DRUG INDUCED IMMUNE HEMOLYSIS IN A THALASSEMIA PATIENT

Drug induced immune hemolytic anemia (DIIHA) is a rare condition that results due to drug induced antibodies, either drug dependent or drug independent result from the administration of an antibiotic, most notably the cephalosporin class, commonly used in both adult & paediatric population. A delay in recognition by a provider may lead to continuation of the offending agent and possibly result in fatal outcomes. The exact incidence of DIIHA is not known, but as per data published by Garratty, the incidence of DIIHA is estimated to be one in million population. We report the case of 10 year old child, known case of Beta thalassemia major admitted with fever, palpitations, pain in the left side of the abdomen & bilateral knee joint pains since 2 days. Patient was suddenly deteriorated after two doses of intravenous ceftriaxone, with increase in pallor, fatigue, decreased oral intake and foul smelling frank hematuria. Laboratory investigations showed signs of hemolysis, presence of schistocytes, tear drop cells & target cells, raised lactic dehydrogenase & indirect bilirubin. Reticulocyte count was 8.5% . Direct antiglobulin test was strong positive (4+) with IgG and C3d positive. Eluate came negative. Suspecting DIIHA drug was stopped immediately. Child was started on oral prednisolone and subseuent transfusions planned in small alliquots and 80 ml leukodepleted, phenotypically matched PRBC with pre transfusion iv hydrocartisone, avil, paracetamol were given As child is having continuous fever spikes antibiotic shifted to iv doxycycline. Patient general condition improved 5 days after stopping the drug. Till day 8 of admission total around 40 ml/kg PRBC transfusion done, however Hb showed no improvement, hence on 9th day of admission IVIG at 1gm/kg transfused and LD-PRBC at 8ml/kg transfused and repeat Hb showed improvement from 4.8 to 5.9 g/dl. Although rare, drug induced immune hemolytic anemia caused by ceftriaxone may be a potentially fatal condition, especially in thalassemia major patients. But with early recognition and withdrawal of the offending agent, successful treatment may ensue. Serological tests should be utilized to obtain denitive diagnosis.