Acute hemolytic reaction by C3d?

[mpmiola 27]

Hello, I need help to understand this Acute Transfusional Hemolytic Reaction.

A patient under investigation for acute promyelocytic leukemia, after transfusion of red blood cells in group O, presented fever (38.6 ° C).

Immunohematological results of the patient:
- pre-transfusion: B negative, negative irregular antibody test, negative DAT, negative compatibility test

- post-transfusion: negative B, negative IAT, positive DAT 2+ (C3d only), negative compatibility test, negative eluate, negative anti-B test with eluate serum

Laboratory results:
- evidence of hemolysis: DAT + in the post-transfusion sample, hemoglobinuria, drop in Hb / Ht,
Elevation of lactic dehydrogenase.

Components installed on the right patient: YES

Transfusion within institutional protocols: YES

Questions?
What triggered this acute hemolytic reaction?
Which test to do now?

Edited August 25, 2020 by mpmiola

[Malcolm Needs ★ 4,921]

Just as a matter of interest, were the samples tested by the Blood Bank for compatibility EDTA samples?  If so, it might be worthwhile testing a clotted sample (i.e., using serum in the tests, rather than plasma) and using broad spectrum AHG.

It would be highly unusual, but it could be an antibody specificity (such as an anti-Vel) that requires active complement to be detected.

[exlimey 386]

1 hour ago, Malcolm Needs said:

It would be highly unusual, but it could be an antibody specificity (such as an anti-Vel) that requires active complement to be detected.

Especially if the beast in question is largely IgM.

[mpmiola 27]

2 hours ago, Malcolm Needs said:

Só por questão de interesse, as amostras foram testadas pelo Banco de Sangue para compatibilidade de amostras de EDTA? Nesse caso, pode valer a pena testar uma amostra coagulada ( ou seja , usando soro nos testes, em vez de plasma) e usar AHG de amplo espectro.

Seria altamente incomum, mas poderia ser uma especificidade de anticorpo (como um anti-Vel) que requer complemento ativo para ser detectado.

Thank you Malcolm, we do not test with serum, I will do the tests now

[Malcolm Needs ★ 4,921]

15 minutes ago, mpmiola said:

Thank you Malcolm, we do not test with serum, I will do the tests now

I hope I am not leading you down a blind alley!

[yan xia 199]

Is there any chance of the anti-B in the donor packed cells caused the heamolysis?

Because the free antibodies attached to the patient's cells, complements actived and cells hemolysis, so there is no free anti-B detected after transfusion. 

Edited August 26, 2020 by yan xia
typo

[mpmiola 27]

19 hours ago, mpmiola said:

Obrigado Malcolm, nós não testamos com soro, vou fazer os testes agora

We performed the tests with serum, everything negative.
The most likely suspicion is passive anti-B

[John C. Staley 1,193]

Just curious but does your facility not stock a supply of group B blood?  I'm only wondering why group O was used for the transfusion.  Only idle curiosity.  

[Baby Banker 85]

How many units of O were given?

[mpmiola 27]

On 26/08/2020 at 13:02, John C. Staley said:

Só por curiosidade, mas suas instalações não estocam sangue do grupo B? Só estou me perguntando por que o grupo O foi usado para a transfusão. Apenas curiosidade ociosa.  

We didn't have B- in stock

Edited September 1, 2020 by mpmiola
B-

[mpmiola 27]

We understand what happened. We received the patient 12 hours before this transfusion. Despite having denied previous transfusions, we contacted the health service of origin who informed us that he had transfused platelets in pool (600 ML) the group O. Therefore, we believe that the reaction after red blood cell transfusion was a coincidence, and the anti-B of the transfused platelets must be the cause of hemolysis.