title: A persistent severe autoimmune hemolytic anemia despite apparent direct antiglobulin test negativization.
abstract: OBJECTIVE
  Not all cases of autoimmune hemolytic anemia (AIHA) are diagnosed by the direct antiglobulin test (DAT). We present and discuss a simple method of enhancing the sensitivity of the standard DAT.
  
  
  METHODS
  We report the case of a five-month-old child diagnosed with a severe IgG-mediated AIHA, characterized by quick DAT negativization despite clinical worsening. Warm AIHA with negative DAT, possibly due to a low affinity autoantibody, unresponsive to conventional therapy, was hypothesized.
  
  
  RESULTS
  The DAT resulted strongly positive with anti-IgG serum using a 4C saline for erythrocyte washing, to reduce the dissociation of the supposed low affinity autoantibody. Very intensive cytoreductive treatment was administered twice until clinical remission was obtained.
  
  
  CONCLUSIONS
  The clinical course of AIHA can be dissociated by the DAT. Since autoantibody-mediated hemolysis with negative DAT rarely occurs, once other causes of high reticulocyte count anemia have been ruled out, the DAT after ice-cold saline washing could be a useful and easy means of corroborating the diagnosis of AHIA, when traditional methods fail.
authors.affiliation: Pediatric Hematology Department, Università di Milano, Ospedale S. Gerardo, Monza, Italy.
authors.forename: E
authors.initials: E
authors.lastname: Biagi
authors.forename: G
authors.initials: G
authors.lastname: Assali
authors.forename: F
authors.initials: F
authors.lastname: Rossi
authors.forename: M
authors.initials: M
authors.lastname: Jankovic
authors.forename: B
authors.initials: B
authors.lastname: Nicolini
authors.forename: A
authors.initials: A
authors.lastname: Balduzzi
mesh_terms: D000744:Anemia, Hemolytic, Autoimmune / Q000175:diagnosis*; D003298:Coombs Test / Q000379:methods*; D005188:False Negative Reactions; D006801:Humans; D007223:Infant