Transfusion reaction

[gagpinks]

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, 2016 by gagpinks

[Malcolm Needs ☆]

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).

[exlimey]

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.

[Malcolm Needs ☆]

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).

[gagpinks]

Thanks Malcolm and exlimey.!!!!

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

[Malcolm Needs ☆]

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.