Ceftriaxone-induced acute hemolytic anemia

摘要

A 7-year-old Caribbean-American boy with a 5-month history of hemophagocytic lymphohistocytosis and previous ceftriaxone exposure presented with fever. He was empirically given amikacin and ceftriaxone after 1:00 PM on Day 1 and acutely developed back and abdominal pain, vomiting, hematuria, and hypotension. Both plasma (see figure, top panel) and urine showed hemolysis. The peripheral blood smear showed diffuse agglutination of RBCs without schis-tocytes (see figure, lower left). Serum LDH was elevated (1787 U/L); urine was negative for myoglobin. The patient's Hb dropped from 11.7 to 4.4 g/dL in 32 hours. The symptoms, hemolysis, and agglutination resolved (see figure, lower right) with discontinuation of ceftriaxone and two double-volume whole blood exchange transfusions. Immunohema-tology studies demonstrated a positive DAT due to C3 only, and serologic drug studies were positive with ceftriaxone, but not with amikacin. The RBC agglutination seen on peripheral smear was most likely due to drug/antidrug immune complexes, a theory supported by the finding of IgM ceftriaxone-dependent antibodies (titer = 32) at presentation. The titer decreased to 8 on Day 2 and to 0 by Day 5, suggesting that the antibody was consumed by the RBCs and/or removed by treatment. Drug-induced immune hemolytic anemia (DIHA) due to ceftriaxone-dependent antibodies is uncommon, but well described.