A 48-year-old man had jaundice for three months. Investigations revealed bicytopenia [hemoglobin, 4.5 g/dL; platelet, 30,000/µL; white blood cell (WBC), 11,000/µL], unconjugated hyperbilirubinemia (3.4 mg/dL), and elevated hepatic transaminases (aspartate aminotransferase, 147 IU/L; alanine aminotransferase, 297 IU/L). The peripheral blood smear (PBS) revealed anisopoikilocytosis, macroovalocytes, polychromasia, nucleated red blood cells (RBCs), microspherocytes, and RBC agglutinates. The corrected reticulocyte count was 9.76%. The direct Coomb's test was positive (4+). The indirect Coombs' test showed panagglutination. Other laboratory investigations were unremarkable. Fibroscan revealed advanced fibrosis (2.0 KPa). For immune-mediated hemolysis, 50 mg of prednisolone once a day was started.
On day 5, PBS showed unremarkable WBC and platelet morphology. On day 15, granulocyte nuclei showed projections