0 Bewertungen0% fanden dieses Dokument nützlich (0 Abstimmungen)
35 Ansichten9 Seiten
Cold-antibody types include primary cold agglutinin disease (CAD) treatment seems indicated more often than previously thought. Most efficient treatment to date is fludarabine and rituximab in combination.
Cold-antibody types include primary cold agglutinin disease (CAD) treatment seems indicated more often than previously thought. Most efficient treatment to date is fludarabine and rituximab in combination.
Cold-antibody types include primary cold agglutinin disease (CAD) treatment seems indicated more often than previously thought. Most efficient treatment to date is fludarabine and rituximab in combination.
Diagnosis and treatment of cold agglutinin mediated autoimmune hemolytic anemia
Sigbjrn Berentsen a, , Geir E. Tjnnfjord b, 1 a Department of Medicine, Haugesund Hospital, Helse Fonna, P.O.Box 2170, NO-5504 Haugesund, Norway b Department of Haematology, Oslo University Hospital, Rikshospitalet and Institute of Clinical Medicine, University of Oslo, P.O.Box 4950, Nydalen, NO-0424 Oslo, Norway a b s t r a c t a r t i c l e i n f o Keywords: Hemolytic anemia Autoimmune Cold agglutinin Cold agglutinin disease Lymphoproliferative Diagnosis Therapy Rituximab Fludarabine Exact diagnosis of the subtype has essential therapeutic consequences in autoimmune hemolytic anemia. Cold-antibody types include primary chronic cold agglutinin disease (CAD) and rare cases of cold agglutinin syndrome (CAS) secondary to cancer or acute infection. Primary CAD is a clonal lymphoproliferative disorder. Not all patients require pharmacological therapy, but treatment seems indicated more often than previously thought. Corticosteroids should not be used to treat primary CAD. Half of the patients respond to rituximab monotherapy; median response duration is 11 months. The most efcient treatment to date is udarabine and rituximab in combination, resulting in responses in 75%, complete responses in 20% and median response duration of more than 66 months. Toxicity may be a concern, and an individualized approach is discussed. Erythrocyte transfusions can be given provided specic precautions are undertaken. No evidence-based ther- apy exists in secondary CAS, but optimal treatment of the underlying disorder is essential when feasible. 2012 Elsevier Ltd. All rights reserved. 1. Introduction Autoimmune hemolytic anemia (AIHA) is a group of uncommon disorders characterized by hemolysis due to autoantibodies against red blood cell surface antigens. The autoantibodies may be warm- reactive with a temperature optimum at 37 C or cold-reactive with a temperature optimum way below the normal body temperature. AIHA can be classied, accordingly, into warm and cold reactive anti- body types and further subdivided based on the presence of underly- ing or associated disorders. A widely accepted classication is shown in Table 1. 13 Altogether, the cold-reactive types probably account for about 25% of all AIHA. 1, 2 The involved autoantibodies are cold agglutinins (CA), dened by their ability to agglutinate erythrocytes at an optimum temperature of 04 C (Fig. 1). 4, 5 Most CAs are of the immunoglobu- lin(Ig)M class, although IgG or IgA CAs are occasionally found. 5, 6 The pathogenesis and management of AIHA differ substantially depend- ing of the characteristics of the autoantibody and, therefore, a correct and precise diagnosis of the subtype has critical therapeutic conse- quences. Particularly in primary cold agglutinin disease (CAD), con- siderable progress has been made during the last 12 decades in the knowledge of clinical features, humoral and cellular immunology and bone marrow pathology. 4, 69 Therapy for primary CAD was largely unsuccessful until 10 years ago, but efcient treatment op- tions have now become available. 10 The term cold (hem)agglutinin disease (CAD, CHAD) is some- times used in a broad sense as a synonym for cold agglutinin syn- drome (CAS), including all types of cold antibody AIHA. 3, 1114 We and others prefer to use the termCAD in a narrowsense, synonymous with primary chronic CAD. 1, 10, 15 This particular, well-dened and well-characterized clinicopathological entity should be called a dis- ease, not syndrome. Although this reviewwill concentrate on primary chronic CAD, we will also discuss the diagnosis and management of acute and chronic secondary CAS. Mixed-type AIHA and paroxysmal cold hemoglobinuria will not be addressed. 2. Pathogenicity of cold agglutinins Cold hemagglutination was described in 1903 and found to occur in humans in 1918. 16, 17 The association between cold hemagglutina- tion and hemolysis was rst reported in 1937. 18 CA can be deter- mined semi-quantitatively by the titer, based on their ability to agglutinate erythrocytes at 4 C. 4 Screening for CA have shown that a high proportion of the adult population has CA in serum without any evidence of hemolysis or other disease. 5, 15 These normally occur- ring CA are polyclonal and are found in low titers, usually below 64 and rarely exceeding 256. 5 On the contrary, in 172 consecutive indi- viduals with monoclonal IgM in serum, signicant CA activity was found in 8.5% with titers between 512 and 65,500, and all individuals with detectable CA had hemolysis. 19 Thus, monoclonal CA are gener- ally far more pathogenic than polyclonal CA. The thermal amplitude is dened as the highest temperature at which the CA will react with the antigen. 4, 20 In general, the pathoge- nicity of CA is more dependent on the thermal amplitude than on the titer. 20, 21 The normally occurring CA have low thermal amplitudes. If Blood Reviews 26 (2012) 107115 Corresponding author. Tel.: +47 52732000; fax: +47 52770189. E-mail addresses: sigbjorn.berentsen@haugnett.no (S. Berentsen), geir.tjonnfjord@oslo-universitetssykehus.no (G.E. Tjnnfjord). 1 Tel.: +47 23070713; fax: +47 23070470. 0268-960X/$ see front matter 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.blre.2012.01.002 Contents lists available at SciVerse ScienceDirect Blood Reviews j our nal homepage: www. el sevi er . com/ l ocat e/ bl r e the thermal amplitude exceeds 2830 C, erythrocytes will aggluti- nate in the circulation in acral parts of the body even at mild ambient temperatures and, often, complement xation and complement- mediated hemolysis will ensue. CA should not be confused with cryo- globulins. Occasionally, however, patients have been reported in whom the cryoprotein had both CA and cryoglobulin properties. 8, 22, 23 CA are most often directed against the Ii blood group system. 4, 24 About 90% of CA are anti-I specic while most of the remaining ones show specicity for i. 3, 5 The I and i antigens are carbohydrate macromolecules and the densities of these antigens on the erythro- cyte surface are inversely proportional. Neonatal red blood cells al- most exclusively express the i antigen, while the I antigen predominates in individuals of 18 months of age and older. 25 Hence, CA with anti-I specicity are generally more pathogenic in children and adults than those specic for the i antigen. 5, 25, 26 Occasionally, CA show specicity against the erythrocyte surface protein antigen designated Pr and such CA can be highly pathogenic. 26, 27 Several other specicities have been reported but are probably very rare. Cooling of blood during passage through acral parts of the circula- tion allows CA to bind to erythrocytes and cause agglutination (Fig. 1). Antigen-bound IgM-CA is more prone than IgG to bind com- plement protein C1 and thereby initiate the classical complement pathway. 2831 C1 esterase activates C4 and C2, generating C3 conver- tase which leads to the formation of C3b. Upon returning to central parts of the body with a temperature of 37 C, IgM-CA detaches from the cell surface, allowing agglutinated erythrocytes to separate from each other, while C3b remains bound. A proportion of the C3b- coated red cells are sequestered by cells of the reticulo-endothelial system (RES), mainly in the liver. On the surface of the surviving erythrocytes, C3b is cleaved, leaving high numbers of C3d molecules on the cell surface. Complement activation may proceed beyond the C3b formation step, resulting in C5 activation, formation of the mem- brane attack complex and intravascular hemolysis. Due to surface- bound regulatory proteins such as CD55 and CD59, however, the complement activation is usually not sufcient to produce clinically signicant activation of the terminal complement pathway. The major mechanism of hemolysis in stable disease, therefore, is the ex- travascular destruction of C3b-coated erythrocytes by the RES. 29, 30, 32, 33 These mechanisms explain why the direct antiglobulin test (DAT) is strongly positive for C3d in patients with CA mediated hemolysis and, in a majority, negative for IgM and IgG. In up to 20% of patients with primary CAD, however, DAT is also weakly positive for IgG, which should not lead to a wrong diagnosis of mixed-type AIHA. 6, 34 3. Primary chronic cold agglutinin disease 3.1. Epidemiology Primary CAD accounts for about 15% of all cases of AIHA. 1, 2, 35 The prevalence in Norway has been estimated to 16 per million inhabi- tants and the incidence rate to 1 per million inhabitants per year. 6 The median age of patients with CAD is 76 years (range, 5196) with a median age at onset of symptoms of 67 years (range, 3092). 6 3.2. Clinical, immunological and pathological characteristics By denition, all patients with CAD have hemolysis, but occasional patients are not anemic because the hemolysis is fully compensated. Most patients, however, have manifest hemolytic anemia. Of 16 pa- tients described in an early publication, ve had hemoglobin (Hgb) levels below 7.0 g/dL and one had levels below 5.0 g/dL. 36 Hgb levels ranged from 4.5 g/dL to normal in a more recent population-based descriptive study of 86 Norwegian patients. 6 In the same study, the median Hgb level was 8.9 g/dL and the lower tertile was 8.0 g/dL. Fifty per cent of the patients had been considered transfusion depen- dent for shorter or longer periods during the course of the disease, and 70% had received drug therapy. Although the term cold refers to the biological properties of the CA, not the clinical features, approx- imately 90% of the patients experienced cold-induced acrocyanosis and/or Raynaud phenomena. 6 These symptoms ranged from slight to disabling. Characteristic seasonal variations in the severity of he- molytic anemia have been well documented. 37 In at least two-thirds of the patients, exacerbation of hemolytic anemia is also triggered by febrile infections or major trauma. 6, 38, 39 The explanation for this paradoxical exacerbation is that during steady-state CAD, most patients are complement-depleted with low levels of C3 and, in par- ticular, C4. During acute phase reactions, C3 and C4 are repleted and complement-induced hemolysis increases. 4, 39 It has been known for decades that the CA in patients with prima- ry CAD are usually monoclonal IgMantibodies, most often with light chain restriction. 40, 41 Our study of 86 unselected patients showed that this was the case in more than 90% of the patients, whereas monoclonal IgG, IgA or light chain restriction were rare ndings. 6 In 6% of the patients, monoclonal Ig could not be detected despite otherwise characteristic primary CAD. This is probably a matter of sensitivity. Anti-I CA in patients with primary CAD show restriction to the IGHV4-34 gene segment. 7 During the last 15 years it has become clear that in a majority of pa- tients, clonality at the B-cell level can also be demonstrated by owcy- tometry and/or immunohistochemistry. 6, 8 We found a clonal, CD20 + B-lymphocyte population and a cellular / ratio of more than 3.5 in 90% of bone marrow aspirates, 6 while the sensitivity of ow cytometry was lowif performed in peripheral blood. 8 A clonal lymphoproliferative bone marrow disorder, usually discrete, was conrmed by immunohis- tochemistry in 75% of the patients. 6 The lymphoproliferation was most frequently classied as lymphoplasmacytic lymphoma (LPL; 50% of the Table 1 Autoimmune hemolytic anemia. Warm-antibody type Primary Secondary Cold-antibody type Primary chronic cold agglutinin disease Secondary cold agglutinin syndrome Associated with malignant disease Acute, infection-associated Paroxysmal cold hemoglobinuria Mixed cold- and warm-antibody type Fig. 1. Peripheral blood smear from a patient with primary CAD. 108 S. Berentsen, G.E. Tjnnfjord / Blood Reviews 26 (2012) 107115 total patient cohort) or marginal zone lymphoma (MZL; 8% of the pa- tients). 6, 42 The histopathology ndings are listed in Table 2. Since LPL is a frequent nding and most if not all patients have monoclonal IgM, a considerable overlap exists between primary CAD and Waldenstrm's macroglobulinemia (WM). 4345 In most pa- tients who do not fulll the criteria for LPL/WM or MZL, primary CAD can be classied as an IgM-related disorder (IgM-RD). IgM-RD is dened as a clinical condition characterized by specic properties of monoclonal IgM proteins, but without lymphoma. 46 In a clinical context, however, CAD with denitive or merely detectable clonal lymphoproliferation should be regarded a continuum, not distinct en- tities. Unlike warm-antibody AIHA, primary CAD does not appear to be associated with other autoimmune diseases, probably reecting a competent regulation of the immune system. 4, 6 3.3. Diagnosis Primary CAD should be suspected in elderly patients with chronic hemolytic anemia and/or the cold-induced circulatory symptoms mentioned above. Although not specic, the observation of aggluti- nated erythrocytes in a peripheral blood smear (Fig. 1) will increase the suspicion of CA-mediated phenomena. When hemolysis has been conrmed by biochemical tests and, often, elevated absolute re- ticulocyte counts, polyspecic DAT is required to detect autoimmune pathogenesis. Monospecic DAT is also mandatory and will be strongly positive for C3d and negative (or weakly positive in 20% of the patients) for IgG. 6, 34 CA titers should be determined using serial two-fold dilutions of serum before adding a suspension of adult 0RhD positive erythrocytes and incubating at 4 C. 4 A titer of 64 or more is required for diagnosis, but most patients have sub- stantially higher titers. 46 Determination of the thermal amplitude may be useful in some situations, but is usually not necessary in order to establish the diagnosis. The concentrations of complement proteins C3 and C4 should be determined, but normal levels do not exclude CAD. 4, 6, 31, 39 Conrming the presence of a clonal lymphoproliferative disorder has potential therapeutic consequences, even though negative nd- ings may be a matter of sensitivity and do not exclude primary CAD. 6, 31 Capillary electrophoresis or agarose electrophoresis with immunoxation should always be performed. If no monoclonal band can be detected on electrophoresis, immunoxation should still be done. A trephine biopsy should be examined by an experi- enced lymphoma pathologist, and we also recommend ow cyto- metric immunophenotyping of bone marrow lymphocytes. 8, 9 History and clinical examination, supplemented by radiological imag- ing as required, will usually be sufcient to exclude cases of second- ary chronic CAS described below. The diagnostic criteria for primary CAD are summarized in Table 3. 6, 31 Fig. 2 shows a diagnostic algorithm. Importantly, in order to achieve sufcient sensitivity, serum for immunoglobulin analyses and CA titration must be obtained from blood specimens kept at 3738 C from sampling until serum has been removed from the clot. 4. Chronic cold agglutinin syndrome secondary to malignant disease 4.1. Denition, frequency and underlying disorders After primary CAD was shown to be a clonal lymphoproliferative disease, there has been some confusion in the literature regarding Table 2 Bone marrow histopathology in primary chronic cold agglutinin disease. Immunohistochemistry ndings n % Normal or reactive lymphocytosis 7 11 Irregular lymphoid hyperplasia 9 13 Non-Hodgkin's B cell lymphoma 50 76 Lymphoplasmacytic lymphoma 33 50 Marginal zone lymphoma 5 8 Small lymphocytic B-cell lymphoma 4 6 Clonal lymphocytosis/other small B-cell lymphoma 8 12 Total 66 100 Table 3 Diagnostic criteria for primary chronic cold agglutinin disease. Level Criteria Procedures and comments Required for diagnosis Chronic hemolysis Polyspecic DAT positive Monospecic DAT strongly positive for C3d DAT is usually negative for IgG, but occasionally weakly positive Cold agglutinin (CA) titer 64 at 4 C Blood specimen must be kept at 3738 C from sampling until serum is removed from the clot No overt malignant disease Clinical assessment. Radiology as required Conrmatory but not required for diagnosis Monoclonal IgM in serum (or, rarely, IgG, IgA or phenotype) Serum must be obtained as for CA titer. Immunoxation should be done even if no band is visible on electrophoresis Cellular / ratio >3.5 (or, rarely, b0.9) in B-lymphocyte population Flow cytometry in bone marrow aspirate Clonal lymphoproliferative bone marrow disorder by immunohistochemistry Trephine biopsy Hemolysis ? Cold-induced circulatory symptoms Anemia Yes No Probably not AIHA Polyspecific DAT Positive Negative Monospecific DAT Positive for C3d Negative for C3d Not AIHA Consider w-AIHA CA-titer > 64 0-32 Assess for infection or overt malignancy None Primary CAD Onset of anemia before infection? Secondary CAS Confirm clonality if possible (Table 3) Yes Acute febrile infection Overt malign- ancy No Fig. 2. Diagnostic algorithm for cold-antibody mediated AIHA. Abbreviations: AIHA, au- toimmune hemolytic anemia; CA, cold agglutinin; CAD, cold agglutinin disease; CAS, cold agglutinin syndrome; w-, warm-antibody type. 109 S. Berentsen, G.E. Tjnnfjord / Blood Reviews 26 (2012) 107115 the terms secondary versus primary. Patients with chronic CAD recognized by us and others as having a clonal B-cell disorder, most often non-progressive and clinically non-malignant, undoubtedly represent the same majority that has traditionally been diagnosed with primary or idiopathic CAD. 1, 6, 8, 36 In these patients, the disease should still be called primary CAD. The term secondary chronic CAS should be reserved for those patients in whom the cold-antibody mediated hemolytic anemia complicates an overt and well-dened malignant disease different from LPL and MZL. 1, 6, 31, 42, 47, 48 Among 295 consecutive individuals with AIHA described by Dacie, 7 patients (2.4%) were classied as having CAS secondary to malignant disease. 1 In the very large series of AIHA by Sokol's group, the frequency seemed higher. 2 CAS has been described in pa- tients diagnosed with diffuse large B-cell lymphoma, Hodgkin's lymphoma, carcinomas, sarcomas, metastatic melanoma and chron- ic myeloproliferative disorders. 1, 2, 12, 13, 4750 For the following rea- sons, however, both the reported frequencies and some of the assumed associations should be regarded uncertain. First, particu- larly in case reports, patients may simply have suffered from two independent diseases; cancer and primary CAD. Second, sufcient details have often not been provided to critically review the diagno- sis of the co-existing or underlying malignancy. In a comprehensive series from a regional transfusion center, for example, advanced se- rological characterization of the AIHA was done at the referral cen- ter, whereas the reported frequencies of malignant disorders were based on more or less poorly specied information from the refer- ring hospitals. 2 Third, althoughrarely, we have observedtransformation to diffuse large B-cell lymphoma of the low-grade lymphoproliferative disorder characteristic for primary CAD. 6 Fourth, changing and more standardized tumor classications should justify a re-interpretation of early reports. This issue is highlighted by a description from1978 of sar- coma in two CAD patients who would probably be classied according to the 2008 version of the World Health Organization (WHO) classica- tion as having LPL or splenic MZL. 42, 51 The re-classication into aggres- sive non-Hodgkin's lymphoma of certain tumors previously perceived as lymphocyte depleted Hodgkin's lymphoma is also well-known. 42 In our experience, true secondary CAS is far more uncommon than primary CAD. The best documentation for a clearly malignant disease resulting in CAS seems to have been provided in non-Hodgkin's lymphoma. 12, 13, 47, 48 4.2. Clinical and pathological features and diagnostic criteria Besides the autoimmune hemolysis, the clinical and pathological features of secondary CAS depend on the underlying malignancy. The diagnosis can sometimes be based on the occurrence of CA medi- ated AIHA in a patient already diagnosed with an aggressive lympho- ma. In other cases, the diagnostic pathway shown in Fig. 2 will be relevant. The DAT features and occurrence of CA in serum do usually not differ substantially from the ndings in primary CAD. 5 In con- trast to the light chain phenotype found in almost all patients with primary CAD, however, the light chain restriction can be as well as . 47, 48 5. Acute cold agglutinin syndrome associated with infection 5.1. Mycoplasma pneumoniae An association between CA and respiratory disease was already observed in 1918. 17 More precisely, the occurrence of high-titer CA in primary atypical pneumonia was described in 1943 and soon thereafter identied as a cause of hemolytic anemia in such pa- tients. 52, 53 Probably as part of the physiological immune response, most patients with M. pneumoniae infections produce CA. In the ma- jority, these CA do not give rise to signicant hemolysis; and before specic tests became widely available, demonstration of CA activity was used as a diagnostic tool in Mycoplasma infections. In some pa- tients, however, production of high-titer, high-thermal amplitude CA may result in AIHA which may occasionally be severe. 5356 In 295 patients with AIHA, Mycoplasma or primary atypical pneumonia was identied as the probable cause in 23 (8%). 1 Conversely, the fre- quency of clinically signicant hemolysis in patients with M. pneumo- niae infection is unknown. Six (24%) of 25 patients admitted to a referral center with this type of pneumonia had hemolysis; severe in two patients and mild to moderate in four. 54 In general hospitals and in the community, however, the frequency of hemolytic compli- cations is probably much lower. The autoantibodies are polyclonal, usually anti-I specic and al- most invariably of the IgM class. 56 CA titers typically range between 512 and 32000. DAT is always positive for C3d. 3, 56 Most reported pa- tients have been adults, and AIHA typically occurs during the second or third week after the febrile illness has started. 56 In most published cases the onset has been sudden with pallor, jaundice and, some- times, prostration. Intravascular hemolysis, as evidenced by hemoglo- binuria, has been reported in several patients. In general, the prognosis is good and the hemolytic complication is self-remitting within 46 weeks, although a lethal course has been described in one patient. 55, 56 5.2. EpsteinBarr virus infection A number of case reports have been published on CA mediated AIHA in infectious mononucleosis with conrmed EpsteinBarr virus (EBV) etiology. 5760 As compared to M. pneumoniae pneumonia, however, infectious mononucleosis is an infrequent cause of AIHA, ac- counting for approximately 1% of the cases. 1, 2 Conversely, the fre- quency of clinically signicant hemolysis in EBV infections is unknown but probably low. Hospital-based data have indicated that hematological complications, being generally mild and including sev- eral manifestations other than AIHA, occur in 2550% of patients with EBV infection. 59 Since patient selection will inuence such gures and most individuals with infectious mononucleosis are not hospitalized, the frequency is probably much lower among patients with EBV- infection in the community. CA found in EBV-infections are polyclonal and almost invariably specic for the i-antigen. 57, 60, 61 The immunoglobulin class may be either IgM or IgG. 60 Rheumatoid factor-like IgM-IgG complexes have also been reported to act as CA in single cases. 60 In most published re- ports, DAT has been positive for C3d only. Anti-i titers are usually modest, typically at 256512, and the hemolytic anemia is transient and generally mild. 60 5.3. Other infections Several authors have reported on transient CAS mediated by anti-i autoantibodies following cytomegalovirus (CMV) infection. 60, 61 Rarely, CA-mediated hemolysis has been described in adenovirus in- fections, inuenza A, varicella, rubella, Legionella pneumophilica pneu- monia, listeriosis and pneumonia caused by Chlamydia species. 11, 60, 6265 We observed a slight, transient CAS in an otherwise healthy 23 year old man two weeks after a Chlamydia pneumoniae pneumo- nia. Severe CAS with a prolonged course and cryoglobulin activity of the CA has been reported following Escherichia coli lung infection. 22 Autoantibody specicities in these rare cases have included anti-I, anti-i and anti-Pr. 5.4. Diagnosis of infection-associated cold agglutinin syndrome Cold-antibody AIHA with infectious etiology typically involves a young adult or adolescent with M. pneumoniae pneumonia or infec- tious mononucleosis. Anemia or hemoglobinuria in such patients should immediately raise the suspicion of secondary AIHA. In addition 110 S. Berentsen, G.E. Tjnnfjord / Blood Reviews 26 (2012) 107115 to the work-up required to diagnose the infection, assessment of hemo- lysis, polyspecic as well as monospecic DAT and CAtitration will usu- ally establish the diagnosis. No monoclonal spike is found on electrophoresis. In some cases, paroxysmal cold hemoglobinuria and infection-induced exacerbation of primary CAD will have to be ruled out as differential diagnoses. 6. Other secondary cold agglutinin syndromes A few case reports have described chronic CA-mediated hemolysis in patients with systemic lupus erythematosus (SLE). In one of these publications, the presence of a clonal disorder was considered but could not be conrmed. 66 These very rare cases of SLE-associated CAS should not be confused with primary CAD. Several authors have reported the development of CA-mediated hemolysis after allogenic stem cell transplantation. In some of these patients, the AIHA seemed related to the transplantation per se; in other cases it was associated with virus infection. 64, 67 CAS has also been described during preg- nancy in one single patient. 68 7. Treatment 7.1. Primary chronic cold agglutinin disease 7.1.1. Non-pharmacological management Until a decade ago, pharmacological therapy for primary CAD was largely ineffective. 6, 69 Partly based on this fact and partly because the severity of the clinical features have not been appreciated, counseling has been regarded the mainstay of management. 3, 6, 36 However, doc- umentation of efcacy is mainly anecdotal. 15, 70 Still, in our clinical experience, staying warm seems to alleviate the symptoms and can probably prevent severe exacerbations of hemolytic anemia. In par- ticular, the head, face and extremities should be protected against cold exposure. 36, 69, 71 Some patients experience increased Hgb levels and alleviation of circulatory symptoms after relocating to warmer regions during the cold season, but severely symptomatic CAD does exist even in the subtropics. Infusion of cold liquids should be avoided. Surgery under hypothermia requires specic precautions, e.g. preoperative plasmapheresis. 72, 73 Erythrocyte transfusions can safely be given provided appropriate precautions are undertaken. 31, 69 In contrast to the compatibility problems characteristic for warm-antibody AIHA, it is usually easy to nd compatible donor erythrocytes, and screening tests for irregu- lar blood group antibodies are most often negative. Antibody screen- ing and, if required, compatibility tests should be performed at 37 C. The patient and, in particular, the extremity chosen for infusion should be kept warm, and the use of an in-line blood warmer is recommended. 72 Failure to observe required precautions has resulted in dismal or, very rarely, even fatal outcome. 72, 74 Because comple- ment proteins can exacerbate hemolysis, transfusion of blood prod- ucts with a high plasma content should probably be avoided. 39 In a population-based retrospective series on primary CAD we iden- tied three splenectomised patients, none of whom had responded to the splenectomy. 6 This observation is not surprising, since clearance of C3b-opsonized erythrocytes primarily occurs in the liver. Improve- ment after splenectomy has been occasionally reported among the rare patients with CAD mediated by IgG instead of IgM autoanti- bodies. 75 Probably because nearly all IgMis intravascular, plasmaphere- sis efciently induces clinical improvement in acute situations or before surgery requiring hypothermia. 7173 These remissions are short-lived, however. 7.1.2. Unspecic immunosuppressive and supportive therapies Although patients with CAD often have received corticosteroids, this practice has never been supported by systematic studies. Among 38 consecutive patients seen at the Hammersmith Hospital in London, only occasional patients responded to therapy with ste- roids. 69 Similar clinical experience has been obtained by others. 36, 71, 76 Studied retrospectively, 43% of unselected Norwegian patients with CAD had been treated with corticosteroids for shorter or longer periods. Responses had been observed in only 14% of those treated, and the few patients who did respond usually required high doses in order to maintain the remission. 6 The requirement for unaccept- ably high maintenance doses in the occasional responders has also been observed by others. 77 Monotherapy with chlorambucil or cyclo- phosphamide has shown some benecial effect on laboratory param- eters, and clinical improvement has been described. 76, 78 The clinical response rates, however, are in the same low order of magnitude as for corticosteroids. 6 A few patients treated with azathioprine have been reported in the literature, none of whom responded. 6, 34 In two small series of therapy with interferon- or low-dose cladribine, respectively, these drugs failed to induce clinical remission, although some conicting data have been published with interferon-. 7982 Symptomatic therapy with erythropoietin or its analogues seems widely used in the USA, but not so often in Western and Northern Europe (S. Berentsen, unpublished observation). Folic acid supple- mentation is rather commonly prescribed. 3 None of these support- ive measures have been systematically studied. In exacerbation of hemolysis triggered by febrile illness, immediate treatment of any bacterial infection is indicated. 4, 31, 39 7.1.3. Therapies directed at the pathogenic B-cell clone The rst major advance in treatment of primary CAD was the achievement of remission following monotherapy with the human- ized, chimeric monoclonal anti-CD20 antibody rituximab. Several case reports on rituximab therapy have been published since 1998, 8385 and we reported in 2001 promising results of a small, pro- spective trial. 86 Two larger, prospective, uncontrolled trials of 37 and 20 courses of therapy, respectively, were published in 2004 and 2006. 87, 88 The dosage of rituximab was 375 mg/m 2 weekly for four weeks in both studies; and the baseline data, response denitions and response data were similar. The response criteria used in our trial are listed in Table 4. 87 We found an overall response rate of 54%. With the exception of complete response (CR) in one patient, all remissions were partial responses (PR). Ten patients were treated for relapse after previously having received rituximab therapy, and six of them responded to a second course. The responders achieved a median increase in Hgb levels of 4.0 g/dL. The median time to re- sponse was 1.5 months (range, 0.54.0 months) and the median ob- served response duration was 11 months (range, 242 months). The treatment was well tolerated. 87 Retrospectively, the results of rituximab monotherapy were also studied in the population-based descriptive study of 86 Norwegian patients. 6 Forty patients were reported to have received rituximab Table 4 Primary chronic cold agglutinin disease: response criteria used in clinical trials. Response level Denition Complete response (CR) Absence of anemia No signs of hemolysis Disappearance of clinical symptoms of CAD No monoclonal serum protein No signs of clonal lymphoproliferation as assessed by bone marrow histology, immunohistochemistry and ow cytometry Partial response (PR) A stable increase in hemoglobin levels by at least 2.0 g/dL or to the normal range A reduction of serum IgM levels by at least 50% of the initial level or to the normal range Improvement of clinical symptoms Transfusion independence No response (NR) Any outcome not meeting the criteria for CR or PR 111 S. Berentsen, G.E. Tjnnfjord / Blood Reviews 26 (2012) 107115 monotherapy. As far as permitted by the retrospective design, the previously published response criteria (Table 4) were used for the data analysis. Twenty-three responders (58%) were identied; two (5%) achieved CR and 21 (53%) achieved PR. Responses were ob- served following a second and even a third course of rituximab in pa- tients who had relapsed after previous therapy. 6 These ndings conrmthe essential results of the prospective studies; rituximab sin- gle agent therapy is an efcient and well tolerated treatment for pri- mary CAD. CR is uncommon, however; the median response duration is relatively short; and 40-50% of the patients do not respond. We wanted to improve on the results achieved by rituximab monotherapy. The purine nucleoside analogues, e.g. udarabine, are powerful therapeutic agents in several lymphoproliferative diseases and remission of CAD has been observed in at least two patients after monotherapy with udarabine. 6, 89 Furthermore, combined treatment with udarabine and rituximab has resulted in high re- sponse rates and sustained remissions in WM and other low-grade non-Hodgkin's lymphoma. 90, 91 We published in 2010 a prospective, uncontrolled trial of udar- abine and rituximab in combination in 29 patients with primary CAD requiring treatment. 92 The median age was 73 years (range, 3987 years). Eligible patients received rituximab 375 mg/m 2 on days 1, 29, 57 and 85; and udarabine orally, 40 mg/m 2 on days 15, 2934, 5761 and 8589. Growth factors, co-trimoxazole or antiviral agents were not used routinely. Table 4 shows the re- sponse criteria. Responses were observed in 22 patients (76%); six (21%) achieved CR and 16 (55%) achieved PR. Ten patients had pre- viously been non-responsive to rituximab monotherapy. In this subgroup, CR was observed in one patient and PR in six. Median in- crease in Hgb level was 3.1 g/dL in the responders and 4.0 g/dL among those who achieved CR. Median time to response was 4.0 months, and estimated median response duration was more than 66 months. 92 Although comparison of non-randomized trials must be interpreted with caution, the much higher response rates, promising frequency of CR and very long response duration ob- served after the combination therapy compare favorably with the results achieved by rituximab monotherapy. Toxicity, however, occurred more frequently with the udarabine- rituximab combination. 92 Hematological toxicity grades 34 were ob- served in 12 patients (41%), including grade 4 neutropenia in four (14%). Seventeen patients (59%) experienced grade 13 infection. All infections were successfully treated except for one old, frail non- responder who died of pneumonia after nine months. Three patients (10%) suffered herpes zoster reactivation, but Pneumocystis jirovecii pneumonia or infection grade 4 was not observed. Fludarabine- induced warm-antibody AIHA did not occur, but three patients (10%) experienced a transient, mild exacerbation of CAD precipitated by infection. 39, 92 The study was not designed to address the risk of myelodysplasia or late-occurring hematological malignancies. Al- though not specic to nucleoside analogues, such late events have been reported after udarabine-based therapy for WM. 90 This con- cern should not be prohibitive to the use of the combination therapy, but lead to a balanced, individualized consideration of risk versus benet. 7.1.4. Recommendations There seems to be a discrepancy between the restrictive attitude to pharmacological therapy for CAD often found in the literature and the real requirement for therapy. 6 Recommendations to avoid medications may simply reect the fact that in the past, treatment was ineffective. Underestimation of the severity of anemia and clini- cal symptoms in this particular patient population may also have inuenced the attitudes. In selected patients, actually, the circulatory symptoms may be sufciently disabling to justify therapy even if the hemolysis is fully compensated. 10, 92 Some patients, however, do have a mild disease in which the anemia is slight and the circulatory symptoms modest or absent. In consequence, CAD should not be regarded an indication for therapy in every patient, and the decision to treat should be based on an individualized assessment. Reasonable criteria for starting drug therapy are symptomatic anemia, transfu- sion dependence, and/or disabling circulatory symptoms. 10, 87, 92 Corticosteroids should not be used to treat primary CAD. 6, 15, 31, 69 Outside clinical trials, the udarabine and rituximab combination should be regarded the most efcient treatment to date and should be considered in elderly patients requiring therapy if they are other- wise reasonably t and have no relevant co-morbidity. The combina- tion has proved useful even in patients non-responsive to monotherapy withrituximab. 92 Given the toxicity, however, a balanced assessment of risk versus benet should be undertaken in every case. In the occasional young patients as well as the very old and co-morbid ones, rituximab monotherapy should be considered rst-line treatment. Those who re- lapse after having responded to rituximab as single agent therapy may, depending on an individualized assessment, receive another course of rituximab or proceed to combination therapy. 7.1.5. Future perspectives Although signicant advances have been made during the last ten years in treating primary CAD, future studies should aim to achieve still higher response rates, increased numbers of CR and even more prolonged response duration. Less toxic regimens and efcient second-line therapies should also be regarded realistic achievements. For example, it has been proposed to explore the safety and efcacy of udarabine and rituximab in combination using reduced doses of u- darabine. 92, 93 It may also be worthwhile investigating combinations of monoclonal antibodies with newer chemotherapeutic agents. The relationship between primary CAD and WMshould encourage studies of several, more or less targeted therapies shown to be feasible and efcient in WM. 94 In primary CAD, improvement has been observed in two patients following bortezomib monotherapy 95 ; and high re- sponse rates have been achieved in WM following treatment with a bortezomib-based combination regimen. 96 The monoclonal anti-C5 antibody, eculizumab, is a potent comple- ment inhibitor shown to be an efcient therapeutic agent in paroxys- mal nocturnal hemoglobinuria (PNH). 97 In steady-state CAD, on the other hand, most of the hemolysis is not thought to be intravascular and C5-mediated. 30, 31 Furthermore, the administration of eculizumab in PNHhas been shown to unmask the low-grade, C3b-mediated extra- vascular hemolysis assumed to predominate in CAD. 98 Infusions of ecu- lizumab have been reported, however, to result in rapid improvement in a patient with primary CAD 99 ; and unpublished observations may in- dicate a marked and sustained suppression of hemolysis during contin- ued therapy (A. Rth, personal communication). These observations should be further explored for two reasons. First, this therapeutic ap- proach might prove useful in subgroups, e.g. in acute situations (infec- tions or surgery with exacerbation of hemolysis) or in severely hemolytic patients not responding to therapy directed against the path- ogenic B-cell clone. Second, if efcacy is conrmed, such results may challenge our present understanding of hemolysis in CAD, theoretically leading to a re-consideration of which hemolytic mechanism is most important. In order to further improve on current treatment options in pri- mary CAD, patients requiring therapy should be considered for inclu- sion in prospective trials if available. 7.2. Management of secondary cold agglutinin syndromes No evidence-based therapy exists for the CAS per se in cold- antibody mediated AIHA secondary to clearly malignant or infectious diseases. Prospective trials or well-designed retrospective series of con- secutive patients have not been published, and all recommendations found in the literature are based on case reports, clinical experience and theoretical considerations. 112 S. Berentsen, G.E. Tjnnfjord / Blood Reviews 26 (2012) 107115 For obvious reasons, however, optimal treatment of the underlying disease is important whenever feasible. 15, 69 Particularly in curable ma- lignancies such as aggressive lymphomas, achieving complete remis- sion is usually accompanied by resolution of the hemolysis. M. pneumoniae pneumonia should be treated according to appropriate guidelines; although due to the time of onset of hemolysis, antibiotic therapy will often have been completed before the hemolytic anemia manifests itself. 15 In some virus infections, causal therapy is not possi- ble; in others, such as CMV infection in immunocompetent individuals, antiviral therapy is not necessary because the CAS is slight and self- remitting. The efcacy of corticosteroid therapy has not been systematically investigated, and opinions promoted in textbooks and review articles differ widely. 3, 14, 15, 69 We treated a 45 year old man admitted with Mycoplasma pneumonia and an initial Hgb level of 3.5 g/dL due to an anti-I mediated severe CAS. He received erythromycin and high- dose prednisolone followed by rapid tapering of the corticosteroid dose. His condition improved rapidly and he became transfusion in- dependent within days. Similar case reports have been published in the literature. 100, 101 Since spontaneous resolution eventually occurs in all patients, however, guidelines can hardly be built upon case ob- servations. Therefore, there is no documentation for using corticoste- roids routinely in CAS secondary to infection. Until more data are provided, corticosteroid therapy may be considered if the hemolysis is severe and spontaneous improvement does not occur within some days. Plasmapheresis may be helpful in selected, extreme cases. 72, 102 If indicated, erythrocyte transfusions can safely be given provided the same precautions are undertaken as in primary CAD. 31 8. Practice points Diagnosing the subtype of AIHA precisely is essential for the choice of therapy. Primary CAD is a well-dened disease characterized by a clonal B- lymphocyte proliferation. Not all patients with primary CAD require pharmacological therapy, but treatment seems indicated more often than previously assumed. Corticosteroids should not be used to treat primary CAD. In primary CAD, the most efcient therapy documented to date is the administration of udarabine and rituximab in combination. Toxicity, however, may be a concern. Rituximab monotherapy is well documented and should be consid- ered in some patients. No evidence-based recommendations can be given for the manage- ment of secondary CAS, but optimal treatment of the underlying disorder is essential when feasible. Erythrocyte transfusions can safely be given in cold-antibody AIHA provided appropriate precautions are observed. 9. Research agenda The molecular, immunological and immunohistochemical charac- teristics of the clonal lymphoproliferation in primary CAD should be further studied. Further therapeutic trials are warranted in primary CAD, aiming at still higher rates of complete remissions, even more prolonged re- sponse duration, less toxic regimens and efcient therapeutic op- tions in the second-line setting. Patients with CAD requiring therapy should be considered included in prospective trials if available. In the rare and diverse cases of secondary CAS, therapeutic trials are probably unrealistic. International, well-designed, descriptive series of consecutive patients, however, might add valuable scientic information. Conict of interest The authors declare no nancial or other conicts of interest. References [1] Dacie J. The auto-immune haemolytic anaemias: introduction. In: Dacie J, editor. The Haemolytic Anaemias, Vol. 3. London: Churchill Livingstone; 1992. p. 15. [2] Sokol RJ, Hewitt S, Stamps BK. Autoimmune haemolysis: an 18-year study of 865 cases referred to a regional transfusion centre. Br Med J (Clin Res Ed) 1981;282(6281):20237. [3] Gehrs BC, Friedberg RC. Autoimmune hemolytic anemia. Am J Hematol 2002;69(4):25871. [4] Ulvestad E, Berentsen S, Bo K, Shammas FV. Clinical immunology of chronic cold agglutinin disease. Eur J Haematol 1999;63(4):25966. [5] Dacie J. Auto-immune haemolytic anaemia (AIHA): cold-antibody syndromes II: immunochemistry and specicity of the antibodies; serum complement in auto- immune haemolytic anaemia. In: Dacie J, editor. The Haemolytic Anaemias, Vol. 3. London: Churchill Livingstone; 1992. p. 24095. [6] Berentsen S, Ulvestad E, Langholm R, Beiske K, Hjorth-Hansen H, Ghanima W, et al. Primary chronic cold agglutinin disease: a population based clinical study of 86 patients. Haematologica 2006;91(4):4606. [7] Pascual V, Victor K, Spellerberg M, Hamblin TJ, Stevenson FK, Capra JD. VH re- striction among human cold agglutinins. The VH4-21 gene segment is required to encode anti-I and anti-i specicities. J Immunol 1992;149(7):233744. [8] Berentsen S, Bo K, Shammas FV, Myking AO, Ulvestad E. Chronic cold agglutinin disease of the idiopathic type is a premalignant or low-grade malignant lym- phoproliferative disease. APMIS 1997;105(5):35462. [9] Berentsen S, Ulvestad E, Tjonnfjord GE. B-lymphocytes as targets for therapy in chronic cold agglutinin disease. Cardiovasc Hematol Disord Drug Targets 2007;7(3):21927. [10] Berentsen S. How I manage cold agglutinin disease. Br J Haematol 2011;153(3): 30917. [11] King JW, May JS. Cold agglutinin disease in a patient with Legionnaires' disease. Arch Intern Med 1980;140(11):15379. [12] Niainle F, Hamnvik OP, Gulmann C, Bermingham C, Kelly J, Mc EP, et al. Diffuse large B-cell lymphoma with isolated bone marrow involvement presenting with secondary cold agglutinin disease. Int J Lab Hematol 2008;30(5):4445. [13] Eskazan AE, Akmurad H, Ongoren S, Ozer O, Ferhanoglu B. Primary gastrointesti- nal diffuse large B cell lymphoma presenting with cold agglutinin disease. Case Rep Gastroenterol 2011;5(2):2626. [14] Powers A, Silberstein LE. Autoimmune hemolytic anemia. In: Hoffman R, Benz EJ, Shattil SJ, Furie B, Silberstein LE, McGlave P, et al, editors. Hematology: basic principles and practice. Philadelphia: Churchill Livingstone Elsvier; 2008. p. 64557. [15] Gertz MA. Management of cold haemolytic syndrome. Br J Haematol 2007;138(4): 4229. [16] Landsteiner K. ber Beziehungen zwischen dem Blutserum und den Krperzel- len. Mnch Med Wochenschr 1903;50:18124. [17] Clough MC, Richter IM. A study of an auto-agglutinin occurring in human serum. Johns Hopkins Hosp Bull 1918;29:8693. [18] Rosenthal F, Corten M. ber das Phnomen der Autohmagglutination und ber die Eigenscaften der Kltehmagglutinine. Folia Haematol (Leipzig) 1937;58: 6490. [19] Stone MJ, McElroy YG, Pestronk A, Reynolds JL, Newman JT, Tong AW. Human monoclonal macroglobulins with antibody activity. Semin Oncol 2003;30(2): 31824. [20] Rosse WF, Adams JP. The variability of hemolysis in the cold agglutinin syn- drome. Blood 1980;56(3):40916. [21] Garratty G, Petz LD, Hoops JK. The correlation of cold agglutinin titrations in sa- line and albumin with haemolytic anaemia. Br J Haematol 1977;35(4):58795. [22] Poldre P, Pruzanski W, Chiu HM, Dotten DA. Fulminant gangrene in transient cold agglutinemia associated with Escherichia coli infection. Can Med Assoc J 1985;132(3):2613. [23] Bhattacharyya J, Mihara K, Takihara Y, Kimura A. Successful treatment of IgM- monoclonal gammopathy of undetermined signicance associated with cryoglo- bulinemia and cold agglutinin disease with immunochemotherapy with rituxi- mab, udarabine, and cyclophosphamide. Ann Hematol Sep. 8 2011 [E-pub ahaead of print]. [24] Issitt PD. I blood group system and its relationship to disease. J Med Lab Technol 1968;25(1):16. [25] Marsh WL. Anti-i: a cold antibody dening the Ii relationship in human red cells. Br J Haematol 1961;7:2009. [26] Roelcke D. Cold agglutination. Transfus Med Rev 1989;3(2):14066. [27] Brain MC, Ruether B, Valentine K, Brown C, ter Keurs H. Life-threatening hemo- lytic anemia due to an autoanti-Pr cold agglutinin: evidence that glycophorin A antibodies may induce lipid bilayer exposure and cation permeability indepen- dent of agglutination. Transfusion 2010;50(2):292301. [28] Jonsen J, Kass E, Harboe M. Complement and complement components in ac- quired hemolytic anemia with high titer cold antibodies. Acta Med Scand 1961;170:7259. [29] Jaffe CJ, Atkinson JP, Frank MM. The role of complement in the clearance of cold agglutinin-sensitized erythrocytes in man. J Clin Invest 1976;58(4):9429. [30] Zilow G, Kirschnk M, Roelcke D. Red cell destruction in cold agglutinin disease. Infusionsther Transfusionsmed 1994;21(6):4105. 113 S. Berentsen, G.E. Tjnnfjord / Blood Reviews 26 (2012) 107115 [31] Berentsen S, Beiske K, Tjonnfjord GE. Primary chronic cold agglutinin disease: an update on pathogenesis, clinical features and therapy. Hematology 2007;12(5): 36170. [32] Lewis SM, Szur L, Dacie JV. The pattern of erythrocyte destruction in haemolytic anaemia, as studied with radioactive chromium. Br J Haematol 1960;6:12239. [33] Kirschnk M, Knoblauch K, Roelcke D. Activation of complement by cold agglu- tinins. Infusionsther Transfusionsmed 1994;21(6):4059. [34] Chandesris MO, Schleinitz N, Ferrera V, Bernit E, Mazodier K, Gayet S, et al. Cold agglutinins, clinical presentation and signicance: retrospective analysis of 58 patients. Rev Med Interne 2004;25(12):85665. [35] Genty I, Michel M, Hermine O, Schaeffer A, Godeau B, Rochant H. Characteristics of autoimmune hemolytic anemia in adults: retrospective analysis of 83 cases. Rev Med Interne 2002;23(11):9019. [36] Schubothe H. The cold hemagglutinin disease. Semin Hematol 1966;3(1):2747. [37] Lyckholm LJ, Edmond MB. Images in clinical medicine. Seasonal hemolysis due to cold-agglutinin syndrome. N Engl J Med 1996;334(7):437. [38] Ulvestad E. Paradoxical haemolysis in a patient with cold agglutinin disease. Eur J Haematol 1998;60(2):93100. [39] Ulvestad E, Berentsen S, Mollnes TE. Acute phase haemolysis in chronic cold ag- glutinin disease. Scand J Immunol 2001;54(12):23942. [40] Harboe M, Deverill J. Immunochemical properties of cold haemagglutinins. Scand J Haematol 1964;61:22337. [41] Harboe M, van Furth R, Schubothe H, Lind K, Evans RS. Exclusive occurrence of K chains in isolated cold haemagglutinins. Scand J Haematol 1965;2(3):25966. [42] WHO classication of tumours of haematopoietic and lympoid tissues. 4 ed. Lyon: International Agency for Resarch on Cancer; 2008. [43] Berentsen S. Cold agglutinin-mediated autoimmune hemolytic anemia in Wal- denstrom's macroglobulinemia. Clin Lymphoma Myeloma 2009;9(1):1102. [44] Owen RG, Treon SP, Al Katib A, Fonseca R, Greipp PR, McMaster ML, et al. Clini- copathological denition of Waldenstrom's macroglobulinemia: consensus panel recommendations from the Second International Workshop on Walden- strom's Macroglobulinemia. Semin Oncol 2003;30(2):1105. [45] Stone MJ, Merlini G, Pascual V. Autoantibody activity in Waldenstrom's macro- globulinemia. Clin Lymphoma 2005;5(4):2259. [46] Cesana C, Barbarano L, Miqueleiz S, Lucchesini C, Ricci F, Varettoni M, et al. Clin- ical characteristics and outcome of immunoglobulin M related disorders. Clin Lymphoma 2005;5(4):2614. [47] Crisp D, Pruzanski W. B-cell neoplasms with homogeneous cold-reacting anti- bodies (cold agglutinins). Am J Med 1982;72(6):91522. [48] Dacie J. Haemolytic anaemias associated with malignant lymphomas other than Hodgkin's disease and chronic lymphocytic leukaemia (CLL). In: Dacie J, editor. The Haemolytic Anaemias, Vol. 4. London: Churchill Livingstone; 1995. p. 2740. [49] Al Matham K, Alabed I, Zaidi SZ, Qushmaq KA. Cold agglutinin disease in brola- mellar hepatocellular carcinoma: a rare association with a rare cancer variant. Ann Saudi Med 2011;31(2):197200. [50] Carlsson J, Batge R, Rahlf G, Tebbe U. Cold agglutinin disease and metastatic mel- anoma. Med Klin (Munich) 1994;89(6):3435. [51] Diebold J, Reynes M, Tricot G, Zafrani E, Weill B, Dao C, et al. Splenic lympho- plasmocytic sarcomas discovered by exploratory laparotomy in 2 cases of cold agglutinin disease. Sem Hop 1978;54(4344):132530. [52] Peterson OL, Ham TH, Finland M. Cold agglutinins (autohemagglutinins) in pri- mary atypical pneumonias. Science 1943;97(2511):167. [53] Ginsberg HS. Acute hemolytic anemia in primary atypical pneumonia associated with high titer of cold agglutinins; report of a case. N Engl J Med 1946;234: 8269. [54] Linz DH, Tolle SW, Elliot DL. Mycoplasma pneumoniae pneumonia. Experience at a referral center. West J Med 1984;140(6):895900. [55] Schubothe H, Merz KP, Weber S, Dahm K, Schmitz W, Altmann HW. Akute auto- immunhmolytische Anemie vom Kltenantikrpertype mit tdlichem Ausgang. Acta Haematol (Basel) 1970;44(1):11123. [56] Dacie J. Auto-immune haemolytic anaemia (AIHA): cold-antibody syndromes III: haemolytic anaemia following mycoplasma pneumonia. In: Dacie J, editor. The Haemolytic Anaemias, Vol. 3. London: Churchill Livingstone; 1992. p. 296312. [57] Jenkins WJ, Koster HG, Marsh WL, Carter RL. Infectious mononucleosis: an unsuspected source of anti-i. Br J Haematol 1965;11:4803. [58] Wentworth P, Bate LR. Acute hemolytic anemia secondary to infectious mononu- cleosis. Can Med Assoc J 1980;123(6):4826. [59] Luzuriaga K, Sullivan JL. Infectious mononucleosis. N Engl J Med 2010;362(21): 19932000. [60] Dacie J. Auto-immune haemolytic anaemia (AIHA): cold-antibody syndromes IV: haemolytic anaemia following infectious mononucleosis and other viral infec- tions. In: Dacie J, editor. The Haemolytic Anaemias, Vol. 3. London: Churchill Liv- ingstone; 1992. p. 31328. [61] Berlin BS, Chandler R, Green D. Anti-i antibody and hemolytic anemia associat- ed with spontaneous cytomegalovirus mononucleosis. Am J Clin Pathol 1977;67(5):45961. [62] Vanherweghem JL, de Jonghe M, Van Geel P. Acute hemolytic syndrome caused by cold agglutinins: unusual manifestation of ornithosis. Nouv Presse Med 1977;6(10):8512. [63] Terada K, Tanaka H, Mori R, Kataoka N, Uchikawa M. Hemolytic anemia associat- ed with cold agglutinin during chickenpox and a review of the literature. J Pediatr Hematol Oncol 1998;20(2):14951. [64] Mori T, Yamada Y, Aisa Y, Uemura T, Ishida A, Ikeda Y, et al. Cold agglutinin dis- ease associated with adenovirus infection after allogeneic bone marrow trans- plantation. Bone Marrow Transplant 2005;36(3):2634. [65] Schoindre Y, Bollee G, Dumont MD, Lesavre P, Servais A. Cold agglutinin syn- drome associated with a 2009 inuenza A H1N1 infection. Am J Med 2011;124(2):e12. [66] Srinivasan N, Oswal A, Garg S, Nahar J, Gosmonova A, Nahar R. Cold agglutinin induced hemolysis in a newly diagnosed systemic lupus erythematosus. Am J Med Sci 2010;339(3):2703. [67] Azuma E, Nishihara H, Hanada M, Nagai M, Hiratake S, Komada Y, et al. Recurrent cold hemagglutinin disease following allogeneic bone marrow transplantation successfully treated with plasmapheresis, corticosteroid and cyclophosphamide. Bone Marrow Transplant 1996;18(1):2436. [68] Batalias L, Trakakis E, Loghis C, Salabasis C, Simeonidis G, Karanikolopoulos P, et al. Autoimmune hemolytic anemia caused by cold agglutinins in a young preg- nant woman. J Matern Fetal Neonatal Med 2006;19(4):2513. [69] Dacie J. Treatment and prognosis of cold-antibody AIHA. In: Dacie J, editor. The Haemolytic Anaemias, Vol. 3. London: Churchill Livingstone; 1992. p. 5028. [70] Bartholomew JR, Bell WR, Shirey RS. Cold agglutinin hemolytic anemia: manage- ment with an environmental suit. Ann Intern Med 1987;106(2):2434. [71] Nydegger UE, Kazatchkine MD, Miescher PA. Immunopathologic and clinical fea- tures of hemolytic anemia due to cold agglutinins. Semin Hematol 1991;28(1): 6677. [72] Roseneld RE, Jagathambal. Transfusion therapy for autoimmune hemolytic ane- mia. Semin Hematol 1976;13(4):31121. [73] Zoppi M, Oppliger R, Althaus U, Nydegger U. Reduction of plasma cold agglutinin titers by means of plasmapheresis to prepare a patient for coronary bypass sur- gery. Infusionsther Transfusionsmed 1993;20(12):1922. [74] Lodi G, Resca D, Reverberi R. Fatal cold agglutinin-induced haemolytic anaemia: a case report. J Med Case Reports 2010;4:252. [75] Silberstein LE, Berkman EM, Schreiber AD. Cold hemagglutinin disease associat- ed with IgG cold-reactive antibody. Ann Intern Med 1987;106(2):23842. [76] Worlledge SM, Brain MC, Cooper AC, Hobbs JR, Dacie J. Immmunosuppressive drugs in the treatment of autoimmune haemolytic anaemia. Proc R Soc Med 1968;61(12):13125. [77] Schreiber AD, Herskovitz BS, Goldwein M. Low-titer cold-hemagglutinin disease. Mechanism of hemolysis and response to corticosteroids. N Engl J Med 1977;296(26):14904. [78] Hippe E, Jensen KB, Olesen H, Lind K, Thomsen PE. Chlorambucil treatment of pa- tients with cold agglutinin syndrome. Blood 1970;35(1):6872. [79] Hillen HF, Bakker SJ. Failure of interferon-alpha-2b therapy in chronic cold ag- glutinin disease. Eur J Haematol 1994;53(4):2423. [80] O'Connor BM, Clifford JS, Lawrence WD, Logue GL. Alpha-interferon for severe cold agglutinin disease. Ann Intern Med 1989;111(3):2556. [81] Rordorf R, Barth A, Nydegger U, Tobler A. Treatment of severe idiopathic cold- agglutinin diseases using interferon-alpha 2b. Schweiz Med Wochenschr 1994;124(12):5661. [82] Berentsen S, Tjonnfjord GE, Shammas FV, Bergheim J, Hammerstrom J, Langholm R, et al. No response to cladribine in ve patients with chronic cold agglutinin disease. Eur J Haematol 2000;65(1):8890. [83] Lee EJ, Kueck B. Rituxan in the treatment of cold agglutinin disease. Blood 1998;92(9):34901. [84] Cohen Y, Polliack A, Zelig O, Goldfarb A. Monotherapy with rituximab induces rapid remission of recurrent cold agglutinin-mediated hemolytic anemia in a patient with indolent lympho-plasmacytic lymphoma. Leuk Lymphoma 2001;42(6): 14058. [85] Engelhardt M, Jakob A, Ruter B, Trepel M, Hirsch F, Lubbert M. Severe cold hemag- glutinin disease (CHD) successfully treated with rituximab. Blood 2002;100(5): 19223. [86] Berentsen S, Tjonnfjord GE, Brudevold R, Gjertsen BT, LangholmR, Lokkevik E, et al. Favourable response to therapy withthe anti-CD20 monoclonal antibody rituximab in primary chronic cold agglutinin disease. Br J Haematol 2001;115(1):7983. [87] Berentsen S, Ulvestad E, Gjertsen BT, Hjorth-Hansen H, Langholm R, Knutsen H, et al. Rituximab for primary chronic cold agglutinin disease: a prospective study of 37 courses of therapy in 27 patients. Blood 2004;103(8):29258. [88] Schollkopf C, KjeldsenL, BjerrumOW, Mourits-AndersenHT, NielsenJL, Christensen BE, et al. Rituximab in chronic cold agglutinin disease: a prospective study of 20 pa- tients. Leuk Lymphoma 2006;47(2):25360. [89] Jacobs A. Cold agglutinin hemolysis responding to udarabine therapy. Am J Hematol 1996;53(4):27980. [90] Treon SP, Branagan AR, Ioakimidis L, Soumerai JD, Patterson CJ, Turnbull B, et al. Long-term outcomes to udarabine and rituximab in Waldenstrom macroglobu- linemia. Blood 2009;113(16):36738. [91] Czuczman MS, Koryzna A, Mohr A, Stewart C, Donohue K, Blumenson L, et al. Rituximab in combination with udarabine chemotherapy in low-grade or follic- ular lymphoma. J Clin Oncol 2005;23(4):694704. [92] Berentsen S, Randen U, Vagan AM, Hjorth-Hansen H, Vik A, Dalgaard J, et al. High response rate and durable remissions following udarabine and rituximab com- bination therapy for chronic cold agglutinin disease. Blood 2010;116(17): 31804. [93] Stone MJ. Heating up cold agglutinins. Blood 2010;116(17):311920. [94] Treon SP. How I treat Waldenstrom macroglobulinemia. Blood 2009;114(12): 237585. [95] Carson KR, Beckwith LG, Mehta J. Successful treatment of IgM-mediated autoim- mune hemolytic anemia with bortezomib. Blood 2010;115(4):915. [96] Treon SP, Loakimidis L, Soumerai JD, Patterson CJ, Hunter ZR, Feiner A, et al. Primary therapy of Waldenstrom's macroglobulinemia with bortezomib, dexamethasone and rituximab: Results of the WMCTG clinical trial 05180. ASCO Annual Meeting 2008: Abstract 8519. J Clin Oncol 2008;26(May 20 suppl). 114 S. Berentsen, G.E. Tjnnfjord / Blood Reviews 26 (2012) 107115 [97] Hillmen P, Young NS, Schubert J, Brodsky RA, Socie G, Muus P, et al. The comple- ment inhibitor eculizumab in paroxysmal nocturnal hemoglobinuria. N Engl J Med 2006;355(12):123343. [98] Hill A, Rother RP, Arnold L, Kelly R, Cullen MJ, Richards SJ, et al. Eculizumab pre- vents intravascular hemolysis in patients with paroxysmal nocturnal hemoglo- binuria and unmasks low-level extravascular hemolysis occurring through C3 opsonization. Haematologica 2010;95(4):56773. [99] Roth A, HuttmannA, Rother RP, DuhrsenU, Philipp T. Long-termefcacy of the com- plement inhibitor eculizumab in cold agglutinin disease. Blood 2009;113(16): 38856. [100] Chu CS, Braun SR, Yarbro JW, Hayden MR. Corticosteroid treatment of hemolytic anemia associated with Mycoplasma pneumoniae pneumonia. South Med J 1990;83(9):11068. [101] Tsuruta R, Kawamura Y, Inoue T, Kasaoka S, Sadamitsu D, Maekawa T. Corticoste- roid therapy for hemolytic anemia and respiratory failure due to Mycoplasma pneumoniae pneumonia. Intern Med 2002;41(3):22932. [102] Geurs F, Ritter K, Mast A, Van M V. Successful plasmapheresis in corticosteroid- resistant hemolysis in infectious mononucleosis: role of autoantibodies against triosephosphate isomerase. Acta Haematol 1992;88(23):1426. 115 S. Berentsen, G.E. Tjnnfjord / Blood Reviews 26 (2012) 107115