Interesting Case Studies from The Mayo Clinic Reference Laboratory

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Interesting Case Studies from The Mayo Clinic
Reference Laboratory

• Georgette Benidt, MT(ASCP)

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Case 1

• 81 year old with B-cell lymphoproliferative
  disorder
• Clinician ordered the Donath Landsteiner Test

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DONATH-LANDSTEINER (DL)
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Case 1 objectives

• Significance of the test
• Incidence of positive tests
• Testing challenges

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DL Significance

• Paroxysymal Cold Hemoglobinuria is an ideopathic
  disorder occurring in
• IgG biphasic autoantibody (usually anti-P)
• Fixes complement at 4 C
• Activates complement at 37 C
• Patient needs to avoid cold exposures (MN
  winters, air conditioners)

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Donath-LandsteinerTesting Challenges

• Need to maintain the specimens and controls at
  37C.
• Length of time from start to finish is minimum of
  2 ½ hours
• Need fresh donor samples for complement and RBCs

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Case 2

• 68 Y.O. male
• O Rh negative
• Myelodyplasia Syndrome
• Transfusion Dependent
• Previous Anti-K, Anti-E, Warm Autoantibody
• Presents now with the following results

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Case 2 Initial Panel
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Case 2

• Do you see a pattern?
• Is there varying reactivity?
• We know that the patient has a warm autoantibody,
  what next?
• At Mayo, we absorb onto 3 different cells R1R1,
  R2R2, and rr

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Case 2 R1R1 Absorbate
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Case 2 R2R2 Absorbate
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Case 2 rr Absorbate
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Case 2

• What antibodies were identified
• Anti-G, Anti-C, Anti-E, Anti-K, Anti-Mur, Anti-V,
  and Warm Auto
• Why do we care about underlying antibodies
• Possible DHTR
• Difficulty of finding antigen negative blood

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Case 2

• What is significant about Anti-G?
• Belongs to the Rh family
• G antigen is present on all D and or C RBCs
• IgG and does not fix complement
• Stimulus from the transfusion of C RBCs
  following trauma

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Case 2

• More on anti-G
• For Transfusion
• Provide D-, C- crossmatch compatible RBCs
• For OB Patients
• Adsorption/elution studies may be necessary to
  determine if anti-D is also present
• RhIG administration??

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Case 2

• Antigen Incidence
• Blacks
• 92
• Caucasians
• 84
• Asians
• 100

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Case 2 Conclusion

• Anti-G has been shown to be present years after
  the exposure of D or C RBCs
• Why did we care in this case?
• The patient had a previous Anti-C
• The patient has only received Rh negative blood
  that we know of
• Do we have a rr, G donor?

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Case 3

• 20 YO female
• A Rh negative
• 38 week gestation in 2nd pregnancy
• No other information available
• Initial panel results are

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Case 3 Initial Panel
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Case 3

• Do you see a pattern?
• What should be done next?
• Why?

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Case 3

• Possible antibody to high incidence antigen
• Perform phenotype
• Test serum against phenotypically similar cell
• If negative, look for multiple common antibodies
• If positive, consider high incidence

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Case 3

• Our results
• Phenotypically similar cell reacted 1 with
  patient serum
• Antibody was titered to determine if it exhibited
  HTLA characteristics
• Antibody did not have a high titer
• Now what?

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Case 3

• DTT and papain treated cells were tested
• The antibody did not react with the treated
  cells. Antigen is assumed to be sensitive to
  treatments
• A list of high incidence antigens was compiled

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Case 3

• Based on the sensitivity of papain and DTT, a
  Yt(a-) cell was thawed and tested
• This cell was negative at AHG, and 2 more Yt(a-)
  cells were thawed and tested
• We now have our 3 negative cells to confirm the
  presence of an Anti-Yta
• The patients antigen status was Yta-

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Case 3

• In most populations, Yta has an antigen incidence
  of 99.8
• Yta can bind complement
• Yta has been shown to cause anywhere from no
  transfusion reactions to moderate/delayed
  reactions
• Yta has not been shown to cause HDN

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Case 4

• 26 Y.O. female
• A Rh negative
• Presented during pregnancy
• No known antibody history
• Patient presents now with the following results

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Case 4 Initial Panel
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Case 4

• Possible Suspects
• Multiple allo-antibodies
• High-Titer-Low-Avidity
• High Incidence

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Case 4

• Phenotype was performed
• Phenotypically similar cell was tested against
  serum and reacted 1 AHG.
• Ruled out the common multiple alloantibodies.
• What would you do next?
• HTLA titers were done x2 with possible HTLA
  identified

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Case 4

• I was not convinced of the HTLA
• HTLA negative cells (Ch,Rg,Kn,Mc) were run with
  similar results
• We papain and DTT treated the same panel cell to
  see if we could rule out antigens
• Papain cell still reacted
• DTT cell did not react, and upon repeating,
  reacted at micro positive.

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Case 4

• Based on the Papain and DTT results, high
  incidence negative cells were tested
• Lu(a-b-) Sc-1,2 K null Yt(a-) Ge-2,-3
  Lu-8 Lu-6 cells were all W
• At this point, we decided to send it to New York
  Blood Centers to see if they could identify the
  antibody

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Case 4

• NYBC identified an Anti-Jra
• We picked ourselves up, dusted off and confirmed
  these results with our own reagents.

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Case 4

• A little about anti-Jra (Junior)
• Anti-Jra can bind complement
• Can cause transfusion reactions but no cases of
  HDN have been identified
• This antigen has an incidence of 99 in most of
  the population

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Case 4

• What went wrong?
• We forgot that antibodies do not read textbooks!
• Jra antigen should be resistant to DTT
• Anti-Jra antibodies shouldnt look like HTLAs
• Our patient wasnt Japanese

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Case 4

• Outcome of patient
• Patient was urged to donate units while she was
  still pregnant in case she needed them
• Baby was antigen positive, but there were no
  complications
• Patient remains an allogeneic blood donor

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Conclusions

• HTLAs and High Incidence antibodies can mimic
  each other
• High Incidence antibodies can titer out to HTLA
  levels
• It is important to differentiate between HTLA and
  High Incidence antibodies
• Certain patient populations will continue to form
  antibodies

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Conclusions

• It is helpful to perform phenotypes, especially
  on patients you expect to have multiple
  transfusions
• Tests that seem like a waste of time can
  sometimes surprise you!
• Remember to take a picture of a positive DLyou
  may never see another one.

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References

• The Blood Group Antigen Facts Book, M.E. Reid,
  C.L. Francis
• Applied Blood Group Serology, P.D. Issitt, D.J.
  Anstee
• Technical Manual, 15th edition
• Mayo Clinic Transfusion Medicine SOPs

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Thanks

• Craig Tauscher for helping me prepare this
  presentation
• Sheila Muenster for reviewing my presentation
• The MT students who had to sit through my rough
  draft
• Bob Stowers for having the DL
• The rest of my coworkers for their help

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Any Questions??