I S O I M M U N I Z A T I O N TO FACTOR P BY BLOOD TRANSFUSION*
B Y ALEXANDER S. W I E N E R M . D .
AND L E S T E R J. U N G E R
M.D.
From the Office of the Chief Medical Examiner of N. Y. C. and the N. Y. Post-Graduate Hospital Blood
Transfusion and Plasma Division
The most common cause of intragroup incompatibility and subsequent post-transfusion reactions is the Rh factor. 1 ' 2 Rarely, do factors other
than the Rh play a r61e in hemolytic transfusion
reactions when donor's and patient's bloods are
of the same blood group.
The factor P of human blood was first described
by Landsteiner and Levine3 in 1928. Although
they produced antiserums to test for this factor by
immunizing rabbits with human blood, this is not
accomplished with ease. Subsequently,4 it was
shown that normal animal serums frequently contain agglutinins giving weak reactions corresponding to anti-P. In fact, when it is necessary to test
for property P, the usual procedure at present is
to prepare the testing reagent from selected normal animal serums, in particular, pig serums or
horse serums. In addition, Landsteiner and Levine5 have reported that occasionally normal human
serums may contain irregular isoagglutinins giving
reactions related to or identical with anti-P. Such
agglutinins were at first designated as extra-agglutinin-1. Since, however, it is now known that they
are the same as anti-P, the former name has been
discarded.
The anti-P agglutinins from normal human serums are usually very weak and react most distinctly at low temperature. 6 For that reason it is
generally accepted that the presence of a natural
anti-P agglutinin in a patient's serum should not
give rise to a hemolytic reaction following transfusion even though the donor's blood is P positive.
There is evidence, however, that the titer of anti-P
agglutinins can be increased by isoimmunization
following blood transfusions. One of us7> 8 has
previously encountered two cases in. which relatively strong anti-P agglutinins developed as a
result of repeated blood transfusions and the
' case which we shall now describe is the third that
has come to our attention.
CASE REPORT
An 86 year old male, a patient of Dr. William V.
Healey, was admitted to a hospital in New York City
* Aided by a grant from United Hospital Fund of
New York Citv.
on May 2, 1944, complaining of loss of weight, intermittent epigastric pain, and tiredness. He was treated
symptomatically and apparently improved although
he continued to lose weight. His past and family
history were unimportant. On admission his hemoglobin was found to be 54 per cent and red cell count
3.5 million. He belonged to group A and was Rh positive. It was decided to transfuse him in preparation
for an operation. He was given three transfusions of
500 cc. each on May 5, 6, and 7 without any untoward
reaction. On May 7, he was also given a transfusion
of 500 cc. of plasma. At the operation, performed on
May 8, an annular carcinoma of the colon was found,
with extensive metastases to the liver and omentum.
On May 9, 500 cc. of plasma; on May 13, 500 cc. of
blood and 500 cc. of plasma; and again on May 14
500 cc. of plasma were given. At no time were the
transfusions followed by an untoward reaction. On
May 20 another blood transfusion was deemed necessary but difficulty was encountered in finding a donor
whose red blood cells were considered compatible with
the patient's serum, although there had been no trouble
previously in this regard. As many as 20 different
donors were tested and all found incompatible. These
donors included Rh negative as well as Rh positive
individuals of group O as well as group A.
Detailed serologic tests were then carried out.
The patient was found to belong to subgroup Ai
and type Rhi. The MN test showed the presence
of a mixture of bloods of types M, N and MN indicating that the blood cells from at least two of
the previous transfusions had survived in the
patient. The patient's serum contained an irregular agglutinin acting on donor's red blood cells
independently of the blood group, MN-type and
Rh-type. This agglutinin, however, did not act
on the patient's own red blood cells proving that
it was not an autoagglutinin. Tests on blood
samples of known P-type proved that the agglutinin in the patient's serum corresponded with
anti-P (see table 1).
The patient's serum was then tested against a
series of bloods at room, refrigerator and blood
temperature and the agglutinin was found to be
active throughout this temperature range. However, the reactions were most intense at low temperature. In fact, the clumping at body temperature was so weak that readings had to be taken by
616
617
ISOIMMUNIZATION TO FACTOR P
inspecting the sediments in each tube or after
centrifuging the tubes in order to accentuate the
agglutination. In titration experiments it was
found that the titer of the anti-P agglutinin in the
patient's serum was 16 in the refrigerator, while
at body temperature it was only 1, so that the
antibody had the properties of a cold agglutinin.
While natural anti-P agglutinins in human serum
are also cold agglutinins, we are convinced that
the agglutinin in our patient's serum was an immune isoantibody rather than a natural one for the
following reasons: 1, The titer of the agglutinin
was exceptionally high, and it was also active at
body temperature. 2, The agglutinin had not
been detected in previous cross-matching tests
carried out by the same technician even though
the antibody gave strong reactions by the common
slide and tube technics at room temperature.
3, Tests carried out on the patient's serum obtained
was up and about and apparently well. On June
18 he suddenly developed epigastric pain, his heart
sounds became poor in quality and his blood pressure was low. He died within three hours, from
coronary thrombosis. No autopsy was performed.
Advantage was taken of the opportunity to use
the patient's serum for testing a random series of
white and colored individuals. Only group A and
group O individuals were tested because the patient belonged to group A and his serum contained
a potent anti-B agglutinin* (titer 128 at room,
body and refrigerator temperature). One drop of
a 1:3 dilution of the patient's serum was mixed
in a small, narrow test tube with a drop of a 2 per
cent suspension of the blood being tested. (The
serum was used in a 1:3 dilution for economy, and
also to eliminate the reaction of a weak autoagglutinin it contained.) The mixtures were allowed
to remain in the refrigerator for one to two hours,
TABLE 1
RESULTS OF TESTS WITH THIS PATIENT'S SERUM ON BLOOD CELLS OF KNOWN GROUPS AND TYPES
PATIENT: B . M. V.
Anti-A & -B Serums; & Abs
B Serum
Anti-M & -N Serums
Anti-Rh Serums
Anti-P Serum
This Patient's Serum
A,
Rh,
Neg.
0
M
Rh 2
Neg.
Neg.
E . B . S.
A,
N
Rh,
Neg.
Neg.
TABLE 2
RESULTS OF TESTS WITH THIS PATIENT'S SERUM ON
RANDOM SERIES OF WHITE AND NEGRO
INDIVIDUALS
REACTIONS WITH PATIENT'S SERUM
BLOOD FROli
NUMBER
Positive
Negative
Number
Per
cent
Number
Per
cent
Whites .
237
176
74.3
61
25.7
Negroes
73
71
97.2
2
2.8
one week later revealed that there had been a pronounced drop in titer.
The patient's serum was now tested against a
series of group A blood samples, until several compatible ones were found. On June 8 the patient
was given 500 cc. of a compatible bank blood
selected in this manner. There was no untoward
reaction of any sort to this transfusion, and the
patient improved following it. He got out of bed,
A,
MN
Rh,Rh2
Pos.
++
W. G.
J. U.
s. s.
J. K.
0
N
Rh,
Pos.
0
MN
Rh,
Pos.
0
M
Neg.
Pos.
A2
MN
Neg.
Neg.
Neg.
++ ++ ++±
A. G.
0
N
Rh,
Pos.
A2
MN
Rh,
Pos.
++ ++
and then the tubes were gently shaken and the
reactions read. Care was taken during the readings not to allow the tubes to warm, because the
reaction reversed very readily on warming.
Where the reactions were indistinct, the tubes
were centrifuged at low speed for one minute in a
cup containing cracked ice, then gently shaken
and the reactions read again. It was found that
the P negative type occurred in approximately
25.7 per cent of white individuals in New York
City while among Negroes only 2.8 per cent were
P negative (see table 2). These results correspond closely with those obtained12 when an immune rabbit anti-P serum was used.
DISCUSSION
Had this patient been given a blood transfusion
from a donor positive for the P factor a hemolytic
•
* The high isoagglutinin titer of this patient's serum
was due to the plasma transfusions he had received.9- 10 '"
618
A. S. WIENER AND L. J. UNGER
transfusion reaction would almost certainly have
resulted. Naturally, there is no direct evidence
to support this statement since care was taken to
give the patient only P negative blood. We have,
however, the following indirect evidence in support
of this conclusion. Before the anti-P agglutinin
was detected in the patient's serum he had received a total of four blood transfusions from
different white donors. Differential agglutination
tests for the M and N properties showed that the
blood of at least two of these donors had survived,
undoubtedly because they were P negative. Since
three-fourths of all white individuals are P positive
it is reasonable to assume that of the remaining
two donors at least one was P positive and this
transfusion must have been the immunizing one.
The situation here is quite similar to that which
exists for property M. Natural anti-M agglutinins are but rarely present in human serum, and
only five such cases have been reported to date.13
One of us 8 ' " has seen two cases in which anti-M
immune isoagglutinins appeared in patients'
sera as a result of repeated blood transfusions.
Both these patients were thereafter transfused
only with type N blood and in this way hemolytic
reactions were prevented. The anti-M agglutinins
in these two patients' serums had properties very
similar to the anti-P agglutinin of the present
case, in that they gave their strongest reactions
at low temperature. I t is significant that Broman16 has recently reported a severe hemolytic
reaction which he proved was due to incompatibility with respect to property M, resulting from isoimmunization by repeated transfusions.
Luckily, the instances of isoimmunization to
properties P and M are extremely rare. Recently, a report16 appeared of supposed isoimmunization to property N, but the data offered in
support of this diagnosis appear inadequate and
unconvincing. In any event, a complete blood
donor service should include a list of at least a few
individuals who have been classified for the
properties M, N and P in order to be prepared
to take care of problem cases such as these when
they arise.
the markedly higher incidence of P positive individuals among Negroes.
REFERENCES
(1) WIENER, A. S., AND PETERS, H. R.: Hemolytic
reactions following transfusions of blood of the
homologous group, with three cases in which
the same agglutinogen was responsible. Ann.
Int. Med., 13: 2306,1940.
(2) WIENER, A. S.: Hemolytic reactions following
transfusions of blood of the homologous group.
II. Further observations on the role of the
property Rh, particularly in cases without
demonstrable isoantibodies. Arch. Path., 32:
227, 1941.
(3) LANDSTEINER, K., AND LEVTNE, P.: On individual
differences in human blood. J. Exper. Med.,
47: 757, 1928.
(4) LANDSTEINER, K., AND LEVINE, P.: The differen-
tiation of a type of human blood by means of
normal animal sera. J. Immunol., 20: 179,
1931.
(5) LANDSTEINER, K., AND LEVINE, P.: On isoagglu-
tinin reactions of human blood other than those
defining the blood groups. J. Immunol., 17:
1, 1929.
(6) WIENER, A. S.: Blood Groups and Transfusions.
Chapter XVI, Ed. 3., Springfield, 111., C. C.
Thomas, 1943.
(7) WIENER, A. S., AND POLAYES, S. H.: Cited by
Wiener and Peters.1
(8) WIENER, A. S.: Hemolytic transfusion reactions.
n i . Prevention, with special reference to the
Rh and cross match tests. Am. J. Clin. Path.,
12: 302, 1942.
(9) AUBERT, E. F., BOORMAN, K. E., AND DODD, B.
E.: Agglutinin inhibiting substance in human
serum. J. Path, and Bact., 54: 98, 1942.
(10) WIENER, A. S.: Meeting of Subcommittee on
Blood Substitutes of the National Research
Council, Washington, D. C. (March) 1943.
(11) WIENER, A. S., SONN, E. B., AND BELKIN, R. B.:
Heredity of the Rh blood types. J. Exper.
Med., 79: 235, 1944.
(12) LANDSTEINER, K., AND LEVINE, P.: On the racial
distribution of some agglutinable structures of
human blood. J. Immunol., 16: 123, 1929.
(13) WIENER, A. S.: Blood Groups and Transfusions'
p. 219. Ed. 3. Springfield, 111., C. C. Thomas,
1943.
(14) WIENER, A. S., AND FORER, S.: A human serum
SUMMARY
A case is described of isoimmunization against
P factor resulting from repeated blood transfusions. The patient was successfully transfused
with P negative blood.
Tests for the P factor on a series of white and
colored individuals confirm previous reports of
containing four distinct isoagglutinins. Proc.
Soc. Exper. Biol. & Med., 47: 215,1941.
(15) BROMAN, B.: The blood factor Rh in man, a
clinico-pathological investigation, with special
regard to morbus hemolyticus neonatorum
("erythroblastosis foetalis"). Acta Paed., vol.
XXXI, Suppl. H, Stockholm, 1944.
(16) SINGER, E.: Isoimmunization against blood factor
N. Med. J. Austral., 2: 29, 1943.