Ceftriaxone-induced hemolytic anemia in a child successfully managed with intravenous immunoglobulin

Abstract

Drug-induced hemolytic anemia is an immune-mediated phenomenon that leads to the destruction of red blood cells. Here, we present a case of lifethreatening ceftriaxone-induced hemolytic anemia (CIHA) in a previously healthy 3-year-old girl. We also reviewed the literature to summarize the clinical features and treatment of hemolytic anemia. Acute hemolysis is a rare side effect of ceftriaxone therapy associated with high mortality. Our patient had a sudden loss of consciousness with macroscopic hematuria and her hemoglobin dropped from 10.2 to 2.2 g/dl over 4 hours, indicating that the patient had life-threatening hemolysis after an intravascular dose of ceftriaxone who had previously been treated with ceftriaxone in intramuscular form for six days. CIHA is associated with a positive direct antiglobulin test, revealing the presence of IgG in all cases and C3d in most cases. Our patient's direct antiglobulin test was positive for IgG (3+) and for C3d (4+). The case was managed successfully with supportive measures and intravenous immunoglobulin therapy. Ceftriaxone is used very frequently in children; an early diagnosis and proper treatment of hemolytic anemia are essential to improve the patient outcome. The pathophysiological mechanism is the same as for non-drug autoimmune hemolytic anemia. However, there is still no consensus treatment for CIHA. Intravenous immunoglobulin can be used in clinical emergencies, such as our case, or in refractory cases.

Hospital Based Surveillance of Severe Paediatric Malaria in Two Malaria Transmission Ecological Zones of Burkina Faso

“…Another trigger is an antibiotic induced haemolysis. Indeed, Ceftriaxone has been found to induce haemolysis in many reports [23,24]. In the current study, it was the most prescribed antibiotic (59.2%), although, predominantly in the LMT area (34.4%vs 25.6%).…”

Ceftriaxone-induced hemolytic anemia with severe renal failure: a case report and review of literature

“…In fact, intravascular hemolysis through complement-mediated lysis is a hallmark of “immune-complex-type” DIIHA [ 1 , 11 ]. In line with this, Coombs’ direct antiglobulin test (DCT) in ceftriaxone-induced IHA is usually positive for C3 and, in some cases, also for IgG [ 1 – 3 , 22 – 24 ]. However, negative DCT has also been described in ceftriaxone-induced IHA, probably because of massive hemolysis and therefore lack of intact complement−/antibody-loaded erythrocytes in this special case [ 25 ].…”

“…Additionally, in cases of drug-independent antibodies, intravenous immunoglobulins (IVIG) can be given, if there is evidence of intravascular hemolysis, like in treatment of WAIHA [ 27 ]. Administration of high-dose IVIG has been successfully used in a child with severe ceftriaxone-induced IHA and a nadir hemoglobin of 2.2 g/dl (1.37 mmol/l) [ 24 ]. However, the question remains open whether the positive outcome of the patient was due to IVIG therapy or due to cessation of ceftriaxone.…”

Ceftriaxone-induced severe hemolytic anemia, renal calculi, and cholecystolithiasis in a 3-year-old child: a case report and literature review

“…Adverse drug reactions caused by ceftriaxone are quite common in children, among which acute immune hemolytic reactions are one of the more severe adverse effects (Vehapoğlu et al, 2016;Leicht et al, 2018). Compared to adults, hemolytic reactions caused by ceftriaxone tend to be more severe in children (Leicht et al, 2018).…”