Blood Bank Case Study: Once Upon a Discrepancy

I have taught Transfusion Medicine to MLS students for a number of years, and one of the more challenging concepts for my students is that of ABO discrepancies. We use ‘dry’ labs for ABO discrepancy examples because it would be difficult to create actual samples that illustrate the various scenarios. Without seeing this in the lab, and actually performing the steps to resolve, visual learners in particular can be at a disadvantage. In reality, some of the more unusual ABO discrepancy problems are found more often on exams than in real life. Consequently, in the Blood Bank lab, when a technologist comes upon an ABO discrepancy, it can be something they are not very experienced with and it can be more scary than exciting. I have always felt that one of the best things about being a medical technologist is that we get to solve puzzles and find answers. So, let’s put on our detective hats and follow along with our case history story of an ABO typing discrepancy.

Once upon a discrepancy… a forward typing did not match a back typing. The first thing the tech did was to repeat the typing. Many labs recommend using a different method in the repeat, so if typings are routinely done by an automated method, a repeat testing might be done by tube typing. In this case, we can see the results of the initial testing and the results of the tube typing below:

Automated typing

Repeat tube typing

As you can see, the repeat typing simply rules out technical or clerical errors and confirmed that the testing was performed correctly. So far so good. However, since we got the same results on repeat testing, what is the next step in resolving this discrepancy?

I teach my students to think of a few ground rules when working on ABO discrepancy problems. The first is that, typically in these situations, it is the weak reaction that is the discrepant one. We have a patient who front types as an A, but the back type looks like an O. With ABO typing we usually get fairly strong reactions, so the 1+ reaction with A1 Cells is the suspect one. The second rule of thumb is that antibody problems are much more common than antigen problems. Having and extra antibody reaction or missing an antibody reaction is more common than extra or missing antigens. In this case we have an extra antibody reaction. This patient looks like a group A who is making anti-A1 which has reacted with our A1 cells.

Our next step is to discover why we have an extra antibody. I would like to emphasize the importance of looking up the patient’s history to help you resolve a discrepancy. This is the third thing that should always be done when investigating an ABO discrepancy. Accurate patient history including any previous Blood Bank results, age, pregnancy history, medications and diagnosis can all be used to help resolve these problems.

At this point techs are probably thinking ‘This is easy!’ and thinking about A subgroups. Remember that about 80% of group A people are group A1 and about 20% are group A2. There are also other less common subgroups of A, but A2 is the one that we encounter most often. Some group A2 people can make anti-A1, either naturally or as an immune response. This patient is a 30 year old woman who is in the Emergency Room and has just been scheduled for surgery. The physician has ordered a type and crossmatch for 2 units of blood. A look at her medical history shows she has never been pregnant nor has ever received blood products. We have no previous Blood bank history on the patient. While an anti-A1 can be from previous transfusions or pregnancy, it can also be naturally occurring. This seems to support our speculation that she is an A2 subgroup with a naturally occurring anti A1, so while we are waiting for our screen results, we perform A1 lectin testing. The results are shown below:

If our patient was group A2 as we thought, her A2 cells would not react with anti-A1 and her plasma would not have anti-A2 and would not react with A2 cells. Our results do not match our original hypothesis that the patient is group A2 and we can rule out a subgroup of A. What is her type, and what is causing the discrepancy?

To help solve this discrepancy, the tech looked at the solid phase screening results only to find that the screen was negative, thus making this puzzle even more perplexing. He repeated the screen in tube at IS, 37C and AHG and found positive reactions. Working up the panel, Anti-M was identified!

So, what type is this patient? She is group A1 pos with an cold reacting anti-M antibody. The policies of the medical center would determine if this patient should be given cross match compatible units that are not antigen typed or crossmatch compatible M negative units.

Anti-M is a naturally occurring cold antibody. Most examples of Anti-M are IgM, do not react at 37C and are not considered to be clinically significant. However, anti M can also present with an IgG component and react at 37C and AHG. In this case, it would be considered clinically significant and any units transfused must be negative for the M antigen.

This patient’s anti-M was only reacting at IS and determined to be not clinically significant. Despite this, we have seen that non-ABO alloantibodies can and do interfere with ABO typing and are a common cause of unexpected reactivity in ABO reverse typing. Performing the ABO testing at warm temperatures or repeating the reverse grouping with reagent A1 and B cells that are negative for M antigen can eliminate the cold reactivity and help resolve the discrepancy. It is important to remember that we must not only recognize discrepant results, but also resolve them adequately. Correct blood typing of patients is essential to prevent ABO incompatible transfusions and to help prevent alloimmunization.

References

1. http://www.haabb.org/images/14_Hamilton-Neg_Ab_screen_For_website.pdf
2. Harmening, Denise M. Modern Blood banking and Transfusion Practices, 6th Ed. 2012
3. Safoorah Khalid, Roelyn Dates, et al. Naturally occurring anti M complicating ABO grouping. Indian Journal of Pathology and Microbiology. Vol 54, Issue 1, 2011. P 170-172

-Becky Socha, MS, MLS(ASCP)^CM BB ^CM graduated from Merrimack College in N. Andover, Massachusetts with a BS in Medical Technology and completed her MS in Clinical Laboratory Sciences at the University of Massachusetts, Lowell. She has worked as a Medical Technologist for over 30 years. She’s worked in all areas of the clinical laboratory, but has a special interest in Hematology and Blood Banking. When she’s not busy being a mad scientist, she can be found outside riding her bicycle.