Hemolytic antibodies

[Antrita]

Has anyone seen an red cell antibody reaction that was only hemolyzed the red cells? I was working with a specimen that was "pink" not "cherry syrup" on a patient that was a hard draw and was thinking about the fact that I have never seen an antibody that only hemolyzed the red cells. It is important for transfusion reaction work-up that you don't start out with "cherry syrup" but where do you draw the hemolytic line on the initial antibody screen?

Antrita

[Malcolm Needs ☆]

Has anyone seen an red cell antibody reaction that was only hemolyzed the red cells? I was working with a specimen that was "pink" not "cherry syrup" on a patient that was a hard draw and was thinking about the fact that I have never seen an antibody that only hemolyzed the red cells. It is important for transfusion reaction work-up that you don't start out with "cherry syrup" but where do you draw the hemolytic line on the initial antibody screen?

Antrita

Hi Antrita,

The answer is "yes", but they are few and far between.

Mostly, this is because the specificity of the antibody is rare, or that the extreme potency is rare.

In the old days, we used to use the total haemolysis of the test cells as a guide to the probable specificity, which was usually anti-H in an Oh patient, anti-Vel in a Vel- patient, anti-I in a ii adult patient or anti-P+Pk+P1 (anti-Tja) in a pp patient.

Just occasionally, we would also see this in a patient who had an extremely potent IgG anti-Lea, reacting strictly at 37oC.

Now, of course, everyone uses EDTA samples and, of course, the EDTA chelates Ca++, Mg++ and Mn++, all of which are required as co-factors in the classical complement pathway, and so I have not seen such an antibody now for many years (although we have seen the odd anti-Vel, anti-H and anti-I - they only caused agglutination because they came from EDTA samples).

Actually, the use of EDTA is a disadvantage to Reference Laboratories in such cases, as we no longer have the guide of haemolysis.

C'est la vie!

:):)

[Yanxia]

And anti-A, anti-B.:)

[Malcolm Needs ☆]

True!

[JOANBALONE]

Back in the day I have seen Lewis antibodies and anti-A1 antibodies hemolyze red cells as well as anti-A and B. This was due to our use of serum instead of plasma. I never see it now using gel technology and plasma. Once, I thought I saw hemolysis in a gel column and when I repeated the test no hemolysis was seen. When we use hemolyzed samples we will run an autocontrol to determine if any additional hemolysis is due to antibody/antigen reaction. Hemolysis may interfere with some automated (Provue) blood typing and antibody screen interpretations. Grossly hemolyzed samples are usually rejected.

[PammyDQ]

We reject grossly hemolyzed specimens. That was unavoidable when I used to work at a hospital with a Burn Center because certain types of burns (eg. gasoline) would cause the patient to hemolyze IN VIVO!

Once (in my 23 year career) I saw a hemolytic anti-LeA in an immediate spin tube crossmatch.

A cell button should be smaller than expected if there is hemolysis as a true reaction.

[Malcolm Needs ☆]

That was unavoidable when I used to work at a hospital with a Burn Center because certain types of burns (eg. gasoline) would cause the patient to hemolyze IN VIVO!

We often see gross haemolysis in patients with a really rampant "cold-reacting" auto-antibody, and this is equally unavoidable.

:)

[adiescast]

We had a patient once whose sample was black with hemolysis. We sent for recollect twice before someone thought to tell us that he had Clostridium sepsis and his blood really looked like that. Poor fellow did not last long after that, even with transfusion.

[AMcCord]

We had a patient with black serum a few hours post-transfusion. I about had a heart attack when the Chem folks showed it to me as a curiosity. I immediately started a workup and called my medical director so he could share my pain - DAT 4+++++, ABO types correct, antibody screen negative. Turns out the patient was an Onc patient who was in the process of taking her last breaths. Her disease state triggered the hemolysis. Her physician was actually aware of the hemolysis (red urine) but didn't think to pass that little tidbit of into on to us. The Onc nurses who were taken caring of her mentioned to me after we were well into the investigation "Oh, does it mean anything if her urine turned black while we were giving her the first unit of blood?". Scared the you-know-what out of me!

Edited January 12, 2010 by AMcCord

[Malcolm Needs ☆]

Other occasions where you might see a haemolysed specimen is when the patient is undergoing a hyperhaemolysis crisis and, I understand, although I have never seen a case myself, March Haemoglobinuria.

:):)

[PammyDQ]

We once worked up a trauma patient, 25yo female MVA. We sent 4 units of uncrossmatched O Negative red cells to the trauma room. While the antibody screen was incubating, a chemistry tech came to us with a specimen that was drawn after our TS specimen, they had just spun it and the serum was so black you couldn't see where the serum and cells met. The screen came out with a 3+ on one cell, and we tried notifying the ER that she was possibly having a hemolytic reaction(they were unimpressed). She unfortunately had a head trauma whose treatment of restricting fluids was opposite that of pushing fluids to treat the hemolytic reaction. She did not survive. The antibody was Kell....she received only 1 of the 4 units we had issued...the only one that was Kell+...

[Malcolm Needs ☆]

We once worked up a trauma patient, 25yo female MVA. We sent 4 units of uncrossmatched O Negative red cells to the trauma room. While the antibody screen was incubating, a chemistry tech came to us with a specimen that was drawn after our TS specimen, they had just spun it and the serum was so black you couldn't see where the serum and cells met. The screen came out with a 3+ on one cell, and we tried notifying the ER that she was possibly having a hemolytic reaction(they were unimpressed). She unfortunately had a head trauma whose treatment of restricting fluids was opposite that of pushing fluids to treat the hemolytic reaction. She did not survive. The antibody was Kell....she received only 1 of the 4 units we had issued...the only one that was Kell+...

In the UK, all the units of group O, D Negative emergency blood are also K Negative, for just such a situation.

Incidentally, whilst I was working at Westminster Hospital (now closed) I had a sample in from a member of staff working at the Houses of Parliament (not an MP) and this had plasma that was a distinct shade of brown. I had never seen a sample like this before, so I called my Reader in Haematology (one down from the Professor) to have a look at it. He had never seen anything like it before either, but it turned out it was a symptom of Legionnaire's disease, and that is what this patient had. As a result, they closed most of Parliament and put in new plumbing and air conditioning.

I always feel that I missed my chance in life to help my country by keeping quiet and letting the politicians get infected too!!!!!!!!!!!!!!!!!!!!

:devilish::devilish:

[L106]

Malcolm...........You are naughty!!!!

[PammyDQ]

Infecting your politicians would help your country? A Fawkes supporter are you?

[LaraT23]

We had a couple of patients with Black plasma/serum a few months back. Both had indweling filters in their arteries due to a clotting abnormality. Both patient's conditons exacerbated so they were hospitalized and given major clot busting drugs to help clear the micro clots clogging their filters. Weird.

Malcolm, I agree you should have kept silent, for all we know you could be running the country by now, what with all the politicos out with Legionnaires!

[Malcolm Needs ☆]

Suffice it to say that most politicians (of any party) are about as popular in the UK (and, I suspect in other countries) as bubonic plague (and about as useful).

:D:D:D:D

[Brenda K Hutson]

Not sure if this is what you are asking....but when a supervisor at a reference lab, we received hemolyzed specimens from a Hospital who first prewarmed away an anti-c, then on another patient, prewarmed away an anti-c and anti-E.

I also recall an interesting case (can't say it was "due" to antibody, but could have masked a transfusion reaction subsequently) where the patient admitted to the Hospital with hemoglobinuria and hemoglobinemia. I don't believe they ever figured out what had caused it but again, since that is something you look for in a transfusion reaction, it can have that added risk.

Again, my apologies if I misunderstood your question.

Brenda Hutson

[TimOz]

Down in this part of the world, in PNG and most of Asia we also have to think of snake bite when we se an undiagnosed patient with visible haemolysis in their blood sample, especially if they are unconscious for unknown reasons. Happens more than you would think.

[bbbirder]

In the Ozarks we can get patients with significant hemolysis from Brown Recluse spider bites.... but I digress from the original post... what was the question?

Oh yes...since we switched to EDTA, we will accept moderately hemolyzed specimens for pre-transfusion testing.

Linda Frederick

[Malcolm Needs ☆]

In the Ozarks we can get patients with significant hemolysis from Brown Recluse spider bites.... but I digress from the original post... what was the question?

Oh yes...since we switched to EDTA, we will accept moderately hemolyzed specimens for pre-transfusion testing.

Linda Frederick

I remember Malcolm Beck coming over to the UK and giving a lecture about Brown recluse spider bits, with some incredibly gruesome photographs (just after lunch, as it happens).

It was a an awful ong time ago, but I'm I also correct in thinking that he said, although the bite causes haemolysis, the antibody resembles an anti-e (which, of course, you would not expect to be haemolytic); or is my brain even more addled with age than I supposed?

:confused::confused:

[TimOz]

Hi Malcolm,

Addled for sure.

The Recluse spiders (Loxeceles spp.) have a range of toxins (digestive enzymes and immobilisation components) such as hyaluronidase, deoxyribonuclease, ribonuclease, alkaline phosphatase, and lipase. Some bites but very few cause symptoms of the so called "necrotising arachnidism" and even fewer show any systemic symptoms. Most are asymptomatic. The main culprit that causes necrosis and haemolysis is said to be sphingomyelinase D. The haemolysis does have complement involvement but there are no antibodies in spider venom and I cannot see how it would appear to have any antibody involvement or have apparent specificity.

L. recluse is the species most often seen in N. America and we now have them here (as if we don't have enough nasty native animals) but there are other S. American species that cause a number of deaths every year.

As with most spider bites the science is sketchy and evidence slim.

[bbbirder]

Ironies abound: as I was on-line on bbtalk last evening at home, we had a patient come to our ER, spider bite one week ago, wound on arm, HGB 4.5. Strong positive DAT (C3), cold agglutinin-like. CBC was a real challenge due to the clumping. Forward type required prewarming.

Our hospital's answer was to send her to the university medical center. We hope she does well.

Very scary! (We have these spiders all over in a detached garage, but have only seen one in our house.)

[Malcolm Needs ☆]

Hi Malcolm,

Addled for sure.

QUOTE]

Thanks for that Tim.

Now, are you referring to my bad memory over Malcolm Beck's talk, or is the "addled for sure" a general observation about my mind!!!!!!!!!!!!!!!!!!!!!!!!!!!!??????????????????

:eek::eek:

[TimOz]

Hi Malcolm,

Must be a typo. I meant NOT addled for sure.

And bbirder, interesting that you had an arachnid bite case with a DAT.

By the way, if you have dangerous spiders (and Loxoceles are dangerous) the best thing is to have resident Daddy Long Lebs spiders. These Pholcus species are the small bodied ones with the long legs that shake their web then you get close (not to be confused with the Mayfly like insect). They prey on other much larger spiders and are harmless to humans. The common rumour that they have the most toxic vennom in the world but their fangs are too short to envenomate humans is a complete myth.

[L106]

My goodness, TimOz, you certainly do know your spiders!! (In addition to lot of other things!) Interesting. Thanks for sharing!