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An unusual Rhesus haplotype, —D—, in Iceland
Forensic
Science
Elsevier
Scientific
22 (1983) 183-187
International, Publishers
AN UNUSUAL
RHESUS
SIGR~DUR ~LAFSD~TTIR, SUNNA SIGURDARD6TTIR The Blood (Iceland)
Bunk
and
183
Ireland Ltd.
HAPLOTYPE,
~LAFUR
‘Department
JENSSON,
of Forensic
-D-,
IN ICELAND
GUDMUNDUR
Medicine,
University
THORDARSON~ of Iceland,
and
Reykjavik
(Received September 13, 1982) (Accepted December 9, 1982)
Summary Two female patients are described who were, following difficulties in blood cross matching, found to be homozygous for the rare Rhesus -Dgene complex. Both patients had formed Rh antibodies, one provoked by .transfusions and the other by three pregnancies. The parents’ relationship of one could easily be traced. Family tracing of the other patient was unsuccessful but her parents were probably related. The frequency of the -Dhaplotype in Icelanders was estimated l/214 by investigating 750 families of disputed paternity.
Key words:
Rhesus; Antigen;
Deletion;
Frequency;
Icelandic
Introduction The first example of blood lacking any representation of either the C or the E series of Rh antigens was described by Race, Sanger and Selwyn in 1950 and 1951 C6,71. Twenty homozygous individuals of this Rh type from various populations are listed by Race and Sanger 151, who estimate that in approximately 80% of cases, parents of such homozygotes, are found to be related. Two homozygotes, -D-/-D-, have been diagnosed in Iceland. Evidence obtained, when families are blood grouped and supplemented by test for -Dwith incomplete anti-D, indicates that this Rhesus haplotype is not all that rare in Iceland. During the last 12 years 2266 individuals of families who have been blood grouped in disputed paternity cases, have all been tested for the presence of -Din heterozygous state by using incomplete anti-D on saline suspended red cells. Furthermore, over 500 individuals belonging to Icelandic first cousin marriage families have been tested in the same way. This paper contains the most relevant clinical details of the two -Dhomozygotes, a pedigree survey of one of them and frequency estimate of -Dheterozygotes in the two groups of families. 0379-0738/83/$03.00 @ 1983 Elsevier Scientific Publishers Printed and Published in Ireland
Ireland Ltd.
184
Materials
and methods
Blood grouping reagent from ORTHO Diagnostics, U.S.A., was used for classifying blood types. Incomplete anti-D was used for detecting -Din the heterozygous state by testing red cells suspended in saline. Two homozygous -Dpatients 1. Patient S.S., female born 1901. She has had no children and had a transfusion in December 1969 when adenocarcinoma of the uterus was diagnosed and radium treatment started. Late in February 1970 she underwent total hysterectomy and bilateral salpingooephorectomy and was given 2 units of blood. In November 1970 she was admitted for transfusions due to severe anaemia, haemoglobin was 5-6 g/100 ml. Between 25 and 30 blood units were crossmatched and none was found compatible. She was typed Rh -D-/-Dand this finding was confirmed in a reference laboratory. Her parents were probably related as they were from the same geographic area, although it has not been possible up to now to demonstrate relationship genealogically. 2. Patient S.H., female born 1925. She is the mother of three children and has never been transfused, although she has been suffering from ulcerative colitis for 17 years. She had rectal bleeding following rectal biopsy and was admitted. She felt giddy and prostrated and her blood pressure was SO/SO on admission, but soon became normal, 120/90. Here haemoglobin was 13.4g/lOO ml and the haematocrit value unchanged. The patient’s blood group is 0 Rh positive and 4 units of blood were ordered for her. It was found impossible to select blood for her from any of the 10 units cross-matched. Fortunately the rectal bleeding stopped and she was not transfused. Further blood group investigation made it clear that the patient lacked the usual Rhesus-blood group antigens of the C and E series. Her parents have a common great-grandfather (Fig. 1). Results The relationship of the parents of the second patient is shown in Fig. 1. haplotype was found to be l/60 in 1st cousin The frequency of the -Dmarriage families and l/214, when parents and children in cases of disputed paternity were investigated (Table 1). The results of testing red cells suspended in saline with incomplete anti-D are shown in Table 2. A clear cut positive reaction was obtained in all 15 members who were -Dheterozygotes, but in four members with usual Rh types the reaction was also positive or ambiguous.
185 I
3
2
I 5
16
7
Is
17
9-16
0
18
00
II
SIBS NOT
TESTED
@rn
POSSIBLE
III
CARRIER
0El
USUAL
Qrn
HETEROZYGOUS
em
TYPE
HOMOZYGOUS
-D-/
-D-/-D-
PROPOSITA
E
P
PI
m Fig. 1. Pedigree of patient S.H. TABLE 1 FREQUENCY
OF Rh -D-
Population type
HAPLOTYPE
Families
Parents
IN ICELAND
Children
-Dheterozygous parents
F’requency of -Dhaplotype
1st cousin marriage families Families of disputed paternity
60
120
182
2
l/60
750
1500
766
7
l/214
18/7 1979.
Discussion From 1970 to 1977 two homozygous Rhesus -D-/-Dfemales have been diagnosed in Icelanders. The total population of Iceland was 220.000 approximately in 1976. Accordingly, Icelanders have a fair share of this type
186 TABLE
2
SEROLOGIC
REACTIONS
Family
WITH INCOMPLETE
Rh system.
No.
Member
1.1 1.2 1.3 1.4 1.5 2.1 2.2 2.3 3.1 3.2 3.3 4.1 4.2 4.3 5.1 5.2 5.3 6.1 6.3 6.4 7.1 7.2 7.3
Mother Daughter Father G.mother 1.3 G.father 1.3 Mother Son Father Mother Daughter Father Mother Son Father Mother Daughter Father Daughter Father G.mother 6.1 Mother Daughter Father
C
+ + + + -
f + t i i
Serologic
D
E
+ + + + f + + ~ + + + + + + + + +
~ + + ~ _ + + -
t t + +
-
IN ANTI-D
reactions
c
e
C”
+ + + + + + + + + + + + + + + ~ + t -
+ + f + + + ~ + + + + + + + + + + + + + +
-
Incomplete anti-D in saline
++t +++ ++t+ f +t+y+ +(+) +(+) +++
+ + C-t) ++(+) (+)++ +++ +(+) ++++ t++ t +++t ++(+)
+++ ++++
Probable Rh genotype cdelcde -D-/cde -D--/CDe -D-&de CDe/CDe CDe/cDE -D--/cDE -D-/cde cdelcde -D--/cde -D-/CDe -D-/cde -D-/cDE cDE/cDE -D-kde -D-/CDe CDelCDe -D--/cde cdelcde -D-/CDe CDe/cde -D-kde -D-/CDe
of Rhesus haplotype in homozygous form, when one refers to the 20 -D-/D- individuals from various corners of the world listed by Race and Sanger [51. A high proportion (80%) of these unusual Rh homozygotes are related [51. It is evident from the past, that heterozygous Rh -Dindividuals are occasionally detected when detailed blood grouping of families is carried out, such as in disputed paternity cases [31, particularly if supplemented by testing red cells suspended in saline with incomplete anti-D serum for demonstrating agglutination. Positive reaction is a strong evidence for the presence of -Din heterozygous form is most instances. However, our results confirm the experience of others 151 that agglutination of red cells of usual Rh types with this technique can give ambiguous or positive results (Table 2), members 1.5, 2.1, 4.3 and 5.3. In two types of family studies conducted in Iceland from 1968 to 1979, nine heterozygous parents were detected and counted by assigning one -Dhaplotype to each of the families containing members with this chromosome (Table 1). When Icelandic blood donors are carefully typed with respect to the Rh system and found
187
to have one of the more rare Rh types, such as cDe, with an estimated frequency of between 1% and 2% or less, masking of the -Dhaplotype can be suspected. Detailed blood grouping of parents in such cases supplemented by testing with incomplete anti-D (see above) is likely to unmask a proportion of -Dheterozygotes. Antibodies made by homozygous -Dindividuals are complex 151. In our two cases these were casued by transfusion in the first patient and by three pregnancies in the second. Blood group frequencies of Icelanders including the Rh system were first published in 1950 121 and in more detail in 1973 [ll. The Rh groups were studied in a large family with hereditary elliptocytosis 141 and only usual Rh types found. Acknowledgements We thank Professor F. Kissmeyer-Nielsen, Aarhus, Denmark and Professor Willi Spielmann in Frankfurt, FDR for confirmatory testing in 1970. We also thank Dr. Ruth Sanger and Dr. Patricia Tippett, MRC, Blood Group Unit, Wolfson House, University College, London for much help, and collaboration. References 1 6. Bjarnason, V. Bjarnason, J.H. Edwards, S. Fridriksson, M. Magnusson, A.E. Mourant and D. Tills, The blood groups of Icelanders. Ann. Hum. Genet. (London), 36 (1973) 425. 2 J.A. Donegani, N. Dungal, E.W. Ikin and A.E. Mourant, The blood groups of the Icelanders. Ann. Eugen., 15 (1950) 147. 3 K. Henningsen, Significance of -Dchromosome in a legal paternity case. VOXSang., 2 (1957) 339. 4 6. Jensson, Studies on four hereditary blood disorders in Iceland. Acta Med. Scand., Suppl. No. 618 (1978). 5 R.R. Race and R. Sanger, Blood groups in man, Backwell, London, 1975, pp. 211-212. 6 R.R. Race, R. Sanger and J.G. Selwyn, A probable delation in a human Rh chromosome. Nature (London), 166 (1950) 520. 7 R.R. Race, R. Sanger and J.G. Selwyn, A possible deletion in human Rh chromosome: A serological and genetical study. Br. J. Exp. PathoZ., 32 (1951) 124.
Science
Elsevier
Scientific
22 (1983) 183-187
International, Publishers
AN UNUSUAL
RHESUS
SIGR~DUR ~LAFSD~TTIR, SUNNA SIGURDARD6TTIR The Blood (Iceland)
Bunk
and
183
Ireland Ltd.
HAPLOTYPE,
~LAFUR
‘Department
JENSSON,
of Forensic
-D-,
IN ICELAND
GUDMUNDUR
Medicine,
University
THORDARSON~ of Iceland,
and
Reykjavik
(Received September 13, 1982) (Accepted December 9, 1982)
Summary Two female patients are described who were, following difficulties in blood cross matching, found to be homozygous for the rare Rhesus -Dgene complex. Both patients had formed Rh antibodies, one provoked by .transfusions and the other by three pregnancies. The parents’ relationship of one could easily be traced. Family tracing of the other patient was unsuccessful but her parents were probably related. The frequency of the -Dhaplotype in Icelanders was estimated l/214 by investigating 750 families of disputed paternity.
Key words:
Rhesus; Antigen;
Deletion;
Frequency;
Icelandic
Introduction The first example of blood lacking any representation of either the C or the E series of Rh antigens was described by Race, Sanger and Selwyn in 1950 and 1951 C6,71. Twenty homozygous individuals of this Rh type from various populations are listed by Race and Sanger 151, who estimate that in approximately 80% of cases, parents of such homozygotes, are found to be related. Two homozygotes, -D-/-D-, have been diagnosed in Iceland. Evidence obtained, when families are blood grouped and supplemented by test for -Dwith incomplete anti-D, indicates that this Rhesus haplotype is not all that rare in Iceland. During the last 12 years 2266 individuals of families who have been blood grouped in disputed paternity cases, have all been tested for the presence of -Din heterozygous state by using incomplete anti-D on saline suspended red cells. Furthermore, over 500 individuals belonging to Icelandic first cousin marriage families have been tested in the same way. This paper contains the most relevant clinical details of the two -Dhomozygotes, a pedigree survey of one of them and frequency estimate of -Dheterozygotes in the two groups of families. 0379-0738/83/$03.00 @ 1983 Elsevier Scientific Publishers Printed and Published in Ireland
Ireland Ltd.
184
Materials
and methods
Blood grouping reagent from ORTHO Diagnostics, U.S.A., was used for classifying blood types. Incomplete anti-D was used for detecting -Din the heterozygous state by testing red cells suspended in saline. Two homozygous -Dpatients 1. Patient S.S., female born 1901. She has had no children and had a transfusion in December 1969 when adenocarcinoma of the uterus was diagnosed and radium treatment started. Late in February 1970 she underwent total hysterectomy and bilateral salpingooephorectomy and was given 2 units of blood. In November 1970 she was admitted for transfusions due to severe anaemia, haemoglobin was 5-6 g/100 ml. Between 25 and 30 blood units were crossmatched and none was found compatible. She was typed Rh -D-/-Dand this finding was confirmed in a reference laboratory. Her parents were probably related as they were from the same geographic area, although it has not been possible up to now to demonstrate relationship genealogically. 2. Patient S.H., female born 1925. She is the mother of three children and has never been transfused, although she has been suffering from ulcerative colitis for 17 years. She had rectal bleeding following rectal biopsy and was admitted. She felt giddy and prostrated and her blood pressure was SO/SO on admission, but soon became normal, 120/90. Here haemoglobin was 13.4g/lOO ml and the haematocrit value unchanged. The patient’s blood group is 0 Rh positive and 4 units of blood were ordered for her. It was found impossible to select blood for her from any of the 10 units cross-matched. Fortunately the rectal bleeding stopped and she was not transfused. Further blood group investigation made it clear that the patient lacked the usual Rhesus-blood group antigens of the C and E series. Her parents have a common great-grandfather (Fig. 1). Results The relationship of the parents of the second patient is shown in Fig. 1. haplotype was found to be l/60 in 1st cousin The frequency of the -Dmarriage families and l/214, when parents and children in cases of disputed paternity were investigated (Table 1). The results of testing red cells suspended in saline with incomplete anti-D are shown in Table 2. A clear cut positive reaction was obtained in all 15 members who were -Dheterozygotes, but in four members with usual Rh types the reaction was also positive or ambiguous.
185 I
3
2
I 5
16
7
Is
17
9-16
0
18
00
II
SIBS NOT
TESTED
@rn
POSSIBLE
III
CARRIER
0El
USUAL
Qrn
HETEROZYGOUS
em
TYPE
HOMOZYGOUS
-D-/
-D-/-D-
PROPOSITA
E
P
PI
m Fig. 1. Pedigree of patient S.H. TABLE 1 FREQUENCY
OF Rh -D-
Population type
HAPLOTYPE
Families
Parents
IN ICELAND
Children
-Dheterozygous parents
F’requency of -Dhaplotype
1st cousin marriage families Families of disputed paternity
60
120
182
2
l/60
750
1500
766
7
l/214
18/7 1979.
Discussion From 1970 to 1977 two homozygous Rhesus -D-/-Dfemales have been diagnosed in Icelanders. The total population of Iceland was 220.000 approximately in 1976. Accordingly, Icelanders have a fair share of this type
186 TABLE
2
SEROLOGIC
REACTIONS
Family
WITH INCOMPLETE
Rh system.
No.
Member
1.1 1.2 1.3 1.4 1.5 2.1 2.2 2.3 3.1 3.2 3.3 4.1 4.2 4.3 5.1 5.2 5.3 6.1 6.3 6.4 7.1 7.2 7.3
Mother Daughter Father G.mother 1.3 G.father 1.3 Mother Son Father Mother Daughter Father Mother Son Father Mother Daughter Father Daughter Father G.mother 6.1 Mother Daughter Father
C
+ + + + -
f + t i i
Serologic
D
E
+ + + + f + + ~ + + + + + + + + +
~ + + ~ _ + + -
t t + +
-
IN ANTI-D
reactions
c
e
C”
+ + + + + + + + + + + + + + + ~ + t -
+ + f + + + ~ + + + + + + + + + + + + + +
-
Incomplete anti-D in saline
++t +++ ++t+ f +t+y+ +(+) +(+) +++
+ + C-t) ++(+) (+)++ +++ +(+) ++++ t++ t +++t ++(+)
+++ ++++
Probable Rh genotype cdelcde -D-/cde -D--/CDe -D-&de CDe/CDe CDe/cDE -D--/cDE -D-/cde cdelcde -D--/cde -D-/CDe -D-/cde -D-/cDE cDE/cDE -D-kde -D-/CDe CDelCDe -D--/cde cdelcde -D-/CDe CDe/cde -D-kde -D-/CDe
of Rhesus haplotype in homozygous form, when one refers to the 20 -D-/D- individuals from various corners of the world listed by Race and Sanger [51. A high proportion (80%) of these unusual Rh homozygotes are related [51. It is evident from the past, that heterozygous Rh -Dindividuals are occasionally detected when detailed blood grouping of families is carried out, such as in disputed paternity cases [31, particularly if supplemented by testing red cells suspended in saline with incomplete anti-D serum for demonstrating agglutination. Positive reaction is a strong evidence for the presence of -Din heterozygous form is most instances. However, our results confirm the experience of others 151 that agglutination of red cells of usual Rh types with this technique can give ambiguous or positive results (Table 2), members 1.5, 2.1, 4.3 and 5.3. In two types of family studies conducted in Iceland from 1968 to 1979, nine heterozygous parents were detected and counted by assigning one -Dhaplotype to each of the families containing members with this chromosome (Table 1). When Icelandic blood donors are carefully typed with respect to the Rh system and found
187
to have one of the more rare Rh types, such as cDe, with an estimated frequency of between 1% and 2% or less, masking of the -Dhaplotype can be suspected. Detailed blood grouping of parents in such cases supplemented by testing with incomplete anti-D (see above) is likely to unmask a proportion of -Dheterozygotes. Antibodies made by homozygous -Dindividuals are complex 151. In our two cases these were casued by transfusion in the first patient and by three pregnancies in the second. Blood group frequencies of Icelanders including the Rh system were first published in 1950 121 and in more detail in 1973 [ll. The Rh groups were studied in a large family with hereditary elliptocytosis 141 and only usual Rh types found. Acknowledgements We thank Professor F. Kissmeyer-Nielsen, Aarhus, Denmark and Professor Willi Spielmann in Frankfurt, FDR for confirmatory testing in 1970. We also thank Dr. Ruth Sanger and Dr. Patricia Tippett, MRC, Blood Group Unit, Wolfson House, University College, London for much help, and collaboration. References 1 6. Bjarnason, V. Bjarnason, J.H. Edwards, S. Fridriksson, M. Magnusson, A.E. Mourant and D. Tills, The blood groups of Icelanders. Ann. Hum. Genet. (London), 36 (1973) 425. 2 J.A. Donegani, N. Dungal, E.W. Ikin and A.E. Mourant, The blood groups of the Icelanders. Ann. Eugen., 15 (1950) 147. 3 K. Henningsen, Significance of -Dchromosome in a legal paternity case. VOXSang., 2 (1957) 339. 4 6. Jensson, Studies on four hereditary blood disorders in Iceland. Acta Med. Scand., Suppl. No. 618 (1978). 5 R.R. Race and R. Sanger, Blood groups in man, Backwell, London, 1975, pp. 211-212. 6 R.R. Race, R. Sanger and J.G. Selwyn, A probable delation in a human Rh chromosome. Nature (London), 166 (1950) 520. 7 R.R. Race, R. Sanger and J.G. Selwyn, A possible deletion in human Rh chromosome: A serological and genetical study. Br. J. Exp. PathoZ., 32 (1951) 124.