Hemolysis induced cross-matching difficulty with intravenous immunoglobulin: a case report

Intravenous immunoglobulin is one of the most common modalities of treatment for Guillain-Barré syndrome. Although minor complications are easily preventable with pre-medications, rare complications like hemolysis occur at unexpected times and carry risks of repeated transfusions. A complication like difficulties in cross-matching blood is an uncommon event and is often not anticipated. We present one such rare case.

A 56-year-old man of Asian origin had presented to our hospital with rapidly progressive weakness of bilateral upper and lower limbs over 4 days. Guillain-Barré syndrome was diagnosed by nerve conduction velocity testing and lumbar puncture examination. On the third day of admission in hospital he was intubated because of respiratory failure. Intravenous immunoglobulin at 0.4 mg/kg per day for 5 days was planned and started. Our patient was scheduled for tracheostomy on a routine basis anticipating prolonged requirement of ventilator support. As the blood was being arranged, the blood bank facilities informed us about difficulties in cross-matching of the blood. Repeated samples and attempts at cross-matching were futile. After reviewing the available literature and diagnosing a case of hemolysis, relevant tests were performed and they were positive.

Anti-A and anti-B antibody present in intravenous immunoglobulin preparations sensitize the red blood cells to hemolysis and this occurrence is often incriminated as a cause of cross-matching and sometimes blood grouping difficulty. Although a high dose of intravenous immunoglobulin or repeated courses are often cited as reasons for hemolysis, individual variability in responses is common and it is not surprising to see one like we had in our case.