Hemolytic reaction?

[Dr. Pepper]

Please forgive the length of this but it has us stumped. We had a patient the other day who presented with a positive antibody screen. She had been worked up by a sister hospital three weeks earlier who found anti-E in gel and a "weak AHG panagglutinin in ficin" that they attributed to a possible cold agglutinin. She received 7 units of blood uneventfully. She has a bleeding duodenal ulcer.

We found very strong anti-E, anti-c, anti-K in her plasma. We do tube testing with LISS (Immucor Immuadd). The antibodies seem to be a mix of IgM and IgG, reacting 3-4+ at immediate spin, room temp, 37o and AHG. We eliminated other antibodies with homozygous (I know Malcolm, it's the genes that are homozygous!) screening and panel cells. A cold autoantibody was detectable at 4o. One c-E-K- unit was minimally reactive (very weak microscopic) in AHG; this reactivity prewarmed away.

She received two units of blood as an outpatient. She complained of a slight chill at the end of the 2nd transfusion, and had a temp rise of about 0.4oC. We got the specs for the reaction workup, and then the fun began. As luck would have it, we had a second shift call-out, so I worked an extra shift and got a little more than I bargained for.

Her post-reaction DAT was positive 1+ with anti-C3 and polyspecific AHG but negative with anti-IgG. So was the pretransfusion sample. The post-reaction sample looked icteric (amber) but not hemolyzed (pink). The pre-reaction sample was a normal straw color. Total bilirubin had risen from 1.0 pre to 3.0 post. We did not have a pre-reaction urine to compare but in the post sample she had 3+ occult blood with no intact RBCs. I didn't like any of this.

So I repeated the testing with the c-E-K- cells, all of which were negative with LISS but weakly positive with PEG (which could have been bringing up the cold agglutinin). Since something seemed to be going on with complement, I repeated some tests with serum and polyspecific AHG. The second unit was weakly incompatible in LISS/AHG, routine technique as well as prewarmed. An eluate from her post-reaction sample showed no antobody activity. We only had EDTA plasma left at this point, and our chem analyzer is not validated with EDTA plasma, but a haptoglobin on the sample was negative.

We were able to the patient back in later that night to our emergency department for examination. Her bilirubin was down to 2.0, her plasma looked better, and the occult blood was gone from her urine but she had 2+ urobilinogen. Her hemoglobin was 9.0. We had not tested her pre-transfusion, but another lab got 7.4 a few days earlier. She weighs 220 lb (100 kilo), one might have expexted a better rise in hemoglobin unless she had bled some more in between the two hgbs. Coag and the rest of her chemistry was normal. She felt fine and they sent her back to the nursing home.

The next day we tried some more testing with poly AHG and found two cells that reacted weakly in AHG, prewarmed. The cells were Jk(b+) and she had been typed before the transfusions 3 weeks earlier as Jk(b-). One of the 7 units she received earlier was K+, another c+, otherwise c-E-K-. Her prereaction cells were DAT-negative with anti-IgG and I saw no mixed-field microscopic reactions with anti-K and anti-c, so it seems that the units incompatible with the newly-appearing antibodies were long gone.

We suspected that there might be an anti-Jkb in there. Our local reference lab, alas, could not find anything other than what we had already identified. Something seemed to have happened with the two units we gave her, but I don't know what. She has the look of a repeat customer, does anyone have any ideas? Thanks - Phil

[Malcolm Needs ☆]

I just wonder if the units were transfused directly from the fridge? If so, given the fact that she is of small stature, I wonder if her peripheral temperature dropped sufficiently for the transfused red cells to be sensitised with the cold antibody and then some of these red cells removed by the RES.

This could explain the positive DAT by anti-C3, the unexpectedly small increase in the level of Hb, her symptoms of being "cold", but would not necessarily cause an overwhelming acute haemolytic transfusion reaction. Remember that the autologous red cells would be coated with C3dg, giving them some protection from in vivo haemolysis, whilst those that have been transfused would only be coated to C3d.

This is only some thoughts!

[galvania]

Hello Malcolm - I am so glad you think that 100kg is small stature. By that token I am sylph-like. You have made my day!!!!! (Would have added a smiley, but they've disappeared) But seriously, it sounds as though this lady makes antibodies very quickly. I would not discount the presence of a 'new' anti-Jkb and would recommend that you try and retest her in about a week's time - and do an enzyme Coombs

[Malcolm Needs ☆]

I'm glad I have made your day Anna. Believe me, compared to my stature, this lady is positively drawfish!

I agree with you entirely about the anti-Jkb and retesting the lady.

[Liz]

Exactly Anna, 100 kgs small!!! what great news!! Thanks Malcolm. I think that makes me underweight.

[Malcolm Needs ☆]

Hmmmm! Methinks I got that wrong!!!!!!!!!!!!!!

[Dr. Pepper]

I wondered about Malcolm's "small stature" myself, since the lady outweighs me by 50 lbs! I thought about the cold auto being the culprit, but it is not reacting much at all outside of 4o. And we couldn't find anything else, and although there were surviving donor cells post-reaction (niced mixed field with anti-Jkb and the hgb rise) there was no IgG on the cells. I remember Issitt saying if you have to go to extraordinary lengths to detect/ID an antibody, it probably is not of any consequence. (As opposed to our staff MD with CHD and a cold agglutinin titer of a half million or so. Her antibody jumps out of the tube and clubs you.)

By the way, our reference lab eliminated anti-Jkb by REST-adsorbing her serum and testing with PEG. We are going to try to get her drawn again and reevaluate.

[JOANBALONE]

Did you antigen type the 2 units she received for Jkb? Did you type her post reaction sample for Jkb?

JB

[Dr. Pepper]

Both units were Jkb(+), she had mixed field agglutination under the microscope.

[Ajac]

I would worry about the REST removing the IgM portion of an apparent Jkb and rendering it weak enough as not to react anymore. I know there are several reports of it removing clinically significant antibodies like Vel too.

Also, I wonder if the panagglutinin seen originally was the patient building the c,K, and possible Jkb. We used to see that type of reactivity and then like magic, a few weeks later a "new" antibody with a specificity would appear and panagglutinin would be gone. I would try to get a full phenotype on this patient. You may need to send her off for molecular typing since she's tranfused. It sounds like she's going to continue to build.

[Yanxia]

Dr.Pepper you say The second unit was weakly incompatible in LISS/AHG, routine technique as well as prewarmed

What about the first units crossmatch result after transfusion?

[Dr. Pepper]

Hi Yanxia - the first crossmatch looked fine, compatible with the specimens from before and after the transfusion.

[Yanxia]

Hi Yanxia - the first crossmatch looked fine, compatible with the specimens from before and after the transfusion.

Thanks, Dr.Pepper.

Now the patient have hemolysis sign and incompatible crossmatch , I prefer it is antibody caused hemolysis. Maybe to low frequency antigen .

The antibody caused hemolysis, it can be consumption, and too weak to be detected . Days later the antibody will produce and been detectable.

Edited February 13, 2012 by shily

[Mabel Adams]

I sure wouldn't ever give her Jkb+ blood in the future!

[Dr. Pepper]

We will try to get her drawn later in the week and take another look.