Texas Tea TMC

From a letter to the editor author Marcos Paulo Miola 2012 www.rbhh.org:
"The LW and Rh antigens are phenotypically related in such a way that
RhD+adult individuals express the anti-LW much more strongly than RhD-
individuals.
The expression of LW antigens may be depressed without any apparent reason during pregnancy and
in some hematologic diseases (Hodgkin’s, leukemias, lymphomas, sarcomas), regaining the normal or almost
normal expression after pregnancy and with remission of the diseases(4). The LW antibodies are not uncommon;
they may be produced without apparent exposure during the suppression periods of antigens, generally associated
with other antibodies. They are generally IgG, do not cause hemolysis, do not activate the complement system,
react to anti-human globulin (AHG) and present strong reactions with RhD+red cells and may or may not react with RhD-.
The LW antigens are resistant to papain and chloroquine treatment but are denatured by treatment
with 0.2m dithiothreitol (DTT)(5,6). To distinguish anti-LW from anti-D, red blood cells must be treated with
DTT (it denatures LW antigens but not Rh) and/or test with red cells from umbilical cord blood (as umbilical
cord blood presents a high expression of LW antigens, the anti-LW reacts well with RhD+and RhD-
cells)(6,7)."

Lol, I somehow knew Malcolm would know one (or many) more this is true for :-D 
 

3 common interference possibilities
Rouleaux - look at the reaction under scope, see if you see the coin stack appearance. Resolve IS interference with saline replacement
Nonspecific cold agglutinin - perform mini cold screen   - one group O big I+ adult cell (screen cell works fine), one group O i cell (cord blood), and autocontrol. 2 drops patient plasma to each of those cells.  Read at IS, RT inc and 4C inc. If autocontrol and adult cell are positive, and reactions increase in strength with refrigeration, its usually presumptive nonspecific cold agglutinin. Resolve with prewarming the plasma to reduce interference at IS phase. May not work if cold agg is strong.
Cold preferring IgM antibody like an Anti-M or P that doesnt show in gel but may interfere in tube if the crossmatched unit is antigen positive.  Run a 3 cell tube screen with IS phase and a RT phase to get clean strengths to id the antibody. Your hospital policy should specify whether you need to antigen type units to get real crossmatch compatible, or just crossmatch untyped units until you get a IS XM compatible one. Most hospitals consider the common suspects (M, P, Le) not clinically significant if they are only showing at IS, but if you work at a place that requires IS XM on all rbc orders, and they want it "compatible" you might be stuck antigen typing.
And lastly always a chance the unit or patient ABO result is incorrect, repeat the ABO typing on patient sample and unit.  
  

3 common interference possibilities
Rouleaux - look at the reaction under scope, see if you see the coin stack appearance. Resolve IS interference with saline replacement
Nonspecific cold agglutinin - perform mini cold screen   - one group O big I+ adult cell (screen cell works fine), one group O i cell (cord blood), and autocontrol. 2 drops patient plasma to each of those cells.  Read at IS, RT inc and 4C inc. If autocontrol and adult cell are positive, and reactions increase in strength with refrigeration, its usually presumptive nonspecific cold agglutinin. Resolve with prewarming the plasma to reduce interference at IS phase. May not work if cold agg is strong.
Cold preferring IgM antibody like an Anti-M or P that doesnt show in gel but may interfere in tube if the crossmatched unit is antigen positive.  Run a 3 cell tube screen with IS phase and a RT phase to get clean strengths to id the antibody. Your hospital policy should specify whether you need to antigen type units to get real crossmatch compatible, or just crossmatch untyped units until you get a IS XM compatible one. Most hospitals consider the common suspects (M, P, Le) not clinically significant if they are only showing at IS, but if you work at a place that requires IS XM on all rbc orders, and they want it "compatible" you might be stuck antigen typing.
And lastly always a chance the unit or patient ABO result is incorrect, repeat the ABO typing on patient sample and unit.  
  

Our blood bank maintained warmers go out mostly to
1)people who are having clinical symptoms from their colds (autoimmune hemolytic anemia with activity at IS/RT, PCH/PNH).
or 2) patients with colds causing significant interference in multiple phases of testing.  Not just minor ABO mismatch that can be resolved, but strong reactions where the screen isnt negative initially either. REST x4 patients with grossly hemolyzed plasma, that kind of problem.  
ER/OR/ICU maintain their own blood warmers for use with patients having multiple unit transfusions fairly quickly. 

IMO AFAIK  LTOWB = low titer o whole blood  TXA= Tranexamic acid
Its the texting, abbreviations have gone wild :-)
 

A bit late for hopping in but. Another possibility suggests from the 2+ strength typing. Yes, it might just be heterozygous expression, but some techs will call a mixed field 2+. I know you said you didn't have transfusion history, but that's where I'd go first in workup before genotype. Try retic separation and retest.
If your patient had a low titer Jka, received unmatched units elsewhere either from this MVA as uncrossmatched units before transfer, or at an outside hospital between july and now, then came to you. I think it is feasible  you'd see this presentation.  DAT positive in c3d first as the Jka re-activates, an anomalous Jka+ result due to transfused cells but a clearly demonstrated anti-Jka. They could also have a weak expression variant of Jka, where they test positive but can form it. Or an auto Jka. But those are way less common than I think my boring scenario :-)
 

IMO AFAIK  LTOWB = low titer o whole blood  TXA= Tranexamic acid
Its the texting, abbreviations have gone wild :-)
 

Thanks, I've read a lot of your posts! Not all 3057, but appreciate the welcome  :-)
I've been in blood banking since 1995. Did a short stint in HPC for 8 years in NJ, but returned to my favorite department when moving back to TX.  I like the range of questions and experience levels on this forum, think it makes everyone feel like there's something useful here. Got a recent promotion so I suspect I will be paying more attention to the regulatory threads     
 

Thanks, I've read a lot of your posts! Not all 3057, but appreciate the welcome  :-)
I've been in blood banking since 1995. Did a short stint in HPC for 8 years in NJ, but returned to my favorite department when moving back to TX.  I like the range of questions and experience levels on this forum, think it makes everyone feel like there's something useful here. Got a recent promotion so I suspect I will be paying more attention to the regulatory threads