Delayed-Onset Autoimmune Hemolytic Anemia in Advanced HIV With Cerebral Toxoplasmosis

Autoimmune hemolytic anemia (AIHA) is an uncommon immune-mediated complication of human immunodeficiency virus (HIV) infection and represents a rare cause of anemia in this population. While anemia in HIV is typically multifactorial, AIHA has most often been reported early in the disease course or around the initiation of antiretroviral therapy. Delayed-onset AIHA developing during prolonged hospitalization is rarely described, particularly in patients with advanced immunosuppression. We report a case of delayed-onset warm AIHA occurring more than two months after admission in a patient with newly diagnosed advanced HIV infection complicated by cerebral toxoplasmosis. The patient developed acute hemolysis with laboratory evidence of immune-mediated destruction of erythrocytes after a period of clinical stability. Secondary causes of hemolysis were excluded, and the patient demonstrated a favorable response to corticosteroid therapy without relapse. This case highlights that AIHA may occur late during hospitalization, including during periods of partial immune recovery following antiretroviral therapy. Clinicians should maintain a high index of suspicion for immune-mediated hemolysis in patients with HIV who develop unexplained anemia. Further studies are needed to better understand the mechanisms underlying delayed-onset AIHA and its relationship to immune reconstitution.