Anti-D with no hx of tranfusion and no recent pregnancies

[cmiller]

Just curious about possible explanations for the following scenerio:

71 year old white female

Group A, Rh Negative

Anti-D identified 2/5/10 with 3+ reactions using Gel.

No other history available.

The patient states that she has NEVER been transfused and her last child is 47 years old, no pregancies or miscarriages after.

I would find it highly unusual for a potential Anti-D produced as a result of pregnancy to still be reactive at all, let alone 3+, 47 years later, at least not without some stimulation.

Any thoughts on what might cause this, medications, medical conditions or diagnosis?

Some one mentioned 5q- syndrome might casue this, but haven't been able to find any info.

Input would be appreciated.

Thanks so much.

Candace

[Malcolm Needs ☆]

Just curious about possible explanations for the following scenerio:

71 year old white female

Group A, Rh Negative

Anti-D identified 2/5/10 with 3+ reactions using Gel.

No other history available.

The patient states that she has NEVER been transfused and her last child is 47 years old, no pregancies or miscarriages after.

I would find it highly unusual for a potential Anti-D produced as a result of pregnancy to still be reactive at all, let alone 3+, 47 years later, at least not without some stimulation.

Any thoughts on what might cause this, medications, medical conditions or diagnosis?

Some one mentioned 5q- syndrome might casue this, but haven't been able to find any info.

Input would be appreciated.

Thanks so much.

Candace

Hi Candace,

Yes, anti-D can be detected for a quite remarkable length of time after the last apparent stimulation.

Just to check my facts, I went back to Mollison's Blood Transfusion in Clinical Medicine, Ed Harvey G. Klein and David J Anstee, 11th edition, 2005, Blackwell Publishing.

In Chapter 3 "Immunology or Red Cells", page 70, it is stated,

"...Some IgG antibodies (e.g. anti-Rh D) decline far more slowly and may be readily detectable 30 years after the last stimulus."

Whilst in Chapter 5 "The Rh Blood Group System (and LW)", page 191, it is stated,

"Anti-D can sometimes bedetected in the serum a very long time after the last known stimulus; for example, it has been found in a woman 38 years after her last pregnancy."

Whilst neither of these cases can compete with your 47 years, it seems likely that such an antibody (particularly if it were very strong when first stimulated) could be detectable for such a length of time.

Incidentally, we have been following an anti-D in a lady in her mid-twenties for about 5 years now, with a quantitation level of 35IU/mL (we start worrying about anti-D causing HDNF with a level above 4IU/mL) and she states quite categorically that she has never had a transfusion and has never been pregnant. I suspect that this anti-D, whatever its cause, will be around for many years to come.

:eek::eek:

[JOANBALONE]

We see this a lot in our Transfusion Service. Usually in older women (before RhIG was available) and some men too.

[jeanne.wall]

Candice, you didn't say how many pregnancies your patient had had but with multiple pregnancies she my keep making that Anti-D for many more years. I remember those Mom’s with babies that needed several exchange transfusions - they would have extremely high titers and then another pregnancy would come along and the titer would go even higher.

In the US, men that would have served in the Korean War show up with Anti-D. In that war, type O blood was transfused to everyone on the battle field, without regard to Rh type. Sensitized the Rh Negative, and a whole unit of blood (and they generally would be receiving more than 1 unit) would produce a high titer response as well. Jeanne Wall (one of those old Blood Bankers that remembers the world pre RhIG)

[jlemmons]

Sometimes women will be pregnant and not know it, then they miscarry and just think that they are having a heavier period. I've seen this several times at our hospital. They then will develop the Anti-D. And yes, it is possible for women to be pregnant and not know it.

[L106]

I agree with jlemmons' post. Sometimes early miscarriages are not recognized.

Regarding cmiller's original post: We have seen many cases of elderly people (in particular, women) with strong Anti-D. It's not that unusual.

[Malcolm Needs ☆]

I agree with jlemmons' post. Sometimes early miscarriages are not recognized.

I also agree, but the lady about whom I wrote swears that she has had no opportunity to have had a miscarriage.

Mind you, having said that, she works at the world famous Kew Botanical Gardens, and she thinks that she "caught" the anti-D from an exotic plant!

You can make of that what you want!

:confused::):confused:

[L106]

Well, what exactly was she doing with the exotic plant ???!!!

[Malcolm Needs ☆]

Well, what exactly was she doing with the exotic plant ???!!!

Only she knows!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

I daren't ask!!!!!!!!!!!

:eek::eek::redface::redface:

[cmiller]

Thanks to all that replied. I was just surprised to see a 3+ reaction 47 years after childbirth.

I may set up a titer just b/c of my own curiosity.

Again thanks.

Happy Monday to you all.

[christineh]

We have had this happen at our hospital also.

[TimOz]

Not that I am suggesting this is the case here, but remember that alloantibodies can come from ANY red cell exposure, even seemingly minute amounts. IV drug use and renal dialysis are examples. There are a range of potential causes that are almost unfeasible but still possible like reused injection needles. Todays careful medical standards were not always so. A careful medical and indeed dental history may throw up some possible causes.

[csjuarez]

You might also consider, as far as the strength goes, that many antibodies seem to give stronger reactions in gel than in some other methods of testing.

[Dr. Pepper]

Candace, we too have seen many women in their 70s and 80s with nice strong anti-Ds. Posters have mentioned many sources of immunization. Pre-regional blood center, when we all had to procure our own donors, one would often run short of the rarer types. We had a neighboring hospital that, to conserve their Rh negative units, would routinely give D+ blood to D- patients if they were male or women past child-bearing age (and please define that!), figuring the worst that would happen was that they would be limited to Rh negs in the future. I did not agree with that strategy.

It's ironic that the IgG antibody that seems to persist in detectable levels the longest is also directed against the only antigen we type for routinely and try to avoid. If only anti-E, -K and -Jka would be as considerate!

[GlenDietz]

When checking transfusion histories for patients who have formed anti-D (or other blood group antibodies) it is important to ask the patient about other forms of blood exposure besides transfusion if the patient denies previous transfusion or pregnancies.

In the past our laboratory identified patients who had formed anti-D in response to a bone transplant. We had another young women who was an intravenous cocaine user and who shared a needle with her boyfriend who was Rh positive (it was their practice to "flag" the hit by drawing back on the syringe to ensure the needle of the syringe was in a vein). We also identified patients who formed anti-D after receiving platelet and/or plasma transfusion.

All of these sources of blood exposure are documented in the literature. We published an article about the IV drug abuser we found had formed anti-D (Chin-Yee I., Dietz G. and Marshall J. Alloimmunization and intravenous drug abuse. CMAJ 1989;141:1160-1161.)

Glen

[Mabel Adams]

It probably wouldn't be so strong in tube testing. Did you ask her if any of her children were jaundiced at birth? We see lots of little old ladies with anti-D that aren't likely to have had any stimulation but pregancy many years ago.

[David Saikin]

Also, this ab was 3+ in gel - if you used tubes it might only be 1+. Remember the sensitivity of your test system is logarhymically more so than tubes.

[Malcolm Needs ☆]

Also, this ab was 3+ in gel - if you used tubes it might only be 1+. Remember the sensitivity of your test system is logarhymically more so than tubes.

Very true David.

[Mabel Adams]

Years ago we had a dialysis patient that made anti-D when there was no stimulating event in her history from all the careful digging I could do. I explored anti-LW and everything I could think of. Eventually, I concluded there must have been some minimal exposure to other dialysis patients' blood that sensitized her. Back then, they were at high risk of hepatitis probably partly for the same reason that she made anti-D and somewhat because of the less sensitive Hep B tests they did back then (remember the Australia antigen test?) so donors transmitted it. Still, kinda creepy to think you were sharing a machine that maybe wasn't clean enough to keep from antigen exposure to D--much less Hepatitis.

[jeanne.wall]

... (remember the Australia antigen test?) ...

Mabel - You are bringing back memories! I can remember going to a state lab meeting and one of the sessions was talking about the implementation of the Australia Antigen test and the potential impact on the Blood Banking industry! I remember drawing donors for emergencies and all we tested for was syphilis, times have certainly changed. The speaker didn’t prophesize where we are today. It is amazing when you think about the progression.

Thanks for reminding me how far we have come. Jeanne

[L106]

Oh, I remember those days, too, when the "AA" (Australian Antigen) test was new and somewhat experimental. I also remember a situation where one of our hematologists/oncologists solicited several of us in Blood Bank to be drawn for a unit of blood in the morning so we could centrifuge them and make "fresh" platelet concentrates to give to a patient having surgery that afternoon. (Boy, what we do for our jobs sometimes!! Talk about customer service!)

[AMcCord]

I've also been a walking blood bank in the past. I got called in one day on my day off years ago because there was a bad trauma case and they needed more hands. Once I got there, I was asked my blood type and the medical director decided they needed my blood worse than they needed my hands! One of our local state troopers and the hosptial CEO were O neg. They got a lot of calls and were always very willing donors.

The craziest situation was that one of our surgeons always wanted 'fresh, whole blood' and he would march over from surgery once his patient was on the way to the recovery room, demand that we draw a unit of his blood, grab the unit out of our hands immediately after we pulled the needle from his arm and take it straight to the patient and hang it. (We scrambled to do the quickest crossmatch we could once he stomped out the door, blood in hand.) Crossmatch? He didn't need no stinking crossmatch!!! His blood was perfect. Our medical director lacked the fortitude to stop him. Those were the days..........and I'm glad they are dead and gone!

[Malcolm Needs ☆]

I've also been a walking blood bank in the past. I got called in one day on my day off years ago because there was a bad trauma case and they needed more hands. Once I got there, I was asked my blood type and the medical director decided they needed my blood worse than they needed my hands! One of our local state troopers and the hosptial CEO were O neg. They got a lot of calls and were always very willing donors.

The craziest situation was that one of our surgeons always wanted 'fresh, whole blood' and he would march over from surgery once his patient was on the way to the recovery room, demand that we draw a unit of his blood, grab the unit out of our hands immediately after we pulled the needle from his arm and take it straight to the patient and hang it. (We scrambled to do the quickest crossmatch we could once he stomped out the door, blood in hand.) Crossmatch? He didn't need no stinking crossmatch!!! His blood was perfect. Our medical director lacked the fortitude to stop him. Those were the days..........and I'm glad they are dead and gone!

Hmmm. I'd be a bit worried about his blood-borne viruses.

I wonder if he ever worried how much the damages would be were his blood to infect the patient with, for example, Hep C?

:eek::eek:

[TimOz]

Walking blood banks are not uncommon in very remote part os Australia. It is organised and potential walking donors are prequalified, tested and are screened for infectious diseases on a routine basis. They are not used except as a last resort like a mining disaster in a very remote area. Better to preplan and keep the potential donors tested. There os not guarantee that you will hit a window period infection but this system lowers the risk significantly.

[jeanne.wall]

Hmmm. I'd be a bit worried about his blood-borne viruses.

I wonder if he ever worried how much the damages would be were his blood to infect the patient with, for example, Hep C?

:eek::eek:

I remember those docs as well! My experiences were when Hep C was non A, non B hepatitis and a long time before litigation - physicians were Gods and no one would consider suing a doctor! Now days, those kinds of docs would be out on their cans – no physician would consider that kind of behavior. Blood Banking certainly has changed in the last 40 years, it isn’t just about the knowledge, the technology, and the reagents – climate too! Maybe even for the better, although there is something to be said for the “good old daysâ€