Contributed by Nicole Nicosia Esposito, MD, Don Kelley, MD, Beth Jochum and Mark H Yazer, MD, FRCPC Published on line in December 2005
Contributed by Nicole Nicosia Esposito, MD, Don Kelley, MD, Beth Jochum and Mark H Yazer, MD, FRCPC
Published on line in December 2005
CASE PRESENTATION:
A 79-year-old man with stage IV mantle cell lymphoma, previously untransfused, presented to a peripheral hospital with symptomatic anemia (Hgb=7 g/dL, Hct=23%). A type and screen revealed that he was group AB with no unexpected antibodies (Table 1).
Two units of group A blood were issued by computer crossmatch. Both units were transfused without incident. Six days later, he returned to hospital with a hemoglobin of 6.8 g/dL (Hct=22%). Routine type and screen at that time was unchanged from the previous specimen. On Day 7, he was transfused with one computer crossmatch compatible unit of group A RBCs followed by 30 cc of another group A unit when he noted painless bright red urine and complained of chills, lower abdominal pain, and required intubation. Chest x-ray performed at the time was unremarkable. He was transferred to the MICU where he was dialyzed for anuria. The patient's blood film was unremarkable.
Questions:
1. What is the differential diagnosis of the patients' symptoms? [ Answer ]
2. From a blood bank perspective, what should the nursing staff do at the bedside when a transfusion reaction is suspected? [ Answer ]
3. What actions does the blood bank take when notified about a transfusion reaction? [ Answer ]
Later that evening, the patient's hemoglobin continued to decline from 6.6 g/dL to a nadir of 5.7 g/dL at midnight. A total of two more units of computer crossmatch compatible group A RBCs were transfused shortly after midnight and in the early morning of Day 8, respectively. His hemoglobin was 6.3 g/dL after the first unit and 6.2 g/dL after the second unit. Subsequently, RBC transfusions were withheld, and his hemoglobin decreased to 5.8 g/dl on the morning of Day 9. That evening, an anti-A1 was identified on reverse typing in a new blood sample, and the DAT was positive with IgG (Table 2):
An eluate was then performed and tested against selected cells using polyethylene glycol (Table 3):
He then received one unit of O RBCs on Day 10, with a resultant increase in hemoglobin to 6.2 g/dL four hours after transfusion. An additional unit of O RBCs was administered, with a further rise in hemoglobin to 8 g/dL. The patient continued to respond well to O RBCs and was discharged from the MICU.
ADDITIONAL LABORATORY INVESTIGATIONS:
Routine pretransfusion serological testing did not reveal the anti-A1 antibody (Table 1); however, when the serum:cell ratio of the pre-transfusion specimen was increased, a weak and 1+ reaction was seen at the immediate spin phase and after a 15 minute incubation at room temperature, respectively (Table 4):
Additionally, a screen using the patient's post-transfusion serum from Day 11 against A1 and A2 cells revealed agglutination at the immediate spin and IgG antiglobulin phase only (Table 5):
Questions:
4. How can a group AB individual produce an anti-A1 antibody? [ Answer ]
5. What is the typical clinical significance of an anti-A1? [ Answer ]
