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ABO Discrepancy in a Multiple Myeloma Patient: a Case Study

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ABO Discrepancy in a Multiple Myeloma Patient: a Case Study REPORTS AND REVIEWS ○○○○○○○○○○○○○○○○○○○ ABO Discrepancy in a Multiple Myeloma Patient: A Case Study JO ANN WILSON, ANGEL JACOBS ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ABBREVIATIONS: AHG = anti-human globulin; LISS = low- The CLS requested additional history on the patient. The diagnosis ionic strength solution. was multiple myeloma; there had been no previous transfusions. INDEX TERMS: ABO discrepancies; antibody identification; DISCUSSION hematology; immunohematology; multiple myeloma; rouleaux. Multiple myeloma is a hematological malignant neoplasm of the bone marrow. It is a neoplastic disease characterized by the infil- Clin Lab Sci 2002;15(4):204 tration of bone and bone marrow by myeloma cells forming mul- Downloaded from tiple tumor masses.1 Production of normal immunoglobulins is Jo Ann Wilson PhD, is an associate professor in the Department of impaired with a significant increase in the number of abnormal Environmental Health, Molecular and Clinical Sciences at Florida plasma cells.2 The condition is usually progressive and generally Gulf Coast University, Fort Myers FL. fatal. The disease causes pain, fractures, anemia, hypercalcemia, kidney failure, bacterial infections, nerve compression with pa- Angel Jacobs is a Clinical Laboratory Science Program graduate from ralysis, skeletal deformities, and changes in mental status rang- http://hwmaint.clsjournal.ascls.org/ the Department of Environmental Health, Molecular and Clinical Sci- ing from mild to severe confusion.3, 4 According to the American ences at Florida Gulf Coast University, Fort Myers FL and is a clinical Cancer Society, about 14,400 new cases will be diagnosed and laboratory scientist at Florida Cancer Specialists, Fort Myers FL. about 11,200 Americans are expected to die of multiple myeloma in 2001.5,6 Address for correspondence: Jo Ann Wilson PhD, Department of Environmental Health, Molecular and Clinical Sciences, Florida Gulf Etiology and epidemiology Coast University, 10501 FGCU Blvd South, Fort Myers FL 33965- The etiology of multiple myeloma is unknown; however, genetics, 6565, (941) 590-7481,( 941) 590-7474 (fax). [email protected] radiation exposure and chronic antigenic stimulation have been suggested as predisposing factors.7 Increases in the incidence of The hospital transfusion services received an order for three units multiple myeloma during this past century implicate environmental of red blood cells for a 45-year-old Caucasian male. His most re- factors as important causal agents. A single insult is not thought to on October 2 2021 cent hematological study revealed a hemoglobin level of 7.0 g/dL be sufficient to induce the disease. However, continued exposure (Table 1). Blood was obtained from the patient and the clinical results in the clonal expansion of an idiotypic plasma cell after laboratory scientist (CLS) proceeded with pre-transfusion testing cumulative mutational damage has altered its genetic makeup.8 of phenotype and antibody screening. The results of the forward Atomic bomb survivors and individuals exposed to radiation in typing of ABO and Rh indicated that the patient was phenotype the workplace have demonstrated an increased incidence of mul- A Rh positive (Table 2). However, a discrepancy was found in the reverse typing with A1 cells and B cells producing agglutination. Using antibody-screening cells, the patient’s serum was tested. The Table 1: Hematological profile results indicated agglutination upon immediate spin, but no ag- ° glutination in subsequent testing including 37 C with LISS en- Analyte Patient Results Reference Range hancement (Table 3). RBC 2.14 4.7 - 6.1 X 106/µL 3 µ ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ WBC 4.5 4.8 – 10.8 X 10 / L The Reports and Reviews Section seeks to publish information on im- HGB 7.0 14 – 18 g/dL portant clinical laboratory-related topics such as technological, clinical, HCT 20.4 42 – 52% and experimental advances and innovations. Case studies and litera- MCV 95.3 80 – 94 fL ture reviews are also included. In addition, brief reviews of books, com- MCH 32.7 27 – 31 pg puter programs, audiovisual materials or other materials of interest to MCHC 34.3 32 – 36% readers are appropriate for this section. Manuscripts and literature re- Platelets 80 150 – 450 X 103/µL views published as a Report are peer reviewed. Direct all inquiries to Isaac Montoya PhD, Affiliated Systems Corporation, 3104 Edloe, Suite Peripheral marked rouleaux no rouleaux 330, Houston TX 77027-6022. (713)439-0210, (713)439-1924 smear (fax). [email protected] 204 VOL 15, NO 4 FALL 2002 CLINICAL LABORATORY SCIENCE 4-Wilson -PAID 204 10/10/02, 11:26 AM REPORTS AND REVIEWS tiple myeloma. Studies of workers at nuclear power plants also Patients may present with persistent unexplained skeletal pain (usu- suggest that chronic exposure to low levels of radiation may lead ally in the back or thorax), weakness and fatigue, confusion, and/ to increased risk.1 The molecular and cytogenetics of cells in mul- or recurrent bacterial infections.2 This disease is diagnosed in some tiple myeloma are under investigation, but the precise causes of patients with no symptoms after a screening blood test reveals ab- these abnormalities are largely unknown. normally high serum protein levels or there is evidence of calcium loss from bones. In some cases, patients are diagnosed only after Chronic stimulation of the immune system has been a suspected they have developed marked changes in their mental state with trigger of multiple myeloma with certain medical conditions such extensive bone destruction and kidney failure.3 Pathological frac- as rheumatoid arthritis, chronic allergic conditions, and chronic tures and vertebral collapse are common. Renal failure may be infections as they are implicated in the stimulation of the aberrant caused by extensive cast formation in the renal tubules, atrophy of production of plasma cells.9 Anticipation, a phenomenon in which tubular epithelial cells, and interstitial fibrosis. Anemia predomi- an inherited disease is diagnosed at an earlier age in each succes- nates in some patients, and a few have manifestations of hypervis- 2 sive generation of a family, has been demonstrated in multiple cosity syndrome. Downloaded from myeloma.10 An expanding plasma cell mass in the bone marrow undergoes The incidence of myeloma is five cases per 100,000 persons each continued clonal replication. As the growth proceeds, normal bone year and males have approximately 50% greater risk than females. marrow is gradually replaced by the steadily growing malignant There is greater incidence in black individuals than white indi- plasma cell colonies. Normal circulating blood cells decrease in viduals; persons of Japanese and Chinese descent experience the number resulting in anemia, thrombocytopenia, and neutrope- http://hwmaint.clsjournal.ascls.org/ least incidence. Age increases the risk of multiple myeloma as the nia. The resulting pancytopenia causes fatigue, delayed hemosta- disease is rarely seen in persons less than 40 years of age with the sis, and an increased susceptibility to bacterial infections.3 mean onset at age 60.1,11 The expanding plasma cells infiltrate bone-causing destruction of CLINICAL PRESENTATION AND PATHOPHYSIOLOGY the surface cortex of the bone. Stretching of the overlying nerve- Multiple myeloma does not have the same biology in all patients; rich periosteum leads to pain that is present at diagnosis in more it is best viewed as a heterogeneous disease with different prog- than two-thirds of patients.11 The destruction of bone tissue re- noses, clinical course, and response to therapeutic interventions in sults in an increase in blood calcium levels (hypercalcemia).5 Dif- different subjects.8 fuse osteoporosis or discrete osteolytic lesions develop, usually in the pelvis, spine, ribs, and skull. Lesions are due to bone replace- ment by expanding plasmocytomas or a factor secreted by malig- nant plasma cells (osteoclast-activating factor). The osteolytic le- on October 2 2021 sions are usually multiple, but occasionally are solitary Table 2. Initial patient ABO and Rh phenotyping intrameduallary masses. Extra-osseous plasmacytomas are unusual, reactions but may occur in any organ, especially the upper respiratory tract.2 Anti-A 4+ Hypercalcemia occurs in 15% of patients with multiple myeloma Anti-B 0 at diagnosis and should be suspected in the presence of anorexia, Anti-D 3+ nausea, vomiting, polyuria, polydipsia, increased constipation, Rh Control 0 weakness, confusion, or stupor. Because calcium affects nerve cell 5 A1 cells 1+ function, hypercalcemia can cause weakness and confusion. If B cells 4+ hypercalcemia is untreated, renal insufficiency develops as well. Table 3. Antibody screening and initial crossmatch results Immediate Spin 37 °C/LISS enhancement AHG AHG control cells Screening Cell I 1+ 0 0 2+ Screening Cell II 1+ 0 0 2+ Screening Cell III 1+ 0 0 2+ Auto Control 1+ 0 0 2+ VOL 15, NO 4 FALL 2002 CLINICAL LABORATORY SCIENCE 205 4-Wilson -PAID 205 10/10/02, 11:26 AM REPORTS AND REVIEWS The malignant plasma cells produce immunoglobulins resulting three years. The patient with multiple myeloma should be care- in an overproduction of intact immunoglobulins (IgG, IgA, IgD, fully evaluated from the standpoint of symptoms, physical find- or IgE) or Bence Jones protein. Plasmacytomas produce IgG in ings, and laboratory data. If there are no symptoms or evidence of about 55% of myeloma patients and IgA in about 20%; of these early or impending complications,
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