November-December 2018, Volume 15, Issue 6
An Older Woman With Hemolytic Anemia
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:
|White blood cells||12.3×109/L|
|Red blood cells||2.43×1012/L|
|Mean corpuscular volume||76.1 fL|
|Mean corpuscular hemoglobin||28.4 pg|
|Mean corpuscular hemoglobin concentration||37.3 g/dL|
|Red cell distribution width||16.3%|
|Absolute neutrophil count||8.93×109/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).
Abnormal red cell findings in peripheral blood.
Trilineage hematopoiesis with erythroid predominance.
Hypercellular marrow shown in core biopsy.
"Hypercellular marrow shown in core biopsy.
Focal areas of marrow damage shown in core biopsy.
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