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Strange Blood Type Discrepancy


Brenda K Hutson

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So we are still playing with this, as well as waiting for history and a new specimen on the patient, but in the meantime, thought I would throw this out (have not seen something like this before).

On automation (ProVue):  Anti-A=4+, Anti-B=2+, Rh OK, Reverse Type (both cells) NEG

In tube:                          Anti-A= 4+, Anti-B= 0, Rh OK, Reverse A1 cells= 0, Reverse B cells= 1-2+

Any thoughts/ ideas?  One thing I am going to do is Manual GEL to see if that matches the ProVue (so if at least, GEL matches GEL).

Thanks, :)

Brenda Hutson, MT(ASCP)SBB

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Ok, here is the rest of what I know at the moment (still trying to reach patient for more information; came in as just a WELL patient getting a flu shot and wanting a blood type):

ProVue Anti-B well= 2+ (Anti-A= 4+); Reverse Type= NEG

Manual Ortho GEL= same as ProVue

Erytra GEL= 4+ in both wells Anti-A and Anti-B; Reverse Type= NEG

So all of our GEL Testing is similar results.....whether automated or manual

Tube: Anti-A= 4+; Anti-B= NEG (but shook off roughly; Tech threw tubes away before I could view under microscope.....so being repeated at the moment); Reverse A1cells= NEG, Reverse B cells= 2+ (on incubation at RT)

Ok, clones (sorry, not sure if this is what you are looking for but is what I can get from Manufacturer's Insert):

The liquid reagent for the Anti-A tube testing is ALBAclone (Murine Monoclonal IgM); Cell Line LA2

The liquid reagent for the Anti-B tube testing is ALBAclone (Murine Monoclonal IgM); Cell Line LB3

We are also doing an Antibody Screen (though not ordered) just to see if there are any other surprises that might help us out (and/or make things worse...who knows)

This is SUCH a mystery to me.....I have never seen a discrepancy between methodologies for a blood type like this.  Could definitely use some assistance.

Thanks again..... :huh:

Brenda Hutson

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Sorry Malcolm...in response to your question about acquired B....I am re-reading inserts but what doesn't make sense to me in considering that is: 

1.  No evidence of acquired B in Tube Testing

2.  Tube testing seems to indicate a straightforward group A patient (though GEL does not); with exception of the fact that the reverse typing with B cells is weak....only becomes 2-3+ if incubated at RT

3.  No Reverse Type in GEL Testing (would expect strong reaction with B cells)

The insert for the Liquid Anti-B does state that "The Anti-B reagent derived from the cell line LB3 does not recognize this 'pseudo B' antigen.

Anti-B of GEL Card is from Line LB-2 (and states that clone was selected because it does not react with acquired B)

Thanks,

Brenda Hutson

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Ok, a little more information.....

The Tube Testing was repeated (incubated at RT for 15 mins.) and this time I got to the cards before they were discarded.  What I found was:

Anti-A= 4+

Anti-B = shakes off roughly; is very strong agglutination microscopically (not Rouleaux)

A1 Cells= Macroscopically NEG but microscopic Rouleaux

B Cells= 2-3+

Antibody Screen not yet performed.....so picture still confusing.:unsure:

Thanks,

Brenda

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ProVue (Automated Ortho GEL)

Erytra (Automated Grifols GEL)

Manual Ortho GEL

Manual Tube (Quotient Reagents)

Anti-A

Anti-B

A1 cells

B Cells

Anti-A

Anti-B

A1 cells

B Cells

Anti-A

Anti-B

A1 cells

B Cells

Anti-A

Anti-B

A1 cells

B Cells

4+

2+

0

0

4+

4+

0

0

4+

2+

0

0

4+

0

 (micro strong agglutination)

0

(Micro rouleaux)

2-3+ (incub RT)

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Thanks for all that Brenda.

It's getting a bit later over this side of the "pond", so I'm going to sleep on it and see if anything comes to mind.  Obviously, and this is very much "teaching my grandmother to suck eggs", if the worst comes to the worst, and the patient suddenly becomes unwell and requires a transfusion (remote under the circumstances, I know), you can always give group O!

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Right, so if there is a need to transfuse, of course we would give group O.....but this is too interesting not to figure out, right?! 

So, patient had just come in for a flu shot and Blood Type.  But looks like they have Chronic Kidney Disease.....and currently, proteinuria.

So I sent this out to one of the leading Antibody ID experts in this country and here were her thoughts (and I have to admit, none of these were my thoughts, but her knowledge is WAY above mine; so now it is even more interesting to me):

  1. First comment was......Well......this is a stumper!
  2. Best guess was an AB with a subgroup of B (and sadly, I have to admit, while I have seen plenty AsubB, I have never seen ABsub).  2+ is weaker than the usual forward group (which is why "I" thought that was 1 of the problems of the type; i.e. that was the part not to be trusted).
  3. Also, a variant B could explain how one monoclonal reagent failed to react.
  4. As for the unexpected reaction with one group B reverse cell, that is probably an antibody to a Low (e.g. Miltenberger) that happened to be on one group B cell.

Wow, I have been around awhile (30+ years of Blood Banking).....and even in reference lab supervisor positions.....but none of that occurred to me (I am embarrassed to say).  I was thinking more along the lines of the patient being A POS and there being something causing the "erroneous" weak reactions with Anti-B.

She recommends just transfusing with group O RBCs rather than an ABO Discrepancy work-up.....but now I really want to know! :) Plus wondering if the blood type was ordered because perhaps the patient is being considered for a kidney transplant?

I welcome any additional comments....suggestions....ideas.  Anything come to you in your dreams Malcolm? :unsure: I guess I will send this out to our Reference Lab and see what they can come up with.  Interesting case, that is for sure!

Thanks,

Brenda Hutson, MT(ASCP)SBB

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Hi Brenda,

Sorry not to have got back to you after my long slumber!

I would agree with everything your Antibody ID expert says, and just wonder, what with the possibility of a B subtype and the possibility of an anti-Mia, if the patient is from one of the Chinese ethnicities, or was originally from elsewhere else around that area of the world (or, of course, his family, if he was born in the US)?

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I like the sound of a weak B sub type.  I have seen several such beasts and they can give very variable results.  The best way to sort it out is of course some molecular biology; and if the patient is a secretor, you could do secretor status......

But never ever transfuse with group AB or B. That reaction with the B cells might just be a real anti-B.  I know of one death that was caused through transfusing B in such conditions.  Sorry.  Can't give any details, but was not in Europe or the States....

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If the reverse typing use the same A and B cells, then the differ between gel and tube are caused by the methods, otherwise, it maybe caused by low antibodies against B cells in tube method. To verify it, we can change to another B cells to test in tube method.

I tend to agree it looks like an ABsubgroup, on my daily use of gel, I find it is not as sensitive to detect reverse reaction as tube method, I  guess that is the cause of no reverse reaction on gel but has reaction in tube.

 

 

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So we sent this to our Reference Lab and they are still trying to figure it out. They ran additional B cells and those were also reactive, so likely not a Low.  Also ran mini-cold panel and A1 cells were reactive at 4C only.  Patient is A1 Negative.  Patient Reactive with several Anti-B Reagents.  They do not use GEL so all of this is tube testing, but they did duplicate our results.   Patient has Glomerulonephritis and is Asian.  The lab is going to try to test with some human antisera.....but may recommend molecular testing IF the physician really has to have a blood type (we could not reach Physician's office for more details Friday but will call today....I thought perhaps they ordered blood type because patient possible kidney transplant recipient in future.....but don't know for sure).  I will also pass on your suggestions to the lab as I think they are also stumped.  I really appreciate your input and will keep you posted.  If physician does not require definitive blood type, we will probably just restrict her to O RBCs and AB FFP and "call it a day." :unsure:

Brenda

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  • 2 weeks later...

Ok, and the winner from molecular testing is......cis AB!  (which was proposed by Monique).  I remember learning about that in Med Tech. training 30+ years ago....but can honestly say I have never come across it (so while it may have been my "thought" when I was a new Tech. (mainly because I hadn't seen or heard of much more than that), I have seen so many strange things since then that your mind kind of looks for the bizarre).  Also in my years, while I have seen plenty of strange and/or complex antibody issues, I have to say, I have not seen "all that many" complex Blood Types.  So very interesting for me! :)

Thanks again for all of your input,

Brenda Hutson

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