Resolution of Serologic Problems Due to Cold Agglutinins in Chronic Lymphocytic Leukemia

Autoimmune hemolytic anemia can be classified depending on presence of warm, cold or mixed type of autoantibodies that are directed against antigens on the red blood cell surface. Here we report a case of pathological cold agglutinin disease which was eventually detected due to blood group discrepancy.

A request was sent to the blood bank for two units of packed red cells in a diagnosed case of CLL which showed type IV discrepancy during blood grouping.The discrepancy was subsequently resolved after warm saline washing of red cells along with repetition of reverse grouping with pre-warmed serum. The direct antiglobulin test was positive and revealed autoanibodies against C3b/C3d only. Indirect antiglobulin test was performed with 3-cell panel in a polyspecific gel card (IgG+C3d) showed a pan-reactive pattern along with a positive autocontrol. Subsequently a cold agglutinin titration was performed and titers of 1024 at 4 °C; titer of 2 at room temperature were detected. Dithiothreitol (DTT) treatment of serum was undertaken and IgM type of autoantibody was detected in this case confirming a case of secondary cold agglutinin disease in this patient. Two units of red cells were transfused to this patient after successfully performing cross-match with pre-warmed serum. It was advised from the blood bank that the blood should be transfused slowly through a blood-warmer and patient should be kept in warm condition to avoid in-vivo hemolysis due to high titer of cold agglutinin. The transfusion was uneventful and patient is on regular follow-up till now.

Thus we concluded that serological discrepancies observed in blood bank can successfully guide the bedside transfusion protocol in case of cold agglutinin disease.