case study: weird wonderful walter jayanna slayten, ms, mt(ascp)sbb manager, ibc-irl and sbb program...
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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