Pure Red Cell Aplasia in Follicular Lymphoma with Bone Marrow Involvement and Isoniazid Exposure.

Pure red cell aplasia.

Thrombocytosis and Megakaryocyte Changes Associated with Pure Red Cell Aplasia

Objectives To investigate distribution of T lymphocyte subsets, absolute value and proportion of large granular lymphocyte(LGL) in peripheral blood and bone marrow of acquired pure red cell aplasia (PRCA) patients, and to evaluate patients′ immune function and efficacy of immunosuppressive agents. Methods From January 2002 to November 2015, a total of 25 patients with acquired PRCA who were treated at Department of Hematology, People′s Hospital of Xinjiang Uygur Autonomous Region at first-visit were enrolled into this study, as study group. Inclusion criteria of study group: patients′ diagnoses were conformed to the diagnostic criteria of PRCA in Diagnosis and Curative Effect of Hematology (3rd edition) and clinical data were complete. Exclusion criteria: other anemia disease and clinical data were not complete. In 25 cases of PRCA patients, 5 cases were secondary PRCA with T cell-large granular lymphocyte leukemia (T-LGLL), other 20 cases were primary PRCA. And 25 cases of health people who were receiving physical examination at the People′s Hospital of Xinjiang Uygur Autonomous Region during the same period were recruited into control group randomly, by simple random method. Inclusion criteria of control group: no abnormality in blood routine examination and biochemical test. Exclusion criteria: abnormality in blood routine examination, and suffering from immune disease, tumor. T lymphocyte subsets of subjects in study group and control group were detected by flow cytometry. Blood routine examination and bone marrow examination were carried out in study group before and after treatment. Then absolute value and proportion of LGL in bone marrow, peripheral blood and curative effect after drug treatment of cyclosporine A and so on of 25 acquired PRCA patients were analyzed retrospectively and compared statistically. The study protocol was approved by the Ethical Review Board of Investigation in Human at People′s Hospital of Xinjiang Uygur Autonomous Region. There were no statistically significant differences of subjects′ clinical data, such as age and gender ratio, between two groups (P>0.05). Results ①Compared with control group, helper T lymphocyte (Th) proportion and Th/suppressor T lymphocyte (Ts) ratio of acquired PRCA patients in study group were significantly lower, Th proportion: (36.6±3.8)% vs (45.1±2.1)%; Th/Ts ratio: 1.2±0.2 vs 2.2±0.4; there were significant differences (t=9.161, 12.174, P=0.032, 0.021), and Ts proportion of study group was significantly higher than that of control group, (30.5±2.8)% vs (20.2±1.9)%; there was significant difference (t=13.460, P=0.021). There was no statistically significant difference of natural killer (NK) cell proportion between two groups, (11.3±1.8)% vs (10.3±1.3)%; and t=1.572, P=0.344. In study group, Th proportion, Th/Ts ratio of secondary PRCA patients with T-LGLL were lower than those of primary PRCA patients, Th proportion: (36.1±3.7)% vs (39.1±6.1)%; Th/Ts ratio: 1.0±0.2 vs 1.2±0.1; but the differences were not significant (t=2.293, 2.513; P=0.301, 0.297), and Ts proportion of secondary PRCA patients with T-LGLL was higher than that of primary PRCA patients, (31.0±2.7)% vs (28.4±2.0)%; but the difference was not significant (t=1.472, P=0.384). There was no statistically significant difference of NK cells proportion between two groups, (11.3±1.8)% vs (11.1±2.7)%; and t=1.572, P=0.364. ② Among 25 acquired PRCA patients in study group, 16 cases had higher proportion of lymphocytes in peripheral blood (64%, 16/25), and 10 cases had 2~3 granules LGL (40%, 10/25); 8 cases had more than 20% LGL of total lymphocytes (32%, 8/25). Four cases had 2~3 granules LGL in bone marrow (16%, 4/25); 3 cases had more than 20% LGL of total lymphocytes (12%, 3/25). The ratio of patients with LGL in peripheral blood was significantly higher than that in the bone marrow (χ2=6.595, P=0.003). ③ After treatment, hemogram of 18 cases returned to normal, including four cases with normal myelogram, fourteen cases with decreased bone marrow erythroid cell hyperplasia, which was higher than that before treatment. Effectiveness evaluation of study group was as follows: four PRCA patients were cured basically; fourteen cases achieved remission; six cases achieved significant progress; one case was invalid. The total effective rate of treatment was 96% (24/25). Five secondary PRCA patients with T-LGLL didn′t need blood transfusion after treatment, but unlike primary PRCA patients, their hemoglobin levels didn′t recover to normal reference range. Conclusions The disorder of T lymphocyte subsets in patients with acquired PRCA caused the disorder of cellular immune function, and LGL detected in peripheral blood would help the diagnosis of acquired PRCA. Effect of cyclosporin A treatment on acquired PRCA was very significant, but curative effect of secondary PRCA patients with T-LGLL was poorer than that of primary PRCA. Key words: Red-cell aplasia, pure; Anemia, aplastic; T-lymphocyte subsets; Leukemia, large granular lymphocytic; Cyclosporine

Pure red cell aplasia (PRCA) is a rare hematologic syndrome characterized by anemia with marked reticulocytopenia and, in Asia, is often accompanied by T-cell large granular lymphocyte leukemia (T-LGL). Minimal research has been done on the epidemiology and sequential events of PRCA combined with T-LGL. This study identified 2801 PRCA and 840 T-LGL patients by using big data of the National Health Insurance Service between 2003 and 2022. The average annual crude incidence of PRCA was 2.77 per million and remained stable over 20 years, while T-LGL incidence was 0.82 per million with an increasing trend, possibly reflecting improved diagnostic accessibility. The average age for PRCA and T-LGL onset increased over the study period, consistent with aged society. Associated PRCA conditions are rheumatic diseases (10.5%), thymoma (4.7%), parvovirus infection (1.0%), inflammatory bowel diseases (0.8%), T-LGL (0.6%) and no specific cause (82.4%). Among 18 patients with both PRCA and T-LGL, PRCA preceded T-LGL (50%) or diagnosed concurrently (44%), suggesting that autoreactive T cells in PRCA which suppress erythropoiesis and sequentially evolve into clonal T cell proliferation and, eventually, T-LGL occurrence. This observation supports the hypothesis that both conditions might share a common pathogenic pathway. Further study should identify the causal relationship of PRCA diagnosis followed by T-LGL diagnosis.

Newly diagnosed and relapsed follicular lymphoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

Newly diagnosed and relapsed follicular lymphoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

Recurrent STAT3 Mutations in the Lymphocytes of Pure Red Cell Aplasia without T-Cell Large Granular Lymphocytic Leukemia

We describe the clinical course of a patient who experienced refractory pure red cell aplasia (PRCA) after undergoing HLA-matched allogeneic peripheral blood stem cell transplantation (allo-PBSCT) for refractory anemia with an excess of blasts in transformation that had evolved from Kostmann syndrome. The treatment for patients with myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML) developing from Kostmann syndrome has not been standardized. We treated this patient with allo-PBSCT using a regimen combining high-dose cytosine arabinoside with granulocyte colony-stimulating factor, in addition to total body irradiation and cyclophosphamide without preceding intensive chemotherapy. The donor was ABO incompatible. Myeloid and platelet recoveries were achieved rapidly. Erythroid engraftment was not evident, however, and the patient was given a diagnosis of PRCA. Regimen-related toxicity and graft-versus-host disease (GVHD) were limited. The PRCA did not respond to various therapies, including the discontinuation of immunosuppressants for the induction of chronic GVHD, human recombinant erythropoietin, immunosuppressive treatment with steroids, cyclosporin A, and human anti-CD20 antibody (rituximab). The patient received transfusions 48 times until the resolution of his anemia by donor leukocyte infusion (DLI) at 25 months after PBSCT. He is now clinically well (performance status, 100%) with normal blood cell counts at 5 years after SCT. An in vitro study demonstrated that serum from the recipient blocked the differentiation of erythroid cells in the bone marrow. The results indicate that the conditioning regimen we describe seems safe and effective for those who have MDS/AML and that DLI might be a valuable approach for refractory PRCA after ABO-incompatible SCT.

Pure red cell aplasia: The second hundred years

TO THE EDITOR: Pure red cell aplasia (PRCA) is a rare syndrome caused by erythropoietic hypoplasia in the absence of leukocytopenia and thrombocytopenia. It is characterized by severe normocytic and reticulocytopenic anemia, with a normally cellular bone marrow (BM) but devoid of erythroblasts [1]. The acquired form of PRCA is a chronic illness that is often diagnosed in conjunction with a variety of diseases [1], such as lymphoproliferative disorders [2], viral infections, autoimmune hemolytic anemia (AIHA) [3], rheumatologic disorders [4], and allogeneic stem cell transplantation [5]. However, this disorder is rarely diagnosed as an idiopathic condition. Acquired PRCA is managed as an immunologically mediated disease, using immunosuppressive therapy (IST) with corticosteroids and cyclosporine A (CSA) as the treatments of first choice [1]. As alternative and salvage treatment, rituximab has been reported to be highly effective [2,3,4,5]; however, to the best of our knowledge, no case of idiopathic PRCA managed with this agent has been reported. A 63-year-old woman was diagnosed in June 2003 as having PRCA after the discovery of isolated normocytic and reticulocytopenic anemia, the course of which had been insidious and progressive. All other possible underlying causes of erythroblastopenia were ruled out by appropriate investigations (Table 1); other laboratory and radiological evaluations revealed no abnormal findings. The patient had required transfusions of almost 2 units of packed red blood cells (RBC) every 2 to 3 weeks. Once the diagnosis was made, she was started on CSA plus corticosteroids, and soon achieved full recovery from BM erythropoiesis and attained normalization of peripheral blood counts. The patient no longer required transfusions. This was considered complete remission (CR) of PRCA. Therefore, the dosage of CSA was gradually reduced and discontinued. However, there was a progressive loss of response, and CSA was resumed in February 2007 due to a full relapse. The patient achieved a second CR, and the dosage of CSA was carefully tapered. However, the patient experienced progressive chronic renal failure (CRF) in January 2011, which fully resolved after discontinuation of CSA. PRCA recurred soon after, and the patient again required frequent RBC transfusions. When she required approximately 4 RBC units per month, steroids were retried, but without any benefit. Azathioprine was tried without any response. By May 2013, the need for transfusions had reached about 6 RBC units/month, and direct and indirect Coombs blood compatibility tests became positive with the appearance of anti-IgG autoantibody; therefore, the availability of required transfusions became a concern due the difficulty of finding compatible RBC units. In view of this life-threatening complication and a severe hematological condition refractory to all standard treatments for PRCA [1], rituximab was started as a salvage measure at a dose of 375 mg/m2/week for a total of 4 cycles, after the patient gave properly informed consent. Given the lack of experience with rituximab in the setting of primary PRCA, this treatment schedule was derived from that reported as safe and effective in patients with PRCA secondary to lymphoproliferative disorders [2]. After the second dose of rituximab, she exhibited a striking rise in her reticulocyte count and an increase in hemoglobin level. Thus, a third CR was achieved and was maintained during the subsequent 24 months (Fig. 1). In conclusion, the present letter describes a case of acquired chronic primary PRCA of idiopathic origin, refractory to standard measures, with remission on rituximab salvage treatment. To the best of our knowledge, this is the first report of idiopathic PRCA managed with rituximab. In our experience, this agent provided important clinical benefits in an elderly patient with a 12-year PRCA history, during which she had become intolerant/unresponsive to the majority of immunosuppressive agents used in this difficult-to-treat disorder. The course of disease and repeated responses to IST pointed to a possible underlying autoimmune pathogenesis. Although this hypothesis has not been proven by extensive clinical and laboratory evaluations; for this case, rituximab was highly effective in inducing long-lasting remission without any adverse effects.

Pure Red Cell Aplasia after ABO Incompatible Hematopoietic Stem Cell Transplantation Successfully Treated with Daratumumab: A Case Report

Besides peripheral cytopenias, bone marrow abnormalities, such as fibrosis, pure red cell aplasia and aplastic anemia have been reported in patients with systemic lupus erythematosus (SLE), suggesting that bone marrow may be a 25 target organ in SLE. Our objective was to describe this bone marrow involvement. This registry is a nationwide retrospective study. Centers provided data concerning medical history, SLE manifestations, type of hematologic disorder, treatments and outcome. Bone marrow aspirations and/or biopsies were transferred for centralized review. Thirty patients from 19 centers were included. Central hematologic manifestations comprised bone marrow fibrosis (n = 17; 57%), pure red cell aplasia (n = 8; 27%), myelodysplastic syndrome (n = 3; 10%), aplastic anemia and agranulocytosis (n = 1; 3% each). Bone marrow involvement was diagnosed concomitantly with SLE in 12 patients. Bone marrow biopsies showed fibrosis in 19 cases, including one case of pure red cell aplasia and one case of agranulocytosis and variable global marrow cellularity. Treatments included corticosteroids (90%), hydroxychloroquine (87%), rituximab (33%), intravenous immunoglobulins (30%), mycophenolate mofetil (20%) and ciclosporine (20%). After a median follow-up of 27 months (range: 1-142), 24 patients manifested complete improvement. No patient died. This registry comprises the largest series of SLE patients with bone marrow involvement. It demonstrates the strong link between SLE and bone marrow fibrosis. Patients with atypical or refractory cytopenia associated with SLE should undergo bone marrow examination to enable appropriate, and often effective, treatment. Long-term prognosis is good.

Pure red cell aplasia (PRCA) is a rare bone marrow failure syndrome defined by a progressive normocytic anaemia and reticulocytopenia without leukocytopenia and thrombocytopenia. Secondary PRCA can be associated with various haematological disorders, such as chronic lymphocytic leukaemia (CLL) or non-Hodgkin lymphoma (NHL). The aim of the present review is to investigate the infrequent association between PRCA and lymphoproliferative disorders. PRCA might precede the appearance of lymphoma, may present simultaneously with the lymphoid neoplastic disease, or might appear following the lymphomatic disorder. Possible pathophysiological molecular mechanisms to explain the rare association between PRCA and lymphoproliferative disorders are reported. Most cases of PRCA are presumed to be autoimmune mediated by antibodies against either erythroblasts or erythropoietin, by T-cells secreting factors selectively inhibiting erythroid colonies in the bone marrow or by NK cells directly lysing erythroblasts. Finally, focus is given to the therapeutical approach, as several treatment regimens have failed for PRCA. Immunosuppressive therapy and/or chemotherapy are effective for improving anaemia in the majority of patients with lymphoma-associated PRCA. Further investigation is required to define the pathophysiology of PRCA at a molecular level and to provide convincing evidence why it might appear as a rare complication of lymphoproliferative disorders.

Acquired pure red cell aplasia is a rare bone marrow failure disorder characterized by many underlying etiologies. The hallmark bone marrow feature is the near absence of erythroid precursors that otherwise exhibit normal cellularity, which has been attributed to both immune- and cellular-mediated mechanisms. Besides being merely speculative and considering the rarity of the disorder, the description of acquired pure red cell aplasia clinical associations represents a unique occasion to improve our current clinical knowledge of the disease, reveal clues on its pathogenesis, and guide therapeutic decisions. The varied clinical scenarios and common acquired pure red cell aplasia associated conditions (i.e., thymoma, T cell/NK-cell large granular lymphocyte leukemia, B cell dyscrasia) suggest a heterogeneity of pathogenic routes. Viral etiologies must always be considered and worked up in the initial assessment of newly diagnosed acquired pure red cell aplasia patients. In this report, we present two cases of hepatitis-C-related acquired pure red cell aplasia and successful use of anti-viral strategies in the achievement of a complete response.

Gene Mutation Profiles of Primary Pure Red Cell Aplasia and Large Granular Lymphocytic Leukemia Associated Pure Red Cell Aplasia