History: Mr. C.O. is a 63 years-old male with lymphoma.He is a politransfused patient.

Day one: Hb 7.8, PLT 3000, Bili.tot 2.13, Bili.Ind. 1.82.

Type and screen: DAT negative, IAT negative, Control group A+.

Transfused with 2 units of RBC (A+) and 1 unit of PLATELET (0+). All units were irradiated and filtered.Chills at the end of the transfusion.

Day two: Hb 8.2, PLT 10000 ,Bili.tot 2.31, Bili Ind. 1.98, LDH normal.

Type and screen: DAT positive 2+(diamed card), IAT negative, Control group A+,Monospecific : only IgG positive 2+ (diamed card), ELUITION negative( gamma elu-kit immucor and diamed panel 11 cells).

We have repeted the Day-one DAT and IAT and it was all negative.

We have cross-matched the two RBC units and they were compatible.

We have done a DAT of the two units and it was all negative.

We repeat on a new sample DAT and IAT : DAT positve 1+ IAT negative.

Transfused with 1 unit of RBC and 1 unit of Platelet.

Why the DAT is positive after 24 hours?

Gracias and sorry for my english...

Edited February 6, 201015 yr by skyanto

Test your eluate with A cell and B cell. You may have given platelet with high titer of anti-A.

Dear skyanto

I don't have an answer to your problem, but you have no reason to apologise for your English, it is excellent. Far better than my Italian!!! which is non existant.

Steve

:)

Edited February 6, 201015 yr by Steven Jeff
Spelling

Aakupaku has given you good advice and the most logical possibility.

Aakupaku has given you good advice and the most logical possibility.

I agree.

We've tested the eluate with A1 and B cells.

The results are: positive 4+ with A1 and negative with B.

So the DAT is positive because in the group 0 PLATELET there were IgG anti-A in high titer.Do you have a procedure to do this titer?

Muchas muchas gracias a todos.

We've tested the eluate with A1 and B cells.

The results are: positive 4+ with A1 and negative with B.

So the DAT is positive because in the group 0 PLATELET there were IgG anti-A in high titer.Do you have a procedure to do this titer?

Muchas muchas gracias a todos.

One way is to treat the plasma/serum/eluate with 0.01M dithiothreitol (DTT) at 37oC for about half-an-hour. This has the effect of disrupting the J-chain holding together the IgM molecule, by reducing some of the sulphydryl bonds. You then perform a titration, using the IAT at 37oC and a monospecific anti-IgG reagent.

Don't forget to use something like an auto-anti-I (which is going to be IgM) as a control.

Hope this helps.

:):):)

We've tested the eluate with A1 and B cells.

The results are: positive 4+ with A1 and negative with B.

So the DAT is positive because in the group 0 PLATELET there were IgG anti-A in high titer.Do you have a procedure to do this titer?

Muchas muchas gracias a todos.

Was there are reason that you wanted to do a titer, skyanto? Based on the results you described, you have investigated and identified what caused the patient's Positive Direct Antiglobulin Test. (There's really no reason that you must do a titer.)

Donna

Malcolm, I don't think we need treat the blood with DTT to destroy IgM . Because IgM react in 37 degree C also have clinical significance in not ABO same type transfusion.

Skyanto do titer want to differ the high and low titer platelet, am I right?

Malcolm, I don't think we need treat the blood with DTT to destroy IgM . Because IgM react in 37 degree C also have clinical significance in not ABO same type transfusion.

Skyanto do titer want to differ the high and low titer platelet, am I right?

Oh yes shily, you are right. It was just that skyanto wanted a method.

IgA-mediated AIHA in lymphoma is not uncommon (i.e. not as a result of Transfusion), but in my experience a Pos DAT does not always give significant AIHA.

However, given the history, particularly with some sort of a reaction would point to the scenario as presented by others. Gonna need low titre platelets from now on. I would be interested in the next few days of the patient's history. Did the Hb drop significantly, was there a rise in LDH or Bili - more platelets given and the outcome?

Interesting case. Thanks for sharing,

Cheers Eoin

IgA-mediated AIHA in lymphoma is not uncommon (i.e. not as a result of Transfusion), but in my experience a Pos DAT does not always give significant AIHA.

However, given the history, particularly with some sort of a reaction would point to the scenario as presented by others. Gonna need low titre platelets from now on. I would be interested in the next few days of the patient's history. Did the Hb drop significantly, was there a rise in LDH or Bili - more platelets given and the outcome?

Interesting case. Thanks for sharing,

Cheers Eoin

I agree entirely with everything you have posted Eoin, particularly about that fact that it is a very interesting case and well worth sharing.

The one thing that I could possibly, not so much disagree with you, but just maybe remind you that many Laboratories do not have access to a monospecific anti-IgA reagent, either in a bottle, or in CAT, and I have my doubts as to whether skyanto would have such access (although, of course, I don't know for certain), which would probably mean that the coating is IgG, C3d or both (hence the anti-A eluted) - but I still agree with you about IgA-mediated AIHA, and about a positive DAT not always giving a significant AIHA.

:):):)

When we have a positive DAT we test the patient red cells with a Diamed card called DC SCREENING I.In this card there are this monospecific AHG reagents: anti-IgG, -IgA, -IgM, -C3c and -C3d.We had a positive reaction (2+) only with IgG so the only antibodies on the red cells of this patient are IgG.At the moment I'm not at work and I don't know nothing about the patient...I was curios about the procedure to do the IgG titre but in my lab there isn't the DTT reagent we only have a reagent called NEUTR-AB that we use to neutralize IgM and then titre the IgG in mom 0 with A or B child...Maybe I can use this reagent to do a test but only for curiosity...

Buen fin de semana a todos.

When we have a positive DAT we test the patient red cells with a Diamed card called DC SCREENING I.In this card there are this monospecific AHG reagents: anti-IgG, -IgA, -IgM, -C3c and -C3d.We had a positive reaction (2+) only with IgG so the only antibodies on the red cells of this patient are IgG.At the moment I'm not at work and I don't know nothing about the patient...I was curios about the procedure to do the IgG titre but in my lab there isn't the DTT reagent we only have a reagent called NEUTR-AB that we use to neutralize IgM and then titre the IgG in mom 0 with A or B child...Maybe I can use this reagent to do a test but only for curiosity...

Buen fin de semana a todos.

I've used NEUTR-AB, and whilst there is no doubt it is "good stuff", I have my doubts that it only neutralises IgM. I think it also neutralises a certain amount of IgG.

:confused::confused::confused:

Our policy is to do anti-A &/or anti-B titer before giving out ABO incompatible platelets. Eg. if we need to give O apheresis platelet to A patient, we would do anti-A titer (15 min @ Rt), and if titer is <64 we would give platelet. If titer is >64 we do not give.

I am concerned that the platelet count was increased from 3000 to only 10000. Was the one unit a SDP? If so then the count should have increased some where in the area of 50000 to 70000. Is the patient recieving chemotherapy? If so, and the therapy is not considered to play a roll in the low increase in the platelt count is it posible that the patient also has an HLA incompatibility with the one unit of platelets that was transfused? Has the patient been HLA typed?

i

I am concerned that the platelet count was increased from 3000 to only 10000. Was the one unit a SDP? If so then the count should have increased some where in the area of 50000 to 70000. Is the patient recieving chemotherapy? If so, and the therapy is not considered to play a roll in the low increase in the platelt count is it posible that the patient also has an HLA incompatibility with the one unit of platelets that was transfused? Has the patient been HLA typed?

i

I totally agree about the possibility of HLA antibodies, particularly as it is likely that this patient will have been transfused in the past, and will almost certainly be transfused with platelets in the future.

One reason why the platelet count might not have gone up as expected (apart from consumption and HLA antibodies) is that the high-titre anti-A would also have sensitised the group A platelets (both those transfused and those native to the patient) and these could have been removed from the circulation).

:confused::confused:

Finally today I've done the anti-A (IgG) titer of the ABO incompatible platelet.

We use five buffy-coat donors to do a platelet unit so I've done the titer on the five donors plasma in this way:

100 microL NEUTRAB+100 microL plasma donor

1 hour at 4°C

I've checked the neutralization with 1 drop A1 cells+1 drop neutralized plasma

if no agglutination

I've diluited the netralized plasma 1/2, 1/4, 1/8 until 1/512

in diamed cards liss/coombs 50microL A1 cells+ 25 microL diluited plasma 1/2, 1/4...

15 minutes at 37°C

centrifugation

Results: 4 donors were negative,titer < 1/2

1 donor was positive,titer >1/512

BUT I've done a mistake...I put the cards in the centrifuge without incubation at 37°C ...I've repeted the test in the correct way and I've obtained the same results.

The positive result is not correct because what I saw are IgM and not IgG...

This method is not right ..Next week I'll ask the correct procedure.

Anyway from the "day two" of this case the patient didn't riceive any transfusion.

The last time he came for a visit ha had Hb 8.2, PLT 25000, LDH 583 and BILI TOT 1.52.

Finally today I've done the anti-A (IgG) titer of the ABO incompatible platelet.

We use five buffy-coat donors to do a platelet unit so I've done the titer on the five donors plasma in this way:

100 microL NEUTRAB+100 microL plasma donor

1 hour at 4°C

I've checked the neutralization with 1 drop A1 cells+1 drop neutralized plasma

if no agglutination

I've diluited the netralized plasma 1/2, 1/4, 1/8 until 1/512

in diamed cards liss/coombs 50microL A1 cells+ 25 microL diluited plasma 1/2, 1/4...

15 minutes at 37°C

centrifugation

Results: 4 donors were negative,titer < 1/2

1 donor was positive,titer >1/512

BUT I've done a mistake...I put the cards in the centrifuge without incubation at 37°C ...I've repeted the test in the correct way and I've obtained the same results.

The positive result is not correct because what I saw are IgM and not IgG...

This method is not right ..Next week I'll ask the correct procedure.

Anyway from the "day two" of this case the patient didn't riceive any transfusion.

The last time he came for a visit ha had Hb 8.2, PLT 25000, LDH 583 and BILI TOT 1.52.

Thanks for this update skyanto, and well done on admitting a mistake. I admire you.

YOU ARE A TRUE BLOOD TRANSFUSIONIST!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Congratulations.

Why can't other people, in other professions within health care be so refreshingly honest????????!!!!!!!!!!!!!!!!!

:D:D:D:D

From mistakes we have to learn.. and in this case I've learned that my procedure isn't correct and I don't understand why.

I've checked the neutralization after 1 hour at 4°C and the plasma was neutralized so in my plasma there were only IgG...

Have a look at this article in Transfusion

Harris SB, Josephson CD, Kost CB, et al. Nonfatal intravascular hemolysis in a pediatric patient after transfusion a platelet unit with high-titer anti-A. Transfusion 2007;47:1412-7.

CK Cheng, MSc, SBB(ASCP), CQA(ASQ)

Hong Kong

Mar 3, 2010