Lyme Disease as a Rare Trigger for Autoimmune Hemolytic Anemia

Lyme Disease as a Rare Trigger for Autoimmune Hemolytic Anemia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Lyme Disease as a Rare Trigger for Autoimmune Hemolytic Anemia Ugur Arzu Kulu, Irem Akdemir Kalkan, Havva Keskin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7647104/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Jan, 2026 Read the published version in BMC Infectious Diseases → Version 1 posted 4 You are reading this latest preprint version Abstract Introduction : Lyme disease, caused by Borrelia burgdorferi, is a zoonotic infection affecting the skin, nervous system, joints, and heart. Diagnosis relies on clinical history, symptoms, and a two steps serologic test confirmed by Western Blot. While typically treated with antibiotics, some cases progress to chronic stages. Although it frequently affects other systems, data on the haematological involvement spectrum of Lyme disease appears to be limited to case reports, and there are few studies that clearly demonstrate its relationship with haemolytic anaemia. This case highlights Lyme disease presenting with autoimmune hemolytic anemia (AIHA) and thrombocytopenia. Case : A 47-year-old woman with alcoholic cirrhosis (Child-Pugh B, Model for End-Stage Liver Disease (MELD) 9) presented with leg swelling, jaundice, and deep vein thrombosis. Laboratory evaluation showed severe anemia, thrombocytopenia, elevated lactate dehydrogenase (LDH), indirect hyperbilirubinemia, and acute kidney injury. Differential diagnoses, including disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, paroxysmal nocturnal hemoglobinuria, and spur cell anemia, were excluded. Coombs-positive hemolysis with low haptoglobin and normal nutritional markers confirmed autoimmune hemolytic anemia (AIHA). Despite prednisone therapy, thrombocytopenia worsened and neuropathic symptoms developed. Given recent European travel, Lyme disease was suspected and confirmed by Borrelia burgdorferi IgM and Western Blot. Following ceftriaxone and doxycycline, hemoglobin improved without transfusion, platelets normalized, and neuropathic symptoms regressed, highlighting Lyme disease as a rare cause of AIHA. Conclusion : Lyme disease, though uncommon, may present with autoimmune hemolytic anemia, emphasizing the need to consider this rare association in differential diagnosis when clinical suspicion arises. Lyme Disease Borrelia Autoimmune Hemolytic Anemia Figures Figure 1 Introduction Lyme disease, a zoonotic infectious disease caused by spirochetes called Borrelia burgdorferi (Bb). Diagnosis is based on history, symptoms and a two-step serologic test [1][2]. Positive immune serology is confirmed by Western Blot. Lyme disease (LD) usually presents initially with an erythematous rash known as erythema migrans (EM). Subsequently, about 4–8% of patients may experience cardiac involvement, 11% develop neurological manifestations, and 45–60% present with arthritis [2] LD is classified as stage 1 (early localized), stage 2 (early disseminated) and stage 3 (late persistent). Although antibiotics are used in treatment, most patients progress to the chronic stage [1][2]. Borrelia burgdorferi sensu lato (Bb), the most common tick-borne infection, has a global distribution. Seroprevalence rates are notably high, particularly in Central Europe, Western Europe, and Eastern Asia [3]. Although it frequently affects other systems, data on the haematological involvement spectrum of Lyme disease appears to be limited to case reports, and there are few studies that clearly demonstrate its relationship with haemolytic anaemia. This case report presents Lyme disease presenting with autoimmune haemolytic anaemia, and thrombocytopenia, which differs from the classic clinical manifestation. Case Report A 47-year-old woman with a known diagnosis of alcoholic liver cirrhosis (Child-Pugh B, MELD 9) was admitted to the emergency department with complaints of swelling in the left leg, pain in the calf region and jaundice which had been present for 1 month and gradually worsening. In the assessment carried out during the emergency admission, deep vein thrombosis was detected on venous doppler ultrasound of the left lower extremity and laboratory tests revealed Hemoglobin (Hb) 4. 2 g/dl, hemotocrit 13.6% , white blood cell (WBC) 30.85 x 10^9 /L (neutrophil: 24.39 x 10^9 /L, lymphocyte: 3.94 x 10^9 /L, platelet: 110 x 10^9 /L, c-reactive protein: 28 mg/L and d-dimer: 13105 ng/ml, total bilirubin: 5.90 U/l, indirect bilirubin: 3.77 U/l, LDH: 465 U/l, international normalized ratio (INR): 2.01, fibrinogen 1.66 g/L, urea 60 mg/dl, creatinine 2.30 mg/dl (basal creatinine: 0.70 mg/dl) and disseminated intravascular coagulation (DIC) was not considered due to the observation of rare schistocytes in the peripheral smear, which was examined with a prediagnosis of DIC. She was admitted to the general internal medicine service to deterimine the etiology of thrombophilia, acute renal injury and anemia. Investigations into the aetiology of the patient's thrombosis ruled out antiphospholipid syndrome, thrombotic thrombocytopenic purpura, paroxysmal nocturnal haemoglobinuria, and hereditary thrombophilia (Supplement 1). The patient was assessed as hypovolaemic on admission and, due to their response to intravenous isotonic saline, her current acute kidneyl injury was assessed as prerenal. In tests sent to determine the aetiology of anaemia in a patient requiring transfusion due to severe anaemia, haptoglobulin <0.058 g/dl, absolute reticulocyte count 2 x103/ml, reticulocyte index 0.80, direct coombs immunoglobulin G (ıg G) pozitive and Cd3 negative, indirect coombs negative, nutritional parameters were normal. In the peripheral smear, poikilocytosis in the erythrocytic series, acanthocytes (4%), schistocytes (2%, 1 schistocytes were seen in 3 out of 10 fields.), platelet count compatible with 100-130 x 10^9 /L and no atypical features were observed in other cell series (Figure 1A and 1B, Table 1 and Table 2). Table 1. Hematologic surveillance. At Administration Day. 0 steroid treatment 15 th day of steroid treatment 3 rd week of dual antibiotherapy At Discharge RBC count, million cells/mm3 1,09 1,86 2,36 2.50 2.57 Hemoglobin, g/dL 4.2 6.2 8.9 9.230 9.1 Hematocrit,% 13.6 19.3 26.3 30.2 29.4 Platelet count, x 10^9 /L 132 129 30 90 174 WBC count, cells/mm3 30,85 27,63 22,25 11.81 10.79 Segments,% 79.0 78.7 17.81 67.3 61.4 Lymphocytes,% 3.94 10.2 10.6 22.3 21.8 Eosinophils,% 0.28 1.8 2.2 1 2 Basophils,% 0.08 0.6 0.2 0.3 0.9 monocytes% 7 8.7 7 9 8 MCV fL 124.8 103.8 111.4 120.8 114 MCH pg/cell 28.5 33.3 37.7 36.8 35.4 haptoglobulin, g/dl <0.058 <0.058 <0.058 NA <0.058 absolute Reticulocyte count x103/ml 2 5.3 4.9 NA 3.3 reticulocyte index 0.80 2.11 3.24 NA 3.3 Direct coombs IgG/C3d NA +/- -/- NA -/- Indirect coombs - - - NA - serum iron, mcg/dl 53 NA 148 NA NA TS,% 29 NA 99 NA NA TIBC, mcg/dl 181 NA 149 NA NA ferritin, ng/ml 977 NA 1312 NA 487 vitamine B12, pg/ml 1311 NA 1077 NA NA folic asit, ng/ml 5.63 NA 7.68 NA NA Abbreviations: RBC: red blood cell, WBC: white blood cell, MCV: mean corpuscular volume, MCH: mean corpuscular hemoglobin, NA: non-avaliable, +: positive test result, -: negative test result, IgG: Immunoglobulin G, TS: transferrin saturation, TIBC: total iron binding capacity Table 2. Broad biochemistric surveillance. At Administration Day. 0 steroid treatment 15 th day of steroid treatment At Discharge Urea nitrogen, mg/dL 60 19 30 21 Creatinine, mg/dL 2.3 0.3 0.32 0.40 Sodium, mmol/L 126 126 134 136 Potassium, mmol/L 5.3 4 3.5 3.6 Calcium, mg/dL 8.9 7.8 8.8 8.2 Magnesium, mg/dl 1.43 1.5 1.41 1.62 Blood glucose, mg/dL 126 110 102 104 Total protein, g/dL 80.5 68.7 75.7 63.2 Albumin, g/dL 32.9 30.7 34.4 31.5 Total bilirubin, mg/dl 5.9 14.3 12.6 4.43 Indirect bilirubin, mg/dl 3.77 10.31 9.84 1.8 AST, IU/L 97 98 74 44 LDH, U/L 465 737 751 390 ALT, IU/L 23 27 58 18 GGT, IU/L 290 139 189 131 ALP, IU/L 113 77 136 102 INR 2.01 2.41 1.94 NA TG, mg/dl 69 NA NA NA LDL, mg/dl 100 NA NA NA Total kolestrol,/mg/dl 202 NA NA NA Abbreviations: AST: Aspartate aminotransferase, LDH: Lactate dehydrogenase, ALT: Alanine aminotransferase, GGT: Gamma-glutamyltransferase, ALP: Alkaline phosphatase, INR International normalized ratio, TG: iglyceride, LDL: Low- Density Lipoprotein, NA: non-avaliable It was evaluated as autoimmune hemolytic anemia in the foreground due to the accompanying elevated lactate dehydrogenase, direct coombs positivity and low haptoglobulin. In this case of secondary alcoholic liver cirrhosis presenting with acute haemolysis, Zieve syndrome was not considered due to normotriglyceridaemia and direct Coombs IgG positivity in the investigations performed. In a patient with 3% acanthocytes/Spurr cells in the peripheral smear, Spurr cell anaemia was also not considered due to direct Coombs positivity. Therefore, autoimmune hemolytic anemia was considered and prednisone 40 mg/day was started on the 10th day of admission. During the clinical follow-up, the patient's laboratory tests showed a decrease in platelet count to 30 x 10^9 /L, a newly developed drop foot in the left lower extremity and nocturnal neuropathic pain in the same extremity. In the patient's existing condition, small vessel vasculitis and autoimmune pathologies were included in our differential diagnosis, but we ruled them out with the immunoserological evaluation performed (Supplement 1). In a case being monitored with cortisone treatment due to autoimmune haemolytic anaemia, the patient's recent travel history to Switzerland led us to consider Lyme disease in our differential diagnosis, despite the absence of typical lesions and known tick exposure, due to the development of new neuropathic pain worsening at night and worsening thrombocytopenia. Therefore, Borrelia burgdorferi immunoblot IgG and IgM tests were performed (Supplement 2). Immunoblot B. burgdorferi Ig M was positive and a confirmation test with Western Blot (WB) was performed and WB Ig M was positive. The patient was accepted as Early Disseminated Lyme Diease and ceftriaxone was started. Doxycycline was added to the treatment upon clinical response in the second week of treatment. Under dual antibiotic treatment, platelet count increased to 176x 10^9 /L and neuropathic pain decreased but the drop foot finding persisted during clinical follow up settings. It was observed that the low foot clinic improved in the 3rd month after discharge. The patient who received prednisone 1 mg/kg for autoimmune hemolytic anemia did not need erythrocyte suspension replacement in the 2nd week of steroid treatment and hemoglobin level increased to 8.9 g/dl. In the patient whose Lyme treatment was completed and steroid was titrated and discontinued during follow-up, hemoglobin reached 10 g/dl. Discussion Lyme disease is a tick-borne infection with multi-organ involvement, especially the skin, nervous system, musculoskeletal system and heart [1][2]. Borrelia burgdorferi sensu lato (Bb) infection, the most frequent tick-transmitted disease, is distributed worldwide. Autoimmune hemolytic anemia (AIHA) is a disease characterized by the breakdown of erythrocytes and anemia as a result of the patient producing antibodies against their own erythrocytes. This condition, which is idiopathic in most patients, can be secondary to some autoimmune, infectious diseases and hematologic/nonhematologic malignancies [4][5]. However, although data on lyme-associated hematologic involvement are scarce, other possible etiologic causes were excluded by diagnostic workup in this case (Supplement 1). There are no studies that clearly demonstrate the relationship between Lyme disease and secondary anemia. Hemolytic anemia is not included in the classical picture of Lyme disease, and in the literature review, there are studies demonstrating Lyme-related anemia and thrombocytopenia in animal and human models [6][7] . However, there are case report studies showing that hemolytic anemia develops in the presence of co-infection with babesseos [8][9]. In our case, a thin peripheral smear was performed to rule out concurrent infection, and babesiosis was found to be negative for concurrent infection. The thrombocytopenia observed in this case may be a component of cirrhosis, as well as Lyme-associated thrombocytopenia, as seen in the case study reported in the literature [6]. In the same report of 6 cases of lyme-associated thrombocytopenia, it is emphasized that improvement in platelets was more pronounced in patients given doxycycline (doxycycline in 2 cases, prednisone in 1 case, ceftriaxone in 3 cases) compared to other treatment options [6]. In our case, we added doxycycline to the treatment in the second week of ceftriaxone, and similarly to the previous study, the platelet count rose from 30 x 10^9/L to 176 x 10^9/L. Previous studies have shown that Lyme borreliosis (Lb) increases autoimmunity, and this may explain Lyme-associated anaemia/thrombocytopenia. Several case reports have described the association between LB and the development of autoimmune diseases such as systemic lupus erythematosus, dermatomyositis, scleroderma and Guillain-Barre syndrome [10][11][12][13]. Although the exact mechanism underlying cytopenias secondary to Lyme disease in human models remains unclear, several processes—such as molecular mimicry, epitope spreading, bystander activation, original antigenic sin, polyclonal activation of B and T cells, and apoptosis of antigen-presenting cells—have been implicated in the development of autoimmunity[14][15] . Furthermore, some studies highlight the role of T regulatory (Treg) cells, Th17 immune responses, and IL-23 levels in the pathogenesis of post-treatment Lyme disease [16] . Findings from the literature support that lyme-associated increased autoimmunity may play a role in the development of autoimmune hemolytic anemia. As a conclusion, although studies have been conducted showing the association between thrombocytopenia, chronic disease anemia, and Lyme disease, it is difficult to demonstrate this correlation, particularly with regard to autoimmune hemolytic anemia. As demonstrated in our multidisciplinary case, we believe that Lyme disease should be considered in the differential diagnosis of autoimmune hemolytic anemia, even if it is rare, when there is a suspicious history. Abbreviations ADAMSTS-13 A Disintegrin and Metalloproteinase with a Thrombospondin Type 1 Motif, Member 13 AFAS Antiphospholipid Antibody Syndrome AIHA Autoimmune Hemolytic Anemia AKI Acute Kidney Injury ANA Antinuclear Antibody ANCA Anti-neutrophil Cytoplasmic Antibody anti-DsDNA Anti-Double Stranded DNA DIC Disseminated Intravascular Coagulation DVT Deep Ven Trombosis hb Hemoglobin Ig Immunoglobulin LDH Lactate Dehydrogenase MELD Model for End-Stage Liver Disease MTHFR Methylenetetrahydrofolate reductase PNH Paroxysmal Nocturnal Hemoglobinuria SLE Systemic Lupus Erythematosus TTP Thrombotic Thrombocytopenic Purpura Declarations Ethics and Informed Consent: Written informed consent was obtained from patient for the publication of this case. Consent for publication : Not applicable Availability of data and materials: Not applicable Interpretation: All; Literature search: All; Writing: All; Approval: All. Financial support and sponsorship: None. Author contributions: Concept: All; Design: All; Data collection or processing: All; Analysis or Interpretation: All; Literature search: All; Writing: All; Approval: All. Acknowledgments and Conflicts of Interest: The authors declare no conflicts of interest. References Biesiada G, Czepiel J, Leśniak MR, Garlicki A, Mach T. Lyme disease: review. Arch Med Sci. 2012 Dec 20; 8(6): 978-82. https://doi.org/10.5114/aoms.2012.30948. Epub 2012 Oct 8. Borchers AT, Keen CL, Huntley AC, Gershwin ME. Lyme disease: a rigorous review of diagnostic criteria and treatment. J Autoimmun. 2015 Feb; 57: 82-115. https://doi.org/10.1016/j.jaut.2014.09.004 Epub 2014 Oct 16. Dong Y, Zhou G, Cao W, Xu X, Zhang Y, Ji Z, Yang J, Chen J, Liu M, Fan Y, Kong J, Wen S, Li B, Yue P, Liu A, Bao F. Global seroprevalence and sociodemographic characteristics of Borrelia burgdorferi sensu lato in human populations: a systematic review and meta-analysis. BMJ Glob Health. 2022 Jun; 7(6): e007744. https://doi.org/10.1136/bmjgh-2021-007744. Michel, M., Crickx, E., Fattizzo, B. et al. Autoimmune haemolytic anaemias. Nat Rev Dis Primers 10, 82 (2024). https://doi.org/10.1038/s41572-024-00566-2 Michalak SS, Olewicz-Gawlik A, Rupa-Matysek J, Wolny-Rokicka E, Nowakowska E, Gil L. Autoimmune hemolytic anemia: current knowledge and perspectives. Immun Ageing. 2020 Nov 20; 17(1): 38. https://doi.org/10.1186/s12979-020-00208-7. Ballard HS, Bottino G, Bottino J. The association of thrombocytopaenia and Lyme disease. Postgrad Med J. 1994 Apr; 70(822): 285-7. https://doi.org/10.1136/pgmj.70.822.285. Athanasiou LV, Spanou VM, Katsogiannou EG, Katsoulos PD. Hematological Features in Sheep with IgG and IgM Antibodies against Borrelia burgdorferi sensu lato. Pathogens. 2021 Feb 4; 10(2): 164. https://doi.org/10.3390/pathogens10020164. Kumar M, Sharma A, Grover P. Triple Tick Attack. Cureus. 2019 Feb 13; 11(2): e4064. https://doi.org/10.7759/cureus.4064. Tole MC, Perez MV, Mekonen YF, Bermudez M, Salazar H. Cohabitating in the City: A Case of Hemolytic Anemia in a Patient Coinfected With Babesiosis, Lyme Disease, and Mononucleosis. Cureus. 2025 Apr 26; 17(4): e83043. https://doi.org/10.7759/cureus.83043. Yehudina Y, Trypilka S. Lyme Borreliosis as a Trigger for Autoimmune Disease. Cureus. 2021 Oct 10; 13(10): e18648. https://doi.org/10.7759/cureus.18648. Novitch M, Wahab A, Kakarala R, Mukerji R. The Emergence of a Forgotten Entity: Dermatomyositis-like Presentation of Lyme Disease in Rural Wisconsin. Cureus. 2018 May 10; 10(5): e2608. https://doi.org/10.7759/cureus.2608. Wackernagel A, Bergmann AR, Aberer E. Acute exacerbation of systemic scleroderma in Borrelia burgdorferi infection. J Eur Acad Dermatol Venereol. 2005 Jan; 19(1): 93-6. https://doi.org/10.1111/j.1468-3083.2004.01074.x Patel K, Shah S, Subedi D. Clinical association: Lyme disease and Guillain-Barre syndrome. Am J Emerg Med. 2017 Oct; 35(10): 1583.e1-1583.e2. https://doi.org/10.1016/j.ajem.2017.07.030. Epub 2017 Jul 8. Snik ME, Stouthamer NEIM, Hovius JW, van Gool MMJ. Bridging the gap: Insights in the immunopathology of Lyme borreliosis. Eur J Immunol. 2024 Dec; 54(12): e2451063. https://doi.org/10.1002/eji.202451063. Epub 2024 Oct 13. Rodríguez Y, Rojas M, Gershwin ME, Anaya JM. Tick-borne diseases and autoimmunity: A comprehensive review. J Autoimmun. 2018 Mar; 88: 21-42. https://doi.org/10.1016/j.jaut.2017.11.007. Epub 2017 Nov 26. PMID: 29183642. Adkison H, Embers ME. Lyme disease and the pursuit of a clinical cure. Front Med (Lausanne). 2023 May 24; 101183344. https://doi.org/10.3389/fmed.2023.1183344. Additional Declarations No competing interests reported. Supplementary Files SupplementsLymeBMC.docx Cite Share Download PDF Status: Published Journal Publication published 03 Jan, 2026 Read the published version in BMC Infectious Diseases → Version 1 posted Editorial decision: Revision requested 25 Sep, 2025 Editor assigned by journal 22 Sep, 2025 Submission checks completed at journal 22 Sep, 2025 First submitted to journal 18 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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1","display":"","copyAsset":false,"role":"figure","size":333305,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA/B.\u003c/strong\u003e Peripheral Blood Smear; poikilocytosis in the erythrocytic series, acanthocytes (4%), schistocytes (2%)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7647104/v1/4c9e0d9b8f31e90f30fd22e4.png"},{"id":99545473,"identity":"07d09408-4a4b-4138-ad28-c1fcce2223cf","added_by":"auto","created_at":"2026-01-05 16:08:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":981952,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7647104/v1/198afd44-573f-4534-af1c-b5ceaa5400ea.pdf"},{"id":92144142,"identity":"8b8fdfd9-0728-4cfe-81b1-7b99c5242fae","added_by":"auto","created_at":"2025-09-25 06:39:50","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":15141,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementsLymeBMC.docx","url":"https://assets-eu.researchsquare.com/files/rs-7647104/v1/5c01cece372b9c1a972a8022.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eLyme Disease as a Rare Trigger for Autoimmune Hemolytic Anemia\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLyme disease, a zoonotic infectious disease caused by spirochetes called Borrelia burgdorferi (Bb). Diagnosis is based on history, symptoms and a two-step serologic test [1][2]. Positive immune serology is confirmed by Western Blot. Lyme disease (LD) usually presents initially with an erythematous rash known as erythema migrans (EM). Subsequently, about 4\u0026ndash;8% of patients may experience cardiac involvement, 11% develop neurological manifestations, and 45\u0026ndash;60% present with arthritis [2] LD is classified as stage 1 (early localized), stage 2 (early disseminated) and stage 3 (late persistent). Although antibiotics are used in treatment, most patients progress to the chronic stage [1][2]. Borrelia burgdorferi sensu lato (Bb), the most common tick-borne infection, has a global distribution. Seroprevalence rates are notably high, particularly in Central Europe, Western Europe, and Eastern Asia [3]. Although it frequently affects other systems, data on the haematological involvement spectrum of Lyme disease appears to be limited to case reports, and there are few studies that clearly demonstrate its relationship with haemolytic anaemia. This case report presents Lyme disease presenting with autoimmune haemolytic anaemia, and thrombocytopenia, which differs from the classic clinical manifestation.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eA 47-year-old woman with a known diagnosis of alcoholic liver cirrhosis (Child-Pugh B, MELD 9) was admitted to the emergency department with complaints of swelling in the left leg, pain in the calf region and jaundice which had been present for 1 month and gradually worsening.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the assessment carried out during the emergency admission, deep vein thrombosis was detected on venous doppler ultrasound of the left lower extremity and laboratory tests revealed \u0026nbsp;Hemoglobin (Hb) \u0026nbsp;4. 2 g/dl, hemotocrit \u0026nbsp;13.6% , white blood cell (WBC) \u0026nbsp;30.85 x 10^9 /L (neutrophil: 24.39 x 10^9 /L, lymphocyte: 3.94 x 10^9 /L, platelet: 110 x 10^9 /L, c-reactive protein: 28 mg/L and d-dimer: 13105 ng/ml, total bilirubin: 5.90 U/l, indirect bilirubin: 3.77 U/l, LDH: 465 U/l, \u0026nbsp;international normalized ratio (INR): 2.01, fibrinogen 1.66 g/L, urea \u0026nbsp;60 mg/dl, creatinine \u0026nbsp;2.30 mg/dl (basal creatinine: 0.70 mg/dl) and disseminated intravascular coagulation (DIC) was not considered due to the observation of rare schistocytes in the peripheral smear, which was examined with a prediagnosis of DIC. She was admitted to the general internal medicine service to deterimine the etiology of thrombophilia, acute renal injury and anemia. \u0026nbsp;Investigations into the aetiology of the patient\u0026apos;s thrombosis ruled out antiphospholipid syndrome, thrombotic thrombocytopenic purpura, paroxysmal nocturnal haemoglobinuria, and hereditary thrombophilia (Supplement 1). The patient was assessed as hypovolaemic on admission and, due to their response to intravenous isotonic saline, her current acute kidneyl injury was assessed as prerenal.\u003c/p\u003e\n\u003cp\u003eIn tests sent to determine the aetiology of anaemia in a patient requiring transfusion due to severe anaemia, haptoglobulin \u0026lt;0.058 g/dl, absolute reticulocyte count 2 x103/ml, reticulocyte index 0.80, direct coombs immunoglobulin G (ıg G) pozitive and Cd3 negative, indirect coombs negative, nutritional parameters \u0026nbsp; were normal. In the peripheral smear, poikilocytosis in the erythrocytic series, acanthocytes (4%), schistocytes (2%, 1 schistocytes were seen in 3 out of 10 fields.), platelet count compatible with 100-130 x 10^9 /L and no atypical features were observed in other cell series (Figure 1A and 1B, Table 1 and Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eHematologic surveillance.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"96%\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eAt Administration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eDay. 0 steroid treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e15 th day of steroid treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e3 rd week of dual antibiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eAt Discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003eRBC count, million cells/mm3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e1,09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e1,86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e2,36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e2.57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003eHemoglobin, g/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e6.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e9.230\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003eHematocrit,%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e13.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e19.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e26.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e30.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e29.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003ePlatelet count, x 10^9 /L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e132\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e129\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e174\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003eWBC count, cells/mm3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e30,85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e27,63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e22,25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e11.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e10.79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003eSegments,%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e79.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e78.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e17.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e67.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e61.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003eLymphocytes,%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e3.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e10.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e22.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e21.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003eEosinophils,%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003eBasophils,%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003emonocytes%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e8.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003eMCV fL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e124.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e103.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e111.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e120.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e114\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003eMCH pg/cell\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e28.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e37.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e36.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e35.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003ehaptoglobulin, g/dl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026lt;0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026lt;0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026lt;0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003eabsolute Reticulocyte count x103/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003ereticulocyte index\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e2.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e3.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003eDirect coombs IgG/C3d\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e+/-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e-/-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e-/-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003eIndirect coombs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003eserum iron, mcg/dl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003eTS,%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003eTIBC, mcg/dl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e181\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003eferritin, ng/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e977\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e1312\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e487\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003evitamine B12, pg/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e1311\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e1077\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003efolic asit, ng/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e5.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 107px;\"\u003e\n \u003cp\u003e7.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: RBC: red blood cell, WBC: white blood cell, MCV: mean corpuscular volume, MCH: mean corpuscular hemoglobin, NA: non-avaliable, +: positive test result, -: negative test result, IgG: Immunoglobulin G, TS: transferrin\u0026nbsp;saturation, TIBC: total iron binding capacity\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eBroad biochemistric surveillance.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"98%\" class=\"fr-table-selection-hover\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eAt Administration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eDay. 0 steroid treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e15 th day of steroid treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eAt Discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eUrea nitrogen, mg/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eCreatinine, mg/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eSodium, mmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e136\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003ePotassium, mmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eCalcium, mg/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e7.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e8.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e8.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eMagnesium, mg/dl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e1.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eBlood glucose, mg/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e104\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eTotal protein, g/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e80.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e68.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e75.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e63.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eAlbumin, g/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e32.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e30.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e34.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e31.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eTotal bilirubin, mg/dl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e14.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e12.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e4.43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eIndirect bilirubin, mg/dl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e3.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e10.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e9.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eAST, IU/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eLDH, U/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e465\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e737\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e751\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e390\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eALT, IU/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eGGT, IU/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e290\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e189\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e131\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eALP, IU/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e136\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e102\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eINR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e2.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e2.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e1.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eTG, mg/dl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eLDL, mg/dl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eTotal kolestrol,/mg/dl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e202\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAbbreviations: AST: Aspartate aminotransferase, LDH: Lactate dehydrogenase, ALT: Alanine aminotransferase, GGT: Gamma-glutamyltransferase, ALP: Alkaline phosphatase, INR International normalized ratio, TG: iglyceride, LDL: Low- Density Lipoprotein, NA: non-avaliable\u003c/p\u003e\n\u003cp\u003eIt was evaluated as autoimmune hemolytic anemia in the foreground due to the accompanying elevated lactate dehydrogenase, direct coombs positivity and low haptoglobulin. \u0026nbsp;In this case of secondary alcoholic liver cirrhosis presenting with acute haemolysis, Zieve syndrome was not considered due to normotriglyceridaemia and direct Coombs IgG positivity in the investigations performed. In a patient with 3% acanthocytes/Spurr cells in the peripheral smear, Spurr cell anaemia was also not considered due to direct Coombs positivity. Therefore, autoimmune hemolytic anemia was considered and prednisone 40 mg/day was started on the 10th day of admission.\u003c/p\u003e\n\u003cp\u003eDuring the clinical follow-up, the patient\u0026apos;s laboratory tests showed a decrease in platelet count to 30 x 10^9 /L, a newly developed drop foot in the left lower extremity and nocturnal neuropathic pain in the same extremity. \u0026nbsp;In the patient\u0026apos;s existing condition, small vessel vasculitis and autoimmune pathologies were included in our differential diagnosis, but we ruled them out with the immunoserological evaluation performed (Supplement 1). In a case being monitored with cortisone treatment due to autoimmune haemolytic anaemia, the patient\u0026apos;s recent travel history to Switzerland led us to consider Lyme disease in our differential diagnosis, despite the absence of typical lesions and known tick exposure, due to the development of new neuropathic pain worsening at night and worsening thrombocytopenia. Therefore, Borrelia burgdorferi immunoblot IgG and IgM tests were performed (Supplement 2). Immunoblot B. burgdorferi Ig M was positive and a confirmation test with Western Blot (WB) was performed and WB Ig M was positive. The patient was accepted as Early Disseminated Lyme Diease and ceftriaxone was started. Doxycycline was added to the treatment upon clinical response in the second week of treatment. Under dual antibiotic treatment, platelet count increased to 176x 10^9 /L and neuropathic pain decreased but the drop foot finding persisted during clinical follow up settings. It was observed that the low foot clinic improved in the 3rd month after discharge. The patient who received prednisone 1 mg/kg for autoimmune hemolytic anemia did not need erythrocyte suspension replacement in the 2nd week of steroid treatment and hemoglobin level increased to 8.9 g/dl. In the patient whose Lyme treatment was completed and steroid was titrated and discontinued during follow-up, hemoglobin reached 10 g/dl.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eLyme disease is a tick-borne infection with multi-organ involvement, especially the skin, nervous system, musculoskeletal system and heart [1][2]. Borrelia burgdorferi sensu lato (Bb) infection, the most frequent tick-transmitted disease, is distributed worldwide. Autoimmune hemolytic anemia (AIHA) is a disease characterized by the breakdown of erythrocytes and anemia as a result of the patient producing antibodies against their own erythrocytes. This condition, which is idiopathic in most patients, can be secondary to some autoimmune, infectious diseases and hematologic/nonhematologic malignancies [4][5]. However, although data on lyme-associated hematologic involvement are scarce, other possible etiologic causes were excluded by diagnostic workup in this case (Supplement 1).\u003c/p\u003e\n\u003cp\u003eThere are no studies that clearly demonstrate the relationship between Lyme disease and secondary anemia. Hemolytic anemia is not included in the classical picture of Lyme disease, and in the literature review, there are studies demonstrating Lyme-related anemia and thrombocytopenia in animal and human models [6][7] . However, \u0026nbsp;there are case report studies showing that hemolytic anemia develops in the presence of co-infection with babesseos [8][9]. \u0026nbsp;In our case, a thin peripheral smear was performed to rule out concurrent infection, and babesiosis was found to be negative for concurrent infection. \u0026nbsp;The thrombocytopenia observed in this case may be a component of cirrhosis, as well as Lyme-associated thrombocytopenia, as seen in the case study reported in the literature [6]. In the same report of 6 cases of lyme-associated thrombocytopenia, it is emphasized that improvement in platelets was more pronounced in patients given doxycycline (doxycycline in 2 cases, prednisone in 1 case, ceftriaxone in 3 cases) compared to other treatment options [6]. In our case, we added doxycycline to the treatment in the second week of ceftriaxone, and similarly to the previous study, the platelet count rose from 30 x 10^9/L to 176 x 10^9/L.\u003c/p\u003e\n\u003cp\u003ePrevious studies have shown that Lyme borreliosis (Lb) increases autoimmunity, and this may explain Lyme-associated anaemia/thrombocytopenia. \u0026nbsp;Several case reports have described the association between LB and the development of autoimmune diseases such as systemic lupus erythematosus, dermatomyositis, scleroderma and Guillain-Barre syndrome [10][11][12][13]. Although the exact mechanism underlying cytopenias secondary to Lyme disease in human models remains unclear, several processes\u0026mdash;such as molecular mimicry, epitope spreading, bystander activation, original antigenic sin, polyclonal activation of B and T cells, and apoptosis of antigen-presenting cells\u0026mdash;have been implicated in the development of autoimmunity[14][15] . Furthermore, some studies highlight the role of T regulatory (Treg) cells, Th17 immune responses, and IL-23 levels in the pathogenesis of post-treatment Lyme disease [16] . Findings from the literature support that lyme-associated increased autoimmunity may play a role in the development of autoimmune hemolytic anemia.\u003c/p\u003e\n\u003cp\u003eAs a conclusion, although studies have been conducted showing the association between thrombocytopenia, chronic disease anemia, and Lyme disease, it is difficult to demonstrate this correlation, particularly with regard to autoimmune hemolytic anemia. As demonstrated in our multidisciplinary case, we believe that Lyme disease should be considered in the differential diagnosis of autoimmune hemolytic anemia, even if it is rare, when there is a suspicious history.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"98%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eADAMSTS-13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eA Disintegrin and Metalloproteinase with a Thrombospondin Type 1 Motif, Member 13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eAFAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eAntiphospholipid Antibody Syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eAIHA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eAutoimmune Hemolytic Anemia\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eAKI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eAcute Kidney Injury\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eANA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eAntinuclear Antibody\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eANCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eAnti-neutrophil Cytoplasmic Antibody\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eanti-DsDNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eAnti-Double Stranded DNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eDIC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eDisseminated Intravascular Coagulation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eDVT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eDeep Ven Trombosis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ehb\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eHemoglobin\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eIg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eImmunoglobulin\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eLDH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eLactate Dehydrogenase\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eMELD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eModel for End-Stage Liver Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eMTHFR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eMethylenetetrahydrofolate reductase\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ePNH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eParoxysmal Nocturnal Hemoglobinuria\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eSLE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eSystemic Lupus Erythematosus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eTTP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 218px;\"\u003e\n \u003cp\u003eThrombotic Thrombocytopenic Purpura\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics and Informed Consent:\u003c/strong\u003e Written informed consent was obtained from patient for the publication of this case.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003eInterpretation: All; Literature search: All; Writing: All; Approval: All.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial support and sponsorship:\u003c/strong\u003e None.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e Concept: All; Design: All; Data collection or processing: All; Analysis or Interpretation: All; Literature search: All; Writing: All; Approval: All.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments and Conflicts of Interest:\u003c/strong\u003e The authors declare no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBiesiada G, Czepiel J, Leśniak MR, Garlicki A, Mach T. Lyme disease: review. Arch Med Sci. 2012 Dec 20; 8(6): 978-82.\u0026nbsp;https://doi.org/10.5114/aoms.2012.30948. Epub 2012 Oct 8.\u003c/li\u003e\n \u003cli\u003eBorchers AT, Keen CL, Huntley AC, Gershwin ME. Lyme disease: a rigorous review of diagnostic criteria and treatment. J Autoimmun. 2015 Feb; 57: 82-115.\u0026nbsp;https://doi.org/10.1016/j.jaut.2014.09.004 Epub 2014 Oct 16.\u003c/li\u003e\n \u003cli\u003eDong Y, Zhou G, Cao W, Xu X, Zhang Y, Ji Z, Yang J, Chen J, Liu M, Fan Y, Kong J, Wen S, Li B, Yue P, Liu A, Bao F. Global seroprevalence and sociodemographic characteristics of Borrelia burgdorferi sensu lato in human populations: a systematic review and meta-analysis. BMJ Glob Health. 2022 Jun; 7(6): e007744.\u0026nbsp;https://doi.org/10.1136/bmjgh-2021-007744.\u003c/li\u003e\n \u003cli\u003eMichel, M., Crickx, E., Fattizzo, B. et al. Autoimmune haemolytic anaemias. Nat Rev Dis Primers 10, 82 (2024). https://doi.org/10.1038/s41572-024-00566-2\u003c/li\u003e\n \u003cli\u003eMichalak SS, Olewicz-Gawlik A, Rupa-Matysek J, Wolny-Rokicka E, Nowakowska E, Gil L. Autoimmune hemolytic anemia: current knowledge and perspectives. Immun Ageing. 2020 Nov 20; 17(1): 38.\u0026nbsp;https://doi.org/10.1186/s12979-020-00208-7.\u003c/li\u003e\n \u003cli\u003eBallard HS, Bottino G, Bottino J. The association of thrombocytopaenia and Lyme disease. Postgrad Med J. 1994 Apr; 70(822): 285-7.\u0026nbsp;https://doi.org/10.1136/pgmj.70.822.285.\u003c/li\u003e\n \u003cli\u003eAthanasiou LV, Spanou VM, Katsogiannou EG, Katsoulos PD. Hematological Features in Sheep with IgG and IgM Antibodies against Borrelia burgdorferi sensu lato. Pathogens. 2021 Feb 4; 10(2): 164.\u0026nbsp;https://doi.org/10.3390/pathogens10020164.\u003c/li\u003e\n \u003cli\u003eKumar M, Sharma A, Grover P. Triple Tick Attack. Cureus. 2019 Feb 13; 11(2): e4064.\u0026nbsp;https://doi.org/10.7759/cureus.4064.\u003c/li\u003e\n \u003cli\u003eTole MC, Perez MV, Mekonen YF, Bermudez M, Salazar H. Cohabitating in the City: A Case of Hemolytic Anemia in a Patient Coinfected With Babesiosis, Lyme Disease, and Mononucleosis. Cureus. 2025 Apr 26; 17(4): e83043.\u0026nbsp;https://doi.org/10.7759/cureus.83043.\u003c/li\u003e\n \u003cli\u003eYehudina Y, Trypilka S. Lyme Borreliosis as a Trigger for Autoimmune Disease. Cureus. 2021 Oct 10; 13(10): e18648.\u0026nbsp;https://doi.org/10.7759/cureus.18648.\u003c/li\u003e\n \u003cli\u003eNovitch M, Wahab A, Kakarala R, Mukerji R. The Emergence of a Forgotten Entity: Dermatomyositis-like Presentation of Lyme Disease in Rural Wisconsin. Cureus. 2018 May 10; 10(5): e2608.\u0026nbsp;https://doi.org/10.7759/cureus.2608.\u003c/li\u003e\n \u003cli\u003eWackernagel A, Bergmann AR, Aberer E. Acute exacerbation of systemic scleroderma in Borrelia burgdorferi infection. J Eur Acad Dermatol Venereol. 2005 Jan; 19(1): 93-6.\u0026nbsp;https://doi.org/10.1111/j.1468-3083.2004.01074.x\u003c/li\u003e\n \u003cli\u003ePatel K, Shah S, Subedi D. Clinical association: Lyme disease and Guillain-Barre syndrome. Am J Emerg Med. 2017 Oct; 35(10): 1583.e1-1583.e2.\u0026nbsp;https://doi.org/10.1016/j.ajem.2017.07.030. Epub 2017 Jul 8.\u003c/li\u003e\n \u003cli\u003eSnik ME, Stouthamer NEIM, Hovius JW, van Gool MMJ. Bridging the gap: Insights in the immunopathology of Lyme borreliosis. Eur J Immunol. 2024 Dec; 54(12): e2451063.\u0026nbsp;https://doi.org/10.1002/eji.202451063. Epub 2024 Oct 13.\u003c/li\u003e\n \u003cli\u003eRodr\u0026iacute;guez Y, Rojas M, Gershwin ME, Anaya JM. Tick-borne diseases and autoimmunity: A comprehensive review. J Autoimmun. 2018 Mar; 88: 21-42.\u0026nbsp;https://doi.org/10.1016/j.jaut.2017.11.007. Epub 2017 Nov 26. PMID: 29183642.\u003c/li\u003e\n \u003cli\u003eAdkison H, Embers ME. Lyme disease and the pursuit of a clinical cure. Front Med (Lausanne). 2023 May 24; 101183344. https://doi.org/10.3389/fmed.2023.1183344.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Lyme Disease, Borrelia, Autoimmune Hemolytic Anemia","lastPublishedDoi":"10.21203/rs.3.rs-7647104/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7647104/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003eIntroduction\u003c/em\u003e: Lyme disease, caused by Borrelia burgdorferi, is a zoonotic infection affecting the skin, nervous system, joints, and heart. Diagnosis relies on clinical history, symptoms, and a two steps serologic test confirmed by Western Blot. While typically treated with antibiotics, some cases progress to chronic stages. Although it frequently affects other systems, data on the haematological involvement spectrum of Lyme disease appears to be limited to case reports, and there are few studies that clearly demonstrate its relationship with haemolytic anaemia. This case highlights Lyme disease presenting with autoimmune hemolytic anemia (AIHA) and thrombocytopenia.\u003c/p\u003e\u003cp\u003e\u003cem\u003eCase\u003c/em\u003e: A 47-year-old woman with alcoholic cirrhosis (Child-Pugh B, Model for End-Stage Liver Disease (MELD) 9) presented with leg swelling, jaundice, and deep vein thrombosis. Laboratory evaluation showed severe anemia, thrombocytopenia, elevated lactate dehydrogenase (LDH), indirect hyperbilirubinemia, and acute kidney injury. Differential diagnoses, including disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, paroxysmal nocturnal hemoglobinuria, and spur cell anemia, were excluded. Coombs-positive hemolysis with low haptoglobin and normal nutritional markers confirmed autoimmune hemolytic anemia (AIHA). Despite prednisone therapy, thrombocytopenia worsened and neuropathic symptoms developed. Given recent European travel, Lyme disease was suspected and confirmed by Borrelia burgdorferi IgM and Western Blot. Following ceftriaxone and doxycycline, hemoglobin improved without transfusion, platelets normalized, and neuropathic symptoms regressed, highlighting Lyme disease as a rare cause of AIHA.\u003c/p\u003e\u003cp\u003e\u003cem\u003eConclusion\u003c/em\u003e: Lyme disease, though uncommon, may present with autoimmune hemolytic anemia, emphasizing the need to consider this rare association in differential diagnosis when clinical suspicion arises.\u003c/p\u003e","manuscriptTitle":"Lyme Disease as a Rare Trigger for Autoimmune Hemolytic Anemia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-25 06:39:45","doi":"10.21203/rs.3.rs-7647104/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-25T08:59:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-22T08:11:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-22T08:11:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2025-09-18T08:19:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1a6d9b0a-85e7-4908-9a02-ec2da7af832a","owner":[],"postedDate":"September 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-05T16:05:07+00:00","versionOfRecord":{"articleIdentity":"rs-7647104","link":"https://doi.org/10.1186/s12879-025-12486-x","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2026-01-03 15:57:44","publishedOnDateReadable":"January 3rd, 2026"},"versionCreatedAt":"2025-09-25 06:39:45","video":"","vorDoi":"10.1186/s12879-025-12486-x","vorDoiUrl":"https://doi.org/10.1186/s12879-025-12486-x","workflowStages":[]},"version":"v1","identity":"rs-7647104","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7647104","identity":"rs-7647104","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}