The changing spectrum of drug-induced immune hemolytic anemia

Drug-induced immune hemolytic anemia (DIIHA) occurs rarely. To date, about 100 drugs have been implicated in causing DIIHA and/or a positive direct antiglobulin test (DAT). The most common drugs associated with DIIHA in the 1970s were methyldopa and penicillin; currently, they are cefotetan and ceftriaxone. Drug antibodies fall into two types: drug-independent ("autoantibodies") and drug-dependent ("penicillin type" or "immune complex type"); some patients have combinations of these antibodies. Some drugs cause nonimmunologic protein adsorption onto drug-treated red blood cells (RBCs). This is known to be the cause of positive indirect antiglobulin tests and is suspected to be a cause of positive DATs. This mechanism may be associated with hemolytic anemia. Twelve cephalosporins have been reported to cause DIIHA; five (primarily cefotetan and ceftriaxone) have been associated with fatalites. Patients with DIIHA due to cefotetan may only have received one dose of the drug prophylactically with surgery. Antibodies to cefotetan react to very high titers against drug-treated RBCs (and at lower titers against untreated RBCs without and/or with drug present). Patients with ceftriaxone-induced DIIHA have received the drug previously; reactions in children often occur minutes after ceftriaxone administration. Antibodies to ceftriaxone are only of the "immune complex type."     

Cephalosporin-induced hemolysis: a case report and review of the literature.

Cephalosporins are commonly used drugs that interact with red blood cell membranes. They frequently cause a positive direct antiglobulin test but rarely cause hemolysis. A case of cefotetan-induced hemolytic anemia is described in which two types of antibodies were detected. One reacted with red blood cells by a hapten mechanism, the other reacted with drug to form immune complexes. This case is compared with the 13 cases of cephalosporin-induced hemolytic anemia reported to date. Understanding the interactions of red blood cells and cephalosporins is critical to the safe use of these commonly prescribed drugs.     

Specific immunoadsorption of IgG antibody in a patient with chronic lymphocytic leukemia and autoimmune hemolytic anemia: A new form of therapy for the acute critical stage

Progressive and severe autoimmune hemolytic anemia developed in a patient with chronic lymphocytic leukemia (CLL) despite treatment with chlorambucil, high doses of corticosteroids and attempts to transfuse packed red blood cells. Splenectomy was not performed because of severe coronary artery disease. Direct antiglobulin tests revealed a warm red blood cell autoantibody of IgG-type with anti-e specificity. The patient was treated by extracorporeal immunoadsorption of plasma IgG using a cell separator and protein A as the immunoadsorbent. The patient responded by an increase in the hemoglobin levels and platelet counts after two treatments. Specificity of the procedure was shown by a decrease in the serum IgG and by the demonstration of the same reactivity to ficin-treated reagent red blood cell panel of the eluate from the protein A. Antibody titers of the patient's red blood cell eluate decreased from 1:128 to 1:64 and eventually the anti-e specificity was lost. This is a report of a novel approach to treatment of the acute phase of an autoimmune hemolytic anemia.     

The Effects of Concentrated Eluted Anti-Red Blood Cell Antibodies on the in Vivo Survival of Normal Red Blood Cells

1. A method has been described for the preparation and sterilization of aconcentrated eluate from human red cell stroma.

2. Red cells sensitized by such an eluate prepared from normal controlred cells showed entirely normal in vivo survival, as did cells sensitized byeluate from anti-H coated cells.

3. Sensitization of red cells by concentrated eluates from a patient withCoombs-negative acquired hemolytic anemia and from a patient with Coombs-positive acquired hemolytic anemia did not cause significant alteration in thein vivo survival of the red cells.

4. Red cells sensitized by the concentrated eluate from anti-D sensitizedcells disappeared from the recipient’s circulation very rapidly and were sequestered in the spleen, indicating preservation of the physiologic propertiesof the antibody throughout the elution, concentration and sterilization procedures.

Submitted on June 22, 1959 Accepted on September 27, 1959     

Cefotetan-induced hemolytic anemia after perioperative prophylaxis

Cephalosporin-induced hemolytic anemia is an acquired form of hemolytic anemia caused by interaction of drug with the immune system. Drug adsorption, drug-dependent antibody, and autoimmune induction are the three mechanisms of hemolysis. Cefotetan-induced hemolytic anemia (CIHA) has been described to occur through all three mechanisms. We report four cases of CIHA that occurred after appropriate perioperative use of cefotetan. All of our patients developed an acute and severe hemolytic episode that caused significant symptoms and led to hospitalization within 1-2 weeks after exposure to cefotetan. The hemolytic process was self-limited, and all our patients responded to supportive measures and blood transfusion. This report adds to our knowledge of CIHA, a rare complication of cefotetan use. Our cases suggest that cefotetan-induced acute severe hemolysis is caused by membrane modification (nonimmunologic protein adsorption) in addition to immune complex formation. Prompt diagnosis and aggressive supportive measures are essential in minimizing morbidity and mortality from hemolysis. Physicians should warn their patients about this complication. Given that hemolysis occurs when the subject is no longer under direct clinical supervision, patient awareness on how to recognize signs and symptoms of hemolysis is paramount to reducing the likelihood of this potentially lethal side effect. Finally, physicians might consider restricting cefotetan use.     

Acquired immune hemolytic anemia associated with IgA erythrocyte coating: investigation of hemolytic mechanisms

We have investigated the hemolytic mechanisms in a patient with acquired immune hemolytic anemia whose red cells appeared to be coated with IgA alone. The clinical course was similar to that of patients with hemolytic anemia mediated by warm-reacting IgG antibody. Splenic sequestration of red cells was demonstrated, and marked reduction of hemolysis occurred after corticosteroid therapy. Antibody was eluted from the patient's red cells and used to sensitize normal red cells in vitro. These sensitized red cells were not lysed by fresh autologous serum, nor did they fix detectable amounts of C3. However, red cells sensitized by eluted antibody were lysed by normal human peripheral blood monocytes in a system designed to demonstrate antibody-dependent cell-mediated cytotoxicity. Monocyte-mediated hemolysis of sensitized red cells was inhibited by the addition of low concentrations of normal serum IgA to the system, but not by IgG. The ability of the eluate to induce monocyte-mediated hemolysis was abolished by its adsorption on Sepharose-bound anti-IgA, but not by preincubation with Sepharose-bound anti-IgG. In addition, normal human monocytes were demonstrated to ingest eluate-sensitized red cells. These data demonstrate an in vitro interaction of IgA-sensitized red cells with leukocytes and suggest a possible mechanism for the patient's hemolysis.     

A New Elution Procedure Using Chloroform, a Nonflammable Organic Solvent

A new method for eluting red cell antibodies using chloroform has been shown to be effective. The method is similar to ether and xylene techniques but can be completed within 10 min after adequate cell washing. Comparison studies using ether, xylene and chloroform showed that antibodies eluted by chloroform yielded equivalent titration scores. Antibodies within the Ss blood group system were easily eluted using chloroform but not using ether. Also, the chloroform method yielded informative eluates when prepared from red cells of patients with warm antibody autoimmune hemolytic anemia, drug-induced immune hemolytic anemia, hemolytic disease of the newborn caused by ABO or Rh fetal-maternal incompatibility, or from patients having a positive direct antiglobulin test as a result of alloantibodies stimulated by recent transfusion ('delayed transfusion reaction'). The advantages of chloroform elution are: (1) chloroform is nonflammable; (2) the eluate is readily obtained from the top layer after centrifugation; (3) no residual solvent remains in the eluate, and (4) the method is rapid.     

Extravascular hemolysis following the administration of cefamandole

Hemolytic anemia occurred in a 70-year-old female after a five-day course of intravenous cefamandole. The patient's serum contained an IgG antibody which was reactive with red blood cells which had been coated in vitro with cefamandole but not with uncoated cells. An in vitro assay of allogeneic mononuclear phagocytosis of cefamandole-coated red cells sensitized with the patient's anti-cefamandole indicated that the anti-cefamandole could induce significant phagocytosis. The anti-cefamandole was easily inhibited in vitro by cefamandole as well as by a variety of related cephalosporins indicating broad cross-reactivity, with the antigenic site primarily the 7-amino-cephalosporanic acid nucleus. Penicillins could inhibit the anti-cefamandole but only when using concentrations 3-10 X those of cephalosporins. Eleven examples of anti-penicillin tested failed to react with cefamandole-coated red cells. Screening of 344 random sera from hospitalized patients found only five (1.5%) reactive with cefamandole-coated red cells; three of these sera were also reactive with penicillin-coated red cells. The patient's hemolysis subsided following cessation of the drug. This is the first report of anti-cefamandole-induced hemolytic anemia.     

Red blood cell antibodies and anemia in pulmonary tuberculosis

To examine the association of anemia with the formation of antibodies to intrinsic red blood cells, 56 phthisiosurgical patients were examined. Red blood cell antibodies were detected in 66.7 of patients with anemia and in 36.9% without anemia. The results were processed by the chi 2 Pierson test, which confirmed a 95% probability of association of hemolytic anemia with the formation of antibodies to red blood cells. The direct antiglobulin test and the enzyme assay may be recommended for examination of patients with pulmonary tuberculosis in the preoperative period to reveal risk factors of progressive clinical manifestations of anemia.     

Auto-Immune Hemolytic Anemia Caused by Anti-U

Abstract. A case of warm antibody auto-immune hemolytic anemia is described in which the serum antibody, and an eluate from the patient's red cells, both had anti-U specificity. The antibody did not react with Rh_null red cells, and gave weaker reactions with -D- red cells than with other U-positive red cells. Five other anti-U sera were tested in comparative titrations and some of these also reacted more weakly against -D- red cells than against red cells having common Rh phenotypes.     

Amoxicillin-induced immune hemolysis

Severe hemolysis occurred in a 51-year-old female after a 17-day course of intravenous amoxicillin. A strongly positive direct antiglobulin test (anti-IgG titer 1:2,000) ensued which disappeared after withdrawal of the drug. Both the patient's serum and eluate obtained from the patient's red cells contained an IgG antibody which reacted with red blood cells coated in vitro with amoxicillin, but not with uncoated cells. In addition, high-titer antipenicillin, antiampicillin and antiamoxicillin IgG antibodies could be demonstrated in her serum by a RAST-based solid-phase radioimmunoassay. The patient's hemolysis gradually subsided within 1 week after discontinuing the drug. This is the first report of amoxicillin-induced immune hemolytic anemia.     

Production of the effector cytokine interleukin-17, rather than interferon-γ, is more strongly associated with autoimmune hemolytic anemia

Background Interleukin-17A is the signature cytokine of the Th17 subset and drives inflammatory pathology, but its relevance to autoantibody-mediated diseases is unclear. Th1 cells secreting interferon-γ have been implicated in autoimmune hemolytic anemia, so the aim was to determine which cytokine is more closely associated with disease severity. DESIGN AND METHODS: Interferon-γ and interleukin-17A were measured in the sera of patients with autoimmune hemolytic anemia and healthy donors, and in peripheral blood mononuclear cell cultures stimulated with autologous red blood cells, or a panel of peptides spanning red blood cell autoantigen. RESULTS: Serum interleukin-17A, but not interferon-γ, was significantly raised in patients with autoimmune hemolytic anemia (P <0.001), and correlated with the degree of anemia. Interleukin-17A was also more prominent in the responses of peripheral blood mononuclear cells from patients with autoimmune hemolytic anemia to red blood cells, and, again unlike interferon-γ, significantly associated with more severe anemia (P <0.005). There were no interleukin-17A responses to red blood cells by peripheral blood mononuclear cells from healthy donors. Specific autoantigenic peptides were identified that elicit patients' interleukin-17A responses. Conclusions Interleukin-17A makes a previously unrecognized contribution to the autoimmune response in autoimmune hemolytic anemia, challenging the model that the disease is driven primarily by Th1 cells. This raises the possibility that Th17, rather than Th1, cells should be the target for therapy.     

Elevated pyruvate kinase activity in patients with hemolytic anemia due to red cell pyruvate kinase "deficiency"

Two patients with non-spherocytic hemolytic anemia were found to have elevated red blood cell pyruvate kinase activities commensurate with the decreased mean red cell age, but the residual pyruvate kinase had marked kinetic abnormalities. Accumulation of metabolic intermediates before pyruvate kinase and reduced levels of activity of the red blood cells of the parents of both patients supported the diagnosis of an inherited abnormal pyruvate kinase causing hemolytic anemia. Although it was observed in two unrelated persons, review of enzyme assays performed on the red blood cells of 651 patients with hereditary non-spherocytic hemolytic anemia suggests that this occurrence is rare.     

Drug-induced blood dyscrasias in Tohoku district

One hundred and thirty-four cases were identified in seven prefectures of the Tohoku district. Fifty-seven per cent of them were over 50 years old, and the incidence had no differences between sexes. They consisted of 51 leukopenia, 32 thrombocytopenia, and nine anemia cases which included seven hemolytic anemia and two pure red cell aplasia. Agents associated with blood dyscrasias were those acting on the central nervous system (CNS) (49 cases), cardiovascular drugs (25 cases), and antimicrobial agents (48 cases). Leukopenia occurred to five patients with cinepazidemaleate (Brendil) administration, 11 with thiamazole (Mercazole), and 14 with antimicrobial agents which were mainly penicillins and cephalosporins. Thrombocytopenia was induced by H2-receptor antagonists (six cases) and antimicrobial agents mostly of penicillins and cephalosporins (12 cases). Anemia contained seven cases of hemolytic anemia, including two patients caused by methyldopa (Aldomet) and two by dried human immunoglobulin (Glovenin). Among 15 cases, 12 out of 19 agents were those affecting the CNS. Six cases were dead from drug-induced blood dyscrasia.     

Erythromycin-Induced Immune Hemolytic Anemia

A 3-year-old female receiving Pediazole (erythromycin ethylsuccinate and sulfisoxazole) for tonsillitis and otitis media developed severe hemolytic anemia. No serum drug-dependent antibodies could be demonstrated with an in vitro 'immune-complex' method using Pediazole, pure erythromycin ethylsuccinate or pure sulfisoxazole. However, a method using red cells coated with erythromycin base showed in vitro lysis of the erythromycin-coated red cells. This is only the second case of immune hemolytic anemia associated with erythromycin and the first where in vitro drug-dependent hemolysis was demonstrable.     

A case of lead intoxication: clinical and biochemical studies

A 23-year-old Japanese male with severe lead intoxication accompanied by hemolytic anemia was studied. The patient had taken 12 g to lead in about a month. He had moderate hemolytic anemia (Hb 8.9 g/100 ml) with reticulocytosis ranging from 2.5 to 11.7%. Peripheral blood smear showed nucleated red cells (42/200 white blood cells) and marked basophilic stippling in the red cells. Activities of erythrocyte enzymes were either normal or increased except for pyrimidine 5'-nucleotidase (P5N) and delta-aminolevulinic acid dehydratase (ALA-D) both of which were found to be decreased, being 48.8% and 4.1% of the normal controls respectively. Erythrocyte reduced glutathione (GSH) was high (145.6 mg/100 ml RBC). Erythrocyte pyrimidine nucleotides were accumulated up to 10.2% of total nucleotides. The level of lead in peripheral blood was 112 microgram per 100 ml blood. Ca2+-Na2-EDTA was given to the patient as treatment. The level of lead in the blood decreased gradually and hemolytic anemia improved. Basophilic stippling in the red cells disappeared. These results confirmed the findings of Valentine et al [1] that lead-induced deficiency of P5N resulted in basophilic stippling and hemolytic anemia just like hereditary hemolytic anemia due to P5N deficiency.     

Autoimmune Hemolytic Anemia Associated with Autoanti-Ge

The first reported example of autoimmune hemolytic anemia due to an autoanti-Gerbich is described. The patient's red blood cells exhibited a strongly positive direct antiglobulin test with both IgG and complement antiglobulin reagents. The serum contained a potent antibody which produced agglutination of red blood cells as well as a positive indirect antiglobulin test. Treatment of the serum with 2-mercaptoethanol demonstrated that the antibody contained both IgG and IgM components. The serum antibody and the antibody eluted from the patient's red blood cells had anti-Gerbich specificity. The patient's cells typed as Gerbich-positive with saline-agglutinating anti-Gerbich sera. Of great interest was the fact that the patient's mother also has acquired immune hemolytic anemia, but the IgG antibody in her serum and eluted from her red blood cells had anti-pdl specificity.     

Congenital hemolytic jaundice; the pathogenesis of the hemolytic crisis

Six cases of congenital hemolytic jaundice with "hemolytic" crises are reported. It is demonstrated that during the development of the anemia an acuteaplastic condition is present in the erythropoietic tissue of the bone marrow withcomplete cessation of the formation of red cells. The reticulocytes disappear fromthe blood; jaundice, serum bilirubin and urobilinuria decrease to normal values;and the serum iron increases. This period is further characterized by leukopeniaand thrombocytopenia.

The spontaneous recovery is caused by a rapid regeneration of the erythropoietictissue resulting in a marked reticulocytosis in the peripheral blood, and there isalso leukocytosis, an increase in thrombocytes and a rapid fall of serum iron.

During the period of severe anemia an increase in the blood urea and uric acidoccurs.

Transfusion experiments revealed an average lifetime of approximately fifteendays for the red cells in congenital hemolytic jaundice, a fact which fully explainsthe development and symptoms of the crisis as a result of cessation in the formation of red cells.

The findings definitely contradict the theory that an acute increase in thehemolytic process is the reason for the crisis.

The crisis should be called aplastic and not hemolytic.

     

Direct antiglobulin test reactive with complement only in warm type autoimmune hemolytic anemia

Direct antiglobulin test (DAT) with only complement detected on red blood cells is a rare laboratory finding, and its significance in the setting of warm autoimmune hemolytic anemia (AIHA) is controversial. During 2 years (2003-2004) 277 patients with positive DAT were recorded in the blood bank registries, 17 of them had DAT reactive with C3 alone with no cold agglutinin or other nonimmune causes for hemolysis diagnosed. Red cell eluate disclosed small amounts of IgG in two patients. In nine patients no signs of clinical hemolysis were found, however, all these patients had underlying conditions that are known to be associated with red cells autoantibodies (autoimmune disorder or malignancy). Eight patients developed AIHA, seven of them with severe hemolysis. Three patients had idiopathic AIHA, and the others have been diagnosed with infectious, lymphoproliferative and autoimmune disorders. In two patients with acute infection the hemolytic process spontaneously resolved, three responded to corticosteroid therapy, while three patients were refractory to two lines of drug therapy and underwent splenectomy. Reticulocytopenia was found in four patients. Our results emphasize that AIHA with DAT reactive with complement alone is a rare disorder and might be accompanied by severe, refractory to conventional treatment and life-threatening hemolysis.