Angela C. Weyand

A biomarker panel for acute graft-versus-host disease.

No validated biomarkers exist for acute graft-versus-host disease (GVHD). We screened plasma with antibody microarrays for 120 proteins in a discovery set of 42 patients who underwent transplantation that revealed 8 potential biomarkers for diagnostic of GVHD. We then measured by enzyme-linked immunosorbent assay (ELISA) the levels of these biomarkers in samples from 424 patients who underwent transplantation randomly divided into training (n = 282) and validation (n = 142) sets. Logistic regression analysis of these 8 proteins determined a composite biomarker panel of 4 proteins (interleukin-2-receptor-alpha, tumor-necrosis-factor-receptor-1, interleukin-8, and hepatocyte growth factor) that optimally discriminated patients with and without GVHD. The area under the receiver operating characteristic curve distinguishing these 2 groups in the training set was 0.91 (95% confidence interval, 0.87-0.94) and 0.86 (95% confidence interval, 0.79-0.92) in the validation set. In patients with GVHD, Cox regression analysis revealed that the biomarker panel predicted survival independently of GVHD severity. A panel of 4 biomarkers can confirm the diagnosis of GVHD in patients at onset of clinical symptoms of GVHD and provide prognostic information independent of GVHD severity.

Zebrafish as a model system for the study of hemostasis and thrombosis.

Purpose of reviewAlthough the zebrafish has been established as a research tool over the past two to three decades, in hematology it has primarily been used to investigate areas distinct from coagulation. The advantages of this vertebrate model include high fecundity, rapid and external development, and conservation of virtually all clotting factors in the zebrafish genomic sequence. Here, we summarize the growing application of this technology to the study of hemostasis and thrombosis. Recent findingsLoss of function studies have demonstrated conservation of function for a number of zebrafish coagulation factors. These include positive and negative regulators of coagulation, as well as key components of the thrombus itself, such as von Willebrand factor, fibrinogen, and thrombocytes. Such analyses have also been leveraged to aid in the understanding of human variation and disease, as well as to perform in-vivo structure/function experiments. SummaryThe zebrafish is an organism that lends itself to a number of unique and powerful approaches not possible in mammals. This review demonstrates that there is a high degree of genetic and functional conservation of coagulation, portending future insights into hemostasis and thrombosis through the use of this model.

Functions of the COPII gene paralogs SEC23A and SEC23B are interchangeable in vivo

Significance In humans, SEC23B deficiency results in congenital dyserythropoietic anemia type II, a disease of abnormal red blood cell development, while SEC23A deficiency results in cranio-lenticulo-sutural-dysplasia, a disease characterized by bone abnormalities due to defective collagen secretion (but no red blood cell defect). In this study, we show that SEC23A and SEC23B overlap in function, and that the disparate phenotypes of SEC23A/SEC23B deficiency within and across species are likely due to evolutionary shifts in gene-expression programs, rather than distinct functions of the SEC23 paralogs. Our studies provide a rationale for increased SEC23A or SEC23B expression as a therapeutic strategy for congenital dyserythropoietic anemia type II or cranio-lenticulo-sutural-dysplasia, respectively. Approximately one-third of the mammalian proteome is transported from the endoplasmic reticulum-to-Golgi via COPII-coated vesicles. SEC23, a core component of coat protein-complex II (COPII), is encoded by two paralogous genes in vertebrates (Sec23a and Sec23b). In humans, SEC23B deficiency results in congenital dyserythropoietic anemia type-II (CDAII), while SEC23A deficiency results in a skeletal phenotype (with normal red blood cells). These distinct clinical disorders, together with previous biochemical studies, suggest unique functions for SEC23A and SEC23B. Here we show indistinguishable intracellular protein interactomes for human SEC23A and SEC23B, complementation of yeast Sec23 by both human and murine SEC23A/B, and rescue of the lethality of sec23b deficiency in zebrafish by a sec23a-expressing transgene. We next demonstrate that a Sec23a coding sequence inserted into the murine Sec23b locus completely rescues the lethal SEC23B-deficient pancreatic phenotype. We show that SEC23B is the predominantly expressed paralog in human bone marrow, but not in the mouse, with the reciprocal pattern observed in the pancreas. Taken together, these data demonstrate an equivalent function for SEC23A/B, with evolutionary shifts in the transcription program likely accounting for the distinct phenotypes of SEC23A/B deficiency within and across species, a paradigm potentially applicable to other sets of paralogous genes. These findings also suggest that enhanced erythroid expression of the normal SEC23A gene could offer an effective therapeutic approach for CDAII patients.

PD‐1 inhibition in congenital pigment synthesizing metastatic melanoma

A newborn female child was born with a congenital pigment synthesizing melanoma of the scalp. Further workup revealed metastatic disease within the liver, lungs, and left tibia. Whole exome sequencing was performed on multiple samples that revealed one somatic mutation, lysine methyltransferase 2C (KMT2C), at low allelic frequency but no v‐Raf murine sarcoma viral oncogene homolog B (BRAF), NF‐1 mutation. Programmed death ligand 1 was moderately expressed. Treatment was initiated with the programmed cell death protein 1 inhibitor nivolumab. The patient tolerated this treatment well with minimal toxicity. She is now over a year out from initial diagnosis, continuing on nivolumab, with stable disease.

The Role of Platelets and ε-Aminocaproic Acid in Arthrogryposis, Renal Dysfunction, and Cholestasis (ARC) Syndrome Associated Hemorrhage

Arthrogryposis, renal dysfunction, and cholestasis (ARC) syndrome is a rare disorder associated with platelet abnormalities resembling gray platelet syndrome. Affected patients have normal platelet numbers but abnormal morphology and function. Bleeding symptomatology ranges from postprocedural to spontaneous life‐threatening hemorrhage. We report a patient with ARC syndrome and compound heterozygous mutations in VPS33B (vacuolar protein sorting 33B) who presented with significant bleeding requiring numerous admissions and transfusions. She was treated with prophylactic platelet transfusions and ε‐aminocaproic acid. This was well‐tolerated and significantly decreased transfusion requirements and admissions for bleeding. Our experience provides support for consideration of prophylactic measures in these patients as well as the possibility of using prophylaxis in related disorders.

A diagnosis of mycosis fungoides in a pediatric patient with recurrent Langerhans cell histiocytosis

To the Editor: An 8-year-old female presented with a reddish-brown papule that tripled in size. She had a history of intermittent hypopigmentation (Fig. 1A). Biopsy of the papule revealed a lymphohistiocytic infiltrate with increased CD1a and S100-positive Langerhans cells, consistent with Langerhans cell histiocytosis (LCH) (Fig. 1D). v-RAF murine sarcoma viral oncogene homolog (BRAF) mutation testing was negative. Workup for other sites of disease was negative. There was minimal response to topical steroids. She began oral prednisonewith partial response but flaredwith taper. Treatmentwith oral methotrexate and prednisone1 resulted in complete response. With discontinuation, she had recurrence of papules and hypopigmentation. Repeat biopsy confirmed LCH. Methotrexate was resumed and she had full resolution of papules but persistent hypopigmentation; however, her papules recurred with discontinuation of therapy. Repeat biopsy revealed atypical epidermotropic CD8-positive T cells that displayed loss of CD2 and diminished expression of CD7

Agent specific effects of anticoagulant induced alopecia

Alopecia has been observed with many anticoagulants although the mechanism is unclear. A 20 year old female with recurrent DVTs developed alopecia with multiple anticoagulants, including heparin derivatives and the new oral anticoagulants. This resolved with discontinuation of the agents. The patient was ultimately able to be anticoagulated with fondaparinux long term without any alopecia. This case addresses the Key Clinical Question of management and recognition of anticoagulant induced alopecia. This side effect can result from almost any of the available agents and is quickly reversible, underlining the importance of tailoring treatment to the individual and their experiences.

Imatinib Treatment in PDGFRA-Negative Childhood Hypereosinophilic Syndrome

We report a 4‐year‐old female who presented with severe hypereosinophilia (215.7 K/μl) and end‐organ dysfunction. Extensive evaluation including whole exome sequencing was performed, revealing no causative mutation. Initial treatment with corticosteroids, leukapheresis, and hydroxyurea decreased her absolute eosinophil count (AEC), although it remained elevated. Despite the absence of a PDGFRA mutation, an imatinib trial resulted in normalization of her AEC. Imatinib was discontinued after sustained normal counts for 1 month. AECs have remained normal for more than 1 year off therapy. This provides support for consideration of imatinib in the treatment of hypereosinophilia even in the absence of a known tyrosine kinase mutation. Pediatr Blood Cancer 2015; 9999:XX–XX