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Neonatal thrombocytopenia caused by passive transfer of anti-PLA1 antibody by blood transfusion
The Journal of Pediatrics Volume 128, Number 1 REFERENCES
1. Gillan E, Christensen R, Suen Y, Ellis R, ran de Ven C, Cairo M. A randomized, placebo-controlled trial of recombinant human granulocyte-colony stimulating factor administration in newbom infants with presumed sepsis: significant induction of peripheral and bone marrow neutrophilia. Blood 1994;84:142733. 2. Rogers S, Donovan C, D'Eugenio D, et al. Early intervention developmental profile. In: Schafer D, Moersch M, eds. Developmental progranaming for infants and young children, vol 2. Ann Arbor, Michigan: The University of Michigan Press, 1981. 3. Lubin B. Reference values in infancy and cbildhood. In: Nathan
Marzich et al.
13 7
D, Oski F, eds. Hematology of infancy and childhood, vol 2. Philadelphia: WB Sannders, 1993:i-xx. 4. Miller L. American society of clinical oncology recommendations for the use of hematopoietic colony-stimulating factors: evidence-based, clinical practice guidelines. J Clin Oncol 1994;12:2471-2508. 5. Williamson W, Wilson G, Lifschitz M, Thurber S. Nonhandicapped very-low-birth-weight infants at one year of age: developmental profile. Pediatrics 1990;85:405-10. 6. Elliman A, Bryan E, Elliman A, Walker J, Harvey D. Coordination of low birthweight seven-year-olds. Acta Paediatr Scand 1991;80:316-22.
Neonatal thrombocytopenia caused by passive transfer of anti-PLA1 antibody by blood transfusion Christine Marzich, MD, Patricia L. Strohm, MT(ASCP)SBB,Mouhab Ayas, MD, and Richard K. Cochran, MD From the Depaffment of Pathology and Laboratory Medicine, Western Reserve Care System, Youngstown, Ohio, the Department of Pediatrics, Division of Pediatric Hematology/ Oncology, Tod Children's Hospital, Youngstown, Ohio, and the Departments of Pediatrics and Pathoiogy, Northeastern Ohio Universities College of Medicine, Rootstown, Ohio
A premature male infant with hyaline membrane disease received a 34 ml transfusion of packed erythrocytes from a CPDAI blood unit on day 2 with no adverse consequences. On day 34 he was given a transfusion, and the platelet count decreased. Intravenous immune globulin therapy was initiated and the platelet count steadUy increased. Human leukocyte (HLA) antigen and platelet antibody testing showed that the thrombocytopenia was due to passive transfer of platelet-specific antibody from the blood donor. (J PEDIATR1996; 128:137-9) The platelet-specific antigens are important immunogens in causing the syndromes of posttransfusion purpura and neonatal alloimmune thrombocytopenia. I We report the rare event of thrombocytopenia induced by passive transfer of anti-PL al antibody present in a unit of packed erythrocytes from a volunteer blood donor. CASE
REPORT
A white male infant was bom at 29 weeks of gestation by spontaneous vaginal delivery to a 22-year-old gravida 2, para 0 woman. The mother's pregnancy had been uncomplicated until there was premature rupture of membranes and onset of labor. The Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. The birth
Submitted for publication June 29, 1995; accepted Aug. 28, 1995. Reprint requests: Christine Marzich, MD, Department of Pathology, Western Reserve Care System, 500 Gypsy Lane, Youngstown, OH 44501. Copyright © 1996 by Mosby-Year Book, Inc. 0022-3476/96/$5.00 + 0 9/24/68981
w e i ß t was 1430 gm, and the infant required mechanical ventilation for 5 days because of respiratory distress syndrome. Laboratory studies showed the baby to have group A, Rh-positive blood, with a hemoglobin concentration of 160 gm/L (16.0 gin/dl), hematocrit of 0.46, leukocyte count of 12.1 x 109/[, (12,100 cells/pl), and a platelet count of 350 x 109/L (350,000/gl). He received 34 ml of packed erythrocytes because the hemoglobin concentration was 130 gm/L (13 grrddl) on day of life 2; there were no adverse consequences. On day of life 34, the hemoglobin concentraüon was 68 gm/L (6.8 grrddl) and 40 ml of group O, Rh-positive, cytomegalovirus-free packed erythrocytes were transfused during a 4-hour period. The infant received the first aliquot from a random-donor CPDA1 blood unit with a hematocrit between 0.68 and 0.72. The pretransfusion platelet count was 379 x 109/L (379,000/pl). Previous platelet counts from birth were also within the normal range. A follow-up complete blood cell count 2 hours after the transfusion revealed the hemoglobin concentration to be 131 gm/L (13.1 gin/dl). However, the platelet count had decreased to 32 x 109/L (32,000/~1). By 17 hours after transfusion, the thrombocytopenia reached a nadir at 10 x 109/L (10,000/gl). The baby had no signs of
138
Marzich et al.
bleeding. There was no clinical or laboratory evidence of infection, hemolysis, disseminated intravascularcoagulation, or hemangioma. The leukocyte count was 6.5 x 109/L (6500 cells/gl) without a left shift. Erythrocyte morphologic features on the peripheral smear included slight anisocytosis. The partial thromboplastin time was 50.7 seconds and the prothrombin time was 12.8 seconds. The fibrinogen concentration was within the normal range at 3.02 gm/L (302 mg/dl), and the result of the D-dimer assay was negative. Intravenous immune globulin therapy was initiated at 1 gin/kg per day for 2 days. The platelet count steadily increased, reaching 65 x 109/L (65,000/~al) 2 days after transfusion, 150 x 109/L (150,000/~1) 3 days later, and 313 x 109/L (313,000/gl) at the time of discharge. Platelet and human leukocyte antigen tests were performed on the mother's serum and on serum from the implicated donor unit at a reference laboratory. A panel of human lymphocytes tested against the mother's serum by the microlymphocytotoxicity technique demonstrated the presence of a polyspecific human leukocyte antigen-related antibody, in which 5 of 42 cells reacted. A panel of 9 random donor platelets tested against the maternal serum sample, by the solid-phase erythrocyte adherence method, demonstrated reactivity with 5 platelets. The serum sample tested against platelets from the transfused unit was showed negative results. By the same methods, the donor serum showed no detectable human leukocyte antigen antibody but did demonstrate the presence of platelet-specific antibody. This was shown to be anti-PLal antibody by the modified antigen capture enzyme-linkedimmunosorbent assay. In tests of this type, patient serum interacts with platelet proteins that have been immobilized by specific monoclonal antibodies bound to a solid phase. Platelet lysate is added to specific monoclonal antibodies bound to a solid phase. Thus the specific platelet protein of interest is immobilized. Patient serum is subsequently added, and after a wash step the binding of the patient antibody to the platelet protein is quantitated with a conjugate molecule.2 Four antigens were used in the capture assay with appropriate controls, and only a PLAI antibody was detected. The donor platelets were confirmed to be free of the PLA1 antigen. DISCUSSION Thrombocytopenia in the newbom infant occurs in infants with congenital megakaryocytic hypoplasia, in intrauterine infection, in infants b o m to mothers taking thiazide drugs during pregnancy, in infants with congenital leukemia, and in the offspring of mothers with idiopathic thrombocytopenic purpura. 3 Up to 20% of cases of neonatal thrombocytopenia occur as a result of matemal sensitization by fetal platelet antigens with the subsequent production of IgG alloantibodies.4 This phenomenon was excluded in out patient because the platelet count at birth was within the normal range and had been appropriately maintained until the second blood transfusion was given. A drop in platelet count may also occur after passive transfer of antibody contained in blood products, which was clinically very compatible with the specific pattem of thrombocytopenia observed in this patient in the absence of
The Journal of Pediatrics January 1996
infection, hemolysis, and disseminated intravascular coagulation. Posttransfusion purpura is a different syndrome, occurring up to 1 week after incompatible platelets are administered to an individual who is lacking a specific antigen and who has been previously sensitized to that antigen. Routine donor screening does not include human leukocyte antigen or platelet antibody testing. The PL al antigen is a common antigen, being found in 98% of the population. 5 PL A2 homozygous individuals can make antibody directed against this immunogen after sensitization by pregnancy or prior transfusion.6 The blood donor in this case was a multiparous woman whose platelets were free of PL A1 antigen. Shulman et al. 7 demonstrated that infusion of 5 to 10 ml of plasma containing anti-PLA1 produced significant decreases in platelet counts; infusion of 10 ml decreased the recipient platelets from 170 x 109/L to 50 x 109/L in 2 hours; at that time, antibody could not be detected in the donor's plasma. An estimated 12 ml of antibody-containing plasma was transfused to the neonate, cansing a 347 x 109/L decrease in the platelet count within 2 hours. We found only one previous reference to the occurrence of thrombocytopenia in an adult after transfusion of packed erythrocytes from a sensitized donor. 8 Intravenous immune globulin therapy has been employed in the management of immune-mediated neonatal thrombocytopenia. 9 Suarez and Anderson l° reported the positive effects of intravenously administered immune globulin (400 mg/kg per day x 5 days) on the thrombocytopenia of five newborn infants, two with isoimmune thrombocytopenia and three with thrombocytopenia caused by maternal thrombocytopenic purpuraJ ° This treatment may be useful in the treatment of patients at risk of having severe bleeding complications. Although the plasma volume in erythrocyte transfusions is small, the possibility of passive transfer of antiplatelet antibody should be considered in cases of acute thrombocytopenia. REFERENCES
1. Kickler TS, Herman JH, Furihata K, Kunicki TJ, Aster RH. Identification of Bakb, a new platelet-specific antigen associated with post-transfusion purpura. Blood 1988;71:894-8. 2. Warkentin TE, Kelton JO. Immune thrombocytopenia and its management. In: Rossi EC, Simon TL, Moss GS, eds. Principles of transfusion medicine. Baltimore: Williams & Wilkins, 1991:233-54. 3. Adner MM, Fisch GR, Starobin SG, Aster RH. Use of "compatible" platelet transfusions in tre~{tmentof congenital isoimmune thrombocytopenic purpura. N Engl J Med 1969; 280:244-7. 4. Deaver JE, Deppert PC, Zaroulis CG. Neonatal alloimmune thrombocytopenic purpura. Am J Perinatol 1986;3:127-31. 5. Katz J, Hodder FS, Aster RH, Bennetts GA, Cairo MS. Neonatal isoimmune thrombocytopenia: the natural course and
The Journal of Pediatrics Volume 128, Number 1
Marzich et al.
management and the detection of matemal antibody. Clin Pediatr 1984;23:159-62. 6. Vogelsang G, Kickler TS, Bell WR. Post-Uansfusionpurpura: a report of five patients and a review of the pathogenesis and management. Am J Hematol 1986;21:259-67. 7. Shulman NR, Aster RH, Leimer A, Hiller MC. Immunoreactions involving platelets. V. Posttransfusion purpura due to a complement-fixing antibody against a genetically controlled platelet antigen: a proposed mechanism for thrombocytopenia and its relevance in autoimmunity.J Clin Invest 1961;40:1597620.
139
8. Ballem PJ, Buskard NA, Decary S, Doubroff P. Post-transfusion purpura secondary to passive transfer of anti-pLA1 by blood transfusion. Br J Hematol 1987;66:113-4. 9. Chirico G, Duse M, Ugazio AG, Rondini G. High-dose intravenous gammaglobulin therapy for passive immune thromhocytopenia in the neonate. J PEDIATR1983;103:654-5. 10. Suarez CR, Anderson C. High-dose intravenous gammaglobulin (IVG) in neonatal immune thrombocytopenia.Am J Hematol 1987;26:247-53.
BOUND VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of the 1996 issues of THE JOURNAL OF PEDIATRICSare available to subscribers (only) from the Publisher, at a cost of $81.00 for domestic, $103.79 for Canadian, and $97.00 for international subscribers, for Vol. 128 (January-June) and Vol. 129 (July-December), shipping charges included. Each bound volume contains subject and author indexes, and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram, with the Journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Dr., St. Louis, MO 63146-3318, USA/800-453-4351, or 314-4534351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular Journal subscription.
1. Gillan E, Christensen R, Suen Y, Ellis R, ran de Ven C, Cairo M. A randomized, placebo-controlled trial of recombinant human granulocyte-colony stimulating factor administration in newbom infants with presumed sepsis: significant induction of peripheral and bone marrow neutrophilia. Blood 1994;84:142733. 2. Rogers S, Donovan C, D'Eugenio D, et al. Early intervention developmental profile. In: Schafer D, Moersch M, eds. Developmental progranaming for infants and young children, vol 2. Ann Arbor, Michigan: The University of Michigan Press, 1981. 3. Lubin B. Reference values in infancy and cbildhood. In: Nathan
Marzich et al.
13 7
D, Oski F, eds. Hematology of infancy and childhood, vol 2. Philadelphia: WB Sannders, 1993:i-xx. 4. Miller L. American society of clinical oncology recommendations for the use of hematopoietic colony-stimulating factors: evidence-based, clinical practice guidelines. J Clin Oncol 1994;12:2471-2508. 5. Williamson W, Wilson G, Lifschitz M, Thurber S. Nonhandicapped very-low-birth-weight infants at one year of age: developmental profile. Pediatrics 1990;85:405-10. 6. Elliman A, Bryan E, Elliman A, Walker J, Harvey D. Coordination of low birthweight seven-year-olds. Acta Paediatr Scand 1991;80:316-22.
Neonatal thrombocytopenia caused by passive transfer of anti-PLA1 antibody by blood transfusion Christine Marzich, MD, Patricia L. Strohm, MT(ASCP)SBB,Mouhab Ayas, MD, and Richard K. Cochran, MD From the Depaffment of Pathology and Laboratory Medicine, Western Reserve Care System, Youngstown, Ohio, the Department of Pediatrics, Division of Pediatric Hematology/ Oncology, Tod Children's Hospital, Youngstown, Ohio, and the Departments of Pediatrics and Pathoiogy, Northeastern Ohio Universities College of Medicine, Rootstown, Ohio
A premature male infant with hyaline membrane disease received a 34 ml transfusion of packed erythrocytes from a CPDAI blood unit on day 2 with no adverse consequences. On day 34 he was given a transfusion, and the platelet count decreased. Intravenous immune globulin therapy was initiated and the platelet count steadUy increased. Human leukocyte (HLA) antigen and platelet antibody testing showed that the thrombocytopenia was due to passive transfer of platelet-specific antibody from the blood donor. (J PEDIATR1996; 128:137-9) The platelet-specific antigens are important immunogens in causing the syndromes of posttransfusion purpura and neonatal alloimmune thrombocytopenia. I We report the rare event of thrombocytopenia induced by passive transfer of anti-PL al antibody present in a unit of packed erythrocytes from a volunteer blood donor. CASE
REPORT
A white male infant was bom at 29 weeks of gestation by spontaneous vaginal delivery to a 22-year-old gravida 2, para 0 woman. The mother's pregnancy had been uncomplicated until there was premature rupture of membranes and onset of labor. The Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. The birth
Submitted for publication June 29, 1995; accepted Aug. 28, 1995. Reprint requests: Christine Marzich, MD, Department of Pathology, Western Reserve Care System, 500 Gypsy Lane, Youngstown, OH 44501. Copyright © 1996 by Mosby-Year Book, Inc. 0022-3476/96/$5.00 + 0 9/24/68981
w e i ß t was 1430 gm, and the infant required mechanical ventilation for 5 days because of respiratory distress syndrome. Laboratory studies showed the baby to have group A, Rh-positive blood, with a hemoglobin concentration of 160 gm/L (16.0 gin/dl), hematocrit of 0.46, leukocyte count of 12.1 x 109/[, (12,100 cells/pl), and a platelet count of 350 x 109/L (350,000/gl). He received 34 ml of packed erythrocytes because the hemoglobin concentration was 130 gm/L (13 grrddl) on day of life 2; there were no adverse consequences. On day of life 34, the hemoglobin concentraüon was 68 gm/L (6.8 grrddl) and 40 ml of group O, Rh-positive, cytomegalovirus-free packed erythrocytes were transfused during a 4-hour period. The infant received the first aliquot from a random-donor CPDA1 blood unit with a hematocrit between 0.68 and 0.72. The pretransfusion platelet count was 379 x 109/L (379,000/pl). Previous platelet counts from birth were also within the normal range. A follow-up complete blood cell count 2 hours after the transfusion revealed the hemoglobin concentration to be 131 gm/L (13.1 gin/dl). However, the platelet count had decreased to 32 x 109/L (32,000/~1). By 17 hours after transfusion, the thrombocytopenia reached a nadir at 10 x 109/L (10,000/gl). The baby had no signs of
138
Marzich et al.
bleeding. There was no clinical or laboratory evidence of infection, hemolysis, disseminated intravascularcoagulation, or hemangioma. The leukocyte count was 6.5 x 109/L (6500 cells/gl) without a left shift. Erythrocyte morphologic features on the peripheral smear included slight anisocytosis. The partial thromboplastin time was 50.7 seconds and the prothrombin time was 12.8 seconds. The fibrinogen concentration was within the normal range at 3.02 gm/L (302 mg/dl), and the result of the D-dimer assay was negative. Intravenous immune globulin therapy was initiated at 1 gin/kg per day for 2 days. The platelet count steadily increased, reaching 65 x 109/L (65,000/~al) 2 days after transfusion, 150 x 109/L (150,000/~1) 3 days later, and 313 x 109/L (313,000/gl) at the time of discharge. Platelet and human leukocyte antigen tests were performed on the mother's serum and on serum from the implicated donor unit at a reference laboratory. A panel of human lymphocytes tested against the mother's serum by the microlymphocytotoxicity technique demonstrated the presence of a polyspecific human leukocyte antigen-related antibody, in which 5 of 42 cells reacted. A panel of 9 random donor platelets tested against the maternal serum sample, by the solid-phase erythrocyte adherence method, demonstrated reactivity with 5 platelets. The serum sample tested against platelets from the transfused unit was showed negative results. By the same methods, the donor serum showed no detectable human leukocyte antigen antibody but did demonstrate the presence of platelet-specific antibody. This was shown to be anti-PLal antibody by the modified antigen capture enzyme-linkedimmunosorbent assay. In tests of this type, patient serum interacts with platelet proteins that have been immobilized by specific monoclonal antibodies bound to a solid phase. Platelet lysate is added to specific monoclonal antibodies bound to a solid phase. Thus the specific platelet protein of interest is immobilized. Patient serum is subsequently added, and after a wash step the binding of the patient antibody to the platelet protein is quantitated with a conjugate molecule.2 Four antigens were used in the capture assay with appropriate controls, and only a PLAI antibody was detected. The donor platelets were confirmed to be free of the PLA1 antigen. DISCUSSION Thrombocytopenia in the newbom infant occurs in infants with congenital megakaryocytic hypoplasia, in intrauterine infection, in infants b o m to mothers taking thiazide drugs during pregnancy, in infants with congenital leukemia, and in the offspring of mothers with idiopathic thrombocytopenic purpura. 3 Up to 20% of cases of neonatal thrombocytopenia occur as a result of matemal sensitization by fetal platelet antigens with the subsequent production of IgG alloantibodies.4 This phenomenon was excluded in out patient because the platelet count at birth was within the normal range and had been appropriately maintained until the second blood transfusion was given. A drop in platelet count may also occur after passive transfer of antibody contained in blood products, which was clinically very compatible with the specific pattem of thrombocytopenia observed in this patient in the absence of
The Journal of Pediatrics January 1996
infection, hemolysis, and disseminated intravascular coagulation. Posttransfusion purpura is a different syndrome, occurring up to 1 week after incompatible platelets are administered to an individual who is lacking a specific antigen and who has been previously sensitized to that antigen. Routine donor screening does not include human leukocyte antigen or platelet antibody testing. The PL al antigen is a common antigen, being found in 98% of the population. 5 PL A2 homozygous individuals can make antibody directed against this immunogen after sensitization by pregnancy or prior transfusion.6 The blood donor in this case was a multiparous woman whose platelets were free of PL A1 antigen. Shulman et al. 7 demonstrated that infusion of 5 to 10 ml of plasma containing anti-PLA1 produced significant decreases in platelet counts; infusion of 10 ml decreased the recipient platelets from 170 x 109/L to 50 x 109/L in 2 hours; at that time, antibody could not be detected in the donor's plasma. An estimated 12 ml of antibody-containing plasma was transfused to the neonate, cansing a 347 x 109/L decrease in the platelet count within 2 hours. We found only one previous reference to the occurrence of thrombocytopenia in an adult after transfusion of packed erythrocytes from a sensitized donor. 8 Intravenous immune globulin therapy has been employed in the management of immune-mediated neonatal thrombocytopenia. 9 Suarez and Anderson l° reported the positive effects of intravenously administered immune globulin (400 mg/kg per day x 5 days) on the thrombocytopenia of five newborn infants, two with isoimmune thrombocytopenia and three with thrombocytopenia caused by maternal thrombocytopenic purpuraJ ° This treatment may be useful in the treatment of patients at risk of having severe bleeding complications. Although the plasma volume in erythrocyte transfusions is small, the possibility of passive transfer of antiplatelet antibody should be considered in cases of acute thrombocytopenia. REFERENCES
1. Kickler TS, Herman JH, Furihata K, Kunicki TJ, Aster RH. Identification of Bakb, a new platelet-specific antigen associated with post-transfusion purpura. Blood 1988;71:894-8. 2. Warkentin TE, Kelton JO. Immune thrombocytopenia and its management. In: Rossi EC, Simon TL, Moss GS, eds. Principles of transfusion medicine. Baltimore: Williams & Wilkins, 1991:233-54. 3. Adner MM, Fisch GR, Starobin SG, Aster RH. Use of "compatible" platelet transfusions in tre~{tmentof congenital isoimmune thrombocytopenic purpura. N Engl J Med 1969; 280:244-7. 4. Deaver JE, Deppert PC, Zaroulis CG. Neonatal alloimmune thrombocytopenic purpura. Am J Perinatol 1986;3:127-31. 5. Katz J, Hodder FS, Aster RH, Bennetts GA, Cairo MS. Neonatal isoimmune thrombocytopenia: the natural course and
The Journal of Pediatrics Volume 128, Number 1
Marzich et al.
management and the detection of matemal antibody. Clin Pediatr 1984;23:159-62. 6. Vogelsang G, Kickler TS, Bell WR. Post-Uansfusionpurpura: a report of five patients and a review of the pathogenesis and management. Am J Hematol 1986;21:259-67. 7. Shulman NR, Aster RH, Leimer A, Hiller MC. Immunoreactions involving platelets. V. Posttransfusion purpura due to a complement-fixing antibody against a genetically controlled platelet antigen: a proposed mechanism for thrombocytopenia and its relevance in autoimmunity.J Clin Invest 1961;40:1597620.
139
8. Ballem PJ, Buskard NA, Decary S, Doubroff P. Post-transfusion purpura secondary to passive transfer of anti-pLA1 by blood transfusion. Br J Hematol 1987;66:113-4. 9. Chirico G, Duse M, Ugazio AG, Rondini G. High-dose intravenous gammaglobulin therapy for passive immune thromhocytopenia in the neonate. J PEDIATR1983;103:654-5. 10. Suarez CR, Anderson C. High-dose intravenous gammaglobulin (IVG) in neonatal immune thrombocytopenia.Am J Hematol 1987;26:247-53.
BOUND VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of the 1996 issues of THE JOURNAL OF PEDIATRICSare available to subscribers (only) from the Publisher, at a cost of $81.00 for domestic, $103.79 for Canadian, and $97.00 for international subscribers, for Vol. 128 (January-June) and Vol. 129 (July-December), shipping charges included. Each bound volume contains subject and author indexes, and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram, with the Journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Dr., St. Louis, MO 63146-3318, USA/800-453-4351, or 314-4534351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular Journal subscription.