Diagnosis Of Autoimmune Hemolytic Anemia Research Articles

Autoimmune hemolytic anemia in treatment-naive chronic hepatitis C infection: a case report and review of literature.

The hepatitis C virus (HCV) is the most common blood-borne pathogen and currently infects over two hundred and fifty million individuals worldwide. Chronic HCV infection may result in cirrhosis, hepatocellular carcinoma, and liver failure. An exceedingly rare extrahepatic manifestation of HCV is autoimmune hemolytic anemia (AIHA). We discuss an interesting case of direct Coombs'-positive AIHA in a treatment-naive 53-year-old male with a past medical history of HCV cirrhosis, genotype 3a, who presented with fatigue, abdominal pain, and jaundice. Complete blood cell count demonstrated anemia, thrombocytopenia, elevated mean corpuscular hemoglobin and corpuscular volume worrisome for hemolytic anemia. Upon further workup, the patient was found to have increased bilirubin, reticulocyte count, and lactate dehydrogenase with concomitant direct Coombs'-positive test, consistent with the diagnosis of AIHA. A comprehensive workup was conducted to elucidate the underlying etiology of the AIHA, including malignancy, systemic lupus erythematosus (SLE), and medication side-effects. Malignancy was ruled out with an imaging and bone marrow biopsy. SLE was subsequently eliminated with a negative anti-nuclear antibody (ANA), and the patient had never received ribavirin, interferon, cephalosporins or other medications associated with drug-induced immune hemolytic anemia (DI-IHA). While the relationship between DI-IHA and HCV is well-described in the literature, primary AIHA in treatment-naive patients is a rare and intriguing extrahepatic manifestation of HCV and only four reports have been described in the literature. Given the prevalence of HCV and this interesting extrahepatic manifestation, HCV testing should be considered in patients presenting with AIHA with an otherwise negative workup and a history of parenteral or lifestyle risk factors.

Comparison of traditional methods and mitogen-stimulated direct antiglobulin test for detection of anti-red blood cell autoimmunity

The diagnosis of autoimmune hemolytic anemia (AIHA) is based on a positive direct antiglobulin test (DAT), which is performed using various methods with different sensitivities. Recently, mitogen-stimulated (MS)-DAT was suggested to be able to identify latent anti-erythrocyte autoimmunity. Traditional methods (tube, microcolumn, and solid phase) and MS-DAT were compared in 54 consecutive cases of suspected AIHA, 28 idiopathic AIHA in clinical remission, and 12 difficult-to-diagnose cases of DAT-negative AIHA, and the results (all cases) were correlated with hematologic and hemolytic parameters. DAT tube was confirmed as the gold standard to diagnose AIHA since almost all positive cases showed hemolytic anemia and positive eluates; 10 out of 26 tube-negative cases were positive on microcolumn and solid phase antiglobulin tests, and 22 out of 26 using MS-DAT, although only half of them showed clear signs of hemolysis. Mitogen stimulation increased the amount of IgG bound to red blood cells in all groups; moreover, MS-DAT was the only positive test in 10 cases of AIHA, and mitogen stimulation facilitated the identification of autoantibody specificity in culture supernatants. We conclude that a battery of tests rather than a single test is useful for the diagnosis of AIHA, including MS-DAT as an additional test for selected cases, although the results have to be cautiously interpreted based on the overall clinical context.

A Case of Autoimmune Hemolytic Anemia Caused by Repeated Administration of Oxaliplatin

Oxaliplatin is widely used as a chemotherapeutic agent for treating unresectable or metastatic gastrointestinal tract cancer, such as gastric cancer and colorectal cancer. The toxic effects commonly associated with oxaliplatin include neuropathy, myelosuppression, hypersensitivity reactions, and chemotherapy-induced hepatotoxicity. However, oxaliplatin-induced hemolytic anemia has rarely been reported in the medical literature. Herein, we describe a case of oxaliplatin-induced autoimmune hemolytic anemia in a patient with metastatic gastric cancer who received biweekly oxaliplatin-based chemotherapy that included fluorouracil and folinic acid. He presented with acute-onset anemia and acute renal failure shortly after the 25th course of oxaliplatin-based chemotherapy. A positive direct and indirect Coombs test and a good response to steroid therapy suggested the diagnosis of autoimmune hemolytic anemia. Afterwards, the patient was switched to an oral 5-fluorouracil agent, TS-1, for further treatment.

Mitogen Stimulated Direct Antiglobulin Test Compared with Traditional Methods for the Detection of Anti-RBC Autoimmunity.

Abstract 5091 BackgroundThe diagnosis of autoimmune hemolytic anemia (AIHA) is based on a positive direct antiglobulin test (DAT), which is performed by various methods with different sensitivity. Recently mitogen stimulated (MS)-DAT was suggested able to disclose a latent anti-erythrocyte autoimmunity Aims: To compare different traditional (tube, microcolumn and solid phase) and new (mitogen stimulated, MS)-DAT methods in different diagnostic conditions: 54 consecutive cases of hemolytic anemia of suspected autoimmune origin, 28 idiopathic AIHA in clinical remission, and 12 difficult cases of DAT-negative AIHA, and 2) to correlate results with hematologic and hemolytic parameters. MethodsDAT tube, microcolumn, solid phase, and eluates were performed by standard techniques. MS-DAT was performed by stimulating whole blood with PHA, PMA and PWM and antibodies were detected by competitive solid phase ELISA. ResultsForty out of 54 consecutive cases of suspected AIHA were positive by one or more tests namely 14 DAT-tube, 19 microcolumn, 19 solid phase and 35 MS-DAT. Among the 14 DAT-tube positive cases, 11 were confirmed by all test, and 3 by one or more (1 microcolumn, 1 solid phase, and 1 MS-DAT), eluates were positive in 11, and the majority of patients (10/14) showed hemolytic anemia. As regards the 26 DAT-tube negative cases, 7 were positive in microcolumn and solid-phase (eluates positive in 2/8, panreactive), and 16 in MS-DAT, although in both groups anemia and hemolytic signs were less clear. Mitogen stimulation increased the amount of RBC-bound IgG in all groups, suggesting that MS-DAT could disclose a latent autoimmunity. Tube-negative/other methods positive cases included patients with B-CLL, myelodysplasia/aplasia, and thalassemia intermedia, in which autoimmune phenomena are more frequently observed than overt clinical autoimmune diseases. MS-DAT failed to detect anti-erythrocyte antibodies in half cases AIHA in clinical remission which still were tube-positive. Finally, MS-DAT was the only positive test in 10 cases of AIHA of difficult diagnosis, and mitogen stimulation allowed the identification of autoantibody specificity in culture supernatants of 2 cases which gave weak positive results in microcolumn/solid phase only. ConclusionWe concluded that a battery of tests rather than a single test is recommended for the diagnosis of AIHA, depending on the specific clinical context: tube is still a good choice for first screening, microcolumn and solid-phase, which are the automated routine, should be confirmed by a positive eluate to diagnose AIHA, although positivity without a clinical equivalent may be taken into account as part of an autoimmune habitus. MS-DAT could be considered as an additional test for selected cases of difficult diagnosis. DisclosuresNo relevant conflicts of interest to declare.

A Rare Cause of Anemia in Inflammatory Bowel Diseases: A Case Report and Review of Literature

Introduction: Anemia is a common problem in patients with inflammatory bowel diseases (IBD), and its etiology is usually multifactorial. It can be produced by chronic blood loss, nutritional deficiencies, and drugs such as salazopyrine; however it can also due to auto immune hemolysis, which is a rare complication of IBD. We report a case of coombs positive autoimmune hemolytic anemia associated with ulcerative colitis both diagnosed at the same presentation.Case Report: A 32 year old man with no significant past medical history presented with complaint of dark colored urine, jaundiced skin and fatigue for 4 weeks. He also reported diarrhea mixed intermittently with blood for last few months. Physical exam was consistent with jaundice and anemia (pallor and icterus) with slightly palpable spleen. Initial lab work up showed Hb of 3.8 with normal platelet and WBC count, high reticulocytes count of 7% .LFT showed serum bilirubin of 3.6 (direct 0.4) with normal serum ALT and AST levels .Serum LDH was high (1032 U/l) while serum haptoglobin was low (0.11 mg/dl). Peripheral smear showed anisopoikilocytosis & spherocytosis. (See Figure 1) Further investigations revealed a positive direct Coombs test consistent with diagnosis of autoimmune hemolytic anemia. CT abdomen and pelvis showed mild splenomegaly & non-specific enlarged mesenteric lymph nodes. Colonoscopy revealed ulcerative pancolitis confirmed by histological findings of biopsies taken. Patient received PRBC transfusions and was started on steroids and mesalamine and was discharged on maintenance dose. His symptoms resolved in 4 weeks and Hb remained stable with no evidence of further hemolysis at 4 month follow up .Repeated CT abdomen & pelvis showed resolution of the lymphadenopathy. [Display omitted] Discussion: Autoimmune hemolytic anemia (AIHA) is a rare complication of IBD. The exact underlying pathogenesis of this association remains obscure; however it has been attributed to the production of cross reacting anti erythrocyte antibodies. In AIHA associated with IBD, corticosteroids are considered to be first line therapy and often cause remission of hemolysis along with treatment for IBD Immunomodulators and splenectomy has been used for patients with refractory AIHA. Colectomy done for fulminant colitis has also been reported to induce remission of AIHA. Further studies for long term follow up and pathogenesis of this association are warranted.

B-lymphoblastic leukaemia presenting as autoimmune haemolytic anaemia

Dear Editor, In the March 2008 issue of Annals of Hematology, Niscola and colleagues reported a case of B-lymphoblastic leukaemia 9 months after the diagnosis of autoimmune haemolytic anaemia (AIHA) [1]. The preceding AIHA was in remission and its treatment was stopped, so nor the preceding AIHA nor its treatment influenced the leukaemia treatment. However, when Blymphoblastic leukaemia presents immediately as AIHA, treatment should be directed against both leukaemia and haemolysis, and toxicity should be limited. Recently, a 61-year-old man was admitted to the emergency department because of dyspnoea. The Hb count was 6.7 g/dl, WBC count 1.2·10/l, 5.8% blasts, neutrophil count 0.3·10/l, platelet count 84·10/l. Despite a normal reticulocyte count, there was evidence of relevant haemolysis suggested by increased lactate dehydrogenase and indirect bilirubin, and decreased haptoglobin. The peripheral blood smear showed no schistocytes. The direct antiglobulin (Coombs’) test was positive (3+) with polyvalent antibodies and anti-C3d, and negative with anti-IgG. Testing for cold agglutinins was negative. Bone marrow examination showed a common acute lymphoblastic leukaemia (ALL) with 97.5% marrow blasts and a normal karyotype. Because he had a history of myocardial ischemia, packed cells were transfused. This caused a very modest Hb increase. Because of neutropenia and the expectation of several more weeks of neutropenia and mucositis, we wanted to reduce the amount of corticosteroids. We chose to start preinduction treatment for ALL with cytarabine, etoposide and methotrexate. After 1 month, the Coombs’ test was only slightly positive, and laboratory evidence of haemolysis had disappeared. Induction therapy for ALL was started, this time with corticosteroids (dexamethasone), vincristine and adriamycin. One month later, the Coombs’ test was negative. After the induction courses, the Hb started to increase. A complete remission of ALL was achieved. After consolidation with cytarabine and asparaginase, the patient was admitted for allogeneic stem cell transplantation. Cases of ALL with a positive Coombs’ test at the time of diagnosis have been reported [2]. All had a positive Coombs’ with anti-Cd3 but not with anti-IgG, and cold agglutinins could not be found. In these patients, the Coombs’ test became negative when complete remission was achieved. Even though cytostatic drug are immunosuppressive, corticosteroids are most often used as first-line therapy for haemolytic anaemia caused by warm antibodies. Our results suggest that corticosteroids may not be necessary in the initial treatment of AIHA caused by ALL, as long as effective treatment directed against ALL is started.

Pure red cell aplasia associated with hemolytic anemia refractory to standard measures and resolved by rituximab in an elderly patient

Acquired pure red cell aplasia (PRCA) simultaneously associated with autoimmune hemolytic anemia (AIHA) has been very rarely described so far [1, 2]. We describe the case of an elderly woman, who was diagnosed as having idiopathic PRCA associated with AIHA which was unresponsive to two lines of immunosuppressive treatment and was then resolved by rituximab given as salvage therapy. A 68-year-old woman kept under our attention because of severe malaise, pallor and fatigue. Her past medical history was unremarkable; in particular, she denied any personal or familiar history of hereditary hemolytic anemia or autoimmune diseases. A past blood count had shown normal hemoglobin. Physical examination at admission was unremarkable, with the exception of pallor and mild jaundice; the patient did not present either spleen or liver enlargement. A comprehensive laboratory evaluation revealed no abnormalities other than those related to anemia and hemolysis. Indeed, severe normochromic and normocytic anemia (hemoglobin, Hb = 2.7 g/dl) was revealed. Reticulocytes were not detectable; white blood cell and platelet counts were normal. Increased indirect serum bilirubin, urinary urobilinogen and serum lactate dehydrogenase were present; serum haptoglobin was undetectable. Direct and indirect Coombs tests were positive. A warm-reactive antibody of the IgG isotype was eluted from the red blood cells (RBC). Serologic tests for parvovirus B19, HIV, Hepatitis virus, human cytomegalovirus, and Epstein-Barr virus were negative. Moreover, no clinical and/or laboratory signs of associated autoimmune disease were detected. Chest X-ray and total body CT scan showed normal findings. On the blood film, spherocytes and polychromasia were found. A bone marrow (BM) aspirate and a trephine biopsy demonstrated normal representation of myeloid and megakaryocytic precursors, but nearly absent erythroid precursors. Based on these findings, a diagnosis of AIHA combined to PRCA was made. Given the symptomatic anemia and the very low Hb levels, the patient received repeated administration of RBC concentrates. Methylprednisolone 2 mg/kg was given for 4 weeks without any benefit; equally ineffective was the concomitant treatment with cyclosporine-A (CSA) during the following 4 weeks. Therefore, in the light of reported experiences concerning the treatment of AIHA [3] and PRCA [2], the patient was offered rituximab as salvage therapy for which she gave her informed consent. Rituximab was administered intravenously at the dose of 375 mg/m as a 4-h infusion, once weekly for a total of four doses, without any adverse reaction or side effects (July 2007). Progressive increase of Hb levels and achievement of transfusion independence followed the rise in reticulocytes after the fourth dose of rituximab. Serum hemolytic parameters normalized, as well as the serologic finding of an auto-antibody also disappeared. A BM aspirate demonstrated no abnormal findings and, in particular, the full recovery of the erythroid matrix. The patient, 10 months after rituximab therapy, shows normal Hb and reticulocyte levels, and she is no longer received immunosuppressive therapy. Treatment of PRCA and of AIHA usually employs immunosuppressive drugs, mainly steroids and CSA, or immunomodulating agents [1]. However, conventional immunosuppressive treatments are often unsatisfactory for which rituximab has been successfully used as salvage therapy in the pediatric setting [2]. Our L. Scaramucci (&) P. Niscola M. Ales M. Giovannini A. Tendas L. Cupelli A. Siniscalchi D. Piccioni T. Dentamaro A. Perrotti P. de Fabritiis Hematology Unit, Sant’Eugenio Hospital, Piazzale dell’Umanesimo 10, 00144 Rome, Italy e-mail: scaramucci.laura@gmail.com

Caractéristiques des anémies hémolytiques auto-immunes à anticorps « chauds » et du syndrome d’Evans de l’adulte

The diagnosis of autoimmune hemolytic anemia (AIHA) relies mainly on the direct antiglobulin test (DAT), that is, Coombs' direct test, which has a sensitivity of about 95%. The classification of different forms of AIHA depends on the characteristics of the autoantibody and is an essential part of the diagnostic procedure. AIHAs mediated by warm-reactive autoantibodies (wAIHA) account for approximately 70% of all types: they may be either idiopathic or secondary to another autoimmune disorder (such as systemic lupus, lymphoma or primary immune deficiencies) or drug-induced. In adults, AIHA may also precede by many years the onset of non-Hodgkin lymphoma (NHL) or myelodysplastic syndrome. The management of wAIHA, based mainly on empirical data and uncontrolled studies, relies principally on corticosteroids as a first-line therapy. In cases of steroid resistance ( approximately 5-10% of the cases) and in cases of steroid-dependency, the most frequent second-line options are splenectomy or immunosuppressive agents. More recently, rituximab has shown promising results in small uncontrolled and retrospective studies and it is now widely used in refractory wAIHA. Future prospective studies should assess its efficacy earlier in the course of disease as a steroid-sparing strategy. Evans syndrome is an autoimmune disorder defined by the simultaneous or sequential combination of AIHA and immune thrombocytopenia or immune neutropenia. It may reveal an underlying condition (e.g., lupus, common variable immunodeficiency, etc.). Its management is usually extrapolated from the standard of care for isolated wAIHA. Before the availability of rituximab, the overall prognosis was relatively poor for adults with both wAIHA and ES, with a mortality rate of 15 to 20%.

Autoimmune Hemolytic Anemia and Common Variable Immunodeficiency

To describe the main characteristics and treatment of autoimmune hemolytic anemia (AHA) in patients with common variable immunodeficiency (CVID), we analyzed data from 18 patients, 4 from an earlier study and 14 from the French DEF-I cohort on adult patients with primary hypogammaglobulinemia. To be included, patients had to have CVID and a previous history of AHA with a hemoglobin level < or =90 g/L at onset. To determine whether AHA is associated with a particular clinical phenotype of CVID, we conducted a case-control study from the DEF-I cohort. The estimated frequency of AHA in CVID patients from the DEF-I cohort was 5.5% (14/252). Median age at AHA diagnosis was 26 years (range, 1-57 yr), and 27.5 years (range, 5-61 yr) at CVID diagnosis. CVID was diagnosed before the onset of AHA in only 2 patients (11%). CVID was diagnosed more than 6 months after AHA in 10 cases (55.5%), and the 2 conditions were diagnosed concomitantly in 6 cases. The 14 patients included in the DEF-I cohort were compared with 238 control patients with CVID but without AHA. Corticosteroids were used as initial treatment for all patients in the current study. An initial response was obtained in 15 of 18 (83%) patients. Overall, 9 of these (60%) achieved a lasting response with steroids alone (7 patients) or in combination with intravenous immunoglobulin (2 patients). Seven patients underwent splenectomy, and 5 additional splenectomies were performed for associated autoimmune thrombocytopenic purpura. After splenectomy, a lasting response was obtained in 3 of the 7 patients with AHA. However, 5 of the 12 splenectomized patients experienced life-threatening infection. Severe infection occurred in 2 of 4 patients receiving immunosuppressive drugs. At the end of follow-up, 13 of 18 (72%) patients were in treatment-free remission (13 complete responses), and 4 of 18 (22%) were in remission while on prednisone < or =20 mg/d. One patient had died, of cancer.

Molecular mechanisms and diagnosis of autoimmune hemolytic anemia

Molecular mechanisms and diagnosis of autoimmune hemolytic anemia

Hemolytic anemia due to warm autoantibodies

The diagnosis of autoimmune hemolytic anemia (AHA) requires evidence of shortened red blood cell (RBC) survival mediated by autoantibodies directed against autologous RBCs. About 80 percent of patients with AHA have warm-reactive antibodies of the IgG isotype; the remainder exhibit cold-reactive autoantibodies. Typical patients exhibit anemia, reticulocytosis, spherocytes and polychromasia on the blood film and a positive direct antiglobulin test (DAT). Increased indirect serum bilirubin, urinary urobilinogen and serum lactate dehydrogenase (LDH), and decreased serum haptoglobin are not required for the diagnosis, but are frequently present. Patients with AHA and no underlying associated disease are said to have primary or idiopathic AHA. AHA in patients with associated autoimmune disease and certain malignant or infectious diseases is classified as secondary. The etiology of AHA is unknown. Patients with symptomatic anemia require transfusion of RBCs. Prednisone and splenectomy may provide long term remission. Rituximab, intravenous immunoglobulin, immunosuppressive drugs and danazol have been effective in refractory cases and for patients who are poor candidates for surgery.

Primary Sclerosing Cholangitis and Autoimmune Hemolytic Anemia: A Casual Association?

Purpose: Primary sclerosing cholangitis (PSC) is a progressive and incurable condition characterized by inflammation, fibrosis, destruction and loss of interlobular-sized bile ducts, leading to biliary cirrhosis and liver failure. It is more common among men, is frequently associated with chronic inflammatory bowel disease (IBD) and with the following HLA haplotypes, -A1, -B8, and -DR3. Patients with PSC have increased prevalence of other autoimmune disorders, e.g. celiac disease. Autoimmune hemolytic anemia (AIHA) has been described in association with PSC, albeit uncommonly. A 55 year-old man with stable PSC, confirmed the previous year, and treated hypothyroidism but without chronic IBD, complained of increasing fatigue, chest pain and dyspnea of two weeks’ duration. He denied overt blood loss, fever, pruritus or jaundice. The principal examination findings were pallor and icterus. Vital signs were stable. Heart sounds were normal, there was no pericardial friction rub and both lung bases were clear. Neither liver nor spleen was palpable, and he had no clinical evidence of ascites. Laboratory data were as follows: Hb 6.7 g% (normal range [NR]: 14–18), and MCV 108.6 fL (NR: 80–94), with normal white cell and platelet counts. The reticulocyte count was 6.2% (NR: 0.5–4). LDH concentration was 164 IU/L (NR: 91–180). However, the serum haptoglobin was 2 mg% (NR: 36–195). His polyspecific, direct antiglobulin test was positive. Serum concentrations of ferritin, folate and vitamin B12 were normal. Total serum bilirubin (BR) was 3.5 mg% (NR: 0.4–1.2), of which the indirect component was 2.6 mg%. The alkaline phosphatase was 420 IU/L (NR: 42–121), but aminotransferase concentrations were normal. Albumin was 4 g% (NR: 3.2–5.5), and his prothrombin time was 12 seconds (NR: 9–13.1). Although his EKG revealed new left bundle branch block, cardiac enzymes were not elevated. A presumptive diagnosis of AIHA was made and treatment with methyl prednisolone begun. Concentrated red cells were transfused cautiously. Four weeks after commencing corticosteroid therapy his Hb had risen to 13.2 g%, and the haptoglobin to 37.8 mg%. His BR was 1.3 mg%. The daily dose of prednisone was 40 mg. Reports of the co-existence of PSC and AIHA include the sequence described above, and vice versa. This is the first report to our knowledge of a patient with PSC, AIHA and autoimmune hypothyroidism. The corticosteroid exposure demands careful attention to minimization of bone density loss.

Immune anaemias in patients with chronic lymphocytic leukaemia treated with fludarabine, cyclophosphamide and rituximab – incidence and predictors

Immune anaemias (IA) [auto-immune haemolytic anaemia (AIHA) and pure red cell aplasia (PRCA)] are complications of chronic lymphocytic leukaemia (CLL). Fludarabine has been associated with AIHA, whereas both rituximab and cyclophosphamide have been used to treat this condition. Combining these agents with fludarabine may reduce the likelihood of AIHA. We report on the incidence, outcome and pretreatment predictors of IA in 300 patients treated with fludarabine, cyclophosphamide and rituximab (FCR). Nineteen patients (6.5%) developed IA [AIHA (5.8%), PRCA (0.7%)] on or after treatment with FCR. Most patients (82.4%) with AIHA had a negative direct antiglobulin test (DAT). Additional markers of haemolysis (indirect hyperbilirubinaemia, reticulocytosis, low haptoglobin and elevated lactate dehydrogenase levels) confirmed the presence of AIHA in these patients. The majority of patients responded to therapies including steroids, ciclosporin, i.v. immunoglobulin, etc. High pretreatment levels of beta-2 microglobulin predicted for development of IA. No haemolytic crisis was observed during FCR therapy in eight patients with AIHA prior to FCR. Thus, the incidence of IA among CLL patients treated with FCR was comparable with historical rates. The diagnosis of AIHA can be considered even if the DAT is negative. Pre-existing AIHA need not preclude front-line FCR therapy.

Immune anemias in patients with chronic lymphocytic leukemia treated with chemoimmunotherapy regimen of fludarabine, cyclophosphamide and rituximab as initial therapy

6604 Background: Auto-immune hemolytic anemia (AIHA) has been reported with the use of fludarabine in the treatment of chronic lymphocytic leukemia (CLL). Since rituximab has been used to treat AIHA, it was anicipated that rituximab might reduce the incidence of AIHA when combined with fludarabine to treat CLL. We analyzed the incidence of immune anemias in 300 patients (pts) with CLL treated with fludarabine, cyclophosphamide and rituximab (FCR) as initial therapy. Methods: Diagnosis of AIHA was based on clinical evidence of hemolysis (elevated indirect bilirubin, reticulocyte count, lactate dehydrogenase) combined with positive Coomb’s test and/or low haptoglobin level. Pure red cell aplasia (PRCA) was diagnosed based on absence of erythroid precursors in bone marrow aspirate and/or biopsy. Results: 29 of 300 (9.5%) pts with CLL treated on a single-arm study of FCR showed evidence of immune anemias (age range18 to 86 years,median 62 years; 24 male and 5 female). 24 pts had AIHA, 3 had PRCA and 2 pts had positive Coomb’s test only (hemoglobin&gt;10 gm/dL). Higher beta2-microglobin and bone marrow lymphocyte percentage were associated with higher risk of developing AIHA in multivariate analysis. Immune anemia was present in 9 pts prior to FCR treatment, developed in 15 on FCR and in 5 after completion of FCR (1 month to 4 years later). AIHA was detected after a median of 4 cycles (range 1 to 6) in pts who developed it while on therapy. Coomb’s test was positive in 14 pts and negative in 15. Haptoglobin levels were low in 16, normal in 10 and not measured in 3 pts. Coomb’s test was negative in 14 of 16 pts with AIHA and low haptoglobin levels. 9 pts were treated with oral prednisone. Others treatments included cyclosporine, intravenous immunoglobulin, rituximab and splenectomy. 3 of 9 pts who had AIHA prior to starting FCR had sustained correction of anemia with FCR treatment alone. 2 pts had inadequate response to treatment of immune anemia; 1 of them developed myelodysplastic syndrome. Conclusions: The incidence of immune anemias in pts treated with FCR is comparable to other series. Low haptoglobin levels in appropriate clinical context can help to establish the diagnosis of AIHA in the face of negative Coomb’s test. [Table: see text]

Quantitation of red cell-bound IgG by an enzyme-linked antiglobulin test in the patients with warm-type autoimmune haemolytic anaemia

We have previously reported the evaluation of a gel-direct antiglobulin test and enzyme-linked antiglobulin test (ELAT) in the laboratory diagnosis of autoimmune haemolytic anaemia (AIHA). We now report our experience with quantitative ELAT performed on a large group of patients under long-term observation. The number of IgG molecules/red blood cell was determined in 658 blood samples from 268 randomly selected patients with warm-type AIHA. Eighty-six patients were tested every 2-4 weeks for several months. Laboratory signs of haemolysis were present in 65.7% of blood samples with a small amount of red cell-bound autoantibody (< 200 IgG molecules/red blood cell) and in 70.4% of blood samples with moderately coated red blood cells (200-1000 molecules/red blood cell). Haemolysis was demonstrated in 87.9% samples with > 1000 IgG molecules/red blood cell, which were predominantly IgG3 and C3 complement, the qualitative factors that may increase haemolysis. In 79% of periodically tested patients, the number of IgG autoantibody molecules/red blood cell decreased and this correlated with the improvement of haemolysis parameters. The number of IgG molecules varied in 21% of AIHAs and was associated with poor prognosis.

Clinical course of autoimmune hemolytic anemia: an observational study

Autoimmune hemolytic anemia is characterized by the production of autoantibodies against erythrocyte membrane antigens. This study was carried out to identify the clinical, immunological and outcome characteristics of autoimmune hemolytic anemia patients treated at the (HC-UFMG) Pediatric Hematology Unit and the Hemocentro de Belo Horizonte. We evaluated 17 patients younger than 15 years old admitted from 1988 to 2003 were evaluated. Autoimmune hemolytic anemia diagnosis was based on the presence of acquired hemolysis and confirmed by positive direct Coombs polyspecific test results. Clinical, laboratory, and outcome data were obtained from patient records. The median age at diagnosis was 10.5 months. The direct Coombs polyspecific test was positive in 13 and negative in four patients. Monospecific testing was performed for 14 patients. The most frequent red cell autoantibody was IgG (five patients), followed by IgM in two. Thirteen patients had severe anemia and needed blood transfusions. Underlying diseases were identified in four patients: systemic lupus erythematosus, Hodgkin's lymphoma, autoimmune hepatitis and Langerhans cell histiocytosis. The remaining patients were classified as having primary disease. The median follow-up period was 11 months (5 to 23 months). Three children died, two after splenectomy and one with complications of the underlying disease. Autoimmune hemolytic anemia is rare in children and adolescents. Although patients usually respond to corticosteroids and/or immunoglobulin, fatal cases can occur. Prognosis is worse in patients with chronic underlying diseases.

Does a negative direct antiglobulin test exclude warm autoimmune haemolytic anaemia? A prospective study of 504 cases

Serological evidence of warm-type autoimmune haemolytic anaemia (AIHA) is generally obtained by a direct antiglobulin test (DAT). With few exceptions, a positive DAT is indicative for the presence of autoantibodies (Gehrs & Friedberg, 2002). However, DAT-negative AIHA is suspected to constitute up to 5% of all warm-type AIHAs. It can occur by several possible mechanisms, including sensitisation by a small amount of IgG that falls below the detection threshold and both IgA and IgM antibodies that remain undetected by polyspecific antiglobulin reagents (Garratty, 1993). A highly sensitive gel technique has been introduced to overcome these problems (Nathalang et al, 1997). Accordingly, a negative DAT is now often interpreted as absence of autoantibodies and thus, as more or less preclusive for the diagnosis of AIHA. We conducted a prospective study enrolling in- and outpatients in whom immune-mediated red blood cell (RBC) destruction was to be excluded (n ¼ 1388). An indirect antiglobulin test (IAT) and DAT including anti-IgG, -IgM, -IgA, -C3d and -C3c specificities, respectively, were performed using the gel technique. Acid elutions were subsequently performed on RBCs from all patients who were non-reactive in IAT and DAT (n ¼ 504). Out of the 504 eluates performed, 481 were non-reactive, but 23 (4AE6%) contained RBC-specific antibodies. Patients’ details are given in Table I. Two groups of patients were identified: patients with previously undiagnosed AIHA (15/23) and patients with allospecific antibodies (5/23). All AIHA patients were found to be anaemic, with one exception (Patient 12) in whom a haemoglobin concentration at the lower end of

A Case of Autoimmune Hemolytic Anemia Associated with an Ovarian Teratoma

Autoimmune hemolytic anemia associated with an ovarian teratoma is a very rare disease. However, treating teratoma is the only method to cure the hemolytic anemia, so it is necessary to include ovarian teratoma in the differential diagnosis of autoimmune hemolytic anemia. We report herein on a case of a young adult patient who had severe autoimmune hemolytic anemia that was induced by an ovarian teratoma. A 25-yr-old woman complained of general weakness and dizziness for 1 week. The hemoglobin level was 4.2 g/dL, and the direct and indirect antiglobulin tests were all positive. The abdominal computed tomography scan revealed a huge left ovarian mass, and this indicated a teratoma. She was refractory to corticosteroid therapy; however, after surgical resection of the ovarian mass, the hemoglobin level and the reticulocyte count were gradually normalized. The mass was well encapsulated and contained hair and teeth. She was diagnosed as having autoimmune hemolytic anemia associated with an ovarian teratoma. To the best of our knowledge, this is the first such a case to be reported in Korea.

Rituximab therapy for chronic lymphocytic leukemia-associated autoimmune hemolytic anemia

Autoimmune hemolytic anemia (AIHA) is a well-known complication of chronic lymphocytic leukemia (CLL). In recent years the anti-CD20 monoclonal antibody rituximab has been used for the therapy of steroid-refractory AIHA and autoimmune thrombocytopenia, either idiopathic or in association with CLL. We report the results of rituximab treatment for 14 patients suffering from CLL-associated AIHA. They developed a direct antiglobulin test positive AIHA at a mean time of 47 months (range 0-135 months) from the diagnosis of CLL. In 3 cases AIHA was diagnosed at the same time as CLL. Only 1 patient had fludarabine-related AIHA. All patients received steroids as first-line treatment. At a mean time of 46 days (range 1-210 days) from the diagnosis of AIHA all patients received rituximab at a dosage of 375 mg/m(2)/weekly for 4 weeks. All patients except 3 (2 died of cardiac failure or sepsis soon after the third cycle and 1 HCV-positive patient experienced a rise in serum amino transferases) completed the scheduled four programmed cycles. First injection side effects of rituximab were minimal. All but 2 patients showed an increase in hemoglobin levels in response to rituximab (mean value 3.6 g/dl; range 0.7-10 g/dl) and a reduction in the absolute lymphocyte count and lymph nodes and spleen volume. Nine patients required packed red cell transfusions before starting rituximab; 5 no longer needed transfusions just after the second cycle and another patient after the fourth cycle. Three patients (22%) were considered to fully respond and 7 (50%) only responded partially. At a mean follow-up of 17 months, 8 patients were still alive, 6 of them transfusion-free. Our results prove that the anti-CD20 monoclonal antibody is an effective and well-tolerated alternative treatment for CLL-associated AIHA.

Laboratory diagnosis of autoimmune cytopenias

The past year's literature shows that little progress has been achieved in the laboratory diagnosis of autoimmune hemolytic anemia. The direct antiglobulin test is the only diagnostic test for autoimmune hemolytic anemia. Advantages of new techniques, such as the gel test, have to be determined. Today, cephalosporins are known to cause both drug-dependent and -independent autoantibodies. The diagnosis of idiopathic thrombocytopenic purpura is a clinical one. The new assays that measure antibodies against specific glycoproteins offer improved specificity. New laboratory advancements and accumulation of data on granulocytes' antigens and antibodies enabled us to recommend guidelines for the laboratory investigation of autoimmune neutropenia.