Correspondence

Submission of Correspondence

Transfusion welcomes correspondence items, which, if found suitable, will be published as space permits. In general, please follow rhese instructions:

Typing: Double space, plain bond paper, in duplicate. Format: As seen in current letters in Transfusion (the typist should consult a current copy of the journal). Length: Not more rhan 2 rypewritten pages. References: Not more rhan 5 (same format as Transfusion). Tables and figures: Not more than 2 in all (may be one of each), in Transfusion formor. Accompanying letter: Correspondence items should be accompanied by a letter signed by all the authors.

These instrucrions should make ir easier to prepare correspondence and, in turn, speed up publicarion. hirers willbe returnedto the sender if they are not in the appropriate format.

We encourage you to conrinue 10 use rhe Correspondence Section for your own observations, for conrention wirh our regular articles, i fyou feel so moved, or for submitring technical or medical quesrions. Shorr presentations thar are more elaborare rhan allowed for in rhe above instructions may be submitted as Brief Reports.

Submit lerters 10: Douglas W. Huestis, M.D., Department of Pathology, University of Arizona College of Medicine, Tucson, AZ 85724.

EDITOR'S NOTE: In order to permit timely publication of correspondence, the references have not been verified as they have been for articles appearing in TRANSFUSION, and, therefore, the accuracy of cited references in Correspondence is the sole responsibility of the authors.

An apparent anti-I reacting only in low-ionic-strength solutions

To the Editor: A variety of blood bank reagents, constituents, and

preservatives have been shown to be responsible for anom- alous serologic reactions. Low-ionic-strength solutions (LISS) have been incriminated in such reactions only recently. Several authors have reported autoagglutininsl and antibodies with ant i -P specificity that react only by LlSS technique^^'^ and antibodies to additives in commercial LlSS reagent^.^-^

In this report, we present a patient having a n autoaggluti- nin with apparent anti-I specificity reactive only by LlSS techniques. Commercial LlSS was used (Prona LISS, His- panagar). Our patient was a 55-year-old white man with bleeding esophageal varices. To our knowledge he had not been transfused before. Pretransfusion tests for serum allo- antibodies using LlSS techniques were strongly reactive (3+) in all test phases (LISS a t 37OC and LISS-indirect antiglobu- lin test).

The direct antiglobulin test using anti-lgG anti-human globulin (AHG), anti-IgM, and anti-C3 was negative.

The patient's serum did not react with conventional saline and albumin techniques a t 4OC, room temperature, 37OC and by the indirect antiglobulin test using both untreated and trypsin-pretreated red cells.

The patient's serum caused direct agglutination (3+, titer 16, score 36) of all 0, I + , and washed autologous red cells when tested by LISS techniques a t 37"C, and by the indirect antiglobulin test (3+, titer 8, score 26), but did not react with 0, 1- cord cells. The patient's serum did not react after treatment with 2-mercaptoethanol. The serum did not react with I(+) red cells in the presence of sodium azide alone. There was no evidence of hemolysis at any time.

Transfusion with saline-a1 bumin crossmatch-compati ble I+ red cells was without adverse effects.

The serum reported here is unique in our experience. because we have not seen additional examples of LISS- dependent auto-anti-l agglutinins in tests on over 25,000 other patients.

J .R. D U R A N - S U A R E Z J . TRUJILLO

1. P R A T J. MALDONADO

Servicio de Hemaio log ia y Hemoterapia.

Ciudad Sanitar ia Carlos H a y a M a l a g a , Spain

References

I . Pfister P, Ellisor SS, Reid ME. LlSS panagglutinins. Trans- fusion 1979; 19: 647-8.

2. Judd WJ, Steiner EA, Capps RD. Autoagglutinins withapparent anti- P specificity reactive only by low-ionic-strength salt tech- niques. Transfusion 1982;22: 185-8.

3. Cohen DW, Nelson L. Auto-anti P reacting only by low-ionic- strength solutions in a patient with hemolysis. Transfusion

4. Judd WJ, Steiner EA, Cochran RK. Paraben-associated auto- anti-Jk" antibodies: three examples detected using commercially prepared low-ionic-strength saline containing parabens. Trans- fusion 1982;22:31-5.

5 . Shulman IA, Hasz LA, Simpson RB. Thimerosal dependent agglutination, a newly described blood bank problem. Trans- fusion 1982;22:24 1-3.

6. Halima D, Garratty G, Bueno R. An apparent anti-Jk" reacting only in the presence of methyl esters of hydroxybenzoic acid. Transfusion I982;22:52 1-4.

1983;23:79-80.

HBsAg in blood donors

To the Editor: I t is unfortunate that in the paper by Jayaprakash et al.

(Transfusion 1983;23:346-7) the authors had access only to

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TKANSFUSION CORRESPONDENCE 19X4-Vol 24. No 3 277

the insensitive counterimmunoelectrophoresis (CIEP) tech- nique for HBsAg detection. I n our experience,' roughly 50 percent more HBsAg-positive donors are detected by radioimmunoassay (RIA) or sensitive reverse passive haemagglutination (RPHA), compared with CIEP. The detection limit fo rCIEPi so f theo rde ro f l000ng HBsAgper ml; HBsAg-positive donors from a n Indian population are likely to have lower titers of HBsAg than in populations where HBsAg infection occurs later in life. Therefore, the 50 percent increment (which adjusts the reported incidence of I .27 to I .9 percent if sensitive tests had been used) is prob- ably only a minimum figurc.

Sensitive R P H A assays (which will detect 95 percent of those HBsAg-positive sera detected by RIA2) need not be too costly, especially if reagents are diluted.2 Such assays might well provide a more suitable alternative for survey and research work in developing countries.

M. CONTRERAS, M D J.A.J. BARBARA, P h D

North London Blood Transfusion Centre Deansbrook Road

Edgware Middlesex

HA8 9BD. U.K.

I .

2.

References

Barbara JAJ. Howell DR, Cleghorn TE, et al. A comparison of different methods of screening blood donations for HBsAg. Vox Sang 1977;32:4-9. Barbara JAJ , Harrison P J , Howell DR, et al. A sensitive single reverse passive haemagglutination test for detecting both HBsAg and anti-HBs. J Clin Pathol 1979:32:1180-83.

The foregoing letter was sent to Dr. Jayaprakash, who replied as follows:

To the Editor: We agree with the comments of Drs. Contreras and

Barbara that the insensitive counterimmunoelectrophoresis (CIEP) technique is not a satisfactory screening method, especially for our population. As facilities for radioimmuno- assay and kits for other third generation tests were not readily available, we were screening donors for HBsAg by C I E P technique. However, recently, when the reverse passive hemagglutination (RPHA) kits became available, we switched over to that technique. We have now observed a positivity rate of 4.8 percent on screening 3300 units of blood collected from volunteer donors.

The probability of missing HBsAgcarriers with low levels of antigenemia, a s suggested by Dr. Contreras, agrees well with our own observation of a case of type B posttransfusion hepatitis in a patient who had open heart surgery for which whole blood and fresh-frozen plasma negative for HBsAg by C I E P had been transfused. We agree that there is an urgent need to start screening all the donations by the more sensitive R P H A technique, since there is a high carrier rate in our population and a majority of our blood banks still depend mainly upon paid blood donors.

DR. P. A. JAYAPRAKASH Chief Blood Transfusion Officer

DR. J . S H A N M U C H A M Associate Professor and Head

Division of Microbiology Sree Chitra Tirunal Institute

for Medical Sciences and Technology Trivandrum. India

A puzzle in fetomaternal bleeding

To the Editor: A 29-year-old white woman recently delivered twins after

an uneventful pregnancy. Cord and postpartum maternal blood specimens were submitted t o the blood bank. The test results were as follows:

Mother-0, Rh-negative, D"-negative, anti- body screen - negative

Baby Girl( l)-O, Rh-negative, D"-negative, direct antiglobulin test (DAT)-negative

Baby Boy (2)-A, Rh-positive, DAT-negative

Testing of the maternal specimen for fetal-maternal hemorrhage was negative using the RZR2 rosetting test; hence, the recommendation for one vial of Rh immuno- globulin (RhlG) was made by the blood bank.

Clinically (unknown to the blood bank) one infant suf- fered significant blood loss during delivery. Laboratory test results on both infants were as follows:

Baby I-Hemoglobin 15.1 g per dl, hematocrit 43.9

Baby 2-Hemoglobin 19.5 g per dl, hematocrit 56.9 percent, bilirubin (total) 3.0 mg per dl

percent, bilirubin (total) 3.8 mg per dl

By Kleihauer-Betke (K-B) test it was determined that 25 ml of whole blood had been lost by baby I . Two vials of RhlG would seem t o be needed t o cover the large fetal hemorrhage.

Two questions were raised as a result of these findings. Why was there an apparent failureofthe R2R2 rosetting test? Should two vials of Rh lG be issued? The answer was clear, because it was the Rh-negative infant (baby 1) who had suffered the hemorrhage.

The discrepancy between the rosetting technique and the K-B test is clarified when the principle of each test is known. The K- B test distinguishes fetal from maternal hemoglobin. The R2R2 study on the other hand is specific for the detection of D-positive cells in D-negative individuals. Thus, cells from the Rh-negative infant caused the rosetting test t o be negative and the K-B test positive.

Inasmuch as the Rh-negative baby had contributed the only detectable fetal blood and the R2R2 study was negative, the administration of one vial of Rh lG was considered suffi- cient in this case.

MARY ANN SHARPE, MT(ASCP)SBB Vanderbilt Medical Center

Nashville, Tennessee

A persistent type of erythrocyte polyagglutinability Th

To the Editor: In 1981, we detected T h erythrocyte polyagglutinability in

a woman with idiopathic thrombocytopenic purpura. She had been grouped as AB when she was transfused with 500 ml of compatible whole blood and 4 units of platelet concentrate when she delivered a baby in 1978. Three years later, she was typed as B by cell tests and AB by serum tests, and a t the same time her red cells were agglutinated with Arachis hypogaea lectin and failed to react with some anti-H reagents. Results of further test on her red cells were as