Hematology:Challenging Cases with

Your ParticipationReed E. Drews, MD

Beth Israel Deaconess Medical CenterHarvard Medical School

Boston, MA

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Question 1COPYRIG

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Question 1

• 64-year-old man is evaluated during routine exam

• He takes aspirin and acetaminophen for osteoarthritis

• On exam, pallor is absent. BP = 116/72 with no orthostatic changes; P = 68.COP

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Labs

• Hgb = 9.7 g/dL• WBC = 5.8 K/μL• MCV = 83 fL• Plts = 265 K/μL• Retic count = 0.5%• LDH = 80 U/L• Iron = 40 μg/dL• TIBC = 200 μg/dL• Ferritin = 210 ng/mL• Peripheral smear is normal

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Which of the following is the most likely diagnosis?

A. Inflammatory anemia

B. Hemoglobin C disease

C. Iron deficiency

D. Thalassemia

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Answer = A

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Anemia of Inflammation (AI)

• Characterized by low serum iron concentration and low TIBC with elevated serum ferritin concentration

• Initially normochromic, normocytic, can become hypochromic, microcytic

• Inflammatory cytokines block iron utilization, erythropoietin (EPO) production, and EPO responsiveness– Hepcidin, made by the liver, decreases iron

absorption from gut and decreases release of iron from macrophages

• Causes internalization of ferroportin ion channel

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Hemoglobin C Disease

• Mild hemolytic anemia in persons of African ancestry

• Serum iron chemistries are typically normal

• Prominent targeting in addition to microcytosis on peripheral blood smearCOP

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Hgb CC

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Iron Deficiency Anemia (IDA)

• Characterized by low serum iron concentration, elevated TIBC, and decreased serum ferritin

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IDA

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Thalassemia

• Hypochromic, microcytic anemia

• Evidence of hemolysis

• Targets, tear drops, and prominent basophilic stippling

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Factors Distinguishing the 3 Most

Common Causes of Microcytosis

• Iron deficiency anemia (IDA)– Low serum ferritin

– Increased total iron binding capacity

– Low serum iron concentration

• Anemia of inflammation (AI)– Low serum iron

– Low total iron binding capacity

– Normal to increased serum ferritin

• Alpha or beta thalassemia minor– Patients may not be “anemic”

– Target cells, tear-drop forms, and basophilic stippling

IDA

b-thalassemia minor

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Laboratory Characteristics ofAI, IDA, and IDA + Inflammation

From MKSAP®15

Parameter AI IDA IDA+AIMCV 72-100 fL <85 fL <100 fL

MCHC <36 g/dL <32 g/dL <32 g/dL

Serum iron <60 μg/dL <60 μg/dL <60 μg/dL

TIBC <250 μg/dL >400 μg/dL <400 μg/dL

TIBC saturation 2%-20%<15%

(usually <10%)<15%

Ferritin >35 ng/mL < 15 ng/mL <100 ng/mL

Bone marrow iron Present Absent Absent

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Iron Deficiency Happens in Stages

• Iron deficiency without anemia

– Ferritin < 20 ng/mL; Fe/TIBC > 15%

• Iron deficiency with mild anemia

– Ferritin < 15 ng/mL; Fe/TIBC < 15%

• Severe iron deficiency with severe anemia

– Ferritin < 10 ng/mL; Fe/TIBC < 10%

• Bone marrow iron absent in all stages

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Ferritin Levels in IDA

• Virtually all patients with serum ferritin levels <10 to 15 ng/mL are iron deficient– Sensitivity 59%, specificity 99%

• 25% of women with absent stainable bone marrow iron have ferritin levels >15 ng/mL

• Assuming no inflammation, higher ferritin cutoff limits provide improved diagnostic efficiency– 30 ng/mL: sensitivity 92%, specificity 98%

– 41 ng/mL: sensitivity 98%, specificity 98%

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Anemia of Inflammation

• Inflammation decreases serum iron and plasma transferrin concentrations

– Transferrin saturations are in “iron deficiency range” in 20% of patients with anemia of inflammation

• 20 to 30% of patients with inflammatory anemia do not have underlying inflammatory condition

Guyatt GH et al. Am J Med 1990;88:205.

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Ferritin Levels in Iron Deficiency AND Inflammatory States

• Inflammation increases ferritin levels by about 3-fold

• Iron deficiency should be suspected in patients with inflammatory states and ferritin levels <100 ng/mL

– In anemic patients with rheumatoid arthritis, ferritin levels < 60 ng/mL predicted response to oral iron therapy with 83% accuracy

(Hansen TM, Hansen NE. Ann Rheum Dis 1986;45:596)

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Question 2COPYRIG

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Question 2

• 27-year-old woman undergoes follow-up evaluation 5 months after diagnosis of unprovoked PE for which she was prescribed a 6-month course of anticoagulant therapy

• Family history– Maternal grandmother took warfarin for many years

for unknown reason

– Older brother with DVT at age 32 years

• Meds: no contraceptives or other medications

• Labs: CBC normal; INR = 3.0

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Which of the following is the most appropriate next step in the evaluation of this patient?

A. Immediate thrombophilic screening

B. JAK2 mutation analysis

C. No further evaluation needed

D. Thrombophilic screening at least 2 weeks after therapy cessationCOP

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Answer = D

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Thrombophilia

• Unprovoked PE + family history of VTE = high likelihood of underlying thrombophilic condition

• Screening decisions– Strongly thrombophilic

• 1st unprovoked VTE before 50 yrs of age; or

• History of recurrent thromboses; or

• 1st-degree relative(s) with documented VTE before age 50 yrs

– Weakly thrombophilic• All others

• Do NOT screen during acute episode or during anticoagulant therapy when heparin or warfarin influence certain tests

• Risk of recurrent VTE cannot be estimated without screening for inherited thrombophilia

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Thrombophilic Disorders with High Risk for Recurrence

• Antithrombin, protein C or protein S deficiency

• Homozygous factor V Leiden (FVL) or prothrombin gene mutation (PTM)

• Compound heterozygous FVL + PTM

• Patients with these disorders are candidates for long-term, if not lifelong, anticoagulation therapy

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Thrombophilia due to Myeloproliferative Neoplasm

• PV and ET predispose to venous and arterial thromboses, particularly when RBC mass and platelet count are not controlled

• JAK2 mutation is found in nearly all pts with PV and ~50% of pts with ET

– Routine screening for this mutation is not recommended unless pts have Budd-Chiari syndrome of portal vein thrombosis

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Target INR

• Target INR of 1.5 to 2 has efficacy in preventing recurrent VTE

• However, target INR of 2 to 3 is more efficacious

• Risk for major bleeding is similar for the two target INR ranges

(1) Ridker PM et al. Long-term, low-intensity warfarin therapy for the prevention of recurrent venous thromboembolism. N Engl J Med 2003; 348:1425-34.

(2) Kearon C et al. Comparison of low-intensity warfarin therapy with conventional-intensity warfarin therapy for long-term prevention of recurrent venous thromboembolism. N Engl J Med 2003; 349:631-9.

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Major Risk Factors for Thrombosis: AcquiredFrom MKSAP®15

• Prior thrombosis

• Advancing age

• Obesity

• Immobilization

• Major surgery

• Estrogens (OCPs, HRT, SERMs)

• Malignancy

• Prolonged air travel

• Antiphospholipid antibody syndrome

• MPNs (PV, ET)

• PNH

• Hemoglobinuria

• HIT

• Inflammatory bowel disease

• Nephrotic syndrome

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Major Risk Factors for Thrombosis: Inherited From MKSAP®15

• Antithrombin deficiency

• Protein C deficiency

• Protein S deficiency

• Factor V Leiden (FVL)

• Prothrombin G20210A

• Dysfibrinogenemias (rare)

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Uncertain Risk Factors for Venous ThrombosisFrom MKSAP®15

• Hyperhomocysteinemia

• High levels of factor VIII

• APC-resistance in the absence of FVL

• High levels of factor IX

• High levels of factor XI

• High levels of TAFI

• Low levels of free TFPI

• Decreased fibrinolytic potential

TAFI = thrombin-activatable fibrinolysis inhibitor; TFPI = tissue factor pathway inhibitor.

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Risks and Incidence of a First Episode of Venous Thrombosis

(From The Leiden Thrombophilia Study)

Relative Risk Incidence/y (%)Normal 1 0.008

Prothrombin G20210A mutation 2.8 0.02

Oral contraceptives 4 0.03

Factor V Leiden heterozygote 7 0.06

Oral contraceptives + factor V Leiden 35 0.29

Factor V Leiden homozygous 80 0.5 to 1.0

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Site of Thrombosis According to Coagulation Defect

Abnormality Arterial VenousFactor V Leiden - +

Antithrombin III deficiency - +

Protein C deficiency - +

Protein S deficiency - +

Prothrombin gene mutation - +

Hyperhomocysteinemia + -

Lupus anticoagulant/APL + +

APL = antiphospholipid antibody syndrome.

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Testing for Risk Factors

• In all patients– Cancer screening

• 20% of all patients with symptomatic VTE have cancer

– Unprovoked venous thrombosis and/or unexplained arterial thrombosis

• Antiphospholipid antibody syndrome (venous and/or arterial)

• Hyperhomocysteinemia (arterial)

• In patients younger than 50 years– AT, protein C, protein S

• Less than 5% over 50

• In patients older than 50 years– FVL, prothrombin G20210A

• 26% of men over 60 in the Physicians’ Health Study

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Indefinite Anticoagulation in Patients at High Risk

• 2 or more spontaneous events

• 1 spontaneous life-threatening event– Near fatal pulmonary embolus

– Cerebral, mesenteric, or portal vein thrombosis

• 1 spontaneous event in association with– Antiphospholipid antibody syndrome

– Antithrombin deficiency

– More than 1 genetic or allelic abnormality

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Question 3COPYRIG

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Question 3

• A 68-year old woman has hypertension for which she takes HCTZ and low-dose aspirin daily. On routine blood testing, she is found to have a high total protein.

• On exam, she appears well without lymphadenopathy, hepatosplenomegaly or bony pain to palpation or percussion.

• Hgb = 12.9 g/dL; WBC = 6.2K/μL; platelets = 245K/μL.

• SPEP shows 1.2 g/dL monoclonal IgG-kappa. UPEP is negative for protein, including Bence Jones protein.

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Question 3 (continued)

Bone marrow biopsy shows 7% plasma cells, and skeletal survey is normal, without lytic lesions. Which is the most appropriate management for this patient?

1. Obtain a bone scan

2. Begin bisphosphonate therapy

3. Begin thalidomide + dexamethasone

4. Monitor expectantly and repeat the SPEP and UPEP in 3 to 6 months

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Answer = 4COPYRIG

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Monoclonal gammopathy of undetermined significance

• No symptoms• No end organ damage related to plasma cell

dyscrasia or a related B cell lymphoproliferative disorder– No lymphadenopathy, organomegaly, hypercalcemia,

renal failure, anemia, bone abnormalities (skeletal survey)*

• Relatively low paraprotein level (<3 g/dL)• < 10% plasmacytosis in bone marrow• Phenomenon of aging

*No role for bone scans or PET scans

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Prevalence of MGUS According to Age Group and Sex among Residents of Olmsted County, Minnesota

Age Men Women Totalpercent

50-59 yr 2.0 1.4 1.7

60-69 yr 3.7 2.3 3.0

70-79 yr 5.6 3.8 4.6

≥ 80 yr 8.3 6.0 6.6

Total 3.7 2.9 3.2

Kyle RA et al. Prevalence of monoclonal gammopathy of undetermined significance. N Engl J Med 2006; 354:1362-9.

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Management of MGUS

• No role for anti-plasma cell therapy

• Monitor expectantly– Monitor for signs and symptoms of progression to

multiple myeloma• Follow CBCs, BUN/cre, albumin/calcium, SPEP, UPEP, and

free serum kappa & lambda light chains

• Assess risk for progression– Lowest with paraprotein levels ≤ 0.9 g/dL

– Highest with paraprotein levels ≥ 3 g/dL

– Serum free light chain assay (FLC)• Ratio of serum free kappa to serum free lambda

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Risk of progression to myeloma or related disorder in 1148 pts with MGUS

Rajkumar SV et al. Blood 2005; 106:812-7

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Risk of progression of MGUS in patients with abnormal FLC ratio

Rajkumar SV et al. Blood 2005; 106:812-7

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Diagnostic criteria for myeloma

• Myeloma– Serum or urinary monoclonal protein

– Clonal plasma cell in bone marrow or plasmacytoma

– End organ damage related to plasma cell dyscrasia

• Aymptomatic (smoldering) myeloma– Serum monoclonal protein ≥ 3 g/dL and/or bone

marrow plasma cells ≥ 10 percent

– No end organ damage related to plasma cell dyscrasia

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Treatment of Myeloma

• Alkylating agent and corticosteroid– Melphalan mainstay of myeloma therapy for more than 40 years– Now use cyclophosphamide + bortezomib +/- lenalidomide +/-

dexamethasone

• Thalidomide– Fetal malformations; VTE; somnolence; neuropathy

• Bortezomib– Neuropathy

• Carfilzomib– Less neuropathy; more heart failure

• Lenalidomide– Myelosuppression; VTE; less somnolence & neuropathy than

thalidomide

• Autologous stem cell transplantation with high-dose melphalan– Improves survival to a median of 4.5 to 5 years

• Bisphosphonate therapy once monthly (1-2 years)– Osteonecrosis of jaw; renal dysfunction

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Other Findings of “Undetermined Significance”

Steensma DP et al. Blood 2015; 126:9.

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Question 4

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Question 4

• A 65-year old presents with cervical adenopathy and splenomegaly.

• HCT = 37%; WBC = 34,000/µL with 2% polys and 98% lymphs; platelets = 177,000/µL.

• Peripheral blood smear review reveals mature appearing lymphocytes and “smudge cells” (see next slide).

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Question 4 (continued)

Which of the following is true of this patient?

1. Patients in late childhood or young adulthood are as likely to have this disease as older patients

2. One should be alert for the “blast phase” of disease

3. The patient might present with autoimmune hemolytic anemia and/or immune thrombocytopenia

4. The evidence favors early treatment

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Answer = 3COPYRIG

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HCL CLL PLL

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Approximate Median Time to Treatment and Median Survival of Patients with Early-Stage Disease according to Prognostic Variables

Prognostic Variable Median Time to Treatment, y Median Survival, yResult of FISH

13q- (sole abnormality) 7.5 >11 to 15

Normal karyotype 4 >10 to 15

+12 3 10

11q- 1 6 to 9

17p- <1 2 to 4

IgVH gene mutation statusMutated ≥8 ≥20

Not mutated <4 7 to 10

ZAP-70Negative 9 to 10 ≥20

Positive 3 to 4 8 to 10

CD38Negative ≥5 ≥20

Positive <4 8 to 10

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Question 5COPYRIG

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Question 5

• A 63-year old patient develops exertional dyspnea.

• On exam, sclerae are slightly icteric.

• HCT = 28% with MCV = 105; reticulocyte count = 9%; WBC and platelet counts are normal.

• The laboratory reports “bite” cells on peripheral blood smear (see next slide).

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Question 5 (continued)

What is the most likely underlying mechanism of anemia in this patient?

1. Autoimmune hemolysis

2. Microangiopathic hemolytic anemia

3. Oxidant hemolysis

4. Paroxysmal nocturnal hemoglobinuria

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Answer = 3COPYRIG

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Bite cells Heinz body prep

By Carola von Kapff, SH (ASCP) from UpToDateÒ

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Drugs and chemicals in glucose-6-phosphate dehydrogenase deficiency

Unsafe for class I, II, and III variants

Acetanilid Phenylhydrazine

Dapsone Primaquine

Furazolidone Sulfacetamide

Methylene blue Sulfamethoxazole

Nalidixic acid Sulfanilamide

Naphthalene (mothballs, henna) Sulfapyridine

Niridazole Thiazosulfone

Nitrofurantoin Toluidine blue

Phenazopyridine Trinitrotoluene

Source: UpToDate®

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Drugs and chemicals in glucose-6-phosphate dehydrogenase deficiency

Safe for class II and III variants*

Acetaminophen Phenacetin

Ascorbic acid (except in very high doses) Phenytoin

Aspirin Probenecid

Chloramphenicol Pyrimethamine

Chloroquine Quinine

Colchicine Streptomycin

Diphenhydramine Sulfisoxazole

Isoniazid Trimethoprim

L-DOPA Vitamin K

* Safety for class I variants is usually not known. Source: UpToDate®

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Question 6COPYRIG

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Question 6

• A 24-year old patient develops dyspnea and is found to be anemic with HCT = 28%, MCV = 104 fL, and reticulocyte count = 6%.

• The laboratory reports 2+ spherocytes on peripheral blood smear (see next slide).COP

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Question 6 (continued)

Coombs testing is positive for IgG and negative for C3. What is the most appropriate management in this patient?

1. Transfuse packed red blood cells

2. Begin prednisone 1 mg/kg and folic acid 5 mg daily

3. Begin danazol

4. Administer rituximab

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Answer = 2COPYRIG

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Macrophage

Ingesting an

IgG-Coated

RBC

Bessis M. Corpuscles. Atlas of

Red Cell Shape. Berlin, Springer-

Verlag, 1974

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Etiologies of WAIHA

• Idiopathic• Viral infections (usually in children)• Autoimmune and connective tissue diseases

(particularly SLE)• Malignancies of the immune system

– NHL; CLL– Treatment with purine nucleoside analogs

• Immune deregulation

• Prior allogeneic blood transfusion or HSCT• Certain drugs

– Hydralazine, isoniazid, methyldopa, penicillin, procainamide, quinidine, quinine

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Lab Findings in WAIHA• Combination of increased LDH and reduced

haptoglobin– 90% specific for diagnosing hemolysis

• Combination of normal LDH and haptoglobin > 25 mg/dL– 92% sensitive for ruling out hemolysis

• Reticulocytosis > 4-5% (median, 9%)– Lower than expected degree of reticulocytosis in 20-37%

• Lag in marrow responsiveness to hemolytic stress• Hemolysis of reticulocytes• Parvovirus B19 infection

• Spherocytosis with elevated MCHC– May not be obvious in milder cases

(1) Liesveld JL et al. Blood 1987; 69:820. (2) Marchand A et al. JAMA 1980;

243:1909. (3) Galen RS. Clin Lab Med 1982; 2:685. (4) Conley CL et al. JAMA

1980; 244:1688.

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Treatment of WAIHA

• Can present as a medical emergency requiring immediate PRBC transfusion

– Contact Blood Bank personnel

• Stop any possible offending drug (e.g., penicillin)

• Treat underlying disease (e.g., SLE, CLL)

• Reduce autoantibody production

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Reduction in Antibody Production

• Corticosteroids (Wendell Rosse & Stanley Schrier)– Prednisone 1 mg/kg per day– Maintain high dose for 1 week beyond goal Hgb level

(e.g., >10 g/dL)– Rapidly taper by 20 mg increments every 1 to 2 weeks

to 20 mg/day– Maintain 20 mg/day for 1 month– If remission persists

• Gradually reduce dose on alternate days to 10 mg/day and maintain for 1 month

• Omit the dose on alternate days• Reduce dose to 10 mg/day on alternate days

– Maintain this dose as long as remission persists and the DAT remains positive

• Danazol (may be steroid sparing)

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Reduction in Antibody Production

• Immunosuppressive and cytotoxic agents– Azathioprine

• 100 to 150 mg/day

– Cyclophosphamide• 100 mg/day by mouth

• 500 to 700 mg IV every 3 to 4 weeks

• High-dose (as in aplastic anemia)

– 50 mg/kg per day IV for 4 days with Mesna and G-CSF

– Cyclosporine and mycophenolate mofetil

– Vincristine

– Rituximab

– Alemtuzumab

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Reduction in Antibody Effectiveness

• Splenectomy

• IVIg

– Less effective than in management of ITP

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The End

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