The Hematologist

November-December 2018, Volume 15, Issue 6

An Older Woman With Hemolytic Anemia

Shiraz S. Fidai, MD Hematopathology Fellow, Department of Pathology
University of Chicago, Chicago, IL
Geoffrey Wool, MD, PhD Assistant Professor; Director of Coagulation Laboratory
University of Chicago, Chicago, IL

Published on: October 10, 2018

A 73-year-old woman with a long-standing history of anemia for which she received intravenous iron infusions, and a history of clinically significant antibody (anti-E), was transfused one unit of matched pRBC in the emergency department for dizziness and anemia with borderline microcytosis (hemoglobin, 6.9 g/dL; mean corpuscular volume, 80.7 fL). The patient also had a history of heart failure and chronic kidney disease. She was admitted approximately one week later with chest pain and was found to have an elevated pro–B-type natriuretic peptide and high-sensitivity troponin. Her hemoglobin subsequently dropped from 8.5 g/dL to 6.9 g/dL, lactate dehydrogenase was elevated (1,209 U/L), and haptoglobin was undetectable (<20 mg/dL). A transfusion reaction evaluation was ordered. No new clinically significant antibodies were detected, direct antiglobulin test (DAT) was negative, and (out of an abundance of caution) an eluate was performed that was negative as well. The patient received ongoing transfusion support and had worsening renal failure and decompensated heart failure.

The patient’s mental status waxed and waned, and ferritin was above the quantifiable range (>100,000 ng/mL). Triglycerides were only mildly elevated, fibrinogen was elevated, and D-dimer was significantly elevated. There was some clinical suspicion for hemophagocytic lymphohistiocytosis (HLH), so a bone marrow biopsy was performed. Complete blood count results on the day of biopsy were as follows:

 Value
White blood cells12.3×109/L
Red blood cells2.43×1012/L
Hemoglobin6.9 g/dL
Mean corpuscular volume76.1 fL
Mean corpuscular hemoglobin28.4 pg
Mean corpuscular hemoglobin concentration37.3 g/dL
Red cell distribution width16.3%
Platelet count102×109/L
Absolute neutrophil count8.93×109/L

Peripheral blood showed abnormal red cell findings (Figure 1) with erythroblastosis (not shown). Aspirate showed trilineage hematopoiesis with erythroid predominance (Figure 2). Core biopsy showed hypercellular marrow (Figures 3 and 4) with focal areas of marrow damage (Figure 5). Hemoglobin high-performance liquid chromatography (HPLC) was performed (Figure 6).

Figure showing abnormal red cell findings in peripheral blood

Abnormal red cell findings in peripheral blood.


Figure showing trilineage hematopoiesis with erythroid predominance

Trilineage hematopoiesis with erythroid predominance.


Figure showing hypercellular marrow in core biopsy

Hypercellular marrow shown in core biopsy.


Figure showing hypercellular marrow in core biopsy

"Hypercellular marrow shown in core biopsy.


Figure showing focal areas of marrow damage in core biopsy

Focal areas of marrow damage shown in core biopsy.


Figure showing hemoglobin high-performance liquid chromatography (HPLC)

Hemoglobin HPLC.

 

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