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Autoimmune Hemolytic Anemia In Chronic Lymphocytic Leukemia
Kelley Newton, MD
Providence Portland Medical Center – Portland, OR
Additional Authors: Janan Markee, MD
Patients with chronic lymphocytic leukemia have a 5-10% risk of developing autoimmune complications, the most common of which is autoimmune hemolytic anemia. Here we present a case of AIHA in a patient with suspected CLL that underscores several of the diagnostic and treatment challenges unique to this process. A 79-year old man with a history of hypertension, atrial fibrillation, type 2 diabetes and hypothyroidism was undergoing workup for suspected CLL due to a persistent leukocytosis. He then presented to his primary care physician after several weeks of worsening exertional chest pain and dyspnea. On exam, he was noted to be confused as well as mildly jaundiced and was sent to the Emergency Department for work up with a specific concern for ACS given his presenting symptoms. Cardiac workup was unremarkable with a negative troponin, normal BNP and no changes on EKG. Pulmonary CTA was negative for pulmonary embolism. However, his lab work revealed an acute macrocytic anemia with a Hgb of 5.1 as well as a Total bilirubin of 4.1. Additional lab work revealed a significantly decreased haptoglobin, elevated reticulocyte count and IgG/complement positive DAT. CT abd/pelvis showed splenomegaly. The patient was admitted, placed on high dose steroids and 2 units of packed red blood cells were ordered. After some delay due to an inability to find compatible blood, he received several ABO and RhD matched units. After several days, his hemoglobin stabilized and reticulocyte count and Tbili down trended. He was discharged on high dose steroids to be tapered down once his Hgb>10 over the course of 4-6 months, with outpatient oncology follow up. This case highlights several important points in the diagnosis and treatment of AIHA in CLL. Firstly, it is important to note that in virtually all cases of warm AIHA cross-matches will be incompatible as auto-antibodies will recognize blood group antigens and react to the vast majority of donor red cells. Consequently, ABO and RhD matched blood should be given in severe anemia requiring urgent blood transfusion. The blood should be given slowly with careful monitoring for transfusion reaction, though the risk of this is low. Another important consideration in the workup and treatment of AIHA is the substantial risk of VTE in these patients. Given the presentation of dyspnea in this patient, ruling out concomitant PE is especially crucial. Lastly, the relatively high rate of AIHA in CLL workup for hematologic malignancy should be considered in patients presenting with apparently idiopathic AIHA.
Graduate Medical Education
Conference / Event Name
Academic Achievement Day, 2020
Providence Portland Medical Center, Internal Medicine Residency, Portland, Oregon
Newton, Kelley and Markee, Janan, "Autoimmune Hemolytic Anemia In Chronic Lymphocytic Leukemia" (2020). Providence Portland Medical Center Internal Medicine. 5.