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wAIHA with IgM and C3c/C3d coating


Letty

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Hello

We have a patient who has flummoxed our Haematologists and I wondered whether any of the experts could shed any light on the situation....

The patient is an 80 yr old female with an apparent warm automimmune haemolytic anaemia post THR.  She has previously had a low-ish but stable haemoglobin of 105 g/L with a history of a positive DAT (C3b) and non-specific reactions in the BioVue IAT panel  (May this year).  She has been actively haemolysing since her operation with evidence of spherocytes and polychromasia in her blood film.

Our reference service has reported the following:

DAT IgM 2+ C3c 2+ C3d 4+ and an enzyme only pan-agglutinin.

There is no evidence of cold agglutinins present in any of her samples.  

Is it possible to have a warm autoimmune haemolytic anaemia associated with IgM antibodies and why would she suddenly start haemolysing post-op with no evidence of previous active disease?

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Well, it could be a WAIHA that is IgM - they are rare, but they do exist (in the same way that cold autoimmune haemolytic anaemia caused by an IgG antibody can exist - again, though, these are very rare), however, it could also be that the hip that was being replaced had some form of bacterial infection, and that, during the THR procedure, some of the bacteria escaped into the circulation.  It COULD be worthwhile just checking for bacteria in the circulation and, if they are present, putting the patient on a broad spectrum antibiotic, until the sensitivities are performed.  It may well be that the patient is already on a broad spectrum antibiotic, and it may just need to be a higher dose.

No way am I saying that this is the answer, but it is one possibility.

The other thing is, have your flummoxed Haematologists spoken to your local Reference Laboratory Consultant, rather than just relied on the laboratory results?  They probably have, but it is worth checking - just in case!

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3 hours ago, SMILLER said:

Isn't it possible, for a new antibody, to have both IgM and undetectable IgG produced at the same time, or even IgM without IgG, at least at first conversion?

Scott

Most certainly it is Scott, but it would be hugely unusual for such an antibody to cause gross haemolysis, particularly in a patient of such an advanced age - but - by no means would I rule out your excellent suggestion.

 

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I agree 100% with you that anti-Vel can be a real problem, but that problem can be a real problem not just when the antibody is new.

It is one of the few antibodies that are best detected by the two-stage indirect antiglobulin technique (see Geoff Daniels' book, Human Blood Groups), but I don't know of anyone in the world who uses that technique as a routine.  The reason that this is the best technique to use for anti-Vel is that it is much more easily detected with anti-C3d than either anti-IgM or anti-IgG, however, of course, in these days of automation, most people use samples that have been anti-coagulated with EDTA.  This means that the calcium, magnesium and manganese ions required as co-factors in the initiation of the classical complement pathway are not available, and so we no longer see the tell-tale haemolysis in our tests that is normally seen with an anti-Vel (and, of course with ABO antibodies, some anti-I antibodies from an adult i individual, anti-P+Pk+P1 from a p individual, and IgG anti-Lea).

Indeed, I think I have noted on Pathlabtalk before that I know of one case of anti-Vel that proved to be fatal, which was only ever detected in a clotted sample from the patient, but NEVER in an EDTA sample.

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6 hours ago, yan xia said:

what is two-stage indirect antiglobulin technique, does it mean we add extra complements from fresh serum? I remember some method like that, but I am not sure about the name.

Yes,   you are completely right Yanxia.

Briefly, the patient's plasma and reagent red cells are incubated at 37oC, as for a normal tube IAT, to allow the antibody in the plasma to sensitise the antigens on the red cells.  The tests are then washed free of unbound antibody (as for the normal tube IAT), but then, instead of adding AHG at this stage, fresh ABO compatible serum (it has to be serum, rather than plasma, to ensure there is complement there to initiate the classical complement pathway), which is known not to contain any atypical antibodies (we used to use AB serum from a source that had been extensively tested and found to be free of any such antibodies) and mixed with the red cells.  The tests are then incubated again at 37oC, to allow for the complement cascade to be initiated, and then washed again, as for a normal tube IAT.  Lastly, monospecific anti-C3d is added, and the tests GENTLY centrifuged, and examined for agglutination.

A negative control, using the inert AB serum, rather than the patient's plasma, must be set up and tested in parallel.

Of course, such a technique can only be performed by tube, capillary, tile or liquid-phase microtitre plate techniques, as column agglutination and solid-phase microtitre plate techniques cannot be used.

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2 hours ago, galvania said:

going back to the AIHA, I wonder if there's a warm IgA component in there?

I would doubt it Anna, because all of the NHSBT Reference Laboratories use the BioRad DAT card that contains the monospecific anti-IgG, anti-IgM, anti-IgA, anti-C3c, anti-C3d sera and the control, so I would have expected an anti-IgA component to have shown up on the patient's red cells; but you never know.

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  • 3 months later...
On 11/21/2017 at 5:58 AM, galvania said:

OK Malcolm, in that case you can exclude it.  I hadn't noticed the little English flag on the first post!

Has anyone thought to do an eluate?  That might be helpful

Hello, I am learning so much from you guys here as usual. I also realized this english flag along with the 2+ IgM on the DAT result. I started wondering what kind of direct antiglobulin test is performed to detect anti-IgM in the UK. Do you have liquid antisera (monoclonal, animal antisera etc) or anti-IgM suspended in gel? 

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14 minutes ago, dothandar said:

I started wondering what kind of direct antiglobulin test is performed to detect anti-IgM in the UK. Do you have liquid antisera (monoclonal, animal antisera etc) or anti-IgM suspended in gel? 

We do have some liquid monospecific anti-IgM (but I am now retired and cannot remember the name of the supplier - I will investigate), but the cards we use are those shown in the photographs in the Kidd HDN thread gagpinks started, which do have an anti-IgM column.

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  • 3 months later...
On 11/20/2017 at 9:27 AM, Malcolm Needs said:

I would doubt it Anna, because all of the NHSBT Reference Laboratories use the BioRad DAT card that contains the monospecific anti-IgG, anti-IgM, anti-IgA, anti-C3c, anti-C3d sera and the control, so I would have expected an anti-IgA component to have shown up on the patient's red cells; but you never know.

I read in Dr.Garratty's Immune Hemolytic Anemias textbook that Spontaneous agglutination is often seen with warm IgM cases. Would it be helpful to spin this patient's cell suspension with either saline or 6-10% albumin if the warm IgM AIHA is in question? And also preform titer and thermal amplitude test to see if antibody titer increases or decreases with higher temperature? 

Edited by dothandar
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9 minutes ago, dothandar said:

I read in Dr.Garratty's Immune Hemolytic Anemias textbook that Spontaneous agglutination is often seen with warm IgM cases. Would it be helpful to spin this patient's cell suspension with either saline or 6-10% albumin if the warm IgM AIHA is in question? And also preform titer and thermal amplitude test to see if antibody titer increases or decreases with higher temperature? 

What would be really helpful, and is quite simple, is to treat the plasma with 0.01M DTT (or ZZAP come to that), which will denature IgM molecules by breaking the J-chains.  This will show if the antibody is IgM or not.  Do not forget that some IgG antibodies can cause agglutination in the "cold" and the "warm", with no potentiating agents being present, so it is worth knowing, from the word "Go", with what you are dealing.

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