Pure red cell aplasia accompanied by COVID-19 successfully treated using cyclosporine

Abstract

A 67-year-old Japanese man was admitted to our hospital with severe coronavirus disease 2019 (COVID-19) in March 2020. Mechanical ventilation was initiated 8 days after admission, due to severe respiratory failure. Multiple severe complications such as liver dysfunction, arrhythmia, brain infarction, and venous thromboembolism were also observed. We initially diagnosed Coombs test-positive warm autoimmune hemolytic anemia. Corticosteroids proved ineffective and anemia worsened with severe erythroid hypoplasia (0.5% erythroblasts in bone marrow), so we diagnosed pure red cell aplasia (PRCA). We also identified massive infiltration of cytotoxic T-lymphocytes expressing CD8, granzyme B, and perforin in bone marrow. Systemic cyclosporine was started, with full resolution of anemia and no need for blood transfusions after 4 weeks. We believe that this represents the first report of COVID-19-associated PRCA successfully treated using cyclosporine.

Exacerbation of autoimmune hemolytic anemia associated with pure red cell aplasia after COVID-19: A case report

“…In our case, AIHA and PRCA were induced after a low-grade symptom of COVID-19 associated with mild fever, suggesting that slight or asymptomatic COVID-19 infection could cause such hematological disturbances. Although previous reports on COVID-19-associated PRCA that were resistant to PSL treatment and recovery after the administration of cyclosporine [ 15 ] or tacrolimus [ 13 ] were published, our case and the case by Karrat et al [ 12 ] showed a good response to PSL as shown in Table 2 . The case by Ghimire et al [ 14 ] also showed a response to dexamethasone.…”

“…Our case was associated with simultaneous occurrence of AIHA and PRCA after COVID-19. As per our search, simultaneous occurrence of AIHA and PRCA [ 14 , 15 ], or occurrence of PRCA [ 12 , 13 ] after COVID-19 have rarely been reported. Those reported patients including our case are summarized in Table 2 .…”

“…The pathogenesis of PRCA after COVID-19 has not yet been clarified. Yamazaki et al [ 15 ] reported PRCA after severe COVID-19 infection. They observed infiltration of cytotoxic lymphocytes in the BM and considered that PRCA might be related to cytotoxic lymphocytes induced by severe inflammatory changes after COVID-19.…”

“…Previous cases [ 5 , 6 , [8] , [9] , [10] , [13] , [14] , [15] ] were mostly associated with severe COVID-19 infections, suggesting that the mechanisms of AIHA or PRCA may be related to the high inflammatory response evoked by COVID-19. However, the AIHA case reported by Liput et al [ 11 ] was induced by asymptomatic COVID-19 infection.…”

“…Currently, reports of AIHA occurrence after COVID-19 are being accumulated [ [5] , [6] , [7] , [8] , [9] , [10] , [11] ]. However, reports of PRCA [ 12 , 13 ] or the simultaneous occurrence of AIHA and PRCA [ 14 , 15 ] have rarely been reported. Moreover, the manifestation of COVID-19 in our case was low-grade and only associated with mild fever.…”