Practice questions answers Blood transfusion II

Practice questions answers

Blood transfusion II

© Jun Wang, MD, PhD

 

1. F. This patient has acute onset of new symptoms during blood transfusion, highly suspicious for transfusion reaction. Regardless of type of transfusion it is, the first thing need to do is to stop transfusion. Others, including clerical check, can be performed after transfusion is stopped. 

2. C. This case is characterized by acute onset of fever, chill, back pain and hypotension. The laboratory findings of high LDH and bilirubin and low levels of haptoglobin are consistent with hemolysis. The presence of blood oozing at surgical site is most likely due to hemolysis caused DIC. These presentations are most likely acute hemolytic transfusion reaction, caused by immune hemolysis resulted from blood type incompatibilities. Direct Coombs test examine antibodies or complements attached to RBC surface, and is positive with immune hemolysis. Anti-H lectin test is used examine the lack of H substance on Bombay group RBCs, that usually has ABO type similar to O, but not type B. Blood culture is used for bacterial infection involving blood stream, such as sepsis. Repeat ABO and Rh typing will be helpful only when the results have discrepancies, but will not confirm immune hemolysis, as seen in this case. Patient serum IgA levels would be markedly reduced or absent if the patient has IgA deficiency, a condition commonly associated with anaphylactic transfusion reaction. 

3. F. See discussion of question 2. Allergic reactions such as urticarial transfusion reaction are associated with IgE mediated immune reaction with donor plasma proteins and has skin manifestations. Donor antibodies against neutrophils are associated with transfusion related acute lung injury. Excessive circulating volume is associated with transfusion associated circulatory overload. These conditions, with or without fever, usually do not have hemolysis. 

4. B. The repeat ABO typing confirms the patient’s blood type as B-. However, the donor unit has phenotype of A-. This is a case of acute hemolytic transfusion reaction, caused by ABO incompatibility. Anti A in the patients plasma caused hemolysis of transfused donor A cells. This is most likely a clerical error resulted in mislabeling the blood units after crossmatch. Bacterial contamination may cause sepsis, but not ABO mismatch. The patient is B-, based on presence of B antigen on the RBCs and anti-A but not anti-B in the serum. Anti-H is seen in Bombay group, that usually has ABO type similar to O, but not type B. 

5. A. See discussion of questions 2 and 4. Acute hemolytic transfusion reaction due to Rh incompatibility is commonly seen when Rh+ RBCs are transfused to a Rh patients. The donor’s blood is Rh-. Delayed hemolytic transfusion reaction usually occurs 24 hours after transfusion, and associated with non-ABO antigens, especially Kidd, Duffy and Kell blood type. Febrile non-hemolytic transfusion reaction is characterized by unexplained fever without other symptoms during or shortly after transfusion. Severe allergic transfusion reaction is characterized by immediate onset of airway obstruction, hives, wheezing and hypotension or shock, but not fever. 

6. E. This case is characterized by fever and mildly elevated reticulocyte count, LDH, bilirubin and reduced haptoglobin. Direct Coombs test is positive. These findings are consistent with immune hemolysis. These presentations in a late onset, 3 days in this case, are consistent with delayed hemolytic transfusion reaction associated with alloantibodies against non-ABO antigens, especially Kidd, Duffy and Kell blood types, and characterized by IgG mediated extravascular hemolysis. Anti-ABO antibodies usually cause intravascular hemolysis. Cytokine produced by donor WBCs during storage is associated with febrile non-hemolytic transfusion reaction. IgE-mediated hypersensitivity to plasma proteins can be seen in urticarial transfusion reaction and  anaphylactic transfusion reaction. Intravascular immune hemolysis is more commonly associated with acute hemolytic transfusion reaction due to ABO or Non-ABO antibodies. 

7. A. Delayed hemolytic transfusion reaction associated with alloantibodies against non-ABO antigens, especially Kidd, Duffy and Kell blood types, and characterized by IgG mediated extravascular hemolysis. Hepatitis may cause jaundice but not hemolysis. Iron deficiency and Parvovirus B19 infection may cause anemia, but not hemolysis. RBC membrane protein defects can be seen in hereditary spherocytosis, a process of non-immune hemolysis with negative direct Coombs test and spherocytes (RBC without central pallor area) in peripheral blood smear. 

8. Delayed hemolytic transfusion reaction associated with alloantibodies against non-ABO antigens, especially Kidd, Duffy and Kell blood types, and characterized by IgG mediated extravascular hemolysis. Since this patient received RBCs that are negative for both K and Kidd antigen, the most likely antibody causing hemolysis is alloantibodies against Duffy. 

9. C. See discussion of questions 2, 5 and 6. Transfusion related iron overload does not have hemolysis or fever. 

10. C. This case is characterized by transfusion associated fever without other significant clinical presentation. His laboratory test results ruled out hemolysis. These features are consistent with febrile non-hemolytic transfusion reaction, associated with donor WBCs-produced cytokines and pyrogens in donor plasma. Also see discussion of question 3. 

11. D. See discussion of questions 6 and 10. 

12. F. See discussion of question 1. 

13. A. This case is characterized by rapid onset of mild allergic symptoms involving skin only. These presentations are consistent with urticarial transfusion reaction due to patient’s IgE against donor plasma proteins. Antihistamine should be used and transfusion can be resumed using the same unit after skin manifestations resolved. Antipyretics can be used for febrile non-hemolytic transfusion reaction. Broad spectrum antibiotics can be used for infection. Epinephrine can be used for hypotension or shock. Clerical check might be needed but the immediate management is to treat the patient. 

14. A. See discussion of questions 2 and 13. 

15. E. See discussion of questions 6, 10 and 13. 

16. B. This patient has a hemoglobin of 7.5 g/dL, suggestive of need to RBCs. Forward typing reveals presence of A but not B antigen, and reverse typing reveals presence of anti-B but not anti-A. Rh factor test is positive. This pattern confirms that he is A+, and the most appropriate RBC for his is B+. O cells can be issued only when no B+ cells are available, or at emergency but patient’s blood type is not known. His platelets and coagulation panels are within normal ranges, ruled out need of platelets or plasma. 

17. E. This case is characterized by rapid onset of non-febrile transfusion reaction with signs of shock, in a patient with IgA deficiency. These features are most consistent recipient anti-IgA associated anaphylactic transfusion reaction. This patient is A+ and there is no anti-A in his blood. Cytokine release from donor leukocytes during storage is commonly associated with febrile non-hemolytic transfusion reaction. Donor antibodies attaching recipient neutrophils is associated with transfusion related acute lung injury. Recipient anti-Kidd antibodies attacking donor RBC may cause severe intravascular hemolysis and delayed hemolytic transfusion reaction. These conditions tend to have fever. 

18. B. See discussion of questions 2, 13 and 17. Transfusion associated circulatory overload is associated with excessive circulatory volume and presents with symptoms and signs of congestive heart failure, including dyspnea, jugular vein distension, bilateral pulmonary edema, etc. Transfusion related acute lung injury is associated with donor anti-neutrophil antibodies and characterized by acute onset of fever, lung manifestations, respiratory distress and hypoxemia. 

19. C. This case is characterized by acute onset of fever, chill, dyspnea, hypoxemia and bilateral pulmonary infiltrate shortly after blood transfusion. These features are most consistent with transfusion related acute lung injury that is associated with donor anti-neutrophil antibodies. Also see discussion of question 17. 

20. E. See discussion of questions 2, 5, 10, and 19. 

21. A. This case is characterized by development of congestive heart failure in an elderly patient with anemia, chronic renal disease and COPD, all risks and clinical presentations of transfusion associated circulatory overload. It is associated with excessive circulatory volume and elevated BNP and N-terminal pro-hormone BNP. D-dimer is elevated when there is active thrombolysis, such as DIC. Indirect bilirubin and LDH are commonly elevated with hemolysis. Total iron binding capacity is elevated in iron deficiency anemia. 

22. D. See discussion of questions 3 and 17. 

23. D. See discussion of questions 2, 5, 10, 19 and 21.

 

 

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