is this a drug induced hemolytic anemia? 1. Is this type of anemia caused by an
ID: 123901 • Letter: I
Question
is this a drug induced hemolytic anemia?
1. Is this type of anemia caused by an intrinsic or extrinsic defect? 2. What does the positive DAT result imply? 3. What mechanisms can lead to the development of drug-induced immune hemolytic anemia? 4. Describe the mechanism that is the most probable cause of this patient's anemia. 5. In addition to the transfusion, what additional action should be taken? A 20-year-old woman sought medical attention for an elevated temperature and a possible insect bite. Physical examination revealed a small bite wound on the right lateral area of the chest that was tender and contained a clear fluid with no pus. Necrosis was not evident. A diffuse erythematous rash also was observed on most of her body. The physician prescribed 40 mL of liquid acetaminophen (Tylenol) and a 10-day regimen of cefuroxime (Ceftin). A secretion from the lesion was subjected to culture, but there was no growth after 72 hours. Blood was drawn for cultures, for which negative results were reported after 5 days. Four days later, the patient went to the emergency department, complaining of being unable to wak. A CBC, urinalysis, urine and sputum cultures, and chemistry profile were ordered Patient Results Reference Range WBCs (x10%) 5.9 4.5-11.5 RBCs (x10) 1.40 .00-5.40 2.0-15.0 Hot (%) 13 35-49 The platelet count was within the reference range. Spherocytes and polychromasia were observed on the peripheral blood film (Figure 25-1). The film also revealed a slight increase in neutrophilic bands and 2 nucleated RBCs per 100 WBCs (not shown in figure). An increase in urobilinogen was noted on the routine urinalysis report, but the result for blood was negative. Urine and sputum culture results were negative. Significant findings from the chemistry profile included elevated levels of serum indirect bilirubin and lactate dehydrogenase. Subsequently. a direct antiglobulin test (DAT) and 3 units of red blood cells were ordered. A positive result on the DAT for lgG was reported. The indirect antiglobulin test on the patient's serum and on an eluate prepared from the patient's cells yielded negative results for all panel cells tested.Explanation / Answer
1. Extrinsic defect. All auto immune hemolytic anemias are extrinsic in nature to the RBCs.
2. A positive DAT implies that a comlplement or antibody is attached to the RBC surface. This is usually seen in hemolytic anemias - immune type.
3 and 4. Ceftin which is cefuroxime sometimes is known to cause (rare) drug induced hemolytic anemias. The drug attaches to the cell membrane of the RBC and causes uptake of these complexes by antibodies and digestion by macrophages. This results in destruction of rbcs.
5. Complete stopage of the drug causing hemolysis. IV steroids may be started.
6. This is a drug induced (immune mediated) hemolytic anemia.
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