Donath-Landsteiner Hemolytic Anemia

The autoantibody responsible for Donath-Landsteiner hemolytic anemia (DLHA) is a cold-reacting immunoglobulin known as the D-L autoantibody. The D-L autoantibody is a biphasic hemolysin capable of causing severe hemolysis even when the titer detected is low. This is due to its ability to detach from lysed RBCs and subsequently bind intact erythrocytes with changes in temperature.

D-L antibodies are directed against antigens expressed on the RBC membrane. Most commonly, the target is the P antigen but I antigen specificity and others have been described.[3]

The antibody attaches to RBC surfaces in the peripheral circulation, where temperatures are cooler (< 30°C). After binding, the D-L autoantibody activates the complement cascade, resulting in perforation of the RBC membrane (ie, intravascular hemolysis). Complement activation and resulting hemolysis occur only after the RBC travels to an area of warmer temperature (37°C) in the central circulation.

Therefore, the direct antiglobulin test (DAT) results are positive with anti-C3 but negative with anti-IgG or anti-IgM, unless the test is begun at 4°C and subsequently incubated at 37°C (see Workup).[11]

The antibody typically appears days to weeks after the trigger and may persist for months.

Donath-Landsteiner hemolytic anemia (DLHA) may be either idiopathic or secondary to an identifiable cause. Historically, the secondary type is most closely associated with late-stage or chronic congenital syphilis. Acute cases are often deemed idiopathic but are generally presumed to be secondary to a preceding viral illness or to an immunization. A definitive causative agent is rarely identified.

Viral infections that have been associated with acute Donath-Landsteiner hemolytic anemia include the following:

• Measles

• Mumps

• Epstein-Barr virus (EBV)

• Cytomegalovirus (CMV)

• Varicella zoster virus

• Adenovirus

• Coxsackievirus A9

• Parvovirus

• Influenza A

Respiratory syncytial virus (RSV) has been reported to have caused paroxysmal cold hemoglobinuria in a child, while Leibrandt et al reported the first documented case in which RSV caused the disease in an adult.[12, 13]

Bacterial infections associated with acute DLHA include those caused by the following pathogens[11] :

• Mycoplasma pneumoniae

• Haemophilus influenza

• Klebsiella pneumonia

• Escherichia coli

Oncologic associations also exist. DLHA has been rarely associated with non-Hodgkin lymphoma[14, 15] and oat cell carcinoma.[16]

Acute autoimmune hemolytic anemia (AIHA) is relatively rare.[11]

Acute Donath-Landsteiner hemolytic anemia (DLHA) is more common in children than in adults. In children, the D-L autoantibody is a common cause of AIHA. However, the condition can occur in patients of all ages, and the diagnosis should be considered when the clinical and laboratory presentations are suggestive of the disorder.[17, 18]

A literature review by Jacobs et al indicated that the epidemiology of DLHA has changed since the mid-20th century. Although currently DLHA generally arises in children, following acute infection, most often upper respiratory infection and gastroenteritis, the investigators reported that between 1950 and 1970, syphilis was present in 53% of patients diagnosed with DLHA. Individuals with DLHA during this 20-year period had a median age of 31 years, with the median age of those whose disease was secondary to syphilis being 42 years. The epidemiology of DLHA is thought to have been impacted by the widespread employment of antitreponemal therapy.[19]

In one review of 52 patients with D-L antibodies, the median age was 5 years (range, 1-82 y).[20] Due to under-diagnosis, the true incidence is unknown but DLHA may represent 30-40% of all pediatric AIHA cases cases.[21]

DLHA appears to be more common in males (52 of 77 cases in 3 combined reviews), with a male-to-female ratio of 2.1:1.[22, 23]  Estimates differ, however, with the study by Jacobs and colleagues reporting the male-to-female ratio to be nearly equal, at 1.17:1, and the ratio in children aged 5 years or under to be 1.25:1.[19]

No racial or ethnic predilection has been noted.

Most patients with Donath-Landsteiner hemolytic anemia (DLHA) do not require intervention. In rare cases, a severe acute drop in hemoglobin may be life threatening. These children may develop hypovolemic shock and cardiac failure.

Another potential complication of DLHA is acute tubular necrosis due to hemoglobinuria.

In general, however, prognosis in DLHA is very good, with most patients recovering spontaneously within 1 month of disease onset.[24]

Mild chronic hemolytic anemia has been observed in several children with the possibility of recurrence on exposure to cold or with illness.[17]

Analysis of cases of recurrent DLHA suggests that repeated episodes of hemolysis may be likely when the child has a D-L antibody to an antigen other than anti-P.[25, 3]

Chronic syphilis-associated DLHA resolves with appropriate treatment of the underlying disease.

The classic signs of Donath-Landsteiner hemolytic anemia (DLHA) include a sudden onset of hemoglobinuria accompanied by pallor and mild jaundice.[8] Hemoglobinuria may be absent if the autoantibody level is not high enough to cause intravascular hemolysis. Patients and their caretakers may report dark, brown, black, or otherwise abnormally colored urine.

A preceding history of upper respiratory tract infection or other viral infection is common, particularly in the younger age group. Preceding exposure to cold may be elicited on the patient history.[11] It is not consistently reported, however. In fact, only 1 in 52 cases of DLHA reported by Sokol et al occurred after documented exposure to cold.[20]

Anemia may be mild, moderate, or severe.

High fevers, chills, back or leg pain, and abdominal cramping may also be reported, along with headache, nausea, vomiting, or diarrhea. These signs and symptoms typically resolve early in the clinical course. Some may be secondary to the causative viral infection.

Signs and symptoms of moderate to severe anemia also include dizziness, lightheadedness, palpitations, and shortness of breath.

Signs of anemia include the following:

• Pallor

• Tachycardia

• Fatigue

• Dyspnea

• Cardiac murmur

• Postural hypotension

Signs of hemolysis include the following:

• Jaundice

• Dark urine caused by hemoglobinuria with or without renal failure

• Splenomegaly - Rare; most likely results from the underlying condition

• Hepatomegaly - Rare; most likely results from the underlying condition

Systemic signs or symptoms include the following:

• Fever, rigors

• Pain or cramping in the back, legs, or abdomen

• Headache

• Nausea, vomiting, diarrhea

Vasomotor signs include the following:

• Cold urticaria

• Cyanosis

• Raynaud phenomenon

The diagnosis of Donath-Landsteiner hemolytic anemia (DLHA) can be elusive. The clinician must have a high index of suspicion.

Laboratory testing is crucial to making the diagnosis, and the medical team should be familiar with the assays available in the treating facility's laboratory. Definitive diagnosis requires performance of the Donath-Landsteiner test. There are several methods of performing this test, and sensitivity varies between assays; false-negative results may occur.[10]

A Canadian study, by Zeller et al, indicated that positive results in paroxysmal cold hemoglobinuria testing are rarer in adults than in children and that even when results are positive, diagnosis in adults is difficult to make. The study involved 52 tests and 124 cumulative testing years, with a positive D-L antibody test found in three adult patients and 14 children. Experts demonstrated poor agreement concerning whether the positive adult test results meant that paroxysmal cold hemoglobinuria was present.[27]

Anemia may be mild, moderate, or severe. Anemia is usually normocytic and normochromic. However, the mean corpuscular volume (MCV) may be elevated when reticulocytosis is present. Reticulocytosis does not develop until later in the disease; in the early stages, reticulocytopenia is often observed.

Leukopenia with or without neutropenia may be present early, but the leukocyte count gradually improves to within the reference range or higher. Leukocytosis may be present during an acute hemolytic episode.

The peripheral blood smear exhibits spherocytosis, polychromasia, nucleated RBCs, anisocytosis, poikilocytosis, and sometimes erythrophagocytosis by neutrophils (see the images below).[8, 9]

Blood smear showing spherocytosis, polychromatophilia, and erythrophagocytosis by neutrophils.

Blood smear showing spherocytosis, polychromatophilia, and erythrophagocytosis by neutrophils.

Blood typing should be performed on all patients even if anemia is mild. This is important because the hemoglobin may fall acutely and transfusion may be needed. Often, the presence of autoantibodies can interfere with blood typing. The D-L autoantibody may react with the RBCs of potential donors, making detection of alloantibodies difficult. Compatibility testing can be improved by performing typing at 37°C.

The direct antiglobulin test (DAT) with anti-IgG usually produces negative results because of dissociation of IgG from the RBC surface at warm temperatures. The DAT may produce weakly positive results if run at a cold temperature. A positive DAT result is due to C3.

The indirect antiglobulin test, if performed, must be carried out at a cold temperature.

Assays using labeled monoclonal anti-immunoglobulin (Ig) G are preferable. The autoantibody is IgG with anti-P specificity, although the specificity may be for other antigens. The titer is usually less than 1:100.

Donath-Landsteiner Bithermic Hemolytic Test

This is a hemolytic assay in which the patient's serum is incubated with normal RBCs and complement at 0-4°C to allow the early components of complement to be fixed. Subsequently, the specimen is incubated at 37°C in order to allow the later components of complement to be activated. The membrane attack complex lyses the RBCs.

The procedure for this test is as follows:

• Incubate normal papainized group O RBCs (papainization exposes RBC membrane P -antigen sites) and normal serum (as complement source) with the patient's serum (containing D-L antibody) at 0-4°C; the use of papainized pooled O-cells results in exposure of more antigen sites on the cell membrane to the antibody.

• Incubate a second group of samples, as above, at 37°C

• Incubate a third group first at 0-4°C for 30 minutes, then at 37°C for 60 minutes

The presence of hemolysis in the third group without hemolysis in either the first or second group of samples constitutes a positive test result and a diagnosis of Donath-Landsteiner hemolytic anemia.

The Donath-Landsteiner test has a low sensitivity, and results are positive only when the serum antibody titer is high and the test is performed precisely.

A false negative test may be seen if the following is present:

• Low level of antibody due to consumption during hemolysis

• Low complement levels from consumption during hemolysis (this can be prevented by mixing the patient sample with fresh normal donor serum as a source of complement)

• If donor serum as a source of complement is added, presence of globoside in the serum may neutralize the Donath-Landsteiner (D-L) antibody[28]

Autoantibody specificity may be indicated if D-L test result is positive. Most cases are associated with anti-P specificity, but other specificities have been reported.

Testing should also be performed to determine whether the D-L antibody is IgG or IgM class.

If the D-L test is negative and there is a high index of suspicion, the negative result may be false. More sensitive tests exist. Discuss what other assays may be available in the local laboratories.

Evidence of hemolysis is elevated levels of indirect bilirubin and lactate dehydrogenase in the presence of a decreased haptoglobin level.

Anemia may be mild, moderate, or severe.

Blood urea nitrogen (BUN) and creatinine levels may be abnormal if renal insufficiency is present.

Complement levels are typically decreased.

On serologic testing, results for syphilis, mycoplasmal infection, or viruses (eg, influenza A, measles, mumps, adenovirus, cytomegalovirus, varicella, Epstein-Barr virus [EBV]) may be positive, depending on the underlying cause.

Microscopic examination of the peripheral blood may show spherocytosis, RBC agglutination and anisopoikilocytosis. Erythrophagocytosis by neutrophils may also be seen.[8]

Reticulocytosis is common. If the etiology of the condition is parvovirus B-19 infection, reticulocytopenia may occur.

Hemoglobinuria, methemoglobinuria, and hemosiderinuria are often present but are not required for diagnosis (see urinalysis).

Proteinuria may also be noted.

Treatment of Donath-Landsteiner hemolytic anemia (DLHA) may not be necessary in children with stable mild anemia and normal renal function.

Indications for hospitalization in patients with DLHA include the following:

• Worsening anemia

• Severe anemia

• Respiratory or circulatory compromise

• Renal failure

• Severe infection

• Social situation that may preclude prompt access to care if the condition worsens

Transfer patients with severe anemia or complications to a facility where pediatric hematology physicians, blood banking, and pediatric intensive care services are available. Transfer severely ill patients to a facility where consultation with pediatric hematologists, pediatric nephrologists, and pediatric critical care specialists are available.

Anticipate severe anemia and/or acute renal failure. Manage symptoms of underlying infection, if present.

Monitor renal function and hemoglobin until normalized and stable.

Go to Pediatric Chronic Anemia, Anemia of Prematurity, Fanconi Anemia, Pediatric Acute Anemia, and Pediatric Megaloblastic Anemia for complete information on these topics.

Transfusion

Avoid unnecessary transfusions because of the expected transient nature of the condition. Risks of blood transfusion include transfusion reactions and transmission of infection. Blood transfusion is indicated only in selected individuals with Donath-Landsteiner hemolytic anemia (DLHA).

In patients with severe, symptomatic, or rapidly worsening anemia, transfusion of red blood cells (RBCs) must be provided. Guidelines for transfusions in neonates and older children have been established.[29]

For blood typing, perform compatibility testing using techniques to minimize the interference caused by the autoantibody. Consultation with a hematologist and a blood bank specialist may be helpful.

Although P antigen–negative RBCs are most efficacious, these units are extremely rare (most banked blood units are P antigen positive). Blood transfusion may be safely accomplished with P antigen–positive units in most cases, resulting in the expected hemoglobin increases based on the amount administered. Use blood warmers if possible to perform the RBC transfusion at 37°C.

Medications

The use of corticosteroids is controversial but responses have been reported. Corticosteroid therapy may be indicated in patients with DLHA and severe anemia.

Rituximab has been used to treat refractory autoimmune hemolytic anemia, including cold agglutinin disease. Although medical therapy of DLHA beyond the use of steroids is rarely required, rare refractory cases (particularly in adults) have been described in which rituximab was used successfully[30] and in which intravenous immunoglobulin (IVIG) has been used successfully.[2, 31]

Procedures

Plasmapheresis has been used successfully in extremely severe cases refractory to transfusion.[32] Anticipate the need for plasmapheresis early in the patient's clinical course.

Although exposure to cold is not always clearly associated with disease presentation, supportive care recommendations include avoidance of extreme cold exposure based on an understanding of disease pathophysiology.

Supportive care may also include interventions to prevent or ameliorate renal failure if hemoglobinuria is present. Maintain adequate hydration and urine output. Consult a pediatric nephrologist if renal compromise is identified.

Folic acid supplementation is appropriate because active hemolysis can consume folate and result in megaloblastosis. Folic acid supplementation aids in the production of erythrocytes and in the resolution of anemia.

Viral infections are self-limited. Treat syphilis and mycoplasmal infections with appropriate therapy. Hemolysis resolves with treatment of the underlying infection.

Splenectomy has no role in treatment of Donath-Landsteiner hemolytic anemia because the hemolysis is intravascular.

Currently, prevention of Donath-Landsteiner hemolytic anemia is not possible.

For chronic idiopathic Donath-Landsteiner hemolytic anemia, avoidance of extreme cold exposure may prevent symptoms from recurring.

Frequency of surveillance testing must be determined by the clinical course. Perform the following periodic evaluations until the values are normal and stable:

• Clinical examination

• CBC count

• Reticulocyte count

• Total bilirubin

• Lactate dehydrogenase

• Microscopic urinalysis

• Direct antiglobulin test (DAT)

Repeat the above testing if the patient presents with similar signs or symptoms. Have a low threshold to evaluate the child for recurrent disease.

Steroids may be effective in controlling hemolysis. The ideal effective dose is unknown. Wean gradually in patients who have been treated with prolonged courses.

Class Summary

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli.

Prednisone (Deltasone, Meticorten, Orasone, Sterapred)

Prednisone is an immunosuppressant for treatment of autoimmune disorders; it may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear neutrophil (PMN) activity. It stabilizes lysosomal membranes and suppresses lymphocytes and antibody production.