A Rare Case of Acute Hemolytic Anemia in a Patient with Newly Diagnosed Multiple Myeloma: Maintaining a Fine Balance between Occam's Razor and Hickam's Dictum

Abstract

Anemia is a common feature in multiple myeloma and is multifactorial. A 52-year-old lady was admitted to our hospital with complaints of fatigue, exertional dyspnea, paresthesia, and a recent-onset confusion state. Fundus examination revealed features of hyperviscosity. The patient received 2 units of packed red blood cell transfusion (PRBC) before the present hospital admission. Laboratory investigations revealed severe anemia and thrombocytopenia. The M-protein was 5.8 g/dL. Bone marrow showed sheets of plasma cells. Immunofixation electrophoresis confirmed the presence of an IgAλ band. FISH was positive for IgH-FGFR3 fusion. The investigations confirmed multiple myeloma R-ISS stage III. The patient was immediately started on CyBorD chemotherapy regimen. The patient had indirect hyperbilirubinemia and symptomatic anemia. Initial testing of the patient's sample showed blood grouping discrepancy with DCT, ICT, and auto control positive. The symptomatic anemia persisted requiring PRC transfusions. Further antibody study revealed the presence of anti-Jka antibody—a warm IgG antibody and cold antibody. Subsequently, the patient received Jka antigen-negative B-positive compatible PRBC transfusions and the hemoglobin normalized. Our patient had transfusion-associated alloimmunization along with hyperviscosity. The timely recognition and early institution of plasmapheresis and myeloma-directed therapy along with transfusion of compatible Jk^a antigen-negative PRBC lead to rapid improvement.

Keywords

alloimmunization - anti-Jk^a - cold antibody - multiple myeloma

Publikationsverlauf

Artikel online veröffentlicht:
28. November 2022

• References

• 1 Palumbo A, Anderson K. Multiple myeloma. N Engl J Med 2011; 364 (11) 1046-1060
• 2 Kumar SK, Rajkumar V, Kyle RA. et al. Multiple myeloma. Nat Rev Dis Primers 2017; 3: 17046
• 3 Kuo HH, Shen EP. Hyperviscosity retinopathy as the initial presentation of aggressive multiple myeloma. Tzu-Chi Med J 2020; 32 (04) 401-403
• 4 Kumar SK, Rajkumar SV. The multiple myelomas - current concepts in cytogenetic classification and therapy. Nat Rev Clin Oncol 2018; 15 (07) 409-421
• 5 Liu L, Yu Z, Cheng H. et al. Multiple myeloma hinders erythropoiesis and causes anaemia owing to high levels of CCL3 in the bone marrow microenvironment. Sci Rep 2020; 10 (01) 20508
• 6 Birgegård G, Gascón P, Ludwig H. Evaluation of anaemia in patients with multiple myeloma and lymphoma: findings of the European CANCER ANAEMIA SURVEY. Eur J Haematol 2006; 77 (05) 378-386
• 7 Naithani R, Dayal N. Autoimmune hemolytic anemia as presenting manifestation of multiple myeloma. Indian J Hematol Blood Transfus 2020; 36 (03) 578-579
• 8 Pacca RL, Silva JBCBD, Souza KCE, Carbinatto RB. Autoimmune hemolytic anemia and hyperglobulinemia leading to the diagnosis of multiple myeloma. Rev Bras Hematol Hemoter 2017; 39 (04) 357-359
• 9 Wada H, Yata K, Mikami M. et al. Multiple myeloma complicated by autoimmune hemolytic anemia. Intern Med 2004; 43 (07) 595-598
• 10 Sanz C, Nomdedeu M, Belkaid M, Martinez I, Nomdedeu B, Pereira A. Red blood cell alloimmunization in transfused patients with myelodysplastic syndrome or chronic myelomonocytic leukemia. Transfusion 2013; 53 (04) 710-715
• 11 Franchini M, Forni GL, Marano G. et al. Red blood cell alloimmunisation in transfusion-dependent thalassaemia: a systematic review. Blood Transfus 2019; 17 (01) 4-15
• 12 Heddle NM, Soutar RL, O'Hoski PL. et al. A prospective study to determine the frequency and clinical significance of alloimmunization post-transfusion. Br J Haematol 1995; 91 (04) 1000-1005
• 13 Mallhi RS, Philip J, Chatterjee T, Dimri U. Presence of atypical antibody (anti Jk(a)) in a multi transfused transfusion dependent anemia patient. Med J Armed Forces India 2015; 71 (0, suppl 2) S482-S485
• 14 Mangwana S, Kacker ANS. Red cell alloimmunization in multi-transfused, oncology patients: risks and management. Glob J Transfus Med 2019; 4 (01) 74-78
• 15 Hauck-Dlimi B, Strobel J, Eckstein R, Zimmermann R. Prevention and management of transfusion-induced alloimmunization: current perspectives. Int J Clin Transfus Med 2014; 2: 59-63
• 16 Young PP, Goodnough LT, Westervelt P, Diersio JF. Immune hemolysis involving non-ABO/RhD alloantibodies following hematopoietic stem cell transplantation. Bone Marrow Transplant 2001; 27 (12) 1305-1310
• 17 Kim MY, Chaudhary P, Shulman IA, Pullarkat V. Major non-ABO incompatibility caused by anti-Jk(a) in a patient before allogeneic hematopoietic stem cell transplantation. Immunohematology 2013; 29 (01) 11-14
• 18 Berentsen S, Barcellini W, D'Sa S. et al. Cold agglutinin disease revisited: a multinational, observational study of 232 patients. Blood 2020; 136 (04) 480-488
• 19 Mark K. . Fung, Brenda J. Grossman, Christopher D. Hillyer, Connie M. Westhoff JRS. Other Blood Group Systems and Antigens AABB Technical Manual; 2014
• 20 Daniels G. Other blood groups. Tech Manual 16th ed. Bethesda, MD: AABB Press USA; 2008. ;411–436
• 21 Sanford KW, Bourikian S, McClain A, Curtis K. Development and detection of kidd antibodies. Lab Med 2015; 46 (03) 235-240
• 22 Mehta J, Singhal S. Hyperviscosity syndrome in plasma cell dyscrasias. Semin Thromb Hemost 2003; 29 (05) 467-471
• 23 Alkner U, Hansson UB, Lindström FD. Factors affecting IgA related hyperviscosity. Clin Exp Immunol 1983; 51 (03) 617-623
• 24 Mina R, Bonello F, Gay F, Zamagni E, Boccadoro M. Daratumumab-based therapy for IgM multiple myeloma with hyperviscosity syndrome: a case report. Clin Lymphoma Myeloma Leuk 2021; 21 (01) e21-e24
• 25 Gertz MA. Acute hyperviscosity: syndromes and management. Blood 2018; 132 (13) 1379-1385
• 26 Wang L, Jin FY, Li Y. et al. IgA type multiple myeloma, clinical features, and prognosis. Chin Med J (Engl) 2018; 131 (10) 1249-1250
• 27 Werle E, Ziebart J, Wasmund E, Eske-Pogodda K. Daratumumab interference in pretransfusion testing is overcome by addition of daratumumab Fab fragments to patients' plasma. Transfus Med Hemother 2019; 46 (06) 423-430
• 28 Quach H, Benson S, Haysom H. et al. Considerations for pre-transfusion immunohaematology testing in patients receiving the anti-CD38 monoclonal antibody daratumumab for the treatment of multiple myeloma. Intern Med J 2018; 48 (02) 210-220
• 29 Sefland Ø, Randen U, Berentsen S. Development of multiple myeloma of the IgA type in a patient with cold agglutinin disease: transformation or coincidence?. Case Rep Hematol 2019; 2019: 1610632