Brief Report Neonatal Th activation

D. w. COHEN, R. E. MONCRIEFF, AND A. J. SILVERGLEID

A case is reported of a 1-month-old infant with bowel obstruction and suspected sepsis whose red cells were found to be Th activated during the course of evaluating weakened A antigen activity. Neither Th activation nor weakened A antigen activity was present on the red cells of either parent. The Th activation and the weak reactivity obtained with commercial anti-A reagents were unrelated. TRANSFUSION 1985;25:81-82.

THE FIRST TWO CASES of Th polyagglutinability were reported by Bird et al.' in 1978, followed shortly by a third case described by Veneziano et a1.2 in the same year. T h activated red cells a re agglutinated by the peanut lectin, Arachis hypogea, and by seed extracts prepared from both Vicia crericd and Medicago disc if or mi^.^ Reactivity with all three lectins is markedly diminished after treatment of Th-activated cells with proteolytic enzymes. N o reactivity is obtained with either the soybean lectin, Glycine soya, or with Bandeiraea simplicifolia 11 (B.S.11). Ex- posure of the T h receptor has been associated with infections by Bacteroides species on more than one occasion, and once exposed, appears to be remarkably persistent. We report a further example of the Th phenomenon in a 1-month-old infant with a bowel obstruction and suspected sepsis. The serologic picture was further complicated by weak reactivity of the infant's red cells t o anti-A.

Case Report The patient was a one-week-old 2400 gram male infant

transferred to Loma Linda University Medical Center (LLUMC) on July 31 for evaluation and care after the finding of a heart murmur and the development of apnea. A gastrojejunostomy had been performed 5 days earlier for gastric outlet obstruction.

Cardiac catheterization at LLUMC showed a large muscular ventricular septa1 defect. Severe congestive heart failure developed at about 2 weeks of age, and this was managed medically. Due to initial intolerance to feedings, a Broviac catheter was placed on August 18. About 2 weeks later, the patient became febrile, with blood cultures and catheter tip cultures positive for Staphylococcus epi- dermidis. Therapy included methicillin, gentamicin. cephalothin, vancomycin, and nafcillin as effectiveness was balanced against renal toxicity. Follow-up cultures after prolonged treatment were negative.

Since radiologic studies at LLUMC showed a probable blind loop syndrome with ileus, the patient had additional

From the Blood Bank of San Bernardino-Riverside Counties and the Pathology Department, Loma Linda University Medical Center, San Bernardino, California.

Submitted for publication February 23, 1984; revision received April 29, 1984, and accepted May 2, 1984.

surgery on September 15. following which oral feedings were gradually advanced and tolerated well.

During hospitalization at LLU MC, the patient received group 0 red cells and ABO compatible plasma from nine donors; some were given at surgery and most were given as aliquots to replace blood drawn for laboratory tests. He was discharged on October 8; digoxin and furosemide were prescribed.

Results Initial tests of the patient's red cells gave strong reactions

with anti-B and anti-A,B, but only I + reactivity with anti-A. Adsorption/elution studies confirmed the presence of A antigen activity. The cells were weakly reactive with A. hypogea, and strongly reactive with M. disciformis. the latter of which reacts with both the T and Th receptors. This reactivity was eliminated when the infant's cells were treated with papain. No reactivity was obtained with G. soya, B.S. 11, Salvia sclarae. Salvia hormimum, and Dolichos bijlorus. The patients cells also did not react with inert adult AB sera at either 22 or 4°C.

Three months later, the patient's cells reacted strongly with commercial anti-A, although not with D. bij7orus. The patient's cells no longer reacted with A. hypogea lectin, but continued to react strongly with M. disciformis.

The father's cells were group B, and the mother's cells group AzB. Neither parent's red cells reacted with A. hypogea or M. disciformis.

Discussion While the first reported cases of the T h phenomenon

occurred in patients with abdominal complications, persistent T h polyagglutinability also has been seen in a n apparently healthy female blood donor and her identical twin sister,' and in both a healthy mother and her child with a yolk sac tumor of the vaginas2 It has been suggested6 that subclinical infections of the bowel, particularly in children, can account for the persistent nature of some forms of bacterially induced polyagglutination.

In addition to Bacteroides species, Clostridia, Escherichia coli, and Proteus mirabilis also have been reported in association with T h polyagglutinability.'p2 I n our patient, only S. epidermidis could be isolated both from blood culture and culture of the Broviac catheter tip. While this organism is a common, usually saprophytic skin contaminant, in this case it was felt to

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82 COHEN. MONCRIEFF, AND SILVERGLEID TRANSFUSION Vol. 25. No. I- 1981

be pathogenic. S. epidermidis has not been reported previously in association with exposure of the Th receptor. Since no attempt was made to expose the Th receptor by treatment of red cells with a culture supernatant derived from this organism, no definitive statement can be made regarding the contribution of S. epidermidis to the Th activation.

Given the known weakened expression of the A gene when paired with a B gene, in conjunction with the lack of complete expression of the A antigen at birth, it is not difficult to explain the weak initial reactivity obtained with anti-A when testing the infant's red cells. He inherited the A' gene from the mother and the B gene from the father, resulting in significantly weakened A antigen strength at birth. Interestingly. if the adsorption/ elution studies on the infant's cells had been performed and the ABO groups of the parents had been determined before testing with the battery of lectins, there would have been no reason to pursue the investigation any further, and the presence of the Th receptor might have gone un- recognized.

Acknowledgments We thank Malcolm Beck and Jill Hardman of the Kansas City

Community Blood Center for their helpful suggestions, and for

testing our patient's red cells with Medicago dhcijormis Iectin. We also thank both Jean Dykes and Liz Dahlseid for their dedicated secretarial assistance.

References I. Bird GWG, Wingham J , Beck ML, Pierce SR, Oates GD,

Pollock A. Th, a "new" form of erythrocyte polyagglutination. Lancet 1978;1:1215-6.

2. Veneziano G, Rasore-Quartino A, Sansone G. Th erythrocyte polyagglutination. Lancet 1978;11:483.

3. Bird GWG, Wingham J. Vicia crerica: a powerful lectin for T- and Th- but not Tk- or other polyagglutinable erythrocytes. J Clin Pathol 1981;3469-70.

4. Bird GWG, Wingham J. "New" lectins for the identification of erythrocyte cryptantigens and the classification of erythrocyte polyagglutinability: Medicago discijormis and Medicago rurbinara. J Clin Pathol 1983;36195-6.

5. Bird GWG. Clinical aspects of red blood cell polyagglutinability of microbial origin. In: Salmon C, ed. Blood groups and other red cell surface markers in health and disease. New York: Masson Publishing USA, Inc, 198255-64.

6. Obeid D, Bird GWG, Wingham J. Prolonged erythrocyte T-polyagglutination in two children with bowel disorders. J Clin Pathol 1977;30953-5.

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David W. Cohen, MT(ASCP)SBB, Reference Laboratory Super- visor, Blood Bank of San Bernardino-Riverside Counties, P.O. BOX 5729, San Bernardino, CA 92412-5729. [Reprint requests]

Robert E. Moncrieff, MD, Department of Pathology and Laboratory Medicine. Loma Linda University School of Medicine.

Arthur J. Silvergleid, MD, Medical and Executive Director, Blood Bank of San Bernardino-Riverside Counties, Associate Clinical Professor of Medicine, UCLA School of Medicine.

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