Transcript PowerPoint Presentation - London Health Sciences Centre

Two Case Reports of Hemolytic Anemia Due to a Low Titred, High Thermal Amplitude, Cold Reactive Autoantibody
• Special Acknowledgements:
Linda Thomson: Poster design
J Kinney, S McManus, D Spriel, L Petkovic, K Leigh
London Health Sciences Centre, London, ON
Introduction
Most antibodies responsible for autoimmine hemolytic anemia (AIHA) generally fall into two serological categories. Antibodies that react optimally at 37oC are usually of the
IgG type while those antibodies that react best at 4oC are of the IgM type.
While the serological investigation carried out in the blood transfusion laboratory does not determine whether a patient has hemolytic anemia, the investigation does aid in
determining if a patient’s hemolysis is immune mediated. The serological findings are significant because the treatment for AIHA is often based on the serological findings.
We reported two cases in which the serological findings were not typical for either warm AIHA or cold agglutinin syndrome.
CASE #2
CASE #1
• 79 year old female referred to Emergency department from family physician due
to fatigue. Her Hb had decreased from 105 g/L to 66 g/L over a 2 month period
• 36 year old male presented in the Emergency department complaining of
fatigue, jaundice and dark coloured urine
Laboratory Findings
Laboratory Findings
• Initial hemoglobin (Hb) 105 g/L
• WBC 9.0 x 109/L
• Total Bilirubin 111.3 umol/L
• Hb 66 g/L
C
c
E
e
V
K
k
Lew is
METHOD
Room
Temp.
D
Kidd
Immediate
spin
Duffy
4oC
0
2+
2+
2+
2+
0
1+
2+
4
MF
2+
2+
+
5
MF
1+
2+
0
+
6
MF
1+
2+
0
+
7
MF
1+
2+
+
0
+
8
0
2+
0
2+
+
+
0
+
9
MF
2+
2+
0
+
0
0
+
10
0
2+
+
+
+
0
+
11
0
2+
P
Fya Fyb Jka Jkb Lea Leb P1
MN
Lutheran
M
N
S
s
Cell #
MTS Gel
Cell #
Kell
Special Ag Type
Lua Lub
1
RZR1
+
+
0
+
+
0
0
+
+
0
+
+
0
+
+
0
+
+
0
0
+
1
MF
2
R1wR1
+
+
0
0
+
0
0
+
0
+
+
+
0
+
+
0
+
0
+
0
+
2
MF
3
R2R2
+
0
+
0
0
0
0
+
0
+
0
+
0
+
+
0
+
0
+
0
+
3
4
Ror
+
0
+
0
+
0
0
+
0
0
+
0
0
0
+
0
+
0
+
0
+
5
r'r
0
+
+
0
+
0
0
+
+
0
+
+
0
+
+
+
0
0
+
0
6
r"r
0
0
+
0
+
0
0
+
+
0
0
+
0
+
+
+
+
0
+
7
rr
0
0
+
0
+
0
0
+
0
+
0
+
0
+
+
0
+
+
+
8
rr
0
0
+
0
+
0
0
+
+
0
+
+
+
0
0
0
+
0
9
rr
0
0
+
0
+
0
0
+
+
0
+
0
+
0
+
+
+
10
rr
0
0
+
0
+
0
0
+
+
+
+
+
0
+
0
+
11
Ror
+
0
+
0
+
+
0
+
+
0
+
0
0
+
+
0
12
Auto
12
13
Cord
13
14
• Donath-Landsteiner test for paroxsymal cold
hemoglobinuria was negative
Name:
PIN:
IS
5'
IgG
Duffy
C
c
E
e
V
K
k
Kidd
Lew is
P
Fya Fyb Jka Jkb Lea Leb P1
MN
Lutheran Special Ag Type
M
N
S
s
Lua Lub
Cell #
2+
2+
0
4+
0
2+
0
4+
0
2+
0
4+
0
2+
2+
0
4+
0
2+
2+
0
4+
0
2+
0
4+
0
+
0
0
+
0
+
0
+
0
+
+
+
0
+
+
0
0
+
0
+
1
+
0
0
+
0
0
+
0
+
0
+
0
+
+
+
+
+
+
0
+
2
2+
3
R2R2
+
0
+
0
0
0
0
+
+
0
+
0
+
0
+
+
0
+
+
0
+
3
2+
4
Ror
+
0
+
0
+
0
0
+
+
0
+
0
0
0
+
0
+
+
0
0
+
4
2+
5
r'sr
0
+
+
0
+
0
0
+
0
0
0
+
0
+
+
+
0
0
+
0
+
5
2+
6
r"r
0
0
+
0
+
0
0
+
0
+
+
+
0
+
+
+
0
+
+
0
+
6
2+
7
rr
0
0
+
0
+
0
+
+
0
+
+
0
0
+
0
+
+
0
+
0
+
7
8
rr
0
0
+
0
+
0
0
+
+
0
+
+
0
+
+
0
+
0
+
0
+
8
2+
9
rr
0
0
+
0
+
0
0
+
0
+
+
0
+
0
+
0
+
0
+
0
+
9
2+
2+
2+
10
rr
0
0
+
0
+
0
0
+
0
0
+
0
0
0
+
+
+
+
0
0
+
10
1+
0
2+
11
R2R2
+
0
+
+
0
0
0
+
+
+
+
0
+
0
+
+
0
0
+
0
+
11
2+
2+
1
2+
12
Auto
12
2+
2+
2+
13
Cord
13
• Tests for Epstein Barr Virus and Cytomegalovirus
IgM antibody were negative
• Tests for hepatitis B and C were negative
14
Outcome
6% Alb
0
0
• Patient Hb dropped to 41 g/L within 48 hours of
admission
Name:
PIN:
4oC
Adult Cells
4
25oC
1
37oC
1
• Patient was also treated with 3 rounds of
plasmapheresis
15
Blood Group:
Case #2
O pos
Further testing, conclusions etc.:
Probable cold agglutinin no obvious specificity
Date of Specimen:
Date of Testing:
Acc#:
Outcome
Eluate non specific
Technologist:
Direct Antiglobulin Test
IS
5'
Poly
3
IgG
2
C3
2
6% Alb
0
• Patient was diagnosed with chronic lymphocytic
leukemia with a secondary AIHA
• Both cases represent the importance of pursuing unusual serological reactions in
relation to the patient’s clinical picture
• Performing cold agglutinin titres and thermal amplitude testing aid in diagnosing
and treatment
• IgM antibodies with a high thermal amplitude and/or high titre may react in MTS
Gel anti-IgG cards often with a mixed field reaction appearance
• In the primary author’s (JK) experience many laboratories would attempt to
prewarm away reactions. These results may lead to incorrect diagnosis and/or
treatment
• Resolving the positive 6% albumin control in case #2 and more accurately
assessing the presence of IgG on the patient’s red cells was helpful in determining
the course of treatment for this patient
• Attempt to keep patient warm to prevent Hb from
decreasing was unsuccessful
Cold Agglutinin Titre and
Thermal Amplitude
• Patient required a total of 12 units of packed red
cells during his 10 day hospital admission
• Patient was discharged from hospital with a Hb of
79 g/L and has had no reoccurrence to date
• Antibody screen was 2+ with both screening cells
using column agglutination
3+
• Due to patient’s worsening condition, and
unknown etiology of hemolysis, the patient was
started on 150 mg/day dose of prednisone
Cold Agglutinin Titre and
Thermal Amplitude
• Differential DAT showed 2+ results with monospecific
anti-IgG and monospecific anti-C3b, -C3d.
14
15
Affix label here:
MF denotes mixed field reactions
C3
Kell
D
+
Direct Antiglobulin Test
Poly
0
0
Rh-Hr
Cell #
METHOD
+
Cold auto agglutinin with no obvious specificity
Technologist:
IMMUCOR LOT# 02405 Exp. 22-January-2004
R1wR1
Date of Testing:
Acc#:
• Our findings are typical serology of warm AIHA associated with IgM autoantibodies
as reported by Garratty et al 1,3
R1R1
Further testing, conclusions etc.:
Date of Specimen:
• An eluate at 48oC was required before the 6% albumin
control was negative (DTT treatment would be an
alternative especially if anti-IgG was negative)
2
15
A pos
Blood Group:
Case #1
• LD, serum 463 U/L
1
14
15
Affix label here:
• Initial DAT was 4+ and 6% albumin control 2+
Last Wash
IMMUCOR LOT# 28811 Exp. 24 July 03
Rh-Hr
• The two cases described are examples of IgM which showed similar reactivity over
wide temperature profile.
• Both patients responded to prednisone which is atypical for Cold Agglutinin
Syndrome2
Acid Eluate
MTS Gel
• DTT treatment of serum to assess IgG reactivity
was invalid due to a negative dilution control
Direct Antiglobulin Test and
Antibody Screen
• Total bilirubin 78.3 umol/L
Cold Auto
Ads X1
• More sensitive DAT techniques including MTS Gel,
and cold wash were used both with negative results
• RBC morphology: polychromasia, macrocytes, nucleated
red cells, spherocytes, agglutination
Warm Auto
Ads X2
• Weak reacting antibody detected in screening cells
using column agglutination with anti-IgG
• IgM autoimmune hemolytic anemia has most commonly been associated with
intravascular hemolysis and preferential cold reactivity1
MTS Gel
Additional Testing
• Direct Antiglobulin Test: Negative
Discussion
4oC
25oC
37oC
Adult
Cells
4
1
1
• Patient Hb decreased to 55 g/L
• Treatment with 75 mg/day prednisone was initiated
• Patient was discharged from hospital 2 weeks after
admission with a Hb 74 g/L
• Patient did not require transfusion of red cells
References
1. Petz LD, Garratty G: Immune Hemolytic Anemias, 2nd edition. Philadelphia: Churchill
Livingstone, 2004.
2. Dacie JV: The Haemolytic Anemias, 3rd ed. vol.3. New York: Churchill Livingstone, 1992
3. Garratty G, Arndt P, Leger R: Serological findings in autoimuunue hemolytic anemia
associated with IgM warm autoantibodies (abstr). Blood 2001;98:61a
Cord Cells
4
1
1
Cord Cells
2
2
2
Auto Cells
4
2
1
Auto Cells
2
1
1