A minor ABO incompatibility is defined by the presence of donor antibodies directed against the antigens of the recipient's red blood cells (RBCs). Delayed immune haemolysis may occur 7–10 days after transplantation, with an unpredictable and rather abrupt onset1 and can be associated with serious consequences, including multiorgan failure and death. This reaction is secondary to transient immune antibody production by donor passenger B lymphocytes carried within the graft and mounting an anamnestic immune response against recipient red cell antigens.2, 3, 4 The occurrence of delayed haemolysis is more often observed in certain settings such as when peripheral blood stem cells (PBSCs) are used instead of bone marrow as the source for stem cells for transplantation,4 and when nonmyeloablative regimen is used compared to myeloablative conditioning regimen.1, 5 It is also noted more often when cyclosporine (CsA) alone is used instead of CsA and methotrexate (MTX) for immunosuppression.2, 6 We report a case of severe delayed intravascular haemolysis and its complications, in a minor mismatched PBSC transplant (PBSCT) despite using myeloablative conditioning regimen and MTX along with CsA for graft-versus-host disease (GVHD) prophylaxis.
A 13-year-old girl, blood group A+, with Philadelphia-positive B cell acute lymphoblastic leukaemia with delayed relapse in second complete remission, underwent an allogeneic PBSCT from her HLA-matched mixed lymphocyte culture nonreactive sister with blood group O+. After conditioning using busulphan and cyclophosphamide, she received 170 ml of PBSC containing 6.1 × 108 viable non-T-cell-depleted cells/kg, from her donor who was primed with recombinant human granulocyte colony-stimulating factor (G-CSF) at 5 mcg/kg/day Q 12 hourly for 4 days (harvesting was performed on day 5). CsA and MTX were administered as GVHD prophylaxis. Neutrophil and platelet engraftment occurred on days 19 and 17, respectively. On day 12, she developed fever, abdominal and bilateral flank pain, with severe intravascular haemolysis as evidenced by a sudden drop in her haemoglobin (Hb) level to 6 g/dl, a lactate dehydrogenase level of 1968 IU/l (n=300–620), plasma Hb level of 600 mg/dl (N<5), a haptoglobin level of less than 50 mg/dl, unconjugated hyperbilirubinemia (maximal bilirubin level reached 32 mg/dl), haemoglobinuria and presence of schistocytes in peripheral smear with normal urea and creatinine levels. The direct Coombs' test was positive, further characterized by a complement-specific antiglobin serum as C3d. A maximal titre of 1:2500 IgM and IgG anti-A antibodies were found in the patient's serum. The patient was treated with adequate hydration, diuretics, morphine infusion, plasmapheresis, A+ fresh-frozen plasma (FFP) and exchange transfusion with 3 l of washed O+ RBCs. She recovered from this haemolytic reaction after 7 days; however, there was a mild derangement of coagulogram suggestive of compensated disseminated intravascular coagulation (DIC).
On day 22, she developed left flank pain associated with constipation and distension of the abdomen. Clinically, she had local tenderness over the left lower abdomen with diminished bowel sounds. Investigations revealed Hb (11 g/dl), leucocytosis (total leukocyte count of 50 000 μl−1 with 90% neutrophils), thrombocytopenia (platelet count 96 000 μl−1) and toxic granules on peripheral smear. Serial serum amylase and lipase levels were normal. Ultrasonography and CECT of the abdomen revealed a hypodense lesion (Hounsefield units 15–20) anteroinferior to the left kidney and posterior to the descending colon (Figure 1a); the pancreas was normal (Figure 1b). She underwent a surgical exploration of the retroperitoneum through a left flank approach, which revealed a large indurated necrotic mass anteroinferior to the left kidney with minimal fluid collection. A piece of the necrosed material was excised and Gram stain of the material showed Gram-positive cocci in chains and anaerobic culture-isolated peptostreptococcus. Aerobic and fungal cultures produced no growth. Histopathological examination of the excised tissue revealed evidence of necrotic material only. Post-operatively she continued to have oozing of blood from the drainage site (1–1.5 l/day) and the coagulogram revealed mild derangement (PT – control 12 s and test 20 s, INR 1.9, APTT – control 32 s and test 48 s). Platelet count was 127 000 μl−1 and D-dimer values ranged from 4 to 16 ng/ml. She was managed with cryoprecipitate and FFP. However, the bleeding continued and she was given activated factor VII (VIIa), after which the bleeding stopped.
She developed septicaemia with acute respiratory distress syndrome and renal failure on day 33. However, there was no evidence of pancreatitis biochemically or radiologically. Her condition continued to deteriorate and she succumbed to her illness on day 35 despite intensive treatment.
The incidence of intravascular haemolysis due to passenger B lymphocytes after allogeneic PBSCT is higher than after allogeneic bone marrow transplantation.7 This syndrome is almost exclusively associated with the use of CsA and more recently Tacrolimus (FK506).3 These drugs, while preventing rejection of donor B cells by residual host T lymphocytes, do not inhibit anamnestic immune responses. CsA may in fact, stimulate the exaggerated immune response by permitting a B-lymphocyte proliferation with the suppression of T-helper lymphocytes. In contrast, MTX, which is often used in combination with CsA to prevent GVHD, may be toxic to B cells, which would explain why patients treated with MTX in addition to CsA have a lower incidence of this syndrome.2, 7 The role of G-CSF in mobilizing PBSC has been studied in the mouse model and seems to be protective in regard to GVHD by modulating T-lymphocyte cytokine production toward a type-2 (interleukin (IL)-4, IL-10) response.8 If the same is true in clinical transplantation, this switch could promote and support the production of antibodies by donor B cells and also help to explain the delayed immune haemolysis syndrome seen with PBSC transplantation.
An infected necrotic mass in the retroperitoneum may have developed due to ischaemic insult and/or concomitant haemorrhage due to DIC, with haematogenous peptostreptococcal seeding. Such necrotic mass in the retroperitoneum is known to occur with acute pancreatitis, which was, however, not found in our patient despite a serial biochemical and imaging search. It is very unusual to develop such a necrotic mass with the delayed haemolysis, which may follow minor group mismatched allogeneic myeloablative PBSCT.
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Journal of Pediatric Gastroenterology and Nutrition (2019)
Bone Marrow Transplantation (2011)
Current Opinion in Hematology (2007)