What is the appropriate management for a patient with mycoplasma pneumonia, on antibiotics, presenting with jaundice, mild abdominal pain, severe anemia, elevated lactate dehydrogenase (LDH), low haptoglobin, and a high reticulocyte count?

Management of Mycoplasma-Induced Hemolytic Anemia

Start high-dose corticosteroids immediately (prednisone 1-2 mg/kg/day) and continue the antibiotics for the mycoplasma pneumonia. 1

Clinical Reasoning

This patient has developed cold agglutinin-mediated hemolytic anemia secondary to Mycoplasma pneumoniae infection, evidenced by:

• Severe anemia (Hb 60 g/L) with elevated reticulocytes and LDH 1
• Undetectable haptoglobin (0.3) 1
• Jaundice with normal liver function tests, confirming hemolytic rather than hepatic pathology 1
• Temporal relationship to mycoplasma pneumonia (onset 2 days after starting antibiotics) 2, 3

Immediate Management Algorithm

Step 1: Initiate Corticosteroids

• Start prednisone 1-2 mg/kg/day orally immediately for Grade 3 hemolytic anemia (Hb <8.0 g/dL) 1
• Delaying corticosteroids in severe hemolysis increases mortality risk 1
• This is the most critical intervention for this life-threatening complication 1

Step 2: Continue Antibiotics

• Do not stop the antibiotics - the hemolysis is caused by cold agglutinins produced in response to the infection, not by the antibiotics themselves 1
• The antibiotics are necessary to treat the underlying mycoplasma pneumonia 2, 3
• Stopping antibiotics does not reverse the hemolytic process 1

Step 3: Supportive Care

• Add folic acid 1 mg daily to support erythropoiesis during active hemolysis 1
• Transfuse packed red blood cells only if symptomatic (dyspnea, chest pain, altered mental status), using minimum units needed 1
• Transfused cells will also hemolyze, so transfusion is temporizing only 1

Monitoring Protocol

• Check hemoglobin weekly until steroid taper begins 1
• Monitor for steroid complications: hyperglycemia, hypertension, mood changes, insomnia 1
• Repeat cold agglutinin titer in 2-4 weeks to assess treatment response 1
• Most patients show favorable recovery within 10 days with appropriate treatment 2

Escalation Criteria

If no improvement after 1-2 weeks of corticosteroids, consider:

• IVIG 0.4-1 g/kg/day for 3-5 days 1
• Rituximab is reserved only for: no response to corticosteroids after 2 weeks, IVIG failure, steroid-dependent hemolysis, or recurrent severe hemolysis after steroid taper 1

Critical Pitfalls to Avoid

• Do not observe without treatment - this patient has severe, life-threatening anemia requiring immediate intervention 1
• Do not stop antibiotics - this will not help the hemolysis and will allow the pneumonia to worsen 1
• Do not start with rituximab - this is reserved for refractory cases only, not first-line therapy 1
• Avoid over-transfusion - transfused cells will also undergo hemolysis 1

Answer to Multiple Choice Question

The correct answer is C: Start corticosteroids. This patient requires immediate high-dose corticosteroid therapy for severe mycoplasma-induced hemolytic anemia while continuing antibiotics for the underlying infection. 1