Successful Management of Severe Hyperhaemolysis with Combined Tocilizumab and Rituximab in Non-Transfusion-Dependent Thalassaemia: A Case Report

Abstract

<b><i>Introduction:</i></b> This is the fourth case reporting the administration of tocilizumab to control hyperhaemolysis. It was administered with rituximab to stop hyperhaemolysis refractory to frontline therapy. Hyperhaemolysis is a rare life-threatening subtype of delayed haemolytic transfusion reaction. Refractory cases pose a clinical challenge with no standard of care to date. <b><i>Case Presentation:</i></b> A 29-year-old lady with non-transfusion-dependent thalassaemia presented with refractory hyperhaemolysis necessitating the administration of rituximab. This was complicated with anaemic heart failure and altered sensorium exacerbated with further transfusions. A nadir haemoglobin of 2.1 g/dL was reached after the initiation of rituximab, and her condition was too critical to wait for the slow expected improvement. Hence, tocilizumab was given as a bridging therapy to block haemolysis till the delayed onset of radical treatment. <b><i>Conclusion:</i></b> Tocilizumab can be effectively combined with rituximab to stop hyperhaemolytic episode refractory to first-line treatment when a prompt response is needed.

A severe case of delayed transfusion reaction in a patient with sickle cell disease while preparing for allogeneic stem cell transplant

“…Target Mechanism Eculizumab C5-convertase inhibitor Prevents cleavage of C5 to C5b and stops formation of the terminal complex C5b-9 to limit inflammatory response and ultimately limit red cell destruction 13 Tocilizumab IL-6 receptor Prevents macrophage activation to limit destruction of red cells by macrophages 14 Rituximab CD20 Depletes B cells and limits antibody-mediated red cell destruction 15 On Day 7 of hospitalization, he was started on erythropoietin and subsequently on Day 8 tocilizumab. He received tocilizumab (200 mg/day) for 4 days, with significant improvement in hemoglobin to 5.6 g/dL (absolute reticulocyte count 450.34 × 10 3 U/L).…”