Autoimmunnyye gyemolitichyeskiye anyemii (AIGA)
Under autoimmune hemolytic anemia understand this form of anemia, in which antibodies are produced against one's own unmodified antigen. In these cases, the immune system will recognize its own antigen as a stranger and produces antibodies against it.
Depending on, that is the object of destroying - erythrocytes erntrokariotsity peripheral blood or bone marrow, distinguish between two groups of autoimmune hemolytic anemia - with antibodies against antigens of peripheral blood erythrocytes with antibodies against antigens erythrokaryocytes.
All autoimmune hemolytic anemia irrespective of cell orientation antibodies can be divided into idiopathic and symptomatic.
Are symptomatic anemia, where the antibodies produced in response to some other disease - hematological malignancies (particularly lymphoproliferative disease, such, as chronic lymphocytic leukemia, Waldenstrom's disease, multiple myeloma, lymphosarcoma), systemic lupus erythematosus, nespetsificheskiy yazvennыy colitis, rheumatoid arthritis, active hepatitis, cancer of various localization, immunodeficiency.
Where, If autoimmune hemolytic anemia occur for no apparent reason, they should be classified as idiopathic. So, AIGA, arising from the flu, angina and other acute infections, during pregnancy or after childbirth, are symptomatic, since these factors are not etiological, and provoking clinical manifestations of latent disease.
Autoimmune hemolytic anemia with antibodies to antigens of red blood cells of the peripheral blood on the basis of serological characteristics of antibodies are divided into four types:
- Incomplete thermal agglutinins;
- with thermal hemolysin;
- with complete cold agglutinins;
- with biphasic hemolysin Kholodov.
Most often identified with AIHA nevolnymi heat agglutinins. This form of anemia occurs at any age. AIHA with complete cold agglutinins occur mainly in the elderly. AIHA with biphasic hemolysin - the most rare form; It occurs mostly in young children. When symptomatic forms of the disease age of the patients may be different.
Autoimmune hemolytic anemia with antibodies against antigens of erythrocytes of the peripheral blood
Anemia, due to incomplete heat agglutinins
Clinical manifestations
Clinical manifestations do not depend, whether in patients with idiopathic or symptomatic anemia. Onset of the disease may be different. Sometimes it is acute: against the backdrop of well-being suddenly appear severe weakness, sometimes pain, in the heart, breathlessness, heartbeat, often marked by fever. Very quickly develop jaundice, which often serves as a basis for the misdiagnosis of infectious hepatitis.
In other cases, there is a progressive disease. There are harbingers of disease - arthralgia, abdominal pain, low-grade fever.
Often the disease develops gradually. Patients feel satisfactory. Breathlessness, they have no heart, despite the expressed anemisation, due to the gradual adaptation of the patient to anemic hypoxia.
Laboratory findings
In acute hemolytic crisis decrease Hemoglobin to extremely low numbers (less 3,1 mmol / l, or 50 g / l). However, in most cases, the hemoglobin decreases not sharply (3,72-4.34 Mmol / l, or 60-70 g / l). A number of patients with chronic autoimmune hemolytic anemia, a slight decrease in hemoglobin (to 5,59 mmol / l, or 90 g / l). Anemia often normochromic or moderately hyperchromic.
The content of reticulocytes for the majority of patients with elevated, sometimes largely (to 87%). When symptomatic form of the disease of reticulocytes below, than in idiopathic. When exacerbation of reticulocytes is sometimes reduced to 0.1-0.3 %. There may be a macrocytosis, but it is most often found microspherocytosis. Number microspherocytes same, as with hereditary microspherocytosis. This symptom is not pathognomonic for this disease. In severe disease found shizotsity.
In the bone marrow, in most cases hyperplastic red sprout, but may decrease the amount of erythrokaryocytes. Probably, These crises are associated with a very large number of antibodies, whereby erythrocytes are destroyed not only the peripheral blood, but erythrokaryocytes. However, we can not exclude, that the cause of crises, as well as at microspherocytosis, and sickle-cell anemia, It is an infection with parvovirus.
Number of leukocytes It depends on the disease, which underlies the AIHA. When idiopathic form AIHA observed significant fluctuations in the number of leukocytes: for acute forms of the disease - up to 50-70 T 1 L with left shift to promyelocytic; In chronic forms - a slight increase or a normal amount. Sometimes there is severe leukopenia.
Platelet count most patients with normal or slightly reduced. There, However, category of patients, in which there is a combination of autoimmune hemolytic anemia with severe autoimmune thrombocytopenia or autoimmune simultaneous failure of all three germ hematopoiesis. In some cases, autoimmune hemolytic anemia begins simultaneously with autoimmune thrombocytopenia, in others - thrombocytopenia, anemia joins only after several months or years. In some patients the disease is detected at the beginning of thrombocytopenia and only after a certain time, anemia. This may not have thrombocytopenia occur. Therefore, there are serious grounds to isolate the disease or syndrome Fisher-Evans, characterized, as is commonly believed, a combination of autoimmune hemolytic anemia and thrombocytopenia.
Osmotic resistance of erythrocytes at AIHA agglutinins with heat in most cases, reduced. Marked parallelism between the degree of change microspherocytosis and osmotic resistance. Changing the osmotic resistance is especially pronounced after day incubation of red blood cells.
Acid resistance of erythrocytes increases, usually, parallel to the degree of intensity and the degree of hemolysis giperretikulotsitoza. Maximum shifting towards resistant cells before 6, 7 or 8th minute hemolysis, height of the curve remains normal. The left branch of the curve becomes flatter, than normal. Total Time hemolysis is normal or slightly increased.
The content of bilirubin in autoimmune hemolytic anemia often raised to 25 45 mmol / l, some patients - up 60 mmol / l. In patients with idiopathic form of AIHA increase in bilirubin is observed more often, than symptomatic form. Increased bilirubin occurs, mainly, by indirect fraction, non-glucuronic acid. It should be noted, that normal bilirubin does not exclude the diagnosis of autoimmune hemolytic anemia. The increase of direct, or associated with glucuronic acid, bilirubin may indicate an accompanying hepatitis or obstruction.
The urine is sometimes increased content urobilin, however, this increase is intermittent and not a sign of hemolytic anemia. In the feces of patients with detected, usually, a significant number of stercobilin.
The hemoglobin content of the plasma It may increase due to existing in these patients small intravascular hemolysis, but often it is normal. Sometimes autoimmune hemolytic anemia with partial heat agglutinins been expressed gemosiderinuriya, occasionally - hemoglobinuria. Often identified changes in the protein fractions, elevated erythrocyte sedimentation rate.
A number of patients increased content of globulins, often at the expense of immunoglobulins. In some cases, autoimmune hemolytic anemia with partial heat agglutinins electrophoresis revealed a homogeneous fraction - M-gradient. Sometimes when AIHA is a positive Wasserman.
In some patients the immune hemolytic anemia, onset of acute, can give adequate therapy at a rapid remission, and after a while it may be a new aggravation. Some patients with autoimmune hemolytic anemia after acute onset goes into a typical chronic. In rare cases, the disease is extremely unfavorable, and despite intensive therapy, may end lethally.
Anemia, associated with thermal hemolysin
Clinical manifestations
This form of autoimmune hemolytic anemia may begin as acute, as a form of agglyutininovaya, but often it is characterized by a more relaxed, soft start. The hemoglobin content is reduced to 2,48-3,72 mmol / l (40-60 G / l). There may be a slight yellowness of the skin and sclera, but this form of anemia, it is less pronounced, agglyutininovyh than the forms of anemia. The slight increase in the spleen and liver observed in almost half of patients.
A characteristic feature of form hemolysin autoimmune hemolytic anemia is a selection of black urine. During this period, it found large amounts of protein, there is a positive benzidine sample (urine!). Hemoglobinuria is comparatively rare and not all patients, However, some patients are constantly found gemosiderinuriya. Or normal levels of bilirubin, or slightly higher.
Sometimes hemolysin disease complicated by thrombosis of peripheral veins. There may be bouts of abdominal pain, associated with thrombosis of small mesenteric vessels.
Laboratory findings
Blood picture is basically the same, as in agglyutininovyh forms of autoimmune hemolytic anemia. Often found a large number of microspherocytes. The number of leukocytes in most patients improved, In many cases, there is a shift to myelocytes leukogram. The number of normal platelets.
Differential diagnosis of AIHA hemolysin form It carried out primarily with paroxysmal nocturnal hemoglobinuria (disease in March- kiafavy Michele).
Anemia, associated with complete cold agglutinins
Clinical manifestations
For this form of AIHA is characterized by a gradual slow start. Patients complain of weakness, malaise, decreased performance, cold intolerance. The majority of patients after exposure to cold are marked blue, and then the whitening of the fingers, Foot, ears, tip of the nose. There is a sharp pain in the extremities. After prolonged exposure to cold may develop gangrene of the fingers or toes. However, Raynaud's syndrome is not a mandatory feature of the disease, in some patients, after cooling, appears urticaria. May increase the liver and spleen.
Laboratory findings
The level of hemoglobin in most patients is in the range 4,96-6,21 mmol / l (80100 g / l), but it may be lower. The content of leukocytes and platelets typically not reduced.
Characteristic feature cold form autoimmune hemolytic anemia – autoagglutination, which occurs once during the taking of blood. This often prevents quantification of red blood cells and ESR. Often seen in a smear autoagglutination. In the case of the blood storage at room temperature (and especially in the refrigerator) it agglutinates in vitro. This agglutination is reversible and disappears completely when warming up. Bilirubin normal or slightly elevated. In the study of protein fractions of blood in some patients found a separate protein fraction (M-gradient), and that is a cold antibodies.
In some patients, the urine protein is detected by the free hemoglobin. However, hemoglobinuria is not a common symptom of the disease.
The combination of mild anemia with signs of increased hemolysis, a sharp increase in ESR, Raynaud's syndrome, changes in protein fractions of blood, and the inability to determine the blood and red blood cell count should be grounds for suspicion to cold hemagglutinin disease, and studies of complete cold agglutinin.
The disease chronic. Clinical manifestations are more pronounced in winter and almost no summer. The majority of patients are not observed crises. Recovery from idiopathic form practically does not occur, but the disease is rarely fatal.
Sometimes a cold form of immune hemolytic anemia occurs during an episode of viral infection (flu, infectious monokuleoz) or directly with a decrease in body temperature after a previous infection. In these cases it may occur clinical signs of disease (Raynaud's syndrome, splenomegaly, decrease in hemoglobin, a sharp increase in ESR, inability to determine the blood group), However, they are fully tested after 1-2 months. This supports geteroimmunnoy, instead autoimmune forms of anemia.
Anemia, Related biphasic hemolysin Kholodov
Anemia, Related biphasic hemolysin Kholodov (paroksizmalynaya holodovaya gemoglobinuriya) - The most rare form of autoimmune hemolytic anemia. It is characterized by bouts of chills, fever, abdominal pain, toshnotoy, vomiting and the appearance of black urine a few hours after hypothermia. Sometimes, as well as in the cold agglyutininovoy disease, Raynaud's syndrome is expressed. Shortly after the cooling may appear harbingers of disease: pain in the back and lower extremities, headache, malaise, and then there is a fever, and at different intervals (from several minutes to several hours) there is a dark selection (almost black) Urine. The body temperature is kept for several hours. Urine black can be released in 1-2 days. In the period of crisis sometimes marked increase in the size of the spleen, It appears yellowness.
The hemoglobin content of paroxysmal cold hemoglobinuria during the period of crisis is normal. In the winter,, during the frequent crises hemoglobin level may be reduced to 4,34-4,96 mmol / l (70- 80 g / l) with a high content of reticulocytes and red growth stimulation of the bone marrow.
Syerologichyeskaya diagnostika autoimmunnykh gyemolitichyeskikh anemia
AIHA diagnostics with partial heat agglutinins
The diagnosis of autoimmune hemolytic anemia is confirmed by positive direct breakdown (reaction) Kumʙsa, which allows, usually, identify incomplete antibody, fixed on the surface of red blood cells.
Previously it was assumed, that incomplete antibodies have one valence, and therefore can not combine the two erythrocyte. It is now known, that incomplete heat agglutinins, fixed on erythrocytes, have two valencies. Lack of agglutination of erythrocytes in saline medium due to the existence of the ion cloud around the erythrocyte and so-called two-potential. The repulsion of negatively charged red blood cells counteracts the force of attraction of a minor, caused by incomplete antibodies. Therefore, in most cases incomplete heat antibodies do not lead to the phenomenon autoagglutination. Sometimes, in severe forms of anemia in patients with thermal antibodies observed phenomenon autoagglutination, which can lead to errors in determining the blood group.
Adding protein to red blood cells (albumin, gelatin) It leads to dispersion of the ion cloud and erythrocyte agglutination, on which the fixed antibody. Based on this method of determining the Rh Facilities. Sometimes the addition of gelatin solution leads to agglutination of erythrocytes, which are fixed autoimmune antibodies. However, the use of gelatin for the detection of antibodies is not recommended, as it allows to identify only a small portion of patients with autoimmune hemolytic anemia. Nevertheless, this phenomenon should be considered, since it is often underestimated to a false positive diagnosis of Rh Facilities.
The main method of detection fixed on erythrocytes incomplete antibodies is direct antiglobulin Coombs. Antysыvorotka, obtained by immunizing rabbits with human serum globulin, It does not cause agglutination of washed red blood cells of normal. Joining antiglobulin serum antibodies to the incomplete, immunoglobulins, fixed on erythrocytes, It leads to the enlargement of the protein, sitting on erythrocytes, and agglutination.
Positive direct Coombs test is observed in the majority of cases, autoimmune hemolytic anemia. However, negative Coombs test does not exclude the diagnosis of autoimmune hemolytic anemia. It can be observed in the period of greatest severity of the disease due to the fact, that in this period there is a destruction of red blood cells, which is fixed sufficiently large number of antibodies. A few patients have negative Coombs during the sharp deterioration of hemolysis and sharply positive - on the background of a massive steroid therapy. Negative Coombs test may be due to an insufficient number of antibodies when expressed mild chronic disease.
Sensitivity Coombs manages to improve with the help of Method agregatgemagglyutinatsii. To study this method uses test erythrocytes, coated aggregate glyutar aldehyde immune serum proteins. This allows a multiplier effect: It increases the likelihood of meeting the antibody through any two studied erythrocytes, due to the huge mass of red blood cell test, loaded with a large number of antibodies, compared to a single molecule of a specific antiglobulin. Aggregation of proteins of the immune serum glutaraldehyde lets put these units on the active sites of antibodies at a considerable distance from the surface of red blood cells, which increases the availability of the active site of the antibody to immunoglobulin determinants, on the surface of the patient's erythrocytes.
The first stage of the method agregatgemagglyutinatsii is almost a regular direct antiglobulin Coombs' test with rabbit antiserum against human gamma globulin. In case of a negative sample erythrocytes from unbound antibody is washed and then added thereto the test erythrocytes, nagruzhennыe agregirovannoy antisыvorotkoy, received from another animal (eg, donkey or sheep), immunized rabbit gamma globulin.
With direct Coombs test antibodies in autoimmune hemolytic anemia detected in 65 % patients, the rest they can be detected only by agregatgemagglyutinatsii.
As false positive, and false negative Coombs test may be due to the poor quality of the antiserum. In the same extent this also applies to the method agregatgemagglyutinatsii. Lack of sorption heteroantibodies leads to false positive results, and the small antibody titer give false negative Coombs. In this study, the need for a donor red blood cells for the negative control and inspection at least 1 once every 3 Quality Week antisera for positive control (donor Rh-positive red blood cells, sensitized small amount of antibodies antirhesus).
Regardless of the method to detect antibodies in most patients they treated IgG class and only in selected patients using agregatgemagglyutinatsionnogo method on the surface of red blood cells revealed IgA.
Nepryamaya Coombs test in the case of autoimmune hemolytic anemia no diagnostic value.
In this reaction, the red blood cells are incubated with donor patient serum, washed them, and then, both with direct sample, define, whether on the surface of red blood cells donors incomplete heat antibodies. Antibodies in serum of the patient can be both auto-, and izoantitelami. To speak of autoantibodies can only be, if they are directed against the same antigen, and that antibody, found on the surface of red blood cells of the patient. The indirect Coombs test is used only for the individual selection of red blood cells.
AIHA diagnostics with thermal hemolysin
AIHA diagnostics with thermal hemolysin based on the determination of the serum of patients. Direct Coombs often negative. Serum of patients in a weakly acidic environment causes hemolysis donor in the presence of complement.
Sucrose sample, which is considered characteristic of paroxysmal nocturnal hemoglobinuria, may be positive when the shape of the hemolysin autoimmune hemolytic anemia. This test is based on the destruction of red blood cells by complement. When paroxysmal nocturnal hemoglobinuria sucrose and complement destroying the red blood cells from the diseased membrane due to the production of defective cells. When the form of hemolysin autoimmune hemolytic anemia cell destruction is due to fixed on the surface of red blood cell antibodies. Sucrose sample can be placed in two additional embodiments. In the first patient's serum is mixed with red blood cells of the donor and investigated the presence of hemolysis of red blood cells of the donor patient serum in the presence of sucrose (Cross version); in the second embodiment of the patient serum is incubated with its own red blood cells.
When paroxysmal nocturnal hemoglobinuria direct positive, chief, version of the sample, negative and positive version perekrestnыy third option, but at the same time less hemolysis, than in the first embodiment. When the shape of the hemolysin autoimmune hemolytic anemia, hemolysis is most pronounced in the third embodiment,, as in the serum of patients have antibodies, are best captured on the surface of its own erythrocytes. To a lesser degree in the first marked hemolysis, direct, version, and sometimes in a cross. Often the method of producing positive results agregatgemagglyutinatsii.
Diagnosis of AIHA with complete cold agglutinins
Diagnosis of AIHA with complete cold agglutinins is based on the determination of their titer in serum. For this patients sera, taken in the heat, titrated in a saline environment, was added thereto and the mixture donor RBCs is placed in various temperature conditions. Normally, serum antibodies are Kholodov, which can cause agglutination of red blood cells in the donor's titer 1:4 at a temperature 4 ° C. In the presence of serum pathological cold antibodies titer is very high.
The agglutination occurs when the patient's blood serum dilution of many thousands of times. In milder forms of the disease in a large agglutination titer is observed only at low ambient temperatures, and at temperatures 20 ° C, and especially 37 ° C, it does not occur. In more severe forms of the disease agglutination may occur at a temperature of 20 ° C. To enhance the sensitivity of the reaction is reasonable treatment of red blood cells of the donor papaya- Books.
Cold antibodies inherently belong to the class IgM. Electrophoresis in most cases M is detected as the gradient disease Waldenström. There are several descriptions of autoimmune hemolytic anemia with cold antibodies, related to IgA class.
Diagnosis of AIHA with biphasic hemolysin
Biphasic hemolysin characteristic of paroxysmal cold hemoglobinuria. They belong to the IgG class.
Their feature is, that the first phase of the study, when the patient's blood serum with erythrocytes of a donor or patient is placed in a refrigerator, hemolysins fixed on the surface of red blood cells. Then erythrocytes are placed in a thermostat (The second phase), where they are hemolysis. Sometimes paroxysmal cold hemoglobinuria, a positive direct Coombs test by identifying on the surface of red blood cells like 1 IgG, Tac and complement.
For sera from different patients is required in the first phase of the reaction varying degrees of cooling - between 0 ° 25 ° C. Those forms of the disease, in which the first phase requires a lesser degree of cooling, typically more severe. The second phase of the reaction occurs best at temperatures 32 ° C in a neutral medium.
Antibody Specificity
In various forms of AIHA antibodies directed against different antigens. So, in autoimmune hemolytic anemia incomplete thermal agglutinins antibody directed against an antigen in most cases, relating to the system of rhesus (Rhnull). However, it is not a common antigen of Rh and has almost all people regardless of their Rhesus accessories. This antigen is associated with the erythrocyte membrane portion, which are attached antigens system Rhesus.
When autoimmune hemolytic anemia with complete cold agglutinins in most cases, have antibodies against antigens of Ii. I antigen found in adult humans and in very small quantities - newborns, i antigen is present in newborns and in very small quantities - adults.
Paroxysmal cold hemoglobinuria When antibodies are directed against an antigen p.
Study of the specificity of antibodies often helps to make a correct diagnosis, recommend treatment, sometimes advance to determine prognosis. It concerns, eg, autoimmune hemolytic anemia with cold agglutinins.
Where, If antibodies directed against the antigen I, the disease is much harder, what then, when they are directed against the antigen i.
Antigen I has on erythrocytes of adults in a large amount, and antigen i - in the small. Therefore, the degree of red cell agglutinability in the presence of antibodies to a small i. Despite the sharp increase in ESR up to 70-80 mm / hr, High antibody titers, prognosis of a good antibody specificity.
Also, the definition of the specificity of cold agglutinins can help diagnose the underlying disease, which was complicated by the cold form of autoimmune hemolytic anemia. So, idiopathic form of cold hemagglutination antibodies often directed against the antigen I, and with lymphosarcoma, macroglobulinemia - against antigen i. These antibodies differ not only in their specificity, and structure. So, idiopathic form of the disease often have antibody light chains ᴂ-, and with lymphosarcoma - λ-light chain.
When infections often polyclonal antibodies, are two types of light chains, and are directed against the antigen i. Cold antibodies react not only with erythrocytes, but with lymphocytes. Antibodies, directed against an antigen i, react predominantly with the B-lymphocytes, and antibody, directed against antigen I - with T-lymphocytes, although a small amount of antigen i and there on the B-lymphocytes, antigen and I - on T-lymphocytes.
In some cases of autoimmune hemolytic anemia with cold agglutinins antibody directed against an antigen Pr, papain and collapsing neyramininazoy. Such antibodies are often classified as IgA.
