73 Clinical Brief Rubella Infection with Autoimmune Hemolytic Anemia Neerja Agrawal, Rahul Naithani and M. Mahapatra Department of Hematology, All India Institute of Medical Sciences, New Delhi, India. [Received January 30, 2006; Accepted January 10, 2007] ABSTRACT A 4-yr-old boy developed autoimmune hemolytic anemia after rubella infection and clinical manifestations cleared up after decrease in rubella specific IgM titer without any specific therapy. [ Indian J Pediatr 2007; 74 (5) : 495-496] E-mail: dr_rahul6@hotmail.com Key words : Rubella; Children; Anemia; Coombs test Autoimmune hemolytic anemia (AIHA) is uncommon cause of anemia but must be considered in differential diagnosis if the patient has a concomitant lymphoproliferative disorder, autoimmune disease, viral or mycoplasmal infection. 1 Positive direct antiglobulin test (Coombs’ test) represents a central criterion for detection of anti- red blood cell (RBC) alloantibodies. High-titer cold agglutinin (CA) may be induced by certain infectious agents, including mycoplasmal pneumonia, EBV, CMV, rubella virus or may develop in chronic (malignant) B cell lymphoproliferation. 2 Here it is presented a case of hemolytic anemia after rubella infection. CASE REPORT A 4-yr-old male child had history of fever and cough of 7 days duration, which subsided with oral antibiotics. He developed profuse weakness, progressive pallor, easy fatigability and limited activity. He was detected to have hemoglobin, 2.5gm%, for which he received 2 units of blood transfusions and referred to our hospital. Examination revealed severe pallor and generalized lymphadenopathy. Lymph nodes were 1-1.5 cm in size, firm and non-tender. There was no icterus, skin rash or sternal tenderness. Spleen and liver were palpable 2 cm below costal margin. Laboratory tests showed Hb 2.8gm% and reticulocyte count was 50%. Peripheral smear showed normocytic normochromic, polychromatophilic RBCs with few spherocytes, and Correspondence and Reprint requests : Dr. Rahul Naithani, Department of Hematology, First floor, IRCH building, All India Institute of Medical Sciences, New Delhi-110029 (India). Phone No: 9868365031 thrombocytopenia. No atypical cell was seen in peripheral smear. Serum bilirubin was 4.5mg% with indirect bilirubin 3.6mg%. Serum protein and transaminases were in normal limit. LDH was raised to 2750 IU/L. He had positive direct and indirect coomb’s test with increased osmotic fragility. Aspiration cytology of lymph node showed reactive changes only. On further evaluation for secondary causes; rubella infection was confirmed by rise of rubella specific IgM antibodies by ELISA. Specificity of these CA was not determined. Tests for antibodies to CMV, EBV, Toxoplasma and Herpes were negative. Child was given 2 units of blood transfusion and followed up for response without corticosteroids. Child recovered in due course of time with decrease in titer of rubella IgM antibodies, confirmed by repeat Elisa test. Coombs test became negative 2 wk later and LDH levels also reached to normal range. DISCUSSION Autoantibodies against red cells optimally reacting at 0 degree C, i.e., CA, are normally found with low titers in the serum of human adults. High-titer CA may be induced by certain infectious agents, including M pneumoniae, EBV, CMV, and rubella virus, or may develop on the basis of chronic (malignant) B cell lymphoproliferation. The main clinical manifestation of cold agglutination is AIHA. 3 Cold reactive autoantibodies account for16-32% of all immune hemolysis. 4 In children autoimmune hemolysis is a rare event but is mild and mostly followed by acute infections. 5 Their present patient also had febrile episode before the onset of hemolysis. Autoimmune thyroid Indian Journal of Pediatrics, Volume 74—May, 2007 495