Severe drug-induced immune hemolysis due to ceftriaxone

Drug-induced immune hemolytic anemia (DIIHA) is a rare condition that results primarily due to drug-induced antibodies, either drug dependent or drug independent. For its diagnosis, specialized immunohematology laboratory is often required for performing complex serological tests. 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.^[1] There are many drugs which are implicated in causing DIIHA ranging from antimicrobials, antineoplastics to anti-inflammatory drugs. Among antimicrobials, cephalosporins are commonly reported to cause hemolytic anemia.^[2] In this report, we present a life-threatening hemolytic reaction to cephalosporin (ceftriaxone) in a 15-year-old child, which was diagnosed and managed in a timely manner. Our patient was suddenly deteriorated after two doses of intravenous ceftriaxone, with increase in pallor, fatigue, and frank hematuria. Repeat laboratory investigations showed signs of hemolysis, presence of schistocytes, raised lactic dehydrogenase, and indirect bilirubin. Reticulocyte count was 3.4%. Direct antiglobulin test was strong positive (4+) with IgG and C3d positive. Testing for drug-dependent antibody confirmed the presence of ceftriaxone-dependent antibody. Drug was stopped immediately. There was a rapid improvement in patient's general condition after discontinuation of drug. Laboratory parameters were improved after 48 h, and the patient was stable with no further drop in hemoglobin and hemolytic episodes. We suggest the need for proper immunohematological services to diagnose and solve such complex cases promptly.