Hematology Oncology · Year 2 · from Hematology Oncology
Case 2: Warm Autoimmune Hemolytic Anemia
Patient Presentation
Demographics: 42-year-old female
Chief Complaint: Sudden onset of fatigue, jaundice, and dark urine for 5 days
History of Present Illness: The patient was in her usual state of health until 1 week ago when she developed an upper respiratory infection. She then noticed progressive fatigue, yellowing of her eyes, and dark "cola-colored" urine. She denies any new medications, recent travel, or family history of anemia or jaundice.
Physical Examination:
- Vital signs: BP 110/65, HR 108, RR 20, Temp 37.4C
- General: Pale, icteric woman in mild distress
- HEENT: Scleral icterus, conjunctival pallor
- Cardiac: Tachycardic, III/VI systolic flow murmur
- Abdomen: Splenomegaly (3 cm below costal margin), no hepatomegaly
- Skin: Jaundice, no petechiae or rashes
Workup and Results
Complete Blood Count:
- WBC: 12,400/uL (elevated)
- Hemoglobin: 6.8 g/dL (severely low, was 13.2 g/dL 6 months ago)
- MCV: 105 fL (elevated due to reticulocytosis)
- Platelets: 235,000/uL (normal)
- Reticulocyte count: 14% (markedly elevated)
- Absolute reticulocyte count: 420,000/uL
Hemolysis Labs:
- LDH: 680 U/L (elevated)
- Total bilirubin: 5.2 mg/dL (elevated)
- Indirect bilirubin: 4.6 mg/dL (elevated)
- Haptoglobin: < 10 mg/dL (undetectable)
- Urinalysis: Urobilinogen elevated, no hemoglobinuria
Peripheral Blood Smear:
- Polychromasia (reticulocytes)
- Spherocytes present
- No schistocytes or sickle cells
- Nucleated RBCs present
Direct Antiglobulin Test (Coombs):
- DAT: Positive
- Monospecific: IgG positive, C3 negative
ANA: Weakly positive (1:80)
Diagnosis
Warm Autoimmune Hemolytic Anemia (AIHA)
Key diagnostic features:
- Evidence of hemolysis: elevated LDH, indirect bilirubin, undetectable haptoglobin
- Elevated reticulocyte count (appropriate marrow response)
- Positive DAT with IgG (characteristic of warm AIHA)
- Spherocytes on smear (from partial phagocytosis)
- Extravascular hemolysis pattern (splenomegaly, no hemoglobinuria)
Treatment Plan
- First-line therapy:
- Prednisone 1 mg/kg/day (60-80 mg daily)
- Folic acid 1 mg daily
- Monitor hemoglobin every 2-3 days initially
- Transfusion if needed:
- Transfuse for symptomatic anemia or hemoglobin < 7 g/dL with symptoms
- Blood may be "least incompatible" - transfuse anyway if clinically needed
- If steroid-refractory (no response by 3 weeks):
- Rituximab (anti-CD20)
- Consider splenectomy for refractory cases
- Workup for secondary causes:
- Evaluate for underlying lymphoproliferative disorder
- Complete autoimmune workup (lupus panel)
Teaching Points
- Warm AIHA involves IgG antibodies that opsonize RBCs for splenic destruction
- The DAT (direct Coombs test) is positive for IgG +/- C3
- Spherocytes form when splenic macrophages remove portions of antibody-coated membrane
- The MCV may be elevated due to reticulocytosis (reticulocytes are larger than mature RBCs)
- Undetectable haptoglobin is the most sensitive marker for hemolysis
- Always look for underlying causes: lymphoma, CLL, lupus, drugs
- Transfusion should not be withheld for life-threatening anemia despite difficulty crossmatching