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首页> 外文期刊>The Internet Journal of Emergency and Intensive Care Medicine >A case of life threatening hemolytic anemia due to Cold Antibodies, and its effect in management of the patient in Intensive Care Unit
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A case of life threatening hemolytic anemia due to Cold Antibodies, and its effect in management of the patient in Intensive Care Unit

机译：一例因感冒抗体导致危及生命的溶血性​​贫血及其对重症监护病房患者管理的影响

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A 21-year-old lady admitted to ICU with fever, abdominal pain and burning micturition, was diagnosed with bilateral renal calculi, urinary tract infection and hematuria. Her stay in the ICU was marked with severe anemia secondary to hematuria. Interestingly, blood transfusion was ruled out due to the presence of cold antibodies in her blood. Management of the case was directed at keeping her warm, maintaining a body temperature of more than 37.5°C – all intravenous fluids were prewarmed prior to infusion. The overall condition of the patient improved with intravenous steroids, meticulous infection control, and stopping of hematuria. However, blood transfusion was still not possible due to the presence of cold antibodies, and ultimately, the patient died due to severe anemia and pulmonary edema. Introduction Cold antibodies are antierythrocytic auto-antibodies which bind red blood cells at cold temperature (28 to 310C, even 370C or more) and produce hemolysis. They are usually IgM but can be IgG antibodies which arise due to infections, malignancies or idiopathic.1 Case Report A 21-year-old female presented with pain abdomen, fever, and burning micturition in the Outpatient Department of our hospital. On admission, she was diagnosed with bilateral renal calculi, and bilateral percutaneous nephrostomy was done under USG guidance. Pyelolithotomy was deferred due to severe anemia with hemoglobin of 6 gm%, and the unavailability of suitable blood donors. She was discharged with hematinics, surgery having been postponed until her hemoglobin improved.The patient came back after one month with fever, dehydration, hematuria, drowsiness, and pus draining through both percutaneous nephrostomy. She was immediately shifted to the ICU. On investigation, her coagulation profile was normal, hemoglobin – 5 gm%, and serum creatinine – 7.9 mg/dL. Blood culture showed growth of Klebsiella pneumoniae, sensitive to Imipenem. Urine culture from right nephrostomy tube showed Klebsiella pneumoniae, and Enterobacter species, both sensitive to Imipenem. Urine from left nephrostomy tube showed growth of Enterobacter species, also sensitive to Imipenem. Urine per urethra showed growth of Enterobacter species, sensitive to Imipenem, and Escherichia Coli which showed resistance to all antibiotics tested. The urethral and nephrostomy tubings were regularly flushed with normal saline. Injection Meropenem was started based on sensitivity and creatinine clearance, at a once daily dose of 1 gram. Dehydration and electrolyte imbalance was corrected. Due to persistent hematuria and low hemoglobin, decision was made to transfuse blood to the patient. Blood group and cross matching samples from the patient showed the presence of cold antibodies, which caused hemolysis at temperatures greater than 37°C. The blood bank refused to release blood after repeatedly confirming the finding with repeat samples from different sites. Management of the patient was immediately directed at reducing hemolysis by maintaining patient’s body temperature above 37.5°C with prewarmed intravenous fluid infusions, and Injection Hydrocortisone 100 mg IV qid. Within 24 hours, hematuria had decreased. However, repeat blood samples still showed presence of cold antibodies, which prevented any decision on transfusing blood. Hence, other measures to improve hemoglobin level such as injectable Iron and Erythropoetin, was undertaken. Gradually, the patient improved with cessation of hematuria and pus discharge, and reduced serum creatinine level of 3.7 mg/dL.On the 11th ICU day, the patient suddenly deteriorated with the development of pulmonary edema and severe anemia (Hb – 2.9 gm%), and she died subsequently. Discussion Landsteiner first described cold antibodies in 1903. In 1904, the connection between cold antibodies and red cell destruction was made. In 1950s, Schubilhe coined the term, cold agglutinin disease (CAD), which consists of primary CAD, secondary CAD, and paroxysmal cold hemoglobin
机译：一名21岁女士因发烧，腹痛和排尿灼热入院，被诊断为双侧肾结石，尿路感染和血尿。她留在重症监护病房的病因是血尿继发的严重贫血。有趣的是，由于血液中存在冷抗体，排除了输血。该病例的处理旨在保持她的温暖，保持体温超过37.5°C –在输注之前对所有静脉输液进行预热。静脉使用类固醇，细致的感染控制和止血可改善患者的整体状况。但是，由于存在冷抗体，仍然无法进行输血，最终，该患者由于严重的贫血和肺水肿而死亡。简介冷抗体是抗红细胞自身抗体，可在低温（28至310C，甚至370C或更高）下结合红细胞并产生溶血作用。它们通常是IgM，但也可能是由于感染，恶性肿瘤或特发性疾病而产生的IgG抗体。1病例报告一名21岁的女性在我院门诊出现腹部疼痛，发烧和排尿灼热。入院时，她被诊断患有双侧肾结石，并在USG指导下进行了双侧经皮肾造口术。由于严重贫血和6 gm％的血红蛋白，以及无法提供合适的献血者，推迟了开石术。她因血红蛋白排出，手术被推迟到血红蛋白好转。患者在一个月后因发烧，脱水，血尿，嗜睡和经皮肾造口术引流脓液而复出。她立即​​被转移到重症监护病房。经调查，她的凝血特性正常，血红蛋白– 5 gm％，血清肌酐– 7.9 mg / dL。血液培养显示对亚胺培南敏感的肺炎克雷伯菌生长。右肾造瘘管的尿液培养显示肺炎克雷伯菌和肠杆菌属细菌，均对亚胺培南敏感。左肾造瘘管的尿液显示肠杆菌种类的生长，对亚胺培南也敏感。每个尿道的尿液显示肠杆菌属细菌的生长，对亚胺培南和肠埃希氏大肠杆菌敏感，对所有测试的抗生素都有抗性。定期用生理盐水冲洗尿道和肾造瘘管。基于敏感性和肌酐清除率开始注射美罗培南，每天一次，剂量为1克。脱水和电解质失衡得到纠正。由于持续性血尿和低血红蛋白，决定将血液输注给患者。患者的血型和交叉匹配样本显示存在冷抗体，在高于37°C的温度下会引起溶血。血库在用来自不同部位的重复样本反复确认发现后拒绝放血。通过预热静脉输液和注射氢化可的松100 mg IV qid将患者的体温保持在37.5°C以上，可以立即对患者进行管理以减少溶血。在24小时内，血尿减少。但是，重复的血液样本仍然显示出冷抗体的存在，这阻止了对输血的任何决定。因此，采取了其他改善血红蛋白水平的措施，例如注射铁和促红细胞生成素。随着血尿的停止和脓液的排出，患者逐渐好转，血清肌酐水平降低了3.7 mg / dL。在ICU第11天，患者突然恶化，出现了肺水肿和严重的贫血（Hb – 2.9 gm％） ，她随后死亡。讨论Landsteiner于1903年首次描述了冷抗体。1904年，在冷抗体与红细胞破坏之间建立了联系。 1950年代，Schubilhe创造了冷凝集素病（CAD）一词，该疾病包括原发性CAD，继发性CAD和阵发性冷血红蛋白

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