title: Plasma exchange and rituximab treatment for lenalidomide-associated cold agglutinin disease.
abstract: BACKGROUND
  Lenalidomide is an amino-substituted analog of thalidomide with potent immunomodulatory properties. The drug has been widely used for treatment of multiple myeloma and myelodysplastic syndrome (MDS) associated with 5q-abnormality. The most common side effects are cytopenias, infections, and deep venous thrombosis.
  
  
  METHODS
  We report a clinical observation of severe autoimmune hemolytic anemia (AIHA) due to cold agglutinin disease (CAD) that developed 11 days after initiation of lenalidomide treatment in a patient with MDS who relapsed after allogeneic bone marrow transplantation.
  
  
  RESULTS
  CAD was diagnosed by the presence of hemolytic variables and cold agglutinin detected in patient's plasma. The antibody screen, which was performed at 37 °C, was negative throughout. The direct antiglobulin test was positive only for complement (C3d). These findings supported the diagnosis of CAD associated with lenalidomide administration. Other causes of hemolysis including ABO incompatibility and infectious etiologies were ruled out. Rituximab therapy in conjunction with daily plasma exchange decreased the rate of hemolysis and transfusion requirement in our case.
  
  
  CONCLUSIONS
  In addition to warm AIHA, lenalidomide use can also be associated with development of CAD. Rituximab given in conjunction with plasma exchange can be effective in treating CAD in this setting.
authors.affiliation: University of Maryland School of Medicine, Marlene and Stewart Greenebaum Cancer Center, Baltimore, Maryland 21201, USA.
authors.forename: David L
authors.initials: DL
authors.lastname: Brauer
authors.forename: Bennett
authors.initials: B
authors.lastname: Edelman
authors.forename: Aaron P
authors.initials: AP
authors.lastname: Rapoport
authors.forename: John R
authors.initials: JR
authors.lastname: Hess
authors.forename: Görgün
authors.initials: G
authors.lastname: Akpek
mesh_terms: D000744:Anemia, Hemolytic, Autoimmune / Q000139:chemically induced* / Q000188:drug therapy*; D058846:Antibodies, Monoclonal, Murine-Derived / Q000627:therapeutic use*; D000970:Antineoplastic Agents / Q000009:adverse effects; D003131:Combined Modality Therapy; D006801:Humans; D007155:Immunologic Factors / Q000627:therapeutic use; D000077269:Lenalidomide; D008297:Male; D008875:Middle Aged; D009190:Myelodysplastic Syndromes / Q000188:drug therapy*; D010951:Plasma Exchange; D000069283:Rituximab; D013792:Thalidomide / Q000009:adverse effects / Q000031:analogs & derivatives*
chemical_list: D058846:Antibodies, Monoclonal, Murine-Derived; D000970:Antineoplastic Agents; D007155:Immunologic Factors; D000069283:Rituximab; D013792:Thalidomide; D000077269:Lenalidomide