Ibuprofen-Induced Hemolytic Anemia

Drug-induced immune hemolytic anemia is a rare condition with an incidence of 1 per million of the population. We report the case of a 36-year-old female who presented to the emergency department complaining of shortness of breath and dark colored urine. Physical examination was significant for pale mucous membranes. The patient reported using ibuprofen for a few days prior to presentation. Complete blood count performed before starting ibuprofen revealed normal platelets and hemoglobin values. On admission, the patient had evidence of hemolytic anemia with hemoglobin of 4.9？g/dL, hematocrit of 14.2%, lactate dehydrogenase 435？IU/L, and reticulocytosis 23.2%. Further testing ruled out autoimmune disease, lymphoma, and leukemia as etiologies for the patient’s new onset hemolytic anemia. Ibuprofen was immediately stopped with a gradual hematologic recovery within 3 days. 1. Introduction Drug-induced immune hemolytic anemia (DIIHA) is a serious condition that can be a rare side effect of commonly used over-the-counter medications. The incidence of DIIHA is estimated to be 1 per million of the population. While no explicit data exist regarding the incidence of ibuprofen induced hemolysis, various case series have found that NSAIDs compromise less than 15% of cases; the majority of cases are caused by beta-lactamase antibiotics (e.g., cephalosporins and penicillins). Timely recognition of this condition along with discontinuation of the offending agent is paramount in treating its potentially fatal complications [1–3]. 2. Case Presentation A 36-year-old healthy caucasian female presented to the emergency department complaining of 1-day duration of shortness of breath. The only medication that she was taking was ibuprofen, which she started to take twice daily one week before presentation for tension headaches. The patient was found to have regular sinus tachycardia of 127 beats per minute. Subsequent physical examination revealed jugular venous distention and pale mucous membranes with no jaundice, lymphadenopathy, or organomegaly. No obvious source of bleeding was identified. Upon initial workup, she was found to be severely anemic with a hemoglobin of 4.9 (normal range 12–15？g/dL), hematocrit of 14.2 (normal range 36%–47%), MCV 98.8 (normal range 80–100？fL), and RDW of 24.6 (normal range 11%–14.5%). Anemia workup was initiated and was significant for an elevated lactate dehydrogenase (LDH) 435 (normal range 135–214？IU/L), reticulocytosis 23.2 (normal range 0.5%–2.8%), and decreased haptoglobin <6 (normal range 36–195？mg/dL). Stool test for occult blood was