Case of cytomegalovirus-associated direct anti-globulin test-negative autoimmune hemolytic anemia

Cytomegalovirus-Associated Hemolytic Anemia in an Infant Born to a Mother with Lupus

A 31-day-old infant was admitted to the pediatric intensive care unit due to shock and anemia. The mother had systemic lupus erythematosus and direct antiglobulin test (DAT)-positive hemolytic anemia. The perinatal course of this infant and the mother was uneventful. Regular health check screenings revealed that activity, growth, and development were unremarkable at birth, 5, and 28 days of life. Passive immune hemolytic anemia due to neonatal lupus erythematosus was diagnosed based on a positive DAT for warm-type IgG antibodies, reticulocytosis, and lupus-specific antibodies at rehospitalization. It was complicated by cytomegalovirus (CMV) antigenemia. Umbilical cord blood and peripheral blood samples obtained from the infant at 5 days after birth were negative for CMV DNA. The infant was curatively treated by intensive care with repeated blood transfusions and antiviral therapy. This is the first report indicating that CMV infection exacerbates hemolytic anemia in patients with maternal red blood cell alloantibodies.

Congenital Cytomegalovirus and Autoimmune Neutropenia: Cause or Coincidence?

BACKGROUND

Congenital cytomegalovirus (CCMV) accounts for high rates of infant morbidity and mortality. Neutropenia is a common finding in CCMV infection, of which the age of presentation overlaps with autoimmune neutropenia (AIN). AIN represents one of the most common forms of chronic neutropenia in childhood.

METHODS

A literature search exploring biologic associations between CCMV and AIN was conducted: PubMed (MEDLINE), Ovid and Web of Science. We further describe 2 cases of concurrent CCMV and AIN. Both cases were confirmed with the indirect granulocyte immunofluorescence test and alternative etiologies for neutropenia excluded.

RESULTS

Our 2 patients represent confirmed cases of AIN in infants with CCMV. One patient demonstrated neutropenia while undergoing treatment with Valganciclovir, while the other was never treated. With interruption of Valganciclovir in infant A, neutrophil counts (ANC) did not improve and upon resumption of treatment ANC remained static.

CONCLUSIONS

Further studies examining a possible biologic link between CCMV and AIN are advocated for. We encourage clinicians to actively consider AIN in the differential diagnosis of all infants with CCMV presenting with neutropenia.