The document presents a case study of a 21-year-old female patient diagnosed with autoimmune hemolytic anemia. Key findings include low hemoglobin and hematocrit levels, elevated reticulocytes, and positive direct Coombs test. She was treated with prednisolone, folic acid, calcium, vitamin D, risedronate, and levothyroxine. Her bilateral knee pain and weakness improved over the course of her treatment.

1. CASE PRESENTATION ON
AUTO-IMMUNE
HEMOLYTIC ANEMIA
BY
M.HEMA SREE
PHARM D 4TH YEAR

2. INTRODUCTION
DEFINITION
• Autoimmune hemolytic anemia[AIHA] is characterized by an
abnormal production of auto antibodies[Ig G,M.E,A] that bind
to Antigens on the erythrocyte surface. These antibodies then
lead to destruction of RBC’s thus shortening their life span.
• Red cell lifespan may decrease to 30days.
CLASSIFICATION
• Warm AIHA
• Cold AIHA – Cold Agglutinin Syndrome
Paroxysmal Cold Hemoglobinuria
• Mixed type AIHA
• Drug Induce Immune hemolytic anemia

3. WARM AIHA
• In this warm AIHA, the autoantibodies attach to & destroy the
RBC at temperature ≥ to 37 degrees celcius.
• More common among women.
• MECHANISM OF DESTRUCTION: Due to Extravascular
hemolysis
• Associated with development of Ig G
• May be due to primary or secondary etiology
Primary – idiopathic
Secondary –due to underlying disease[eg: lymphoproliferative
or autoimmune disorders]

4. COLD AIHA
• The autoantibodies become most active and attack RBC below
normal body temperature.
• Mainly effects in middle aged or elderly.
• Due to development of IgM & G antibody.
• Either primary or secondary in etiology
• MECHANSIM OF DESTRUCTION: Extravascular and Intravascular
hemolysis
COLD AGGLUTINATION SYNDROME – IgM antibodies
• Hemolysis – extravascular
• Causes – mononucleosis infections, lymphoproliferative disorders)
PAROXYSMAL COLD HEMOGLOBINURIA : Ig G antiodies
• Intravascular hemolysis
• Occurs due to infections( sypihils, pneumoniae, measles, infulenza)
also due to vaccines

6. MIXED TYPE AIHA
• Features similar to WAIHA & CAS
• Both IgG & C3d[activated by IgM cold Ab] are detected
DRUG INDUCED AIHA
• Antibodies directed against or one of its metabolites
• All may involve IgG &C3
• Eg: Pencillin , Cephalosporins , Quinidine , Methyldopa

7. PATHO or IMMUNOLOGIACL VIEW
• WAIA
IgG binds to RBC surface antigens
This drives monocytes and macrophages to
grab & pick off portions of RBC membrane
RBC becomes spherocytes
Destructed in spleen
Extravascular hemolysis

8. COLD AGGLUTINATION DISEASE
In cold temperature, IgM binds to
polysaccharide region of glycoprotein on RBC
surface
This triggers complement system to lyse RBC
If complement system fails to form membrane
attack complex, complement proteins deposit
on RBC surface
This opsonisation enhances RBC phagocytosis
in liver, spleen & lungs
Extravascular hemolysis

9. PAROXYSMALCOLD HEMOGLOBINURIA
During infections , microbes trigger formation of
Abs which react with p antigen of RBC surface
These polyclonol anti-P autoAb binds to P-Ag of
RBC in cold temp
Activation of complement system,
Lysis of RBCs
Intravascular hemolysis

10. CLINICAL MANIFESTATIONS
• Paleness of skin
• Fatigue
• Fever and chills
• Confusion
• Lightheadedness
• Weakness
• Body ache
COMMON SYPTOMS LESS COMMON SYMPTOMS
• Dark urine
• Yellowing of skin and eyes
• Increased HR
• Enlarged spleen
• Enlarged liver

11. DIAGNOSIS
• CBC : Hb - decreased
Hematocrit – decreased
Reticulocytes- increased
• peripheral smear – microcytic, anisocytosis , spherocytes ,
hypochromic , poikilocytosis
• Other lab data : elevated LDH, indirect bilirubin and
decreased haptoglobin
• Direct coombs test

12. TREATMENT
WARM AHIA
• Folic acid supplements
• Corticosteriods like
prednisolone[1-
1.5mg/kg/day]
• Immunoglobulins like
rituximab, azathioprine
etc..
• If ineffective splenectomy
considered
• Blood transfusion
• Splenectomy
COLD AIHA
• Removal of underlying
disease.
• Use antibiotics like pencillin
in case of infections
• Rituximab is given majorly
• Avoid cold weather an cold
drinks
• Blood transfusion
• Splenectomy

14. PATIENT
PROFILE FORM

15. DEMOGRAPHIC DETAILS
• Patient name: XYZ
• Age: 21 Years
• Gender: Female
• Height:165cm
• Weight: 85kg
• BMI: 31.2Kg/sqmm[over weight]
• IP No:472890
• Dept: General medicine-554
• DOA:11/NOV/19
• DOD:14/NOV/19

16. COMPLAINTS
• B/L knee pain
• Mild swelling at knees
• Chills
• Headache
• Weakness and pale skin
• Fatigue
HISTORY
• Past medical history: Hypothyroid
• Past medication history: Tab Thyronorm 100mcg

17. PROVISIONAL DIAGNOSIS
AUTO-IMMUNE
HEMOLYTIC ANEMIA..?
Osteoarthritis..?
Osteonecrosis..?
Jaundice..?

18. DAY TO DAY ASSESMENT
DAY-1
• O/E patient conscious , coherent and afebrile
• c/o bilateral knee pain,
Headache(+),
Generalised weakness
• Hypothyroid (℞ on 1oomcg thyronorm)
• No organomegaly and lymphadenopathy
• Patient was evaluated outside and given Tab HCQS -400mg od
3 days
• Beta thalassemia minor-negative

19. Day 2
• B/L Knee pain
• Weakness reduced
• No other issues
• T.GEMFOS[Risedronate]-35mg/week on empty stomach with 1full
glass of water, Don’t EAT, LIE DOWN, BEND for 2hrs, can walk and sit
Day -3
• B/L Knee pain reduced
No weakness
No headache
• Can be discharged tomorrow

20. Day -4
• DISCHARGE RECOMMENDATIONS
1. Consider treatment with biphosphonates and calcium and
vitamin D - Tab SHELCAL 5OOmg OD
2. Tab GEMFOS 35mg/Week
3. Tab WYSOLONE 1.5mg/alternate day
4. No squatting, strain, inclines, walking on uneven surface
5. Reduce and maintain weight
6. Physiotherapy
7. Continue Tab THYRONORM 100mcg OD
8. Tab. FOLACIN 800mcg OD

21. PHYSICAL EXAMINATION
VITALS
• RR -19/min
• BP -110/7OmmHg
• SPO2 – 98%
• Respiratory system – BAE (+)
No added sounds
• CNS – no focal deficits
• CVS –S1S2 Heard
• LIMBS – distal pulses (+)
• ABDOMEN – non-tender, soft

22. LABORATORY VALUES
PARAMETER RESULT NORMAL RANGE
Haemoglobin 10.10gms% 12-16gms%
RBC 3.59million/cumm 4.5-5.5 million/cumm
PCV 37% 35-48%
Platelets 3.63lakhs/cumm 1.5-4.5lakhs/cumm
WBC 6,720cells/cumm 4k-10kcells/cumm
Hematocrit 12% 37-48%
Reticulocytes 3.76% 0.5-2.5%
ESR 25mm 0-20mm
LDH Total 197 IU/L 120-246 1U/L

23. PARAMETER RESULT NORMAL RANGE
T.Bilirubin 0.50mg/dl 0.1-1.2 mg/dl
BC.Conjugated 0.00mg/dl 0-0.35mg/dl
BC.unconjugated 0.99mg/dl 0-0.65mg/dl
T.Protein 7.20g/dl 6.3-7.9g/dl
Albumin 4.10g/dl 3.5-5.0g/dl
Gobulin 3.10g/dl 2-3.5g/dl
A/G Ratio 1.30 Approx 1
GGT 25.00 IU/L 8-62 IU/L
ALP 64.OO IU/L 40-129 IU/L
SGOT 26 IU/L 5-40 IU/L
SGPT 23 IU/L 5-40IU/L

24. IMMUNOSEROLOGY
• Rheumatoid factor assay : <8.6 IU/L [ normal : <121 IU/L]
PERIPHERAL SMEAR
• RBC Morphology : Microcytic Hypochromic with Anisocytosis,
spherocytes
• WBC : normal in count & disturbances
• PLATELET : Adequate
BIOCHEMISTRY
LUPUS ANTICOAGULANT
• DIL RUSSEL VIPER VEN TIME : 58.00 sec
• DRVVT CONTROL : 49.00 sec
• DRVVT:DRVVTC Ratio – 1.18 sec
• REFERENCE VALUE [ <1.30sec]

25. URINE
• Total Input- 1300ml
• Total Output – 1200ml
MRI OF KNEE JOINTS
• Findings : few irregular areas of altered signal intensity with T1
isointense &peripheral hyperintense rim, hyperintense on T2
weighed fat
• Marrow edema noted in femoral condyle with ill defined
margins of sub-chondral altered signal area
• Findings suggestive of medullary infracts in distal femur with
sub-chondral osteonecrosis in medial femoral condyle
• Mildly reduced fibro femoral joint space with reduced articular
cartilage thickness[grade-2]

26. MEDICATION CHART
S.
no
BRAND
NAME
GENERIC NAME DOSE FREQ ROA D
1
D
2
D
3
1 T.SHELCAL Ca++ with vit D3 500mg OD PO + + +
2 T.GEMFOS Risedronate 35mg OD PO - + +
3 T.
WYSOLONE
Prednisolone 1.5 mg Alterna
te day
PO + - +
4 T.FOLACIN
800
Folic acid 800mc
g
OD PO + + +
5 T.THYRONOR
M
levothyroxine 100mc
g
OD PO + + +

27. SOAP ANALYSIS

28. SUBJECTIVE EVIDENCE
• Fatigue
• Chills
• Headache
• Weakness
• Pale skin

29. OBJECTIVE EVIDENCE
• Haemoglobin- 10.10gms% [low]
• Hematocrit -12%[low]
• Reticulocytes - 3.76%[ high]
• Bc Unconjugated -1.67mg/dl [high]
• RBC Morphology – microcytic hypochromic with anisocytosis,
spherocytes
• Direct Coombs test - positive

30. ASSESSMENT
• Based on above subjective and objective
evidence data patient was diagnosed with
or found to be suffering from AUTO-
IMMUNE HEAMOLYTIC ANEMIA

31. PLANNING
GOALS OF TREATMENT
• To reduce signs and symptoms
• To correct the underlying disease
• Reduce or stop the destruction of RBCs
• To prevent relapse
• Prevent further complications like
jaundice, hepatosplenomgaly,
hyperbilirubinemia

32. TREATMENT OPTIONS
Tab. SHELCAL
• MOA-calcium improves
functioning of muscles,
bones and vit D3 increases
absorption of calcium and
phosphorus .
• USES – weak bone,
osteonecrosis,
hypothyroid, to maintain
healthy immune system
• SE –constipation, nausea,
vomiting, rashes
• MP- Ca++ levels, vit D3,
bone density
Tab. GEMFOS
• MOA- it is a
biphosphonate binds to
hydroxyapatite crystals in
bone & inhibits
osteoclast - mediated
bone resorption
• Uses- bone or joint pain
• SE – headache, arthralgia
constipation
• MP – Ca++ levels ,vit d &
phosphorus levela

33. Tab.WYSOLONE
• MOA- Prednisolone is a
steriod , modify immune
responses of body and
decreases hemolysis.
• USES- 1st line therapy for AIHA
• SE- acne, dry skin, bloating,
eye problems
• MP- BP, opthalmic exam,
blood glucose
Tab.FOLACIN
• MOA- It helps / stimulates
body to produce and
maintain blood cells
• SE- allergic rxn, fever,
bronchospasm
• USES- AIHA
• MP- Vit B12 and B9 levels

34. Tab.THYRONORM
• MOA-levothyroxine is synthetic form of T4, binds to thyroid
receptors in cell nucleus and causes metabolic effects
• USES-Hypothyroid
• SE-increased appetite, weight loss , headache, excessive
sweating
• MP- TSH, T4, and T3 levels

35. PROBLEMS IDENTIFIED
DRUG INTERACTIONS
Risedronate < > calcium ( Moderate )
• Calcium decreases effectiveness and absorption of risedronate
into systemic circulation .
• MANAGEMENT - 30 mins time gap should be there between
the administration of drugs
• Levothyroxine < > Calcium ( Moderate )
• Using calcium together with levothyroxine may decrease the
effects of levothyroxine.
• MANGEMENT : you should separate the administration of L-
thyroxine and calcium by at least 4hrs

36. ADR
NIL
MEDICATION
ERRORS
NIL

37. GOALS ACHIEVED
•B/L knee pain reduced
•No headache by the 3rd day
•No more weakness

38. MONITORING PARAMETERS
• Hemogoblin levels
• Hematocrit levels
• Reticulocytes levels
• Indirect bilirubin levels
• LDH levels
• ESR
• Peripheral smear
• Haptoglobin

39. PATIENT COUNSELLING
ABOUT THE DISEASE
• The patient must be counselled about
the disease i.e., AUTOIMMUNE
HEMOLYTIC ANEMIA which is a condition
that causes your RBCs to die sooner than
normal. And your bone marrow cannot
make new RBCs fast enough to replace
the ones that have died.
• Further the disease complications
[jaundice, hemogobinuria, arrhythmias
or cardiomyopathy ] also have to be
explained.

40. ABOUT MEDICATIONS
• Tab.GEMFOS -Should be taken with 1 full of glass of water,
don’t eat, lie down, bend down, for 2hrs. Can walk and sit.
• Tab.THYRONORM-should be taken morning only and a
30mins- 1hr time gap have to be maintained even to drink
water.
• There should be time gap of 30mins between CALICIUM and
RISEDRONATE.
• Parameters specific for each drug must be monitored
• Follow the medication as per the prescription
• Don’t miss the dose and double the dose if missed
• If any ADRs or SE seen report it to physician immediately.

41. LIFESTYLE MODIFICATIONS
• NO squatting/strains/walking on uneven surface.
• Reduce weight
• Physiotherapy should be continued
• Staying away from people who are sick and avoid large crows
of people
• Stay away from cold temperatures
• During cold weather wear a hat, scarf, & warm coat
• Take adequate amount of rest
• Avoid infections by maintain good hygiene conditions

42. DIET
FOODS TO BE TAKEN
• Leafy greens – [spinach, kale, broccoli] – Helps to prevent
relapse of anemia
• Meats- [chicken, beef ,ham] –useful in treating anemia
• Honey, amla juice, jack fruit & custard apple increases Hb
content in body.
• Beetroot is good remedy for treating anemia
• Banana and figs helps to stimulate production of RBC
• Enriched cereals or pastas helps to treat anemia
• Spices- including mustard seeds and ginger

44. FOODS TO BE AVOIDED
• Tea and coffee
• Foods that contain tannins, such as grapes, corn causes
nausea and impairs absorption of iron
• Foods rich in gluten like wheat, barley, oats – it triggers
autoimmune response and causes further complications.
• Foods that contain phytic acid like brown rice impairs
absorption of vitamins and minerals.
• Foods that contain oxalic acid such as peanuts parsely and
chocolates impair mineral absorption

45. REFERENCES
• Harshamohan – textbook of pathophysiology
• Drugs.com
• Medscape.com
• Healthline.com
• British journal of hematology
• The new england journal of autoimmune hemolytic anemia