Mysterious Transfusion reaction

[gagpinks]

Interesting case

3 units were crossmatch electronically. After 1st unit patient developed chills,rigor and Temperature, therefore transfusion was stopped and requested for transfusion investigation requested.  

upon investigation it was found pre and post transfusion Antibody screen  and identification  Panel was also performed and negative on both sample. DAT was negative on pre transfusion sample and positive in post transfusion sample. Ig G 1+ C3d negative.  However crossmatch was performed by IAT and found to be positive 3+ reaction.  Pre and post Samples were sent to RCI for investigation.  Patien Billirubin and LDH went up significantly. Case was discussed with both consultants immediately.  

Reference lab found same result as lab result.  They also tested donor unit for some low frequency antigen such as Wra, Doa Dob , Coa Lua Kpa and found negative.  Unfortunately  due to unavailability of rare reagent RCI unable to solve the case. 

Patient was excluded from electronic issues. 

 

 

 

 

[jayinsat]

This looks like a typical reaction due to an antibody against a low frequency antigen (like anti-Dia). This is how they are usually found. If you have the ability, I would run a selected cell panel on the pre and post using panel cells that are positive for Dia, co, V, LuA, KpA, etc. If not, send it to your reference lab to identify the antibody against the low frequency antigen. In the meantime, as you have already done, all xm's should be AHG.

Edited August 28, 2023 by jayinsat

[Malcolm Needs ☆]

Interesting case, and I agree entirely that the patient should be excluded from electronic issue, but how this decision be made known to any other hospital?

I am somewhat surprised that the RCI Laboratory did not pursue the case further, unless no further samples were available, given that the patient underwent a classic acute haemolytic transfusion reaction, but I would also dispute that they tested the plasma against many (sufficient) low prevalence antigens.  Of those you list, Do(a), Do(b), Lu(a) and Kp(a) would all be classified as polymorphic in the UK greater than1% expression in the population - although I fully realise that this classification is NOT the same throughout the world), and Co(a) is a HIGH prevalence antigen.  In reality, therefore, the only low prevalence antigen against which they appear to have tested the plasma is Wr(a).

It may be helpful in such a case to know the ethnicity of the patient, the sex and, if female, any pregnancies (and if these all went to term, or were any of the babies affected by HDFN), and, if the male partner is still available, whether or not his red cells could be typed and, possibly, tested against the patient's plasma (assuming for the moment, the patient is a female).

I really am somewhat amazed that the RCI Laboratory did not submit a sample to the IBGRL.

[gagpinks]

1 hour ago, Malcolm Needs said:

I really am somewhat amazed that the RCI Laboratory did not submit a sample to the IBGRL.

Agree with you. No further samples were requested nor followed up 

Bit disappointed.

patient was transfusion dependent and doing well.

[gagpinks]

Patient is not sickle or Thal, however Patient is child bearing age. 

Do you think should RCI have to investigated more?

[Malcolm Needs ☆]

Thanks gagpinks.

Fine, but is the patient of anything other than (I'm not sure how to put this without offending people, but here goes) of pure UK ethnicity?

As the patient is of child-bearing potential, AND is transfusion-dependent, I am CONVINCED that RCI should have taken the investigation further!