Cold Hemolytic Anemia a Rare Possibility in Mononucleosis Patients, Case Report Shows

Despite being extremely rare, cold type autoimmune hemolytic anemia, or cold agglutinin disease (CAD), should be considered in patients with infectious mononucleosis, especially those who also have anemia, a case study reports.

The case report, “Cold type autoimmune hemolytic anemia- a rare manifestation of infectious mononucleosis; serum ferritin as an important biomarker,” was published in the journal BMC Infectious Diseases.

Mononucleosis, also known as kissing disease, is an infectious disease caused by the Epstein-Barr virus (EBV), which is estimated to affect up to 95% of adults worldwide. The main symptoms associated with EBV infection include fever, tonsillar-pharyngitis (inflammation of the tonsils and throat), swollen lymph nodes, and an abnormal white blood cell count.

Cold type autoimmune hemolytic anemia (AIHA) is a medical condition characterized by the production of autoantibodies that attack red blood cells, causing them to stick to each other at low temperatures and destroying them. Cold type AIHA is normally associated with some types of blood cancers and, in rare cases, with bacterial infections and infectious mononucleosis.

In this case report, a team of researchers from the Sri Jayawardanapura General Hospital in Sri Lanka described a patient with infectious mononucleosis who had high levels of ferritin — a protein responsible for storing iron in the body — which is extremely rare in cold type AIHA.

The 18-year-old girl arrived at the hospital with a fever, general discomfort, fatigue and sore throat. Laboratory tests showed signs of mild anemia, hepatitis (liver inflammation), swollen lymph nodes, and an enlarged spleen.

She tested positive for EBV infection, and her serum ferritin levels were abnormally high — more than 1,650 ng/ml, when normal values range between 6.9 and 282.5 ng/ml. Based on these symptoms, clinicians diagnosed the patient with cold type AIHA associated with high levels of ferritin.

She was prescribed analgesics, advised to rest, and started taking 5 mg of folic acid every day to recover from anemia. After six weeks of treatment, her hemoglobin and ferritin levels normalized, and her swollen lymph nodes went back to normal size without further interventions.

“We believe though, a rare manifestation, cold type autoimmune hemolytic anemia should be considered in infectious mononucleosis patients who are presenting with anemia,” the researchers wrote.

“This case report highlights the importance of conservative management of anemia secondary to EBV infection specially in a child bearing age female, and also the value of serum ferritin as an initial biomarker since usual biomarkers such as C reactive protein levels remains within normal range during viral infections,” they concluded.