Idiopathic Autoimmune Hemolytic Anemia*

Response of a Patient to Repeated Courses of Alkylating Agents

LAWRENCE TAYLOR, M.D.

Bryn Mawr, Pennsylvania

EMISSIONS may be obtained in patients with R autoimmune hemolytic anemia by sple- nectomy and by adrenocorticotrophic and corticosteroid hormone therapy. Although the remissions may be prolonged, laboratory evi- dence of the disease remains [ 71, and the patient may eventually succumb in a relapse.

The concept of the use of alkylating agents, antimetabolic agents and radioactive colloids to suppress abnormal antibody formation in auto- immune diseases has not been frequently explored. In the following case, the patient responded temporarily to steroid therapy and splenectomy, then to further steroid therapy, but eventually became resistant to the effects of the hormone. It was found that excellent remissions could be obtained by the use of alkylating agents, remissions occurring during eight periods in the subsequent six years.

CASE REPORT

A sixty-seven year old white man was hospitalized on April 27, 1955, with complaints of weakness, weight loss and shortness of breath of four months’ duration. There was no history of exposure to drugs or chemicals. His family had noticed a sallow yellow color of his skin. He had lost 20 pounds. Mild exertion produced dyspnea and palpitation, and his appetite had decreased.

On physical examination, the patient’s pale, slightly jaundiced and cachectic appearance was striking. There were no abnormalities of the eyes, ears, nose or throat. The thyroid gland was normal and there was no lymphadenopathy. The lungs were clear and resonant. The heart was not enlarged and no murmurs were heard. There was mild sinus tachycardia. The blood pressure was 138/62 mm. Hg. The liver was palpated 1 cm. below the right costal margin. The edge was sharp and nontender. The spleen was also palpable on deep inspiration. There were no other definite physical findings.

Laboratory studies were as follows: hemoglobin

was 6.0 gm. per cent, red blood count 1,950,OOO per cu. mm., hematocrit 17.8 per cent, white blood count 7,900 per cu. mm. with a normal differential. The smear showed marked rouleaux formation and gross agglutination of the red blood cells. The indices were normal. The reticulocyte count was 3.2 per cent, platelets 194,000 per cu. mm. A sternal marrow aspiration revealed marked normoblastic hyper- plasia, the other elements being normal. The serum total bilirubin was 2.2 mg. per cent; serum total protein 6.9 gm. per cent; albumin 3.3 gm. per cent, globulin 3.6 gm. per cent; prothrombin 56 per cent; bromosulfophthalein 5 per cent retention in forty five minutes; zinc turbidity 17.1 units; thymol turbidity 11.9 units; cephalin flocculation test result negative; alkaline phosphatase 6.0 Bodansky units; cholesterol 248 mg. per cent, esters 57 per cent; uric acid 5.0 mg. per cent. A lupus erythematosus prepa- ration was negative. A four day stool collection revealed 147 mg. of urobilinogen per day, producing an increased hemolytic index based on the total circulating hemoglobin. A chromiumsl red cell survival study showed a rapid loss of radioactivity over a ten day period. The direct Coombs’ test result was positive. The urinalysis, blood sugar, blood urea nitrogen, amylase and lipase were normal. Chest roentgenograms, cholecystogram, x-ray series of the upper gastrointestinal tract, barium enema and intravenous urogram were all within normal limits. The outline of the spleen could not be seen. An electrocardiogram revealed no abnormalities.

A diagnosis of autoimmune hemolytic anemia was made and prednisone therapy was instituted. The patient was given seven transfusions of whole blood. At the time of discharge on May 24, 1955, the hematocrit was 33.6 per cent, hemoglobin 10.7 mg. per cent, red blood count 3,120,OOO per cu. mm. The amount of prednisone given daily was gradually reduced from 20 to 5 mg. and stopped completely on June 30, 1955. The hematocrit rose to a peak of 45 per cent on June 21, but fell to 35 per cent by June 29. The patient was re-admitted on July 13 and a splenectomy was performed. The spleen weighed 194 gm. A liver biopsy revealed normal liver with

* From the Service of Hematology, Department of Medicine, Bryn Mawr Hospital, Bryn Mawr, Pennsylvania. Manuscript received August 13, 1962.

130 AMERICAN JOURNAL OF MEDICINE

Idiopathic Autoimmune Hemolytic Anemia- Z”‘qZw

TABLE I RESUME OF REPEATED RESPONSES TO ALKYLATING AGENTS

Therapy Duration (wk.1

Triethylene melamine. I .......... . 5 Chlorambucit. ................. 9 Chiorambucil. ................. 6 Preclnisone ..................... 14 Chlorambucil .................. 5 Predniione . . . . . . . Chlorambucil. . . . . . c2ilhamblIcii...... Chiorambucil...... Cyclophosphamide . . Cyclophosphamide . .

‘ I .

. . .

. . .

. .

43 10 7 6

42 . .

.

_-

I’otal Dose (mg.1

40 264 390

1,950 336

9,000 620 172 226

13,200 . . .

moderate increase in p&portal lymphocytes. Sections of the spleen showed prominent sinus lining celfs and hemosiderosis. No abnormal l~phadenopa~y was found at operation. Cortisone was administered intramuscularly preoperatively; this was followed by prednisone therapy which was tapered gradually and stopped entirely on September 7, 1955. ACTH gel was given intermittently as the prednisone dose was reduced. The serum gamma gbbufm was followed by zinc turbidity determinations, which fluctuated be- tween 12 and 20 units. The hemoglobin gradually declined to 12.2 gm. per cent on November 8, at which time prednisone was again administered, 20 mg. daily.

Despite an increase in the amount of prednisone given daily (to 25 mg.), the hemoglobin had fallen to 12 gm. per cent by January 3, 1956. The oral administration of triethylene melamine was started on January 4; first 15 mg. in three days, then 5 mg. weekly for a total dose of 40 mg., while prednisone was tapered and stopped. By February 1 the clumping and aggiu~ation of red celIs was much leas marked and the hemoglobin was maintained above 13 gm. per cent, The chromiums’ survival study was almost normal, and the fecal urobilinogen had deciiied to 109 mg. per day to produce a normal hemolytic index based on a normal amount of circulating hemo- globin. There was no leukopeuia or thrombocyto- penia. Subsequent courses of chlorambucil, predniine and ~~~~~~de are sumnxized in ‘Fable I and Figure 1. After the first course of chlorambucil, therapy was withheld until the patient became more anemic in order to establish a cause and effect rela- tionship. It became apparent that a better response could be obtained with alkylating agents than with prednisone, the patient actually having a relapse during the last course of predrdsone therapy. Dosage

VOL. 35, JULY 1963

-

H~OglObii at Start of

Course (gm. %)

12.0 11.4 9.3 9.7 7.5 7.4 9.1 9.1 7.9 7.6 6.7

1

_-

-

m&mum Gnoglobin

After Response (gm. %I

13.0 12.6 12.0 10.5 11.2

9.1 12.6 10.0 10.7 10.0 . . .

Period Without Therapy

(wk.)

17 6 9

5: 0 3

13 15 11 . . .

-

1

i

-

131

Lowest White WCaunt at End of

course $cr cu. mm.)

5,500 4,450 3,700 . . .

2,800 . . .

4,100 5,100 4,900 2,850 . . 1

was guided by the results of frequent white blood cell counts. Platelet counts remained normal. The gamma globulin fraction of the serum electrophoretic pattern varied from 1.67 to 1.92 gm. per cent. The Coombs’ test result remained positive. A macrogiobulin determination showed no significant elevation. The patient’s blood could not be cross matched because of a panagglutinin, and no transfusions were given subsequent to the first admission.

During the six year period of therapy, the patient was asymptomatic even during relapses, except for an episode of pneumonia, and two uretcral calculi which were passed with difficulty. Intermittent but often prolonged courses of therapy were carried out, administration of the drugs sometimes being stopped because of leukopenia or complicating illnesses, but sometimes to defer the time when permanent sup- pression of marrow activity might supervene.

COMMENTS

Autoimmune hemolytic anemia is produced

by the coating of erythrocytes with an antibody of unknown nature, which makes the ceils more susceptible than normal cells to erythrophago- cytosis by the reticuloendothelial system. Sacks, Workman and Jahn [Z] reported 147 cases of idiopathic autoimmune hemolytic anemia, twenty-seven cases of autoimmune hemolytic anemia associated with lymphomas, and a few associated with infectious and collagen diseases. The association of the condition with lupus erythematosus has been reported by Dausset and Colombani [3] and by Damashek and Kominos [4].

Although most cases occur in the young sub-

132 Idiopathic Autoimmune Hemolytic Anemia- Taylor

ORAMBUCIL

1966 1955 IS56 I956

I3

12

11

IO

9

6

? cHLO9AMWCIL ClWRAM6WIL

6

s

IS96 l95? IS57 1966 1956

Fro. 1A. Results of hemoglobin determinations following splenectomy, courses of prednisone triethylcne melamine and chiorambucii.

jects, a case has been reported by Dacie [S] in a seventy-eight year old subject. The auto- antibodies may be nonspecific panagglutinins, or specific agglutinins, usually against Rh antigens (e, D, E, c, C), as reported by Weiner et al. [S].

Dausset and Malinvaud [7] reported that splenectomy was effective in 50 per cent of cases, whereas steroid therapy reduced the mortality from 37 to 30 per cent. Failures with steroid therapy and splenectomy have also been reported by Welch and Dameshek [S].

Radioactive colloidal gold (Auns) has been effective in producing remissions in five cases of idiopathic autoimmune hemolytic anemia re- ported by Tocantins and Wang [9]. Colloidal gold is taken up by the reticuIoendothelia1 cells mm where they postulate that erythro- phagocytosis and antibody formation is sup-

pressed. They state that the result of a Coombs’ test is not a reliable indicator of a clinical remission.

Dameshek, Rosenthal and Schwartz [12] administered mechlorethamine hydrochloride to patients resistant to splenectomy and steroid therapy with variable success. Four patients were treated. In the only one who showed a beneficial effect, there was a striking reduction and then complete disappearance of antibody simultaneously with complete remission of the blood picture. The patient, who had idiopathic hemolytic anemia, has remained completely well for over a year [ 131. No subsequent attempts to treat such patients with alkylating agents have been reported. Dameshek and Schwartz [74] subsequently produced more consistent remissions with 6-mercaptopurine and &thio- guanine, three of six patients having complete

AMERICAN JOURNAL OF MEDICINE

Idiopathic Autoimmune Hemolytic Anemia- Taylor 133

6

5 AU0 SEPT OCT NOV DEC JAN FEG MAR APR MAY JUNE JULY AUG 6WT GCT NOV MC JAN FEE MAR 1958 13% 1939 I%3 1960 I%0

I5

7 (ILORAMGUCIL CYCLWHGGWAu(DE

, *, , , , I,, 1,, t I I I / I,

API! M&Y JUNE JULY AUG 3EPT GCT ,,GV GEC JIN FEE MAR AH MAY JUNE JULY AU4 SEPT WY NOV 1960 13% 1361 I361

Fxo. 1B. Reaubs of hezn~lobii determinations following subsequent courses of prednisone, chlorambucil and cyclophosphamide.

remissions. Patients with systemic lupus ery- thematosus and lupoid hepatitis also benefited from antimetabolite therapy. More recently a patient with Hodgkin’s disease and autoimmune hemolytic anemia, who had a relapse following corticosteroid therapy and splenectomy, was treated successfully with heparin by McFarland, Galbraith and Maife [75l.

The case here presented is characterized by a long course of progressive severity, with remis- sions produced by steroid therapy, splenectomy and alkylating agents. Initially steroid therapy, followed by splenectomy, produced only a brief remission. Following sptenectomy, increased susceptibility to steroid therapy did not occur, so that an alkylating agent (triethylene mel- amine) was administered with the hope of suppressing antibody formation and erythro- phagocytosis. A remission occurred, encouraging

VOL. 35, JULY 1963

further courses of chlorambucil and cyclo- phosphamide, interspersed with further courses of prednisone in the hope that the disease had again become responsive to steroid therapy. Subsequent courses produced more striking remissions than the first, since the patient was allowed to become more .anemic before institu- tion of therapy.

Long-continued steroid therapy will in- evitably produce complications, such as bleeding ulcer, osteoporosis with pathologic fractures, diabetes or hypertension. In this patient there was no complication except for diffuse pig- mentation. Because of presumed adrenal sup pression, preoperative and postoperative steroid therapy was given before minor surgical pro- cedures and during the stress of infections [14].

The large total doses of alkylating agents have failed to produce permanent marrow damage.

134 Idiopathic Autoimmune Hemolytic Anemia- Taylor

The use of these drugs, when effective, would therefore compare favorably with steroid therapy and its many complications. Cyclophosphamide appeared to be more easily handled than chlorambucil on a long-term basis, since marrow suppression was of shorter duration when the dose was reduced.

SUMMARY

A case of idiopathic autoimmune hemolytic anemia of six and a half years’ duration is presented. After failure of splenectomy and steroid therapy to sustain a remission, numerous courses of aklylating agents were found to be effective for varying periods of time.

ADDENDUM

The patient died on October 23, 1962, of acute congestive heart failure, during a severe hemolytic crisis, having been hospitalized only a few hours before death. Several remissions had been obtained during the previous year follow- ing courses of therapy with cyclophosphamide.

At autopsy, an accessory spleen and moder- ately enlarged para-aortic and mediastinal lymph nodes were found. There was disagree- ment between several groups of physicians con- cerning the final diagnosis. One group diagnosed Hodgkin’s disease, while another did not believe that the microscopic changes in the lymph nodes were sufficient to diagnose a lymphoma. The absence of lymphadenopathy during severe crises of autoimmune hemolytic anemia, and when carefully explored at laparotomy, as well as the absence of hepatomegaly or marrow involvement at autopsy, weighed against the diagnosis of a lymphoma. Previous chemo- therapy, however, may have modified any changes which were originally present in the lymph nodes.

REFERENCES

1. WILKINBON, J. F. Modern Trends in Blood Diseases, p. 180. New York, 1955. Paul B. Hoeber, Inc.

2. SACKS, M. S., WORKMAN, J. B. and JAI-IN, E. F. Diagnosis and treatment of acquired hcmolytic anemia. J. A. M. A., 150: 1556, 1952.

3. DAUSSET, J. and COLOMBANI, J. The serology and prognosis of 128 cases of autoimmune hcmolytic anemia. Blood, 14: 1280, 1959.

4. DAMESHEK, W. and KOMINOS, Z. D. The present status of treatment of autoimmune hemolytic anemia with ACTH and cortisone. Blood, 11: 648, 1956.

5. DACI~, J. V. The Haemolitic Anemias. New York, 1960. Grune & Stratton, Inc.

6. WEINER, W., BATTEY, D. A., CLECHORN, T. E., MARSON, F. G. W. and MEYNELL, M. J. Serologic findings in a case of hemolytic anemia. Brit. M. J., 2: 125, 1953.

7. DAUSSET, J. and MALINVAUD, G. Acquired hemo- lytic anemia with autoantibodies-course, prog- nosis and treatment. Scmaine h@. Paris, 30: 3130, 1954.

8. WELCH, C. S. and DAMESHEK, W. Splenectomy in blood dyscrasias. New England J. Med., 242: 601, 1950.

9. TOCANTINS, L. M. and WANG, G. C. Radioactive colloidal gold in the treatment of severe acquired hemolytic anemia refractory to splenectomy. In: Progress in Hematology, vol. 1, p. 138. Edited by Tocantins, L. M. New York, 1956. Grune & Stratton, Inc.

10. SHEPPARD, C. W., WELLS, E. B., HAHN, P. F. and GOODELL, J. P. B. Studies of the distribution of intravenously administered colloidal sols of man- ganese dioxide and gold in human beings and dogs using radioactive isotopes. J. Lab. G’ Clin. Med., 32: 274, 1947.

11. WAQLEY, P. F., SHAW, S. C., GARDNER, F. H. and CASTLE, W. B. Studies on the destruction of red blood cells. J. Lab. H Clin. Med., 33: 1197, 1948.

12. DAMESHEK, W., ROSENTHAL, M. C. and SCHWARTZ, L. I. The treatment of acquired hemolytic anemia with adrenocorticotrophic hormone (ACTH). New England J. Med., 244: 117, 1951.

13. DAMESHEK, W. Personal communication. 14. DAMESHEK, W. and SCHWARTZ, R. Treatment of

certain “autoimmune” diseases with antime- tabolitcs. Tr. A. Am. Physicians, 73: 113, 1960.

15. MCFARLAND, W., GALBRAITH, R. G. and MAILE, A. Heparin therapy in autoimmune hemolytic anemia. Blood, 15: 741, 1960.

16. TAYLOR, L. Death following brief steroid with- drawal before palliative surgery in a case of reticulum cell sarcoma. Am. Pratt. G3 Digest. Treat., 7: 965, 1956.

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