Alessandri, C

Caputo, Md

Colafigli, G

Coluzzi, S

De Propris, Ms

Foà, R

Giovannetti, G

Girelli, G

Guarini, Ar

Mauro, Fr

Pepe, S

Porrazzo, M

Riemma, C

Trastulli, F

Valesini, G

Haematologica

English

Mauro FR

Trastulli F

Alessandri C

Valesini G

Giovannetti G

Riemma C

Porrazzo M

Pepe S

Colafigli G

Caputo MD

De Propris MS

Guarini AR

Girelli G

Coluzzi S

Foà R

Archivio della ricerca- Università di Roma La Sapienza

Clinical relevance of silent red blood cell autoantibodiesThe diagnosis of autoimmune hemolytic anemia(AIHA) is based on the evidence of anemia, hemolysisand the detection of red blood cell (RBCs) autoantibod-ies.1-2 The absence of detectable RBC autoantibodies doesnot always exclude autoimmune hemolysis. Conversely,the presence of RBC autoantibodies is not always associ-ated with hemolytic anemia. Silent RBC autoantibodieshave been detected in healthy blood donors,3,4 in preg-nant females5 and in patients with autoimmune disor-ders.6 While the occurrence of clinically non-significantRBC autoantibodies is a well-known phenomenon inimmunohematology laboratories, there is little informa-tion about the clinical course of subjects with silent RBCautoantibodies and whether disorders known to be asso-ciated with AHIA could also be present in these subjects.To address these issues, we retrospectively analyzed thecharacteristics and the long-term outcome of 60 subjectswith silent RBC autoantibodies who were referred to ourHematology Center between January 1995 andDecember 2012 and followed on a regular basis overtime.Our results showed that the development of AHIA insubjects with silent RBC autoantibodies was a rare eventand that disorders known to be associated with AHIAwere present in a relevant proportion of cases with silentagglutinins.Subjects with silent RBC autoantibodies showed nor-mal Hb values, no signs of hemolysis, acrocyanosisand/or Raynaud phenomena, and no previous history ofdrugs known to be associated with AHIA, vaccinations,infections, lymphoproliferative diseases or autoimmunedisorders. The initial assessment included complete blood count,immunohematologic evaluation, reticulocyte count, hap-toglobin, bilirubin, LDH, serum electrophoresis and clin-ical examination. Data on blood counts, bilirubin levelsand immunohematologic tests performed during followup were also recorded. More details about the clinicalworkout performed at baseline and during follow up arereported in the Online Supplementary data.Silent RBC autoantibodies were detected in 5 (8%)pregnant females, 34 (57%) healthy individuals (blooddonors, 32; subjects with an abnormal agglutination ofblood samples, 2) and 21 (35%) subjects screened prior tosurgery (benign disorder, 16; malignancy, 5). The median follow up was 60 months (range, 10-204months), the median age 48 years (range, 19-74 years),and the median Hb value 138.5 g/L (range, 124-167 g/L)with a median reticulocyte count of 74.5 x 109/L(range:11.580-186000). Four blood donors showed anincreased reticulocyte count with Hb values rangingbetween 130 and 160 g/L. Haptoglobin, bilirubin, andLDH levels were normal in all cases (Table 1).IgG autoantibodies were detected in 24 (40%) cases,IgM in 35 (58%) and IgM+IgG in 1 (2%). Cold agglu-tinins with a median titer of 1:512 and a thermal ampli-tude around 30°C were recorded in 23/35 (66%) cases,and warm agglutinins in 12 (34%). The median numberof immunohematologic tests per patient was 4 (range 2-13) (Table 2). Clinical and serologic characteristics of sub-jects with silent RBC autoantibodies according to theassociated condition or disorder are described in Figure 1.Asymptomatic RBC autoantibodies were detected in 5(8%) pregnant females at the time of the first trimesterscreening (IgG 3 cases, IgM 1, IgG+IgM 1) and persistedduring and after pregnancy. No signs of hemolytic ane-mia were observed in either the mothers or the new-borns.In 31 of the remaining 55 (56%) cases, no evidence ofan underlying disorder was observed, while it was pres-ent in 24 (44%) cases; in 5 /21 (24%) with IgG autoanti-bodies and in 19/34 (56%) with IgM autoantibodies (P<0.05).Five (5/55, 9%) cancer-bearing subjects (breast cancer2; thyroid cancer, 3) revealed silent RBC autoantibodies(IgG, 2; IgM, 3) at the time of the pre-surgery screeningfor cancer removal. RBC autoantibodies disappeared in 2cases (IgG 1; IgM 1) after removal of thyroid cancer,while they persisted in 3 with active disease.The significant positivity of other autoantibodiesdirected further serologic and clinical evaluations allow-haematologica 2017; 102:e473LETTERS TO THE EDITORTable 1. Clinical characteristics of subjects at the time of the firstdetection of the silent red blood cell autoantibodies.N (%)No. of patients 60Median follow up, months (range) 60 (10-204)Gender M/F 33/27(55/45)Median age, years (range) 48 (19-74)Median Hb value, g/L (range) 138.5 (124-167)Median reticulocytes x 109/L (range)1 7450 (11.580-186000)Median bilirubin value mg/dl (range) 0.9 (0.4-1.2)Median PLTS x 109/L (range) 237000 (135-396)Framework in which the RBC autoantibodies were detectedBlood donation screening 32 (53)Pre-surgery screening 21(35)Pregnancy screening 5 (9)Medical check-up1 2 (3)F: females; M: males; Hb: hemoglobin; PLTS: platelets. 1Reticulocytes, normalranges: 22-139x109/L. Four blood donors with increased reticulocytes, and Hb valuesranging between 130 and 160 g/L. Two patients with abnormal agglutination ofblood samples. Table 2. Serological characteristics of the silent red blood cellautoantibodies.N (%)No. of subjects with RBC autoantibodies 60 (100)Median number of tests per subject 4 (2-13)(range)Warm IgG RBC autoantibodies 24/60 (40)+complement 6/24 (25)reactive eluate 24/24 (100)IgM RBC autoantibodies 35/60 (58)Cold IgM1 23/35 (66)median titer at 4°C (range) 512 (1:128-1:4096)+ complement 10/35 (43.5)Warm IgM2 12/35 (34)+complement 4/12 (33)Warm IgG+IgM+C 1 (2)RBC: red blood cell; Ig: immunoglobulin, C, complement. 1Thermal amplitude: until32°C, 1 case; 22 cases <37°C. 2Thermal amplitude: 37°C.ing the identification of an autoimmune disorder in 11(11/55, 20%) subjects (Hashimoto thyroiditis, 4; anti-phospholipid syndrome, 5; systemic lupus erythemato-sus, 1; autoimmune glomerulonephritis, 1). IgM autoan-tibodies were detected in the majority of cases (9/11cases, 82%). Before surgery to remove colonic polyps, IgG RBCautoantibodies associated with an active HCV hepatitiswere detected in 1 (1/55, 1.8%) patient. Both the HCVvirus and the RBC autoantibodies disappeared after treat-ment with peg alpha2-interferon.Bone marrow (BM) biopsy or aspirate with a flow-cytometry analysis revealed the presence of a lympho-proliferative disorder in 7 (7/55, 13%) cases, all with RBCIgM autoantibodies (cold IgM, 4 cases; warm IgM, 3).  A marginal zone lymphoma was diagnosed in 1 patientwho also showed enlarged abdominal lymph-nodes. Inthe other 6 cases, all with no enlarged lymph-nodes, alimited infiltration of small clonal B-lymphocytes wasdetected in the BM. In all cases, monoclonal B-cell lym-phocytes (MBLs) were also detected in the peripheralblood by flow-cytometry. MBLs showed lymphoma-likefeatures in 3 cases and chronic lymphocytic leukemia-likefeatures in 3 (Online Supplementary Table S1). The medianMBL count was low (0.135 x109/L; range, 0.56-0.215x109/L) and remained stable during follow up in 5 cases,while it gradually increased over 10 years in 1. (OnlineSupplementary Figure S1). None of these subjects devel-oped a clinically overt lymphoma/chronic lymphocyticleukemia.The IgG autoantibodies disappeared in 10/24 (42%)cases; in 7 subjects without an associated disorder, in 2after the removal of a thyroid cancer and in 1 cured of theHCV hepatitis. Agglutinins persisted in all cases after amedian follow up of 93 months (range,10-204). Only twopatients, both with agglutinins (2/60 total cases 3%; 2/35IgM cases, 6%) and no evidence of a lymphoproliferativedisorder, experienced AHIA after 14 and 17 years, respec-tively, from the first detection of cold autoantibodies.Survival of subjects with silent agglutinins was lower,though not significantly lower, than those with silentwarm autoantibodies (at 15 years, 75% vs. 100%; P=0.2)(Online Supplementary Figure S2).The retrospective nature of this study, and the fact thatnot all cases with silent RBC were referred to our insti-tute, should be underlined. This is an understandablephenomenon as healthy subjects are not usually investi-gated for asymptomatic RBC autoantibodies. The lack ofa denominator did not permit us to ascertain the inci-dence and prevalence of silent autoantibodies among dif-ferent patient populations. In addition, the number ofcases was too small to be able to define the relative dis-tribution of different disease states among subjects withsilent RBC autoantibodies. The abnormal agglutination of blood samples in thepresence of cold agglutinins was common. This phenom-enon was influenced both by the elapse of time fromobtaining samples and the temperature on storage. The development of a clinically manifest AHIA wasrecorded in only 2 (6%) of the 35 subjects with asympto-matic agglutinins. Multiple factors are likely to haveplayed a role in preventing hemolysis. As observed insome cases of CAD, the complement pathway probablycould not be activated given the protective effect of thephysiological complement inhibitors CD55 and CD59 onthe RBC membrane.7 The lack of hemolysis could also bedue to an ineffective complement activation by some IgGsubclasses or binding by the FC-receptors of phagocyticcells.7 In some cases, cross-reacting antiphospholipidautoantibodies, adsorbing non-specifically onto the ery-throcyte membrane, may be an incidental cause of falsepositive tests.8 In addition, an effective erythropoiesiscould play a relevant compensatory effect in preventinganemia.As in a previous study,5 RBC autoantibodies detected in5 pregnant females had no effect on the course of preg-nancy, on the fetus development, or on the health of thenewborns.An associated disorder was observed in 24 (44%) of theremaining 55 cases and was significantly more frequentin subjects with silent agglutinins. Given the known relationship between AHIA andautoimmune diseases,6 cancers,9 HCV infection,10 andlymphoproliferative disorders,11,12 the detection of theseconditions in subjects with silent RBC autoantibodieswas not surprising. haematologica 2017; 102:e474LETTERS TO THE EDITORFigure 1. Serologic characteristics of subjects with silent red blood cell autoantibodies according to the associated condition or disorder. (1) Autoimmune dis-orders: Hashimoto thyroiditis, 4 cases; anti-phospholipid syndrome, 5; systemic lupus erythematosus, 1; autoimmune glomerulonephritis, 1. (2)Lymphoproliferative disorders: bone marrow involvement with MBL, 6 cases, marginal cell lymphoma, 1. (3) Cancers: breast cancer, 2; thyroid cancers, 3. A lymphoproliferative disorder was detected only insubjects with silent agglutinins. Subjects with cold agglu-tinin and a limited clonal B-cell disorder involving the BMwere described by Randen et al.13 as having a primarycold agglutinin disease (CAD) or “cold agglutinin (CA)-associated lymphoproliferative disease”. The 6 cases withasymptomatic agglutinins, BM involvement and MBLshowed similar characteristics of primary CAD, even inthe absence of hemolytic anemia. Interestingly, none ofthese subjects developed clinical signs of hemolysis orclinical evidence of lymphoma during follow up. Lowcount MBL have also been detected in patients withAIHA, immune thrombocytopenic purpura,14 and inhealthy blood donors.15 Although a low count MBL isassociated with a negligible risk of progression to a lym-phoproliferative disease, they may have a pathogeneticrelationship in the development of RBC autoantibodies. IgG autoantibodies disappeared after the cure of hepa-titis in 1 patient and the removal of a thyroid cancer in 2.This finding suggests that, in some cases, the removal ofan immune stimulation could have led to the clearance ofthe autoantibodies. Taken together, the results of this study showed that insubjects with silent RBC autoantibodies, the develop-ment of a clinically overt AHIA was a rare event, whiledisorders known to be associated with AHIA were pres-ent in a relevant proportion of cases and more frequentlyin subjects with silent agglutinins. Francesca R. Mauro,1 FabioTrastulli,1 Cristiano Alessandri,2Guido Valesini,2 Gianluca Giovannetti,3 Costantino Riemma,1Marika Porrazzo,1 Sara Pepe,1 Gioia Colafigli,1Maria D. Caputo,1 Maria S. De Propris,1 Anna R. Guarini,1Gabriella Girelli,3 Serelina Coluzzi3 and Robin Foà1SC and RF contributed equally to this work.1Hematology, Department of Cellular Biotechnologies andHematology, Policlinico Umberto 1, Sapienza University;2Reumatologia, Dipartimento di Medicina Interna e SpecialitàMediche, Sapienza University and 3Immunohematology andTransfusion Medicine Unit, Sapienza University, Rome, Italy Correspondence: mauro@bce.uniroma1.itdoi:10.3324/haematol.2017.177675Information on authorship, contributions, and financial & other disclo-sures was provided by the authors and is available with the online versionof this article at www.haematologica.org.References1. Packman CH. The clinical pictures of autoimmune hemolytic ane-mia. Transfus Med Hemother. 2015;42(5):317-324.2. Go RS, Winters JL, Kay NE. How I treat autoimmune hemolytic ane-mia. Blood. 2017;129(22):2971-2979.3. Gorst DW, Rawlinson VI, Merry AH, Stratton F. Positive directantiglobulin test in normal individuals. Vox Sang. 1980;38(2):99–105.4 Bareford D, Longster G, Gilks L, Tovey LA. Follow-up of normalindividuals with a positive antiglobulin test. Scand J Haematol.1985;35(3):348-353. 5. Hoppe B, Stibbe W, Bielefeld A, Pruss A, Salama A. Increased RBCautoantibody production in pregnancy. Transfusion. 2001;41(12):1559–1561.6. Comellas-Kirkerup L, Hernández-Molina G, Cabral AR.Antiphospholipid-associated thrombocytopenia or autoimmunehemolytic anemia in patients with or without definite primaryantiphospholipid syndrome according to the Sapporo revised classi-fication criteria: a 6-year follow-up study. Blood. 2010;116(16):3058-3063.7. Berentsen S. Complement, cold agglutinins, and therapy. Blood.2014;123(26):4010-4012. 8. Ünlü O, Zuily S, Erkan D. The clinical significance of antiphospho-lipid antibodies in systemic lupus erythematosus. Eur J Rheumatol.2016;3(2):75-84.9. Nenova IS, Valcheva MY, Beleva EA, et al. Autoimmune phenomenain patients with solid tumors. Folia Medica (Plovdiv). 2016;58(3):195-199.10. Basseri RJ, Schmidt MT, Basseri B. Autoimmune hemolytic anemiain treatment-naive chronic hepatitis C infection: a case report andreview of literature. Clin J Gastroenterol.  2010:3(5):237-2421.11. Mauro FR, Foa R, Cerretti R, et al. Autoimmune hemolytic anemia inchronic lymphocytic leukemia: clinical, therapeutic, and prognosticfeatures. Blood. 2000;95(9):2786-2792. 12. Barcellini W, Capalbo S, Agostinelli RM, et al. GIMEMA ChronicLymphocytic Leukemia Group. Relationship between autoimmunephenomena and disease stage and therapy in B-cell chronic lympho-cytic leukemia. Hematologica. 2006;91(12):689-692.13. Randen U, Trøen G, Tierens A etal. Primary cold agglutinin-associat-ed lymphoproliferative disease: a B-cell lymphoma of the bone mar-row distinct from lymphoplasmacytic lymphoma. Haematologica.2014;99(3):497-504.14. Mittal S, Blaylock MG, Culligan DJ, Barker RN, Vickers MA. A highrate of CLL phenotype lymphocytes in autoimmune hemolytic ane-mia and immune thrombocytopenic purpura. Hematologica. 2008;93(1):151-152.15. Shim YK, Rachel JM, Ghia P, et al. Monoclonal B-cell lymphocytosisin healthy blood donors: an unexpectedly common finding. Blood.2014;123(9):1319-1326.haematologica 2017; 102:e475LETTERS TO THE EDITOR

Clinical relevance of silent red blood cell autoantibodies.

https://iris.uniroma1.it/bitstream/11573/1070195/1/Mauro_Clinical%20Relevance_2017.pdf

Clinical relevance of silent red blood cell autoantibodies.

Abstract

Similar works

Full text

Available Versions

Archivio della ricerca- Università di Roma La Sapienza