Transient Production of Anti-LM! by LW-positive People B. CHOWN, H. KAITA, B. LOWEN, AND M. LEWIS
From the Rh Laboratory, Winnifieg, Canada
As the result of pregnancy immunization two Rhaegative women produced anti-D and anti-LW, while an Rh-pasitive woman produced anti-LW in response to transfusion. The 6rst two were both initially LW-negative and direct antiglobulin test negative. One then became direct antiglobulin test positive, and this lasted as long as anti-LW was present in her plasma Other observationa suggest thii may not be a rare occurrence.
tests, and an antibody that reacted by saline, al- bumin, Lows papain and indirect antiglobulin tests with all Rh-negative cells but not a t all with Rh..,, cells. We assumed its specificity to be anti-LW. Her cells, which were direct antiglobulin test negative, did not react with anti-LW by Uws technic. We classed her as LW-negative with anti-D and anti-LW in her serum. No further tests were done at that time.
Fourteen months later, her cells reacted strongly with anti-LW by Liiws technic, and her Serum no longer contained anti-LW. She entered her fourth pregnancy a year later; during it her anti-D titer rose to 1:2,048. Anti-LW did not develop and her red blood cells remained LW-positive and direct antiglobulin negative.
IN THE PAST five years we have seen four examples of anti-LW. Three were pro- duced by LW-psitive in con- mCtion with pregnancy and one following transfusion, while one was produced by an LW-negative woman, Mrs. Big. The fol- lowing is a reprt Of the first three. The
Case 3. Miss I. W., group 0 R,r, aged 46, does not admit to any pregnancies but she did have three transfusions in Aurmst 1965. receiving eight
fourth has been reported by deVeber, units of blood in seven iays. There was no sere Clark, Hunking, and: Str0uP.i Anti-LW logical compatibility problem. In February 1966,
when more blood was requested, she was found by serum in this report refers to anti-LM7, Big. the Winnipeg Division of the Canadian Red Cross
Case 1. Brenda G. was 18 years old and in the fifteenth week of her first pregnancy when we first examined her blood in December 1967. She was A, Rh-negative, and had no anti-LW or anti-D at 15, 21, 25, 28, 39, or 40 weeks of gestation. Three days before her due date, fetal movements stopped. The fetus was stillborn. No cause of death was found at autopsy.
Seven weeks later we again examined Brendas blood: Powerful anti-LW and anti-D were present. Her red blood cells did not react with anti-LW either by Liiws papain or indirect antiglobulin tests. We classed her as LW-negative. Around this time, she became pxwnant again. Her husband is
Blood Trakfusion Service to have a weak antibody that reacted with the blood of all random donors. This was identified as anti-LW. Miss I. W.s cells were weakly positive by direct antiglobulin test and were not agglutinated by anti-LW by papain technic. We were in doubt as to her LW status, and submitted a sample of her blood to Miss Marjory Stroup and Mario Celano. They too could not agree on her LW status. Four siblings of Miss I. W. were all LW-positive. A specimen of her blood obtained in December 1969, four years after the first one, was LW-positive and direct anti- globulin test negative. The serum contained a weak antibody that reacted only with R2R2 and R2r cells.
Further Observations Rlr, .and he, her $areits, and-five siblings are LW- positive. A summary of the essential facts con- cerning Brendas cells and serum during her first two pregnancies are given in Table 1.
her husband. 0 R A LW-positive. She had a normal baby in April 1960 and another in December 1961. During her third pregnancy in 1967, RII antibody was not found in
The following two observations are com- patible with the theory that the antibody involved in the three cases was anti-LW; but in no way do they prove that it was. They are recorded because they are sug- gestive and because, if the antibody
Case 2. MIS. Des. is 0
- - her serum at 8. 13, 17, 23, and 30 weeks of gesb- tion, but the delivery sample contained anti-D
anti-LW, its transient production by LW-
event. There would then be material avail- with a titer of 1~16 both by saline and albumin positive people be an rare
Received for publication February 24, 1971; ac-
Supported in part by a grant from the Medical
able on which to base further investigation. First, over the past 28 years we have
occasionally seen a pregnant Rh-negative cepted March 26, 1971.
Research Council of Canada.
Transfusion July-Aug. 1971
Volume 11 Number 4
Volume 11 Number 4
TRANSIENT PRODUCTION OF ANTI-LW 22 1
TABLE 1. Serum and Cells of an Rh-negative, LW-positive Woman, Brenda G., DurinR her First Two Pregnancies
~ ~ ~~ ~
Patient's Cells Patient's Serum vs.
Following Cells Direct Reaction Antiglobulin with Anti LW
Time in Pregnancy Rhn.1 I D+ D- Test (Big)
Seven weeks after delivery
15,21.28,39,40 weeks 0 0 N.D. N.D.
Second pregnancy started -20' C < l ' C < l ' -20' -20'
12 weeks C < l ' +6' 16 weeks +y +3' ?+ 20 weeks +y +7' 24 weeks -20' - 10' 35 weeks -20' -10' POS.
Did not react in saline suspension whereas normal Rh-negatives did. Weaker than the normals by papain. Indirect antiglobulin test of both Brenda and normals +2', which was not different from Brenda's +3' direct antiglobulin test.
The times giwn are the reaction times by indirect or direct antiglobulin capillary tests. C < 1' = com- plete agglutination in less than one minute. A +9' reaction is a very, very weak one. -10' and -20' mean no reaction in ten minutes or twenty minutes, the test usually being read only to ten minutes.
When first found the anti-LW also reacted by saline, albumin and IBw's papain tests, the reactions with Rh-negative cells heing much weaker than those with Rh-positive cells by these technics. Twelve weeks later there was no reaction with Rh-negative cells by saline or albumin tests. The papain test reaction with Rh-negative cells persisted to 24 weeks. The anti-D titer rose in the second pregnancy from 1:16 to 1:2.048 hut no anti-LW appeared.
woman produce a weak antibody that ini- tially reacted with both Rh-positive and Rh-negative cells, only to have it change shortly so that the serum contained only anti-D. A direct antiglobulin test was never done on these women. The specificity of the antibody that reacted with Rh-negative cells was never determined, but this was before LW and Rh,,,,, were recognized.
Second, in March 1970 at a meeting on the prevention of Rh immunization, Dr. I. A. Cook, Regional Director of the Blood Transfusion Service of Inverness, Scotland, reported3 the following:
1. They had immunized 18 Rh-nega- tive men as anti-Rh plasma donors. 2. Each man had given about five liters of plasma. 3. When the 5-liter pools were ex- amined, 11 reacted with ficinized or papainized Rh-negative cells. 4. Two donors were observed to have
a positive direct antiglobulin reaction. This diminished in time, one lasting five months. Neither man had any evi- dence of a pathologic hemolytic proc- ess. 5. The IgG extracted from the total pool (about 65 liters) reacted with ficinized Rh-negative cells. 6. Neither Rh,,,, nor Rh-negative, LW-negative cells had been available for testing.
The story of one woman, Mrs. J., whose observed Rh and LW course was almost identical with that of Brenda G.. was re- ported in 1967 by Giles and Lundsgaard.5 Mrs. J. was Rh-negative and, at the end of
*Two RhnUll cells have since become available to Dr. Cook. He tested the serum of three of the men against three random Rh-negative cells and the two Rh,,,, cells. By the ficin technic the serum of all three reacted with Rh-negative cells but not with the RhnUll cells.
her first pregnancy, anti-D and anti-LW were present in her serum. Her cells were positive by direct antiglobulin test and did not react with either Swanson and Matsons anti-LW known as Mrs. V. W. or with the anti-LW Big which we used. (This is designated Mrs. B. by Giles and Lundsgaard) . Later Mrs. J.s cells became negative by direct antiglobulin test and reacted with both the anti-LW sera.
Giles and Lundsgaard did not observe a phase during which Mrs. J.s cells were negative both with the direct antiglobulin test and with anti-LW, and we can never know whether such a phase ever existed. On the other hand, they made two impor- tant observations which are missing from our study. First, while Mrs. J.s cells were not agglutinable by either serum V. W. or serum Big., they nevertheless caused a marked reduction of anti-LW in serum V.W. but not in serum Big. Second, the antibody eluted from Mrs. J.s Rh-negative cells had a different specificity from that which was absorbed from her plasma by adult Rh-negative cells and then eluted from them. The scoring of the two for various Rh, LW phenotypes was different and, while the eluate from Mrs. J.s cells did not react with cells typed as D-negative, LW-negative, the eluate of the antibody derived from Mrs. J.s plasma did react with these cells.
We think that our observations make a different, potentially important contribu- tion to the solution of the problem of why some LW-positive people may for a time have anti-LW in their plasma. The obser- vation is that the red blood cells were direct antiglobulin test negative when they were first observed not to react with anti-LW. This strongly suggests that the LW-negativity of the red blood cells at this time did not depend on the LW sites being blocked by a globulin, but on some other unexplained process.
We would argue then that the anti-LW
ET AL Transfusion July-Aug. 1971
is probably actively produced only during the time that the subject is functionally LW-negative. From this it follows that at the time of production the antibody is not an anti-self or so-called autoimmune antibody as anti-LW may be in hemolytic anemia.1 Later it has die appearance of an anti-self antibody because the LW-posi- tivity returns to the red blood cells and they become positive by direct antiglobulin test. From this point on, the course of the antibody is essentially that of a passively acquired incompatible antibody, such as one sees when, for example, one gives anti-Rh IgG to an Rh-positive subject.2 It is evident Ithat much remains to be dis- covered before we understand how the curious situation recorded here is brought about.
Acknowledgment We are indebted to Miss Catherine Anderson for
referring Case 3 and to Miss Marjory Stroup and Mario Celano for their investigation of this case; to Dr. I. A. Cook for making his observations avail- able to us; and to Dr. deVeber and Dr. Philip Levine for a generous supply of the serum of Mrs. Big.
References 1. Celano, M., and P. Levine: Anti-LW specificity
in autoimmune acquired hemolytic anemia. Transfusion 7: 265, 1967.
2. Chown, B., J. M. Bowman, J. Pollock. B. Lowen, and A. Pettett: The effect of anti-D I g G on D-positive recipients. Canad. Med. Ass. J. 102: 1161, 1970.
3. Cook, I. A.: Letter to authors concerning an informal meeting on Rh prevention, London, March 1970.
4. de Veber, L. L., G. Clark, M. Hunking, and M. Stroup: Maternal anti-LW. Transfusion
5. Giles, C. M., and A. Lundsgaard: A complex serological investigation involving LW. Vox Sang. IS:406, 1967.
11: 33-35, 1971.
Bruce Chown. M.D.. Director, Rh Laboratory. 735 Notre Dame Avenue, Winnipeg 3. Canada; Professor of Paediatrics, University of Manitoba.
Hiroko Kaita, Research Technician, Rh Labora- tory.
Bonnie Lowen, Senior Technician, Rh Labora- tory.
Marion Lewis, B.A.. Technical Director. Rh Laboratory, Demonstrator in Paediatrics, Univer- sity of Manitoba.