An immediate hemolytic transfusion reaction due to anti-C and a delayed hemolytic transfusion reaction due to anti-Ce+e: hemoglobinemia, hemoglobinuria and transient impaired renal function

A curious case of delayed hemolytic transfusion reaction with evanescent antibodies in a patient with hereditary hemorrhagic telangiectasia

BACKGROUND

Delayed hemolytic reactions are potential complications of incompatible transfusions and are usually associated with the identification of a new antibody on serologic studies, following a second immunization event. However, in rare cases, the antibody investigation remains negative even if the clinical presentation would lead one to suspect otherwise.

CASE REPORT

A 44-year-old woman with hereditary hemorrhagic telangiectasia presented to the emergency department with hematuria and low back pain after she had received three units of RBCs 2 weeks earlier. Hematology and biochemistry results were consistent with delayed hemolytic transfusion reaction, but surprisingly, serologic antibody investigations were negative. It was only when her plasma was tested with enzyme (ficin)-treated panel cells that anti-e was finally detected, with a 3+ reaction with all homozygous e+ cells. No reaction was seen with heterozygous e+ cells. Four months later, an anti-K was also detected on standard panels, while the anti-e remained detectable only with ficin-treated panel cells. Three years later, both antibodies had vanished and remained undetectable. The weakness of anti-e reaction, combined with the quick evanescence of both antibodies led to the suspicion of a potential underlying immunodeficiency disorder, which was confirmed by low immunoglobulin levels on two occasions.

CONCLUSION

To our knowledge, this is the first case of immunodeficiency disorder diagnosed after the identification of evanescent antibody reactions. This case also outlines the importance of a good clinical history that should lead to further investigations when a hemolytic transfusion reaction is suspected.

Fatal massive hemolysis caused by immunoglobulin M anti-c antibody in a patient with newly diagnosed B-cell acute lymphoblastic leukemia: a case report

Delayed hemolytic transfusion reactions (DHTRs) occur secondary to slow, mild IgG-mediated processes against minor red blood cell antigens. Herein, we report the case of a rapidly fatal alloimmune anti-c IgM-mediated hemolysis, a rare, previously undescribed, pathophysiologic scenario. Early recognition of such phenomena can expedite supportive measures and optimize patient outcomes.

An acute hemolytic transfusion reaction due to the "anti-c" rhesus antibody: A case report emphasizing the role of transfusion medicine

Rhesus (Rh) mediated hemolytic transfusion reactions (HTR) are usually immunoglobulin G mediated and delayed onset. Rh antibodies being the cause of acute HTR (AHTR) and intravascular hemolysis are still under debate. We report here a case of a 53-year-old male who developed AHTR due to "anti-c" antibodies within 3 h of blood transfusion, precipitating fatal acute liver failure in a patient with hepatitis C related chronic liver disease. This case emphasizes the need of inclusion of antibody screening in routine pretransfusion testing as well as a critical role of transfusion medicine specialists for early diagnosis and minimizing transfusion-related morbidity and mortality.

Mechanisms Responsible for Delayed and Immediate Hemolytic Transfusion Reactions in a Patient with Anti‐E + Jkb+ Diband Anti‐HLA Alloantibodies

Immediate hemolytic transfusion reactions (IHTR) occurred in the course of delayed hemolytic transfusion reactions (DHTR). An 84-year-old man had received a blood transfusion 20 years ago. Progressive anemia developed, because of continuous bleeding from a bladder tumor. He was transfused with concentrated red blood cells (CRC) which were Rh-E antigen negative, because he had anti-E antibodies (day 0). He received CRC on day 3, and underwent resection of bladder tumor on day 6. Although crossmatch-compatible CRCs were prepared for the operation, those were not required and were kept in a refrigerator in the ward. On day 9, when a CRC kept in the ward was transfused, he suddenly had a IHTR. In order to analyze a mechanism of IHTR, the anti-Jk(b) and anti-Di(b) antibodies, anti-HLA antibodies and the concentrations of inflammatory cytokines were measured in serum samples. The anti-Jk(b) and anti-Di(b) antibodies increased prior to IHTR experienced on day 9. The concentrations of IL-6 and IL-1beta increased from day 2, while the concentration of IL-8 increased from day 7. The anti-HLA class I antibody could be detected 2 days before IHTR. Thus, the anti-Jk(b) and anti-Di(b) antibodies induced the production of inflammatory cytokines and symptoms of DHTR and IHTR. The anti-HLA class I antibody could be produced in spite of using the filer for removing leukocytes, and may take part in the induction of IHTR. Further, blood products should be transfused soon after completing a crossmatch test in patients with anti-RBC alloantibodies.

Haemolytic disease of the newborn due to anti-Ce

A baby was readmitted to the hospital 3 days after delivery when she developed jaundice. At admission, the direct antiglobulin test was also found to be positive. The baby required emergency exchange transfusion. A strongly reacting IgG anti-Ce (Rh7) was found in the serum of the mother. Severe haemolytic disease of the newborn due to anti-Ce is very rare. The mother's serum had been screened and found negative for red cell antibodies at 16 weeks gestation but the test was not repeated later in pregnancy when this antibody might have been detected.

Severe HDN due to anti-Ce that required exchange tranfusion

BACKGROUND

Rh system antibodies are commonly encountered in blood bank practice as well as during pregnancy. Nevertheless, no examples of anti-Ce (RH7) have been reported as a cause of HDN that requires exchange transfusion.

CASE REPORT

A 38-year-old woman in her fourth pregnancy was typed as blood group O D+, C-, c+, E+, e-. Anti-C and anti-e were detected in her serum during a routine prenatal work-up. Further evaluation, including flow cytometric analysis, revealed the presence of a strong anti-Ce and a weak anti-e. Her partner was typed as group A D+, C+, c-, E-, e+. A seemingly healthy male infant was delivered at 40 weeks of gestation. The infant's RBCs were typed as group O D-, C+, c+, E+, e+ with a positive DAT (titer 128). Twenty-five hours after birth, the baby had to be transferred to the neonatal intensive care unit because of rapidly rising total serum bilirubin. Despite intensive treatment, including double phototherapy, albumin infusion, and the administration of furosemide and IVIG, the total serum bilirubin level increased during the following day and exchange transfusion with 2 units of type O D-, C-, c+, E+, e- had to be performed; this resulted in a prompt decrease in total serum bilirubin without relapse.

CONCLUSION

Anti-Ce caused severe HDN requiring exchange transfusion. This highlights the need for a close follow-up throughout pregnancy if unexpected RBC antibodies are present, to permit the provision of compatible blood in case of a rare antibody.