hemolytic anemia/autoimmune hemolysis

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Question 1 / 3

683ba6ed31242d93219d31b0

Hematology

hemolytic anemia

autoimmune hemolysis

Case History

A 25-year-old woman presents to an urgent care facility with acute onset severe fatigue and lightheadedness for the past 2 days. She reports difficulty performing routine activities due to profound weakness. Approximately 3 weeks ago, she completed a course of oral amoxicillin/clavulanate for bacterial sinusitis. On examination, her temperature is 37.50C, blood pressure is 105/70 mmHg, pulse is 115/min, and respirations are 20/min. Physical examination is notable for marked conjunctival pallor, mild scleral icterus, and a rapid capillary refill time. There is no palpable hepatosplenomegaly. A peripheral blood smear reveals microcytic spherocytes and polychromasia. Laboratory studies were performed in the urgent care setting.

Lab Parameter	Value	Reference Range
Hemoglobin	7.5 g/dL	12-16 g/dL
Platelet count	260 x 10^9/L	150-450 x 10^9/L
Mean corpuscular volume	89 fL	80-100 fL
Reticulocyte count	12%	0.5-2.5%
Total bilirubin	4.8 mg/dL	0.3-1.2 mg/dL
Indirect bilirubin	4.3 mg/dL	<0.8 mg/dL
Lactate dehydrogenase	450 U/L	140-280 U/L
Haptoglobin	<0.1 g/L	0.5-2.2 g/L
Urinalysis	Positive for blood (no red blood cells seen on microscopy)	Negative
White Blood Cell Count	9.2 x 10^9/L	4.0-11.0 x 10^9/L
Serum Creatinine	70 micromol/L	53-106 micromol/L
Sodium	138 mmol/L	135-145 mmol/L
Potassium	4.0 mmol/L	3.5-5.0 mmol/L
Direct Antiglobulin Test (DAT)	Positive for C3d and IgG	Negative

A ) High-dose corticosteroids and risk of avascular necrosis

B ) Intravenous immunoglobulin (IVIG) and risk of acute kidney injury

C ) Splenectomy and risk of overwhelming post-splenectomy infection

D ) Red blood cell transfusion and risk of delayed hemolytic transfusion reaction

E ) Rituximab and risk of progressive multifocal leukoencephalopathy

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Question 2 / 3

683ba6ed31242d93219d31b1

Hematology

hemolytic anemia

autoimmune hemolysis

Case History

A 62-year-old male presents to an outpatient clinic with a 2-week history of progressive fatigue, generalized weakness, and dyspnea on exertion. He reports recent dark urine and occasional palpitations. His medical history is notable for hypertension, well-controlled with medication. He recalls a self-limited viral illness approximately one month prior, which resolved without specific treatment. On physical examination, he appears pale and mildly jaundiced. His vital signs include a temperature of 37.0°C, blood pressure 135/88 mmHg, heart rate 105 beats/min, and respiratory rate 18 breaths/min. Abdominal palpation reveals mild splenomegaly. No lymphadenopathy or rash is noted. Peripheral blood smear shows marked polychromasia, numerous microspherocytes, and occasional nucleated red blood cells. A Direct Antiglobulin Test (DAT) was performed and was strongly positive for IgG and weakly positive for C3d. Considering these findings, what is the most likely diagnosis and the most appropriate initial therapeutic approach?

Lab Parameter	Value	Reference Range
Hemoglobin	71 g/L	130-170 g/L
White Blood Cell Count	7.2 x 10^9/L	4.0-11.0 x 10^9/L
Platelet Count	280 x 10^9/L	150-450 x 10^9/L
Mean Corpuscular Volume (MCV)	95 fL	80-100 fL
Reticulocyte Count	0.10 (10%)	0.005-0.015 (0.5-1.5%)
Lactate Dehydrogenase (LDH)	510 U/L	140-280 U/L
Haptoglobin	< 0.10 g/L	0.41-1.65 g/L
Indirect Bilirubin	55 µmol/L	0-17 µmol/L
Direct Bilirubin	8 µmol/L	0-5 µmol/L
Creatinine	80 µmol/L	60-110 µmol/L
Alanine Aminotransferase (ALT)	30 U/L	7-56 U/L
Aspartate Aminotransferase (AST)	35 U/L	10-40 U/L
Urinalysis	Positive for blood (3+), no red blood cells on microscopy	Negative

A ) Warm Autoimmune Hemolytic Anemia and high-dose glucocorticoids

B ) Hereditary Spherocytosis and splenectomy

C ) Cold Agglutinin Disease and rituximab monotherapy

D ) Microangiopathic Hemolytic Anemia and urgent plasma exchange

E ) Paroxysmal Nocturnal Hemoglobinuria and eculizumab

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Question 3 / 3

683ba6ed31242d93219d31af

Hematology

hemolytic anemia

autoimmune hemolysis

Case History

A 35-year-old woman presents to the emergency department with a chief concern of profound fatigue and lightheadedness that began abruptly a few days prior and has been progressively worsening. She also reports mild yellowing of her eyes noticed by her family. Her past medical history includes a history of mood disturbance and chronic constipation. She is currently taking trimethoprim-sulfamethoxazole (TMP-SMX) for a recent urinary tract infection. Two months ago, she presented to an urgent care center with an episode of severe, generalized body aches which resolved spontaneously. She adheres to a strict vegan diet. On examination, her temperature is 36.8°C, blood pressure is 120/70 mmHg, pulse is 110/min, respirations are 16/min, and oxygen saturation is 97% on room air. She appears pale with scleral icterus. Abdominal palpation reveals mild splenomegaly. A peripheral blood smear is ordered, showing numerous spherocytes as seen in Figure A. What is the most likely diagnosis and the appropriate immediate therapeutic intervention?

Lab Parameter	Value	Reference Range
Hemoglobin	8.5 g/dL	12.0-15.5 g/dL
Hematocrit	28%	36-48%
Leukocyte count	8.2 x 10^9/L	4.5-11.0 x 10^9/L
Platelet count	210 x 10^9/L	150-450 x 10^9/L
Sodium	138 mmol/L	135-145 mmol/L
Potassium	5.5 mmol/L	3.5-5.0 mmol/L
Chloride	101 mmol/L	98-107 mmol/L
Bicarbonate	24 mmol/L	22-29 mmol/L
Blood Urea Nitrogen (BUN)	9.6 mmol/L	2.1-7.1 mmol/L
Creatinine	97 µmol/L	53-106 µmol/L
Glucose	5.5 mmol/L	3.9-6.1 mmol/L
Calcium	2.45 mmol/L	2.15-2.55 mmol/L
Lactate Dehydrogenase (LDH)	620 U/L	140-280 U/L
Total Bilirubin	47.9 µmol/L	3.4-20.5 µmol/L
Aspartate Aminotransferase (AST)	18 U/L	10-40 U/L
Alanine Aminotransferase (ALT)	15 U/L	7-56 U/L
Haptoglobin	<0.2 g/L	0.3-2.0 g/L
Reticulocyte Count	6%	0.5-2.5%
Direct Antiglobulin Test (DAT/Coombs)	Positive	Negative

A ) Warm autoimmune hemolytic anemia and initiation of systemic corticosteroids

B ) Hereditary spherocytosis and a positive eosin-5-maleimide binding test

C ) Drug-induced immune hemolytic anemia (e.g., from TMP-SMX) requiring cessation of the offending agent

D ) Sickle cell disease with an acute pain crisis and intravenous hydration

E ) Cobalamin deficiency and initiation of intramuscular vitamin B12 supplementation

undefined ) Cold agglutinin disease identified by a positive cold agglutinin titer and avoidance of cold exposure

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