Rapidly Fatal Adult Case of Ceftriaxone-Induced Immune Hemolytic Anemia

Document Type

Conference Proceeding

Publication Date

9-2025

Publication Title

Transfusion

Abstract

Background/Case Studies: A 78-year-old female was admitted through the ED (April 2025) for suspected hemorrhagic versus septic shock. Over the past 2 years, she had four prior admissions for urinary tract infections, diabetic ulcers with osteomyelitis and infected prosthetic joints, which were treated with ceftriaxone 1-2g IV. Last prior treatment was in Dec 2024 (2g IV x1 dose, 1g IV x3doses). On this admission, she had similar mixed infections and chronic anemia (Hgb 11.9 g/dL and type and screen and urinalysis were unremarkable). Two hours after admission she was given 2g ceftriaxone IV. Shortly thereafter, she became hemodynamically unstable and received IV fluids and 4 units of uncrossmatched blood. At 2.5 h after admission (30 min after ceftriaxone), her Hgb dropped to 7.0 g/dL (partially hemodilution). Subsequent specimens collected at 2.5-, 4-, 6-, and 7-h post-admission showed progressively increasing hemolysis and were panreactive in solid phase screens, panels and autocontrols. No specificity was identified in PEG or LISS panels. DAT polyspecific (poly) was positive. Eluate without drug on the 4.5-hour post-drug specimen (red cells only) was negative. At 7.5 h after admission a transfusion reaction was called on the 4 uncrossmatched RBC units. Transfusion reaction plasma was brown with positive type and screen and panel, DAT was 2+ poly AHG (3+anti-IgG and negative anti-C3) and eluate was negative. On the final sample, the LDH was >1800 U/L and patient's red cells began gelling and hemolyzing in the EDTA collection tube. She developed DIC, secondary to hemolysis, with D-Dimers >35,000 ng/ml, fibrin split products >20 mcg/ml, and undetectable fibrinogen. Patient died approximately 8 h after receiving ceftriaxone.

Study Design/Methods: Antibody screens and panels were performed using solid phase testing methods (Werfen, Barcelona Spain). DATs were performed in tube. Acid eluates (Werfen) were prepared and tested using IAT. Titrations were performed using standard serial dilution with normal saline and tested in tubes. Drug testing was performed in tube according to Judd's Methods in Immunohematology, 4th ed. 2022.

Results/Findings: Additional DATs, elution and ceftriaxone drug study results are in Table 1. Drug studies performed in the presence of ceftriaxone (1 mg/mL) was positive in all samples after administration of drug.

Conclusions: This is the first rapidly fatal case of aceftriaxone-induced immune hemolytic anemia in an adult.

Volume

65

Issue

Suppl 2

First Page

19A

Comments

Annual Meeting of the Association for the Advancement of Blood and Biotherapies (AABB) Oct 25-28, 2025 San Diego, CA

Last Page

20A

DOI

10.1111/trf.18417Digital Object Identifier (DOI)

ISSN

0041-1132

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