Transfusion and Apheresis Science 58 (2019) 30–31

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Transfusion and Apheresis Science

journal homepage: www.elsevier.com/locate/transci

Submitted Papers

Acquired-B phenomenon in a neonate presenting with necrotizing enterocolitis T

a a,⁎ a b a
Arunpreet Kaur , Ashish Jain , Neelam Marwaha , J.K. Mahajan , Ratti Ram Sharma
a
Department of Transfusion Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh-160012, India
b
Department of Pediatric Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh-160012, India

ABSTRACT

Objective: We are reporting a case of acquired B phenomenon in a 14 days old pre-term baby presenting with necrotizing enterocolitis (NEC) where it was detected as
an ABO discrepancy.
Method: The forward and reverse grouping was done using tube technique as well as column agglutination technique (ABD card and LISS Coombs AHG gel cards,
Biorad, Switzerland). The direct antiglobulin test (DAT) was also done on gel card. Further work up was done using acidified (0.1 N HCl) anti-B (pH 6–6.5) polyclonal
anti-B (from group A donors) for resolution of ABO discrepancy.
Results: The forward grouping was AB RhD positive with a ‘mixed-field’ agglutination with anti-B. The reverse grouping using pooled A cells, B cells and O cells
gave ‘negative’ result with both the techniques. Anti-A1 gave 2+ agglutination, anti-H gave 1+ agglutination and autologous control was negative. The DAT
was also negative. The patient’s previous group on day 1 of life was A RhD positive and had received 1 PRBC (pedibag) transfusion. As the patient’s blood
culture was positive for Klebsiella pneumoniae, it could have contributed to ‘acquired-B’ phenomenon. Acidified (0.1 N HCl) anti-B (pH 6–6.5) and polyclonal
anti-B yielded no agglutination with patient red cells. The patient was kept on antibiotics subsequently and the blood group after 3 weeks was found to be A
RhD positive.
Conclusion: This case of ‘acquired-B’ phenomenon in a neonate with NEC emphasizes the relevance of clinical findings as a guide to resolve blood group discrepancy
and deciding further transfusion strategy.

1. Introduction 2. Case report

ABO discrepancy resolution is very important for assigning correct
blood group and deciding transfusion protocol for patients. It should be
done using appropriate techniques to minimize the delay in transfusion
and at the same time without compromising patient safety. Acquired B
phenomenon occurs when the bacterial deacetylase converts N-acet-
ylgalactosamine to α-galactosamine, which is quite similar to the B-
antigen immunodominant sugar, galactose. This variety of acquired B is
the ‘deacetylase type’ and is observed in the setting of A1 red cells
(RBCs) only. The second variety of acquired B is the ‘passenger antigen’
type, occurs only in vitro and is due to adsorption of B-like bacterial
products on to O or A cells [1]. The phenomenon is frequently asso-
ciated with gastrointestinal tract pathology where the integrity of its
luminal wall is compromised, more often the carcinoma of the stomach
or intestine. Under these circumstances the commensals of the gastro-
intestinal tract or their metabolic by-products may leach into the blood
circulation and lead to changes in RBCs in vivo [2]. There are only few
reported cases of acquired B phenomenon [3].
A requisition for packed red blood cells (PRBC) was received for a
14-day old pre-term baby having necrotizing enterocolitis with per-
foration who required transfusion in the post-operative period. The
forward (=cell) blood grouping using conventional tube technique
(CTT) was AB RhD positive with a ‘mixed-field’ agglutination with anti-
B antisera. The blood grouping using column agglutination technique
(ABD card, Biorad, Switzerland) also gave similar result with a ‘mixed-
field’ agglutination with anti-B antisera column. In view of unclear
results on forward grouping, a reverse grouping using pooled A cells, B
cells and O cells was also performed which gave ‘negative’ result with
CTT as well as LISS Coombs AHG gel cards (Biorad, Switzerland). On
further testing, anti-A1 gave 2+ agglutination, anti-H gave 1+ ag-
glutination and autologous control was negative. The direct anti-
globulin test (DAT) on LISS Coombs AHG gel card was also negative. On
checking the historical records, it was found that the patient had re-
ceived one A RhD positive PRBC (pedibag) on day 1 of life, when no
discrepancy was observed during blood grouping and it was A RhD
positive. Thus, it was an ABO discrepancy possibly due to ‘acquired-B’
phenomenon. Further work up using acidified (0.1 N HCl) anti-B (pH
6–6.5) yielded no agglutination with patient red cells. Also, the patient

⁎
Corresponding author.
E-mail address: ashishjain16@gmail.com (A. Jain).

https://doi.org/10.1016/j.transci.2018.10.021
Received 24 September 2018; Received in revised form 25 October 2018; Accepted 25 October 2018
1473-0502/ © 2018 Elsevier Ltd. All rights reserved.
A. Kaur, et al. Transfusion and Apheresis Science 58 (2019) 30–31

Table 1
Testing with acidified antisera.
Test step Test Controls

Antisera/ normal saline/ 100 μl of acidified anti-B 100 μl of acidified anti-B 100 μl of Normal 100 μl of Normal saline 100 μl of pooled sera (from
pooled sera antisera (pH: 6-6.5) antisera (pH: 6-6.5) saline group A donors)
Add +
RBC suspension (5%) 50 μl of patient RBC (5%) 50 μl of pooled B cells 50 μl of patient 50 μl of pooled B cells 50 μl of patient RBC (5%)
suspension (5%) RBC (5%) suspension (5%)
Centrifugation immediate spin at 1000 rpm for 1 minute
Result Negative 4+ Negative Negative Negative

Table 2
Test results of serial samples of patient.
Forward grouping Reverse grouping*

Time of testing Anti-A Anti-B Anti-D Anti-H Anti-A1 lectin A cells B cells O cells
Day of 1st requisition 3+ Negative 3+ nt nt nt nt nt
Day of 2nd requisition 3+ mf 3+ 1+ 2+ Negative Negative Negative
After 3 weeks 3+ Negative 3+ nt nt Negative Negative Negative

mf = mixed field agglutination; nt: not tested.

* testing with pooled A cells, B cells and O cells performed in AHG phase also.

red cells did not give any agglutination with polyclonal anti-B (from
group A donors). Appropriate controls were used to validate the test
(Table 1). The results were suggestive of ‘acquired B’ phenomenon.
Subsequently one A RhD positive PRBC, which was compatible by AHG
gel technique was then issued and transfused to the patient without any
adverse reaction. The patient’s blood culture was positive for Klebsiella
pneumoniae at the time when the blood group discrepancy was ob-
served, which could have contributed to the appearance of ‘acquired-B’
antigen. The patient was kept on antibiotics subsequently and the blood
group after 3 weeks was found to be A RhD positive (Table 2).
3. Discussion
patient developed an acquired-B antigen and it was observed that the
A1 receptors were partially destroyed along with an increase in H re-
activity and Tk transformation of the red cells. The authors also de-
monstrated that agglutination of anti-B was suppressed on all serial
samples of the patient at pH 4 and also destroyed after in vitro acet-
ylation. In a compilation of 46 cases of acquired B antigen [4] it was
observed that all the individuals belonged to A1 blood group and the
phenomenon was found to be reversible. The blood grouping of our
patient also resolved back to A RhD positive after 3 weeks when the
infection was cured after the antibiotic therapy. The acquired B has also
been linked to ES4 strain as the source of murine monoclonal anti-B
antisera, as reported from some parts of North America [2].

The acquired B phenomenon is mostly observed during a bacterial 4. Conclusion

infection, usually of the gastrointestinal tract and frequently colic in
nature, in patients with A blood group [4]. The bacterial deacetylase
modifies the terminal α-N-acetyl-D-galactosaminyl residues (A antigen)
into α-D-galactosamine, which is biochemically quite similar to α-D-
galactose (B antigen) and thus reacts with anti-B antibody [2]. Young
et al [5] reported that the red cells of a premature infant with gastro-
enteritis due to E coli O127 and an another neonate affected with E coli
O86 induced diarrhea, were agglutinated by hyperimmune rabbit
serums prepared against the specific E coli serotype. The blood group of
these patients we O and A. However, the RBCs of both the patients did
not agglutinate with human anti-B. In our case also, the time at which
the blood group discrepancy was observed, the patient had necrotizing
enterocolitis and the patient’s blood culture was positive for Klebsiella
pneumoniae and his red cells did not agglutinate with human poly-
clonal anti-B and acidified anti-B but a mixed field agglutination with
anti-B under normal test conditions. Garraty et al [6] reported a fatal
hemolytic transfusion reaction (HTR) in a patient after transfusion of
four red cells units of AB group over a period of 7 days, which were
compatible after an immediate spin crossmatch. The acquired B was
mistyped as AB and led to immune hemolysis by patient’s anti-B after
transfusion [6]. Byrne et al [7] reported a case of septicemia, where the
This case of ‘acquired-B’ phenomenon in a neonate with A RhD
positive blood group who presented with NEC with positive blood
culture emphasizes that clinical observation and history is of relevance
in correlating the findings, which further guides in resolving blood
group discrepancy and deciding appropriate transfusion strategy.
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