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Medical Forum / General / Laboratory / July 2008autoimmune Rh antibodies
It's a bit of a long shot posting here, but I'm hoping there a some old timers / lurkers who can help me out. I had a case the other night where someone came into ER with 70 hgb and a previous history of anti-e. Had been positive for anti e 4 times, couldn't R/O ant-C and anti-K. So I order up e neg C neg K neg units, set up the screen and panel, and long story short, she comes up with an anti-E. WTF?!?!, repeat specimen,same thing, check previous records to make sure the anti e wasn't some kind of terrible mistake, nope. Phenotype the lady, E- negative, e positive.No previous phenotype. I say again WTF?. I handed it off to the next shift Friday @ 2300 and come in tonight expecting some answers, and get a big shrug, apparently it's nobody's job to get to the bottom of this. One of the newbies said she has seen cases where people form antibodies to thier own antigens, but I've always understood this to be immunologically impossible, a cornestone of BBK investigation rules. Any advice/ suggestions? TIA Rick H > It's a bit of a long shot posting here, but I'm hoping there a some > old timers / lurkers who can help me out. [quoted text clipped - 13 lines] > investigation rules. > Any advice/ suggestions? OK...... several points come to mind 1 Why couldn't you rule out anti-C and/or anti-K ? 2 With a history of blood group antibodies, why was no previous phenotype done? Isn't that routine ? 3 Given the phenotype is E-negative, e-positive and she has anti-e, then she's got some auto-immune condition - does no one investigate this? 4 The anti-E is probably a reaction to the transfusions. 5 The big shrug? - are you serious - does no one look into such discrepancies? 6 "immunologically impossible" - again, are you serious? This is not uncommon. > > It's a bit of a long shot posting here, but I'm hoping there a some > > old timers / lurkers who can help me out. [quoted text clipped - 17 lines] > > 1 Why couldn't you rule out anti-C and/or anti-K ? Because little "e" is so common there are only 1-3 panel cells out of 12-20 that are e neg. I assume you are familiar with the way exclusions are done on a panel. All panel cells that were e neg were "C" neg and also K neg, so these antibody specificities could not be ruled out. > 2 With a history of blood group antibodies, why was no previous phenotype > done? Isn't that routine ? I believe it's because hen we first saw her she had been recently transfused and therefore phenotyping was invalid. > 3 Given the phenotype is E-negative, e-positive and she has anti-e, then > she's got some auto-immune condition - does no one investigate this? I'm familiar with auto immune conditions causing panagglutinating antibodies, but I have never seen one with blood group antigen specificity, particularly four times over 2 years, often warm autoimmune antibodies are drug induced and go away after a while. > 4 The anti-E is probably a reaction to the transfusions. Agreed > 5 The big shrug? - are you serious - does no one look into such > discrepancies? I'm sad to say there seems to be a lack of oversight in some areas. The "technical resource" aka senior tech gave me vauge answers twice, so I went to the manager today and I think we'll get to the bottom of this. Often the attitude seems to be, "they got compatable / least incompatable units and did not have transfusion reaction, why waste time on a big workup when the patient got thier blood and is gone" Sometimes makes sense with pesky cold antibodies, or what we call no CSA (clinically signifigant antibody), but in a case like this, I think a thourough investigation is in order. > 6 "immunologically impossible" - again, are you serious? This is not > uncommon.- As above, I am familiar with autoimmune disorders, but have never seen one directed at a specific antigen, and where was it this time? By immunologically imposible I was refering to the fact that if someone phenotypes positive for an antigen, that rules out that antibody specificity, which is why we do phenotyping. Hide quoted text - > - Show quoted text - >> > It's a bit of a long shot posting here, but I'm hoping there a some >> > old timers / lurkers who can help me out. [quoted text clipped - 58 lines] >someone phenotypes positive for an antigen, that rules out that >antibody specificity, which is why we do phenotyping. Assuming that you have the correct blood in the tube, this is an interesting result. Was the DAT positive on the samples that showed the anti-e? According to a textbook I read 20 years ago, many autoantibodies have some Rh specificity. From what I have seen personally, our auto anti-e antibodies will react most strongly with e+ cells, but will react with a few other cells as well, and when we do an elution, it is panagglutinating.  SignatureDS > On Tue, 8 Jul 2008 21:07:02 -0700 (PDT), rickh > [quoted text clipped - 80 lines] > > - Show quoted text - The DAT was positive on the 3 (not 4) previous occasions when she presented with a positive antibody screen. The first time her screen was neg. An eluate was only done once, and it is hard to interpret now without the antigrams in front of me but it was almost panagglutinating, there were some negative cells, particularly some that were selected for being e neg. So our results are similar to what you've experienced. Thanks for the reply The manager thinks the previous results may have been a cold agglutinin wich mimiced an anti-e. Well, I guess the short answer is that autoantibodies can show specificity, I've just never seen it in such an extreme presentation, going from anti-e to anti-E. I do hope your management team investigates this and the apathetic response of your senior tech. The accreditation agencies would have a field with this incident when your lab gets inspected. Marsha On Jul 8, 2:02 am, "Manky Badger" <you.m...@be.joking> wrote: > "rickh" <harrison6...@rogers.com> wrote in message > [quoted text clipped - 21 lines] > > 1 Why couldn't you rule out anti-C and/or anti-K ? Because little "e" is so common there are only 1-3 panel cells out of 12-20 that are e neg. I assume you are familiar with the way exclusions are done on a panel. All panel cells that were e neg were "C" neg and also K neg, so these antibody specificities could not be ruled out. > 2 With a history of blood group antibodies, why was no previous phenotype > done? Isn't that routine ? I believe it's because hen we first saw her she had been recently transfused and therefore phenotyping was invalid. > 3 Given the phenotype is E-negative, e-positive and she has anti-e, then > she's got some auto-immune condition - does no one investigate this? I'm familiar with auto immune conditions causing panagglutinating antibodies, but I have never seen one with blood group antigen specificity, particularly four times over 2 years, often warm autoimmune antibodies are drug induced and go away after a while. > 4 The anti-E is probably a reaction to the transfusions. Agreed > 5 The big shrug? - are you serious - does no one look into such > discrepancies? I'm sad to say there seems to be a lack of oversight in some areas. The "technical resource" aka senior tech gave me vauge answers twice, so I went to the manager today and I think we'll get to the bottom of this. Often the attitude seems to be, "they got compatable / least incompatable units and did not have transfusion reaction, why waste time on a big workup when the patient got thier blood and is gone" Sometimes makes sense with pesky cold antibodies, or what we call no CSA (clinically signifigant antibody), but in a case like this, I think a thourough investigation is in order. > 6 "immunologically impossible" - again, are you serious? This is not > uncommon.- As above, I am familiar with autoimmune disorders, but have never seen one directed at a specific antigen, and where was it this time? By immunologically imposible I was refering to the fact that if someone phenotypes positive for an antigen, that rules out that antibody specificity, which is why we do phenotyping. Hide quoted text - > - Show quoted text - >I do hope your management team investigates this and the apathetic response >of your senior tech. The accreditation agencies would have a field with >this incident when your lab gets inspected. This was my immediate thought, but I'm assuming it's a US lab - what is the accreditation like over there? Is there an equivalent of the UK's CPA ? > I do hope your management team investigates this and the apathetic response > of your senior tech. The accreditation agencies would have a field with this [quoted text clipped - 3 lines] > > <snip> We are a Canadian lab. It's kind of ironic that our management is too busy preparing for acceditation inspection to come out of thier offices and see what's going on in the lab, particularly since we have a lot of newbies. Back in the day, the charge techs would pour over master logs and make sure everything was followed up appropriately, now they are to busy formatting manuals to do any actual supervision. Kind of ironic that the very thing (accreditation & standardisation) that's supposed to make things safer/ better for patient care actually diverts the resources we need to do that job properly My 2 cents Kind of ironic that the very thing (accreditation & standardisation) that's supposed to make things safer/ better for patient care actually diverts the resources we need to do that job properly --------------------------------------------------------------------------------------------------- Seems it's the same the world over :o( |
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