Autoimmune hemolytic anemia and idiopathic thrombocytopenic purpura in pediatric solid organ transplant recipients, report of five cases and review of the literature

Abstract

Cytopenias are common among pediatric SOT; however, autoimmune cytopenias are infrequently reported. We report five cases of autoimmune cytopenias in pediatric LT patients: two with isolated IgG-mediated AIHA, two with ITP, and one with Evans syndrome (ITP and AIHA). All patients were maintained on tacrolimus as immunosuppression. Viral illness commonly preceded the autoimmune cytopenias. All patients responded well to medical therapy (steroids, intravenous immunoglobulin, and rituximab) and lowering tacrolimus serum level. Prognosis appears to be worse when more than one cell line (e.g., Evans syndrome) is affected, and/or there is no preceding viral illness. A critical literature review of autoimmune cytopenias in children following SOT is conducted. Autoimmune cytopenias are a rarely reported complication of pediatric SOT, but clinicians taking care of pediatric transplant recipients need to be aware of this complication.

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“…7 Long-term remission can be achieved in most patients by these therapies. 5,6 As shown in this patient, immunoglobulin infusion is effective therapy in LT patients with ITP. Also, IVIG can be used successfully for relapses of thrombocytopenia.…”

“…Miloh and associates suggest that tacrolimus may be continued, but reduced immunosuppression may be preferred. 5 In conclusion, ITP should be borne in mind as a reason of late onset severe thrombocytopenia after LT.…”

“…6 Miloh and associates reported 2 cases of new-onset ITP after LT with an incidence of 1.3% among 158 pediatric patients. 5 Additionally, they found 2 isolated autoimmune hemolytic anemia and 1 Evans syndrome cases. 5 Median time from transplant time to ITP onset was 13 months (range, 1 d-5 y).…”

“…5 Median time from transplant time to ITP onset was 13 months (range, 1 d-5 y). 5 Associated cytomegalovirus, Epstein-Barr virus, and parvovirus B19 infections are described with ITP after LT. 5,6 Preexisting ITP in liver donors, or those with alloimmune thrombocytopenia because of human platelet antigen-1, may cause thrombocytopenia after LT. 6 Corticosteroids, immunoglobulin infusions, anti-D antibody, rituximab, or splenectomy may be chosen as a treatment. 7 Long-term remission can be achieved in most patients by these therapies.…”

“…Autoimmune hemolytic anemia and Evans syndrome (ITP and autoimmune hemolytic anemia) are reported as autoimmune cytopenias in pediatric LT patients. 5 We report a child with ITP after having had an LT.…”