Case Report: Autoimmune Hemolytic Anemia

Case Report: 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Share Download PDF Case Report Case Report: Autoimmune Hemolytic Anemia Rajvardhan Kapshikar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5696477/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract AIHA, or autoimmune hemolytic anemia, is rare and causes premature destruction of red blood cells associated with anti-erythrocyte antibodies (1). Muscle pain and exhaustion are typical signs of vitamin B12 insufficiency. While performing a complete blood count (CBC) on an automated machine is a standard procedure, smear analysis is more useful in determining the cause of medical disorders and should not be disregarded. According to the result of this study, neutrophils participate in AIHA together with other leucocytes, such as monocytes and eosinophils. If a person is currently receiving vitamin treatment for anemia, the automated CBC alone may be misleading, and blood smear analysis provides a better understanding of AIHA cases. The patient can benefit from multivitamin supplementation; folic acid, ascorbic acid, B12, zinc, and iron supplements should be continued as dietary supplements. Immunology Pathology Hematology hemolysis leucocyte erythrocyte rosette autoimmune hemolytic anemia (AIHA) complete blood count (CBC) Figures Figure 1 Introduction Bone marrow produces RBCs. Old RBCs and abnormal RBCs are destroyed in the liver and spleen by macrophages (2). Hemoglobin and iron are recycled (3,4). When there are no underlying health issues, anemia may be the cause of generalized weakness, headache, lightheadedness, and irregular heartbeat. Vitamin deficiencies, particularly those involving vitamin B12 and folic acid (B9), can result in anemia. Iron deficiency may be the cause. These can be shown on an automated cell counter or under a microscope by staining the blood smear. Parameters such as MCV and MCHC are useful. A mean corpuscular volume (MCV) of less than 80 indicates microcytic anemia, whereas a MCV of more than 90 indicates macrocytic anemia. Iron deficiency can result in microcytic anemia, whereas B12 deficiency can produce macrocytic anemia. Hypochromic anemia is defined as having a mean corpuscular hemoglobin concentration (MCHC) of less than 32 g/dL, whereas hyperchromic anemia is defined as having an MCHC of greater than 36 g/dL. Iron deficiency is the primary cause of hypochromic anemia, whereas other illnesses, such as thalassemia, blood loss, chronic inflammation, and kidney problems, are also linked to microcytic anemia. Sickle cell disease, autoimmune diseases, hereditary spherocytosis, and other disorders can all result in hyperchromic anemia. With the aid of complement protein and immunoglobin, normal red blood cells can, nevertheless, cling to neutrophils in some circumstances, such as autoimmune hemolytic anemia, and then be destroyed by the blood flow itself (5–7). It generates a reaction, elicits a response, and heptoglobins are synthesized. Heptoglobins bind to free hemoglobin and prevent oxidative toxicity. Eosinophils and monocytes may bind to RBCs, but many studies are not available (8,9). Primary hemolytic anemia is less common, whereas secondary hemolytic anemia is associated with other diseases or disorders, viz. SLE (systemic lupus erythematosus), CLL (chronic lymphocytic anemia), colitis, certain infections, such as Epstein bar virus (EBV), and certain drugs, such as fludarabine, are used in CLL treatment (1). Case Report Clinical vignette A 36-year-old man arrived at the center with chief complaints of muscle pain, lethargy, weakness, headache, and a pricking sensation in his soles. These symptoms persisted for more than a year. He had undergone a vitamin B12 injection course prescribed by his physician one month before visiting our center. However, the symptoms still persisted. He did not have any rashes on his skin or a history of fever during the previous week. The patient did not have jaundice, swelling of the lymph nodes, pharyngitis, hepatomegaly, or splenomegaly. The patient did not have a drug history, excessive alcohol consumption, or unsafe sexual intercourse. In this study, common hematological parameters, such as complete blood cell count (CBC), liver function tests, kidney function tests, sugar level parameters, urinalysis, and serum electrolytes, were considered for investigation at the initial stage. The direct Coombs test was performed. The electrophoretic mobility of hemoglobin was assessed to check for any hemoglobinopathy. Serum heptaglobin was checked for its response to hemolysis. Methods All tests were performed as per standard guidelines. All biochemical assays were performed via standard kits available on the market following the manufacturer’s instructions. Results CBC Report Blood was collected in an EDTA tube. It was done on three parts blood cell counter. It had shown WBCs (8.0x10 9 /L, [4-9x10 9 ]), lymphocytes (2.5 x10 9 /L, [0.6–4.1 x10 9 ]), RBCs (4.36 x10 9 /L, [3.5–5.5 x10 12 ]), Hemoglobin (13.5 g/dL, [12–16]), HCT (40.5%, [36–48]), MCV (88.6 fL, [80–99]), MCH (30.9 pg, [26–32]), MCHC (33.3 g/dL, [32–36]), RDW CV (12.5%, [11.5–14.5]), RDW SD (34.8 fL, [37 − 5 ]), platelets (273x10 9 /L, [150–450 x10 9 ]), MPV (8.1 fL, [7.4–10.4]), PDW (9.3, [10–17]), PCT (0.221%, [0.1–0.28]), P-LCC (49 x10 9 /L, [Not available), and P-LCR (18.1%, [13–43]). Freshly obtained EDTA-Blood Smear was fixed with absolute methanol. It was air dried. Furthermore, the samples were stained with Field Stain-B for three minutes and washed with water, followed by staining with Field Stain-A for three minutes. Microscopically, many cells are normal, and a few cells have less hemoglobin. There were no inclusion bodies in the RBCs. All the leucocytes found attached to RBCs form rosettes, as shown in Fig. 1 . Many cells were normochromic and normocentric, while approximately 10% of the population was hypochromic, and aninsocytosis was observed. The CBC report was cross-analyzed on the other reference laboratory machine. The microscopic results revealed one sickle cell. These sickle cells were not observed elsewhere, nor were boat cells confirmed. Liver function Serum glutamate‒pyruvate transaminase (SGPT 16.09 U/L, [< 45]), serum glutamate‒oxaloacetate transaminase (SGOT 18.26 U/L, [< 45]), total bilirubin (0.55 mg/dL, [0.1‒1.2]), direct bilirubin (0.31 mg/dL, [0.1‒0.3]), total protein (5.4 mg/dL, [6.0‒8.3]), and albumin (4 mg/dL, [3.2‒5]). Kidney function Serum creatinine (1.3 mg/dL, [0.6–1.4]), serum uric acid (4.76 mg/dL, [3.6–7.2]), serum urea (51 mg/dL, [13–45]), serum sodium (128 mmol/L, [135–155]), serum potassium (5.8 mmol/L, [3.5–5.5]), and serum calcium (9.05 mmol/L, [8.8–10.2]). Urine analysis revealed the following: clear pale urine pH (6.0, [6–7.5]) and specific gravity (1.03 g/mL, [1.005–1.030]). Traces of urobilinogen, bilirubin, ketone and nitrate were detected, whereas protein, glucose, red blood cells (RBCs), and white blood cells (WBCs) were not detected via indicator paper strips. Microscopic observation revealed no crystals, pus cells, red blood cells (RBCs), urinary casts, candida cells or a few dead epithelial cells. Other biochemical tests, such as random blood glucose (90 mg/dL, [90–140]), HbA1c (5.61%, [< 5.7]), rheumatoid arthritis factor (3 U/mL, [< 18]), and CRP (2.1 mg/dL, [< 6]), were performed. Discussion In this study, the patient’s liver and kidney functions were normal. The CBC counts were within the normal range. The levels of the inflammatory marker C-reactive protein (CRP) were within this range. The glucose, sodium and potassium concentrations were in this range. The patient showed no signs of rheumatoid arthritis. RBCs are mostly normochromic and normocytic. This may be because vitamin B12 is injected by physicians before patients visit the center. The attachment of more than three RBCs to a leukocyte is considered a rosette (10). RBCs form rosettes with neutrophils called neutrophil–erythrocyte rosettes (NERs). NER has been reported by many researchers in the case of hemolytic anemia (6,11). RBCs form rosettes with monocytes and are called monocyte erythrocyte rosettes (MERs). The MER was reported as early as by Ehrlich 1891 (12) as the rosette of RBCs with eosinophils was called the Eosinophil Erythrocyte Rosette (EER) (9). Eosinophils are primarily secretory cells and are rarely phagocytosed (9). This patient did not have a history of any cancer. This patient did not exhibit any type of leukocytosis. In this study, I demonstrate that RBCs can attach to other leukocytes, although the exact mechanism is not known. Here, the machine-based CBC report was normal, and the blood smear revealed the cause of hemolysis. Currently, many diagnostic laboratories provide only machine-based reports. In chronic cases or other medical conditions, smear studies are much more informative. When the patient continued with vitamin supplements B12-15 mcg, ferrous fumarate was 300 mg, folic acid was 4.5 mg, zinc sulfate was 40 mg, and vitamin C was 25 mg for one month. He had shown considerable relief from symptoms. The patient’s counseling was provided. He was made aware of the nutritional requirements needed in such a condition (2,13). In combination with other medicines, it may be helpful for treating other autoimmune hemolytic conditions and underlying conditions. Declarations Source of Financial Support All the test costs were financially supported by the patient and the Orange Diagnostics Clinics and Research Centre, Kolhapur, Maharashtra, India. No external funding was obtained. Conflict of interest The author reports no conflicts of interest in this work. Acknowledgments Thank you to the Orange Diagnostics Clinics and Research Centre, Kolhapur, for publishing this work. I thank the patient for his kind support. Ethical Consent Consent for publishing the data for the case study was obtained from the patient. This study did not intend for a drug trial. References Go, R. S., Winters, J. L., & Kay, N. E. How I Treat How I treat autoimmune hemolytic anemia. Blood 2017; 129 (22): 2971–2979. https://doi.org/10.1182/blood-2016-11-693689 Mebius, R. E., & Kraal, G. Structure and function of the spleen. Nature Reviews Immunology 2005 5(8), 606–616. https://doi.org/10.1038/nri1669 Back DZ, Kostova EB, van Kraaij M, van den Berg TK, van Bruggen R. Of macrophages and red blood cells; A complex love story. Frontiers in Physiology 2014; Vol. 5 https://doi.org/10.3389/fphys.2014.00009 Thiagarajan, P., Parker, C. J., & Prchal, J. T. How Do Red Blood Cells Die? Frontiers in Physiology 2021; (Vol. 12). https://doi.org/10.3389/fphys.2021.655393 Hershkowitz I, Haran A, Hershko AY. Neutrophil-erythrocyte rosette formation: Case report and proposed mechanism. QJM: An International Journal of Medicine 2023;116(4):303–4. https://doi.org/10.1093/qjmed/hcac238 Schulman S, Awad MM, Kuter DJ. Neutrophil-erythrocyte rosettes in autoimmune hemolytic anemia. American Journal of Hematology. 2013; Vol. 88, p. 333–4. https://doi.org/10.1002/ajh.23277 Yadav G, Rahman K, Gupta R. Neutrophil Erythrocyte Rosettes: An Unusual Manifestation of Autoimmune Hemolytic Anemia. Indian Journal of Hematology and Blood Transfusion 2016; Vol. 32,. https://doi.org/10.1007/s12288-015-0546-x Abramson N, Gelfand EW, Jandl JH, Rosen FS. The interaction between human monocytes and red cells. J Exp Med. 1970;132(6):1207-15. https://doi.org/10.1084/jem.132.6.1207 Kuk, J. S., MacEachern, J. A., Soamboonsrup, P., McFarlane, A., Benger, A., et al., Chronic eosinophilic leukemia presenting with autoimmune hemolytic Anemia and erythrophagocytosis by eosinophils. American Journal of Hematology 2006; 81 (6), 458–461. https://doi.org/10.1002/ajh.20601 Mirchandani I, Palutke M, Kithier K, Tabaczka P, Suffian J. In vitro neutrophil-erythrocyte rosette formation mediated by a serum factor (IgG). American Journal of Hematology 1984;17(1). https://doi.org/10.1002/ajh.2830170110 Cogan JC, Vianna PG, Akpan IJ. Neutrophil-erythrocyte rosettes suggestive of Coombs-negative autoimmune haemolysis. The Lancet Haematology 2022; Vol. 9,. https://doi.org/10.1016/s2352-3026(21)00373-2 Zupanska B. Rosetting, Phagocytosis and immune red cell damage. Clin. lab. Haemat. 1990; Vol 12. https://doi.org/10.1111/j.1365-2257.1990.tb00041.x Lechner, K., and Jager, U. How I treat autoimmune hemolytic anemias in adults. Blood (2010) 116(11), 1831–1838. https://doi.org/10.1182/blood-2010-03-259325 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted 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. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5696477","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":393509167,"identity":"ea303fc9-b719-4758-b19c-b84c42186d8f","order_by":0,"name":"Rajvardhan Kapshikar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEUlEQVRIie3PMUvDQBTA8VcOziV2fiGQfALhlUC0Sz6G85WCt6ToJIEOPSjkO0gGv4JF6HxQsEs/QCAO7eKcSVzUXopIhiY6Ct6fEO7C+/EIgM32B8PvVwHA3j8+/fqst78l4HAWHoj4iUCDjFR96SKuOt1Vwyy+7pfzly06XN5frnZmS+yfqePEg5MQ3Ww8vHt+OidCZ7Ior8iQcRjp48QHDogbRlSICAXhZJGLmujRsp2wN9zMDJGvqAXJQS6rTuIB54jpypAkcpUWIvCS7i3unPMLTNfkFsmt11N68OAlN2Zb+7/gOmMl0pT6hVzWJAhy+VhVaey3EWDmweYHOkxSy/hXvap5C1T3tM1ms/2/9nkyWohVG9WAAAAAAElFTkSuQmCC","orcid":"","institution":"Orange Diagnostics Clinics and Research Centre, Kolhapur, Maharashtra India","correspondingAuthor":true,"prefix":"","firstName":"Rajvardhan","middleName":"","lastName":"Kapshikar","suffix":""}],"badges":[],"createdAt":"2024-12-23 04:45:41","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-5696477/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5696477/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":72278061,"identity":"5e61eb86-5e02-4cf8-bdc6-30235df990e9","added_by":"auto","created_at":"2024-12-24 15:33:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":369141,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eRosette formation of red blood cells (RBCs) with different types of leukocyte erythrocyte rosette (LER): a) monocytes, b) neutrophils and eosinophils, and c) neutrophils (450X magnification and mobile camera and screen shots were cropped and enlarged to show details)\u003c/em\u003e.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5696477/v1/ee895a01a3fe865db3f52df5.png"},{"id":72279131,"identity":"911cbaaf-bf59-42f7-bd26-2f2b37a8bdc1","added_by":"auto","created_at":"2024-12-24 15:41:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":685349,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5696477/v1/060ab5c2-a70f-4dd1-b0e9-7a141a01b67b.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eCase Report: Autoimmune Hemolytic Anemia\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBone marrow produces RBCs. Old RBCs and abnormal RBCs are destroyed in the liver and spleen by macrophages (2). Hemoglobin and iron are recycled (3,4). When there are no underlying health issues, anemia may be the cause of generalized weakness, headache, lightheadedness, and irregular heartbeat. Vitamin deficiencies, particularly those involving vitamin B12 and folic acid (B9), can result in anemia. Iron deficiency may be the cause. These can be shown on an automated cell counter or under a microscope by staining the blood smear. Parameters such as MCV and MCHC are useful. A mean corpuscular volume (MCV) of less than 80 indicates microcytic anemia, whereas a MCV of more than 90 indicates macrocytic anemia. Iron deficiency can result in microcytic anemia, whereas B12 deficiency can produce macrocytic anemia. Hypochromic anemia is defined as having a mean corpuscular hemoglobin concentration (MCHC) of less than 32 g/dL, whereas hyperchromic anemia is defined as having an MCHC of greater than 36 g/dL. Iron deficiency is the primary cause of hypochromic anemia, whereas other illnesses, such as thalassemia, blood loss, chronic inflammation, and kidney problems, are also linked to microcytic anemia. Sickle cell disease, autoimmune diseases, hereditary spherocytosis, and other disorders can all result in hyperchromic anemia. With the aid of complement protein and immunoglobin, normal red blood cells can, nevertheless, cling to neutrophils in some circumstances, such as autoimmune hemolytic anemia, and then be destroyed by the blood flow itself (5\u0026ndash;7). It generates a reaction, elicits a response, and heptoglobins are synthesized. Heptoglobins bind to free hemoglobin and prevent oxidative toxicity. Eosinophils and monocytes may bind to RBCs, but many studies are not available (8,9). Primary hemolytic anemia is less common, whereas secondary hemolytic anemia is associated with other diseases or disorders, viz. SLE (systemic lupus erythematosus), CLL (chronic lymphocytic anemia), colitis, certain infections, such as Epstein bar virus (EBV), and certain drugs, such as fludarabine, are used in CLL treatment (1).\u003c/p\u003e"},{"header":"Case Report","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eClinical vignette\u003c/h2\u003e \u003cp\u003eA 36-year-old man arrived at the center with chief complaints of muscle pain, lethargy, weakness, headache, and a pricking sensation in his soles. These symptoms persisted for more than a year. He had undergone a vitamin B12 injection course prescribed by his physician one month before visiting our center. However, the symptoms still persisted. He did not have any rashes on his skin or a history of fever during the previous week. The patient did not have jaundice, swelling of the lymph nodes, pharyngitis, hepatomegaly, or splenomegaly. The patient did not have a drug history, excessive alcohol consumption, or unsafe sexual intercourse. In this study, common hematological parameters, such as complete blood cell count (CBC), liver function tests, kidney function tests, sugar level parameters, urinalysis, and serum electrolytes, were considered for investigation at the initial stage. The direct Coombs test was performed. The electrophoretic mobility of hemoglobin was assessed to check for any hemoglobinopathy. Serum heptaglobin was checked for its response to hemolysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cp\u003eAll tests were performed as per standard guidelines. All biochemical assays were performed via standard kits available on the market following the manufacturer\u0026rsquo;s instructions.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cstrong\u003eCBC Report\u003c/strong\u003e \u003cp\u003eBlood was collected in an EDTA tube. It was done on three parts blood cell counter. It had shown WBCs (8.0x10\u003csup\u003e9\u003c/sup\u003e/L, [4-9x10\u003csup\u003e9\u003c/sup\u003e]), lymphocytes (2.5 x10\u003csup\u003e9\u003c/sup\u003e/L, [0.6\u0026ndash;4.1 x10\u003csup\u003e9\u003c/sup\u003e]), RBCs (4.36 x10\u003csup\u003e9\u003c/sup\u003e/L, [3.5\u0026ndash;5.5 x10\u003csup\u003e12\u003c/sup\u003e]), Hemoglobin (13.5 g/dL, [12\u0026ndash;16]), HCT (40.5%, [36\u0026ndash;48]), MCV (88.6 fL, [80\u0026ndash;99]), MCH (30.9 pg, [26\u0026ndash;32]), MCHC (33.3 g/dL, [32\u0026ndash;36]), RDW CV (12.5%, [11.5\u0026ndash;14.5]), RDW SD (34.8 fL, [37\u0026thinsp;\u0026minus;\u0026thinsp;5 ]), platelets (273x10\u003csup\u003e9\u003c/sup\u003e/L, [150\u0026ndash;450 x10\u003csup\u003e9\u003c/sup\u003e]), MPV (8.1 fL, [7.4\u0026ndash;10.4]), PDW (9.3, [10\u0026ndash;17]), PCT (0.221%, [0.1\u0026ndash;0.28]), P-LCC (49 x10\u003csup\u003e9\u003c/sup\u003e/L, [Not available), and P-LCR (18.1%, [13\u0026ndash;43]). Freshly obtained EDTA-Blood Smear was fixed with absolute methanol. It was air dried. Furthermore, the samples were stained with Field Stain-B for three minutes and washed with water, followed by staining with Field Stain-A for three minutes. Microscopically, many cells are normal, and a few cells have less hemoglobin. There were no inclusion bodies in the RBCs. All the leucocytes found attached to RBCs form rosettes, as shown in \u003cb\u003eFig.\u0026nbsp;1\u003c/b\u003e. Many cells were normochromic and normocentric, while approximately 10% of the population was hypochromic, and aninsocytosis was observed. The CBC report was cross-analyzed on the other reference laboratory machine. The microscopic results revealed one sickle cell. These sickle cells were not observed elsewhere, nor were boat cells confirmed.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLiver function\u003c/strong\u003e \u003cp\u003eSerum glutamate‒pyruvate transaminase (SGPT 16.09 U/L, [\u0026lt;\u0026thinsp;45]), serum glutamate‒oxaloacetate transaminase (SGOT 18.26 U/L, [\u0026lt;\u0026thinsp;45]), total bilirubin (0.55 mg/dL, [0.1‒1.2]), direct bilirubin (0.31 mg/dL, [0.1‒0.3]), total protein (5.4 mg/dL, [6.0‒8.3]), and albumin (4 mg/dL, [3.2‒5]).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eKidney function\u003c/strong\u003e \u003cp\u003eSerum creatinine (1.3 mg/dL, [0.6\u0026ndash;1.4]), serum uric acid (4.76 mg/dL, [3.6\u0026ndash;7.2]), serum urea (51 mg/dL, [13\u0026ndash;45]), serum sodium (128 mmol/L, [135\u0026ndash;155]), serum potassium (5.8 mmol/L, [3.5\u0026ndash;5.5]), and serum calcium (9.05 mmol/L, [8.8\u0026ndash;10.2]).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eUrine\u003c/b\u003e analysis revealed the following: clear pale urine pH (6.0, [6\u0026ndash;7.5]) and specific gravity (1.03 g/mL, [1.005\u0026ndash;1.030]). Traces of urobilinogen, bilirubin, ketone and nitrate were detected, whereas protein, glucose, red blood cells (RBCs), and white blood cells (WBCs) were not detected via indicator paper strips. Microscopic observation revealed no crystals, pus cells, red blood cells (RBCs), urinary casts, candida cells or a few dead epithelial cells.\u003c/p\u003e \u003cp\u003eOther biochemical tests, such as random blood glucose (90 mg/dL, [90\u0026ndash;140]), HbA1c (5.61%, [\u0026lt;\u0026thinsp;5.7]), rheumatoid arthritis factor (3 U/mL, [\u0026lt;\u0026thinsp;18]), and CRP (2.1 mg/dL, [\u0026lt;\u0026thinsp;6]), were performed.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, the patient\u0026rsquo;s liver and kidney functions were normal. The CBC counts were within the normal range. The levels of the inflammatory marker C-reactive protein (CRP) were within this range. The glucose, sodium and potassium concentrations were in this range. The patient showed no signs of rheumatoid arthritis. RBCs are mostly normochromic and normocytic. This may be because vitamin B12 is injected by physicians before patients visit the center. The attachment of more than three RBCs to a leukocyte is considered a rosette (10). RBCs form rosettes with neutrophils called neutrophil\u0026ndash;erythrocyte rosettes (NERs). NER has been reported by many researchers in the case of hemolytic anemia (6,11). RBCs form rosettes with monocytes and are called monocyte erythrocyte rosettes (MERs). The MER was reported as early as by Ehrlich 1891 (12) as the rosette of RBCs with eosinophils was called the Eosinophil Erythrocyte Rosette (EER) (9). Eosinophils are primarily secretory cells and are rarely phagocytosed (9). This patient did not have a history of any cancer. This patient did not exhibit any type of leukocytosis. In this study, I demonstrate that RBCs can attach to other leukocytes, although the exact mechanism is not known. Here, the machine-based CBC report was normal, and the blood smear revealed the cause of hemolysis. Currently, many diagnostic laboratories provide only machine-based reports. In chronic cases or other medical conditions, smear studies are much more informative. When the patient continued with vitamin supplements B12-15 mcg, ferrous fumarate was 300 mg, folic acid was 4.5 mg, zinc sulfate was 40 mg, and vitamin C was 25 mg for one month. He had shown considerable relief from symptoms. The patient\u0026rsquo;s counseling was provided. He was made aware of the nutritional requirements needed in such a condition (2,13). In combination with other medicines, it may be helpful for treating other autoimmune hemolytic conditions and underlying conditions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eSource of Financial Support\u003c/h2\u003e \u003cp\u003eAll the test costs were financially supported by the patient and the Orange Diagnostics Clinics and Research Centre, Kolhapur, Maharashtra, India. No external funding was obtained.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConflict of interest\u003c/h2\u003e \u003cp\u003eThe author reports no conflicts of interest in this work.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eThank you to the Orange Diagnostics Clinics and Research Centre, Kolhapur, for publishing this work. I thank the patient for his kind support.\u003c/p\u003e\n\u003ch3\u003eEthical Consent\u003c/h3\u003e\n\u003cp\u003eConsent for publishing the data for the case study was obtained from the patient. This study did not intend for a drug trial.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Go, R. S., Winters, J. L., \u0026amp; Kay, N. E. How I Treat How I treat autoimmune hemolytic anemia. \u003cem\u003eBlood\u003c/em\u003e 2017; 129 (22): 2971\u0026ndash;2979. https://doi.org/10.1182/blood-2016-11-693689\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Mebius, R. E., \u0026amp; Kraal, G. Structure and function of the spleen. \u003cem\u003eNature Reviews Immunology 2005 5(8), 606\u0026ndash;616.\u003c/em\u003e https://doi.org/10.1038/nri1669\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Back DZ, Kostova EB, van Kraaij M, van den Berg TK, van Bruggen R. Of macrophages and red blood cells; A complex love story. \u003cem\u003eFrontiers in Physiology\u003c/em\u003e 2014; Vol. 5 https://doi.org/10.3389/fphys.2014.00009\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Thiagarajan, P., Parker, C. 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How I treat autoimmune hemolytic anemias in adults. \u003cem\u003eBlood (2010) 116(11), 1831\u0026ndash;1838.\u003c/em\u003e https://doi.org/10.1182/blood-2010-03-259325\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Orange Diagnostics Clinics and Research Centre, Near Rankala Stand, Kolhapur, Maharashtra India 416012","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"hemolysis, leucocyte erythrocyte rosette, autoimmune hemolytic anemia (AIHA), complete blood count (CBC)","lastPublishedDoi":"10.21203/rs.3.rs-5696477/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5696477/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAIHA, or autoimmune hemolytic anemia, is rare and causes premature destruction of red blood cells associated with anti-erythrocyte antibodies (1). Muscle pain and exhaustion are typical signs of vitamin B12 insufficiency. While performing a complete blood count (CBC) on an automated machine is a standard procedure, smear analysis is more useful in determining the cause of medical disorders and should not be disregarded. According to the result of this study, neutrophils participate in AIHA together with other leucocytes, such as monocytes and eosinophils. If a person is currently receiving vitamin treatment for anemia, the automated CBC alone may be misleading, and blood smear analysis provides a better understanding of AIHA cases. The patient can benefit from multivitamin supplementation; folic acid, ascorbic acid, B12, zinc, and iron supplements should be continued as dietary supplements.\u003c/p\u003e","manuscriptTitle":"Case Report: Autoimmune Hemolytic Anemia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-24 15:33:44","doi":"10.21203/rs.3.rs-5696477/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7003836d-cab1-4b8c-ac2b-864952460ce3","owner":[],"postedDate":"December 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":41943258,"name":"Immunology"},{"id":41943259,"name":"Pathology"},{"id":41943260,"name":"Hematology"}],"tags":[],"updatedAt":"2024-12-24T15:33:44+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-24 15:33:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5696477","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5696477","identity":"rs-5696477","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}