Autoimmune hemolytic anemia in patients with relapsed Hodgkin's lymphoma after treatment with penpulimab, a monoclonal antibody against programmed death receptor-1.

In August 2021, penpulimab, an anti-programmed cell death 1 (PD-1) monoclonal antibody, was approved in China for the treatment of adult patients with relapsed or refractory classic Hodgkin's lymphoma who completed at least second-line chemotherapy. Penpulimab is currently in clinical trials in China and Australia for the treatment of nasopharyngeal cancer and non-small cell lung cancer. Several clinical studies have shown that penpulimab is safe and effective, and no immune-related adverse events (irAEs) above grade 3 were observed. A 60-year-old woman with relapsed Hodgkin's lymphoma developed nausea and fatigue after receiving penpulimab monotherapy (200 mg every 2 weeks). Ten days after the second injection, the patient's condition worsened, and biochemical test results confirmed autoimmune hemolytic anemia (AIHA), with a hemoglobin level of 70 g/L (normal range, 115-150 g/L), an unconjugated bilirubin level of 19.08 µmol/L (normal range, 0-17 µmol/L), and positive direct antiglobulin test (DAT) results. On the same day, we treated her with prednisone (2 mg/kg), but her hemoglobin level continued to decline to 51 g/L one day after hormone therapy, so she received an intravenous infusion of washed red blood cells and underwent plasmapheresis, which eventually resolved the AIHA. Considering that the hemoglobin level was < 65 g/L and the irAE was grade 4, penpulimab was discontinued, and the symptoms of AIHA disappeared. From this event, we know that severe AIHA can occur after penpulimab use similar to other PD-1 antibodies. In this case, plasmapheresis showed a good therapeutic effect and should be used as a supplementary means when hormonal and immunosuppressive therapies cannot provide rapid symptom relief. In addition, we recommend regular direct antiglobulin testing, as well as haptoglobin, lactate dehydrogenase and other hemolysis-related laboratory tests, in patients prescribed penpulimab and similar drugs for the early diagnosis and treatment of AIHA.