Int J Hematol DOI 10.1007/s12185-014-1652-5
CASE REPORT
Anti-erythropoietin receptor antibody-associated pure red cell aplasia accompanied by Coombs-negative autoimmune hemolytic anemia in a patient with T cell/histiocyte-rich large B cell lymphoma Akihito Fujimi • Yusuke Kamihara • Yuji Kanisawa • Akari Hashimoto • Chisa Nakajima • Naotaka Hayasaka Naoki Uemura • Toshinori Okuda • Shinya Minami • Satoshi Iyama • Koichi Takada • Tsutomu Sato • Akinori Hara • Yasunori Iwata • Kengo Furuichi • Takashi Wada • Junji Kato
•
Received: 18 March 2014 / Revised: 20 July 2014 / Accepted: 22 July 2014 Ó The Japanese Society of Hematology 2014
Abstract A 79-year-old female diagnosed with T cell/ histiocyte-rich large B cell lymphoma in complete remission after six cycles of rituximab-combined chemotherapy developed severe anemia, reticulocytopenia, and bone marrow erythroid hypoplasia. She was diagnosed with pure red cell aplasia (PRCA) accompanied by Coombs-negative autoimmune hemolytic anemia evidenced by a lack of glycophorin-A-positive cells in the bone marrow, haptoglobin under the detection level, and a high titer of RBCbound IgG. Anti-erythropoietin receptor (EPOR) antibody was detected in the serum, and oligoclonal a/b and c/d T cells were also detected in her peripheral blood by Southern blotting analysis. Parvovirus B19 DNA was not detected by PCR. Although the treatment with rituximab had limited efficacy (specifically, only for hemolysis), subsequent cyclosporine therapy led to prompt recovery of erythropoiesis with the disappearance of anti-EPOR
A. Fujimi (&) Y. Kamihara Y. Kanisawa A. Hashimoto Department of Hematology and Oncology, Oji General Hospital, 3-4-8 Wakakusa-Cho, Tomakomai 053-8506, Japan e-mail: [email protected] C. Nakajima N. Hayasaka N. Uemura T. Okuda S. Minami Department of Gastroenterology, Oji General Hospital, Tomakomai, Japan S. Iyama K. Takada T. Sato J. Kato Department of Medical Oncology and Hematology, Sapporo Medical University, Sapporo, Japan A. Hara Y. Iwata K. Furuichi T. Wada Division of Nephrology, Kanazawa University Hospital, Kanazawa, Japan
antibody and oligoclonal T cells. This is the first case report of anti-EPOR antibody-associated PRCA in a patient with malignant lymphoma treated successfully with cyclosporine. Keywords T cell/histiocyte-rich large B cell lymphoma Pure red cell aplasia Autoimmune hemolytic anemia Anti-erythropoietin receptor antibody Rituximab
Introduction Autoimmune hematological disorders such as pure red cell aplasia (PRCA) and autoimmune hemolytic anemia (AIHA) may develop during the course of lymphoproliferative neoplasms [1–3]. It has been reported that the complication rate of AIHA in lymphoproliferative neoplasms was 1.8–2.2 % [1, 2], while 4.3 % of all PRCA appeared in secondary to malignant lymphoma [3]. In addition, complication with both PRCA and AIHA in malignant lymphoma could occur [4]. Hauswirth et al. [4] reported that, among a total of 98 patients with AIHA complicated in malignant lymphoma, 12 (12.2 %) were also complicated with PRCA. Several mechanisms of the pathogenesis of PRCA in patients with lymphoproliferative disorder have been proposed: autoreactive antibodies against erythroid progenitors [5] or erythropoietin (EPO) [6] produced by neoplastic lymphoma clones, large granular lymphocytes of c/d T cell type, which directly inhibit erythroid precursors [7], persistent parvovirus B19 (PVB19) infection [3], and autoreactive mechanisms irrespective of malignant lymphoma [3]. Among these, the most common pathogenesis following the treatment of malignant lymphoma is persistent PVB19 infection [3].
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A. Fujimi et al.
Recently, we reported a novel autoantibody to EPO receptor (EPOR) that can cause erythroid hypoplasia by interfering with the EPO–EPOR interaction in patients with autoimmune disorders such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and lymphoproliferative disorders [8]. Here, we present a case of T cell/histiocyte-rich large B cell lymphoma (THRLBCL) in first complete remission complicated with PRCA caused by anti-EPOR antibody accompanied by Coombs-negative AIHA, in which treatment with rituximab was effective only for hemolysis, but subsequent cyclosporine led to prompt recovery of erythropoiesis.
Case presentation A 79-year-old female presented with a right cervical mass in February 2012. She had a medical history of hypertension and chronic thyroiditis with good control. 18F-FDG PET/CT revealed multiple cervical and supraclavicular lymph nodes and mild splenomegaly with 18F-FDG accumulation. Lymph node biopsy from the right cervical lymph node showed scattered large CD20-positive lymphocytes with atypical nuclei surrounded by numerous small CD3-positive T lymphocytes and CD68-positive histiocytes. These large lymphocytes were negative for CD15 and CD30 staining. Laboratory data of peripheral blood were as follows: WBC 4,500/lL, RBC 3639104/lL, Hb 11.5 g/dL, reticulocytes 9 %, platelets 13.89104/lL, LDH 205 U/L, and soluble IL-2R 2,060 U/mL. Bone marrow biopsy showed normal cellularity without lymphoma cell infiltration. The patient was diagnosed with stage IIIA THRLBCL and underwent six cycles of R-THP-COP (rituximab 375 mg/m2, cyclophosphamide 500 mg/m2, pirarubucin 30 mg/m2, vincristine 1.0 mg/m2, prednisolone 30 mg/m2) chemotherapy, which resulted in complete remission of the THRLBCL. In December 2012, 4 months after the end of the chemotherapy, the hemoglobin level dropped to 4.5 g/ dL. An accompanying rise in the reticulocyte count from 8 % (21,600/lL) in November 2012 to 41 % (63,550/lL) and haptoglobin under the detection level (\10 mg/dL) suggested a diagnosis of AIHA, but the direct Coombs test was negative, and serum LDH and indirect bilirubin were within the normal ranges. There was no evidence of gastrointestinal bleeding, and serum iron and ferritin levels were both elevated. Bone marrow examination showed normal cellularity without lymphoma cell infiltration, but the M/E ratio was increased to 22.7. She received red cell transfusion and was followed up again without any treatment because the anemia was stable for about 3 weeks. However, the hemoglobin level was then slightly decreased, and severe anemia of Hb 5.2 g/dL appeared again in March
123
2013. At this time, the anemia was accompanied by reticulocytopenia (2 %, 4,920/lL) with normal leukocyte and platelet counts, together with marked erythroid hypoplasia in the bone marrow evidenced by a lack of glycophorin-A staining, which led to the diagnosis of PRCA. PVB19 infection was not detected by a serological test for antiPVB19 IgM antibody and by PCR analysis for PVB19 DNA. There was no overt THRLBCL recurrence on the CT findings, and no monoclonal B cells were detected both in the peripheral blood and in the bone marrow by PCR analysis for immunoglobulin heavy chain gene rearrangement. No increased number of large granular lymphocytes was observed. On the other hand, the diagnosis of Coombsnegative AIHA was made based on 122 RBC-bound IgG on 1 RBC (normal range, 33 ± 13) [9] with negative results of the direct Coombs test and haptoglobin persistently under the detection level. She had never received any EPO-stimulating agents, but serum erythropoietin was markedly elevated at 2,710 mU/mL (normal range, 9.1–32.8). To elucidate the cause of PRCA, we measured the anti-EPOR antibody in her serum by enzyme-linked immunosorbent assay at the Division of Nephrology, Kanazawa University Hospital, as reported previously [8], which showed a positive result with optical density (OD450) of 2.176 (normal range, \1.5). Initially, we conducted four cycles of rituximab monotherapy (375 mg/m2/week) on the suspicion that these autoantibodies might have been produced by the subclinical recurrence of THRLBCL. At 2 months after the start of rituximab administration, slight recovery of anemia and normalization of haptoglobin level were obtained; however, reticulocytopenia and marrow erythroid hypoplasia were not recovered, with a sustained positive result for anti-EPOR antibody (OD450 2.022). Furthermore, Southern blotting analysis of both Cb1 and Jc T cell receptor gene rearrangement showed oligoclonal rearranged bands in the peripheral blood. Therefore, we subsequently administered cyclosporine, which has been reported to be a promising therapy for PRCA [10], at a starting dose of 2 mg/kg, which brought about reticulocytosis in just 2 weeks, and complete recovery of anemia with the disappearance of anti-EPOR antibody and oligoclonal T cells was obtained. She remained in remission of PRCA and AIHA as well as THRLBCL for 12 months from the initiation of cyclosporine. The clinical course of the patient is summarized in Fig. 1.
Discussion THRLBCL is a malignant B cell neoplasm characterized by a limited number of scattered, large, atypical B cells embedded in a background of abundant T cells and frequently histiocytes [11]. Oyaizu et al. reported a case of
Anti-erythropoietin receptor antibody-associated pure red cell aplasia
Fig. 1 Clinical course: R-THP-COP, chemotherapy with rituximab, pirarubicin, cyclophosphamide, vincristine, and prednisolone; CyA cyclosporine A, TCR T cell receptor, RBC red blood cell, EPOR erythropoietin receptor, Hb hemoglobin, Reti reticulocyte, RCC red cell concentrates
THRLBCL that developed PRCA one year after autologous peripheral blood stem cell transplantation accompanied by a high suspicion of disease relapse in the bone marrow, and rituximab treatment was effective in both PRCA and the bone marrow lesion [12]. The present case developed PRCA and AIHA concomitantly during the complete remission of THRLBCL identified with anti-EPOR antibody. Anti-EPOR antibody is a newly identified autoantibody to EPOR, which functionally neutralizes EPO activity by interfering with EPO–EPOR interaction, resulting in erythroid hypoplasia [8]. It has been reported that not only rheumatological diseases, such as SLE, RA, and ANCAassociated vasculitis, but also three of nine samples from patients with lymphoproliferative disorder, were positive for anti-EPOR antibody [8]. As no signs of THRLBCL relapse were observed during the course of PRCA and AIHA, the oligoclonal a/b or c/d T cells detected in the peripheral blood might have been pathogenic clones that produce anti-EPOR antibody or anti-RBC IgG. In addition, the oligoclonal c/d T cells might have inhibited erythroid progenitors directly, as reported previously [7]. Regarding the diagnosis of AIHA, although most AIHA cases have elevated serum LDH and bilirubin levels with marked
reticulocytosis in general, the present case showed normal LDH and bilirubin levels and mild reticulocytosis of 63,550/lL. The mild reticulocytosis could be explainable by erythroid hypoplasia with an elevated M/E ratio of 22.7 in the bone marrow, leading to subsequent overt PRCA, and the normal LDH and bilirubin levels suggested the existence of relatively mild hemolysis. Interestingly, although the anti-EPOR antibody could not be eliminated by rituximab therapy in 2 months, subsequent cyclosporine led to complete recovery of the PRCA with disappearance of the antibody. On the other hand, AIHA emerged 3 months preceding overt PRCA and was improved by rituximab monotherapy. The limited efficacy of rituximab only for AIHA raises the possibility that autoreactive T cell clones might stimulate and create two or more B cell clones, one being anti-EPOR antibodyproducing B cells and the other anti-RBC IgG-producing B cells. However, the exact reason why rituximab could not eliminate the pathogenic B cell clones that produce antiEPOR antibody cannot be clarified. Referring to the mechanisms of rituximab therapy for refractory ITP patients [13–15], two possible explanations can be proposed. First, the anti-EPOR antibody-producing B cells might be CD20-negative, such as long-lived plasma cells.
123
A. Fujimi et al.
Second, a normal dose of rituximab at 375 mg/m2 was insufficient to suppress the two pathogenic B cell clones; in other words, rituximab as well as effector cells might be consumed ahead of the elimination of anti-RBC antibodyproducing B cell clones. Although subsequent cyclosporine might reduce the anti-EPOR antibody indirectly by inhibiting oligoclonal T cell clones and resolve the PRCA, there remains the possibility of the late effect of rituximab on the negative conversion of anti-EPOR antibody additively to cyclosporine. At present, we can only speculate on the reason why overt PRCA and AIHA appeared in this setting. It is suspected that chemotherapy including rituximab for THRLBCL might be a trigger of the onset via the liberation of endogenous autoreactive T cell clones that might have existed before or along with the THRLBCL, similar to how secondary AIHA occurs in patients with chronic lymphocytic leukemia treated with fludarabine [16]. Worsening of AIHA induced by rituximab in a patient with lymphoproliferative disorder has also been reported [17], with a speculated mechanism that the reduction of CD20-positive B cells by rituximab resulted in liberation of important cytokines, leading to the overexpression of anti-erythrocyte autoreactive plasma cells. Thus, the present case emphasizes the necessity of identifying the anti-EPOR antibody in PRCA patients, which plays a significant role in some proportion of erythroid hypoplasia cases with unknown etiology. Further investigation is anticipated to resolve the exact mechanism of anti-EPOR antibody-associated PRCA.
4.
5.
6. 7.
8.
9.
10.
11.
12.
Acknowledgments The authors would like to thank Dr. Toyomi Kamesaki at the Center for Community Medicine, Jichi Medical University, Tochigi, Japan, for measuring RBC-bound IgG.
13.
Conflict of interest The authors declare that they have no conflicts of interest.
14. 15.
References 1. Du¨hrsen U, Augener W, Zwingers T, Brittinger G. Spectrum and frequency of autoimmune derangements in lymphoproliferative disorders: analysis of 637 cases and comparison with myeloproliferative diseases. Br J Haematol. 1987;67:235–9. 2. Grønbaek K, D’Amore F, Schmidt K. Autoimmune phenomena in non-Hodgkin’s lymphoma. Leuk Lymphoma. 1995;18:311–6. 3. Hirokawa M, Sawada K, Fujishima N, Kawano F, Kimura A, Watanabe T, et al. Acquired pure red cell aplasia associated with malignant lymphomas: a nationwide cohort study in Japan for the
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PRCA Collaborative Study Group. Am J Hematol. 2009;84:144–8. Hauswirth AW, Skrabs C, Schu¨tzinger C, Gaiger A, Lechner K, Ja¨ger U. Autoimmune hemolytic anemias, Evans’ syndromes, and pure red cell aplasia in non-Hodgkin lymphomas. Leuk Lymphoma. 2007;48:1139–49. Alter R, Joshi SS, Verdirame JD, Weisenburger DD. Pure red cell aplasia associated with B cell lymphoma: demonstration of bone marrow colony inhibition by serum immunoglobulin. Leuk Res. 1990;14:279–86. Fisch P, Handgretinger R, Schaefer HE. Pure red cell aplasia. Br J Haematol. 2000;111:1010–22. Handgretinger R, Geiselhart A, Moris A, Grau R, Teuffel O, Bethge W, et al. Pure red-cell aplasia associated with clonal expansion of granular lymphocytes expressing killer-cell inhibitory receptors. N Engl J Med. 1999;340:278–84. Hara A, Furuichi K, Higuchi M, Iwata Y, Sakai N, Kaneko S, et al. Autoantibodies to erythropoietin receptor in patients with immune-mediated diseases: relationship to anaemia with erythroid hypoplasia. Br J Haematol. 2013;160:244–50. Kamesaki T, Oyamada T, Omine M, Ozawa K, Kajii E. Cut-off value of red-blood-cell-bound IgG for the diagnosis of Coombsnegative autoimmune hemolytic anemia. Am J Hematol. 2009;84:98–101. Sawada K, Hirokawa M, Fujishima N, Teramura M, Bessho M, Dan K, et al. Long-term outcome of patients with acquired primary idiopathic pure red cell aplasia receiving cyclosporine A. A nationwide cohort study in Japan for the PRCA Collaborative Study Group. Haematologica. 2007;92:1021–8. De Wolf-Peeters C, Delabie J, Campo E, Jaffe ES, Delsol G. T cell/histiocyte-rich large B cell lymphoma. In: WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. 4th ed. Lyon: International Agency for Research on Cancer; 2008. p. 238–9. Oyaizu N, Kozai Y, Kodo H, Sunaga S, Iwabuchi K, Higashihara M, et al. A case of pure red cell aplasia complicated with diffuse large B cell lymphoma, T-cell-rich/histiocyte-rich variant: effectiveness of rituximab and implications for a common immunopathogenic role of B lymphocytes. Acta Haematol. 2005;113:194–7. Bennett CM, de Jong JL, Neufeld EJ. Targeted ITP strategies: do they elucidate the biology of ITP and related disorders? Pediatr Blood Cancer. 2006;47:706–9. Taylor RP, Lindorfer MA. Antigenic modulation and rituximab resistance. Semin Hematol. 2010;47:124–32. Cˇervinek L, Cˇerna´ O, Cˇaniga M, Konı´rˇova´ E, Hlusˇ´ı A, Sˇimkovicˇ M, et al. Efficacy of rituximab in primary immune thrombocytopenia: an analysis of adult pretreated patients from everyday hematological practice. Int J Hematol. 2012;96:594–9. Dearden C, Wade R, Else M, Richards S, Milligan D, Hamblin T, et al. The prognostic significance of a positive direct antiglobulin test in chronic lymphocytic leukemia: a beneficial effect of the combination of fludarabine and cyclophosphamide on the incidence of hemolytic anemia. Blood. 2008;111:1820–6. Jourdan E, Topart D, Richard B, Jourdan J, Sotto A. Severe autoimmune hemolytic anemia following rituximab therapy in a patient with a lymphoproliferative disorder. Leuk Lymphoma. 2003;44:889–90.
CASE REPORT
Anti-erythropoietin receptor antibody-associated pure red cell aplasia accompanied by Coombs-negative autoimmune hemolytic anemia in a patient with T cell/histiocyte-rich large B cell lymphoma Akihito Fujimi • Yusuke Kamihara • Yuji Kanisawa • Akari Hashimoto • Chisa Nakajima • Naotaka Hayasaka Naoki Uemura • Toshinori Okuda • Shinya Minami • Satoshi Iyama • Koichi Takada • Tsutomu Sato • Akinori Hara • Yasunori Iwata • Kengo Furuichi • Takashi Wada • Junji Kato
•
Received: 18 March 2014 / Revised: 20 July 2014 / Accepted: 22 July 2014 Ó The Japanese Society of Hematology 2014
Abstract A 79-year-old female diagnosed with T cell/ histiocyte-rich large B cell lymphoma in complete remission after six cycles of rituximab-combined chemotherapy developed severe anemia, reticulocytopenia, and bone marrow erythroid hypoplasia. She was diagnosed with pure red cell aplasia (PRCA) accompanied by Coombs-negative autoimmune hemolytic anemia evidenced by a lack of glycophorin-A-positive cells in the bone marrow, haptoglobin under the detection level, and a high titer of RBCbound IgG. Anti-erythropoietin receptor (EPOR) antibody was detected in the serum, and oligoclonal a/b and c/d T cells were also detected in her peripheral blood by Southern blotting analysis. Parvovirus B19 DNA was not detected by PCR. Although the treatment with rituximab had limited efficacy (specifically, only for hemolysis), subsequent cyclosporine therapy led to prompt recovery of erythropoiesis with the disappearance of anti-EPOR
A. Fujimi (&) Y. Kamihara Y. Kanisawa A. Hashimoto Department of Hematology and Oncology, Oji General Hospital, 3-4-8 Wakakusa-Cho, Tomakomai 053-8506, Japan e-mail: [email protected] C. Nakajima N. Hayasaka N. Uemura T. Okuda S. Minami Department of Gastroenterology, Oji General Hospital, Tomakomai, Japan S. Iyama K. Takada T. Sato J. Kato Department of Medical Oncology and Hematology, Sapporo Medical University, Sapporo, Japan A. Hara Y. Iwata K. Furuichi T. Wada Division of Nephrology, Kanazawa University Hospital, Kanazawa, Japan
antibody and oligoclonal T cells. This is the first case report of anti-EPOR antibody-associated PRCA in a patient with malignant lymphoma treated successfully with cyclosporine. Keywords T cell/histiocyte-rich large B cell lymphoma Pure red cell aplasia Autoimmune hemolytic anemia Anti-erythropoietin receptor antibody Rituximab
Introduction Autoimmune hematological disorders such as pure red cell aplasia (PRCA) and autoimmune hemolytic anemia (AIHA) may develop during the course of lymphoproliferative neoplasms [1–3]. It has been reported that the complication rate of AIHA in lymphoproliferative neoplasms was 1.8–2.2 % [1, 2], while 4.3 % of all PRCA appeared in secondary to malignant lymphoma [3]. In addition, complication with both PRCA and AIHA in malignant lymphoma could occur [4]. Hauswirth et al. [4] reported that, among a total of 98 patients with AIHA complicated in malignant lymphoma, 12 (12.2 %) were also complicated with PRCA. Several mechanisms of the pathogenesis of PRCA in patients with lymphoproliferative disorder have been proposed: autoreactive antibodies against erythroid progenitors [5] or erythropoietin (EPO) [6] produced by neoplastic lymphoma clones, large granular lymphocytes of c/d T cell type, which directly inhibit erythroid precursors [7], persistent parvovirus B19 (PVB19) infection [3], and autoreactive mechanisms irrespective of malignant lymphoma [3]. Among these, the most common pathogenesis following the treatment of malignant lymphoma is persistent PVB19 infection [3].
123
A. Fujimi et al.
Recently, we reported a novel autoantibody to EPO receptor (EPOR) that can cause erythroid hypoplasia by interfering with the EPO–EPOR interaction in patients with autoimmune disorders such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and lymphoproliferative disorders [8]. Here, we present a case of T cell/histiocyte-rich large B cell lymphoma (THRLBCL) in first complete remission complicated with PRCA caused by anti-EPOR antibody accompanied by Coombs-negative AIHA, in which treatment with rituximab was effective only for hemolysis, but subsequent cyclosporine led to prompt recovery of erythropoiesis.
Case presentation A 79-year-old female presented with a right cervical mass in February 2012. She had a medical history of hypertension and chronic thyroiditis with good control. 18F-FDG PET/CT revealed multiple cervical and supraclavicular lymph nodes and mild splenomegaly with 18F-FDG accumulation. Lymph node biopsy from the right cervical lymph node showed scattered large CD20-positive lymphocytes with atypical nuclei surrounded by numerous small CD3-positive T lymphocytes and CD68-positive histiocytes. These large lymphocytes were negative for CD15 and CD30 staining. Laboratory data of peripheral blood were as follows: WBC 4,500/lL, RBC 3639104/lL, Hb 11.5 g/dL, reticulocytes 9 %, platelets 13.89104/lL, LDH 205 U/L, and soluble IL-2R 2,060 U/mL. Bone marrow biopsy showed normal cellularity without lymphoma cell infiltration. The patient was diagnosed with stage IIIA THRLBCL and underwent six cycles of R-THP-COP (rituximab 375 mg/m2, cyclophosphamide 500 mg/m2, pirarubucin 30 mg/m2, vincristine 1.0 mg/m2, prednisolone 30 mg/m2) chemotherapy, which resulted in complete remission of the THRLBCL. In December 2012, 4 months after the end of the chemotherapy, the hemoglobin level dropped to 4.5 g/ dL. An accompanying rise in the reticulocyte count from 8 % (21,600/lL) in November 2012 to 41 % (63,550/lL) and haptoglobin under the detection level (\10 mg/dL) suggested a diagnosis of AIHA, but the direct Coombs test was negative, and serum LDH and indirect bilirubin were within the normal ranges. There was no evidence of gastrointestinal bleeding, and serum iron and ferritin levels were both elevated. Bone marrow examination showed normal cellularity without lymphoma cell infiltration, but the M/E ratio was increased to 22.7. She received red cell transfusion and was followed up again without any treatment because the anemia was stable for about 3 weeks. However, the hemoglobin level was then slightly decreased, and severe anemia of Hb 5.2 g/dL appeared again in March
123
2013. At this time, the anemia was accompanied by reticulocytopenia (2 %, 4,920/lL) with normal leukocyte and platelet counts, together with marked erythroid hypoplasia in the bone marrow evidenced by a lack of glycophorin-A staining, which led to the diagnosis of PRCA. PVB19 infection was not detected by a serological test for antiPVB19 IgM antibody and by PCR analysis for PVB19 DNA. There was no overt THRLBCL recurrence on the CT findings, and no monoclonal B cells were detected both in the peripheral blood and in the bone marrow by PCR analysis for immunoglobulin heavy chain gene rearrangement. No increased number of large granular lymphocytes was observed. On the other hand, the diagnosis of Coombsnegative AIHA was made based on 122 RBC-bound IgG on 1 RBC (normal range, 33 ± 13) [9] with negative results of the direct Coombs test and haptoglobin persistently under the detection level. She had never received any EPO-stimulating agents, but serum erythropoietin was markedly elevated at 2,710 mU/mL (normal range, 9.1–32.8). To elucidate the cause of PRCA, we measured the anti-EPOR antibody in her serum by enzyme-linked immunosorbent assay at the Division of Nephrology, Kanazawa University Hospital, as reported previously [8], which showed a positive result with optical density (OD450) of 2.176 (normal range, \1.5). Initially, we conducted four cycles of rituximab monotherapy (375 mg/m2/week) on the suspicion that these autoantibodies might have been produced by the subclinical recurrence of THRLBCL. At 2 months after the start of rituximab administration, slight recovery of anemia and normalization of haptoglobin level were obtained; however, reticulocytopenia and marrow erythroid hypoplasia were not recovered, with a sustained positive result for anti-EPOR antibody (OD450 2.022). Furthermore, Southern blotting analysis of both Cb1 and Jc T cell receptor gene rearrangement showed oligoclonal rearranged bands in the peripheral blood. Therefore, we subsequently administered cyclosporine, which has been reported to be a promising therapy for PRCA [10], at a starting dose of 2 mg/kg, which brought about reticulocytosis in just 2 weeks, and complete recovery of anemia with the disappearance of anti-EPOR antibody and oligoclonal T cells was obtained. She remained in remission of PRCA and AIHA as well as THRLBCL for 12 months from the initiation of cyclosporine. The clinical course of the patient is summarized in Fig. 1.
Discussion THRLBCL is a malignant B cell neoplasm characterized by a limited number of scattered, large, atypical B cells embedded in a background of abundant T cells and frequently histiocytes [11]. Oyaizu et al. reported a case of
Anti-erythropoietin receptor antibody-associated pure red cell aplasia
Fig. 1 Clinical course: R-THP-COP, chemotherapy with rituximab, pirarubicin, cyclophosphamide, vincristine, and prednisolone; CyA cyclosporine A, TCR T cell receptor, RBC red blood cell, EPOR erythropoietin receptor, Hb hemoglobin, Reti reticulocyte, RCC red cell concentrates
THRLBCL that developed PRCA one year after autologous peripheral blood stem cell transplantation accompanied by a high suspicion of disease relapse in the bone marrow, and rituximab treatment was effective in both PRCA and the bone marrow lesion [12]. The present case developed PRCA and AIHA concomitantly during the complete remission of THRLBCL identified with anti-EPOR antibody. Anti-EPOR antibody is a newly identified autoantibody to EPOR, which functionally neutralizes EPO activity by interfering with EPO–EPOR interaction, resulting in erythroid hypoplasia [8]. It has been reported that not only rheumatological diseases, such as SLE, RA, and ANCAassociated vasculitis, but also three of nine samples from patients with lymphoproliferative disorder, were positive for anti-EPOR antibody [8]. As no signs of THRLBCL relapse were observed during the course of PRCA and AIHA, the oligoclonal a/b or c/d T cells detected in the peripheral blood might have been pathogenic clones that produce anti-EPOR antibody or anti-RBC IgG. In addition, the oligoclonal c/d T cells might have inhibited erythroid progenitors directly, as reported previously [7]. Regarding the diagnosis of AIHA, although most AIHA cases have elevated serum LDH and bilirubin levels with marked
reticulocytosis in general, the present case showed normal LDH and bilirubin levels and mild reticulocytosis of 63,550/lL. The mild reticulocytosis could be explainable by erythroid hypoplasia with an elevated M/E ratio of 22.7 in the bone marrow, leading to subsequent overt PRCA, and the normal LDH and bilirubin levels suggested the existence of relatively mild hemolysis. Interestingly, although the anti-EPOR antibody could not be eliminated by rituximab therapy in 2 months, subsequent cyclosporine led to complete recovery of the PRCA with disappearance of the antibody. On the other hand, AIHA emerged 3 months preceding overt PRCA and was improved by rituximab monotherapy. The limited efficacy of rituximab only for AIHA raises the possibility that autoreactive T cell clones might stimulate and create two or more B cell clones, one being anti-EPOR antibodyproducing B cells and the other anti-RBC IgG-producing B cells. However, the exact reason why rituximab could not eliminate the pathogenic B cell clones that produce antiEPOR antibody cannot be clarified. Referring to the mechanisms of rituximab therapy for refractory ITP patients [13–15], two possible explanations can be proposed. First, the anti-EPOR antibody-producing B cells might be CD20-negative, such as long-lived plasma cells.
123
A. Fujimi et al.
Second, a normal dose of rituximab at 375 mg/m2 was insufficient to suppress the two pathogenic B cell clones; in other words, rituximab as well as effector cells might be consumed ahead of the elimination of anti-RBC antibodyproducing B cell clones. Although subsequent cyclosporine might reduce the anti-EPOR antibody indirectly by inhibiting oligoclonal T cell clones and resolve the PRCA, there remains the possibility of the late effect of rituximab on the negative conversion of anti-EPOR antibody additively to cyclosporine. At present, we can only speculate on the reason why overt PRCA and AIHA appeared in this setting. It is suspected that chemotherapy including rituximab for THRLBCL might be a trigger of the onset via the liberation of endogenous autoreactive T cell clones that might have existed before or along with the THRLBCL, similar to how secondary AIHA occurs in patients with chronic lymphocytic leukemia treated with fludarabine [16]. Worsening of AIHA induced by rituximab in a patient with lymphoproliferative disorder has also been reported [17], with a speculated mechanism that the reduction of CD20-positive B cells by rituximab resulted in liberation of important cytokines, leading to the overexpression of anti-erythrocyte autoreactive plasma cells. Thus, the present case emphasizes the necessity of identifying the anti-EPOR antibody in PRCA patients, which plays a significant role in some proportion of erythroid hypoplasia cases with unknown etiology. Further investigation is anticipated to resolve the exact mechanism of anti-EPOR antibody-associated PRCA.
4.
5.
6. 7.
8.
9.
10.
11.
12.
Acknowledgments The authors would like to thank Dr. Toyomi Kamesaki at the Center for Community Medicine, Jichi Medical University, Tochigi, Japan, for measuring RBC-bound IgG.
13.
Conflict of interest The authors declare that they have no conflicts of interest.
14. 15.
References 1. Du¨hrsen U, Augener W, Zwingers T, Brittinger G. Spectrum and frequency of autoimmune derangements in lymphoproliferative disorders: analysis of 637 cases and comparison with myeloproliferative diseases. Br J Haematol. 1987;67:235–9. 2. Grønbaek K, D’Amore F, Schmidt K. Autoimmune phenomena in non-Hodgkin’s lymphoma. Leuk Lymphoma. 1995;18:311–6. 3. Hirokawa M, Sawada K, Fujishima N, Kawano F, Kimura A, Watanabe T, et al. Acquired pure red cell aplasia associated with malignant lymphomas: a nationwide cohort study in Japan for the
123
16.
17.
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