Anti-Coa Implicated in Hemolytic Disease of the Newborn C. MCINTYRE,L. FINIGAN, A N D A. L. LARSEN From the Clinical Laboratories. University of Nebraska Medical Center. Omaha, Nebraska
at 4 C and an anti-Coa detected a t the albumin antiglobulin and enzyme antiglobulin phases. Anti-Coa was detected following treatment of the serum with 2-mercapto-ethanol, indicating an IgG antibody presumably capable of crossing the placental barrier. The first record of a type on Mrs. D.M. is from the obstetrician's office on September 6, 1969. It shows her to be Group 0 Rho (D) positive. There is no record of any tests to detect irregular antibodies being done at that time. In 1970, Mrs. D.M.'s first pregnancy terminated in a spontaneous, normal, vaginal delivery a t 40 weeks. The hospital records indicate the child was typed as Group 0 Rho (D) negative with a negative direct Coombs. The physician's records indicate that on June 14, 1973, an irregular antibody was detected but not identified. Her second pregnancy terminated in a spontaneous abortion on June 30, 1973. There appeared to be no further investigation of the antibody. Mrs. D.M. has not received blood or any blood components.
I N 1967, Heisto et al.' reported the first three examples of anti-Co". This antibody detects a high frequency antigen found in 99.7 per cent of Northern Europeans. Testing to date shows the Co" antigen to segregate independently of the major blood group systems. Because of inadequate data, its association with Diego, Yta, and Sm-Bua has not yet been e~tablished.'.~.~ Anti-Coa is usually found in conjunction with other antibodies. It has been known to show dosage effect, and is usually IgG. Generally, the antibody reacts best with antiglobulin and enzyme antiglobulin techn i q ~ e s . l *Anti-Co" ~.~ appears to be stimulated through transfusion and pregnancy and has been implicated in hemolytic disease of the newborn in two published case^.^-^ This is a case history of an obstetrical patient with an anti-Coa which was stimulated by pregnancy and caused occult hemolytic disease of the newborn in her third pregnancy.
Serological Studies
The members of the family were tested for ABO, Rh-Hr, and for the CO' and C o bantigens. The results of these studies and the most probable Rh-Hr genotypes are shown in Figure 1. No irregular antibody was found in the serum of any other member of the family. Blood samples were drawn from Mrs. D.M. on three occasions to titer the antibody. At 15 weeks gestation, the titer was 1:32 using the antiglobulin technique and was also 1:32 using the enzyme antiglobulin technique. The titer remained unchanged at 24 and at 33 weeks gestation. The titers were determined with the cells of S.D., a member of the blood bank staff, who is Group 0, most probable Rh-Hr genotype R'R', Co(a+b-). (Colton typings performed by
Case History Mrs. D.M. was first seen for routine prenatal testing on April 5, 1974 at approximately five weeks gestation. She was found to be Group 0 and of the most probable Rh-Hr genotype R'r. The patient's serum showed the presence of an antibody which reacted a t the antiglobulin phase with all cells tested except the patient's own. Another sample was tested on April 26, 1974, with the same results. On June 9, 1974, samples of Mrs. D.M.'s blood were sent to the Consultation Service at Spectra Biologicals. They reported a cold autoagglutinin Received for publication March 19, 1975; accepted April 7, 1975.
76 Transfusion Jan.-Feb. 1976
Volume 16
Numkr I
Volume 16 Number I
77
ANTI-CO~ Family of Mrs. D.M.
I
I
I
FIG 1. Studies of family members. The solid symbols denote Co (a-), the open symbols denote Co
0 Group 0 R’r Co (a+ b t )
(a+).
Group A R’r
Group 0 R‘r
Group 0 R’r
Group A rr
Co(atb+)
Cola+b-)
Co(a-b+l
Co(a. b+l
Group 0 rr
Co(a+b+l
Minneapolis War Memorial Blood Bank). Samples of serum were frozen on each drawing and the previous specimen retested with each new titer. An amniocentesis was performed on the patient immediately before delivery. The spectral absorbance revealed an O.D. difference at 450 nm of 0.00. A sample of blood drawn from Mrs. D.M. prior to delivery was sent to the AABB Reference Laboratory at Minneapolis War Memorial Blood Bank where the presence of anti-Con reactive by antiglobulin technique was confirmed. No atypical antibodies were detected when the serum was tested against a panel of Co (a-) test cells. Mrs. D.M. delivered a 7 lb. 5 oz. male infant on November 19, 1974. Serological
examination of the cord blood gave the following results: group, 0; most probable Rh-Hr genotype, R’R’; direct coombs, positive (1 + agglutination); and cord bilirubin, total- I .2 mg/ 100 ml, direct-0.22 mg/100 ml. Anti-Co” was detected in the cord serum and in an eluate prepared from cord cells. A blood sample drawn from the infant immediately after birth gave normal results except for a hemoglobin of 16.6 gm/100 ml, a PCV of 47.7 per cent, and a slightly elevated reticulocyte count of 6.3 per cent. Six nucleated RBC/ 100 WBC were noted on the blood smear. At 24 hours, the infant’s bilirubin was 4.0 mg/100 ml. The highest bilirubin level of 6.4 mg/100 ml was reached on the third day,
Table 1. Results Obtained from Testing Cord Serum and Eluates Against a Panel of Co (a+Jand Co (a-J Cells Using the Antiglobulin Technique (Eluates Were Prepared by the Landsteiner Heat Method)
Specimen
MM Co(a+b)
8336-0 Co(a+)
Cord serum Cord eluate (saline) Cord eluate (6 per cent albumin)
2+
2+
2+ 2+
2+ 2+
SD Co(a+b-)
2+ 2+ 2+
8322-0 Co(a-) 0 0 0
DM Co(a-b+) 0 0 0
1 11874#10 Co(a-)
0
0
0
78
Transfusion Jan.-Feb. 1976
MclNTYRE ET AL.
after which the bilirubin decreased. The infant required no treatment and was dismissed on the fourth day.
Independence of Colton blood group. Transfusion 11:223, 1971. 3. Simpson, W. K. H.: anti-Coa and severe hemolytic disease of the newborn. S. Afr. Med. J. 47:1302,
Acknowledgments
1973. 4. Smith, D. S., F. Stratton, P. Howell, and R.
We thank Dr. J. Scott, Chairman, Department of Obstetrics and Gynecology, University of Nebraska Medical Center, and the family of Mrs. D.M. for their assistance in this project. The Cob tests reported in Figure I were performed by Spectra Biologicals. The Coa tests on group A individuals were confirmed by Ortho Diagnostics.
References 1.
Heisto, H., M. Ven Der Hart, G. Madsen, M. Moes, J. Noades, M. M. Pickles, R. R. Race, R. Sanger, and J. Swanson: Three examples of a new red cell antibody, anti-Con. Vox Sang. 12:18,
2.
Lewis, M., H. Kaita, C. Anderson, and B. Chown:
1967.
Riches: An example of anti-Coa found in pregnancy. Vox Sang. 18:62, 1970. 5. Wray, E. and S. Simpson: A further example of anti-Coa and two informative families with Co (a-) members. Vox Sang. 14:130, 1968.
Carleen Mclntyre MT (ASCP) SBB, Instructor in School of Allied Health Professions, University of Nebraska Medical Center, 42nd & Dewey Avenue, Omaha, Nebraska 68105. Linda Finigan MT (ASCP) SBB, Assistant Instructor in School of Allied Health Professions, University of Nebraska Medical Center. A. L. Larsen, M.D., Professor of Pathology, University of Nebraska Medical Center.
Announcements Postgraduate Course A postdoctoral training program for Blood Bank Directors has been underway at the Lindsley F. Kimball Research Institute of the Community Blood Council of Greater New York, Inc., substantially supported by a training grant from the National Heart and Lung Institute. Awardees must have had at least one year of postgraduate training in clinical medicine or pathology. The amounts of the stipends are based on previous experience and training. The program is accredited by the Department of Education of the State of New York, and by the Veterans Administration. Further information may be obtained from Benjamin Alexander, M.D., Associate Director for Educational Programs, The New York Blood Center, 310 East 67th Street, New York, N.Y. 10021.
First International Symposium on HLA and Disease The First International Symposium on HLA and Disease will be held June 23-25,1976 in Paris,
France. The association of HLA antigens with numerous diseases, the clinical implications of recent discoveries on nosology, diagnosis, prognosis, and even prevention will be discussed by clinicians and biologists. Several workshops (rheumatology, dermatology, gastroenterology, allergy, irnmunopathology, endocrinology) will cover the different facets of this new approach to epidemiology and hereditary diseases. The possible mechanisms and biological significance of association will be considered by geneticists, virologists, and immunologists. Proceedings of the Symposium will be published by Munksgaard (Copenhagen) in a book covering the fundamental as well as the clinical aspects of these associations. For further information, please contact: Congres Services I, Rue Jules Lefebvre 75009 Paris. France.
at 4 C and an anti-Coa detected a t the albumin antiglobulin and enzyme antiglobulin phases. Anti-Coa was detected following treatment of the serum with 2-mercapto-ethanol, indicating an IgG antibody presumably capable of crossing the placental barrier. The first record of a type on Mrs. D.M. is from the obstetrician's office on September 6, 1969. It shows her to be Group 0 Rho (D) positive. There is no record of any tests to detect irregular antibodies being done at that time. In 1970, Mrs. D.M.'s first pregnancy terminated in a spontaneous, normal, vaginal delivery a t 40 weeks. The hospital records indicate the child was typed as Group 0 Rho (D) negative with a negative direct Coombs. The physician's records indicate that on June 14, 1973, an irregular antibody was detected but not identified. Her second pregnancy terminated in a spontaneous abortion on June 30, 1973. There appeared to be no further investigation of the antibody. Mrs. D.M. has not received blood or any blood components.
I N 1967, Heisto et al.' reported the first three examples of anti-Co". This antibody detects a high frequency antigen found in 99.7 per cent of Northern Europeans. Testing to date shows the Co" antigen to segregate independently of the major blood group systems. Because of inadequate data, its association with Diego, Yta, and Sm-Bua has not yet been e~tablished.'.~.~ Anti-Coa is usually found in conjunction with other antibodies. It has been known to show dosage effect, and is usually IgG. Generally, the antibody reacts best with antiglobulin and enzyme antiglobulin techn i q ~ e s . l *Anti-Co" ~.~ appears to be stimulated through transfusion and pregnancy and has been implicated in hemolytic disease of the newborn in two published case^.^-^ This is a case history of an obstetrical patient with an anti-Coa which was stimulated by pregnancy and caused occult hemolytic disease of the newborn in her third pregnancy.
Serological Studies
The members of the family were tested for ABO, Rh-Hr, and for the CO' and C o bantigens. The results of these studies and the most probable Rh-Hr genotypes are shown in Figure 1. No irregular antibody was found in the serum of any other member of the family. Blood samples were drawn from Mrs. D.M. on three occasions to titer the antibody. At 15 weeks gestation, the titer was 1:32 using the antiglobulin technique and was also 1:32 using the enzyme antiglobulin technique. The titer remained unchanged at 24 and at 33 weeks gestation. The titers were determined with the cells of S.D., a member of the blood bank staff, who is Group 0, most probable Rh-Hr genotype R'R', Co(a+b-). (Colton typings performed by
Case History Mrs. D.M. was first seen for routine prenatal testing on April 5, 1974 at approximately five weeks gestation. She was found to be Group 0 and of the most probable Rh-Hr genotype R'r. The patient's serum showed the presence of an antibody which reacted a t the antiglobulin phase with all cells tested except the patient's own. Another sample was tested on April 26, 1974, with the same results. On June 9, 1974, samples of Mrs. D.M.'s blood were sent to the Consultation Service at Spectra Biologicals. They reported a cold autoagglutinin Received for publication March 19, 1975; accepted April 7, 1975.
76 Transfusion Jan.-Feb. 1976
Volume 16
Numkr I
Volume 16 Number I
77
ANTI-CO~ Family of Mrs. D.M.
I
I
I
FIG 1. Studies of family members. The solid symbols denote Co (a-), the open symbols denote Co
0 Group 0 R’r Co (a+ b t )
(a+).
Group A R’r
Group 0 R‘r
Group 0 R’r
Group A rr
Co(atb+)
Cola+b-)
Co(a-b+l
Co(a. b+l
Group 0 rr
Co(a+b+l
Minneapolis War Memorial Blood Bank). Samples of serum were frozen on each drawing and the previous specimen retested with each new titer. An amniocentesis was performed on the patient immediately before delivery. The spectral absorbance revealed an O.D. difference at 450 nm of 0.00. A sample of blood drawn from Mrs. D.M. prior to delivery was sent to the AABB Reference Laboratory at Minneapolis War Memorial Blood Bank where the presence of anti-Con reactive by antiglobulin technique was confirmed. No atypical antibodies were detected when the serum was tested against a panel of Co (a-) test cells. Mrs. D.M. delivered a 7 lb. 5 oz. male infant on November 19, 1974. Serological
examination of the cord blood gave the following results: group, 0; most probable Rh-Hr genotype, R’R’; direct coombs, positive (1 + agglutination); and cord bilirubin, total- I .2 mg/ 100 ml, direct-0.22 mg/100 ml. Anti-Co” was detected in the cord serum and in an eluate prepared from cord cells. A blood sample drawn from the infant immediately after birth gave normal results except for a hemoglobin of 16.6 gm/100 ml, a PCV of 47.7 per cent, and a slightly elevated reticulocyte count of 6.3 per cent. Six nucleated RBC/ 100 WBC were noted on the blood smear. At 24 hours, the infant’s bilirubin was 4.0 mg/100 ml. The highest bilirubin level of 6.4 mg/100 ml was reached on the third day,
Table 1. Results Obtained from Testing Cord Serum and Eluates Against a Panel of Co (a+Jand Co (a-J Cells Using the Antiglobulin Technique (Eluates Were Prepared by the Landsteiner Heat Method)
Specimen
MM Co(a+b)
8336-0 Co(a+)
Cord serum Cord eluate (saline) Cord eluate (6 per cent albumin)
2+
2+
2+ 2+
2+ 2+
SD Co(a+b-)
2+ 2+ 2+
8322-0 Co(a-) 0 0 0
DM Co(a-b+) 0 0 0
1 11874#10 Co(a-)
0
0
0
78
Transfusion Jan.-Feb. 1976
MclNTYRE ET AL.
after which the bilirubin decreased. The infant required no treatment and was dismissed on the fourth day.
Independence of Colton blood group. Transfusion 11:223, 1971. 3. Simpson, W. K. H.: anti-Coa and severe hemolytic disease of the newborn. S. Afr. Med. J. 47:1302,
Acknowledgments
1973. 4. Smith, D. S., F. Stratton, P. Howell, and R.
We thank Dr. J. Scott, Chairman, Department of Obstetrics and Gynecology, University of Nebraska Medical Center, and the family of Mrs. D.M. for their assistance in this project. The Cob tests reported in Figure I were performed by Spectra Biologicals. The Coa tests on group A individuals were confirmed by Ortho Diagnostics.
References 1.
Heisto, H., M. Ven Der Hart, G. Madsen, M. Moes, J. Noades, M. M. Pickles, R. R. Race, R. Sanger, and J. Swanson: Three examples of a new red cell antibody, anti-Con. Vox Sang. 12:18,
2.
Lewis, M., H. Kaita, C. Anderson, and B. Chown:
1967.
Riches: An example of anti-Coa found in pregnancy. Vox Sang. 18:62, 1970. 5. Wray, E. and S. Simpson: A further example of anti-Coa and two informative families with Co (a-) members. Vox Sang. 14:130, 1968.
Carleen Mclntyre MT (ASCP) SBB, Instructor in School of Allied Health Professions, University of Nebraska Medical Center, 42nd & Dewey Avenue, Omaha, Nebraska 68105. Linda Finigan MT (ASCP) SBB, Assistant Instructor in School of Allied Health Professions, University of Nebraska Medical Center. A. L. Larsen, M.D., Professor of Pathology, University of Nebraska Medical Center.
Announcements Postgraduate Course A postdoctoral training program for Blood Bank Directors has been underway at the Lindsley F. Kimball Research Institute of the Community Blood Council of Greater New York, Inc., substantially supported by a training grant from the National Heart and Lung Institute. Awardees must have had at least one year of postgraduate training in clinical medicine or pathology. The amounts of the stipends are based on previous experience and training. The program is accredited by the Department of Education of the State of New York, and by the Veterans Administration. Further information may be obtained from Benjamin Alexander, M.D., Associate Director for Educational Programs, The New York Blood Center, 310 East 67th Street, New York, N.Y. 10021.
First International Symposium on HLA and Disease The First International Symposium on HLA and Disease will be held June 23-25,1976 in Paris,
France. The association of HLA antigens with numerous diseases, the clinical implications of recent discoveries on nosology, diagnosis, prognosis, and even prevention will be discussed by clinicians and biologists. Several workshops (rheumatology, dermatology, gastroenterology, allergy, irnmunopathology, endocrinology) will cover the different facets of this new approach to epidemiology and hereditary diseases. The possible mechanisms and biological significance of association will be considered by geneticists, virologists, and immunologists. Proceedings of the Symposium will be published by Munksgaard (Copenhagen) in a book covering the fundamental as well as the clinical aspects of these associations. For further information, please contact: Congres Services I, Rue Jules Lefebvre 75009 Paris. France.
