Letters to the Editor
A suspected transfusion transmitted malaria case Sir, Malarial parasite (MP) detection in donated blood by conventional peripheral blood smear examination (PBS) is quite labor intensive and requires technical skill with big scope for subjectivity. Output in terms of positive yield is also very low in healthy blood donor population.[1] Rapid detection tests (RDT) score over microscopy in terms of sensitivity,[2] objectivity, and less stringent requirement for training. RDT although seem expensive per test vis-à-vis PBS, they do save cost in terms of man-hours per test and almost no requirement for repeat testing. We hereby present a case which highlights the utility of MP test using RDT in blood centers as well as for patients. A 5-year-old female child presented to emergency with highgrade fever and shock with altered sensorium in the form of drowsiness since morning. There was a history of moderate grade fever for last 7 days relieving temporarily by medications. Past history was not significant. Child was investigated on the lines of malaria (PBS), hepatitis, enteric fever (Widal), and dengue and was found to be negative for these. Child was managed with I.V. fluids and paracetamol along with other supportive treatment. Child responded and became afebrile after initiation of treatment.
Chloroquine phosphate was initiated in appropriate dose and child responded to treatment. Her hemoglobin also improved (11.4 g/dl) and was discharged on day 4. In a malaria endemic country like India, malaria must always be considered in any patient developing febrile illness post-blood transfusion. This becomes even more important at centers which use leukodepleted blood components, known to decrease incidence of febrile transfusion reactions.[3] Transfusion transmitted malaria (TTM) assumes significance due to high morbidity and mortality associated with it. There is hardly any systematic study on TTM and a study in beta-thallasemia estimates its incidence to be as high as 6.4%.[4] In our case, it was patient’s pre-transfusion sample which helped in clinching the cause of post-transfusion febrile illness and also absolved incriminated blood unit. Pre-transfusion thick and thin PBS of patient did not detect MP. Study by Stauffer et al.[5] clearly showed superiority of RDTs over PBS in terms of higher sensitivity and negative predictive value (NPV) for malaria (sensitivity-97% vs. 85% and NPV-99.6% vs. 98.2% respectively; P = 0.001). In addition, testing by RDT is more objective and reproducible.
In view of anemia (hemoglobin – 6.9 g/dl) on day 2 of admission, 1 unit of packed red cells was ordered from blood bank. A leukodepleted and compatible unit was transfused uneventfully within 3.5 hours. Patient developed fever which spiked at 103.8°F nearly 7 hours post-transfusion. Fever responded to the treatment and patient became afebrile at 11 am next day as shown in Figure 1. Gradual peaking of fever with absence of other signs and symptoms practically ruled out febrile non-hemolytic transfusion reaction (leukodepleted RBC), sepsis, transfusion related acute lung injury, hemolytic reaction, and other causes of post-transfusion fever. A possibility of blood transfusion acquired malaria was kept and patient was re-tested for malaria. She tested positive for malaria antigen by RDT. Blood bank received a call to investigate the case of post-transfusion malaria. Routine post-transfusion reaction investigation was inconclusive. TTI record for implicated unit was checked and was found to be correct. Our blood center tests all donated units for MP using RDT (SD Bioline Malaria Ag Pf/Pan [Bio Standard Diagnostics Pvt. Ltd., Gurgaon, India]) and implicated blood unit tested negative initially. It was re-tested for malaria antigen by RDT, thick and thin PBS and was found negative for MP. Patient’s pre-transfusion EDTA sample was also tested for malaria antigen in blood bank by RDT, which tested positive for p-lactate dehydrogenase and negative for HRP-II specific for P. falciparum [Figure 2]. The same was confirmed by diagnostic laboratory finding on patient’s post-transfusion sample. Asian Journal of Transfusion Science - Vol 8, Issue 1, January - June 2014
Figure 1: Temperature charting before and after red cell transfusion
Figure 2: Malaria antigen detection in pre-transfusion sample of the patient 61
Letters to the Editor
All donated blood units, thus need to be screened for MP, preferably by RDTs, to prevent and defend all suspected TTM. Naveen Agnihotri, Lokesh Kumar Pal Department of Transfusion Medicine, Fortis Hospital, Blood Bank, Shalimar Bagh, New Delhi, India Correspondence to: Dr. Naveen Agnihotri, Department of Transfusion Medicine, Fortis Hospital, Blood Bank, A-Block Shalimar Bagh, New Delhi – 110 088, India. E-mail: [email protected]
References 1. Bahadur S, Pujani M, Jain M. Use of rapid detection tests to prevent transfusion-transmitted malaria in India. Asian J Transfus Sci 2010;4:140-1. 2. Choudhury N, Jolly JG, Mahajan RC, Ganguly NK, Dubey ML, Agnihotri SK. Malaria screening to prevent transmission by transfusion: An evaluation of techniques. Med Lab Sci 1991;48:206-11. 3. Pomper GJ. Febrile, allergic, and nonimmune transfusion reactions. In: Simon TL, Snyder EL, Solheim BG, Stowell CP, Strauss RG, Petrides M, editors. Rossi’s Principles of Transfusion Medicine. 4th ed. Bethesda: Blackwell Publishing Ltd.; 2009. p. 839. 4. Choudhury NJ, Dubey ML, Jolly JG, Kalra A, Mahajan RC, Ganguly NK. Post-transfusion malaria in thalassaemia patients. Blut 1990;61:314-6. 5. Stauffer WM, Cartwright CP, Olson DA, Juni BA, Taylor CM, Bowers SH, et al. Diagnostic performance of rapid diagnostic tests versus blood smears for malaria in US clinical practice. Clin Infect Dis 2009;49:908-13. Access this article online Website: www. ajts. org
Quick Response Code:
DOI: 10.4103/0973-6247.126697
Investigating weak A subgroups in a healthy lady: The blood bank limitations Sir, Weak A subgroups such as A3, Ax, Aend, Am, Ay, and Ael are often mistyped as group O and may be potentially dangerous with regards to whole blood transfusion. These subgroups can be serologically differentiated using recommended techniques. [1,2] Special tests like serum glycosyltransferase estimation and genotyping are performed in advanced laboratories to confirm these blood groups.[3,4] We observed a discrepancy between the routine forward and 62
Table 1: Test on red cells and serum
Test on red cells Anti-A Anti-B Anti-A, B Anti-D Anti-A1 Anti-H 0 0 0 ++++ 0 ++++
Table 2: Adsorption-elution test Eluate reactivity A cells
O cells
37°C 22°C 4°C ++ ++ ++
37°C 22°C 4°C 0 0 0
Test on serum Regular Irregular Anti-B None
Final wash reactivity A cells B cells B cells O cells
0
0
0
0
reverse blood grouping of a 45-year old healthy lady. The forward group revealed ‘O’ positive and reverse showed ‘A’ group. No clerical errors and reagent problems were observed. We performed a detailed serological investigation on the lady’s red cells with both tube technique and Gel method (DiaMed, Cressier s/Morat, Switzerland) [Table 1]. Since the red cells showed no agglutination with either Anti-A and Anti-AB, we suspected a possible Am or Ay or Ael phenotype. The red cells were then subjected to adsorption – elution tests using human polyclonal Anti-A as described elsewhere.[2] To our surprise the eluate reacted with the reagent ‘A’ cells indicating the presence of ‘A’ antigen on the test red cells. The result was then validated with a) the eluate showing agglutination with two different reagent ‘A’ cells at all phases b) eluate failing to agglutinate reagent ‘O’ cells and c) the final wash solution failing to agglutinate with all the four reagent red cells ‘A’, ‘B’, ‘AB’ and ‘O’[2] [Table 2]. Blood groups of her husband and one son who were available then were confirmed to be ‘O’ positive. Saliva study showed that the lady was a secretor and carried both ‘A’ and ‘H’ substances thus excluding the probability of Ael phenotype. Serologically ‘Ay’ is almost similar to ‘Am’ and even adsorption – elution test fails to differentiate the two phenotypes. In the present study Anti-A eluted from the lady’s red cells reacted weakly with the corresponding reagent ‘A’ cells (Agglutination strength: 1+ by tube technique and 2+ by Gel) which is in favor of ‘Ay’ phenotype. In case of ‘Am’ phenotype such agglutination strength is significantly stronger.[1] Finally we reported the patient as “Weak A subgroup” Rh positive. We advised both serum glycosyltransferase estimation and genotyping of the lady for confirmation of her weak ‘A’ subgroup. We were really in a dilemma as to how the reporting should be done in the present case. We were not sure whether designating the lady as “Weak A subgroup” Rh positive was a proper reporting format. Since confirmatory tests for weak ‘A’ phenotype is beyond the scope of most blood banks, there should be a system to report these weak ‘A’ individuals. Sudipta Sekhar Das, R. U. Zaman, Md. Safi, Subrata Sen, Tirtha Pratim Sardar, Susanta Ghosh Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, India
Correspondence to: Dr. Sudipta Sekhar Das, Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata - 700 054, India. E-mail: [email protected] Asian Journal of Transfusion Science - Vol 8, Issue 1, January - June 2014
Copyright of Asian Journal of Transfusion Science is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
A suspected transfusion transmitted malaria case Sir, Malarial parasite (MP) detection in donated blood by conventional peripheral blood smear examination (PBS) is quite labor intensive and requires technical skill with big scope for subjectivity. Output in terms of positive yield is also very low in healthy blood donor population.[1] Rapid detection tests (RDT) score over microscopy in terms of sensitivity,[2] objectivity, and less stringent requirement for training. RDT although seem expensive per test vis-à-vis PBS, they do save cost in terms of man-hours per test and almost no requirement for repeat testing. We hereby present a case which highlights the utility of MP test using RDT in blood centers as well as for patients. A 5-year-old female child presented to emergency with highgrade fever and shock with altered sensorium in the form of drowsiness since morning. There was a history of moderate grade fever for last 7 days relieving temporarily by medications. Past history was not significant. Child was investigated on the lines of malaria (PBS), hepatitis, enteric fever (Widal), and dengue and was found to be negative for these. Child was managed with I.V. fluids and paracetamol along with other supportive treatment. Child responded and became afebrile after initiation of treatment.
Chloroquine phosphate was initiated in appropriate dose and child responded to treatment. Her hemoglobin also improved (11.4 g/dl) and was discharged on day 4. In a malaria endemic country like India, malaria must always be considered in any patient developing febrile illness post-blood transfusion. This becomes even more important at centers which use leukodepleted blood components, known to decrease incidence of febrile transfusion reactions.[3] Transfusion transmitted malaria (TTM) assumes significance due to high morbidity and mortality associated with it. There is hardly any systematic study on TTM and a study in beta-thallasemia estimates its incidence to be as high as 6.4%.[4] In our case, it was patient’s pre-transfusion sample which helped in clinching the cause of post-transfusion febrile illness and also absolved incriminated blood unit. Pre-transfusion thick and thin PBS of patient did not detect MP. Study by Stauffer et al.[5] clearly showed superiority of RDTs over PBS in terms of higher sensitivity and negative predictive value (NPV) for malaria (sensitivity-97% vs. 85% and NPV-99.6% vs. 98.2% respectively; P = 0.001). In addition, testing by RDT is more objective and reproducible.
In view of anemia (hemoglobin – 6.9 g/dl) on day 2 of admission, 1 unit of packed red cells was ordered from blood bank. A leukodepleted and compatible unit was transfused uneventfully within 3.5 hours. Patient developed fever which spiked at 103.8°F nearly 7 hours post-transfusion. Fever responded to the treatment and patient became afebrile at 11 am next day as shown in Figure 1. Gradual peaking of fever with absence of other signs and symptoms practically ruled out febrile non-hemolytic transfusion reaction (leukodepleted RBC), sepsis, transfusion related acute lung injury, hemolytic reaction, and other causes of post-transfusion fever. A possibility of blood transfusion acquired malaria was kept and patient was re-tested for malaria. She tested positive for malaria antigen by RDT. Blood bank received a call to investigate the case of post-transfusion malaria. Routine post-transfusion reaction investigation was inconclusive. TTI record for implicated unit was checked and was found to be correct. Our blood center tests all donated units for MP using RDT (SD Bioline Malaria Ag Pf/Pan [Bio Standard Diagnostics Pvt. Ltd., Gurgaon, India]) and implicated blood unit tested negative initially. It was re-tested for malaria antigen by RDT, thick and thin PBS and was found negative for MP. Patient’s pre-transfusion EDTA sample was also tested for malaria antigen in blood bank by RDT, which tested positive for p-lactate dehydrogenase and negative for HRP-II specific for P. falciparum [Figure 2]. The same was confirmed by diagnostic laboratory finding on patient’s post-transfusion sample. Asian Journal of Transfusion Science - Vol 8, Issue 1, January - June 2014
Figure 1: Temperature charting before and after red cell transfusion
Figure 2: Malaria antigen detection in pre-transfusion sample of the patient 61
Letters to the Editor
All donated blood units, thus need to be screened for MP, preferably by RDTs, to prevent and defend all suspected TTM. Naveen Agnihotri, Lokesh Kumar Pal Department of Transfusion Medicine, Fortis Hospital, Blood Bank, Shalimar Bagh, New Delhi, India Correspondence to: Dr. Naveen Agnihotri, Department of Transfusion Medicine, Fortis Hospital, Blood Bank, A-Block Shalimar Bagh, New Delhi – 110 088, India. E-mail: [email protected]
References 1. Bahadur S, Pujani M, Jain M. Use of rapid detection tests to prevent transfusion-transmitted malaria in India. Asian J Transfus Sci 2010;4:140-1. 2. Choudhury N, Jolly JG, Mahajan RC, Ganguly NK, Dubey ML, Agnihotri SK. Malaria screening to prevent transmission by transfusion: An evaluation of techniques. Med Lab Sci 1991;48:206-11. 3. Pomper GJ. Febrile, allergic, and nonimmune transfusion reactions. In: Simon TL, Snyder EL, Solheim BG, Stowell CP, Strauss RG, Petrides M, editors. Rossi’s Principles of Transfusion Medicine. 4th ed. Bethesda: Blackwell Publishing Ltd.; 2009. p. 839. 4. Choudhury NJ, Dubey ML, Jolly JG, Kalra A, Mahajan RC, Ganguly NK. Post-transfusion malaria in thalassaemia patients. Blut 1990;61:314-6. 5. Stauffer WM, Cartwright CP, Olson DA, Juni BA, Taylor CM, Bowers SH, et al. Diagnostic performance of rapid diagnostic tests versus blood smears for malaria in US clinical practice. Clin Infect Dis 2009;49:908-13. Access this article online Website: www. ajts. org
Quick Response Code:
DOI: 10.4103/0973-6247.126697
Investigating weak A subgroups in a healthy lady: The blood bank limitations Sir, Weak A subgroups such as A3, Ax, Aend, Am, Ay, and Ael are often mistyped as group O and may be potentially dangerous with regards to whole blood transfusion. These subgroups can be serologically differentiated using recommended techniques. [1,2] Special tests like serum glycosyltransferase estimation and genotyping are performed in advanced laboratories to confirm these blood groups.[3,4] We observed a discrepancy between the routine forward and 62
Table 1: Test on red cells and serum
Test on red cells Anti-A Anti-B Anti-A, B Anti-D Anti-A1 Anti-H 0 0 0 ++++ 0 ++++
Table 2: Adsorption-elution test Eluate reactivity A cells
O cells
37°C 22°C 4°C ++ ++ ++
37°C 22°C 4°C 0 0 0
Test on serum Regular Irregular Anti-B None
Final wash reactivity A cells B cells B cells O cells
0
0
0
0
reverse blood grouping of a 45-year old healthy lady. The forward group revealed ‘O’ positive and reverse showed ‘A’ group. No clerical errors and reagent problems were observed. We performed a detailed serological investigation on the lady’s red cells with both tube technique and Gel method (DiaMed, Cressier s/Morat, Switzerland) [Table 1]. Since the red cells showed no agglutination with either Anti-A and Anti-AB, we suspected a possible Am or Ay or Ael phenotype. The red cells were then subjected to adsorption – elution tests using human polyclonal Anti-A as described elsewhere.[2] To our surprise the eluate reacted with the reagent ‘A’ cells indicating the presence of ‘A’ antigen on the test red cells. The result was then validated with a) the eluate showing agglutination with two different reagent ‘A’ cells at all phases b) eluate failing to agglutinate reagent ‘O’ cells and c) the final wash solution failing to agglutinate with all the four reagent red cells ‘A’, ‘B’, ‘AB’ and ‘O’[2] [Table 2]. Blood groups of her husband and one son who were available then were confirmed to be ‘O’ positive. Saliva study showed that the lady was a secretor and carried both ‘A’ and ‘H’ substances thus excluding the probability of Ael phenotype. Serologically ‘Ay’ is almost similar to ‘Am’ and even adsorption – elution test fails to differentiate the two phenotypes. In the present study Anti-A eluted from the lady’s red cells reacted weakly with the corresponding reagent ‘A’ cells (Agglutination strength: 1+ by tube technique and 2+ by Gel) which is in favor of ‘Ay’ phenotype. In case of ‘Am’ phenotype such agglutination strength is significantly stronger.[1] Finally we reported the patient as “Weak A subgroup” Rh positive. We advised both serum glycosyltransferase estimation and genotyping of the lady for confirmation of her weak ‘A’ subgroup. We were really in a dilemma as to how the reporting should be done in the present case. We were not sure whether designating the lady as “Weak A subgroup” Rh positive was a proper reporting format. Since confirmatory tests for weak ‘A’ phenotype is beyond the scope of most blood banks, there should be a system to report these weak ‘A’ individuals. Sudipta Sekhar Das, R. U. Zaman, Md. Safi, Subrata Sen, Tirtha Pratim Sardar, Susanta Ghosh Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, India
Correspondence to: Dr. Sudipta Sekhar Das, Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata - 700 054, India. E-mail: [email protected] Asian Journal of Transfusion Science - Vol 8, Issue 1, January - June 2014
Copyright of Asian Journal of Transfusion Science is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
![[Reality and importance of transfusion-transmitted malaria in a stable endemic context: Cotonou case in Benin].](/assets/img/hold.png)
