Transcript Challenging Case Studies from The Mayo Clinic Reference

Interesting Case Studies from
The Mayo Clinic Reference
Laboratory
Georgette Benidt, MT(ASCP)
Case 1
• 81 year old with B-cell
lymphoproliferative disorder
• Clinician ordered the Donath
Landsteiner Test
2
DONATH-LANDSTEINER (DL)
3
Case 1 – objectives
• Significance of the test
• Incidence of positive tests
• Testing challenges
4
DL Significance
• Paroxysymal Cold Hemoglobinuria is
an ideopathic disorder occurring in
<1% of hemolytic anemias
• 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)
5
6
Donath-Landsteiner
Testing Challenges
• Need to maintain the specimens and
controls at 37°C.
• Length of time from start to finish is
minimum of 2 ½ hours
• Need fresh donor samples for
complement and RBC’s
7
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:
8
Case 2: Initial Panel
D
C
Cw
E
c
e
f
v
K
k
Fya
Fyb
Jka
Jkb
M
N
S
s
IS
PEG AHG
R1R1
+
+
+
0
0
+
0
0
0
+
+
0
0
+
+
0
+
+
0
2+
R2R2
+
0
0
+
+
0
0
0
0
+
0
+
0
+
+
0
+
+
0
4+
rr
0
0
0
0
+
+
+
0
+
+
0
+
0
+
+
+
+
+
0
2+
rr
0
0
0
0
+
+
+
+
0
+
0
0
+
0
+
+
+
+
0
1+
rr
0
0
0
0
+
+
+
0
0
+
+
+
+
+
+
0
+
0
0
w+
rr
0
0
0
0
+
+
+
0
0
+
+
0
0
+
+
0
+
+
0
W+
rr
0
0
0
0
+
+
+
0
0
+
0
+
+
+
+
0
+
0
0
w+
rr
0
0
0
0
+
+
+
0
0
+
0
+
0
+
+
0
+
0
0
w+
Ror
+
0
0
0
+
+
+
0
0
+
0
0
+
0
0
+
0
+
0
2+
Auto
C
C
w+
9
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
10
Case 2: R1R1 Absorbate
I
S
D
C
Cw
E
c
e
f
v
K
k
Fya
Fyb
Jka
Jkb
M
N
S
s
rr
0
0
0
0
+
+
+
0
+
+
0
+
0
+
+
+
+
+
2+
rr
0
0
0
0
+
+
+
+
0
+
0
0
+
0
+
+
+
+
2+
R1R1
+
+
0
0
0
+
+
+
+
+
+
+
0
+
0
r"r
0
0
0
+
+
+
+
0
0
+
0
+
+
+
0
+
0
+
4+
rr
0
0
0
0
+
+
+
0
0
+
0
+
+
+
+
0
+
0
0
2+
rr
0
0
0
0
+
+
+
0
0
+
0
0
+
0
0
+
0
+
0
2+
rr
0
0
0
0
+
+
+
0
0
+
+
0
+
+
0
+
0
+
0
2+
+
0
0
0
+
0
0
0
0
Absorbing
Cell
R1R1
+
+
0
0
0
0
+
PEG AHG
CC
2+
11
Case 2: R2R2 Absorbate
I
S
D
C
Cw
E
c
e
f
v
K
k
Fya
Fyb
Jka
Jkb
M
N
S
s
r'r
0
+
0
0
+
+
+
0
0
+
0
+
+
+
+
+
0
+
1+
rr
0
0
0
0
+
+
+
0
+
+
0
+
0
+
+
+
+
+
2+
rr
0
0
0
0
+
+
+
+
0
+
0
0
+
0
+
+
+
+
2+
rr
0
0
0
+
+
+
+
+
+
+
0
+
0
2+
rr
0
0
0
0
+
+
+
0
0
+
0
+
0
+
+
0
+
0
0
2+
R2R2
+
0
0
+
+
0
+
0
0
+
0
+
+
+
+
0
+
0
0
2+
rr
0
0
0
0
+
+
+
0
0
+
+
0
+
+
0
+
0
+
0
2+
0
0
+
+
0
0
0
0
Absorbing
Cell
R2R2
+
0
0
0
0
+
0
0
PEG AHG
CC
12
Case 2: rr Absorbate
I
S
D
C
Cw
E
c
e
f
v
K
k
Fya
Fyb
Jka
Jkb
M
N
S
s
r'r
0
+
0
0
+
+
+
0
0
+
0
+
+
+
+
+
0
+
1+
Ror
+
0
0
0
+
+
+
0
0
+
0
0
+
0
+
+
+
0
1+
r"r
0
0
0
+
+
+
+
0
0
+
0
+
+
+
0
+
0
+
4+
rr
0
0
0
0
+
+
+
+
0
+
0
0
+
0
+
+
+
+
2+
rr
0
0
0
0
+
+
+
0
0
+
+
+
+
+
+
0
+
0
3+
rr
0
0
+
+
+
+
+
+
+
+
0
+
0
2+
rr
0
0
0
0
+
+
+
0
0
+
0
0
+
0
0
+
0
+
0
2+
rr
0
0
0
0
+
+
+
0
0
+
+
0
0
+
+
0
+
+
0
2+
R1R1
+
+
0
0
0
+
0
0
0
+
0
+
+
+
+
0
+
0
1+
rr
0
0
0
0
+
+
+
+
+
0
+
+
+
+
2+
rr
0
0
0
0
+
+
0
0
0
Absorbing
Cell
0
0
+
0
+
0
0
+
+
0
0
PEG AHG
CC
13
Case 2
• What antibodies were identified:
• Anti-G, Anti-C, Anti-E, Anti-K, AntiMur, Anti-V, and Warm Auto
• Why do we care about underlying
antibodies:
• Possible DHTR
• Difficulty of finding antigen
negative blood
14
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
15
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??
16
Case 2
• Antigen Incidence
• Blacks
• 92%
• Caucasians
• 84%
• Asians
• 100%
17
Case 2: Conclusion
• Anti-G has been shown to be present
years after the exposure of D+ or C+
RBC’s
• 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?
18
Case 3
• 20 YO female
• A Rh negative
• 38 week gestation in 2nd pregnancy
• No other information available
• Initial panel results are:
19
Case 3: Initial Panel
D
C
c
E
e
K
k
Fya
Fyb
Jka
Jkb
M
N
S
s
IS
PEG
AHG
R1R1
+
+
0
0
+
0
+
0
+
0
+
0
+
0
+
0
W+
R1R1
+
+
0
0
+
+
+
+
+
+
0
0
+
0
+
0
1+
R1R1
+
+
0
0
+
0
+
+
0
0
+
+
0
+
0
0
1+
R2R2
+
0
+
+
0
0
+
+
0
+
+
+
0
0
+
0
1+
R2R2
+
0
+
+
0
+
+
0
+
0
+
+
0
+
+
0
1+
R2R2
+
0
+
+
0
0
+
0
+
+
0
0
+
0
+
0
1+
R2r
+
0
+
+
+
+
0
+
+
+
+
0
+
0
+
0
1+
r'r
0
+
+
0
+
0
+
0
+
0
+
+
+
+
+
0
1+
r"r
0
0
+
+
+
0
+
+
W
+
+
+
0
+
+
0
W+
rr
0
0
+
0
+
+
+
0
+
+
+
+
0
+
0
0
W+
rr
0
0
+
0
+
0
+
0
0
+
0
0
+
0
+
0
1+
rr
0
0
+
0
+
0
+
+
0
+
0
0
+
+
+
0
1+
rr
0
0
+
0
+
0
+
0
0
+
0
0
+
0
+
0
W+
0
0
AUTO
CC
+
20
Case 3
• Do you see a pattern?
• What should be done next?
• Why?
21
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
22
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?
23
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
24
25
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 patient’s antigen status was Yta26
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
27
Case 4
• 26 Y.O. female
• A Rh negative
• Presented during pregnancy
• No known antibody history
• Patient presents now with the
following results:
28
Case 4: Initial Panel
D
C
c
E
e
K
k
Fya
Fyb
Jka
Jkb
M
N
S
s
IS
PEG
AHG
RZR1
+
+
0
+
+
0
+
+
0
+
+
+
0
+
+
0
1+
R2R2
+
0
+
+
0
0
+
0
+
0
+
0
+
+
+
0
1+
r'r
0
+
+
0
+
0
+
0
+
+
0
+
0
0
+
0
1+
r"r
0
0
+
+
+
0
+
+
0
+
+
+
0
0
+
0
1+
rr
0
0
+
0
+
0
+
+
0
+
0
+
+
0
+
0
1+
RZR1
+
+
0
+
+
0
+
0
+
+
0
+
0
0
+
0
1+
R1R1
+
+
0
0
+
+
+
+
+
+
0
0
+
0
+
0
1+
rr
0
0
+
0
+
0
+
0
0
+
0
+
+
+
0
0
1+
rr
0
0
+
0
+
+
+
+
0
0
+
+
0
+
0
0
1+
0
0
AUTO
CC
+
29
Case 4
• Possible Suspects
• Multiple allo-antibodies
• High-Titer-Low-Avidity
• High Incidence
30
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
31
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.
32
33
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
34
Case 4
• NYBC identified an Anti-Jra
• We picked ourselves up, dusted off
and confirmed these results with our
own reagents.
35
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
36
Case 4
• What went wrong?
• We forgot that antibodies do not read
textbooks!
• Jra antigen should be resistant to
DTT
• Anti-Jra antibodies shouldn’t look
like HTLAs
• Our patient wasn’t Japanese
37
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
38
Conclusions
• HTLA’s 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
39
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 DL…you may never see
another one.
40
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
SOP’s
41
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
42
Any Questions??