Case Presentation: A 32-year-old African American male past medical history significant for recently diagnosed Guillain-Barre syndrome (GBS) was admitted for recurrent mechanical falls at home. One week prior to his admission, he was treated for GBS with high dose Intravenous Immunoglobulin (0.4 g/kg/day) for 5 consecutive days and subsequently discharged home where he stayed for 3 days. At home, he suffered a mechanical fall while ambulating in the house and was brought to the emergency room. Upon initial evaluation, physical examination was unremarkable except for scleral icterus and lower extremity weakness. Blood work revealed acute anemia with a significant drop in hemoglobin from 12.4 mg/dL on the day of completion of his IVIG to 8.3 mg/dL on the day of admission. Additional laboratory workup revealed elevated indirect bilirubin (2.7mg/dL), decreased haptoglobin (<15 mg/dL) and increased LDH (885 IU/L), consistent with hemolytic anemia. Peripheral smear showed nucleated RBCs. His reticulocyte count was elevated to 8.6%. Autoimmune hemolysis was ruled out a negative direct Coombs test. The patient was diagnosed with IVIG induced hemolytic anemia and managed conservatively as his Hb remained stable above 8 mg/dL throughout the hospital course.
Discussion: Acute Inflammatory demyelinating polyradiculoneuropathy is the most common variant of GBS and is usually treated with plasma exchange or IVIG. IVIG is frequently used in a variety of immunologic, hematologic, neurologic and rheumatologic conditions. Although safe in most cases, it has diverse side effect profile. Our patient developed hemolytic anemia following administration of IVIG to treat Guillain-Barre syndrome (GBS). IVIG induced hemolysis is a rare and serious complication with a reported incidence of ~1 per 1000 IVIG treatment episodes, most occurring within 48 hours of exposure although delayed reactions have also been documented. Usually self-limited, a small proportion may be clinically significant. The etiology is multifactorial but may relate to the quantity of blood group antibodies administered via the IVIG product.
Conclusions: Hemolytic anemia is one of the rare complication following IVIG administration and hemoglobin should be monitored closely during treatment course as well as 24 hours after the completion of IVIG and at one-week post-discharge, especially if retreatment is necessary. It is imperative that clinicians must be aware of this potential complication for early recognition as well as to counsel the patient and their families regarding the same.