Intravascular [correction of intracellular] hemolysis and renal failure in a patient with T polyagglutination

Red blood cell polyagglutination: clinical aspects

Polyagglutination is the term applied to red blood cells (RBCs) that are agglutinated by almost all samples of human sera from adults but not by autologous serum or sera of newborns. The polyagglutinable state may be transient or persistent. Transient polyagglutinability results from the exposure of normally cryptic antigens by bacterial enzymatic activity during the course of an infectious process. RBCs are polyagglutinable because most sera from adults contain agglutinins for the exposed antigens. This type of polyagglutination can often be reproduced in vitro with bacterial culture fluids or isolated enzymes. Persistent polyagglutination may be a consequence of somatic mutation leading to a cellular lineage characterized by an enzyme deficiency that results in exposure of a normally cryptic antigen, Tn. Most human sera contain anti-Tn. Tn polyagglutination is regularly accompanied by leukopenia and thrombocytopenia and has been associated with leukemia. Other forms of persistent polyagglutination are due to the inheritance of rare blood groups or are associated with a hematologic dyscrasia.

Th polyagglutination with fatal outcome in a patient with massive intravascular hemolysis and perforated tumor of colon

Polyagglutination is a rare disorder which has been associated with intravascular hemolysis (Levene et al.: Transfus Med Rev 2:176-185, 1988). In this condition cryptantigens exposed on the red blood cell membrane agglutinate with compatible sera and with lectins. A 76 year-old man with an acute abdomen due to a perforated tumor of the colon and severe fatal intravascular hemolysis is described. Th polyagglutination of the red blood cells was found.

The pathobiology of red cell cryptantigen exposure

This article has defined in part the circumstances in which red cell cryptantigen exposure occurs and its significance in children. Bacteria-induced cryptantigens (T and Tk) are the most commonly encountered and, when present, suggest a guarded prognosis, a complicated clinical course, and a need for care in transfusion management with particular attention to the avoidance of plasma-containing products. Nonbacterial-induced cryptantigens (Th and Tn) are much less commonly seen and are encountered as a complicating feature of a serious hematologic condition and may be a potential source of confusion in the neonate.

Transfusion of infants with activation of erythrocyte T antigen

A protocol for transfusion of infants with erythrocyte T-antigen activation was evaluated for safety and effectiveness in a prospective, 3-year, sequential series of 1672 infants admitted for intensive care. Erythrocyte T antigens are activated by enzymes produced by clostridia or other bacteria in infants with sepsis, often in association with necrotizing enterocolitis. Transfusion of these infants with blood products containing plasma carries the risk of causing intravascular hemolysis. Our transfusion protocol included testing for T-antigen activation, restricting transfusion of patients with activated T antigens to washed erythrocytes or washed platelets whenever possible, and selecting donors with low-titer anti-T when plasma-containing blood products were required. In this series, 10 patients had T-antigen activation, including four with clostridial infections. Severe hemolysis occurred in one patient who received plasma before T-antigen activation developed. Of five patients who received low-titer anti-T plasma, mild hemolysis occurred in three and no hemolysis in two. Four patients who received no plasma-containing blood products experienced no hemolysis. Used cautiously, this protocol allows a full range of transfusion therapy to infants with T-antigen activation.