Case presentation on immunohematological problems and evaluation of a case of autoimmune hemolytic anemia

autoimmune hemolytic anemia
immunohematological problems
abo rh typing
cross matching
classification of AIHA
anemias
coombs testing
gel cards
dct ict
antibody screening and identification

1. A case of ABO-Rh and cross match discrepancy with possible hemolytic pathology in a 52 year old female patient Presenter- Dr. Shiny Moderator- Dr. Yadwinder Kaur

2. IP a dmission 1

3. Day of presentation- 10/08/2024 We received requisition along with EDTA and Plain vial samples of 52 year old female patient for Blood grouping and 2 units of PRBC. K/c/o CA ovary post-operative to carcinoma removal surgery at an outside hospital.

4. Course outside hospital Operated for CA ovary- Exploratory laparotomy with total abdominal hysterectomy with B/L salpino -oophorectomy with omentectomy with cholecystectomy (on 31/07/2024) Pt. received 1 unit PRBC preop and 1 unit PRBC intraop due to low Hb (7 g/dl) which raised to 12g/dl post op as documented on discharge card. The Hb again fell to 7 g/dl till POD 4 with bilirubin 12 mg/dl. She was discharged on POD 6 with Hb 7 and bilirubin 7mg/dl. She again presented to the same hospital on POD 8 with low oral intake, vomiting, hypokalemia , hyponatremia, HB 3.5 and jaundice (bilirubin 6mg/dl). For this, she was again given 2 units of PRBC. She was started on oral methylprednisolone in view of hemolysis . She was referred to higher centre with Hb 5.2 g/dl.

5. Outside Investigations 22/07/2024 Pre-surgical investigations 31/07/2024 surgery and transfusion of PRBCs 03/08/2024 05/08/2024 Steroid therapy started 08/08/2024 2 units of PRBCs 09/08/2024 Hb 6.9 10.1 11.5 7.3 3.7 5.2 T. Bilirubin 1.96 8.5 11.01 6.4 D. Bilirubin 0.79 2.16 3.86 1.9

6. ABO-Rh typing Firstly- pan reactive in control and reverse grouping, at RT, and incubation at both 37 and 4 degrees. Discrepancy corrected with negative pooled cells. Tube method- Anti-B antibodies present Auto control- positive (confirmed microscopically) Negative pooled cells

7. Pre-transfusion testing 1. Cross match (10/08/2024) For finding the best matched, least incompatible unit, we cross matched 5 O negative,1 O positive, 4 B positive and 2 B negative PRBC units upto AHG phase, by both tube and gel card method. Major cross match was mostly incompatible due to presence of Anti-D and Anti-B antibodies.

8. 2. Coombs testing (10/08/2024) DCT- Negative ICT- 4+ Positive

9. 3. Antibody screening & identification 3 cell- pan reactive 11 cell- 1,2,3,4,7,8,10 reactive Identification- Anti-D, Anti-C, Anti- FyB , Anti- Jka

10. Evaluation At AIMSR On Presentation (10-11 Aug 2024) Signs & symptoms- generalised weakness, vomiting, dark colored urine, icterus + Hb- 4.3 g/dl Retic count- 2% LDH- 2660 units/L Total bilirubin- 28.1 mg/dl (Direct 17.5 mg/dl) Platelet count- 1,11,000/ ul TLC- 28600/ ul USG- Mild hepatosplenomegaly

11. Peripheral blood film

12. Transfusion- 11/08/2024 Issue time Unit number Component Volume Blood group 2.20 am 2157 PRBC- TB 380 mL O NEG 12.30 pm 2200 PRBC- TB 391 mL O NEG 7.25 pm 2216 PRBC- TB 374 mL O NEG Hb hike- 4.3 to 9.6 g/dL No transfusion reaction was reported. After considering all the described parameters-

13. 12/08/2024 (Post Transfusion) Request for Coombs testing- DCT- 2+ ICT with positive pooled cells- 4+ ICT with negative pooled cells- 2+

14. 20/08/2024 Patient was put on Inj. Solumedrol for these 1 week. A new requisition for 2 units of PRBCs received on 20/08/2024, along with repeat ICT and DCT. We repeated our serological evaluation process.

15. Cross matching- -Done with 8 bags -Still incompatible with B negative and B positive -Least incompatible with O neg DCT- Neg ICT- 1+ weak reaction Direct bilirubin- 1.1 (total- 2.3) LDH- 521 Repeat USG- Mild hepatosplenomegaly Repeat PBF- Dimorphic anemia with neutrophilia

16. Transfusion- 20/08/2024 and 21/08/2024 Issue time Unit number Component Volume Blood group 10.50 am 2218 PRBC- TB 380 mL O NEG 1.00 pm 2260 PRBC- TB 379 mL O NEG Hb hike- 7.7 to 10.1 g/dl No transfusion reaction was reported. Patient was discharged with Hb 9.6 g/dl Again, after considering all the described parameters-

17. IP admission 2

18. 02/09/2024 Received requisition for 2 units of PRBC. Repeat DCT- 1+ weak reaction Repeat ICT- 2+ Repeat PBF- Dimorphic anemia with thrombocytopenia Direct bilirubin- 1.1 Total bilirubin- 2.2 LDH- 330 Repeat USG- same Active medications- oral corticosteroids (tab methylprednisolone 40mg)

19. Antibody screening- Rh antibodies Eliminated. Left With Fyb And Jka

20. Phenotyping- Antigen c, e present

21. Cross match done with 3 B positive,1 B neg, 1 O neg This time best match least incompatible w with B positive PRBC (on gel card, tube and microscopically)

22. Transfusion- 03/09/2024 and 04/09/2024 Hb hike- 6.2 to 8.3 g/dl Patient discharged at Hb 10 g/dL Issue time Unit number Component Volume Blood group 10.50 am 2415 PRBC- DB 376 mL B positive 1.00 pm 2436 PRBC- DB 372 mL B positive

23. IP admission 3- 11/09/2024 Repeat Coombs- DCT 1+ weak reaction, ICT Neg Transfusion unit- Compatible with 1 st unit of B positive Hb hike- 7.4 to 11 g/dl Issue time Unit number Component Volume Blood group 5 pm 2429 PRBC- DB 370 mL B positive

24. Serial evaluation of the case

25. Date ICT DCT 10-08-2024 4+ Neg 12-08-2024 4+ 2+ with negative pooled cells 2+ 21-08-2024 1+ weak reaction Neg 02-09-2024 2+ 1+ weak reaction 10-09-2024 Neg 1+ weak reaction Total transfusions- 3 PRBCs outside hospital 5 O negative PRBCs 3 B positive PRBCs

26. Differential diagnosis/inferences

27. The diagnosis was inclined towards autoimmune hemolytic anaemia because of clear signs of hemolysis on presentation and positive coombs tests which slowly dissolved on subjecting the patient to corticosteroids. Other possible differentials of autoimmune hemolytic anemia are- hereditary spherocytosis that may present for the first time during adult life (positive family history and negative antiglobulin test ) drug induced immune haemolytic anaemia ( h/o recent drug exposure) Microangiopathic haemolytic anaemia (schistocytes, thrombocytopenia, and evidence of intravascular coagulation).

28. Wrong transfusion based hemolysis

29. Literature In autoimmune haemolytic anaemia , the auto antibodies are mostly pan reactive and react with autologous as well as allogenic cells. PBF in AIHA shows microcytosis, mild neutrophilic leucocytosis, and reticulocytosis. Fragmented red cells, and nucleated red cells may be present The blood transfusions are avoided as far as possible. The auto antibodies have masking effect so detection of underlying alloantibodies is very difficult. Increase survival rate of RBCs have been observed whenever antigen negative blood cells is given to the patient . Finding a compatible Blood unit is practically impossible, so least incompatible unit is chosen when the transfusion is unavoidable

30. Treatment 1 . Majority of patients respond to corticosteroids (1 mg/kg body weight/day ). Steroids inhibit macrophage phagocytosis and reduce synthesis of antibodies by spleen. 2 . Splenectomy is indicated when improvement does not occur with corticosteroids. Splenectomy removes the major site of red cell destruction in AIHA. 3 . Rituximab (monoclonal antibody against CD20 antigen of B lymphocytes) is another option for unresponsive cases. 4. Other forms of treatment which may be of benefit are azathioprine, cyclophosphamide, and cyclosporine. 5. Blood transfusion is only a supportive treatment.

31. LIMITATIONS Bone marrow examination not done due to recent transfusion. Hb electrophoresis not done due to recent transfusion. Erythropoeitin levels not done to evaluate red cell production.

32. cURRENTLY Signs of hemolysis have been nearly dissolved. Signs of any significant auto/alloantibodies have resolved. Current Hb of the patient is 11g/dl after transfusion of 12 PRBC units in around 45 days (no transfusion reaction reported). Final diagnosis- Autoimmune hemolytic anemia due to underlying disease condition/idiopathic/wrong transfusion related, now recovering with normal S. bilirubin, LDH levels and being managed under the cover of antibiotics, iron folic acid supplementation, steroid therapy along with supportive transfusion therapy.

33. Thankyou