Transfusion Exam III

  1. A child is admitted to the ED department with a viral infection. The patient's Donath-Landsteiner test is positive. The patient's diagnosis is most probably:

    C. PCH
  2. A specimen is sent to the Transfusion Service for testing on a patient with PCH. That DAT on the patient is positive for:

    D. C3
  3. The patient with PCH and a positive DAT for C3 has a positive antibody screen with a specifity of:

    D. anti-P
  4. A 30-year-old female is admitted with anemia of undetermined origin. A type and cross was received in the Transfusion Servce. The patient is in the computer system as an A neg and states she has no history of transfusion or pregnancy. The following are her results using tube testing:
                                   IS    37C  IAT
    Screening Cell I          0     0     3+
    Screening Cell II         0     0     3+
    Autocontrol                0     0     3+
    4 donor units              0     0     3+

    The antibody panel resulted 3+ for all cells at IAT. The next step to find compatible blood would be:

    B. Perform warm autoabsorption
  5. A patient diagnosed with mycoplasma pneumoniae. The patient is also exhibiting some hemolysis and a type and screen is sent to the Transfusion Service. The specimen has a positive antibody screen. What antibody would you expect to be exhibited in the patients plasma?

    C. Anti-I
  6. A patient has a life threatening anemia due to warm autoantibodies. The patient's serum was 2+ at IAT with cells on a routine panel. A technique that would be beneficial to preparing the patient's plasma for compatibility testing is:

    D. Autoadsorption using the patient's heat-eluted, enzyme-treated red cells.
  7. A 40-year-old man with autoimmune hemolytic anemia with a specificity of auto anti-e has a hemoglobin level of 10.8gm/dL. The patient will most likely be treated with:

    B. no transfusion
  8. A patient presents to their physician with bluing of the hands and feet after cold exposure. The Physician orders blood work on the patient. Their hemoglobin is 10 g/dL with an elevated retic count. The DAT is positive with complement only. What is the most probable explanation for this?
    Cold Autoantibody
  9. Refer to the following data:

    Hemoglobin  7.4g/dL
    Retic count   22%
    BS DAT        3+
    IgG             3+
    C3               0
    SI               3+
    SII              3+
    Autocontrol   3+

    Which clinical condition is consistent with the lab results given?

    C. Warm autoimmune hemolytic anemia

    (cold hemagglutinin disease - would see pos. complement C3; Penicillin-induced hemolytic anemia - would see negative screen; delayed transfusion reaction - would see weaker DAT)
  10. A 50 year old man with autoimmune hemolytic anemia has been feeling tired. His Physician orders a hemoglobin that is reported at 10.8g/dL. This patient should be treated with:

    A. Nothing - would hemolyze newly transfused cells
  11. The drug cephalosporin can cause a positive direct coombs test by which mechanism?

    C. membrane modification
  12. Refer to the following data:

    Hemoglobin 7.4g/dL
    Retic  count 22%
    PS 2+
    IgG 2+
    C3 0
    SCI 3+
    SCII 3+

    What clinical diagnosis do you suspect?

    D. warm autoimmune hemolytic anemia
  13. The mechanism that best explains hemolytic anemia due to penicillin is:

    D. drug adsorption
  14. A 35 year old female with lupus is admitted to an inpatient unit. A type and screen is ordered. Both screen cells are 3+ at IAT. The most likely explanation is:

    B. warm autoantibody


    d. alloantibodies
  15. Which of the following medications are most likely to cause the production of autoantibodies?

    A. methyldopa
  16. A patient has a negative antibody screen but their DAT is positive. The eluate is negative. The most likely drug involved is:

    C. cephalothin
  17. PCH is associated with which blood group?

    B. P
  18. Which is characteristic of anti-i?

    A. found in serum of patients with infectious mono
  19. In which situation is a red cell separation indicated?

    C. recently transfused patient with alloantibodies
  20. A patient has warm autoimmune hemolytic anemia and must be transfused immediately. What technique would you perform? The patient has no transfusion history.

    C. autoadsorp patient's plasma with the has no transfusion history
  21. A patient has cold autoimmune hemolytic anemia. A cold panel is performed at 4 degrees. The patient's plasma will react with:

    A. all cells from the panel and his own cells
  22. A 25 year old female is admitted to the ED and her type and screen results suggest she may have cold autoimmune hemolytic anemia. A DAT is performed. What is going to be detected?

    D. C3d
  23. A patient types:

    Anti-A 3+, A1 cells 1+
    Anti-B 0, B cells 4+
    Anti-D 4+
    SCI 3+, SCII 3+, DAT 3+

    What do you suspect this discrepancy is due to?

    a. A2 with anti-A1
    b. Cold autoimmune hemolytic anemia
    c. Warm autoimmune hemolytic anemia
    d. Drug induced
    • a. A2 with anti-A1
    • b. Cold autoimmune hemolytic anemia
    • c. Warm autoimmune hemolytic anemia
  24. A patient is admitted to the ED and is suffering from massive trauma. Blood is needed right away. The antibody screen is 3+ with both cells and the 6 units crossmatched are all 3+. What will you do?
    Call lab director, run panel, perform a crossmatch
  25. What is the definition of a hemolytic transfusion reaction?
    the lyses or accelerated clearance of RBCs in the transfusion recipient due to immunologic incompatibility between donor and recipient.
  26. What are some characteristics of intravascular hemolysis?
    • 1. activated complement
    • 2. hemoglobinemia/hemoglobinuria
    • 3. DIC/renal failure
  27. What are the symptoms of Intravascular hemolysis?
    • 1. Fever, chills
    • 2. back pain
    • 3. hypotension
    • 4. shock
    • 5. hemoglobinuria
    • 6. sense of impending doom
  28. What are characteristics of extravascular hemolysis?
    • 1. usually non-ABO
    • 2. incomplete complement activation
    • 3. no release of free hemoglobin
    • 4. mild symptoms
    • 5. fever, chills
    • 6. increases serum bilirubin
    • 7. by-stander hemolysis
    • 8. cytokines implicated in hemolysis
    • 9. cells destroyed in liver and spleen
  29. What are some causes of hemolytic reactions?
    • 1. clerical errors
    • 2. ABO mismatch
  30. What are causes of hemolyzed units?
    • 1. improper temp/storage
    • 2. mechanical malfunctions
    • 3. incompatible solutions
    • 4. bacterial growth
  31. What factors contribute to hemolytic severity?
    • 1. class and subclass of immunoglobulin
    • 2. ability of antibody to activate complement
    • 3. plasma concentration of antibody
    • 4. amount of incompatible RBCs transfused
    • 5. Condition of patient
  32. What is the treatment for a hemolytic reaction?
    Depends on severity but you want to maintain adequate renal blood flow and treat hypotension.
  33. What is the definition of a Delayed Hemolytic Reaction?
    Transfusion of an apparently well tolerated compatible unit of blood where the antibody is not detected at the time of transfusion producing a primary or secondary response.
  34. What is a primary response regarding a delayed hemolytic reaction?
    When a patient is transfused and builds an antibody 10-14 days after the transfusion. The antibody will react with positive donor cells.

    Risk of alloimmunization is 1-1.6% for each RBC unit. Usually a mild reaction.
  35. What is a secondary response regarding delayed hemolytic reactions?
    When an antibody titer is detectable 3-7 days after transfusion

    Transfusion of antigen positive unit stimulates the patient to produce more antibody.

    DHTR is usually caused by anti-Jka, anti-E, anti-D, anti-C, anti-K, and anti-Fya.
  36. What are signs and symptoms of a delayed hemolytic transfusion reaction?
    • 1. Low hematocrit
    • 2. Extravascular hemolysis
  37. What is the action of the healthcare provider in the instance of a delayed hemolytic transfusion reaction?
    • 1. Stop transfusion immediately
    • 2. Notify Physician
    • 3. Notify Blood Bank
    • 4. Clerical Check
  38. What are the clinical results after a DHTR?
    • 1. Low hematocrit
    • 2. Low hemoglobin
    • 3. Increased bilirubin
    • 4. Increased plasma bilirubin
    • 5. Increased retics
  39. What serological testing may be performed in the case of a hemolytic transfusion reaction?
    DAT and antibody screen
  40. What is the work up performed in the Blood Bank in case of an HTR?
    • 1. Compare pre and post specimen for hemolysis
    • 2. Clerical check
    • 3. Perform DAT on post specimen
    • 4. Perform ABO/Rh group and type on post specimen
    • 5. Additional serological work (type and screen, crossmatch, ABO/Rh on donor unit, antibody panel, eluate, antigen screen)
  41. Describe Immune complex/Drug dependent antibody formation:
    • 1. Drugs do not bind well to cell membrane
    • 2. Causes intravascular hemolysis
    • 3. Drug stimulates antibody production
    • 4. Drug-anti-drug complex is formed
    • 5. complex nonspecifically attaches to RBCs
    • 6. Binding maybe loose and complex falls off
    • 7. Complement is activated
    • 8. Antibody is directed against drug, not RBC antigen
    • 9. RBCs maybe hemolyzed by complement or resulting RBC may have positive DAT
  42. What serological tresting is performed and what are the expected results during an immune complex/drug dependent antibody response?
    • 1. PS-positive (polyspecific)
    • 2. IgG-negative (monospecific)
    • 3. C3-positive
    • 4. Antibody screen-negative
    • 5. Eluate-non reactive
  43. What drugs are implicated during an immune complex/drug dependent antibody response?
    • Acetaminophen
    • Phenacetin
    • Quinidine
  44. Describe a drug adsorption:
    • 1. Drug is firmly bound to protein membrane on RBCs
    • 2. Antibodies to drug are produced
    • 3. Antibodies attach to drugs on RBC surface
    • 4. Antibodies are usually IgG
    • 5. No complement is activated
    • 6. Extravascular hemolysis
  45. What serological testing is performed during a drug adsorption and what are the expected results?
    • 1. PS-positive (polyspecific)
    • 2. IgG-positive (monospecific)
    • 3. C3-negative
    • 4. Antibody screen-negative
    • 5. Eluate-negative
  46. What drugs are implicated during a drug adsorption?
    • Penicillin
    • Tetracycline
    • Streptomycin
  47. Describe RBC modification:
    • 1. Drug alters the RBC membrane in to where it nonspecifically absorbs proteins
    • 2. Cells are coated with IgG, IgA, IgM and complement
  48. What serological testing is performed during RBC modification and what are the expected results?
    • 1. PS-positive (polyspecific)
    • 2. IgG-positive (monospecific)
    • 3. C3-positive
    • 4. Antibody screen-negative
    • 5. Eluate-negative
  49. What drugs are implicated during RBC modification?
  50. Describe antibody formation and autoimmunity induction:
    • 1. Autoimmune mechanism
    • 2. Some drugs induce formation of autoantibodies
    • 3. Serologically indistinguishable from WAHIA
  51. What serological testing is performed during antibody formation/autoimmunity induction and what are the expected results?
    • 1. PS-positive (polyspecific)
    • 2. IgG-positive (monospecific)
    • 3. C3-negative
    • 4. Antibody screen-positive
    • 5. Eluate-positive
  52. What drugs are implicated in antibody formation/autoimmunity induction?
    • Aldomet
    • L-dopa
    • Ibuprofen
  53. What are the four mechanisms described in which drugs cause a positive DAT?
    • 1. Drug adsorption
    • 2. Immune complex mechanism/Drug dependent mechanism
    • 3. Autoimmunity induction/antibody formation
    • 4. Red cell membrane modification
  54. Which of the four mechanisms are responsible for drug induced hemolysis?
    • 1. Immune complex/ Drug dependent antibody
    • 2. Drug Adsorption
    • 3. Antibody Formation/Autoimmunity Induction
  55. How is drug induced hemolysis usually resolved?
    Discontinue drug
  56. Describe the Blood Bank investigation process:
    • 1. Check medical history to determine if positive DAT is due to delayed transfusion reaction, drug therapy, or autoimmune disorder
    • 2. Ask for medications, diagnosis, transfusion history or pregnancies
    • 3. Determine what component is coating the cells
    • 4. Determine if the serum antibody is allo- or auto-
    • 5. May need to perform and adsorption
  57. Define cold autoimmune hemolytic anemia.
    AIHA due to cold reactive autoantibodies reacting at temperatures below 32C. (Accounts for 15-25% of all autoimmune cases)
  58. What are the two basic types of cold autoimmune hemolytic anemia?
    • 1. Cold hemagglutinin disease/cold agglutinin syndrome
    • 2. Paroxysmal cold hemaglobinuria (PCH)
  59. The acute form of cold hemagglutinin disease is usually secondary to which disorders?
    lymphoproliferative disorders such as lymphomas or mycoplasmal pneumonia.
  60. When is the chronic form of cold hemagglutinin disease often seen?
    In elderly patients with CLL or Waldenstrom's macroglobinemia
  61. What autoantibody is usually indicated in cold hemagglutinin disease?
    Anti-I. An IgM antibody of secondary hemolytic episodes that follow mycoplasma pneumonia infections.
  62. What autoantibody is indicated in cold hemagglutinin disease during episodes involving Mono?
  63. What is the prevalence of anti-i? During hemolytic episodes?
    Anti-i is present 50% of the time but less than 1% have hemolytic episodes.
  64. What are the features of cold agglutinin syndrome?
    • 1. chronic anemia
    • 2. hemoglobinemia/hemaglobinuria
    • 3. jaundice
    • 4. linked to temperature of climate
  65. What are the laboratory findings during cold agglutinin syndrome?
    • 1. Interferes with ABO testing. (Remedy by washing with saline at 37C; allow red top to clot at 37C; autoadsorp autoantibody prior to testing; prewarm; perform a titer).
    • 2. Rh typing with monnoclonal reagents will usually give valid results.
    • 3. Antibody screen depends on technique used.
  66. During a transfusion of a patient with cold agglutinin syndrome, how is acute hemolysis treated?
    Reduce patient by keeping them warm and use a blood warmer during transfusion. Otherwise, 50% of cells will be destroyed.
  67. What are characteristics of paroxysomal cold hemoglobinria?
    • 1. During PCH, IgG is a biphasic hemolysin that do not hemolyze while body temp is normal.
    • 2. Upon exposure to cold, the autoantibody binds to RBCs.
    • 3. As the patients body temp returns to normal, the antigen-antibody complexes fix complement and result in severe intravascular hemolysis.
  68. What are thew laboratory findings of PCH?
    • 1. antibody has anti-P specificity
    • 2. Low crit
    • 3. Reticulocytosis
    • 4. Blood stained UA (hematuria)
  69. Describe the Donath-Landsteiner test:
    Used to determine PCH:

    • 1. Two clotted specimens are drawn from patient
    • 2. One at 37C
    • 3. The other at 4C for 30min, then at 37C for 30min
    • 4. Spin both tubes
  70. What is the treatment for PCH?
    • 1. With Chronic PCH, keep patient warm.
    • 2. During acute PCH, it usually terminates with resolution of infection.
    • 3. Transfusion is un-necessary unless hemolysis is severe.
  71. How would you perform a serological investigation of PCH?
    • 1. Keep specimen at 37C.
    • 2. Make a saline suspension using warm saline.
    • 3. Make sure reagents are room temp.
    • 4. Eluate autoantibody of cells if needed to type.
    • 5. Positive DAT - complement - no eluate
    • 6. Do panels at different temps to establish thermal amplitude of antibody
    • 7. Run cold autoadsorptions
    • 8. Titer
  72. What are the characteristics of a normal cold antibody?
    • 1. Reactive <22C
    • 2. No spontaneous agglutination
    • 3. No clinical significance
    • 4. DAT negative
  73. What are the characteristics of a pathological cold antibody?
    • 1. Reactive up to 32C
    • 2. Spontaneous agglutination
    • 3. Titer >1000
    • 4. Causes AIHA
    • 5. DAT positive
  74. Which of the following is a characteristic of anti-i?

    B. found in the serum of patients with infectious mononuclesis.
  75. In the case of cold autoimmune hemolytic anemia, the patient's serum would most likely react 4+ at immediate spin with:

    D. all cells of a group O cell panel and his own cells
  76. Cold agglutinin syndrome is associated with an antibody specificity toward which of the following?

    A. I (associated with cold agglutinin syndrome)
  77. Which of the following is a characteristic of anti-i?

    C. reacts best at room temperature or 4C

    anti-i is an IgM  antibody and reacts with cord cells and i adult cells. Not associated with HDFN since IgM does not cross the placenta.
  78. An obstetrical patient has had 3 previous pregnancies. Her first baby was healthy, the second was jaundiced at birth and required an exchanged transfusion, while the third was stillborn. Which of the following is the most likely cause?

    D. Rh incompatibility
  79. What is an alloantibody?
    An antibody made against a foreign antigen.
  80. What is an autoantibody?
    An antibody made against self-antigens. Occurs when the immune system malfunctions.
  81. Define autoimmune hemolytic anemia (AIHA):
    A type of autoimmune disease in which the autoantibody targets the red cell antigens.
  82. Define autoimmune disease:
    When an autoantibody is directed to destroy cells and tissue that carry the target antigen.
  83. What is hemolytic anemia?
    • The destruction of red blood cells by hemolysis where
    • --compensated anemia is the result of red cell production equals destruction and
    • --uncompromised anemia is the inability of bone marrow to compensate red cell destruction. Hematocrit decreases.
  84. What are the two categories of warm autoimmune hemolytic anemia?
    • 1. Primary - idiopathic
    • 2. Secondary - disorders associated with WAIHA
  85. What are the two categories of cold agglutinin syndrome?
    • 1. Primary - idiopathic
    • 2. Secondary - due to Mycopasma pneumonia, Infectious Mono
  86. What are the two categories of paroxyomal cold hemoglobinuria?
    • 1. Primary - idiopathic
    • 2. Secondary - due to syphilis or viral infections (measles, mumps)
  87. What would the DAT result during AIHA?
  88. What disorders are frequently associated with WAIHA?
    • 1. Reticuloendothial neoplasms: CLL, Hodgkins, Non-Hodgkins, Thymomas
    • 2. Collagen disease: SLE (lupus), rheumatoid arthritis
    • 3. Viral syndromes and infectious diseases
    • 4. Immunological disease: Hypogammaglobulinemias, dysglobulinemias etc.
    • 5. GI disease: Ulcerative colitis
    • 6. Benign tumors
  89. What is the immunoglobulin class of WAIHA?
  90. Where does hemolysis occur during WAIHA?
  91. What is the specificity of WAIHA?
    Frequently broad Rh-like.
  92. What is the titer of WAIHA?
  93. What is the optimal reactivity for WAIHA?
    >32C (37C)
  94. What is the optimal reactivity for Cold AIHA?
    <30C (4C, 22C)
  95. What is the immunoglobulin class of Cold AIHA?
    IgM (exception: PCH-IgG)
  96. Where does hemolysis occur during Cold AIHA?
    Extravascular and intravascular (cell lysis within vascular system, free plasma Hgb, and hemosiderin is formed from Hgb and is excreted in urine.
  97. What is the frequency of WAIHA?
    70-75% of cases.
  98. What is the frequency of Cold AIHA?
    16% of cases (PCH: 1-2%)
  99. What is the specificity of Cold AIHA?
    Ii system (PCH: autoanti-P)
  100. What is the titer for Cold AIHA?
  101. What type of warm autoantibodies react with normal Rh types but do not react when tested with rare cells lacking Rh Antigens?
  102. What is relative specificity?
    When an autoantibody reacts stronger with (reagent) red cells possessing the corresponding antigen than with cells lacking the antigen.
Card Set
Transfusion Exam III
Hemolytic Anemia