The Importance of Early Suspicion for Cold Autoimmune Hemolytic Anemia

Cold autoimmune hemolytic anemia (cAIHA) is a form of autoimmune hemolytic anemia (AIHA) that most often involves agglutinin antibodies that specifically react to cold temperatures. This process most commonly involves an immunoglobulin M (IgM)-mediated agglutination of erythrocytes and can result in complement-mediated hemolysis, which can range greatly in severity from case to case. Here, we present a case of cAIHA in a 64-year-old male who presented with rapidly progressive and severe hemolytic anemia, which resulted in irreversible decompensation. This case highlights the importance of maintaining a high index of suspicion for cAIHA in patients older adult patients with a previous history of autoimmune hematologic diseases presenting in a rapidly progressive hemolytic state, which can allow for prompt diagnosis, treatment, and mitigation of adverse outcomes.

Autoimmune Hemolytic Anemia in a Patient With COVID-19 Pneumonia: A Case Report on a Rare Presentation

Patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)/coronavirus disease 2019 (COVID-19) pneumonia can have a range of clinical presentations ranging from being asymptomatic to having severe acute respiratory syndrome (SARS). Autoimmune hemolytic anemia (AIHA) is a very rare presentation of COVID-19. We present the case of a 67-year-old male with a past medical history of chronic obstructive pulmonary disease (COPD) who presented to the emergency department (ED) with shortness of breath and was found to be COVID-19-positive. His laboratory results demonstrated autoimmune hemolytic anemia with decreased hemoglobin (Hgb), elevated lactate dehydrogenase (LDH), decreased haptoglobin, peripheral smear showing spherocytes, and a positive direct antiglobulin (Coombs) test. The patient was started on glucocorticoids, but his hemoglobin continued to worsen. The dose of glucocorticoids was increased significantly, and his hemoglobin started improving with the resolution of hemolysis. Autoimmune hemolytic anemia is usually treated with glucocorticoids, but escalating glucocorticoid doses increases the risk of side effects. This case report highlights the importance of further research needed to establish guidelines for AIHA in the context of COVID-19 pneumonia.

Mixed Warm and Cold Autoimmune Hemolytic Anemia With Concomitant Immune Thrombocytopenia Following Recent SARS-CoV-2 Infection and Ongoing Rhinovirus Infection

Mixed-type autoimmune hemolytic anemia (AIHA) is a term used to describe hemolysis occurring in the context of both warm and cold reactive autoantibodies to red blood cells. Immune thrombocytopenia (ITP) is an acquired form of thrombocytopenia potentially complicated by hemorrhage due to autoantibodies reactive with platelets and megakaryocytes. Diagnosis of ITP requires exclusion of other known causes of thrombocytopenia. AIHA and ITP may be primary disorders or associated with lymphoproliferative, autoimmune, or viral infections. Here, we report a rare case of simultaneous mixed-type autoimmune hemolytic anemia with immune thrombocytopenia following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection treated with Paxlovid followed by Rhinovirus infection.

A Compelling Case of Autoimmune Hemolytic Anemia and Its Potential Association With SARS-CoV-2

Autoimmune hemolytic anemia can be caused by infections, lymphoproliferative disorders, autoimmune disorders, or triggered by drugs or toxins. We present the case of a 92-year-old man admitted with gastrointestinal symptoms. He presented with autoimmune hemolytic anemia. The etiologic study was negative for autoimmune conditions or solid masses. Viral serologies were negative, and RT-PCR for SARS-CoV-2 was positive. The patient began treatment with corticoid, with resulted in cessation of hemolysis and improvement of the anemia. A few cases of autoimmune hemolytic anemia have been reported in COVID-19 patients. In this case, the infection seems to coincide with the hemolysis period, and we found no other cause for this event. So, we highlight the need to search for SARS-CoV-2 as a possible infective cause of autoimmune hemolytic anemia.

Naproxen-Induced Evans Syndrome

Evans syndrome is an autoimmune disorder characterized by the simultaneous occurrence of autoimmune hemolytic anemia and immune thrombocytopenic purpura. It can further be classified as primary Evans syndrome when it occurs by itself, or secondary Evans syndrome when it is associated with other autoimmune and lymphoproliferative disorders. Corticosteroids and immunoglobulins are the first-line treatments for primary Evans syndrome, and subsequent options include other immunosuppressive medications. Medical literature provides little information about the triggers of primary Evans syndrome. Knowing such information, however, is essential to recognize, treat and prevent the recurrence of the disease effectively.  We report a 68-year-old female who presented with shortness of breath, cough, bruises, scleral icterus, and dark urine after several days of naproxen therapy for pain. Further workup noted direct antiglobulin test positive for IgG, anemia, and thrombocytopenia. Imaging studies showed deep venous thrombosis. She was diagnosed with Evans syndrome and improved following prompt treatment with corticosteroids, anticoagulants, blood transfusion therapies, and discontinuation of naproxen. The prognosis of Evans syndrome is poor, variable, and characterized by relapses. Early diagnosis and treatment are therefore associated with better prognosis.  This case is critical because it shines a light on one of the major causes of Evans syndrome, reports a practical approach to treating the condition, and paves the way for future research on Evans syndrome. This case is also the first reported naproxen-induced Evans syndrome in the world's literature.

Lymphoplasmacytic Lymphoma/Waldenstrom Macroglobulinemia Masquerading as IgM Warm Antibody Autoimmune Hemolytic Anemia in Association With Mycoplasma pneumoniae Infection: A Case Report

Warm antibody autoimmune hemolytic anemia (AIHA) is mostly of IgG subtype. IgM subtype is extremely rare and has not been reported in association with lymphoplasmacytic lymphoma (LPL)/Waldenström macroglobulinemia (WM). We are reporting the case of a 75-year-old female patient who presented with severe hemolytic anemia and Mycoplasma pneumoniae pneumonia (MPP). Cold agglutinin and serum protein electrophoresis (SPEP) were negative but immunofixation was positive for IgM. Ultimately, hemolytic anemia was labeled warm antibody AIHA in association with MPP. She presented again one year later with more severe hemolytic anemia. Persistently elevated IgM was seen in immunofixation and triggered bone marrow biopsy that confirmed LPL/WM. This case highlights the clinical pearl that warm antibody AIHA in association with MPP is a rare entity and more intensive investigation to rule out other etiologies is mandated. Also, this case is rare as it is of IgM subtype warm AIHA and observed in the context of LPL/WM.

Exacerbation of Secondary Cold Agglutinin Syndrome in the Setting of SARS-CoV-2

In this report, we present a case of exacerbation of cold agglutinin syndrome (CAS) potentially due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia. An 83-year-old female with a history of cold agglutinin hemolytic anemia presented with shortness of breath, productive cough, worsening orthopnea, darkening fingers and urine, and jaundice. Laboratory investigations found elevated white blood cells (WBC) and total bilirubin, severely low hemoglobin, and positive direct Coombs test. Moreover, SARS-CoV-2 RNA was also found to be positive in a sample from the nasal swab by reverse transcription-polymerase chain reaction (RT-PCR), indicating exacerbation of CAS secondary to viral coronavirus 2019 (COVID-19) infection. A treatment regime for SARS-CoV-2 consisting of five days of remdesivir and seven days of dexamethasone 6 mg IV was initiated, resulting in significant improvement in the patient's condition.

Autoimmune Hemolytic Anemia Exacerbation Associated With COVID-19 Infection and Markedly Elevated Inflammatory Markers

The association between previously diagnosed autoimmune hemolytic anemia and exacerbations due to coronavirus disease 2019 (COVID-19) infection is a rare phenomenon that is not well understood. In this case, we present a 68-year-old female with a past medical history significant for systemic lupus erythematosus (SLE), splenectomy, and autoimmune hemolytic anemia (AIHA) since childhood that had been very well controlled with only one previous exacerbation. This patient's chief complaint and clinical symptoms at admission were related to hemolytic anemia and not active COVID-19 infection. This case report reveals a possible association between the hyperinflammatory syndrome caused by COVID-19 and the exacerbation of previously well-controlled autoimmune diseases.

Warm and Cold Autoimmune Hemolytic Anemia in the Setting of COVID-19 Disease

Known associations with autoimmune hemolytic anemia (AIHA) include lymphoproliferative neoplasms, autoimmune conditions, and viral infections. There are a few case reports that implicate a potential relationship between COVID-19 and either warm or cold AIHA. We present the case of combined warm and cold AIHA in the setting of COVID-19. A 51-year-old male with no known past medical history presented with weakness and jaundice. Initial workup revealed white blood cells 41.4, hemoglobin 3.1, platelets 343, total bilirubin 5.3, direct bilirubin 1.6, and COVID-19 positive. Direct antiglobulin test (DAT) found IgG and C3 antibodies and pathology revealed cold agglutinins, consistent with both warm and cold AIHA. He received a total of five blood transfusions and was started on prednisone 1 mg/kg daily with a gradual taper over months. Hemolysis labs normalized within two weeks after discharge although antibodies remained positive 70 days after admission. Our patient presented with IgG and C3 antibodies as well as cold agglutinins, consistent with both warm and cold AIHA. To our knowledge, this is the first case of both warm and cold AIHA presenting simultaneously in COVID-19 infection. Unlike most cases in the existing literature, this patient had no history of underlying hematologic malignancy and both warm and cold AIHA.

A Case of COVID-19-Associated Autoimmune Hemolytic Anemia With Hyperferritinemia in an Immunocompetent Host

We report an interesting case of a middle-aged gentleman who presented with diabetic ketoacidosis (DKA) and tested polymerase chain reaction (PCR) positive for COVID-19 infection. His hospital stay was complicated by acute kidney injury, hematuria, and normocytic anemia. Initial chest x-ray demonstrated bibasilar opacities. D-dimer and C-reactive protein were elevated. During his hospital stay, his hemoglobin decreased from 13.4 g/dL to 9 g/dL, and further workup demonstrated ferritin of 49,081 ng/mL with lactate dehydrogenase of 1665 U/L. He was treated with prednisone and folic acid for autoimmune hemolytic anemia (AIHA). Ferritin was downtrended, and hemoglobin stabilized. As demonstrated by this case report and prior literature review, COVID-19 infection can be associated with AIHA.

Autoimmune Hemolytic Anemia After Cyanocobalamin Replacement in a Patient With a Previous Diagnosis of Pernicious Anemia: A Case Report

Pernicious anemia (PA) is associated with other autoimmune diseases, such as hypothyroidism, type 1 diabetes mellitus (DM1), Addison's disease, and vitiligo. The association between PA and autoimmune hemolytic anemia (AIHA) is rare, with less than 30 cases reported in the literature. In this paper, we report a case of a patient with a confirmed diagnosis of PA, who, six months after starting treatment with cyanocobalamin, presented with severe hemolysis with a positive direct antiglobulin test (DAT) for warm antibodies; the patient responded well to glucocorticoid treatment. AIHA in PA patients can be triggered by cyanocobalamin replacement due to the expression of membrane antigens by mature red blood cells entering into the peripheral circulation. This association should be considered because these patients, in addition to cyanocobalamin replacement, will require immunosuppressive treatment, usually with glucocorticoids.