Hemolytic disease of the fetus and newborn caused by anti-E
A full-term male neonate born to a 32-year-old G2P2 Malay lady was noticed to have jaundice on day 1 after birth. His birth weight was 2.96 kg. The mother and the baby were grouped AB and B, respectively, both being positive for RhD antigen. The baby was shifted to neonatal intensive care unit (NICU) on the following day with hepatomegaly 3 cm and splenomegaly 5 cm below the costal margin. Direct antiglobulin test (DAT) on the neonate's red cells was strongly positive (4+). Hemoglobin was 6.2 g/dL. A sudden rise of total serum bilirubin (TSB) level from 102 μmol/L on day 1 to 401 μmol/L within 24 h prompted to double volume exchange transfusion (ET). The hyperbilirubinemia was mainly of conjugated bilirubin 1 day post-ET [].\nInvestigations for infectious causes such as blood culture, urine microscopy, and culture were negative. Liver enzymes such as alkaline phosphatase, alanine transaminase, and aspartate amino transferase were also within the normal ranges. G6PD screening was negative. No evidence of biliary atresia was found. Anti-E was detected and identified in the mother's serum and eluate from the baby's red cells. Rh genotype was performed for the mother, father, and the neonate. The mother was typed as R1R1 (DCe/DCe), father R1R2 (DCe/ DcE). Although the baby's red cells reacted with all the Rh subtype reagents there by typing as R1R2 (DCe/ DcE), the results could not be validated as the auto-control test was positive as well. The neonate was placed on single phototherapy and was given intravenous immunoglobulin (IVIG) at a dose of 0.5 g/kg over 4 h.\nThe peripheral blood film of the neonate showed evidence of hemolysis such as polychromasia, nucleated red blood cells (NRBCs), and red cell fragments. The baby also presented with thrombocytopenia that was not associated with any known infection. We presumed this could be allo-immune in nature, though no attempt to test for platelet-specific antibodies was made due to lack of facility. He was clinically fit at day 8 of life with slightly lower total serum bilirubin of 230 μmol/L at the time of discharge. The baby was discharged on day 8 of life hale and hearty.