Cancer-related Microangiopathic Hemolytic Anemia

An 85-year-old, female patient presented to the emergency department with a seven-day history of progressive fatigue. She had received a diagnosis of breast cancer two years earlier and was receiving outpatient chemotherapy. She had no valvular prostheses. Physical examination revealed pallor, jaundice, and cachexia with no neurological abnormalities. Laboratory tests revealed hemoglobin 6.1 g/dL (reference range: 11.3-14.7), a normal platelet count, normal prothrombin time and activated partial thromboplastin time, hyperbilirubinemia, lactate dehydrogenase 1707 IU/L (reference range: 115-245), undetectable haptoglobin, and negative direct Coombs’ test. A peripheral blood smear revealed marked schistocytosis including helmet cells (Figure A , red arrows) and other fragmented red cells (Figure A, blue arrows). Platelets were normal (Figure A, dashed arrows). Bone marrow aspiration and a biopsy revealed the presence of tumor cells (Figure B) indicative of bone marrow carcinomatosis. A subsequent ADAMTS13 assay indicated 40% activity, ruling out thrombotic thrombocytopenic purpura (TTP). Based on these findings, cancer-related microangiopathic hemolytic anemia (CR-MAHA) was diagnosed. After a discussion with the oncology team, we concluded that her breast cancer was unlikely to respond to further chemotherapy. She was discharged home with palliative care and died 11 days after the diagnosis.