\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Autoimmune hemolytic anemia associated with vitamin B12 deficiency and
viral illness in DiGeorge syndrome. Case report and literature review.}



\author[1]{Zohaib Yousaf}%
\author[1]{Fateen Ata}%
\author[1]{Phool Iqbal}%
\author[1]{Bassam Muthanna}%
\author[1]{Adeel  Khan}%
\author[1]{Jaweria Akram}%
\author[1]{Anand Kartha}%
\affil[1]{Hamad Medical Corporation}%


\vspace{-1em}



  
  \date{May 27, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
DiGeorge syndrome, an immunodeficiency disorder due to long arm
microdeletion of chromosome 22. Isolated hemolysis is rarely seen in
DiGeorge syndrome and is usually reported in conjunction with idiopathic
thrombocytopenic purpura. We report a case of DiGeorge syndrome with
AIHA, which was successfully managed by intravenous steroids and
intravenous immunoglobulins.%
\end{abstract}%



\sloppy


\textbf{Title: Autoimmune hemolytic anemia associated with vitamin B12
deficiency and viral illness in DiGeorge syndrome. Case report and
literature review}

\textbf{Running Title:} Autoimmune hemolysis in DiGeorge syndrome

\textbf{Introduction:}

DiGeorge syndrome is a primary immunodeficiency resulting from a
microdeletion 22q11.2 and leads to a multifaceted disorder. This
microdeletion results in abnormal development of third and fourth
pharyngeal pouches. The presentation and clinical features vary from
person to person and commonly include facial abnormalities,
hypoparathyroidism, heart defects, thymic hypoplasia, immunodeficiency,
and other clinical problems {[}1{]}. It is occasionally associated with
cytopenias, including idiopathic thrombocytopenic purpura (ITP) and
autoimmune hemolytic anemia (AIHA.) Usually, more than one cell line is
affected by the patient experiencing cytopenias. We report a case of
AIHA secondary to DiGeorge syndrome in an adult female, likely
precipitated by a viral illness and vitamin B12 deficiency.

\textbf{Keywords:} DiGeorge Syndrome, Autoimmune hemolysis, AIHA, B12
deficiency, Viral illness.

\textbf{Case report:}

18-year-old Qatari lady, known case of DiGeorge syndrome, presented with
a history of intermittent high-grade fever, runny nose, and cough
productive of whitish sputum. On the day of presentation, the patient
developed nausea and three episodes of yellowish, non-blood-stained
vomiting. There were no sick contacts or recent travel. The review of
the system was remarkable for dark urine and 5 Kg of weight loss over
the preceding 10days. The patient had no history of alcohol use and did
not follow a specific diet; however, meat was limited in her diet due to
dietary preferences.

Her history was significant for recurrent childhood infections,
attributed to immunosuppression secondary to DiGeorge syndrome. She was
also diagnosed with patent ductus arteriosus and a small ventricular
septal defect. Both were hemodynamically insignificant and managed
conservatively. The patient also suffered from a learning disability and
attention deficit hyperactivity disorder (ADHD), which were also
attributed to the DiGeorge syndrome.

Upon presentation, the patient was febrile (38.7 C) and tachycardiac
(118 beats per minute) but had no desaturation, tachypnea, or
hypotension. Physical examination revealed a young lady sitting
comfortably in bed, not in any distress. The conjunctivae were pale and
scleral icterus was noted. The rest of the physical exam was within
normal limits. A complete sepsis screen, including a chest X-ray, urine
culture, blood cultures, malaria screen, and a nasopharyngeal swab for
the respiratory viral screen, including RT-PCR for COVID-19, was sent
looking for an underlying infection. The results were negative except
for the presence of rhinovirus and adenovirus in the nasopharyngeal
swab. A complete blood count showed neutrophilic leukocytosis and severe
macrocytic, hypochromic anemia (hemoglobin 3.5gm/dL) with high red cell
distribution width. {[}Table 1{]}

An anemia workup showed reticulocytosis, a high LDH, and low haptoglobin
with indirect hyperbilirubinemia keeping in line with intravascular
hemolysis. Peripheral blood smear showed marked macrocytic anemia with
anisocytosis, basophilic stripling, nucleated red blood cells, increased
rouleaux formation, and red cell agglutination. Hyper-segmented
neutrophils (\textgreater{}6 lobes) were also noted. Other laboratory
workup was unrevealing. {[}Table 1{]}

With a working diagnosis of hemolytic anemia likely precipitated by an
underlying infection, the direct Coomb's test for polyspecific antihuman
globulin (AHG) was sent and was positive. The monospecific AHG was
positive for anti-IgG and negative for anti-C3d. An eluate was prepared
and tested for confirmation of antibodies, and the positive elution test
confirmed the presence of warm IgG antibody-induced autoimmune hemolytic
anemia (AIHA). A complete autoimmune screen was negative. Serum IgG,
IgM, C3, and C4 levels were within normal limits. A computerized
tomography scan of the chest, abdomen, and pelvis was performed to rule
out any underlying malignancy as the cause of hemolysis and was
unrevealing. Bone-marrow examination showed features consistent with
active hematopoiesis and a normal B and T-cell population.

The patient received two units of packed red cells and 100mg intravenous
of methylprednisolone. A hematology opinion was sought, and the patient
was planned to receive seven days of intravenous (IV)
methylprednisolone, followed by a tapering course of oral steroids.
Also, she received intravenous immunoglobulin (IVIG) for three days. She
also received IV cyanocobalamin 1000mcg daily for the duration of her
hospital stay and will continue oral vitamin B12 therapy. The patient's
hemoglobin was stable throughout her hospital stay, and she will be
followed up in the hematology clinic for further management. {[}Figure
1{]}

\textbf{Discussion:}

Hemolytic anemia is a diverse group of hematologic disorders that can be
either congenital or acquired. An extensive workup for identifying an
underlying etiology of hemolysis is needed due to the wide range of
causes ranging from drugs to autoimmune and infectious to deficiency of
B12 or folate. A deficiency of vitamin B12 can lead to megaloblastic
anemia. Vitamin B12 is involved in DNA synthesis and red cell maturation
{[}2{]}. The deficiency of vitamin B12 can lead to hemolysis in up to
10\% of the affected {[}3{]}. Several mechanisms are attributed to this
deficiency. Ineffective erythropoiesis due to intramedullary destruction
of red blood cells (RBC) is one of the mechanisms. Deficiency of vitamin
B12 inhibits purine and thymidylate syntheses, which impairs DNA
synthesis. This impairment of DNA synthesis causes erythroblast
apoptosis, resulting in anemia from ineffective erythropoiesis {[}4{]}.
A deficiency of vitamin B12 can increase the precursors, including
methylmalonic acid and Homocysteine. The accumulation of Homocysteine
can increase hemolysis by oxidative damage and interaction with RBC
structural and enzymatic proteins {[}5{]}. Homocysteine's hemolytic
action depends on a high ratio of PMNL to RBC, which was high in our
patient {[}6{]}.

A literature review of reporting of autoimmune hemolysis associated with
DiGeorge syndrome (DS) using the search strategy of ``((hemolysis) OR
(hemolytic anemia)) AND (DiGeorge)'' on PubMed yielded fifteen results.
The literature consists of 8 case reports and a retrospective
multicenter case-control study with 23 patients of 22q11.2 deletion
syndrome (22q11.2DS) with hemolysis discussed the predictors for
hematologic development autoimmunity (HA) {[}7-15{]} {[}Table 2{]}.

Most of the cases describe AIHA associated with ITP or triple line
cytopenia. To the best of our knowledge, 3 cases with AIHA as the sole
autoimmune cell line involvement associated with DiGeorge syndrome are
reported. This makes it the 4\textsuperscript{th} reported case in the
literature to the best of our knowledge. What makes this case unique is
the single-cell line involvement and the late presentation. The other
unique attribute of this case is vitamin B12 deficiency. The patient had
a low normal vitamin B12 level, a normal thyroid function, a normal
folate level, and was a non-alcohol user, with multi-lobulated
neutrophils on the peripheral smear suggestive of vitamin B12 induced
macrocytic anemia.

\textbf{Conclusion:}

Even though AIHA is associated with DiGeorge syndrome, our patient did
not develop any AIHA episodes since birth. The authors believe that the
combination of viral respiratory infection and vitamin B12 deficiency
were the triggers associated with the onset of hemolysis. Combining
these triggers is possibly the underlying reason for the late-onset AIHA
in our patient with a history of DiGeorge syndrome. Authors suggest
checking serum B12 levels regularly in patients with DiGeorge syndrome
and a diet deficient in vitamin B12, which may prevent severe hemolytic
episodes in this cohort of patients.

\textbf{Tables and figures with legends:}

\textbf{Table 1:} Laboratory Parameters.

\textbf{Table 2:} A literature review for the association of AIHA with
DiGeorge Syndrome

(NA: not available, TOF: Tetralogy of Fallot, IVIG, intravenous
immunoglobulins, ITP: immune thrombocytopenia purpura, AIHA: autoimmune
hemolytic anemia, MMF: mycophenolate mofetil, PAVSD: Pulmonary atresia
with ventricular septal defect, DORV: Double outlet right ventricle,
BMT: bone marrow transplant, Y: year, Mo: month, M: male, F: female,
Age: at the time of diagnosis of cytopenias)

\textbf{Figure 1:} Hemoglobin through the hospital stay.

\textbf{Acknowledgments:}

Qatar National Library funded the publication of this manuscript.

\textbf{Statement of Ethics}

The patient and her family has given verbal consent to publish this
case. ~The study is conducted ethically in accordance with the World
Medical Association Declaration of Helsinki.

\textbf{Approval from the institutional research body:}

The manuscript will complete the review process by the medical research
council of Hamad Medical Corporation, using their online platform
''www.abhath.hamad.qa''. It will only be published once all relevant
institutional approvals are obtained.

\textbf{Conflict of interest/Disclosure statement}

The authors certify that they have no conflict of interest and no
affiliations with or involvement in any organization or entity with any
financial or non-financial interest in the subject matter or materials
discussed in this manuscript.

\textbf{Patient consent:}

Subject has given his verbal informed consent to publish the case.

\textbf{Funding Sources}

Qatar National Library has funded the publication of the manuscript.

\textbf{Authors:}

Zohaib Yousaf\textsuperscript{1}, Fateen Ata\textsuperscript{2}, Phool
Iqbal\textsuperscript{2}, Bassam Muthanna \textsuperscript{2}, Adeel
Ahmad Khan2, Jaweria Akram\textsuperscript{2}, Anand
Kartha\textsuperscript{2}

\textbf{Affiliations:}

Chief Clinical Fellow, Internal Medicine, Hamad Medical Corporation,
Doha, Qatar

Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar.

\textbf{Authors and their contributions:}

Zohaib Yousaf:

Contribution: Case identification, manuscript writing and literature
review.

Email: Zohaib.yousaf@gmail.com.

Fateen Ata:

Contribution: literature review and manuscript writing

Email: docfateenata@gmail.com

Phool Iqbal:

Contribution: manuscript writing, editing and review before submission.

Email: dr.phooliqbal89@gmail.com

Bassam Muthanna:

Contribution: manuscript writing and review.

Email: bassam.alsojri123@gmail.com

Adeel Ahmad Khan:

Contribution: Manuscript writing and review.

Emial: ak4636261@gmail.com

Jaweria Akram:

Contribution: corresponding author, manuscript writing, editing and
submission

Email: jiaamajad91@gmail.com

Anand Kartha:

Contribution: manuscript review and supervision

Email: Akartha@hamad.qa

\textbf{Corresponding Author:}

\textbf{Jaweria Akram.}

Hamad Medical Corporation, Doha, Qatar.

PO Box 3050, Doha, Qatar.

Phone number: +974 6640 5836

\textbf{Email:}jiaamajad91@gmail.com

All authors reviewed and approved the final manuscript.

\textbf{References:}

1. Fomin A.B., Pastorino A.C., Kim C.A., Pereira C.A., Carneiro-Sampaio
M., and Abe-Jacob C.M., \emph{DiGeorge Syndrome: a not so rare
disease.}Clinics (Sao Paulo), 2010. \textbf{65} (9): p.
865-9.10.1590/s1807-59322010000900009

2. Dali-Youcef N. and Andr\selectlanguage{ngerman}ès E., \emph{An update on cobalamin deficiency
in adults.} Qjm, 2009. \textbf{102} (1): p. 17-28.10.1093/qjmed/hcn138

3. Acharya U., Gau J.T., Horvath W., Ventura P., Hsueh C.T., and Carlsen
W., \emph{Hemolysis and hyperhomocysteinemia caused by cobalamin
deficiency: three case reports and review of the literature.} J Hematol
Oncol, 2008. \textbf{1} : p. 26.10.1186/1756-8722-1-26

4. Koury M.J. and Ponka P., \emph{New insights into erythropoiesis: the
roles of folate, vitamin B12, and iron.} Annu Rev Nutr, 2004.\textbf{24}
: p. 105-31.10.1146/annurev.nutr.24.012003.132306

5. Ventura P., Panini R., Tremosini S., and Salvioli G., \emph{A role
for homocysteine increase in haemolysis of megaloblastic anaemias due to
vitamin B(12) and folate deficiency: results from an in vitro
experience.} Biochim Biophys Acta, 2004. \textbf{1739} (1): p.
33-42.10.1016/j.bbadis.2004.08.005

6. Olinescu R., Kummerow F.A., Handler B., and Fleischer L., \emph{The
hemolytic activity of homocysteine is increased by the activated
polymorphonuclear leukocytes.} Biochem Biophys Res Commun,
1996.\textbf{226} (3): p. 912-6.10.1006/bbrc.1996.1449

7. Pinchas-Hamiel O., Mandel M., Engelberg S., and Passwell
J.H.,\emph{Immune hemolytic anemia, thrombocytopenia and liver disease
in a patient with DiGeorge syndrome.} Isr J Med Sci, 1994. \textbf{30}
(7): p. 530-2

8. Kratz C.P., Niehues T., Lyding S., Heusch A., Janssen G., and Göbel
U., \emph{Evans syndrome in a patient with chromosome 22q11.2 deletion
syndrome: a case report.} Pediatr Hematol Oncol, 2003. \textbf{20} (2):
p. 167-72.10.1080/0880010390158685

9. DePiero A.D., Lourie E.M., Berman B.W., Robin N.H., Zinn A.B., and
Hostoffer R.W., \emph{Recurrent immune cytopenias in two patients with
DiGeorge/velocardiofacial syndrome.} J Pediatr, 1997. \textbf{131} (3):
p. 484-6.10.1016/s0022-3476(97)80085-6

10. Davies J.K., Telfer P., Cavenagh J.D., Foot N., and Neat
M.,\emph{Autoimmune cytopenias in the 22q11.2 deletion syndrome.} Clin
Lab Haematol, 2003. \textbf{25} (3): p.
195-7.10.1046/j.1365-2257.2003.00508.x

11. Bruno B., Barbier C., Lambilliotte A., Rey C., and Turck
D.,\emph{Auto-immune pancytopenia in a child with DiGeorge syndrome.}
Eur J Pediatr, 2002. \textbf{161} (7): p.
390-2.10.1007/s00431-002-0976-y

12. Soldatou A., Anastassiou T., Vougiouka O., Goussetis E., and Kossiva
L., \emph{Transient effect of anti-CD20 therapy in a child with 22q11.2
deletion syndrome and severe steroid refractory cytopenias: a case
report.} J Pediatr Hematol Oncol, 2013. \textbf{35} (4): p.
311-4.10.1097/MPH.0b013e31828be602

13. Sakamoto O., Imaizumi M., Suzuki A., Sato A., Tanaka T., Ogawa E.,
et al., \emph{Refractory autoimmune hemolytic anemia in a patient with
chromosome 22q11.2 deletion syndrome.} Pediatr Int, 2004.\textbf{46}
(5): p. 612-4.10.1111/j.1442-200x.2004.01940.x

14. Damlaj M. and Séguin C., \emph{Refractory autoimmune hemolytic
anemia in a patient with DiGeorge syndrome treated successfully with
plasma exchange: a case report and review of the literature.} Int J
Hematol, 2014. \textbf{100} (5): p. 494-7.10.1007/s12185-014-1648-1

15. Montin D., Marolda A., Licciardi F., Robasto F., Di Cesare S.,
Ricotti E., et al., \emph{Immunophenotype Anomalies Predict the
Development of Autoimmune Cytopenia in 22q11.2 Deletion Syndrome.} The
Journal of Allergy and Clinical Immunology: In Practice, 2019.\textbf{7}
(7): p. 2369-2376.https://doi.org/10.1016/j.jaip.2019.03.014

\selectlanguage{english}
\FloatBarrier
\end{document}

