MKK.

SISTEM HEMATOLOGI dan MYELOPROLIFERATIF IMMUNE HEMOLYTIC 20 Oktober 2011 ANEMIA

REZDY TOFAN BHASKARA 105070107121003 PDKBI 2010

1. Describe in brief classification and pathogenesis of immune hemolytic anemia! The pathogenesis of IHA ultimately overlaps for these three classifications. The degree of hemolysis depends on characteristics of the bound antibody (e.g. quantity, specificity, thermal amplitude, ability to fix complement, ability to bind tissue macrophages) as well as the target antigen (density, expression, patient age). IgG antibodies are relatively poor activators of the classical complement pathway, but they (in particular IgG1 and IgG3 antibodies) are recognized rapidly by Fc receptors on various phagocytic cells. Therefore, IgG-sensitized RBCs generally are eliminated by phagocytes of the reticuloendothelial system. Since reticuloendothelial cells also have receptors for complement factors C3b and iC3b, these complement components, if present, can potentiate the extravascular hemolysis. On the other hand, IgM-sensitized RBCs generally are associated with a combination of intravascular and extravascular hemolysis. Intravascular hemolysis occurs because IgM antibodies, unlike IgG antibodies, readily activate the classical complement pathway and produce cytolysis. However, due to the presence of regulatory RBC proteins such as decay accelerating factor (DAF, CD55) and membrane inhibitor of reactive lysis (MIRL, CD59), overhelming complement activation usually is required to produce clinically evident intravascular hemolysis, e.g. as seen with ABO-incompatible blood transfusions. More commonly, IgM-sensitized RBCs undergo extravascular hemolysis. While reticuloendothelial cells do not have receptors for the Fc fragment of IgM antibodies with comparable activity to the receptors directed against the Fc fragment of IgG, they do have receptors for the abundant RBC-bound C3b and iC3b resulting from complement activation. Whereas the spleen is the principal site of IgG-associated extravascular hemolysis, Kupffer cells in the liver are the principal effectors of IgM-associated extravascular hemolysis. AUTOIMMUNE HEMOLYTIC ANEMIA Autoimmune hemolytic anemia (AIHA) are caused by antibody production by the body against its own red cells. They are characterized by a positive direct antiglobulin test (DAT) also known as the Coombs test (Figure 1) and divided intro warm, cold and mixed-types (Table 1) according to whether the antibody reacts more strongly with red cells at 370C or 40C. Warm hemolysis refers to IgG autoantibodies, which maximally bind red blood cells at body temperature (37C [98.6F]). In cold hemolysis, IgM autoantibodies (cold agglutinins) bind red blood cells at lower temperatures (0 to 4C [32 to 39.2F]).

MKK. SISTEM HEMATOLOGI dan MYELOPROLIFERATIF IMMUNE HEMOLYTIC 20 Oktober 2011 ANEMIA

REZDY TOFAN BHASKARA 105070107121003 PDKBI 2010

Figure 1. Direct antiglobulin test (DAT), demonstrating the presence of autoantibodies (shown here) or complement on the surface of the red blood cell. (RBCs = red blood cells)

WARM AUTOIMMUNE HEMOLYTIC ANEMIA When warm autoantibodies attach to red blood cell surface antigens, these IgG-coated red blood cells are partially ingested by the macrophages of the spleen, leaving microspherocytes, the characteristic cells of AIHA. These spherocytes, which have decreased deformability compared with normal red blood cells, are trapped in the splenic sinusoids and removed from circulation.

MKK. SISTEM HEMATOLOGI dan MYELOPROLIFERATIF IMMUNE HEMOLYTIC 20 Oktober 2011 ANEMIA

REZDY TOFAN BHASKARA 105070107121003 PDKBI 2010

2. Describe in brief classification, clinical features and laboratory findings of: Warm AIHA Cold AIHA Warm AIHA The disease may occur at any age in either sex and present as a hemolytic anemia of varying severity. The spleen in often enlarged. The disease tend to remit and relapse. It may occur alone or in association with other diseases or arise in some patients as a result of methyldopa therapy (Table 1). When associated with immune thrombocytopenic purpura (ITP), which is a similar condition affecting platelets, it is known as Evans syndrome. When secondary to systemic lupus erythematosus, the cells typically are coated with immunoglobulin and complement.

MKK. SISTEM HEMATOLOGI dan MYELOPROLIFERATIF IMMUNE HEMOLYTIC 20 Oktober 2011 ANEMIA

REZDY TOFAN BHASKARA 105070107121003 PDKBI 2010

Laboratory Findings The hematological and biochemical findings are typical of an extravascular hemolytic anemia with spherocytosis prominent in the peripheral blood (Figure 2). The DAT is positive as a result of IgG, IgG and complement or IgA on the cells and, in some cases, the autoantibody shows specificity within the rhesus system. The antibodies both on the cell surface and free in serum are best detected at 370C.

Figure 2. Blood film in warm autoimmune hemolytic anemia.

Cold AIHA In these syndrome the autoantibody, whether monoclonal (as in the idiopathic cold hemagglutinin syndrome or associated with lymphoproliferative disorders) or polyclonal (as following infection, e.g. infectious mononucleosis or mycoplasma pneumonia) attaches to red cells mainly in the peripheral circulation where the blood temperature is cooled. The antibody is usually IgM and binds to red cells best at 40C. IgM antibodies are highly efficient at fixing complement and both intravascular and extravascular hemolysis can occur. Complement alone is usually detected on the red cells, the antibody having eluted off the cells in warmer parts of the circulation. Interestingly, in nearly all these cold AIHA syndromes (CAS), the antibody is directed against the I antigen on the red cell surface. In infectious mononucleosis it is anti-i. Clinical Features The patient may have a chronic hemolytic anemia aggravated by the cold and often associated with intravascular hemolysis. Mild jaundice and splenomegaly may be present. The patient may develop acrocyanosis (purplish skin discoloration) at the tip of the nose, ears, fingers, and toes caused by the agglutination of red cells in small vessles.

MKK. SISTEM HEMATOLOGI dan MYELOPROLIFERATIF IMMUNE HEMOLYTIC 20 Oktober 2011 ANEMIA

REZDY TOFAN BHASKARA 105070107121003 PDKBI 2010

Laboratory Findings Laboratory findings are similar to those of warm AIHA, except that spherocytosis is less marked, red cells agglutinate in the cold (Figure 3) and the DAT reveals complement (C3d) only on the red cell surface.

Figure 3. Blood film in cold autoimmune hemolytic anemia.

MKK. SISTEM HEMATOLOGI dan MYELOPROLIFERATIF IMMUNE HEMOLYTIC 20 Oktober 2011 ANEMIA

REZDY TOFAN BHASKARA 105070107121003 PDKBI 2010

3. Describe in brief the treatment of warm AIHA and cold AIHA! Warm AIHA Remove the underlying cause (e.g. methyldopa, fludarabine) Corticosteroids. Prednisolone is the usual first-line treatment; 60 mg daily is a typical starting dose in adults and should then be tapered down. Those with predominantly IgG on red cells do best whereas those with complement often respond poorly, both to corticosteroids or splenectomy. Splenectomy may be of value in those who fail to respond well or fail to maintain a satisfactory hemoglobin level on an acceptably small steroid dosage. Immunosupression may be tried after other measures have failed but is not always of great value. Azathioprine, cyclophosphamide, chlorambucil, cyclosporine and mycophenolate mofetil have been tried. Folic acid is given to severe cases. Blood transfusion may be needed if anemia is severe and causing symptoms. The blood should be the least incompatible and if the specificity of the autoantibody is known, donor blood is chosen which lacks the relevant antigen(s). The patients also readily make alloantibodies against donor red cells. High-dose immunoglobulin has been used but with less success than in ITP.

Cold AIHA Treatment consists of keeping the patient warm and treating the underlying cause, if present. Alkylating agents such as chlorambucil may be helpful in the chronic varieties. Splenectomy does not usually help unless massive splenomegaly is present, and steroids are not helpful. Underlying lymphoma should be excluded in idiopathic cases.

MKK. SISTEM HEMATOLOGI dan MYELOPROLIFERATIF IMMUNE HEMOLYTIC 20 Oktober 2011 ANEMIA

REZDY TOFAN BHASKARA 105070107121003 PDKBI 2010

4. Describe in brief the treatment of refractory cases of AIHA! The standard therapeutic approaches to treatment of AIHA include corticosteroids, splenectomy and immunosuppressive drugs. In the past several years, certain newer therapies have become available, and have shown evidence of success. These are primarily used in patients who are not candidates for or fail to respond to splenectomy, those who relapse after splenectomy, and those who cannot maintain stable hemoglobin levels without unacceptably high doses of corticosteroids. 1. Intravenous immune globulin (IVIG) Flores et al reviewed the cases of 73 patients treated with IVIG, and found responses in 29 (40%).37 Children were more likely to respond, as were patients with initial hepatomegaly and lower initial hemoglobin levels. 2. Danazol Danazol, which has been used more in refractory cases of immune thrombocytopenia, has also been used in AIHA. Ahn reported good to excellent results in the majority of patients treated.38 In another series of 17 patients treated with the combination of prednisone and danazol, excellent responses were noted in 80% who received the combination as firstline therapy; treatment was less effective in patients who had relapsed and in those with Evans syndrome. 3. Newer immunosuppressives Howard et al reported on the use of mycophenolate mofetil in 4 patients with refractory AIHA.40 Patients were treated with 500 mg per day initially, then 1000 mg per day. All 4 had a complete or good response. 4. Monoclonal antibodies There has been considerable interest in the past several years in the use of the monoclonal antibodies widely used in the treatment of B-cell lymphoid neoplasms, namely rituximab (Rituxan), and to a lesser extent alemtuzumab (Campath-1H). Zecca et al first reported on a child with pure red cell aplasia and AIHA treated successfully with rituximab and IVIG.41 Another report, in 5 children with AIHA, described excellent responses, but with a resultant not-unexpected prolonged B-cell deficiency. Shanafelt et al reported on 5 patients, of whom 2 had a complete response. In an additional 4 patients with Evans syndrome, complete responses occurred in either the immune thrombocytopenia or the AIHA, but not both. Trape et al noted the benefits of rituximab for residual AIHA in 5 patients following chemotherapy of a lymphoproliferative disorder. Mantadakis et al offered a case report of a patient with refractory Evans

MKK. SISTEM HEMATOLOGI dan MYELOPROLIFERATIF IMMUNE HEMOLYTIC 20 Oktober 2011 ANEMIA

REZDY TOFAN BHASKARA 105070107121003 PDKBI 2010

syndrome who responded for 7 months to rituximab, and then responded a second time after relapse. Ramanathan et al noted 2 patients with refractory disease who demonstrated prolonged remissions with rituximab. Not all reports have been favorable, however: Zaja et al noted no response to rituximab in 2 patients with AIHA, though a patient with cold agglutinin disease responded well. Gupta et al reported on the combined use of rituximab, cyclophosphamide and dexamethasone in 8 patients with refractory AIHA in the setting of chronic lymphocytic leukemia. The results were excellent, including in relapsed patients, with 5 patients converting to negative DAT status. There has been only limited experience with alemtuzumab in AIHA, with one report noting responses in 3 of 4 patients treated. The role of monoclonal antibodies in the therapy of autoimmune cytopenias has been reviewed in detail recently. It is reasonable to conclude that monoclonal antibody therapy, specifically rituximab, is a safe and effective therapy for AIHA. It is likely that as our experience with the drug evolves, it will be used at an earlier point in therapy, before more toxic immunosuppressives, rather than only in refractory cases.

MKK. SISTEM HEMATOLOGI dan MYELOPROLIFERATIF IMMUNE HEMOLYTIC 20 Oktober 2011 ANEMIA

REZDY TOFAN BHASKARA 105070107121003 PDKBI 2010

5. Describe the complications of AIHA! Thromboembolism In an early review of AIHA, the most common cause of death was pulmonary embolism (4 of 47 patients). All of these patients had had a splenectomy, and all were receiving corticosteroid therapy. In a more recent review by Pullarkat et al, 8 of 30 patients (27%) suffered from an episode of venous thromboembolism. A total of 9 had a detectable lupus anticoagulant and 17 had anticardiolipin antibodies detected. Among the 8 with thrombosis, 5 had a lupus anticoagulant and 4 had anticardiolipin antibodies. The authors attributed the thrombosis to disruption and loss of red cell membranes, resulting in exposure of phosphatidyl serine, and a subsequent surface for formation of tenase and prothrombinase complexes. Other factors implicated in the thrombotic tendency in patients with AIHA included cytokine-induced expression of monocyte or endothelial tissue factors. The authors postulated that the detection of a lupus anticoagulant identifies patients with AIHA at particularly high risk for venous thromboembolism and suggested that serious consideration be given to prophylactic anticoagulation in such patients. However, they point out that thrombosis also occurred in 15% of AIHA patients who did not have a lupus anticoagulant, so other factors are likely at work. Kokori et al, in a review of AIHA in patients with systemic lupus erythematosus, found the risk of thrombosis to be increased more than 4-fold, particularly in the presence of IgG anticardiolipin antibody. The association of serologic indications of lupus, namely a false-positive test for syphilis, has been noted in the past in patients with AIHA by Conley and Savarese. Hendrick has reviewed this issue recently and concluded that patients with AIHA are indeed at high risk for thromboembolism. In an audit of 23 patients with warm antibody AIHA and 5 with cold agglutinin hemolysis, venous thromboembolism was noted in 6, of which 4 cases were fatal. These patients did not have detectable antiphospholipid antibodies. In an analysis of 36 hemolytic episodes, venous thromboembolism occurred in 5 of 15 without anticoagulant prophylaxis, but in only 1 of 21 in which prophylaxis was used. Although it is premature to recommend anticoagulant prophylaxis in general for patients with hemolytic episodes from AIHA, consideration might be given to those at particularly high risk, such as those with evidence of coexisting antiphospholipid antibodies. Lymphoproliferative disorders Patients with lymphoproliferative disorders are well known to have a higher risk for development of AIHA; this is particularly true of chronic lymphocytic leukemia.

MKK. SISTEM HEMATOLOGI dan MYELOPROLIFERATIF IMMUNE HEMOLYTIC 20 Oktober 2011 ANEMIA

REZDY TOFAN BHASKARA 105070107121003 PDKBI 2010

Interestingly, there may also be an increased risk for future development of lymphoproliferative disorders in patients with AIHA. Sallah et al reported on 107 patients with AIHA, of 16 American Society of Hematology whom 67 had idiopathic AIHA, and 40 had an associated immune disorder (e.g., rheumatoid arthritis, temporal arteritis, Crohns disease, lupus, thyroiditis, Sjgrens syndrome). Nineteen of the 107 (18%) subsequently developed a malignant lymphoproliferative disorder, at a median of 26 months after onset of the AIHA.36 Risk factors for development of such a disorder were age, the presence of an underlying autoimmune disease, and a coexistent serum gammopathy. None of the patients had underlying HIV infection. The authors postulate that the development of a malignant lymphoid disorder is likely a multistep process, with an earlier proliferative phase involving chronic antigenic stimulation prior to a mutation leading to malignant change.