Anti-D Epidemic

[Brenda K Hutson]

I recently posted a Thread under Case Studies which is continuing to be problematic; so thought I would try it here also to see if I get any other "thoughts."

We have just added yet another patient to this mystery!

In just the last couple of weeks, using Ortho GEL technique; we have had 3 Rh Positive individuals (typing strongly Rh POS) who appear to have Anti-D; all other major Allos ruled-out. 2 of the 3 have a Positive Autocontrol; but negative DAT with IgG and C3.

We sent the 1st one off to our Reference Lab and they called it a Cold Agglutinin?? So, I have not sent the other 2 yet as this does not make sense to me (and as I have always taught my staff anywhere I have worked, "things should make sense."). I'm not saying their conclusion was incorrect; just that there is something strange going on.

I would not expect that many Anti-LW's (1 person's suggestion; but anything is possible), anymore than I would expect 3 Anti-D in Rh POS patients in that short of a time-frame.

Auto-D Mimicking D 3 Partial D patients with Anti-D

And since 2 of them have been pregnant women, I cannot just settle for transfusing Rh NEGATIVE RBCs; I need to figure this out. I think I will call Ortho Technical Support today also.

HELP MR. WIZARD.....

Brenda Hutson, CLS(ASCP)SBB

[Malcolm Needs ☆]

Auto-anti-D, and auto-anti-D-like antibodies are much more common than a lot of people think. Even though the DAT is negative with the 2 that are DAT negative, but auto positive, it may still be worthwhile performing an elution if you are able so to do in your laboratory. You may find that the antibody in the eluate reacts more strongly with D positive red cells than D negative.

I would also go with the idea of testing with group O, D negative cord cells, just to see if one or more of these patients has actually got an auto-anti-LW.

I can well understand your reluctance to send samples from the second and third patients to your Reference Laboratory (especially as they don't have the extended anti-D panel - seems a bit strange that, to me) but, that notwithstanding, I still think that it would be a good idea so to do - and get them to send the samples on to someone who has got the necessary extended anti-D panel and, possibly, to perform tests at the molecular level to see if any of these three have a Partial D phenotype.

I'm not sure how much more you can do in your own laboratory - which must be extremely frustration.

[Brenda K Hutson]

Thanks Malcolm! (and everyone else who is trying to assist with this enigma)

So here is my direction at this point:

1. I am having a Tech. perform a Cold Panel on 1 of the 2 patients we have not sent to the

Reference Lab (just so that if we do end up sending it out, I can know for myself whether

there is a Cold Agglutinin there).

2. We "can" perform an eluate; I'll give that some thought.

3. I am having my Lead call Ortho Technical Support to see if they have any "words of wisdon."

And these are not weak antibodies; we are talking 2-3+. Very strange.

Brenda

Auto-anti-D, and auto-anti-D-like antibodies are much more common than a lot of people think. Even though the DAT is negative with the 2 that are DAT negative, but auto positive, it may still be worthwhile performing an elution if you are able so to do in your laboratory. You may find that the antibody in the eluate reacts more strongly with D positive red cells than D negative.

I would also go with the idea of testing with group O, D negative cord cells, just to see if one or more of these patients has actually got an auto-anti-LW.

I can well understand your reluctance to send samples from the second and third patients to your Reference Laboratory (especially as they don't have the extended anti-D panel - seems a bit strange that, to me) but, that notwithstanding, I still think that it would be a good idea so to do - and get them to send the samples on to someone who has got the necessary extended anti-D panel and, possibly, to perform tests at the molecular level to see if any of these three have a Partial D phenotype.

I'm not sure how much more you can do in your own laboratory - which must be extremely frustration.

[John C. Staley]

Do the 3 patients have any thing in common such as work enviroment. At a donor center that I supervised in the distant past we had a number of donors (3+ if I remember correctly) show up with an anti-K and no red cell exposure in any of their histories. We discovered that they were all working in the same area at the local Air Force base and exposed to the same enviromental possibilities such as chemicals. We eventually wrote it off as a reaction to the work enviroment as their antibody screens became negative when each of them moved on to other jobs.

Some times strange things just happen.

[goodchild]

I find that to be extremely interesting John, thanks for the anecdote.

[Brenda K Hutson]

Wow, now that is interesting! I don't know of any such similarities (except that 2 of them are pregnant). We did perform a cold panel on 1 of the 2 we have not yet sent to the Reference Lab (since that was their conclusion to the one we did send); it was Negative.

Thanks

Brenda

Do the 3 patients have any thing in common such as work enviroment. At a donor center that I supervised in the distant past we had a number of donors (3+ if I remember correctly) show up with an anti-K and no red cell exposure in any of their histories. We discovered that they were all working in the same area at the local Air Force base and exposed to the same enviromental possibilities such as chemicals. We eventually wrote it off as a reaction to the work enviroment as their antibody screens became negative when each of them moved on to other jobs.

Some times strange things just happen.

[John Eggington]

Any recent IVIg treatment?

[Rh-fan]

I have seen this kind of situation. 4 patient with an auto anti D, in 3 different hospitals.

They all received an organ from the same donor and this donor had a strong anti D. It took some time to see the connection.

Because 2 of your 3 are pregnant I dont think your cases can be due to organ transplant.

Peter

[Brenda K Hutson]

No IVIg.

Thanks

Brenda

Any recent IVIg treatment?

[Brenda K Hutson]

Well, I have seen my share of Auto Anti-D; and even a few partial D's with Anti-D; but 3 in a 2 week period? From a statistical standpoint, just doesn't seem right....

Brenda

I have seen this kind of situation. 4 patient with an auto anti D, in 3 different hospitals.

They all received an organ from the same donor and this donor had a strong anti D. It took some time to see the connection.

Because 2 of your 3 are pregnant I dont think your cases can be due to organ transplant.

Peter

[dcubed]

When I did my clinical training as a Med Tech student I remember my blood bank instructor saying "antigens and antibodies don't read the text books". And boy oh boy I have seen several examples over the years of things, that according to statistics should not have happened. One of the most memorable was in the days when an AHG crossmatch was done all the time, had a patient react with 3 of 4 random red cell units....turned out to be an anti V!!

Well, I have seen my share of Auto Anti-D; and even a few partial D's with Anti-D; but 3 in a 2 week period? From a statistical standpoint, just doesn't seem right....

Brenda

[Brenda K Hutson]

It's true; you just can't trust those pesky little critters!

Brenda

When I did my clinical training as a Med Tech student I remember my blood bank instructor saying "antigens and antibodies don't read the text books". And boy oh boy I have seen several examples over the years of things, that according to statistics should not have happened. One of the most memorable was in the days when an AHG crossmatch was done all the time, had a patient react with 3 of 4 random red cell units....turned out to be an anti V!!

[EDibble]

I don't suppose they are ITP patients getting WinRho? Being pregnant, probably not.

[Sko681]

Any WinRho? Had the pregnant woman had any prenatal work up done elsewhere recently? We merged with 2 other hospitals a few years back and we had a few instances where a patient had a history of being Rh negative and then when we got blood work for a subsiquent pregnancy...the patient was actually Rh Positive. We can only speculate that the tech doing the Rh typing missed the tube when putting in drops of anti-D. Sounds crazy....but did they get any RhoGam??

[Mabel Adams]

One fall a few years back we had a veritable outbreak of warm autoantibodies-several times the number we usually saw in such a time period. Since autoantibodies of some types are known to be stimulated by viral infections, I figured that they had all contracted the same infection. It would still seem strange that you would have such strong reactions in the screen/panel cells with such weak DATs but it still might be just the way this autoantibody reacts. ....assuming it is an autoantibody. Or statistics could just be catching up with you. Random events do sometimes cluster.

[kate murphy]

Could the pregnant patients have received RHIG from another source? There is such variability in anti-D reagents now to different epitopes of the D antigen by different manufacturers, that another lab could have typed them as Rh Neg and they could have received RHIG from another source. So the anti-D you are seeing could be passive.

The non-pregnant patient may really be a D partial that made her own anti-D.

[Dr. Pepper]

Do the 3 patients have any thing in common such as work enviroment. At a donor center that I supervised in the distant past we had a number of donors (3+ if I remember correctly) show up with an anti-K and no red cell exposure in any of their histories. We discovered that they were all working in the same area at the local Air Force base and exposed to the same enviromental possibilities such as chemicals. We eventually wrote it off as a reaction to the work enviroment as their antibody screens became negative when each of them moved on to other jobs.

Some times strange things just happen.

I agree, that's interesting. There are other precedents like the anti-P1/pigeon fancier connection.

[Brenda K Hutson]

That is an interesting thought...I will have my Tech. call the Physicians just to rule that out.

I also know pregnant women can certainly get Warm Autos; but the one's I have seen have been non-specific and hitting all cells.

Thanks

Brenda

Could the pregnant patients have received RHIG from another source? There is such variability in anti-D reagents now to different epitopes of the D antigen by different manufacturers, that another lab could have typed them as Rh Neg and they could have received RHIG from another source. So the anti-D you are seeing could be passive.

The non-pregnant patient may really be a D partial that made her own anti-D.

[Brenda K Hutson]

Ah yes, I know at some places I have worked with a LOT of Reference work, we have thought there must be a Warm Autoantibody Season!

Brenda

One fall a few years back we had a veritable outbreak of warm autoantibodies-several times the number we usually saw in such a time period. Since autoantibodies of some types are known to be stimulated by viral infections, I figured that they had all contracted the same infection. It would still seem strange that you would have such strong reactions in the screen/panel cells with such weak DATs but it still might be just the way this autoantibody reacts. ....assuming it is an autoantibody. Or statistics could just be catching up with you. Random events do sometimes cluster.

[Malcolm Needs ☆]

I agree, that's interesting. There are other precedents like the anti-P1/pigeon fancier connection.

I'm glad you brought that up Phil. I say that whenever I am lecturing on the P1Pk Blood Group System, and none of the students ever believe me any more, as racing pigeons in the UK is a very minority sport these days.

[James Smith]

What about D mosaic where missing parts of the antigen caused formation of a "D like antibody" which is the antibody to the parts the patient is missing...Jamie

[Dr. Pepper]

I'm glad you brought that up Phil. I say that whenever I am lecturing on the P1Pk Blood Group System, and none of the students ever believe me any more, as racing pigeons in the UK is a very minority sport these days.

I have attached part of my lecture on the blood groups that I've been doing for a few years. (I've added my voiceovers in quotes.) It may not help Brenda with her autoanti-Ds but might brighten up your day for a moment. Most BB lectures are pretty dry, I try to have a little fun with my students.

[Barbarakym]

2 of the 3 have a Positive Autocontrol; but negative DAT with IgG and C3.

there is something strange going on. Brenda Hutson, CLS(ASCP)SBB

Do you do Tube method of Auto Control or Gel? Same for all DAT tests?

[Barbarakym]

Could the pregnant patients have received RHIG from another source? There is such variability in anti-D reagents now to different epitopes of the D antigen by different manufacturers, that another lab could have typed them as Rh Neg and they could have received RHIG from another source. So the anti-D you are seeing could be passive.

The non-pregnant patient may really be a D partial that made her own anti-D.

Very good point. Some places call women POSITIVE if weak D and do not give rhogam, but with AABB standards re-defined in last few years.... Weak D patients should still get rhogam. AND since reagents are so variable..... perhaps these women DID get rhogam... Was that ruled out?

[Brenda K Hutson]

That would be the Partial D with Anti-D which has been mentioned in some of the other responses. So yes, that is a definite possibility.

Brenda

What about D mosaic where missing parts of the antigen caused formation of a "D like antibody" which is the antibody to the parts the patient is missing...Jamie