Had an interesting one today

 

- Antenatal lady 36W

- Booking bloods A+, negative antibody screen

- Missed 28w screen

- 2nd pregnancy, plus transfused 2 A+ units on delivery of first child

- Came into maternity at 36w with high blood pressure

 

And the results

 

APos with 4+ reaction strength in both D clones

Postitve 3 cell screen in cells one and 2

Confirmatory D - negative

Panel shows anti-D strongly reacting

DCT is neg

Phenotype is C+E-c+e+K-

 

There is no evidence of her being given Rhophylac in error (though this wouldn't show up as a positive antibody screen in a Rh+ woman, but a pos DCT??)

 

My first thought was maybe an anti-f but as the phenotype is c+e+ this blew this theory out of the water.

 

So the question is - is there a D subgroup that shows 4+ reactivity but illicits an allo-D?

 

I'm confuddled...

Yes, there are quite a few.

 

Could you tell us the lady's ethnic background please?

She is caucasian according to her haemoglobinopathy questionnaire.

 

The lady has now been induced so we will have baby to deal with very shortly.

Then it could be Partial D IIIb or IIIc, or it could be a Weak D Type 33.

 

Good luck with the baby!

Thanks Maclolm

Update:

 

Baby has been born and had IUGR. The baby results were Bilirubin 30 and no Hb obtained as the sample was clotted. The DCT was 3+ and the baby has been given immunoglobulins and phototherapy.

 

The sample that was sent to Liverpool has beaten them and they have forwarded the sample to Bristol - so it looks like it is possibly something quite novel.

Not necessarily beaten!  RCI at NHSBT-Speke Centre, in common with all other NHSBT RCI Departments can do wonders, but they can't do RHD gene sequencing, which is what is probably required here.  This would need to be done by the IBGRL.

Ha ha yes, perhaps being a bit flip there... This case has piqued my interest though

APos with 4+ reaction strength in both D clones

Confirmatory D - negative 

I don't know what Rh testing protocol you follow there so pardon my ignorance.

 

You routinely use two different anti-D clones for Rh typing, which ones are they?

When you say confirmatory D - negative, does that mean you tried a third anti-D reagent which was negative? If so, which clone is that reagent?

 

Very curious to hear what you say, we're still working on our policy relating to this situation.

We, at Liverpool, suspect mother is DIII but, as Malcolm said, we will need some (sequencing) help from IBGRL to 'pin it down'!

I don't know what Rh testing protocol you follow there so pardon my ignorance.

 

You routinely use two different anti-D clones for Rh typing, which ones are they?

When you say confirmatory D - negative, does that mean you tried a third anti-D reagent which was negative? If so, which clone is that reagent?

 

Very curious to hear what you say, we're still working on our policy relating to this situation.

 

I'm in a new lab now so I'm not sure what the clones are as of yet (though I will find out). There is more than one clone per well.

 

The confirmatory-D is our quick screen to determine if the antibody is Rh - to help with prophylaxis ID rather than doing a full 11-cell panel. It is just a 3 cell screen without the Rh antigens(rr). If this is negative we know we have an Anti-D (or E or C). 

 

We, at Liverpool, suspect mother is DIII but, as Malcolm said, we will need some (sequencing) help from IBGRL to 'pin it down'!

 

Hi John *waves* 

 

I'm trying to organise a sweep on what D it is - would it be cheating if I changed my guess now??

I'm going for

1.  DIV

2.  DVII

3.  DNB

In that order....

Anna

 

But - daft question probably.  Did you elute anti-D off the baby's red cells?  Could be something nothing to do with D at all..........

Anna - yes we did and baby is Rh positive. I can't recall if they are the same ABO though.

 

What else are you thinking that would give an apparent Anti-D in a panel?

Edited October 15, 201410 yr by Auntie-D

anti-LW?

Resasonably sure it's not DVI or DVII

Sorry, meant DIV!

Sorry, meant DIV!

 

Ha ha yer div! *said in the most pathetic Scouse accent* 

Well Mr Egg, she's got you bang to rights there!!!!!!!!!!!!!!!!!!!

What else are you thinking that would give an apparent Anti-D in a panel?

 

I was thinking that maybe the mother had another antibody too.  That's why I asked about the eluate.  (Unlikely I know)

 

To John - why are you sure it's not DIV or DVII?

He probably used the Albaclone anti-D panel Anna.  We all use it in RCI in NHSBT.

Ah - well that changes things.  So, Auntie-D - you want to organise a sweep and you withold vital information , huh!!!!    

Malcom is correct,we have used the 'ALBA' panel of monoclonal anti-Ds. So we've (hopefully) ruled out a few things already.

As for my scouse accent; anyone whose had the pleasure to her my voice will know I haven't managed to pick one up in the 30 odd years I've lived here (although I do have a 'lecky' meter)

It maybe not anti-LW, but I don't know why it can not be anti-LW. Because some D pos iS Lw neg.

Edited October 17, 201410 yr by shily

The patient is a DIIIc D variant. The variant gene controlling this expression of the antigen has D gene exons 1, 2, 4-10, but has exon 3 of the CE gene. So it's a hybrid of the D and CE genes. 

Interesting case.