Microangiopathic hemolytic anemia (MAHA) is an uncommon complication of mucin-producing adenocarcinomas usually of the stomach or breast. We present a case of MAHA as the first manifestation of bronchoalveolar carcinoma (BAC). This is only the third reported case of MAHA associated with lung cancer.
A 55 year-old never smoking female presented with fatigue and dyspnea on exertion for 4 months. Evaluation revealed Coombs negative MAHA. Serologies for collagen vascular diseases were negative. A bone marrow biopsy revealed erythroid hyperplasia. Her therapy included plasmapheresis, two cycles of cyclosphosphamide, prednisone, 20 units of packed red blood cells and a splenectomy without improvement. On arrival to our tertiary care center, laboratory revealed a hematocrit of 33.7%, hemoglobin 10.4 g/dL, platelet count of 228,000/mm3, INR 1.1, PTT 29 seconds, reticulocyte count of 16%, LDH 1219 units/mL and a haptoglobin <10 mg/dL. The peripheral blood smear revealed many schistocytes and microspherocytes. Mammogram and abdominal/pelvic computed tomography (CT) were unremarkable. Chest CT revealed a left lower lobe consolidation and subcarinal and left hilar lymphadenopathy suggestive of lymphoma. The patient underwent bronchoscopy with transbronchial biopsy and transbronchial needle aspirate which was sent for flow cytometry. Both revealed mucin-producing adenocarcinoma consistent with BAC. She received chemoradiation with carboplatinum and taxol with partial remission of her MAHA.DISCUSSION: MAHA is a well-documented but rare complication of disseminated adenocarcinomas, usually of the stomach and breast, but has been reported with other organ malignancies including pancreas, colon and lung. MAHA is a marker for poor prognosis, and survival in non-treated patients has ranged from 3 to 61 days. Rapid initiation of chemotherapy usually controls the microangiopathic process.
MAHA is an infrequent manifestation of lung adenocarcinoma of the lung. Extensive evaluation for malignancy, including lung cancer, should be performed in patients presenting with Coombs negative MAHA.
P.E. Molina, None.