A Case of Piperacillin Induced Hemolytic Anemia. By: John Rapp, MLS (ASCP) CM

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1 A Case of Piperacillin Induced Hemolytic Anemia By: John Rapp, MLS (ASCP) CM

2 Patient History Patient is an 86 year old female who was admitted to the hospital on 1/14/2011 due to a motor vehicle accident. She suffered major facial trauma including at least 5 separate facial fractures. The patient also suffered from a very serious liver laceration. She had a fracture of the right humerus. Patient was actively bleeding into her abdomen.

3 Patient History On the date of admission, 1/14/2011, the patient received a total of 8 units of packed red blood cells. She was given 3 units of fresh frozen plasma, and 1 unit of apheresis platelets in an attempt to stabilize her. Due to the facial fractures, doctors wanted her placed on broad spectrum antibiotics to minimize the risk of osteomyelitis and infection of the central nervous system.

4 Patient History On 1/15/2011 the patient was taken to surgery in order to determine the severity of trauma to her liver. Patient underwent several surgeries in order to correct the damage to her liver, and to stabilize her still fluctuating vital signs. The patient was started on piperacillin/tazobactam on 1/22/2011 in order to help prevent infection due to recurrent surgeries.

5 Laboratory Trends Over the course of the next several days, the following trends in laboratory results were noted: A steadily decreasing hemoglobin that could not be corrected with transfusion. A highly elevated lactate dehydrogenase. The absence of haptoglobin. Increase in the reticulocyte count. This data indicated the development of acquired autoimmune hemolytic anemia.

6 Hemoglobin Levels Throughout Patient Admission H e m o g lo b in (g ) Jan 17-Jan 27-Jan 6-Feb 16-Feb 26-Feb 8-Mar 18-Mar Date

7 Laboratory Trends Over the course of the next several days, the following trends in laboratory results were noted: A steadily decreasing hemoglobin that could not be corrected with transfusion. A highly elevated lactate dehydrogenase. The absence of haptoglobin. Increase in the reticulocyte count. This data indicated the development of acquired autoimmune hemolytic anemia.

8 Lactate Dehydrogenase Levels Throughout Admission 1200 Lactate Dehydrogenase (m g/dl) Feb 6-Feb 8-Feb 10-Feb 12-Feb 14-Feb 16-Feb Date

9 Laboratory Trends Over the course of the next several days, the following trends in laboratory results were noted: A steadily decreasing hemoglobin that could not be corrected with transfusion. A highly elevated lactate dehydrogenase. The absence of haptoglobin. Increase in the reticulocyte count. This data indicated the development of acquired autoimmune hemolytic anemia.

10 Blood Bank Results Prior to 2/8/2011 all antibody screens were negative, except for the presence of a historical anti-e. A type and screen performed on 2/8/2011 indicated the presence of two antibodies. The antibody screen was positive at 37 C PEG AHG, a nd gave a 2+ reaction with all three screening cells. A DAT was then performed which reacted with both IgG and C3. These results suggested the development of a warm autoantibody. An elution was then performed due to the positive DAT.

13 Blood Bank Results The elution revealed an anti-e antibody. Anti-E was also present in an allogeneic adsorption utilized to determine the presence of an antibody that may be hidden by a warm autoantibody. The patient was known to have the anti-e antibody and was receiving E Negative units. The blood bank then began an investigation into some rare causes of anemia.

15 Discovery of Drug Induced Hemolytic Anemia Following review of the patient s medications, it was decided there was a possibility of drug induced hemolytic anemia. The remaining eluate was differentially tested against all reagents in previous reaction mixtures, as well as piperacillin. The reaction mixture was incubated at 37 C for 1 hour, and it was tested with and without anti-human globulin. All tests were performed in duplicate with untreated red blood cells and ficin treated red blood cells.

16 Discovery of Drug Induced Hemolytic Anemia Continued Any reaction mixture that contained the eluate, piperacillin, and red blood cells was positive for agglutination. Any reaction mixture without piperacillin was negative for agglutination. This also served as an agglutination control for all reagents present in the testing. This indicated the presence of an antibody to piperacillin and the classification of a drug induced hemolytic anemia.

18 Treatment Upon discovery of the causative agent, the patient was discontinued from the piperacillin/tazobactam. She was infused with another unit of packed red blood cells. Within a few days, her hemoglobin rose to an acceptable level, her LD decreased to normal ranges, and her haptoglobin was detectable again. Patient was discharged to the rehabilitation hospital on 2/22/2011. She was discharged from rehabilitation hospital on 3/16/2011.

20 Drug Induced Hemolytic Anemia: General Information DIHA is a very rare condition estimated to occur in about 1:1,000,000 people. Two different mechanisms of drug induced hemolytic anemia: 1. Drug independent antibodies: These antibodies can be detected in vitro in the absence of the causative drug. Essentially, these drugs stimulate the immune system to produce autoantibodies to red blood cells.

21 Drug Induced Hemolytic Anemia: General Information Two different mechanisms of drug induced hemolytic anemia: 2. Drug dependent antibodies. These drugs bind to the surface of red blood cells and stimulate the immune system to produce antibodies directed at the drug itself or at an epitope created by the combination of drug and RBC membrane. These antibodies can only be detected in vitro in the presence of the causative drug.

22 Drug Induced Hemolytic Anemia: General Information The patient in this case suffered from the drug dependent form of DIHA. This mechanism typically only involves the development of IgG antibodies, but may sometimes activate the complement cascade. The DAT of the patient revealed a positive reaction with C3, which indicates the drug dependent antibodies were capable of activating complement. Complications associated with complement fixation include: Acute intravascular hemolysis Renal Failure DIC Death

23 Piperacillin as a Cause of Drug Induced Hemolytic Anemia Piperacillin is an antibiotic typically used to treat patients infected by gram negative bacteria. It is the third most common cause of drug induced hemolytic anemia. Typically, it causes the destruction of red blood cells through complement fixation. It has been associated with a positive DAT for both IgG and C3.

24 Acknowledgments and References Thanks to: Laurie Hollis, MT(ASCP) SBB Mary Signaigo, MT(ASCP) Dr. Paula Chor, M.D. Garratty, George. "Drug-Induced Immune Hemolytic Anemia." Hematology. 1. (2009): 73-9.

Hemolysis. Intravascular vs. Extravascular. Classification. Warm vs. Cold Auto. Warm Auto. WAIHA Serologic Investigation

Hemolysis. Intravascular vs. Extravascular. Classification. Warm vs. Cold Auto. Warm Auto. WAIHA Serologic Investigation Positive Direct Antiglobulin Test and Autoimmune Hemolytic Anemias Jeffrey S. Jhang, M.D. Assistant Professor of Clinical Pathology College of Physicians and Surgeons of Columbia University Direct Antiglobulin