Evans Syndrome Associated with Hematological Malignancies: A Literature Review
Main Article Content
Abstract
Evans syndrome (ES) is a rare disorder in which the immune system produces antibodies that accidentally destroy red blood cells and platelets. The diagnosis of ES is made by the simultaneous presence of autoimmune hemolytic anemia and immune thrombocytopenia. However, the diagnosis of ES associated with hematologic malignancies necessitates a comprehensive evaluation of clinical course, clinical findings, and laboratory test results. Hematological malignancies are the most significant underlying diseases factors impacting ES and the prognosis, but there is no established standard therapy for autoimmune cytopenia associated with hematological malignancies. In ES associated with hematologic malignancies, achieving remission of the underlying disease seems to be the key to long-term remission.
Keywords:
Evans syndrome, hematological malignancies, autoimmune hemolytic anemia, immune thrombocytopenia
Article Details
How to Cite
SHIBUSAWA, Motoharu.
Evans Syndrome Associated with Hematological Malignancies: A Literature Review.
Medical Research Archives, [S.l.], v. 9, n. 9, sep. 2021.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/2538>. Date accessed: 24 dec. 2024.
doi: https://doi.org/10.18103/mra.v9i9.2538.
Section
Review Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. Evans RS, Takahashi K, Duane RT, Payne R, Liu C. Primary thrombocytopenic purpura and acquired hemolytic anemia; evidence for a common etiology. AMA Arch Intern Med. 1951;87(1):48-65.
2. Hansen DL, Möller S, Andersen K, Gaist D, Frederiksen H. Evans syndrome in adults - incidence, prevalence, and survival in a nationwide cohort. Am J Hematol. 2019;94(10):1081-90.
3. Michel M, Chanet V, Dechartres A, Morin A-S, Piette J-C, Cirasino L, et al. The spectrum of Evans syndrome in adults: new insight into the disease based on the analysis of 68 cases. Blood. 2009;114(15):3167-72.
4. Hill QA, Stamps R, Massey E, Grainger JD, Provan D, Hill A. Guidelines on the management of drug-induced immune and secondary autoimmune, haemolytic anaemia. British Journal of Haematology. 2017;177(2):208-20.
5. Liebman HA, Stasi R. Secondary immune thrombocytopenic purpura. Curr Opin Hematol. 2007;14(5):557-73.
6. Kalfa TA. Warm antibody autoimmune hemolytic anemia. Hematology Am Soc Hematol Educ Program. 2016;2016(1):690-7.
7. Ahmad E, Elgohary T, Ibrahim H. Naturally occurring regulatory T cells and interleukins 10 and 12 in the pathogenesis of idiopathic warm autoimmune hemolytic anemia. J Investig Allergol Clin Immunol. 2011;21(4):297-304.
8. Barcellini W, Fattizzo B, Zaninoni A, Radice T, Nichele I, Di Bona E, et al. Clinical heterogeneity and predictors of outcome in primary autoimmune hemolytic anemia: a GIMEMA study of 308 patients. Blood. 2014;124(19):2930-6.
9. Barcellini W. New Insights in the Pathogenesis of Autoimmune Hemolytic Anemia. Transfusion Medicine and Hemotherapy. 2015;42(5):287-93.
10. Berentsen S, Ulvestad E, Langholm R, Beiske K, Hjorth-Hansen H, Ghanima W, et al. Primary chronic cold agglutinin disease: a population based clinical study of 86 patients. Haematologica. 2006;91(4):460-6.
11. Berentsen S. Complement Activation and Inhibition in Autoimmune Hemolytic Anemia: Focus on Cold Agglutinin Disease. Semin Hematol. 2018;55(3):141-9.
12. Audia S, Mahévas M, Samson M, Godeau B, Bonnotte B. Pathogenesis of immune thrombocytopenia. Autoimmun Rev. 2017;16(6):620-32.
13. Packman CH. Hemolytic anemia resulting from immune injury. In: Kenneth K, Marshall A L, Josef P, M M, Oliver W P, Linda J B, et al., editors. Williams Hematology. 9th: McGraw-Hill Education; 2016.
14. Hato T, Shimada N, Kurata Y, Kuwana M, Fujimura K, Kashiwagi H, et al. Risk factors for skin, mucosal, and organ bleeding in adults with primary ITP: a nationwide study in Japan. Blood Advances. 2020;4(8):1648-55.
15. Barcellini W, Fattizzo B. Clinical Applications of Hemolytic Markers in the Differential Diagnosis and Management of Hemolytic Anemia. Dis Markers. 2015;2015:635670.
16. Lian X, Liu C, Hou X, Zhang W, Hao J. Evans syndrome in a female with erythrophagocytosis by monocytes in peripheral blood smear. Int J Lab Hematol. 2020;42(4):e150-e1.
17. Yarali N, Arikoglu T, Oruc M, Isik P, Tunc B. Erythrophagocytosis in cold agglutinin disease. J Pediatr Hematol Oncol. 2011;33(5):398.
18. Rodeghiero F, Stasi R, Gernsheimer T, Michel M, Provan D, Arnold DM, et al. Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood. 2009;113(11):2386-93.
19. Barros MM, Blajchman MA, Bordin JO. Warm autoimmune hemolytic anemia: recent progress in understanding the immunobiology and the treatment. Transfus Med Rev. 2010;24(3):195-210.
20. Campo E, Ghia P, Montserrat E, Harris NL, Müller-Hermelink HK, Stein H, et al. Chronic lymphocytic leuaemia/small lymphocytic lymphoma. In: H SS, Elias C, Nancy LH, S JE, A PS, Harald S, et al., editors. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Revised 4th Edition. Lyon: International Agency for Research on Cancer; 2017. p. 216-21.
21. Duek A, Shvidel L, Braester A, Berrebi A. Clinical and immunologic aspects of B chronic lymphocytic leukemia associated with autoimmune disorders. Isr Med Assoc J. 2006;8(12):828-31.
22. Visco C, Barcellini W, Maura F, Neri A, Cortelezzi A, Rodeghiero F. Autoimmune cytopenias in chronic lymphocytic leukemia. Am J Hematol. 2014;89(11):1055-62.
23. Moreno C, Hodgson K, Ferrer G, Elena M, Filella X, Pereira A, et al. Autoimmune cytopenia in chronic lymphocytic leukemia: prevalence, clinical associations, and prognostic significance. Blood. 2010;116(23):4771-6.
24. Caligaris-Cappio F. B-chronic lymphocytic leukemia: a malignancy of anti-self B cells. Blood. 1996;87(7):2615-20.
25. Hamblin TJ, Oscier DG, Young BJ. Autoimmunity in chronic lymphocytic leukaemia. Journal of Clinical Pathology. 1986;39(7):713-6.
26. Lad DP, Varma S, Varma N, Sachdeva MU, Bose P, Malhotra P. Regulatory T-cells in B-cell chronic lymphocytic leukemia: their role in disease progression and autoimmune cytopenias. Leuk Lymphoma. 2013;54(5):1012-9.
27. Christopoulos P, Pfeifer D, Bartholomé K, Follo M, Timmer J, Fisch P, et al. Definition and characterization of the systemic T-cell dysregulation in untreated indolent B-cell lymphoma and very early CLL. Blood. 2011;117(14):3836-46.
28. Hervé M, Xu K, Ng Y-S, Wardemann H, Albesiano E, Messmer BT, et al. Unmutated and mutated chronic lymphocytic leukemias derive from self-reactive B cell precursors despite expressing different antibody reactivity. Journal of Clinical Investigation. 2005;115(6):1636-43.
29. Shvidel L, Tadmor T, Braester A, Bairey O, Rahimi-Levene N, Herishanu Y, et al. Pathogenesis, prevalence, and prognostic significance of cytopenias in chronic lymphocytic leukemia (CLL): a retrospective comparative study of 213 patients from a national CLL database of 1,518 cases. Ann Hematol. 2013;92(5):661-7.
30. Yevstakhevych YL, Vyhovska YI, Yevstakhevych IY, Vyhovska OY, Pelenyo NV, Semerak MM, et al. Autoimmune cytopenia in chronic lymphocytic leukemia: diagnosis and treatment. Exp Oncol. 2020;42(4):318-23.
31. Hampel PJ, Larson MC, Kabat B, Call TG, Ding W, Kenderian SS, et al. Autoimmune cytopenias in patients with chronic lymphocytic leukaemia treated with ibrutinib in routine clinical practice at an academic medical centre. Br J Haematol. 2018;183(3):421-7.
32. Zent CS, Ding W, Schwager SM, Reinalda MS, Hoyer JD, Jelinek DF, et al. The prognostic significance of cytopenia in chronic lymphocytic leukaemia/small lymphocytic lymphoma. British Journal of Haematology. 2008;141(5):615-21.
33. Stein H, Pileri SA, Weiss LM, Poppema S, Gascoyne RD, Jaffe ES. Hodgkin lymphomas: Introduction. In: Steven HS, Elias C, Nancy LH, S JE, A PS, Harald S, et al., editors. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Revised 4th Edition. Lyon: International Agency for Research on Cancer; 2017. p. 424-30.
34. Pinczés LI, Szabó R, Miltényi Z, Illés Á. The impact of autoimmune cytopenias on the clinical course and survival of Hodgkin lymphoma. Int J Hematol. 2021;113(2):175-82.
35. Dimou M, Angelopoulou MK, Pangalis GA, Georgiou G, Kalpadakis C, Pappi V, et al. Autoimmune hemolytic anemia and autoimmune thrombocytopenia at diagnosis and during follow-up of Hodgkin lymphoma. Leuk Lymphoma. 2012;53(8):1481-7.
36. Dogan A, Gaulard P, Jaffe ES, Müller-Hermelik HK, Leval Ld. Angioimmunoblastic T-cell lymphoma and other nodal lymphomas of T follicular helper cell origin. In: H SS, Elias C, Nancy LH, S JE, A PS, Harald S, et al., editors. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Revised 4th Edition. Lyon: International Agency for Research on Cancer; 2017. p. 407-10.
37. Crickx E, Poullot E, Moulis G, Goulabchand R, Fieschi C, Galicier L, et al. Clinical spectrum, evolution, and management of autoimmune cytopenias associated with angioimmunoblastic T-cell lymphoma. Eur J Haematol. 2019;103(1):35-42.
38. Gallamini A. Peripheral T-cell lymphoma unspecified (PTCL-U): a new prognostic model from a retrospective multicentric clinical study. Blood. 2004;103(7):2474-9.
39. Zhu F, Li Q, Pan H, Xiao Y, Liu T, Liu X, et al. Successful Treatment of Chidamide and Cyclosporine for Refractory/Relapsed Angioimmunoblastic T Cell Lymphoma With Evans Syndrome: A Case Report With Long-Term Follow-Up. Front Oncol. 2020;10:1725.
40. McKenna RW, Kyle RA, Kuehl WM, Harris NL, Coupland RW, Fend F. Plasma cell neoplasms. In: Steven HS, Elias C, Nancy LH, S JE, A PS, Harald S, et al., editors. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Revised 4th Edition. Lyon: International Agency for Research on Cancer; 2017. p. 241-58.
41. Khan MS, Kasmani R, Khan G, Changal K, Singh H. A Case of Multiple Myeloma Presenting with Gastrointestinal Bleeding and Evans Syndrome. Cureus. 2019;11(10):e5969.
42. Karapetians A, Bajaj T, Valdes A, Heidari A. A Rare Case of Multiple Myeloma Presenting as Evan's Syndrome. J Investig Med High Impact Case Rep. 2019;7:2324709619852760.
43. Bechir A, Haifa R, Nesrine BS, Emna B, Senda M, Asma A, et al. Multiple myeloma associated with an Evan's syndrome. Pan Afr Med J. 2016;25:127.
44. Al-Ammari M, Adam S. Concomitant multiple myeloma, gastric adenocarcinoma and Evan's syndrome in a patient presenting with anaemia. BMJ Case Rep. 2016;2016.
45. Chihara D, Sakamoto T, Arimoto-Miyamoto K, Kishimoto W, Takeoka T, Tsuji M, et al. Refractory Evans syndrome after autologous stem cell transplantation for multiple myeloma: management with a second transplantation. Intern Med. 2010;49(7):683-7.
46. Yonekura S, Nagao T, Arimori S, Miyaji M, Ogoshi K, Tsutsumi Y. Evans' syndrome associated with gastric plasmacytoma: case report and a review of the literature. Jpn J Med. 1990;29(5):512-5.
47. Kashyap R, Singh A, Kumar P. Prevalence of autoimmune hemolytic anemia in multiple myeloma: A prospective study. Asia Pac J Clin Oncol. 2016;12(2):e319-22.
48. Xiao X, Zhong HY, Zhang GS, Deng MY. Thrombotic thrombocytopenic purpura as initial and major presentation of multiple myeloma. J Thromb Thrombolysis. 2013;36(4):422-3.
49. Alpay N, Uzun S, Bahat G, Yavuz S, Erten N, Tascioglu C. Thrombotic thrombocytopenic purpura associated with multiple myeloma. Blood Coagulation & Fibrinolysis. 2008;19(5):439-41.
50. García-Muñoz R, Rodriguez-Otero P, Pegenaute C, Merino J, Jakes-Okampo J, Llorente L, et al. Splenic marginal zone lymphoma with Evans' syndrome, autoimmunity, and peripheral gamma/delta T cells. Ann Hematol. 2009;88(2):177-8.
51. Ustun C, Savage N, Manaloor E, Kunavarapu C, Jillella A. Amyloidosis, Evans syndrome and management options of lymphoplasmacytic lymphoma. Amyloid. 2009;16(1):42-6.
52. Motta G, Vianello F, Menin C, De Nicolo A, Agata S, Altavilla G, et al. Hepatosplenic gammadelta T-cell lymphoma presenting with immune-mediated thrombocytopenia and hemolytic anemia (Evans' syndrome). Am J Hematol. 2002;69(4):272-6.
2. Hansen DL, Möller S, Andersen K, Gaist D, Frederiksen H. Evans syndrome in adults - incidence, prevalence, and survival in a nationwide cohort. Am J Hematol. 2019;94(10):1081-90.
3. Michel M, Chanet V, Dechartres A, Morin A-S, Piette J-C, Cirasino L, et al. The spectrum of Evans syndrome in adults: new insight into the disease based on the analysis of 68 cases. Blood. 2009;114(15):3167-72.
4. Hill QA, Stamps R, Massey E, Grainger JD, Provan D, Hill A. Guidelines on the management of drug-induced immune and secondary autoimmune, haemolytic anaemia. British Journal of Haematology. 2017;177(2):208-20.
5. Liebman HA, Stasi R. Secondary immune thrombocytopenic purpura. Curr Opin Hematol. 2007;14(5):557-73.
6. Kalfa TA. Warm antibody autoimmune hemolytic anemia. Hematology Am Soc Hematol Educ Program. 2016;2016(1):690-7.
7. Ahmad E, Elgohary T, Ibrahim H. Naturally occurring regulatory T cells and interleukins 10 and 12 in the pathogenesis of idiopathic warm autoimmune hemolytic anemia. J Investig Allergol Clin Immunol. 2011;21(4):297-304.
8. Barcellini W, Fattizzo B, Zaninoni A, Radice T, Nichele I, Di Bona E, et al. Clinical heterogeneity and predictors of outcome in primary autoimmune hemolytic anemia: a GIMEMA study of 308 patients. Blood. 2014;124(19):2930-6.
9. Barcellini W. New Insights in the Pathogenesis of Autoimmune Hemolytic Anemia. Transfusion Medicine and Hemotherapy. 2015;42(5):287-93.
10. Berentsen S, Ulvestad E, Langholm R, Beiske K, Hjorth-Hansen H, Ghanima W, et al. Primary chronic cold agglutinin disease: a population based clinical study of 86 patients. Haematologica. 2006;91(4):460-6.
11. Berentsen S. Complement Activation and Inhibition in Autoimmune Hemolytic Anemia: Focus on Cold Agglutinin Disease. Semin Hematol. 2018;55(3):141-9.
12. Audia S, Mahévas M, Samson M, Godeau B, Bonnotte B. Pathogenesis of immune thrombocytopenia. Autoimmun Rev. 2017;16(6):620-32.
13. Packman CH. Hemolytic anemia resulting from immune injury. In: Kenneth K, Marshall A L, Josef P, M M, Oliver W P, Linda J B, et al., editors. Williams Hematology. 9th: McGraw-Hill Education; 2016.
14. Hato T, Shimada N, Kurata Y, Kuwana M, Fujimura K, Kashiwagi H, et al. Risk factors for skin, mucosal, and organ bleeding in adults with primary ITP: a nationwide study in Japan. Blood Advances. 2020;4(8):1648-55.
15. Barcellini W, Fattizzo B. Clinical Applications of Hemolytic Markers in the Differential Diagnosis and Management of Hemolytic Anemia. Dis Markers. 2015;2015:635670.
16. Lian X, Liu C, Hou X, Zhang W, Hao J. Evans syndrome in a female with erythrophagocytosis by monocytes in peripheral blood smear. Int J Lab Hematol. 2020;42(4):e150-e1.
17. Yarali N, Arikoglu T, Oruc M, Isik P, Tunc B. Erythrophagocytosis in cold agglutinin disease. J Pediatr Hematol Oncol. 2011;33(5):398.
18. Rodeghiero F, Stasi R, Gernsheimer T, Michel M, Provan D, Arnold DM, et al. Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood. 2009;113(11):2386-93.
19. Barros MM, Blajchman MA, Bordin JO. Warm autoimmune hemolytic anemia: recent progress in understanding the immunobiology and the treatment. Transfus Med Rev. 2010;24(3):195-210.
20. Campo E, Ghia P, Montserrat E, Harris NL, Müller-Hermelink HK, Stein H, et al. Chronic lymphocytic leuaemia/small lymphocytic lymphoma. In: H SS, Elias C, Nancy LH, S JE, A PS, Harald S, et al., editors. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Revised 4th Edition. Lyon: International Agency for Research on Cancer; 2017. p. 216-21.
21. Duek A, Shvidel L, Braester A, Berrebi A. Clinical and immunologic aspects of B chronic lymphocytic leukemia associated with autoimmune disorders. Isr Med Assoc J. 2006;8(12):828-31.
22. Visco C, Barcellini W, Maura F, Neri A, Cortelezzi A, Rodeghiero F. Autoimmune cytopenias in chronic lymphocytic leukemia. Am J Hematol. 2014;89(11):1055-62.
23. Moreno C, Hodgson K, Ferrer G, Elena M, Filella X, Pereira A, et al. Autoimmune cytopenia in chronic lymphocytic leukemia: prevalence, clinical associations, and prognostic significance. Blood. 2010;116(23):4771-6.
24. Caligaris-Cappio F. B-chronic lymphocytic leukemia: a malignancy of anti-self B cells. Blood. 1996;87(7):2615-20.
25. Hamblin TJ, Oscier DG, Young BJ. Autoimmunity in chronic lymphocytic leukaemia. Journal of Clinical Pathology. 1986;39(7):713-6.
26. Lad DP, Varma S, Varma N, Sachdeva MU, Bose P, Malhotra P. Regulatory T-cells in B-cell chronic lymphocytic leukemia: their role in disease progression and autoimmune cytopenias. Leuk Lymphoma. 2013;54(5):1012-9.
27. Christopoulos P, Pfeifer D, Bartholomé K, Follo M, Timmer J, Fisch P, et al. Definition and characterization of the systemic T-cell dysregulation in untreated indolent B-cell lymphoma and very early CLL. Blood. 2011;117(14):3836-46.
28. Hervé M, Xu K, Ng Y-S, Wardemann H, Albesiano E, Messmer BT, et al. Unmutated and mutated chronic lymphocytic leukemias derive from self-reactive B cell precursors despite expressing different antibody reactivity. Journal of Clinical Investigation. 2005;115(6):1636-43.
29. Shvidel L, Tadmor T, Braester A, Bairey O, Rahimi-Levene N, Herishanu Y, et al. Pathogenesis, prevalence, and prognostic significance of cytopenias in chronic lymphocytic leukemia (CLL): a retrospective comparative study of 213 patients from a national CLL database of 1,518 cases. Ann Hematol. 2013;92(5):661-7.
30. Yevstakhevych YL, Vyhovska YI, Yevstakhevych IY, Vyhovska OY, Pelenyo NV, Semerak MM, et al. Autoimmune cytopenia in chronic lymphocytic leukemia: diagnosis and treatment. Exp Oncol. 2020;42(4):318-23.
31. Hampel PJ, Larson MC, Kabat B, Call TG, Ding W, Kenderian SS, et al. Autoimmune cytopenias in patients with chronic lymphocytic leukaemia treated with ibrutinib in routine clinical practice at an academic medical centre. Br J Haematol. 2018;183(3):421-7.
32. Zent CS, Ding W, Schwager SM, Reinalda MS, Hoyer JD, Jelinek DF, et al. The prognostic significance of cytopenia in chronic lymphocytic leukaemia/small lymphocytic lymphoma. British Journal of Haematology. 2008;141(5):615-21.
33. Stein H, Pileri SA, Weiss LM, Poppema S, Gascoyne RD, Jaffe ES. Hodgkin lymphomas: Introduction. In: Steven HS, Elias C, Nancy LH, S JE, A PS, Harald S, et al., editors. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Revised 4th Edition. Lyon: International Agency for Research on Cancer; 2017. p. 424-30.
34. Pinczés LI, Szabó R, Miltényi Z, Illés Á. The impact of autoimmune cytopenias on the clinical course and survival of Hodgkin lymphoma. Int J Hematol. 2021;113(2):175-82.
35. Dimou M, Angelopoulou MK, Pangalis GA, Georgiou G, Kalpadakis C, Pappi V, et al. Autoimmune hemolytic anemia and autoimmune thrombocytopenia at diagnosis and during follow-up of Hodgkin lymphoma. Leuk Lymphoma. 2012;53(8):1481-7.
36. Dogan A, Gaulard P, Jaffe ES, Müller-Hermelik HK, Leval Ld. Angioimmunoblastic T-cell lymphoma and other nodal lymphomas of T follicular helper cell origin. In: H SS, Elias C, Nancy LH, S JE, A PS, Harald S, et al., editors. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Revised 4th Edition. Lyon: International Agency for Research on Cancer; 2017. p. 407-10.
37. Crickx E, Poullot E, Moulis G, Goulabchand R, Fieschi C, Galicier L, et al. Clinical spectrum, evolution, and management of autoimmune cytopenias associated with angioimmunoblastic T-cell lymphoma. Eur J Haematol. 2019;103(1):35-42.
38. Gallamini A. Peripheral T-cell lymphoma unspecified (PTCL-U): a new prognostic model from a retrospective multicentric clinical study. Blood. 2004;103(7):2474-9.
39. Zhu F, Li Q, Pan H, Xiao Y, Liu T, Liu X, et al. Successful Treatment of Chidamide and Cyclosporine for Refractory/Relapsed Angioimmunoblastic T Cell Lymphoma With Evans Syndrome: A Case Report With Long-Term Follow-Up. Front Oncol. 2020;10:1725.
40. McKenna RW, Kyle RA, Kuehl WM, Harris NL, Coupland RW, Fend F. Plasma cell neoplasms. In: Steven HS, Elias C, Nancy LH, S JE, A PS, Harald S, et al., editors. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Revised 4th Edition. Lyon: International Agency for Research on Cancer; 2017. p. 241-58.
41. Khan MS, Kasmani R, Khan G, Changal K, Singh H. A Case of Multiple Myeloma Presenting with Gastrointestinal Bleeding and Evans Syndrome. Cureus. 2019;11(10):e5969.
42. Karapetians A, Bajaj T, Valdes A, Heidari A. A Rare Case of Multiple Myeloma Presenting as Evan's Syndrome. J Investig Med High Impact Case Rep. 2019;7:2324709619852760.
43. Bechir A, Haifa R, Nesrine BS, Emna B, Senda M, Asma A, et al. Multiple myeloma associated with an Evan's syndrome. Pan Afr Med J. 2016;25:127.
44. Al-Ammari M, Adam S. Concomitant multiple myeloma, gastric adenocarcinoma and Evan's syndrome in a patient presenting with anaemia. BMJ Case Rep. 2016;2016.
45. Chihara D, Sakamoto T, Arimoto-Miyamoto K, Kishimoto W, Takeoka T, Tsuji M, et al. Refractory Evans syndrome after autologous stem cell transplantation for multiple myeloma: management with a second transplantation. Intern Med. 2010;49(7):683-7.
46. Yonekura S, Nagao T, Arimori S, Miyaji M, Ogoshi K, Tsutsumi Y. Evans' syndrome associated with gastric plasmacytoma: case report and a review of the literature. Jpn J Med. 1990;29(5):512-5.
47. Kashyap R, Singh A, Kumar P. Prevalence of autoimmune hemolytic anemia in multiple myeloma: A prospective study. Asia Pac J Clin Oncol. 2016;12(2):e319-22.
48. Xiao X, Zhong HY, Zhang GS, Deng MY. Thrombotic thrombocytopenic purpura as initial and major presentation of multiple myeloma. J Thromb Thrombolysis. 2013;36(4):422-3.
49. Alpay N, Uzun S, Bahat G, Yavuz S, Erten N, Tascioglu C. Thrombotic thrombocytopenic purpura associated with multiple myeloma. Blood Coagulation & Fibrinolysis. 2008;19(5):439-41.
50. García-Muñoz R, Rodriguez-Otero P, Pegenaute C, Merino J, Jakes-Okampo J, Llorente L, et al. Splenic marginal zone lymphoma with Evans' syndrome, autoimmunity, and peripheral gamma/delta T cells. Ann Hematol. 2009;88(2):177-8.
51. Ustun C, Savage N, Manaloor E, Kunavarapu C, Jillella A. Amyloidosis, Evans syndrome and management options of lymphoplasmacytic lymphoma. Amyloid. 2009;16(1):42-6.
52. Motta G, Vianello F, Menin C, De Nicolo A, Agata S, Altavilla G, et al. Hepatosplenic gammadelta T-cell lymphoma presenting with immune-mediated thrombocytopenia and hemolytic anemia (Evans' syndrome). Am J Hematol. 2002;69(4):272-6.