Idiopathic autoimmune hemolytic anemia due to lecithin overdose: a case report
© Lentzas et al; licensee BioMed Central Ltd. 2009
Received: 10 December 2008
Accepted: 29 January 2009
Published: 29 January 2009
Idiopathic Autoimmune Hemolytic Anemia is a potentially fatal condition which requires prompt and potent treatment. Diagnosis of idiopathic autoimmune hemolytic anemia requires both serologic evidence of autoantibody presence and hemolysis. Although most of the times it is considered idiopathic, several underlying causes have been identified, like autoimmune and connective tissue diseases, viral infections, drugs or hyper function of the immune system. To our knowledge, this is the first case in the international literature describing lecithin-induced autoimmune hemolytic anemia.
This case report is to highlight a rare but dangerous adverse reaction to overdose of lecithin. A 38 year old white female from Greece, presented to our emergency room with progressive fatigue over a period of ten days and icteric discoloration of her skin and conjunctiva. The patient had been taking lecithin supplements (1200 mg, 3 capsules a day) over a period of ten days for weight loss. She reports that the last 3 days, prior to the examination, she took 5 capsules/day, so that the supplement would take effect more rapidly. Her past medical, social and family history showed no disturbance. Relatives of the patient were requested to submit any blood-tests taken over a period of 20 days prior to the onset of symptoms caused by Lecithin. All tests proved that all functions were within normal scale. Her physical examination revealed pallor and jaundice without palpable hepatosplenomegaly. Blood biochemistry tests showed total bilirubin 7.5 mg/dl, with indirect bilirubin 6.4 mg/dl and complete blood count showed hemoglobin 7.6 g/dl with blood levels 21.4%.
In every case of idiopathic autoimmune hemolytic anemia the administration of pharmaceutical substances should always be examined, except for the standard reasons that cause it. In this case the cause of hemolysis was attributed to the excessive intake of lecithin capsules for the loss of body weight. It is important that clinicians and immunologists are aware of this adverse effect.
Idiopathic Autoimmune Hemolytic Anemia is a potentially fatal condition which requires prompt and potent treatment. Diagnosis of idiopathic autoimmune hemolytic anemia (IAIHA) requires both serologic evidence of autoantibody existence and hemolysis. Sensitized red blood cells (RBCs) are destroyed by intravascular and/or extravascular hemolysis. Although most of the times it is considered idiopathic (the cause of autoimmunization remains obscure in 50% of the patients) , several underlying causes have been identified, like autoimmune and connective tissue diseases, viral infections, drugs or malignancies of the immune system . In the absence of a clinically apparent underlying disorder, testing for the presence of antinuclear antibodies, a serum protein electrophoresis (SPE) and a Computer Tomography (CT)-scan must be systematic. Conversely, if no abnormalities are revealed, the relevance of a systematic medullar biopsy (MB) at AIHA onset seems very low . Phospholipids, which include the compound phosphatidyl choline, the chemical name for lecithin are lipids containing a phosphoric acid residue. The main phospholipids in lecithin from soya and sunflower are phosphatidyl choline, phosphatidyl inositol, phosphatidyl ethanolamine, and phosphatidic acid. Although lecithin was first observed and isolated from egg yolk in 1846, it was only 20 years later that the choline component in lecithin was identified . The role of polyunsaturated fatty acids in decreasing the cholesterol levels in the blood is well founded in literature. In addition, dietary phospholipids from various origins, particularly polyunsaturated fatty acid phospholipids, such as those of soy bean lecithin have a cholesterol-lowering effect in humans . There are studies which exhibit that soy-derived lecithin has significant effects on lowering cholesterol and triglyceride, while increasing high density lipoproteins (HDL) levels in the blood. [5, 6]. This case study is to highlight a rare but hazardous adverse reaction to lecithin or to the other substances that the capsules contain. Consent was obtained from the patient for publication of the hereby study. The legal authorities have been notified of the adverse effect of over consumption of lecithin.
Idiopathic autoimmune hemolytic anemia results from auto antibodies' production. Depending on the special characteristics of those antibodies, there are different types of autoimmune hemolytic anemia, a) Cold agglutinin disease, b) Warm agglutinin disease c) Donath-Landsteiner disease and d) drug-induced where auto antibodies are Ig-G type.
Drug-absorption. An epitope of the drug (lecithin) attach to the proteins of the erythrocyte membrane and finally leads to IgG antibodies formations.
Immune Complex Formation. When the substance combines with the plasma protein, it creates a complex which triggers the formation of antibodies against it. The new immune complex attaches to the RBC membrane and activates the complement which consequently leads to intravascular haemolysis.
The drug affects immune cells, so that it causes immune answer: DAT positive.
Probably the drug changes RBC membrane and that makes it vulnerable to the complement but nonspecifically, so that RBC's are destroyed extravascularly and that results in a negative DAT. .
In everyday clinical practice it is sometimes difficult to define the exact mechanism with which a pharmaceutical substance causes hemolysis, because more than one of the mechanisms that are mentioned before is involved. Fundamental step to the differential diagnosis of autoimmune hemolytic anemia is the exclusion of the remaining pathological conditions that cause it such as lymphohyperplastic disease, neoplasia, connective tissue disorders, thyroid gland disease, chronic hepatitis, and infections such as Ebstein-Barr Virus (EBV), Cytomegalovirus (CMV), Human Immunodeficiency Virus (HIV) and Mycoplasma.
In the present case all the above were excluded based on the history, the objective examination, and the laboratory findings. Consequently, the cause of autoimmune haemolytic anemia due to the administration of overdose of lecithin (or to the other components of the capsule) is very probable. The causing mechanism which is based on the positive DAT as antibody Ig-G and the action of lecithin as a drug absorption mechanism, or antibodies induction due to modification of RBC membrane by lecithin.
To our knowledge this is the first case in the international literature describing lecithin-induced idiopathic autoimmune hemolytic anemia. Our treatment was in compliance with the recommended standard treatment of hemolytic anemia, with the discontinuation of the pharmaceutical agent, and namely the discontinuation of lecithin capsules, and the beginning of treatment with corticoids and it was efficient. It is important to the clinicians to be aware of this adverse effect and conduct more research. In every case of autoimmune hemolytic anaemia the administration of pharmaceutical substances should always be examined detached from the standard reasons that cause it. In this case the cause of hemolysis was attributed to the intake of an overdose of lecithin capsules for the loss of body weight.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
A special thanks to Katsanaki Aikaterini for acquisition of patient data.
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