Is This a Hemolytic Transfusion Reaction?

Christopher M. Lough, MD; Leonard I. Boral, MD, MBA; Julie Ribes, MD


December 11, 2013

In This Article

Clinical Presentation

A 59-year-old man with a history of IgG kappa multiple myeloma presented to an outpatient facility for evaluation of left hip pain, which was found to be a pathologic fracture. He has had 2 autologous stem cell transplants, 7 years and 1 year ago. Despite therapy with dexamethasone and lenalidomide, his serum concentration of monoclonal protein had been increasing.

Two weeks before the current visit, he received a transfusion of 2 units of red blood cells to treat anemia, but complications were documented. He was admitted to the hospital for surgical repair of the pathologic fracture of his left hip.

While being evaluated at the hospital, the patient became short of breath, with a respiratory rate of 23 breaths/min, and was observed to have cyanosis of the right second toe with concurrent right leg and right groin pain. A temperature of 38.9°C was recorded, and concern was high for pulmonary embolism (PE) and deep vein thrombosis. He continued to deteriorate rapidly and developed cardiac arrhythmias with hypotensive shock, resulting in 2 cardiopulmonary resuscitations.

Staff attempted to draw blood for work-up before a CT evaluation of the patient's lungs, but had difficulty in obtaining a specimen that the laboratory would accept. Two separate samples were rejected for analysis by the laboratory because of clotting and hemolysis (Figure 1).

Figure 1.

The patient's plasma, demonstrating visible hemolysis.

The second blood specimen was kept at 37°C because of the possibility of a cold agglutinin, but this specimen likewise revealed clotting and hemolysis, as reported by the laboratory. The unofficial results from the clotted specimen are listed in the Table.

Diagnostic Test Results

Table. Laboratory Results

Test 2 Weeks Earlier
(Before Transfusion)
On Admissiona
Hematocrit 23% 10%
White blood cell count 4500 cells/μL 1500 cells/μL
Platelet count 83,000 cells/μL 20,000 cells/μL
IgG monocolonal protein 4.5 g/dL  

a Values from the current admission were questioned because of hemolysis and clotting on 2 separate phlebotomy specimens. Blood was said to look like "wine, very thin." The specimen for prothrombin time/activated partial thromboplastin time was rejected because of hemolysis.

The peripheral blood smear confirmed severe anemia with spherocytosis, thrombocytopenia, and leukopenia. No schistocytes were noted.

As a result of persistent hypotension, the patient was transfused with 3 units of uncrossmatched, type O red blood cells. A type and antibody screen specimen obtained before the transfusions revealed that his red cells were type B positive, a screen for unexpected antibodies was negative, and direct antibody tests (DAT) for both anti-IgG and anti-C3b were also negative.

The transfusion medicine service was consulted because of clinical suspicion of a hemolytic transfusion reaction or cold agglutinin disease. The investigation into the transfused units revealed that the clerical check was conducted correctly, the units were compatible, and the DAT was negative. Hemolysis of the plasma was present.

The patient was eventually transferred to the intensive care unit, where he was found to have a temperature of 39.1°C. He began bleeding from the nose and mouth. Despite further resuscitative efforts, the patient died 13 hours after his initial presentation at the outpatient facility.


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