Asian Journal of Transfusion Science
Home About Journal Editorial Board Search Current Issue Ahead of print Back Issues Instructions Subscribe Login  Users: 128 Print this page  Email this page Small font sizeDefault font sizeIncrease font size 


 
LETTER TO THE EDITOR Table of Contents   
Year : 2016  |  Volume : 10  |  Issue : 2  |  Page : 165-166
Delayed hemolytic transfusion reaction due to anti-D in Rh (D) positive patient


Department of Transfusion Medicine, Global Health City, Chennai, Tamil Nadu, India

Click here for correspondence address and email

Date of Web Publication8-Aug-2016
 

How to cite this article:
Sachan D, Kumar AS. Delayed hemolytic transfusion reaction due to anti-D in Rh (D) positive patient. Asian J Transfus Sci 2016;10:165-6

How to cite this URL:
Sachan D, Kumar AS. Delayed hemolytic transfusion reaction due to anti-D in Rh (D) positive patient. Asian J Transfus Sci [serial online] 2016 [cited 2021 Apr 15];10:165-6. Available from: https://www.ajts.org/text.asp?2016/10/2/165/187935


Sir,

Individuals, whose cells have a qualitative variation of the D antigen lacking one or more components of the D antigen, are said to have a partial-D phenotype. D-positive individuals harboring a “partial” D antigen may produce an allo-anti-D. We encountered a case of delayed hemolytic transfusion reaction (DHTR) due to anti-D developed in Rh (D) positive female patient.

A 57-year-old female, Para 4, from Kenya, was referred to our hospital as a case of recurrent Carcinoma left breast stage IV for 3rd line chemotherapy. She had a history of few episodes of transfusion 6 months before admission to our hospital. Historical records showed her blood group as “B-Positive.”

On admission, patient's hemoglobin (Hb) was 6.6 g/dl, and she received 4 units of compatible packed red cells (PRCs) transfusion which was uneventful. After a week, another blood request was received for 2 units of PRC due to low Hb 7.0 g/dl. Patient blood group was done using automated platform (Autovue Innova , Ortho Clinical Diagnostics, USA) and was B Rh (D) positive. Her serum was screened for irregular antibodies using commercial three cell antibody screening panel (Diacell, DiaMed, Cressier sur Morat, Switzerland) showed a positive reaction with panel I (1+) and II (2+) giving possibilities of Anti-D, C, E, Fy a, Jk a, Le b antibodies. Antibody identification using ID-Diapanel (Biorad, Diamed, Cressier sur Morat, Switzerland) showed only P2 (2+) and P8 (1+) positive and was not conclusive. Routine crossmatching showed 2+ incompatibility with all 10 B Rh (D) positive units crossmatched. Polyspecific direct antiglobulin test (DAT) and auto control was 2+ positive. To rule out autoimmune etiology, elution test was performed using acid elution kit (Diacidel, Biorad Diamed, Cressier sur Morat, Switzerland). Antibody screening of eluate was positive in panel I and II with the possibility of Anti-D, C, E, Fy a, Jk a, Le b Antibodies. On antibody identification Panel I, II, III, and VIII were positive and Anti-D Rh antibody was confirmed using negative exclusion in the eluate obtained from patients Red blood cells (RBCs) [Figure 1]a and [Figure 1]b.
Figure 1: Patient eluate (a) antibody screening and (b) antibody identification results

Click here to view


For confirmation of Rh group, her blood group was repeated using conventional tube method using monoclonal eryclone anti-D (IgM and IgG + IgM) (Tulip Diagnostics, India), which showed 4+ reaction. B-Negative units were crossmatch compatible were transfused, and the patient was discharged with Hb 9.4 g% with stable status. On review of our records, we found that antibody screening was negative at the time of admission and all crossmatches were compatible. We also noticed that there was the inadequate rise of Hb from 6.6 to 8.0 g/dl after 4 units of transfusion which subsequently fell to 7 g/dl in week duration. However, other hemolytic investigation parameters were not available. There was no history of passive administration of anti-D.

The history of 4 PRC transfusions a week before, rapid fall of Hb, development of positive DAT with confirmation of anti-D in the eluate, incompatibility with all B-positive units and compatibility with Rh negative units confirmed DHTR. The samples were sent for partial D-confirmation and Rh genotype to a reference laboratory in South India. However, it could not be confirmed due to inadequate sample.

DHTR is defined as the posttransfusion finding of a positive DAT and a newly developed RBC alloantibody with clinical signs of hemolysis. DHTR may sometimes manifest as an inadequate rise of posttransfusion Hb level or unexplained fall in Hb after a transfusion.

Partial D has a significant implication in transfusion and pregnancy. Individuals with Partial D have missing portions of D antigen and can develop anti-D antibody if exposed to missing epitopes.[1] A case reported by Ipe et al. on severe hemolytic transfusion reaction in sickle cell disease was due to anti-D in a RhD positive patient.[2] Her Rh genotype revealed homozygosity for RHD*DAU4 that encodes partial D antigen.

This case highlights that some cases of partial-D can be missed during routine serological Rh testing and can lead to anti-D alloimmunization. They should be distinguished serologically by a pattern of reactivity using advance partial D typing kit or monoclonal antisera and by Rh genotyping. Therefore, an accurate D-antigen identification is essential for pretransfusion and antenatal evaluation to prevent anti-D alloimmunization.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Vaglio S, Perrone MP, Arista MC, Laurenti L, Girelli G. Anti-D in a D-positive patient: Autoantibody or alloantibody? Blood Transfus 2007;5:44.  Back to cited text no. 1
    
2.
Ipe TS, Wilkes JJ, Hartung HD, Westhoff CM, Chou ST, Friedman DF. Severe hemolytic transfusion reaction due to anti-D in a D+ patient with sickle cell disease. J Pediatr Hematol Oncol 2015;37:e135-7.  Back to cited text no. 2
    

Top
Correspondence Address:
Deepti Sachan
Department of Transfusion Medicine, Global Health City, #439, Cheran Nagar, Perumbakkam, Chennai - 600 100, Tamil Nadu
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-6247.187935

Rights and Permissions


    Figures

  [Figure 1]



 

Top
 
  Search

  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  


    References
    Article Figures

 Article Access Statistics
    Viewed1822    
    Printed23    
    Emailed0    
    PDF Downloaded28    
    Comments [Add]    

Recommend this journal

Association Contact us | Sitemap | Advertise | What's New | Feedback | Copyright and Disclaimer

2006 - Asian Journal of Transfusion Science | Published by Wolters Kluwer - Medknow
Online since 10th November, 2006