The immune haemolytic anaemias: a century of exciting progress in understanding (2001)

The growth in knowledge of the scientific basis of disease and consequent advances in the practice of medicine that have taken place in the past century have been truly remarkable. This is certainly true of the haemolytic anaemias, which have been a main interest of the author since the mid-1930s. At that time, the cause and mechanism of important disorders such as the acquired antibody-determined (immune) haemolytic anaemias, haemolytic disease of the newborn, hereditary spherocytosis and paroxysmal nocturnal haemoglobinuria were unknown or but partially understood. The purpose of this short review is to record and highlight some of the most significant advances in knowledge of the acquired immune haemolytic anaemias that have been made between the first decade and the end of the twentieth century. First, however, a diversion. According to Crosby (1952), William Hunter of London, in an article on pernicious anaemia published in 1888, was the first to use the term 'haemolytic' to denote an anaemia caused by excessive blood destruction. By the turn of the century, the term was being widely used in clinical literature, e.g. by Widal et al (1908a,b) and Micheli (1911), and in experimental studies, e.g. by Cantacuzène (1900). At that time, however, and for a decade or so later, no reliable data were available as to the life-span of the erythrocyte in health. Peyton Rous, in his comprehensive review 'Destruction of the red blood corpuscles in health and disease' (Rous, 1923), concluded that the generally held view in the early 1930s was that about one-fifteenth of the erythrocyte mass was destroyed daily. Rous was aware of the pioneer work of Winifred Ashby (1919a,b), who, by following the survival of serologically distinct but compatible transfused erythrocytes, had found that normal erythrocytes might live for up to 100 d in the recipients' circulation. The difficulty in accepting Ashby's conclusions without question was that she was unable, using her technique, to measure the life-span of the experimental subjects' cells in their own environment. Subsequent work using radioactive chromium (51Cr) as an erythrocyte label, showed that Ashby's data and conclusions were in fact correct, i.e. that normal erythrocytes in health circulate in the peripheral blood for approximately 110 d. Both Asby's differential agglutination method and 51Cr labelling have been used with brilliant effect in the investigation of patients suffering from many types of increased haemolysis. Thus, in contrast to the finding in hereditary haemolytic anaemias, e.g. hereditary spherocytosis (HS), that the life-span of transfused normal erythrocytes is normal, that of normal erythrocytes transfused to patients with an acquired immune haemolytic anaemia is characteristically shortened (Brown et al, 1944; Mollison, 1947). Erythrocyte labelling with 51Cr also had a further advantage over the Ashby method in addition to enabling the life-span of the patients' erythrocytes to be assessed in his or her own circulation, namely, that it was possible, by surface counting, to detect and measure the accumulation of radioactivity in the spleen and liver, i.e. the presence in the organ of the labelled erythrocytes, and thereby assess the organs' role in haemolysis (Szur, 1970). It was in France in the first decade of the twentieth century that Widal et al (1908a) and Le Gendre & Brulé (1909) reported that autohaemoagglutination was a striking finding in some cases of ictère hémolytique acquis. At about the same time, Chauffard & Trosier (1908) and Chauffard & Vincent (1909) had described the presence of haemolysins in the serum of patients suffering from intense haemolysis. These observations suggested that abnormal immune processes, i.e. the development of auto-antibodies damaging the patients' own erythrocytes, might play a part in the genesis of some cases of acquired haemolytic anaemia. That this might be so had in fact been antedated by the classic observations of Donath & Landsteiner (1904) and Eason (1906) on the mechanism of haemolysis in paroxysmal cold haemoglobinuria, the clinical aspects of which had been well described in the 19th century. That blood might auto-agglutinate when chilled had been described by Landsteiner (1903) and that an unusual degree of the phenomenon might complicate some types of respiratory disease was reported by Clough & Richter (1918) and later by Wheeler et al (1939). It was not until a few years later, however, that it was reported by Peterson et al (1943) and Horstmann & Tatlock (1943) that cold auto-agglutinins at high titres were frequently to be found in the serum of patients who had suffered from the then so-called primary atypical pneumonia. Significantly, two of their patients had developed acute haemolytic anaemia. Earlier, in the 1930s, a chronic syndrome of unknown origin, not associated with respiratory disease, had been recognized in which a markedly raised titre of cold agglutinins associated with intravascular haemolysis and haemoglobinuria were prominent features (Ernstene & Gardner, 1935; Roth, 1935; Salén, 1935). Stats & Wasserman's (1943) review on cold haemagglutination was a valuable contribution to contemporary knowledge. They listed in a table as many as 94 references to papers published between 1890 and 1943 in which cold haemagglutination had been described. In 32 of the papers the patients referred to had suffered from increased haemolysis. Recognition that cold auto-antibodies played an important role in the pathogenesis of some cases of haemolytic anaemia led to the concept that auto-immune haemolytic anaemia (AIMA) might usefully be classified into warm-antibody or cold-antibody types, according to whether the patient is forming (warm) antibodies which react (perhaps optimally) at body temperature or (cold) antibodies which react strongly at low temperatures (e.g. 4°C) but progressively less well as the temperature is raised and are perhaps inactive at 37°C. The clinical syndrome suffered by the patient would depend not only on the amount of antibody produced but also on its temperature requirement. Another important advance in understanding has been the realization that both types of AIHA could develop in association with a wide range of underlying disorders (secondary AIHA) as well as 'idiopathically', i.e. for no obvious cause (primary AIHA). Published data on the relative proportion of primary to secondary cases, based on large numbers of patients, date from the 1950s. For instance, Lal & Speiser (1957) reported that 48 out of 97 cases of warm-antibody AIHA had been secondary cases and van Loghem et al (1958) reported 60 out of 122 cases. Subsequently, somewhat higher proportions of secondary cases were reported, e.g. by Videbaek (1962a), 36 out of 41 cases, Homberg et al (1967), 60 out of 95 cases, and Pirofsky (1969), 190 out of 234 cases. The author's own experience was summarized in a review (Dacie & Worlledge, 1969): 99 out of 210 cases of warm AIHA were judged to be secondary as were 39 out of 85 cases of cold AIHA. Petz & Garratty (1980), summarized the data from six centres: 55% out of a total of 656 cases had been reported as secondary. They listed the disorders with which warm-antibody AIHA had been associated as chronic lymphocytic leukaemia, Hodgkin's disease, non-Hodgkin's lymphomas, thymomas, multiple myeloma, Waldenström's macroglobulinaemia, systemic lupus erythematosus, scleroderma, rheumatoid arthritis, infectious disease/childhood viral disorders, hypogammaglobulinaemia, dysglobulinaemias, other immune deficiency syndromes, ulcerative colitis and ovarian dermoid cysts. Conley (1981), in an interesting review of warm-antibody AIHA patients seen at the Johns Hopkins Hospital, emphasized how important it was to carry out a careful enquiry into the patient's past history and also to undertake a prolonged follow-up. He stated that a retrospective review of 33 patients whose illnesses 'in the past have been designated 'idiopathic'' had revealed an associated immunologically related disorder in 19 of them. An additional three patients had developed a lymphoma 2–10 years after they had developed AIHA. As already referred to, warm-antibody AIHA is now known to complicate a wide range of underlying diseases, particularly malignant lymphoproliferative disorders, other auto-immune disorders and immune deficiency syndromes. There is an extensive literature. Reports of the occurrence of haemolytic anaemia in chronic lymphocytic leukaemia (CLL) and Hodgkin's disease date from the 1920s and 1930s (Netousěk, 1922–23; Holler & Paschkis, 1927; Paschkis, 1927), but whether auto-antibodies played a part in the haemolysis in their patients is unknown. Reports of patients in whom the direct antiglobulin test (DAT) had been carried out and found to be positive date from the early 1950s (Hutt, 1950; Dameshek et al, 1951). It was not long before it was reported that in some patients the haemolytic anaemia had appeared to antedate the development of the lymphoma; in other patients, however, the reverse appeared to be true (Rosenthal et al, 1955). Most of the patients who had developed AIHA appear to have suffered from CLL. Pirofsky (1968a, 1969) reported that, of 113 personally observed patients, 48 had had CLL, 10 acute lymphocytic leukaemia (ALL), 13 Hodgkin's disease, seven lymphosarcoma, one giant-follicle lymphoma and four reticulum-cell sarcoma. What proportion of patients suffering from a lymphoproliferative disorder develop AIHA is an interesting question. Dührsen et al (1987) stated that this had occurred in 12 out of 637 patients. It has also been reported (D. Catovsky, personal communication) that the DAT had been positive in 57 out of 788 CLL patients at the time their leukaemia was diagnosed. AIHA is well known to develop in a minority of patients suffering from SLE. The first reports date from the late 1940s and early 1950s (Aegerter & Long, 1949; Zoutendyk & Gear, 1950). Occasionally, haemolytic anaemia dominates the clinical picture; it may even antedate the development of overt SLE by many months or even years (Michael et al, 1951; Wasserman et al, 1955; Videbaek, 1962b). Early data on the incidence of a positive DAT in SLE were provided by Harvey et al (1954)– in six out of 34 patients tested the DAT had been positive. Later, Mongan et al (1967), who had studied a large number of patients suffering from a variety of connective tissue disorders, reported that the DAT had been positive in 15 out of 23 patients with SLE, none of whom, however, had suffered from overt haemolytic anaemia. AIHA has been recorded; the incidence, however, is low. de Gruchy (1954) and Evans & Weiser (1957) recorded single cases of the association. The author (Dacie, 1967) reported that two out of 250 patients with AIHA had given a history of rheumatoid arthritis and Pirofsky (1969) reported five out of 234 patients. Rather rarely, AIHA complicates ulcerative colitis. Lorber et al (1955) referred to four such patients. The author (Dacie, 1967) reported that two out of about 250 patients with AIHA he had seen between 1947 and 1965 had ulcerative colitis and that the DAT had been positive in the absence of clear evidence of haemolysis in a third patient. It has been realized since the 1960s that warm-antibody AIHA may develop in patients suffering from a variety of immune deficiency syndromes, both congenital and acquired. The author (Dacie, 1992) listed 25 papers published between 1961 and 1988 in which 33 such patients were described. Earlier reports of splenomegaly and hypersplenism in association with agammaglobulinaemia had been reviewed by Citron (1957) and Prasad et al (1957). The rare occurrence of generally severe haemolytic anaemia in patients with ovarian dermoid cysts or teratomata has been recognized since the late 1930s (West-Watson & Young, 1938; Singer & Dameshek, 1941). A remarkable feature of these early reports was that haemolysis had subsided following removal of the tumour. This has been true in similar patients described in later reports. The DAT has been found to be positive in almost all the patients in which the test has been carried out; typically, the test has become negative 3–6 months after surgery. The haematological and serological findings have been indistinguishable from those of 'idiopathic' AIHA. It was in the mid-1960s that it was realized that, in a significant proportion of patients thought to have 'idiopathic' warm-antibody AIHA, the development of the causal auto-antibodies had been triggered in some way by a drug the patient was taking. The first drug implicated was the antihypertensive drug α-methyldopa (Aldomet) (Carstairs et al, 1966a,b). According to Worlledge et al (1966), who had investigated 40 patients, the clinical, haematological and serological findings were indistinguishable from those of 'idiopathic' AIHA. An interesting question was the proportion of hypertensive patients being treated with α-methyldopa (who were not suffering from overt haemolytic anaemia) in whom the DAT was positive. The author (Dacie, 1999) listed 22 reports published between 1966 and 1972. Remarkably, the incidence of positive DATS varied widely – from 0% to 27%. There were hints of a possible genetic influence, for the lowest percentages (0–4%) were found in African, coloured, Indian and Chinese patients (it is possible, however, that these patients had been treated with lower doses of the drug or had failed to take their medicine regularly). Following the finding that treating hypertensive patients with α-methyldopa led to the formation of anti-erythrocyte auto-antibodies in a significant percentage of patients, renewed interest was taken in the possibility that other drugs might have the same effect. Case histories had in fact been reported earlier that supported the possibility, e.g. Snapper et al (1953) in the case of mesantoin and Schwartz & Costea (1966) in the case of dilantoin. Mefenamic acid (Ponstan) and levodopa (l-dopa) were the next drugs to be implicated. Scott et al (1968) reported that three patients being treated with mefenamic acid had developed severe AIHA and Cotzias & Papavasiliou (1969) reported that the DAT of four out of 43 patients receiving levodopa had been positive. The author (Dacie, 1999) listed 15 other drugs the use of which had been reported as being, rarely, the apparent cause of AIHA or a positive DAT. Two main hypotheses have been advanced in relation to how certain drugs in some patients appear to have caused the development of anti-erythrocyte auto-antibodies. One hypothesis was that the drug or its metabolites act on the immune system so as to impair immune tolerance; the other was that the drug affects antigens at the erythrocyte surface in such a way that a normally active immune system responds by developing anti-erythrocyte antibodies. Clearly, too, the patient's individuality must be an important factor, for only a proportion of patients receiving the same dosage of the offending drug for the same period of time develop a positive DAT and only a small percentage develop overt AIHA. These interesting questions have been discussed in detail in numerous reviews, e.g. Worlledge (1969, 1973) and Garratty (1989, 1994). An interesting development in the history of the immune haemolytic anaemias was the realization in the mid-1950s that, rather rarely, haemolysis was brought about by the patient developing antibodies that were directed against a drug the patient had been taking and that the erythrocytes were in some way secondarily involved. The first drug to be implicated was Fuadin (stibophen), which had been used to treat a patient with schistosomiasis (Harris, 1954, 1956). The patient's serum contained an antibody that agglutinated his own or normal erythrocytes and/or sensitized them to agglutination by antiglobulin sera; however, this occurred only in the presence of the drug. Other drugs, e.g. quinidine, phenacetin and penicillin, were later reported to be a cause of haemolytic anaemia by a similar mechanism. The author (Dacie, 1999) listed 12 drugs that had been implicated between 1954 and 1961. It is now realized in fact that a wide range of drugs are capable of causing the DAT to be positive in susceptible recipients and, occasionally, causing clinically significant haemolysis. Habibi (1987) listed as many as 78 drugs and Garratty (1994) lists 71 drugs. Remarkably, some patients have been reported to have formed both drug-induced auto-antibodies and drug-dependant antibodies (Habibi, 1985). The importance of patient individuality, i.e. genetic factors, has been repeatedly referred to in the foregoing brief descriptions of the clinical syndromes associated with AIHA. The occurrence of more than one case of AIHA in the same family is, however, most unusual, but it has happened. The author (Dacie, 1969) reported that he had encountered only one example – a sister and brother – out of more than 100 cases of AIHA seen up to that time. Writing in 1992, he was, however, able to list 20 published descriptions of the occurrence of AIHA in more than one family member, included in the relationships were four pairs of twins. The reported occurrence of an immune-mediated disorder, other than AIHA, in the family of a patient with AIHA is, however, not rare. Dreyfus (1964), in an important review, mentioned the occurrence of thrombocytopenia, polyarteritis nodusa, rheumatoid arthritis, pernicious anaemia and hypogammaglobulinaemia. Pirofsky (1968b, 1969) stated that one or more relatives of eight out of 43 patients had suffered from a wide range of possible or probable auto-immune disorders. Conley (1981) reported an even higher incidence – 14 out of 33 patients. In the late 1940s, several accounts of patients with AIHA who had persistently low platelet counts were published, e.g. Fisher (1947) and Evans & Duane (1949); and it was suggested that the patients might have been forming auto-antibodies directed against platelets. This concept was further developed by Evans et al (1951). Eight out of their 18 patients with AIHA were thrombocytopenic; four had clinically obvious purpura. Evans et al (1951) suggested that there exists 'a spectrum-like relationship between acquired haemolytic anaemia and thrombocytopenic purpura'; also that 'on the one hand, acquired haemolytic anaemia with sensitization of the red cells is often accompanied with thrombocytopenia, while, on the other hand, primary thrombocytopenic purpura is frequently accompanied with red cell sensitization with or without haemolytic anaemia'. Many further case reports of AIHA accompanied by severe thrombocytopenia have since been published, e.g. in the later 1950s by Crosby & Rappaport (1957) and Dausset & Colombani (1959). AIHA was even reported to have developed in patients who had previously undergone splenectomy for thrombocytopenic purpura. Earlier, Waugh (1932), had described a possible example. The author (Dacie, 1954, 1962) described two similar occurrences. Some patients, too, have suffered from granulocytopenia as well as thrombocytopenia and haemolytic anaemia, e.g. as reported by Fisher (1947) and Evans et al (1951). Later descriptions include reports of the presence of antibodies against platelets and leucocytes in such cases, e.g. in patients described by Baumgartner (1956) and Müller & Weinreich (1956) (who coined the descriptive term 'Immunopancytopenien'). There are two features in the blood film of a patient with an acquired haemolytic anaemia which indicate that he or she is suffering from AIHA; one is auto-agglutination, the other is erythrophagocytosis. Spherocytosis, often to a is of found in other types of haemolytic anaemia. The early descriptions by published in the first decade of the century have already been referred descriptions published in the 1940s of patients suffering from acute haemolysis in which was include those of & Evans & (1947) and & by in the peripheral blood has been frequently It is most seen in & de et al had earlier described a patient suffering from acute haemolysis in whom both and were as It was not until the late 1930s that spherocytosis was recognized to be a phenomenon in acquired haemolytic anaemias, in addition to being a finding in congenital however, been earlier than this as a feature of the blood in experimental haemolytic anaemia in e.g. by & who described the cells as and & The of by Dameshek & Schwartz in the blood of to which immune had been and their of similar cells in the blood of patients suffering from acute haemolytic anaemia to be a most important contribution to knowledge & to that time, the in the at was that perhaps of the cases of acquired haemolytic anaemia with in the peripheral blood were in cases of previously congenital & The pioneer observations on already referred to were generally until the late 1930s, and serological to have been until the of Dameshek & in which they described the presence of in cases of acute acquired haemolytic anaemia. Dameshek & Schwartz summarized contemporary knowledge in an extensive They concluded that it was not that haemolysins of types and were in fact for many cases of haemolytic anaemias, congenital haemolytic anaemia, which they suggested might be caused by the or less of an Dameshek and concept of the important role of haemolysins in haemolytic anaemia was with some by their a difficulty in its being that, in the of cases, the presence of a could not be by that were then years were to before the concept that an abnormal immune mechanism played a role in some cases of acquired haemolytic anaemia was by et al who reported that the erythrocytes of five patients with acquired had been agglutinated by an antiglobulin i.e. that the described antiglobulin or test et al, was the test had been negative in patients suffering from congenital This work interest and was and by other the Early reports included those of & van who the presence of antibody in their patients' by of an test and also that normal cells varied in their to the (1947) reported that direct and were positive in three patients and that antibody could be from patients' Evans et al (1947) also showed that could be from of patients' cells by at and that the could be to normal They too, that their patients' cells when in and they to the in between the antibody of haemolytic anaemia and that of work was directed to the of the positive antiglobulin and on the of the antibodies involved. & (1947) that the in antiglobulin that with antibody erythrocytes was in all an van Loghem et al reported that, in AIHA, when of antiglobulin serum were the might be in the of antiglobulin i.e. there was a so-called In the author had reported that the effect on the agglutination of erythrocytes from patients with AIHA of to antiglobulin was (Dacie, 1951). the test was carried out with the erythrocytes of two patients with warm-antibody AIHA, the was by small of in more was to the in two patients whose serum contained cold These findings In interest was on the of the erythrocytes that were agglutinated by antiglobulin to which large of had been – a so-called the cells by antibody other than or was the between and antibodies in the antiglobulin or were being to Subsequent work that the the of of (Dacie et al, et al, work has been to the involved. According to et al using the erythrocytes of patients with the disease which a are with et al also that erythrocytes were agglutinated by both and the the auto-antibodies for AIHA were generally concluded to be According to et al cell auto-antibodies react not only with the own red cells but also with the erythrocytes of all other The on the red blood cell with which the auto-antibodies are the and that, in the the blood with which the auto-antibodies react are not but are by all They suggested that the auto-antibodies might be directed to the of the Earlier work however, that the of normal erythrocytes to a patient's might & van & That auto-antibodies might have a e.g. was described by & (1954) in the of their to et al they clear investigation made the that a by one of them in in had after all been the serum of a who had of a haemolytic anaemia contained his cells were A similar i.e. an was described by et al too, reported that he had a in a case of the patient's probable was was in serum and and a in erythrocyte (1953) and & (1954) were able to on the of the auto-antibodies formed by 10 patients with warm-antibody AIHA. of the patients had developed antibodies that appeared to be three of them were also forming and one further patient had formed and at As the probable of these patients was it was clear that the antibodies were as auto-antibodies. The antibodies were interesting in three patients the antibodies appeared to have two – a with all the cells tested and a with all the cells tested those of The of carried out by van Loghem & van were auto-antibodies were in five out of six namely, and The reports summarized without that many of the auto-antibodies in warm-antibody AIHA were with in all cases the The relative proportions of to antibodies was, however, as cases in which a had been were more to be recorded that those in which no had been The data available up to in that auto-antibodies of were being formed by almost of patients. The referred to were and A It has been for instance, in relation to antigens that several antibodies of may be at the same time and that some with normal