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Introduction - Cold agglutinin disease is associated with circulating antibodies that react preferentially in cold temperatures. Patients present with hemolytic anemia, acrocyanosis and hemoglobinuria. While column agglutination technology is very helpful in warm red cell antibodies, it has its own disadvantages in resolving cold antibodies. Case report - A 54 year old female was admitted in the intensive care unit with complaints of breathlessness, weakness and extreme fatiguability. Her Hb was 8.5 gm. There was               spontaneous agglutination of collected blood samples and all laboratory parameters tested were spurious so, she was  suspected to have immune haemolytic anemia. The sample was then warmed to 370 C for 30 minutes which cleared all agglutination. The 2- 5 cell suspension was maintained at 370 C. Thermal amplitude of the antibody showed the titre to be 1024 at 40 C. When crossmatching was performed with gel column, red cell units were incompatible (2 reactions) but crossmatching done with tube technique maintaining samples at 370 C found two red cell units to be compatible. The patient was advised to be shifted out of the air conditioned ICU and kept in warm environment. She was transfused with two units of crossmatch compatible packed red blood cells, slowly with the help of blood warmer. Conclusion - Cold agglutinin  disease poses difficulty in evaluating patients as their blood samples agglutinate spontaneously at room temperature. The column agglutination technology is not very helpful in evaluating cold agglutinins, especially when the agglutinins have high thermal amplitude as the temperature is not   maintained at 370 C while centrifuging. Tube technique, is very simple and the prime modality in resolving cold  agglutinins where the CAT fails.


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