Management of Mycoplasma-Induced Hemolytic Anemia
Initiate high-dose corticosteroids immediately with prednisone 1-2 mg/kg/day orally, as this patient has Grade 3 hemolytic anemia (hemoglobin 68 g/L, which is <80 g/L) secondary to Mycoplasma pneumoniae infection. 1
Clinical Reasoning
This patient presents with classic Mycoplasma-induced cold agglutinin hemolytic anemia, evidenced by:
- Severe anemia (Hb 68 g/L) with elevated reticulocytes (4%), undetectable haptoglobin, and elevated LDH—the hallmark laboratory pattern of hemolysis 1, 2
- Jaundice with normal liver function confirms hemolytic rather than hepatic pathology 1
- Temporal relationship to Mycoplasma pneumonia treatment (3 days post-antibiotic initiation) 3, 4, 5
The hemoglobin of 68 g/L places this patient in Grade 3 hemolytic anemia (defined as Hb <80 g/L), which mandates specific management according to established guidelines 6, 1.
Immediate Management Algorithm
First-Line Treatment: Corticosteroids
- Administer prednisone 1-2 mg/kg/day orally (or IV equivalent if unable to take oral medications) 6, 1
- Do NOT delay corticosteroid initiation, as delays increase mortality risk in severe hemolysis 1
- Continue antibiotics for Mycoplasma pneumonia—stopping antibiotics does not reverse the hemolysis, as the cold agglutinins persist regardless of antibiotic continuation 1
Supportive Care
- Folic acid 1 mg daily to support erythropoiesis during ongoing hemolysis 6, 1
- Consider RBC transfusion only if symptomatic (dyspnea, chest pain, altered mental status), using the minimum units necessary to achieve Hb 70-80 g/L 6, 1
- Coordinate with blood bank before transfusion, as transfused cells will also hemolyze 1
Hematology Consultation
- Obtain hematology consultation for Grade 3 hemolysis to guide ongoing management 6
- Consider hospital admission based on clinical judgment, particularly given severe anemia and symptoms 6
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
- Track reticulocyte count and hemolysis markers (LDH, haptoglobin, bilirubin) to gauge response 2, 7
When Other Therapies Are Indicated
IVIG (Second-Line)
- Consider IVIG 0.4-1 g/kg/day for 3-5 days if no improvement after 1-2 weeks of corticosteroids 1
Rituximab (Reserved for Refractory Cases)
Rituximab should ONLY be considered if: 1
- No response to corticosteroids after 2 weeks
- IVIG failure
- Steroid-dependent hemolysis requiring prolonged high-dose steroids
- Recurrent severe hemolysis after steroid taper
Rituximab is NOT first-line therapy for Mycoplasma-induced hemolytic anemia and should not be initiated at this stage 6, 1.
Critical Pitfalls to Avoid
- Do not stop antibiotics thinking this will resolve hemolysis—the cold agglutinins drive the hemolysis independent of ongoing antibiotic therapy 1
- Do not delay corticosteroids while waiting for additional testing or hematology consultation in Grade 3 hemolysis 1
- Do not over-transfuse—transfused RBCs will also undergo hemolysis from circulating cold agglutinins 1
- Do not jump to rituximab as initial therapy—corticosteroids are first-line with excellent response rates in Mycoplasma-induced hemolysis 1, 3, 4, 5
Expected Clinical Course
- Clinical improvement typically occurs within 10 days of appropriate treatment with antibiotics and corticosteroids 4, 5
- Hemolysis is usually self-limited once the immune response to Mycoplasma resolves 3, 8, 5
- Steroid taper can begin once hemoglobin stabilizes and reticulocytosis resolves, typically over 4-6 weeks 1
Answer: C - Corticosteroids