Medicine:Evans syndrome

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Evans syndrome

Evans syndrome is an autoimmune disease in which an individual's immune system attacks their own red blood cells and platelets, the syndrome can include immune neutropenia.[1][2] These immune cytopenias may occur simultaneously or sequentially.[1][3]

Its overall phenotype resembles a combination of autoimmune hemolytic anemia and immune thrombocytopenic purpura.[1][4][5] Autoimmune hemolytic anemia is a condition in which the red blood cells that normally carry oxygen are destroyed by an autoimmune process. Immune thrombocytopenic purpura is a condition in which platelets are destroyed by an autoimmune process. Platelets are a component of blood that contribute to the formation of blood clots in the body to prevent bleeding.

The syndrome was first described in 1951 by R. S. Evans and colleagues.[1]

Signs and symptoms

The symptoms of Evans syndrome vary between patients depending on which blood cells are affected. If red blood cells are attacked, symptoms may include weakness and fatigue, paleness or jaundice, shortness of breath, lightheadedness, and/or a fast heartbeat. If platelets are attacked, symptoms may include increased bruising, prolonged nosebleeds, increased bleeding from minor cuts, and/or Petechiae. In the less common instance that white blood cells are attacked, symptoms may include increased proneness to infection, fevers, and/or mouth sores.[6][7]

It has been variously reported that between 7.8%[4] and 23%[8] of patients who have autoimmune hemolytic anemia, will also have thrombocytopenia and thus Evans syndrome. The two cytopenias may occur together or sequentially.[1][3][9]

Causes

Although Evans syndrome seems to be a disorder of immune regulation, the exact pathophysiology is unknown, but a gradual loss of self-tolerance is postulated.[5] Autoantibodies targeted at different antigenic determinants on red cells and platelets are assumed to cause isolated episodes of hemolytic anemia and thrombocytopenia, respectively.[10]

Diagnosis

Diagnosis of Evans syndrome is separated into primary and secondary presentation. There is no single test to confirm a diagnosis of either form of Evans syndrome. It is instead a diagnosis made after a thorough clinical history, documentation of common symptoms, clinical evaluation, and exclusion of all other possible conditions.[1]

The diagnosis of primary Evans syndrome is made upon blood tests to confirm not only hemolytic anemia and immune thrombocytopenic purpura, but also a positive direct antiglobulin test (DAT) and an absence of any known underlying cause.[3] Additional tests used to eliminate the possibility of other conditions include a computed tomography (CT) scan and a biopsy of bone marrow.[1]

A diagnosis of secondary Evans syndrome is indicative of occurrence after another autoimmune disease is already present.[11] In 27% to 50% of cases there is an associated malignancy or a predisposing autoimmune disease.[4][5][12] Pre-existing autoimmune diseases can include autoimmune lymphoproliferative syndrome (ALPS), combined variable immunodeficiency (CVID), systemic autoimmune disease, or another disorder of immune dysregulation.[13]

Other antibodies may occur directed against neutrophils and lymphocytes,[14] and "immunopancytopenia" has been suggested as an alternative term for this syndrome.[15]

Treatment

Initial treatment is with glucocorticoid corticosteroids or intravenous immunoglobulin, a treatment that is also used in ITP cases.[5][16][17]  In children, it can remain well controlled with a long term immunosuppressant therapy that will occasionally lead to a spontaneous complete resolution of the condition.[18]  Although the majority of cases initially respond well to treatment, relapses are not uncommon[3][5] and immunosuppressive drugs[3][5] (e.g. ciclosporin,[19][20] mycophenolate mofetil, vincristine[21] and danazol[22]) are subsequently used,[3] or combinations of these.[23]

The off-label use of rituximab (trade name Rituxan) has produced some good results in acute and refractory cases,[3][5][24][25] although further relapse may occur within a year.[3]  Splenectomy is effective in some cases,[26] but relapses are not uncommon.[27]

The only prospect for a permanent cure is the high-risk option of an allogeneic hematopoietic stem cell transplantation (SCT).[28][29]

Prognosis

In a nationwide study of Evans syndrome the median survival was 7.2 years (primary Evans syndrome: 10.9 years; secondary Evans syndrome: 1.7 years). Secondary Evans syndrome was associated with higher mortality rate than primary Evans syndrome, with a 5-year survival of 38%. Among patients with Evans syndrome, the prevailing causes of death were bleeding, infections, and hematological cancer.[4]

It has been observed that there is a risk of developing other autoimmune problems and hypogammaglobulinemia,[30] in one cohort 58% of children with Evans syndrome had CD4-/CD8- T cells which is a strong predictor for having autoimmune lymphoproliferative syndrome.[31]

Epidemiology

Evans syndrome is considered a very rare autoimmune disease. Only one study has estimated incidence and prevalence adults. In Denmark in 2016 the annual incidence was 1.8 per 1,000,000 person years, and the prevalence was 21.3 per 1,000,000 living persons.[4] In pre-pubertal children the incidence has been estimated to be between 0.7 and 1.2 per 1,000,000 person-years.[32][33]

See also

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 "Evans Syndrome" (in en-US). https://rarediseases.org/rare-diseases/evans-syndrome/. 
  2. ↑ "Evans syndrome". Genetic and Rare Diseases Information Center. https://rarediseases.info.nih.gov/diseases/6389/evans-syndrome#ref_7882. 
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 "Management of Evans syndrome". Br. J. Haematol. 132 (2): 125–37. 2006. doi:10.1111/j.1365-2141.2005.05809.x. PMID 16398647. 
  4. ↑ 4.0 4.1 4.2 4.3 4.4 Hansen DL; Möller S; Andersen K; Gaist D; Frederiksen H (2019). "Evans syndrome in adults - incidence, prevalence, and survival in a nationwide cohort". Am J Hematol 94 (10): 1081–1090. doi:10.1002/ajh.25574. PMID 31292991. 
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 Michel M; Chanet V; Dechartres A; Morin A-S; Piette J-C; Cirasino L; Emilia G; Zaja F et al. (2009). "The spectrum of Evans syndrome in adults: new insight into the disease based on the analysis of 68 cases". Blood 114 (15): 3167–3172. doi:10.1182/blood-2009-04-215368. PMID 19638626. 
  6. ↑ "Evans syndrome | Genetic and Rare Diseases Information Center (GARD) – an NCATS Program". https://rarediseases.info.nih.gov/diseases/6389/evans-syndrome#:~:text=Evans%20syndrome%20is%20a%20very,destruction%20of%20red%20blood%20cells. 
  7. ↑ "Evans Syndrome | Symptoms & Causes | Boston Children's Hospital". https://www.childrenshospital.org/conditions-and-treatments/conditions/e/evans-syndrome/symptoms-and-causes. 
  8. ↑ "[Autoimmune hemolytic anemia: clinical analysis of 100 cases]" (in zh). Zhonghua Nei Ke Za Zhi 28 (11): 670–3, 701–2. 1989. PMID 2632179. 
  9. ↑ Ng SC (1992). "Evans syndrome: a report on 12 patients". Clinical and Laboratory Haematology 14 (3): 189–93. doi:10.1111/j.1365-2257.1992.tb00364.x. PMID 1451398. 
  10. ↑ EVANS SYNDROME. 2019-10-22. http://emedicine.medscape.com/article/955266-overview#showall. 
  11. ↑ (in en-gb) Immune Hematology | SpringerLink. 2018. doi:10.1007/978-3-319-73269-5. ISBN 978-3-319-73268-8. https://link.springer.com/content/pdf/10.1007/978-3-319-73269-5.pdf. 
  12. ↑ "Evans syndrome". Genetic and Rare Diseases Information Center. https://rarediseases.info.nih.gov/diseases/6389/evans-syndrome#ref_7882. 
  13. ↑ (in en-gb) Immune Hematology | SpringerLink. 2018. doi:10.1007/978-3-319-73269-5. ISBN 978-3-319-73268-8. https://link.springer.com/content/pdf/10.1007/978-3-319-73269-5.pdf. 
  14. ↑ "The Evans syndrome: characterization of the responsible autoantibodies". Br. J. Haematol. 51 (3): 445–50. 1982. doi:10.1111/j.1365-2141.1982.tb02801.x. PMID 7104228. 
  15. ↑ "Evans syndrome in childhood". J. Pediatr. 97 (5): 754–8. 1980. doi:10.1016/S0022-3476(80)80258-7. PMID 7191890. 
  16. ↑ "Intravenous gamma globulin for thrombocytopenia in children with Evans syndrome". The American Journal of Pediatric Hematology/Oncology 9 (2): 164–7. 1987. doi:10.1097/00043426-198722000-00012. PMID 2438958. 
  17. ↑ "Intravenous immunoglobulin therapy of idiopathic thrombocytopenia". The Journal of the Association of Physicians of India 40 (5): 340–2. 1992. PMID 1483999. 
  18. ↑ "Evan's Syndrome". https://www.childrenshospital.org/conditions-and-treatments/conditions/e/evans-syndrome/diagnosis-and-treatment. 
  19. ↑ "Long-term salvage treatment by cyclosporin in refractory autoimmune haematological disorders". Br. J. Haematol. 93 (2): 341–4. 1996. doi:10.1046/j.1365-2141.1996.4871026.x. PMID 8639426. 
  20. ↑ "[The effectiveness of cyclosporin A in the treatment of autoimmune hemolytic anemia and Evans syndrome]" (in zh). Zhonghua Xue Ye Xue Za Zhi 22 (11): 581–3. 2001. PMID 11855146. 
  21. ↑ Yokoyama K; Kojima M; Komatsumoto S et al. (1992). "[Thrombotic thrombocytopenic purpura achieving complete remission by slow infusion of vincristine]" (in ja). Rinsho Ketsueki 33 (8): 1084–9. PMID 1404865. 
  22. ↑ Koike M; Ishiyama T; Saito K et al. (1993). "[Effective danazol therapy for a patient with Evans syndrome]" (in ja). Rinsho Ketsueki 34 (2): 143–6. PMID 8492411. 
  23. ↑ "Evans syndrome. Results of a pilot study utilizing a multiagent treatment protocol". J. Pediatr. Hematol. Oncol. 17 (4): 290–5. 1995. doi:10.1097/00043426-199511000-00003. PMID 7583383. 
  24. ↑ Zecca M; Nobili B; Ramenghi U et al. (15 May 2003). "Rituximab for the treatment of refractory autoimmune hemolytic anemia in children". Blood 101 (10): 3857–61. doi:10.1182/blood-2002-11-3547. PMID 12531800. 
  25. ↑ "Rituximab for immune cytopenia in adults: idiopathic thrombocytopenic purpura, autoimmune hemolytic anemia, and Evans syndrome". Mayo Clin. Proc. 78 (11): 1340–6. November 2003. doi:10.4065/78.11.1340. PMID 14601692. http://www.mayoclinicproceedings.com/pdf/7811/7811a3.pdf. Retrieved 2007-04-18. 
  26. ↑ "Prolonged remission after splenectomy for refractory Evans syndrome--a case report and literature review". Southeast Asian J. Trop. Med. Public Health 36 (3): 762–4. 2005. PMID 16124452. 
  27. ↑ "Evans syndrome: results of a national survey". J. Pediatr. Hematol. Oncol. 19 (5): 433–7. 1997. doi:10.1097/00043426-199709000-00005. PMID 9329465. 
  28. ↑ "Peripheral blood stem cell mobilization in refractory autoimmune Evans syndrome: a cautionary case report". Bone Marrow Transplant. 20 (6): 521. 1997. doi:10.1038/sj.bmt.1700924. PMID 9313889. 
  29. ↑ "Allogeneic stem cell transplantation for Evans syndrome". Bone Marrow Transplant. 28 (9): 903–5. 2001. doi:10.1038/sj.bmt.1703237. PMID 11781654. 
  30. ↑ Wang WC (1988). "Evans syndrome in childhood: pathophysiology, clinical course, and treatment". The American Journal of Pediatric Hematology/Oncology 10 (4): 330–8. doi:10.1097/00043426-198824000-00013. PMID 3071168. 
  31. ↑ Teachey DT; Manno CS; Axsom KM et al. (2005). "Unmasking Evans syndrome: T-cell phenotype and apoptotic response reveal autoimmune lymphoproliferative syndrome (ALPS)". Blood 105 (6): 2443–8. doi:10.1182/blood-2004-09-3542. PMID 15542578. 
  32. ↑ Mannering N; Hansen DL; Frederiksen H (2020). "Evans syndrome in children below 13 years of age - A nationwide population-based cohort study". PLOS ONE 15 (4): e0231284. doi:10.1371/journal.pone.0231284. PMID 32271826. Bibcode: 2020PLoSO..1531284M. 
  33. ↑ Aladjidi N; Fernandes H; Leblanc T; Vareliette A; Rieux-Laucat F; Bertrand Y; Chambost H; Pasquet M et al. (2015). "Evans Syndrome in Children: Long-Term Outcome in a Prospective French National Observational Cohort". Front Pediatr 3 (79): e0231284. doi:10.3389/fped.2015.00079. PMID 32271826. 

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