JECSONS MEDICAL CENTER

Department of Pathology and Laboratory Medicine

BLOOD BANK

Mixed-field appearance
This describes a dual population of agglutinated and non-agglutinated red
cells, which may be observed in both ABO and D grouping. It is important to
recognize this as a mixed-field picture and not to confuse it with weak
agglutination. The most likely cause of a mixed-field picture is the transfusion
(either deliberate or accidental) of non-identical ABO or D red cells.
Investigation will be required to determine the actual blood group of the
patient, who may have been transfused in an emergency or at a different
establishment or who may have received an intrauterine transfusion. A mixed-
field ABO group may be the first indication of a previous ABO-incompatible
transfusion.
An ABO- or D-incompatible haemopoietic stem cell transplant will result in a
mixed-field picture until total engraftment has occurred; the mixed-field picture
may subsequently reappear if the graft is failing. Rarely, a dual population of
cells is permanent and results from a weak subgroup of A (A 3 ) or a blood
group chimerism. D variant phenotypes
Interpretation of a dual population of red cells will depend on the technique
Most people are either D positive or D negative, but a minority have a variant
used. In a tube, microscopic reading will reveal strong agglutinates in a
D type, historically categorized as weak or partial D. People with a partial D
background sea of free cells. In CAT cards/cassettes there will be a line of
antigen can make anti-D to the epitope(s) of the D antigen which they lack,
agglutinated cells at the top of the column, with the non-agglutinated cells
when sensitized to D-positive red cells by transfusion or pregnancy.
travelling through to the bottom of the column ( Fig. 22-5 ). In liquid-phase
Historically, those classified as weak D, with fewer D antigen sites per red
techniques, if the reaction grade is not a strong positive or an obvious
cell, but no missing epitopes, were considered unable to make anti-D, and
negative then the reaction requires further investigation, which may include
could therefore be treated as D positive. There are two problems with using
microscopic examination. In a solid-phase technique a mixed field is seen as
this concept to decide on whether to treat a patient as D positive or D
a dual population of cells, with the agglutination being surrounded by free
negative: firstly, it is not always possible to distinguish serologically between
cells. Automated systems should be set up to detect mixed-field pictures, and
weak and partial D, as many partial D antigens are also phenotypically weak;
this should be used in conjunction with local policies.
secondly, there have been many reports of patients with a variant defined as
weak D having made anti-D. They has suggested replacing the terms weak
and partial D with a single term of D variant.