I hate left overs! Remember when you mother would drag yesterdays dinner and reheat it for today!!!!! and all you wanted was to start fresh, well here was one of those antibody ID left overs........

Patient recently transfused with six units of red cells in the past month. Patient requires additional units and now the antibody screen is pos, dat is pos and hospital is questioning a WAA.

Patient is an O pos. Probable R1R1. DAT is micro with AhG, Micro with IgG and negative with C3b,C3d.

Liss panel is set up and some cells react 3+ at imm spin and some are neg. all but one cell reacts at 37'C with different strengths from wk+ to 3+. All cells react at IgG from micro to 4+.

Ficin treated cells (demonstrates a perfect little c at 37'C reacting 3+) at IgG all cells react.

The previous tech had performed a differencial absorption with papain treated cells and left it for me to test. All cells were positive, some reacted at IS, some at 37'C and all at IgG.

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So, now it becomes a STAT! and you are no further along then the tech was last shift, So, how would you proceed?

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And remember, suicide or calling in sick are not options that can be entertained!

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ok,, who said go home and hand it off?

(only kidding)

Next: since the patient appears to be an R1R1 with clean typings, I gave antigen typing a try. Some typing were weaker than controls and some were only micro. So, basically you might conclude that the patient was S, Fya neg.

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Next I tried R1R1, S(-), Fya(-) cells and they all were neg at IS, neg at 37'C and wk+ to 1+ at IgG.

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going back to the original panel you could then see that the IS reactions were Anti-E, and maybe anti-S. The Anti-K was suspicious and in ficin you know you had at least a Anti-c. But, we still have no negative cells and can not rule anything out!

Eluate had been run against the origianl panel and reacted from micro to 3+ and then it was run against two R1R1 cells and two rr cells and with the R1R1 cells it was micro and it was 2+ with the rr cells. and there was no more left for me to test, So I busted up the two clots and made more.

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What cells would you select to run with the new eluate?

What serum testing would you do to try and rule out ?

I will fill you in after some replies, thanks

I hope you like these things.........Melanie

What is the patient's original dx? and current dx? DON'T say "anemia". Would it be safe to "assume" that the current need for transfusion is related to destruction of the transfused cells or is there some other process occurring along with the +DAT? By-the-by, how strong is the original DAT and why did the patient need to be transfused in the first place?

Tell me more . . .

ok....This one was a real challenge to my brain. The patient was post surgical, and anemic.

New eluate showed ony Anti-Fya using saline-IgG. Anti-c, Anti-Fya with Peg enhancement.

So, not a WAA reacting in serum? Ran a titer of R1R1 S,K,Fya neg cell and it was 128....Probably and HTLA.

Since R1R1, S, K, Fya neg cells that are neg for various HTLA's are not that available, I had to absorb and elute to rule out, I used "untreated" absorption cells and prepared eluates off the first passes. I then tested the eluates with selected cells to try and rule out. The eluates run with saline-IgG showed only Anti-c, E, Fya. When tested with Peg enhancement, I also found a Anti-S.

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So we now know the patient had Anti-E, c, S, Fya for sure and all other common allos except K are ruled out. So, in a pinch I sent out units that were Antigen neg "least incompatible". Now to prove what HTLA it is........

Any thoughts on that?

Hey Mel,

Why don't you try to adsorb out all the allos then perform the ID with what is left. An "HTLA" on top of all that is quite unfair.