A Fatal Case of Cefazolin-Induced Immune Hemolytic Anemia in Iran

Introduction: Drug-induced immune hemolytic anemia (DIIHA) is known as an unpredictable and in some cases serious complication occurring upon pharmacotherapy. Cefazolin, as a first generation cephalosporin used against gram-negative bacteria, has rarely been reported to cause hemolytic anemia. Here, we report the first fatal case of hemolytic anemia associated with cefazolin treatment. Materials and methods: A 24-year-old woman undergoing operative hysteroscopy for resection of the uterine septum developed hemolytic anemia upon receiving cefazolin immediately before and after the operation. A few hours after surgery, clinical signs of disseminated intravascular coagulation (DIC) appeared. Despite all supportive medical measures that were taken, the patient died of multiple organ failure about 24 hours after admission to ICU. The patient had no history of transfusion or allergies to any types of drugs including antibiotics. Direct anti-globulin test (DAT) was conducted, and the presence of antibody and complement on patient’s RBCs was investigated. In addition, the reaction between patient’s RBC eluate and cefazolin-coated control RBCs was explored. Results: DAT was strongly positive (4+); in addition, the presence of IgG4 and C3d on the patient’s RBCs was shown. Moreover, the eluate from patient’s RBCs reacted (3+) with RBCs pre-coated with cefazolin. Discussion: The results confirmed the presence of cefazolin-dependent antibodies. This case reveals the importance of taking precaution before using cefazolin even in cases where there is no previous evidence of drug sensitization.