Case Study: Weird WonderfulWalter

Jayanna Slayten, MS, MT(ASCP)SBBManager, IBC-IRL and SBB Program Education CoordinatorIndiana Blood Center

Case History

Patient History Mr. Walter Wright - 80 year old Male

Diagnosed with anemia Patient had hip surgery in July 2009

Has been anemic for the last 6 months

Current values have been 7.0-9.5 g/dL

History of transfusion July 2009

At that time, patient had a cold reactive

antibody that “prewarmed” away

Initial Blood Bank Testing Sample sent to lab

ABO/RH: A, D Positive DAT: Polyspecific = 3+ Antibody Screen: 4+ with all cells by Echo Autocontrol (AC): Positive

Investigation

Results

A, D Positive

DAT Positive

Panel testing

PEG-AHG

Ortho Gel

Panel Testing

Rh

Kell

Duffy Kidd Lewis P MN Serum

CELL D C E c e K k Fya Fyb Jka Jkb Lea Leb P1 M N S s PEG Gel

1 + 0 + + + 0 + 0 + + + 0 + + + 0 0 + 1+ 2+

2 + 0 + + 0 + + + 0 0 + + 0 +S + + 0 + 1+ 2+

3 + + 0 0 + 0 + + 0 + 0 0 + 0 + 0 0 + 1+w 2+

4 + 0 + + + 0 + + + 0 + + 0 + + 0 0 + 1+w 2+

5 + 0 + + + 0 + 0 + + 0 0 + + 0 + 0 + 1+ 2+

6 + 0 0 + + 0 + + 0 + 0 0 0 + 0 + 0 + 1+w 2+

7 + + 0 + + 0 + 0 0 0 + + 0 0 + + 0 + +w 1+

8 + + 0 + + 0 + 0 0 0 + + 0 0 + + 0 + +w 1+

9 + + 0 0 + + + 0 0 0 + + 0 0 + + + 0 +w 1+

10 + 0 + + + 0 + + + + 0 0 0 + + + 0 + 1+w 2+

Autocontrol 3+ 3+

Eluate Testing

Rh

Kell

Duffy Kidd Lewis P MN Eluate

CELL D C E c e K k Fya Fyb Jka Jkb Lea Leb P1 M N S s IgG LW

1 + 0 + + + 0 + 0 + + + 0 + + + 0 0 + 3+ 0

2 + 0 + + 0 + + + 0 0 + + 0 +S + + 0 + 3+ 0

3 + + 0 0 + 0 + + 0 + 0 0 + 0 + 0 0 + 3+ 0

4 + 0 + + + 0 + + + 0 + + 0 + + 0 0 + 3+ 0

5 + 0 + + + 0 + 0 + + 0 0 + + 0 + 0 + 3+ 0

6 + 0 0 + + 0 + + 0 + 0 0 0 + 0 + 0 + 3+ 0

7 + + 0 + + 0 + 0 0 0 + + 0 0 + + 0 + 3+ 0

8 + + 0 + + 0 + 0 0 0 + + 0 0 + + 0 + 3+ 0

9 + + 0 0 + + + 0 0 0 + + 0 0 + + + 0 3+ 0

10 + 0 + + + 0 + + + + 0 0 0 + + + 0 + 3+ 0

EGA-treated Autocontrol (DAT Negative) 3+ 0

Further Investigation Results (continued)

Full phenotype: R1 R1 (D+C+E-c-e+)

K-; Fy(a+b+); Jk(a+b+); M+S-s+, A1+, Le(a-b-), P1-

Tested phenotypically similar cells Reactive by PEG-AHG (1+) Reactive by Gel (2+) Reactive with the eluate (3+)

EcKS

Confusion and Delay!! Possibilities to consider…

Transfusion Reaction? The patient has not been recently

transfused

Autoantibody

All panel cells reactive

DAT positive, eluate is panreactive

Pursue autoadsorption Prove autoantibody

Exclude any underlying alloantibodies.

Panel Testing

Rh

Kell

Duffy Kidd Lewis P MN Auto

Absorb x 4

CELL D C E c e K k Fya Fyb Jka Jkb Lea Leb P1 M N S s LISS-AHG

1 + 0 + + + 0 + 0 + + + 0 + + + 0 0 + 3+

2 + 0 + + 0 + + + 0 0 + + 0 +S + + 0 + 3+

3 + + 0 0 + 0 + + 0 + 0 0 + 0 + 0 0 + 3+

4 + 0 + + + 0 + + + 0 + + 0 + + 0 0 + 3+

5 + 0 + + + 0 + 0 + + 0 0 + + 0 + 0 + 3+

6 + 0 0 + + 0 + + 0 + 0 0 0 + 0 + 0 + 3+

7 + + 0 + + 0 + 0 0 0 + + 0 0 + + 0 + 3+

8 + + 0 + + 0 + 0 0 0 + + 0 0 + + 0 + 3+

9 + + 0 0 + + + + 0 0 + + 0 0 0 + + 0 3+

10 + + 0 0 + 0 + 0 + + 0 0 + + + 0 0 + 3+

Autoantibody Stronger? Initial Panel 1-2+, now it’s 3+?

Initial Conclusions

Autoantibody

Patient’s autoantibody is not removed by a

4x autoadsorption?

What about provision of blood?

Additional Testing

Started alloadsorption Same results as autoadsorption! 4+ with all cells…..

Completed Crossmatches

Matched LISS-AHG Unit 1 Gp A+ E-c-K-S- Compatible! Unit 2 Gp A+ E-c-K-S- Compatible ! Unit 3 Gp A+ E-c-K-S Compatible !

Gp A Panel Testing

Rh

Kell

Duffy Kidd Lewis P MN Gp A

CELL D C E c e K k Fya Fyb Jka Jkb Lea Leb P1 M N S s LISS-AHG

1 + 0 + + + 0 + 0 + + + 0 + + + 0 0 + 3+

2 + 0 + + 0 + + + 0 0 + + 0 +S + + 0 + 3+

3 + + 0 0 + 0 + + 0 + 0 0 + 0 + 0 0 + 0√

4 + 0 + + + 0 + + + 0 + + 0 + + 0 0 + 3+

5 + 0 + + + 0 + 0 + + 0 0 + + 0 + 0 + 3+

6 + 0 0 + + 0 + + 0 + 0 0 0 + 0 + 0 + 3+

7 + + 0 + + 0 + 0 0 0 + + 0 0 + + 0 + 3+

8 + + 0 + + 0 + 0 0 0 + + 0 0 + + 0 + 3+

9 + + 0 0 + + + + 0 0 + + 0 0 0 + + 0 0√

10 + + 0 0 + 0 + 0 + + 0 0 + + + 0 0 + 0√

What antibody is present?

Further Investigation

Autoantibody Verified auto with positive DAT and eluate Serum reactivity in PEG-AHG and LISS-AHG

consistent with autoantibody Is this a preference for ABO specific cells?

Repeat panel testing found Group O panel washed x 1 = demonstrated anti-c This disproved a preference for ABO cells (rare)

Conclusions

Autoantibody reactivity in this case was enhanced when tested with Reagent red cells (re-suspended in diluent)

Autoantibody not detected when tested with washed cells (donor or panel)

Conclusion

The patient’s sample demonstrated Anti-c Warm autoantibody

This is an atypical presentation

of an autoantibody………

Patient received xm compatible E-c-K-S- units