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- 2. © 2016 Virginia Mason Medical Center 2 Objectives Warm Autoimmune Hemolytic Anemia • Review diagnostic criteria • Do a couple questions • Discuss clinical presentation • Review illness script • Discuss treatment
- 3. © 2016 Virginia Mason Medical Center Question 1 27 y/o woman with 2 year hx of SLE presents with new onset fatigue and shortness of breath for 10 days duration. On exam, pulse=109/min, R=14/min, BP=130/80. Other than pale conjunctivae and pallor, exam normal. Hgb= 5.2 g/dl, compared with a normal value 3 months ago. Peripheral smear is notable for spherocytes, and polychromasia Which of the following is the most appropriate initial treatment for the patient? A. Oral Ferrous Sulfate B. Corticosteroid therapy C. Erythropoetin D. Plasmapheresis 3
- 4. © 2016 Virginia Mason Medical Center Diagnostic criteria When you might start to suspect it… Hemolytic Anemia • Anemia, high LDH, low haptoglobin, high indirect bilirubin Blood Smear • Spherocytes • Polychromasia Gold standard for diagnosis DAT • Positive for IgG and/or C3d 4
- 5. © 2016 Virginia Mason Medical Center Clinical presentation 5 • Anemia: pallor, fatigue, dyspnea • Hemolysis: jaundice, dark urine, hepatosplenomegaly • Important associations: • Recent antibiotic use? • Underlying malignancy? • Other autoimmune disorders, or fam hx?
- 6. © 2016 Virginia Mason Medical Center Question 2… You have a patient with known warm AIHA and DM, and her A1c is found to be 4.9. She gets excited because her last A1c was 9, How do you interpret this? A. She has had excellent glycemic control recently B. Her A1c will be falsely elevated C. Her A1c will be falsely low 6
- 7. © 2016 Virginia Mason Medical Center Illness Scripts 7 Warm AIHA Iron Deficiency Anemia Pathophysiology IgG autoantibodies against Rh antigens (Maximally reactive at 37 degrees) Decreased intake, decreased absorption, chronic blood loss, increased demand Epidemiology 50-60 yo (our patient is 72) F > M Associated with malignancy, autoimmune disorders, infections, drugs (mostly beta-lactams) Women of childbearing age Also common in elderly F > M Time course chronic/gradual variable Clinical presentation Anemia: fatigue, dizziness, dyspnea, pallor Hemolysis: Jaundice, dark urine, splenomegaly Anemia: fatigue, dyspnea, dizziness, pallor More specific: atrophic glossitis, pica, brittle nails/hair, cold intolerance Diagnostics Labs: Low: hemoglobin, haptoglobin High: reticulocyte count, MCV, LDH, indirect bilirubin Blood Smear: Spherocytes Coombs: DAT (+) for IgG and/or C3 Labs: low hemoglobin, low MCV, high RDW Iron studies: Low ferritin, high TIBC, low iron (duh) Blood Smear: microcytes, hypochromic cells Therapeutics First line: high dose corticosteroids Second line: Rituximab Third: splenectomy Iron supplementation, increase intake through diet, treat underlying cause of blood loss
- 8. © 2016 Virginia Mason Medical Center Some lessons and pitfalls… • Don’t want to miss malignancy, etc – but don’t anchor too early • A1c is useless in hemolytic anemia - our patient had A1c of 4.9 8
- 9. © 2016 Virginia Mason Medical Center Acknowledgements Dr. Carly Magnusson And thanks to everyone at VM! 9
Editor's Notes
- Discuss my patient here