Cephalosporin-induced hemolytic anemia: a case study

Drug-induced immune hemolytic anemia (DIIHA) represents a rare but dangerous medical condition that more often affects children who are administered cephalosporins. A 10-year-old girl developed severe hemolysis after administration of cefuroxime and ceftriaxone for treating an infection linked to parotid lymphangioma. The patient had previously tolerated ceftriaxone and clindamycin but developed dizziness, pallor, and tachycardia, and her hemoglobin (Hb) levels decreased from 12.9 to 2.6 g/dL during her fourth day of treatment, which led to hypovolemic shock and transient renal dysfunction. Our objective is to establish cefuroxime and ceftriaxone as the responsible drugs for DIIHA through immunohematologic testing. The laboratory tests included the direct antiglobulin test (DAT) and the indirect antiglobulin test (IAT) along with drug-dependent antibody testing using the patient's serum (1) to react against group O red blood cells (RBCs) treated with cefuroxime and (2) to react separately against group O RBCs not treated with, but in the presence of, ceftriaxone, with and without complement, at both room temperature and by the IAT. The DAT showed positivity for IgG and C3d. The patient's serum reacted with cefuroxime-treated RBCs by the IAT and reacted with untreated RBCs when ceftriaxone and complement were present. The laboratory results showed that drug-dependent antibodies were present to target RBCs. The patient's condition improved rapidly after stopping cephalosporins and starting ciprofloxacin/levofloxacin and clindamycin, which resulted in an Hb increase to 9.1 g/dL within 48 hours and the absence of hemoglobinuria. This case shows why health care professionals must identify DIIHA early through diagnostic testing even when patients have shown previous tolerance to antibiotics. This case report also shows that both cefuroxime and ceftriaxone were the drugs responsible for the DIIHA.