'VA', a new type of erythrocyte polyagglutination characterized by depressed H receptors and associated with hemolytic anemia. II. Observations by immunofluorescence, electron microscopy, cell electrophoresis and Biochemistry

Polyagglutinability phenomenon: a case report and review of the literature

BACKGROUND

Polyagglutinability of red blood cells is a rare immunological phenomenon, it is due to a cryptic antigen that is abnormally present on the surface of red blood cells. The aim of our work is to shed light on polyagglutinability, which is still poorly understood cause of discordance between the cell and serum tests and can sometimes have harmful transfusion consequences.

CASE PRESENTATION

We report the case of a 70-year-old African patient admitted for management of hemolytic anemia.

RESULTS

During the erythrocyte grouping, a discordance between the cell and serum tests was observed, with polyagglutinability for the RH phenotype, a positive AB control, and even a positive control. The direct antiglobulin test and the Coombs test were also positive. The same results were obtained even after washing the red blood cells and incubating them at 37 °C for 30 min. For transfusion purposes, erythrocyte genotyping was performed, and the patient was transfused with an A+ red blood cell unit with an RH Kell-compatible phenotype.

CONCLUSION

Polyagglutinability should always be taken into account when grouping anomalies are encountered. Although it may not show any symptoms, hemolysis is frequently observed during transfusions.

Altered glycosylation leads to Tr polyagglutination

BACKGROUND

Polyagglutination refers to red blood cells (RBCs) that are agglutinated by a high proportion of ABO-matched adult sera but not by cord sera. Polyagglutinable RBCs have been associated with microbial infection, myeloproliferative disorders, and myelodysplasia. Lectins aid in the identification of polyagglutination.

CASE STUDY

A Hispanic male infant with mild hemolytic anemia, a "Bernard-Soulier-like" syndrome, intermittent neutropenia, mitral valve regurgitation, ligament hyperlaxity, and mild mental retardation was studied. The patient's Group O RBCs were polyagglutinable; they were agglutinated by normal human sera, several lectins [including Arachis hypogea, Salvia sclarea, Salvia horminum, Glycine max, Ulex europaeus, Griffonia simplicifolia I, and Gr. simplicifolia II], and some monoclonal antibodies. His RBCs were not agglutinated by cord sera, Dolichos biflorus, or Phaseolus lunatus. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis on the RBC membranes followed by staining with periodic acid-Schiff stain showed markedly reduced staining of glycophorins A and B. Staining with Coomassie brilliant blue revealed that Band 3 has a faster mobility than normal.

CONCLUSIONS

Collectively, the results suggest that the patient's RBCs have a reduction in N-acetylneuraminic acid on both N- and O-glycans, exposing, respectively, beta1,4-galactosidase and beta1,3-galactosidase. The patient likely has an altered glycosyltransferase that results in defective glycosylation in RBCs and other cell lineages. This type of polyagglutination was named Tr.

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.

The classification, recognition and significance of polyagglutination in transfusion medicine

Polyagglutination, although an uncommon phenomenon in transfusion medicine, is becoming increasingly recognized as a potential pitfall in correct ABO typing and can hinder the rapid allocation of accurately crossmatched blood products. Polyagglutination refers to erythrocytes which demonstrate agglutination with the majority of adult sera upon initial ABO crossmatch testing. Most types of polyagglutination involve alteration of red cell surface antigens through microbial enzymatic activity in patients with sepsis, and subsequent interaction of these newly exposed 'cryptantigens' with naturally occuring IgM antibody which is present in most adult sera. Less common variants include essential inborn variations in red cell development, and have been associated with myelodysplastic syndromes, congenital anemias, and various leukemias; it has been suggested that patients shown to possess these types of polyagglutination may benefit from increased hematologic surveillance. Recognition of polyagglutination in these settings is important to allow successful resolution of ABO typing discrepancies and permit efficient administration of appropriate blood products to these patients, who are often quite ill. The classification and method of laboratory recognition of polyagglutination is reviewed.

Tn polyagglutinability occurring in a patient with B cell lymphoma

A case of polymorphic immunocytoma (B cell lymphoma) coinciding with expression of Tn antigen on a population of erythrocytes is presented. Tn activation was found incidentally by screening blood samples of patients suffering from hematologic malignancies with a Tn specific lectin from Salvia sclarea. So far, Tn activation has been reported only in apparently healthy subjects or in subjects suffering from or developing myeloid leukemia.

An inherited RBC characteristic, NOR, resulting in erythrocyte polyagglutination

This report describes a new inheritable red blood cell characteristic, termed NOR, that is associated with polyagglutination. The NOR factor was shown to be inherited in an apparent dominant manner by 5 members of a two-generation family. NOR was clearly demonstrated to be a unique form of polyagglutination distinguishable from previously reported forms by serological tests using seed lectins, snail agglutinins, enzymes and absorption techniques. The NOR factor was characterized by the lack of reactivity with various seed and snail lectins, enhanced serum agglutinability after RBC proteolytic enzyme treatment, and the ability of hydatid cyst fluid to inhibit the serum hemagglutination reaction.

The role of lectins in blood group serology

Many lectins display blood group activity, and extracts from Dolichos biflorus (anti-A1), Ulex europaeus (anti-H), and Vicia graminea (anti-N) seeds provide an alternative to human sera as a source of blood-typing reagents. However, the major application of lectins in blood group serology undoubtedly lies in the recognition and elucidation of red celll polyagglutination. In this respect, lectins from Arachis hypogaea (anti-T/Tk), Salvia sclarea (anti-Tn). Salvia horminum (anti-Tn + Cad). Dolichos biflorus (anti-Tn/Cad) Glycine max, and the N-acetyl-D-glucosminyl-binding lectin, BS II (anti-Tk) from Bandeiraea simplicifolia seeds, provide an invaluable source of reagents for use in investigative immunohemotology. Because of their specific carbohydrate-binding properties, lectins have also been used as probes in studies on the topography of the red cell surface. This latter appliction has provided much information on the structure of the MN, T, and Tn red cell surface receptors and has aided in defining the red cell membrane abnormalities associated with certain uncommon phenotypes within the MN blood group system.

Tk polyagglutination associated with reduced A and H activity

Tk polyagglutinable erythrocytes are described in which A and H activities were reduced. It is suggested that Bacteroides fragilis isolated from cultures of the patient's blood was responsible for each of these membrane modifications.