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on discovery that cefotetan and cefazolin were administered prophylactically forsurgery. To evaluate for possible DIIHA, the patient’s serum and eluate were sentto the American Red Cross Reference Laboratory (Pomona, CA) with the followingresults: The patient’s undiluted serum caused complete hemolysis of cefotetan-coatedRBCs; a 1:100 dilution of serum strongly agglutinated cefotetan-coated RBCs; theeluate also reacted with cefotetan-coated RBCs; all test results of non–drug-coatedRBCs were negative; and parallel test results for cefazolin drug-dependent antibodieswere negative. The findings confirmed the diagnosis of DIIHA due to cefotetan.Furthermore, the in vitro lysis of cefotetan-coated RBCs supported the suspicion thatintravascular hemolysis had occurred in vivo. Cefotetan DIIHA typically presentswith IgG-mediated extravascular hemolysis, which the patient clearly had, basedon the positive IgG, unconjugated hyperbilirubinemia, and the microspherocyteson the peripheral smear. Occasionally, cefotetan DIIHA involves complementmediatedintravascular hemolysis producing a DAT positive for C3. 3 The evidenceof intravascular hemolysis in the patient included hemoglobinemia, nearly absenthaptoglobin, and a very high lactate dehydrogenase level. Although C3 was notdetected in the patient’s DAT, the authors suspect that this was due to total hemolysisof the complement-coated RBCs in vivo.transfusion medicineTM 11-4© ASCP 2011Despite the patient’s severe anemia, she recovered after transfusion of several units ofRBCs and was discharged in stable condition. After the diagnosis of 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 therapy. Hematology. 2007;12(5):361–370.3. Ogose T, Wakata Y, Kaneko M, et al.A case of recurrent paroxysmal coldhemoglobinuria with the differenttemperature thresholds of Donath-Landsteiner antibodies. J Pediatr HematolOncol. 2007;29(10):716-719.4. Viraghavan R, Chakravarty A, Soreth J.Cefotetan-induced haemolytic anaemia. Areview of 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: the serologyand drugs associated with drug-inducedimmune hemolytic anemia-a new paradigm.Transfusion. 2007;47(4):697-702.9. Arndt PA, Garratty G. The changingspectrum of 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