Patient pre transfusion antibody screen was negative but DAT is positive IgG 2+. Pre transfusion Hb was 74 g/l.  After transfusion Patient bilirubin went up to 230 and Hb drop to 60 g/l  so clinician suspected transfusion reaction. Post transfusion sample :     antibody screen positive and found to  auto anti -e because auto control is positive and Patient is rrK-.   Sample sent to reference lab for eluate and reported as auto anti e. DAT positive Ig G 3+ and C3d 3+. Few hours later patient haemoglobin drop to 39 g/l. No underlying bleeding in this patient. Can auto anti-e cause this severe transfusion reaction or could be something else. Concerns was raised to reference lab and they suggested patient could be e varient . I was suspecting it could be anti Ce. How would you differentiate anti e from anti Ce ? Still waiting for reference lab report.

Edited December 19, 20168 yr by gagpinks

To me, it sounds like a possible case of hyperhaemolysis.  Is the patient of Black ethnicity?  If so, that would explain the apparent auto-anti-e (which, actually, may not be an auto-anti-e at all, but either an allo-anti-hr^B, or, more likely in this case, as the patient is an apparent rr, K-, an allo-anti-hr^S, which would explain the positive DAT and the eluate appearing to contain an anti-e in the post-transfusion sample), and the possible hyperhaemolysis.  I really cannot see any other reason for the drop in the post-transfusion Hb to well below the pre-transfusion Hb (and hyperhaemolysis can occur in individuals from ethnicities outside of the Black populations, e.g. a fatality involving a White patient with MDS, reported a few years ago by Win et al).

17 hours ago, gagpinks said:

I was suspecting it could be anti Ce. How would you differentiate anti e from anti Ce ?

I wouldn't worry about the possibility that the auto/allo antibody is Ce. Since the patient is Rh-negative (rr), any transfusions would also be Rh-negative  - the very great majority of which are also C-. Only a very small chance of finding a random r'r in your D- donor pool, not impossible, but remote.

I agree with Malcolm - hyperhemolysis (US spelling).  These folk have wacky immune systems anyway and the massive dose of foreign antigens delivered by a transfusion can cause them to react in strange ways. Earlier workers used the term "bystander hemolysis".

I understand that even with very low hemoglobiin levels, avoidance of transfusion in these persons seems to be the best practice.

2 hours ago, exlimey said:

I understand that even with very low hemoglobiin levels, avoidance of transfusion in these persons seems to be the best practice.

This is absolutely true, unless the low Hb becomes life-threatening in itself (in which case, the transfusion should be given with IVIgG and, possibly, methylprednisolone, or similar steroid, if time allows).

Thanks Malcolm and exlimey.!!!!

This is what our consultants suggested. Patient is stable now.  Could you please explain bit more about anti ce.  

Anti-ce is a so-called compound antibody (and is also known as anti-f).  It is an antibody that will only react with red cells that are derived from an individual who has the RHCE:ce gene, or, to put it more simply, it is an antibody that will only react with red cells that express both the c and the e antigens derived from the same haplotype (i.e. in the cis position), rather than derived from different haplotypes (i.e. in the trans position).  So, for example, the anti-ce will react with red cells that are DCE/dce (R_zr), but will not react with red cells that are DCe/DcE (R₁R₂).  It is actually usually made by an individual with the R₁R₂ phenotype (or probable genotype).  It is of fairly doubtful clinical significance (BUT, NEVER trust an Rh antibody).

Anti-hr^S, usually seen in individuals of Black ethnicity (who have an e variant, but who have been exposed to a "normal e antigen through pregnancy or transfusion - or both!), mimics an anti-ce.