False D antibody on Echo panel/screen cells? Patient D pos

[ckuehnl]

Hi. We encountered an interesting case tonight. A male patient with no history of transfusion (also said he's never been transfused) typed beautifully A Pos. His screen, however,  was positive 3+ for cells 1 and 2 and then D pos panel cells ranged from 1+ to 3+. The D negative panel was negative and antibody ID panel was positive for all D pos cells.

We then looked as his med list. He's on Bicalutamide, but there's no mention of BB interference in any literature I've Googled. He has a hx of prostate cancer and family hx of malignant neoplasms.

Tube results were negative across the board (I used both LISS and no LISS to see if any difference). They were text book, beautifully  negative at that for all phases.

DAT negative.

What could be an explanation of this??? Is there any cases of solid phase D reacting due to meds? Meds are the only conclusion we've come to so far. Any thoughts???

 

[Malcolm Needs ☆]

What were the auto and DAT results?

It may be a case of an auto-anti-LW, which sometimes comes about when the LW antigen disappears from the red cells, and an apparent "allo-anti-LW" is found in the plasma, witha negative auto and DAT.

[ckuehnl]

Negative and Negative. Patient isn't on TPN or any thrombocytopenia med  either.

His confirmation type specimen was drawn at 6am and all negative- Ran fine on the Echo. 

RN said both draws were in non-IV arm. 

[Malcolm Needs ☆]

I suppose that he is not a high-grade Weak or Partial D; they can make anti-D, sometimes with no apparent stimulus.

[galvania]

Was the tube test done on the same sample as the test on the Echo?

[jayinsat]

On ‎2‎/‎28‎/‎2016 at 7:46 AM, ckuehnl said:

Negative and Negative. Patient isn't on TPN or any thrombocytopenia med  either.

His confirmation type specimen was drawn at 6am and all negative- Ran fine on the Echo. 

RN said both draws were in non-IV arm. 

You state that the patient isn't on any thrombocytopenia meds.  Does that include WinRHO or RhoGAM?  Is the patient being followed for thrombocytopenia?  I'm sure you're aware that WinRHO (which is ANTI-D) is a common treatment for ITP when the patient is RH Positive and has not had a splenectomy.

[ckuehnl]

Yes. Same tube. We figured it must be a contaminant since the 2nd sample (drawn about 8 hours later) was fine on the Echo. P;us manual run of first sample yielding no issue. 

Plus original sample pointed to Echo issue. I'm thinking there's something in the prostrate drug that interfered. I'm not sure how long after administration of said drug the first sample was drawn (or if it was in fact from the arm like the RN stated (although I like to give benefit of doubt).

 

[galvania]

Could it be carry over?  Was there another patient tested just before who had a very high titre anti-D?

[ckuehnl]

jayinsat. No, the patient's platelets have remained in the 240 range. No thrombocytopenia diagnosis, nor meds on his list that would show any probs with our testing. It's an interesting mystery to all of us. I've Googled, PubMed and book searched and not coming up with an explanation so I'm wondering if we're going to see issues with the newer targeted cancer treatments. I know the ARC sent out a notification of 1 drug that's an issue. 

[AMcCord]

The Echo/solid phase is very sensitive for Rh antibodies. Just thinking out loud here (so to speak)... Did he receive (a large volume of) fluids between the time the two samples were drawn? If so, an antibody with a low titer might be diluted in the second sample and no longer detectable, whether allo- or auto-. 

Is the variability of reaction (1+ to 3+) consistent with the ID panel donor type? - in other words are the R1 cells reacting less strongly than the R2 cells or are the reactions variable without regard to the donor type.

[Malcolm Needs ☆]

33 minutes ago, AMcCord said:

The Echo/solid phase is very sensitive for Rh antibodies. Just thinking out loud here (so to speak)... Did he receive (a large volume of) fluids between the time the two samples were drawn? If so, an antibody with a low titer might be diluted in the second sample and no longer detectable, whether allo- or auto-. 

Is the variability of reaction (1+ to 3+) consistent with the ID panel donor type? - in other words are the R1 cells reacting less strongly than the R2 cells or are the reactions variable without regard to the donor type.

Good set of questions, if I may so say!