1

MEDICAL TECHNOLOGY ASSESSMENT PROGRAM 2 (MTAP2)

IMMUNOHEMATOLOGY
CASE STUDY

Name: ALCALA, KARA F.

Answer the questions of the given cases.

Case 1: Mr. Paul, a 55 year old, was admitted with an intestinal obstruction. The following results were recorded by the
blood bank technologist:
Forward Grouping Reverse Grouping Rh Testing

Anti-A Anti-B A1 cells B cells Anti-D D control

Mr. Paul 4+ 1+ 0 4+ 3+ 0

ANTIBODY SCREEN
Screening Cell I Screening Cell II Screening Cell III Autocontrol

Mr. IS 37 AHG CC IS 37 AHG CC IS 37 AHG CC IS 37 AHG CC

Paul
0 0 0 4+ 0 0 0 3+ 0 0 0 3+ 0 0 0 4+
Abbreviations: IS –Immediate Spin; 37-37oC incubation; AHG-Antihuman globulin; CC- check cells

1. What is Mr. Paul’s probable ABO type?

According to the above results, Paul's blood type in forward blood typing is AB; nevertheless, in his
reverse blood typing results, his type is A. He also tested positive for Rh. So, this indicates that Paul's blood
type is most likely an A (Rh D) positive or A+.

2. What is the discrepant result in ABO grouping?

Forward typing shows that the response with anti-B is substantially weaker, with a 1+ agglutination
reaction, than of the anti-A, which has a 4+ agglutination reaction. Thus, the 1+ reaction with anti-B in the
forward typing is the discrepant result.

3. Explain the phenomenon that caused this pattern, and briefly describe two processes by which this can occur.

The situation can be associated with an acquired B phenotype, given that these antigens can occur
from the presence of a bacteria due to an intestinal obstruction, which is Paul’s medical condition for
why he is admitted.

There are two processes that can result in the acquisition of B. Firstly, this phenomenon can be
associated by a bacterial enzymatic effect on the A receptors in the group A1 individual. This alters the
group A immunodominant sugar, N-acetyl-D-galactosamine into D-galactosamine - leading it to cross react
with the anti-B antisera. Secondly, this phenomena appears to be associated with carcinoma of the colon
or rectum, infection with gram negative organisms and intestinal obstruction because of the absorption of
B-like bacterial polysaccharides into cells. This explains why Paul’s RBC antigens appear to be group AB
with a weak B antigen, but the serum only contains Antibody B.

Questions retrieved from Senior Seminar Blood Bank Case studies

 2

4. What bacteria are most likely involved?

The bacteria most likely implicated are Escherichia coli O-86, which has a high blood group B activity and a
low blood group A activity. This is due to the structure of the cell surface O-antigen, which is similar to that
of human blood group B antigen. The other is Proteus vulgaris, which can remain dormant in the intestines.

5. What steps would you take to confirm your suspicions?

➢ Check the patient's diagnosis.
○ Because this is linked to colorectal cancer, gastrointestinal blockage, or gram-negative
sepsis.
➢ Test the patient's serum against autologous red cells.
○ Since introducing the patient's own serum to his RBCs (auto-incubation) indicates no
incompatibility.
➢ Test the patient's RBCs with monoclonal anti-B reagent or use a different kind of monoclonal
anti-B in the patient's red cell grouping test
○ Because non-human monoclonal antibodies will not react with acquired B antigen.
➢ Acidify the patient's RBC reaction mixture with human anti-B (non-self) to pH 6.0
○ Since the Acquired B will not react with anti-B at pH 6.0
➢ Incubate the acquired B RBCs in acetic anhydride
○ This can lead to the "re-acetylation" of the modified A antigen and loss of B-like activity.

6. Is the result of the antibody screen useful? Why or why not?

The antibody screen was useful because the negative antibody screen results demonstrated that the
existence of common alloantibodies and autoantibodies in the Patient's serum had been eliminated, and it
assisted in shifting the medical technologist's emphasis to other causes of ABO discrepancies.

7. a. Define secretor.
The term “secretor,” which is utilized in blood banking, refers to the production of ABH antigens
in bodily fluids such as saliva, sweat, tears, sperm, and serum. People who are secretors will secrete
antigens based on their blood group. For example, people in group O will secrete H antigen, while
people in group A will secrete A and H antigens.

b. What percent of the population are secretors?

A large percentage of people, specifically 80%, are secretors, which means that antigens found
in the blood are also found in other body fluids such as saliva.

c. Assuming he is SeSe, what ABO antigens will be present in Mr. Paul’s secretions?

H and A antigens would be present in Paul's secretions since he is in blood group A. Because
he lacks the B gene, B antigens would not be found in his secretions.

8. Will Paul’s ABO reactions convert back to normal? If so, when?

As soon as the infection or other medical condition causing contact with bacterial enzymes
clears, the ABO difference will diminish. Also, when the underlying cause of the bacterial enzyme
removal of the acetyl group is identified, a patient's blood type will no longer show an acquired B
antigen.
Questions retrieved from Senior Seminar Blood Bank Case studies
 3

Case 2: Ms. Liza, a 25 year-old woman pregnant with her second child, had routine orders for a “type and screen” with
the following results:
Forward Grouping Reverse Grouping Rh Testing

Anti-A Anti-B A1 cells B cells Anti-D D control

Ms. Liza 3+ 0 0 4+ 4+ 0

ANTIBODY SCREEN
Screening Cell I Screening Cell II Screening Cell III Autocontrol

Ms. IS 37 AHG CC IS 37 AHG CC IS 37 AHG CC IS 37 AHG CC

Liz
a 0 0 0 4+ 0 2+ 3+ 0 2+ 3+ 3+ 0 0 0 4+
Abbreviations: IS –Immediate Spin; 37-37oC incubation; AHG-Antihuman globulin; CC- check cells

1. What is Liza’s blood type?

Liza’s Blood type is A Rh D (Positive) or A+

2. What would be the interpretation of the antibody screen?

The antibody screen came up positive. This means that Liza's serum contains unexpected antibodies.

3. What immunoglobulin class is the most probable for this antibody?

Since the immediate spin (IS) is negative and the strongest stage of reaction was with the antihuman
globulin (AHG) phase, immunoglobulin G or IgG is the most likely antibody, indicating that the antibody
causing a positive antibody screen is a warm-reacting antibody.

4. Is the antibody an alloantibody and/or autoantibody? Can either be ruled out? Explain.

It is a type of alloantibody. On the evidence of the negative control, autoantibody can be

excluded.

5. What detail in the patient history would provide further evidence for your answer to question 4?

It has been previously stated above that Liza's pregnant with her second child, implying that Lisa
had a previous pregnancy. So, perhaps she was sensitized with her first child.

6. What procedure would the technologist perform next?

If the antibody screen shows that antibodies are present in the serum in one or more screen
cells, a more definitive test termed antibody identification or panel is conducted. The antibody
detected in the antibody screen is identified using an antibody panel.

Questions retrieved from Senior Seminar Blood Bank Case studies

 4

7. How are antibodies ruled out in the cross-out method of antibody panel interpretation? Explain the procedure
in two or three sentences.

Firstly, the method by which antibodies are recognized as unlikely in a given sample due to the
absence of reaction observed with a cell that is positive for the relevant antigen is known as rule-out.
Secondly, antibodies that could not be responsible for the observed responses are ruled out or rejected.
Lastly, a cell must not have reacted in any phase of testing in a specific panel or screen to be categorized
as non-reactive.

Take a look at this antibody panel done for Ms. Liza:

8.
Why are antibodies ruled out only when there is no reaction with homozygous cells?

Most laboratories will rule-out utilizing only cells that are homozygous for the relevant antigen
for those systems commonly show dosage to ensure that rule-out will not inadvertently eliminate a
weakly-reacting antibody that exhibits dosage. Generally these include: Anti-M, anti-N, anti-S, anti-s,
anti-C, anti-E, anti-c, anti-e, anti-Fya, anti-Fyb, anti-Jka, and anti-Jkb antibodies.

9. What antibody (ies) cannot be ruled out by the panel results?

Anti-E, anti-c, anti-f, anti-V, anti-M, anti-N, anti-Lua, anti-K, anti-Jsa, and anti-Fya antibodies
cannot be ruled out. Because the cells were with heterozygous dosage effect, anti-M, anti-N, anti-K,
and anti-Fya antibodies were not ruled out.

10. What is/are the most likely antibody (ies)? Why?

Because the pattern of reactions with the patient's serum corresponds closely with the c antigen
column, it is positive with cells 1 to 6, 10, and 11. But it is negative with cells 7 to 9. So, the most likely
antibody is anti-c.

Questions retrieved from Senior Seminar Blood Bank Case studies

 5

11. a. Discuss the 3 + 3 Rule (rule of three).

This rule of three denotes that at least three cells in the panel must be positive for the antigen and
respond with the antibody, whereas at least three cells must be negative for the antigen and do not react
with the antibody. If three cells that express the antigen in issue all respond with the patient's plasma,
and three cells that do not express the antigen are all non-reactive, the antibody is thought to have
established specificity against the antigen in question.

b. Do(es) the antibodies(y) you identified in Question 10 meet the 3 + 3 rule?

Yes. The anti-c antibody identified actually fits the conditions of the rule of three.

Ms. Liza was phenotyped for the following antigens:

Anti-C Anti-c Anti-E Anti-e Anti-K

Ms. Liza 3+ 0 2+ 2+ 3+

12. a. What is Liza’s Fisher-Race phenotype?

Liza’s Fisher-Race phenotype is DCCEe. The antigen phenotype adds to the evidence supporting
anti-c and ruling out anti-E. Lisa is c-negative, ruling out anti-E and anti-K alloantibodies. Anti-f is
also ruled out because Lisa is c negative since a patient of c negative or e negative, indicates that he
or she is f negative.

b. Does Liza’s antigen phenotype confirm or conflict with your antibody identification?

No. Lisa is c-negative, which enables the ruling out of anti-E and anti-K alloantibodies. Anti-f is
also ruled out because Lisa is c negative since a patient of c negative or e negative, indicates that he
or she is f negative.

13. Does the screening cell antigram (above) confirm or refute your antibody identification?

Yes. The screening antigram aided in the detection of anti-c.

14. How would you rule out the remaining antibodies?

Additional cells that can be created include the following. If anti-c is the only antibody present,
these five cells should be negative with the patient's serum. The antibodies are ruled out if they are
negative. Lua is rarely clinically significant.

a 2 cells: c negative
V positive

b 1 cell: c negative
M positive

Questions retrieved from Senior Seminar Blood Bank Case studies

 6

N negative

c 1 cell: c negative
N positive
M negative

d 1 cell: c negative
Jsa positive

e c negative: Fya positive

Fyb negative

15. If Lisa required crossmatching for 3 U, what additional step would be added to the crossmatch procedure?

Since the crossmatch units must be c negative, antigen typing for c-negative units is added to the
crossmatch technique.

Questions retrieved from Senior Seminar Blood Bank Case studies