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  IN THIS Article
 ::  Abstract
 ::  Case history
 ::  Discussion
 ::  Acknowledgments
 ::  References

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CASE REPORT
Year : 2002  |  Volume : 48  |  Issue : 1  |  Page : 37-8

Acquired pure red cell aplasia in a child.


Division of Paediatric Haematology-Oncology, L.T.M.G. Hospital, Sion, Mumbai - 400022, India., India

Correspondence Address:
R A Sharma
Division of Paediatric Haematology-Oncology, L.T.M.G. Hospital, Sion, Mumbai - 400022, India.
India
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Source of Support: None, Conflict of Interest: None


PMID: 12082327

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 :: Abstract 

Primary acquired pure red cell aplasia is a rare occurrence in childhood. An eleven-year old boy presented to us with pallor, which required multiple packed red cell transfusions. He did not have hepatosplenomegaly, jaundice or lymphadenopathy. Bone marrow examination revealed the diagnosis of pure red cell aplasia. All possible investigations were done to exclude secondary causes of pure red cell aplasia. No secondary cause was found on investigations. Rheumatoid factor and anti-nuclear antibodies were positive. He was started on oral steroids, to which he did not respond. He was then given cyclosporine A. Response to cyclosporine was dramatic and the child now does not require any transfusions.


Keywords: Blood Transfusion, Bone Marrow, pathology,Case Report, Child, Chronic Disease, Cyclosporine, therapeutic use,Hemoglobins, analysis,Human, Immunosuppressive Agents, therapeutic use,Male, Red-Cell Aplasia, Pure, diagnosis,drug therapy,


How to cite this article:
Sharma R A, Hiwarkar P, Manglani M V, Muralidhar H P. Acquired pure red cell aplasia in a child. J Postgrad Med 2002;48:37

How to cite this URL:
Sharma R A, Hiwarkar P, Manglani M V, Muralidhar H P. Acquired pure red cell aplasia in a child. J Postgrad Med [serial online] 2002 [cited 2019 Apr 21];48:37. Available from: http://www.jpgmonline.com/text.asp?2002/48/1/37/155


Acquired pure red cell aplasia (PRCA) is a disease characterised by normocytic, normochromic anaemia, low haematocrit, reticulocytopaenia and selective erythroid hypoplasia. PRCA can occur as a chronic or acute form; the former is predominantly seen in adults and latter in children.[1] Pathogenesis involves immune dysfunction with antibodies directed against erythroid precursor cells or erythropoietin, or due to T-cell mediated suppression of erythropoiesis. Due to its rare occurrence in the paediatric age group, we report a case of chronic acquired PRCA who was treated with cyclosporine A.


  ::   Case history Top


An eleven-year-old boy presented with a history of pallor, noticed two months prior to admission, and fever of four days duration, one month prior to admission. He was transfused four units of blood over a period of two months. There was no history of lump in abdomen, bleeding from any site, jaundice, bone pains, drug ingestion, joint swellings or rash. There was no history of blood transfusions received by him or his family members any time in the past. There was no history of tuberculosis or contact with tuberculosis.

Apart from pallor, his general examination findings were non-contributory. A functional systolic murmur was heard at the base of the heart. Other systemic examination did not reveal any abnormality.

On investigations, haemoglobin was 2.2gm%, haematocrit 8.8%, reticulocyte count 0%, total red cell count 0.94 million/cmm, mean corpuscular volume 93.3 fl, mean corpuscular haemoglobin 31.8 pg, mean corpuscular haemoglobin concentration 34.1%, and red cell distribution width 18.3%. The total white cell count was 4,800/cmm, with 57% polymorphs, 32% lymphocytes, 4% eosinophils and 7% monocytes, and the platelet count was 3,67,000/cmm. Peripheral blood smear showed normochromic, normocytic red cells with occasional macrocytes and tear drop cells. Stool for occult blood was negative. Serum bilirubin was 0.6mg%. Haemoglobin F was 0.40%. The direct and indirect antiglobulin tests were negative. Liver and renal function tests were normal. Chest X-ray was within normal limits and Mantoux test was negative. Bone marrow aspiration and trephine biopsy showed red cell hypoplasia, without giant pronormoblasts, with normal myeloid and megakaryocytic series. The M:E ratio was 11.2:1. A high resolution computed tomography of chest ruled out thymoma. Serum immunoglobulins revealed an IgG level of 2200 mg% (N - 565 to 1570 mg%), IgM and IgA of 87.5 mg% (N - 28 to 135 mg%) and 360 mg% (N - 102 to 545 mg%) respectively. Rheumatoid factor was positive (>128 IU/ml), anti-nuclear antibodies were also positive (1: 40) and anti-dsDNA was negative. Paul-Bunnel test, antibodies to HIV by ELISA, and HBsAg were negative. Parvovirus B19 DNA or IgM (ruled out on the basis of absence of giant pronormoblasts on bone marrow examination), and antibodies to erythroid precursors and erythropoietin could not be done, because these tests were not available. A diagnosis of primary acquired PRCA was made.

On diagnosis, the child was put on oral prednisolone in the dose of 2mg/kg/ day in four divided doses. A partial

response was observed after a week, with an increase in reticulocytes (corrected reticulocyte count 1.8%). However, over the next three weeks, haemoglobin dropped from 9.2gm% to 6.1gm%, and hence he was started on cyclosporine A in the dose of 12 mg/kg/day in 2 divided doses and titrated to maintain blood trough levels of 100 to 250 ng/ml (done by radio-immunoassay). Steroids were tapered and omitted. After starting cyclosporine A he is maintaining haemoglobin between 8.5 and 10.5 gm% without blood transfusion during a period of nine months.


  ::   Discussion Top


Pure red cell aplasia, first described by Kaznelson, more than 70 years ago,[2] may be congenital or acquired. Congenital PRCA is also known as Diamond-Blackfan syndrome. Acquired PRCA, rare in children, may be primary or secondary to conditions like Parvovirus B19 infection, thymoma, myelodysplatic diseases, drugs (including alpha-interferons, diphenylhydantoin, isoniazid, lamivudine), collagen vascular diseases and infections including tuberculosis.[1],[3],[4],[5],[6]

Acquired primary PRCA commonly occurs at a mean age of 60 years. Rare familial cases have been reported. The male to female ratio is 2:1. It has been postulated that primary PRCA has an autoimmune basis, which has been confirmed by in-vivo and in-vitro studies.[2] It can be due to humoral or cellular mechanisms. Evidence of clonal rearrangement of the T-cell receptor beta chain gene has suggested it to be a clonal T-cell proliferative disorder, in which T cells suppress erythropoiesis.[7] Since immune basis is commonly known to cause primary acquired PRCA, treatment includes immunosuppression and/or immunomodulation. Various drugs including immunosuppressive agents, such as corticosteroids, androgens, cytotoxic drugs like cyclophosphamide, azathioprine, 6-mercaptopurine, vincristine, daunorubicin etc. and immunomodulators like anti-thymocyte globulin/ anti-lymphocyte globulin, intravenous immunoglobulin G and cyclosporin have been tried with variable success.[8],[9],[10] Other modalities include splenectomy, plasmapheresis and stem cell transplantation.[11] Recently Anti-CD20 monoclonal antibody (Rituximab), which is highly effective for in-vivo B-cell depletion, has been tried with success in PRCA.[12]

Cyclosporin A (cyclic undecapeptide), a fungal metabolite, acts by inhibiting IL-2 production by T-lymphocytes, which, in turn, prevents cytotoxic T-cell activation. Amongst the various modalities tried, cyclosporin A has been the most successful drug.[9] For patients on cyclosporine, monitoring is essential to prevent complications, especially, renal failure.


  ::   Acknowledgments Top


We are grateful to Dr. A. R. Fernandez, Dean of the institution for permitting to publish this article and Dr. Madhuri Kulkarni, Head of Department of Paediatrics for her encouragement towards the writing of this article.

 
 :: References Top

1.Frickhofen N, Chen J, Young NS, Cohen BJ, Heimpel H, Ambokowitz JL. Parvovirus as a cause of acquired pure red cell aplasia. Br J Haematol 1994;87:818-824.   Back to cited text no. 1    
2.Malthotra OP, Mohan A, Saxena R. Cyclosporine in pure red cell aplasia. J Assoc Physicians India 1994;42:664-665.   Back to cited text no. 2    
3.Maggi G, Casido C, Cianci R, Molinati M, Ruffini E. Thymoma: results of 241 operated cases. Ann Thorac Surg 1991;51:152-156.   Back to cited text no. 3    
4.Dutta S, Mohta R, Pati HP. Tuberculosis and pure red cell aplasia. Int J Tuberc Lung Dis. 1999;3:61-362.   Back to cited text no. 4    
5.Marseglia GL, Locatelli F. Isoniazid- induced pure red cell aplasia in two siblings. J Pediatrics. 1998;132:898-900.   Back to cited text no. 5    
6.Majluf-Cruz A, Luna-Castaros G, Trevino-Perez S, Santoscoy M, Nieto-Cisneros L. Lamivudine-induced pure red cell aplasia. Am J Hematol 2000;65:189-191.  Back to cited text no. 6    
7.Nidorf D, Saleem A. Immunosuppressive mechanisms in pure red cell aplasia - a review. Ann Clin Lab Sci 1990;20:214-219.  Back to cited text no. 7    
8.Douglas AC, Dessypris EN, Krantz SB. Studies on Pure red cell aplasia XI. Results of Immunosupressive Treatment of 37 patients. Blood 1984;63:277-286.   Back to cited text no. 8    
9.Mamiya S, Itoh T, Miura AB. Acquired pure red cell aplasia in Japan. Eur J Haematol 1997;59:199-205.  Back to cited text no. 9    
10.Patel AP, Chandy M, Sudarsanam A. Refractory chronic pure red cell aplasia (PRCA) treated with vincristine and daunorubicin. Br J Haematol 1991;78:457-458.   Back to cited text no. 10    
11.Muller BU, Tichelli A, Passweg JR, Nissen C, Wodnar-Filipowicz A, Gratwohl A. Successful treatment of refractory acquired pure red cell aplasia (PRCA) by allogeneic bone marrow transplant. Bone Marrow Transplant 1999;23:1205-1207.   Back to cited text no. 11    
12.Zecca M, De Stefano P, Nobili B, Locatelli F. Anti-CD20 monoclonal antibody for the treatment of severe, immune-mediated, pure red cell aplasia and hemolytic anemia. Blood 2001;97:3995-3997.  Back to cited text no. 12    



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Online since 12th February '04
2004 - Journal of Postgraduate Medicine
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