Lyme disease as a rare trigger for autoimmune hemolytic anemia

Lyme disease, caused by Borrelia burgdorferi, is a zoonotic infection affecting the skin, nervous system, joints, and heart. Diagnosis relies on clinical history, symptoms, and a two steps serologic test confirmed by Western Blot. Although it frequently affects other systems, data on the haematological involvement spectrum of Lyme disease appears to be limited to case reports, and there are few studies that clearly demonstrate its relationship with haemolytic anaemia. This case highlights Lyme disease presenting with autoimmune hemolytic anemia (AIHA) and thrombocytopenia. A 47-year-old woman with alcoholic cirrhosis (Child-Pugh B, Model for End-Stage Liver Disease (MELD) 9) presented with leg swelling, jaundice, and deep vein thrombosis. Laboratory evaluation showed severe anemia, thrombocytopenia, elevated lactate dehydrogenase (LDH), indirect hyperbilirubinemia, and acute kidney injury. Differential diagnoses, including disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, paroxysmal nocturnal hemoglobinuria, and spur cell anemia and other source of infection were excluded. Coombs-positive hemolysis, normal nutritional markers and peripheral blood smear confirmed autoimmune hemolytic anemia (AIHA). Despite prednisone therapy, thrombocytopenia worsened and neuropathic symptoms developed. Given recent European travel, Lyme disease was suspected and confirmed by Borrelia burgdorferi IgM and Western Blot. Following ceftriaxone and doxycycline, hemoglobin improved without transfusion, platelets normalized, and neuropathic symptoms regressed, highlighting Lyme disease as a rare cause of AIHA. Lyme disease, though uncommon, may present with autoimmune hemolytic anemia, emphasizing the need to consider this rare association in differential diagnosis when clinical suspicion arises.