Asian Journal of Transfusion Science
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   Table of Contents - Current issue
January-June 2018
Volume 12 | Issue 1
Page Nos. 1-94

Online since Friday, February 16, 2018

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Haemovigilance Programme of India: Analysis of transfusion reactions reported from January 2013 to April 2016 and key recommendations for blood safety Highly accessed article p. 1
Akanksha Bisht, Neelam Marwaha, Ravneet Kaur, Debasish Gupta, Surinder Singh
DOI:10.4103/ajts.AJTS_5_18  PMID:29563667
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Unconjugated hyperbilirubinemia in a blood donor: Chance finding due to unusual plasma discoloration p. 8
Ashish Jain, Dheeraj Khetan
DOI:10.4103/ajts.AJTS_34_17  PMID:29563668
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First Indian initiative for preparation of low-titer group “O” single-donor platelets with platelet additive solution p. 10
Puneet Jain, Anita Tendulkar, Abhaykumar Gupta
DOI:10.4103/ajts.AJTS_2_17  PMID:29563669
Background: Guidelines recommend ABO-identical platelet (PLT) transfusions. Hemolytic reactions after a minor ABO-incompatible PLT transfusion have escalated due to single-donor platelets (SDP) containing ABO-incompatible plasma. Avoiding such events by examining titers or performing plasma reduction is cumbersome. The introduction of platelet additive solutions (PAS) has enabled to reduce these reactions by avoiding passive transfer of isoagglutinin. Our aim was to study antibody titers (anti-A, anti-B) in “O” SDP by adding PAS at source and the quality parameters with reference to viability, morphology, and metabolism. Materials And Methods: Group “O” SDP (n = 50) were prepared on a standard cell separator. PAS in a ratio of 70:30 (PAS: plasma) was added at source under sterile conditions (study arm). The units were studied on day of collection (day 0) and day 4 and compared with SDP containing 100% plasma (control arm). A titer study was performed after PAS addition. Results: In the study group, the median antibody titers (anti-A, anti-B) reduced from 128 to16, post-PAS addition (P < 0.001). Morphology scores were superior in PAS platelet concentrates (P < 0.001). Metabolic parameters pO2and pCO2were similar in the two arms signifying good unit storage and stable oxygen consumption (P > 0.05). Lactate levels, glucose consumption rate, and lactate production rates were significantly low in study arm showing the advantage of PAS. Conclusion: O group SDPs can be prepared with PAS and the beneficial effects were significant with respect to antibody titers. Quality parameters were well maintained. Availability of PAS units has benefitted patients.
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Prevalence of irregular red cell antibody in healthy blood donors attending a tertiary care hospital in North India p. 17
Raj Nath Makroo, Saroj Rajput, Soma Agarwal, Mohit Chowdhry, Bindu Prakash, Prashant Karna
DOI:10.4103/ajts.AJTS_4_17  PMID:29563670
Background: Alloantibodies may be detected in blood donors who have either been transfused previously or female donors with previous obstetric events. These antibodies can occasionally cause severe transfusion reaction, if a large amount of plasma or whole blood is transfused, as in massive transfusions and pediatric patients. Aims: The present study aims to assess the prevalence of red cell antibodies in healthy blood donors at a tertiary care hospital-based blood bank in India. Materials And Methods: A total of 82,153 donor samples were screened for irregular red cell antibodies between January 2012 and December 2015 at the Department of Transfusion Medicine, Indraprastha Apollo Hospitals, New Delhi. Antibody screening was performed by solid phase method using Immucor Capture–R ready screen (pooled cells) on fully automated immunohematology analyzer Galileo Neo (Immucor Inc., Norcross, GA, USA). Positive tests were further confirmed using Capture-R ready screen (4 cell panel). Advanced investigations to identify the antibody/ies were performed on confirmed positive samples. Antibody identification was conducted using various cell panels (Immucor Capture-R Ready-ID, Panocell-10, Ficin Treated). An advanced technique such as adsorption and elution was performed as per requirement. Results: Screening with pooled cells and 4 cell panel was positive in 227 donors (0.27%), 150 of these donors had autoantibodies, 1 had autoantibodies with underlying alloantibody anti-Jka (0.001%), and 76 had alloantibodies (0.09%) alone in their plasma. Anti-M was the most common antibody (43 donors) identified, followed by anti-D (21 donors). Anti-N was detected in 4; anti-Jka, anti-C, and anti-E in two donors each followed by anti-P1 and anti-Leb in 1 donor. Conclusion: Antibodies against red cells can be present in healthy donors detection of which is important in providing safe blood to the patient. The prevalence of red blood cell antibody in healthy donors in this study was found to be 0.27%, while the prevalence of alloantibodies was 0.09%. The majority of alloantibodies were anti-M (56.57%) and anti-D (27.63%).
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Human immunodeficiency virus/acquired immune deficiency syndrome: A survey on the knowledge, attitude, and practice among medical professionals at a tertiary health-care institution in Uttarakhand, India p. 21
Ananya Doda, Gita Negi, Dushyant Singh Gaur, Meena Harsh
DOI:10.4103/ajts.AJTS_147_16  PMID:29563671
Introduction: Health-care professionals are trained health-care providers who occupy a potential vanguard position in human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) prevention programs and the management of AIDS patients. This study was performed to assess HIV/AIDS-related knowledge, attitude, and practice (KAP) and perceptions among health-care professionals at a tertiary health-care institution in Uttarakhand, India, and to identify the target group where more education on HIV is needed. Materials And Methods: A cross-sectional KAP survey was conducted among five groups comprising consultants, residents, medical students, laboratory technicians, and nurses. Probability proportional to size sampling was used for generating random samples. Data analysis was performed using charts and tables in Microsoft Excel 2016, and statistical analysis was performed using the Statistical Package for the Social Science software version 20.0. Results: Most participants had incomplete knowledge regarding the various aspects of HIV/AIDS. Attitude in all the study groups was receptive toward people living with HIV/AIDS. Practical application of knowledge was best observed in the clinicians as well as medical students. Poor performance by technicians and nurses was observed in prevention and prophylaxis. All groups were well informed about the National AIDS Control Policy except technicians. Conclusion: Poor knowledge about HIV infection, particularly among the young medical students and paramedics, is evidence of the lacunae in the teaching system, which must be kept in mind while formulating teaching programs. As suggested by the respondents, Information Education Communication activities should be improvised making use of print, electronic, and social media along with interactive awareness sessions, regular continuing medical educations, and seminars to ensure good quality of safe modern medical care.
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Assessment of bedside transfusion practices at a tertiary care center: A step closer to controlling the chaos p. 27
Dheeraj Khetan, Rahul Katharia, Hem Chandra Pandey, Rajendra Chaudhary, Rajesh Harsvardhan, Hemchandra Pandey, Atul Sonkar
DOI:10.4103/ajts.AJTS_29_17  PMID:29563672
Background: Blood transfusion chain can be divided into three phases: preanalytical (patient bedside), analytical (steps done at transfusion services), and postanalytical (bedside). Majority (~70%) of events due to blood transfusion have been attributed to errors in bedside blood administration practices. Survey of bedside transfusion practices (pre-analytical and post analytical phase) was done to assess awareness and compliance to guidelines regarding requisition and administration of blood components. Materials And Methods: Interview-based questionnaire of ward staff and observational survey of actual transfusion of blood components in total 26 wards of the institute was carried out during November–December 2013. All the collected data were coded (to maintain confidentiality) and analyzed using SPSS (v 20). For analysis, wards were divided into three categories: medical, surgical, and others (including all intensive care units). Results: A total of 104 (33 resident doctors and 71 nursing) staff members were interviewed and observational survey could be conducted in 25 wards during the study period. In the preanalytical phase, major issues were as follows: lack of awareness for institute guidelines (80.6% not aware), improper sampling practices (67.3%), and prescription related (56.7%). In the postanalytical phase, major issues were found to be lack of consent for blood transfusion (72%), improper warming of blood component (~80%), and problems in storage and discarding of blood units. Conclusion: There is need to create awareness about policies and guidelines of bed side transfusion among the ward staff. Regular audits are necessary for compliance to guidelines among clinical staff.
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Transfusion support in preterm neonates <1500 g and/or <32 weeks in a tertiary care center: A descriptive study p. 34
RA Shanmugha Priya, R Krishnamoorthy, Vinod Kumar Panicker, Binu Ninan
DOI:10.4103/ajts.AJTS_148_16  PMID:29563673
Background: Lack of recent studies focusing on indications, pattern, and benefits of transfusions in low birth weight (B.Wt) and low gestational age (GA) preterm neonates prompted us to undertake this study. Aim: To estimate the transfusion requirements and outcomes in preterm neonates <1500 g and/or <32 weeks. Settings And Design: This is a cross-sectional study conducted over a period of 2 years in a tertiary care center. Materials And Methods: This study was conducted with 101 preterm neonates <1500 g and/or <32 weeks who received blood transfusions in the Neonatal Intensive Care Unit. Restrictive pattern of transfusion was followed. Demographic details and antenatal, neonatal, laboratory, and transfusion parameters were collected. Statistical Analysis Used: Statistical analyses were performed using SPSS 16. Results: The study participants received 311 transfusions. Transfusion requirements decreased with increasing GA and B.Wt. Majority of blood transfusions occurred during the first 2 weeks of life. Packed red blood cells (PRBCs) were the most frequent blood components transfused. Ninety-six percent of the study population had an uneventful transfusion. Mean hemoglobin improvement after PRBC transfusions was 2.3 ± 2.1 g/dl. Improvement in apnea occurred in 76% PRBC transfusions. Infants with sepsis, patent ductus arteriosus, bronchopulmonary dysplasia, disseminated intravascular coagulation, and dyselectrolytemia received more number of transfusions. Conclusion: This study would serve as an audit for neonatal blood transfusion therapy. Close adherence to neonatal transfusion policy and restrictive transfusion guidelines helps reduce inappropriate use of blood products and adverse transfusion reactions.
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Advantages of type and screen policy: Perspective from a developing country! p. 42
Geet Aggarwal, Aseem K Tiwari, Dinesh Arora, Ravi C Dara, Devi P Acharya, Gunjan Bhardwaj, Jyoti Sharma
DOI:10.4103/ajts.AJTS_31_17  PMID:29563674
Introduction: The authors' center recently changed their pretransfusion testing protocol from “conventional” type and screen (TS) with anti-human globulin (AHG) crossmatch (Policy A) to TS with immediate-spin (IS) crossmatch (Policy B). Red blood cell (RBC) units were issued after compatible IS crossmatch as and when required instead of AHG crossmatch. This study was conducted to compare the effects of change of policy from A to B over 1-year period on crossmatch-to-transfusion (C/T) ratio, RBC issue turnaround time (TAT), outdating of RBC, man-hours consumption, and monetary savings. Materials And Methods: This was a comparative, prospective study conducted by the Department of Transfusion Medicine of a tertiary hospital-based blood bank in Northern India. The Policy B was implemented in the department from January 2014. Relevant retrospective data for comparison of the previous 1 year, when Policy A was practiced, were derived from hospital information system. Results: 23909 and 24724 RBC units transfused to patients admitted to the hospital during respective 1-year period of practice for Policy A and B. There was significant reduction in C/T ratio (1.94 vs. 1.01) and RBC issue TAT (79 vs. 65 min) with Policy B. Expiry due to outdating reduced (37 vs. zero) along with man-hours (16% reduction) and monetary (33% reduction) savings. Conclusion: Use of 'TS with IS crossmatch' policy provides multiple advantages to all the stakeholders; blood banker, clinician, patient, and the hospital management.
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Identification of iron status of blood donors by using low hemoglobin density and microcytic anemia factor p. 46
Ashutosh Singh, Rajendra Chaudhary, Hem C Pandey, Atul Sonker
DOI:10.4103/ajts.AJTS_30_17  PMID:29563675
Background: Two new parameters low hemoglobin density (LHD) and microcytic anemia factor (Maf) have been used by Beckman–Coulter LH series analyzers as an easy screening tool for the early detection of iron deficiency. The main objective of this study was to assess if LHD and Maf could be used for assessment of iron status in blood donors and also to establish a cut-off for these two parameters at which a tentative iron deficiency could be reported conclusively. Materials And Methods: LHD% and Maf could be calculated by knowing mean cell hemoglobin (Hb) concentration, Hb, and mean cellular volume and we used SPSS in calculating LHD and Maf from these parameters. Results: Significant differences were detected in LHD% and Maf values when iron deficient and iron-depleted donors were compared with control donors, while these were insignificant for iron reduced donors. LHD and Maf were able to differentiate between iron deficient and iron-depleted donors from normal donors. A cutoff of 9.18% for LHD% was able to differentiate iron deficient and depleted state from normal iron states with a sensitivity and specificity of 91.9% and 71% respectively. Similarly, a cutoff of 10.16 and10.71 for Maf was able to differentiate between iron-deficient and iron-depleted donors from normal donors, respectively. Conclusion: LHD% and Maf in the screening of blood donors raise the possibility of early detection of iron deficiency, without the need of extra cost and blood sampling.
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An approach to incompatible cross-matched red cells: Our experience in a major regional blood transfusion center at Kolkata, Eastern India p. 51
Prasun Bhattacharya, Eeshita Samanta, Nowroz Afroza, Archana Naik, Rathindranath Biswas
DOI:10.4103/ajts.AJTS_157_16  PMID:29563676
Introduction: With the increased utilization of immunohematology (IH) analyzers in the transfusion medicine, type, and screen policy is the method of choice. Still, the importance of routine crossmatching could not be overruled. Here, we tried to understand the clinical conditions and safety of red cell transfusion and their outcomes. Materials And Methods: This prospective study was conducted by IH laboratory, Medical College Kolkata, Blood Bank from October 1, 2015 to March 31, 2016. A set of 3cc ethylenediaminetetraacetic acid and clotted blood samples of the patients were received according to sample acceptance criteria. Blood grouping by conventional tube technique followed by crossmatching was performed by column agglutination technology (CAT) in polyspecific (IgG + C3d) gel media. Any positive result was rechecked in duplicate with additional two group-specific donor units. The persistent incompatibility was further evaluated using direct anti-human globulin test, auto control, antibody screening, and antibody identification by CAT. Results: On the evaluation of 14,387 sets of patients' sample, only 100 were found to be incompatible (0.69%). Incompatibility rate is higher in females (59%). Eighty-five of these patients were repeatedly transfused. Only 38% of incompatible crossmatch were positive on indirect anti-human globulin test/antibody screening. Antibody could be identified in 16 of them. Seventeen of 100 incompatible samples (17%) presented with panagglutination, were managed with Rh, Kell phenotype/best-matched red cell units. In these 16 patients, 23 alloantibodies were identified; allo anti-E was the most common. Conclusion: This study showed antibody against the Rh system as the most common cause of incompatibility.
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Effect of plasma component transfusion on conventional coagulation screening tests p. 57
Manish Raturi, Shamee Shastry, Mohandoss Murugesan, Poornima B Baliga, Kalyana Chakravarthy
DOI:10.4103/ajts.AJTS_24_17  PMID:29563677
Background: Conventional coagulation screening tests such as Prothrombin time, International normalized ratio (INR) and activated partial thromboplastin time are often used to predict bleeding in various clinical situations. We aimed to observe the effect of Fresh-frozen plasma (FFP) on these parameters. Methods: Patients' demographics, pre- and post-transfusion coagulation parameters were noted to assess the level of correction. The magnitude of improvement in INR was determined using the formula given by Holland and Brooks. Data was analyzed using IBM SPSS Statistics 20. Results: Among 2082 episodes, 4991 units of FFP were transfused at an average of 5 units per patient. Median dose of FFP administered per episode was 10 mL/kg (5.8–13.4). The mean change in INR following transfusion was 8.9% of the pre-transfusion INR and thus considered to be statistically significant. Conclusion: FFP transfusions as a prophylactic measure especially in patients with mildly deranged conventional coagulation screening tests without any empirical evidence of clinical bleeding needs further scrutiny. Reduction in INR following FFP transfusions was better in cohort having higher pre-transfusion INR value (> 3.0).
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Heterogeneity of O blood group in India: Peeping through the window of molecular biology p. 62
Harita Gogri, Sabita Ray, Snehal Agrawal, S Aruna, Kanjaksha Ghosh, Ajit Gorakshakar
DOI:10.4103/ajts.AJTS_12_17  PMID:29563678
Background: Molecular genotyping of ABO blood group system has identified more than 60 “O” group alleles based on the single-nucleotide polymorphisms present in the ABO gene. Heterogeneity of O group alleles has been observed in various countries from South America, Europe, Middle East, and Asia. India is a vast country with more than 1300 million population which is divided into various ethnic and tribal groups. However, very little is known about the heterogeneity of O alleles in Indians. Materials And Methods: A total of 116 O group individuals from the mixed population of Mumbai, India, were enrolled in the present study. DNA was extracted using the standard phenol–chloroform method. The exons 6 and 7 of the ABO gene were genotyped by polymerase chain reaction-single-strand conformation polymorphism and/or DNA sequencing. The genotyping results were compared with our earlier findings. Results And Discussion: Overall, ten different genotypes were identified. Three rare alleles, namely, O05, O11, and O26 were seen in the mixed group category. These results suggest that there is an internal heterogeneity in the mixed group while Dhodias and Parsis, the groups which were screened earlier, seem to be more homogenous groups. An important piece of information emerges out from this study, that is, O01O02 genotype is expressing some selective force in population groups screened in India as well as many other groups worldwide. Conclusion: In the future, molecular genotyping of the ABO blood group system among different ethnic and tribal Indian groups would help in generating data to fill up the gaps in the molecular ABO map of the world.
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Relationship between T2* magnetic resonance imaging-derived liver and heart iron content and serum ferritin levels in transfusion-dependent thalassemic children p. 69
Kiran Suthar, Vishnu Kumar Goyal, Pramod Sharma, Bindu Deopa, Pradeep Singh Rathore, Rama Krishan Bishnoi
DOI:10.4103/ajts.AJTS_3_17  PMID:29563679
Context: T2* magnetic resonance imaging (MRI) is being increasingly used for the assessment of organ iron content in thalassemics, but cost is a major prohibitive factor for repeated measurements. If serum ferritin correlates well with the T2* MRI liver and heart, it will be economical and more simple tool to assess organ iron deposition. Aims: The aim of this study was to find out the relationship between serum ferritin level and T2* MRI-derived liver and heart iron content in transfusion-dependent thalassemic children Settings: Thalassemia day-care center of a teaching hospital Design: This was a cross-sectional study Subjects And Methods: Seventy-three transfusion-dependent beta thalassemic children belonging to 2–18 years of age were subjected to T2* MRI of heart and liver to assess their iron content. Values obtained here were related to serum ferritin. Statistical Analysis Used: Keeping the correlation between serum ferritin and T2* MRI as primary outcome, spearman's correlation coefficient was calculated. Results: We found poor (negative) correlation between serum ferritin level and T2* MRI liver (r = -0.448, P = 0.000) but no correlation between serum ferritin and T2*MRI heart (r = -0.221, P = 0.060). Conclusions: Serum ferritin cannot reliably predict the liver and heart iron content in Indian children with β thalassemia.
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A rare case of hemolytic disease of newborn due to weak D (D unknown) antigen in child p. 75
Nirav Ramesh Dava, Alok Upadhyaya, Neha Agarwal, Amarjeet Mehta, Vijaypal Choudhary, Gourav Goyal
DOI:10.4103/ajts.AJTS_21_17  PMID:29563680
We are reporting a rare case of hemolytic disease of newborn with weak D antigen in child. A 3rd order male child of G3P3A0mother was admitted at 8th h of life with jaundice. Blood group of both mother and child were A Rh D negative. Baby's direct coombs test was positive. Weak D antigen was positive in baby. Hematological parameters showed all the signs of ongoing hemolysis, and the bilirubin level was in the zone of exchange transfusion. Exchange transfusion was done. An intravenous immunoglobulin was given to child after that. Mother had a history of first normal healthy male child with O Rh D positive blood group. Second male child expired on 3rd postnatal day due to bilirubin encephalopathy that had A Rh D negative blood group with positive direct coombs test.
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Jehovah's Witness and consent for blood transfusion in a child: The Indian scenario p. 78
KG Gopakumar, T Priyakumari, Manjusha Nair, P Kusumakumary
DOI:10.4103/ajts.AJTS_50_17  PMID:29563681
In India, the clinical guidelines and laws governing consent for blood transfusion in a minor are meager and vague. In an elective situation, whether the parents can make a decision for the child on his/her behalf or whether the doctor has the right to make the decision in the best interests of the child is not clear. We present the case scenario of a child belonging to Jehovah's Witness denomination diagnosed with Burkitt lymphoma. His parents were in a dilemma whether to opt for blood transfusion or not. In the absence of laws and guidelines in this context, and considering the complications that he developed during the treatment period, it was very challenging for us to manage the situation both medically and medico-legally. This situation highlights the need for framing consensus guidelines/laws regarding elective blood transfusion in a minor to make health-care delivery, smooth, transparent and flawless.
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Anti Kpa alloantibody: Development of a rare alloantibody in a non-Hodgkin's lymphoma patient of Indian origin p. 81
Sadhana Mangwana, Vivek Gangwar
DOI:10.4103/ajts.AJTS_23_17  PMID:29563682
The Kell blood group system is complex, contains many antigens, highly immunogenic, and potent in triggering immune reactions. Antibodies to Kell blood group system are the most common immune red cell antibodies, following ABO and Rh. However, among the anti-Kell antibodies; anti-Kpa is extremely rare. We report an interesting case of Anti-Kpa in a 59-year-old female patient of Non-Hodgkin's Lymphoma, post radiotherapy, who first developed warm autoantibody and later developed anti-Kpa alloantibody on multiple transfusions.
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Hemophagocytic lymphohistiocytosis in an infant with multiple triggers!! p. 85
Sataroopa Mishra, Amitabh Singh, Lavleen Singh, Anirban Mandal, Rahul Jain
DOI:10.4103/ajts.AJTS_142_16  PMID:29563683
Hemophagocytic lymphohistiocytosis (HLH) is a disorder of immune dysregulation secondary to a massive unregulated cytokine storm and its downstream consequences. HLH is being increasingly recognized as a cause of pyrexia of unknown origin, unexplained cytopenias, and hepatic dysfunction. However, this potentially treatable condition is often missed due to lack of suspicion, variable, and nonspecific presentations, inability to fulfil all the diagnostic criteria and availability of diagnostic tests in resource limited settings. Both familial and acquired forms of HLH can be triggered by multiple factors in a susceptible patient. We report a 9-month old infant who developed HLH in association with Stevens–Johnson syndrome following massive blood transfusion.
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Detection of antibodies to co-trimoxazole (preservative drug) interfering with routine red cell antibody screening p. 89
Deepti Sachan, S Aswin Kumar
DOI:10.4103/ajts.AJTS_119_16  PMID:29563684
Drug-dependent antibodies can rarely cause interference in pretransfusion antibody screening. The diluents for commercial reagent red blood cells contain different antibiotics, such as chloramphenicol, neomycin sulfate, and gentamycin as a preservative. The presence of antibodies to a given drug in patient may lead to positive results when performing antibody identification. We present a rare case of detection of anti-co-trimoxazole antibody during routine antibody screening in a female patient undergoing neurosurgery. These antibodies mimicked as antibody against high-frequency red cell antigens reacting in both saline phase as well as antiglobulin phase. Anti-co-trimoxazole antibody was confirmed by repeating antibody screen using reagent red cells of different manufacturers with and without co-trimoxazole drug as preservative as well as using washed red cell panels. There were no associated clinical or laboratory evidence of hemolysis.
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A curious case of thick white slick in a blood bag p. 93
Anju Dubey, Atul Sonker
DOI:10.4103/ajts.AJTS_22_17  PMID:29563685
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2006 - Asian Journal of Transfusion Science | Published by Wolters Kluwer - Medknow
Online since 10th November, 2006