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And lack of a steady response to previous medications, a trial of rituximab 375 mg M2 ; was given followed by a significant hematological improvement after the first dose Hb of 11.8 and platelet count of 139 000 mm3 ; . He was then evaluated by neurosurgery and a lumboperitoneal shunt was placed with further improvement of his neurological symptoms. The patient did not experience any adverse reactions to the first infusion of rituximab and continued receiving the same dose once a month accompanied by IVIG initially 1 gr kg dose, then 500 mg kg dose ; . The patient completed twelve courses of this treatment without any side effects. His Hb and platelet counts have remained normal last Hb of 11.8 gr dl and platelet count of 268 000 mm3 ; and he has not required any additional hospitalizations. His neurological symptoms subsided, and the last ophthalmological evaluation showed an almost complete resolution of the papilledema with significant improvement in visual acuity Right eye 20 Left eye 20 25 ; . Discussion AIHA is a disorder in which autoantibodies directed against red blood cells are produced. A positive direct Coombs' test is important for making the diagnosis. Eighty percent of patients with AIHA exhibit warm-reactive antibodies of the IgG class. The rest of the patients have cold-reactive autoantibodies of the IgM isotype. Approximately 50% of the cases of AIHA are idiopathic. Secondary cases are associated with underlying autoimmune, malignant, or infectious disorders and also with ingestion of certain medications. It is believed that patients with AIHA secondary to an autoimmune process have a genetic susceptibility and immune dysregulation that leads to the expansion and proliferation of auto reactive B-lymphocytes. Signs and symptoms of AIHA may include jaundice, pallor, tachycardia, low-grade fever, hepatosplenomegaly or lethargy. Laboratory studies reveal normocytic normochromic anemia with reticulocytosis or rarely reticulocytopenia. Peripheral smear may show changes due to hemolysis including schistocytes, spherocytes, poikilocytes, anisocytes, polychromasia, and nucleated red blood counts RBCs ; . Rouleaux formation may be seen on the smear in cold agglutinin disease.6, 7 In the pediatric population, AIHA may follow an acute infection or immunization. Most of these patients and flovent.

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