Prognostic significance of hemoglobin level and autoimmune hemolytic anemia in SARS-CoV-2 infection

Abstract

Higher levels of D-dimer, LDH, and ferritin, all have been associated with the poor prognosis of COVID-19. In a disease where there are acute inflammation and compromised oxygenation, we investigated the impact of initial hemoglobin (Hgb) levels at Emergency Department (ED) triage on the severity and the clinical course of COVID-19. We conducted a cross-sectional study on 601 COVID-19 patients in a COVID-19 national referral center between 13 and 27 June 2020. All adult patients presented at our hospital that required admission or hotel isolation were included in this study. Patients admitted to the intensive care unit (ICU) had a lower initial Hgb than those admitted outside the ICU (12.84 g/dL vs. 13.31 g/dL, p = 0.026) and over the course of admission; the prevalence of anemia (Hgb < 12.5 g/dL) was 65% in patients admitted to ICU, whereas it was only 43% in non-ICU patients (odds ratio of 2.464, 95% CI 1.71-3.52). Anemic ICU patients had a higher mortality compared with non-anemic ICU patients (hazard ratio = 1.88, log-rank p = 0.0104). A direct agglutination test (DAT) for all anemic patients showed that 14.7% of ICU patients and 9% of non-ICU patients had autoimmune hemolytic anemia (AIHA). AIHA patients had significantly longer length of hospital stay compared with anemic patients without AIHA (17.1 days vs. 14.08 days, p = 0.034). Lower Hgb level at hospital presentation could be a potential surrogate for COVID-19 severity.

The Affinity of Hemoglobin for Oxygen Is Not Altered During COVID-19

“…Twelve patients presented with autoimmune hemolytic anemia (AIHA), among them 4 had B lymphoid malignancy, one had monoclonal gammapathy (Jensen et al, 2020;Lazarian et al, 2020;Lopez et al, 2020) and 2 had Evans syndrome (Li et al, 2020;Wahlster et al, 2020). Later, it was stated that AIHA could concern 12% of the subgroup of anemic COVID-19 patients (Algassim et al, 2021). Fourteen additional patients were described: five with paroxysmal nocturnal hemoglobinuria (Kulasekararaj et al, 2020;Pike et al, 2020) and 9 with previously undiagnosed glucose-6-phosphate dehydrogenase (G6PD) deficiency uncovered in context of acute hemolysis (Aguilar and Averbukh, 2020;Beauverd et al, 2020;De Franceschi et al, 2020;Kuipers et al, 2020;Maillart et al, 2020;Palmer et al, 2020;Sasi et al, 2020;Sgherza et al, 2020;Lopes et al, 2021).…”

Autoimmune and Rheumatic Manifestations Associated With COVID-19 in Adults: An Updated Systematic Review

“…Most of these patients with thrombocytopenia were diagnosed by exclusion and had a favorable response to corticosteroids, IVIG, and even thrombopoietin receptor agonists. Positive direct Coomb's test was shown in 13% of 267 anemic COVID-19 patients and 46% of the other 113 COVID-19 patients (114,115). Furthermore, both warm and cold AIHA have been reported in COVID-19 patients and most of them recovered spontaneously (116)(117)(118)(119)(120)(121)(122).…”

Autoimmune hemolytic anemia in COVID-19 patients, the « transmissible » direct Coombs test

“…Accordingly, patients developing a positive DAT might be more at risk for admission in the ICU. This inding can be linked to the study showing that a lower hemoglobin level at admission is associated with a more severe disease evolution [6].…”

“…A growing number of complications have been associated with the virus, notably the occurrence of AIHA, as well as other autoimmune disorders. A study has shown a correlation between the hemoglobin level at hospital admission and the severity of the coronavirus disease 2019 (COVID-19) [6]. This highlights the clinical importance of inding the cause and correctly treating the anemia occurring in these patients.…”