Infants at high risk of severe hyperbilirubinemia are those with jaundice in the first 24 hours, predischarge bilirubin levels in the high-risk zone, blood group incompatibility by positive DAT (direct antiglobulin test or the
direct Coombs test) or hemolytic disease, gestational age between 35 to 36 weeks, a previous sibling with phototherapy treatment, and cephalohematoma.
The pro-thrombin time was 11.8sec, and indirect and
direct Coombs test was negative.
The patient is still being followed up by us and the hemoglobin, reticulocyte, and bilirubin levels have been found to be normal, the
direct Coombs test became negative and has not become positive again.
[2] concluded that 'post-phototherapy neonatal bilirubin rebound to clinically significant levels may occur, especially in cases of prematurity,
direct Coombs test positivity, and those treated [greater than or equal to] 72 hours'.
Moreover, results of a
direct Coombs test were negative, although a routine peripheral blood smear revealed the presence of "bite cells." An enzymopathy with a drug-induced acute episode of hemolytic anemia was suspected.
Laboratory findings were as follows: total bilirubin: 17.6 mg/dL, direct bilirubin: 0.5 mg/dL, hemoglobin: 15.7 g/dL, white blood cells (WBC): 7730 /[mm.sup.3], platelet count: 274,000 /[mm.sup.3], blood group: 0 Rh (+), reticulocyte count: 1.56%, and
direct Coombs test: (++++).
Arthralgias, lymphopenia, raised globulins and markedly raised ESR brought our mind towards some autoimmune process, but antinuclear antibody (ANA) and
direct Coombs test were negative.
The presented patient's negative
direct Coombs test indicated that erythroid suppression, rather than hemolysis was the predominant mechanism responsible for fetal anemia secondary to maternal Kell alloimmunization.
(This would pertain providing the intended recipient has a negative atypical antibody screen and
direct Coombs test and a negative transfusion reaction history.)
Antiplatelet and anti-neutrophil antibodies, together with anti-erythrocyte antibodies detected with a positive
direct Coombs test are the most common autoantibodies found in ALPS (23, 24).
The lactate dehydrogenase (LDH) level was elevated to 1014U/L and
direct coombs test (DAT) was repeated and again negative.