Ceftriaxone-induced hemolytic anemia with severe renal failure: a case report and review of literature

Abstract

BackgroundDrug induced immune hemolytic anemia (DIIHA) is a rare complication and often underdiagnosed. DIIHA is frequently associated with a bad outcome, including organ failure and even death. For the last decades, ceftriaxone has been one of the most common drugs causing DIIHA, and ceftriaxone-induced immune hemolytic anemia (IHA) has especially been reported to cause severe complications and fatal outcomes.Case presentationA 76-year-old male patient was treated with ceftriaxone for cholangitis. Short time after antibiotic exposure the patient was referred to intensive care unit due to cardiopulmonary instability. Hemolysis was observed on laboratory testing and the patient developed severe renal failure with a need for hemodialysis for 2 weeks. Medical history revealed that the patient had been previously exposed to ceftriaxone less than 3 weeks before with subsequent hemolytic reaction. Further causes for hemolytic anemia were excluded and drug-induced immune hemolytic (DIIHA) anemia to ceftriaxone could be confirmed.ConclusionsThe case demonstrates the severity of ceftriaxone-induced immune hemolytic anemia, a rare, but immediately life-threatening condition of a frequently used antibiotic in clinical practice. Early and correct diagnosis of DIIHA is crucial, as immediate withdrawal of the causative drug is essential for the patient prognosis. Thus, awareness for this complication must be raised among treating physicians.

Ceftriaxone: clinical review, consumption in Portugal and safety alerts

“…(4,6,9,(22)(23)(24)(25)(26)(27)(28)(29) Esta cefalosporina distribui-se no: líquido sinovial (média de 14 mg/L após 1 g IV às 24 horas) e peritoneal (média de 15,3 a 20,1 mcg/ml após 1 g IM às 12 horas), saliva e muco do trato respiratório (média de 1,54 a 2,16 mcg/ml após 1 g IM/dia durante 7 dias), tecido brônquico (média 11,2 ± 7,9 mcg/ml após 1 g IV às 12 horas), humor aquoso (média 2,47 mcg/ml após 2 g IV às 2 horas), fluido cerebrospinal (média 20 mcg/ml após 100 mg/kg às 2 horas), tecido hepático (média 130 mg/kg após 1 g IV às 12 horas), pulmonar e brônquico inflamado (média 31,8 mcg/ml após 2 g IV às 1 a 2 horas), ouvido médio (média 35 mcg/ml após 50 mg/ kg às 24,3 horas), placenta (média 19,6 a 40,6 mcg/ml) e glândula prostática (média 1 a 50 mcg/ml após 2 g IV às 4 horas). (4,6,9,11,16,(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39) Volume de Distribuição O volume de distribuição (Vd) é dose dependente e varia entre 5,78 e 13,5 L. (4) Foram observados os seguintes volumes de distribuição da ceftriaxona: 6,40-9,73 L (500 mg IV), 7,21-10,58 L (1 g IV), e 8,87-11,85 L (2 g IV). Nos doentes críticos, os parâmetros farmacocinéticos da ceftriaxona encontram-se alterados, pelo que se recomenda a monitorização da concentração sérica do antibiótico.…”

“…dialysis patients), ceftriaxone serum concentrations should be monitored, and dosage adjusted in order to prevent overdose. (5,(30)(31)(32) Patients with hematological or immuno-compromised diseases…”

“…The treatment with ceftriaxone should be stopped, and blood transfusions may be considered in case of unstable hemodynamic conditions. (5,(30)(31)(32) Liver, gallbladder, biliary, or pancreas disease Due the possibility of formation of biliary sediment, the administration of ceftriaxone should be done with caution if patients have had a previous disease in the liver, gallbladder, biliary tract or pancreas. At the start of therapy with ceftriaxone, abdominal ultrasonography or other tests are recommended in case of colicky abdominal pain.…”

“…doentes dialisados) deve--se monitorizar as concentrações séricas de ceftriaxona e ajustar a posologia de forma a impedir situações de sobredosagem. (5,(30)(31)(32) Doentes com doenças hematológicas ou imunocomprometidos Embora existam apenas alguns casos descritos na literatura (<1%), doentes imunocomprometidos e com doenças hematológicas estão sujeitos a um risco acrescido de sensibilização dos eritrócitos com o aparecimento de anemia hemolítica súbita que pode ser letal. Esta sensibilização pode desenvolver-se entre 5 minutos a 34 dias durante o tratamento com a ceftriaxona.…”

“…O tratamento com ceftriaxona deve ser descontinuado, podendo ser consideradas transfusões sanguíneas se a condição hemodinâmica for instável. (5,(30)(31)(32)…”