□ CASE REPORT □

Coombs-negative Autoimmune Hemolytic Followed by Anti-erythropoetin Receptor Antibody-associated Pure Red Cell Aplasia: A Case Report and Review of Literature

Mayumi Yoshimi 1, Yutaka Kadowaki 2, Yuji Kikuchi 1 and Tsuyoshi Takahashi 1

Abstract

A 76-year-old woman was referred to our hospital because of anemia. The laboratory findings revealed hemolysis. Although a direct Coombs test was negative, a high titer of RBC-bound IgG was detected, and a diagnosis of Coombs-negative autoimmune was made. She was successfully treated with prednisolone. One year and five months later, she again presented anemia and was diagnosed with pure red cell aplasia. Anti-erythropoietin receptor antibody was detected in the serum. She was treated with cy- closporine and obtained prompt recovery. We herein report this rare case and review the pertinent literature.

Key words: autoimmune hemolytic anemia, pure red cell aplasia, anti-erythropoietin receptor antibody, cyclosporine

(Intern Med 55: 511-514, 2016) (DOI: 10.2169/internalmedicine.55.5436)

genesis of PRCA is not yet well known, various autoim- Introduction mune mechanisms have been described, such as the produc- tion of antibodies against erythroid progenitors or erythro- Both autoimmune hemolytic anemia (AIHA) and pure red poietin (EPO). Cellular immunity is also proposed to be in- cell aplasia (PRCA) are rare hematological disorders. The volved in the pathogenesis, through the direct or indirect in- etiology of these diseases is not yet well understood; how- jury of erythroblasts, by T cells or natural killer cells. ever, abnormal immune reactions might be responsible for Although rare, the simultaneous or sequential occurrence their development. AIHA is a disease in which autoantibod- of PRCA and AIHA has been the subject of several re- ies against autologous (RBC) membrane pro- ports (3-19). This indicates that there are some mechanisms teins are produced, which shortens the survival of RBCs. that occur in the pathogenesis of these diseases. Recently, a The cause of AIHA is idiopathic or secondary. Secondary case of a malignant lymphoma patient in whom PRCA was AIHA is associated with malignancies, such as lymphoma, accompanied by Coombs-negative AIHA was reported in leukemia or ovarian tumors; with autoimmune disorders, which the PRCA was found to be anti-EPO receptor such as systemic lupus erythematosus (SLE) or ulcerative antibody-associated (20). We herein report a case of primary colitis; and with drugs, such as α-methyldopa (1). PRCA is Coombs-negative AIHA followed by anti-EPO receptor a disease in which the numbers of erythroid progenitors in antibody-associated PRCA and discuss the basis of the pa- the are reduced but granulopoiesis and tient’s pathological status. megakaryopoiesis are normal. There are two main types of PRCA: a congenital type (Diamond-Blackfan anemia) and Case Report an acquired type. The acquired type of PRCA, can be asso- ciated with infections such as , autoimmune A 76-year-old woman was referred to our hospital be- diseases and neoplasms such as , lymphoma or car- cause of anemia. She had a medical history of diabetes mel- cinoma; it can also be idiopathic (2). Although the patho- litus with under good control and was not be treated with

１Department of , Mitsui Memorial Hospital, Japan and ２Department of Medicine, Mitsui Memorial Hospital, Japan Received for publication March 24, 2015; Accepted for publication June 11, 2015 Correspondence to Dr. Tsuyoshi Takahashi, [email protected]

511 Intern Med 55: 511-514, 2016 DOI: 10.2169/internalmedicine.55.5436

Figure. The clinical course. PSL: prednisolone, CyA: cyclosporine A, RBC: red blood cell transfu- sion, Hb: hemoglobin, Ret: reticulocyte any medications. The peripheral blood laboratory data were started at a dose of 150 mg/day 6 weeks after the diagnosis as follows: WBC 2,700/μL, Hb 6.1 g/dL, reticulocyte 7.1 %, of PRCA. Reticulocytosis appeared 10 days after the start of 16.9×104/μL, lactate dehydrogenase (LDH) 236 U/ treatment and the patient’s anemia promptly recovered (Fig- L, T.Bil 1.8 mg/dL. The patient’s haptoglobin of <10 mg/dL ure). was under the detection level. Bone marrow aspiration re- vealed erythroid hyperplasia and abdominal ultrasonography Discussion indicated splenomegaly. There was no lymph node swelling. Although a direct Coombs test was negative, 76 RBC-bound There are several reports of cases in which both AIHA IgG on 1 RBC (normal range, 33±13) indicated that the pa- and PRCA occurred simultaneously or sequentially (3-19). tient had Coombs-negative AIHA (21). She was treated with Table is a list of the published reports. Usually, this occurs prednisolone (50 mg/day) and promptly recovered (Figure). in association with other diseases, including: hematological However, after one year and 5 months, severe anemia (Hb malignancies such as lymphoma (6, 8, 20) and chronic lym- 4.7 g/dL) appeared while she was still taking a reduced dose phocytic leukemia (15); autoimmune diseases such as of prednisolone (5 mg/day). (0.3%, 7,140/ Sjögren syndrome (9, 11, 17) and SLE (13); infections such μL) was observed in the peripheral blood and marked as (19); or due to the use of immunosuppressive erythroid hypoplasia was observed in the bone marrow. A drugs after transplantation, such as alemtuzumab (10, 14). cytogenetic analysis of the bone marrow was normal. Based Although rare, cases of primary AIHA followed by PRCA on the findings, the patient was diagnosed with PRCA. At that are not associated with other have been re- this time, the patient’s laboratory data were as follows: LDH ported (3, 7, 12, 16). The diagnosis of the patient of our 150 U/L, T.Bil 0.7 mg/dL and haptoglobin 21 mg/dL. Par- present case is also considered to be primary AIHA fol- vovirus B19 infection was not detected by a serological test lowed by PRCA. Although the precise mechanism by which for anti-parvovirus B19 IgM antibody. No abnormalities (in- these rare diseases occur together or sequentially remains to cluding thymoma and other abnormalities) were detected by be elucidated, several studies have explored the pathogene- systemic contrast-enhanced computer tomography and no sis. In a case of chronic lymphocytic leukemia (CLL), a par- monoclonal lymphocytes were detected by a polymerase vovirus B19 infection was considered to have caused chain reaction (PCR) to investigate the immunoglobulin PRCA (15), while anti-EPO antibody caused the PRCA in a heavy chain and T cell receptor β chain rearrangement in patient with SLE (13). In a case of primary AIHA followed the peripheral blood. The drugs that the patient took when by PRCA, the cytotoxic mononuclear cells directly affected the PRCA occurred included esomeprazole, prednisolone, the erythroid precursors and caused PRCA (3). Recently, voriconazole, linagliptin (after starting prednisolone treat- Fujimi et al. reported a case of anti-EPO receptor antibody- ment), and risedronate. All of the drugs, with the exception associated PRCA that was accompanied by Coombs- of voriconazole had been administered for more than one negative AIHA in a lymphoma patient (20). The anti-EPO year. Voriconazole was administered for three months before receptor antibodies are newly identified autoantibodies that the onset of PRCA because of a slight increase in the serum are associated with the pathogenesis of anemia (22). In our level of aspergilus antigen. To examine the cause of PRCA, case, the patient’s serum was positive for anti-EPO receptor the serum level of anti-erythropoietin receptor antibody was antibody when the PRCA occurred; thus this was a potential measured by an enzyme-linked immunosorbent assay which cause of the PRCA. Drug use sometimes causes PRCA. In indicated a positive result with an optical density (OD450)of our case, with the exception of voriconazole, the drugs that 1.647 (normal range, <1.5) (22). Cyclosporine therapy was the patient was taking when PRCA occurred had been ad-

512 Intern Med 55: 511-514, 2016 DOI: 10.2169/internalmedicine.55.5436

Table. Published References of AIHA and PRCA.

Pts age/sex disease AIHA/PRCA duration ref 35/F primary AIHAĺPRCA 4yrs 3 52/F lymphoma AIHA, PRCA concurrent 4 23/F LGL AIHA, PRCA concurrent 5 62/F lymphoma AIHA, PRCA concurrent 6 1.5/F primary AIHA, PRCA concurrent 7 53/M lymphoma AIHA, PRCA concurrent 8 68/F Sjögren syndrome AIHAĺPRCA 11mo 9 74/F Sjögren syndrome AIHA, PRCA concurrent 11 68/F Primary AIHA, PRCA concurrent 12 42/F SLE AIHA, PRCA concurrent 13 54/M alemutuzumab AIHA, PRCA concurrent 14 73/M CLL AIHA, PRCA concurrent 15 26/F primary AIHA, PRCA concurrent 16 36/F Sjögren syndrome AIHA, PRCA concurrent 17 80/M PLL AIHA, PRCA concurrent 18 49/F AIHAĺPRCA 3wks 19 76/F primary AIHAĺPRCA 1yr5mo this case Abbreviation: LGL: large granular lymphocytes, SLE: systemic lupus erythematosus, CLL: chronic lymphocytic leukemia, PLL: prolymphocytic leukemia. ministered for more than one year, thus it seems unlikely patients will be elucidated in the near future. that the patient’s condition was related to the administration of these drugs. The administration of voriconazole was The authors state that they have no Conflict of Interest (COI). started three months before the onset of PRCA. Although the myelosuppression and are rare side ef- Acknowledgement fects of voriconazole administration, the possibility that The authors would like to thank Dr. Akinori Hara and Takashi voriconazole was the cause of the patient’s PRCA cannot to- Wada at the Department of Nephrology, Kanazawa University tally be denied. To the best of the authors’ knowledge, this Hospital, Kanazawa, Japan, for measuring of the anti-EPO recep- is the second report to describe the association between tor antibody levels, and Dr. Toyomi Kameishi at the Center for PRCA following AIHA and anti-EPO receptor antibody Community Medicine, Jichi Medical University, Tochigi, Japan, positivity (20). Furthermore, this is the first report in rela- for measuring the RBC-bound IgG levels. tion to PRCA with primary AIHA. Because the method for References detecting anti-EPO receptor antibody was recently devel- oped, it is possible that anti-EPO receptor antibody might 1. Lechner K, Jäger U. How I treat autoimmune hemolytic have been the cause of PRCA in some of the cases in which in adults. Blood 116: 1831-1838, 2010. both AIHA and PRCA occurred. Why both AIHA and 2. Sawada K, Fujishima N, Hirokawa M. Acquired pure red cell aplasia: updated review of treatment. Br J Haematol 142: 505-514, PRCA occur at the same time or sequentially is a puzzle. 2008. The target antigens in AIHA are the membrane proteins of 3. Tohda S, Nara N, Tanikawa S, Imai Y, Murakami N, Aoki N. Pure mature RBCs. On the other hand, the target antigens in red cell aplasia following autoimmune haemolytic anaemia. Cell- PRCA are the molecules that are expressed in precursor mediated suppression of erythropoiesis as a possible pathogenesis erythroblasts. In some cases there might be the mechanisms of pure red cell aplasia. Acta Haematol 87: 98-102, 1992. 4. Suzuki A, Takahashi T, Taniguchi A, et al. Pure red cell aplasia that bridge these erythroid cells, such as antigen drift from associated with non-Hodgkin’s lymphoma and hemolytic anemia. mature RBCs to precursor erythroid cells during dysregu- Jpn J Clin Oncol 21: 384-387, 1991. lated autoimmune responses. The further accumulation of 5. Akashi K, Shibuya T, Taniguchi S, et al. Multiple autoimmune such cases and analyses to investigate the associated im- haemopoietic disorders and insidious clonal proliferation of large mune dysregulation are needed. granular lymphocytes. Br J Haematol 107: 670-673, 1999. 6. Zeldman A, Fradin Z, Barac Y, Bendayan D, Mittelman M, Orlin The Coombs test of the patient of our present case was J. Splenic lymphoma presenting as warm autoimmune hemolytic negative. It has been reported that up to 10% of AIHA cases anemia associated with pure red cell aplasia. Vox Sang 78: 126- are Coombs-negative (23). In the reported cases in which 129, 2000. both AIHA and PRCA occurred, the ratio of Coombs- 7. Zecca M, Stefano PD, Nobili B, Locatelli F. Anti-CD20 monoclo- negative AIHA was approximately 30%; thus, in this patho- nal antibody for the treatment of severe, immune-mediated, pure red cell aplasia and hemolytic anemia. Blood 97: 3995-3997, logical status, the negative rate of the Coombs test might be 2001. high. However, the number of reported cases is very small. 8. Katayama H, Takeuchi M, Yoshino T, et al. Epstein-Barr virus as- As a result, this might be an issue in the future. sociated diffuse large B-cell lymphoma complicated by autoim- In conclusion, we herein reported a rare case of primary mune hemolytic anemia and oure red cell aplasia. Leuk Lym- AIHA followed by anti-EPO receptor antibody-associated phoma 42: 539-542, 2001. 9. Shitatsuchi M, Kitamura Y, Suehiro Y, et al. Successful treatment PRCA. We hope that the pathological mechanisms of such

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