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Hassanein H, Hajdenberg J. High Thermal Amplitude Red Blood Cell Agglutinating Cold Type Autoantibodies in a Case of Severe Acute Respiratory Syndrome Coronavirus 2 Pneumonia and Multiorgan Failure. J Med Cases 2021; 12:16-17. [PMID: 34434421 PMCID: PMC8383634 DOI: 10.14740/jmc3608] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/20/2020] [Indexed: 11/30/2022] Open
Abstract
A 48-year-old man diagnosed with multiorgan failure and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia developed anemia and polyclonal cold agglutinins that reacted at 37 °C. He recovered after a 2-month hospitalization where he received intensive care support. Cold agglutinins resolved after 2 weeks of supportive care. As red blood cell (RBC) cryptic antigens and warm type autoimmune hemolysis have been recently described in coronavirus disease 2019 (COVID-19) patients, we believe this mechanism may also give rise of clinically detectable cold immunoglobulin M (IgM) autoantibodies. Given the thermal amplitude of this particular agglutinin we believe it is possible that in vivo RBC agglutination could contribute to disease severity.
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Affiliation(s)
- Hatem Hassanein
- UF Health Cancer Center/Orlando Health, Orlando, FL 32806, USA
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2
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Falvella FS, Chibireva M, Panteghini M. Prospective validation of an automatic reflex test for identifying spurious elevations of mean corpuscular haemoglobin concentration due to the presence of cold agglutinins. Scand J Clin Lab Invest 2021; 81:598-600. [PMID: 34346820 DOI: 10.1080/00365513.2021.1959051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Cold agglutinins (CA) in blood may cause false reduction in red blood cell (RBC) count and false increases of RBC indices, such as mean corpuscular haemoglobin concentration (MCHC). Preheating at 37 °C for 2 h is used to overcome this problem. We previously proposed the integration in a total laboratory automation (TLA) setting of a customized reflex test in the presence of MCHC >385 g/L for identifying spurious elevations due to CA. Here, we prospectively evaluate this approach after its introduction in our clinical practice. We evaluated 73 consecutive blood samples from 34 adult patients. Short heating (<1 min) at 41 °C using the reticulocyte channel of Sysmex XN-9000 platform was followed by calculation of optical parameters by the instrument software to ensure quick solution of the CA-dependent problems. After the reflex test in the reticulocyte channel, MCHC dropped below 385 g/L in 50 samples. The reflex markedly corrected the RBC number in eight samples obtained from three patients with CA condition. Two samples from markedly anaemic patients had low blood haemoglobin and RBC count before and after reflex. The remaining 13 samples were obtained from 12 patients, most of whom were on antiretroviral therapy or suffered severe electrolyte disorders, known conditions associated to increased MCHC. The implementation of the proposed automatic reflex by reticulocyte channel on the Sysmex XN-9000 platform in a TLA setting may solve the problem of spuriously high MCHC due to RBC agglutination for CA in a few minutes instead of waiting hours for sample preheating.
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Affiliation(s)
| | - Mariia Chibireva
- Clinical Pathology Unit, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Mauro Panteghini
- Clinical Pathology Unit, ASST Fatebenefratelli-Sacco, Milan, Italy
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Jensen CE, Wilson S, Thombare A, Weiss S, Ma A. Cold agglutinin syndrome as a complication of Covid-19 in two cases. Clin Infect Pract 2020; 7:100041. [PMID: 32924007 PMCID: PMC7480768 DOI: 10.1016/j.clinpr.2020.100041] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/21/2020] [Accepted: 09/01/2020] [Indexed: 12/12/2022] Open
Abstract
Background Cold agglutinins are autoantibodies against RBC antigens, leading to hemolysis at less-than-physiological temperatures through complement fixation. Production can be triggered by infections, resulting in secondary cold agglutinin syndrome (CAS). This syndrome has been classically described in the setting of Mycoplasma pneumoniae infection, as well as with several viral pathogens. Cases Here, we present two cases of cold agglutinins identified in the context of Covid-19 in critically ill patients treated at our institution. Each case was characterized by little in-vivo hemolysis, but these antibodies complicated laboratory assessment and renal replacement therapy. Management included anticoagulation and warming of dialysis circuit. Conclusions Despite minimal in-vivo hemolysis, these antibodies are of clinical significance given their implications for laboratory assessment and renal replacement therapy, particularly with the frequency of multi-organ system dysfunction associated with severe Covid-19. Cold agglutinins are autoantibodies to RBCs that drive hemolysis at sub-physiologic temperatures via complement fixation. Cold agglutinin syndrome (CAS) has been recently reported in the setting of Covid-19. We present two cases of cold agglutinins identified in the context of Covid-19. Presence correlated with dialysis circuit failure, which was managed with anticoagulation and warming of circuit.
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Affiliation(s)
- Christopher E Jensen
- Division of Hematology and Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Samuel Wilson
- Division of Hematology and Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Department of Pediatrics, University of North Carolina School of Medicine, USA
| | - Aparna Thombare
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, USA
| | - Susan Weiss
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, USA
| | - Alice Ma
- Division of Hematology and Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Roccaforte V, Sciarini F, Proserpio V, Buonocore R, Zavaroni EM, Burati S, Bussetti M, Liuzzi G, Russo RM, Porreca WP, Angelis MLD, Perno CF, Bonato C, Pastori S. Use of the reticulocyte channel warmed to 41°C of the XN-9000 analyzer in samples with the presence of cold agglutinins. Hematol Transfus Cell Ther 2020; 43:147-155. [PMID: 32199923 PMCID: PMC8211624 DOI: 10.1016/j.htct.2020.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 11/25/2019] [Accepted: 01/09/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES The purpose of this study was to compare data obtained from the reticulocyte channel (RET channel) heated to 41°C with those obtained from impedance channel (I-Channel) at room temperature in the samples with the mean corpuscular hemoglobin concentration (MCHC)<370g/L and in samples with the MCHC>370g/L, in the presence of cold agglutinins. METHODS In this study, 60 blood samples (group 1) with the MCHC<370g/L (without cold agglutinins) and 78 blood samples (group 2) with the MCHC>370g/L (with cold agglutinins) were used to compare the two analytical channels of the XN-9000 analyzer in different preanalytical conditions. The parameters evaluated in both groups were the following: red blood cell (RBC), hemoglobin (HGB), hematocrit (HCT), mean cell volume (MCV), RBC-most frequent volume (R-MFV), mean hemoglobin concentration (MCH) and mean cellular hemoglobin concentration (MCHC). RESULTS The results of this study showed an excellent correlation with both channels of the XN-9000 analyzer in samples with and without cold agglutinins, except for the MCHC. The bias between the values obtained in the I-channel and those obtained in the RET channel of both groups was insignificant and remained within the limits of acceptability, as reported by Ricos et al. for all considered parameters, except for MCHC. CONCLUSIONS The presence of cold agglutinins in blood samples can be detected by a spurious lowering of the RBC count and by a spurious increase in the MCHC. The RET channel represents a great opportunity to correct the RBC count in a rapid manner without preheating. However, neither methodology can completely solve the residual presence of cold agglutinins in all samples, despite the MCHC values being < 370g/L.
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Affiliation(s)
- Vincenzo Roccaforte
- ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Hospital Alessandro Manzoni, Lecco, Italy; University of Study Milan, Milan, Italy.
| | | | | | | | | | - Silvia Burati
- ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco Bussetti
- ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Jäger U, Barcellini W, Broome CM, Gertz MA, Hill A, Hill QA, Jilma B, Kuter DJ, Michel M, Montillo M, Röth A, Zeerleder SS, Berentsen S. Diagnosis and treatment of autoimmune hemolytic anemia in adults: Recommendations from the First International Consensus Meeting. Blood Rev 2020; 41:100648. [PMID: 31839434 DOI: 10.1016/j.blre.2019.100648] [Citation(s) in RCA: 226] [Impact Index Per Article: 45.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 11/21/2019] [Accepted: 11/25/2019] [Indexed: 12/15/2022]
Abstract
Autoimmune hemolytic anemias (AIHAs) are rare and heterogeneous disorders characterized by the destruction of red blood cells through warm or cold antibodies. There is currently no licensed treatment for AIHA. Due to the paucity of clinical trials, recommendations on diagnosis and therapy have often been based on expert opinions and some national guidelines. Here we report the recommendations of the First International Consensus Group, who met with the aim to review currently available data and to provide standardized diagnostic criteria and therapeutic approaches as well as an overview of novel therapies. Exact diagnostic workup is important because symptoms, course of disease, and therapeutic management relate to the type of antibody involved. Monospecific direct antiglobulin test is considered mandatory in the diagnostic workup, and any causes of secondary AIHA have to be diagnosed. Corticosteroids remain first-line therapy for warm-AIHA, while the addition of rituximab should be considered early in severe cases and if no prompt response to steroids is achieved. Rituximab with or without bendamustine should be used in the first line for patients with cold agglutinin disease requiring therapy. We identified a need to establish an international AIHA network. Future recommendations should be based on prospective clinical trials whenever possible.
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Jouini H, Chouaieb S, Boussetta K, Toumi NEH. Hemophagocytic lymphohistiocytosis associated with an IgG Cold agglutinin. Transfus Clin Biol 2019; 26:324-8. [PMID: 30220463 DOI: 10.1016/j.tracli.2018.08.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 08/23/2018] [Indexed: 11/23/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease eventually caused or reactivated by a viral infection, which can also lead to the production of cold agglutinins (CA). The nature of these autoantibodies is usually an IgM, less frequently an IgA or IgG, they agglutinate red blood cells at low temperatures. They can interfere with hematological parameters causing interpretation difficulties. We report a case of a 4-year-old boy who developed an IgG CA during recurrent HLH reactivated by EBV infection. The purpose of this observation is to underline HLH criteria and to analyze CA interference as well as its biological and clinical characteristics.
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Garg S, Sharma V, Kumar R, Kumar L, Chopra A. Rapid Onset Anemia in Chronic Myeloid Leukemia Due to Red Cell Agglutination: A Rare Occurrence. Indian J Hematol Blood Transfus 2018; 34:758-759. [PMID: 30369759 DOI: 10.1007/s12288-018-0944-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 02/27/2018] [Indexed: 11/28/2022] Open
Affiliation(s)
- Shikha Garg
- 1Laboratory Oncology Unit, Dr. BRA-IRCH, All India Institute of Medical Sciences, Room. 423, New Delhi, India
| | - Vinod Sharma
- 2Medical Oncology Unit, Dr. BRA-IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Rajive Kumar
- 1Laboratory Oncology Unit, Dr. BRA-IRCH, All India Institute of Medical Sciences, Room. 423, New Delhi, India
| | - Lalit Kumar
- 2Medical Oncology Unit, Dr. BRA-IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Anita Chopra
- 1Laboratory Oncology Unit, Dr. BRA-IRCH, All India Institute of Medical Sciences, Room. 423, New Delhi, India
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Javed R, Datta SS, Basu S, Chakrapani A. Resolution of Serologic Problems Due to Cold Agglutinins in Chronic Lymphocytic Leukemia. Indian J Hematol Blood Transfus 2016; 32:290-3. [PMID: 27408415 DOI: 10.1007/s12288-016-0644-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 01/13/2016] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Autoimmune hemolytic anemia can be classified depending on presence of warm, cold or mixed type of autoantibodies that are directed against antigens on the red blood cell surface. Here we report a case of pathological cold agglutinin disease which was eventually detected due to blood group discrepancy. CASE DETAILS A request was sent to the blood bank for two units of packed red cells in a diagnosed case of CLL which showed type IV discrepancy during blood grouping.The discrepancy was subsequently resolved after warm saline washing of red cells along with repetition of reverse grouping with pre-warmed serum. The direct antiglobulin test was positive and revealed autoanibodies against C3b/C3d only. Indirect antiglobulin test was performed with 3-cell panel in a polyspecific gel card (IgG+C3d) showed a pan-reactive pattern along with a positive autocontrol. Subsequently a cold agglutinin titration was performed and titers of 1024 at 4 °C; titer of 2 at room temperature were detected. Dithiothreitol (DTT) treatment of serum was undertaken and IgM type of autoantibody was detected in this case confirming a case of secondary cold agglutinin disease in this patient. Two units of red cells were transfused to this patient after successfully performing cross-match with pre-warmed serum. It was advised from the blood bank that the blood should be transfused slowly through a blood-warmer and patient should be kept in warm condition to avoid in-vivo hemolysis due to high titer of cold agglutinin. The transfusion was uneventful and patient is on regular follow-up till now. CONCLUSION Thus we concluded that serological discrepancies observed in blood bank can successfully guide the bedside transfusion protocol in case of cold agglutinin disease.
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Affiliation(s)
- Rizwan Javed
- Department of Transfusion Medicine, TATA Medical Center, 14 MAR (E-W), New Town, Rajarhat, Kolkata, West Bengal 700156 India
| | - Suvro Sankha Datta
- Department of Transfusion Medicine, TATA Medical Center, 14 MAR (E-W), New Town, Rajarhat, Kolkata, West Bengal 700156 India
| | - Sabita Basu
- Department of Transfusion Medicine, TATA Medical Center, 14 MAR (E-W), New Town, Rajarhat, Kolkata, West Bengal 700156 India
| | - Anupam Chakrapani
- Department of Clinical Hematology, TATA Medical Center, Kolkata, India
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Bartolmäs T, Yürek S, Balola AHA, Mayer B, Salama A. Evidence Suggesting Complement Activation and Haemolysis at Core Temperature in Patients with Cold Autoimmune Haemolytic Anaemia. Transfus Med Hemother 2015; 42:328-32. [PMID: 26696802 PMCID: PMC4678319 DOI: 10.1159/000437200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 06/21/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It is unclear why haemolysis may somewhat persist in patients with cold autoimmune haemolytic anaemia (cAIHA) at 37 °C (core temperature). METHODS Seven patients with cAIHA were included in this study. Serological testing was performed using standard techniques. Bound autoantibodies (aab) on patients' RBCs were analysed by the direct antiglobulin test (DAT), dual antiglobulin test (DDAT) and flow cytometry (FC) using pre-warmed RBCs (37 °C). Temperature-dependent complement binding was determined by incubation of patients' serum samples with group O RBCs and fresh serum complement. RESULTS The DAT was strongly positive with anti-C3d in all cases, independent of season and outside temperature. Haemolysis usually improved during warm periods of time, but decompensated following febrile infections, and persisted throughout the year, though exposure to the cold was strictly avoided. In addition, trace amounts of IgM aab were infrequently detectable on patients' RBCs even at 37 °C, and complement activation was demonstrated following incubation of RBCs with the causative aab at 37 °C. CONCLUSIONS Binding of trace amounts of IgM aab at 37 °C may provide an explanation for the durable C3d-positive DAT and haemolysis in patients with cAIHA.
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Affiliation(s)
- Thilo Bartolmäs
- Institute for Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Salih Yürek
- Institute for Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Beate Mayer
- Institute for Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Abdulgabar Salama
- Institute for Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Cho SH, Kim DH, Kwak YT. Normothermic cardiac surgery with warm blood cardioplegia in patient with cold agglutinins. Korean J Thorac Cardiovasc Surg 2014; 47:133-6. [PMID: 24782963 PMCID: PMC4000870 DOI: 10.5090/kjtcs.2014.47.2.133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 02/19/2014] [Accepted: 03/06/2014] [Indexed: 11/29/2022]
Abstract
Cold agglutinins are predominately immunoglobulin M autoantibodies that react at cold temperatures with surface antigens on the red blood cell. This can lead to hemagglutination at low temperatures, followed by complement fixation and subsequent hemolysis on rewarming. Development of hemagglutination or hemolysis in patients with cold agglutinins is a risk of cardiac surgery under hypothermia. In addition, there is the potential for intracoronary hemagglutination with inadequate distribution of cardioplegic solutions, thrombosis, embolism, ischemia, or infarction. We report a patient with incidentally detected cold agglutinin who underwent normothermic cardiac surgery with warm blood cardioplegia.
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Affiliation(s)
- Sang-Ho Cho
- Department of Thoracic and Cardiovascular Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Korea. ; Department of Thoracic and Cardiovascular Surgery, Chungbuk National University College of Medicine, Korea
| | - Dae Hyun Kim
- Department of Thoracic and Cardiovascular Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Korea
| | - Young Tae Kwak
- Department of Thoracic and Cardiovascular Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Korea
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