A case of hypertensive nephropathy who died of piperacillin- tazobactam induced immune hemolytic anemia which aggravated renal dysfunction: complete follow-up of serology and disease course

Background: Severe drug-induced immune hemolytic anaemia (DIIHA) cases leading to death are very rare. Among the reported cases of DIIHA, the serological characteristics and course of the disease are rarely described completely. Piperacillin is a semi-synthetic penicillin against pseudomonas widely used in the treatment of bacterial infections. It is one of the most common drugs that cause DIIHA. Methods: In this study, a 79-year-old male patient with hypertensive nephropathy who developed severe hemolytic anemia during intravenous piperacillin-tazobactam anti-infective treatment due to lung infection, and worsened renal function. Serological tests included direct antiglobulin test (DAT), acid elution test, irregular red blood cell (RBC) antibody detection, and the drug-dependent antibodies associated with piperacillin or tazobactam were detected by the standard methods for the detection of drug-dependent antibodies both in the presence of soluble drug and with drug-coated RBCs. Fully described the patient's course of disease and the serological changes after stopping the administration of piperacillin-tazobactam.Results: Serological tests showed that the results of DAT for anti-IgG was positive (4+) and anti-C3d was negative. The IgG piperacillin-dependent antibodies (the highest titer reached 128) were detected in the plasma incubated with O-type RBCs and 3 mg/mL piperacillin. But the plasma or the acid eluent incubated with piperacillin-coated RBCs, or the acid eluent incubated with O-type RBCs and 3 mg/mL piperacillin did not detect antibodies. The patient was diagnosed as piperacillin-induced DIIHA. Although blood transfusion and continuous renal replacement therapy were given, the patient still died of multiple organ failure 15 days after the administration of piperacillin-tazobactam was stopped.Conclusions: DIIHA caused by piperacillin exacerbated renal damage and was an important cause of the patient's eventual death from multiple organ failure. Which has helped to deepen the understanding of DIIHA and draw lessons from it.