Original Paper Acta Haematol 1992;88:96-99
G.M. Gandolfoa G. Girellib L. Contia M. P Perronec M.C.Aristab C. Damico0
Hemolytic Anemia and Thrombocytopenia Induced by Cyanidanol
Department of Experimental Medicine, ‘La Sapienza’ University of Rome and Regina Elena National Cancer Institute; Department of Experimental Medicine and Hematology Institute and Department of Human Biopathology, Hematology Section, ‘La Sapienza’, University of Rome, Italy
Abstract
Five patients who received cyanidanol for 4-36 months are presented. Three developed both hemolytic anemia and thrombocytopenia, while 2 had only thrombocytopenia. After suspending the drug the hematological values re turned to normal in all of the patients. Drug-dependent platelet antibodies were detected in 4 of the 5 patients and cyanidanol-dependent red blood cell antibodies were present in 3. There are various mechanisms involved in the cyanidanol-induced immune cytopenias and, as in the present study, were sometimes simultaneously observed in the same patient.
Introduction
Cyanidanol [(+) - 2 - (3,4 - dehydroxy - phenyl) - 3,5,7chromantrial] is a flavonoid which has been employed in acute and chronic liver disease, although nonconclusive results have been obtained in some clinical trials [1]. Its ef fect has been attributed to a free radical scavenger activity and to possible activity on the immune system [2, 3], The flavonoid cyanidanol has been associated with im mune hemolytic anemia, at times with life-threatening episodes. Several authors have demonstrated the pres
Received: November 8,1991 Accepted: April 21,1992
ence of drug-dependent antibodies against red blood cells [4-8], In particular, Salama and Mueller-Eckhardt [8] showed that cyanidanol strongly combines with erythro cyte membranes, thus inducing the development of drugdependent antibodies and autoantibodies. In the present study, similar findings were observed af ter the administration of cyanidanol: 3 patients developed both immunohemolytic anemia and thrombocytopenia and 2 thrombocytopenia alone. To date, very few cases of cyanidanol-related anemia have been reported and the presence of platelet antibodies has never been analyzed.
Prof. Giuseppe M. Gandolfo Istituto Regina Elena Viale Regina Elena 291 1-00161 Roma (Italy)
©1992S. Karger AG, Basel 0001-5792/92/0883-00% $ 2.75/0
Downloaded by: UCL 144.82.238.225 - 4/26/2018 5:35:46 AM
Key Words Cyanidanol Drug-dependent immune thrombocytopenia Drug-dependent immunohemolytic anemia Immune cytopenias
Table 1. Patient characteristics
Patients Age/ sex
Diagnosis
Signs of Hb hemolysis g/dl
Hemorrhagic Platelets syndrome pl
1 2 3 4 5
mitral-aortic valve prosthesis, hepatic congestion cirrhosis chronic hepatitis biological valve prosthesis, hepatic congestion chronic hepatitis
yes no no yes yes
yes yes no no no
Materials and Methods Five patients, 4 males and 1 female (age range: 50-78years), were investigated. The patients’ clinical data are presented in table 1. All patients were thrombocytopenic, while 3 patients (cases 1, 4,5) were anemic. The treatment with cyanidanol was stopped for nearly 1 month, when no more drug was present in the patients’ blood, as this could influence laboratory results. All of the patients were system atically studied for platelet and RBC drug-dependent antibodies. Determination o f Platelet Antibodies
Platelet-associated IgG (PAIgG) was assayed on platelets ob tained from the patients during thrombocytopenia. The PAIgG were evaluated by means of the antiglobulin consumption assay described by Dixon et al. [9] modified by Kelton et al. [10]: the lysis of sheep erythrocytes coated with human IgG by the addition of antihuman IgG and complement was inhibited by the prior addition of a preestablished concentration of IgG to obtain a standard curve or dilu tions of patient platelets. Serum platelet-bindable IgG (S-PBIgG) was determined by a modification of the indirect assay described by Kelton et al. [10]. In the present study, the hemolytic system for detecting serum IgG, fixed on normal platelets, was employed rather than the microtiter evaluation of lysis of 51Cr-sheep erythrocytes as proposed by Kelton et al. [10]. The determination of the drug-dependent platelet antibodies was made by means of the S-PBIgG assay in the presence of purified cya nidanol (Zyma, Nyon, Switzerland), dissolved in saline (1 mg/ml) ac cording to two different schemes: Scheme A: The patients’ serum (200 pi) was incubated with the drug (200 pi) for 2 h at 37 °C; normal platelet suspension, obtained from 10 donors was then added (400,000 platelets/pl, 200 pi) and in cubated for another 2 h. Scheme B: Normal platelet suspension (200 pi) and cyanidanol (200 pi) were incubated for 2 h at 37 °C; the platelets were then washed 5 times with phosphate-buffered saline (pH 7.5) and incu bated with the patients’ serum (200 pi). Control tubes contained saline solution alone, drug solution alone, saline with fresh normal serum (as a source of complement), and drug solution with fresh serum. At the end of both experimental conditions, normal sensitized platelets were washed 5 times and the concentrations of S-PBIgG were determined. In normal subjects, the PAIgG were 33.5 + 26.4 ng/107 platelets, while an evident increase in S-PBIgG, after incuba tion of the drug, was considered significant for the presence of drugdependent platelet antibodies.
10.5 14.6 15.3 7.5 9.1
85,000 60,(XX) 60,(XX) 70,000 80,(XX)
Determination o f RBC Antibodies
A complete serological analysis was made with standard tech niques: blood group and Rh-phenotype direct antiglobulin test (DAT) with broad-spectrum antiserum (Ortho) and with anti-IgG, anti-IgGl, anti-IgG2, anti-IgG3, anti-IgG4, anti-IgA, anti-IgM and anti-C monospecific antisera (Janssen); agglutination tests against untreated and papain-treated red cells at 4,20 and 37 °C; indirect an tiglobulin test (IAT); tests for monophasic and biphasic hemolysin and Ham’s test. For antibody elution, Rubin’s [11] method was em ployed. Detection of drug-dependent antibodies was carried out as previously described: Scheme A: Patient serum (100 pi) was incubated with the drug (100 pi) for 2 h at 37 °C and the untreated and enzyme (papain)treated RBC (50 pi of a 3% suspension) were then added. After in cubation (2 h at 37 °C), the reactions were read for agglutination and hemolysis. The erythrocytes were washed 3 times with saline and tested by IAT. Scheme B: One hundred microliters of a 5% suspension of un treated and enzyme-treated group 0 RBCs and 100 pi of cyanidanol were incubated for 2 h at 37 °C; the cells were then washed 3 times in 0.9% saline; resuspended and incubated (2 h at 37 °C) with 100 pi of serial dilutions of patient serum. The reactions were read for agglut ination and hemolysis. Thereafter the RBCs were washed 3 times with saline and tested by IAT using polyvalent antiglobulin serum (Ortho). Control tubes contained saline solution alone, drug solution alone, saline with fresh normal serum (as a source of complement) and drug solution with fresh serum. The sera were added with the fresh compatible human serum (0.05 ml) as a source of complement, if not used on the same day.
Results
Clinical Data No demonstrable viral infections or autoimmune dis eases were detected in any of the patients. All had re ceived therapeutic doses of cyanidanol (2 g/day) and were thrombocytopenic at the time of the study, after receiving cyanidanol for a long time (4-36 months). In addition, all of the patients presented normal platelet counts after dis continuing the drug (4-10 months later). Hemolysis oc curred in 3 patients after prolonged intake; 2 were initially
97
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61/M 69/M 50/M 64/F 78/M
Table 2. Hb, reticulocytes and immunological findings in 3 patients with drug-dependent immune hemolysis
Patients
First observation After 6 months 4 First observation After 6 months After 12 months 5 First observation After 6 months After 12 months 1
Hb g/dl
%
10.5 12.7 7.5 14.1 14.5 9.1 15.2 15.3
4.0 0.7 20.0 2.0 1.0 11.0 0.8 0.8
Reticulocytes
DAT
IAT
negative negative ++++
++ negative
++++ ++ negative
Drug-dependent antibodies
negative negative negative negative negative negative negative negative
scheme A
scheme B
positive positive positive -
negative positive -
negative -
-
Table 3. Platelet studies
Patients
1 2 3 4 5
Thrombocytopenia duration months
regression after suspension
4 36 24 4 6
yes yes yes yes yes
PAIgG
250 220 750 0 n.e.
S-PBIgG
480 220 480 150 500
Drug-dependent antibodies scheme A
scheme B
420 (negative) 300 (±) 470 (negative) 220 (±) 800 (positive)
280 (negative) 900 (positive) 1,500 (positive) 400 (positive) 1,200 (positive)
Platelet antibodies are expressed as nanograms of IgG/107 platelets, n.e. = Not examined.
Serological Data In 3 out of 4 patients examined, the PAIgG values were high, while high S-PBIgG values were detected in all of the patients (table 3). After incubation of the sera with cyanid anol (scheme A), 3 patients (cases 2, 4 and 5) presented a slight increase in S-PBIgG in relation to the data obtained without the drug. However, if the drug was first incubated with platelets, followed by the addition of sera, a signif icant increase in S-PBIgG was detected in 4 patients. In 2 out of 5 patients, the DAT was strongly positive with both the polyvalent antiglobulin and anti-IgG monospecific sera. In both cases, the IgGl subclass was respon sible for hemolysis. Antibodies eluted from the patients’ RBCs and tested against a panel of selected erythrocytes (Resolve AB, Ortho) showed no clear specificity pattern.
98
The IAT was negative in all patients. When cyanidanol was added, agglutination of the normal red cells with IAT occurred in 3 (patients 1,4 and 5): positive results were ob tained with scheme A in 2 cases (patients 1 and 5) and with both schemes (A and B) in 1 case (patient 4). Positivity of the test performed with scheme A is com patible with the presence of antibodies reactive by the im mune complex mechanism, though direct drug binding to cells cannot be excluded. On the contrary, a positive test obtained with cyanidanol-pretreated cells suggests a sensi tization of drug absorption type.
Discussion
This study demonstrates that patients affected by cyanidanol-induced anemia and thrombocytopenia pre sented RBC and platelet antibodies related to the drug ad ministration. With regard to the platelet antibodies, all the patients had increased serum platelet-bindable IgG values in the absence of cyanidanol and 3 had high platelet-asso ciated IgG levels. These findings are very similar to those
Gandolfo/Girelli/Conti/Perrone/Arista/ Damico
Cyanidanol-Dependent Anemia and Thrombocytopenia
Downloaded by: UCL 144.82.238.225 - 4/26/2018 5:35:46 AM
diagnosed as having idiopathic autoimmune hemolytic anemia, treated with prednisone. After suspending cyanidanol, the hemoglobin levels promptly increased, even though autoantibodies on RBCs were persistent, but with decreasing positivity (table 2). At the same time, the corticosteroid therapy was suspended.
observed in autoimmune thrombocytopenic purpura or could be due to the presence of drug-related immune complexes. However, the cyanidanol-dependent antibod ies were reactive with only platelets that had been pre treated with the drug. In effect, this reactivity was much less evident when the antibodies were preincubated with cyanidanol. These data are in accordance with the hypoth esis of a drug absorption mechanism (whereby cyanidanol, like penicillin, binds firmly to cells) and against the im mune complex mechanism. With regard to RBC antibodies, the IAT was negative in all the subjects, whereas drug-dependent antibodies were detected in 3 patients when the sera were preincu bated with cyanidanol (as in the immune complex mecha nism). One of these 3 subjects also had antibodies that were reactive with the drug-cell conjugate. The results herein presented are similar to those re ported by Salama and Mueller-Eckhardt [8] and Casaril et al. [12] in patients with cyanidanol-induced immune he
molysis. The IgG autoantibodies could not be distin guished serologically from those observed in warm au toimmune hemolytic anemia; the hematological findings were also normal after suspending cyanidanol. Therefore, production of autoantibodies, as in immunohemolytic anemia induced by alpha-methyldopa, is possible. In conclusion, the data presented support the hypothe sis that cyanidanol-induced immune cytopenias can be caused by the production of RBC and platelet autoanti bodies and/or drug-dependent antibodies, as well as by immune complex mechanism and by the drug absorp tion mechanism. Heterogeneity of the antibody response has been reported for other drugs as well [13]. Various mechanisms may be involved in drug-induced immune cytopenia and be sometimes simultaneously present in the same patient, as very recently reported in 2 patients with cephalosporin-induced hemolysis by drug-depen dent antibodies reactive by both immune complex and drug adsorption mechanisms [14,15].
References 7 Schoremus H, Wiedmann KH, Dolle W, Peerenboon H, Strohmeyer G, Balzer K, Goebel H, Durr HK, Bode CH, Blum AL, Frosner G, Gerlich W, Berg PA, Dietz K: (+)-cyanidanol-3 in the treatment of acute viral hepatitis: A ran domized controlled trial. Hepatology 1984;4: 331-335. 8 Salama A, Mueller-Eckhardt C: Cyanidanol and its metabolites bind tightly to red cells and are responsible for the production of autoand/or drug-dependent antibodies against these cells. Br J Haematol 1987;66:263-266. 9 Dixon R, Rosse W, Ebbert L: Quantitative de termination of antibody in idiopathic thrombo cytopenic purpura: Correlation of serum and platelet-bound antibody with clinical response. N Engl J Med 1975;992:230-235. 10 Kelton JG, Neame PB, Bishop J, Ali M, Gauldie Jirsh J: The direct assay for platelet-associ ated IgG (PAIgG): Lack of association be tween antibody level and platelet size. Blood 1979;53:73-79. 11 Rubin H: Antibody elution from red blood cells. J Clin Pathol 1963;16:70-73.
12 Casaril M, Gabrielli GB, Pecci R, Venturini L, Corrocher R: A case of chronic haemolytic anemia induced by cyanidanol. Ital J Gastroen terol 1987;19:180-181. 13 Habibi B: Drug induced red blood cell autoan tibodies codeveloped with drug specific anti bodies causing haermolytic anemias. Br J Hae matol 1985;61:139-143. 14 Chambers LA, Donovan LM, Kruskall MS: Ceftazidime-induced hemolysis in a patient with drug-dependent antibodies reactive by im mune complex and drug adsorption mecha nism. Am J Clin Pathol 1991;95:393-396. 15 Shulman IA, Arndt PA, McGehee W, Garratty G: Ceftaxime-induced immune hemolytic ane mia due to antibodies reacting in vitro by more than one mechanism. Transfusion 1990;30:263266.
99
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1 Vido I, Schmidt FW, Muller R, Ranft V, Wildhirt E, Holzer E, et al: Influence of (+)-cyanidanol-3 on the course of acute viral hepatitis. Dtsch Med Wochenschr 1980;105:330-332. 2 Slatter TF, Eakins MN: Interaction of (+)-cyanidanol-3 with free radical generating systems; in Bertelli A (ed): New Trends in the Therapy of Liver Diseases. Basel, Karger, 1975. 3 Kakumu S, Murakami H, Kuriki J: Activation of suppressor functions of human peripheral blood T cells by (+)-cyanidanol-3: Its applica tion to chronic active liver disease. Clin Exp Immunol 1983;52:43CM32. 4 Blum AL, Doelle W, Kortum K, Peter P, Strohmeyer G, Berthet P, Goebell H, Pelloni S, Poulsen H, Tygstrup N: Treatment of acute viral hepatitis with (+)-cyanidanol-3. Lancet 1977;ii: 1153-1155. 5 Di Nola F: (+)-cyanidanol-3 in acute viral hep atitis. Lancet 1980;ii:1378— 1380. 6 Piazza M, Guadagnino V, Picciotto L, De Mercato R, Chiaranni A, Orlando R, Golden G: Ef fect of (+)-cyanidanol-3 in acute HAV, HBV, and non-A, non-B viral hepatitis. Hepatology 1983;3:45-49.
G.M. Gandolfoa G. Girellib L. Contia M. P Perronec M.C.Aristab C. Damico0
Hemolytic Anemia and Thrombocytopenia Induced by Cyanidanol
Department of Experimental Medicine, ‘La Sapienza’ University of Rome and Regina Elena National Cancer Institute; Department of Experimental Medicine and Hematology Institute and Department of Human Biopathology, Hematology Section, ‘La Sapienza’, University of Rome, Italy
Abstract
Five patients who received cyanidanol for 4-36 months are presented. Three developed both hemolytic anemia and thrombocytopenia, while 2 had only thrombocytopenia. After suspending the drug the hematological values re turned to normal in all of the patients. Drug-dependent platelet antibodies were detected in 4 of the 5 patients and cyanidanol-dependent red blood cell antibodies were present in 3. There are various mechanisms involved in the cyanidanol-induced immune cytopenias and, as in the present study, were sometimes simultaneously observed in the same patient.
Introduction
Cyanidanol [(+) - 2 - (3,4 - dehydroxy - phenyl) - 3,5,7chromantrial] is a flavonoid which has been employed in acute and chronic liver disease, although nonconclusive results have been obtained in some clinical trials [1]. Its ef fect has been attributed to a free radical scavenger activity and to possible activity on the immune system [2, 3], The flavonoid cyanidanol has been associated with im mune hemolytic anemia, at times with life-threatening episodes. Several authors have demonstrated the pres
Received: November 8,1991 Accepted: April 21,1992
ence of drug-dependent antibodies against red blood cells [4-8], In particular, Salama and Mueller-Eckhardt [8] showed that cyanidanol strongly combines with erythro cyte membranes, thus inducing the development of drugdependent antibodies and autoantibodies. In the present study, similar findings were observed af ter the administration of cyanidanol: 3 patients developed both immunohemolytic anemia and thrombocytopenia and 2 thrombocytopenia alone. To date, very few cases of cyanidanol-related anemia have been reported and the presence of platelet antibodies has never been analyzed.
Prof. Giuseppe M. Gandolfo Istituto Regina Elena Viale Regina Elena 291 1-00161 Roma (Italy)
©1992S. Karger AG, Basel 0001-5792/92/0883-00% $ 2.75/0
Downloaded by: UCL 144.82.238.225 - 4/26/2018 5:35:46 AM
Key Words Cyanidanol Drug-dependent immune thrombocytopenia Drug-dependent immunohemolytic anemia Immune cytopenias
Table 1. Patient characteristics
Patients Age/ sex
Diagnosis
Signs of Hb hemolysis g/dl
Hemorrhagic Platelets syndrome pl
1 2 3 4 5
mitral-aortic valve prosthesis, hepatic congestion cirrhosis chronic hepatitis biological valve prosthesis, hepatic congestion chronic hepatitis
yes no no yes yes
yes yes no no no
Materials and Methods Five patients, 4 males and 1 female (age range: 50-78years), were investigated. The patients’ clinical data are presented in table 1. All patients were thrombocytopenic, while 3 patients (cases 1, 4,5) were anemic. The treatment with cyanidanol was stopped for nearly 1 month, when no more drug was present in the patients’ blood, as this could influence laboratory results. All of the patients were system atically studied for platelet and RBC drug-dependent antibodies. Determination o f Platelet Antibodies
Platelet-associated IgG (PAIgG) was assayed on platelets ob tained from the patients during thrombocytopenia. The PAIgG were evaluated by means of the antiglobulin consumption assay described by Dixon et al. [9] modified by Kelton et al. [10]: the lysis of sheep erythrocytes coated with human IgG by the addition of antihuman IgG and complement was inhibited by the prior addition of a preestablished concentration of IgG to obtain a standard curve or dilu tions of patient platelets. Serum platelet-bindable IgG (S-PBIgG) was determined by a modification of the indirect assay described by Kelton et al. [10]. In the present study, the hemolytic system for detecting serum IgG, fixed on normal platelets, was employed rather than the microtiter evaluation of lysis of 51Cr-sheep erythrocytes as proposed by Kelton et al. [10]. The determination of the drug-dependent platelet antibodies was made by means of the S-PBIgG assay in the presence of purified cya nidanol (Zyma, Nyon, Switzerland), dissolved in saline (1 mg/ml) ac cording to two different schemes: Scheme A: The patients’ serum (200 pi) was incubated with the drug (200 pi) for 2 h at 37 °C; normal platelet suspension, obtained from 10 donors was then added (400,000 platelets/pl, 200 pi) and in cubated for another 2 h. Scheme B: Normal platelet suspension (200 pi) and cyanidanol (200 pi) were incubated for 2 h at 37 °C; the platelets were then washed 5 times with phosphate-buffered saline (pH 7.5) and incu bated with the patients’ serum (200 pi). Control tubes contained saline solution alone, drug solution alone, saline with fresh normal serum (as a source of complement), and drug solution with fresh serum. At the end of both experimental conditions, normal sensitized platelets were washed 5 times and the concentrations of S-PBIgG were determined. In normal subjects, the PAIgG were 33.5 + 26.4 ng/107 platelets, while an evident increase in S-PBIgG, after incuba tion of the drug, was considered significant for the presence of drugdependent platelet antibodies.
10.5 14.6 15.3 7.5 9.1
85,000 60,(XX) 60,(XX) 70,000 80,(XX)
Determination o f RBC Antibodies
A complete serological analysis was made with standard tech niques: blood group and Rh-phenotype direct antiglobulin test (DAT) with broad-spectrum antiserum (Ortho) and with anti-IgG, anti-IgGl, anti-IgG2, anti-IgG3, anti-IgG4, anti-IgA, anti-IgM and anti-C monospecific antisera (Janssen); agglutination tests against untreated and papain-treated red cells at 4,20 and 37 °C; indirect an tiglobulin test (IAT); tests for monophasic and biphasic hemolysin and Ham’s test. For antibody elution, Rubin’s [11] method was em ployed. Detection of drug-dependent antibodies was carried out as previously described: Scheme A: Patient serum (100 pi) was incubated with the drug (100 pi) for 2 h at 37 °C and the untreated and enzyme (papain)treated RBC (50 pi of a 3% suspension) were then added. After in cubation (2 h at 37 °C), the reactions were read for agglutination and hemolysis. The erythrocytes were washed 3 times with saline and tested by IAT. Scheme B: One hundred microliters of a 5% suspension of un treated and enzyme-treated group 0 RBCs and 100 pi of cyanidanol were incubated for 2 h at 37 °C; the cells were then washed 3 times in 0.9% saline; resuspended and incubated (2 h at 37 °C) with 100 pi of serial dilutions of patient serum. The reactions were read for agglut ination and hemolysis. Thereafter the RBCs were washed 3 times with saline and tested by IAT using polyvalent antiglobulin serum (Ortho). Control tubes contained saline solution alone, drug solution alone, saline with fresh normal serum (as a source of complement) and drug solution with fresh serum. The sera were added with the fresh compatible human serum (0.05 ml) as a source of complement, if not used on the same day.
Results
Clinical Data No demonstrable viral infections or autoimmune dis eases were detected in any of the patients. All had re ceived therapeutic doses of cyanidanol (2 g/day) and were thrombocytopenic at the time of the study, after receiving cyanidanol for a long time (4-36 months). In addition, all of the patients presented normal platelet counts after dis continuing the drug (4-10 months later). Hemolysis oc curred in 3 patients after prolonged intake; 2 were initially
97
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61/M 69/M 50/M 64/F 78/M
Table 2. Hb, reticulocytes and immunological findings in 3 patients with drug-dependent immune hemolysis
Patients
First observation After 6 months 4 First observation After 6 months After 12 months 5 First observation After 6 months After 12 months 1
Hb g/dl
%
10.5 12.7 7.5 14.1 14.5 9.1 15.2 15.3
4.0 0.7 20.0 2.0 1.0 11.0 0.8 0.8
Reticulocytes
DAT
IAT
negative negative ++++
++ negative
++++ ++ negative
Drug-dependent antibodies
negative negative negative negative negative negative negative negative
scheme A
scheme B
positive positive positive -
negative positive -
negative -
-
Table 3. Platelet studies
Patients
1 2 3 4 5
Thrombocytopenia duration months
regression after suspension
4 36 24 4 6
yes yes yes yes yes
PAIgG
250 220 750 0 n.e.
S-PBIgG
480 220 480 150 500
Drug-dependent antibodies scheme A
scheme B
420 (negative) 300 (±) 470 (negative) 220 (±) 800 (positive)
280 (negative) 900 (positive) 1,500 (positive) 400 (positive) 1,200 (positive)
Platelet antibodies are expressed as nanograms of IgG/107 platelets, n.e. = Not examined.
Serological Data In 3 out of 4 patients examined, the PAIgG values were high, while high S-PBIgG values were detected in all of the patients (table 3). After incubation of the sera with cyanid anol (scheme A), 3 patients (cases 2, 4 and 5) presented a slight increase in S-PBIgG in relation to the data obtained without the drug. However, if the drug was first incubated with platelets, followed by the addition of sera, a signif icant increase in S-PBIgG was detected in 4 patients. In 2 out of 5 patients, the DAT was strongly positive with both the polyvalent antiglobulin and anti-IgG monospecific sera. In both cases, the IgGl subclass was respon sible for hemolysis. Antibodies eluted from the patients’ RBCs and tested against a panel of selected erythrocytes (Resolve AB, Ortho) showed no clear specificity pattern.
98
The IAT was negative in all patients. When cyanidanol was added, agglutination of the normal red cells with IAT occurred in 3 (patients 1,4 and 5): positive results were ob tained with scheme A in 2 cases (patients 1 and 5) and with both schemes (A and B) in 1 case (patient 4). Positivity of the test performed with scheme A is com patible with the presence of antibodies reactive by the im mune complex mechanism, though direct drug binding to cells cannot be excluded. On the contrary, a positive test obtained with cyanidanol-pretreated cells suggests a sensi tization of drug absorption type.
Discussion
This study demonstrates that patients affected by cyanidanol-induced anemia and thrombocytopenia pre sented RBC and platelet antibodies related to the drug ad ministration. With regard to the platelet antibodies, all the patients had increased serum platelet-bindable IgG values in the absence of cyanidanol and 3 had high platelet-asso ciated IgG levels. These findings are very similar to those
Gandolfo/Girelli/Conti/Perrone/Arista/ Damico
Cyanidanol-Dependent Anemia and Thrombocytopenia
Downloaded by: UCL 144.82.238.225 - 4/26/2018 5:35:46 AM
diagnosed as having idiopathic autoimmune hemolytic anemia, treated with prednisone. After suspending cyanidanol, the hemoglobin levels promptly increased, even though autoantibodies on RBCs were persistent, but with decreasing positivity (table 2). At the same time, the corticosteroid therapy was suspended.
observed in autoimmune thrombocytopenic purpura or could be due to the presence of drug-related immune complexes. However, the cyanidanol-dependent antibod ies were reactive with only platelets that had been pre treated with the drug. In effect, this reactivity was much less evident when the antibodies were preincubated with cyanidanol. These data are in accordance with the hypoth esis of a drug absorption mechanism (whereby cyanidanol, like penicillin, binds firmly to cells) and against the im mune complex mechanism. With regard to RBC antibodies, the IAT was negative in all the subjects, whereas drug-dependent antibodies were detected in 3 patients when the sera were preincu bated with cyanidanol (as in the immune complex mecha nism). One of these 3 subjects also had antibodies that were reactive with the drug-cell conjugate. The results herein presented are similar to those re ported by Salama and Mueller-Eckhardt [8] and Casaril et al. [12] in patients with cyanidanol-induced immune he
molysis. The IgG autoantibodies could not be distin guished serologically from those observed in warm au toimmune hemolytic anemia; the hematological findings were also normal after suspending cyanidanol. Therefore, production of autoantibodies, as in immunohemolytic anemia induced by alpha-methyldopa, is possible. In conclusion, the data presented support the hypothe sis that cyanidanol-induced immune cytopenias can be caused by the production of RBC and platelet autoanti bodies and/or drug-dependent antibodies, as well as by immune complex mechanism and by the drug absorp tion mechanism. Heterogeneity of the antibody response has been reported for other drugs as well [13]. Various mechanisms may be involved in drug-induced immune cytopenia and be sometimes simultaneously present in the same patient, as very recently reported in 2 patients with cephalosporin-induced hemolysis by drug-depen dent antibodies reactive by both immune complex and drug adsorption mechanisms [14,15].
References 7 Schoremus H, Wiedmann KH, Dolle W, Peerenboon H, Strohmeyer G, Balzer K, Goebel H, Durr HK, Bode CH, Blum AL, Frosner G, Gerlich W, Berg PA, Dietz K: (+)-cyanidanol-3 in the treatment of acute viral hepatitis: A ran domized controlled trial. Hepatology 1984;4: 331-335. 8 Salama A, Mueller-Eckhardt C: Cyanidanol and its metabolites bind tightly to red cells and are responsible for the production of autoand/or drug-dependent antibodies against these cells. Br J Haematol 1987;66:263-266. 9 Dixon R, Rosse W, Ebbert L: Quantitative de termination of antibody in idiopathic thrombo cytopenic purpura: Correlation of serum and platelet-bound antibody with clinical response. N Engl J Med 1975;992:230-235. 10 Kelton JG, Neame PB, Bishop J, Ali M, Gauldie Jirsh J: The direct assay for platelet-associ ated IgG (PAIgG): Lack of association be tween antibody level and platelet size. Blood 1979;53:73-79. 11 Rubin H: Antibody elution from red blood cells. J Clin Pathol 1963;16:70-73.
12 Casaril M, Gabrielli GB, Pecci R, Venturini L, Corrocher R: A case of chronic haemolytic anemia induced by cyanidanol. Ital J Gastroen terol 1987;19:180-181. 13 Habibi B: Drug induced red blood cell autoan tibodies codeveloped with drug specific anti bodies causing haermolytic anemias. Br J Hae matol 1985;61:139-143. 14 Chambers LA, Donovan LM, Kruskall MS: Ceftazidime-induced hemolysis in a patient with drug-dependent antibodies reactive by im mune complex and drug adsorption mecha nism. Am J Clin Pathol 1991;95:393-396. 15 Shulman IA, Arndt PA, McGehee W, Garratty G: Ceftaxime-induced immune hemolytic ane mia due to antibodies reacting in vitro by more than one mechanism. Transfusion 1990;30:263266.
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1 Vido I, Schmidt FW, Muller R, Ranft V, Wildhirt E, Holzer E, et al: Influence of (+)-cyanidanol-3 on the course of acute viral hepatitis. Dtsch Med Wochenschr 1980;105:330-332. 2 Slatter TF, Eakins MN: Interaction of (+)-cyanidanol-3 with free radical generating systems; in Bertelli A (ed): New Trends in the Therapy of Liver Diseases. Basel, Karger, 1975. 3 Kakumu S, Murakami H, Kuriki J: Activation of suppressor functions of human peripheral blood T cells by (+)-cyanidanol-3: Its applica tion to chronic active liver disease. Clin Exp Immunol 1983;52:43CM32. 4 Blum AL, Doelle W, Kortum K, Peter P, Strohmeyer G, Berthet P, Goebell H, Pelloni S, Poulsen H, Tygstrup N: Treatment of acute viral hepatitis with (+)-cyanidanol-3. Lancet 1977;ii: 1153-1155. 5 Di Nola F: (+)-cyanidanol-3 in acute viral hep atitis. Lancet 1980;ii:1378— 1380. 6 Piazza M, Guadagnino V, Picciotto L, De Mercato R, Chiaranni A, Orlando R, Golden G: Ef fect of (+)-cyanidanol-3 in acute HAV, HBV, and non-A, non-B viral hepatitis. Hepatology 1983;3:45-49.
