key: cord-0689305-mumnjs2f authors: Murdych, Tomas M. title: A case of severe autoimmune hemolytic anemia after a receipt of a first dose of SARS‐CoV‐2 vaccine date: 2021-07-31 journal: Int J Lab Hematol DOI: 10.1111/ijlh.13653 sha: 0ed44b0a01f65058a03e6db7c213860c8e1df18d doc_id: 689305 cord_uid: mumnjs2f SARS-CoV-2 mRNA vaccine made by Pfizer and BioNTech was approved by the U.S. Food and Drug Administration for use under an Emergency Use Authorization for active immunization to prevent coronavirus disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on December 11, 2020 (1). Intolerance reactions to the vaccine identified in the initial study were usually transient and mild to moderate (2). More serious and rare cases of anaphylaxis were reported following the emergency authorization with widespread vaccination efforts (3). Later, occurrence of immune thrombocytopenia and thromboembolic events in vaccine recipients (from different manufacturers) reached attention in general press (4) and in medical literature (5, 6). This is the first case published in the scientific literature of an individual with symptomatic, severe autoimmune hemolytic anemia diagnosed in the third week after receiving Pfizer-BioNTech Covid-19 vaccine, with recovery after corticosteroid therapy. The patient, in this case, is an 84-year-old man, a Vietnam War veteran of Greek-Turkish descent, whose medical history is significant for major depression/anxiety, prostate cancer (status post remote prostatectomy), colon cancer (status post remote laparoscopic right hemicolectomy with patent anastomosis and no evidence for recurrence on recent colonoscopy within the last year), nonocclusive coronary artery disease, hypertension, emphysema, trace cryoglobulinemia (evaluated by Hematology two years ago and considered clinically insignificant), evidence for duodenitis on recent endoscopy (within 6 months), chronic alcohol consumption, and mild chronic anemia with baseline hemoglobin of 13.3 g/dL 4 months prior to presentation (reference range, 13.5-17.5 g/dL). He received the first dose of Pfizer-BioNTech BNT16B2b2 mRNA vaccine through the Veterans Administration system in early 2021. On day 19 post-vaccine, the patient presented to his primary clinic with increased urinary frequency and dizziness. Urine analysis showed a small amount of bilirubin and few bacteria but no WBC or RBC. Urine culture was positive for 10 000-50 000 col/mL of Enterobacter cloacae. The patient was initiated on oral ciprofloxacin, of which he took 5 doses but then later self-discontinued due to worsening symptoms. (Other chronic, scheduled medications included atorvastatin, cholecalciferol, cyanocobalamin, finasteride, metoprolol SR, sertraline, and ocuvite capsule). Worsening of the patient's chronic anemia was also noted during the appointment. Hemoglobin level was now 8.8 g/dL, MCV 107 fL (reference range, 80-100 fL), and reticulocyte count 0.163 mill/μL (reference range, 0.010-0.110 mill/μL). The patient was referred to outpatient hematology, but his symptoms worsened before his scheduled appointment. These symptoms included dizziness/vertigo, nausea, anorexia, shortness of breath, chest pain, palpitations, "ashen" appearance, and dark urine, ultimately causing an emergency presentation to our hospital and inpatient admission 5 days after his initial visit to the outpatient clinic. The patient appeared pale, but his vital signs including oxygenation were normal. Frequent PVCs were noted on cardiac examination and on otherwise normal EKG. Rest of the physical examination was normal. Chest radiograph was clear. Admission hemoglobin was now noted to be 5.6 g/dL and on repeat draw, 4.9 g/dL. Further abnormalities noted on peripheral blood tions. An association between ciprofloxacin, prescribed shortly before the patient's autoimmune hemolytic anemia diagnosis, has been carefully examined as such a relation had been documented previously. 11 The fact that laboratory indices such as hemoglobin decline, macrocytosis, and reticulocytosis pointed toward hemolysis prior to the initiation of the antibiotic all speak against such association in this case. In conclusion, the purpose of reporting a case of serious autoimmune hemolytic anemia that has developed in the absence of other likely causes shortly after a receipt of an initial SARS-CoV-2 vaccine is to raise awareness about a possible, rare, and previously unreported hematological side effect of the vaccine. It does not provide proof of a causative relationship but rather serves to alert the clinicians to this possible association, so that they can obtain laboratory evidence of hemolysis should individuals with a sudden hemoglobin drop post SARS-CoV-2 vaccine present to their practice. autoimmune hemolytic anemia, COVID-19 vaccine The author has no competing interests. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. COVID-19 Vaccine Emergency Use Authorization Review Memorandum. U.S. Food and Drug Administration. www.fda. gov Safety and efficacy of the BNT162b2 mRNA covid-19 vaccine Allergic reactions including anaphylaxis after receipt of the first dose of Pfizer-BioNTech COVID-19 vaccine -United States Doctor's death after Covid vaccine is being investigated. The New York Times Immune thrombocytopenia in a 22-year-old post Covid-19 vaccine Thrombocytopenia following Pfizer and Moderna SARS-CoV-2 vaccination Covid-19: European countries suspend use of Oxford-AstraZeneca vaccine after reports of blood clots Thrombotic thrombocytopenia after Ad26.COV2.S vaccination SARS-CoV-2 vaccine-induced immune thrombotic thrombocytopenia Autoimmune haemolytic anaemia associated with COVID-19 infection Autoimmune haemolytic anaemia associated with ciprofloxacin