Gast-3. Autoimmune hemolytic anemia in treatment-naive chronic hepatitis C infection.

A 48-year-old black male with a history of illicit drug use and alcohol abuse was diagnosed with hepatitis C liver disease 5 years prior to presentation. He was never treated with interferon. He presented with upper abdominal pain of 2 days' duration and had scleral icterus, hepatomegaly with moderate ascites. His hematocrit was 27.9 g/dl, reticulocyte count of 5.5%, AST 109, ALT 30, alkaline phosphatase of 235, amylase of 189, and lipase, 790. He had an LDH of 1115. Total bilirubin was 3.7 and indirect bilirubin, 2.9. Direct Coombs test was positive. On the second day of admission his hematocrit dropped to 21.9. Potential etiologies of autoimmune hemolytic anemia were ruled out (tests for HIV, autoimmune hepatitis and cryoglobulins assay were negative). A diagnosis of warm agglutinin autoimmune hemolytic anemia was made. In view of the autoimmune nature of his anemia, it was felt that treatment with prednisone was indicated. However, patient signed out against medical advice and was lost to follow-up. A range of immunological abnormalities has been shown to occur in patients with chronic HCV infection. These include essential mixed cryoglobulinemia and membranoproliferative glomerulonephritis. Induction of autoimmune hemolytic anemia during or after interferon treatment of HCV infection has been reported. The development of direct Coombs positive autoimmune hemolytic anemia de novo in patients with chronic HCV infection (in the absence of interferon therapy) is rare. Our review of the literature revealed one reported case which had a similar presentation except that the patient received prednisone with improvement of his anemia and reduction in his liver chemistries although there was an increase in his hepatitis C viremic load. Hepatitis C should be included as a secondary cause of immunohemolytic anemia.

Bolanle Akakabota, MD, and Zakari Y. Aliyu, MD, MPH. Department of Medicine, St Agnes Hospital, Baltimore, MD.