Vox Sang. 41: 32-35 (1981)

Dipyrone-Induced Immune Haemolytic Anaemia

Anna Ribera, Jasone Monasterio, Gemma Acebedo, Jose Triginer, Carmen Martin Servicio de Hematologia y Hemoterapia, Ciudad Sanitaria Valle Hebron, Barcelona, Spain

Abstract. We report a new case of immune haemolytic anaemia induced by dipyrone. The haemolytic crisis was followed by acute renal failure. The direct antiglobulin test on the red cells was positive. The responsible antibody was of the IgG class; it was complement binding and produced haemolysis in vitro. The clinical and serological findings suggest that the red cells became sensitized as the result of the adsorption to the cell membrane of drug-antibody immune complexes.

Introduction Case Report

Immune haemolytic anaemia caused by drugs is rare and that induced by pyrazole derivatives is particularly infrequent, espe- cially if we take into account the widespread use of these drugs [ll].

In this report we describe the case of a patient who developed immune haemolysis due to antibodies against dipyrone. In vitro, these antibodies could only be detected by tests in which the drug had been added to the patient’s serum. This is different from au- toimmune haemolytic anaemia in which the antibody is directed against intrinsic red cell antigens and can be detected without adding a drug to the serum.

The patient, M. H., male, aged 20 years, was diag- nosed at 6 months of age to suffer from severe haemo- philia A. Since then he has had several haemarthroses with resulting serious functional limitation and epi- sodes of haematuria, haematoma and epistaxis.

On March 3,1979, he came to the Emergency Room with pain in the right inguinal region and was treated with 700 U of factor VIII. At the end of the transfusion an itchy skin rash developed which disappeared within a few hours without treatment. Later he experienced chills, fever, vomiting, and passed dark urine, for which he was admitted to the Haematology Department, with a diagnosis of severe haemolytic crisis, cause unknown. Following admission he was treated with mannitol and furosemide for oliguria.

On March 11,1979, after the intravenous injection of Baralgin (2.5 g of dipyrone), he experienced another haemolytic crisis. When questioned again, the patient

Dipyrone-Induced Immune Haemolytic Anaemia 33

Table I. Patient's main clinical and laboratory data

1 1

Haematocrit, % Haemoglobin, g/100 ml Free haemoglobin, g/100 ml Haptoglobin, mg/100 ml Bilirubin, mg/100 ml Blood urea, mg/100 ml Haemoglobinuria' Urine output, mV24 h

37

12.7

1.25

19

13

66 +

1.680

33 31 24 20

1 1 . 1 10.5 8.5

1 S O

0

15

127 143 199 101 +

480 360 0 0

27 26 25 26 29

9.2 9 8.8 8.9 10

0.004

I20

0.6 0.4

180 118 197 169 62 -

50 360 1,240 9,260 2,400

t m .- E

I

* No red cells were seen in the urine sediment. 2 units of packed red cells.

said that he had taken a suppository which contained 1 g of dipyrone a few hours before the first crisis. The patient became anuric. He was subjected to peritoneal dialysis. He recovered completely and was discharged after 20 days of the onset. The patient's course can be seen in table I.

Materials and Methods

Blood samples were obtained from the patient with and without sodium citrate (3.8%). A panel of human red cells from our own laboratory was used. They were suspended in phosphate-buffered saline (pH 7.4) (PBS). The elution procedures described by Lundsteiner and Miller [5] and Rubin [lo] were used. For 2-mercaptoeth- anol(2-ME) reduction the method described by Molli-

son [7] was employed. Two commercial 'broad spec- trum' antiglobulin sera were obtained from Dade and from Spectra Biologicals. Rabbit anti-human IgG and rabbit anti-human complement were obtained from Organon Technica.

Serological tests : the direct antiglobulin test (DAT) was performed with the patient's red cells. The serum was tested with a panel ofhuman red cells suspended in saline at room temperature, with enzyme (trypsin)- treated cells at 37'C and using the indirect antiglobulin test (IAT). The same procedure was done with the eluate.

Tests on the serum in the presence of dipyrone: the technique used was that described by Plu et al. [9]. An equal volume of a saturated solution in saline of dipy- rone was added to the patient's serum and to 3 vol of the mixture were added I vol ofa 5% suspension of red cells in PBS and 1 vol of fresh AB serum. We looked for

34 RibedMonasterio/Acebedo/Triginer/Martin

agglutination and/or haemolysis and then camed out an IAT. Negative controls were set up substituting AB serum for the patient’s serum and PBS for the drug.

Results

On March 8,1979, the DAT was weakly positive and the antibody was shown to be IgG. On March 11, 1979, the DAT showed the same result. No antibodies were detected in eluates made from the patient’s red cells and none were detected in his serum when no drug was added. However, if dipyrone was added to the serum, an antibody could be shown to be present which reacted with the red cells in the antiglobulin technique with the two broad spectrum antiglobulin sera, with the anti-IgG and weaker with the anti-complement,

The dilution of serum at which the anti- body could be detected was 1 : 8 with saline- suspended red cells and 1 : 128 when the IAT was performed. We observed also haemoly- sis up to 1:4 in serum dilution. When the antiglobulin test was carried out after the serum had been treated with 2-ME, the titre of the antibody was unaltered. The antibody thus appeared to be of the IgG class. 12 days later the DAT was negative, but we detected the antibody in the patient’s serum at the same titre.

Discussion

Two facts led us to conclude that the hae- molytic crisis was due to a drug-induced antibody: one was that the haemolysis led to acute renal failure; the other was the finding of a positive DAT in the apparent absence of antibody in the serum [12].

We have found reports of only 2 cases of immune haemolytic anaemia induced by pyrazol derivatives, although De Gruchy [4] and Biittiger [2] both referred to its occur- rence. In 1961, Bernasconi et al. [l] described a patient who had developed an antibody against aminopyrine. The antibody aggluti- nated and haemolysed the patient’s red cells if they had been previously incubated in vitro with the drug. The DAT was negative and the antibody was of the IgG class. In 1966, Lay [6] published the case of a patient who had several haemolytic crises, some accompanied by acute renal failure, whose serum reacted with human red cells in the presence of dipyrone. The antibody was of the IgG class and thermolabile. The DAT was not carried out during the haemolytic crisis.

In our case, we have detected the anti- body in the presence of dipyrone in the serum without previously incubating the red cells with the drug. Agglutination was ob- served with red cells suspended in PBS at 37°C and the titre of the antibody was sub- stantially higher when the IAT was used. Haemolysis took place without pre-treat- ment of the red cells with trypsin. The anti- body was of the IgG type and complement- binding. From a clinical point of view it should be noted that a small dose of dipy- rone was suficient to provoke a haemolytic crisis with haemoglobinuria and acute renal failure. We believe that in this case the anti- body probably combined with the drug to form a complex which was adsorbed on to the red cells and activated complement. For this reason it could be included in the im- mune-complex type of drug-immune hae- molytic anaemia described by Worlledge [ll], Gurrutty [3] and Petz and Gurrutty [81.

Dipyrone-Induced Immune Haemolytic Anaemia 35

References

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1 1 Worlledge, S. M.: Immune drug-induced haemo- lytic anaemias. Semin. Haematol. 4: 327-344 (1973).

12 Worlledge, S. M.: The interpretation of a positive direct antiglobulin test. Br. J. Haemat. 39: 157-162 (1978).

Received: March 24,1980 Accepted: January 5, 1981

Anna Ribera Crusafont, Servicio de Hematologia y Hemoterapia, Ciudad Sanitaria Valle Hebron, Paseo Valle Hebron, s/n, Barcelona-35 (Spain)