Management of Mycoplasma-Induced Autoimmune Hemolytic Anemia
Start corticosteroids immediately—this patient has Grade 3-4 autoimmune hemolytic anemia triggered by Mycoplasma pneumoniae, and corticosteroid therapy is the definitive treatment, not stopping antibiotics. 1, 2
Immediate Actions Required
Administer intravenous methylprednisolone 1-2 mg/kg/day immediately for this Grade 3-4 hemolytic anemia (hemoglobin 60 g/L represents critically severe anemia). 1, 2 The severity is confirmed by the constellation of elevated LDH, undetectable haptoglobin (0.3), and markedly elevated reticulocytes indicating active hemolysis. 1
Continue the antibiotics—do not stop them. 2 Mycoplasma pneumoniae infection triggers cold agglutinin-mediated autoimmune hemolytic anemia through antibodies against erythrocyte "I" antigen, but the hemolysis is immune-mediated, not directly caused by the antibiotic itself. 3, 4 The infection needs to be treated while simultaneously managing the immune-mediated hemolysis with corticosteroids. 5
Transfusion Strategy
Transfuse red blood cells only if the patient is symptomatic or hemodynamically unstable, targeting hemoglobin 70-80 g/L in stable patients. 1, 2 Given her hemoglobin of 60 g/L with symptoms (jaundice, mild abdominal pain), transfusion is likely indicated, but avoid over-transfusion—give only the minimum necessary to relieve symptoms. 1
Add folic acid 1 mg daily to support the increased erythropoiesis during active hemolysis. 1, 2
Monitoring Protocol
- Monitor hemoglobin weekly during corticosteroid therapy and tapering. 1, 2
- Check daily LDH, haptoglobin, and reticulocyte count during the acute phase to assess response. 2
- Expect clinical response within 3-7 days with stabilization of hemoglobin levels. 1
Escalation if No Response
Reassess at 1-2 weeks—if hemoglobin continues to drop or fails to stabilize despite corticosteroids: 2
- Add IVIG 0.4-1 g/kg/day for 3-5 days as second-line therapy. 1, 6
- Consider rituximab if still refractory to both corticosteroids and IVIG. 1
- Plasmapheresis may be considered in severe refractory cases with evidence of complement activation. 7
Critical Pitfalls to Avoid
Delaying corticosteroids increases mortality in severe hemolysis—this is the most important intervention, not stopping antibiotics. 1 The hemolysis is immune-mediated (cold agglutinin disease), requiring immunosuppression regardless of antibiotic continuation. 3, 4, 5
Do not confuse this with drug-induced hemolytic anemia—Mycoplasma triggers autoantibody formation against red cell antigens, not a direct drug effect. 3 The antibiotics are treating the underlying infection that triggered the immune response.
Answer to Multiple Choice
The correct answer is C (start corticosteroids). 1, 2 Observation alone (A) is inappropriate with hemoglobin of 60 g/L. Stopping antibiotics (B) is incorrect because the infection needs treatment and the hemolysis is immune-mediated, not drug-induced. Rituximab (D) is reserved for refractory cases after corticosteroid failure. 1