Difficulty in LW Typing as Revealed by a Family Study 0. BEHZAD, M. POTHIAWALA, S. D. ROLIH,P. D. ISSITT,A N D C. L. LEE From the Mid-America Regional Red Cross Blood Program, Chicago, Illinois, The Paul I . Hoxworth Blood Center of the University of Cincinnati. Cincinnati, Ohio, Mount Sinai Blood Center and the Rush Medical College. Chicago, Illinois
A family b described in which two members of the second generation are of the phenotype LW,. In the courae of the investigation the mother of the LW, propositus was at Brst believed to be phenotypidy LW, as well. Eventually, it was shown that she is, in fact, phenotypidy LWz but that her R-' (no D), LWlw, genotype had resulted in less LW being present on her red blood cells than is expected in LW, persons. This reduced level of LW could not be detected with one example of anti-LW made by an LW, individual.
used to describe D-positive, LW-positive red blood cells which carry more LW antigen than do any others. The D-negative, LW-positive phenotype is described as LW2for in the genotype R-' (no D), L W LW , the amount of LW antigen produced is less than in LW, but readily detected by most anti-LW antibodies. The terms LW, and LW, are used to describe the red blood THELW ANTIGEN is known to be phenocells of persons previously considered to typically related to the Rh antigens although be genetically LW-negative. Two phenoits production has been shown to be contype designations are in order for not all trolled by genes that do not reside at the such red blood cells carry the same amount CDE locus.1o For some time it was beof LW antigen, LW, samples have more lieved that two alleles could substitute at LW than do those that are LW,. LW, the LW locus. L W , in double or single people are able to make an anti-LW that dose, was thought to code for presence of reacts with LW, and LW, but not with LW antigen, while the presence of two rare other LW,, or with LW,, red blood cells. Iw alleles, at that locus, was thought to Weak examples of this antibody, which result in the LW-negative phenotype. More react only with LW, samples, may be misrecently, it has become apparent that the taken for anti-D unless adsorption tests only red blood cells that totally lack LW with D-negative (LW,) red blood cells are are those of the phenotype Rh,,,,. Vos er performed. LW, individuals are able to al." and Polesky ef ~ 1 demonstrated . ~ that make an anti-LW that reacts with LW,, the red blood cells of persons previously LW,, and LW,, but not with other LW,, considered to be genetically LW-negative, samples. White et a1.I2 have pointed out stimulate production of anti-LW when inthat if an anti-LW made by an LW, indijected into guinea pigs, just as do LW-posividual is used in typing tests, LW, red tive red blood cells. Further, Vos er al." blood cells may be classed as LWfound that red blood cells of some, prepositive and may not be differentiated from viously considered genetically LW-negative, other LW-positive samples. The phenopeople are able to adsorb some examples of types LW, and LW, both occur in D-posianti-LW to exhaustion. Based on these, tive and D-negative individuals thus showand other findings, several a ~ t h o r s have ~ * ~ * ~ing that the effect of D , in determining proposed a modified terminology to dethe LW, and LW, phenotypes, is apparscribe the various LW phenotypes. LW, is ently not at play in LW, and LW, persons. In all of the typing and adsorption studies that have been completed2.g*Y*11~12 no eviReceived for publication June 18,1977; accepted July 10. 1977. dence has been obtained to suggest a quali0041-1 132-78-0700-0488-0075 0 J. B. Lippincott Co. Volume 18 Number 4
488
Transfusion July-August 1978
Volume 18 Number 4
489
LW TYPING DIFFICULTY
tative difference between the LW antigen of the four phenotypes. It appears that the same LW antigen is present on the red blood cells of persons of all four phenotypes and decreases, quantitatively, in the sequence LWI, LW2, LW,, LW,. In spite of the serologic classification, described above, little is known about the genetic mechanism that results in the production of different strength LW antigens. For example, the same LW gene is probably responsible for the LW, and LW, phenotypes with its actions being influenced by the presence or absence of the gene L). Similarly, the same allele of LW (which will be called lw in this report) may well be responsible for the LW, and LW, phenotypes. The mechanism by which the genotype lwfw can result in either the phenotype LW,, or the phenotype LW4, is not known. Thus, although we appreciate the incongruity of using the symbol lw for a gene that allows some LW antigen to be made, we believe this to be justified at the present time. The alternative would be to introduce separate gene symbols to indicate the genetic backgrounds that result in the phenotypes LW, and LW, when there is, at present, scant evidence for any genetic difference. Similarly, the term L W will be used in this report to describe the gene whose presence results in the LW, phenotype in D-positive, and the LW2 phenotype in D-negative, individuals. In all probability, Rh,,,, individuals, whose red blood cells are LW-negative," have two LW genes that are unable to effect production of LW antigen in those individuals because of lack of suitable substrate for gene a c t i ~ n . ~ . ~ We describe here a new example of antiLW, made by an individual of the LW, phenotype. In the course of a family study, undertaken in an attempt to find compatible blood for the propositus, it initially appeared that not only a sib, but also the mother of the propositus, was LW,. Eventually we were able to demonstrate that the mother,
who is genetically R - 1 (no D), LWlw, has red blood cells of the LW2phenotype. However, the study has demonstrated yet another difficulty in the correct determination of red blood cell LW antigen status, namely that the red blood cells of a D-negative, LW heterozygote, may fail to react with some examples of anti-LW. case History F.P. is a 35-year-old Caucasian male. In September, 1976, he was admitted to the hospital having suffered severe bums over 22 per cent of his body in an industrial fire. On September 27, 1976, he was transfused with three units of whole blood. At that time no unexpected antibodies were found in his serum and the transfusions caused no untoward reaction. Prior to this occasion F.P. had never received a blood transfusion or an injection of blood. On October 19, 1976, two additional units of blood were ordered for transfusion to F.P. and it was at this time that an unexpected antibody, weakly reactive in albumin at 37 C, and more strongly reactive in indirect antiglobulin tests, was first detected. After the family study, reported below, F.P. was transfused with two units of washed red blood cells donated by his serologically compatible sister. These transfusions caused no ill effects and resulted in the expected increment of hemoglobin in the patient. Thereafter F.P. made an uneventful recovery from his bums.
Materials and Methods Red blood cells used in this study were fresh, or were stored by one of a number of conventional means. Those of F.P., and his family, were collected into anticoagulant and tested within five days of collection in Chicago. Immediately following collection, part of the blood sample from each of these individuals was frozen in glycerol. These glycerol preserved red blood cells were later shipped to Cincinnati and recovered there using a standard technique.s Other red blood cell samples used were from commercially supplied, antibody identification panels, stored in the preservative solutions employed by various companies. Some rare red blood cell samples (LW,, LW,, Rh,,,, etc.) had been stored frozen in liquid nitrogen prior to use.7 Antisera used were either commercially obtained reagents or antibodies identified in, or sent by other workers to, Chicago and Cincinnati. All noncommercially supplied sera had been
490
Transfusion
BEHZAD ET AL.
stored frozen. All typing and titration methods were standard ones that have been described el~ewhere.~
Results When first tested, the red blood cells of F.P. were shown to be group A, Rh(D) positive. Later his Rh phenotype was shown to be D + , C-, E + , c + , e + , for a probable Rh genotype of RZr.The presumed Rh genotypes of other members of the family are shown in Figure 1. In October, 1976, when the antibody in F.P.'s serum was first detected, full studies to determine antibody specificity were undertaken. It was found that the F.P. serum reacted with all samples on commercial red blood cell panels and with a large number of rare red blood cell samples (recovered from liquid nitrogen storage) known to lack high frequency antigens. However, the F.P. serum failed to react with two LW,, and with two RhnUllsamples, indicating the presence of anti-LW in the serum. Because blood was required to transfuse F.P., a family study was undertaken. Red blood cell samples from his parents and his two sibs, were tested
July-August 1578
with the propositus's anti-LW, an anti-LW made by an LW, individual (van der Weyst)s and an anti-LW made by an LW, (Big.)z.3Although not tested at the same time, red blood cells from F.P.'s wife and child were later typed with some of the same reagents. The results of all of these tests are shown in Table 1. Because the undiluted anti-LW of Big., reacted with all samples (including those of the propositus) a titration study was performed. The results of this study are included in Table 1. After the tests depicted in Table 1 were completed F.P. was transfused with the blood of his sister, M.J.S. The initial studies showed that F.P. and his sister are phenotypically LW,. Unexpectedly, however, the red blood cells of the mother of F.P. also appeared to be LW,. Since the mating that produced F.P. and M.J.S. was not believed to be consanguineous it seemed highly unlikely that the mother (G.P.) would be of the LW, phenotype. For this reason red blood cell samples of all family members and a serum sample from F.P. were referred to Cincinnati for further study. The anti-LW specificity of F.P.'s antibody was confirmed as it was shown to be nonreactive with the LW, red blood cells of S.C. and J.P.,I2
I ? .P.Sr
\
G o P o
R
rr
LFzi
L"2 LWtw
1
I
I1 4
J
F.P.Jr. R8r
R.P. R1r
W1 LW
m3
tutu
I11
w1
LWtw
M. 5 . 8 . R8r
*
BOPR8P
Lw
Lw1
t J W
LY
F I G . I . Results of studies of F.P. and his family to show presumed Rh genotypes, L W phenotypes, and interpretation of LW genotypes.
Volume 18 Number 4
49 1
LW TYPING DIFFICULTY Table 1. Initial L W Typing Results of F.P. and His Family Direct Tests with van der Weyst Anti-LW
Direct Tests with Big. Anti-LW
Titer Using Big. Anti-LW
Direct Tests with F.P.'s Anti-LW
2+
4+ 4+ 4+ 4+ 4+
64
3+ 0
F.P. Snr. (father) G.P. (mother) F.P. Jr. (propositus) M.J.S. (sister) B.P. (brother) R.P. (wife) J.P. (daughter)
0 0 0
2+ 2+ 2+
8 8 8
0 0
3+
64 N.T. N.T.
4+
4+
N.T. N.T.
NOTE:N.T. = not tested. the L W 4 red blood cells o f and with two Rh, samples different from those tested in Chicago. The red blood cells o f the family members were then tested with the anti-LW made by S.C. who is LW,,12 and with a different serum sample from Big. the LW, proposita of de Veber et a/.2.3The results o f these tests are shown in Table 2. As can be seen, the anti-LW from the LW, individual does not distinguish well between the L W , (F.P.Sr. and B.P.),LW, (G.P.)and LW, (F.P.Jr. and M.J.S.) red blood cells. On the other hand, the anti-LW from S.C., an LW, individual, makes a very clear differentiation.
Discussion It has already been establishedIz and is demonstrated again in this family, that if an anti-LW made by an LW, person is used, the LW, phenotype may be indistinguishable from the LW, and LW, phenotypes. With such findings it might appear that an LW-positive individual has produced antiLW that does not react with hidher own red blood cells. Although this situation might, at first, appear to represent heterogeneity of the LW antigen it is more likely to actually represent simple quantitative difference of LW antigen in different individuals. The family described in this current study demonstrates yet another difficulty in determining the actual LW phenotype of red blood cell samples. The figure shows the presumed Rh genotypes (based on serologic tests for Rh phenotypes), the observed LW phenotypes, and the interpreted LW genotypes of the family members. As can be
seen, 1-1 and 1-2 have produced two (11-2 and 11-3) LW, children. It follows, therefore, that 1-1 and 1-2 must each be genetically LWlw (using the lw gene notation as defined earlier). 1-1 is Rh(D) positive and 1-2 is Rh(D) negative. Apparently the genotype R - 1 (no D), LWlw, results in less LW antigen being made than the genotype R-' (no D), L W LW , for it initially appeared that 1-2 was phenotypically LW,, not LW,. By using a more potent anti-LW from an LW, individual,I2 than that used in the original typings, the true LW, status of 1-2 was determined. The anti-LW used in the initial typings was from van der Weysts and had been stored frozen in Chicago for about 12 years. It appears that during that time the antibody had deteriorated to the point that it was unable to detect the reduced amount of LW antigen on the red blood cells of the Rh(D)-negative, LWlw, individual. However, this deterioration was not apparent from control tests using LW,( L W LW ) , LW2 ( LW LW )and LW,( lwlw) red blood cell samTable 2. Additional L W Typing Results of F.P. and His Family
F.P. Snr. (father) G.P. (mother) F.P. Jr. (propositus) M.J.S. (sister) B.P. (brother)
Tests with S.C. Anti-LW
Tests with Big. Anti-LW
4+
3+
2+ 0 0
2+ 2+ 3+ 3+
4+
BEHZAD ET AL.
ples. Further, it can be anticipated that other examples of anti-LW from LW, persons might similarly fail to detect the reduced LW of Rh(D)-negative, LWIw, heterozygotes, if weaker than the anti-LW from S.C. that was used in later studies. As stated, F.P.’s transfusion needs were met with blood from his LW, sister. However, it is entirely possible that his genetically R-’(no D ) , LWlw, mother would also have been a suitable donor. Since antibodies detect red blood cell-borne antigens, and do not define genetic backgrounds, the mother’s LW, red blood cells, with their low level of LW antigen, might well have been unaffected in vivo by F.P.’s anti-LW. LW typing is, at best, a difficult procedure. It is already well established that variation in the levels of LW antigen on different red blood cell samples, and variation of strength of different examples of antiLW, affect typing results and subsequent genetic interpretations. To these considerations must now be added the finding that zygosity of LW and In’ can have an effect, at least in terms of the LW, phenotype. Acknowledgment We are greatly indebted to Ms.1. Davis ofthe Billings Hospital of the University of Chicago for supplying us with blood specimens from the propositus and his family members.
References 1. Beck, M. L.: The LW system: A review and current concepts. I n : A Seminar on Recent Ad-
vances in Immunohematology, AABB, Washington, D.C.. 1973, p 83. 2. de Veber. L. L.. G. W. Clark, M. Hunking, and M. Stroup: Maternal anti-LW. Transfusion 11: 33, 1971. 3. : Letter to the Editor regarding the case
4. 5.
6.
7.
8. 9.
10.
11.
12.
Transfusion July-August 1978
reported in reference 2. above. Transfusion 11: 389, 1971. Giblett, E. R.: Genetic Markers in Human Blood, Philadelphia, Davis, 1969. Issitt, P. D.. and C. H. Issitt: Applied Blood Group Serology, 2nd Ed. Oxnard Spectra Biologicals, 1975. Polesky. H. F.. J. Swanson, and C. Olson: Guinea pig antibodies to? Rh-Hr precursor. Biblo. Haematol. 29:384, 1968. Rowe, A. W., and F. H. Allen. Jr.: Freezing of blood droplets in liquid nitrogen for use in blood group studies. Transfusion 5:379. 1965(Abst ract ). Swanson, J . , and G. A. Matson: Third example of a human ”D-like” antibody or anti-LW. Transfusion 4:257, 1964. , M. Azar, J. Miller, and J. J. McCullough: Evidence for heterogeneity of LW antigen revealed in a family study. Transfusion 14:470, 1974. Tippett, P. A.: Serological Study ofthe Inheritance of Unusual Rh and Other Blood Group Phenotypes. Ph.D. Thesis, Univ. of London, 1963. Vos, G. H., L. D. Petz, G. Garratty, and H. H. Fudenberg: Autoantibodies in acquired hemolytic anemia with special reference to the LW system. Blood 42:445, 1973. White, J. C., S. Rolih, S. L. Wilkinson. B. J . Hatcher, and P. D. Issitt: A new example of anti-LW and further studies on heterogeneity of the system. Transfusion 15:368. 1975.
Oscar Behzad, Technical Director, Special Laboratories, and Mohammad Pothiawala. M.T. (ASCP)SBB, Reference Laboratory Technologist, Mid-America Red Cross Blood Program, 43 East Ohio, Chicago. Illinois, 6061 1. Susan D. Rolih, M.S.. M.T. (ASCP)SBB, Supervisor. Serum Production and Teaching Laboratory and Peter D. lssitt, F.I.M.L.S., L.1.Biol.. (REPRINTS) Director of Laboratories and Associate Professor of Research Surgery, The Paul I. Hoxworth Blood Center of the University of Cincinnati, 3231 Burnet Avenue, Cincinnati, Ohio, 45267. Chang L. Lee, M.D., Director. Mount Sinai Hospital Blood Center, and Scientific Director, Mid-America Red Cross Program, and Professor of Medicine and Pathology. Rush Medical College, 2746 West 15th Street, Chicago, Illinois, 60608.
A family b described in which two members of the second generation are of the phenotype LW,. In the courae of the investigation the mother of the LW, propositus was at Brst believed to be phenotypidy LW, as well. Eventually, it was shown that she is, in fact, phenotypidy LWz but that her R-' (no D), LWlw, genotype had resulted in less LW being present on her red blood cells than is expected in LW, persons. This reduced level of LW could not be detected with one example of anti-LW made by an LW, individual.
used to describe D-positive, LW-positive red blood cells which carry more LW antigen than do any others. The D-negative, LW-positive phenotype is described as LW2for in the genotype R-' (no D), L W LW , the amount of LW antigen produced is less than in LW, but readily detected by most anti-LW antibodies. The terms LW, and LW, are used to describe the red blood THELW ANTIGEN is known to be phenocells of persons previously considered to typically related to the Rh antigens although be genetically LW-negative. Two phenoits production has been shown to be contype designations are in order for not all trolled by genes that do not reside at the such red blood cells carry the same amount CDE locus.1o For some time it was beof LW antigen, LW, samples have more lieved that two alleles could substitute at LW than do those that are LW,. LW, the LW locus. L W , in double or single people are able to make an anti-LW that dose, was thought to code for presence of reacts with LW, and LW, but not with LW antigen, while the presence of two rare other LW,, or with LW,, red blood cells. Iw alleles, at that locus, was thought to Weak examples of this antibody, which result in the LW-negative phenotype. More react only with LW, samples, may be misrecently, it has become apparent that the taken for anti-D unless adsorption tests only red blood cells that totally lack LW with D-negative (LW,) red blood cells are are those of the phenotype Rh,,,,. Vos er performed. LW, individuals are able to al." and Polesky ef ~ 1 demonstrated . ~ that make an anti-LW that reacts with LW,, the red blood cells of persons previously LW,, and LW,, but not with other LW,, considered to be genetically LW-negative, samples. White et a1.I2 have pointed out stimulate production of anti-LW when inthat if an anti-LW made by an LW, indijected into guinea pigs, just as do LW-posividual is used in typing tests, LW, red tive red blood cells. Further, Vos er al." blood cells may be classed as LWfound that red blood cells of some, prepositive and may not be differentiated from viously considered genetically LW-negative, other LW-positive samples. The phenopeople are able to adsorb some examples of types LW, and LW, both occur in D-posianti-LW to exhaustion. Based on these, tive and D-negative individuals thus showand other findings, several a ~ t h o r s have ~ * ~ * ~ing that the effect of D , in determining proposed a modified terminology to dethe LW, and LW, phenotypes, is apparscribe the various LW phenotypes. LW, is ently not at play in LW, and LW, persons. In all of the typing and adsorption studies that have been completed2.g*Y*11~12 no eviReceived for publication June 18,1977; accepted July 10. 1977. dence has been obtained to suggest a quali0041-1 132-78-0700-0488-0075 0 J. B. Lippincott Co. Volume 18 Number 4
488
Transfusion July-August 1978
Volume 18 Number 4
489
LW TYPING DIFFICULTY
tative difference between the LW antigen of the four phenotypes. It appears that the same LW antigen is present on the red blood cells of persons of all four phenotypes and decreases, quantitatively, in the sequence LWI, LW2, LW,, LW,. In spite of the serologic classification, described above, little is known about the genetic mechanism that results in the production of different strength LW antigens. For example, the same LW gene is probably responsible for the LW, and LW, phenotypes with its actions being influenced by the presence or absence of the gene L). Similarly, the same allele of LW (which will be called lw in this report) may well be responsible for the LW, and LW, phenotypes. The mechanism by which the genotype lwfw can result in either the phenotype LW,, or the phenotype LW4, is not known. Thus, although we appreciate the incongruity of using the symbol lw for a gene that allows some LW antigen to be made, we believe this to be justified at the present time. The alternative would be to introduce separate gene symbols to indicate the genetic backgrounds that result in the phenotypes LW, and LW, when there is, at present, scant evidence for any genetic difference. Similarly, the term L W will be used in this report to describe the gene whose presence results in the LW, phenotype in D-positive, and the LW2 phenotype in D-negative, individuals. In all probability, Rh,,,, individuals, whose red blood cells are LW-negative," have two LW genes that are unable to effect production of LW antigen in those individuals because of lack of suitable substrate for gene a c t i ~ n . ~ . ~ We describe here a new example of antiLW, made by an individual of the LW, phenotype. In the course of a family study, undertaken in an attempt to find compatible blood for the propositus, it initially appeared that not only a sib, but also the mother of the propositus, was LW,. Eventually we were able to demonstrate that the mother,
who is genetically R - 1 (no D), LWlw, has red blood cells of the LW2phenotype. However, the study has demonstrated yet another difficulty in the correct determination of red blood cell LW antigen status, namely that the red blood cells of a D-negative, LW heterozygote, may fail to react with some examples of anti-LW. case History F.P. is a 35-year-old Caucasian male. In September, 1976, he was admitted to the hospital having suffered severe bums over 22 per cent of his body in an industrial fire. On September 27, 1976, he was transfused with three units of whole blood. At that time no unexpected antibodies were found in his serum and the transfusions caused no untoward reaction. Prior to this occasion F.P. had never received a blood transfusion or an injection of blood. On October 19, 1976, two additional units of blood were ordered for transfusion to F.P. and it was at this time that an unexpected antibody, weakly reactive in albumin at 37 C, and more strongly reactive in indirect antiglobulin tests, was first detected. After the family study, reported below, F.P. was transfused with two units of washed red blood cells donated by his serologically compatible sister. These transfusions caused no ill effects and resulted in the expected increment of hemoglobin in the patient. Thereafter F.P. made an uneventful recovery from his bums.
Materials and Methods Red blood cells used in this study were fresh, or were stored by one of a number of conventional means. Those of F.P., and his family, were collected into anticoagulant and tested within five days of collection in Chicago. Immediately following collection, part of the blood sample from each of these individuals was frozen in glycerol. These glycerol preserved red blood cells were later shipped to Cincinnati and recovered there using a standard technique.s Other red blood cell samples used were from commercially supplied, antibody identification panels, stored in the preservative solutions employed by various companies. Some rare red blood cell samples (LW,, LW,, Rh,,,, etc.) had been stored frozen in liquid nitrogen prior to use.7 Antisera used were either commercially obtained reagents or antibodies identified in, or sent by other workers to, Chicago and Cincinnati. All noncommercially supplied sera had been
490
Transfusion
BEHZAD ET AL.
stored frozen. All typing and titration methods were standard ones that have been described el~ewhere.~
Results When first tested, the red blood cells of F.P. were shown to be group A, Rh(D) positive. Later his Rh phenotype was shown to be D + , C-, E + , c + , e + , for a probable Rh genotype of RZr.The presumed Rh genotypes of other members of the family are shown in Figure 1. In October, 1976, when the antibody in F.P.'s serum was first detected, full studies to determine antibody specificity were undertaken. It was found that the F.P. serum reacted with all samples on commercial red blood cell panels and with a large number of rare red blood cell samples (recovered from liquid nitrogen storage) known to lack high frequency antigens. However, the F.P. serum failed to react with two LW,, and with two RhnUllsamples, indicating the presence of anti-LW in the serum. Because blood was required to transfuse F.P., a family study was undertaken. Red blood cell samples from his parents and his two sibs, were tested
July-August 1578
with the propositus's anti-LW, an anti-LW made by an LW, individual (van der Weyst)s and an anti-LW made by an LW, (Big.)z.3Although not tested at the same time, red blood cells from F.P.'s wife and child were later typed with some of the same reagents. The results of all of these tests are shown in Table 1. Because the undiluted anti-LW of Big., reacted with all samples (including those of the propositus) a titration study was performed. The results of this study are included in Table 1. After the tests depicted in Table 1 were completed F.P. was transfused with the blood of his sister, M.J.S. The initial studies showed that F.P. and his sister are phenotypically LW,. Unexpectedly, however, the red blood cells of the mother of F.P. also appeared to be LW,. Since the mating that produced F.P. and M.J.S. was not believed to be consanguineous it seemed highly unlikely that the mother (G.P.) would be of the LW, phenotype. For this reason red blood cell samples of all family members and a serum sample from F.P. were referred to Cincinnati for further study. The anti-LW specificity of F.P.'s antibody was confirmed as it was shown to be nonreactive with the LW, red blood cells of S.C. and J.P.,I2
I ? .P.Sr
\
G o P o
R
rr
LFzi
L"2 LWtw
1
I
I1 4
J
F.P.Jr. R8r
R.P. R1r
W1 LW
m3
tutu
I11
w1
LWtw
M. 5 . 8 . R8r
*
BOPR8P
Lw
Lw1
t J W
LY
F I G . I . Results of studies of F.P. and his family to show presumed Rh genotypes, L W phenotypes, and interpretation of LW genotypes.
Volume 18 Number 4
49 1
LW TYPING DIFFICULTY Table 1. Initial L W Typing Results of F.P. and His Family Direct Tests with van der Weyst Anti-LW
Direct Tests with Big. Anti-LW
Titer Using Big. Anti-LW
Direct Tests with F.P.'s Anti-LW
2+
4+ 4+ 4+ 4+ 4+
64
3+ 0
F.P. Snr. (father) G.P. (mother) F.P. Jr. (propositus) M.J.S. (sister) B.P. (brother) R.P. (wife) J.P. (daughter)
0 0 0
2+ 2+ 2+
8 8 8
0 0
3+
64 N.T. N.T.
4+
4+
N.T. N.T.
NOTE:N.T. = not tested. the L W 4 red blood cells o f and with two Rh, samples different from those tested in Chicago. The red blood cells o f the family members were then tested with the anti-LW made by S.C. who is LW,,12 and with a different serum sample from Big. the LW, proposita of de Veber et a/.2.3The results o f these tests are shown in Table 2. As can be seen, the anti-LW from the LW, individual does not distinguish well between the L W , (F.P.Sr. and B.P.),LW, (G.P.)and LW, (F.P.Jr. and M.J.S.) red blood cells. On the other hand, the anti-LW from S.C., an LW, individual, makes a very clear differentiation.
Discussion It has already been establishedIz and is demonstrated again in this family, that if an anti-LW made by an LW, person is used, the LW, phenotype may be indistinguishable from the LW, and LW, phenotypes. With such findings it might appear that an LW-positive individual has produced antiLW that does not react with hidher own red blood cells. Although this situation might, at first, appear to represent heterogeneity of the LW antigen it is more likely to actually represent simple quantitative difference of LW antigen in different individuals. The family described in this current study demonstrates yet another difficulty in determining the actual LW phenotype of red blood cell samples. The figure shows the presumed Rh genotypes (based on serologic tests for Rh phenotypes), the observed LW phenotypes, and the interpreted LW genotypes of the family members. As can be
seen, 1-1 and 1-2 have produced two (11-2 and 11-3) LW, children. It follows, therefore, that 1-1 and 1-2 must each be genetically LWlw (using the lw gene notation as defined earlier). 1-1 is Rh(D) positive and 1-2 is Rh(D) negative. Apparently the genotype R - 1 (no D), LWlw, results in less LW antigen being made than the genotype R-' (no D), L W LW , for it initially appeared that 1-2 was phenotypically LW,, not LW,. By using a more potent anti-LW from an LW, individual,I2 than that used in the original typings, the true LW, status of 1-2 was determined. The anti-LW used in the initial typings was from van der Weysts and had been stored frozen in Chicago for about 12 years. It appears that during that time the antibody had deteriorated to the point that it was unable to detect the reduced amount of LW antigen on the red blood cells of the Rh(D)-negative, LWlw, individual. However, this deterioration was not apparent from control tests using LW,( L W LW ) , LW2 ( LW LW )and LW,( lwlw) red blood cell samTable 2. Additional L W Typing Results of F.P. and His Family
F.P. Snr. (father) G.P. (mother) F.P. Jr. (propositus) M.J.S. (sister) B.P. (brother)
Tests with S.C. Anti-LW
Tests with Big. Anti-LW
4+
3+
2+ 0 0
2+ 2+ 3+ 3+
4+
BEHZAD ET AL.
ples. Further, it can be anticipated that other examples of anti-LW from LW, persons might similarly fail to detect the reduced LW of Rh(D)-negative, LWIw, heterozygotes, if weaker than the anti-LW from S.C. that was used in later studies. As stated, F.P.’s transfusion needs were met with blood from his LW, sister. However, it is entirely possible that his genetically R-’(no D ) , LWlw, mother would also have been a suitable donor. Since antibodies detect red blood cell-borne antigens, and do not define genetic backgrounds, the mother’s LW, red blood cells, with their low level of LW antigen, might well have been unaffected in vivo by F.P.’s anti-LW. LW typing is, at best, a difficult procedure. It is already well established that variation in the levels of LW antigen on different red blood cell samples, and variation of strength of different examples of antiLW, affect typing results and subsequent genetic interpretations. To these considerations must now be added the finding that zygosity of LW and In’ can have an effect, at least in terms of the LW, phenotype. Acknowledgment We are greatly indebted to Ms.1. Davis ofthe Billings Hospital of the University of Chicago for supplying us with blood specimens from the propositus and his family members.
References 1. Beck, M. L.: The LW system: A review and current concepts. I n : A Seminar on Recent Ad-
vances in Immunohematology, AABB, Washington, D.C.. 1973, p 83. 2. de Veber. L. L.. G. W. Clark, M. Hunking, and M. Stroup: Maternal anti-LW. Transfusion 11: 33, 1971. 3. : Letter to the Editor regarding the case
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reported in reference 2. above. Transfusion 11: 389, 1971. Giblett, E. R.: Genetic Markers in Human Blood, Philadelphia, Davis, 1969. Issitt, P. D.. and C. H. Issitt: Applied Blood Group Serology, 2nd Ed. Oxnard Spectra Biologicals, 1975. Polesky. H. F.. J. Swanson, and C. Olson: Guinea pig antibodies to? Rh-Hr precursor. Biblo. Haematol. 29:384, 1968. Rowe, A. W., and F. H. Allen. Jr.: Freezing of blood droplets in liquid nitrogen for use in blood group studies. Transfusion 5:379. 1965(Abst ract ). Swanson, J . , and G. A. Matson: Third example of a human ”D-like” antibody or anti-LW. Transfusion 4:257, 1964. , M. Azar, J. Miller, and J. J. McCullough: Evidence for heterogeneity of LW antigen revealed in a family study. Transfusion 14:470, 1974. Tippett, P. A.: Serological Study ofthe Inheritance of Unusual Rh and Other Blood Group Phenotypes. Ph.D. Thesis, Univ. of London, 1963. Vos, G. H., L. D. Petz, G. Garratty, and H. H. Fudenberg: Autoantibodies in acquired hemolytic anemia with special reference to the LW system. Blood 42:445, 1973. White, J. C., S. Rolih, S. L. Wilkinson. B. J . Hatcher, and P. D. Issitt: A new example of anti-LW and further studies on heterogeneity of the system. Transfusion 15:368. 1975.
Oscar Behzad, Technical Director, Special Laboratories, and Mohammad Pothiawala. M.T. (ASCP)SBB, Reference Laboratory Technologist, Mid-America Red Cross Blood Program, 43 East Ohio, Chicago. Illinois, 6061 1. Susan D. Rolih, M.S.. M.T. (ASCP)SBB, Supervisor. Serum Production and Teaching Laboratory and Peter D. lssitt, F.I.M.L.S., L.1.Biol.. (REPRINTS) Director of Laboratories and Associate Professor of Research Surgery, The Paul I. Hoxworth Blood Center of the University of Cincinnati, 3231 Burnet Avenue, Cincinnati, Ohio, 45267. Chang L. Lee, M.D., Director. Mount Sinai Hospital Blood Center, and Scientific Director, Mid-America Red Cross Program, and Professor of Medicine and Pathology. Rush Medical College, 2746 West 15th Street, Chicago, Illinois, 60608.
