INTERNATIONAL JOURNAL OF LABORATO RY HEMATO LOGY
A case of paroxysmal nocturnal hemoglobinuria presenting with intra-abdominal bleeding due to splenic rupture, developing renal infarct S. UZUN*, N. ALPAY*, G. B. OZTURK*, B. SAKA*, M. YENEREL †, N. ERTEN*, M. A. KARAN*, C. TAS¸ CIOGLU*
*Division of General Internal Medicine, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey † Division of Hematology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey Correspondence: Sami Uzun, Division of General Internal Medicine, Department of Internal Medicine, Istanbul Medical Faculty, Istanbul University, 34 390, Capa, Istanbul, Turkey. Tel.: +90 212 414 2000/31478; Fax: +90 212 532 4208; E-mail:
[email protected]
SUMMARY
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disorder characterized by intravascular hemolysis, hemoglobinuria, and thrombosis. Thrombotic attacks are life threatening and are responsible for nearly 50% of PNH-related deaths. Compared with thrombotic events, bleeding related to thrombocytopenia in PNH is quite rare. This report describes an atypical clinical presentation with problems in the diagnosis and management of a woman who presented with a splenic infarct followed by massive intra-abdominal bleeding due to splenic rupture. She also developed a renal infarct during hospitalization after diagnosis.
doi:10.1111/j.1751-553X.2007.00949.x
Received 27 January 2006; accepted for publication 19 March 2007 Keywords Intrabdominal bleeding, paroxysmal nocturnal hemoglobinuria, renal infarct, splenic rupture, thrombocytopenia
INTRODUCTION Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired clonal stem cell disorder, characterized by
increased sensitivity of the erythrocytes to complement. It is characterized with intravascular hemolysis, hemoglobinuria, and life-threatening thrombosis. Usually, PNH begins insidiously with a chronic course. The
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disorder generally manifests by two clinical pictures: hemolytic type, in which intravascular hemolytic attacks are encountered and bone marrow is particularly rich in erythroid progenitors; the hypoplastic type shows severe bone marrow insufficiency and may be confused with aplastic anemia (AA). Currently, PNH is classified into three subcategories; (i) classic PNH, (ii) PNH in the setting of another specified bone marrow disorder, and (iii) subclinical PNH. Patients with classic PNH have clinical evidence of intravascular hemolysis without any evidence of another defined bone marrow abnormality. Among the acquired stem cell disorders, pathophysiological links between myelodysplastic syndromes (MDS), AA and PNH have often been described (De Planque et al., 1989; Nakakuma et al., 1995; Yenerel et al., 2001). Recent studies indicated that PNH also might follow or precede myelofibrosis (Nakahata et al., 1993). Sometimes, the PNH clone can be detected by sensitive flow cytometric analysis without any clinical or laboratory evidence of hemolysis. These patients are subcategorized as subclinical PNH (Yenerel et al., 2001). Pathogenetically, the X-linked somatic point mutation of the ‘phosphatidylinositol glycan complementation class A’ (PIG-A) gene in multipotent hematopoetic stem cells is responsible. The antigenic protein coded by the PIG-A gene is expressed on the cell membrane and displays different functional features. Its expression is mediated by glycosylphosphatidylinositol (GPI), a molecule that is connected to the cell membrane by the GPI anchor. Somatic point mutation in PIG-A gene averts the synthesis of GPI anchor, preventing the linkage of GPI-associated proteins to the cell membrane (Hillmen et al., 1993; Miyata, Takeda & Lida, 1993; Takahashi et al., 1993; Takeda et al., 1993). Paroxysmal nocturnal hemoglobinuria is associated with a striking predisposition to intravascular thromboses, especially within the venous circulation. Thrombotic disease accounts for about 50% of all deaths in patients with PNH. Fatal thromboses usually involve the portal system or the brain, but thromboses are also common in the extremities or other sites (AlSamman et al., 1994; Melandri et al., 2001; Parker & Ware, 2004). Hepatic venous thrombosis (Budd–Chiari syndrome) is a serious, often rapidly fatal complication of PNH. In various series, 15–30% of patients with PNH developed hepatic venous thrombosis; this
complication might be even more common because affected individuals can be asymptomatic in the early stages (Leibowitz & Hartmann, 1981; Valla, 1987; Parker & Ware, 2004). In addition to more commonly seen venous thrombosis, there are reports of cerebral and coronary artery thrombosis related to PNH. Compared with thrombotic complications, bleeding is very rare and is mostly due to portal hypertension-related oesophagus varices secondary to portal thrombosis and occasionally due to severe thrombocytopenia (Socie et al., 1996). Deficiencies of CD55 (decay acceleration factor, DAF) and CD59 (membrane inhibitor of reactive lysis, MIRL) proteins result in intravascular hemolysis, whereas deficiency of urokinase plasminogen activator receptor (u-PAR) is thought to be an important factor giving rise to susceptibility to thrombosis in these patients (Wilcox et al., 1991; Holguin & Parker, 1992; Ploug et al., 1992). There are also reports indicating that increased platelet activation may contribute to thrombotic tendency (Gralnick et al., 1995; Hugel et al., 1999). Herein, we report a PNH patient who presented with intra-abdominal bleeding related to splenic rupture secondary to diffuse splenic necrosis, and who developed renal infarct during hospitalization after diagnosis.
CASE REPORT A 32-year-old woman presented with severe abdominal pain, weight loss (17 kg in 4 months) and fatigue for 4 months. She occasionally had transient and poorly localized abdominal pain. Fatigue and abdominal pain had worsened during the previous week. Her body temperature was 38 C. On abdominal examination, generalized tenderness and guarding were noted, organomegaly could not be determined because of guarding. On chest examination, respiratory sounds were diminished in the left lower zone. Laboratory results were as follows: hemoglobin (Hb) 47 g/l, hematocrit (Hct) 14%, mean corpuscular volume (MCV) 100 fl, white blood cell (WBC) count 25 · 109/l, platelet count 75 · 109/l, reticulocyte count 4%, lactate dehydrogenase (LDH) 965 U/l, alkaline phosphatase (ALP) 552 U/l, gamma-glutamyl transpeptidase (GGT) 278 U/l, aspartate transaminase (AST) 60 U/l, alanine transaminase (ALT) 184 U/l, total bilirubin 35.57 lmol/l, and indirect bilirubin 2007 The Authors
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28.2 lmol/l. Direct Coombs test was negative, haptoglobin level was 1.06 lmol/l. The prothrombin time and the partial thromboplastin time was 13.5 s (1200 ) and 27 s (3300 ) respectively. Fibrinogen level was 3.8 g/l. Peripheral blood smear was noncontributory except for thrombocytopenia and mild macrocytosis in red cell morphology without any fragmentation. Vitamin B12 level was normal. Serological tests for cytomegalovirus, Epstein-Barr virus, herpes simplex virus, and Hepatitis B and C viruses were negative. Ultrasonography (USG) identified splenomegaly and ascites. Hemorrhagic fluid was seen in paracentesis and 2500 ml of hemorrhagic fluid was drained. Three units of packed red cells were transfused. A computed tomography (CT) scan of the abdomen (Figure 1) showed almost complete splenic necrosis in addition to the findings of USG. The patient’s anemia worsened and she required further transfusions. Urgent laparatomy was performed: the spleen had a longitudinal diameter of 40 cm, multiple lacerations and active bleeding on its surface. A splenectomy and wedge biopsy of the liver was performed. The spleen was severely degenerated macroscopically, and histological examination revealed intracapsulary hemorrhage and complete parenchymal necrosis. No thrombus was seen in arteries or veins. Liver biopsy showed only reactive findings. After surgery, the Hb stabilized, but the platelet count gradually decreased. Bone marrow
Figure 1. Computed tomography (CT) of the abdomen before splenectomy, showing splenic necrosis.
biopsy showed mild hypercellularity and megaloblastic erythropoesis without any other dysplastic features. The Acid HAM lysis test was negative on two occasions. Laboratory findings of intravascular hemolysis persisted. Flow cytometry showed an abnormal PNH clone. Ninety percent of granulocytes and 30% of erythrocytes were negative for both CD55 and CD59. The patient was treated with 64 mg/day methylprednisolone and oral folic acid. Under this treatment, her abdominal pains recurred and the platelet count decreased to 15 · 109/l. A repeated abdominal CT scan (Figure 2) showed signs of ischemia in the liver related to thrombosis of hepatic artery or venules and an infarct zone on the right kidney consistent with right renal artery thrombosis. We were also concerned about disseminated intravascular coagulation with severe thrombocytopenia, but repeated hemostasis tests were normal with elevated fibrinogen levels. In spite of thrombocytopenia, low dose low molecular weight heparin was started because of recurring intraabdominal thromboses. Because of the atypical presentation and thrombosis at unusual sites, we screened the patient for additional hereditary or acquired thrombophilia. Protein C, protein S, and antithrombin analyses could not be performed because of the new onset thrombosis and anticoagulant medication, but
Figure 2. Computed tomography (CT) of the abdomen following treatment with methyl-prednisolone and oral folic acid, showing damage to the right kidney consistent with right renal artery thrombosis.
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factor V Leiden mutation and prothrombin gene mutation was negative and the fasting homocysteine level was normal. When the platelet count exceeded 50 · 109/l, full-dose anticoagulation was applied and warfarin was started. She has been followed in our hematology outpatient clinic since June 2004 without any further thrombotic events. Her blood cell counts are stable except the Hb, which ranges between 74 and 99 g/l. The last whole blood counts (performed 26/ 11/2004) were: Hb, 97 g/l; WBC count, 9.8 · 109/l; neutrophil count, 7.2 · 109/l; platelet count, 465 · 109/l.
DISCUSSION Paroxysmal nocturnal hemoglobinuria is a stem cell disorder caused by the somatic mutation in the PIG-A gene of multipotent stem cells, affecting not only the erythroid lineage but also all other hemopoietic lineages. The demonstration of increased hemolysis of defective erythrocytes, sensitive to complement, in acid medium (Acid HAM test), has been the most important laboratory method for years. However, this test lacks diagnostic sensitivity because defective erythrocytes disappear at the time of hemolysis and/or are diluted after blood transfusions. In our patient, the test was negative when repeated twice. This result was explained by the recent transfusion of 5 units of packed red cells and the destruction of defective erythrocytes by ongoing severe hemolysis. More is now known about the pathogenesis of this condition; flow cytometric analysis using antibodies directed against GPI-alkaline phosphatase, such as CD55 and CD59, is the most sensitive and informative assay for the diagnosis of PNH. Although hemolytic attacks and transfusions affect the ratio of defective erythrocytes, other peripheral blood cells are not affected by these factors, and so the CD55 and CD59 expression ratio of the granulocytes is very important. In the present case, these antigens were expressed by only 10% of the granulocytes compared with the 99% that is expected. The same antigens were found to be expressed by 70% of erythrocytes in this patient. Recent red blood cell transfusions and/or hemolysis of the PNH red blood cells were probably responsible for the higher expressions of CD55 and CD59 on erythrocytes and the negative Acid HAM tests. Flow cytometric analysis of
neutrophils for the detection of unexpressed GPI-related proteins increases the accuracy of diagnosis, enables risk estimation and provides evidence for prophylactic anticoagulation, because the defective neutrophil clone is not affected by hemolytic attacks, there is no dilution problem after transfusions and the amount of defective neutrophil clone is related to disease activity (Hall, Richards & Hillmen, 2003). The Acid HAM test has now been replaced by flow cytometric analysis of the GPI-related surface markers for the diagnosis of PNH and should be performed in every case where PNH is part of the differential diagnosis. We could not find any underlying bone marrow disorder in this patient. We did not perform cytogenetic investigation but diagnosed and subcategorized the patient as having classical PNH, according to the minimal essential criteria proposed by an international PNH interest group (Parker et al., 2005). Thromboembolic event as the presenting manifestation of PNH is uncommon. It is usually seen in the course of the disease and considered the leading cause of mortality. Venous thrombosis is seen in about one third of patients with PNH, and is responsible for nearly half of the deaths related to this disease. Most common localities are the hepatic veins (Budd–Chiari syndrome) mesenteric veins, sagittal sinus, inferior vena cava, and renal veins. Arterial thrombosis is very rare. There have been reports of cerebral artery thrombosis and acute myocardial infarction (Al-Samman et al., 1994; Melandri et al., 2001). There have also been reports of bleeding due to severe thrombocytopenia, but this is quite rare and easier to manage (Socie et al., 1996). Gastrointestinal complaints, such as abdominal pain and dysphagia, may be the initial manifestation of the disease in approximately 10% of the patients, but acute abdomen as a presenting feature, as in our case, is extremely rare. Recurrent abdominal pain is an important clinical feature of PNH. In some cases, it can be so severe that is confused with acute abdomen requiring emergency surgery. Abdominal pain often accompanies hemolytic attacks and it is thought to be related to increased smooth muscle contractions due to interaction between free hemoglobin and nitric oxide or it may be caused by occlusion of intra-abdominal veins. In our case, there was fever reaching 38 C and physical examination findings consistent with acute abdomen. 2007 The Authors
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Intra-abdominal fluid detected by USG was of hemorrhagic character indicating visceral organ injury. Abdominal CT and histological analysis of the spleen did not identify arterial or venous thrombosis but showed enlargement and congestion of the spleen with diffuse necrosis. The fact that splenic congestion does not result in necrosis in other conditions leading to splenic and portal vein thrombosis and in other conditions leading to portal hypertension, makes splenic artery thrombosis a possible explanation of splenic infarct and rupture. The cause of hypercoagulability in PNH is not clear. Increased procoagulant activity of platelets lacking CD55 and CD59, increased platelet production, and a fibrinolytic system defect due to GPI-associated u-PAR deficiency may explain the mechanism of thrombotic complications (Wilcox et al., 1991; Holguin & Parker, 1992; Ploug et al., 1992; Gralnick et al., 1995; Hugel et al., 1999). During steroid treatment after splenectomy, our patient developed severe abdominal pain as the result of a urinary tract infection. In this period, because of increased hemolysis, transfusion was required and the platelet count decreased to 15 · 109/l. An abdominal CT scan showed an infarcted area in the right kidney, related to renal artery thrombosis and ischemic findings that were probably related to thrombosis of hepatic artery or small hepatic veins. Although hepatic and renal veins are common sites of thrombosis, renal arteriole infarct is so rare that we could find only one paper that described renal cortical infarcts and thinning confirmed by autopsy studies that were related to PNH (Braren et al., 1975). Enlargement of the kidney, papillary necrosis, acute renal atrophy, retroperitoneal hematoma, and ureteral infarction were also the other renal complications seen in those PNH patients (Braren et al., 1975). Thrombolytic therapy could not be used in our patient because of the severe thrombocytopenia. How-
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ever, because of the recurrent life threatening venous and arterial thromboses we planned indefinite anticoagulation in our patient. Initially, we used low molecular weight heparin (LMWH) at a dose of 4000 U/day because of the severe thrombocytopenia; this was increased to 8000 U/day when the platelet count reached 50 · 109/l, resulting in the amelioration of the patients’ symptoms. Obvious hemolytic attacks and thrombosis did not recur. The Hb remained stable, between 95–100 g/l and the patient did not require further transfusion. Two more urinary tract infection episodes developed under steroid and heparin treatments without any further complications. LMWH treatment was switched to warfarin therapy when the platelet counts reached the normal range. In conclusion, abdominal pain, a commonly encountered symptom associated with intra-abdominal thrombosis and/or hemolytic attacks, may be due to an acute abdomen in these patients. Intra-abdominal bleeding should also be considered in patients with PNH, especially if there is a rapidly developing anemia requiring multiple transfusions. Decreased PNH-defective red blood cells with hemolysis and a dilution effect of recent blood transfusions, as in our case, can affect complement sensitivity tests and may delay the diagnosis. Flow cytometric analysis of the GPI-related surface markers is now the most reliable test for the PNH diagnosis and should be performed immediately when PNH is suspected. The unusual features of our case include renal artery thrombosis, which has rarely been reported and presumed splenic vessel thromboses, which is unusual without evidence portal vein thrombosis (Gayer et al., 2001; Tsatalas et al., 2003). Splenic infarction is relatively more common but splenic rupture has not previously been reported in a patient with PNH (Zimmerman & Bell, 1980; Tsatalas et al., 2003). Anticoagulation with low molecular weight heparin may be life-saving in patients with PNH and thrombosis with thrombocytopenia.
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