Diagnosis Of Pure Red Cell Aplasia Research Articles

#1572 Recurrent parvovirus B19 infection-associated pure red cell aplasia in kidney transplantation

Abstract Background and Aims Anemia is frequent in kidney transplant (KT) recipients, with multiple potential causes. Parvovirus B19 (PVB19) infection-associated pure red cell aplasia (PRCA) becomes an important diagnosis in KT recipients experiencing persistent anemia, in whom other etiologies have been excluded. PVB19-associated PRCA is described in up to 27% of KT recipients with anemia and recurrent disease in up to 33% of cases. The authors describe a case of a recurrent PVB19-associated PRCA in a KT recipient. Method - Results A 42-year-old male with chronic kidney disease of unknown etiology underwent KT from a deceased donor after circulatory death in January 2021. He received induction immunosuppression (IS) with thymoglobulin and maintenance IS with prednisolone, tacrolimus, and mycophenolate mofetil (MMF). Three months after KT, the patient complained of progressive asthenia, and normocytic normochromic (NN) anemia was detected. A thorough investigation revealed normal leucocyte and platelet counts, low reticulocyte count, and no signs of bacterial infection, iron deficiency, or hemolysis; thyroid function, erythropoietin, folate, and vitamin B12 levels were normal, direct Coombs test was negative and no monoclonal spike was detected on protein electrophoresis. Endoscopic studies and cervico-thoraco-abdomino-pelvic computer tomography were unremarkable. Serum PCR of PVB19 was positive and confirmed the diagnosis of PVB19-associated PRCA. MMF was discontinued but anemia continued aggravating (nadir hemoglobin [Hg] level of 6.6 g/dL) with a sustained PVB19 load. He was admitted to the hospital, received blood transfusions, and was started on intravenous immunoglobulin (IVIG) 2 g/kg. A bone marrow aspirate was performed and was compatible with recovery after erythroid aplasia. The patient was discharged with Hg 8 g/dL and reduced PVB19 load. Although MMF remained suspended, and close monitoring of Hg and PVB19 load was performed, four months later he developed recurrent PVB19-associated PRCA, which motivated another hospital admission for IVIG with excellent response. In addition, he presented kidney dysfunction, and a kidney biopsy revealed borderline acute T-cell mediated rejection. In this setting, IS was altered to TRANSFORM SCHEEME. Four months later, he presented a second recurrence of PVB19-associated PRCA, requiring new hospitalization and treatment with IVIG. Considering the recurrent PVB19-associated PRCA, in a patient with chronic allograft dysfunction, high immunologic risk, and the foscarnet's probable nephrotoxicity, preventive therapy with IVIG (0.4 mg/kg) every 4 weeks was started. After 7 months of preventive IVIG infusion, no relapse was identified, the Hg is 11.5 g/dL (and increasing, without erythropoiesis stimulants) and the PVB19 load remains low. Conclusion PVB19-associated PRCA is characterized by persistent NN anemia with low reticulocyte counts, which is unresponsive to erythropoietin. One significant risk factor is induction IS, particularly thymoglobulin. In the setting of solid organ transplants, the absence of PVB19 antibodies does not exclude this diagnosis and viral detection should be performed. The initial therapeutic approach involves reducing IS. However, the risk of allograft rejection must be acknowledged. If this approach proves insufficient, IVIG treatment is usually successful. In our patient, considering the facts that allograft rejection limits the reduction of IS, the need for blood transfusions, and the inherent immunization, in a young patient that will possibly require a second KT, the undesirable nephrotoxicity of foscarnet, the successful response to IVIG, and patient's quality of life, chronic IVIG therapy was thought to be the best choice and proved efficacious in preventing relapses. Despite the absence of precise guidelines for chronic PVB19 infection management, maintenance therapy with prolonged IVIG infusions may be a therapeutic option for recurrent PRCA, but more studies are necessary to define the appropriate duration of treatment.

Unveiling the Spectrum of Inborn Errors of Immunity: Lessons from T-Cell LGL Clonal Expansions

T-cell LGL clonal proliferations occur in the context of various diseases of the immune system. These associations constitute a unique research framework to discern whether the expanded clones are triggers or sequels of the concomitant disorders and, more importantly, when and how they should be targeted. While the relationship of LGL leukemia (LGLL) with autoimmune diseases is well established, the exact pathogenic connection between them remains unknown and, probably, it is not a one-way process. We previously described a syndrome whereby LGLL co-occurred with pure red cell aplasia (PRCA), thymoma, and Ig deficiency. 1 Thus, one could speculate that, paradoxically, certain forms of immunodeficiency may lead to compensatory overreactions, resulting in autoimmunity and, ultimately, in clonal LGL proliferations. Indeed, Ig deficiency is frequently encountered in our series of LGLL (n=62, 32%). While acquired conditions ( e.g., thymoma, B-cell dyscrasia) may explain some (31/62, 48%) of these cases, congenital immune defects may have a complementary, even overlapping, pathogenic contribution. Here, we identified a 36-year-old woman with history of candidiasis, IgA deficiency, T1DM and Crohn's disease, with concurrent diagnosis of PRCA and LGLL. NGS revealed a germline heterozygous variant of uncertain significance (VUS) in BACH2, a gene involved in a recently reported inborn error of immunity (IEI) characterized by lymphocyte defects, Ig deficiency, and intestinal inflammation -features all depicted in our index case. This patient inspired us to posit that germline variants involved in IEI may also contribute to the pathogenesis of LGLL. To that end, we assessed the presence of IEI defects in 90 LGLL cases by performing WGS. We screened for variants in 90 IEI genes, covering different immune pathways. After applying a stringent variant calling, rare variants were defined as those with allele freq.<1% across genome resources. Variant pathogenicity was assessed according to ACMG criteria. For analysis, we selected all pathogenic/likely pathogenic (P/LP) variants, and VUS overrepresented in our cohort (significant p-values for Obs. vs Exp. freq. after multiple-testing correction). We found 21 variants in 15 IEI genes, carried by 20 LGLL patients (22%). The combined allelic burden for these variants was 12% ( vs the expected 2% in normal population). According to the role in immunity, the variants clustered in 2 main IEI categories: autoimmunity/immune dysregulation, and combined T-/ B-cell defects ( FigA). All variants were heterozygous, and 10/21 involved genes associated with dominant traits. Four defects in 3 patients were P/LP, and mono-allelic burden of 3/4 of these variants, involving the genes PRF1, AIRE and TNFAIP3, appeared to be a sufficient basis for immune imbalance leading to disease. When we analyzed the clinical features of the carriers of IEI variants, we observed that they were associated with diagnosis of LGLL at a younger age (median: 58 vs 64 yrs., FigB), including the patient with the earliest diagnosis of LGLL in our cohort, 17 yrs., who carried a PRF1 pathogenic variant. Carriers vs non-carriers had a higher proportion of autoimmunity (63 vs 43%), Ig deficiency (33 vs 23%) and other B-cell dyscrasias (58 vs 39%). Finally, carriers also had a significantly higher prevalence of cytopenias (94 vs 73%, p=.05) and particularly immune-mediated cytopenias (42 vs 17%, p=.02) than non-carriers. Most of these associations, including the predisposition to bone marrow failure (BMF) and immune cytopenias, persisted for the carriers of P/LP and dominant defects (since VUS in genes involved in dominant vs recessive traits are more likely to be of clinical relevance). Our findings suggest that variants predisposing to IEI can be found in the setting of LGLL. For some of these cases, the genetic burden might be strong enough to overshoot autoimmunity, promoting clonal LGL expansions. Environmental agents may have cooperative roles, and particularly infections, to which these patients may be intrinsically predisposed. Such atypical cases might exhibit distinct features, e.g., earlier onset of LGLL diagnosis, or concurrent BMF, which may serve as red flags tied to the underlying adult-onset IEI. Our study proposes an alternative pathogenesis for a significant fraction of cases with LGLL, and gives us the impetus to expand the IEI spectrum to the field of BMF and clonal hematological disorders.

Thrombocytosis and Megakaryocyte Changes Associated with Pure Red Cell Aplasia

J.A., R.G.W, and G.R. contributed equally to this abstract. Introduction: Acquired pure red cell aplasia (PRCA) is a rare hematological disorder characterized by normocytic, normochromic anemia with severe reticulocytopenia and a notable absence of identifiable erythroid precursors in the bone marrow. PRCA is often without a clear etiology and can be associated with conditions such as Large Granular Lymphocytic (LGL) Leukemias, B-cell dyscrasias, thymomas, immunodeficiencies or infections. Discovery of an IgG inhibitor in primary autoimmune pure red cell aplasia (PRCA) has been an immensely significant breakthrough. This finding has not only shed light on the critical role of IgG inhibitors in the pathophysiology of PRCA but has also underscored the importance of aberrant T cell activity in this condition. Thrombocytosis refers to an elevation in platelet count of >450,000/μL, which is not a typical feature associated with PRCA. Based on observations in our clinical practice of patients with PRCA with concomitant thrombocytosis, we screened our cohort for the combination of these features to discover potential mechanisms underlying this phenomenon. Methods: In order to address this objective, we conducted a retrospective analysis of medical records from 90 patients diagnosed with acquired PRCA at the University of Texas Southwestern and Cleveland Clinic Foundation between 2000 and 2022. Our primary goal was to determine the frequency of thrombocytosis among these patients. For those in the subset displaying thrombocytosis, longitudinal hemoglobin and platelet counts before and after treatment of the condition were also collected for relevant comparisons utilizing paired t-tests after assessing for normality with Shapiro-Wilk test. Results: Among a cohort of 90 patients diagnosed with acquired PRCA, 12 individuals exhibited thrombocytosis at the time of PRCA diagnosis (Table 1). Demographically, this subset of individuals had a median age of 53.5, and a 3:1 ratio of women to men. 66.7% of those with thrombocytosis also exhibited megakaryocyte hyperplasia on bone marrow biopsy. Molecular analysis ruled out the presence of myeloproliferative neoplasms, and blood work was obtained ruling out iron deficiency. Patients were treated for PRCA with a variety of medications including prednisone, cyclosporine, tacrolimus, rituximab, and cyclophosphamide. After treatment, 8 of the 12 patients demonstrated complete resolution of their PRCA, defined as transfusion independence with hemoglobin levels above 10. Further examination of those 8 patients with resolution of PRCA revealed statistically significant differences in mean hemoglobin and platelet counts before and after treatment (Figure 1). Specifically, the mean hemoglobin count increased from 7.9 (SD 2.5) g/dL to11.6 (1.8) g/dL (p=0.0168), while the platelet count decreased from 557,300 (SD 104,700) /μL to 414,400 (SD 109,600) /μL (p=0.0049). Conclusion: Our report is the most comprehensive case series to date reporting on thrombocytosis in patients with acquired PRCA. We speculate that the arrest of erythropoiesis generating PRCA may lead to skewing of precursors towards the megakaryocytic lineage. Alternatively, EPO production secondary to PRCA could stimulate TPO receptors and thus stimulate platelet production. Clinicians should be aware of this particular PRCA presentation. Further investigations will aid in elucidating whether one of these mechanisms may also be playing a role in PRCA-related thrombocytosis. The significance of thrombocytosis or megakaryocyte alterations in PRCA remains enigmatic, necessitating further investigations to elucidate their role in disease pathophysiology, as well as their utility as biomarkers for treatment response prediction. The limitations of this study encompass a small sample size and the absence of post-treatment bone marrow biopsy results, which would have facilitated the visual assessment of any resolved megakaryocyte abnormalities. Future directions include examining megakaryocyte hyperplasia and other megakaryocyte abnormalities such as hyper- and hypo-lobation associated with PRCA.

Adult pure red cell aplasia at Universitas Academic Hospital, Bloemfontein, South Africa: A 9-year review.

Pure red cell aplasia (PRCA) is characterised by severe normochromic, normocytic anaemia and partial or complete absence of reticulocytes from the peripheral blood. With bone marrow of normal cellularity, an almost complete absence of erythroblasts but preservation of other cell lines is observed. It may be congenital or acquired, with the latter presenting as a primary haematological disorder or secondary to various contributing factors. Management focuses on treatment of the underlying cause and supportive transfusions. Occasionally, immunosuppression or intravenous immunoglobulin (IVIG) is required. To describe the clinical characteristics, treatment and outcomes of adult patients diagnosed with PRCA at Universitas Academic Hospital (UAH) in Bloemfontein, South Africa, from 2010 to 2018. A retrospective descriptive file review was performed. All adult patients diagnosed with PRCA and treated in the Division of Clinical Haematology at UAH during the study period were included. Variables recorded included demographic information, clinical details of the PRCA diagnosis, classification of the PRCA, HIV and parvovirus B19 test results, results of special investigations, medical and drug history, treatment and response to treatment. Twenty-seven patients' files were included, with a female predominance (n=22; 81.5%). The median age at diagnosis was 35 years (range 20 - 62). The median number of days from onset of symptoms to date of diagnosis was 61 days (range 27 - 114). Approximately half (n=13; 48.2%) of the patients presented with a haemoglobin concentration of 1 - 3 g/dL. Most patients (n=26; 96.3%) were infected with HIV, with 76.9% (n=20) having a suppressed viral load. Parvovirus B19 infection accounted for 44.4% of cases (n=12), and all these patients were HIV positive. Lamivudine was a probable cause of PRCA in 18.5% of cases, although the true causal relationship was uncertain. Corticosteroids and IVIG were first-line therapy in 44.4% (n=12) and 37.0% (n=10) of cases, respectively. Thirteen patients (48.2%) achieved a complete response and 7 (25.9%) a partial response, while 2 (7.4%) showed no response, with continued transfusion dependence. In this population, women were disproportionately affected by PRCA. HIV was the single most important cause of acquired PRCA, which was independent of virological control. Parvovirus B19 and drugs were also important causes of acquired PRCA and played a critical part in the evaluation and work-up of PRCA. Nearly half of the patients achieved a complete response to therapy, which was sustained over 24 months.

Thymoma and pure red cell aplasia: A single institution experience.

e20625 Background: Thymoma is an uncommon malignancy often associated with paraneoplastic syndromes including pure red cell aplasia (PRCA), occurring in up to 5% of patients with thymoma. Considering the rarity of thymoma-associated PRCA, optimal treatment regimens and impact on thymoma disease course have yet to be established. Methods: A retrospective chart review was conducted for patients seen at the IUSCCC with thymoma and PRCA to extract and synthesize data on patient demographics, thymoma histology, hemoglobin levels, timeline of diagnoses, treatment regimens, and outcomes. Results: From 1993 to 2022, 10 patients (M:F = 4:6) with thymoma and PRCA were identified. Median follow-up duration was 75.0 months (range 32-202). Median age at thymoma diagnosis was 53.5 (range 40-80). Median age at PRCA diagnosis was 64.0 (range 40-80). Mean hemoglobin at PRCA diagnosis was 6.6. WHO classifications of thymoma included 10.0% A, 40.0% B1, 10.0% B2, 10.0% B2/B3, 30.0% not otherwise specified. Masoaka stages of thymoma included 20.0% stage I, 10.0% stage II, 10.0% stage III, 30.0% stage IVA, 30.0% stage IVB. Patients initially presented with thymoma (n = 7), PRCA (n = 1), or concurrent thymoma and PRCA (n = 2). For those initially presenting with thymoma, PRCA was subsequently diagnosed after a median 19.5 months (range 9-144). Of these 7 patients 3 experienced a relapse or progression of their thymoma at time of PRCA diagnosis, 3/7 had stable disease (1-insufficient data). Additional paraneoplastic syndromes were seen in 6 patients (hypogammaglobulinemia-2; pure white cell aplasia-1; myasthenia gravis-1; autoimmune neutropenia-1; colitis -1). Other diminished immunologic parameters observed were: immunoglobulin levels (n = 3); CD4 counts (n = 2); CD4:CD8 ratio (n = 4); and total B cell (n = 6). The primary outcome of the study was transfusion dependence, defined as requiring ≥1 PRBC transfusion per month for ≥3 months. Six achieved transfusion independence, while 3 remained transfusion dependent despite therapy (1 LTFU). Both patients with concurrent thymoma and PRCA underwent thymectomy, but only one achieved transfusion independence with additional adjuvant immunosuppressive therapies. Median duration of transfusion independence was 18.5 months (range 4-204). Median survival after bone marrow biopsy diagnosis of PRCA was 50.0 months (range 9-202). Conclusions: The impact of PRCA on thymoma disease course is variable. Most patients will recover with immunosuppressive therapy, but approximately 30.0% patients remained transfusion dependent. Our experience does not support thymectomy alone as primary treatment of PRCA. More research is needed to evaluate the mechanism of developing PRCA in thymoma and to define the optimal therapeutic approach.

Pure red cell aplasia in systemic lupus erythematosus, a nationwide retrospective cohort and review of the literature.

To characterize the clinical and biological course, management and response to treatment in SLE-associated pure red cell aplasia (PRCA). This was a nationwide, multicentre, retrospective cohort study. From 2006 to 2018, we included adults with a diagnosis of PRCA supported by bone marrow examination and SLE or biologic manifestations of SLE after ruling out parvovirus B19 infection. We enrolled 24 patients (20 women). SLE was diagnosed before PRCA for 14 patients (median delay 81 months). At PRCA diagnosis, mean age, haemoglobin level, and reticulocyte and differential erythroblast count were 39.2 (13.2) years, 62 ( 20) g/l, 9.1 (7.6) × 109/l and 2.8 ( 2.5)%, respectively. Eleven (45%) patients experienced multiple PRCA flares (median 6, range 2-11). CS therapy resulted in only three complete sustained responses, and 19 (79%) patients required immunosuppressive agents with highly variable regimens. After a median follow-up of 76 months (range 13-173), 17 (71%) patients showed complete response for PRCA, 5 (21%) partial response and 2 (8%) treatment failure. In total, 21 (87%) patients required red blood cell transfusion; 5 had a diagnosis of transfusion-related iron overload. Eighteen (75%) patients experienced severe infectious events requiring hospitalization. SLE-associated PRCA is a severe condition. Repeated red blood cell transfusions and several lines of immunosuppressant therapy are mostly required, with high risk of severe infectious events and iron overload. Despite sustained response for PRCA and SLE obtained in most patients, the best therapeutic strategy remains to be determined.

Pure Red Cell Aplasia Related to Parvovirus B19 Infection in Simultaneous Pancreas and Kidney Recipient: A Case Report

A 42-year-old woman received a simultaneous pancreas and kidney transplantation (SPK). Immunosuppression consisted of tacrolimus modified release, prednisone, mycophenolate mofetil (MMF), and thymoglobulin as induction. The function of both grafts was good. Eight months after SPK, the patient suffered from weakness and arthralgia. Normocytic anemia with reticulocytopenia was revealed. In a bone marrow examination, giant pronormoblasts were found. Immunohistochemical staining of bone marrow and serum examination were positive for Parvovirus B19 (Parvo B19) confirming diagnosis of pure red cell aplasia (PRCA).The treatment consisted of MMF withdrawal, red-cell transfusions, immunoglobulins subcutaneously (SCIg) and immunosuppression reduction. Rapid improvement was observed with the rise of reticulocyte count and hemoglobin. Two months after the achievement of remission, the low dose of everolimus was added considering the high risk of rejection and antiviral potential of mTOR inhibitors. Three months later, PRCA relapsed. Retherapy with SCIg was still effective. Subsequent SCIg was supplemented due to low reticulocyte count and recurrent herpes zoster. The replication of Parvo B19 was persistent (serum qualitative test). Everolimus was withdrawn after 9 months of therapy due to the recurrence of PRCA and serious infections. The observation period after PRCA diagnosis lasts for 15 months. The patient is in good condition with no anemia and excellent grafts function. In conclusion, pure red cell aplasia related to Parvo B19 infection should be considered in transplant recipients with normocytic anemia and reticulocytopenia. The treatment with immunoglobulin G and immunosuppression reduction is an effective therapy. The role of everolimus in Parvo B19 infection requires future studies.

Pathophysiologic Mechanisms And Management Of Large Granular Lymphocytic Leukemia Associated Pure Red Cell Aplasia.

Large granular lymphocytic leukemia (LGLL) is a chronic clonal lymphoproliferative disease of mature T or NK cells, and produces a variety of hematological abnormalities. Pure red cell aplasia (PRCA) is a rare haematological disease and is one of the most common complications of LGLL. LGLL-associated PRCA may represent a relatively indolent type and may be more common than reported, but its natural history and clinical course have not been well described. The ethnic origin of the patients is an important consideration in determining the relationship between PRCA and LGLL. Guidelines and progresses for management of LGLL-associated PRCA rely on accumulation of empirical experiences, integrative analyses of several cases and clinical trials. The purpose of this review is to evaluate occurrence, possible mechanisms, diagnosis, clinical features, treatments and outcomes of LGLL-associated PRCA.

Pure red cell aplasia associated with thymoma: a report of a single-center experience.

Pure red cell aplasia (PRCA) associated with thymoma is relatively rare, and relevant reports are limited. We investigated the clinical features and outcomes of PRCA associated with thymoma in this study. A retrospective review of all PRCA patients who underwent surgical resection of thymoma from April 1, 2004, to December 31, 2015, was performed. We experienced eight patients with PRCA among 146 patients who underwent surgical resection of thymoma. Extended thymectomy (n=4) and thymectomy (n=4) were performed for thymoma. Regarding the WHO classification of thymoma, the subtypes were type B2 or B3 in seven patients, and the stage of thymoma was advanced in seven patients. Complete resection was achieved macroscopically in only five patients. Recurrence of thymoma occurred in four patients who underwent complete resection. PRCA was diagnosed after surgical resection of thymoma in six patients (range 1-101 months, median 56.5 months). Cyclosporine was used for PRCA in six patients. Pneumonia of treatment-related complications due to cyclosporine occurred in all patients. The follow-up period ranged from 13-147 months (median 54.5 months) after the PRCA diagnosis. Three patients obtained complete remission of anemia by cyclosporine. Although one patient was able to stop taking cyclosporine because of complete remission of anemia, transfusion was needed due to relapse of PRCA. Five patients died, with the main causes of death diagnosed as pneumonia (n=4) and cardiac failure (n=1). PRCA associated with thymoma was diagnosed postoperatively in three-quarter of patients. We should be alert for the occurrence of PRCA even after resection of thymoma, especially in patients with incomplete resection or advanced disease. Cyclosporine was effective for PRCA, but treatment-related complications occurred, particularly pneumonia. As treatment for PRCA associated with thymoma and its complications were combined in a complex manner, treating PRCA associated with thymoma can be quite difficult.

Clinical Spectrum, Evolution and Management of Autoimmune Cytopenia Associated with Angioimmunoblastic T-Cell Lymphoma: A Retrospective, Multicenter Study

IntroductionAngioimmunoblastic T-cell lymphomas (AITL) are frequently associated with immune system activation such as hypergammaglobulinemia, positive direct antiglobulin test, anti-smooth muscle antibodies and clinical autoimmunity. Autoimmune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP) have been reported, but to date, there is no specific study focusing on autoimmune cytopenia (AIC) in AITL. We sought to determine the clinical characteristics, evolution and response to treatment of AITL presenting with autoimmune cytopenia, including ITP, AIHA, auto-immune neutropenia (AIN) and pure red cell aplasia (PRCA) in a large cohort of patients from the multicentric T-cell lymphoma consortium (TENOMIC).Patients and methodsWe conducted a retrospective, multicenter study of patients diagnosed with AITL between 2001 and 2015 and presenting with at least one AIC (i.e. AHAI and/or ITP and/or AIN and/or PRCA, defined according to the international criteria). Patients were retrospectively selected from a cohort of 293 patients with AITL from a multicentric T-cell lymphoma consortium (TENOMIC). Medical charts were collected using a standardized from. Patients with AIC were matched for age and sex to control patients (5/1 ratio) diagnosed with AITL without AIC from the cohort.Results28 patients were included, with a mean age of 63 years (range 39 - 83), and 50% were females. There were 41 AIC (AIHA, n=21 (including 5 cold agglutinin diseases), ITP, n=12, PRCA, n=7, AIN, n=1). Among them, 17 patients had only one AIC, 7 had both ITP and AIHA (Evan’s syndrome) and 4 had PCRA associated with another AIC. One hundred and thirty six control patients were included (mean age 64 years (range 35 - 84), 49% female). Clinical characteristics of AITL at diagnosis showed more stage IV disease in AIC patients versus control patients (86% vs 66%, P= 0.0442), as well as more bone marrow (71% vs 34%, P=0.0005) and splenic (61% vs 19%, P< 0.0001) involvement. Immune activation markers such as anti-smooth muscle antibodies (71% vs 0.9%, P< 0.0001), gammaglobulins titers (27 g/l vs 18 g/l, P= 0.0019), and EBV replication (89% vs 61%, P= 0.0232), were significantly increased in AIC patients versus control patients. AIC were mainly concomitant with AITL diagnosis (83%). Only 2 patients had AIC before AITL diagnosis (2 and 8 months), and 4 patients developed AIC during the disease course (median 14 months (8 - 114)). Mean hemoglobin level at AIHA and PRCA diagnosis were 7.1 g/dl and 5.3 g/dl, and red blood cell transfusions were required in 52% and 86% of patients, respectively. Mean platelet count was 35 x 109/L at ITP diagnosis, and 42% of patients had bleeding manifestations, although no life threatening bleeding manifestation was observed. First line treatments of AIC included corticosteroids (88%), chemotherapy for AITL (71%), intravenous immunoglobulin (27%), or other treatments (12%), and were effective in all patients except for two patients who presented with refractory ITP. Ten patients had a relapse of AIC (5 ITP, 4 AIHA, 3 PRCA) with a median time to relapse of 4 months (1 - 18)). All AIC relapses were associated with AITL relapse. Only 3 patients had active AIC while AITL was considered in remission, including one patient who developed ITP after autologous stem cell transplantation. Sixty-four percent versus 66% of patients experienced AITL relapse in AIC and control group, respectively (P=1). Median overall survival (OS) and median progression free survival (PFS) were 77 and 12 months in the AIC group, and 41 and 12 months in the control group, respectively (P=ns).ConclusionIn summary, AITL associated with AIC had more advanced disease with increased immune activation compared to our control group, although it did not impact OS and PFS. AIC were mainly inaugural and responded well to chemotherapy. Interestingly, all AIC relapses were associated with AITL relapse. These findings are of interest for management of AITL patients presenting with AIC. DisclosuresCasasnovas:Abbvie: Consultancy, Honoraria; Takeda: Consultancy, Honoraria; Gilead: Consultancy, Honoraria, Research Funding; ROCHE: Consultancy, Honoraria, Research Funding; Sanofi: Consultancy, Honoraria; BMS: Consultancy, Honoraria. Leblond:Roche: Honoraria; Gilead: Honoraria; Janssen: Honoraria; Abbvie: Honoraria. Michel:Amgen: Honoraria; Novartis: Honoraria. Dupuis:janssen: Honoraria; ABBVIE: Membership on an entity's Board of Directors or advisory committees.

Analysis and observation of T lymphocyte subsets and curative effects in patients with acquired 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 induced by epoetin zeta.

Pure red cell aplasia (PRCA) may develop in patients with chronic kidney disease receiving erythropoiesis-stimulating agents (ESA). We report on a 72-year-old patient who developed hypo-proliferative anaemia unresponsive to ESA following the administration of epoetin zeta subcutaneously for 7 months. On the basis of severe isolated hypoplasia of the erythroid line in the bone marrow and high-titre neutralizing anti-erythropoietin antibodies (Ab), a diagnosis of Ab-mediated PRCA was made. Epoetin zeta was discontinued and the patient was given steroids. This was associated with anaemia recovery. To our knowledge this is the first PRCA case related to epoetin zeta.

Pure red cell aplasia in chronic lymphocytic leukemia: Case report and review of literature

Despite being immune deficient, chronic lymphocytic leukemia (CLL) patients have an increased incidence of autoimmune cytopenias secondary to autoantibody formation. These are: warm autoimmune hemolytic anemia; idiopathic thrombocytopenia; pure red cell aplasia (PRCA), and In this case report, we describe a patient with CLL who developed severe anemia requiring frequent red cell transfusion after the third cycle of chemotherapy. Blood film showed no evidence of hemolysis and absolute reticulocytopenia. Bone marrow showed erythroid hypoplasia and residual interstitial infiltrate of CLL. The diagnosis of CLL-induced PRCA was made, and the patient showed a prompt and dramatic response to treatment with cyclosporine.

Pure Red Cell Aplasia - a New Manifestation of CTLA4 Mutation

The cytotoxic T lymphocyte antigen-4 (CTLA4) is an essential negative regulator of immune responses. Its loss causes fatal autoimmunity in mice. Patients with heterozygous mutations in CTLA4 were recently reported to present with an autosomal dominant immune dysregulation syndrome characterized by hypogammaglobulinemia, recurrent infections and multiple autoimmune clinical features (Schubert, D. et al., Nat. Med. 20: 1410-1416, 2014; Kuehn, H.S. et al., Science 345, 1623-1627, 2014). Here we report a family with a CTLA4 mutation that presents with hematological manifestations not previously associated with CTLA4 loss.The index case was a girl referred to our hospital with a very severe thrombocytopenia and anemia at the age of 17. Bone marrow examination revealed no megakaryocytes and just a few erythroblasts. In contrast, granulopoiesis was normal and clonal lymphocytes were not detected. No etiology of the lack of thrombopoiesis and erythropoiesis was discovered. Lack of response to high-dose steroid treatment, platelet counts below 10x109/l, short-lasting effect of transfused platelets and a bleeding tendency urged us to start treatment with horse anti-thymocyte globulin (ATG) and cyclosporine after 2 months. A positive clinical response was observed in 2 weeks. Hb and platelet counts were normalized by 4 weeks, and all medication discontinued by 5 months. Two months later, the patient suffered from generalized tonic-clonic seizures. MRI revealed multiple cerebral lesions, lymphadenopathy and multiple infiltrates in lungs and kidneys. A core kidney biopsy revealed no clonal lymphoid infiltrates. A cerebral biopsy suggested crystal-storing histiocytosis. Steroids were administered, and the infiltrates disappeared gradually during the following months. More than two years later the patient suffered from a Salmonella-induced gastroenteritis, and again she became severely anemic. Her bone marrow revealed now lack of erythropoiesis whereas thrombopoiesis and granulopoiesis were normal. She was then diagnosed with pure red cell aplasia (PRCA).An uncle of the index case had been referred to us with the diagnosis MDS at the age of 47, one year prior to the index patient's last referral and PRCA diagnosis. Dysplasia was not verified, and since the patient completely lacked red cell precursors, the diagnosis was changed to PRCA. In addition, both he, his mother and the index case had been suffering from diarrhea for years without any diagnosis. His mother also had pernicious anemia.The two familial cases of PRCA, a rare hematological manifestation, prompted us to conduct whole exome sequencing which revealed that the two patients with PRCA were both heterozygous for a 5 base pair-insertion in exon 1 of the CTLA4 gene, leading to a frameshift and premature stop codon causing haploinsufficiency. Familial segregation was tested by Sanger sequencing and showed that also the grandmother and the mother of the index case were carriers of the same mutation.Functional assays of our index patient, the two family members with autoimmunity (her uncle and grandmother) and her unaffected mother revealed fewer CD19+ B- and naïve T cells than normal. Furthermore, we found dysregulation of regulatory T (Treg) cells, reduced levels of T cell CTLA4, particularly FoxP3+ Treg CTLA4 (mean fluorescence intensity as well as frequency of CTLA4+ T cells and Tregs) and signs of hyperactivity of effector T cells. Our findings were as reported in the above cited publications.The discovery of a CTLA4 mutation in this family with 3 affected members and one unaffected carrier might have immediate implications for our index patient. As she did not respond to high-dose steroids as her uncle did, her genetic diagnosis opens up to additional treatment opportunities. Actual medication for patients with mutations in CTLA4 and autoimmunity could be mTOR inhibitors like sirolimus and possibly CTLA4 fusion proteins (abatacept and belatacept). These fusion proteins bind to CD80 and CD86 and inhibit CD28-mediated immune activation.In conclusion, we have detected a mutation in the CTLA4 gene with corresponding T cell aberrations in this family through the new manifestation PRCA. These findings may be of clinical importance for the family we have characterized as well as for other patients with similar manifestations. DisclosuresOff Label Use: Abatacept and belatacept are fusion protein consisting of a part of CTLA4. It can modulate a signal necessary for activating specific T lymphocytes and can be effective in patients with CTLA4 mutations..

Pure red cell aplasia with thymoma/T-cell large granular lymphocyte leukemia: two cases report and literatures review

To investigate the clinical and laboratory features of 2 cases of pure red cell aplasia (PRCA) with thymoma/T-cell large granular lymphocyte leukemia (T-LGLL), and to improve the recognition of the disease and the role of lymphocyte in its mechanism. Two cases of PRCA with thymoma/T-LGLL were reported and the related literatures were reviewed. Case 1 was a 63-years old male with hemoglobin level of 54 g/L at admission. Case 2 was a 52-years old female with hemoglobin level of 79 g/L at admission. They were both diagnosed as PRCA with thymoma before admission to our hospital and had no benefit from their thymectomy. Further examinations in our hospital showed that CD3⁺CD4⁻CD8⁺CD57⁺ large granular lymphocytes amplified with clonal TCR rearrangement in their peripheral blood. The diagnosis of PRCA with thymoma/T-LGLL was clarified. Case 1 did not respond to any of the frontline therapies while case 2 responded completely to cyclosporine. Both thymoma and T-LGLL could be the cause of secondary PRCA, lymphocyte proliferation may play critical role in the pathogenesis.

Efficacy and Long-Term Outcome of Treatment for Pure Red Cell Aplasia after Allogeneic Stem Cell Transplantation from Major ABO-Incompatible Donors

No standard of care for pure red cell aplasia (PRCA) after major ABO-incompatible hematopoietic stem cell transplantation (HSCT) has been established. We conducted a retrospective cohort study to learn the efficacy and outcome of treatment for PRCA. One hundred forty-five recipients who showed delayed recovery of erythropoiesis and survived >100 days after transplantation without early disease progression were selected from 2846 records of major ABO-incompatible transplantation in the registry database in Japan, and detailed data of 46 recipients were collected. Treatment of PRCA, such as rapid tapering of calcineurin inhibitors, corticosteroids, or additional immunosuppressants, was given to 22 patients but not to the other 24 patients. The overall response rate of the treatment group was 54.5%. The number of days from diagnosis of PRCA to recovery of reticulocytes >1% and the cumulative number of red blood cell transfusions were not significantly different between the 2 groups. Infections accounted for the death of 7 of 11 patients in the treatment group. Univariate analysis identified 5 variables influencing survival, including graft-versus-host disease, disease progression, and treatment of PRCA; disease progression remained as the only factor negatively affecting survival by multivariate analysis. The present study could not provide supportive evidence for the beneficial effects of treatment for PRCA after major ABO-mismatched HSCT.

Successful Rechallenge with Darbepoetin Following Immunosuppressive Therapy in a Dialysis Patient with Erythropoietin-Induced Pure Red Cell Aplasia

Patients with erythropoiesis-stimulating agent (ESA)-induced pure red cell aplasia (PRCA) should not routinely be switched to an alternative ESA or to darbepoetin-α because anti-erythropoietin (anti-EPO) antibodies cross-react with all kinds of recombinant ESAs. We present a case of ESA-induced PRCA in a 69-year-old man on hemodialysis whose anemia improved with reintroduction of darbepoetin-α following immunosuppressive therapy. The patient developed severe anemia after 15 months of subcutaneous administration of erythropoietin-α. After the diagnosis of PRCA, erythropoietin-α was discontinued and immunosuppressive therapy with a combination of prednisolone and oral cyclophosphamide was initiated. After 4 months of immunosuppressive therapy, the anti-EPO antibody titer was markedly decreased; however, esophageal candidiasis developed. Additional therapy with cyclosporine alone instead of prednisone and cyclophosphamide was performed, and anti-EPO antibody was subsequently not detected. Darbepoetin-α was then reintroduced, and the patient’s anemia improved without red cell transfusion. In conclusion, ESA-induced PRCA was successfully treated with reintroduction of darbepoetin-α following immunosuppressive therapy. (Korean J Med 2013;84:742-746)

Immunogenicity of recombinant human erythropoietin in Korea: A two-year cross-sectional study

Immunogenicity of erythropoietin (EPO) is related with pure red cell aplasia (PRCA). We sought to determine the prevalence of antibody (Ab)-mediated PRCA in Korea and threshold diagnostic criteria by dual parameters: Ab titer and neutralizing activity. This study was a multi-center, cross-sectional study for two years. In the first year study (1 YS), 209 samples suspected to be EPO resistance were collected. In the second year study (2 YS), all the patients who consented to participate (N = 946) were enrolled. In 1 YS, we found three and six serum samples that were positive and borderline for anti-EPO Abs, respectively. The first three patients had neutralizing activity (NT) and were diagnosed as PRCA. In 2 YS, seven patients were anti-EPO positives and six had borderline levels. Among them, one patient with NT was diagnosed as PRCA and one with NT as aplastic anemia. The prevalence of PRCA was 0.106%. The correlation analysis of the 22 patients who had anti-EPO Ab showed that dual crossed cut-off lines (anti-EPO Ab titer ≥ 40 ng/ml, % NT ≥ 25%) were able to clearly isolate red cell aplasia. We suggest novel diagnostic criteria for diagnosis and prediction of Ab-mediated PRCA with data from both Ab titer assays and NT bioassays.

Treatment of Pure Red-Cell Aplasia With Cyclosporine in a Renal Transplant Patient

Acquired pure red-cell aplasia is a rare disorder that can be either idiopathic or associated with certain autoimmune diseases, pregnancy, lymphoproliferative disorders, nutritional deficiencies, or medicines. We present a deceased-donor renal transplant patient who developed pure red-cell aplasia associated with mycophenolate mofetil or tacrolimus and was treated with cyclosporine. A 20-year-old woman was transplanted from a deceased donor 1 month earlier and presented to us with symptoms of fatigue, prostration, and palpitation. The results of a laboratory examination revealed anemia. A diagnostic work-up resulted in a diagnosis of pure red-cell aplasia. Mycophenolate mofetil was discontinued. Tacrolimus also was replaced with cyclosporine 2 months after mycophenolate mofetil was halted because of a lack of improvement in anemia. Three months later, her anemia improved with cyclosporine. Starting cyclosporine instead of tacrolimus or mycophenolate mofetil showed good improvement in our patient within 6 months of therapy.

Pure red cell aplasia caused by pegylated interferon-α-2a plus ribavirin in the treatment of chronic hepatitis C

Pure red cell aplasia (PRCA) is a rare hematological disorder which is characterized by severe anemia, reticulocytopenia and almost complete absence of erythroid precursors in bone marrow. The pathophysiology of PRCA may be congenital or acquired. To our knowledge, there is only one case report in the English literature of PRCA after pegylated interferon combination therapy for chronic hepatitis C. We report a second case of PRCA after pegylated interferon combination treatment for chronic hepatitis C. The diagnosis of PRCA was confirmed by the typical findings of bone marrow biopsy. The possible etiologies of our case are also discussed in this paper.