Management of Mycoplasma-Induced Autoimmune Hemolytic Anemia
Start corticosteroids immediately (Option C) for this patient with severe Grade 3-4 autoimmune hemolytic anemia secondary to Mycoplasma pneumoniae infection.
Clinical Presentation Analysis
This 30-year-old woman presents with classic severe autoimmune hemolytic anemia (AIHA):
- Hemoglobin 60 g/L (6 g/dL) - critically low, representing Grade 3-4 severity 1
- Elevated reticulocytes - appropriate bone marrow response to hemolysis 2
- Elevated LDH and undetectable haptoglobin (0.3) - confirming active intravascular hemolysis 2
- Jaundice and abdominal pain - clinical manifestations of hemolysis 3, 4
- Normal platelets and WBC - isolated hemolytic process 1
The temporal relationship (2 days post-antibiotic initiation for Mycoplasma) strongly suggests cold agglutinin-mediated AIHA, a well-documented complication of Mycoplasma pneumoniae infection occurring in up to 50% of cases, though severe hemolysis is less common 3, 4, 5, 6.
Immediate Management Algorithm
First-Line Treatment: Corticosteroids
Administer intravenous methylprednisolone 1-2 mg/kg/day immediately for this Grade 3-4 hemolytic anemia 1, 2. With hemoglobin at 6 g/dL, this represents life-threatening anemia requiring aggressive immunosuppression 1.
Continue Antibiotics
Do NOT stop the antibiotics (Option B is incorrect). The hemolysis is immune-mediated, not drug-induced 3, 4, 6. Mycoplasma infection triggers cold agglutinin production, and treating the underlying infection is essential 3, 5, 6. The antibiotics themselves are not causing the hemolysis - the immune response to Mycoplasma is 4, 6.
Supportive Care
- RBC transfusion should be considered if symptomatic or to maintain hemoglobin 7-8 g/dL in this stable patient 1, 2
- Warm all blood products and IV fluids to prevent cold agglutinin-mediated hemolysis during transfusion 3, 4
- Folic acid 1 mg daily to support increased erythropoiesis 2
- Avoid cold exposure as cold agglutinins are temperature-dependent 4, 6
Observation Alone is Inadequate
Option A (observe) is inappropriate given the severity. Hemoglobin of 6 g/dL with active hemolysis requires immediate intervention to prevent cardiovascular compromise and death 1, 2.
Rituximab is Premature
Option D (rituximab) is reserved for refractory cases that fail to respond to corticosteroids within 1-2 weeks 1, 2. Starting with rituximab bypasses standard first-line therapy and is not indicated initially 2.
Expected Clinical Course
- Response to steroids typically occurs within 3-7 days with stabilization of hemoglobin 2
- Monitor hemoglobin weekly until steroid taper is complete 1, 2
- Cold agglutinin titers decrease as Mycoplasma infection resolves with antibiotic therapy 3, 4, 6
- Most cases resolve completely within 4 weeks with combined antibiotic and steroid therapy 6
Escalation Strategy if No Response
If hemoglobin continues to drop or fails to stabilize after 1-2 weeks of corticosteroids 2:
- Add IVIG 0.4-1 g/kg/day for 3-5 days 2
- Consider rituximab if still refractory 1, 2
- Plasmapheresis may be necessary for severe refractory cases with vascular complications 3
Critical Pitfalls to Avoid
- Do not delay corticosteroids - mortality increases with delayed treatment in severe hemolysis 2
- Do not transfuse cold blood products - this will exacerbate cold agglutinin-mediated hemolysis 4
- Do not stop antibiotics - the underlying Mycoplasma infection must be treated 3, 5, 6
- Do not over-transfuse - transfuse only minimum necessary to relieve symptoms or achieve hemoglobin 7-8 g/dL 1, 2
The correct answer is C: Start corticosteroids immediately while continuing antibiotic therapy for the underlying Mycoplasma infection.