Case Study #3-02 Patient: Medical History/Clinical Information:
The patient is a 54 year old female admitted to the Emergency Room with upper G.I. bleeding. Her hemoglobin today is 7.4 gm/dl. NOTE: During out-patient testing performed two days ago, her hemoglobin and hematocrit were 11.2gm/dl and 33.1%.
Transfusion/Pregnancy History:
The patient was transfused with 2 units of red blood cells during open-heart surgery in June of 1999. At that time her antibody screen was negative and all crossmatched units were compatible. The patient had 3 uncomplicated pregnancies between 1976 and 1982.
Medications: Hospital Blood Bank Serologic Findings:
The hospital blood bank staff reported the patient’s serum reacted with both screening cells and 8 of 10 panel cells using GEL testing. All units crossmatched were incompatible and the auto control was negative.
Case Study #3-02
Initial Testing Performed By Greater Alleghenies Region Reference
Cell Typing Serum Typing
NOTE: The patient appears to be a group A in cell testing and group O in serum testing. She is Rh positive with a negative Direct Antiglobulin Test
Antibody Screening:
1009598 1 + + 0 0 + 0 0 / 0 0 + + 0 + 0 + 0 + 0 + 0 0 + 0 + + 0 + 0
1009598 3 0 0 0 + + + 0 / 0 + 0 0 + 0 0 + 0 + + + 0 0 + + + + /
1009598 1 + + 0 0 + 0 0 / 0 0 + + 0 + 0 + 0 + 0 + 0 0 + 0 + + 0 + 0
1009598 3 0 0 0 + + + 0 / 0 + 0 0 + 0 0 + 0 + + + 0 0 + + + + /
Case Study #3-02 Serum Testing: NOTE: Unless otherwise noted all cells are H+, I+, Kp(b+), Js(b+), Co(a+) and Wr(a-),He-,Yt(a-), Di(a-)
Patient anti-CW anti-S anti-s anti-K anti-Fya anti-Fyb anti-Jka anti-Jkb
Case Study #3-02 Case Study #3-02
0 0 / 0 0 + 0 + + 0 0 0 + + + + 0 0 + + 0
Case Study #3-02
* Reagent Red Cells used in initial serum typing
Additional Group A1, A2, and B Donor cells tested to confirm serum typing: Donor Whole Blood # ABO Group
DISCUSSION:
In initial testing: a. The patient's red cells typed as a group A, Rh positive; however, in serum typing the patient appeared to be a group O. It
was noted that strongest agglutination was observed with group B cell, while weaker agglutination was observed with A1
b. The patient's serum demonstrated reactivity in saline room temperature (RT) testing with 2 of 3 cells and in the
antiglobulin phase using PEG solution (PEG AGT) with 3 of 3 cells. In LISS testing only 1 of 3 cells demonstrated reactivity after 37oC incubation and 3 of 3 cells were reactive in LISS antiglobulin testing (LISS AGT).
c. It was noted that the cell that demonstrated reactivity in LISS 37oC testing was also positive in saline RT testing; however,
the cell demonstrating strongest agglutination in saline RT testing did not demonstrate reactivity in LISS 37oC testing.
When the patient's serum was tested with a Reagent Red Cell Panel (Panel #1), the same variety of reactivity seen in initial antibody screening procedures was observed. In immediate spin testing, possible anti-M specificity was suggested; however, in room temperature testing agglutination was observed with two cells that did not demonstrate agglutination at immediate spin. This finding suggests the presence of at least one additional antibody. In PEG antiglobulin testing, agglutination was observed with a majority of the cells that previously demonstrated reactivity; however, one previously reactive cell did not demonstrate agglutination in PEG antiglobulin testing.
In order to determine the patient's red cell phenotype, her cells were typed for several common red cell antigens. She was found to lack the CW, S, K, Fya, Jkb, and M antigens. In addition, initial Rh testing showed that the patient's cells lack both the E and c antigens. Review of the first Reagent Red Cell Panel tested suggested the possible presence of anti-M, -E, and -Fya.
When the patient's serum was tested with a Selected Reagent Red Cell Panel (Panel #2) the following results were observed: a. Agglutination was observed with M+ cells at immediate spin and room temperature, but not in the PEG antiglobulin phase. b. Agglutination was observed with E+ cells at room temperature and in the PEG antiglobulin phase. c. Agglutination was observed with Fy(a+) cells only in PEG antiglobulin testing. d. Antibodies to c, S and Lea were ruled out only with 1 cell and it was not possible to rule out antibodies to V,VS,CW,Lua,Jsa
When an additional panel of selected Fy(a-) Reagent Red Cells (Panel #3) was tested, it was possible to confirm the presence of anti-M at room temperature, anti-E at room temperature and in the PEG antiglobulin phase. It was possible to exclude the presence of V,VS,CW,Lua,Jsa and Cob with at least one cell. There were additional cells that ruled out for c, S, and Lea. DISCUSSION: (Con't)
Finally, additional testing was performed to investigate the ABO discrepancy that was observed in initial serum typing. Because routine antibody investigation showed the patient's serum contained an anti-M that was reactive at immediate spin and at room temperature and an anti-E that was reactive at room temperature, the A1, A2, and B cells used in serum typing were
typed for the M and E antigens. All cells were found to be M+, while only the B cells were found to be E+. Several A1, A2 and
B donor cells were tested and at least one M-, E- A1, A2 and B cell was identified for testing with the patient's serum. In
immediate spin and room temperature testing, no agglutination was observed with A1 or A2 cells, while B cells continued to
demonstrate strong agglutination. This testing confirms the patient is a group A individual.
Questions to be answered for 0.5 ARC-GAR Continuing Education Credits *
When M+ cells on the first panel (page #3) were tested at immediate spin, cells #3, 5, and 6 demonstrated stronger reactivity than cells #1,2, and 9. This same variation of reactivity was observed in room temperature testing. What possible explanation is there to describe this observation?
My laboratory does not have multiple Reagent Red Cell panels available for testing, but does have ficin. Would ficin be of any help in identifying and/or excluding the possible presence of antibodies in the patient's serum?
How can the information regarding the type of variation of reactivity observed in question #1 be applied, when interpreting test result of other samples tested with a Reagent Red Cell panel.
* Answers must be forwarded to Nancy Steffey at the Reference Laboratory, ARC-Great Alleghenies Region Johnstown Headquarters, Johnstown, PA or via E-Mail at [email protected]. If you have any question please call 814-533-6508.
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