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Cold auto? Something else? Help!


MOBB

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Patient denies any previous transfusion and has a history of 2 surgeries at a surgery center (highly unlikely to transfuse, but not impossible). Patient does not remember the name of the surgery center. Patient is pretesting for surgery.

Thursday: Sample 1

  • Patient type: O pos
  • Patient Screen: 4+ for cell I and II in grifols gel
  • Patient Panel: 4+ for cells 1-11 and auto control is negative in grifols gel. 

Patient was called back in to collect additional samples.

Friday: Sample 2

  • Ref lab reports probable cold auto with DAT IgG (gel) negative and DAT C3 (tube) 2+
  • Ref lab said they used ortho gel with immucor RBCs and had no reactions. They did get 2+ reactions in tube with PEG and positive reactions with a papain panel in ortho gel. 

Monday:

  • Back at the hospital lab, we were confused by the ref lab reports.
    • We questioned why the auto was negative and they suggested possibly the patient did not fully develope I antigens and had some i antigens which would explain the 4+ on reagent RBCs and negative on autocontrol. 
    • It was discussed that the positive complement DAT pointed to the autoantibody and gel does not typically pick up complement well hence the negative auto, but it does not explain the 4+ reactions with the 0.8% reagent RBCs.
  • Our pathologist recommended a blood warmer for any transfusions. When communicated to the Surgery Coordinator, she said the OR room will be 50-60°F and the patient temp will be dropped to 34°C. Would a blood warmer be helpful with already low temps? Could the cold temperatures cause a reaction in the patient without any transfusions?
  • Out of curiousity we did additional testing on Sample 1 (day 4) 
    • Grifols Tube screen: negative at IS, 37°C with LISS, and AHG
    • Grifols gel screen: still 4+ cell I and cell II
    • 2 random O pos units XM in grifols gel: both compatible-I'm thinking this rules out the undeveloped I antigen theory
  • If we didn't have the ref lab workup, I would suspect a reaction due to an additive or something in the 0.8% reagent RBCs.

Tuesday:

  • Contact the ref lab to ask if their medical director recommends a blood warmer for this patient considering the antibody ID and temperature requirements for surgery.
  • Medical director recommends thermal amplitude studies at 30, 34, and 37°C on their sample collected on Friday.
  • No reactivity in the sample-ref lab thinks the it auto absorbed. We can't explain why my 4 day old sample had reactivity, but their's did not.

Patient did not want to come in last Friday and probably won't come back before surgery. He claimed ARC never had any issue finding him blood. I've heard ARC does not do gel testing so based on my testing, maybe their screens were negative and all crossmatches were compatible.

Ref lab is confused. We're confused. I'd love any insight. I keep hoping I'm missing something obvious...

Do you think it's a cold auto?

If so, would you do a tube type, screen and crossmatch for surgery and skip gel altogether?

Would a warmer be helpful?

Thanks!

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You could still be looking at an additive/preservative issue.

You state that Gel testing performed by your site was Grifols and the Reference Lab was Ortho Gel with Immucor reagent red cells. Immucor does not make reagent red cells for use in gel systems so the Reference lab would have had resuspend the 3% cells to 0.8% for use in gel. If I remember correctly that involves taking an aliquot of the red cells, adding saline to make them easier to decant to a "dry" button and then adding MTS Diluent. So you are essentially washing away the additive/preservative in the reagent cells and thereby removing that as a potential problem.

The fact that the crossmatch performed in Grifols gel was negative also points to the reagent cells as being the issue. I would suggest that you try rerunning the specimen in Grifols with "washed" reagent red cells to remove the additive/preservatives and resuspend them in the same diluent you use for the donor cells and see what you get.

As to the C3d being positive. Have you checked patient's meds list? Some meds cause the DAT to be Complement Positive e.g. antihistamines containing brompheniramine, phyenyltoloxamine

 

 

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34 minutes ago, jalomahe said:

You could still be looking at an additive/preservative issue.

You state that Gel testing performed by your site was Grifols and the Reference Lab was Ortho Gel with Immucor reagent red cells. Immucor does not make reagent red cells for use in gel systems so the Reference lab would have had resuspend the 3% cells to 0.8% for use in gel. If I remember correctly that involves taking an aliquot of the red cells, adding saline to make them easier to decant to a "dry" button and then adding MTS Diluent. So you are essentially washing away the additive/preservative in the reagent cells and thereby removing that as a potential problem.

The fact that the crossmatch performed in Grifols gel was negative also points to the reagent cells as being the issue. I would suggest that you try rerunning the specimen in Grifols with "washed" reagent red cells to remove the additive/preservatives and resuspend them in the same diluent you use for the donor cells and see what you get.

As to the C3d being positive. Have you checked patient's meds list? Some meds cause the DAT to be Complement Positive e.g. antihistamines containing brompheniramine, phyenyltoloxamine

 

 

The patient takes loratadine. It doesn't look like brompheniramine or phyenyltoloxamine are ingredients and I see loratadine listed anywhere interfere with their reagents.

We diluted our 3% reagent RBCs to a 0.8% suspension with Grifols diluent and the gel screen is negative.

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