Autoimmune hemolytic anemia in a patient with Malaria
A 20 year old male patient was admitted at our hospital with chief complaints of intermittent fever with chills since seven days and yellow discoloration of sclera and urine since five days. He was transfused three units of blood at a private clinic for anemia before one month. On Examination, relevant findings were pallor +++, icterus ++ and per abdomen examination showing palpable spleen. On admission, complete blood counts were as follows: Hemoglobin (Hb) 3.2 gm/dL, Mean Corpuscular Volume (MCV) 122 fL, Retic Count 7 %, Total and Differential Count in normal reference range, Platelet count 3.52 lacs/μL. In Peripheral Smear, ring forms of both Plasmodium vivax and P. falciparum were seen with Grade 4 parasitemia. Spherocytes were absent. Other relevant lab findings included Renal Function Tests (RFT): within normal reference range, S. Bilirubin 8.3 mg/dL (Indirect 4.7 mg/dL and Direct 3.6 mg/dL), serum Lactate Dehydrogenase (LDH) 355 U/L, Glucose 6 Phosphate Dehydrogenase (G6PD) enzyme activity: Present, Sickling test: Negative and NESTROFT (Naked Eye Single tube Red Cell Osmotic Fragility Test): Negative.\nBlood Bank Investigations: (On admission)\nCell grouping Serum grouping\nThis patient’s blood group was determined to be B +ve with positive autocontrol and no auto-clumps with saline. So, fresh sample was obtained which showed the duplicate results as above and further tested as follows:\nIndirect Antiglobulin Test (IAT) and Antibody screening with 3 cell panel (DiaMed) Antibody identification using 11 cell panel (DiaMed) was pan-positive (+4). Direct Antiglobulin Test (DAT) with Polyspecific and mono-specific Coomb’s sera Acid Elution of the patient’s sample was performed and the eluate was Pan-positive (+4) in the same 3 cell and 11 cell panels (DiaMed). On Major Cross Matching, multiple donor units (of the same group and ABO-Rh compatible group) were Grade 4 Incompatible.\nThese serologic findings are suggestive of auto-antibodies. On 2nd day of admission, Hb dropped further to 1.4 mg/dL.\nPatient was treated with intravenous Artesunate (2.4 mg/kg/day). Simultaneously, intravenous Methylprednisone 1 mg/kg/day for five days was started, followed by oral route and dose tapering. On 2nd and 3rd day, patient was transfused one unit O Neg and one unit B Neg Packed Red Cells respectively. Both the units were least incompatible and saline washed with uneventful post-transfusion period. On 4th day, Hb was raised to 6.1 mg/dL and Serum Bilirubin decreased to 4.3 mg/dL suggesting role of antimalarials in clearing parasitemia and steroids in reducing hemolysis by autoantibodies in this case. Patient was discharged on 9th day after admission with Hb 7.0 gm/dL and platelet count 2.5 lacs/μL with tapering dose of oral steroids. On routine follow-up after 15 days of discharge, patient had Hb of 8.1 gm/dL and was asymptomatic throughout this period.