Background/Case Studies: Delayed hemolytic transfusion reactions (DHTRs) are typically caused by an anamnestic immune response to a foreign blood group antigen. Hemolysis due to DHTRs is usually extravascular with mild or even subclinical signs and symptoms. These reactions often go unidentified due to the absence of follow up testing in patients who do not require subsequent transfusion support and the evanescence of the antibodies themselves. Here we report a rare case of a life-threatening DHTR caused by four newly identified blood group alloantibodies following transfusion of multiple units of RBCs in the setting of severe post-operative hemorrhage.
Study
Design/Methods: A 58-year-old woman with coronary artery disease received quintuple coronary artery bypass grafting at an outside hospital complicated by post-op hemorrhage and cardiac tamponade requiring transfusion of nine units of RBCs. Her pre-operative antibody screen was negative. She recovered and was discharged to a skilled nursing facility. One day later she presented to our emergency department with dyspnea, fever and chest pain, and was admitted to the ICU. On day 2 of her hospitalization, she developed severe anemia, with her hemoglobin dropping from 10.1 g/dL to 6.6 g/dL, and hyperbilirubinemia with total bilirubin of 4.4 mg/dL and direct bilirubin of 0.9 mg/dL. A type and screen was ordered with antibody identification panel positive for anti-C, -E, -Jkb, and -S. A direct antiglobulin test was positive for IgG (3+) and her plasma was icteric. The eluate contained anti-C, -E, -Jkb, and -S. Haptoglobin was undetectable (< 10 mg/dL) and lactate dehydrogenase was markedly elevated (1408 IU/L).
Results/Findings: A life-threatening delayed hemolytic transfusion reaction was diagnosed and she was treated with intravenous immunoglobulin (0.4 g/kg) and intravenous methylprednisolone 80 mg.Hemodialysis was initiated for anuria and a rising creatinine. Due to worsening anemia, transfusion with four units of crossmatch-compatible, antigen-negative RBCs was given over days 2 to 3 (Figure A). Because all nine RBC units she received peri-operatively were likely incompatible, a five-unit red blood cell exchange was performed with crossmatch-compatible, antigen-negative RBCs on day 3, resulting in improvement of anemia, decreased hemolysis, and ultimately recovery from her life-threatening DHTR. She was discharged on day 11 with outpatient dialysis and recovered her renal function within 2-3 weeks after discharge. Conclusions: Our case highlights the utility of RBC exchange as a safe and effective treatment for severe DHTRs due to large volumes of incompatible RBCs by removing the incompatible RBCs and replacing them with crossmatch-compatible, antigen-negative RBCs to ameliorate life-threatening sequelae of hemolytic transfusion reactions.
