Friday live case MR with Justin Louie: Hemolysis

A middle aged woman with history of bipolar disorder (on lamotrigine, escitalopram, buproprion, and olanzapine)presenting after a syncopal episode in the setting of 2.5 months of petechiae, macules, and ecchymosis, found to have an acute normocytic anemia. Work up revealed an elevated LDH, D-dimer, and reticulocyte count. Autoimmune labs were unremarkable. Skin biopsy is pending.

Kinetic approach to anemia

->Decrease in RBC production (low retic)

->Blood loss

->Increased destruction of RBCs

o   Intravascular hemolysis  (MAHA, PNH, clostridium perfringens, cold agglutinin disease, paroxysmal cold hemoglobinuria)

– Often increased LDH, indirect bili, and decreased hapto

– Clinical observations: jaundice, renal damage, dark urine (hgb), acrocyanosis, livedo reticularis

– Additional lab studies: free hemoglobin in plasma (hemoglobinemia), hemoglobinuria, hemosiderin in stained urine sediment (if ongoing for at least a week)

Algorithm take aways: 1) When to consider urgent treatment 2) Transfusion related? 3) Get a direct-coombs 4) schistocytes suggest hemolysis, but the sensitivity is not 100%


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