A 63-year-old lady presented with fever, right hypochondriac pain, and jaundice for a week. Her full blood count showed severe anemia (Hb 64g/L) with presence of red cell agglutination (Panel A and B) and neutrophil-erythrocyte rosette (Panel A) in the peripheral blood film. Erythrocyte phagocytosis by monocytes were also seen (Panel B and C). There was raised reticulocytes (3.3%), LDH (303U/L [135-225]) and bilirubin (45.6umol/L [0-21] with positive direct Coomb’s test to C3d and IgG. Her cold agglutinin (CA) showed auto anti I specificity with titer of 32 at 4⁰Celsius. Anti-nuclear antibody (ANA) showed speckled pattern with titer of 80. C3 and C4 levels were within reference range. Apart from acute calculus cholecystitis, lymphadenopathy or hepatosplenomegaly was not detected in CT scan. She was initially treated with prednisolone before started on rituximab. She is currently stable and due for her 4^th cycle of rituximab.

Erythrophagocytosis is a rarely seen phenomena in CAD and usually associated with high titer CA, however this patient had low agglutinin titer yet demonstrated significant erythrophagocytosis. Neutrophil-erythrocyte rosette is an uncommon finding in autoimmune hemolytic anemia (AIHA) however it was not associated with CAD, but this patient demonstrated this in her peripheral blood film. This could be due to presence of IgG in the patient’s coating the erythrocytes which react with neutrophils Fc receptor.