Research Article: Hodgkin lymphoma patients have an increased incidence of idiopathic acquired aplastic anemia

Date Published: April 5, 2019

Publisher: Public Library of Science

Author(s): Taylor Linaburg, Adam R. Davis, Noelle V. Frey, Muhammad R. Khawaja, Daniel J. Landsburg, Stephen J. Schuster, Jakub Svoboda, Yimei Li, Yuliya Borovskiy, Timothy S. Olson, Adam Bagg, Elizabeth O. Hexner, Daria V. Babushok, Francesco Bertolini.


Idiopathic acquired aplastic anemia (AA) is a rare lymphocyte-mediated bone marrow aplasia. No specific mechanisms or triggers of AA have been identified. We recently observed several patients who developed AA after Hodgkin lymphoma (HL). We hypothesized that the co-occurrence of HL and AA is not random and may be etiologically significant. To test this hypothesis, we determined the incidence of AA in HL patients at our institution. We identified four patients with co-occurring HL and AA, with the incidence of AA in HL patients >20-fold higher compared to the general population. We identified 12 additional patients with AA and HL through a systematic literature review. Of the 16 total patients,15 (93.8%) developed AA after or concurrent with a HL diagnosis. None of the patients had marrow involvement by HL. Five of 15 patients were in complete remission from HL at the time of AA diagnosis, and six had a concurrent presentation with no prior cytotoxic therapy, with diagnostic timeframe information unavailable for four patients. The median interval between HL diagnosis and AA onset was 16 months, ranging from concurrent to 14 years after a HL diagnosis. The median survival after AA diagnosis was 14 months (range: 1 month to 20 years). Our results show that patients with HL have a higher incidence of AA compared to the general population and suggest that HL-related immune dysregulation may be a risk factor for AA. Better recognition and management of AA in HL patients is needed to improve outcomes in this population.

Partial Text

Idiopathic acquired aplastic anemia (AA) is a rare, life-threatening disease characterized by pancytopenia and a hypocellular marrow that is caused by lymphocyte-mediated destruction of hematopoietic stem and progenitor cells [1]. Treatment of AA relies on lymphocyte-directed immunosuppression, administered either as anti-thymocyte globulin (ATG) and cyclosporine A (CsA) or as part of a bone marrow transplant (BMT) conditioning regimen [2]. Despite recent progress in outcomes of AA patients, the understanding of the autoimmune mechanism in AA remains limited; no triggers of autoimmunity in AA have been identified, and there are no known prevention strategies for this condition. The diagnosis of AA is established clinically through the systematic exclusion of mimicking entities, with T-cell immunosuppressive treatments continuing to be largely empiric.

Our data demonstrate that patients with HL have at least a 20-fold higher incidence of AA compared to the general population. We show that in HL patients, AA is significantly more likely to arise concurrently with or after a diagnosis of HL, and thus is probably not linked to previous exposure to cytotoxic chemotherapy. Our results indicate that AA occurs without marrow involvement by HL and in 25% of patients, AA emerges multiple years after achieving a complete remission from HL. We show that outcomes of HL patients who develop AA are extremely poor with current management strategies for AA, with 80% of patients in our study for whom outcome information was available dying from AA-related complications. Taken together, our findings suggest that the occurrence of HL increases the risk of developing AA and underscore the need for improved recognition and treatment of this patient population.