Clinical Pathological Conference

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Clinical Pathological Conference

• Elizabeth Ross, M.D.
• Chief Resident
• Department of Medicine
• October 12th, 2007

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Chief Complaint

• A 46 year old Dominican woman presents with 3
  months of increasing abdominal distention and one
  month of diffuse epigastric pain

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History of Present Illness

• 2-3 years prior to admission patient first
  noticed easy bruisability, she was diagnosed with
  anemia and iron supplementation was started.
• 3 months pta she noticed abdominal distention
  and was started on a water pill.
• 1-2 months pta Her abdominal distention
  progressed, she felt like she looked pregnant.
• 2-3 weeks pta unrelenting diffuse epigastric
  pain and discomfort.

4
HPI, continued

• Her pain persisted so she sought medical
  attention and was admitted to an outside hospital
• Imaging and lab studies revealed abnormal LFTs
  and portal and splenic vein thrombosis
• She was started on a heparin drip and transferred
  to Bellevue
• Repeat imaging confirmed IVC and hepatic vein
  thrombosis and also showed portal and splenic
  vein thrombosis

5
Additonal History

• Past Medical History As above
• Past Surg History Tuboligation 15 years ago
• Medications iron, multivitamin
• On transfer heparin drip
• Allergies none
• Family History Denies history of clotting
  disorders, bleeding disorders, malignancy
• Social History Born in Dominican Republic, has
  lived in the US for 10 years, no recent travel.
  Ten pack-year tobacco history, quit 9 years ago.
  No etoh, no illicit drug use. Lives with
  husband. Worked as HHA until four months ago.

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Review of Symptoms

• Monthly, regular menstruation since menarche,
  with heavy bleeding

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Physical Exam

• General well-developed woman with apparent
  ascites, moaning in pain, appears stated age,
  mildly jaundice
• Vital signs BP 127/82, HR 108 and regular, RR
  18, Temp 97.6, SpO2 97 room air
• HEENT oropharynx dry, mild scleral icterus
• Lymph no cervical, axillary or inguinal
  lymphadenopathy
• Neck supple, no jugular venous distension
• Pulmonary clear to auscultation bilaterally

8
Physical Exam, continued

• Heart tachycardic, regular rhythm, normal heart
  sounds, no murmurs
• Abdominal Distended, diffusely tender, shifting
  dullness present, fluid wave present, no masses
  palpable
• Extremities trace lower extremity edema
  bilaterally, 2 peripheral pulses
• Skin no rashes
• Rectal guaiac negative
• Neuro Alert and oriented to person, place and
  time
• Asterixis present

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Hematology

• 11.7
• 9.3 59 MCV 85
  (80-100)
• 34.9 MPV 9.9
  (7.4-10.4)
• Differential - wnl
• INR 1.67, PT 21, PTT 66
• HIT Antibody Positive
• Thrombin Time 133.6 (21.5 29.9)
• RVVT No Inhibitor Detected

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Chemistry

• 130 95 13
• 90
  Ca 8.0
• 4.6 26 0.5 Mg 1.7
• Phos 2.0

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Chemistry/Serology

• 311 129 6.8 6.0
• 193 4.3 3.0
• LDH 783 (110-225)
• ANA positive
• Hep Bs Ab positive
• Hep Bs Ag negative
• Hep Bc Ab positive
• Hep C Ab negative

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• Urinalysis
• orange colored, clear no glucose, moderate (2)
  bilirubin, no ketones, Specific gravity 1.048,
  trace blood, trace protein, pH 6.5, Urobilinogen
  4.0 eu/dL (0-2), no nitrite, trace leukocyte
  esterase, WBC 0-2, RBC 0-2

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EKG, sinus tachycardia
14
Abd/Pelvic CT with contrast

• Hepatic vein, portal vein, splenic vein and IVC
  thromboses
• A diagnostic procedure was performed

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Student Discussants

• Marty Wolf Paroxysmal Nocturnal Hematuria
• Leo Drozhinin Anti-phospholipid Antibody
  Syndrome
• Marci Cherit Autoimmune Hepatitis
• Cristobal Gao Gastric Cancer

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• Abdominal/pelvic CT with IV contrast
• Dr. Kay Cho

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Faculty Discussant

• Dr. Mitchell Charap

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• A DIAGNOSTIC PROCEDURE WAS PERFORMED

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Hematologist/Hematopathologist

• Dr. David Araten

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FLOW CYTOMETRY
WBC
Normal
99
68
RBC
CD 59
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Flow Analysis of Red Cells
Normal Control
Patient
Events
CD59 Expression
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Flow Analysis of Red Cells
Normal Control
Patient
65
25
10
Events
CD59 Expression
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Flow Analysis of Red Cells
Normal Control
Patient
65
25
10
Events
PNH II
PNH III
CD59 Expression
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Paroxysmal Nocturnal Hemoglobinuria
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More Typical PNH Patient
PNH III
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CD55 CD59 CD14 CD48 CD87 TFPI
stem cell
lymphocyte
CD55 CD59 CD48 CD52 CD87
monocytes
platelets
red cell
neutrophil
CD55 CD59
CD55 CD59 CD66 CD24 CD16
CD55 CD59 acetylcholinesterase
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C5b
C5
Eculizumab
C3b
Eculizumab
Classical pathway C5 convertase
C4b
C2a
C5
Bb
C3b
C3b
Alternative Pathway C5 convertase
Bb
C3b
C3b
X
Alternative Pathway C3 convertase
CD55
X
C4b
C2a
Classical Pathway C3 convertase
CD59
C5b
X
C6
C8
C1r/C1s
GPI
C7
Classical pathway
C1q
Antibody
C9 Membrane Attack Complex (MAC)
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Immune Lysis Test
Two populations of cells
Rosse 1974
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Immune Lysis Test
Three populations of cells
Rosse 1974
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Immune Lysis Test
PNH II
PNH III
Three populations of cells
Rosse 1974
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Loss of all GPI-linked proteins
CD48 CD55 CD59
GPI-linked protein
OC
N
trans- membrane protein
GPI
Extracellular
Intracellular
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Acquired Somatic Mutations in PIG-A (Xp22.1) in
PNH patients
L
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4
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3
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Null mutations












982
1189
849
716
1
1452






H











4
6
5
3
2
1
Ava
I
50 bp
polymorphism
non coding region
coding region
TM, Transmembrane domain (nt 1246-1326, aa
415-442)
GlcNAc transferase homologous region (nt
912-1185, aa 304-395)
H Hot spot reported by Mortazavi et al 2003
nonsense mutation
changes very close to each other, presumably

splice site mutation
resulting from a single mutational event
From Luzzatto Nafa 2000
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Marked Geographical Disparity

• High rates of thrombosis reported in the United
  States, Europe and India
• Much lower rates in Mexico, Japan, China, and
  Thailand

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Ethnicity as a Risk Factor for Thrombosis and
Death
Araten et al 2005
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Wrap-Up

• Dr. Elizabeth Ross

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Final Diagnosis

• Paroxysmal Nocturnal Hemoglobinuria
• -with granulocyte and erythrocyte clone size
  greater than 50

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PNH

• An acquired hemolytic anemia ? somatic mutation
  of the PIG-A gene in a multipotent hematopoietic
  stem cell
• This results in the impaired synthesis of the GPI
  anchor so proteins (CD 55, 59) cant link
  antigens to cell surface
• Used to be diagnosed with Hams test,
  illustrating red cells susceptibility to lysis
  by complement, now flow cytometry is used

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PNH

• See intravascular hemolysis, cytopenias and
  venous thrombosis
• Venous thrombosis occurs in 50 of patients
  which is the most common cause of death
• When granulocyte clone size is larger than 50,
  patients are at increased risk of thrombosis
  (Hall et al, Blood, 2003)
• PNH accounts for 15-25 of patients with hepatic
  venous thrombosis

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Hillmen et al, NEJM, 1995
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PNH

• Management
• Note 15 spontaneous remission (Hillmen, 1995)
• Thrombolysis for hepatic vein thrombosis as soon
  as possible case reports with TPA (McMullin et
  al, Jrnl of Int Med, 1994)
• Warfarin should be used as primary prophylaxis in
  patients if platelets gt100 (Hall et al, Blood,
  2003)
• Monoclonal Ab, Eculizumab inhibit lytic effect
  of complement by binding to C5 (Hillmen et al,
  NEJM, 2006)
• Cure? bone marrow transplant, gene therapy

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Pathogenesis of Patients Disease

• Acquire PIG-A mutation ?
• Defect of GPI anchor on cell surface ?
• GPI-linked proteins (CD 55, 59) cant link
  antigens to cell surface ?
• Multipotent hematopoietic stem cells are
  susceptible to complement
• Platelets RBCs
• Platelet activation Intravascular hemolysis
• Anemia
• Thrombosis
  Thrombocytopenia
• Venous Thrombosis Heparin gtt
  HIT Ab

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Follow-up

• The patients abdominal pain and distention
  continued to cause her distress as an inpatient
• She was evaluated by the transplant service for
  liver transplant and GI for a portocaval shunt
  but given the presence of extrahepatic
  thrombosis, neither was pursued
• Once the HIT Ab was found to be positive she was
  taken off of heparin and transferred to the MICU
  so that she could receive TPA based on
  hematologys consultation

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Follow-up

• She received 6 cycles of tissue plasminogen
  activator (Alteplase) which was stopped
  secondary to a thigh hematoma and she was started
  on lepirudin (Refludan) and started on warfarin
  with a goal INR 2.8-3.4
• Abd/Pel CT and doppler ultrasound 2 weeks after
  admission (approximately 1 week after the TPA)
  revealed some flow through the hepatic vein

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Follow-up

• Once her ascites and epigastric pain improved,
  and her INR was at goal, she was discharged
• Approximately one year later she had an abd
  ultrasound with doppler which revealed
• -patent main portal vein, collateral flow in
  the porta hepatis supplying the left portal
  vein, patent hepatic and splenic veins. No
  ascites.
• Abd/pel CT showed portal venous hypertension
• Her platelets remain near 90,000

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Thank You

• Martin Blaser, MD
• Mitchell Charap, MD
• David Araten, MD
• Kay Cho, MD
• Josh Olstein, MD