Blood Res 2019; 54(3): 164-164
Neutrophil-erythrocyte rosettes in direct antiglobulin test-negative autoimmune hemolytic anemia
Hee Sue Park1, Kyeong Seob Shin1,2, Bo Ra Son1,2
1Department of Laboratory Medicine, Chungbuk National University Hospital, 2Department of Laboratory Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
Correspondence to: Bo Ra Son, M.D., Department of Laboratory Medicine, Chungbuk National University College of Medicine, 1 Chungdaero, Seowon-gu, Cheongju-si, Chungbuk 28644, Korea, E-mail:
Received: May 16, 2019; Revised: August 6, 2019; Accepted: August 9, 2019; Published online: September 30, 2019.
© The Korean Journal of Hematology. All rights reserved.

cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


An 83-year-old woman was transferred for antifungal therapy for candidemia that occurred during an intracerebral hemorrhage treatment at another hospital. At admission, complete blood count results were as follows: hemoglobin, 8.8 g/dL; white blood cell (WBC), 18.51×109/L; neutrophil, 16.66×109/L; platelet, 52×109/L; and elevated C-reactive protein (CRP) and procalcitonin, 32.47 mg/dL and 6.60 ng/mL, respectively. After anidulafungin treatment, WBC count and CRP level were normalized, but hemoglobin level continued to decrease. Test results for anemia were as follows: ferritin, 741.82 ng/mL; iron, 198 µg/dL; transferrin saturation, 87.6%; total iron-binding capacity, 226 µg/dL; folate, 6.4 ng/mL; vitamin B12, >2,000 pg/mL; lactate dehydrogenase, 538 U/L; total bilirubin, 4.99 mg/dL; collected reticulocyte count, 3.4%; and haptoglobin, 24 mg/dL. The direct antiglobulin test for IgG+ C3d was negative; hematuria was not observed. Considering these findings, autoimmune hemolytic anemia (AIHA) was suspected, and peripheral blood (PB) smear conclusively showed frequent neutrophil-erythrocyte rosettes [composite image of PB smear, Wright-Giemsa staining, ×400; (A) red blood cell (RBC) rosettes around neutrophils. (B) Few nucleated RBC were observed, but schistocyte or spherocytes were not observed]. The neutrophil-erythrocyte rosettes formation is a very rare AIHA phenomenon. This phenomenon is caused by the interaction between neutrophil Fc receptors and IgG-decorated RBCs.


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