[Paroxysmal nocturnal hemoglobinuria. Clinical experiences with 40 patients at one center over 25 years]

In one centre (the medical department of the University of Ulm), over a period of 25 years, the diagnosis of paroxysmal nocturnal haemoglobinuria (PNH) had been made in 40 patients (27 women, 13 men). The data on these patients were analysed and the findings compared with those reported in the literature. Criteria for inclusion were a positive sucrose haemolysis and acid-serum test. Leading clinical symptoms were anaemia, tendency towards bleeding and infections, haemolysis, abdominal pain and thromboembolism. The age at which main symptoms first appeared was most often in the third and fourth decade of life. The sex ratio of 2:1 (female to male) was unusual. PNH was frequently (in 22 patients) associated with aplastic anaemia. If bone marrow transplantation, at present the only curative procedure, was not possible and there was PNH alone, treatment was supportive and directed at relief of symptoms. The course of the disease was highly variable. Lack fo prognostic criteria made it difficult to define indications for intensive therapeutic measures. While haemolytic crisis and thromboembolism are frequent complications in isolated PNH haematopoetic insufficiency defines clinical outcome in PNH combined with aplastic anaemia.

Markedly high population of affected reticulocytes negative for decay-accelerating factor and CD59 in paroxysmal nocturnal hemoglobinuria

Paroxysmal nocturnal hemoglobinuria (PNH) blood cells lack glycosylphosphatidylinositol-anchored membrane proteins such as decay-accelerating factor (DAF) and CD59. This lack is of diagnostic value in PNH. Because reticulocytes in PNH are not yet well characterized, we analyzed reticulocytes obtained from 12 patients with PNH and from 5 healthy volunteers by two-color flow cytometry with a membrane-permeable fluorescent dye, thiazole orange, to identify reticulocytes and monoclonal antibodies to DAF and CD59. Healthy individuals had no affected cells. In all patients, the population of affected reticulocytes negative for DAF and CD59 was markedly higher than the population of affected erythrocytes. Moreover, the population of affected erythrocytes became obviously low in patients who received transfusions and suffered from hemolytic precipitation, whereas the population of affected reticulocytes was unchanged. The persistently high population of affected reticulocytes, despite cytolytic exclusion and an inherently short lifetime, might possibly be explained by relative reticulocytosis caused by an anemia-induced feedback stimulation of erythropoiesis in PNH. Thus, affected reticulocytes could be a reliable marker for the diagnosis of PNH and for the evaluation of erythropoiesis by PNH stem cell.

Paroxysmal nocturnal haemoglobinuria and Budd-Chiari syndrome

An 11 year old boy developed pancytopenia, haemolysis, and Budd-Chiari syndrome. The venous thrombosis extended to involve other intra-abdominal vessels before paroxysmal nocturnal haemoglobinuria was recognised as the underlying haematological abnormality. Earlier diagnosis would have made curative bone marrow transplantation a possibility.

A pathogenetic link between aplastic anemia and paroxysmal nocturnal hemoglobinuria is suggested by a high frequency of aplastic anemia patients with a deficiency of phosphatidylinositol glycan anchored proteins

The clinical interrelationship between paroxysmal nocturnal hemoglobinuria (PNH) and aplastic anemia (AA) promoted a search for a pathogenetic link. Since the molecular defect in PNH is a failure to express phosphatidylinositol glycan-anchored proteins (PIG-AP), we investigated whether this defect could also be demonstrated on peripheral blood cells of patients with typical AA. Quantification of the expression of PIG-AP was performed by flow cytometry using the monoclonal antibodies (MAbs) CD16 and CD66b for granulocytes, CD14 and CD48 for monocytes, CD48 and CD52 for lymphocytes, and CD55 and CD59 for erythrocytes. We analyzed cells from 52 patients with acquired AA. A PIG-AP-defective population was identified in 27 of 52 patients (52%) in at least one cell lineage. Granulocytes were involved in 25 of 27, monocytes in 18 of 25, lymphocytes in seven of 27, and erythrocytes in seven of 27 AA patients who were affected by a PIG-AP deficiency. The response rate to standard immunosuppressive therapy was significantly higher in the group of patients without a PIG-AP-deficient population than in patients with a PIG-AP-deficient population in at least one cell lineage (85.7 vs. 30.4%; p < 0.0003). Our results demonstrate that on the basis of PIG-AP expression, the proportion of AA patients who show features of typical AA along with a PNH phenotype is substantially higher than previously recognized. The pattern of PIG-AP expression might identify subgroups of AA patients who differ in the underlying mechanism as well as in the course of their disease.

Pregnancy and paroxysmal nocturnal hemoglobinuria

A patient is described who developed symptoms of paroxysmal nocturnal hemoglobinuria (PNH) in her first pregnancy. This was uneventful except for a spontaneous preterm delivery. The second pregnancy was complicated by severe anemia and a hemolytic crisis with Budd-Chiari syndrome at 31 weeks' amenorrhoea. Delivery was again preterm and was the result of induced labour after premature rupture of membranes at 34 weeks. Literature shows a high maternal mortality among PNH patients (5.8%). The most common cause of death is liver vein thrombosis (Budd-Chiari syndrome). Fetal wastage (30%) and prematurity rate (16%) are also high. Recommendations for follow-up and therapy are given such as anticoagulation therapy, platelets and washed erythocytes transfusions, screening for Budd-Chiari syndrome and infections.

Paroxysmal nocturnal haemoglobinuria and pregnancy

A woman with paroxysmal nocturnal haemoglobinuria (PNH) who was successfully delivered of 3 healthy infants after 4 pregnancies is reported. The obstetric literature of women with PNH is reviewed and the consequent view presented that judicious advice should not preclude pregnancy in such women.

[Treatment of paroxysmal nocturnal hemoglobinuria with antilymphocyte globulin]

OBJECTIVE

To evaluate the effectiveness of antilymphocyte globulin therapy (ALG) in patients with paroxysmal nocturnal hemoglobinuria (PNH).

DESIGN

Prospective, non-controlled trial.

SETTING

Hematology Service, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS, Mexico City.

PATIENTS

Six patients were included. The median age was 37.5 years and the male/female ratio was 1:1. All the patients had clinical disease consistent with PNH (hemolytic anemia with some degree of transient or persistent pancytopenia) and also erythrocytes with enhanced sensitivity to complement mediated lysis in vitro, as documented by either the Ham test or the sucrose lysis assay. The criterion for severity was the existence of continuous hemolysis in all and transfusion requirements of two or more packed red cells per month in four cases. Prior to ALG therapy, androgens and/or steroids had been given to five patients with no improvement.

INTERVENTION

A single batch of ALG was used during the trial (E 0034, Lymphoglobulin Mérieux, Lyon, France). Patients received an infusion of 10 mg/kg per day in a 20 hours lapse during four consecutive days. Also 500 mg/day of methylprednisolone were started simultaneously with the ALG; it was given for seven days and was gradually tapered off and stopped on day 30.

MEASUREMENTS

The increases in hemoglobin, granulocytes and/or platelets as well as decreases in red cell transfusion requirements were used to evaluate the results of therapy.

RESULTS

Two patients suffered anaphylaxis after the first administration of ALG and were withdrawn from the study. Two of the four remaining patients responded, one response was total and the other minimal. The responses were transient, and no response was seen in the follow-up of 11-14 months.

CONCLUSION

ALG therapy for PNH in the doses and time periods used by us had no beneficial effect in patients with a severe form of PNH.

[Clinical profile and course of paroxysmal nocturnal hemoglobinuria]

PURPOSE

To evaluate the clinical characteristics, laboratory findings, course, treatment and survival of a series of patients with PNH.

PATIENTS AND METHODS

The clinical records of 21 patients diagnosed of PNH in the La Fe University Hospital between 1970 and July 1991 were revised. Positivity to Ham's and sucrose tests was the major diagnostic criterion. Haemolysis was studied by means of reticulocyte count, unconjugated bilirubin, LDH levels, haptoglobin, serum iron, and haemosiderinuria. The survival analysis was performed in accordance with Kaplan and Meier.

RESULTS

The median age in the group was 38 years (range: 18-72 years) and the M/F ratio was 11/10. The commonest symptoms at onset were weakness (76%), dark urine (47%), jaundice (33%), and purpura (24%). All the patients had anaemia, six of them (28%) presenting with aplastic anaemia. The complications most frequently seen included thrombosis (documented in 7 cases, clinically suspected in 6 others), infection (6 cases) and haemorrhage (6 cases). One patient developed aplastic anaemia after 16 years of follow-up, and another one had AML. None of the patients with PNH-associated aplastic anaemia developed thrombosis. The incidence of severe cytopenia was: Hb < 80 g/L, 62%; platelet count < or = 20 x 10(9)/L, 29%, and white cell count < or = 2 x 10(9)/L, 14%. The haemolysis-related findings were as follows: unconjugated hyperbilirubinemia, 100%; haemosiderinuria, 87%; decreased haptoglobin, 80%. Transfusion support consisted of washed red cells (total amount, 1,684 units) and platelets (137 units). A female patient with anticoagulant therapy developed haemolysis after non-isogroup plasma transfusion. Five patients required no transfusions. One patient was subjected to splenectomy and other underwent a successful bone-marrow transplant. The cause of death was related to PNH in three of the five patients who had died when this study was finished (mesenteric thrombosis, subcapsular haematoma of the liver and AML). The actuarial survival at 10 years was 68%.

CONCLUSIONS

1) The incidence of PNH is very low in our experience, excessive delay in diagnosis being the rule, as in other reported series. 2) Early anti-thrombotic treatment should be carried out in PNH whenever severe thrombocytopenia is not associated. 3) Allogeneic BMT is the only curative treatment.

[Paroxysmal nocturnal hemoglobinuria]

Paroxystic nocturnal hemoglobinuria (PNH) is an acquired hemolytic anaemia related to an increase susceptibility of erythrocytes to complement-mediated lysis. PNH is a clonal disease of an hematopoietic stem cell which lost, by mutation, the ability to synthesized phospholipid anchor of membranous proteins, i.e. complement regulatory proteins: DAF, C8BP or CD59. The clinical features of PNH are hemoglobinuria episodes associated with chronic hemolytic anaemia or pancytopenia with active bone marrow or aplastic anaemia. The clinical course is marked by severe thrombotic complications (such as Budd-Chiari syndrome), hemorrhages or infections. The diagnosis is confirmed by in vitro hemolysis tests, and now by facs analysis of cell membrane expression of deficient proteins. Different treatments have been proposed with various results (corticosteroid therapy, androgens, chemotherapy...) but the only way to eliminate the abnormal clone appears to be related bone marrow allograft.

Late marrow allograft rejection following alpha-interferon therapy for hepatitis in a patient with paroxysmal nocturnal hemoglobinuria

We describe a case of allograft rejection that occurred 23 months after successful bone marrow transplantation for severe aplastic anemia in a patient with paroxysmal nocturnal hemoglobinuria. The allograft rejection appears to have been induced by recombinant alpha-interferon (rINF-alpha) treatment for non-A, non-B hepatitis that developed 11 months after transplantation. During the 9 months of active hepatitis, the donor graft functioned normally; however, 3 months after rINF-alpha therapy was started, pancytopenia and a chimeric hematopoietic state developed. rINF-alpha was discontinued, cyclosporin A was reintroduced, and autologous bone marrow recovery followed. rINF-alpha treatment may be detrimental to some recipients of allogeneic bone marrow transplants.

Marrow transplantation for paroxysmal nocturnal hemoglobinuria

Between 1971 and 1990, nine patients ranging in age from 14-38 years received marrow transplants for paroxysmal nocturnal hemoglobinuria (PNH). Six were transplanted for aplastic complications of PNH. Four of these were from HLA-identical siblings, and the patients were conditioned with cyclophosphamide. One graft was form a syngeneic twin without conditioning, and one from a two HLA-antigen nonidentical father after conditioning with cyclophosphamide and total body irradiation. Three of the four recipients of allogeneic marrow developed acute and two chronic graft-versus-host disease (GVHD). Five of six transplanted for severe aplastic anemia are long-term survivors with follow-up ranging from more than 6.2 to more than 19.1 years. The HLA nonidentical transplant recipient experienced graft rejection and died of a pulmonary hemorrhage. Three patients were transplanted for nonaplastic complications of PNH consisting of life threatening recurrent thromboses or refractory hemolysis. Two of these patients received marrow grafts from HLA-identical siblings after conditioning with busulfan and cyclophosphamide. They are surviving with normal hemograms greater than 2.2 and greater than 2.5 years and had mild chronic GVHD which resolved, although one has biochemical evidence of PNH in 15% of the red cells. One received a syngeneic marrow graft without conditioning but reverted to PNH. He is alive greater than 8.6 years after transplantation. Marrow transplantation for aplastic complications of PNH is successful, well tolerated, and compatible with long-term survival when an HLA-identical sibling or a syngeneic donor is available. For patients without aplasia, one must weigh the complications of transplantation with the life threatening nature of thrombotic episodes and hemolysis.

Paroxysmal nocturnal hemoglobinuria: analysis of 40 cases

Forty cases of paroxysmal nocturnal hemoglobinuria (PNH) were studied from 1978 to 1988. Thirty patients were male and 10 were female. Their ages ranged from 15 to 58 years with a median of 32 years. Symptoms related to anemia (85%) and dark colored urine (45%) were the most frequent clinical manifestations. Seven patients (17.5%) had a previous history of aplastic anemia. The interval between the diagnosis of aplastic anemia and PNH ranged from 11 months to 26 years. All the patients had anemia with varying combinations of cytopenia. In 36 patients, bone marrow examinations were performed, and 32 were hypercellular, one normocellular and 3 hypocellular. Documented thrombosis was noted in 3 patients, involving the intra-abdominal, cerebral and renal veins, respectively. The patient with intra-abdominal venous thrombosis subsequently died of E. coli septicemia. The remaining two patients achieved complete recovery. All 40 patients were treated with corticosteroids and/or anabolic agents, 32 (80%) patients improved and 4 (10%) achieved normal hemoglobin levels. Our studies demonstrate that there is a male predominance in Chinese PNH patients and the incidence of thrombotic complications is much lower than that reported by Western countries.

[Paroxysmal nocturnal hemoglobinuria, a cell surface molecular defect]

Paroxysmal nocturnal haemoglobinuria is an acquired haemolytic anaemia that may develop into aplastic anaemia or myeloid leukaemia. It has recently been shown that paroxysmal nocturnal haemoglobinuria is due to a defective coupling of specific proteins to glycolipids on the cell surface of haematopoietic cells. One of these proteins is decay-accelerating factor (DAF), and the absence of DAF on the surfaces of blood cells leads to the haemolytic symptoms. The molecular biology of DAF and its relationship to paroxysmal nocturnal haemoglobinuria symptoms is described in this brief review. The molecular defect of paroxysmal nocturnal haemoglobinuria is illustrated in a case report.

[Paroxysmal nocturnal hemoglobinuria]

Paroxysmal nocturnal hemoglobinuria, first described in the late 19th century, is an acquired disorder characterized by hemoglobinemia and hemoglobinuria. The major clinical manifestation of PNH is chronic intravascular hemolysis of various severity. Patients-mostly young adults - may also present with episodes of abdominal or back pain. Common cause of death is thrombosis especially of the hepatic veins. Granulocytopenia and thrombocytopenia may be the initial manifestation of PNH, indicating that the disorder is a primary bone-marrow disease, affecting not only the erythrocytes but also other peripheral blood cells and the haematopoietic stem cell. The course of the disease is variable. Partial complete recovery was described, but also fatal thrombosis. The major phenotypic expression of PNH is an increased susceptibility of the erythrocytes to the lytic action of complement in vitro. The enhanced complement susceptibility is most probably due to membrane defects: two membrane proteins regulating the complement cascade in PNH cells were missing, the decay-accelerating factor, DAF, inhibiting the activation of the lytic complement complex and the C8 binding protein, C8bp, which interferes with the lytic process. Aside from the lack of the complement regulators also other membrane defects have been described (e.g. of acetylcholinesterase or alkaline phosphatase). The proteins as well as DAF and C8bp are linked to the cell membrane via a phosphatidylinositol (PI) anchor, leading to the speculation that the disease results from a deficiency in the post-translational PI anchoring mechanism. The diagnosis of PNH is based on the Hamtest, but will be extended to the quantitation of the above described membrane proteins.(ABSTRACT TRUNCATED AT 250 WORDS)

[Paroxysmal nocturnal hemoglobinuria: physiopathology and therapeutic management]

The authors study the pathophysiology and the therapy of patients with paroxysmal nocturnal hemoglobinuria according with the literature reviewed. They also refer to have studied seven cases with HPN, two of which were women and five men, between the ages of 26 and 76 years of age, with symptomatology that varied from moderate, chronic hemolytic anemia and acholuria, to severe pancytopenia with bleeding, infections, and requiring transfusions, antibiotics, corticosteroids, androgens and other supportive measures. Most of them had enlargement of the spleen and liver, especially during hemolytic crises.

Pregnancy and paroxysmal nocturnal hemoglobinuria

Our study concerns eight pregnancies, six of which were successful, in four patients with paroxysmal nocturnal hemoglobinuria (PNH). Several complications of PNH during pregnancy were prevented: chronic anemia, folate and iron deficiency, and deep-vein thrombosis. During puerperium, acute hemolytic crises, most probably triggered by delivery, were observed in two patients. Thrombotic complications could be prevented by early initiation of an anticoagulant therapy after delivery. The only neonatal complication, observed in two cases, was isoimmune hemolytic anemia related to the multiple blood transfusions received before and during pregnancy. These results show that successful pregnancies are possible in women with PNH provided that both the obstetricians and physicians in charge monitor the pregnancies closely.

[Splenectomy in paroxysmal nocturnal hemoglobinuria with pancytopenia]

Two patients with long known paroxysmal nocturnal haemoglobinuria (PNH) were hospitalized for progressive severe pancytopenia or thrombocytopenia. Clinical and laboratory findings revealed a hematologic complication related to the course of PNH. In view of normocellular bone marrow hematopoiesis and documented increased splenic sequestration of RBC, functional hypersplenism was diagnosed. Selective splenectomy confirmed this hypothesis and was followed by long-standing remission of pancytopenia for 10 or more years in both patients.

Bone marrow transplantation for paroxysmal nocturnal hemoglobinuria: eradication of the PNH clone and documentation of complete lymphohematopoietic engraftment

Paroxysmal nocturnal hemoglobinuria (PNH) involves the proliferation of an abnormal and possibly premalignant hematopoietic stem cell. Successful treatment of PNH by marrow grafting requires that the PNH clone be eradicated by the pretransplant conditioning regimen. Four patients with PNH-associated marrow aplasia were transplanted with marrow from their HLA-matched, MLR-nonreactive siblings. Three patients were conditioned with cyclophosphamide, procarbazine, and antithymocyte serum (CTX/PCZ/ATS), and one was conditioned with busulfan/CTX/PCZ/ATS. Persistent complete engraftment of myeloid, lymphoid, and erythroid cell lines was demonstrated in all four patients by DNA sequence polymorphism analysis or cytogenetics, and RBC typing. There was no recurrence of the abnormal clone of cells for up to five years after transplantation despite the use of a conditioning regimen in three of them, which is not usually associated with permanent marrow aplasia. Bone marrow transplantation is a curative therapy in patients whose illness is severe enough to warrant the risk.

Long-term survival after marrow transplantation for paroxysmal nocturnal hemoglobinuria with aplastic anemia

Four patients with paroxysmal nocturnal hemoglobinuria and severe marrow aplasia were given marrow grafts either from allogeneic human-leukocyte-antigen-identical siblings (three patients) or from a syngeneic donor (one patient). The patients with allogeneic grafts were conditioned with regimens that included cyclophosphamide and had sustained and complete marrow engraftment; subsequent tests were negative for paroxysmal nocturnal hemoglobinuria. One patient developed chronic graft-versus-host disease that resolved over 4 years. The patient receiving a syngeneic graft received marrow infusion without preceding immunosuppression. He had prompt engraftment, and hematologic variables returned to normal. A Ham's test done at 3 years was negative, but a complement lysis sensitivity test done 10 years after grafting was positive; the patient, however, remains asymptomatic. All four patients are alive and well 4, 9, 10, and 12 years after transplantation. Paroxysmal nocturnal hemoglobinuria apparently can be treated successfully by allogeneic or syngeneic marrow transplantation without subsequent maintenance therapy.

Paroxysmal cold haemoglobinuria. The most frequent acute autoimmune haemolytic anaemia in children?

Paroxysmal cold haemoglobinuria (PCH) is a disease which today is met mainly in its acute form in children. The diagnosis is revealed by a careful serological examination. Case reports of four children with PCH are given in this paper. They all showed typical clinical pictures of PCH, and displayed the expected serological findings, including a bithermic autoantibody (haemolysin), the Donath-Landsteiner antibody. Children with PCH often require immediate transfusion therapy, but certain precautions should be taken regarding transfusion policy in these patients. When the acute phase is overcome, the prognosis is excellent.

Paroxysmal nocturnal haemoglobinuria. A clinicopathological study of 26 cases

26 patients, 13 male and 13 female, with paroxysmal nocturnal haemoglobinuria (PNH) are described. The diagnosis was based on the finding of a positive Ham's test. PNH developed in 4 patients with aplastic anaemia, and 3 patients with established PNH developed marrow hypoplasia during the course of the disease. In 2 cases autoimmune haemolysis was also present; this association has not been described previously. The majority of patients presented with anaemia and dark urine, or with evidence of thrombosis. A high index of suspicion was needed to avoid missing the diagnosis. Haemolytic crises were usually precipitated by infection, and renal failure requiring dialysis sometimes resulted; a positive direct antiglobulin test was often found at times of increased haemolysis. Thromboses were the most frequent complication, and when intra-abdominal vessels were affected, pain was particularly troublesome. The disease had a widely variable course; 4 patients made a complete recovery and 10 died, 8 from thrombotic complications and 2 from infections associated with marrow hypoplasia. Survival ranged from 1 year to 30 years and the median survival in those who died was 3.5 years.

Autoimmune hemolytic anemia

Nowhere in the management of patients with autoimmune hemolytic anemias is the communication between clinician and laboratory personnel more important than in regard to blood transfusion. A clinical decision that blood transfusion is necessary must be tempered by the knowledge that transfusion has a greater-than-usual risk in this setting, both because the autoantibody may cause a shortened red cell life-span of transfused red cells and because the autoantibody makes detection of red cell alloantibodies in the patient's serum more difficult. Nevertheless, when transfusion is indicated because of anemia of life-threatening severity, blood must be provided even when there is an incompatible crossmatch caused by the autoantibody. Improved methods for the typing of antibody-coated red blood cells have been described, and several eminently practical serologic techniques are now available for detection of alloantibodies even when the patient's autoantibody reacts with all donor cells. These methods include the warm autoabsorption and the differential absorption tests as well as tests for autoantibody specificity. Thus, it is no longer justifiable to omit a search for allo-antibodies in the serum of patients with autoimmune hemolytic anemia prior to blood transfusion, and the use of "least incompatible" units without more detailed compatibility testing should be considered obsolete.

Paroxysmal cold hemoglobinuria in a patient with Klebsiella pneumonia

A case of paroxysmal cold hemoglobinuria (PCH) occurring in a patient with Klebsiella pneumonia is described. The first sign of PCH in the patient was erythrophagocytosis. The Donath-Landsteiner (D-L) antibody exhibited anti-P specificity both serologically and biochemically. The appearance of D-L antibody during fulminating Klebsiella pneumonia strongly suggests their causal relationship.

Treatment of paroxysmal nocturnal hemoglobinuria

Patients with PNH may be treated with a number of known agents. As in all patients with a chronic disease, a regimen tolerable over a long period of time must be selected. Knowledge and anticipation of complications and their proper treatment are essential parts in the treatment. When these principals are used, many patients may live reasonable lives for very long periods of time.

Autoimmune haemolysis associated with Donath-Landsteiner antibodies

The clinical pattern of haemolysis associated with Donath-Landsteiner antibodies has undergone a change over the years. In the current study 13 patients developed the acute form of the disease whilst only 1 presented with the classical picture of chronic paroxysmal cold haemoglobinuria. The acute illness typically occurred in young children with a male predominance of about 2.5:1; 10 patients were less than 5 years old. There was often a history of a preceding infection, the onset was sudden, prostration, haemoglobinuria and pallor were prominent. The patients were very ill but rapid and complete recovery usually occurred within a few days; however, 1 patient died. Treatment consisted of rest and warmth; in addition blood transfusion was needed in 7 patients. The chronic disease (which was non-syphilitic in origin) followed a benign course, warmth and avoidance of cold being all that were necessary to maintain the patient's well-being. It is felt that the general term for this disorder should be Donath-Landsteiner haemolysis rather than the traditional paroxysmal cold haemoglobinuria.