Patcharee Komwilaisak

The use of recombinant activated factor VII for controlling life-threatening bleeding in Dengue Shock Syndrome.

To report the use of recombinant activated factor VII (rFVIIa) in controlling life-threatening bleeding episodes in patients with grades III and IV Dengue Hemorrhagic Fever (DHF), also known as Dengue Shock Syndrome. Fifteen patients (seven boys, eight girls), whose median age was 8 years, were enrolled in the study. They were divided into two groups. Group 1 included nine patients, mainly grade III, waiting for platelet concentrate, and group 2 included six patients, mainly grade IV, who had already received platelet concentrate with unresponsiveness. A single dose or repeated doses of 100 μg/kg rFVIIa was/were given at intervals of 4 h according to the bleeding symptoms. The median times from the onset of bleeding to rFVIIa initiation were 6.5 and 29.8 h in groups 1 and 2, respectively. Each patient received one to three doses. An effective response was found in eight patients (53.3%), including six patients in group 1 and two patients in group 2. They had complete cessation of bleeding without recurrence for 48 h. An ineffective response was found in seven patients (46.7%) including three patients in group 1 and four patients in group 2 for which the bleeding recurred (n = 2), temporarily slowed down (n = 3), continued (n = 1) or occurred at a new site (n = 1). These included three patients in profound shock 24–48 h before referral to comprehensive treatment centers, two patients receiving ibuprofen before hospitalization, one patient with extensive volume overloading, and one patient requiring surgical intervention to ligate the torn intercostal artery and vein. The platelet concentrate was promptly transfused to stop bleeding in patients with ineffective responses. The results revealed that the earlier initiation of rFVIIa in the mainly grade III DHF in group 1 yielded a higher effective response (66.7%) than the delayed initiation in the mainly grade IV DHF in group 2 (33.3%). Moreover, patients previously receiving ibuprofen or volume expander of low molecular weight dextran or urea-linked gelatin tended to have lower effective responses (28.6%) than patients without associated medication (75.0%). Ultimately, three of six patients with grade IV DHF died, while all nine patients with grade III DHF survived. Thus, the case-fatality rate in this study was 20%. No clinical evidence of thromboembolic complications was observed. rFVIIa seems to be effective in restoring hemostasis in a limited series of patients with Dengue Shock Syndrome exhibiting life-threatening bleeding episodes. Further study is warranted.

Thalassemia and hemoglobinopathies in Southeast Asian newborns: diagnostic assessment using capillary electrophoresis system

BACKGROUND We have investigated the Capillarys 2 Hemoglobin testing system to assist in presumptive diagnosis of thalassemia and hemoglobinopathies commonly found in Southeast Asia. METHODS Study was conducted on 226 newborns. Hematological parameters were recorded and Hb profiles were examined on the Capillarys 2 Hemoglobin analyzer (SEBIA). DNA analyses were used to establish the final diagnoses. RESULTS Among 226 newborns examined, 122 had thalassemias with 17 different genotypes. The capillary electrophoresis system could provide useful data for presumptive diagnoses of cases, especially those with Hb E and α-thalassemia. Hb E was found to be 2.6-6.2% in heterozygote whereas Hb Barts were clearly observed in cases with compound heterozygous or homozygous α(+)-thalassemia and heterozygous α(0)-thalassemia. Hb H disease and other forms of α-thalassemia could be differentiated based on the presence of Hb Barts and its percentage. CONCLUSION The capillary electrophoresis system is applicable to newborn screening for common forms of thalassemia in Southeast Asia.

Triple Heterozygosity of a Hemoglobin Variant : Hemoglobin Pyrgos With Other Hemoglobinopathies

This article is the first report of hemoglobin (Hb) Pyrgos along with other Hbs forming triple-heterozygous patterns. Of 2 cases, the first occurred in a Thai girl with thalassemic facies, marked anemia, and hepatosplenomegaly, who had Hb Pyrgos in association with Hb H disease with Hb Constant Spring (CS). This case represents a triple heterozygosity comprising Hb Pyrgos, α-thalassemia 1, and Hb CS. Hb electrophoresis revealed an abnormal Hb in addition to Hbs CS, A2, A, Bart’s, and H. This abnormal Hb moved slightly faster than Hb A but more slowly than Hb Bart’s. Polymerase chain reaction revealed that the abnormal Hb was caused by a missense mutation within codon 83 of the β-globin gene (GGC to GAC) resulting in a glycine-to-aspartic acid substitution, which corresponds to Hb Pyrgos. The patient required blood transfusions by the age of 3 years. A splenectomy was performed when she was 5 years old, after which her hematocrit level remained above 32%. The second case was the patient’s older sister who was also triple heterozygous (Hb Pyrgos, E, and CS) but was healthy.

Association of Hb Thailand [α56(E5)Lys→Thr] and Hb Phnom Penh [α117(GH5)-Ile-α118(H1)] with α0-Thalassemia: Molecular and Hematological Features and Differential Diagnosis

We report the molecular and hematological characteristics of two rare hemoglobin (Hb) variants found in associations with a common α0-thalassemia (α0-thal) in Thai patients. The first case (P1) was a generally healthy 27-year-old man discovered during our ongoing thalassemia screening program. Hemoglobin and DNA analyses identified a previously undescribed condition of compound heterozygosity for Hb Thailand [α56(E5)Lys→Thr] and α0-thal (SEA deletion). The second case (P2) was a 4-year-old boy with hypochromic microcytic anemia. Hemoglobin and DNA analyses also identified a compound heterozygosity for Hb Phnom Penh [α117(GH5)-Ile-α118(H1)] in association with α0-thal (SEA deletion). Although Hb H (β4) inclusion bodies were observed in both cases, Hb analysis using both high performance liquid chromatography (HPLC) and capillary electrophoresis (CE) did not show Hb H. While the two Hb variants could be recognized on Hb HPLC analysis, their corresponding Hb A2 derivatives: the Hb A2-Thailand and Hb A2-Phnom Penh, were clearly observed on CE. Apparently, combination of these two Hb variants with α0-thal are not expressed as Hb H disease. The two Hb variants could be confirmed by polymerase chain restriction-restriction fragment length polymorphism (PCR-RFLP) and allele-specific PCR assays.

The first two cases of MYH9 disorders in Thailand: an international collaborative study

Dear Editor, MYH9 disorders are the autosomal dominant platelet disorders characterized by giant platelets, thrombocytopenia, and granulocyte Döhle body-like cytoplasmic inclusion bodies and are due to mutations in MYH9, the gene encoding non-muscle myosin heavy chain IIA (NMMHC-IIA). Patients show variable expression of non-hematological complications, such as glomerulonephritis, hearing inability, and cataracts [1, 2]. Although granulocyte inclusion bodies are the laboratory hallmark, they are often overlooked due to their inconspicuous appearance on conventionally stained blood smears. Abnormal NMMHC-IIA protein accumulates in the granulocyte cytoplasm, and an immunofluorescence analysis of NMMHC-IIA localization is now used as a reliable diagnostic test [3–5]. Because the complications are progressive and there are strict genotype/phenotype correlations, an early genetic diagnosis is crucial to confirm and determine the prognosis, and if possible, to select appropriate treatment [6]. We conducted an international collaborative MYH9 disorders study between Thailand and Japan. Patients were registered in the pediatric macrothrombocytopenia registry in Thailand. The criteria for registration were platelet counts <150,000/μL and large platelets. All patients were investigated for the common causes of macrothrombocytopenia, including the von Willebrand factor indices, flow cytometry for CD42b and CD41/CD61, and platelet aggregation studies. In the present study, peripheral blood smears from 10 patients were sent to Japan, where the immunofluorescence analysis for NMMHC-IIA was performed [3]. Two out of the 10 patients (patients 6 and 8) (20 %) were positive in the analysis, andMYH9 gene sequencing was further performed [3]. Local institutional ethics committees approved the study, and informed consent was obtained from the patients. Patient 6 was a 12-year-old female. The hematological examination showed a platelet count of 67,000/μL, MPV of 17.6 fL, giant platelets, and conspicuous granulocyte inclusion bodies (Fig. 1a). Blood chemistry and urinalysis were unremarkable. The hearing test showed a high-tone drop in the left ear. Her father was also hematologically affected (Fig. 1b). He had mild hearing loss in both ears. Cataracts were absent in both individuals. Patient 8 was a 12-year-old female presenting with persistent hypertension, nephritis, and thrombocytopenia. She had a history of intermittent epistaxis, gum bleeding, and menorrhagia. She had previously been treated with prednisolone and nifedipine without any response. The laboratory investigation showed a platelet count of 67,000/μL and MPV of 11.3 fL. A peripheral blood smear showed giant platelets and only faint inclusion bodies in neutrophils (Fig. 1c). The BUN was 64.5 mg/dL (normal range, 5– 18 mg/dL), and creatinine was 1.63 mg/dL (normal range, 0.5–1.1 mg/dL). Urinalysis showed protein 2+ and blood 3+. Hearing test was not performed.Mild cataracts were observed. Her father and brother died from bleeding. The immunofluorescence analysis for NMMHC-IIA revealed type II localization, consisting of several cytoplasmic spots with a circular or oval shape in both patients (Fig. 1d, e, f). Genomic DNAwas extracted from the remaining smears. N. Sirachainan : S. Hongeng Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

Propranolol was effective in treating cutaneous infantile haemangiomas in Thai children

The aim of this study was to explore the efficacy and safety of propranolol in treating infantile haemangiomas, the most common benign vascular tumours in children.

Genotypes and phenotypes of protein S deficiency in Thai children with thromboembolism

The prevalence of protein S (PS) deficiency in Asian patients with venous thromboembolism is around 8–30%, higher than that in Caucasian populations. The present study reports the genotypes (including one novel mutation) and phenotypes of children with PS deficiency at a tertiary care institute. A total of six patients were included, three with arterial ischemic stroke, two with cerebral venous sinus thrombosis, and one with deep vein thrombosis. PS mutations were identified in four patients: p.R355C, p.G336D, p.E67A, and p.N188KfsX9. p.N188KfsX9 is a novel mutation with less than 20% PS activity noted in heterozygotes.