Haemolytic anaemia as a consequence of COVID-19: A BMJ case
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A man in his early 50s was admitted feeling non-specifically unwell for 5 days. His family had noticed a yellow discoloration in his eyes. His urine was dark and he had an episode of frank per rectum (PR) bleeding. He described a previous episode of PR bleeding 6 months prior to admission. He had had one episode of diarrhoea. He had coryzal symptoms 2 weeks prior to admission and was experiencing some shortness of breath on mild exertion.

Medical history included obstructive sleep apnoea and hypertension. He was not on any medication on admission. He had struggled with side effects from bisoprolol and ramipril for his hypertension. He had been prescribed aspirin and atorvastatin but he had stopped these medications. His blood pressure had not required treatment since October 2019.

His clinical examination was unremarkable except for mild jaundice. PR did not show blood or melaena. His blood pressure was 173/104 mm Hg, heart rate 110 beats/min, temperature 36.4°C, respiratory rate 20/min and O2 saturations 96% on room air.

There was evidence of an acute kidney injury (AKI) stage 1 and raised bilirubin. His ECG on admission showed sinus tachycardia with heart rate of 122 beats/min.

A urine dip was positive for protein and blood. Due to the abnormal renal function, raised blood pressure and positive urine dip, a vasculitic screen was performed. This was negative. In view of the presumed haemolysis, further investigations were performed as detailed below.

An AIHA was suspected because of symptomatic anaemia, evidence of ongoing haemolysis on the blood tests and a history of a viral infection. In addition, the history of reddish urine, a positive urine dipstick for blood and protein and AKI stage 1 on presentation could have been suggestive of acute pyelonephritis. Gilberts syndrome was considered because of the mild hyperbilirubinaemia on the initial blood tests and clinical suspicion of viral infection as suggested by his coryzal symptoms.

Given the other abnormalities found, a haemolytic anaemia was the most likely diagnosis.

He was initially treated with intravenous fluids and his renal function recovered. No antibiotics were prescribed. For the first few days of his admission, haemoglobin (Hb) continued to fall before stabilising. There was no evidence of overt bleeding.

On the third day of his admission, he developed a supraventricular tachycardia which responded to adenosine 6 mg. Bisoprolol was initiated following this with the patients agreement.

Doctors suspected that this patient had haemolytic anaemia secondary to COVID-19 infection. This was suggested by a raised lactate dehydrogenase (LDH), decline in Hb, low haptoglobin levels and positive anti-C3d. ASOT were not performed as his symptoms could have been secondary to a streptococcal infection. However, the temporal relationship between the coryzal symptoms and the COVID-19 positive swab suggests that this infection was the precipitant of the haemolytic anaemia.

Learning points:
- Haemolytic anaemia may be a complication of COVID-19.

- It is important to be aware of late presentations so that patients who are potentially still infectious have appropriate infection control precautions.

- There may be other late manifestations of COVID-19 that become obvious as our experience of this disease increases.

Source: https://casereports.bmj.com/content/13/12/e238118?rss=1
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