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Lou C, Liu M, Ma T, Yang L, Long D, Li J, Lei H, Xiang D, Wang X, Li L, Cai X. Case report: Decreased hemoglobin and multiple organ failure caused by ceftizoxime-induced immune hemolytic anemia in a Chinese patient with malignant rectal cancer. Front Immunol 2024; 15:1390082. [PMID: 38756782 PMCID: PMC11096485 DOI: 10.3389/fimmu.2024.1390082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/16/2024] [Indexed: 05/18/2024] Open
Abstract
Background Drug-induced immune hemolytic anemia (DIIHA) is a rare but serious condition, with an estimated incidence of one in 100,000 cases, associated with various antibiotics. This study reports on a case of ceftizoxime-induced hemolysis observed in a patient in China. Case description A Chinese patient diagnosed with malignant rectal cancer underwent antimicrobial therapy after laparoscopic partial recto-sigmoid resection (L-Dixon). After receiving four doses of ceftizoxime, the patient developed symptoms including rash, itchy skin, and chest distress, followed by a rapid decline in hemoglobin levels, the presence of hemoglobin in the urine (hemoglobinuria), renal failure, and disseminated intravascular coagulation. Laboratory analysis revealed high-titer antibodies against ceftizoxime and red blood cells (RBCs) in the patient's serum, including immunoglobulin M (IgM) (1:128) antibodies and immunoglobulin G (IgG) (1:8) antibodies, with noted crossreactivity to ceftriaxone. Significant improvement in the patient's hemolytic symptoms was observed following immediate discontinuation of the drug, two plasma exchanges, and extensive RBC transfusion. Conclusion This case, together with previous reports, underscores the importance of considering DIIHA in patients who exhibit unexplained decreases in hemoglobin levels following antibiotic therapy. A thorough examination of the patient's medical history can provide crucial insights for diagnosing DIIHA. The effective management of DIIHA includes immediate cessation of the implicated drug, plasma exchange, and transfusion support based on the identification of specific drug-dependent antibodies through serological testing.
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MESH Headings
- Humans
- Rectal Neoplasms/drug therapy
- Rectal Neoplasms/immunology
- Rectal Neoplasms/surgery
- Hemoglobins/metabolism
- Anti-Bacterial Agents/adverse effects
- Male
- Ceftizoxime/adverse effects
- Multiple Organ Failure/etiology
- Middle Aged
- Anemia, Hemolytic/chemically induced
- Anemia, Hemolytic/immunology
- Anemia, Hemolytic/diagnosis
- Anemia, Hemolytic/etiology
- Anemia, Hemolytic, Autoimmune/chemically induced
- Anemia, Hemolytic, Autoimmune/immunology
- Anemia, Hemolytic, Autoimmune/diagnosis
- China
- East Asian People
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Affiliation(s)
- Can Lou
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Blood Transfusion, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Meng Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ting Ma
- Blood Group Reference Laboratory, Shanghai Institute of Blood Transfusion, Shanghai Blood Center, Shanghai, China
- Department of Blood Transfusion, Shaanxi Provincial People’s Hospital, Xian, Shaanxi, China
| | - Liu Yang
- Blood Group Reference Laboratory, Shanghai Institute of Blood Transfusion, Shanghai Blood Center, Shanghai, China
- Department of Blood Transfusion, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Dan Long
- Department of Blood Transfusion, The Second Affiliated Hospital of Guizhou Medical University, Kaili, Guizhou, China
| | - Jiaming Li
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Blood Transfusion, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hang Lei
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Blood Transfusion, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dong Xiang
- Blood Group Reference Laboratory, Shanghai Institute of Blood Transfusion, Shanghai Blood Center, Shanghai, China
| | - Xuefeng Wang
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Blood Transfusion, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lei Li
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaohong Cai
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Blood Transfusion, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Malaponte G, Arcidiacono C, Mazzarino C, Pelligra S, Volti GL, Bevelacqua V, Volti SL. Cephalosporin-induced Hemolytic Anemia in a Sicilian Child. Hematology 2016; 5:327-34. [DOI: 10.1080/10245332.2000.11746527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- G. Malaponte
- Departments of General Pathology, Via Androne 83, 95124 Catania, Italy
| | - C. Arcidiacono
- Departments of Pediatrics, Via S. Sofia 78, 95123 Catania, Italy, University of Catania, Italy
| | - C. Mazzarino
- Departments of General Pathology, Via Androne 83, 95124 Catania, Italy
| | - S. Pelligra
- Departments of General Pathology, Via Androne 83, 95124 Catania, Italy
| | - G. Li Volti
- Departments of Pediatrics, Via S. Sofia 78, 95123 Catania, Italy, University of Catania, Italy
| | - V. Bevelacqua
- Departments of General Pathology, Via Androne 83, 95124 Catania, Italy
| | - S. Li Volti
- Departments of Pediatrics, Via S. Sofia 78, 95123 Catania, Italy, University of Catania, Italy
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Abstract
Autoimmune hemolytic anemia (AIHA) is not an uncommon clinical disorder and requires advanced, efficient immunohematological and transfusion support. Many AIHA patients have underlying disorder and therefore, it is incumbent upon the clinician to investigate these patients in detail, as the underlying condition can be of a serious nature such as lymphoproliferative disorder or connective tissue disorder. Despite advances in transfusion medicine, simple immunohematological test such as direct antiglobulin test (DAT) still remains the diagnostic hallmark of AIHA. The sensitive gel technology has enabled the immunohematologist not only to diagnose serologically such patients, but also to characterize red cell bound autoantibodies with regard to their class, subclass and titer in a rapid and simplified way. Detailed characterization of autoantibodies is important, as there is a relationship between in vivo hemolysis and strength of DAT; red cell bound multiple immunoglobulins, immunoglobulin G subclass and titer. Transfusing AIHA patient is a challenge to the immunohematologist as it is encountered with difficulties in ABO grouping and cross matching requiring specialized serological tests such as alloadsorption or autoadsorption. At times, it may be almost impossible to find a fully matched unit to transfuse these patients. However, transfusion should not be withheld in a critically ill patient even in the absence of compatible blood. The “best match” or “least incompatible units” can be transfused to such patients under close supervision without any serious side-effects. All blood banks should have the facilities to perform the necessary investigations required to issue “best match” packed red blood cells in AIHA. Specialized techniques such as elution and adsorption, which at times are helpful in enhancing blood safety in AIHA should be established in all transfusion services.
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Affiliation(s)
- R K Chaudhary
- Department of Transfusion Medicine, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Sudipta Sekhar Das
- Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, West Bengal, India
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Baek EJ, Lee S, Kim S, Choi HK, Kim HO. A case of immune hemolytic anemia induced by ceftizoxime and cefobactam (sulbactam/cefoperazone). Korean J Lab Med 2010; 29:578-84. [PMID: 20046091 DOI: 10.3343/kjlm.2009.29.6.578] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Simultaneous drug-induced immune hemolytic anemia (DIIHA) caused by multiple drugs is rare. We report a case of a patient who developed DIIHA caused by 2 drugs. The patient's serum exhibited agglutination of ceftizoxime- or sulbactam-coated red blood cells (RBCs; via a drug-adsorption mechanism) and of uncoated RBCs in the presence of sulbactam (via an immune-complex mechanism). Although ceftizoxime is known to exhibit a positive reaction by an immune-complex method with or without reactivity with drug-coated RBCs, this patient's antibodies were reactive only against drug-coated RBCs. On the other hand, sulbactam, which is known to cause hemolytic anemia by nonimmunologic protein adsorption, exhibited positive reactions in tests with both drug-coated RBCs and in the presence of sulbactam. This is the first report of DIIHA due to a sulbactam-cefoperazone combination and the fourth report of DIIHA due to ceftizoxime. Owing to the patient's complicated laboratory results, DIIHA was suspected only at a late stage. We propose that for the prompt diagnosis of DIIHA, tests for all possible causative drugs should be conducted by 2 methods.
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Affiliation(s)
- Eun Jung Baek
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
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Novaretti MCZ, Sopeleti CR, Dorlhiac-Llacer PE, Chamone DAF. Use of gel microcolumn assay for the detection of drug-induced positive direct antiglobulin tests. J Clin Lab Anal 2005; 19:219-27. [PMID: 16170814 PMCID: PMC6807894 DOI: 10.1002/jcla.20081] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Drugs can result in broad variety of hematologic abnormalities including positive direct antiglobulin test. In this study, we evaluated gel microcolumn assay for the detection of drug-induced antibodies. Direct antiglobulin test was performed by conventional tube and by gel microcolumn assay in 139 hospitalized patients. Drug in vitro studies were done in 34 patients with positive direct antiglobulin test by tube test and gel microcolumn assay using serum and eluate. None of them had signs of hemolytic anemia. A total of 1,000 blood samples from donors were used as control group. Gel microcolumn assay was more sensitive than in tube test for direct antiglobulin test (P<0.01). Positive direct antiglobulin test was more frequent in patients than in donors (P<0.01). Drug in vitro studies were positive with at least one drug in 76.5% of patients with positive direct antiglobulin test by immune complex and/or adsorption mechanisms. We found a high incidence of positive drug in vitro tests in positive direct antiglobulin test patients. Gel microcolumn assay showed appropriate results for drug in vitro studies. The combination of tube and gel microcolumn assay can improve detection of drug-induced positive direct antiglobulin tests.
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Affiliation(s)
- M C Z Novaretti
- Immunohematology Division, Hematology Department, University of São Paulo Medical School, São Paulo, Brazil.
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Arndt PA, Garratty G. Cross-reactivity of cefotetan and ceftriaxone antibodies, associated with hemolytic anemia, with other: cephalosporins and penicillin. Am J Clin Pathol 2002; 118:256-62. [PMID: 12162687 DOI: 10.1309/jfje-vukn-221t-g6ev] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Most drug-induced immune hemolytic anemias since the late 1980s have been caused by the second- and third-generation cephalosporins, cefotetan and ceftriaxone, respectively. Cross-reactivity of cefotetan and ceftriaxone antibodies with other cephalosporins or penicillin has been studied only minimally. We tested 7 serum samples previously identified to contain cefotetan antibodies and one serum sample previously identified to contain ceftriaxone antibodies against 9 other cephalosporins, penicillin, and 7-aminocephalosporanic acid in the presence of RBCs and also used hapten inhibition to indicate cross-reactivity. Serum samples containing cefotetan antibodies showed some cross-reactivity with cephalothin and cefoxitin (and to a much lesser extent with penicillin and ceftazidime). The ceftriaxone antibodies showed very weak cross-reactivity with cefotaxime, cefamandole, and cefoperazone. There was very little cross-reactivity between cefotetan antibodies and the drugs tested in the present study. We have no data to determine whether the in vitro data relate to in vivo reactivity.
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Affiliation(s)
- Patricia A Arndt
- American Red Cross Blood Services, Southern California Region, Los Angeles 90006, USA
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Abstract
Red blood cell (RBC) autoantibodies are a relatively uncommon cause of anemia. However, autoimmune hemolytic anemia (AIHA) must be considered in the differential diagnosis of hemolytic anemias, especially if the patient has a concomitant lymphoproliferative disorder, autoimmune disease, or viral or mycoplasmal infection. Classifications of AIHA include warm AIHA, cold agglutinin syndrome, paroxysmal cold hemoglobinuria, mixed-type AIHA, and drug-induced AIHA. Characteristics of the autoantibodies are responsible for the various clinical entities. As a result, diagnosis is based on the clinical presentation and a serologic work-up. For each classification of AIHA, this review discusses the demographics, etiology, clinical presentation, laboratory evaluation, and treatment options.
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Affiliation(s)
- Bradley C Gehrs
- Department of Pathology, University of Alabama at Birmingham, USA
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Calhoun BW, Junsanto T, Donoghue MT, Naureckas E, Baron JM, Baron BW. Ceftizoxime-induced hemolysis secondary to combined drug adsorption and immune-complex mechanisms. Transfusion 2001; 41:893-7. [PMID: 11452157 DOI: 10.1046/j.1537-2995.2001.41070893.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Immune hemolytic anemia has been associated with the administration of various antibiotics, including cephalosporins. Presented here is a patient who developed severe acute hemolysis while receiving ceftizoxime (Ceftizox, Fujisawa USA), a third-generation cephalosporin. This is the fourth reported case of hemolysis in association with ceftizoxime. In the previous cases, ceftizoxime was shown to induce hemolysis by the immune-complex mechanism. However, in one of those reports, the concentration of drug used to treat the target RBCs in vitro may not have been optimal. CASE REPORT The patient's antemortem blood samples were analyzed retrospectively for drug-dependent antibodies by the drug-adsorption and immune-complex methods. Antibody class and titer were evaluated. RESULTS The patient's sample agglutinated RBCs coated with ceftizoxime as well as uncoated RBCs in the presence of ceftizoxime. The antibodies to ceftizoxime were IgM and IgG. CONCLUSION This is the first report on both the immune-complex and drug-adsorption mechanisms of ceftizoxime-induced hemolysis. The differential diagnosis of a falling Hct in a patient receiving antibiotics should include drug-related hemolysis; once this diagnosis is considered, management includes the appropriate serologic workup, immediate cessation of the implicated drugs, and possible transfusion support.
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Affiliation(s)
- B W Calhoun
- Department of Pathology (Blood Bank), The University of Chicago, Chicago, IL 60637, USA
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