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A rare case of a clinically significant anti-M alloantibody in a heart transplant recipient

  • Author Footnotes
    1 Co-first authors.
    Deva Sharma
    Correspondence
    Corresponding author at: Division of Transfusion Medicine, Department of Pathology, Microbiology and Immunology. Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA.
    Footnotes
    1 Co-first authors.
    Affiliations
    Division of Transfusion Medicine, Department of Pathology, Microbiology and Immunology. Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA

    Division of Hematology-Oncology, Department of Internal Medicine, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA
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  • Author Footnotes
    1 Co-first authors.
    Mary Johnson
    Footnotes
    1 Co-first authors.
    Affiliations
    Division of Transfusion Medicine, Department of Pathology, Microbiology and Immunology. Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA
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  • Josef Venable
    Affiliations
    Division of Transfusion Medicine, Department of Pathology, Microbiology and Immunology. Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA
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  • Quentin Eichbaum
    Affiliations
    Division of Transfusion Medicine, Department of Pathology, Microbiology and Immunology. Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA

    Vanderbilt Pathology Program in Global Health, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA
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  • Elijah Stiefel
    Affiliations
    Division of Transfusion Medicine, Department of Pathology, Microbiology and Immunology. Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA
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  • Author Footnotes
    1 Co-first authors.
Published:September 24, 2021DOI:https://doi.org/10.1016/j.transci.2021.103284

      Abstract

      Introduction

      Anti-M antibodies are usually inactive at physiologic temperatures (37 °C). Rarely, these antibodies have been reported to react at physiologic temperatures, resulting in clinically significant hemolytic transfusion reactions or hemolytic disease of the fetus and newborn.

      Patient and methods

      We describe a case of an acute hemolytic transfusion reaction due to an anti-M alloantibody reacting at physiologic temperatures in a critically ill patient.

      Results

      Proper identification and management of anti-M antibody-mediated acute hemolysis rapidly improved and stabilized her hemoglobin.

      Conclusion

      Differentiation between anti-M antibody-mediated acute hemolysis and its differential diagnoses is of critical importance to guide therapeutic decisions in these rare clinical scenarios.

      Keywords

      1. Introduction

      Alloantibodies directed against the M antigen of the MNS Blood Group System are common on routine blood bank testing. They are typically IgM antibodies that react below physiologic temperatures and are clinically insignificant [
      • Cooling L.
      • Downs T.
      Immunohematology.
      ,
      • Fung M.K.
      • Eder A.
      • Spitalnik S.L.
      • Westhoff C.M.
      AABB. Technical manual.
      ,
      • Stetson B.
      • Scrape S.
      • Markham K.B.
      Anti-m alloimmunization: management and outcome at a single institution.
      ]. The antigens of the MNS system are on one or both of two glycoproteins (glycophorin A or B), with the M antigen being located at the N-terminus of glycophorin A. M antibodies are relatively common, especially in pregnant women, and can be either IgM or IgG immunoglobulins. Anti-M alloantibodies of the IgG subtype have been rarely reported to cause hemolytic disease of the fetus and newborn (HDFN) as well as acute and delayed hemolytic transfusion reactions [
      • Fung M.K.
      • Eder A.
      • Spitalnik S.L.
      • Westhoff C.M.
      AABB. Technical manual.
      ,
      • Klein H.G.
      • Anstee D.J.
      Mollison’s blood transfusion in clinical medicine.
      ] Table 1] summarizes select published reports of anti-M alloantibodies causing hemolytic transfusion reactions. The IgG class is more prominent in the Asian population for unclear reasons [
      • Li S.
      • Mo C.
      • Huang L.
      • et al.
      Hemolytic disease of the fetus and newborn due to alloanti‐M: three Chinese case reports and a review of the literature.
      ].
      Table 1Summary of select published cases of clinically significant anti-M alloantibodies within the medical literature.
      ReferencePatient demographicsPresenting factors prompting antibody screenDirect antiglobulin (DAT) results:Anti-M antibody type (IgG or IgM):Phases of reactivity
      Tondon et al. 2008.Case # 1: 32 year-old multiparous femaleCase # 1: symptomatic anemia with hemolysisCase # 1: negative IgG & C3dCase # 1: IgG & IgMCase # 1: positive IS, positive 37°C, positive AHG
      PMCID: PMC2798772Case # 2: 15-year-old male patient with SLECase # 2: asymptomatic anemia without hemolysisCase # 2: negative IgG & C3d(DTT treatment completed)Case # 2: positive IS, negative 37°C, posistive AHG
      Case # 2: IgM only
      (DTT treatment completed)
      Fadeyi et al. 202028-year-old man presenting with hemorrhagic shock following motor vehicle collisionSevere anemia after cessation of bleeding, with evidence of hemolysisPositive IgG; negative C3dIgG presumed (no DT testing completed)Positive AHG
      PMID: 31756244
      Parry-Jones et al. 1999. PMID: 1067199533 year-old man with renal cell carcinomaAcute on chronic anemia with suspected hemolysisPositive IgG & C3dNot reported (no DTT testing performed)Positive IAT
      Kaur et al. 2012. PMID: 22980914Case # 1: 11 year old male with Ewing’s sarcomaCase # 1: incompatible crossmatch on pre-operative type and screenCase # 1: negative IgG & C3dCase # 1: IgG & IgM (DTT treatment completed)Case # 1: Positive 37 °C
      Case # 2: One year old child admitted with pneumonitis and congestive heart failureCase # 2: severe anemia with forward and reverse type discrepancy on type and screenCase # 2: negative IgG & C3dCase # 2: IgM only (DTT treatment completed)Positive AHG
      Case # 2: positive IS, negative 37°C, positive AHG
      Alperin et al. 1983. PMID: 6879672.
      Abbreviations: DAT = direct antiglobulin test; AHG = anti-human globulin; IS = immediate spin; SLE = systemic lupus erythromatosus; DTT = dithiothreitol.
      We report a case of a 22-year-old female with multiple comorbidities and no known pregnancy history who was found to have a high titer anti-M alloantibody reacting at physiologic temperatures, laboratory evidence of clinically significant hemolysis, and acute on chronic anemia that improved with intravenous immunoglobulin. This case is unique for the following reasons: 1) the anti-M antibody reported was at an unusually high titer in an immunosuppressed patient; 2) the majority of cases of clinically significant anti-M antibodies, unlike this case, have been in association with HDFN; 3) the initial diagnosis in this case was challenging, and management of an alternative diagnosis could have led to patient harm.

      2. Case presentation

      A 22-year-old female with a complex medical history, including heart transplant in 1998 secondary to aortic stenosis and aortic insufficiency, irritable bowel syndrome, intravenous drug use, and hypertension presented to an outside hospital after two months of dry cough, dyspnea, intermittent diarrhea, fevers, and palpitations. A CT chest showed necrotizing pneumonia, but a transesophageal echocardiogram was negative for valvular vegetations. Ultimately, she was discharged home on linezolid and levofloxacin. Two weeks later, she presented to the emergency department of Vanderbilt University Medical Center with worsening dyspnea, tachycardia, and a CT scan showing progression to multifocal pneumonia with cavitary lesions. Her course was complicated by fronto-temporal brain hemorrhages on MRI, acute kidney injury, pancytopenia of unknown etiology, and splenomegaly. An infectious workup was performed, which was largely unrevealing except for positivity for adenovirus and rhinovirus. Given her critical illness, she was empirically treated for disseminated tuberculosis and started on empiric antibiotic therapy. Over the course of her hospital stay, she received the following anti-infective agents: vancomycin, cefepime, rifampin, ethambutol, isoniazid, levofloxacin, acyclovir, fluconazole, metronidazole, amphotericin and azithromycin. COVID-19 testing was negative. Bone marrow, axillary lymph node and transbronchial biopsies were negative for post-transplant lymphoproliferative disorder. As her health continued to decline, she was placed on venoarterial extracorporeal membrane oxygenation (VA ECMO) and ventilator support. Despite maximum support efforts, she eventually succumbed to her critical illness. The patient did receive red blood cells on admission to Vanderbilt University Medical Center, but it is unknown if she received a transfusion at the outside hospital prior to admission to our facility.
      Blood bank workup showed the patient’s blood type was A negative but required pre-warming to clarify discrepant results on reverse typing. A direct antiglobulin test (DAT) was performed on the patient’s red blood cells that had been warmed to 42 °C and was found to be negative for both C3d and IgG. The patient’s antibody panel revealed an anti-M alloantibody that agglutinated M positive red blood cells at a high strength (4+ on our antibody screening panel). Serologic phenotyping was attempted but invalid due to a mixed field reaction, likely due to transfusions performed 6 and 3 days prior. However, there is a high likelihood that she was positive for the M antigen, given its relatively high frequency in the general population (78 %). Further workup of the anti-M antibody showed positive reactivity at 37 degrees Celsius and at room temperature at the immediate spin phase. The lowest dilutional titer at which her anti-M antibody was shown to agglutinate red blood cells was 1:256, and then 1:64 after 30 min of incubation at room temperature. No red blood cell clumping was observed on peripheral smear, arguing against cold agglutinin disease. Additional labs were concerning for clinically significant hemolysis with a hemoglobin of 4.7 g/dL (an acute drop from hemoglobin of 16.2 the day prior), hematocrit 17 %, platelet count 9000/mcL, haptoglobin 20 mg/dL, total bilirubin 6.3 mg/dL, and lactate dehydrogenase 551 units/L (Table 2). The patient was given a single dose of intravenous immunoglobulin (Gamunex-C 1 g per kilogram) that improved her anemia and hemolysis labs within 24 h. She had negative antibody screens 7 days and 4 days prior to detection of the anti-M alloantibody, and received 2 red cell units that were not typed for the M antigen during this hospitalization, raising concern for M antigen sensitization from transfusion.
      Table 2Summary of key laboratory and serologic findings in this patient supporting the presence of a clinically significant anti-M alloantibody.
      ABO typeAntibody screenRBC pheno-typingDATAnti-M antibody titerPhases of reactivityAnti-M antibody type (IgG, IgM)
      A negative, although pre-warming of the sample was required to eliminate the forward and reverse type discrepancyAnti-M alloantibody present that agglutinated M positive red blood cells at a high strength (4+)Invalid due to a mixed field reaction, likely due to recent transfusionsNegative for IgG or C3dInitially 1:256, and then 1:64 after 30 min of incubationPositive at ISSuspected IgG and IgM based on reactivity at all 3 phases of testing, although DTT testing was not performed to confirm this
      Positive at 37°C
      Positive at AHG
      Abbreviations: RBC = red blood cell; DAT = direct antiglobulin test; IS = immediate spin; AHG = antihuman globulin.

      3. Discussion

      Anti-M antibodies are naturally occurring, usually of the IgM isotype, show dosage, and react stronger with homozygous (M/M) than heterozygous cells (M/N). Most anti-M antibodies are not active at physiologic temperatures and therefore do not prompt specific management in patients with anti-M alloantibodies. However, anti-M antibodies have been rarely implicated in acute and delayed hemolytic transfusion reactions, as well as hemolytic disease of the fetus and newborn [
      • Chaudhry R.
      • Tondon R.
      • Kataria R.
      Anti-M: Report of two cases and review of literature.
      ,
      • Alperin J.
      • Riglin H.
      • Branch D.
      • Gallagher M.
      • Petz L.
      Anti-M causing delayed hemolytic transfusion reaction.
      ,
      • Sancho J.M.
      • Pujol M.
      • Fernández F.
      • Soler M.
      • Manzano P.
      • Feliu E.
      Delayed haemolytic transfusion reaction due to anti-M antibody.
      ,
      • Duguid J.K.
      • Bromilow I.M.
      • Entwistle G.D.
      • Wilkinson R.
      Haemolytic disease of the newborn due to anti-M.
      ]. Additionally, anti-M autoantibodies have been reported to cause signs and symptoms of cold agglutinin disease [
      • Sacher R.A.
      • Abbondanzo S.L.
      • Miller D.K.
      • Womac B.
      Auto anti-M: clinical and serological findings of seven patients from one hospital and review of the literature.
      ].
      In this case, the patient was found to have an acute drop in hemoglobin and labs suggestive of hemolysis within hours after receiving M-positive donor red cells, without any evidence of bleeding. Although drug-induced hemolysis has been reported to occur secondary to cold-reacting antibodies [
      • Tobian A.A.
      • Shirey R.S.
      • Savage W.J.
      Transfusion med illustrated: ceftriaxone-induced acute hemolytic anemia.
      ] and is a differential consideration here, this patient’s presentation closely mimics another case of delayed hemolytic transfusion reaction in a woman with similar laboratory and serologic findings suggestive of a clinically significant anti-M antibody [
      • Sancho J.M.
      • Pujol M.
      • Fernández F.
      • Soler M.
      • Manzano P.
      • Feliu E.
      Delayed haemolytic transfusion reaction due to anti-M antibody.
      ]. Several aspects of her immunohematologic testing suggested that the anti-M alloantibody was clinically significant, include the following:
      • 1.)
        Consistently high strength of agglutination on the antibody screen in homozygous M cells (4+)
      • 2.)
        Agglutination of the anti-M alloantibody at physiologic temperatures (37 degrees Celsius) and anti-human globulin (AHG) phase
      • 3.)
        Agglutination of the anti-M alloantibody to M + red cells at high titers: 256, and then 64 after 30 min of incubation
      • 4.)
        Positive hemolysis labs after the transfusion of M + red cell units in this patient in less than 24 h, suggestive of an acute hemolytic transfusion reaction
      Notably, the patient was reported to have a cold agglutinin in her plasma at the same titer as the anti-M alloantibody. However, no agglutination or spherocytes were noted on her peripheral smear; and the quick resolution of her hemolysis and stabilization of her hemoglobin with a single dose of intravenous immunoglobulin argue against primary cold agglutinin disease, which typically does not resolve spontaneously when monoclonal IgM production is secondary to an underlying lymphoproliferative disorder [
      • Gertz M.A.
      Cold hemolytic syndrome.
      ]. Therefore, she was diagnosed as having an acute hemolytic reaction due to the anti-M alloantibody; and she was thereafter transfused with crossmatch compatible, M-negative red cells, with no subsequent drop in hemoglobin to suggest hemolysis.
      The distinction between a clinically significant anti-M alloantibody versus cold agglutinin syndrome was pertinent to this case. In this patient, immunosuppressive therapies for treating primary cold agglutinin syndrome could have been harmful due to the patient’s underlying septic shock, adenovirus, and rhinovirus infections [
      • Gertz M.A.
      How I treat cold agglutinin hemolytic anemia.
      ,
      • Wilen C.B.
      • Booth G.S.
      • Grossman B.J.
      • Lane W.J.
      • Szklarski P.C.
      • Jackups Jr., R.
      Using direct antiglobulin test results to reduce unnecessary cold agglutinin testing.
      ]. Cold agglutinin syndrome is typically caused by antibodies binding to the I, i (little) or Pr minor red cell antigens and does not involve the M antigen. The patient was therefore not treated with agents that reduce monoclonal IgM production in primary cold agglutinin disease.
      The following aspects of her laboratory testing and clinical course argued against cold agglutinin syndrome:
      • 1.)
        Absence of red cell clumps or spherocytes on peripheral smear
      • 2.)
        Absence of C3 or IgG coating her pre-warmed, washed red cells
      • 3.)
        Improvement in hemolysis within 24 h of intravenous immunoglobulin
      • 4.)
        Absence of an underlying lymphoproliferative disorder on bone marrow, transbronchial, and lymph node biopsies that might drive a secondary cold agglutinin syndrome characterized by monoclonal IgM production
      Although most anti-M antibodies are of the IgM subtype and do not activate complement [
      • Branch D.R.
      • McBroom R.
      • Jones G.L.
      Discrepant in vitro versus in vivo interaction of M-positive donor red cells with IgG1 anti-M.
      ], an IgG component may also be present and activate complement, resulting in hemolysis [
      • Kaur G.
      • Basu S.
      • Kaur P.
      • Kaur R.
      Clinically significant anti M antibodies--a report of two cases.
      ]. In this patient’s case, given the quick resolution of hemolysis and stabilization of her hemoglobin with a single treatment of intravenous immunoglobulin, testing to distinguish whether her anti-M alloantibody was an IgG versus IgM subtype was not performed.

      4. Conclusion

      Anti-M auto- and alloantibodies can rarely cause acute and delayed hemolytic transfusion reactions as well as hemolytic disease of the fetus and newborn. A cold agglutinin may be initially reported in the plasma of patients with acute or delayed hemolytic transfusion reactions secondary to an anti-M antibody that is reactive at physiologic temperatures. In these complex clinical scenarios, we recommend joint consultation with hematology and transfusion medicine physicians to help distinguish between cold agglutinin syndrome and a clinically significant anti-M antibody. Specifically, immunosuppressive therapies used to treat primary cold agglutinin syndrome driven by monoclonal IgM antibody production may have negative clinical consequences in septic and immunocompromised patients. Such patients may be managed by future administration of crossmatch compatible, M antigen negative donor red cells.

      CRediT authorship contribution statement

      Deva Sharma, Mary Johnson and Elijah Stiefel wrote a first draft of this manuscript. Quentin Eichbaum, Mary Johnson and Josef Venable edited and revised three additional drafts of this manuscript. Deva Sharma created both tables. Deva Sharma and Mary Johnson wrote responses to all reviewer comments to prior to submission of this manuscript. Deva Sharma and Mary Johnson are listed as co-first authors for this manuscript, as their contributions were equal.

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