Introduction. Case Reports 18/08/2011. Intravenous Immunoglobulin (IVIg) Prepared from large pools of plasma.

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1 Introduction Intravenous Immunoglobulin (IVIg) Prepared from large pools of plasma. By Friend Maviza Consists of IgG with minimal levels of other immunoglobulin classes. IVIg is prescribed for several haematologic, neurologic and immunologic conditions. Case Reports Reported adverse reactions include volume overload, allergic reactions and pulmonary reactions. Passive transfer of blood group alloantibodies has been reported to cause positive DAT. Clinically significant haemolysis associated with IVIg administration is rare. Mild to moderate haemolysis can easily be missed and true incidence is unknown. Literature Review Daw et al., cases of haemolytic transfusion reactions associated with IVIg administration. 15/16 patients received 100g in 2 to 4 days. 15/16 non O blood group. Decrease in Hb 8 52 g/l (mean decrease 32 g/l) 1

2 14 patients had positive DAT; 12 IgG only specificity Majority of tested patients showed evidence of underlying inflammatory condition. Case Reports Case 1 Female patient X presenting with ITP 3 rbc units requested. Non secretors might be more prone to haemolysis 1 st Sample Antibody screen: Positive Group AB+ Anti E identified Crossmatch: 1 AB+ (E ) and 2 A+ (E ) units compatible. 2

3 2 nd Sample (Day 8) Ab Screen: Positive Discrepant Group Anti E identified Crossmatch: Reserved units now incompatible with 2 nd sample Retrospective Observations Day 3: 72g IVIg Day 4: 36g IVIg Day 5: 36g IVIg 144g administered within 3 days Hb decreased by 33 g/l Elevated C reactive protein Case 1: Laboratory Conclusion Passively acquired anti A from IVIg No patient sample to perform DAT and Lewis phenotype. 3 E group O rbcs crossmatch compatible 3

4 2 nd Case Report 45 year old male patient Mr. B 3 week history of petechial rash Platelet count <10 Laboratory Findings On admission: Hb 149g/l Plt <10 x 10⁹/l CRP 58 mg/l (ref range 0 5mg/l) Fibrinogen 6.8 g/l Never been transfused Primary diagnosis ITP Placed under Haematologists care Sample received 7 days after IVIg infusion Mr. B given 1g/kg IVIG over two days 198g over two days Discrepant group Forward group: A Rh(D) neg Reverse group: A1 cells 2+; B cells 4+ Antibody screen: Positive 4

5 Anti M identified DAT Positive; Specificity IgG only Anti A eluted Phenotype: M, Le(a+b ) Hb decreased from 149 g/l to 128 g/l Case 2: Laboratory Conclusion Naturally occurring anti M Passively acquired anti A from IVIg Discussion Haemolysis was mild to moderate. Large doses of IVIg associated with haemolysis. Non group O patients at more risk. Underlying inflammation observed in both cases Non secretor status observed in tested patient. 5

6 Conclusion Mild haemolytic reactions may be of little clinical significance and are outweighed by the benefits of IVIg. Clinicians and laboratory staff need to be alert for signs of haemolysis after IVIg treatment. Recommendations include pretransfusion testing and posttransfusion testing within 36 hours which includes DAT, full blood count and blood film, serum bilirubin and LDH. References Daw Z. Et.al. Haemolytic transfusion reactions after administration of intravenous immune (gamma) globulin: a case series analysis. Transfusion 2008; 48: Lazarus AH, Crow AR. Mechanism of action of IVIG and anti D in ITP. Transfusion & Apheresis Science 2003; 28: Morgan S, Sorensen P, Vercellotti G and Zantek D. Hemolysis after treatment with intravenous immunoglobulin due to anti A. Transfusion Medicine 2011, 21, Acknowledgements Jovelyn Iringan; Ann Bymolt; Donna Grace Menia; Dr Dhana Gounder and Dr Dorothy Dinesh 6