Hemolytic transfusion reactions due to anti-e+f detectable only by nonstandard serologic techniques

A patient was transfused with a total of 14 units of red blood cells (RBCs) over 33 days (January 14 to February 15) at two hospitals. Febrile transfusion reactions were noted on three occasions, and hemoglobinuria was seen twice. Alloantibodies were not detected in a sample dated February 14, following a transfusion reaction, and this sample was referred to the North London Blond Transfusion Centre. Further samples were also obtained from before and after all transfusions at both hospitals. The patient's RBCs typed as A, D+, probable Rh phenotype (cDE/cDE). The direct antiglobulin test was negative, and serum samples following the second transfusion were red/brown in color. Serologic investigations were inconclusive on all samples taken until February 13 (after the fourth transfusion). At this time, a weak anti-e reacting by manual polybrene technique and an anti-e+f reacting by two-stage papain technique were detected. The serum also contained potent HLA antibodies. The patient subsequently received leukocyte-depleted group A, cDE/cDE RBCs with out any untoward effect. This case demonstrates the importance of a complete transfusion history and emphasizes that alloantibodies detectable only by nonstandard techniques can be clinically significant.