DRUG-INDUCED IMMUNE HEMOLYTIC ANEMIA ASSOCIATED WITH ROMIPLOSTIN
(Abstract release date: 05/19/16)
EHA Library. H. 06/09/16; 133128; E1579
Dr. Heidy
Contributions
Contributions
Abstract
Abstract: E1579
Type: Eposter Presentation
Background
Drug-induced immune hemolytic anemia (DIIHA) is a rare condition with an estimated incidence of about one per million patients per year. The exposure to a specific drug induces a sudden drop in circulating red blood cells (RBCs). Many drugs have been implicated in causing red cell (RCBs) destruction, with the most common being second and third generation cephalosporins. The initial serologic presentation is not fully appreciated, causing the disorder to be underdiagnosed. Romiplostim is a thrombopoietin receptor agonist approved for adult patients with chronic immune thrombocytopenic (ITP) who have been refractory to other treatments. It has also been used in some hyporegenerative thrombocytopenia cases.Here we report the case of a patient who gradually developed DIIHA with Romiplostim-related antibodies
Aims
.
Methods
CASE REPORT: A 67-year-old female was diagnosed with acute myeloid leukemia in February 2014. She received induction chemotherapy (QT) with Idarubicin and Cytarabine (3 + 7) achieving complete remission (CR) without hematological recovery. Persistent pancytopenia did not allow consolidation QT. In June 2014, she initiated erythropoietin (EPO) and Romiplostim treatment. EPO was suspended two months later and Romiplostin dose, which had come to 4 µg/kg/week was reduced to 0.5 µg/kg/week, keeping platelets count >100 X 103/µL. Subsequent bone marrow aspirations confirmed maintained complete remission. In October 2015, hemoglobin (Hb) concentration was 12.8 gr/dL (normal range 13.5-16.5 gr/dL) and platelets count 133 x 103/µL (normal range 130-400 x 103/µL). Four weeks later the patient referred asthenia. Laboratory tests showed Hb 9.7gr/dl. We ruled leukemia relapse and discontinued romiplostim. Ten days after last dose of romiplostim, laboratory analysis was notable for the following: Hb 10.2 gr/dl, reticulocytes 9.3%, LDH 513 mg/dl, bilirrubin 0.63 mg/dl and haptoglobin 117 mg/dl. Peripheral blood smear showed anisocytosis, polychromasia and spherocytes. Based on her clinical history and laboratory evaluation there was a high suspicion of a potential inmune hemolytic process. Serologic findings showed a strong positive DAT with polyspecific antiglobulin sera (3+) and monospecific anti-C3d sera (2+), being negative with monospecific anti-IgG sera. Eluate with group O RBCs was nonreactive and IAT (indirect antiglobuling test) was negative. Cold agglutinin anti-I was detected in patient´s plasma, titer 32 and thermal activity <20ºC.Patient´s plasma was strong reactive (2+) with romiplostin-treated RBCs (ID-Card LISS/Coombs, BIORAD). Eluate reacted weakly with romiplostim treated RBCs but did not react with the untreated RBCs. Both of them, plasma and eluate, were non reactive with saline-suspended untreated RBCs.After discontinuating the drug, Hb concentration and reticulocyte count were normalized. At the present time, her Hb concentration is 13.5gr/dl and DAT is negative.
Conclusion
This case highlights the importance for clinicians to maintain high index of suspicion for DIIHA in patients with unexplained hemolysis. It is also important to provide of specialized serological testing to clarify the suspected diagnosis. Romiplostim should be considered as a possible risk factor in development of immune hemolytic anemia. To our knowledge, this is the second report that implicates Romiplostim as a drug inducing DIIHA, being the other one in a patient with ITP.
Session topic: E-poster
Type: Eposter Presentation
Background
Drug-induced immune hemolytic anemia (DIIHA) is a rare condition with an estimated incidence of about one per million patients per year. The exposure to a specific drug induces a sudden drop in circulating red blood cells (RBCs). Many drugs have been implicated in causing red cell (RCBs) destruction, with the most common being second and third generation cephalosporins. The initial serologic presentation is not fully appreciated, causing the disorder to be underdiagnosed. Romiplostim is a thrombopoietin receptor agonist approved for adult patients with chronic immune thrombocytopenic (ITP) who have been refractory to other treatments. It has also been used in some hyporegenerative thrombocytopenia cases.Here we report the case of a patient who gradually developed DIIHA with Romiplostim-related antibodies
Aims
.
Methods
CASE REPORT: A 67-year-old female was diagnosed with acute myeloid leukemia in February 2014. She received induction chemotherapy (QT) with Idarubicin and Cytarabine (3 + 7) achieving complete remission (CR) without hematological recovery. Persistent pancytopenia did not allow consolidation QT. In June 2014, she initiated erythropoietin (EPO) and Romiplostim treatment. EPO was suspended two months later and Romiplostin dose, which had come to 4 µg/kg/week was reduced to 0.5 µg/kg/week, keeping platelets count >100 X 103/µL. Subsequent bone marrow aspirations confirmed maintained complete remission. In October 2015, hemoglobin (Hb) concentration was 12.8 gr/dL (normal range 13.5-16.5 gr/dL) and platelets count 133 x 103/µL (normal range 130-400 x 103/µL). Four weeks later the patient referred asthenia. Laboratory tests showed Hb 9.7gr/dl. We ruled leukemia relapse and discontinued romiplostim. Ten days after last dose of romiplostim, laboratory analysis was notable for the following: Hb 10.2 gr/dl, reticulocytes 9.3%, LDH 513 mg/dl, bilirrubin 0.63 mg/dl and haptoglobin 117 mg/dl. Peripheral blood smear showed anisocytosis, polychromasia and spherocytes. Based on her clinical history and laboratory evaluation there was a high suspicion of a potential inmune hemolytic process. Serologic findings showed a strong positive DAT with polyspecific antiglobulin sera (3+) and monospecific anti-C3d sera (2+), being negative with monospecific anti-IgG sera. Eluate with group O RBCs was nonreactive and IAT (indirect antiglobuling test) was negative. Cold agglutinin anti-I was detected in patient´s plasma, titer 32 and thermal activity <20ºC.Patient´s plasma was strong reactive (2+) with romiplostin-treated RBCs (ID-Card LISS/Coombs, BIORAD). Eluate reacted weakly with romiplostim treated RBCs but did not react with the untreated RBCs. Both of them, plasma and eluate, were non reactive with saline-suspended untreated RBCs.After discontinuating the drug, Hb concentration and reticulocyte count were normalized. At the present time, her Hb concentration is 13.5gr/dl and DAT is negative.
Conclusion
This case highlights the importance for clinicians to maintain high index of suspicion for DIIHA in patients with unexplained hemolysis. It is also important to provide of specialized serological testing to clarify the suspected diagnosis. Romiplostim should be considered as a possible risk factor in development of immune hemolytic anemia. To our knowledge, this is the second report that implicates Romiplostim as a drug inducing DIIHA, being the other one in a patient with ITP.
Session topic: E-poster
Abstract: E1579
Type: Eposter Presentation
Background
Drug-induced immune hemolytic anemia (DIIHA) is a rare condition with an estimated incidence of about one per million patients per year. The exposure to a specific drug induces a sudden drop in circulating red blood cells (RBCs). Many drugs have been implicated in causing red cell (RCBs) destruction, with the most common being second and third generation cephalosporins. The initial serologic presentation is not fully appreciated, causing the disorder to be underdiagnosed. Romiplostim is a thrombopoietin receptor agonist approved for adult patients with chronic immune thrombocytopenic (ITP) who have been refractory to other treatments. It has also been used in some hyporegenerative thrombocytopenia cases.Here we report the case of a patient who gradually developed DIIHA with Romiplostim-related antibodies
Aims
.
Methods
CASE REPORT: A 67-year-old female was diagnosed with acute myeloid leukemia in February 2014. She received induction chemotherapy (QT) with Idarubicin and Cytarabine (3 + 7) achieving complete remission (CR) without hematological recovery. Persistent pancytopenia did not allow consolidation QT. In June 2014, she initiated erythropoietin (EPO) and Romiplostim treatment. EPO was suspended two months later and Romiplostin dose, which had come to 4 µg/kg/week was reduced to 0.5 µg/kg/week, keeping platelets count >100 X 103/µL. Subsequent bone marrow aspirations confirmed maintained complete remission. In October 2015, hemoglobin (Hb) concentration was 12.8 gr/dL (normal range 13.5-16.5 gr/dL) and platelets count 133 x 103/µL (normal range 130-400 x 103/µL). Four weeks later the patient referred asthenia. Laboratory tests showed Hb 9.7gr/dl. We ruled leukemia relapse and discontinued romiplostim. Ten days after last dose of romiplostim, laboratory analysis was notable for the following: Hb 10.2 gr/dl, reticulocytes 9.3%, LDH 513 mg/dl, bilirrubin 0.63 mg/dl and haptoglobin 117 mg/dl. Peripheral blood smear showed anisocytosis, polychromasia and spherocytes. Based on her clinical history and laboratory evaluation there was a high suspicion of a potential inmune hemolytic process. Serologic findings showed a strong positive DAT with polyspecific antiglobulin sera (3+) and monospecific anti-C3d sera (2+), being negative with monospecific anti-IgG sera. Eluate with group O RBCs was nonreactive and IAT (indirect antiglobuling test) was negative. Cold agglutinin anti-I was detected in patient´s plasma, titer 32 and thermal activity <20ºC.Patient´s plasma was strong reactive (2+) with romiplostin-treated RBCs (ID-Card LISS/Coombs, BIORAD). Eluate reacted weakly with romiplostim treated RBCs but did not react with the untreated RBCs. Both of them, plasma and eluate, were non reactive with saline-suspended untreated RBCs.After discontinuating the drug, Hb concentration and reticulocyte count were normalized. At the present time, her Hb concentration is 13.5gr/dl and DAT is negative.
Conclusion
This case highlights the importance for clinicians to maintain high index of suspicion for DIIHA in patients with unexplained hemolysis. It is also important to provide of specialized serological testing to clarify the suspected diagnosis. Romiplostim should be considered as a possible risk factor in development of immune hemolytic anemia. To our knowledge, this is the second report that implicates Romiplostim as a drug inducing DIIHA, being the other one in a patient with ITP.
Session topic: E-poster
Type: Eposter Presentation
Background
Drug-induced immune hemolytic anemia (DIIHA) is a rare condition with an estimated incidence of about one per million patients per year. The exposure to a specific drug induces a sudden drop in circulating red blood cells (RBCs). Many drugs have been implicated in causing red cell (RCBs) destruction, with the most common being second and third generation cephalosporins. The initial serologic presentation is not fully appreciated, causing the disorder to be underdiagnosed. Romiplostim is a thrombopoietin receptor agonist approved for adult patients with chronic immune thrombocytopenic (ITP) who have been refractory to other treatments. It has also been used in some hyporegenerative thrombocytopenia cases.Here we report the case of a patient who gradually developed DIIHA with Romiplostim-related antibodies
Aims
.
Methods
CASE REPORT: A 67-year-old female was diagnosed with acute myeloid leukemia in February 2014. She received induction chemotherapy (QT) with Idarubicin and Cytarabine (3 + 7) achieving complete remission (CR) without hematological recovery. Persistent pancytopenia did not allow consolidation QT. In June 2014, she initiated erythropoietin (EPO) and Romiplostim treatment. EPO was suspended two months later and Romiplostin dose, which had come to 4 µg/kg/week was reduced to 0.5 µg/kg/week, keeping platelets count >100 X 103/µL. Subsequent bone marrow aspirations confirmed maintained complete remission. In October 2015, hemoglobin (Hb) concentration was 12.8 gr/dL (normal range 13.5-16.5 gr/dL) and platelets count 133 x 103/µL (normal range 130-400 x 103/µL). Four weeks later the patient referred asthenia. Laboratory tests showed Hb 9.7gr/dl. We ruled leukemia relapse and discontinued romiplostim. Ten days after last dose of romiplostim, laboratory analysis was notable for the following: Hb 10.2 gr/dl, reticulocytes 9.3%, LDH 513 mg/dl, bilirrubin 0.63 mg/dl and haptoglobin 117 mg/dl. Peripheral blood smear showed anisocytosis, polychromasia and spherocytes. Based on her clinical history and laboratory evaluation there was a high suspicion of a potential inmune hemolytic process. Serologic findings showed a strong positive DAT with polyspecific antiglobulin sera (3+) and monospecific anti-C3d sera (2+), being negative with monospecific anti-IgG sera. Eluate with group O RBCs was nonreactive and IAT (indirect antiglobuling test) was negative. Cold agglutinin anti-I was detected in patient´s plasma, titer 32 and thermal activity <20ºC.Patient´s plasma was strong reactive (2+) with romiplostin-treated RBCs (ID-Card LISS/Coombs, BIORAD). Eluate reacted weakly with romiplostim treated RBCs but did not react with the untreated RBCs. Both of them, plasma and eluate, were non reactive with saline-suspended untreated RBCs.After discontinuating the drug, Hb concentration and reticulocyte count were normalized. At the present time, her Hb concentration is 13.5gr/dl and DAT is negative.
Conclusion
This case highlights the importance for clinicians to maintain high index of suspicion for DIIHA in patients with unexplained hemolysis. It is also important to provide of specialized serological testing to clarify the suspected diagnosis. Romiplostim should be considered as a possible risk factor in development of immune hemolytic anemia. To our knowledge, this is the second report that implicates Romiplostim as a drug inducing DIIHA, being the other one in a patient with ITP.
Session topic: E-poster
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