A team from the Security Forces Hospital, Saudi Arabia, reported a rare case of a patient with severe thrombocytopenia and mild autoimmune hemolytic anemia, of which cold agglutin disease (CAD) is a form, who was infected with brucellosis.

“This is our region’s first published case of severe thrombocytopenia and mild autoimmune hemolytic anemia associated with brucellosis,” the team wrote in Case Reports in Infectious Diseases.

The 73-year-old female patient presented to the hospital with a fever and recent history of general body fatigue, generalized body rashes, left knee pain, and one episode of gingival bleeding. She had a positive antinuclear antibody test, a C-reactive protein level of 19 mg/L, an erythrocyte sedimentation rate of 85 mm/h, a left knee effusion with hotness and pain, and multiple joint abnormalities in both hands. Otherwise, physical examination and initial biochemical analyses were mostly normal.

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One day later, the patient developed critically low thrombocytopenia with generalized body rash in the form of
purpura and petechiae and gum bleeding. Idiopathic thrombocytopenic purpura was suspected. Further analysis revealed some reactive lymphocytes and significant thrombocytopenia, with no aberrant cells. The patient received 6 units of platelets, dexamethasone, and intravenous immunoglobulin. As the platelet count slowly came up, the patient started eltrombopag.

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Her hemoglobin level started to drop on day 8 of her hospital stay. A laboratory workup revealed mild normocytic normochromic anemia. Further analysis showed low haptoglobin, high reticulocytes, positive direct antiglobulin, and increased indirect bilirubin. The patient was diagnosed with autoimmune hemolytic anemia and severe critically low thrombocytopenia.

She had previously consumed raw milk and unpasteurized dairy products and she lived in a brucellosis endemic area, so brucellosis was suspected. Serological analysis confirmed the infection. She initiated doxycycline and rifampicin, and stopped eltrombopag and intravenous immunoglobulin.

The patient’s platelet count returned to normal levels 5 days after initiating Brucella treatment. She was discharged with an indication to continue rifampicin and doxycycline. At follow-up (5 days later), her platelet count remained normal and her hemoglobin had raised to 12.1 g/dL.


Ahmed WAM, Ahmed Khalil K, Azwari A, Ebid GTA, Nazir I, Aly MH. Life-threatening severe thrombocytopenia and mild autoimmune hemolytic anemia associated with brucellosis. Case Rep Infect Dis. Published online January 20, 2023. doi:10.1155/2023/6608279