Case Study

Day 1 is day of admission. On the evening of day 2, his oxygen saturation was found to be 85-86%, his CBC is shown in blue (and indicated by the arrowhead), and hemolysis labs/liver function tests were drawn at the same time. The patient received one unit of pRBCs on the morning of day 3.

64 yo M presents with B symptoms, generalized adenopathy and evidence of tumor lysis syndrome. He is given a dose of Rasburicase in the ED. The next day he develops shortness of breath. His SaO₂ is 85% and does not increase with supplemental O₂. Compared with baseline on admission, his labs now show:

Drop in Hb
Increased AST:ALT ratio (normal on admission)
Elevated LDH (about 500 IU/L on admission)
Low haptoglobin (normal on admission)

Taken together, these data are consistent with hemolysis.

Peripheral smear (actual smear from this patient shown below) demonstrated a multitude of blister cells, occasional bite cells. The Heinz body prep was positive (not shown).

The ICU team noted that G6PD activity levels, which were drawn the night before (day 2), came back earlier that day showing deficiency. This clued them into the possibility of Rasburicase-mediated methemoglobinemia (MHb). Indeed the MHb level came back at 7%, confirming their suspicion.

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