Life-threatening vancomycin-induced immune hemolytic anemia: A rare case report

Drug-induced immune hemolytic anemia is a rare but serious cause of autoimmune hemolytic anemia, most frequently triggered by antimicrobials. Vancomycin is an exceedingly rare culprit, with only a handful of cases reported.

A 64-year-old woman developed acute-onset fever, tachycardia, dyspnea, and dark-colored urine on the 7th day after revision knee arthroplasty, during which she was receiving intravenous vancomycin prophylaxis.

Laboratory findings revealed a dramatic drop in hemoglobin, indirect hyperbilirubinemia, elevated lactate dehydrogenase, and reticulocytosis, consistent with hemolysis. The direct antiglobulin test was positive for IgG and C3, confirming immune-mediated hemolysis. A comprehensive workup ruled out infections, autoimmune diseases, and malignancies. The association with vancomycin was categorized as "probable" on the Naranjo scale.

Vancomycin was immediately discontinued. The patient received intravenous methylprednisolone and immunoglobulins. Due to rapid progression to life-threatening anemia and hemodynamic instability, therapeutic plasma exchange and washed red blood cell transfusions were initiated.

Following these interventions, the patient's condition gradually stabilized. Hemoglobin levels improved, hemolytic markers normalized, and she was successfully weaned from mechanical ventilation. She was discharged after 1 month on a prolonged steroid taper, with a full hematologic recovery observed on follow-up.

Vancomycin can induce life-threatening immune hemolytic anemia. Clinicians must maintain a high index of suspicion for drug-induced immune hemolytic anemia in patients with abrupt hemolysis after initiating a new drug, as immediate discontinuation of the offending agent is the cornerstone of management.