V. P. Choudhry

Inherited bleeding disorders in Indian women with menorrhagia.

Summary.  In order to define the prevalence of haemostatic defects in women presenting with menorrhagia in our region, the coagulation data on women bleeders investigated in the Department of Haematology, AIIMS, were analysed. A total of 337 of the 2200 menorrhagic women investigated were characterized to have an inherited bleeding disorder; 221 of these 337 women presented with menorrhagia alone while 116 also had other associated bleeding manifestations as prolonged bleeding from injury site, ecchymotic patches in the skin, epistaxis, haematomas, haemarthroses and major bleeds like intracerebral bleeding. The tests performed included bleeding time (BT), platelet count, prothrombin time (PT), prothrombin consumption index (PCI), activated partial thromboplastin time (APTT), PF3 release with adenosine diphosphate (ADP) at 0 and 20 min, total PF3 assay and platelet Aggregation studies with collagen, ADP, adrenaline, arachidonic acid and ristocetin. Coagulation factor assays, von Willebrand antigen estimation, ristocetin cofactor assay and electron microscopy were performed wherever necessary.

Molecular defects in ITGA2B and ITGB3 genes in patients with Glanzmann thrombasthenia

Summary.  Background: Glanzmann thrombasthenia (GT) is an autosomal recessive inherited platelet function defect that is characterized by reduction in, or absence of, platelet aggregation in response to multiple physiologic agonists. The defect is caused by mutations in the genes encoding ITGA2B or ITGB3. This results in qualitative or quantitative abnormalities of the platelet receptor, αIIb‐β3. Objectives: The aim of this study was to identify the mutations in GT patients and to correlate these with patient phenotype. Subjects and methods: A total of 45 unrelated patients with GT were enrolled in the present study to identify the causative molecular defects, and also to correlate their phenotype with their genotype. Platelet aggregation, flow cytometry, Western blotting, and mutation screening by conformation sensitive gel electrophoresis (CSGE) followed by sequencing were performed in all patients. Novel mutations were analyzed for penetrance in individual families. Results: A total of 22 novel mutations were identified in 45 unrelated GT patients. Mutations were identified in 36 of the 45 (80%) patients. Missense mutations were seen in most of the GT patients (59%). The remaining mutations were heterogeneous and were distributed throughout the length of the gene. Analysis of family members showed heterozygous mutations in all families. Conclusions: The severe type I GT was the most common subtype found in this study. Missense mutations were identified as the defects responsible for most GT patients. Carrier detection and genetic counseling in these families is a potentially effective alternative for decreasing the burden of severe type of GT.

AUTOIMMUNE HEMOLYTIC ANEMIA IN CHILDREN

The clinical and hematological profile and treatment outcome of children with warm autoimmune hemolytic anemia (AIHA) were assessed using retrospective case record analysis. There were 26 (17 idiopathic; 9 secondary) patients with a median age of 11 years. Pallor (100%), fever (39%), and jaundice (59%) were the main presenting complaints. Jaundice was much more common in idiopathic (70%) compared to secondary (44%). Direct antiglobulin test was negative in 3 patients. Oral prednisolone produced remission in 81% patients. Four patients relapsed after a median period of 7 months (2 months to 2 year) after response. All responded to a second course of steroids in median 14 days. One child required cyclosporin A in addition. No correlation was found between response and parameters such as age, sex, jaundice, low pretreatment hemoglobin, reticulocyte count, total leukocyte count, platelet count, subtype of AIHA, and hepatosplenomegaly. Relapse correlated with increased duration between the onset of symptoms and treatment. This study indicates that oral prednisolone is an effective therapy for autoimmune hemolytic anemia. In refractory cases cyclosporine A may be useful.

Pregnancy Associated Aplastic Anemia—A Series of 10 Cases with Review of Literature

Abstract Introduction: Pregnancy induced aplastic anemia is a rare entity and the association is not well explained. There are approximately 80 cases in the literature and we are presenting the largest series, so far, of 10 cases. Results: Total of 10 cases had 11 pregnancies. Mean age at presentation was 25.45 years and mean gestation when symptoms first developed was 17.09 weeks. Pallor and bleeding manifestations were the most common presenting complaints. Mean Hb, TLC, ANC and platelets were 4.97 g/dl, 2.74×109/l, 1.11×109/l and 41×109/l, respectively. Bone biopsy cellularity ranged from <5 to 25%. Nine out of 11 (81%) pregnancies were successful of which 7 was full term and 2 were premature. Two babies were small for dates. One spontaneous abortion and one intra uterine death (IUD) were observed. Two out of 11 mothers died due to disease after delivery. Two of the 8 surviving mothers, had spontaneous partial response (22%); 4 mothers were asymptomatic after therapy with immunosuppressives given for 6 months and 3 were lost to follow up without response. Specific therapy (cyclosporin) was tried in two mothers antenatally with partial response in one. One child whose mother was given cyclosporin antenatally had jejunal atresia at birth. Conclusion: Pregnancy associated aplastic anemia is a rare association. Spontaneous remission can occur in 25-30% of patients. In the first trimester patients, pregnancy can be terminated while in advanced pregnancy patients can be followed up with stringent supportive care. Cyclosporin may be a safe drug antenatally in such patients. Patients with established aplastic anemia should avoid pregnancy.

Postpartum acquired haemophilia: clinical recognition and management

Postpartum acquired haemophilia is a rare but serious complication of an otherwise normal pregnancy. Patients usually present with postpartum haemorrhage (PPH) or uncontrolled bleeding following surgical interventions, which fail to respond to conservative treatment. A high index of clinical suspicion along with early laboratory diagnosis and prompt institution of appropriate therapy is essential for the management of acute bleeding episodes. Our patient, a 32‐year‐old female, presented with severe PPH and shock. She had undergone dilation and curettage three times, with subsequent total abdominal hysterectomy and internal iliac artery ligation, before she was diagnosed with acquired haemophilia (factor VIII autoantibodies) and an inhibitor level of 8 Bethesda units (BU). The patient underwent an abdominal laprotomy for removal of the abdominal packing used in the previous operation, and blood and blood clots, and was given FEIBA® therapy. The patient responded to these measure and the factor VIII inhibitor level decreased to 2 BU at the time of discharge 10 weeks later.

Pregnancy in a Patient of Glanzmann's Thrombasthenia with Antiplatelet Antibodies

Glanzmanns thrombasthenia is an autosomal recessive, inherited platelet function disorder. There is an absence of glycoprotein (GP) IIb/IIIa on the platelet membrane which causes reduced platelet aggregation with a defective platelet haemostatic plug formation. The management of bleeding episodes in these patients with platelet transfusions may result in alloimmunization and make the successive transfusions less effective. Pregnancy and delivery is rare in these patients and is associated with a high risk of severe haemorrhage. We describe a primigravida with Glanzmanns thrombasthenia and alloimmunization who developed secondary postpartum haemorrhage and was successfully treated with oral prednisolone.

Do alpha deletions influence hydroxyurea response in thalassemia intermedia

Abstract Thalassemia intermedia patients show variable phenotypes. Hydroxyurea (HU) may benefit some of the thalassemia intermedia cases (1), however, the parameters influencing the response to HU have not been reported. In this study, the molecular parameters, a-globin and ß-globin genotype and the Xmn I polymorphism, were correlated with the HU response. Twenty patients with thalassemia intermedia were given HU (10–20?mg/kg) and responses were evaluated over a one year period. Twelve patients (60%) showed a good response to therapy with a significant increase in Hb and HbF levels and with elimination of the transfusion requirement in four patients. Four out of the twelve (33%) patients were positive for -a 3.7 deletions whereas none of the 8 non-responders were positive for alpha deletions. One each of the responders and non-responders were positive for aaa anti-3.7 triplication. Three (25%) responsive and one non-responsive patients were homozygous for the IVS1-1 (G?T) mutation. Three of the responsive patients with alpha deletions were also homozygous positive for Xmn I polymorphism. Thus, in addition to acting in synergy with the XmnI polymorphism, alpha deletions may be an independent factor predicting good response to HU in thalassemia intermedia, although this needs to be confirmation in larger studies.

Factor V Leiden—the commonest molecular defect in arterial and venous thrombophilia in India

Several genetic factors are believed to predispose to thrombophilia [1,2]. These include Factor V Leiden defect, Prothrombin G20210A and MTHFR C677T gene polymorphism. FV Leiden is the most frequent molecular defect seen in thrombophilia in Caucasians. It has been found in 20% of consecutive patients with juvenile deep vein thrombosis (DVT), 3% arterial thrombosis and about 4.2% of healthy Caucasians [3–7]. Moderate hyperhomocysetinemia secondary to homozygous C-to-T substitution at nucleotide position 677 of the 5,10 MTHFR gene, has been found to underlie 19% of arterial, 11% of venous thrombophilia and 12% of controls [8]. Mutation at nucleotide position 20210 of the prothrombin gene is believed to influence the regulation of prothrombin gene expression and is associated with approximately threefold increase in risk for DVT in the West [9]. There it has been seen in 2% of arterial and 8% of venous thrombophilia and 2.1% of controls. Since no study exists from India on molecular defects underlying arterial thrombosis [10], and only one study is available, for venous thrombosis, the aim in this study was to determine the occurrence of these mutations in Indian subjects with arterial and venous thrombosis.

Mutation reports: Intron 1 and 22 inversions in Indian haemophilics

Intron 1 and 22 inversions were looked for in 80 severe haemophilia A patients in India using PCR and multiplex Long-Distance Subcycling-PCR, respectively. Intron 1 inversion was seen in 3 (3.75%) and intron 22 inversion was seen in 35 (43.75%) patients. Of severe haemophilics, 47.5% had either of these inversions. It is thus suggested that screening for inversions may be the first step in genetic testing of Indian haemophilics.

Pathogenetic factors underlying juvenile deep vein thrombosis (DVT) in Indians

Abstract: The role of hereditary antithrombotic protein defects in juvenile deep vein thrombosis (DVT) was evaluated. Fifty six young patients (age <45 yr) with doppler‐proven DVT were investigated for the presence of resistance to activated protein C (APC‐R), lupus anticoagulant (LA), anticardiolipin antibodies and deficiencies of protein C, protein S, ATIII activities. Fifty nine normal healthy individuals served as controls. APC‐R was observed to be the commonest defect underlying the Indian DVT as seen in 39.2% of patients followed by elevated ACA (5.3%), PAI (2.8%), presence of LA (2.8%) and reduced ATIII levels (2.8%). None of the subjects had protein C or S deficiency. APC‐R was associated with ATIII deficiency in one case, and elevated ACA in two cases. In two subjects, APC‐R was associated with elevated PAI levels. Patients with more than one prothrombotic factor had a higher prevalence of pulmonary thromboembolism, suggesting that the thrombogenic potential of APC‐R is enhanced by the presence of coexisting hereditary or acquired prothrombotic defect.