TO THE EDITOR: Hemolytic uremic syndrome (HUS) is characterized by a triad of non-immune
hemolytic micro-angiopathic anemia, thrombocytopenia, and acute renal failure [1].
The majority of cases are "typical HUS," caused by an enteric infection of Shiga toxin-producing
Escherichia coli. Rarely, however, HUS is caused by dysregulation of the alternative
pathway of the complement system and is known as atypical HUS (aHUS). One rare subtype
is caused by anti-complement factor H (CFH) antibodies. Such patients are commonly
treated by nephrologists; however, they will usually present to a hematologist for
variable cytopenias. We report here one such patient who presented to us primarily
for cytopenias.
CASE
A 9-year-old girl presented to our hematology clinic complaining of vomiting for 15
days and generalized weakness and back and neck pain of similar duration. She also
complained of vague abdominal pain. She had no fever or diarrhea immediately preceding
the episode. There was no history of significant past illness. Her growth and development
was normal for her age. She was born out of non-consanguineous marriage with no perinatal
complications. She has one older brother who is apparently normal. On examination,
she had significant pallor and icterus, without cyanosis or edema. On admission, her
blood pressure was 118/78 mmHg, pulse 98 beats/min, respiratory rate 26 breaths/min.
Abdomen was soft, nontender with normal bowel sounds. Liver was 3 cm palpable; there
was no splenomegaly, lymphadenopathy, or skin rash. A summary of her laboratory parameters
at admission is shown in Table 1.
A peripheral smear examination showed 20 NRBCs/100 WBCs, polychromasia, anisopoikilocytosis
and microspherocytes with presence of fragmented cells (Fig. 1). Differential count
was normal with no atypical cells found. She was diagnosed with a case of thrombotic
microangiopathy. Plasma exchange therapy was started. The laboratory parameters started
improving after 1 day (Fig. 2).
She responded to the therapy and her vomiting, abdominal pain, and icterus improved.
Based on the clinical features, normal stool culture, and low C3 level, diagnosis
of aHUS was considered and a genetic screen was performed for common mutations associated
with aHUS. Results of the genetic screen are shown in Table 2. She was started on
immunosuppressants with pulse cyclophosphamide and daily prednisolone. The patient
is currently on a tapering dose of prednisolone. She has been doing well for the last
14 months, with no evidence of recurrence to date.
DISCUSSION
The patient presented with the classic triad of HUS. Although the most common cause
of HUS in childhood is infection with a Shiga toxin-containing strain of E. coli,
such an etiology was unlikely for this patient because of the absence of any suggestive
history and a negative stool culture. We therefore considered aHUS, a genetic disorder
in which 50-60% of cases are due to mutations in the alternate complement regulatory
pathway. These mutations lead to endothelial damage and uncontrolled complement activation
[2]. The disease is severe, and associated with poor prognosis and increased mortality.
The most common mutation identified is in the gene for CFH (13%), a protein important
in down-regulating the alternative complement pathway. Mutations in a variety of other
genes for proteins that either regulate or are components of the alternative pathway
may also cause aHUS, such as complement factor I (10%), membrane cofactor protein
(11%), and thrombomodulin gene (4%) proteins. Importantly, in a minority of patients
(5-10%), aHUS may develop due to auto-antibodies to CFH [3]. These antibodies interfere
with binding of CFH to C3 convertase C3bBb, resulting in dysregulated complement activation.
Anti-CFH-associated aHUS behaves differently clinically than the other aHUS subtypes,
with the former frequently occurring in children less than 2 years of age, and the
latter being more common in teenagers. Our patient was 9 years old at presentation.
Additionally, clinical presentation of anti-CFH-associated aHUS is more aggressive,
with a higher frequency of abdominal pain, vomiting, extra-renal complications, seizures,
pancreatitis, and hepatitis [3, 4]. Our patient presented with abdominal pain and
transaminasemia suggestive of hepatitis. Frequency of relapses is also higher with
anti-CFH-associated aHUS when compared to most other types [5, 6].
Plasma therapy has been the cornerstone of aHUS therapy and was essentially the only
therapy available until recently. Plasma therapy is effective due to its ability to
deliver normal levels of complement factors and, when an exchange is done, to remove
mutant complement factors and auto-antibodies, as in this case [7, 8]. It is recommended
that plasma therapy be started within 24 hours of suspected diagnosis of aHUS. Efficacy
of exchange should be monitored by daily creatinine, platelet count, LDH, and hemoglobin
levels. Persistence of hemolysis or lack of improvement in thrombocytopenia after
3-5 days of plasma therapy should be considered no response to therapy, and an indication
to stop plasma exchange and start complement inhibitor therapy with eculizumab. It
is, however, important to note that patients with aHUS due to membrane cofactor protein
mutations are unlikely to respond to plasma therapy because membrane cofactor protein
is not a plasma protein.
For anti-CFH-associated aHUS, plasma exchange can induce complete remission in 25%,
and partial remission in another 50% of the patients [6]. There are reports that concomitant
immunosuppression (with steroids, cyclophosphamide, rituximab, mycophenolate, or other
drugs) along with plasma exchange can improve results [3, 7, 8]. The major limitation
in the management of aHUS is the high recurrence rate and progression to chronic kidney
failure in significant number of patients. Although kidney transplants have been tried,
their efficacy was limited by the high recurrence rates in the transplanted kidneys.
Eculizumab is a humanized monoclonal antibody to C5 that inhibits the terminal phase
of complement activation. It has been approved by the American Food and Drug Administration
for the treatment of paroxysmal nocturnal hemoglobinuria [9]. Subsequently, a few
investigators have used eculizumab successfully in patients with aHUS, especially
plasmapheresis-resistant cases [10, 11]. Since eculizumab acts by inhibiting the alternative
pathway of complement, patients are at risk for meningococcal infections. Therefore,
all patients treated with eculizumab should receive the meningococcal vaccine as well
as prophylactic antibiotics for the first 2 weeks after immunization to protect them
while their immune response develops. Despite its good efficacy in aHUS, data regarding
its utility in anti-CFH-associated aHUS patients is sparse.
In conclusion, this case highlights several points which clinicians would do well
to remember: firstly, HUS must be strongly suspected in any patient who presents with
non-specific abdominal or respiratory symptoms along with anemia and thrombocytopenia;
secondly, the possibility of thrombotic microangiopathy should be investigated by
using a battery of tests including reticulocyte count, LDH, and peripheral smear examination
for schistocytes, and, if in doubt, confirmed with renal biopsy; thirdly, complement
level should always be assessed before plasma therapy or exchange is initiated; and
fourthly, in cases of suspected aHUS, samples should be sent to a reference laboratory
to test for mutations.