Management of Mycoplasma-Induced Hemolytic Anemia
Start high-dose corticosteroids immediately—this patient has severe cold agglutinin-mediated hemolytic anemia triggered by Mycoplasma pneumoniae, and corticosteroids are the first-line treatment for Grade 3 hemolytic anemia (hemoglobin <8.0 g/dL). 1
Immediate Actions
Initiate prednisone 1-2 mg/kg/day orally for this severe hemolytic anemia (Hb 60 g/L = 6.0 g/dL). 1, 2 The FDA-approved indication for prednisone includes acquired (autoimmune) hemolytic anemia. 2
Continue antibiotics for the underlying Mycoplasma pneumonia—stopping antibiotics is incorrect because the hemolysis is caused by cold agglutinins produced in response to the infection, not by the antibiotics themselves. 1 The antibiotics do not cause the hemolysis, and the disease can persist or worsen regardless of antibiotic continuation. 1
Add folic acid 1 mg daily to support erythropoiesis during this period of accelerated red cell turnover. 1
Why Not the Other Options?
Observation alone (Option A) is dangerous in a patient with hemoglobin of 60 g/L—delaying corticosteroids in severe hemolysis increases mortality risk. 1
Stopping antibiotics (Option B) is inappropriate because the hemolysis is immune-mediated by cold agglutinins, not drug-induced. 1 The Mycoplasma infection itself triggers autoantibody production. 3, 4
Rituximab (Option D) is premature—it is reserved only for refractory cases with no response to corticosteroids after 2 weeks, IVIG failure, steroid-dependent hemolysis, or recurrent severe hemolysis after steroid taper. 1
Understanding the Pathophysiology
This patient has cold agglutinin disease secondary to Mycoplasma pneumoniae. 3, 4 The infection triggers production of IgM antibodies (typically anti-I specificity) that cause complement-mediated hemolysis. 3, 4 The laboratory findings confirm hemolysis: elevated reticulocytes, elevated LDH, low/absent haptoglobin, and indirect hyperbilirubinemia (causing jaundice). 1, 5
Monitoring Protocol
Check hemoglobin weekly until steroid taper begins. 1 Monitor for steroid complications including hyperglycemia, hypertension, mood changes, and insomnia. 1
Repeat cold agglutinin titer in 2-4 weeks to assess treatment response. 1
Escalation Strategy if No Improvement
If no improvement occurs within 1-2 weeks of corticosteroids, consider IVIG 0.4-1 g/kg/day for 3-5 days. 1 Only after failure of both corticosteroids and IVIG should rituximab be considered. 1
Critical Transfusion Considerations
If transfusion becomes necessary, transfuse only the minimum units needed for symptoms—transfused cells will also undergo hemolysis due to the circulating cold agglutinins. 1 Use a blood warmer if transfusion is required. 3
Prognosis
Most cases of Mycoplasma-induced cold agglutinin hemolytic anemia respond well to corticosteroids combined with antibiotic treatment of the underlying infection. 3, 4 However, marked cytokine storm can lead to rapid deterioration and multiple organ failure in severe cases. 5
The correct answer is C: Start corticosteroids.