There are three patients that you have been asked to manage.
Patient 1. This patient is in the hospital for a review of his blood pressure and cardiac status. He is 68 year old retired college lecturer whose only complaint is that he cannot cope with his daily routine. You ask him what his daily routine is and he says “I do the grocery shopping for my wife, go to the mosque for my morning and evening prayers, read books, write an article for the newspaper or magazine. I have stopped my evening walk, I used to walk for 3 miles but now I get too tired.”
You examine him and except for significant anemia and a firm spleen which is 2 cm enlarged below the costal margin you find no abnormality. He has no jaundice, has not lost weight recently and his appetite is not decreased.
What questions will you ask him? Does he have angina or shortness of breath when he walks. Has he vomited blood or had black granular material in the vomit or has he passed soft, sticky black stools. Does he have heartburn? Has he had jaundice in the past and has he ever tested positive for hepatitis B or C? He gives a negative answer to all these. A blood study shows anemia, neutropenia, thrombocytopenia. There are 5% blast cells in the blood. A bone marrow exdamination was requested.
What does this patient have?
A myelodysplastic syndrome which shares clinical and pathologic features with acute myeloid leukemia (AML), but MDS has a lower percentage of blasts in peripheral blood and bone marrow (by definition, <20 percent). Patients with MDS are at risk for symptomatic anemia, infection, bleeding, and transformation to AML, the incidence of which varies widely across MDS subtypes.
Patient 2. This patient is a 44 year old housewife who has come for evaluation for backache, abdominal pain and jaundice. She feels very tired and has had a tinge of jaundice for the past 4 days and has noticed that her urine is dark coloured. On examination she has anemia, jaundice and hepatomegaly of two cm and a spleen of 4 cm, both are soft and difficult to feel.
What questions will you ask her?
What medicines has she recently used? She was given ciprofloxacin for a UTI ten days ago. It is possible for ciprofloxacin to cause hemolytic anemia. Her direct antigen test (Coombs test) was positive for IgG. She seems to have reacted to ciprofloxacin.
The clinical presentation in severe hemolysis, patients may experience sudden onset of pallor, fatigue, jaundice, and in some cases dark urine, abdominal pain, or back pain. Typical symptoms of hemolytic anemia include those associated with anemia (fatigue, weakness, dyspnea, symptoms related to volume depletion like fainting and lightheadedness or vertigo) as well as hemolysis (jaundice; in some cases dark or red urine due to hemoglobinuria).
The Berlin Case-Control Surveillance Study from 2011, which included 134 cases of drug-induced autoimmune hemolytic anemia (AIHA), mostly in an outpatient setting, reported commonly implicated drugs to include beta-lactam antibiotics such as piperacillin, ceftriaxone, cotrimoxazole, ciprofloxacin, fludarabine, lorazepam, and diclofenac and anticancer drugs. Oxidant injury can be caused by dapsone, primaquine and phenazopyridine.
Drugs tend to cause immune reactions in the following ways.
- Penicillin like reaction. The drug induces antibodies. So long as the drug coats the RBC the antibodies will react against it. Stopping the drug will reduce the reaction and eliminate it in the time taken to eliminate the drug from the system.
- Immune complex reaction. The drug induces immune complexes which react against the RBCs and activate complement which causes the hemolysis. Just stopping the drug will not eliminate the reaction. The antigen complexes have to be metabolised for the reaction to be stopped and will take a longer time for recovery.
- Passive absorption. In the passive absorption type, administration of antibody preparations introduces antibodies that can react with the recipient’s RBCs. Intravenous immune globulin (IVIG) or Rho(D) immune globulin frequently contain allo-antibodies that react with the recipient’s RBC antigens (eg, anti-D, anti-A, or anti-B) producing alloimmune hemolysis.
- Alteration of RBC surface antigen – In this type of reaction, the drug alters a normal membrane component of the RBC membrane. It can cause immune hemolysis several weeks to months after drug initiation. The DAT (direct Coombs) test is positive.
A great number of drugs cause Auto-Immune-Hemolytic Anemia (AIHA) including aspirin, acetaminophen, chlorpropamide, ciprofloxacin etc.
Patient 3. A 20 year old soldier who recently went home to the interior of Sindh for his summer leave for one month. He comes back feeling very tired and unable to cope with the PT and parade practice which is the daily routine in his regiment. He fainted once when the sargent forced him to run. He has noticed a tinge of jaundice and dark colored urine. You find that he is markedly anemic, has a lemonish tone of jaundice, has an enlarged, hard spleen about 8 cm below the costal margin. The liver is not enlarged and he has no stigmata of chronic liver disease.
What questions will you ask him? Has he had episodes of jaundice in the past, or has he needed a blood transfusion? Has he got a family member specially a sibling who has episodes of jaundice? Did he have fever while he was on leave? Has a family member ever been told that their spleen was enlarged or ever needed a blood transfusion? on asking he says that he had fever with rigors twice during the month he was on leave. The doctor in the small town where he lives told him it was malaria and treated him for it. He says that every one in his home town suffers from malaria fever several times in the summer. His younger brother has been told he has an enlarged spleen. His parents are first cousins and he is engaged to his first cousin as the family always marry other close family members.
What are we chasing? A hemoglobinopathy which unlike thalasemia presents in early adulthood: HbD disease, HbE disease, HbC disease or an RBC membrane disease like congenital spherocytosis, elliptocytosis, stomatocytosis. Remember the these can be combined like HbD with thalasemia trait or thalasemia beta minor or with spherocytosis. These are very much present in Pakistan so much so that HbD is also known as Hemoglobin Punjab disease.
This patient had a hemoglobin of 6gm/dl. He needed 3 blood transfusions to raise his hemoglobin to 9.8 gm/dl. Why did his hemoglobin drop to this level suddenly? In addition to the condition causing his hemolysis he had 2 episodes of malaria in which the hemoparasite causes hemolysis as well.
Patient 1 had a hemoglobin of 10 gm/dl and patient 2 had a hemoglobin of 8.5 gm/dl. How will you determine that these patients are hemolysing their blood? In all patients who are anemic without any evidence of bleeding from anywhere hemolytic anemia should be suspected. The reticulocyte of 6% or between 6 to 10% is proof of ongoing hemolysis unless the patient has had a recent bleed or been given nutrients like iron, folic acid or B12. Remember reticulocytes have a survival of 4 days; 3 days in the bone marrow and 1 day in the systemic circulation. Next measure the haptoglobin; in hemolysis it will be low. The LDH will be high and so will the serum bilirubin.
The next is the blood smear. The blood smear will show abnormalities in the RBCs like broken cells or schistocytes, spherocytes; round cells with no pallor in the centre and a smaller size than normal discoid RBCs and on, Heinz bodies may be present on the cells.
Patient number 3 had spherocytes and fragmented cells and on hemoglobin electrophoresis HbD was detected so his diagnosis was hereditary spherocytosis and HbD disease. His younger brother was also investigated and carried both the diseases. Both were advised splenectomy as the destruction of the RBCs takes place in the splenic cords and the survival time of the RBCs can be increased by removing the spleen. Hemolysis will be reduced though not eliminated.
What does the consistency of the spleen (and liver) tell us? A firm spleen means that the spleen has been enlarged for some months, a soft spleen tells you about recent enlargement of the organ and a hard spleen tells you about a spleen that has been enlarged for many months or years even.
When should a direct Coombs (direct antigen test or DAT) test be done?
A DAT should be obtained in all patients who present with anemia, laboratory evidence of hemolysis (ie, increased lactate dehydrogenase, increased indirect bilirubin, reduced haptoglobin), and an absence of schistocytes on the peripheral blood smear.
The direct antiglobulin test (DAT; direct Coombs test) is performed by adding anti-human globulin to patient RBCs. The immune globulin is on the patient’s RBCs. The indirect antiglobulin test (IAT; indirect Coombs test) is performed by adding patient plasma to test RBCs followed by the addition of anti-human globulin. In either case, the presence of an anti-RBC antibody (autoantibody or alloantibody) causes RBCs to be agglutinated when the anti-human globulin is added. In the indirect test the antigen is in the patient’s plasma.
Patient number 2 had a history of intake of ciprofloxacin which could have caused hemolysis. She was negative for RA factor but positive for anti-dsDNA antibodies. The possibility of AIHA was raised. It is important to distinguish between warm-AIHA and cold agglutinin disease, which is typically caused by IgM autoantibodies that react with polysaccharide antigens on red cells at temperatures below core body temperature and result in RBC agglutination and complement-mediated hemolysis. In cold agglutinin disease, the DAT is typically negative for IgG but positive for C3 fragments.
What does pink serum, positive serum free hemoglobin, positive urine dipstick for heme, positive urine for hemosiderin indicate? It points to intravascular hemolysis rather than in the reticuloendothelial system and may indicate one of the following conditions;
- AHTR (acute hemolytic transfusion)
- Overwhelming bacterial infection (eg, from clostridium perfringens)
- Paroxysmal nocturnal hemoglobinuria (PNH)
- Paroxysmal cold hemoglobinuria (PCH)
Let us examine some unusual situations.
Is it possible to have hemolysis without reticulocytosis?
Hemolytic anemia can be seen in the absence of an appropriate reticulocyte response, often resulting in a more profound degree of anemia. This occurs when the bone marrow is not capable of responding appropriately to anemia. If hemolysis is suspected or confirmed but the reticulocyte count is inappropriately low, there are several possible concomitant conditions that may be responsible for blunting the reticulocyte response: such as iron deficiency anemia, vitamin B12 or folate or copper deficiency, alcohol induced anemia, anemia of chronic inflammatory disease or myelodysplastic syndrome, drug induced bone marrow suppression and temporary bone marrow suppression as in parvovirus disease.
Hemolysis without anemia
Hemolysis without anemia can be seen if the bone marrow capacity to increase RBC production is sufficient to overcome the anemia caused by the hemolysis.
Reticulocytosis without hemolysis
A patient thought to have hemolytic anemia based on an increased reticulocyte count may in fact have another cause of reticulocytosis. They may be recovering from an episode of bleeding or ongoing bleeding or may have been deficient in a nutrient which has been repleted such as iron, vitamin B12, or folate; been administered erythropoietin or is recovering from a bone marrow insult such as an infection (eg, parvovirus), medication, or alcohol.