Microangiopathic hemolytic anemia differential diagnosis

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Associate Editor(s)-in-Chief: Mydah Sajid, MD[1]

Microangiopathic hemolytic anemia must be differentiated from following diseases:

Disease	Findings
Pseudo-TTP (Vitamin B12 deficiency)	Patients have neurological symptoms like numbness, ataxic gait and tingling along with macrocytic anemia. There is a reduced level of reticulocytes, with elevated levels of Lactate dehydrogenase (i.e. greater than 5000 U/L), methylmalonate, and homocysteine.
Pregnancy induced fatty liver	Patients presents with right upper quadrant or epigastric abdominal pain, nausea and vomiting. On laboratory work-up, there is hypoglycemia along with deranged liver function tests. There is elevated levels of bilirubin, alanine aminotransferase, aspartate aminotransferase, reduced antithrombin III and coagulation factors level.
Disseminated intravascular coagulation	Can occur in sepsis, and different malignancies like prostate cancer, Acute promyelocytic leukemia and Gastric cancer, there in increased consumption of fibrin. On laboratory work-up, there is reduced fibrinogen level, Auer rod in Acute promyelocytic leukemia and leukoerythroblastic picture, with nucleated [[red blood cell]s, poikilocytosis, left shift of white blood cells. In sepsis, there is elevation of procalcitonin along with positive blood culture and reduced levels of coagulation factors.
Endocarditis	Patients have multi-system involvement presenting with fever, sepsis, polyartharalgia, Janeway lesion, Osler’s node, and a new-onset or changed heart murmur. It is diagnosed clinically by Duke’s criteria. It is confirmed by blood culture and trans-esophageal echocardiography.
Evan's syndrome	Immune mediated thrombocytopenia and autoimmune hemolytic anemia. Coombs test positive. On peripheral blood smear, there are no schistocytes.
Antiphospholipid syndrome	Women have a history of artery thrombi and deep venous thrombosis in lower extremeties, recurrent abortion, stroke and headache. These patients have prolonged activated partial thromboplastin time and positive serology for anti-cardiolipin antibodies.
Malaria, Babesiosis	Patients presents with periodic spikes of high-grade fever with rigors, chills, nausea, vomiting, fatigue, myalgia and malaise. The intra-cellular parasite are identified on special stained peripheral blood smear.
Viral Infections	In specific viral diseases like Dengue hemorrhagic fever, hantavirus and filoviridae, there is significant thrombocytopenia. Patients have a recent history of travel. There are no signs of hemolysis on laboratory workup.