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A 20-year-old college student presents for evaluation of anemia. Patient reports a his tory of sore throat 2 weeks previously. Physical examination reveals bilateral cervical lymphadenopathy and mild splenomegaly. Laboratory studies note a leukocyte count of 11 .200/,uL. hemoglobin 8.7 g/dL, mean corpuscular volume (MCV) 108 FL. and platelet count of 250.000/,uL. Peripheral blood smear is shown below. Monospot test ing is positive.
What is the most likely diagnosis?
- Warm autoimmune hemolytic anemia (AIHA)
- Cold agglutinin induced hemolysis
- Vitamin B12 deficiency
- Paroxysmal nocturnal hemoglobinuria (PNH)
- Acute lymphoblastic leukemia (ALL)
Medicine
B. Peripheral blood smear demonstrates the presence of reactive lymphocytes and red blood cell (RBC) agglutination, which results in spurious elevation of MCV Cold agglutinin-induced hemolysis is characterized by the presence of IgM antibodies directed against the RBC 'T' or "i" anti gen. The underlying etiology can range from benign conditions like infections (infectious mononucle osis or mycoplasma pneumoniae) to aggressive lymphomas. The cause of anemia is extravascular hemolysis. Treatment options range from cold avoidance to rituximab, cytotoxic chemotherapy, or plasma exchange for rapid removal of IgM from the circulation. Contrary to their benefit in the man agement of warm AIHA, corticosteroids have no proven benefit in the treatment of cold agglutinin disease (Blood. 1977;50(2):195, Br J Haematol. 2011;153(3):309, Br J Haematol. 2007;138(4):422).
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