AJCP / Case Report
Transiently Pink-Tinged Serum in a Patient With Multiple Myeloma and Anemia Undergoing Lenalidomide Treatment Whitney Wedel, MD, and Alina G. Sofronescu, PhD From the Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha. Key Words: In vivo hemolysis; Chemotherapy; Anemia; Lenalidomide; Multiple myeloma; Macrocytosis Am J Clin Pathol August 2015;144:329-332 DOI: 10.1309/AJCP4RB3YNAWZPZN
ABSTRACT Objectives: While in vitro hemolysis is a preanalytical interferent, in vivo hemolysis is a pathologic process requiring investigation. We present a case of an anemic patient with multiple myeloma undergoing chemotherapy with lenalidomide who had multiple serum samples drawn before and after chemotherapy treatment. Some of these samples showed hemolysis. This triggered further investigations to differentiate the cause of the hemolysis. Methods: Various laboratory tests and additional investigations were necessary to establish the root of the hemolytic process. Results: Multiple laboratory tests and a rigorous review of the samples, time of collection, and laboratory results revealed that only samples collected shortly after lenalidomide administration showed hemolysis. This indicates that the chemotherapeutic agent itself was most likely the proximate cause of the in vivo hemolysis in a non– immune-mediated manner. Conclusions: Upon administration, chemotherapeutic agents, such as lenalidomide, can immediately induce transient hemolysis, which can be visualized as transiently pink-tinged serum samples.
© American Society for Clinical Pathology
Serum discoloration is a frequent finding in laboratory medicine, commonly attributed to hemolysis. Of all causes that can be the root of hemolysis, drug-induced hemolysis is one of the most difficult to investigate, especially if the culprit acts fast during a restricted interval of time and the hemolysis is limited by dilution during vascular distribution. While drug-induced autoimmune hemolytic anemia (AIHA) is very well documented in the literature, the mechanisms of drug-induced non–immune-mediated hemolysis have yet to be defined for most drugs. Lenalidomide, a strong antineoplastic agent, is commonly used in patients with multiple myeloma. Although adverse events and toxicity remain important issues for all patients, lenalidomide significantly improves the overall survival in patients with multiple myeloma. The drug has been associated with thrombosis, neutropenia, thrombocytopenia, and an increased risk of additional hematologic malignancies. However, evidence regarding involvement of lenalidomide in RBC hemolysis, decreased hematocrit, anemia, and macrocytosis is just emerging. Furthermore, the mechanisms in which this drug induces hemolysis are yet to be uncovered. Here we present the case of an anemic patient with multiple myeloma undergoing chemotherapy with lenalidomide who had multiple serum samples drawn within a short interval before and after chemotherapy treatment, some of which showed hemolysis. This triggered a complex investigation of potential preanalytical factors, as well as multiple additional laboratory tests and cooperation of different health care providers (hematologist-oncologist, laboratory scientists, and pharmacists) in the effort to identify the root of the hemolytic process.
Am J Clin Pathol 2015;144:329-332 329 DOI: 10.1309/AJCP4RB3YNAWZPZN
Wedel and Sofronescu / Pink-Tinged Serum and Multiple Myeloma
❚Table 1❚ Patient’s RBC Indices and Additional Laboratory Results Analyte ×103/mL
WBC, Hemoglobin, g/dL Mean corpuscular volume, fL Platelets, ×103/mL Potassium, mmol/L Haptoglobin, mg/dL Direct Coombs test (direct anti–human globulin) RBC morphology
Result (Reference Range) 1.4 (4.0-11.0) 7.8 (11.0-15.1) 126.0 (79.0-97.0) 25 (150-400) 4.5 (3.6-5.1)
Transiently Pink-Tinged Serum in a Patient With Multiple Myeloma and Anemia Undergoing Lenalidomide Treatment Whitney Wedel, MD, and Alina G. Sofronescu, PhD From the Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha. Key Words: In vivo hemolysis; Chemotherapy; Anemia; Lenalidomide; Multiple myeloma; Macrocytosis Am J Clin Pathol August 2015;144:329-332 DOI: 10.1309/AJCP4RB3YNAWZPZN
ABSTRACT Objectives: While in vitro hemolysis is a preanalytical interferent, in vivo hemolysis is a pathologic process requiring investigation. We present a case of an anemic patient with multiple myeloma undergoing chemotherapy with lenalidomide who had multiple serum samples drawn before and after chemotherapy treatment. Some of these samples showed hemolysis. This triggered further investigations to differentiate the cause of the hemolysis. Methods: Various laboratory tests and additional investigations were necessary to establish the root of the hemolytic process. Results: Multiple laboratory tests and a rigorous review of the samples, time of collection, and laboratory results revealed that only samples collected shortly after lenalidomide administration showed hemolysis. This indicates that the chemotherapeutic agent itself was most likely the proximate cause of the in vivo hemolysis in a non– immune-mediated manner. Conclusions: Upon administration, chemotherapeutic agents, such as lenalidomide, can immediately induce transient hemolysis, which can be visualized as transiently pink-tinged serum samples.
© American Society for Clinical Pathology
Serum discoloration is a frequent finding in laboratory medicine, commonly attributed to hemolysis. Of all causes that can be the root of hemolysis, drug-induced hemolysis is one of the most difficult to investigate, especially if the culprit acts fast during a restricted interval of time and the hemolysis is limited by dilution during vascular distribution. While drug-induced autoimmune hemolytic anemia (AIHA) is very well documented in the literature, the mechanisms of drug-induced non–immune-mediated hemolysis have yet to be defined for most drugs. Lenalidomide, a strong antineoplastic agent, is commonly used in patients with multiple myeloma. Although adverse events and toxicity remain important issues for all patients, lenalidomide significantly improves the overall survival in patients with multiple myeloma. The drug has been associated with thrombosis, neutropenia, thrombocytopenia, and an increased risk of additional hematologic malignancies. However, evidence regarding involvement of lenalidomide in RBC hemolysis, decreased hematocrit, anemia, and macrocytosis is just emerging. Furthermore, the mechanisms in which this drug induces hemolysis are yet to be uncovered. Here we present the case of an anemic patient with multiple myeloma undergoing chemotherapy with lenalidomide who had multiple serum samples drawn within a short interval before and after chemotherapy treatment, some of which showed hemolysis. This triggered a complex investigation of potential preanalytical factors, as well as multiple additional laboratory tests and cooperation of different health care providers (hematologist-oncologist, laboratory scientists, and pharmacists) in the effort to identify the root of the hemolytic process.
Am J Clin Pathol 2015;144:329-332 329 DOI: 10.1309/AJCP4RB3YNAWZPZN
Wedel and Sofronescu / Pink-Tinged Serum and Multiple Myeloma
❚Table 1❚ Patient’s RBC Indices and Additional Laboratory Results Analyte ×103/mL
WBC, Hemoglobin, g/dL Mean corpuscular volume, fL Platelets, ×103/mL Potassium, mmol/L Haptoglobin, mg/dL Direct Coombs test (direct anti–human globulin) RBC morphology
Result (Reference Range) 1.4 (4.0-11.0) 7.8 (11.0-15.1) 126.0 (79.0-97.0) 25 (150-400) 4.5 (3.6-5.1)
