side effects from antihypertensive drugs

To sum up, some hematological side effects are seen after antihypertensive drugs. They are, however, few, usually not severe and furthermore reversible. And so, from the viewpoint of the hematologist, there are no contraindications against antihypertensive treatment. The prevalence of side effects on blood and blood-forming organs from antihypertensive drugs is low. Of certain interest are 1) the tendency of modern diuretics (thiazides) to cause a moderate and reversible thrombocytopenia and 2) the positive antiglobulin reaction (Coomb's test) sometimes seen after alpha-methyldopa therapy and in a few cases causing autoimmune hemolytic anemia. Even though case reports have appeared on leukopenia/agranulocytosis related to almost all drugs used in the treatment of hypertension, none of these drugs seem to be especially prone to cause any damage to leukocytes and/or leukocyte production.

Immunological side-effects of antihypertensive drugs

The immunological side-effects under treatment with antihypertensive drugs are mainly limited to autoimmunity and autoimmune disease caused by alpha-methyldopa and hydralazine. Autoimmune hemolytic anemia is more common during treatment with alpha-methyldopa. Hydralazine may induce antinuclear antibodies. Some patients develop a SLE-like syndrome. Its clinical picture is less severe and its prognosis is more favourable than that of spontaneous SLE. During treatment with low doses the disease develops exclusively in patients who are slow acetylators. It may appear also in rapid acetylators during the high dose treatment. The symptoms are usually reversible after withdrawal of the drug.

Catastrophic multiple organ ischemia due to an anti-Pr cold agglutinin developing in a patient with mixed cryoglobulinemia after treatment with rituximab

Cold agglutinin disease occurring with cryoglobulinemia is a rare occurrence. Here, we report a patient with mixed cryoglobulinemia that was treated with rituximab and, after response, developed an anti-Pr cold agglutinin that manifested with hemolysis and microvascular occlusion causing mesenteric ischemia and cerebral infarction. Unlike previous reports of patients with cryoglobulinemia and cold agglutinin disease, our patient did not have a detectable cryoprecipitate when his cold agglutinin manifested.

Immune hemolytic anemia--selected topics

Autoimmune hemolytic anemia (AIHA) is most often idiopathic. However, in recent years, AIHA has been noted with increased incidence in patients receiving purine nucleoside analogues for hematologic malignancies; it has also been described as a complication of blood transfusion in patients who have also had alloimmunization. As the technology of hematopoietic stem cell transplantation has become more widespread, immune hemolysis in the recipients of ABO-mismatched products has become better recognized. The syndrome is caused by passenger lymphocytes transferred from the donor and, although transient, can be quite severe. A similar syndrome has been observed in recipients of solid organ transplants when there is ABO-incompatibility between donor and recipient. Venous thromboembolism is a little-recognized, though likely common, complication of AIHA, and may in some instances be related to coexistent antiphospholipid antibodies. While AIHA is a well-documented complication of malignant lymphoproliferative disorders, lymphoproliferative disorders may also paradoxically appear as a consequence of AIHA. A number of newer options are available for treatment of AIHA in patients refractory to corticosteroids and splenectomy. Newer immunosuppressives such as mycophenolate mofetil may have a role in such cases. Considerable experience has been accumulating in the last few years with monoclonal antibody therapy, mainly rituximab, in difficult AIHA cases; it appears to be a safe and effective option.

Drug-induced immune hemolytic anemia

Drug-induced immune hemolytic anemia (DIIHA) is rare, and a specialized laboratory is often required to provide the optimal serological tests to confirm the diagnosis. The most common drugs associated with DIIHA and the hypotheses for the mechanisms thought to be involved have changed during the last few decades. The drugs most frequently associated with DIIHA at this time are cefotetan, ceftriaxone, and piperacillin. DIIHA is attributed most commonly to drug-dependent antibodies that can only be detected in the presence of drug (eg, cephalosporin antibodies). DIIHA can also be associated with drug-independent antibodies; such antibodies do not need drug to be present to obtain in vitro reactions (eg, fludarabine). In these latter cases, the drug affects the immune system, causing production of red cell (RBC) autoantibodies; the clinical and laboratory findings are identical to autoimmune hemolytic anemia (AIHA), other than the remission associated with discontinuing the drug. Some of the mechanisms involved in DIIHA are controversial. The most acceptable one involves drugs, like penicillin, that covalently bind to proteins (eg, RBC membrane proteins); RBCs become coated with drug in vivo and, a drug antibody (usually IgG) attaches to the drug-coated RBCs that are subsequently cleared by macrophages. The most controversial is the so-called immune complex mechanism, which has been revised to suggest that most drugs are capable of binding to RBC membrane proteins, but not covalently like penicillins. The combined membrane plus drug can create an immunogen; the antibodies formed can be IgM or IgG and often activate complement, leading to acute intravascular lysis and sometimes renal failure; fatalities are more common in this group. It is still unknown why and how some drugs induce RBC autoantibodies, sometimes causing AIHA.

Late onset of autoimmune hemolytic anemia and pure red cell aplasia after allogeneic hematopoietic stem cell transplantation using in vivo alemtuzumab

Hemolytic anemia and pure red cell aplasia (PRCA) after allogeneic hematopoietic stem cell transplantation (HSCT) have been reported to be mainly related to ABO-incompatibility between donor and recipient. Autoimmune hemolytic anemia (AIHA) without ABO-incompatibility has been also reported after allogeneic HSCT, especially with T-cell depletion. However, optimal management of AIHA or PRCA remains unclear. A 54-year-old male with myelodysplastic syndrome (MDS) underwent haploidentical human leukocyte antigen-mismatched HSCT using in vivo alemtuzumab and developed AIHA and PRCA simultaneously 15 months after transplantation, following the administration of cidofovir and probenecid for persistent cytomegalovirus (CMV) antigenemia and retinitis. AIHA was successfully treated with rituximab, and subsequently PRCA with cyclosporine without relapse of MDS or recurrence of CMV infection. The clinical course suggested that AIHA was mainly caused by humoral immune response, while PRCA was mainly caused by cell-mediated immune response in this patient, although these immune responses might be related to each other.

Oxaliplatin-induced immune hemolytic anemia: a case report and review of the literature

We report a 59-year-old woman diagnosed with metastasic colorectal cancer who developed immune hemolytic anemia during FOLFOX chemotherapy (oxaliplatin/leucovorin/5-fluorouracil). Immunohematologic studies demonstrated that immune hemolysis was oxaliplatin-mediated. On the basis of this case and in a review of the literature in which 13 cases of previously reported oxaliplatin-induced immune cytopenia have been identified, we suggest some clinical clues regarding the use of oxaliplatin in cancer patients.

Red cell aplasia and autoimmune hemolytic anemia following immunosuppression with alemtuzumab, mycophenolate, and daclizumab in pancreas transplant recipients

BACKGROUND AND OBJECTIVES

Acquired red cell aplasia (RCA) is a rare disorder and can be either idiopathic or associated with certain diseases, pregnancy, or drugs. In exceptionally rare cases, it has been reported to co-exist with other autoimmune cytopenias. We report a high incidence of RCA and autoimmune hemolytic anemia (AIHA) in pancreas transplant recipients on alemtuzumab-based maintenance therapy.

DESIGN AND METHODS

Between February 2003 and July 2005, 357 pancreas transplant recipients were treated with immunosuppressive regimens containing the lymphocyte-depleting antibody alemtuzumab, the T-cell activation inhibitor daclizumab, and the anti-metabolite mycophenolate mofetil (MMF). We retrospectively reviewed medical records, blood bank data and bone marrow biopsy specimens of patients with a Transplant Information Services database diagnosis of RCA and AIHA from February 2003 to November 2005.

RESULTS

Severe RCA, AIHA, and idiopathic thrombocytopenic purpura (ITP) occurred independently or in combination, in 20 out of 357 (5.6%) pancreas transplant recipients, 12 to 24 months following the initiation of the aforementioned immunosuppressive regimens. Severe opportunistic infections developed late in 14/20 (70%) of these patients. Atypical morphologic features, including variable dysgranulopoiesis, variable megakaryocytic hyperplasia with normal or low peripheral platelet counts, and atypical lymphoid aggregates were found in bone marrow trephine sections of 11 patients in whom the diagnosis of RCA was made.

INTERPRETATION AND CONCLUSIONS

We hypothesize that the combination of alemtuzumab, daclizumab and MMF can result in immune dysregulation thereby permitting autoantibody formation. Because the use of these three immune suppressants is becoming increasingly common, it is important to recognize the severe hematologic complications that can arise.

Mixed-type autoimmune haemolytic anaemia: unusual cases and a case associated with splenic T-cell angioimmunoblastic non-Hodgkin's lymphoma

The diagnosis of mixed-type autoimmune haemolytic anaemia (AIHA) is based on demonstrating the presence of "warm" IgG auto-antibody and "low titre" ( < 64 at 4 degrees C), "high thermal amplitude" (reacting at or >30 degrees C) "cold" IgM auto-antibody. Mixed-type AIHA is uncommon. Red cell agglutination on the peripheral blood film is a common finding in mixed-type AIHA and can lead, initially, to a mis-diagnosis of cold haemmagglutinin disease (CHAD). Mixed-type AIHA is rare and can be idiopathic or secondary, often associated with systemic lupus erythematosus (SLE) and lymphoma. In general, patients with mixed-type AIHA show a dramatic response to steroid therapy and frequently require few or no transfusions. We report two unusual cases of mixed-type AIHA. Case one was unusual as the patient developed AIHA while on steroid medication. Case two, we believe, is the first reported case of splenic T cell angioimmunoblastic non-Hodgkins lymphoma (NHL) associated with mixed-type AIHA. The patient failed to respond to steroids, intravenous immunoglobulin, chemotherapy and treatment with rituximab. The patient received 33 units of red cells over a 9-week period. She finally underwent splenectomy with resolution of haemolysis. DAT tested with monospecific reagents, and thorough serological investigations is required to reach the diagnosis of mixed-type AIHA. Awareness of this condition is important as management may be different from either treating warm AIHA or CHAD.

Oxaliplatin-induced hemolytic anemia during adjuvant treatment of a patient with colon cancer: a case report

We report the case of a 64-year-old patient who developed autoimmune hemolytic anemia with thrombocytopenia and acute renal failure shortly after the infusion of the 11th cycle of adjuvant chemotherapy with oxaliplatin, folinic acid and 5-fluorouracil (FOLFOX 4), and was successfully treated by means of plasmapheresis, corticosteroids and dialysis. To the best of our knowledge, only seven other cases have been described in the literature, but we believe this serious adverse event induced by oxaliplatin is more frequent than this would suggest.

One center's experience: the serology and drugs associated with drug-induced immune hemolytic anemia?a new paradigm

BACKGROUND

Drug-induced immune hemolytic anemia (DIIHA) is an uncommon finding characterized by a sudden decrease in hemoglobin after treatment with the putative drug. The full range of drugs causing DIIHA and the initial serologic presentation are not fully appreciated. This work identifies additional drugs associated with DIIHA and offers additional insights about diagnosis.

STUDY DESIGN AND METHODS

A 20-year retrospective review of testing in one laboratory was performed. Patient sex, age, medication history, initial direct antiglobulin test (DAT) and indirect antiglobulin test, method of drug-dependent antibody (DDA) detection, and specificity were reviewed.

RESULTS

Seventy-one patients with 73 DDAs to 23 different drugs were identified. The following DDA specificities were identified: cephalosporins (37), penicillin and/or penicillin derivatives (12), nonsteroidal anti-inflammatory drugs (NSAIDs) (11), quinine and/or quinidine (7), and others (6). Fifty-two percent (37) were due to cephalosporins with 27 cefotetan-dependent antibodies detected. Four NSAIDs required urinary metabolite for detection. DAT was strongly positive, at least 2+, in 75 percent (51/68) of patients with a positive DAT. Initial eluate was negative in 52 patients, weak positive (<2+) in 14 patients, and strong positive (>or=2+) in 2 patients. Serologic results showed characteristics of warm autoimmune hemolytic anemia (AIHA) in 22 or 31 percent of all cases and cold-reactive AIHA in 2 cases.

CONCLUSIONS

It is important to consider DIIHA when a patient serologically presents as either warm- or cold-type AIHA to avoid erroneous diagnosis. Based on these findings, the strength of the initial DAT is much stronger than previously reported for all types of drug-induced immune hemolysis. This report is also unique in the number of NSAIDs reported. A new classification of categorizing DDA is proposed.

Autoimmune hemolytic anemia during interferon-beta-I b treatment for multiple sclerosis

A 31-year-old patient with multiple sclerosis (MS), treated with interferon beta-1b (IFNB-1b) for two years, presented with fatigue and dizziness. Coombs' positive autoimmune hemolytic anemia (AIHA) was found. Other potential etiologies of AIHA were ruled out. An association with IFNB-1b was highly suspected. Interferon therapy was discontinued and prednisone therapy instituted. There was resolution of the hemolytic anemia, and prednisone therapy was tapered gradually. To the best of our knowledge, there is no reported case of the development of AIHA associated with IFNB-1b use in MS patients. We conclude that if an unexplained drop in hematocrit occurs with a MS patient receiving IFNB-1b, autoimmune mediated hemolysis should also be considered.