1
bookmark

A 51-year-old female has had fatigue, weakness, and SOB with exertion during the past 4-5 days


History of Present Illness
A 51 year old female with Symptoms were exacerbated by activity and relieved by rest and laying supine. She also felt palpitations intermittently presents with:

fatigues
modifiers: past 4-5 days
exertion

weakness
modifiers: past 4-5 days
exertion

shortness of breath
modifiers: exertion
past 4-5 days

patient denies:
abdominal pain, chest pain, congestion, N/V/D/C, dysuria, headache, chills, hemoptysis, neck pain, rash, or sore throat

Past Medical History
DM2

Past Surgical History

Medications
Lantus (Insulin Glargine, rDNA origin) 25 mg SQ QHS, Humalog (insulin lispro) SSI SQ with Accu-Chek Blood Glucose Monitoring TID.

Allergies

Family and Social History

Vital Signs and Physical Exam
VS: mild tachycardia, no hypotension.
General appearance: pale, non-icteric.
Eyes: EOMI, PERRLA, sclerae non-icteric
ENT: Oropharynx clear, no plaques or exudates
Chest: CTA (B)
CVS: Clear S1S2
Abd: Soft, NT, ND, BS
Ext.: no c/c/e
Neurologic: AAA x 3
No lymphadenopathy

Labs and Studies
She called her PCP who recommended she had hemoglobin checked. He called her back with the results, and told her to go to the ER for further treatment of severe anemia.

Hemoglobin (Hgb) was 4.2 mg/dL, MCV 144 fl, reticulocyte count 41%.


Initial Treatment or Question For Discussion
Likely to be severe anemia that is symptomatic with fatigue and shortness of breath (SOB). The patient most likely has hemolytic anemia.

But what are the likely causes?
Blood loss?
Hemolytic anemia?
Iron-deficiency?

Images



Presented by Certified Health Provider on May 16, 2013

add comment
2

Final diagnosis: Warm Antibody Autoimmune Hemolytic Anemia (AIHA)

Differential Diagnosis
The patients has autoimmune hemolytic anemia (AIHA) mediated by warm antibodies because the hemolysis is observed at normal body temperature. By contrast, in the cold antibody AIHA, the autoantibodies attack the red blood cells only at temperatures significantly below normal body temperature, e.g. when working outside in the winter.

Treatments or interventions at this time
Solu-Medrol (methylprednisolone) 100 mg IV q 6 hr.
Consider immune globulin infusion.
Follow-up on the Hem/Onc recommendations.

Additional Workup
Direct and indirect Coombs\\\' test
ANA, RF
C3, C4
CXR
CT c/a/p (chest, abdomen and pelvis)

Assessment
The patient was admitted to a regular medical floor and a hematology consult was called. The direct Coombs\\\' test was reported as positive.

CXR and CT scans were negative for neoplastic disease.

Final diagnosis: Warm Antibody Autoimmune Hemolytic Anemia (AIHA)

Peer Reviewed References
See References Image.


Original Case Author: A. Rajaminackam, M.D., Department of Hospital Medicine at Cleveland Clinic
Reviewer: V. Dimov, M.D.


Images

Caption: CBC and CMP



Caption: CBC and CMP



Caption: Immunology



Caption: Hemoglobin response to steroid treatment in AIHA. Taper glucocorticoids very gradually to avoid a relapse of hemolysis.



Caption: References Image


Answered by Certified Health Provider on May 16, 2013

add comment



Your Answer


YesNo (default)