What is the appropriate management for a patient with suspected Autoimmune Hemolytic Anemia (AIHA) and severe anemia, elevated LDH, and low Haptoglobin, who is currently on antibiotics for Mycoplasma pneumonia?

Management of Mycoplasma-Induced Autoimmune Hemolytic Anemia with Severe Anemia

Start intravenous methylprednisolone 1-2 mg/kg/day immediately—this patient has Grade 3-4 autoimmune hemolytic anemia (hemoglobin 60 g/L) triggered by Mycoplasma pneumonia, and corticosteroids are the first-line treatment that can prevent mortality in severe hemolysis. 1, 2

Why Corticosteroids Are the Correct Answer

Your patient has classic Mycoplasma-induced cold agglutinin autoimmune hemolytic anemia with critically low hemoglobin (60 g/L = 6 g/dL), which represents Grade 3-4 severity requiring immediate intervention. 1 The American Society of Hematology and American College of Physicians recommend IV methylprednisolone 1-2 mg/kg/day as first-line therapy for severe AIHA. 1, 2 Delaying corticosteroids increases mortality in severe hemolysis. 1

Continue the antibiotics—stopping them (Option B) would be inappropriate because the patient needs treatment for the underlying Mycoplasma infection, which is the trigger for the hemolysis. 3 The hemolysis will resolve as the infection is treated and corticosteroids suppress the autoimmune response. 3

Why Rituximab Is Premature

Rituximab is reserved for refractory cases that fail to respond to corticosteroids after 1-2 weeks. 1, 2 The treatment algorithm requires trying high-dose steroids first, then adding IVIG (0.4-1 g/kg/day for 3-5 days) if no response, and only considering rituximab if still refractory after these interventions. 1, 2 Starting with rituximab bypasses established first-line therapy and exposes the patient to unnecessary immunosuppression when steroids alone have a 70-80% response rate. 2

Complete Management Protocol

Immediate Actions (First 24-48 Hours)

• Administer IV methylprednisolone 1-2 mg/kg/day immediately for Grade 3-4 hemolytic anemia. 1, 2
• Continue antibiotic therapy for Mycoplasma pneumonia—do not discontinue. 3
• Consider RBC transfusion only if the patient is symptomatic or to maintain hemoglobin 7-8 g/dL; avoid over-transfusion. 1, 2
• Start folic acid 1 mg daily to support increased erythropoiesis from hemolysis. 1, 2

Monitoring Strategy

• Check hemoglobin levels weekly until steroid taper is complete. 1, 2
• Monitor for steroid-related complications including hyperglycemia, hypertension, mood changes, and fluid retention. 2
• Expect response to steroids within 3-7 days with stabilization of hemoglobin. 1

Escalation if No Response After 1-2 Weeks

• Add IVIG 0.4-1 g/kg/day for 3-5 days if hemoglobin continues to drop or fails to stabilize. 1, 2
• Consider rituximab only if still refractory after steroids plus IVIG. 1, 2
• Consult hematology for refractory cases requiring second-line immunosuppressive agents (cyclosporine, mycophenolate mofetil, azathioprine). 2, 4

Critical Pitfalls to Avoid

• Never delay corticosteroids while waiting for additional workup—this increases mortality in severe hemolysis. 1, 2
• Never stop antibiotics for Mycoplasma—the infection is the trigger and must be treated. 3
• Never transfuse unnecessarily—only transfuse if symptomatic or hemoglobin <7-8 g/dL to avoid over-transfusion complications. 1, 2
• Never start with rituximab—it is second or third-line therapy, not first-line. 1, 2
• Never observe alone (Option A)—with hemoglobin of 60 g/L, observation without treatment is dangerous and can lead to cardiovascular collapse. 1

Why This Case Is Mycoplasma-Induced AIHA

The temporal relationship (hemolysis starting 2 days after Mycoplasma pneumonia diagnosis), the presence of jaundice, elevated LDH, undetectable haptoglobin, high reticulocytes, and normal platelets/WBC all point to isolated immune-mediated hemolysis. 3 Mycoplasma pneumoniae commonly triggers cold agglutinin disease, a form of AIHA that responds to treating the underlying infection plus corticosteroids. 3