Dr Abdul Mannan FRCPath FCPS
Blood 🩸Doctor
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Dr. Helena Richards was paged urgently to the geriatric ward where a 97-year-old female patient, Mrs. Margaret Collins, had been admitted with profound weakness, dizziness, and shortness of breath. Upon examination, Mrs. Collins appeared markedly pale with tachycardia and a systolic ejection murmur. Recent blood tests revealed severe anaemia with haemoglobin of 65 g/L.
The blood bank called with concerning news: Mrs. Collins had an extremely complex antibody profile. She had both auto anti-I and anti-HI cold antibodies, as well as a history of anti-e (though currently undetectable). Her direct antiglobulin test was strongly positive (+5) for C3d but negative for IgG, suggesting cold agglutinin-mediated haemolysis. Additionally, her albumin levels were significantly decreased, indicating hypoalbuminemia.
Dr. Richards now faced a critical transfusion challenge: how to safely and urgently transfuse this elderly patient with complex cold antibodies while minimizing the risk of both haemolytic transfusion reactions and transfusion-associated circulatory overload (TACO), especially given the patient's hypoalbuminemia and advanced age.
The transfusion medicine team would need to select appropriate blood units (likely AB RhD-positive, e-negative) and implement comprehensive warming protocols to prevent cold antibody activation during transfusion. They would also need to consider slower transfusion rates and close monitoring to prevent volume overload.
This case exemplifies the complex decision-making required when transfusing elderly patients with multiple antibodies and comorbidities, where both serological compatibility and physiological considerations are equally critical to patient safety.
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Patient Profile:
Initial Challenge: The patient presented with a rare combination of cold autoantibodies (anti-I + anti-HI) requiring careful transfusion strategy. The presence of previously detected anti-e, though currently undetectable, added complexity to donor selection¹.
Strategic Decision-Making: