Anemia with Hemoglobin 4.2 mg/dL. What is the Cause?

Author: A. Rajaminackam, M.D., Department of Hospital Medicine at Cleveland Clinic
Reviewer: V. Dimov, M.D.[/b]

A 51-year-old female has had fatigue, weakness, and SOB with exertion during the past 4-5 days. She called her PCP who recommended she had hemoglobin checked. He called her back with the results, and told her to go to the ER for further treatment of severe anemia. The patient denied abdominal pain, chest pain, congestion, N/V/D/C, dysuria, headache, chills, hemoptysis, neck pain, rash, or sore throat.

Symptoms were exacerbated by activity and relieved by rest and laying supine. She also felt palpitations intermittently.

Past Medical History (PMH)

DM2.

Medications

Lantus (Insulin Glargine, rDNA origin) 25 mg SQ QHS, Humalog (insulin lispro) SSI SQ with Accu-Chek Blood Glucose Monitoring TID.

Physical Examination

VS: mild tachycardia, no hypotension.
General appearance: pale, non-icteric.
Eyes: EOMI, PERRLA, sclerae non-icteric
ENT: Oropharynx clear, no plaques or exudates
Chest: CTA (
CVS: Clear S1S2
Abd: Soft, NT, ND, +BS
Ext.: no c/c/e
Neurologic: AAA x 3
No lymphadenopathy

What is the most likely diagnosis?

Severe anemia that is symptomatic with fatigue and shortness of breath (SOB).

What are the likely causes of anemia in this patient?

Blood loss?
Hemolytic anemia?
Iron-deficiency?

What laboratory workup would you order?

CBC+Diff
CMP
Reticulocyte count
LDH
Haptoglobin
Peripheral smear

_____________

What happened?

Hemoglobin (Hgb) was 4.2 mg/dL, MCV 144 fl, reticulocyte count 41%. The patient most likely has hemolytic anemia.

What other tests would you order?

Direct and indirect Coombs' test
ANA, RF
C3, C4
CXR
CT c/a/p (chest, abdomen and pelvis)


CBC and CMP


Immunology tests

What happened next?

The patient was admitted to a regular medical floor and a hematology consult was called. The direct Coombs' test was reported as positive.

CXR and CT scans were negative for neoplastic disease.

The patients has autoimmune hemolytic anemia (AIHA) mediated by warm antibodies because the hemolysis is observed at normal body temperature. By contrast, in the cold antibody AIHA, the autoantibodies attack the red blood cells only at temperatures significantly below normal body temperature, e.g. when working outside in the winter.

Would you transfuse this patient?

The hemoglobin was 4.2 mg/dL and if the patient was symptomatic. A blood transfusion was indicated.

In general, it may be difficult to find compatible blood in AIHA because of the presence of autoantibodies. RBC transfusions are generally avoided unless absolutely necessary.

How would you treat this patient?

Solu-Medrol (methylprednisolone) 100 mg IV q 6 hr.
Consider immune globulin infusion.
Follow-up on the Hem/Onc recommendations.


Hemoglobin response to steroid treatment in AIHA. Taper glucocorticoids very gradually to avoid a relapse of hemolysis.

Final diagnosis

Warm Antibody Autoimmune Hemolytic Anemia (AIHA)

References


Coombs' test (click to enlarge the diagram). Source: A. Rad. GNU Free Documentation License. Wikipedia.
Hemolytic Anemia. eMedicine.
Autoimmune Hemolytic Anemia. Merck Manual.
Seasonal Hemolysis Due to Cold-Agglutinin Syndrome. Lyckholm L. J., Edmond M. B.
N Engl J Med 1996; 334:437, Feb 15, 1996. Images in Clinical Medicine.

Further Reading

Robin Coombs, 85, Inventor of a Diagnostic Blood Test, Dies. The New York Times, March 27, 2006