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A 60-year-old female with a history of hypertension and hyperl ipidemia presen ts in Decem ber for further evaluation of several months history of general ized fatigue. Patien t denies bleeding. weigh t loss, or changes in appetite. Physical exami nation reveals no jaundice. lymphadenopathy, or organomegaly. Laboratory evaluation shows hemoglobi n of 8.7 g/dL, mean corpuscular volume (MCV) of 1 1 0 FL. leukocyte count of 5,600/J.LL, and platelet count of 1 7LJ ,OOO/J.LL. Peripheral blood smear is shown below.
What is the most likely diagnosis based on the clinical presentation and peripheral blood smear?
- Autoimmune hemolytic anemia
- Reticulocytosis
- Liver disease
- Multiple myeloma
- Cold agglutinin disease
Medicine
E. Peripheral slide reveals areas of red blood cells (RBC) clumping, which result in a spurious elevation of MCV. Patient's presentation is consistent with cold agglutinin disease, which is characterized by the presence of IgM antibodies directed against I antigen on the surface of RBCs. Abnormal antibodies react with RBC at less than physiologic body temperatures and result in hemolytic anemia. High titer of cold agglutinins is used to confirm the diagnosis. Warming of the blood, as de-picted below, results in disappearance of RBC agglutination. Cold agglutinin disease can be related to underlying infections, such as mycoplasma, EBV, CMV or hepatitis virus, lymphoproliferative disor-ders, connective tissue disease, or other autoimmune disorders or may be idiopathic.
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