1 / 43

Interesting Case Studies from The Mayo Clinic Reference Laboratory

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. DONATH-LANDSTEINER (DL). Case 1 – objectives. Significance of the test

darcie
Download Presentation

Interesting Case Studies from The Mayo Clinic Reference Laboratory

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Interesting Case Studies from The Mayo Clinic Reference Laboratory Georgette Benidt, MT(ASCP)

  2. Case 1 • 81 year old with B-cell lymphoproliferative disorder • Clinician ordered the Donath Landsteiner Test

  3. DONATH-LANDSTEINER (DL)

  4. Case 1 – objectives • Significance of the test • Incidence of positive tests • Testing challenges

  5. 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)

  6. Donath-LandsteinerTesting 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

  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

  11. Case 2: R2R2 Absorbate

  12. Case 2: rr Absorbate

  13. 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

  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

  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. 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 Yta-

  25. 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

  26. Case 4 • 26 Y.O. female • A Rh negative • Presented during pregnancy • No known antibody history • Patient presents now with the following results:

  27. Case 4: Initial Panel

  28. Case 4 • Possible Suspects • Multiple allo-antibodies • High-Titer-Low-Avidity • High Incidence

  29. 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

  30. 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.

  31. 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

  32. Case 4 • NYBC identified an Anti-Jra • We picked ourselves up, dusted off and confirmed these results with our own reagents.

  33. 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

  34. Case 4 • What went wrong? • Weforgot 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

  35. 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

  36. 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

  37. 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.

  38. 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

  39. 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

  40. Any Questions??

More Related