Autoimmune Hemolytic Anemia After Inactivated Virus COVID-19 Vaccination: A Report of 2 Cases

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Somchai Insiripong
Tanakorn Anantasetagoon
Likhasit Sanglutong


Very few cases of autoimmune hemolytic anemia (AIHA) have been reported after mRNA COVID-19 vaccinations. But herein we found 2 cases of AIHA after inactivated virus COVID-19 vaccination. Case 1: a 47-year-old Thai woman suffered from malaise, fatigue, and feverish feeling since the evening of the day of the first dose of inactivated virus COVID-19 vaccination (Sinopharm). She did not have any serious health problem prior this illness. Physical examination revealed marked pallor and body temperature was 38.1°C. Blood tests showed hemoglobin (Hb) 55 g/L, white blood cell (WBC) 12.2 × 109/L, platelet 310 × 109/L, nucleated red blood cell (RBC) 8/100 WBC, reticulocyte count 25.0%, direct antiglobulin test-4+ positive, indirect antiglobulin test-2+ positive. She was diagnosed with severe AIHA and well responsive to steroid therapy. Case 2: a 78-year-old Thai woman felt fatigue without fever 3 days after the second dose of inactivated virus COVID-19 vaccine (Sinopharm). Her underlying disease was anemia of the elderly with alpha thalassemia-1 heterozygosity. Her averaged Hb concentration before transfusion was 85 ± 3 g/L and she always needed transfusion every 2 months. Physical examination revealed only pallor. Blood test showed Hb 79 g/L, WBC 3.7 ×109/L, platelet 104 × 109/L, direct antiglobulin test-4+ positive, indirect antiglobulin test-4+ positive. She was diagnosed with AIHA and treated with cyclophosphamide and blood transfusion. Although the association between the inactivated virus COVID-19 vaccination and AIHA could not be simply concluded and the mix-and-match combination of different COVID-19 vaccines is promoted by Thai government, both of our patients chose to postpone the next dose of any kind of COVID-19 vaccine.


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How to Cite
Insiripong, S., Anantasetagoon, T., & Sanglutong, L. (2022). Autoimmune Hemolytic Anemia After Inactivated Virus COVID-19 Vaccination: A Report of 2 Cases . Ramathibodi Medical Journal, 45(3), 42–47.
Case Reports


Chen C, Wang L, Han B, Qin L, Ying B. Autoimmune hemolytic anemia in hospitalized patients: 450 patients and their red blood cell transfusions. Medicine (Baltimore). 2020;99(2):e18739. doi:10.1097/MD.0000000000018739

Gani I, Hinnant G, Kapoor R, Savage N. Autoimmune hemolytic anemia in a renal transplant patient following seasonal influenza vaccination. Case Rep Hematol. 2019;2019:3537418. doi:10.1155/2019/3537418

Montagnani S, Tuccori M, Lombardo G, et al. Autoimmune hemolytic anemia following MF59-adjuvanted influenza vaccine administration: a report of two cases. Ann Pharmacother. 2011;45(1):e8. doi:10.1345/aph.1P480

Seltsam A, Shukry-Schulz S, Salama A. Vaccination-associated immune hemolytic anemia in two children. Transfusion. 2000;40(8):907-909. doi:10.1046/j.1537-2995.2000.40080907.x

Gaignard ME, Lieberherr S, Schoenenberger A, Benz R. Autoimmune hematologic disorders in two patients after mRNA COVID-19 vaccine. Hemasphere. 2021;5(8):e618. doi:10.1097/HS9.0000000000000618

Brito S, Ferreira N, Mateus S, et al. A case of autoimmune hemolytic anemia following COVID-19 messenger ribonucleic acid vaccination. Cureus. 2021;13(5):e15035. doi:10.7759/cureus.15035

Gadi SRV, Brunker PAR, Al-Samkari H, et al. Severe autoimmune hemolytic anemia following receipt of SARS-CoV-2 mRNA vaccine. Transfusion. 2021;61(11):3267-3271. doi:10.1111/trf.16672

Okuno S, Hashimoto K, Shimizu R, Takagi E, Kajiguchi T. Development of autoimmune hemolytic anemia after BNT162b2 mRNA COVID-19 vaccination. Rinsho Ketsueki. 2021;62(10):1510-1514. doi:10.11406/rinketsu.62.1510

Hidaka D, Ogasawara R, Sugimura S, et al. New-onset Evans syndrome associated with systemic lupus erythematosus after BNT162b2 mRNA COVID-19 vaccination. Int J Hematol. 2022;115(3):424-427. doi:10.1007/s12185-021-03243-2

Murdych TM. A case of severe autoimmune hemolytic anemia after a receipt of a first dose of SARS-CoV-2 vaccine. Int J Lab Hematol. 2022;44(1):e10-e12. doi:10.1111/ijlh.13653

Michalak SS, Olewicz-Gawlik A, Rupa-Matysek J, Wolny-Rokicka E, Nowakowska E, Gil L. Autoimmune hemolytic anemia: current knowledge and perspectives. Immun Ageing. 2020;17(1):38. doi:10.1186/s12979-020-00208-7

Packman CH. The Clinical pictures of autoimmune hemolytic anemia. Transfus Med Hemother. 2015;42(5):317-324. doi:10.1159/000440656

Quinn R, Murakhovskaya I. SARS-CoV-2 and autoimmune cytopenia. Hematol. 2021;2(3):463-476. doi:10.3390/hemato2030029

Yilmaz F, Albayrak M, Reis Aras M, et al. Recurrent autoimmune hemolytic anemia after mRNA COVID-19 vaccine (Pfizer Biontech). Hematol Transfus Cell Therap. 2021;43(S3):S50. doi:10.1016/j.htct.2021.10.1057

Campos-Cabrera G, Torres-Salgado FG, Campos-Cabrera S, Campos-Villagomez JL, Campos-Cabrera V. Autoimmune cytopenias and COVID-19 vaccination: relapse and suggested treatment. Blood. 2021;138(suppl 1):4141. doi:10.1182/blood-2021-145532

Terracina KA, Tan FK. Flare of rheumatoid arthritis after COVID-19 vaccination. Lancet Rheumatol. 2021;3(7):e469-e470. doi:10.1016/S2665-9913(21)00108-9

Jeon YH, Lim DH, Choi SW, Choi SJ. A flare of Still's disease following COVID-19 vaccination in a 34-year-old patient. Rheumatol Int. 2022;42(4):743-748. doi:10.1007/s00296-021-05052-6

Tuschen K, Bräsen JH, Schmitz J, Vischedyk M, Weidemann A. Relapse of class V lupus nephritis after vaccination with COVID-19 mRNA vaccine. Kidney Int. 2021;100(4):941-944. doi:10.1016/j.kint.2021.07.019

Velikova T, Georgiev T. SARS-CoV-2 vaccines and autoimmune diseases amidst the COVID-19 crisis. Rheumatol Int. 2021;41(3):509-518. doi:10.1007/s00296-021-04792-9

Platton S, Mendes N, Booth C, et al. Positive direct antiglobulin tests in patients with COVID-19. Transfusion. 2021;61(1):333-334. doi:10.1111/trf.16156

Vojdani A, Kharrazian D. Potential antigenic cross-reactivity between SARS-CoV-2 and human tissue with a possible link to an increase in autoimmune diseases. Clin Immunol. 2020;217:108480. doi:10.1016/j.clim.2020.108480

Algassim AA, Elghazaly AA, Alnahdi AS, et al. Prognostic significance of hemoglobin level and autoimmune hemolytic anemia in SARS-CoV-2 infection. Ann Hematol. 2021;100(1):37-43. doi:10.1007/s00277-020-04256-3

CDC COVID-19 vaccine breakthrough case investigations team. COVID-19 vaccine breakthrough infections reported to CDC - United States, January 1-April 30, 2021. MMWR Morb Mortal Wkly Rep. 2021;70(21):792-793. doi:10.15585/mmwr.mm7021e3

Akinosoglou K, Tzivaki I, Marangos M. Covid-19 vaccine and autoimmunity: awakening the sleeping dragon. Clin Immunol. 2021;226:108721. doi:10.1016/j.clim.2021.108721

Boekel L, Kummer LY, van Dam KPJ, et al. Adverse events after first COVID-19 vaccination in patients with autoimmune diseases. Lancet Rheumatol. 2021;3(8):e542-e545. doi:10.1016/S2665-9913(21)00181-8

Rosenblum HG, Hadler SC, Moulia D, et al. Use of COVID-19 vaccines after reports of adverse events among adult recipients of Janssen (Johnson & Johnson) and mRNA COVID-19 vaccines (Pfizer-BioNTech and Moderna): update from the Advisory Committee on Immunization Practices - United States, July 2021. MMWR Morb Mortal Wkly Rep. 2021;70(32):1094-1099. doi:10.15585/mmwr.mm7032e4

Curtis JR, Johnson SR, Anthony DD, et al. American College of rheumatology guidance for COVID-19 vaccination in patients with rheumatic and musculoskeletal diseases: Version 1. Arthritis Rheumatol. 2021;73(7):1093-1107. doi:10.1002/art.41734