Undetectable A BO Isoagglutinin in a Patient with Chronic Myelocytic Leukemia

H. OGATA A N D S . HASEGAWA

From rhe Blood Bank Section and the Department of Pediarrics. Universiry of Shinshu Medical School, Matsumoro. Japan

An instance of undetectable anti(A+B) was described in a patient, group 0, in acute crisis of chronic myelocytic leukemia. The finding was not parallel to the level of gamma globulin in the patient and a possibility of func- tional abnormality of the related antibody was discussed.

IT IS W E L L K N O W N that A, B and H antigens on the erythrocytes become weaker and sometimes vanish in some leuke.mic patients during the course of the disease.' Al- though antigen A has been most frequently affected, there is even a report of a patient, group AB, with acute myelocytic leukemia, in which both A and B antigens sustained modification giving a result of group 0 on a routine ABO cell grouping2 I n addition to the alteration of antigens, ABO isoagglu- tinins are also affected in some leukemic patients. A low titer of isoagglutinin is not an infrequent finding in them. However, a com- plete lack of the isoagglutinin is fairly rare. '2 It is necessary to investigate both antigens and antibodies, when a discrepancy between the cell grouping and the serum grouping is found in a leukemic patient. Recently we en- countered a patient, group 0, in acute crisis of chronic myelocytic leukemia, for whom an ABO typing gave us difficulty because of un- detectable A B O isoagglutinin. The cause of

Received for publication November I I , 1976; ac- cepted December 19, 1976. -

65 1 Trmsfurion Nov.-Dec. 1977

its disappearance was considered to be more closely related to a qualitative abnormality of the isoagglutinin than to the quantity of the immunoglobulin.

Case Report

A 13-year-old girl was admitted to U.S.M.S.H. in April, 1976, because of fever and epistaxis. She had been suffering from chronic myelocytic leukemia for six years. She was born of healthy parents with no problems at birth and had uneventful development. No symptom of hypo- globulinemia had ever been noted. At eight years of age, she was mildly anemic and there was a prominent hepatosplenomegaly. A large number of lymph nodes were palpated in the neck, axillas, and inguinal areas. The skin was free from pete- chiae or ecchymosis. The laboratory data were as follows: Hct. 13 per cent; Hgb. 6.4 gm/dl; RBC 1.72 x 106/p1; platelet count 39.4 x I04/pl; WBC 4.86 x I04/pl with 4 per cent myeloblasts, 28 per cent promyelocytes, 24 per cent myelocytes, 12.5 per cent metamyelocyte, 21 per cent neutrophil, 4.5 per cent eosinophils, 2 per cent basophil and 4 per cent lymphocyte. Ph' chromosome was demonstrated. Myleran I mg/day was instituted and the hospital course was uneventful. The blood picture improved gradually and no blood transfu- sion was given. She was discharged on the 66th hospital day.

After discharge she was transfused twice with a total 300 ml of group 0 blood without transfusion reaction. She was well until March, 1976, when in- termittent fever developed. She experienced also frequent epistaxis at night and was hospitalized again. On the second admission she was a small

Volume 17 Number 6

652 OGATA A N D HASEGAWA Transfusion Nov.-Dec. 1911

Table 1 . Neutralization Test for A. B and H Substance in the Patient's Saliva

Patient's saliva 1 32 64 128 256 512 2% A cells and anti-A (Titer 4) +++ +++ +++ +++ +++ +++ 2% B cells and anti-B (Titer 4) +++ +++ +++ +++ +++ +++ 2% 0 cells and lectin H (Titer 8) - - +w + ++ +++

girl with moderate anemia. Clotted blood was noted in the nostrils bilaterally. Tonsils were described to be infected. Some moist rales were audible on the anterior wall of the right chest. The abdomen was distended with splenomegaly, which was extended beyond the umbilicus. The edge of the liver was palpable 4 cm below the right costal margin. There was no lymphadenopathy except for several small nodes on her neck. No subcutaneous bleeding was present. Hct. was 21.1 per cent, Hgb. 6.8 gm/dl, RBC 2.2 x 106/pl and platelet count was 3.6 x I04/pl. WBC was I I x 104/pl with 78 per cent myeloblasts. Prothrombin time and partial thromboplastin time were within normal limits. A routine ABO typing for transfu- sion gave an unexpected result. The patient's red blood cells showed no agglutination with anti-A, anti-B or anti(A+B). The patient's serum did not agglutinate group A cells, group B cells or group 0 cells. The Rh blood typing gave a result of ccDEE without any difficulty. Then a more detailed examination was undertaken to detect isoagglutinin in her serum: ten group A red blood cells and ten group B cells were selected and in- cubated with t h e patient's serum a t room temperature for 90 minutes and also a t 4 C for 90 minutes. No agglutination was observed. Anti- globulin tests after 60 minutes of incubation at 37 C also failed to detect isoagglutinin. The pre- vious record was checked: cell grouping was recorded as group 0, but there was no description of the serum grouping. The diminished A and B antigens due to leukemia were suspected. An absorption and elution test was performed show- ing no A or B antigen on the patient's red blood cells. The patient's saliva was examined with neu- tralization test.l She was a secretor, but there was neither A nor B substance in her saliva (Table I). The parents were examined for ABO grouping: mother, group 0, ccDEE and father, group A, CcDEe. The patient was concluded to be group 0, secretor, without detectable anti(A+ B). Fresh whole blood of group 0 was transfused without any transfusion reaction.

The data of clinical chemistry became available later: total protein 6.4 g/dl with 62.5 per cent albumin, 6.5 per cent alpha, globulin, 8.6 per cent alpha, globulin, 11.2 per cent beta globulin and 11.2 per cent gamma globulin: IgG 540 mg/dl (normal range 1,224 to 496 mg/dl), IgM 60 mg/dl

(165-63 mg/dl) and IgA 90 mg/dl (148 to 50

After the admission the patient's condition de- teriorated with acute crisis of the leukemia, sepsis and hemorrhagic diathesis. She expired on the 60th hospital day in spite of aggressive antibiotic and antileukemic chemotherapy and multiple blood transfusions.

mg/dI).

Discussion

On a routine A B O grouping, it sometimes happens that the cell grouping disagrees with the serum grouping. A variety of possibilities must be taken into consideration to obtain a correct grouping. I n our patient, the cell grouping indication group 0 and the serum grouping indicated group AB. Technical er- rors were ruled out with repetition using freshly taken blood. The possible explanation included 1 ) AB variant, 2) modified A B O antigens due to leukemia, 3) excessive A B O substance in the patient's serum, 4) congen- ital absence of ABO isoagglutinin in healthy status and 5 ) hypogammaglobulinemia, con- genital or acquired.

The excess of A B O substance in the serum was easily denied by washing the patient's red blood cells for three times and by the fact that such a phenomenon has never been reported in a leukemic patient.5 Although there is no definite proof, congenital absence of A B O isoagglutinin is so rare that it ap- pears to be unreasonable to explain our case with that cause.".'4

Since van Loghem and his colleagues'3 described a case of modified A antigen in a patient of acute myelocytic leukemia, a large number of cases has been reported showing t h a t cer ta in leukemic pat ients develop changes in the A, B, and H antigen during the course of their disease. No A or B antigen was demonstrated on the red blood cells of our patient with elution test. There was

Volume 17 Number b UNDETECTABLE ABO ISOAGGLUTININ 653

Table 2. Agglutinability of the Patient's Red Blood Cells with Human Anti-H and Lectin H

Anti-ti. human 1 2 4 8 16 32

Control 0 cells ++ ++ + + Lectin H (Titer 8) 1 2 4 8 16 32

Patient's red cells 4- +w - - - - - -

Patient's red cells +++ + + +w - - Control 0 cells +++ ++ + +w - -

neither A nor B substance ,in her saliva, in which H substance was contained. These findings appear to rule out the possibility of modified A and B antigens on the patient's erythrocytes. The H antigen has been shown to be affected with acute leukemia.8 Al- though no detailed study was performed for the H antigen in this case, there was evidence suggestive of a decrease of agglutinability of H antigen on the patient's red blood cells. The cells were less agglutinable with anti-H of human origin than were group 0 cells from normal control. However, any significant difference was demonstrated by using lectin H (Table 2). It is uncertain why the patient's red blood cells were differently agglutinated with human anti-H and wiih lectin H.

The remaining choice for this case was the absence of anti-(A+ B) related to hypogam- maglobulinemia. The lack of ABO isoagglu- tinin is rather common in the cases of con- genital immunoglobulin deficiencies4 and of plasma cell m ~ e l o m a . ~ . ' ~ . ' ~ Ho wever, it is considerably rare in a leukemic patient, al- though the titer of isoagglutinin is often low in the chronic cases." The absence of isoag- glutinin was associated with the complete iack of gamma globulin in a patient of chronic lymphocytic leukemia r e p ~ r t e d . ' ~ I n comparison with that case, the IgG level was in low normal and IgM was mildy below the normal range in our patient. It is true that the titer of isoagglutinin are not necessarily correlated to the gamma globulin concentra- tion in the cases of hypogammaglobulinemia, both congenital and acquired.'".'2 It has been demonstrated quantitatively that anti-B was reduced in its affinity for B cells in a patient of A I O genotype, when the A antigen was modified during the course of the acute myelocytic leukemia.' This functional abnor-

mality of anti-B was explained as the conse- quence of the alteration of the antigen A.9 If the hypothesis was true, the undetectable anti(A+B) in our patient might be a conse- quence of the decrease of H antigen that was suggested with the reduced agglutinability of the patient's cells with anti-H of human origin. The functional abnormality of ABO isoagglutinin appears to be a reasonable explanation of the undetectable anti(A+ B) in our patient in consideration of the level of the gamma globulin.

A cknowledgrnent The authors a re grateful to Professor Dr. Akahane,

Department of Pediatrics, and Associate Professor Dr. Maruyama, Department of Clinical Pathology, a t University of Shinshu Medical School Hospital for their warm encouragemen t.

References I . American Association of Blood Banks: Technical

Methods and Procedures, 6th ed. Washington, D.C., 1974, p. 322.

2. Ayres, M., F. M. Salzano, and 0. K. Ludwig: Multiple antigenic changes in a case of acute leukemia. Acta Haematol. 37:150, 1967.

Lawson, H. A., C. A. Stuart, A. M. Paull, A. M. Phillips, and R. W. Phillips: Observation on the antibody content of the blood in patients with multiple myeloma. N. Engl. J. Med. 252:13, 1955.

4. Mollison, P. L.: Incidence o f isoagglutinin, In: Hypogammaglobul inemia i n t h e United Kingdom, Medical Research Council, Special Report Series 310, London, 1971, p. 86.

Race, R. R., and R. Sanger: Blood Groups in Man, 6th ed. Oxford, Blackwell Scientific, 1975, p. 40.

Salmon, C., and D. Salmon: Anomalies thermody- namiques d e I 'ant icorps ant i -B chez un leucimique avec antigene A modifii. Nouv. Rev. Fr. Hematol. Blood Cells 3:653, 1963.

-, and D. Salmon: Deficit en antigene H chez certains subjets d e groupe 0 atteints d e leucemie aigue. Rev. Fr. Etud. Clin. Biol. 10:212, 1965.

3.

5.

6. lbid p. 29. 7.

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654 OGATA AND HASEGAWA Tranrfusion Nov.-Oec. 1977

9. -: Donnees quantitatives de groupes san- guins sur les modifications IeucCmiques d e groupes sanguins ABO. Proc. 10th Cong. Int. SOC. Blood Transfus., Stockholm, Biblio. Hae- matol. 23:337, 1965.

Soothill, J . F., and D. S. Rowe: lmmunoglobulin in hypogammaglobulinemia. In: Hypogamma- globulinemia in the United Kingdom, Medical Research Council, Special Report Series 310, London, I97 I , p. 45.

Springer, G . F., and H. Tegtmeyer: Absence of B antibody in a blood group A , person. Vox Sang. 26 ~247, 1974.

Teitelbaum, J. I . , J . Wiener, and J . F. Desforges: A serologic and electrophoretic study of the ma- lignant and proliferative disorders of the hematopietic and reticuloendothelial systems. J. Lab. Clin. Med. 53535, 1959.

van Loghem, J. J., H. Dorfmeier. and M. van der Hart: Two A antigens with abnormal serologic properties. Vox Sang. 2:16, 1977.

10.

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Weisert, O., and A . M. Heier: A case of a "defec- tive" ABOgroup. Vox Sang. 6:692, 1961.

Wiener, A. S., D. K. Briggs, L. Weiner, and L. Burnett: Studies on human serum gamma globulin. 1 1 . Observation in a case of acquired hemolytic anemia due to cold autoantibodies, in multiple myeloma and in other clinical problems. J. Lab. Clin. Med.51:539, 1958.

Hiroyuki Ogata, M.D., Associate Pathologist, Blood Bank Section, University of Shinshu Medical School Hospital, 3-1-1 Asahi, Matsumoto, Nagano-ken, Japan.

Sumie Hasegawa, M.D., Associate Pediatrician, De- partment of Pediatrics, University of Shinshu Medical School, 3-1-1 Asahi, Matsumoto, Nagano-ken, Japan.

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