Cold Agglutinin Disease
Cold Agglutinin Disease
Case presentation
72F, p/w hgb 3.8. A little tired.
- Some discoloration of fingers, she says it's worse (and painful) when it's cold.
- No notable icterus.
- Elevated indirect bili.
- LDH elevated. Hapto undetectable.
- Retic elevated.
- +RBC clumping on smear. Other cells normal in morphology and number.
- DAT: IgG+ (weak), C3+
- Cold agglutinin titre: way >64
Pathophysiology
Berentsen, Frontiers in Immunology, 2020
Confirming the diagnosis
- flow cytometry
- SPEP, SFLC (usu IgM kappa)
- maximal thermal amplitude (>28C)
- cold-temperature titre (>=64 @ 4C)
- BMBx (sometimes)
Differential diagnosis
- no B symptoms (may be difficult to separate from infx)
- no extramedullary disease (may push you toward MZL)
- CD5- (>50% CAD -ve for CD5), CD10- B cells: MZL vs IgM LPL (Waldenstrom)
- MYD88 L265P -ve (usu + in LPL)
- certain clusters of genomic and cytogenetic changes, e.g. KMT2D variant (69%) complete or partial gain of chromosome 3 (93%)
- WHO 2022: CAD is now a distinct lymphoid neoplasm (CAD-associated LPD) (hopefully, more diagnostic consensus will follow)
Diagnostic algorithm
Berentsen, Fattizzo, Barcellini, Frontiers in Immunology, 2023
Case presentation
- 2010: p/w hemolytic anemia, eventually found to have cold agglutinin disease
- 2010 - 2015: rituximab, multiple cycles
- 2016: rituximab + fludarabine
- 2018: rituximab + bortezomib
- 2019: rituximab + bendamustine
- 2022: sutimlimab recommended
A jaunt through history
1200s
Johannes Actuarius, Constantinople court physician, publishes De Urinis, which notes: "Yea indeed an extremely black urine... signifies extreme chilliness."
- (syphilis causes paroxysmal cold hemoglobinuria, so used to be much more common)
- (but watch out for a resurgence - syphilis cases went up 80%, to 207,000 in 2022)
A jaunt through history
1800s
Trypanosomiasis (N'gana, sleeping sickness) is found to cause deep anemias, partially via hemolysis.
A jaunt through history
1898
Mssrs. Kanthack, Durham, and Blandford describe agglutination in red blood cells of animals infected with trypanosomes.
"Instead of forming rouleaux, the red corpuscles tend to clump into masses and to lose their outlines, especially when the anaemia is pronounced (rabbit, ass, and horse). The serum of such blood, when mixed with normal blood of the same species of animal, causes the red corpuscles to clump together also."
A jaunt through history
1903
Karl Landsteiner publishes "About Relationships Between the Blood Serum and the Body Cells" (Über Beziehungen zwischen dem Blutserum und den Körperzellen), which contains a description of blood agglutination at cold temperatures (thermal amplitude 0-5C).
He's the guy who discovered blood types, under the term "iso-agglutination," and won the Nobel Prize in Medicine for this in 1930.
A jaunt through history
1918
Clough and Richter publish "A study of an autoagglutinin occurring in a human serum," first definite cases of cold agglutination in humans, describing the relationship between agglutination, hemolysis, and pneumonia.
A jaunt through history
1937
McCombs and McElroy note that the huge increase in surgical transfusions since Landsteiner's discovery has revealed a number of cases of cold agglutination found in the blood bank (thermal amplitude 0-25 C), confusing technicians nation-wide.
(And occasionally leading to death)
A jaunt through history
1946
Lubinski and Goldbloom collect and describe 7 cases of cold agglutination with a thermal amplitude of 0-37C, all associated with hemolytic anemia (5 primary cases, 1 sepsis, 1 syphilis).
A jaunt through history
1957
Christenson et al perform the first isolation of a monoclonal protein, a cold agglutinin. One of the pts also has a cryoglobulin.
A jaunt through history
1964
Olesen publishes the first paper with a successful drug treatment for CAD, choosing chlorambucil based on the then-recent success of this drug in Waldenstrom macroglobulinemia. Follow-up in 1970 with 4 pts has similar results.
(One pt got cyclophosphamide for 4mo, switched to chlorambucil later on d/t drAE).
A jaunt through history
1997
Rituximab comes to market.
1998
Lee and Kueck try rituximab (375 x4) in a pt w CAD, and it works.
2001
Berentsen et al report on a small prospective ritux study: 1 CR, 3 PR, 2 no response.
2006, 2013
Berentsen et al retrospective study: ritux-based regimens RR 67-83%.
A jaunt through history
2017
Berentsen et al, prospective study using BR: 71% RR, 40% CR, 31% PR. 50% RR in the retreatment setting. TTR 2mo. 77% response rate at 5y. Median DOR >88mo.
2018
Rossi et al report on 2L bortezomib (GIMEMA) (single cycle): 32% RR, median DOR 16mo.
2020, 2021
Case reports on CAS d/t pembro (Atiq 2020) and atezo (Acikgoz 2021).
A jaunt through history
2021
Roth et al report (NEJM) on sutimlimab monotherapy (CARDINAL) (nonrandomized)
2022
Roth et al report (Blood) on sutimlimab monotherapy (CADENZA) (phase III placebo-controlled RCT)
A jaunt through history
Blood 2022, Roth et al
Tx options overview
Berentsen, Fattizzo, Barcellini, Frontiers in Immunology 2023
Tx sequencing overview
Berentsen, Fattizzo, Barcellini, Frontiers in Immunology 2023
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