A 20y male patient with known AIHA 6 yaear back , physician wan to transfused blood

as the hemaglobin is 3.4 gm/dl .

His initial serology was performed and the forward blood group is"B" Rh positive

his reverse grouping showed agglutination with "A" cell but not agglutinated with "B" "O" cells. Direct Coomb test= 4+, Anti-IgG=4+ , Anti-C3d=negative , Auto Control= 4+

50 units of pc of group B & O Rh positive & negative were Xm,all the unit were incompatible at coomb phase with Anti-IgG the rectivity were 3-4+ . At this stage

we tested patient's cell for H antigen , the reaction was negative with Anti-H a swell

as with Anti-Leb= negative.

Is that para Bombay B along with AIHA or else ? Any suggestion regarding this

please reply.

Salman

Charge Technologist

Blood bank (AKUH)

Karachi-Pakistan

Is his ab screen positive? I would think that the incompatibility is due to his AIHA if his screen is positive. I do not know if the strong +DAT will interfere with your H or Leb testing. H substance is reduced in group A individuals, but there should be some to be detected. Did you try to absorb out any autoab?

A 20y male patient with known AIHA 6 yaear back , physician wan to transfused blood

as the hemaglobin is 3.4 gm/dl .

His initial serology was performed and the forward blood group is"B" Rh positive

his reverse grouping showed agglutination with "A" cell but not agglutinated with "B" "O" cells. Direct Coomb test= 4+, Anti-IgG=4+ , Anti-C3d=negative , Auto Control= 4+

50 units of pc of group B & O Rh positive & negative were Xm,all the unit were incompatible at coomb phase with Anti-IgG the rectivity were 3-4+ . At this stage

we tested patient's cell for H antigen , the reaction was negative with Anti-H a swell

as with Anti-Leb= negative.

Is that para Bombay B along with AIHA or else ? Any suggestion regarding this

please reply.

Salman

Charge Technologist

Blood bank (AKUH)

Karachi-Pakistan

Hi Salman,

I almost entirely agree with David.

I, too, think that the reactions you are seeing are due entirely to the patient's auto-antibody.

I do not think that this is a "para-Bombay".

The anti-H in a para-Bombay individual would be IgM, as well as IgG, and you would, therefore, expect to see a reaction with both group B and group O red cells in the reverse group. In addition, this should have been detected six years ago when this patient first presented.

The fact that the patient's Hb is 3.4g/dL strongly suggests that he is in the middle of an acute phase of the warm auto-immune disease, and that, together with the strongly positive DAT and the positive auto all suggests that what you are detecting in the patient's plasma is free auto-antibody. This almost certainly has a specificity of either anti-Rh17 or anti-Rh18.

It is very difficult to prove this, without having both Oh and Rhnull red cells avilable to you (the Oh cells would give positive results in a cross-match against the patient's plasma, whilst the Rhnull cells would be compatible).

I agree with David that differential alloadsorption studies would show that there is auto-antibody present (although, of course, such studies would also remove an alloanti-H).

I would not take too much notice of the results with the anti-H, as the avidity of anti-H reagents (particularly lectin anti-H reagents) varies enormously (did you test a range of AB individuals at the same time as positive controls - using just one is not sufficient?).

I would take even less notice of the negative reaction with the anti-Leb. A large enough percentage of people are Le(a+b-) or Le (a-b-) that your patient, by chance, could be amongst these, and, in any case, marrow stress, together with a "defunct" immune system (as you would get in AIHA) will have a tendency to "change" Le (a-b+) red cells to either Le(a+b-) or Le(a-b-) - you have to remember that the Lewis antigens are adsorbed onto the surface of the red cell, rather than being an integral part of the red cell.

I am not in the least surprised that 50 units of blood were found to be incompatible in such a case. I would not be surprised if 50, 000 units were found to be incompatible, given the rarity of individuals who are Rh17/Rh18 negative.

Like David, I think that alloadsorption is your answer.

:):):)

Hi

David & Malcom

Thank you for guidence, Yes the Antibody Screening was positive with Diamed -ID cell aswell as with

Immucor Gama panno Cell , For Phenotytyping of Le( we had used the BIORAD Antisera and used a

ABpositive cells as positive control but not for a series.

We had performed Allogenic adsorption with ZAAP treated cells and and after 4th adsorption , the screening and

Identtification were performed, Anti-e Identified (Test performed with Pre-Transfusion sample) ,Xm were also

performed we found 2 compatible units were found out of 37 units. Both units have been transfused and

the hemoglobin is 5.9 g/dl.

Thanks you very much.

Hi globe,

Thanks for that.

Was the anti-e an auto-antibody or an alloantibody?

:confused::confused:

Some time your patient may be e+ and you may have anti-e like specificity instead of auto anti-e. You need to have resources to confirm this to make sure you are not dealing with varient of e.

Some time your patient may be e+ and you may have anti-e like specificity instead of auto anti-e. You need to have resources to confirm this to make sure you are not dealing with varient of e.

I agree. That was why I was asking the question.

:):)

Hi Malcom and aakupaku,

We had performed the Antibody Identification with Immucor Gamma as well as with Diamed ID pannel,

both were giving the result pattren of Anti-e more over earlier we had performed the Antibody screen

with two said manufacturer and the result pattren were same.

Hi Malcom and aakupaku,

We had performed the Antibody Identification with Immucor Gamma as well as with Diamed ID pannel,

both were giving the result pattren of Anti-e more over earlier we had performed the Antibody screen

with two said manufacturer and the result pattren were same.

Thanks for that globe, but I think what both of us are getting at is, is the patient himself e+ or e-?

:confused:

Your DAT is very strong so you may need to make sure you are not getting false positive reaction with anti-e. You may need to treat pt's cells to remove bound IgG/antibody before you type the patient. (check package insert for anti-e) If patient is e+, it may be auto anti-e or anti-e like specificity. Other possibility is variant of e. This is more often seen in african american. I do not have the info on asian population.

2nd step: I do not know if you have a access to molecular testing, send the specimen for molecular typing because your patient may be e+, doesn't mean it is auto anti-e. You may be seeing anti-e like specigicity and you may not need to give e- blood. (of course transfusion requirement must be evaluated by your medical director).

In small lab it is harder to differ the allo and auto anti-e like this case. I don't think there is any mean to know whether it is allo or auto anti-e in blood transfusion. Beacause we need give him e neg blood in two case.

If patient is e+, it may be auto anti-e or anti-e like specificity. Other possibility is variant of e. This is more often seen in african american. I do not have the info on asian population.

2nd step: I do not know if you have a access to molecular testing, send the specimen for molecular typing because your patient may be e+, doesn't mean it is auto anti-e. You may be seeing anti-e like specigicity and you may not need to give e- blood. (of course transfusion requirement must be evaluated by your medical director).

I am curioius about this case because we just had a patient who has, according to our reference lab, an anti-e like auto antibody in addition to an anti-C. The reference lab told me that they "might not always be able to send us e negative units." My question is, if the antibody reacts with e positive cells, why don't you have to give e negative units?

I am curioius about this case because we just had a patient who has, according to our reference lab, an anti-e like auto antibody in addition to an anti-C. The reference lab told me that they "might not always be able to send us e negative units." My question is, if the antibody reacts with e positive cells, why don't you have to give e negative units?

If the antibody is a true alloanti-e, you would have to give e- blood.

If, however, the antibody is, in reality, an auto-anti-e-like specificity (almost all of such antibodies are, in fact, auto-antibodies, unless the antibody is made in a patient with Rh deletions), such antibodies have a wide specificity and will actually react preferentially in vitro with e+ red cells, but will actually react with both e- and e+ red cells (the antibody specificity is usually a weak auto-anti-Rh17 or Rh18), and so in vivo e+ and e- red cells will actually last as long as each other (in most cases) and, indeed, as long as the patient's own red cells.

I would think, from what has been said, the antibody actually has an auto-anti-e-like specificity, and so e- red cells are not actually required, unless e+ red cells bring about striking haemolysis, in which case e- red cells should be made available.

:):)

Hi Malcom / akupaku

Antigen e was negative on patient's pre transfusion sample. Rh Phenotype of patient

was DCE/DCE, (Test was performed through the treatment of choloroquine diphosphate

on patient's rbcs according to AABB) a positive control was also performed parallel with test .

Hi Malcom / akupaku

Antigen e was negative on patient's pre transfusion sample. Rh Phenotype of patient

was DCE/DCE, (Test was performed through the treatment of choloroquine diphosphate

on patient's rbcs according to AABB) a positive control was also performed parallel with test .

Gosh, that is an unusual Rh type (give or take, about 1 in 100, 000 of the White Population, and rare even in the Asian.

In that case, the anti-e MUST be an alloantibody, and e- blood is essential.

It would be better for the patient, in the long run, if blood that is RzRz, Rzry or ryry is provided, but these types are all extremely rare. Given that he has not yet produced an anti-c, R2R2 blood could be given for now, but the c antigen is, itself, highly immunogenic, and if he produces an anti-c in addition to his anti-e, he is going to be a problem to transfuse.

:eek::eek:

Edited March 3, 201015 yr by Malcolm Needs

wow...this is very rare phenotype...and yes I agree with Malcom, you need to give e- blood.