Autoimmune pancytopenia occurring late after simultaneous pancreas and kidney transplantation

Abstract

A 35-year-old woman presented with a widespread petechial rash and pancytopenia. She underwent simultaneous pancreas and kidney transplantation for type 1 diabetes 8 years previously followed by a renal transplant 1 year prior to presentation, and was taking tacrolimus as long-term immunosuppression. The full blood count showed haemoglobin 97 g/L, platelet count 2×109/L and neutrophil count 0.22×109/L. Peripheral blood film examination confirmed genuine thrombocytopenia in the absence of any haemolytic or malignant features. Serological testing identified autoantibodies against all three blood lineages, consistent with a diagnosis of autoimmune pancytopenia. Treatment with steroids, intravenous immunoglobulins, romiplostim and mycophenolate mofetil achieved only fleeting remissions. Blood counts eventually normalised following the administration of rituximab and a change from tacrolimus to ciclosporin immunosuppression. Cytopenias are a well-recognised complication of post-transplantation care but we believe this to be the first reported case of autoimmune pancytopenia following solid organ transplantation. In this case report, we discuss the approach to investigation of haematological abnormalities post-transplant and the rationale for, and outcome of, the management of this rare case.

Transplant‐associated thrombotic microangiopathy and immune haematological complications following intestine‐containing organ transplantation: experience from over 100 consecutive cases

“…Bortezomib warrants further studies in this patient group. Of note, only one patient had an attempted switch from tacrolimus to ciclosporin (and was then switched back to tacrolimus as the immune haemolysis continued unabated); this is relevant because tacrolimus has been described as a cause of late ITP after renal transplant, resolving when it is replaced by ciclosporin 27,28 . In a case series of four children with intestinal transplant the authors recommended switching from a CNI to sirolimus as management of refractory haemolytic anaemia 29 …”

“…Of note, only one patient had an attempted switch from tacrolimus to ciclosporin (and was then switched back to tacrolimus as the immune haemolysis continued unabated); this is relevant because tacrolimus has been described as a cause of late ITP after renal transplant, resolving when it is replaced by ciclosporin. 27,28 In a case series of four children with intestinal transplant the authors recommended switching from a CNI to sirolimus as management of refractory haemolytic anaemia. 29 We have also described a case of acquired Glanzmann's thrombasthenia (Table I, case 5) which had previously been described in a small number of case reports and typically occurs in association with lymphoproliferative disorders and also post solid organ transplant and has recently been reviewed in detail.…”