Drug-induced hemolysis: Cefotetan-dependent hemolytic anemia mimicking an acute intravascular immune transfusion reaction

Numerous cases of drug-induced hemolytic anemia have been described in pati ents treated with penicillin or cephalosporin. Second and third generation cephalosporins are more commonly implicated in hemolytic reactions than fir st generation cephalosporins. We report a case of severe cefotetan-induced hemolytic anemia in a previously healthy 46-year-old woman undergoing an el ective hysterectomy. The patient received 2 g of intravenous cefotetan intr aoperatively and subsequently at 12 and 24 h post-operatively. She complain ed of diarrhea and fever on the third post-operative day and was seen in he r gynecologist's office on the fifth post-operative day (hemoglobin = 10.5 g/dL). On the seventh post-operative day, she complained of fever and soren ess around the suprapubic catheter site and was given a prescription for 50 0 mg oral cephalexin four times a day. The next day she was seen in the gyn ecologist's office and reported feeling better. Ten days after the operatio n her fatigue worsened and her hemoglobin was 4.8 g/dL, She was transfused with 3 units of packed red blood cells (PRBC) and was given 1 g of cefoteta n intravenously, During the transfusion of the second unit of PRBC nursing staff observed gross hemoglobinuria and she subsequently developed acute re nal failure. Laboratory chemistry parameters were consistent with severe ac ute hemolysis, The patient's direct antiglobulin test was reactive and her serum reacted with cefotetan-coated red blood cells (RBCs) and serum plus s oluble cefotetan reacted with untreated RBCs, The titration endpoint of the serum against cefotetan-coated RBCs was 40,960, while the serum plus solub le cefotetan against uncoated RBCs was 2,560, This case of severe cefotetan -induced hemolysis was complicated by an acute hemolytic event that occurre d during the transfusion of PRBC. Clinical and transfusion service staff mu st consider drug-induced hemolysis in the differential diagnosis of acute a nemia. Am. J. Hematol. 64:67-70, 2000, Published 2000 Wiley-Liss, Inc.dagge r