Status:
Ready to upload
Record number:
1605
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
Case report
Time to detection:
hours
Alerting signals, symptoms, evidence of occurrence:
Hours after receiving IVIG patient began noticing urinary discoloration which progressed to jaundice, right-sided chest pain, palpitations, and dyspnea.
Demonstration of imputability or root cause:
Patients hemoglobin (Hb) level decreased from the baseline of 12.9 mg/dL to 8.4 mg/dL within 3-days on IVIG administration. A sample of centrifuged whole blood was frankly hemoglobinemic, while the urine appeared red. The peripheral blood film demonstrated marked spherocytosis with some agglutination and polychromasia, not present at baseline. Laboratory investigations indicated hemolysis.
Patient was an ABO mismatch bone marrow transplant recipient (patient O and recipient A) and she typed as A1 RhD positive. Post IVIG patient had a positive DAT (polyspecific 1+ for IgG with anti-A IgG eluted, negative for C3d), together with the acquisition of a (new) 2+ reaction toward A1 cells on reverse typing.
Imputability grade:
3 Definite/Certain/Proven
Groups audience:
Keywords:
Suggest new keywords:
hemolysis after IVIG
anti-A in IVIG
Positive MMA
Synergizing host factors
Reference attachment:
Suggest references:
Michelis, F. V., Branch, D. R., Scovell, I., Bloch, E., Pendergrast, J., Lipton, J. H. and Cserti-Gazdewich, C. M. (2014). Acute hemolysis after intravenous immunoglobulin amid host factors of ABO-mismatched bone marrow transplantation, inflammation, and activated mononuclear phagocytes, Transfsuion 54(3):681-690.
Expert comments for publication:
A case of severe post IVIG hemolysis likely due to synergizing host factors like obesity-unadjusted dosing and existing inflammation. This was demonstrated by:
1. MMA revealed significant activity between patient RBCs, monocytes, and IVIG. However, normal A1 cells opsonized with IVIG were not significantly phagocytosed by either normal or patient monocytes.
2. Proinflammatory markers were significantly elevated before and after IVIG
3. Even though there were signs of intravascualar hemolysis, there was no evidence of complement activation and it was speculated that the plasma free hemoglobin reflected an overflow from a predominantly extravascular process.