Himesh Zaver, MD, Karn Wijarnpreecha, MD, Surakit Pungpapong, MD, Raj Satyanarayana, MD, Barry Rosser, MD, Andrew Keaveny, MD; Mayo Clinic, Jacksonville, FL
Introduction: We present a rare case of non-immune hemolytic anemia associated with acute hepatitis B infection in a previously healthy middle-aged female.
Methods: A 54 year old female presented to our center with symptoms of generalized weakness, pruritus and dark urine. The patient was previously healthy and had been diagnosed with acute HBV infection one month earlier. Her hemoglobin was normal at that time. Antiviral therapy was not prescribed initially as the patient manifested no evidence of acute liver failure. However, she started tenofovir disoproxil fumarate two weeks after diagnosis due to the persistence of symptoms and progressive hyperbilirubinemia with a total bilirubin of 31.5 mg/dL. On admission, her vitals were stable and the physical exam was significant for right upper quadrant abdominal pain and scleral icterus without evidence of asterixis or confusion. Laboratory work, as shown in Table 1, was significant for acute anemia and worsening bilirubin, although her liver transaminitis and viral load had improved. Renal function and coagulation studies were normal. Magnetic resonance imaging of the abdomen showed diffuse periportal edema supportive of acute hepatitis. Further work up of her anemia revealed normal manual smear, reticulocyte count 1.55 (0.60-2.71 %), lactate dehydrogenase 891 (122-222 U/L), and haptoglobin 14 (20-200 mg/dL). Additional testing included manual smear, vitamin B12, folate, iron, % saturation, disseminated intravascular coagulation panel, direct Coombs testing, cold agglutinins, glucose-6-phosphate dehydrogenase, Hgb electrophoresis, peripheral blood flow cytometry, immunoglobulins screen, which were all unremarkable. Serologic testing for autoimmune hepatitis, hepatitis A and C infections, were negative. The patient’s Hgb dropped to a nadir of 6.4 g/dL. The patient was transfused and discharged with a stable Hgb. Subsequent follow up revealed resolution of her anemia, transaminases and an undetectable HBV DNA level (Table 1). She has seroconverted with loss of HBs antigen; however the development of HBsAb, confirming resolution of infection 5 months after starting tenofovir is still pending.
Discussion: Non-immune hemolytic anemia is a rare extrahepatic complication of acute HBV infection. The anemia may be due to direct viral cytotoxicity and/or a heightened immune response following initiation of antiviral treatment. Treatment is predicated on suppressing HBV replication, necessitating a low threshold to start antiviral therapy.
Laboratory trends of patient diagnosed with hemolytic anemia associated with acute hepatitis B
Disclosures: Himesh Zaver indicated no relevant financial relationships. Karn Wijarnpreecha indicated no relevant financial relationships. Surakit Pungpapong indicated no relevant financial relationships. Raj Satyanarayana indicated no relevant financial relationships. Barry Rosser indicated no relevant financial relationships. Andrew Keaveny indicated no relevant financial relationships.