Drug Induced Immune Haemolytic AnaemiaA rare case of Drug-Induced Immune Haemolytic Anaemia due to Cefuroxime

• Patient nauseated, jaundiced, oliguric.

• Serum bilirubin 239 umol/L

• Serum creatinine 547 umol/L

• Haemoglobinuria.

• Severe metabolic acidosis,

• Transferred to ICU

• Coombe’s Direct Antiglobulin test (DAT)

• Strongly positive for both IgG and C3d

• Pigment induced acute tubular necrosis.

• Undetectable serum haptoglobins

• Peak reticulocyte count of 4%

Maria Boylan, Philip Murphy, Fintan Doyle, Sinead GalvinAnaesthetics Department, Beaumont Hospital, Dublin, Ireland

INTRODUCTION

REFERENCES

1. Garratty G. Immune hemolytic anemia caused by drugs. Expert OpinDrug Saf. 2012;11(4):635-42.

2. Leicht HB, Weinig E, Mayer B, Viebahn J, Geier A, Rau M. Ceftriaxone-induced hemolytic anemia with severe renal failure: a case report and review of literature. BMC Pharmacol Toxicol. 2018;19(1):67.

3. Malloy CA, Kiss JE, Challapalli M. Cefuroxime-induced immune hemolysis. J Pediatr. 2003;143(1):130-2

4. Barton LL. Cefuroxime-induced immune hemolysis. The Journal of Pediatrics. 2004;144(5):690.

5. Garratty G. Immune hemolytic anemia associated with drug therapy. Blood Rev. 2010;24(4-5):143-50.

CASE REPORT

CONCLUSION

A 67-year-old female was electively admitted for surgical repair of a right quadriceps’ tendon tear. She received a single dose of Cefuroxime at induction and three further doses of Cefuroxime, 1.5g were administered to the patient on the ward post-operatively

• Day 1 Post Op - Hb dropped to 9.7g/dL

• 1 unit of red blood cells

• Hb continued to fall

• Day 3 Post-Op – Reached a nadir of 4.8g/dL

• Transfusion of a further 6 units of RBCs

Drug induced immune haemolytic anaemia (DIIHA) occurs when the underlying cause of autoimmune haemolytic anaemia is secondary to medication administration. Over 130 medicines have been implicated in DIIHA (1).

This case report describes a case of a patient with drug induced immune haemolytic anaemia secondary to Cefuroxime based on biochemical results, blood film findings and a positive Coombe’s Direct Antiglobulin Test (DAT) who responded to cessation of the offending drug and administration of intravenous immunoglobulin and pulsed steroids. The incidence of drug induced immune haemolytic anaemia

(DIIHA) is about one in a million (2). Cessation of the drug is the single most important aspect of treatment of DIHAA. Blood transfusion and renal dialysis may be necessary, and many case reports advocate the use of IVIG, steroids and plasmapheresis. DIHAA is rare, however this case demonstrates the severity of cephalosporin induced DIHAAwith a commonly used antibiotic in daily practice.

• Treatment

• IV hydrocortisone 200mgs for 5 days

• IVIG (400mgs /Kg) for 3 days.

• Resolution

• Within 48 hours, Hb had risen to 9g/dl,

• Resolution of ARF and hyperbilirubinemia.