[Low-titer cold agglutinin disease following Salmonella gastroenteritis]

We encountered a patient with cold agglutinin disease (CAD) that worsened after Salmonella gastroenteritis. A 52-year-old male complained pain in the left fingers with cyanosis and was admitted in a local hospital. After treatment for ischemia, he demonstrated diarrhea with fever. Because of progressive anemia, he was referred to our hospital. Salmonella gastroenteritis was diagnosed based on the results of microbiological examination. Severe hemolysis was noted at admission, and Coombs test was positive (IgG-, C3d+). Cold agglutinin titer was elevated (x256). There were no findings of malignancy or infection demonstrating CA. A diagnosis of CAD with Salmonella gastroenteritis was made. Because spherocytosis was noted during admission, we measured the mean channel fluorescence (MCF) of eosin-5-maleimide (EMA) in erythrocytes from patients. MCF of EMA of the patient's erythrocytes was similar to that of normal subjects. Therefore, we concluded that coexisting hereditary spherocytosis was unlikely. We also examined the in vitro hemolytic effect of Salmonella infection on his blood and on blood from normal subjects. Treatment with Salmonella enteritidis isolated from this patient was found to induce hemolysis in the patient's blood, but not in blood from a normal subject. Moreover, treatment with Salmonella increased the titer of cold agglutinin in vitro. These data suggested that Salmonella infection might worsen hemolysis in CAD.