Age: 53.0
Sex: F
Vaccine: FLU4, TDAP
Symptoms: Pyrexia, Reticulocyte percentage normal, Serum ferritin increased, Slow response to stimuli, Somnolence
Clinical narrative: Hospital Course: 8/27: 53 year old female with h/o DMT2, presenting with jaundice, palpitations, light-headedness, and SOB for 4 days. On Thursday 8/23, patient received a BOOSTRIX TdaP Vaccine and FLUARIX QUAD (Influenza Vaccine) at pharmacy. Afterwards, she noticed first that her urine became more darker in color. No dysuria nor increase in urinary frequency. She then started to feel more light-headed and short of breath. Associated with palpitations. No CP. On Saturday 8/25, family members started to notice that her eyes and skin became more yellow. No previous reactions with vaccines. No history of bleeding/clotting disorders. No RUQ tenderness. No splenomegaly. In the ED, patient was afebrile, tachycardic 130s, hemodynamically stable. Maintaining SpO2 greater than 94% on RA. Laboratory results significant for: H/H 5.8/15.5. Normal WBC and PLT. Elevated LDH 356 and TB 7.9 (mostly indirect). DAT Positive. Reticulocyte Index 1.03. Elevated ferritin 1,454. Paged by nursing - Pt had developed nausea and vomiting, confusion, and SOB. At bedside pt had slurred speech. Oriented to day and self, but slow to respond/somnolent. Assessment/Plan Severely symptomatic anemia. Discussed with blood bank, pt's blood not yet received by send out lab, recommends in vivo protocol for matching. Discussed w/Dr. who approved emergent release of blood products, recommends O-. Stat H/H sent. Hgb 3.7. Discussed w/Dr. recommends transfusion of 2u of pRBC, O-. Discussed w/ICU attending Dr. who recommends DOU status and collection of DIC panel. Monitored pt during initial transfusion.  Developed fever to 101.6 after approximately 15 minutes of infusion. Held infusion, gave 1g IV TYLENOL, 25 mg IV BENADRYL. Temp decreased to 100.2 after 15 minutes, restarted transfusion. Pt tolerating transfusion well. After approximately 1/2u her confusion has resolved, coloration improving. Continue transfusion of 2u total, check H/H after completion. 8/28: Pt feeling much better this morning. No more confusion or SOB. Tachycardia resolved. Tolerated blood transfusion well, post transfusion H&H 7.0. Minimal memory of events last night. AIHA. Admission Hgb of 5.8, downtrended to 3.7. S/p 2u pRBC O-. Appreciate hem/onc management. Continue methylprednisone 125 mg daily.  Started RITUXAN today. CBC BID, last hgb 6.5. Started LOVENOX prophy today. 8/29: Subjective Pt feeling well this morning. Denies SOB, palpitations, or dizziness. Discouraged to hear that Hgb continues to trend down, but overall positive. AIHA. Admission Hgb of 5.8, downtrended to 3.7. S/p 2u pRBC O-, 2 doses IVIG, 1 dose RITUXAN 8/28. Appreciate hem/onc management.  Continue methylprednisone 125 mg daily, currently day 4/5 planned dosing, then begin taper per hem recs. CBC BID in pedi tubes. LOVENOX prophylaxis. 8/30: 53 year old obese woman with h/o DM2 admitted AIHA likely precipitated by recent vaccination. Overnight transfused another 2u pRBC for a Hbg 4.1 yesterday evening. This morning Hgb 7.5. She feels well, asymptomatic. Clinically stable. Appreciate input/recs from Drs. of heme/onc. S/p rituximab 8/28. Cont steroids, now oral with slow taper. Cont to monitor for symptoms while awaiting blood analysis. If symptomatic or Hgb less than 5, plan to transfuse. Blood tests in pedi-tubes only. Hyperglycemia improved on insulin gtt and will continue for now. Cont enoxaparin 40mg SC qday for dvt ppx. Anticipate dc pending clinical improvement, possibly later this week or weekend. AIHA. Admission Hgb of 5.8, downtrended to 3.7. S/p 2u pRBC O-, 2 doses IVIG, 1 dose RITUXAN 8/28. Transfused 2u O+ least incompatible last night, post H/H 7.5, down to 6.4 this afternoon. Appreciate hem/onc management. Continue Prednisone 110 mg (s/p 4 doses SOLUMEDROL 125 mg). CBC BID in pedi tubes. LOVENOX prophylaxis. 8/31: Subjective: No acute events overnight. Afebrile, VSS, wnl. Feeling well this morning. No acute complaints. Tolerating diet, ambulating, voiding, stooling. Anemia, hemolytic, autoimmune (Medical; Confirmed) Hgb 5.7 this AM. HR stable, wnl overnight, however this morning when evaluating the patient she had mild tachycardia up to 107. Has received total of 6u PRBC during this hospitalization. Has also received IVIG x2 doses (8/26/18 and 8/28/18), RITUXAN once (8/28/18), SOLU-MEDROL 125 mg IV q24h (8/26/18-8/28/18), and prednisone 110mg PO daily (8/29/18-present). Continue prednisone 110mg PO daily. CBC BID. All lab draws in Ped tubes. Repeat type/screen 9/2/18. Will likely need transfusion today, given Hgb nearing 5.5 and patient is becoming tachycardic. Will discuss with Heme/Onc prior to transfusing. 9/1: Pt feels fine this morning, frustrated by continued blood transfusions. Voiding and stooling without issue, no SOB, no N/V. No acute events overnight. Anemia, hemolytic, autoimmune (Medical; Confirmed). Hgb 6.1 this AM. HR stable. Has received total of 7u PRBC during this hospitalization. Has also received IVIG x2 doses (8/26/18 & 8/28/18), RITUXAN once (8/28/18), SOLU-MEDROL 125 mg IV q24h (8/26/18-8/28/18), and prednisone 110mg PO daily (8/29/18-present). Continue prednisone 110mg PO daily. CBC BID. All lab draws in Ped tubes. Repeat type/screen 9/2/18.