Lethal autoimmune hemagglutination due to an immunoglobulin A autoagglutinin with Band 3 specificity.

BACKGROUND: We describe a patient with a high-titer warm immunoglobulin (Ig)A autoantibody resulting in death due to hemagglutination rather than to hemolysis. CASE REPORT: A 47-year-old male patient presented with an intriguing pronounced vascular erythema of the skin. A livedo reticularis associated with cold agglutinin of high thermal amplitude was suspected. The patient's condition unexpectedly and abruptly deteriorated resulting in death 3 days after admission. STUDY DESIGN AND METHODS: Conventional serologic procedures and immunochemical methods were used. RESULTS: Serologic and immunochemical examinations revealed a warm IgA autoantibody of high titer with anti-Band 3 specificity. Although the patient presented with severe anemia, only mild signs of hemolysis were observed, with no evidence of complement activation. The autopsy revealed an enormous accumulation of agglutinated red blood cells in liver and spleen and a B-cell lymphoma and cerebral edema. Thus, the patient's death was largely caused by hypoxia related to hemagglutination rather than to hemolysis and/or anemia per se. CONCLUSION: Strongly hemagglutinating antibodies may not only cause immune hemolysis but also hypoxia due to intravascular hemagglutination.

A major target for warm immunoglobulin G autoantibodies: the third external loop of Band 3.

BACKGROUND: Rh proteins and the Wr(b) antigen, which results from an interaction between Band 3 and glycophorin A, are the most common targets for warm immunoglobulin (Ig)G autoantibodies. Apart from autoanti-Di(b) , a scarce specificity, IgG warm autoantibodies specific for Band 3 have never been characterized by serologic methods. STUDY DESIGN AND METHODS: Blood samples from 120 patients with autoimmune hemolytic anemia (AIHA) and IgG-coated red blood cells (RBCs) were studied by serologic methods. Some autoantibodies were investigated by immunochemical methods. RESULTS: Autoantibodies against the third external loop of Band 3 have a distinctive pattern of reactivity in that they fail to react after RBC treatment with α-chymotrypsin and pronase, whereas papain, ficin, and trypsin have no effect. Eleven (9%) patients had pure anti-Band 3 autoantibodies. Autoanti-Band 3 antibodies were associated with other specificities in 66 (55%) patients. Immunoprecipitation and rare RBCs from a Wu+ homozygote, known to have an unusual pattern of reactivity after protease treatment, were used to confirm the Band 3 specificity. Treatment with sodium hypochlorite, believed to oxidize the Met residue at Position 559 in the third loop, showed that these autoantibodies were heterogeneous. Most antibodies reacted optimally at 37 °C, but two patients had incomplete cold IgG autoantibodies. Unlike autoantibodies to Rh proteins, warm autoanti-Band 3 activate complement and are almost totally bound to autologous RBCs. CONCLUSION: We describe the first cases of warm IgG autoantibodies specific for the third loop of Band 3. This external loop also appears as a major target in patients with warm antibody AIHA.

Anti-U-like as an alloantibody in S-s-U- and S-s-U+(var) black people.

BACKGROUND: S, s, and U antigens belong to the MNS system. They are carried by glycophorin B (GPB), encoded by GYPB. Black people with the low-prevalence S-s- phenotype, either U- or U+(var), can make a clinically significant anti-U. Anti-U-like, a cold immunoglobulin G autoantibody quite commonly observed in S-s+U+ black persons, was previously described to be nonreactive with ficin-, α-chymotrypsin-, and pronase-treated red blood cells (RBCs); nonreactive or weakly reactive with papain-treated RBCs; and reactive with trypsin-treated RBCs. Here we describe, in S-s- people from different molecular backgrounds, an alloantibody to a high-prevalence GPB antigen, which presents the same pattern of reactivity with proteases as autoanti-U-like. STUDY DESIGN AND METHODS: Four S-s- patients with an alloantibody to a high-prevalence GPB antigen were investigated by serologic and molecular methods. RESULTS: An alloantibody was observed in two S-s-U-/Del GYPB, one S-s-U+(var)/GYPB(P2), and one S-s-U+(var)/GYPB(NY) patients. As this alloantibody showed the same pattern of reactivity with proteases as autoanti-U-like, we decided to name it "anti-U-like." Anti-U-like made by the two S-s-U- patients was reactive with the S-s-U+(var) RBCs of the two other patients. CONCLUSION: S-s-U-/Del GYPB, S-s-U+(var)/GYPB(P2), and S-s-U+(var)/GYPB(NY) patients can make an alloanti-U-like. Anti-U-like made by S-s-U- people appears reactive with GYPB(P2) and GYPB(NY) RBCs, which both express a weak and partial U-like reactivity. We recommend transfusing S-s-U- RBCs in S-s-U- patients showing alloanti-U-like. Our study contributes to a better understanding of alloimmunization to GPB in black people and confirms importance of genotyping in S-s- patients, especially those with sickle cell disease to be frequently transfused.

IgA-mediated human autoimmune hemolytic anemia as a result of hemagglutination in the spleen, but independent of complement activation and FcαRI.

Autoimmune hemolytic anemia (AIHA) due to warm-acting IgA autoantibodies is rare. We explored the pathogenic mechanisms underlying destruction of red blood cells (RBCs) in a patient with severe AIHA mediated exclusively by polymeric immunoglobulin A (pIgA) anti-Band 3 autoantibodies. The follow-up period was 17 months. RBCs were not destroyed by complement activation as no deposition of complement was observed on the patient's RBCs. pIgA eluted from the patient's RBCs did not induce RBC destruction through phagocytosis by monocytes or antibody-dependent cell-mediated cytotoxicity by natural killer cells. Induction of eryptosis (ie, RBC apoptosis) due to direct alteration of the RBC membrane by pIgA autoantibodies was also excluded. By contrast, upon incubation with pIgA-opsonized RBCs, substantial RBC membrane transfers (ie, trogocytosis) to monocytes were observed that might contribute to RBC immune destruction. This effect was poorly inhibited by blockers of Fc receptors, excluding a major contribution of FcαRI to this process. Histologic analysis revealed a massive accumulation of agglutinated RBCs with little sign of erythrophagocytosis in the spleen. These results, together with the efficacy of splenectomy 17 months after AIHA onset, suggest that the trapping and subsequent sequestration of agglutinated RBCs in the spleen are the principal pathogenic mechanisms of pIgA-mediated AIHA.

A new cold autoagglutinin specificity: the third external loop of band 3.

BACKGROUND: Cold autoagglutinins (CAs) are almost always of immunoglobulin (Ig)M class and specific for carbohydrate antigens. We report a case of hemolytic anemia caused by a mixture of IgM and IgG cold agglutinins. Both agglutinins were specific for the third extracellular loop of band 3. CASE REPORT: The patient, a 46-year-old man with no medical history, was admitted for an acute, life-threatening hemolytic anemia caused by a cold agglutinin. Improvement was obtained after plasmapheresis, red blood cell (RBC) transfusions, and steroid therapy. Recovery was complete and no etiology was found. STUDY DESIGN AND METHODS: Conventional serologic procedures and immunochemical methods were used. RESULTS: The patient's autoantibody was directed to an antigen equally expressed by adult and cord RBCs, resistant to papain, neuraminidase, and endo-beta-galactosidase treatments. This pattern of reactivity excluded all known specificities of cold agglutinins. The antibody failed to react with RBCs treated by alpha-chymotrypsin or pronase, suggesting that it may be directed to the third extracellular loop of band 3. Serum fractionation showed that the cold agglutinin was composed of IgM and IgG class antibodies. Antibody specificity was confirmed by blocking tests using murine monoclonal antibodies against band 3 and by immunoprecipitation. CONCLUSION: This is to our knowledge the first observation of a CA specific for band 3. The coexistence of IgM and IgG molecules, a very unusual feature for a CA, may be related to the peptidic nature of the target antigen.

Severe autoimmune hemolytic anemia caused by a warm IgA autoantibody directed against the third loop of band 3 (RBC anion-exchange protein 1).

BACKGROUND: Autoimmune hemolytic anemia associated with only IgA autoantibodies reacting optimally at 37 degrees C (WAIHA) is exceedingly rare. When identified, warm IgA autoantibodies specificities are usually directed to antigens of the Rh system. However, like IgG autoantibodies, the specificity of the majority of these antibodies is not identified. CASE REPORT: A case of a 3-year-old boy in whom a life-threatening IgA WAIHA occurred suddenly is reported. Following initial RBC transfusions and treatment with steroids at a dose of 3 mg per kg, which was slowly tapered, stabilization to a state of compensated hemolysis was achieved, persisting 4 months before complete resolution. There was no recurrence within a 16-month follow-up. STUDY DESIGN AND METHODS: The standard DAT in a gel column method with anti-IgG and anticomplement reagents was negative. However, the same method with an anti-IgA was strongly positive. RESULTS: The serum and the eluate obtained after acid elution reacted with all normal RBCs tested. Enzymatic treatment of panel RBCs by alpha-chymotrypsin and pronase abolished the reactivity. The reaction was completely inhibited by RBC incubation with four different MoAbs directed against the third extracellular loop of band 3, the RBC anion-exchange protein 1 (AE1), whereas MoAbs against other specificities showed no effect. CONCLUSIONS: This is the first report of an IgA autoantibody directed against the band 3 (AE1) protein and, more specifically, against the third loop. Moreover, this case underlines the importance of including IgA research in the initial diagnostic evaluation when a hemolytic anemia is suspected to be autoimmune and when IgG and complement are not detected on the patient's RBCs.

A novel cis AB allele derived from a B allele through a single point mutation.

BACKGROUND: The very rare cis AB phenotype, first described in 1964, corresponds to a special ABO allele encoding a glycosyltransferase that is capable of synthesizing both A and B substances. Until now, gene sequences of only two cis AB alleles were partially characterized. One involved the A1*02 allele with a single nonsynonymous substitution at codon 268, whereas the second arose from a single nonsynonymous substitution at codon 266 in exon 7 of a B1*01 allele. STUDY DESIGN AND METHODS: A cis AB phenotype was identified in a French family. The serologic characteristics of this phenotype were determined. The cis AB allele was characterized from exon 6 to exon 7 by cloning and sequencing. RESULTS: The cis AB.tlse(*)01 allele is identical to B(1*)01 except for a single point mutation at nucleotide position 700, where a T replaces a C, implying a change of amino acid 234 (the B(1*)01 proline being replaced by a serine). CONCLUSION: The cis AB.tlse(*)01 allele clearly differs from all previously reported ABO, including the two previous cis AB described.