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Adverse Occurrence type:
Time to detection:
Alerting signals, symptoms, evidence of occurrence:
Twenty-five minutes (60 mL) into the transfusion the patient developed back pain, dyspnea, wheeze, chills and rigors.
Demonstration of imputability or root cause:
Post transfusion plasma sample demonstrated hemoglobinemia. Positive direct antiglobulin test with elution of anti-A1 from the RBCs. Post transfusion decrease in hemoglobin and increased lactate dehydrogenase (LDH) levels
Suggest new keywords:
Preece, J., Magrin, G., Webb, A., Akers,C. and Davis, A. Transfusion medicine illustrated. A bloody mistake: unrecognized warm reactive anti-A1 resulting in acute hemolytic transfusion reaction. Transfusion 51(5):914-915.
Expert comments for publication:
A case report, where the presence of warm reacting anti-A1 was missed as the reaction pattern observed was attributed to transfusion of B plasma in a AB patient. This anti-A1 resulted in acute hemolytic reaction. It is not clear why the patient was not typed as A2B with interfering anti-A1 earlier. Patient received autologous bone marrow transplant for myeloma and should have been typed before the transplant.