Splenic arterial embolization for idiopathic warm auto-immune haemolytic anaemia

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Figure 1.

A 19-year-old female Jehovah's Witness presented to the emergency ward on Day 0 complaining of light-headedness. Her initial serum lactate dehydrogenase (LDH) was 617 iu/l [60–210], and haemoglobin concentration (Hb) was 71 g/l (top left). A peripheral blood film was consistent with warm auto-immune haemolytic anemia (AIHA) and a direct antiglobulin test showed strong agglutination to anti-IgG and weak reactivity to anti-C3. The eluate was equally positive against all cells tested. No precipitating cause could be identified. Despite immediate initiation of intravenous methylprednisolone and immunoglobulin, she became dyspnoeic and lethargic as her Hb gradually declined to 27 g/l. Although she was in a critical condition, transfusion was refused due to her religion. Therefore, selective arterial embolization was performed as an alternative to splenectomy.

The initial arteriogram (right panel, top) obtained on Day 4 showed normal splenic anatomy. The superior branch of the splenic artery was selectively embolized on Day 4 using a microcatheter with 700 μm particles followed by a 6 mm coil (right panel, centre). The inferior branch of splenic artery was embolised in a similar fashion on Day 8. A post-embolization arteriogram (right panel, bottom) showed a small patent lobar branch with minimal residual supply to the splenic parenchyma. Computed tomography (CT) with intravenous contrast obtained prior to selective embolization on Day 4 showed a normal spleen (bottom panel, left). At Day 8, a CT showed necrosis of the superior-lateral portion of the spleen consistent with selective embolization of the superior branch (bottom panel, centre). CT at Day 92 demonstrated that her spleen had undergone virtually complete necrosis (bottom right).

In summary, this was an unusual case of a teenage female with acute idiopathic AIHA whose religion precluded blood transfusion, and whose severe anaemia made her ineligible for splenectomy. She underwent a partial, followed by near-total, splenic artery embolization and experienced sustained remission of AIHA. Thus, splenic embolization may be a therapeutic option in selected cases of severe warm AIHA.

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