Case Study:
Weird Wonderful
Walter
Jayanna Slayten, MS, MT(ASCP)SBB
Manager, IBC-IRL and
SBB Program Education Coordinator
Indiana 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:
DAT:
Antibody Screen:
Autocontrol (AC):
A, D Positive
Polyspecific = 3+
4+ with all cells by Echo
Positive
Investigation

Results

A, D Positive

DAT Positive

Panel testing

PEG-AHG

Ortho Gel
Panel Testing
Rh
Kell
Duffy
Kidd
P
Lewis
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+
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+
2+
3+
Eluate Testing
Kidd
Duffy
Kell
Rh
Eluate
MN
P
Lewis
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+)
E
c
K
S
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
P
Lewis
Auto
Absorb x 4
MN
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



Unit 1 Gp A+
Unit 2 Gp A+
Unit 3 Gp A+
E-c-K-SE-c-K-SE-c-K-S
LISS-AHG
Compatible!
Compatible !
Compatible !
Gp A Panel Testing
Rh
Kell
Duffy
Kidd
P
Lewis
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