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: A, D Positive DAT: Polyspecific = 3+ Antibody Screen: 4+ with all cells by Echo Autocontrol (AC): Positive

Investigation Results A, D Positive DAT Positive Panel testing PEG-AHG Ortho Gel

Panel Testing

Eluate Testing

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

Initial Conclusions Autoantibody Patient’s autoantibody is not removed by a 4x autoadsorption? What about provision of blood?

Additional Testing Started alloadsorption Completed Crossmatches Same results as autoadsorption! 4+ with all cells….. Completed Crossmatches Matched LISS-AHG Unit 1 Gp A+ E-c-K-S- Compatible! Unit 2 Gp A+ E-c-K-S- Compatible ! Unit 3 Gp A+ E-c-K-S Compatible !

Gp A Panel Testing

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 This is an atypical presentation of an autoantibody……… 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