Severe Haemolytic Anaemia Complicating Infectious Mononucleosis

Summary: Severe haemolytic anaemia complicating infectious mononucleosis. R. K, Woodruff and A. J. McPherson, Aust. N.Z, J. Med., 1976, 6, pp. 569–570.
The case record of a patient suffering from infectious mononucleosis, complicated by severe haemolytic anaemia with overt intravascular haemolysis, is reported. Investigation of such cases usually shows a high titre of cold agglutinins with anti-i specificity. In the case reported, the results of serological investigations were atypical, and suggested that cold agglutinins with anti-l activity (rather than anti-i) were predominant in the aetiology of the haemolysis.     

Haemolytic Anaemia of Pregnancy

Haemolytic anaemia apparently induced by pregnancy is reported in an otherwise healthy woman, with a negative family history. Folate deficiency, haemoglobino-pathies, enzymopathies, hereditary spherocytosis, paroxysmal nocturnal haemoglobin-uria, interstitial haematomata, hypertensive toxaemia, auto-immunity and infections were excluded. The autohaemolysis test showed increased lysis in the presence of added glucose. This abnormality was corrected by insulin when excess glucose was present, but not by insulin alone. It is suggested that this patient's erythrocytes may have been altered by placental lactogen and/or prolactin in such a way as to make them abnormally dependent on insulin for the uptake of glucose.     

Ticarcillin-Induced Immune Haemolytic Anaemia

Immune haemolytic anaemia may be induced by high doses of benzylpenicillin. A small number of cases have also followed the administration of semisynthetic penicillins in addition to benzylpenicillin. We have observed immune haemolytic anaemia consequent on ticarcillin administration in a patient who had previously received benzylpenicillin. Although the antibody agglutinated penicillin-treated and ticarcillin-treated cells it was demonstrated by serum fractionation to be IgG.     

Autoimmune Haemolytic Anaemia in Children

S ummary . Forty-four children with autoimmune haemolytic anaemia (AIHA) are described: 31 had acute, subacute or chronic disease with warm autoantibodies and 13 had acute or chronic anaemia with cold autoantibodies. The commonest forms were the acute and subacute types with warm autoantibodies and these were more frequent in young children, while chronic AIHA occurred mainly among children at puberty. In about 16% the anaemia was accompanied by a chronic disorder but in over 50% the anaemia was preceded by an acute infection or immunization. The former gave rise mainly to chronic anaemia, but the latter was associated with the acute and subacute forms. In general the prognosis was good and death was never caused by anaemia per se. The prognosis was worse in patients with clinical features of thrombocytopenia and bleeding and with the immunological findings of free autoantibodies in the serum and a positive direct antiglobulin test. In acute and subacute forms, treatment with corticosteroids and sometimes with blood transfusions was effective. In chronic forms of the disease it was often necessary to give additional immunosuppressive drugs or/and to perform a splenectomy.     

Auto-Immune Haemolytic Anaemia in Childhood

We describe 29 children with auto-immune haemolytic anaemia (AIHA). The patients could be followed up for long periods of time. The auto-antibodies, responsible for the AIHA, are described as well as the associated diseases that could be diagnosed, the clinical course and some clinical aspects of special importance. Finally, the treatment given to these patients and its results are discussed.     

Malabsorption in Infectious Mononucleosis

A case of infectious mononucleosis, complicated by malabsorption, is presented. Malabsorption was documented by abnormal d-xylose, small bowel series, 72-hour stool fat and jejunal biopsy. Small bowel abnormalities and other gastrointestinal manifestations of infectious mononucleosis are discussed.     

Activated T-Cells in Autoimmune Haemolytic Anaemia

In 12 of 14 patients with clinically active autoimmune haemolytic anaemia high levels (9-78%) of homologous and autologous rosetting cells were found in the peripheral blood. In 10 of these patients, who were observed over a period of 2 years, the levels bore a direct relationship to the activity of the disease. The cells so identified were T-lymphocytes. The role of cells, identified by this method in AIHA, is discussed.     

ABO Haemolytic Anaemia in Transplanted Patients

A case of severe intravascular haemolysis, due to an 'auto-anti-B antibody', and a case of transient haemolytic anaemia, due to an 'auto-anti-A antibody', following allogeneic organ transplantation, are reported. Both patients were receiving immunosuppressive therapy with cyclosporin A and were non-secretors of A, B and H substances.     

Fibrinogen Catabolism in Microangiopathic Haemolytic Anaemia

S ummary . Fibrinogen catabolism has been studied in six patients with microangiopathic haemolytic anaemia, three patients with fragmentary haemolytic anaemia following the insertion of valve prostheses into the heart and ten control patients. Increased rates of catabolism of ¹³¹ I-fibrinogen were found in the patients with microangiopathic haemolytic anaemia. Evidence of enhanced fibrinolysis was not present.
This finding suggests that intravascular coagulation is a feature of some cases of microangiopathic haemolytic anaemia and supports the hypothesis that the interaction of red cells with fibrin may result in the characteristic morphological appearances in these cases.     

Platelet Levels in Infectious Mononucleosis

Platelet levels in 57 patients with infectious mononucleosis are recorded.Approximately 50 per cent of cases show some degree of thrombocytopeniaduring the first 4 weeks of the disease. Possible mechanisms for the changeare reviewed and other acute infections complicated by thrombocytopeniabriefly discussed.

Submitted on July 31, 1964 Accepted on September 29, 1964     

Elucidation of Alloantibodies in Autoimmune Haemolytic Anaemia

Forty-one patients with autoimmune haemolytic anaemia (AIHA), who had free antibody in their sera, were investigated for the presence of alloimmune erythrocyte antibodies using the ZZAP autoabsorption technique. Patients were subdivided into three risk categories: (I) no prior pregnancy or transfusion; (II) history of pregnancy and/or one to five transfusions; and (III) greater than 5 transfusions. A total of 13 (32%) of the 41 patients exhibited significant alloantibodies. Of 11 category-I patients 2 (18%) had significant alloantibodies. Eight (31%) of the 26 category-II patients had significant alloantibodies and 3 (75%) of the 4 category-III patients had significant alloantibodies after absorption. The majority showed Rh specificity: anti-E(8), -C(3), -Cw(1). Anti-K was found in 6 samples and 1 had anti-Fya. Alloantibodies had not been suspected prior to autoabsorption in 10 (77%) of the 13 patients with alloantibodies. These findings underline the importance of performing autoabsorption in AIHA when free autoantibody is present in the serum. Additionally, Rh phenotyping performed on ZZAP-treated cells showed complete agreement with that ascertained using pure IgM Rh typing sera and untreated cells.     

Immunochemical Studies of Infectious Mononucleosis

Abstract. The major sialoglycopeptide released from bovine erythrocytes by papain has been purified and characterized. The glycopeptide contains 82% by weight carbohydrate in molar ratios of galactose -5. 5 :N-acetylglucosamine -3. 6 :sialic acid -2. 6 :N-acetylgalactosamine -1.0. The carbohydrate and amino acid composition is quite different from the glycoprotein extracted from bovine erythrocyte stroma with hot 75% ethanol. The glycopeptide is devoid of reactivity with Paul-Bunnell heterophile antibody of infectious mononucleosis - an activity expressed to high degree on the bovine erythrocyte and associated with glycoprotein. The glycopeptide does react, however, with another antibody found in infectious mononucleosis as well as most normal human sera tested.     

Pirimicarb Induced Immune Haemolytic Anaemia in Dogs

The feeding of pirimicarb (2-dimethylarnino-5,6-dimethylpyrimidin-4-yl dimethyl-carbamate) to normal beagle dogs resulted in anaemia in a small number of animals. Dosing studies confirmed pirimicarb as the causative agent and the anaemia was characterised as haemolytic. Serological tests revealed the presence of an IgG antibody active only in the presence of pirimicarb. The level of antibody detected was related to the dose of pirimicarb given.     

Microangiopathic Haemolytic Anaemia and Mucin-forming Adenocarcinoma

S ummary . Twelve patients are described who developed well-marked micro-angiopathic haemolytic anaemia in association with metastatic carcinoma. The tumours originated in the stomach in six cases, in the breast in two cases, in the lung in one case and the origin was uncertain in three cases. All 11 tumours studied were found to be mucin-secreting adenocarcinomas.
Ten out of the 12 patients were thrombocytopenic. Fibrinogen metabolism was studied in four patients and in each patient the catabolism of fibrinogen was found to be greatly increased despite normal or near normal plasma fibrinogen levels and an absence of overt fibrinolysis. Fibrin degradation products were demonstrated in the serum of five out of six patients. Hyaline thrombi were seen in the small blood vessels in the kidneys and suprarenals in one patient and in the myocardium in two patients, while changes suggestive of organized thrombi were present in the interlobular arteries of the kidneys in three patients.
It is thought likely that the microangiopathic haemolytic anaemia develops secondarily to intravascular coagulation brought about by thromboplastins derived from mucin-forming tumour cells which have entered blood vessels, and that contact between circulating red cells and tumour emboli within blood vessels may be an additional cause of red-cell damage.