What is the appropriate management for a 30-year-old female with mycoplasma pneumonia, severe anemia, elevated lactate dehydrogenase (LDH), low haptoglobin, and high reticulocyte (Retic) count, who is already on antibiotics?

Management of Mycoplasma-Induced Autoimmune Hemolytic Anemia

Start corticosteroids immediately with prednisone 1-2 mg/kg/day for this Grade 3-4 autoimmune hemolytic anemia triggered by Mycoplasma pneumoniae. 1, 2

Clinical Reasoning

This patient presents with classic Mycoplasma-induced cold agglutinin autoimmune hemolytic anemia (AIHA), evidenced by:

• Severe hemolysis markers: Hemoglobin 60 g/L (critically low, Grade 3-4 severity), elevated LDH, undetectable haptoglobin (0.3), and elevated reticulocytes indicating appropriate bone marrow response 1, 2
• Isolated hemolytic process: Normal platelets and WBC exclude thrombotic microangiopathy (TMA) or disseminated intravascular coagulation 1
• Timing: Hemolysis occurring 2 days after starting antibiotics for confirmed Mycoplasma pneumoniae is the classic presentation window 3, 4

Immediate Management Algorithm

Primary intervention:

• Administer intravenous methylprednisolone 1-2 mg/kg/day immediately for Grade 3-4 hemolytic anemia 1, 2
• This takes priority over stopping antibiotics, as the hemolysis is immune-mediated and already triggered 2

Supportive measures:

• RBC transfusion should be given only if symptomatic or to maintain hemoglobin 7-8 g/dL in stable patients—avoid over-transfusion 1, 2
• Folic acid 1 mg daily to support increased erythropoiesis during active hemolysis 1, 2

Regarding antibiotics:

• While stopping the antibiotic alone (Answer B) is insufficient as primary management, the Mycoplasma infection still requires treatment 3, 4
• The hemolysis is triggered by the infection itself, not the antibiotic, so continuing antimicrobial coverage is appropriate 5, 3

Why Other Options Are Inadequate

Observation alone (Answer A) is dangerous with hemoglobin of 60 g/L—delaying corticosteroids increases mortality in severe hemolysis 1

Stopping antibiotics alone (Answer B) addresses neither the severe hemolysis nor the underlying infection that triggered it 2

Rituximab (Answer D) is reserved for refractory cases that fail to respond to corticosteroids after 1-2 weeks, not as first-line therapy 1, 2

Expected Clinical Course and Monitoring

• Response to steroids typically occurs within 3-7 days with hemoglobin stabilization 1
• Monitor hemoglobin weekly during steroid therapy and tapering 1, 2
• Daily monitoring of LDH, haptoglobin, and reticulocyte count during the acute phase 2

Escalation Strategy if No Response

• Add IVIG 0.4-1 g/kg/day for 3-5 days if hemoglobin continues dropping after 1-2 weeks of corticosteroids 1
• Consider rituximab if still refractory to both steroids and IVIG 1, 2

Critical Pitfalls to Avoid

• Do not delay corticosteroids—this is a medical emergency with hemoglobin of 60 g/L 1
• Do not over-transfuse—transfuse only to relieve symptoms or achieve hemoglobin 7-8 g/dL 1, 2
• Do not assume the antibiotic caused the hemolysis—Mycoplasma infection itself triggers cold agglutinin formation 5, 3, 4