Undetermined blood loss due to accidental injury and its management in a male patient of classical Bombay (Oh) phenotype in a hospital in the remote part of east India.

Sir,

Absence of A, B, and H antigen on red cell surface, commonly known as Bombay (Oh) phenotype, is an extremely rare blood group type as it is found in 1 in 10,000 individual in India and 1/1,000,000 individuals in Europe.[1] The presence of anti-H antibody in the serum of Oh phenotype makes the transfusion of identical Oh phenotype blood necessary in such patients.[2] Bombay phenotype can be either classical Bombay or para-Bombay, with classical Bombay phenotype more common in India.[3] Characterization of Bombay phenotype in the recipient as well as in donor is extremely important for transfusion management. Furthermore, recipients requiring multiple units of Oh blood during an emergency, as the case mentioned here, can be a challenge for transfusion service providers.

A 25-year-old male patient presented to the emergency department due to inability to transfuse cross match compatible blood elsewhere. Laboratory investigations revealed requirement of 3 units of Oh blood urgently. Pretransfusion testing in the form of blood grouping and antibody screening indicated recipient to be Oh phenotype. Further testing with anti-H lectin and saliva testing confirmed the recipient to be of Oh phenotype. Direct coomb's test, indirect coomb's test, dithiothreitol treatment and titration with thermal amplitude testing confirmed the recipient to be of classical Oh phenotype [Table 1]. Screening first degree relatives revealed classical Oh phenotype in elder brother. Several places in different states of India were contacted telephonically, but most of them had no information of even a single Oh donor in spite of several cases reported in the country.[1] Two more units of Oh Rh positive blood were arranged from the western part of India situated about 1953 km from our hospital [Figure 1]. Recipient had to wait for 18 h till the blood units were arranged.

Table 1

Immuno-hematological workup

Figure 1

Map of India showing places which were contacted in black diamonds and distance of Mumbai from our hospital from where the blood was transported

This experience of ours clearly indicates that some times, even 1 unit of blood from family relatives is not sufficient for management of acutely bleeding (Oh) patients. Differentiating Bombay phenotype into classical and para-bombay would be of great help, as procuring blood for a para-bombay phenotype patient is relatively easier.[4] Also transfusion of blood donated from first degree family relative may be associated with life-threatening complication such as transfusion-associated graft-versus-host disease.[5] In order to deal with such typical situation, a vigorous effort should be taken to establish rare donor registry program at state as well as national level.