ARTICLE IN PRESS Transfusion and Apheresis Science ■■ (2014) ■■–■■
Contents lists available at ScienceDirect
Transfusion and Apheresis Science j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / t r a n s c i
Case Report
Red cell antigen loss in a patient with chronic myeloid leukemia: A case of ABO discrepancy Maria Shafiq, Farheen Karim * Section of Hematology, Department of Pathology and Microbiology, The Aga Khan University Hospital, Karachi, Pakistan
A R T I C L E
I N F O
Article history: Received 13 October 2014 Accepted 7 November 2014 Keywords: ABO Discrepancy Myeloid Leukemia
A B S T R A C T
Change in ABO antigen expression on the surface of neoplastic cells have been seen for a variety of tumor types. This phenomenon has been linked with myeloid neoplasms as well but is reported infrequently. Here, we report a rare cause of ABO discrepancy in an elderly female having chronic myeloid leukemia. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction The ABO blood group system is considered to be the most important blood group system in transfusion medicine and organ transplantation [1]. The blood group antigens present on red cell membrane are either sugar or proteins and they determine an individual’s blood group. Correct identification of blood group of an individual is of utmost importance as errors can lead to fatal transfusion reactions [2]. A discrepancy in blood group exists when reactions in forward typing fail to match with the reverse typing or when there is no concordance between the previous and the current results [2]. It is essential that all ABO group discrepancies are resolved through detailed blood typing for proper identification of a person’s blood group [3]. Among the many causes of ABO discrepancies, alteration or loss of ABH antigens from the red cell surface secondary to an underlying malignancy is a rare cause. Changes in ABO antigen expression on the surface of neoplastic cells have been seen for a variety of tumor types [4]. This phenomenon has been linked with myeloid neo-
* Corresponding author. Section of Hematology, Department of Pathology and Microbiology, The Aga Khan University Hospital, Stadium Road, Karachi 74800, Pakistan. Tel.: +00 92 213 4861307; fax: +00 92 213 4934294. E-mail address: [email protected] (F. Karim).
plasms as well but is reported infrequently [5]. Here, we report a rare cause of ABO discrepancy in an elderly female having chronic myeloid leukemia. 2. Case report We received blood sample of a 60-year-old-lady for blood grouping and cross matching. Blood group was performed by gel card method [Diamed-Switzerland] with commercially available antisera. The blood grouping results showed no agglutination with Anti-A and Anti-B in forward typing. In the reverse typing, there was a 4 + agglutination with B cells only whereas no agglutination with A cell. In order to resolve this discrepancy, the test was repeated on same sample. The results turned out to be similar. For further workup, a fresh blood sample along with patient’s history was requested by blood bank. Patient’s history revealed that her blood group was reported as A positive in the past. She had developed chronic myeloid leukemia 3 years back and was currently being treated at some cancer hospital. The fresh sample was tested on gel card as well as by tube method. Similar kind of reactions was observed with the fresh sample as well. The sample was incubated at 4 °C for 30 minutes. After incubation, the forward testing showed very weak reaction with Anti-A. The rest of the reactions remained the same. Elution and adsorption studies were also performed. Patient’s red
http://dx.doi.org/10.1016/j.transci.2014.11.004 1473-0502/© 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Maria Shafiq, Farheen Karim, Red cell antigen loss in a patient with chronic myeloid leukemia: A case of ABO discrepancy, Transfusion and Apheresis Science (2014), doi: 10.1016/j.transci.2014.11.004
ARTICLE IN PRESS M. Shafiq and F. Karim/Transfusion and Apheresis Science ■■ (2014) ■■–■■
2
cells were incubated with Anti-A sera, followed by elution of adsorbed Anti-A on patient’s cells. That eluate was then tested with three group A and group O red cells each obtained from three different blood donors. The eluate showed positive results with A red cells while negative reaction with group O red cells. The Auto control and direct anti globulin test were also performed which were negative. Based on the current results, the previous blood group and history of the patient, it was concluded that patient had blood group A and the discrepancy in this case was due to decreased expression of A antigens from the surface of the red cells secondary to underlying leukemia. 3. Discussion A rare cause of ABO discrepancy was observed in this case with loss of A antigens from red cells most likely secondary to chronic myeloid leukemia. ABO blood group genes are mapped at 9q34.2 region which is the common site of genetic alteration in many cancers. Change in ABH antigens related to hematologic malignancy was first reported in 1975 when it was observed that a patient with acute myeloid leukemia expressed weak A antigen on red cells while previously he had normal A antigenic expression [6]. Since then, this phenomenon has been described in few case reports. It is now known that the loss of A or B antigens in myeloid leukemias may be secondary to decreased expression of H antigen or an intrinsic decrease of A or B antigens themselves [5]. Loss of ABO has been reported in few pa-
tients with chronic myeloid leukemia but it is not a common observation and thus it is assumed that it is not related to Philadelphia translocation [7]. Detailed workup including proper history is essential in resolving ABO discrepancies. We emphasize that rare causes should be kept in mind when resolving such cases. Authors contribution MS wrote the initial manuscript and took the images. FK diagnosed the case, reviewed and edited the final manuscript. References [1] Novaretti MC, Domingues AE, Manhani R, et al. ABO genotyping in leukemia patients reveals new ABO variant alleles. Genet Mol Res 2008;7(1):87–94. [2] Sharma T, Garg N, Singh B. ABO blood group discrepancies among blood donors in Regional Blood Transfusion Centre GTB Hospital, Delhi, India. Transfus Apher Sci 2014;50(1):75–80. [3] Khan MN, Khan TA, Ahmed Z. Discrepancy in ABO blood grouping. J Coll Physicians Surg Pak 2013;23(8):590–2. [4] Gates MA, Xu M, Chen WY, Kraft P, et al. ABO blood group and breast cancer incidence and survival. Int J Cancer 2012;130(9):2129–37. [5] Bianco T, Farmer BJ, Sage RE, Dobrovic A. Loss of red cell A, B, and H antigens is frequent in myeloid malignancies. Blood 2001;97(11): 3633–9. [6] Van Loghem JJ Jr, Dorfmeier H, Van Der Hart M. Two A antigens with abnormal serologic properties. Vox Sang 1957;2(1):16–24. [7] Salmon C, Cartron JP, Lopez M, et al. Level of the A, B and H blood group glycosyltransferases in red cell membranes from patients with malignant hemopathies. Rev Fr Transfus Immunohematol 1984;27: 625–37.
Please cite this article in press as: Maria Shafiq, Farheen Karim, Red cell antigen loss in a patient with chronic myeloid leukemia: A case of ABO discrepancy, Transfusion and Apheresis Science (2014), doi: 10.1016/j.transci.2014.11.004
Contents lists available at ScienceDirect
Transfusion and Apheresis Science j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / t r a n s c i
Case Report
Red cell antigen loss in a patient with chronic myeloid leukemia: A case of ABO discrepancy Maria Shafiq, Farheen Karim * Section of Hematology, Department of Pathology and Microbiology, The Aga Khan University Hospital, Karachi, Pakistan
A R T I C L E
I N F O
Article history: Received 13 October 2014 Accepted 7 November 2014 Keywords: ABO Discrepancy Myeloid Leukemia
A B S T R A C T
Change in ABO antigen expression on the surface of neoplastic cells have been seen for a variety of tumor types. This phenomenon has been linked with myeloid neoplasms as well but is reported infrequently. Here, we report a rare cause of ABO discrepancy in an elderly female having chronic myeloid leukemia. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction The ABO blood group system is considered to be the most important blood group system in transfusion medicine and organ transplantation [1]. The blood group antigens present on red cell membrane are either sugar or proteins and they determine an individual’s blood group. Correct identification of blood group of an individual is of utmost importance as errors can lead to fatal transfusion reactions [2]. A discrepancy in blood group exists when reactions in forward typing fail to match with the reverse typing or when there is no concordance between the previous and the current results [2]. It is essential that all ABO group discrepancies are resolved through detailed blood typing for proper identification of a person’s blood group [3]. Among the many causes of ABO discrepancies, alteration or loss of ABH antigens from the red cell surface secondary to an underlying malignancy is a rare cause. Changes in ABO antigen expression on the surface of neoplastic cells have been seen for a variety of tumor types [4]. This phenomenon has been linked with myeloid neo-
* Corresponding author. Section of Hematology, Department of Pathology and Microbiology, The Aga Khan University Hospital, Stadium Road, Karachi 74800, Pakistan. Tel.: +00 92 213 4861307; fax: +00 92 213 4934294. E-mail address: [email protected] (F. Karim).
plasms as well but is reported infrequently [5]. Here, we report a rare cause of ABO discrepancy in an elderly female having chronic myeloid leukemia. 2. Case report We received blood sample of a 60-year-old-lady for blood grouping and cross matching. Blood group was performed by gel card method [Diamed-Switzerland] with commercially available antisera. The blood grouping results showed no agglutination with Anti-A and Anti-B in forward typing. In the reverse typing, there was a 4 + agglutination with B cells only whereas no agglutination with A cell. In order to resolve this discrepancy, the test was repeated on same sample. The results turned out to be similar. For further workup, a fresh blood sample along with patient’s history was requested by blood bank. Patient’s history revealed that her blood group was reported as A positive in the past. She had developed chronic myeloid leukemia 3 years back and was currently being treated at some cancer hospital. The fresh sample was tested on gel card as well as by tube method. Similar kind of reactions was observed with the fresh sample as well. The sample was incubated at 4 °C for 30 minutes. After incubation, the forward testing showed very weak reaction with Anti-A. The rest of the reactions remained the same. Elution and adsorption studies were also performed. Patient’s red
http://dx.doi.org/10.1016/j.transci.2014.11.004 1473-0502/© 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Maria Shafiq, Farheen Karim, Red cell antigen loss in a patient with chronic myeloid leukemia: A case of ABO discrepancy, Transfusion and Apheresis Science (2014), doi: 10.1016/j.transci.2014.11.004
ARTICLE IN PRESS M. Shafiq and F. Karim/Transfusion and Apheresis Science ■■ (2014) ■■–■■
2
cells were incubated with Anti-A sera, followed by elution of adsorbed Anti-A on patient’s cells. That eluate was then tested with three group A and group O red cells each obtained from three different blood donors. The eluate showed positive results with A red cells while negative reaction with group O red cells. The Auto control and direct anti globulin test were also performed which were negative. Based on the current results, the previous blood group and history of the patient, it was concluded that patient had blood group A and the discrepancy in this case was due to decreased expression of A antigens from the surface of the red cells secondary to underlying leukemia. 3. Discussion A rare cause of ABO discrepancy was observed in this case with loss of A antigens from red cells most likely secondary to chronic myeloid leukemia. ABO blood group genes are mapped at 9q34.2 region which is the common site of genetic alteration in many cancers. Change in ABH antigens related to hematologic malignancy was first reported in 1975 when it was observed that a patient with acute myeloid leukemia expressed weak A antigen on red cells while previously he had normal A antigenic expression [6]. Since then, this phenomenon has been described in few case reports. It is now known that the loss of A or B antigens in myeloid leukemias may be secondary to decreased expression of H antigen or an intrinsic decrease of A or B antigens themselves [5]. Loss of ABO has been reported in few pa-
tients with chronic myeloid leukemia but it is not a common observation and thus it is assumed that it is not related to Philadelphia translocation [7]. Detailed workup including proper history is essential in resolving ABO discrepancies. We emphasize that rare causes should be kept in mind when resolving such cases. Authors contribution MS wrote the initial manuscript and took the images. FK diagnosed the case, reviewed and edited the final manuscript. References [1] Novaretti MC, Domingues AE, Manhani R, et al. ABO genotyping in leukemia patients reveals new ABO variant alleles. Genet Mol Res 2008;7(1):87–94. [2] Sharma T, Garg N, Singh B. ABO blood group discrepancies among blood donors in Regional Blood Transfusion Centre GTB Hospital, Delhi, India. Transfus Apher Sci 2014;50(1):75–80. [3] Khan MN, Khan TA, Ahmed Z. Discrepancy in ABO blood grouping. J Coll Physicians Surg Pak 2013;23(8):590–2. [4] Gates MA, Xu M, Chen WY, Kraft P, et al. ABO blood group and breast cancer incidence and survival. Int J Cancer 2012;130(9):2129–37. [5] Bianco T, Farmer BJ, Sage RE, Dobrovic A. Loss of red cell A, B, and H antigens is frequent in myeloid malignancies. Blood 2001;97(11): 3633–9. [6] Van Loghem JJ Jr, Dorfmeier H, Van Der Hart M. Two A antigens with abnormal serologic properties. Vox Sang 1957;2(1):16–24. [7] Salmon C, Cartron JP, Lopez M, et al. Level of the A, B and H blood group glycosyltransferases in red cell membranes from patients with malignant hemopathies. Rev Fr Transfus Immunohematol 1984;27: 625–37.
Please cite this article in press as: Maria Shafiq, Farheen Karim, Red cell antigen loss in a patient with chronic myeloid leukemia: A case of ABO discrepancy, Transfusion and Apheresis Science (2014), doi: 10.1016/j.transci.2014.11.004
