5. CLASSIFICATION
• Warm-Autoantibody Type: Autoantibody Maximally
Active at Body Temperature (37°C)
– Primary or idiopathic warm autoimmune hemolytic
anemia (AHA)
– Secondary warm AHA
• Associated with lymphoproliferative disorders (e.g., Hodgkin
lymphoma)
• Associated with the rheumatic disorders, particularly systemic
lupus erythematosus (SLE)
• Associated with certain nonlymphoid neoplasms (e.g., ovarian
tumors)
• Associated with certain chronic inflammatory diseases (e.g.,
ulcerative colitis)
• Associated with ingestion of certain drugs (e.g., α-methyldopa)
6. • Cold-Autoantibody Type: Autoantibody Optimally
Active at Temperatures <37°C
– Mediated by cold agglutinins
• Idiopathic (primary) chronic cold agglutinin dis- ease (usually
associated with clonal B-lymphocyte proliferation)
• Secondary cold agglutinin hemolytic anemia
– Postinfectious (e.g., Mycoplasma pneumoniae or infectious
mononucleosis)
– Associated with malignant B-cell lymphoproliferative disorder
– Mediated by cold hemolysins
• Idiopathic (primary) paroxysmal cold hemoglobinuria (very rare)
• Secondary
– Donath-Landsteiner hemolytic anemia, usually associated with an acute
viral syndrome in children (relatively common)
– Congenital or tertiary syphilis in adults (very rare)
7. • Mixed Cold and Warm Autoantibodies
-Primary or idiopathic mixed AHA
-Secondary mixed AHA
1. Associated with the rheumatic disorders,particularly SLE
• Drug-Immune Hemolytic Anemia
1. Penicillin-type (drug adsorption)
2. Immune complex
3. Membrane modification
4. Drug-independent
10. Warm vs. Cold Auto
WARM
• Reacts at 37 degC
• Insidious to acute
• Anemia severe
• Fever, jaundice frequent
• Intravascular not common
• Splenomegaly
• Hematomegaly
• Adenopathy
• None of these
COLD
• Reacts at room temperature
• Often chronic anemia
• 9-12 g/dL (less severe)
• Autoagglutination
• Hemoglobinuria,
acrocyanosis and raynaud’s
with cold exposure
• No organomegaly
15. 1. Cold-reactive (IgM) antibody. Red cell agglutination at room temperature.
2. Same blood examined at 37°C. Note marked reduction in agglutination.
1 2
16. TABLE 54–4. Major Reaction Patterns of the Direct Antiglobulin Test
and Associated Types of Immune Injury
Reaction Pattern Type of Immune Injury
Immunoblobulin (Ig) G alone
Warm-antibody autoimmune
hemolytic anemia
Drug-immune hemolytic anemia:
hapten drug adsorption type or
autoantibody type
Complement alone
Warm-antibody autoimmune
hemolytic anemia with subthreshold
IgG deposition
Cold-agglutinin disease Paroxysmal
cold hemoglobinuria
Drug-immune hemolytic anemia:
ternary complex type
IgG plus complement
Warm-antibody autoimmune
hemolytic anemia
Drug-immune hemolytic anemia:
autoanti- body type (rare)
18. • WAIHA
– Prednisone: corticosteroid used as antiinflammatory
– Splenectomy may be required if no response to steroids
– Azothioprine: when previous treatments fail;
immunosuppressive antimetabolite
• CAS or PCH
– Chlorambucil or cyclophosphamide (cytotoxic)
– Transfusion (using blood warming devices)
• Drug-Induced
– Discontinue drug
– Transfuse only if insufficient oxygen delivery occurs
28. Observations Conclusions
1 Positive
Control
(PC)
(A) Agglutination
(B) No Agglutination
Correctly performed
test procedure.
Coombs serum may
not be proper.
Repeat the test
again.
2 Negative
control
(NC)
It should show no agglutination, since saline
does not contain Anti-D or any other antibodies.
3 Test (Serum)
(T)
(A) Agglutination
(and if PC results
are correct)
(B) No Agglutination
Patients serum
contains Anti-D.
Patients serum does
not contain Anti-D.
Test Interpretation:
