Autoimmune Hemolytic Anemia Can Follow Chronic Myeloid Leukemia Relapse, Case Study Shows

Autoimmune hemolytic anemia (AIHA) can be a cause for anemia in people with chronic myeloid leukemia (CML), a case report found.

The study “Autoimmune Hemolytic Anemia After Relapse of Chronic Myeloid Leukemia: A Case Report” was published in the journal Clinical Medicine Insights: Blood Disorders.

AIHA, an autoimmune disease characterized by the production of autoantibodies that attack and destroy red blood cells, includes two variants: cold agglutinin disease (CAD), and warm antibody autoimmune hemolytic anemia (warm AIHA). In CAD, autoantibodies bind more easily to red blood cells at lower temperatures, and at higher temperatures in warm AIHA.

AIHA is one of the causes of anemia in certain cancers, including a type of leukemia (a blood cancer) called chronic lymphocytic leukemia. But  it is rarely associated with chronic myeloid leukemia.

Whether leukemia is myeloid or lymphocytic depends on the bone marrow cell of origin that the cancer starts from: in lymphocytic leukemias, cancer starts in cells that become lymphocytes (white blood cells); in myeloid leukemias, cancer originates in early myeloid cells, which will give rise to additional types of blood cells, including forms of  white blood cells (other than lymphocytes), red blood cells, or platelet-making cells.

In this case report, clinicians at Hamad Medical Corporation in Qatar describe a CML patient who developed AIHA when his cancer relapsed.

The patient, a 51-year-old Egyptian man, was diagnosed with CML in 2007. He was treated with imatinib (U.S. brand name Gleevec, EU brand name Glivec), but failed to respond completely. He was then switched to Novartis’ Tasigna (nilotinib) for six years and found to be in treatment-free remission, (i.e., able to prevent cancer’s spread after stopping therapy).

Six years later, the man was admitted to the hospital with abdominal pain associated with anorexia and fatigue. Clinical examination, including a biopsy of the bone marrow, confirmed that the CML had returned (relapse) and was accompanied by anemia (hemoglobin levels of 6.6 g/dL; the normal range for adult males is 13.5 to 17.5 g/dL). He was treated for the anemia and given blood transfusions, but these failed to increase his hemoglobin levels.

His anemia was initially attributed to the CML relapse, but further examination revealed the destruction of red blood cells (hemolysis), elevated reticulocyte count, lactate dehydrogenase (LDH), and the presence of autoantibodies against red blood cells. He was diagnosed with AIHA and discharged with prednisolone to manage his AIHA, and restarted treatment for CML one week later.

Within six weeks of prednisolone treatment, his hemoglobin levels rose to 9 g/dL. The patient achieved complete hematologic remission (absence of cancer cells) and a molecular response  three months after restarting CML therapy.

Findings in this case reports suggests “AIHA is a rare cause of anemia in CML, it should be kept in mind during the evaluation of anemia especially after CML relapse,” the authors concluded.