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Autoimmune Hemolytic Anemia (AIHA)

Also Known As: Acquired hemolytic anemia, Immune hemolytic anemia, Warm autoimmune hemolytic anemia (WAIHA), Cold agglutinin disease (CAD), Mixed-type autoimmune hemolytic anemia
System: Immune System, Heart and Vascular System, and Blood
Autoantibodies:
  • IgG antibodies (warm AIHA)

  • IgM antibodies (cold AIHA)

  • Complement proteins (e.g., C3)

Primary Organ or Body Part Affected:
  • Blood (red blood cells)

  • Spleen (site of destruction for warm AIHA)

  • Liver (helps clear destroyed cells)

Acceptance as Autoimmune: Confirmed
Autoimmune Hemolytic Anemia

What is Autoimmune Hemolytic Anemia (AIHA)?

Autoimmune Hemolytic Anemia (AIHA) is a rare autoimmune condition in which the body’s immune system mistakenly produces antibodies that attack and destroy its own red blood cells (RBCs). This destruction leads to anemia—meaning the blood can’t carry enough oxygen to tissues—causing fatigue, weakness, and a range of other symptoms. AIHA may occur on its own (primary) or as a result of another disease (secondary), such as lupus, lymphoma, or certain infections.

There are two main types:

  • Warm AIHA – Antibodies react at normal body temperature (most common form)

  • Cold AIHA (Cold Agglutinin Disease) – Antibodies are active at cooler temperatures, especially in fingers, toes, or ears

What are the signs and symptoms of Autoimmune Hemolytic Anemia (AIHA)?

General symptoms of anemia:

  • Fatigue

  • Pale or yellowish skin (jaundice)

  • Shortness of breath

  • Rapid heartbeat or palpitations

  • Dizziness or lightheadedness

  • Dark-colored urine

Cold AIHA-specific symptoms:

  • Numbness or pain in fingers or toes when exposed to cold

  • Bluish discoloration (cyanosis) in extremities

  • Worsening symptoms in cold weather

Warm AIHA-specific symptoms:

  • Often more acute onset

  • Fever

  • Enlarged spleen (splenomegaly)

What are the causes of Autoimmune Hemolytic Anemia (AIHA)?

AIHA is caused by the production of autoantibodies that bind to red blood cells, marking them for destruction by the immune system.

Primary AIHA:

  • Idiopathic (no known cause, most cases of warm AIHA)

Secondary AIHA:

  • Autoimmune diseases (e.g., systemic lupus erythematosus, rheumatoid arthritis)

  • Lymphomas and leukemias

  • Infections (e.g., Mycoplasma pneumoniae, EBV)

  • Medications (e.g., penicillin, methyldopa)

Diagnosis

  • Complete blood count (CBC): Shows anemia, elevated reticulocytes

  • Peripheral blood smear: May show spherocytes or agglutination

  • Direct antiglobulin test (Coombs test): Confirms the presence of antibodies on RBCs

    • Positive for IgG in warm AIHA

    • Positive for complement (C3) in cold AIHA

  • Lactate dehydrogenase (LDH): Elevated

  • Haptoglobin: Low

  • Bilirubin (indirect): Elevated

Treatment

Treatment depends on severity and type:

Warm AIHA:

  • First-line: Corticosteroids (e.g., prednisone)

  • Second-line: Immunosuppressants (azathioprine, rituximab), splenectomy

  • Supportive: Blood transfusions (carefully cross-matched)

Cold AIHA:

  • Avoid cold exposure

  • Rituximab (commonly used)

  • Sometimes plasmapheresis or immunosuppressants

  • Transfusions may be needed cautiously

Prognosis

  • Many cases respond well to treatment, particularly warm AIHA

  • Some patients may relapse or require long-term immunosuppression

  • Cold agglutinin disease is often chronic and relapsing

  • Early diagnosis and proper management lead to good long-term outcomes for most

Prevalence

  • Estimated 1–3 cases per 100,000 people per year

  • More common in females and older adults

  • Warm AIHA accounts for about 70–80% of all cases

  • Cold AIHA is rarer and often linked to other conditions

Citations

  • Barcellini W, Fattizzo B. Clinical Applications of Hemolytic Markers in the Differential Diagnosis and Management of Hemolytic Anemia. Dis Markers. 2015.

  • Berentsen S. How I manage patients with cold agglutinin disease. Blood. 2021;137(10):1295–1303.

  • Jäger U, et al. Diagnosis and treatment of autoimmune hemolytic anemia in adults: Recommendations from the First International Consensus Meeting. Blood Rev. 2020.

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