title: Immune hemolytic anemia with drug-induced antibodies to carboplatin and vincristine in a pediatric patient with an optic pathway glioma.
abstract: BACKGROUND
  Drug-induced immune hemolytic anemia (DIIHA) is a rare, but important condition requiring specialized laboratory testing for diagnosis. We report a case of DIIHA with antibodies against carboplatin and vincristine (VCR) in a child with an optic pathway glioma. Platinum-based drugs are established to cause DIIHA; to our knowledge, this is the first report implicating VCR.
  
  
  METHODS
  A 35-month-old girl with an optic pathway glioma developed hemolytic anemia while receiving carboplatin and VCR. Specialized blood bank testing was performed to determine the presence of drug-dependent antibodies and thus DIIHA.
  
  
  RESULTS
  Initial direct antiglobulin test (DAT) was negative. A repeat DAT 3 days later was positive, 3+ with polyspecific-antiglobulin sera, weak+ with anti-immunoglobulin (Ig)G, and 2+ with anti-C3d. An eluate from the DAT-positive red blood cells (RBCs) was nonreactive. The patient's serum reacted without specificity to all RBC tested using papain-IgG-antiglobulin test (AGT) and polyethylene glycol-IgG-AGT. No alloantibodies to common RBC antigens were detected. When the serum was evaluated for the presence of drug-specific antibody, reactivity was shown with VCR and carboplatin using the drug addition solution method, but only with carboplatin using the drug-coating method.
  
  
  CONCLUSIONS
  The patient developed hemolytic anemia during chemotherapy. Initial detection of a panagglutinin suggested a warm-type autoimmune process. However, since DIIHA could not be excluded, chemotherapy was discontinued and further work-up was initiated. The findings confirmed the presence of antibodies to carboplatin and VCR. This case highlights the importance for clinicians to maintain a high index of suspicion for DIIHA in patients with unexplained hemolysis and the importance of specialized serologic testing.
authors.affiliation: Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Marisol
authors.initials: M
authors.lastname: Betensky
authors.forename: Char
authors.initials: C
authors.lastname: Witmer
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Fisher
authors.forename: Sandra
authors.initials: S
authors.lastname: Nance
authors.forename: Mitchell J
authors.initials: MJ
authors.lastname: Weiss
authors.forename: Deborah A
authors.initials: DA
authors.lastname: Sesok-Pizzini
mesh_terms: D000744:Anemia, Hemolytic, Autoimmune / Q000097:blood* / Q000139:chemically induced*; D000906:Antibodies / Q000097:blood*; D000972:Antineoplastic Agents, Phytogenic / Q000008:administration & dosage / Q000009:adverse effects*; D016190:Carboplatin / Q000008:administration & dosage / Q000009:adverse effects*; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D020339:Optic Nerve Glioma / Q000097:blood / Q000188:drug therapy*; D014750:Vincristine / Q000008:administration & dosage / Q000009:adverse effects*
chemical_list: D000906:Antibodies; D000972:Antineoplastic Agents, Phytogenic; D014750:Vincristine; D016190:Carboplatin