USE OF CYCLOSPHAMIDE IN AUTOIMMUNE HEMOLYTIC ANEMIA

USE OF CYCLOSPHAMIDE IN AUTOIMMUNE HEMOLYTIC ANEMIA

PRELIMINARY
Autoimmune hemolytic anemia is anemia that arises due to the formation of autoantibodies against erythrocytes, causing destruction/hemolysis of erythrocytes.
The classification of autoimmune hemolytic anemia based on the nature of the antibody reaction is divided into 2 groups, namely warm type hemolytic anemia (warm AIHA) and cold type hemolytic anemia (cold AIHA).
The incidence of autoimmune hemolytic anemia in children is relatively rare, which is about 1/80,000 children in the general population. The frequency of warm-type autoimmune hemolytic anemia is more frequent, which is about 50-70% of all autoimmune hemolytic anemias

The causes of autoimmune hemolytic anemia are mostly idiopathic. Other causes are secondary to lymphoploriferative disease (non-Hodgkin’s lymphoma, chronic lymphocytic leukemia), autoimmune diseases (systemic lupus erythematosus), and infectious diseases.

Clinical symptoms of autoimmune hemolytic anemia include pallor, jaundice, and hepatosplenomegaly. If there is severe anemia, it will be found shortness of breath, tachycardia, and impaired consciousness
The diagnosis of autoimmune hemolytic anemia is by finding evidence of hemolysis (destruction of erythrocytes, increased hemoglobin catabolism, increased erythropoiesis activity) and evidence of autoantibodies against erythrocytes (positive Coomb’s test). 1,4,5

Because it is a rare case, the management of autoimmune hemolytic anemia is challenging, mainly due to the absence of evidence-based consensus guidelines and limited clinical trial studies to define standard therapy. Currently, first-line therapy is corticosteroids. Alternative second-line therapy is the administration of strong immunosuppressives (cyclophosphamide, cyclosporine A, azathioprine, mycophenolate mofetil), immunoglobulins. The third line of therapy is splenectomy.6,7

This paper will report a case of autoimmune hemolytic anemia in a child who was treated with high-dose methylprednisolone, but did not show improvement. Treatment was then replaced with high-dose cyclophosphamide and showed improvement with increasing hemoglobin levels.

CASE REPORT
AP, daughter, age 10 years 5 months admitted to RSUP Dr. Wahidin Sudirohusodo on September 18, 2013 with a working diagnosis of hemolytic anemia and malnutrition.
History
Paleness was noticed since 5 days before admission to the hospital. No fever. No cough. No vomiting. No stomach pain. There is weakness, fatigue, and heart palpitations. Children are lazy to eat and drink. CHAPTER = normal, yellow color, BAK = smooth impression, color like strong tea. History of frequent fever, no history of spontaneous bleeding, no history of previous drug consumption, no history of visiting malaria endemic areas, history of transfusion there was no previous blood, no history of malignancy in the family, history of being treated at Haji General Hospital for 1 day and planned to do a blood transfusion, but it was canceled due to incompatibility results then the patient was referred to Dr. Wahidin Sudirohusodo.

Physical examination

The child appears to be seriously ill, malnourished (weight 24 kg, PB 134 cm), aware of GCS 15 (E4M6V5). Blood pressure 100/60 mmHg; pulse 124 x/minute, regular, contains; respiration 32 x/minute, temperature 37.10 Celsius, puberty status A1M1P1. There is pallor, there is jaundice. No enlarged lymph nodes. Examination of chest wall inspection within normal limits. On auscultation of the chest, there were no crackles or wheezing, pure regular I/II heart sounds, no heart murmurs. Abdominal examination of the liver and spleen was not palpable. There were no bleeding manifestations either spontaneous or provocation.

Laboratory examination
Routine blood (18/9/2013):
Hb 3.4 g/dL, hematocrit 7.1%, leukocytes 7100/mm3, platelets 183,000/mm3, erythrocytes 0.6 million/mm3. MCV 118.3 fL, MCH 56.7 pg, MCHC 47.9 gr/dL. Count types: neutrophils 89.5%, eosinophils 0.1%, basophils 0.1%, monocytes 1.1%, lymphocytes 9.2%.
Reticulocytes: 19.7%
Peripheral blood smear (18/9/2013):
Erythrocytes: normocytic normochromic, anisopoikilocytosis, ovalocytes (+), cell fragments (+), stomatocytes (+), target cells (+), polychromasia (+), inclusion objects (-), normoblasts (+)
Leukocytes: sufficient number, PMN>lymphocytes, toxic granulation (+), hypersegmentation (+), young cells (-)
Platelets: sufficient number, normal morphology
Impression: normochromic normocytic anemia with hemolytic signs accompanied by leukocytes, signs of infection
Suggestion: bilirubin I/II, Coomb’s test
Routine urine (18/9/2013)
Yellow color, pH 7, Bj 1.005, protein (-), glucose (-), bilirubin (-), urobilinogen (++), blood (-), erythrocyte sediment 1-2, leukocyte sediment 0-1.
Blood chemistry:
Total Bilirubin : 2.7 mg/dL; direct bilirubin 0.4 mg/d; indirect bilirubin 2.3 mg/dL; albumin 4.1 g/dL; SGOT 31 U/L; SGPT 15 U/L
DDR : negative
Coomb’s test: positive

DEFINITIVE DIAGNOSIS
– Autoimmune hemolytic anemia
– Malnutrition

MANAGEMENT
Medical Care
– Oxygen via nasal cannula 2 liters/minute
– IVFD dextrose 5% 20 drops/minute
– Methylprednisolone 20 mg/kg/day

Nutritional care
– Regular food:energy 1440 kcal, protein 54 grams.
Follow-up observations to:
3: KU: weak, vital signs T= 90/60 mmHg, N= 124x/minute, P= 38x/minute, S = 37.10 Celsius. No fever, cough, or shortness of breath. There is still weakness, fatigue, and heart palpitations. There is still pallor, there is still jaundice, no organ enlargement.
Medical care: Oxygen nasal cannula 2 liters/minute, IVFD dextrose 5% 20 drops/minute, dose of methylprednisolone is increased to 30 mg/kgBW/day = 360 mg/intravenous
Nutritional care: Regular food 1440 kcal energy, 54 grams protein.

Laboratory :
routine blood : WBC 7200; Hb 2.5 g/dL; RBC 0.46 million/uL; HCT 5.6%, PLT 172,000; MCV 121.7 fl; MCH 47.8 pg; MCHC 39.3 g/dL, neut 55.9%, Lymphocytes 35.3%, mono 6.7%, eos 0.3%, basophils 1.8%
Coomb’s test: positive 2, the results of cross matching showed major and minor incompatibility (+2) and IgG was found in DAT.
6: KU: weak, vital signs T= 100/70 mmHg, N= 116x/min, P= 28x/min, S = 36.80 Celsius. There is still pallor and jaundice, no organ enlargement.
Medical care: Supportive therapy is continued, methylprednisolone is replaced with cyclophosphamide 100-200 mg/m2/day = 175 mg/intravenous

Nutritional care: Regular food 1440 kcal energy, 54 grams protein.
Routine blood: WBC 11,090; Hb 2.5 g/dL; RBC 0.48 million/uL; HCT 6.4%, PLT 170,000; MCV 133.3 fl; MCH 52.1 pg; MCHC 39.1 g/dL, neut 63%, lymphocytes 28.1%, monocytes 8.0%, eos 0.5%, basophils 0.4%.
Coomb’s test: positive 2, there are still major and minor incompatibility (+2).
9: KU: weak, vital signs T= 100/70 mmHg, N= 116x/min, P= 28x/min, S = 36.80 Celsius. There is still pallor and jaundice, no organ enlargement.

Medical care: Continued supportive therapy, continued cyclophosphamide 100-200 mg/m2hr = 175 mg/intravenous
Nutritional care: Regular food 1440 kcal energy, 54 grams protein.
Routine blood: WBC 7500; Hb 3.6 g/dL; RBC 0.48 million/uL; HCT 6.4%, PLT 167,000; MCV 147.8 fl; MCH 39.1 pg; MCHC 26.5 g/dL, neut 67%, lymphocytes 22.7%, monocytes 7.0%, eos 2.0%, basophils 0.4%
Coomb’s test: positive 2, there are still major and minor incompatibility (+2).
12 : KU : weak, vital signs T= 100/70 mmHg, N= 106x/min, P= 24x/min, S = 36.80 Celsius. There is still pallor, no jaundice, no organ enlargement.

Medical care : Cyclophosphamide was discontinued after 6 days of administration, then continued with oral methylprednisolone 1 mg/kgBW/day = 24 mg = 2-2-2/oral (4 mg tablets)
Nutritional care: Regular food 1440 kcal energy, 54 grams protein.
Routine blood: WBC 4900; Hb 4.0 gr/dL; RBC 0.48 million/uL; HCT 11.8%, PLT 150.000; MCV 120 fl; MCH 40.5 pg; MCHC 33.8 g/dL, neut 66.8%, lymphocytes 21.1%, monocytes 8.7%, eos 2.9%, basophils 0.5%
Reticulocytes: 3.1%
15 : KU : weak, vital signs T= 100/70 mmHg, N= 96x/minute, P= 20x/minute, S = 36.50 Celsius. No pallor and jaundice.
Medical care : Methylprednisolone tablets 2-1-1/oral (tapering off)
Nutritional care: Regular food 1440 kcal energy, 54 grams protein.
Routine blood: WBC 8200; Hb 9.5 gr/dL; RBC 4.03 million/uL; HCT 29.2%, PLT 297,000; MCV 72 fl; MCH 23.5 pg; MCHC 32.4 g/dL, neut 39.7%, lymphocytes 50.3%, monocytes 7.7%, eos 1.2%, basophils 1.1%
The patient was allowed to go home, and was recommended for control at the pediatric polyclinic.

DISCUSSION
Autoimmune hemolytic anemia in children is associated with several diseases such as: immunodeficiency syndromes, malignancies, and systemic autoimmune diseases.1 Sometimes no underlying disease can be detected as in this case.

Autoimmunity is a condition in which a person’s immune system responds to itself (self response) resulting in disease. To understand the pathogenesis of the autoimmune response, it is necessary to understand the mechanism of the immune system’s self-tolerance. Failure of tolerance due to induction of foreign antigens will result in autoimmunity. A B or T cell that does not respond to a “self” antigen is called tolerance (normal), but B or T Cell Tolerance is also referred to if it does not respond to a foreign antigen (abnormal). For autoimmune speech, tolerance is self-tolerance. B cells or T cells whose receptors are in accordance with self antigens should not develop so that there is no immune response to self antigens, but for some reason these T cells or B cells actively respond to self antigens, autoimmune diseases occur.

Antibody-mediated destruction of erythrocytes occurs through activation of the complement system, activation of cellular mechanisms, or a combination of both. Overall activation of the complement system will cause the destruction of the erythrocyte cell membrane and intravascular hemolysis occurs. IgM is called cold-type agglutinin, because these antibodies bind to polysaccharide antigens on the surface of red blood cells at temperatures below body temperature. 2,3,4

 

Figure 1. Pathomechanisms of intravascular and extravascular hemolysis

Figure 1. Pathomechanisms of intravascular and extravascular hemolysis

IgG antibodies are called warm-type agglutinins because they react with erythrocyte cell surface antigens at normal body temperature. If lysed blood cells are synthesized with IgG that is not bound to complement components but no further complement activation occurs, then the red blood cells will be destroyed by reticuloendothelial cells. This erythrocyte destruction process is mainly mediated by IgG-FcR which will cause phagocytosis. This causes extravascular hemolysis.

The diagnosis of autoimmune hemolytic anemia in this case was based on history, physical examination, and investigations. In the anamnesis it was found that there was pallor which was noticed since 5 days before admission to the hospital. On physical examination, he was pale and icterus. Investigations revealed anemia with hemoglobin levels of 3.6 mg/dL, reticulocytosis of 19.7%, an increase in indirect bilirubin of 2.3 g/dL, the presence of normoblasts on the peripheral blood smear, the presence of urobilinogenuria, and a positive Coomb’s test. This case is classified as warm type autoimmune hemolytic anemia because hemolysis occurs at body temperature > 37o Celsius, evidence of extravascular hemolysis, and the presence of IgG antibodies on cross-matching examination. In addition, an alloimmune process was found in this case, because the results of major and minor incompatibility were obtained on cross matching examination.

Immunosuppressive therapy with corticosteroids is the first-line therapy for warm-type AIHA. A response is seen in about 80% of cases.7 Studies conducted by Naithani et al in 2007 and Nazan et al in 2010 showed that corticosteroid therapy is effective in the treatment of autoimmune hemolytic anemia.7,11 (Level III, recommendation A). Research by Gurgey in 1999 that corticosteroid therapy is effective in acute cases, while in chronic cases the response varies.12 (Level III, recommendation C). Research by Yetgin et al in 2007 that high-dose corticosteroids are more effective than conventional doses in haematological disorders.13 (Level I, recommendation A). Research by Gehrs in 2002 that the response to steroid therapy will usually be seen within 1 week of treatment

Corticosteroids are believed to inhibit Fc receptors from binding to IgG so that phagocytosis by macrophages in extravascular hemolysis can be inhibited,15 while cyclophosphamide is an immunosuppressive agent that suppresses the production of autoantibodies in B lymphocytes and T lymphocytes.
In this case, after administration of high-dose methylprednisolone for 6 days, the patient did not respond to steroids. Seen by a decrease in hemoglobin levels on monitoring to 2.5 g / dl. This means that the hemolysis process is still continuing. So in this case steroid therapy was replaced with cyclophosphamide.

A case report by Panceri et al in 1992 showed that autoimmune hemolytic anemia responded well to cyclophosphamide after no response to steroids.16 (Level III, recommendation C) while Ettore et al reported a good therapeutic response after 10 days of combined steroids and cyclophosphamide. .17 (Level III, recommendation C). A report by Ahmad et al in 2013 that cyclophosphamide is good for refractory autoimmune hemolytic anemia. In his study showed a significant increase in hemoglobin levels after cyclophosphamide therapy. (Level III, recommendation C).6 A study by Moyo et al in 2002 showed that 9 patients with autoimmune hemolytic anemia unresponsive to corticosteroid treatment and other treatments were given cyclophosphamide for 4 days, and it was seen that 6 patients had complete remission without transfusion. blood. (Level III, recommendation C).18
In this case, after administration of cyclophosphamide for 6 days, the patient’s hemoglobin level increased without blood transfusion. The following is a graph showing the increase in hemoglobin levels in our case, after six days of cyclophosphamide administration.

Graph 1. Increased hemoglobin levels after administration of cyclophosphamide

Graph 1. Increased hemoglobin levels after administration of cyclophosphamide

After administration of cyclophosphamide, the reticulocyte level decreased from 19.7% to 3.1%, which means that the hemolysis process began to decrease. The following is a graph showing the decrease in reticulocyte levels in our case after six days of cyclophosphamide administration.

Graph 2. Decreased reticulocyte levels after administration of cyclophosphamide

Graph 2. Decreased reticulocyte levels after administration of cyclophosphamide

 

Several case reports reported an increase in hemoglobin levels after administration of cyclosporine A. In contrast to cyclophosphamide, cyclosporine A only suppresses the production of autoantibodies by T lymphocytes so that in this case the second-line therapy chosen was cyclophosphamide. There are also reports of successful treatment of autoimmune hemolytic anemia using immunoglobulins as second-line therapy. Immunoglobulins function in the blockade of phagocytosis by macrophages because immunoglobulins bind to receptors on macrophages so that they cannot bind to IgG.

In this case, conventional steroid therapy was given to achieve complete remission and prevent relapse. Research by Nathalie et al in 2011 that complete remission mostly occurs in the first month of therapy. Patients with refractory autoimmune hemolytic anemia require approximately 1 to 7 years of therapy. After multivariate analysis, it was found that only IgG/IgG+C3d DAT was significantly associated with complete remission with a Hazard ratio of 0.43; 95% CI 0.21-0.68, p=0.01.12 (Level III, recommendation C). A report by Moyo et al in 2002 that in 6 patients who experienced complete remission after administration of cyclophosphamide none experienced a relapse with a median follow-up of 15 months (range 4 months-29 months).18

Several case reports of autoimmune hemolytic anemia unresponsive to steroids and second-line therapy reported splenectomy. Splenectomy plays a role in blocking the site of destruction of erythrocytes and suppressing the production of B lymphocytes, because the spleen is a lymphoid organ.7 In this case, splenectomy was not considered because with second-line therapy clinical and laboratory improvements have been seen.
The prognosis of this case is dubia, because there has been an increase in hemoglobin levels, although it has not reached normal values. Monitoring and adherence to medication is required for complete remission to occur.

SUMMARY
A case of autoimmune hemolytic anemia has been reported in a girl 10 years 5 months. The diagnosis is based on history, physical examination and investigations. Therapy in this case was high-dose corticosteroids, but no improvement was seen so they were replaced with high-dose cyclophosphamide. Improvement was seen with increasing hemoglobin levels without blood transfusion.

 

REFERENCES

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  19. Nathalie A, Guy L, Thierry L, Marie P, Gerard M, Yves B, Alain R, Virginia G, Alain F, Caroline T, et al. New Insight into Childhood Autoimmune Hemolytic Anemia : A French National Observational Study of 265 Chilren. Henatologica 2011; 96(5): 655-663.

By :

dr.Besse Sarmila, SpA, Dr.dr.Nadirah Rasyid Ridha,M.Kes,Sp.A(K), Prof.Dr.dr.H.Dasril Daud,Sp.A(K)

PROGRAM PENDIDIKAN DOKTER SPESIALIS

DEPARTEMEN ILMU KESEHATAN ANAK

FAKULTAS KEDOKTERAN

UNIVERSITAS HASANUDDIN

MAKASSAR

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