What is the appropriate management for a patient with suspected hemolytic anemia, severe anemia, elevated reticulocyte count, and elevated lactate dehydrogenase, who is currently on antibiotics for Mycoplasma pneumonia?

Management of Mycoplasma-Associated Hemolytic Anemia

Start corticosteroids immediately with prednisone 1-2 mg/kg/day for this Grade 3 hemolytic anemia (Hb 60 g/L with severe hemolysis markers), continue the antibiotics for the underlying Mycoplasma pneumonia, and provide supportive care with transfusion only if symptomatic. 1, 2

Severity Classification and Immediate Action

This patient has Grade 3 hemolytic anemia based on hemoglobin <80 g/L (60 g/L), elevated reticulocytes, elevated LDH, and undetectable haptoglobin (0.3), indicating severe hemolysis triggered by Mycoplasma pneumoniae infection. 1, 2

The yellowing of eyes (jaundice) and mild abdominal pain with normal platelets and WBC distinguish this from thrombotic microangiopathy (TTP/HUS), which would present with severe thrombocytopenia and precipitous platelet drops. 3

Primary Treatment: Corticosteroids

Initiate prednisone 1-2 mg/kg/day orally (or IV methylprednisolone 1-2 mg/kg/day if unable to take oral medications) immediately to suppress the autoimmune hemolysis. 1, 2 This is the cornerstone of therapy for Mycoplasma-induced autoimmune hemolytic anemia.

• Add folic acid 1 mg daily to support erythropoiesis during active hemolysis. 1, 2
• Monitor hemoglobin levels weekly during corticosteroid therapy and tapering. 1, 2
• Monitor daily during the acute phase: CBC, LDH, haptoglobin, and reticulocyte count. 1

Antibiotic Management: Continue Treatment

Do NOT stop the antibiotics for Mycoplasma pneumonia. 2 While some guidelines mention stopping antibiotics in drug-induced hemolysis, Mycoplasma-associated hemolytic anemia is an immune-mediated complication triggered by the infection itself, not the antibiotic. 1, 2 The underlying infection requires completion of therapy.

This is a critical distinction: the hemolysis is caused by cold agglutinins produced in response to Mycoplasma infection, not by the antibiotic agent. 4, 5

Transfusion Strategy: Conservative Approach

Transfuse RBCs only if the patient is symptomatic or hemodynamically unstable, targeting hemoglobin 70-80 g/L in stable, non-cardiac patients. 1, 2

• Do not over-transfuse, as excessive transfusion can worsen hemolysis. 1
• The minimum number of RBC units necessary should be used. 6

Escalation for Refractory Cases

If there is no improvement within 1-2 weeks or worsening on corticosteroids, escalate therapy: 1, 2

• Add IVIG 0.4-1 g/kg/day for 3-5 days. 1
• Consider rituximab, cyclosporine, or mycophenolate mofetil for steroid-refractory cases. 1, 2

Critical Pitfalls to Avoid

• Do not delay corticosteroid initiation while awaiting further testing (such as direct Coombs test results), as delay increases morbidity and mortality. 1
• Do not stop antibiotics for the underlying Mycoplasma infection, as this is not drug-induced hemolysis. 2
• Do not transfuse to "normal" hemoglobin levels—target only 70-80 g/L to avoid worsening hemolysis. 1, 2
• Do not observe without treatment given the severity (Hb 60 g/L is Grade 3). 1

Why Not the Other Options?

• Option A (Observe): Inappropriate for Grade 3 anemia with Hb 60 g/L, which requires immediate corticosteroid therapy. 1
• Option B (Stop antibiotics): Incorrect, as the hemolysis is infection-triggered, not antibiotic-induced, and the Mycoplasma pneumonia requires treatment completion. 2
• Option D (Rituximab): Reserved for refractory cases that fail corticosteroids after 1-2 weeks, not first-line therapy. 1, 2

Answer: C - Start corticosteroids