Cold Agglutinins Cold Agglutinins

Jennifer L. Rogers, MDJennifer L. Rogers, MD

2/13/082/13/08

UNC Internal Medicine UNC Internal Medicine

OverviewOverview

IntroductionIntroduction Cold Agglutinin DiseaseCold Agglutinin Disease • PathophysiologyPathophysiology• Clinical presentation Clinical presentation • Diagnosis Diagnosis • Differential Differential • Treatment Treatment Summary Summary

Autoimmune Hemolytic AnemiaAutoimmune Hemolytic Anemia

Immunologic destruction of RBCs Immunologic destruction of RBCs mediated by autoantibodies against mediated by autoantibodies against antigens on the RBC surfaceantigens on the RBC surface

Classified by isotype (IgG, IgM, IgA) and Classified by isotype (IgG, IgM, IgA) and the temperature at which they maximally the temperature at which they maximally reactreact

In general, cold-reacting antibodies are In general, cold-reacting antibodies are IgM and warm-reacting antibodies are IgG IgM and warm-reacting antibodies are IgG causing extravascular hemolysiscausing extravascular hemolysis

What does cold and warm What does cold and warm agglutinin mean?agglutinin mean?

Based on immunology of cold agglutininsBased on immunology of cold agglutinins Cold AIHA IgM-RBC agglutination occurs Cold AIHA IgM-RBC agglutination occurs

at 4at 4ooC without the use of antiglobulin C without the use of antiglobulin Warm AIHA IgG-RBC agglutination occurs Warm AIHA IgG-RBC agglutination occurs

when RBCs are incubated with when RBCs are incubated with antiglobulin antisera at 37antiglobulin antisera at 37ooC for 2 hrsC for 2 hrs

Cold-Induced HemolysisCold-Induced Hemolysis

Two different clinical entities due to cold-Two different clinical entities due to cold-reacting antibodies: reacting antibodies:

• Cold Agglutinin disease Cold Agglutinin disease • Paroxysmal cold hemoglobinuriaParoxysmal cold hemoglobinuria

Cold Agglutinin DiseaseCold Agglutinin Disease

Characterized by IgM antibodies (rarely IgA or Characterized by IgM antibodies (rarely IgA or IgG) directed against polysaccharide antigens IgG) directed against polysaccharide antigens (anti-I or i) on the RBC surface(anti-I or i) on the RBC surface

Cold agglutinins found frequently in normal Cold agglutinins found frequently in normal adults at low titers adults at low titers

Pathology results with high titer antibody Pathology results with high titer antibody production: production:

• Oligoclonal antibodies due to infectionOligoclonal antibodies due to infection• Monoclonal antibodies due to paraneoplastic or Monoclonal antibodies due to paraneoplastic or

or neoplastic process or neoplastic process

Postinfectious Postinfectious

Oligoclonal antibody usually with a kappa Oligoclonal antibody usually with a kappa light chain light chain

Commonly moderate titer cold agglutinin Commonly moderate titer cold agglutinin Titer peaks 2-3 weeks after the onset of Titer peaks 2-3 weeks after the onset of

infection and can persist for 2-3 monthsinfection and can persist for 2-3 months Hemolysis usually mild lasting for 2-4 Hemolysis usually mild lasting for 2-4

weeks weeks

Associated InfectionsAssociated Infections

Mycoplasma pneumoniae (anti-I) 50-75%Mycoplasma pneumoniae (anti-I) 50-75% Infectious mononucleosis (anti-i) 60%Infectious mononucleosis (anti-i) 60%

Other viruses: Other viruses: CMV, Varicella, Rubella, CMV, Varicella, Rubella, Parvovirus B19, Hepatitis B, HIV, Influenza BParvovirus B19, Hepatitis B, HIV, Influenza B

Listeria monocytogenes (anti-I)Listeria monocytogenes (anti-I)

Other bacteria: Other bacteria: Legionella pneumophila, Legionella pneumophila,

Chlamydia psittacosisChlamydia psittacosis

Monoclonal Cold AgglutininsMonoclonal Cold Agglutinins Paraneoplastic or neoplastic growth of an Paraneoplastic or neoplastic growth of an

immunocyte cloneimmunocyte clone Kappa light chain anti-I antibodiesKappa light chain anti-I antibodies Spectrum from benign chronic cold agglutinins to Spectrum from benign chronic cold agglutinins to

high-grade malignant lymphoma high-grade malignant lymphoma • CLL, Waldenstrom’s macroglobulinemia, lymphocytic CLL, Waldenstrom’s macroglobulinemia, lymphocytic

lymphomalymphoma 5-10% patients with chronic cold agglutinins 5-10% patients with chronic cold agglutinins

develop a malignant clonedevelop a malignant clone• Trisomy 3 Trisomy 3 Titer can be used as a tumor marker Titer can be used as a tumor marker

EpidemiologyEpidemiology

Cold-agglutinin disease constitutes 7-25% Cold-agglutinin disease constitutes 7-25% of AIHA casesof AIHA cases

Incidence is roughly 1 in 300,000 Incidence is roughly 1 in 300,000 Average age is >60 and peaks in 70s-80sAverage age is >60 and peaks in 70s-80s No racial predilectionNo racial predilection More common in women 1.5:1 More common in women 1.5:1

Pathophysiology of HemolysisPathophysiology of Hemolysis

RBC destruction occurs mainly by RBC destruction occurs mainly by immunoadherence mediated immunoadherence mediated indirect lysis resulting in indirect lysis resulting in extravascular hemolysis by extravascular hemolysis by phagocytic cells in liver phagocytic cells in liver (spherocytes, elevated LDH/bili)(spherocytes, elevated LDH/bili)

Can also occur by complement-Can also occur by complement-mediated direct lysis if sufficient mediated direct lysis if sufficient polymers are produced resulting in polymers are produced resulting in intravascular hemolysis intravascular hemolysis (hemoglobinemia, hemoglobinuria, (hemoglobinemia, hemoglobinuria, hemosiderinuria) hemosiderinuria)

ImmunoadherenceImmunoadherence

IgM antibody fixation to antigen occurs at peripheral IgM antibody fixation to antigen occurs at peripheral areas where temperature is low enough to bindareas where temperature is low enough to bind

Complement is then activated resulting in C3 and C4 Complement is then activated resulting in C3 and C4 binding binding

Phagocytosis then occurs (phagocytes do not have IgM Phagocytosis then occurs (phagocytes do not have IgM receptors unlike IgG, IgA)receptors unlike IgG, IgA)

Hemolysis limited by enzymes that inactivate C3 and C4 Hemolysis limited by enzymes that inactivate C3 and C4 resulting in C3dresulting in C3d

IgM dissociates from antigen when blood returns to the IgM dissociates from antigen when blood returns to the core of the body thus also limiting hemolysis core of the body thus also limiting hemolysis

Severity of hemolysisSeverity of hemolysis

Amount of hemolysis depends upon:Amount of hemolysis depends upon:• Antibody titer ( the higher the titer, the Antibody titer ( the higher the titer, the

more hemolysis)more hemolysis)• Thermal amplitude (the higher the temp, Thermal amplitude (the higher the temp,

the more hemolysis)the more hemolysis)• Degree of antibody inhibition by C3d Degree of antibody inhibition by C3d

Clinical PresentationClinical Presentation

Signs and SymptomsSigns and Symptoms Related to anemia and hemolysisRelated to anemia and hemolysis• Dyspnea, fatigue, tachycardiaDyspnea, fatigue, tachycardia• Scleral icterus, splenomegalyScleral icterus, splenomegaly

Related to cold exposureRelated to cold exposure• Acrocyanosis Acrocyanosis

DiagnosisDiagnosis

Hemolytic anemiaHemolytic anemia• Elevated LDH, indirect bilirubin, reticulocyte Elevated LDH, indirect bilirubin, reticulocyte

countcount• Decreased haptoglobinDecreased haptoglobin Spurious macrocytosis Spurious macrocytosis • RBC agglutination due to cooling during RBC agglutination due to cooling during

automated counting automated counting Agglutination on peripheral smearAgglutination on peripheral smear

Peripheral Smear Peripheral Smear

DiagnosisDiagnosis

Direct antiglobulin test (Coombs’ test) Direct antiglobulin test (Coombs’ test) • Positive anti-C3dPositive anti-C3d• Negative anti-IgG Negative anti-IgG

Cold agglutinins titerCold agglutinins titer • Upper limits of normal 1:40Upper limits of normal 1:40• Hemolysis usually occurs at titers >1:500Hemolysis usually occurs at titers >1:500

Direct Coombs’ TestDirect Coombs’ Test

Differential DiagnosisDifferential Diagnosis

1.1. Anti-IgG Positive + Anti-C3 Negative -Anti-IgG Positive + Anti-C3 Negative - Idiopathic Warm AIHA, Drug induced warm AIHA Idiopathic Warm AIHA, Drug induced warm AIHA

(penicillin, methyldopa)(penicillin, methyldopa)

2.2. Anti-IgG Positive + Anti-C3 Positive +Anti-IgG Positive + Anti-C3 Positive + SLE, idiopathic warm AIHA, rarely drug associatedSLE, idiopathic warm AIHA, rarely drug associated

3.3. Anti-IgG Negative - Anti-C3 Positive + Anti-IgG Negative - Anti-C3 Positive + Cold agglutinin disease, Paroxysmal cold Cold agglutinin disease, Paroxysmal cold

hemoglobinuria, rarely warm AIHA if low-affintiy IgGhemoglobinuria, rarely warm AIHA if low-affintiy IgG

Treatment Treatment

Depends on underlying etiologyDepends on underlying etiology Treat the infectionTreat the infection Supportive care Supportive care TransfusionTransfusion• ABO typing can be difficultABO typing can be difficult• If unclear typing, use group O RBCs If unclear typing, use group O RBCs Avoidance of cold Avoidance of cold • Warm IVF, blood productsWarm IVF, blood products

Treatment cont.Treatment cont.

PrednisonePrednisone Not useful for cold agglutinin diseaseNot useful for cold agglutinin disease Can be used if IgG co-antibodiesCan be used if IgG co-antibodies

SplenectomySplenectomy Not useful because the liver is the main site of Not useful because the liver is the main site of

immune clearance immune clearance Can be used if IgG co-antibodies are presentCan be used if IgG co-antibodies are present

Rituximab Rituximab

Rituximab anti-CD20 monoclonal antibodyRituximab anti-CD20 monoclonal antibody Mostly case reports and small prospective trialsMostly case reports and small prospective trials Prospective uncontrolled study of 27 patients Prospective uncontrolled study of 27 patients

treated with Rituxan. treated with Rituxan. (Berensten)(Berensten)

• 54% response rate with 1 complete remission, 54% response rate with 1 complete remission, 19 partial responses over 11 months. 19 partial responses over 11 months.

Prospective study of 20 patient, phase II trial. 5 Prospective study of 20 patient, phase II trial. 5 doses over 22 days, followed 48 weeks. doses over 22 days, followed 48 weeks. ((SchollkopfSchollkopf))

• 45% response to treatment with 1 CR, 8 PR45% response to treatment with 1 CR, 8 PR

Plasmapheresis Plasmapheresis

Adjunctive treatment to remove IgM Adjunctive treatment to remove IgM antibody antibody

Effect is short lived with 5 day half lifeEffect is short lived with 5 day half life Used for severe hemolysis in acute Used for severe hemolysis in acute

infection when thermal amplitude is highinfection when thermal amplitude is high Used in preparation for surgeryUsed in preparation for surgery Severe acrocyanosis Severe acrocyanosis

Other AgentsOther Agents

Cyclophosphamide, azathioprine, Cyclophosphamide, azathioprine, interferon, and fludarabine have been interferon, and fludarabine have been used to suppress IgM synthesis used to suppress IgM synthesis

Generally not useful, response rates <20%Generally not useful, response rates <20% One on-going phase II trial using Rituxan One on-going phase II trial using Rituxan

and fludarabine “preliminary results and fludarabine “preliminary results encouraging” encouraging” (Berensten)(Berensten)

Chemotherapy should be used to treat Chemotherapy should be used to treat underlying lymphoma or malignancyunderlying lymphoma or malignancy

Take Home PointsTake Home Points

Cold agglutinin disease AIHA due to IgM Cold agglutinin disease AIHA due to IgM antibodies antibodies

Infection (Mycoplasma or Infectious Mono) Infection (Mycoplasma or Infectious Mono) Monoclonal antibodies as part of spectrum from Monoclonal antibodies as part of spectrum from

benign cold agglutinins to malignant lymphoma benign cold agglutinins to malignant lymphoma Coombs test: Positive anti-C3, negative IgGCoombs test: Positive anti-C3, negative IgG Treatment: Supportive, avoid cold, treat Treatment: Supportive, avoid cold, treat

underlying disease. ?Rituxanunderlying disease. ?Rituxan

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Berensten S et al. B-lymphocytes as targets for therapy in chronic cold agglutinin Berensten S et al. B-lymphocytes as targets for therapy in chronic cold agglutinin disease. Cardiovasc hematol Disord Drug Targets. 2007 Sep;7(3)219-27. disease. Cardiovasc hematol Disord Drug Targets. 2007 Sep;7(3)219-27.

Jacobs A. Cold agglutinin hemolysis responding to fludarabine therapy. Am J Jacobs A. Cold agglutinin hemolysis responding to fludarabine therapy. Am J Hematol. 1996 Dec 53(4):279-80. Hematol. 1996 Dec 53(4):279-80.

Koppel A et al. Rituximab as successful therapy in a patient with refractory Koppel A et al. Rituximab as successful therapy in a patient with refractory paroxysymal cold hemoglobinuria. Transfusion. 2007 Oct;47(10): 1902-4.paroxysymal cold hemoglobinuria. Transfusion. 2007 Oct;47(10): 1902-4.

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