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Sudden Onset Hemolysis with weakened D antigen

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Does anyone have any experience with acute onset of hemolysis associated with decreased expression of D antigen?  Recently worked on a sample from 8 yr old child presenting with a 2.6 g/dL hemoglobin. Patient initially presented with weakened D expression and 23 days after discharge was typing as strongly Rh positive (verified with second sample).  Is it possible that the acute hemolysis was related to the weakened D typing?

Initial testing results:

                     Ortho MTS-Gel           Tube Method

Anti-A                  3+                              0

Anti-B =               3+                              0            

Anti-D=                3+                             1+

Control =              3+                             NT

Acells =              4+                             4+

B cells =               4+                             4+

Antibody screen         LISS/IgG (tube)              37C        IgG        Ortho Gel (IgG)

                                     SC 1                         W+          1+            3+

                                     SC 2                         W+          1+            3+

                                     SC 3                         W+          1+            3+

Differential PEG adsorption was performed and adsorbed plasma was non-reactive when tested against screening cells (same cells used in LISS/IgG screen).

DAT was 1+ using polyspecific AHG and anti-IgG. (Negative with anti-C3b,C3d).  Eluate was reactive with all cells tested using Ortho MTS-Gel IgG.

Patient received multiple transfusions (approx. 1250 mL) of O NEG , incompatible, leukoreduced, packed red cells over a 5-day period.

The patient returned for followup approximately 16 days after the last transfusion. 

Testing results 23 days after initial presentation:

                  Ortho MTS-Gel           

Anti-A                    0                          

Anti-B =                0                                       

Anti-D=                4+                            

Control =              0                           

Acells =              4+                            

B cells =               4+                            

Antibody screen   Ortho-MTS (IgG)

SC 1                         0

SC 2                         0

SC 3                         0

Any ideas about D antigen expression?  Hemolysis?

 

 

 

 

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I haven't personally, but I just wonder if this was actually a case of auto-anti-LW, with concomitant weakening of the LW antigen.  I remember my former boss and mentor, Carolyn Giles, wrote about just such a case.

Giles CM, Lundsgaard A.  A complex serological investigation involving LW.  Vox Sang 1967; 13: 406-416.

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Very interesting case! Here are my questions related to this case. 

1) If it is a case of auto-anti-LW, should we expect the autoantibody to have a "relative specificity" to D antigen, especially with a 3+ reaction by ortho gel. Would a transient suppression of LW antigen effect D antigen typing by a monoclonal reagent? 

2) Antigen loss during AIHA is shown in Kell blood group system. Is it possible in Rh blood group system as well? 

Zimring JC, et al. Antigen loss from antibody-coated red blood cells.  Transfus Med Rev. 2009 Jul;23(3):189-204. PMID 19539874

Edited by dothandar

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1)  Yes, the auto-anti-LW would look like an anti-D, rather in the same way that allo-anti-LW looks like a anti-D.  Both react far more strongly with D Positive than D Negative red cells, unless the D Negative red cells are from cord or neonatal blood, and yes, there would also be a concomitant weakening of the antigen.

2)  This was the finding of Giles and Lundsgaard with their LW case.  I repeat that I have not seen this myself, but given that LW, Rh and RHAG (amongst other antigens) are all part of the Band 3 macromolecule and, as such, if the expression of one is affected, the expression of the others will also be affected. 

Edited by Malcolm Needs

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Interesting - this antibody behaved as a warm autoantibody with 3+ reactions against all cells tested using MTS-IgG cards.  Eluate was 4+ when tested with the same panel of reagent cells.  There was no obvious difference in reactivity between D positive and D negative cells.  Does anti-LW always demonstrate reactivity that is stronger with D positive when compared with D negative red cells?  I try to remember that antibodies don't read books.... and do whatever they like!

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The patient received 1250ml o neg packed cells , after the last transfusion, the D antigen  buzztest of this patient was 4+, where was the transfused cells? Have it been destroyed by the antibodies? sorry for my dizzy 

buzz after the night shift.:)

 I have noticed the initial Gel test result is D 4+ which is the same as the after 23 days test in Gel.

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9 hours ago, applejw said:

Does anti-LW always demonstrate reactivity that is stronger with D positive when compared with D negative red cells?  I try to remember that antibodies don't read books.... and do whatever they like!

No, so I don't think it is that anymore.  I'll have another think!

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12 hours ago, yan xia said:

The patient received 1250ml o neg packed cells , after the last transfusion, the D antigen  buzztest of this patient was 4+, where was the transfused cells? Have it been destroyed by the antibodies? sorry for my dizzy 

buzz after the night shift.:)

 I have noticed the initial Gel test result is D 4+ which is the same as the after 23 days test in Gel.

The initial A/B/D reverse card result is invalid as the Rh Control was 3+ as were anti-A and anti-B.  This is why the testing was repeated using tube reagents. The reaction with anti-D was 1+ with the initial sample (this was repeated multiple times)

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Posted (edited)

It's very common for a weak/partial D person to react strongly with gel and weak or negative with I.S. tube method. I even had one today! Remember, the reagent anti-D in your bottle and the anti-D in your Monoclonal ABD card are not from the same clones used in manufacturing. And it's not the methodology because before the prepared monoclonal ABC cards we used to make our own with the buffered gel cards...but didn't see the different reaction patterns until patients returned after us getting the monoclonal cards. And now we do our 2nd confirmatory with 2nd specimen by tube method so we see patients with "discrepant" strengths when they're a weak D. That said,  with a 4+ in gel (your subsequent workup) and a 1+ in tube (from the initial workup) I would venture to guess the child is a weak or partial D.

Next issue...As far as the 1st case of gel testing shown, with the agglutination with Anti-A, Anti-B, anti-D and the control, I suspect the diluent. I've been using gel for greater than 16 years, yet over the past couple years we're having problems with the Ortho Diluent 2 getting funky at the end, and reacting exactly like that, sometimes only affecting one specimen in the batch. It's possible if you made a new suspension with fresh diluent you may have not seen that and the typing was unrelated to the antibody screening. Or perhaps the patient cells needed washing because they were coated with whatever was causing your positive screen.

So, my suspicion is that the child had a typical case of WAIHA that had nothing to do with his D type, and he was successfully treated with steroids and/or other drugs before returning for the follow-up workup.

 

Edited by PammyDQ

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Could it be because of warm autoantibodies "saturating" the D epitopes? We see a lot of WAIHA cases from where I work and the suppression of antigens , especially D, which D-like specificites are far too common. After subjecting these patients with immunosuppressants, their antigen test remarkably improve as well.

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