Continuing Education Case Studies A-Level Case A5: Adverse Reaction to Intravenous Rh Immune Globulin in a Patient with ITP
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Lat updated 12 July 2011
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Contributed by: Maureen Wyatt, ART, Kelowna General Hospital
Mr. H.M. is an 83 year-old male diagnosed with immune thrombocytopenic purpura (ITP).
On November 20 HM presented to his physician's office with nosebleeds. Subsequent investigations showed an underlying low grade lymphoproliferative disorder. His medical history includes ischemic heart disease, treated with medical therapy after occlusion of a bypass graft performed in 1971 and chronic obstructive pulmonary disease. He is considered a high surgical risk, therefore, splenectomy is not an option. At the time of admission he was treated with oral prednisone for the ITP. This was followed by two courses of high dose intravenous immunoglobulin (IVIG) therapy. He initially responded well but was unable to sustain the platelet increments.
In January vincristine was prescribed. While not recommended as a primary treatment it has been shown to be useful in ITP that is refractory to steroids and splenectomy. On January 4, the hematologist ordered Rh immune globulin (RhIG).
| Reference Ranges | |
|---|---|
| Hemoglobin | 131-169 g/L |
| Platelets | 140 - 450 X 109/L |
| Creatinine | 50 - 130 mmol/L |
| Haptoglobin | 0.60 - 2.00 g/L |
| Total bilirubin | 3 - 17 mmol/L |
HM was admitted to hospital for hematological workup following numerous uncontrolled nosebleeds.
|
Initial Laboratory Results (Nov. 20) |
|
|---|---|
| Hemoglobin | 83 g/L |
| Platelets | 2 X 109/L |
| Creatinine | 109 mmol/L |
| Haptoglobin | 0.85 g/L |
The hematologist requested 0.4 gm IVIG /kg x 5 days. Patient weight was 81.9 kg. Patient was also started on prednisone.
Based on these results, red cells were electronically crossmatched and Mr. HM was transfused with one unit of RBC on November 20 and two RBC on each of 3 days (November 21-23) as he exhibited anemia-related symtoms. No adverse reactions were reported.
35 gm IVIG (Nov.20) and 30 gm IVIG (Nov. 21, 22, 23) were also transfused without incident.
|
Laboratory Results (Nov. 21-24) |
||
|---|---|---|
| Date | Hemoglobin | Platelets |
| Nov. 21 | 86 g/L | 3 X 109/L |
| Nov. 22 | 100 g/L | 5 X 109/L |
| Nov. 23 | 122 g/L | 13 X 109/L |
| Nov. 24 | 136 g/L | 31 X 109/L |
Five platelet concentrates were requested by the on-call oncologist on Dec. 30. The patient was ABO and Rh retyped and the platelets were transfused as a pool without incident.
On Jan. 4, HM's hemoglobin was 129 g/L and his platelet count was 13 X 109/L. 4000 micrograms of RhIG were given in the ambulatory care unit.
|
Laboratory Results (Jan. 11) |
|
|---|---|
| Hemoglobin | 103 g/L |
| Platelets | 73 X 109/L |
| Creatinine | 122 mmol/L |
| Haptoglobin | 0.06 g/L |
| Total bilirubin | 12 mmol/L |
HM came to Emergency complaining of chest pain and was admitted to hospital.
|
Laboratory Results (Jan. 17) |
|
|---|---|
| Hemoglobin | 79 g/L |
| Platelets | 34 X 109/L |
| Creatinine | 121 mmol/L |
The patient's hemoglobin dropped 50g/L (129 g/L on Jan. 4 to 79 g/L on Jan. 17).
Two red cell concentrates were ordered.
Two group O Rh negative red cell concentrates were crossmatched (PEG-IAT) and transfused without incident on Jan. 17. The patient's chest pain had abated, his CBC showed a satisfactory increment, and he was discharged on Jan.18.
|
Laboratory Results (Jan. 18) |
|
|---|---|
| Hemoglobin | 92 g/L |
| Platelets | 31 X 109/L |
| Creatinine | 104 mmol/L |
| Haptoglobin | <0.06 g/L |
| Total bilirubin | 17 mmol/L |
On Jan. 25 two red cell concentrates were ordered. Two group O Rh positive RBC were crossmatched (PEG-IAT) and transfused without incident on Jan. 26 in the Ambulatory Care Unit. The patient's DAT was still positive but weaker (1+).
|
Laboratory Results (Jan. 25 - 26) |
|||
|---|---|---|---|
| Jan. 25 | Jan. 26 | ||
| Hemoglobin | 91 g/L | 113 g/L | |
| Platelets | 15 X 109/L | 56 X 109/L | |
After reviewing the case summary, consider these questions.
American Society of Hematology. Diagnosis and Treatment of Idiopathic Thrombocytopenic Purpura: Recommendations of the American Society of Hematology (Annals of Internal Medicine 1997;126:319-26.)
Blanchette V,Freedman J, Garvey B. Management of chronic immune thrombocytopenic purpura in children and adults. Semin Hematol. 1998 Jan;35(1 Suppl 1):36-51.
Cangene Corporation. WinRho SDF
Engelfriet CP, Reesink HW, Bussel J, Godeau B, Bierling P, Panzer S, et al. The treatment of patients with autoimmune thrombocytopenia with intravenous IgG-anti-D (International Forum). Vox Sang. 1999;76(4):250-5.
Gaines AR. Acute onset hemoglobinemia and/or hemoglobinuria and sequelae following Rho(D) immune globulin intravenous administration in immune thrombocytopenic purpura patients. Blood. 2000;95(8):2523-9.
Sandler SG. Treating immune thrombocytopenic purpura and preventing Rh alloimmunization using intravenous rho (D) immune globulin. Transfus Med Rev 2001 Jan;15(1):67-76.
Sandler SG, Novak, SC, Roland B. The cost of treating immune thrombocytopenic purpura using intraveous Rh immune gloulin versus intravenous immune globulin. (Am J Hematol 2000 Mar;63(3):156-8.)
Scaradavou A, Woo B, Woloski BM, Cunningham-Rundles S, Ettinger LJ, Aledort LM, Bussel JB. Intravenous anti-D treatment of immune thrombocytopenic purpura: experience in 272 patients. Blood 1997 Apr 15;89(8):2689-700.
Simpson KN, Couglin CM, Eron J, Bussel JB. Idiopathic thrombocytopenia purpura:Treatment patterns and an analysis of cost associated with intravenous immunoglobulin and anti-D therapy. Semin Hematol 1998 Jan;35(1 Suppl 1):58-64. [ Medline ]
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