transfusion medicineTM 11-4© ASCP 2011Factors that favor DIITinclude: unexplainedacute thrombocytopeniafollowing any drugadministration, severethrombocytopenia(a platelet count <strong>of</strong>
on discovery that cefotetan and cefazolin were administered prophylactically forsurgery. To evaluate for possible DIIHA, <strong>the</strong> patient’s serum and eluate were sentto <strong>the</strong> American Red Cross Reference Laboratory (Pomona, CA) with <strong>the</strong> followingresults: The patient’s undiluted serum caused complete hemolysis <strong>of</strong> cefotetan-coatedRBCs; a 1:100 dilution <strong>of</strong> serum strongly agglutinated cefotetan-coated RBCs; <strong>the</strong>eluate also reacted with cefotetan-coated RBCs; all test results <strong>of</strong> non–drug-coatedRBCs were negative; and parallel test results for cefazolin drug-dependent antibodieswere negative. The findings confirmed <strong>the</strong> diagnosis <strong>of</strong> DIIHA due to cefotetan.Fur<strong>the</strong>rmore, <strong>the</strong> in vitro lysis <strong>of</strong> cefotetan-coated RBCs supported <strong>the</strong> suspicion thatintravascular hemolysis had occurred in vivo. Cefotetan DIIHA typically presentswith IgG-mediated extravascular hemolysis, which <strong>the</strong> patient clearly had, basedon <strong>the</strong> positive IgG, unconjugated hyperbilirubinemia, and <strong>the</strong> microspherocyteson <strong>the</strong> peripheral smear. Occasionally, cefotetan DIIHA involves complementmediatedintravascular hemolysis producing a DAT positive for C3. 3 The evidence<strong>of</strong> intravascular hemolysis in <strong>the</strong> patient included hemoglobinemia, nearly absenthaptoglobin, and a very high lactate dehydrogenase level. Although C3 was notdetected in <strong>the</strong> patient’s DAT, <strong>the</strong> authors suspect that this was due to total hemolysis<strong>of</strong> <strong>the</strong> complement-coated RBCs in vivo.transfusion medicineTM 11-4© ASCP 2011Despite <strong>the</strong> patient’s severe anemia, she recovered after transfusion <strong>of</strong> several units <strong>of</strong>RBCs and was discharged in stable condition. After <strong>the</strong> diagnosis <strong>of</strong> cefotetan DIIHAwas confirmed, she was advised to avoid cefotetan, and her drug allergy list wasupdated.REFERENCES1. Petz L, Garratty G. Immune HemolyticAnemia. 2nd ed. Philadelphia, PA:Churchill Livingston: 2004.2. Berentsen S, Beiske K, Tjønnfjord G.Primary chronic cold agglutinin disease: anupdate on pathogenesis, clinical featuresand <strong>the</strong>rapy. Hematology. 2007;12(5):361–370.3. Ogose T, Wakata Y, Kaneko M, et al.A case <strong>of</strong> recurrent paroxysmal coldhemoglobinuria with <strong>the</strong> differenttemperature thresholds <strong>of</strong> Donath-Landsteiner antibodies. J Pediatr HematolOncol. 2007;29(10):716-719.4. Viraghavan R, Chakravarty A, Soreth J.Cefotetan-induced haemolytic anaemia. Areview <strong>of</strong> 85 cases. Adv Drug React ToxicolRev. 2002;21:101-107.5. Garratty G. Drug-induced immunehemolytic anemia. Hematology Am SocHematol Educ Program. 2009:73-79.6. Salama A. Drug-induced immunehemolytic anemia. Expert Opin Drug Saf.2009;8(1):73-79.7. Garratty G, Arndt PA. An update ondrug-induced immune hemolytic anemia.Immunohematology. 2007;23(3):105-119.8. Johnson ST, Fueger JT, Gottschall JL.One center’s experience: <strong>the</strong> serologyand drugs associated with drug-inducedimmune hemolytic anemia-a new paradigm.Transfusion. 2007;47(4):697-702.9. Arndt PA, Garratty G. The changingspectrum <strong>of</strong> drug-induced immunehemolytic anemia. Semin Hematol.2005;42(3):137-144.10. Garratty G. Drug-induced immunehemolytic anemia. Clin Adv Hematol Oncol.2010;8(2):98-101.11. Arepally GM, Ortel TL. Heparin-inducedthrombocytopenia. Annu Rev Med.2010;61:77-90.12. Aster RH, Curtis BR, McFarland JG, et al.Drug-induced immune thrombocytopenia:pathogenesis, diagnosis, and management.J Thomb Haemost. 2009;7(6):911-918.13. Aster RH, Bougie, DW. Drug-inducedimmune thrombocytopenia. N Engl J Med.2007;357(6):580-587.49
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