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Cold agglutinin syndrome with severe haemolytic anaemia in a patient diagnosed of disseminated tuberculosis and concomitant Mycoplasma pneumoniae infection

Sir, It has been frequently observed that tuberculosis patients, especially disseminated cases, have minor degrees of anaemia (Cameron, 1974). But severe haemolytic episodes are rarely documented. We describe an episode of severe immune haemolytic anaemia due to cold agglutinin syndrome in a young woman with disseminated tuberculosis and concomitant Mycoplasma pneumoniae infection. A 24-year-old woman presented to the emergency department of our hospital in October 2010 with a 10-day history of continuous fever around 39–40 ◦C and non-productive cough. She had taken a 3-day course of intravenous azithromycin and another 3-day course of combined intravenous azithromycin and cefoperazone in local health facility but shown no improvement. She was diagnosed tuberculosis of lymph node via biopsy in 2001 and given a 3-month course of antituberculosis therapy. The family history was unremarkable. On admission, the patient’s temperature was 40·2 ◦C, the pulse rate was 115 beats min−1, and the respiratory rate was 24 breaths min−1. The BP was 125/55 mmHg. The spleen was palpable below left costal margin. The patient’s chest radiograph showed opacity in bilateral lower lobes and pleural effusion of left side. CT scan revealed mediastinal and hilar lymphadenopathy, patchy opacities in both lung fields, and mild pleural thickening. The results of laboratory findings were as follows: haemoglobin level, 7·7 g dL−1; total leukocyte count, 8·3 × 109 L−1 (87% neutrophils, 10% lymphocytes and 2% monocytes); platelet count, 300 × 109 L−1; reticulocyte count, 0·5%; albumin level, 2·5 g dL−1; globulin level, 3·0 g dL−1; total bilirubin level, 0·8 mg dL−1 (with a direct component of 0·3 mg dL−1) (normal range: 0·2–1·2 mg dL−1 with a direct component <0·4 mg dL−1); aspartate aminotransferase level, 53 U L−1 (normal range: <75 U L−1); alanine aminotransferase level, 32 U L−1 (normal range: <75 U L−1); lactate dehydrogenase level, 559 U L−1 (normal range: 109–245 U L−1). The serum levels of urea nitrogen and creatine were normal. The results of the direct Coombs’ test were positive (positive for C3 but not IgG). Cold agglutinin with a titer of 1024 in 4 ◦C and 8 in room temperature was detected. Serum protein electrophoresis