Background: The phenomena of co-incidence of transfusion-induced allo- and autoantibodies, blockage and/or loss of red blood cell (RBC) antigens are conspicuous and may result in confusion and misdiagnosis. Case Report: A 67-year-old female was transferred to the intensive care unit due to hemolysis which developed 2 days following transfusion of three Rh(D)-negative RBC units in the presence of strongly reactive autoantibodies. Standard serological testing and genotyping were performed. Upon arrival, the patient was typed as Ccddee. Her hemolysis was decompensated, and an immediate blood transfusion was required. In addition, direct and indirect antiglobulin tests (DAT and IAT) as well as the eluate were strongly positive. Emergency transfusion of Rh(D)-negative RBCs resulted in increased hemolysis and renal failure. An exhaustive testing revealed anti-D, anti-c, CCddee phenotype and CCD.ee genotype. Three units of cryopreserved CCddee RBCs were transfused, and the patient's condition immediately improved. The discrepancy between Rh-D phenotyping and genotyping was likely caused by masking of the D-epitopes by the autoantibodies. In fact, further enquiry revealed that the patient had been phenotyped as Rh(D)-positive 6 months ago and had been transfused at that time following hip surgery. Conclusion: The phenomena of transfusion-induced autoantibodies, masked alloantibodies, antigen blockage and/or loss are rare but important features which should be considered in patients presenting with autoimmune hemolytic anemia and/or hemolytic transfusion reactions.

Keywords:
Hemolytic anemia, Transfusion reaction, Auto-anti-D, Rh(D)-blocked phenomenon, Antigen suppression
1.
Beauregard P, Blajchman MA: Hemolytic and pseudo-hemolytic transfusion reactions: an overview of the hemolytic transfusion reactions and the clinical conditions that mimic them. Transfus Med Rev 1994;8:184-199.
2.
Petz LD, Garratty G: Immune Hemolytic Anemias, 2nd ed. Philadelphia, Churchill Livingstone, 2004.
3.
Packman CH: Hemolytic anemia due to warm autoantibodies. Blood Rev 2008;22:17-31.
4.
Salama A, Mueller-Eckhardt C: Delayed hemolytic transfusion reactions. Evidence for complement activation involving allogeneic and autologous red cells. Transfusion 1984;24:188-193.
5.
Young PP, Uzieblo A, Trulock E, Lublin DM, Goodnough LT: Autoantibody formation after alloimmunization: are blood transfusions a risk factor for autoimmune hemolytic anemia? Transfusion 2004;44:67-72.
6.
Garratty G: Autoantibodies induced by blood transfusion. Transfusion 2004;44:5-9.
7.
Salama A, Berghöfer H, Mueller-Eckhardt C: Red blood cell transfusion in warm-type autoimmune haemolytic anaemia. Lancet 1992;340:1515-1517.
8.
Ahrens N, Pruss A, Kähne A, Kiesewetter H, Salama A: Coexistence of autoantibodies and alloantibodies to red blood cells due to blood transfusion. Transfusion 2007;47:813-816.
9.
Sulochana PV, Rajesh A, Mathai J, Sathyabhama S: Blocked D phenomenon, a rare condition with Rh D haemolytic disease of newborn - a case report. Int J Lab Hematol 2008;30:244-247.
10.
Moiz B, Salman M, Kamran N, Shamsuddin N: Transfusion medicine illustrated: blocked D phenomenon. Transfusion 2008;48:1545-1546.
11.
Lee E: Blocked D phenomenon. Blood Transfus 2013;11:10-11.
12.
Halverson GR, Tossas E, Velliquette RW, Lobo C, Reid ME, Frame T, Castilho L, Lee AH, Storry JR, Grodecka M, Waśniowska K, Duk M, Lisowska E: Murine monoclonal anti-s and other anti-glycophorin B antibodies resulting from immunizations with a GPB.s peptide. Transfusion 2009;49:485-494.
13.
Lee E, Burgess G, Halverson GR, Huang TJ, Reid ME: Applications of murine and humanized chimaeric monoclonal antibodies for red cell phenotyping. Br J Haematol 2004;126:277-281.
14.
Lee E, Hart K, Burgess G, Halverson GR, Reid ME: Efficacy of murine monoclonal antibodies in RBC phenotyping of DAT-positive samples. Immunohematology 2006;22:161-165.
15.
Wagner FF, Eicher NI, Jørgensen JR, Lonicer CB, Flegel WA: DNB: a partial D with anti-D frequent in Central Europe. Blood 2002;100:2253-2256.
16.
Daniels G: Variants of RhD - current testing and clinical consequences. Br J Haematol 2013;161:461-470.
17.
von Zabern I, Wagner FF, Moulds JM, Moulds JJ, Flegel WA: D category IV: a group of clinically relevant and phylogenetically diverse partial D. Transfusion 2013;53:2960-2973.
18.
Zimring JC, Cadwell CM, Chadwick TE, Spitalnik SL, Schirmer DA, Wu T, Parkos CA, Hillyer CD: Nonhemolytic antigen loss from red blood cells requires cooperative binding of multiple antibodies recognizing different epitopes. Blood 2007;110:2201-2208.
19.
Zimring JC, Cadwell CM, Spitalnik SL: Antigen loss from antibody-coated red blood cells. Transfus Med Rev 2009;23:189-204.
20.
Powers A, Mohammed M, Uhl L, Haspel RL: Apparent nonhemolytic alloantibody-induced red-cell antigen loss from transfused erythrocytes. Blood 2007;109:4590.
© 2015 S. Karger GmbH, Freiburg
2015
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.