A rare, potentially life‐threatening presentation of passenger lymphocyte syndrome

• Published in: Transfusion (Philadelphia, Pa.) Pa.), 2017-05, Vol.57 (5), p.1262-1266
• Main Authors: Gniadek, Thomas J., McGonigle, Andrea M., Shirey, R. Sue, Brunker, Patricia A., Streiff, Michael, Philosophe, Benjamin, Bloch, Evan M., Ness, Paul M., King, Karen E.
• Format: Article
• Language: English
• Subjects: ABO Blood-Group System; Adult; Anemia; Anemia, Hemolytic - etiology; Blood Group Incompatibility - immunology; Humans; Liver Transplantation - adverse effects; Lymphocytes; Lymphocytes - immunology; Male; Reticulocyte Count; Rh-Hr Blood-Group System - immunology; Rho(D) Immune Globulin - immunology; Tissue Donors; Transplants & implants
• ISSN: 0041-1132; 1537-2995
• DOI: 10.1111/trf.14055

BACKGROUND Passenger lymphocyte syndrome occurs when donor lymphocytes are transplanted with a solid organ and produce alloantibodies that react with antigens on the recipient's red blood cells (RBCs). Typically, passenger lymphocyte syndrome presents as immunoglobulin G antibody‐mediated, extravascular hemolytic anemia with reticulocytosis. Often, the donor was alloimmunized before transplantation. CASE REPORT A 34‐year‐old Group O, D+ man with a negative antibody screen received a liver transplant from a Group O, D− donor. Twenty Group O, D+ RBC units were transfused on Postoperative Days (PODs) 0 through 2. On POD 7, the patient developed anemia, a weakly positive antibody screen, and a positive direct antiglobulin test with anti‐D in the eluate. After POD 8, a D− transfusion protocol was initiated. Despite laboratory evidence of hemolysis, two initial peripheral blood smears showed no increase in schistocytes or spherocytes, the reticulocyte count was depressed, and a marrow biopsy revealed erythroid hyperplasia. Eventually, anemia resolved after a period of medication non‐compliance; however, a positive direct antiglobulin test persisted to the last follow‐up date (POD 233). RESULTS Other potential causes of aplastic anemia were investigated, but no alternative cause was found. History excluded passive anti‐D. D+, LW− cells were reactive, excluding anti‐LW. Genotyping showed no evidence of a partial D genotype. Chart review revealed that the liver donor had a history of anti‐D. A diagnosis of passenger lymphocyte syndrome was reached. CONCLUSION Although antibody‐mediated hemolytic anemia has been reported to cause reticulocytopenia in the presence of marrow erythroid hyperplasia, this report of passenger lymphocyte syndrome causing a similar post‐transplant anemia in association with reticulocytopenia is noteworthy.