Case Presentation: A Korean 55-year-old female with a history of leiomyoma and kidney stones presented to the emergency department with abdominal pain. Further work up also showed new onset anemia. A pelvic exam demonstrated a large distended fibroid protruding into the vagina. Pelvic MRI noted a large multilobulated complex mass, consistent with a uterus replaced by multiple fibroids, measuring to be approximately 15 x 10 x 10.8 cm. This mass had been previously identified and measured seven and 1 year prior at, 13.5 x 9.7 x 10.0 cm, and 9.8 x 9.7 x 5.3 cm. The anterior of the mass displayed calcifications compatible with a degenerating uterine fibroid, 7 cm in diameter, while the posterior aspect was more lobulated and pushed on the left external iliac vein and ureter. The margins of the lobulated components were well-defined. A biopsy was performed, revealing endometrioid carcinoma with genetic testing negative for BRCA1/BRCA2. The patient’s CA15-3 was high at 460 U/mL and CA-125 was within normal limits. A positive Direct Coombs Test (DAT) with warm autoantibodies was noted. Peripheral blood smear revealed Spherocytic Hemolytic Anemia alongside basophilic stippling, giant platelets, polychromasia, poikilocytosis and stomatocytes. CBC and Diff showed Hgb of 4.2g/dL and platelets of 604 10e3/uL with a reticulocyte count of 4.1%. A total hysterectomy, tumor debulking, and omentectomy were performed. A Prednisone taper was prescribed to the patient, starting with 50mg. The patient was also started on Paclitaxel 309mg and Carboplate Dextrose 5% 250mL chemotherapy. Repeat CT scans in the following months displayed residual irregular soft tissue nodularity measuring 5.5 x 3.0 cm along the pelvic sidewall, indicating incomplete disease eradication, but no new metastatic disease.

Discussion: Autoimmune hemolytic anemia (AIHA) is characterized by autoantibodies directed against host red blood cells. Previous studies have shown AIHA being predominantly associated with hematological, autoimmune, and infectious pathologies. The specific underlying cause of AIHA still remains a mystery. This patient presents with a rare case of AIHA following a uterine neoplasm diagnosis. Common symptoms of AIHA can include hepatosplenomegaly and fever. Our patient presented with neither yet had two small low-density lesions in the liver – indicating that common clinical findings are not always reliable in identifying AIHA. General treatment of AIHA includes a regimen of glucocorticoids with splenectomy, depending on severity. For cases of AIHA induced by ovarian neoplasms, tumor removal is integral in effective treatment. However, in our patient tumor removal, total hysterectomy, omentectomy and glucocorticoid treatment proved only temporarily effective; Hemoglobin levels and reticulocyte count normalized, yet cessation of prednisone caused hemoglobin levels to decline once again. This is one of the first reported cases of endometrial carcinoma triggering AIHA.

Conclusions: Clinicians should maintain weariness for non-classical manifestations of AIHA, especially within the context of East-Asian populations and uterine neoplasms. This case report highlights a varying cause of AIHA and highlights the difficulties associated with diagnosis for even the most experienced clinicians.