Ver el código de «Hemolytic anemia»

==Background==
*Wide variety of clinical presentation given the large differential diagnosis 
*Clinical presentation and lab findings differ depending on intravascular vs. extravascular hemolysis, acute vs. chronic
*Common findings
**low hemoglobin and hematocrit
**reticulocytosis
**elevated indirect bilirubin
*Most important lab to elucidate diagnosis is blood smear
*Most common emergent presentations are due to acute intravascular hemolytic anemias

===Etiologies===
''Divided by etiology: acquired vs. hereditary''
*Acquired:
**Microangiopathic ([[MAHA]]), [[Autoimmune hemolytic anemia|autoimmune]], infection
*Hereditary:
**[[Sickle cell disease]], [[thalassemia]], [[G6PD]], [[hereditary spherocytosis]]

==Clinical Features==
===History===
*[[Anemia]] symptoms
**[[Dyspnea]]/dypsnea on exertion
**Fatigue
*Stigmata of intravascular hemolysis
**[[Jaundice]] (new onset)
**Dark urine
**Changes in stool color
**Neuro ([[TTP]])
***[[Headache]]
***[[Altered mental status]]
***[[Seizure]]
***[[Focal neuro deficits]]
***[[Coma]]
**[[Rectal bleeding]] ([[HUS]])
*Stigmata of [[thrombocytopenia]]
**[[Petechiae]]
**Bleeding
*Stigmata of extravascular RBC destruction
**[[Abdominal pain]]
**[[Back pain]]
*Systemic Symptoms
**[[Fever]]
**Night sweats
**Weight loss
**Confusion
*Other 
**Trauma
**Initiation of new medication
**Recent travel
**Recent [[insect bites]]

===PMH===
*[[Hereditary spherocytosis]]
*[[Sickle cell disease]]
*[[G6PD]] Deficiency recently started new medication:
**[[Dapsone]]
**Phenazopyridine
**[[Nitrofurantoin]]
**Primaquine
**[[Rasburicase]]
**[[Methylene blue]]
**Tolonium chloride (toluidine blue)
*Malignancy
*[[Renal failure]]
*[[Connective tissue disease]]
*Family history of Anemia/Bleeding

===Physical Exam===
*Cardiovascular
**[[Tachycardia]] with flow murmur
**Heart murmur – prosthetic heart valve
*Abdominal Exam
**Hepatomegaly, splenomegaly
**[[Ascites]]
*Skin
**[[Petechiae]]
**Bruising
**[[Lymphadenopathy]] 
**[[Brown recluse]] spider bites

==Differential Diagnosis==
===Acquired Hemolytic Anemia===
====Microangiopathic Hemolytic Anemia====
*[[HUS]]
*[[TTP]]
*[[DIC]]
*[[Hypertensive emergency]]
====Autoimmune====
*[[Autoimmune hemolytic anemia]]
====Infection====
*[[Malaria]]
*[[Babesiosis]]

====Other====
*[[Brown recluse spider venom]]
===Hereditary/Congenital Hemolytic Anemia===
*[[G6PD]] – medication induced hemolytic anemia
*[[Sickle cell disease]]
*[[Thalassemia]]
*[[Hereditary spherocytosis]]

==Evaluation==
===Workup===
*CBC
**Low hemaglobin/hematocrit
**Low platelet count → microangiopathic hemolytic anemia
*Blood smear
*Reticulocyte count
*CMP
**Most important:  indirect bilirubin and creatinine
*[[UA]] (for hemoglobin, hemosiderin), uHCG
*PT/INR
*Hemolysis labs
**LDH
**Haptoglobin
**Fibrinogen 
*Direct Anti-Globulin Test or Coombs test
*If concern for Malaria:
**Thick and thin prep
**Parasitemia 
*HIV
*Blood cultures, urine cultures
*Consider [[LP]] if neuro symptoms

===Lab Interpretation===
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Microangiopathic Hemolytic Anemia'''
| align="center" style="background:#f0f0f0;"|'''H/H'''
| align="center" style="background:#f0f0f0;"|'''Platelets'''
| align="center" style="background:#f0f0f0;"|'''Indirect Bili'''
| align="center" style="background:#f0f0f0;"|'''Creatinine'''
| align="center" style="background:#f0f0f0;"|'''Blood Smear'''
| align="center" style="background:#f0f0f0;"|'''PT/INR'''
| align="center" style="background:#f0f0f0;"|'''LDH'''
| align="center" style="background:#f0f0f0;"|'''Haptoglobin'''
| align="center" style="background:#f0f0f0;"|'''Fibrinogen'''
| align="center" style="background:#f0f0f0;"|'''DAT/Coombs Test'''
| align="center" style="background:#f0f0f0;"|'''Thick/Thin Prep'''
|-
| [[HUS]]||low||low||elevated||highly elevated||schistocytes||wnl||elevated||low||wnl||negative||negative
|-
| [[TTP]]||low||low||elevated||elevated||schistocytes||wnl||elevated||low||wnl||negative||negative
|-
| [[DIC]]||low||low||elevated||elevated||schistocytes||elevated||elevated||low||low||negative||negative
|-
| Malignant Hypertension||low||low||elevated||variable||schistocytes||||elevated||low||||negative||negative
|-
| align="center" style="background:#f0f0f0;"|'''Autoimmune'''
| align="center" style="background:#f0f0f0;"|'''H/H'''
| align="center" style="background:#f0f0f0;"|'''Platelets'''
| align="center" style="background:#f0f0f0;"|'''Indirect Bili'''
| align="center" style="background:#f0f0f0;"|'''Creatinine'''
| align="center" style="background:#f0f0f0;"|'''Blood Smear'''
| align="center" style="background:#f0f0f0;"|'''PT/INR'''
| align="center" style="background:#f0f0f0;"|'''LDH'''
| align="center" style="background:#f0f0f0;"|'''Haptoglobin'''
| align="center" style="background:#f0f0f0;"|'''Fibrinogen'''
| align="center" style="background:#f0f0f0;"|'''DAT/Coombs Test'''
| align="center" style="background:#f0f0f0;"|'''Thick/Thin Prep'''
|-
| Warm Antibody AHA||low||wnl||elevated||||spherocytes||||elevated||low||wnl||positive||negative
|-
| align="center" style="background:#f0f0f0;"|'''Infection'''
| align="center" style="background:#f0f0f0;"|'''H/H'''
| align="center" style="background:#f0f0f0;"|'''Platelets'''
| align="center" style="background:#f0f0f0;"|'''Indirect Bili'''
| align="center" style="background:#f0f0f0;"|'''Creatinine'''
| align="center" style="background:#f0f0f0;"|'''Blood Smear'''
| align="center" style="background:#f0f0f0;"|'''PT/INR'''
| align="center" style="background:#f0f0f0;"|'''LDH'''
| align="center" style="background:#f0f0f0;"|'''Haptoglobin'''
| align="center" style="background:#f0f0f0;"|'''Fibrinogen'''
| align="center" style="background:#f0f0f0;"|'''DAT/Coombs Test'''
| align="center" style="background:#f0f0f0;"|'''Thick/Thin Prep'''
|-
| [[Malaria]]||low||wnl||elevated||||see thick/thin prep||variable||elevated||low||wnl||negative||paracytes
|-
| Babesia||||||||||see thick/thin prep||||||||||negative||paracytes
|-
| align="center" style="background:#f0f0f0;"|'''Other'''
| align="center" style="background:#f0f0f0;"|'''H/H'''
| align="center" style="background:#f0f0f0;"|'''Platelets'''
| align="center" style="background:#f0f0f0;"|'''Indirect Bili'''
| align="center" style="background:#f0f0f0;"|'''Creatinine'''
| align="center" style="background:#f0f0f0;"|'''Blood Smear'''
| align="center" style="background:#f0f0f0;"|'''PT/INR'''
| align="center" style="background:#f0f0f0;"|'''LDH'''
| align="center" style="background:#f0f0f0;"|'''Haptoglobin'''
| align="center" style="background:#f0f0f0;"|'''Fibrinogen'''
| align="center" style="background:#f0f0f0;"|'''DAT/Coombs Test'''
| align="center" style="background:#f0f0f0;"|'''Thick/Thin Prep'''
|-
| [[Brown recluse]]||low||wnl||elevated||||||||elevated||||||positive||negative
|}

==Management==
*ABC’s and resuscitation if necessary, 2 large bore IVs
*Emergent hematology consultation if patient is very ill appearing
===Acquired Hemolytic Anemia===
====Microangiopathic Hemolytic Anemia====
*[[HUS]]
**Supportive Care
***Hydration
***Pain control
**Hemodialysis if acute renal failure
**Do NOT give antibiotics: results in increased expression of Shiga Toxin from E. Coli O157:H7
*[[TTP]]
**'''Avoid''' platelet transfusion, except in life-threatening bleeding or intracranial hemorrhage
**[[Plasma exchange]]
**If Plasma exchange cannot be performed immediately, give FFP and plasmapharese later.
**Factor VIII concentrate
*[[DIC]]
**Platelet transfusion if count is <50,000 and/or significant bleeding
**pRBC if active bleeding or hemodynamically unstable
**[[FFP]] if active bleeding
**[[Cryoprecipitate]] if fibrinogen <150 and bleeding
**[[TXA]] is only indicated for active or massive bleeding
*[[Malignant hypertension]]
**Reduce blood pressure as clinically indicated

====Autoimmune====
*Warm antibody autoimmune hemolytic anemia
**High-dose [[corticosteroids]] PO (1-2mg/kg per day for 3-4 weeks)
**Monoclonal antibodies and immunosuppressive agents
**Plasma exchange for severe hemolysis
**Allogeneic RBC transfusion for life-threatening anemia

====Infection====
*[[Malaria]]
**Visit CDC website to determine resistance pattern: https://www.cdc.gov/malaria/diagnosis_treatment/treatment.html
**CDC Malaria Hotline: (770) 488-7788 or (855) 856-4713 toll-free Monday-Friday 9 am to 5 pm EST - (770) 488-7100 after hours, weekends and holidays
*[[Babesiosis]]
**Mild/moderate Disease
***[[Atovaquone]] 750mg PO q12hr '''AND''' 
***[[Azithromycin]] 500mg PO on day 1, then 250mg/day PO
**Severe Disease
***[[Clindamycin]] 300-600mg IV QID '''OR''' 600mg PO TID '''AND'''
***[[Quinine]] 650mg PO TID x7-10 days
***Consider exchange transfusion if parasitemia >10%
**Supportive treatment

====Other====
*[[Brown recluse spider bite]]
**Supportive care
***Hemodynamic support with fluids and pressers if necessary
***Blood product transfusion if necessary

===Hereditary/Congenital Hemolytic Anemia===
*[[G6PD]]
**Stop new medications
**Treat any infections aggressively
**Ovoid oxidant drugs
**Blood transfusion if severe illness
*[[Sickle Cell Disease]], [[Thalassemia]], [[Hereditary spherocytosis]]
**Hemolytic anemia in the above diseases typically chronic, usually does not require treatment in ED

==Disposition==
*Depends on severity, complications, etc.

==See Also==
*[[Anemia]]

==External Links==


==References==
<references/>

[[Category:Heme/Onc]]