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There remains controversy about this, but we have been using leukoreduction as our only method of CMV risk reduction for close to 30 years, with no reported cases of CMV transmission. We have a 70 bed newborn intensive care unit, do about 180 stem cell transplants (about 40% allogeneic), and do the occasional intrauterine exchange transfusion. CMV serotesting is never necessary for donor blood in my opinion. The existing literature isn't entirely definitive but studies have not shown that combining leukoreduction and CMV serotesting has much, if any clinical benefit. Both observational series and randomized trials demonstrate that CMV transmission after leukoreduction is not any more common than after CMV serotesting. Indeed, most CMV transmissions are likely due to seronegative donors who have recently acquired virus, but are still seronegative, or at least that's one theory. Bottom line, if you are 100% leukoreduced there is no need for CMV serotesting.

The forward type is an AB patient, your reverse type looks like you have multiple things going on. Because of the negative xm with group O donor red cells and the 1+ reactions with your group A donor red cells, I suspect an anti-A1. However, that 4+ reaction on the B cells cannot be due to the anti-A1 and I highly doubt that it is due to rouleaux; At least from my experience I don't typically see rouleaux this strong and we should have seen it with similar strength against the A1 cells. I agree that you probably have a cold reactive allo antibody going on with the B cells. In order for you to clear the ABO discrepancy I would do an IS antibody screen and see if you find a patter for a common cold antibody. Hopefully your find something; if you find a Lewis antibody I would find some random group B units and you should statistically land on one that can give you a negative result against your patient plasma to confirm it is not an ABO incompatibility issue. If you find something like an M, you could antigen type a group B unit but that will take 5-6 units before you find one, and then test it again your patient plasma to confirm negative results. The easier way out is to prove your anti-A1 and then take your reverse cell testing to the AHG phase to rule out ABO incompatibility. Consult with your pathologist of course, since this might be out of your standard operating procedure.

Most CMV infections are acquired through environmental exposure, including breastfeeding from and close contact with a CMV infected mother. The likely source of the infection in question was exposure to family members, not transfusion. That's why close to 80% of adults in some populations are CMV seropositive. The virus is ubiquitous and highly infectious, but rarely causes any serious clinical effects except in utero and in severely immunocompromised patients.

Almost certainly because it is anti-A1, rather than rouleaux, or any other "cold" antibody specificity, such as anti-ALeb, but, come what may, unless the reactions are positive at STRICTLY 37oC, it will not be a clinically significant antibody.