Negative Direct Coombs Test Research Articles

One Haemolytic Anaemia May Hide Another: Paroxysmal Nocturnal Haemoglobinuria Masquerading As Plasmodium Falciparum Infection.

Paroxysmal nocturnal haemoglobinuria (PNH) is a rare, genetic and acquired haematologic disease that causes complement-mediated intravascular haemolytic anaemia, thrombosis and bone marrow failure. A 27-year-old migrant patient attended the emergency department in a context of fever and chills over the previous few days as well as chronic fatigue, dyspnoea and chest pain. His medical history included chronic anaemia and erectile dysfunction. Initial biology showed a haemoglobin of 6.3 g/dl, platelets of 25,000/μl, total leucocytes of 3,500/μl with 1,500 neutrophils. B12 vitamin, folic acid, ferritin and thyroid stimulating hormone were normal. Lactate dehydrogenase levels were high and haptoglobin was non-measurable. C-reactive protein was 46.1 mg/l. A thick blood smear revealed Plasmodium falciparum infection with 0.1% parasitaemia. The patient was treated with an oral combination of artemether and lumefantrine. Three weeks later, the patient consulted the infectious disease department given the lack of clinical improvement. The cytopenias worsened, and lactate dehydrogenase (LDH) and reticulocytes increased. Tests for schistocytes, a thick blood smear for malaria and a direct Coombs test were negative; a myelogram was reassuring. An abdominal, pelvic and thoracic CT scan showed a mild hepatomegaly with no focal lesion and no splenomegaly or adenomegaly. A 12-colour flow cytometry unveiled a PNH clone on 90.9545% of neutrophils and 80.7371% of monocytes. PNH patients can be vulnerable to parasites infection (such as P. falciparum) as it may trigger breakthrough haemolysis through uncontrolled resurgence of activity of the complement system. In our patient, P. falciparum infection was a confounding factor, as it commonly causes haemolytic anaemia and thrombocytopenia, and patients living in malaria-endemic regions can carry low parasitaemia while being slightly symptomatic or asymptomatic. Plasmodium falciparum infection can cause breakthrough haemolysis in patients with paroxysmal nocturnal haemoglobinuria.Low P. falciparum parasitemia in patients living in malaria-endemic regions is not always significant as these patients often carry acquired immunity.Patients from malaria-endemic regions presenting with severe sickness and low P. falciparum parasitemia must be assessed for other diseases, as it cannot explain heavy illness.Patients presenting with haemolytic anaemia, no schistocytes, a negative direct Coombs test and other unexplained cytopenia such as thrombocytopenia/neutropenia and other unexplained clinical manifestations such as dyspnoea, chest pain or erectile dysfunction should be assessed for paroxysmal nocturnal haemoglobinuria.

Abstract PO5-20-10: Treatment with CDK4/6 Inhibitor in a Patient with Metastatic Breast Cancer Causing Myelophthisis

Abstract Background: Symptomatic bone marrow metastasis causing myelophthisis is a rare manifestation of metastatic breast cancer, indicating a poor prognosis due to significant cytopenias. CDK4/6 inhibitors are first-line therapies for metastatic hormone-positive breast cancer but remain an unclear choice in breast cancer patients with significant cytopenias due to associated hematological adverse effects. We present a case of biopsy-proven hormone-positive breast cancer with bone marrow infiltration causing profound pancytopenia. CDK4/6 inhibitors were safely administered despite their cytopenic effects. Case Presentation: A 59-year-old female presented after an abnormal annual mammogram and biopsy showed calcifications stromal fibrosis, cyst formation, and usual ductal hyperplasia in the right upper outer quadrant. One month later, she presented to an outside hospital with gingival bleeding, epistaxis, progressive dyspnea on exertion, and generalized weakness. Labs showed severe anemia with a hemoglobin of 4.8 g/dL (baseline 12.1 g/dL), thrombocytopenia with platelets of 5 K/mm (baseline 215 K/mm), LDH of 879, reticulocyte count of 5%, and negative direct Coombs test. Peripheral smear showed no schistocytes, but showed nucleated RBCs, severely reduced platelets, and occasional giant platelets. The patient was treated for presumed ITP, and the presence of nucleated RBCs prompted bone marrow biopsy which confirmed metastatic invasive lobular carcinoma breast cancer (ER 90-95%, PR 90-95%, HER2 1+). She was discharged on letrozole 2.5 mg daily with close outpatient oncologic follow-up. One week later, she presented to our institution with persistent symptomatic anemia and thrombocytopenia. Inpatient systemic therapy was begun using dose-reduced Palbociclib (75mg) and letrozole with close CBC monitoring while also receiving packed red blood cells (goal >6.5) and platelet transfusions (goal >10). Repeat bone marrow biopsy showed extensive marrow fibrosis, but no significant hematopoietic elements. ADAMTS13 was 134%, ruling out TTP, and she was treated again for presumed ITP with dexamethasone and IVIG, Throughout the 4-week admission, her right breast mass decreased in size and she was discharged after completing 3 weeks of Palbociclib with biweekly outpatient transfusions. During follow-up, the patient’s hemoglobin and platelets slowly started to respond allowing her to become transfusion-independent and allowing dose escalation. Restaging scans 2 months after hospitalization showed an overall improvement of disease burden. The patient continued to do well for almost 18 months, however, later redeveloped visceral crisis and is responding to chemotherapy. Discussion: There is limited data on the management of breast cancer with bone marrow infiltration at presentation. A wide range of survival data in different case reports exists, ranging from 5 to 44 months. However, chemotherapy was used in these studies rather than CDK4/6 inhibitors. By far, cytopenias are the most concerning grade 3 and 4 side effect of Palbociclib. Data from the PALOMA-1 trial suggest that hematologic toxicities, specifically neutropenia, were different from those associated with cytotoxic chemotherapies and are more transient and reversible in nature. Studies have examined the in vitro mechanism of bone marrow suppression in Palbociclib versus cytotoxic chemotherapy, and its cytostatic effect on neutrophil precursors allows for hematological toxicities to be transient. With strong supportive care measures, patients in bone marrow visceral crisis can be safely treated with cytopenic CDK4/6 inhibitors. Citation Format: Nikita Dahake, Jordan Senchak, Jalil Nasibli, Jason Incorvati. Treatment with CDK4/6 Inhibitor in a Patient with Metastatic Breast Cancer Causing Myelophthisis [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-20-10.

A rare case of compound Hemoglobin Lansing/Hemoglobin S coinherited with alpha thalassemia trait (-alpha3.7) presented with spurious hypoxemia and moderate hemolytic anemia

Abstract We present a case of a 27-year-old female at 27 weeks of gestation, who presented at the emergency department for vaginal spotting. She was also found to have low oxygenation on pulse oximetry of approximately 82% at room air. Her SpO2 did not improve with O2 supplement. She had a similar presentation a month before, with mild light-headedness and low oxygenation. However, two repeated air blood gas (ABG) findings were normal for oxygen saturation. Hemoglobinopathy was suspected due to the disparity. She was anemic during her presentation, with hemoglobin 8.3 g/dl, RBC count 3.36 million/ul, MCV 81 fl and MCH 24.7 pg. Additional workup showed increased reticulocyte count, decreased haptoglobin, negative direct Coombs test, negative G6PD test, and no evidence of a PNH clone. Capillary hemoglobin electrophoresis showed HbA 59.8%, HbS 34.5%, HbA2 3.6% and a small peak (2.1%) in the Z8 zone with a trailing edge at HbF window. HPLC revealed an “unknown peak” of 8.2% with a retention time of 1.93 minutes as well as the HbS peak. There was also a tiny additional A2 peak unresolved from the main A2 peak. Alpha globin gene sequencing revealed one copy of the -alpha3.7 alpha-globin deletion and one copy of Hb Lansing variant in the alpha2-globin gene. This is consistent with the compound Hemoglobin Lansing/Hemoglobin S coinherited with alpha thalassemia trait. Hemoglobin Lansing is a rare unstable alpha hemoglobin variant with mutation of c.264C>G resulting with a substitution of His by Gln at codon 87. The mutation was first discovered in the alpha 2 gene. Then the same mutation was found in alpha 1 gene later and named as Hemoglobin Lansing-Ramathibodi. To the best of our knowledge, this is the first reported case of Hemoglobin Lansing with alpha thalassemia trait (-alpha3.7) and HbS. Spuriously low pulse oximetry measurements have previously been reported in Hb Lansing variants. It was speculated to be due to different absorption spectra of Hb Lansing which is under study now. The patient also presented with hemolytic anemia. The exact cause was undetermined yet although it might be related to her hemoglobinopathy. Mild hemolytic anemia was reported in two cases of co-inheritance of Lansing-Ramathibodi and Hb Pakse (a non-deletional alpha thalassemia) but not in the members of the same family with Hb Lansing alone. It was also reported that some unstable alpha chain variants, when associated with another alpha thalassemia defect, present with a more severe phenotype including hemolytic anemia even though essentially asymptomatic in a heterozygous state.

Association between umbilical cord clamping time, hemoglobin and total serum bilirubin in term neonates admitted for phototherapy

BackgroundThe aim of the study was to investigate relationship between cord clamping status, total hemoglobin (THb) and total bilirubin (TBil) in term infants requiring phototherapy for neonatal jaundice. MethodsThis retrospective study included term infants admitted at the study hospital for management of physiological neonatal jaundice between 2013 and 2019. Associations between THb, TBil, cord clamping status and Direct Coombs Test (DCT) status, as well as correlation between laboratory and blood gas analyzer (BGA) methods were investigated. Results258 term infants were included. 147 infants had cord clamping status documented; 111 had unknown cord clamping status. Delayed cord clamping (DCC) was associated with significantly higher mean THb in DCT negative infants only. Negative DCT was associated with higher THb and TBil regardless of cord clamping status. Mean TBil concentration did not change with increasing THb or cord clamping status. The incidence of term infants admitted for phototherapy increased over the study period. There was strong positive correlation between BGA and laboratory assays. ConclusionsDCC was associated with a higher THb in DCT negative infants only. There was no correlation between THb and TBil. There was strong positive correlation of TBil between BGA and laboratory assays thus supporting BGA use in ambulatory care settings.

Fluctuating neurological symptoms: should I call the neurologist or the hematologist?

The objective of this study was to highlight the role of the clinical laboratory and the relevance of reporting the case immediately to the unit of hematology for the diagnosis and early administration of treatment in the presence of such an urgent hematologic disease as thrombotic thrombocytopenic purpura (TTP). An elderly patient was referred to the emergency department of our hospital by his general practitioner for speech difficulty, facial asymmetry and weakness in the upper limb. Stroke code was activated. However, laboratory findings (anemia, thrombocytopenia, elevated creatinine, total bilirubin and LDH, negative direct Coombs test) and presence of schistocytes in the peripheral blood smear test were consistent with a completely different diagnosis: TTP thrombotic microangiopathy. The first diagnostic approach of left hemispheric stroke was not confirmed in the laboratory, with findings of nonautoimmune hemolytic anemia, thrombocytopenia without apparent cause and presence of schistocytes. We should not forget that the clinical manifestations of this condition are widely variable and may include multiorganic dysfunction. Although confirmation of diagnosis is based on ADAMTS-13, its associated high mortalitiy requires immediate treatment on mere suspicion.

Spectrum of acute kidney injury associated with cocaine use: report of three cases

BackgroundThe consequences of cocaine use are multisystemic, such as, for instance, renal failure, hepatotoxicity and pulmonary toxicity, with renal alterations being the focus of the present study. The use of substances that modify the base composition of cocaine (or adulterants) aiming to potentiate its effects also has an impact on these manifestations. The present study aims to report three cases with different diagnosis of acute kidney injury related to cocaine use.Case presentationCase 01 - A 30-year-old female patient, who regularly used cocaine, started to have lower-limb edema, which showed a progressive and ascending evolution, affecting the face a few days later, associated with an isolated febrile episode and oligoanuria. The presence of cytoplasmic antineutrophil cytoplasmic antibodies (C-ANCA) was verified: reactive 1:80, with renal biopsy compatible with rapidly progressive glomerulonephritis (RPGN). Case 02 - A 34-year-old female patient, with difficult-to-control hypertension and a frequent user of cocaine, showed generalized sudden edema together with diffuse and progressive pruritus associated with oliguria, fever, nausea, and vomiting. Schistocyte screening was positive, with negative direct Coombs test, and negative serologies for hepatitis B, C and HIV, as well as negative anti-double-stranded DNA, Anti-SSA and Anti-SSB. The renal biopsy was compatible with thrombotic microangiopathy, associated with moderate interstitial fibrosis and acute tubular necrosis Case 03 - A 25-year-old male patient who had been a cocaine user for 5 years had a sudden onset of generalized disabling myalgia (especially in the lower limbs) associated with recent frontotemporal headache, palpitation, dizziness, and a non-measured febrile episode; the patient had used cocaine at the night before symptom onset. CPK was 1731 U/L.The final probable diagnosis was AKI secondary to cocaine-induced rhabdomyolysis.ConclusionsIn conclusion basically, 05 etiologies of acute kidney injury should always be remembered: rhabdomyolysis, thrombotic microangiopathy, vasculitis, acute interstitial nephritis and renal infarction. Emphasis should be given to rhabdomyolysis due to its higher prevalence. Considering the increasing rates of cocaine use, especially with the use of adulterating substances, these pathologies will likely be increasingly prevalent.

Significances of red cell bound immunoglobulin G as detected by flow cytometry in patients with Coombs-negative immune hemolysis.

This study was to investigate the use of flow cytometry for detection and quantitation of red blood cells (RBC) bound IgG in immune hemolysis of patients with autoimmune hemolytic anaemia (AIHA) and systematic lupus erythematosus (SLE). Two to ten percent of patients with warm-autoimmune hemolytic anaemia (WAIHA) exhibit a negative direct Coombs test. Flow cytometry has been applied to detect RBC bound IgG with high accuracy, reproducibility and sensitivity. In this study 45 and 75 patients with AIHA and SLE, respectively were evaluated for RBC bound IgG by direct Coombs test and flow cytometry. Seventy-one percent (32/45) and 31% (23/75) of patients with AIHA and SLE respectively, had laboratory evidence of hemolysis. A positive flow cytometry, as defined by mean fluorescent intensity (MFI) values >0·21 and IgG molecules >28, was found in 4 of 32 (12·5%) and 4 of 23 (17·4%) patients with AIHA and SLE who had hemolysis with a negative direct Coombs test. There were very strong and strong correlations between the strength of direct Coombs test with MFI values and IgG molecules in patients with AIHA and SLE, respectively. Flow cytometry can be applied in the diagnosis of Coombs-negative hemolytic anaemia in patients with AIHA and SLE.

Thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura (TTP) is a disease with a high rate of mortality if a proper treatment is not instated. Plasmapheresis with plasmatic exchange is the treatment of choice. Diagnosis is performed demonstrating microangiopathic hemolytic anemia, a negative direct Coombs test and thrombocytopenia. Among the clinical data, neurological and renal alterations stand out. When there is a reasonable suspicion in the diagnosis, plasmapheresis must be initiated immediately. There are different diseases that may be similar to the TTP signs and symptoms, especially in pregnant women. TTP has a high risk of relapse and may leave sequelae.

Cmv Mononükleozis, Direkt Coombs Testi (-) Hemolitik Anemi ve Trombositopeni Birlikteliği

Cmv Mononükleozis, Direkt Coombs Testi (-) Hemolitik Anemi ve Trombositopeni Birlikteliği

Successful Remission of Hemolytic-Uremic Syndrome during the Third-line Weekly Gemcitabine for Metastatic Breast Cancer

Sequential palliative chemotherapy for metastatic breast cancer incorporating weekly gemcitabine administered as three-weeks-on, one-week-off schedule is widely adopted throughout the East Asia region. Hemolytic-uremic syndrome (HUS) associated with weekly gemcitabine for a breast cancer patient is extremely rare. We report here a case of 43-year-old woman with metastatic breast cancer who received weekly gemcitabine as a third-line palliative chemotherapy for her disease. She developed HUS after a cumulative dose of 11,000 mg/m2 gemcitabine, evidenced by microangiopathic hemolytic anemia (MAHA) with schistocytes seen in peripheral blood smear, decreased haptoglobin level (<0.29 mmol/L), thrombocytopenia, negative direct Coombs test, and acute kidney injury. Owing to the ease of administration of weekly gemcitabine, gemcitabine-induced thrombocytopenia, multifactorial anemia in metastatic breast cancer, and possibility of cancer progression, HUS could have gone unnoticed. Breast cancer oncologist should be cognizant of this rare HUS even during weekly gemcitabine treatment.

P22 Immunohematologic Monitoring and Blood Component Support in a Major ABO Mismatch Allogeneic Peripheral Blood Stem Cell Transplant Recipient

Background Close clinical and immunohematologic monitoring is essential in ABO mismatch peripheral blood stem cell transplantation (PBSCT) in order to anticipate potential complications and to plan appropriate blood component support throughout the disease course.Case Report We describe here a first case of a ABO incompatible PBSCT from our center‐ a 19‐year‐old male patient of aplastic anemia (O Rh positive) who had a successful HLA matched but major ABO mismatch PBSCT from his sibling donor (A Rh positive). On admission patient's hemoglobin (Hb) was 4.7 g dL−1, platelet count (PC) 12 × 109 L−1, total leukocyte count (TLC) 2 × 109 L−1. Patient was typed as O Rh positive with negative direct coombs test (DCT) and IgM isohemagglutinin anti‐A titer‐512 and anti‐B‐512. In the pretransplant period total number of blood components (recipient type) transfused were 35, 1, and 10 random donor platelets (RDP), single donor platelets (SDP) and packed red cells (PRBC) respectively. On day of transplant patient had Hb 9 g dL−1, PC 20 × 109 L−1, TLC 2.6 × 109 L−1, IgM anti‐A‐32, anti‐B‐16 (due to immunosuppressive regimen) and negative direct and indirect coombs tests (ICT). Adequate dose of peripheral blood stem cells harvested from donor by a continuous cell separator was infused to patient as per the institute protocol. Engraftment occurred on 12th day of transplant. During these 12 days patient received a total of four PRBC (recipient type) and 8, 3 units of RDP and SDP (stem cell donor type) respectively. After the engraftment patient's laboratory parameters were Hb 8.2 g dL−1, PC 40 × 109 L−1, TLC 5 × 109 L−1. Patient received very few transfusions after the engraftment and was discharged with Hb of 9.2 g dL−1, PC 146 × 109 L−1, TLC 10.9 × 109 L−1 and with blood group still O Rh positive. Post‐transplant immunohematological workup was done on a weekly basis for first 3 weeks and then on each outpatient visit. On follow up DCT showed mixed field reaction from 1st week till 3rd week post transplant, which became negative by 9th week. ABO cell grouping changed from O to A and thus a cell‐serum discrepancy was noted by 9th week (cell group A Rh positive and serum group O) and by 16th week his blood group finally changed to A Rh positive with IgM anti‐A‐undetectable, IgM anti‐B‐512 along with negative DCT. Throughout the disease course the patient received irradiated blood to avoid transfusion‐associated graft‐versus‐host disease.Conclusion Our patient had uneventful course with appropriate component support and immunohematologic monitoring during and after the transplant and ABO incompatible stem cell could be transplanted without negative outcome on stem cell engraftment.

Hepatitis E Virus Infection with Nonimmune Hemolytic Anemia

Hepatitis E Virus Infection with Nonimmune Hemolytic Anemia

Index of Suspicion

Index of Suspicion

過去３年間における対象別赤血球抗体のひん度

Anti-erythrocyte antibodies were detected in 56 (0.99%) of 5619 patients with various diseases and most of them contained anti-Lewis, Rh and P1 antibodies.The antibodies were detected in 14 (5.3%) of 264 pregnant women and most of them contained anti-RhD and E antibodies. Moreover, the antibodies were detected in 33 (0.22%) of 14, 900 healthy blood donors, and most of them contained anti-Lewis and P1 antibodies.The other antibodies seemed to be natural antibodies of type IgM in all healthy blood donors expect three cases, of whom one had a history of blood transfusion and the other two had a history of pregnancy. Most of patients with unidentified antibodies were positive for direct Coombs test but in patients with negative direct Coombs test, the antigen-antibody reaction occurred at low temperature zone by using saline and 22% albumin methods.These results suggested that such methods as detecting anti-RhD, E Lewis and P1 antibodies should be used in the identification of anti-erythrocyte antibodies.Moreover, autoimmune hemolytic anemia (AIHA) characterised by positive direct Coombs test developed in a patient with severe epilepsy who had been administered a large amount of anti-epilepsy agents for long term. It was appeared that the cause of AIHA was due to phenitoin (Aleviatin) following clinical course. In case like this patient, all chemicals should be immediately discontinied and other drugs being different structures should be used property, also, hematological and immunological examination should be done.

Monitoring of fetus with osteogenesis imperfecta and severe anemia

The patient was a 27-year-old woman, gravida 3, para 2, with two previous normal term deliveries. The blood was type 0, Rh positive, with no abnormal antibodies. The prenatal course was unremarkable until 26 weeks of gestation when she complained of spotting. Examination revealed the cervix to be 80 per cent effaced and 1 cm. dilated. A cerclage was placed on the cervix and she was treated with bed rest. At 36 weeks of gestation spontaneous contractions ensued and the cerclage was removed. Fetal monitoring revealed a base-line heart rate of 160 b.p.m. with a beat-to-beat variability of up to 12 b.p.m. Contractions registered every three and a half minutes and the peak of each contraction was followed by a typical late deceleration. The severity of bradycardia varied from 10 to 50 b.p.m. and its duration ranged from 80 to 200 seconds. In addition to the uniform patterns of late fetal bradycardia there were wide and erratic shifts of the base-line from 160 down to 65 b.p.m. for three to five minutes unassociated with contractions. To confirm the presence of a congenital malformation, an abdominal roentgenogram was obtained and it revealed the characteristic skeletal hypomineralization and the multiple intrauterine fractures of osteogenesis imperfecta. A female infant, weighing four pounds and nine ounces, was delivered by cesarean section. The newborn infant had severe deformities due to the fractures and marked hydrops and died 15 minutes after birth. Cord blood evaluation revealed: hemoglobin, 8.4 Gm.; hematocrit, 27.5 per cent: reticulocytes, 14.7 per cent; a negative direct Coombs test was 100 per cent hemoglobin F on electrophoresis.

最近経験した不規則性抗体の数例

Recently 4 cases of irregular antibodies of serological importance were detected in our laboratory. Case 1 was a mixture of anit-D and anti-e found on prenatal examination. Case 3 also showed the presence of anti-e and furthermore was contaminated with non-specific cold antibody. Anti-e antibody of Case 1 was probably an isoantibody and that of Case 3 was an autoantibody. Hitherto reported cases of anti-e are very few. In both cases the antibodies were of incomplete nature. In Case 2 antibody of apparently anti-D specificity was detected in a D positive woman, and this paradoxical phenomenon was explained by the different antigenic structures of various D antigens. In case 4 we showed a case of a hemolytic disease of the newborn with negative direct Coombs test, probably due to the special character of the incomplete anti-E antibody. The mechanism of formation and the practical significance of these antibodies were discussed.