We have an interesting case that we could use some help on. We have a patient that has been getting transfusions for the past two years for anemia. No known cause for the anemia per the physician. Last week, he came in and screen adn crossmatches all neg. About 50 cc's into the transfusion, he spiked a fever. They stopped the unit and transfusion reaction workup was normal, including culture and gram stain.(no growth even after 5 days). They started the second unit after giving tylenol and Benadryl, about 15 cc's into the unit, he spiked a fever again. He walked out AMA after second reaction. Again everything normal. Today he came back in and his sample is icteric(previoulsy it was not). We did DAT, screen and full crossmatches. Everything is negative. According to the physician, there is no reason clinically why he should be hemolytic, nor does he have any known liver problems. They still want to transfuse tomorrow. Any ideas on why his serum would suddenly be icteric?

I am very interesting what kind of method you use to do screening and crossmatches.

We actually used gel and tubes. We have been trying everything to get an antibody to come up.

Looks like may be Kidd antibodies, since they come and go.

I would do an eluate from pre and post transfusion samples, eventhough DAT is negative

Could the patient have an antibody to an antigen that is not on your screening or panel cells? Might want to send specimen to a reference to test against cells with rare antigens. Just a thought.

I am assuming in your workup you did some full crossmatches to detect an antibody to an antigen not found on the screening cells and undetected by an immediate spin or electronic crossmatch. (We had a reaction due to anti-Wra last month that fell through this serological crack.) I agree that eluates are still a good idea; the technique can actually concentrate an antibody, particularly if tested with PEG or enzyme-treated cells. I have read about some antibodies causing reactions that were only detectable using Polybrene.

Hemolysis of red blood cells by a red cell antibody is just one of the possibilities in the differential diagnosis of icterus. Does the Hemoglobin/Hematocrit level suggest there is increased destruction of red blood cells? Has any laboratory testing been done for the common infectious diseases associated with icterus, e.g., Hepatitis A, Hepatitis B, Hepatitis C, CMV, EBV.........?

Is there a possiblity of red cell destruction caused an outside mechanical force, e.g. additional IV fluid running or medication?

What is the race of the patient. Some black patients will present with low levels of antibodies that sometimes are not picked up with conventional testing. The destruction can be immediate such as you might have found. I agree reference testing might be the best option especially if the eluate does not show anything. I would also try another method such as polybrene or LIS and increase the reaction time. We have found that the anti-S and anti-C are not always picked up with the Gel method. Don't forget to look at immediate spin reactions after a few days after transfusions to see if there is an anmnestic response.

Perhaps the patient is reacting to something other than RBC's. Could be a reaction to residual plasma or anticoagulant on the unit. Maybe other plasma proteins. Washing the unit (maybe even a double wash) may help and give you additional clues. We once had a patient similar to yours that reacted to everything (FFP, PLT PHERESIS,RBC, CRYO). The cause was determined to be plasma proteins. We had to double was all cellular products (RBC,PLT) and could not give plasma of any sort. She then tolerated transfusions well.

Hope this helps.

It sounds to me that somewhere along the line the point is being missed. This patient has been receiving transfusion for 2 years because of anaemia of 'no known cause'. Surely anaemia ALWAYS has a cause. Just transfusing the patient isn't really doing anyone any good. It is important to find out the cause of the anaemia and try treating the underlying cause.

Check the units - where did they come from; were they received in the same shipment (any problem with ice); were the units left out at RT for an extended period?

How thorough were your antibody id's? Maybe antibody to a low incidence ag. I encountered a scenario like this years ago (when we did AHG xm's on everyone). Absc negative, 3 out of 4 units were 3+ at coombs', panel negative. Was anti-Kpa, Jsa,-Lua. But I ramble and as I write this, it seems that if you did ahg xms you would have found incompatible units . . . did you recross the transfused units with the new sample? You were a bit vague on that point . . . if you did, then my diatribe is pointless. Your post-rx specimen may not have had enough transfused cells left to provide a +DAT since only about 60 cc were tx'd . . . I'd look low incident or send out to a reference lab.

What about the hematology disease, like hemoglobin disease or the erythrocyte membrane disorder?

Kidd antibody usually is involve in delayed hemolytic transfusion reaction... By the way you say it, maybe the patient is IgA difficient so he/she contains anti-IgA. The common reaction of this is anaphylactic type. So maybe you wanna try using washed red cells for that patient.