A 84 years old lady was unwell for a week and upon contact with the health services she was found to have a hemoglobin of 3.6 g%.  To the left is her blood picture.

She started having mild lethargy and fever over that one week.  There was no dark urine.  She was not aware of turning yellow.  She had mild cough but no shortness of breadth.  

On examination, she appeared pale and had tinge of jaundice.  Her hemodynamics was normal.   Temperature was 37.6C.  There was gallop rhythm and flow murmur, Grade 2 ESM over the aortic area.  She had coarse crepitations over the left lower zone otherwise there was no other signs of consolidation.  There was no hepatosplenomegaly, neither was there any palpable lymphadenopathy. 

There was consolidative changes over the left lower zones .  Her 12-lead ECG showed normal sinus rhythm.

Her blood counts were as follow.

Hb 3.6g%, MCV 110 fL, MCH 100, TWBC 18.1 x 10⁹/L and Platelet 324 x 10⁹/L.

Figure 1.  The following photomicrograph showed her peripheral blood smear.  Notice that her red blood cells were clumped together. We were not able to assess the morphology of individual red cell.

Figure 2.  There was relative neutrophilia with left shift.  Majority of the neutrophil show toxic granulation and vacuolation as shown below.  

Figure 3.  When her slides were prepared at 37^oC, we can grossly notice the difference in the degree of clumping on each slides.  The lower slide were warmth.

Figure 4.  When the warmth slide was observed under x400, noticed that the degree of clumping has remarkably reduced.  Compare this photomicrograph with figure 1.  The morphology of individual red cells can be clearly visualized and we can see a lot of spherocytes which has lost its central pallor and numerous polychromatic cells (red cells whose cytoplasm appeared bluish) indirectly indicating reticulocytosis.

Figure 5:  In fact the clumping can even be observed on the wall of the specimen tube as shown below.  If it is immersed in ice water (say for a minute) the clumping will become more pronounced.  

Her direct antiglobulin test (DAT) was positive with strong reaction 3+ for C3d and 1+ for IgG.  Her DAT for IgM was negative.  Her indirect antiglobulin test was negative.

Liver function test: TP 60, Alb 33 g/L, Glob 27 g/L, AST 34, ALT 27 IU/L, ALP 102 IU/L, Total Bili 65 μmol/L (D 25 ID 40)

Renal function test: BUN 7.1, Na 141, K 4.3 mmol/L, Creat 101 μmol/L, Ca 2.10 mmol/L

Lactate Dehydrogenase: 718 IU/L

Urine for hemoglobin was negative.

Mycoplasma serology was negative

Student asked:

Is this patient having cold AIHA?