Severe hemolysis with negative direct antiglobulin test: A case report

Abstract

A 49-year-old woman with type 2 diabetes mellitus (T2DM) presented to the emergency department. Her examination showed marked pallor, exhaustion, lethargy, yellowish eyes, anorexia, nausea and vomiting. Hematuria; negative standard direct antiglobulin test (DAT); normal glucose 6 phosphate dehydrogenase (G6PD); hemoglobin (Hb), 4.8 g/dl; Mean cell volume (MCV), 91fl; platelet count, 233 × 10⁶/L; Total bilirubin, 7.0 mg/dl; Glucose, 316 mg/dl; lactate dehydrogenase (LDH), 1750U/L. Undoubtedly, therapeutic panel should have been used for hemolytic anemia. Intravenous (IV) fluids and 2 units of packed cell were transfused. Methylprednisolone with rituximab were started for the patient. After 3 weeks of the patient admission, she was discharged home with stable vital signs and Hb, 10 g/dl. We concluded in the cases that presented along with a severe drop in Hb and evidence of hemolysis which non immune hemolytic anemia is excluded in spite of negative standard DAT limited transfusion besides corticosteroids combined with rituximab, could be helpful in saving the patient.

Keywords: Anti-human globulin; Autoimmune hemolytic anemia; Coomb's test; DAT; Direct antiglobulin test.

Fig. 1

The various immunologic mechanisms involved in AIHA pathogenesis, including macrophages, APC, B and T lymphocytes, cytokines, complement cascade, ADCC in the spleen, and/or CDC in the liver. MAC, membrane attack complex; ADCC, Antibody-dependent cell mediated cytotoxicity; APC, antigen presenting cells; CDC, complement-dependent cytotoxicity.