Un-expected Antigen & Antibody in a A group male patient.

[reagansimon]

Hello all,

The case

A 68 years male with a previous record(our hospital's) of A positive clinical data-NHL is undergoing regular transfusion.All of a sudden in our ortho biovue cassettes he showed reaction(2+) with reverse A1 cells.But on running parrallel with immucor method there was no discripancy.

On the otherhand we performed the blood grouping with the same sample by Grifols method.shockingly in this method we got 2+ reaction in forward B and the forward typing gave as AB and the reverse typing showed a result as O.

[TABLE=class: MsoTableGrid]

[TR]

[TD=bgcolor: transparent]Method

[/TD]

[TD=bgcolor: transparent]Anti-A

[/TD]

[TD=width: 62, bgcolor: transparent]Anti-B

[/TD]

[TD=width: 62, bgcolor: transparent]Anti-AB

[/TD]

[TD=width: 60, bgcolor: transparent]A1 cells

[/TD]

[TD=width: 60, bgcolor: transparent]A2 cells

[/TD]

[TD=width: 65, bgcolor: transparent]Bcells

[/TD]

[TD=width: 62, bgcolor: transparent]Anti-D

[/TD]

[TD=width: 83, bgcolor: transparent]Rh/control

[/TD]

[/TR]

[TR]

[TD=width: 73, bgcolor: transparent]Ortho

[/TD]

[TD=width: 62, bgcolor: transparent]4+

[/TD]

[TD=width: 62, bgcolor: transparent]0

[/TD]

[TD=width: 62, bgcolor: transparent]-

[/TD]

[TD=width: 60, bgcolor: transparent]2+

[/TD]

[TD=width: 60, bgcolor: transparent]-

[/TD]

[TD=width: 65, bgcolor: transparent]4+

[/TD]

[TD=width: 62, bgcolor: transparent]4+

[/TD]

[TD=width: 83, bgcolor: transparent]0

[/TD]

[/TR]

[TR]

[TD=width: 73, bgcolor: transparent]Immucor

[/TD]

[TD=width: 62, bgcolor: transparent]4+

[/TD]

[TD=width: 62, bgcolor: transparent]0

[/TD]

[TD=width: 62, bgcolor: transparent]4+

[/TD]

[TD=width: 60, bgcolor: transparent]0

[/TD]

[TD=width: 60, bgcolor: transparent]0

[/TD]

[TD=width: 65, bgcolor: transparent]4+

[/TD]

[TD=width: 62, bgcolor: transparent]4+

[/TD]

[TD=width: 83, bgcolor: transparent]0

[/TD]

[/TR]

[TR]

[TD=width: 73, bgcolor: transparent]Grifols

[/TD]

[TD=width: 62, bgcolor: transparent]4+

[/TD]

[TD=width: 62, bgcolor: transparent]2+

[/TD]

[TD=width: 62, bgcolor: transparent]-

[/TD]

[TD=width: 60, bgcolor: transparent]4+

[/TD]

[TD=width: 60, bgcolor: transparent]-

[/TD]

[TD=width: 65, bgcolor: transparent]4+

[/TD]

[TD=width: 62, bgcolor: transparent]4+

[/TD]

[TD=width: 83, bgcolor: transparent]0

[/TD]

[/TR]

[/TABLE]

In all the methods the antibody screen was negative.How can we sort this out?please shed light.

[lalamb]

edited - I got off topic...

Edited February 26, 2013 by lalamb

[Dansket]

Have you tested with anti-A1 lectin? Has patient been successfully transfused with group A rbcs? Current diagnosis?

[Malcolm Needs ☆]

There are several things that spring to mind.

1. As Dan asks, have you tested the patient with Dolichos biflorus?

2. Although your screen was negative (presumably at 37oC?), have you performed a room temperature panel? It may be that there is an anti-M (or other such specificity) there. No all methods detect all antibody specificities. It may be that Grifols' technology is particularly sensitive to detecting such antibodies, Ortho's slightly less so, and Immucor's still less so (no bad thing if it is a clinically insignificant "cold" antibody).

3. If Grifols' technology is particularly sensitive to detecting such antibodies, it could be that transfused red cells still in circulation could be sensitised with the "cold" antibody, and that this is what is being "detected" in the anti-B (although, it goes without saying, it shouldn't be, unless the cells are agglutinating prior to testing - but if this were so, you expect similar reactions by all techniques).

4. If this patient has recently had an infection, particularly one involving the alimentary tract, it could be that he has an acquired-B, and that the Grifols' anti-B is detecting that - again, I would hope not, but you never know.

[reagansimon]

Thank you all for the replies.....

will get back to you soon with more informations regarding this patient.

[Jyoung]

What method do you use for your antibody screen?

[galvania]

1. Your result in the Grifols method. Are you using Grifols cards? If so, I think the most likely reason for your reaction with anti-B in the Grifols cards is carry-over - drops from the anti-A well being carrieed over into the anti-B column. You should also check to see that the anti-B gel is not dried out. That would also give you a false positive result.

2. Your discrepant result with A cells. My guess is that you have a specific cold-reacting antibody that is present on some of those cells and not on others, and maybe even showing dosage. If your suppliers cells are pooled, look out for a mixed field result - that's usually quite a give-away.

3. You should also check to see whether this patient has had a non-ABO identical marrow transplant. That might give you all sorts of funny results.

[Malcolm Needs ☆]

Certainly hadn't thought of 3 Anna. Perhaps I should, before my lecture!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

[Jyoung]

Do you use gel method with all your different reagents or do you perform some tube?

I would start with ruling out.......

1. Rouleax

2. Anti-A1

3. Cold

4. Anti-M: Run back type with Ficin. If it goes away probably anti-M. Then you can go from there.

Lets us know what you find.. I'm curious.?

[drwajiha]

1) If this is an acquired B antigen the it can be identified / differentiated from true B antigen by using acidified anti-B.

2) Bone marrow transplant induced blood group changes usually give chimerism.

3) Have you done DCT ?

4 ) Try using O and auto control as part of panel of cells used in reverse typing. (O cells with known absence of M antigen will exclude interference form Anti-M)

5) Check if the patient has elevated levels of globulins.

Edited February 27, 2013 by drwajiha

[reagansimon]

Hello all

1)yes we did tested for A1 lectin -found to be positive(how significant it is? cos patient is undergoing regular transfusion)

2)The current diagnosis is Non-Hodgkins Lymphoma.No there was no marrow transplant done.

3)yes we did a DCT the results are as follows AHG Poly-2+,IgG-0,c3d-0,ctrl-0.Elution was non-reactive to all cells tested.

4)The interesting phase is ,yes we did an immucor panel(AHG phase is clear-37'c shows reactions) and came up with non specific antibody(probably cold).we concluded that the grouping discrepancy is due to this cold antibody.

Though the patient shows crossmatch compatible with A pos blood, we have been instructed to give cross match compatible O packed cells.

Thank you all for your interests and your suggestions were really helpful.

Routinely we use Ortho-Biovue for antibody screening,Grouping by both Ortho Cassettes and immucor tube technique.Only in this case we compared with Grifols to rule out the discripancy

[Rh-fan]

In method 1 and 3 you see no reaction with anti A,B is that a typing error or do I mis something?

[reagansimon]

@ Rh-fan both are reactions from cassettes which doesn't have anti AB.