History

Mr. H.M. is an 83 year-old male diagnosed with ITP. On November 20 HM presented to his physician's office with nosebleeds and was later diagnosed as having an underlying low grade lymphoproliferative disorder. His medical history included ischemic heart disease and chronic obstructive pulmonary disease. Because he was considered a high surgical risk, splenectomy was not done. At the time of admission he was treated with oral prednisone for the ITP, followed by two courses of high dose IVIG therapy. He initially responded well but was unable to sustain the platelet increments.

NOVEMBER 20 - 24

  • Nov. 20: Hemoglobin 83 g/L and platelet count 2 X 109/L
  • Group O Rh positive
  • Antibody screen negative by PEG-IAT
  • Crossmatched (electronically) and transfused with 7 units of RBC without incident (Nov. 20-23)
  • Nov. 24: Hemoglobin 136 g/L and platelet count 31 X 109/L

NOVEMBER 25 - DECEMBER 28

  • Re-admitted Dec. 8 and discharged Dec. 15
  • Transfused daily with IVIG (Dec.8 - 11)
  • Dec. 28: Hemoglobin 138g/L and platelet count 17 X 109/L

DECEMBER 30 - JANUARY 11

  • Dec. 30: Received 5 platelet concentrates
  • Jan. 4: Hemoglobin 129 g/L and platelet count 13 X 109/L
  • Jan. 4: 4000 micrograms of RhIG transfused in ambulatory care unit

JANUARY 17 - 18

  • Jan.17: Admitted to hospital after coming to Emergency complaining of chest pain
  • Hemoglobin 79 g/L (~50g/L drop from Jan. 4) and platelet count 34 X 109/L
  • Two RBC were ordered
  • Antibody screen negative but DAT positive (2+) with IgG on the red cells.
  • Eluate showed passive anti-D from the RhIG.
  • Two units of group O Rh negative RBC were crossmatched (PEG-IAT) and transfused without incident (17 Jan.)

JANUARY 25 - 26

  • Jan. 25: Hemoglobin 91 g/L and platelet count 15 X 109/L
  • Jan. 26: Two units of group O Rh positive RBC were crossmatched (PEG-IAT) and transfused uneventfully in ambulatory care unit
  • HM's post-transfusion hemoglobin rose to 113 g/L and platelet count 56 X 109/L

RECOMMENDATIONS

Because of this adverse reaction to RhIG, the following recommendations were made:

  • If RhIG for ITP is given on an outpatient basis, arrangements should be made for follow up.
  • RhIG is contraindicated in pt. with any disease process that may mask signs of hemolysis.
  • RhIG is contraindicated in pt. with renal disease and/or heart disease.
  • All patients who receive RhIG for ITP should be followed up to check for evidence of hemolysis.