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about 30 years ago , methyldopa and penicillin were the two medications most commonly associated with drug - induced autoimmune hemolytic anemia ( diiha ) .
methyldopa and intravenous penicillin accounted for 67% and 25% , of all drug - induced immune hemolytic anemia , respectively .
currently , most cases of diiha are attributed to second- and third - generation cephalosporins , most commonly ceftriaxone , and this drug has become the most common cause of antibiotic - induced hemolysis .
we present a case of diiha following ceftriaxone use , managed successfully with withdrawal of the drug and supportive measures . since this antibiotic is widely used by clinicians across all specialties
, it is important to be aware of this possibility to enable us to make an early diagnosis .
a 60-years - old lady , with no past history of any drug allergies , presented with fever and productive cough of five days duration . clinically , she had fever , tachycardia , tachypnea with crackles in the right mammary area .
x - ray chest confirmed pneumonia in the right middle zone [ figure 1 ] . on admission ,
her investigation were as in [ table 1 ] x - ray chest of the patient showing consolidation in right middle zone laboratory parameters of the patient suffering from ceftrixone - induced hemolysis a diagnosis of community - acquired pneumonia was made , and patient was started on intravenous ceftriaxone one gram 12 hourly .
her hemoglobin dropped down to 7.5 g / dl within 24 hrs and further to 5.5 g / dl after 72 hrs , with peripheral blood smear showing marked polychromasia with three nucleated red cells per 100 white blood cells , schistocytes , a corrected reticulocyte count of 4.0% and ldh of 1221 units / l .
serum bilirubin rose to 2 mg / dl with indirect of 1.5 mg / dl .
a diagnosis of ceftriaxone - induced aiha was made , and the drug was stopped immediately .
two units of packed red blood cells were transfused as she had symptomatic anemia , her hemoglobin increased to 8.6 g / dl and thereafter to 9.8 g / dl at discharge , after two weeks with no further deterioration .
ceftriaxone - induced urticaria , rash , exanthem , and pruritus are the most common adverse effects and occur in about three percent of patients .
the first case of hemolysis induced by ceftriaxone was reported in 1991 by garratty et al . in a 52-year - old woman who was treated with ceftriaxone .
this was the first case of immune hemolytic anemia associated with ceftriaxone , and also the first case of fatal cephalosporin - induced hemolytic anemia .
thereafter , in 1995 , a case report of a 24-month - old boy with sickle cell disease who had cardiac arrest and died 36 hours later from multiple organ failure after starting ceftriaxone .
another case of a 16-year - old girl was reported in 1999 who had developed ceftriaxone - induced intravascular hemolysis leading to acute renal failure and death .
drug - dependent antibodies ( antibodies react in vitro with rbc 's , only in presence of drug ) are produced by antibiotics like ceftriaxone and pipercillin .
these drugs attach to rbc , but do not bind covalently to rbc membrane proteins .
combination of drug and antibody creates an immunogen , which activates complement and results in acute intravascular hemolysis .
drug - independent antibodies ( drug not required to be present to detect antibodies in vitro ) are produced by drugs as fludarabine , methyldopa , and penicillins .
these drugs combine covalently with rbc membrane proteins , and the antibody - coated rbc are taken up by macrophages .
ceftriaxone - induced aiha , though rare , can be fatal if not thought of .
it needs high index of clinical suspicion in patients treated with ceftriaxone who develop sudden drop in hemoglobin , hemoglobinuria , and evidence of hemolysis in peripheral blood smear .
beta lactam antibiotics should be used with caution in patients who have history of adverse effects to ceftriaxone because of cross reactivity . according to the world health organization ( who ) system of causality definitions , the adr ( adverse drug reaction ) in this reported case is categorized as probable with naranjp algorithm score of six , as the patient developed hemolysis after intravenous administration of ceftriaxone .
there was no other possible cause of hemolysis as no other drug was used with ceftriaxone .
rechallenge was not done due to inherent risk involved , but the patient showed improvement after stopping the drug .
though drug - induced autoimmune hemolytic anemia is a rare adverse reaction , they may be fatal in some cases .
immune hemolytic anemia is a rare adverse effect of ceftriaxone , a third - generation cephalosporin , which is a commonly used antibiotic . 
 we describe a 60-years - old lady , a case of community - acquired pneumonia , who developed severe hemolysis after the first dose of ceftriaxone . 
 her hemoglobin dropped from 9.6 g /dl to 5.5 g /dl . 
 however , she improved after discontinuation of the drug and blood transfusion . 
 this report serves as a reminder to medical fraternity that life - threatening hemolysis can rarely follow administration of ceftriaxone .