Diagnosis of Cold Agglutinin Disease

A physical examination can identify typical symptoms of cold-induced hemolytic anemia such as pale bluish tinge on fingertips, toes, and nose (acrocyanosis), patchy, reticulated vascular pattern on the skin with a red-blue or violet coloration (livida reticularis), weakness, weight loss, dizziness, headaches, pain in the back or legs, vomiting or diarrhea, chest pain, and jaundice. Sometimes, physical examination can reveal a spleen enlargement (splenomegaly).

Biochemical assays for lactate dehydrogenase (LDH) enzyme activity and amounts of bilirubin and haptoglobin protein are generally performed to confirm hemolytic anemia in CAD. In general, bilirubin and LDH levels are high, whereas haptoglobin protein levels are low in CAD samples compared to normal ones. Biochemical tests require a blood sample that is drawn by inserting a needle into a vein in the arm.

Some tests detect the levels of cold agglutinins and the number of red blood cells for CAD diagnosis. Blood smear analysis provides additional visual confirmation of the clumping (agglutination) of red blood cells that leads to their disintegration (lysis). However, this test alone is not sufficient to diagnose CAD, and it cannot differentiate between other disorders that may cause red blood cell clumping.

The cold agglutinin (CA) titer refers to the number of dilutions after which the antibodies can still cause the agglutination of red blood cells. It is a measure of autoantibody concentration and red blood cell-binding strength. Cold agglutinins are present at very low concentrations in all people. They may also be detected in individuals with pneumonia. CA titers exceeding 1:64 dilution can be used as an indication of CAD.

A complete blood count is a count of each cell type in the blood, including white blood cells, red blood cells, and platelets. A complete blood count also may be used as a measure of hemoglobin — the protein in red blood cells that carries oxygen. The complete blood count of a patient with CAD will have fewer red blood cells than normal.

The Coomb’s test can detect cold agglutinin antibodies in the blood. The test comes in two types: direct and indirect. The direct Coomb’s test detects antibodies and other immune system-related proteins that are attached to red blood cells. The indirect Coomb’s test detects free-floating autoantibodies such as cold-agglutinins in the serum, the liquid component of blood.

The thermal amplitude test measures the temperatures at which red blood cells clump together when combined with a blood sample from a CAD patient. This clumping is visible both under a microscope and with the naked eye. Normal plasma should not cause clumping during the thermal amplitude test. The plasma of people with CAD will cause clumping of blood cells at temperatures below 98.6 F.

Nailfold cappillaroscopy is a test used to diagnose Raynaud’s phenomenon, one of the symptoms of CAD. It is a simple diagnostic test where the bed of the fingernails is examined under a microscope to visualize the capillary blood vessels. For some patients with primary Raynaud’s phenomenon, the capillary blood vessels look normal. These patients have a good prognosis with a low risk of developing other conditions.