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An Interesting Case of EBV-Associated Autoimmune Hemolytic Anemia


 We report a case of a 28-year-old male with no significant past medical history who presented with a weeklong history of flu-like symptoms, dark urine, and cold-induced pain and discoloration in his fingers. Upon presentation, he was noted to be significantly jaundiced. Abdominal ultrasound showed splenomegaly. Laboratory test results returned as follows: hematocrit, 26.4%; hemoglobin, 9.0 g/dL; WBC count, 9.8 × 109/L; and automated differential, 0.42 segmented neutrophils, 0.44 lymphocytes, and 0.08 monocytes. Manual differential showed 0.26 atypical lymphocytes, 0.21 lymphocytes, 0.10 monocytes, 0.03 metamyelocytes, and 0.05 segmented neutrophils. He was found to have a normochromic macrocytic anemia with absolute lymphocytosis, monocytosis, and thrombocytopenia. Peripheral blood smear revealed normochromic macrocytic RBCs with anisocytosis. Downey type II cells, plasmacytoid lymphocytes, large activated lymphocytes, and monocytes were present in addition to a neutrophilic left shift up to metamyelocytes. Liver function tests showed elevated levels of total bilirubin (8.4 mg/dL), direct bilirubin (2.6 mg/dL), aspartate aminotransferase (193 U/L), alanine aminotransferase (102 U/L), and alkaline phosphatase (132 U/L). Urinalysis was positive for urobilinogen. Serology was nonreactive for anti–hepatitis A IgM, hepatitis B surface antigen, and anti–hepatitis C antibody. Positive results were obtained for a rapid monoscreening test and Epstein-Barr virus viral capsid antigen IgM. Direct antiglobulin testing showed positivity for IgG, and complement and cold autoantibody were detected. He was transfused and treated with prednisone, IVIG, and external warmth. After improvement, the patient was discharged with recommendations for follow-up. Hemolytic anemia is a relatively rare complication of patients with infectious mononucleosis and occurs in approximately 1% to 3% of these patients. The pathogenesis of EBV-related autoimmune hemolytic anemia is unknown, with a suspicion for inadequate B-cell function after infection. Appropriate laboratory testing and analysis are critical for rapid diagnosis in these patients to ensure adequate treatment with no long-term sequelae.