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Barg AA, Yeshayahu Y, Avishai E, Budnik I, Cohen O, Brutman-Barazani T, Dardik R, Raas-Rothschild A, Levy-Mendelovich S, Livnat T, Pinhas-Hamiel O, Kenet G. Bleeding phenotype and hemostatic evaluation by thrombin generation in children with Noonan syndrome: A prospective study. Pediatr Blood Cancer 2024; 71:e30761. [PMID: 37974388 DOI: 10.1002/pbc.30761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/04/2023] [Accepted: 10/27/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND This study aimed to evaluate the bleeding phenotype and to conduct a comprehensive hemostatic evaluation in individuals with Noonan syndrome (NS), a dominantly inherited disorder caused by pathogenic variants in genes associated with the Ras/MAPK signaling pathway. METHODS Children with a genetically confirmed diagnosis of NS underwent clinical evaluation, routine laboratory tests, platelet function testing, and thrombin generation (TG) assessment. RESULTS The study included 24 children. The most frequently reported bleeding symptoms were easy bruising and epistaxis, while bleeding complications were observed in 15% of surgical procedures. Various hemostatic abnormalities were identified, including platelet dysfunction, von Willebrand disease, and clotting factor deficiencies. Abnormal platelet function was observed in 50% of the patients, and significantly lower TG parameters were found compared to controls. However, no significant correlation was observed between bleeding symptoms and TG results. CONCLUSIONS The study suggests that the bleeding diathesis in NS is multifactorial, involving both platelet dysfunction and deficiencies of plasma coagulation factors. The potential role of TG assay as an ancillary tool for predicting bleeding tendencies in individuals with NS undergoing surgery warrants further investigation.
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Affiliation(s)
- Assaf A Barg
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Ashdod, Israel
| | - Yonatan Yeshayahu
- Pediatrics Department, Samson Assuta Ashdod Hospital, Ashdod, Israel
- Noonan Multidisciplinary Clinic, Pediatric Endocrinology and Diabetes Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
- Faculty of Health Sciences, Ben-Gurion University, Beer Sheva, Ashdod, Israel
| | - Einat Avishai
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Ashdod, Israel
| | - Ivan Budnik
- Department of Internal Medicine, Division of Hematology/Oncology, University of Iowa, Iowa City, Iowa, USA
| | - Omri Cohen
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Ashdod, Israel
| | - Tami Brutman-Barazani
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Ashdod, Israel
| | - Rima Dardik
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Ashdod, Israel
| | - Annick Raas-Rothschild
- The Institute for Rare Diseases, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Ashdod, Israel
| | - Sarina Levy-Mendelovich
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Ashdod, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Tami Livnat
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Ashdod, Israel
| | - Orit Pinhas-Hamiel
- Noonan Multidisciplinary Clinic, Pediatric Endocrinology and Diabetes Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Gili Kenet
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Ashdod, Israel
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Bruno L, Lenberg J, Le D, Dimmock D, Thornburg CD, Briggs B. Novel Approach to Improve the Identification of the Bleeding Phenotype in Noonan Syndrome and Related RASopathies. J Pediatr 2023:S0022-3476(23)00019-7. [PMID: 36646249 DOI: 10.1016/j.jpeds.2022.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/10/2022] [Accepted: 12/01/2022] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To characterize bleeding phenotype in Noonan Syndrome, to test the utility of following national guidelines in detecting this phenotype, to evaluate thromboelastography (TEG) as a diagnostic tool and to evaluate the cohort for genotype-phenotype correlations. STUDY DESIGN Participants with a clinical diagnosis NS or related RASopathy were enrolled in a cohort study. Study procedures included clinical bleeding assessment, coagulation testing per guidelines and hematology consultation. TEG was completed in a subset and genetic testing was conducted for those without a molecular diagnosis. International Society of Haemostasis and Thrombosis Bleeding Assessment Tool (ISTH-BAT) scores were calculated with hematology consultation. Bleeding phenotype was defined as abnormal bleeding score. RESULTS Twenty participants enrolled; 12completed clinical and laboratory evaluation, five of whom met the definition for bleeding phenotype. Four of the five participants with a bleeding phenotype had platelet aggregation defects and at least one additional coagulation defect. TEG was performed in nine participants, four with bleeding phenotype and five without, and results were normal in all cases. No genotype-phenotype correlation was found. CONCLUSION Five of 20 participants had a bleeding phenotype identified. Based on available data we do not recommend incorporating TEG into clinical practice for NS patients. Platelet aggregation defects were the most common abnormalities, which would not be detected on Tier 1 testing of current guidelines, therefore we propose a new algorithm.
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Affiliation(s)
- Leah Bruno
- Department of Pediatrics, Division of Hematology and Oncology, University of California San Diego, La Jolla, California; Rady Children's Institute of Genomic Medicine, San Diego, California
| | - Jerica Lenberg
- Rady Children's Institute of Genomic Medicine, San Diego, California
| | - Dzung Le
- Department of Pathology, University of California San Diego, La Jolla, California
| | - David Dimmock
- Rady Children's Institute of Genomic Medicine, San Diego, California
| | - Courtney D Thornburg
- Department of Pediatrics, Division of Hematology and Oncology, University of California San Diego, La Jolla, California; Hemophilia and Thrombosis Treatment Center, Rady Children's Hospital San Diego, San Diego, California
| | - Benjamin Briggs
- Rady Children's Institute of Genomic Medicine, San Diego, California.
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Tang X, Chen Z, Shen X, Xie T, Wang X, Liu T, Ma X. Refractory thrombocytopenia could be a rare initial presentation of Noonan syndrome in newborn infants: a case report and literature review. BMC Pediatr 2022; 22:142. [PMID: 35300644 PMCID: PMC8928670 DOI: 10.1186/s12887-021-02909-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 09/22/2021] [Indexed: 01/01/2023] Open
Abstract
Background Noonan syndrome (NS) is a relatively rare inherited disease. Typical clinical presentation is important for the diagnosis of NS. But the initial presentation of NS could be significant variant individually which results in the difficult of working diagnosis. Here we report a rare neonatal case of NS who presented with refractory thrombocytopenia as the initial manifestation. Case presentation This was a preterm infant with refractory thrombocytopenia of unknown origin transferred from obstetric hospital at 6 weeks of age. During hospitalization, typical phenotypes of NS in addition to thrombocytopenia were observed, such as typical facial characteristics, short stature, atrial septal defect, cryptochidism, coagulation defect and chylothorax. Genetic testing showed a pathogenic variant at exon 2 of the PTPN11 gene with c.124A > G (p.T42A). Respiratory distress was deteriorated with progressive chylothorax. Chest tube was inserted for continuous draining. Chemical pleurodesis with erythromycin was tried twice, but barely effective. Finally, parents decided to withdraw medical care and the patient died. Conclusions Thrombocytopenia could be the first symptom of Noonan syndrome. After ruling out other common causes of thrombocytopenia, NS should be considered as the working diagnosis.
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Affiliation(s)
- Xiujun Tang
- Children's Hospital, Zhejiang University School of Medicine, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China.,National Clinical Research Center for Child Health, National Children's Regional Medical Center, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China
| | - Zheng Chen
- Children's Hospital, Zhejiang University School of Medicine, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China.,National Clinical Research Center for Child Health, National Children's Regional Medical Center, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China
| | - Xiaoxia Shen
- Children's Hospital, Zhejiang University School of Medicine, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China.,National Clinical Research Center for Child Health, National Children's Regional Medical Center, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China
| | - Tian Xie
- Children's Hospital, Zhejiang University School of Medicine, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China.,National Clinical Research Center for Child Health, National Children's Regional Medical Center, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China
| | - Xiaohong Wang
- Children's Hospital, Zhejiang University School of Medicine, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China.,National Clinical Research Center for Child Health, National Children's Regional Medical Center, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China
| | - Taixiang Liu
- Children's Hospital, Zhejiang University School of Medicine, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China.,National Clinical Research Center for Child Health, National Children's Regional Medical Center, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China
| | - Xiaolu Ma
- Children's Hospital, Zhejiang University School of Medicine, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China. .,National Clinical Research Center for Child Health, National Children's Regional Medical Center, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China.
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Di Candia F, Marchetti V, Cirillo F, Di Minno A, Rosano C, Pagano S, Siano MA, Falco M, Assunto A, Boccia G, Magliacane G, Pinna V, De Luca A, Tartaglia M, Di Minno G, Strisciuglio P, Melis D. RASopathies and hemostatic abnormalities: key role of platelet dysfunction. Orphanet J Rare Dis 2021; 16:499. [PMID: 34857025 PMCID: PMC8638204 DOI: 10.1186/s13023-021-02122-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 11/06/2021] [Indexed: 11/23/2022] Open
Abstract
Background Bleeding anomalies have been reported in patients affected by Noonan syndrome. No study has been performed in patients with molecularly confirmed RASopathy. We aimed to characterize the frequency and types of bleeding disorders in patients with RASopathies and evaluate any significant association with laboratory findings. Patients and methods Forty-nine individuals (PTPN11, n = 27; SOS1, n = 7; RIT1, n = 3; SPRED1, n = 1; LZTR1, N = 3; RAF1, n = 2; BRAF, n = 4; MEK1, n = 1; MEK2, n = 1), and 49 age- and sex-matched controls were enrolled. The “Paediatric Bleeding Questionnaire Scoring Key” was administered to patients and families. Laboratory screening tests including clotting factors dosing, platelet count, Prothrombin Time and Partial Thromboplastin Time, were employed both in patients and controls to characterize the bleeding diathesis. A subgroup of 29/49 patients and 29/49 controls was also tested for platelet function. Results Regardless of the gene involved, pathological paediatric bleeding scores were recorded in 14/49 (28.5%) patients. Indeed, 7 were mutated in PTPN11, 3 in SOS1, 2 in RIT1, 1 in BRAF, and 1 in MEK1. Compared to patients with normal bleeding scores, those with pathologic bleeding score showed higher prevalence of splenomegaly (p = 0.006), prolonged aPTT (p = 0.04), lower levels of coagulation factor V (FV, p = 0.001), FVII (p = 0.003), FX (p = 0.0008) and FXIII (p = 0.002), higher vWAg (p = 0.04), and lower platelet sensitivity to Ristocetin (p = 0.001), arachidonic acid (AA) (p = 0.009) and collagen (p = 0.01). The presence of hematomas inversely correlated with factor V (p = 0.002), factor VII (p = 0.003), factor X (p = 0.002) and factor XIII (p = 0.004) levels, and directly correlated with platelet response to collagen (p = 0.02) and AA (p = 0.01). The presence of splenomegaly directly correlated with the presence of hematoma (p = 0.006), platelet response to Ristocetin (p = 0.04) and AA (p = 0.04), and inversely correlated with factor V levels (p = 0.03). Conclusions Patients with RASopathies and a bleeding tendency exhibit multiple laboratory abnormalities, including platelet-related disorders. Splenomegaly is frequently detected and might be a suggestive sign for qualitative platelet dysfunction. A comprehensive clinical assessment should be carried out at diagnosis, during the follow-up and before any surgical procedures. Since there is currently no consensus on management of bleeding complications, it is important that physicians closely monitor these patients.
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Affiliation(s)
- Francesca Di Candia
- Dipartimento di Scienze Mediche Traslazionali, Università degli studi di Napoli Federico II, Naples, Italy
| | - Valeria Marchetti
- Dipartimento di Scienze Mediche Traslazionali, Università degli studi di Napoli Federico II, Naples, Italy
| | - Ferdinando Cirillo
- Regional Reference Centre for Coagulation Disorders, Department of Clinical and Experimental Medicine, Federico II University of Naples, Naples, Italy
| | - Alessandro Di Minno
- Regional Reference Centre for Coagulation Disorders, Department of Clinical and Experimental Medicine, Federico II University of Naples, Naples, Italy
| | - Carmen Rosano
- Dipartimento di Scienze Mediche Traslazionali, Università degli studi di Napoli Federico II, Naples, Italy
| | - Stefano Pagano
- Dipartimento di Scienze Mediche Traslazionali, Università degli studi di Napoli Federico II, Naples, Italy
| | - Maria Anna Siano
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy.,Pediatric Unit, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy
| | - Mariateresa Falco
- Pediatric Unit, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy
| | - Antonia Assunto
- Dipartimento di Scienze Mediche Traslazionali, Università degli studi di Napoli Federico II, Naples, Italy
| | - Giovanni Boccia
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Gerardo Magliacane
- Clinic Pathology, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy
| | - Valentina Pinna
- Medical Genetics Division, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Alessandro De Luca
- Medical Genetics Division, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Marco Tartaglia
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Giovanni Di Minno
- Regional Reference Centre for Coagulation Disorders, Department of Clinical and Experimental Medicine, Federico II University of Naples, Naples, Italy
| | - Pietro Strisciuglio
- Dipartimento di Scienze Mediche Traslazionali, Università degli studi di Napoli Federico II, Naples, Italy
| | - Daniela Melis
- Dipartimento di Scienze Mediche Traslazionali, Università degli studi di Napoli Federico II, Naples, Italy. .,Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy. .,Pediatric Unit, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy.
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Le Quellec A, Edouard T, Audebert-Bellanger S, Pouzet A, Bourdet K, Colson C, Oriot C, Poignant S, Saraux A, Devauchelle-Pensec V. Joint involvement in Noonan syndrome. A retrospective paediatric descriptive study. Joint Bone Spine 2021; 89:105270. [PMID: 34534690 DOI: 10.1016/j.jbspin.2021.105270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 08/26/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Noonan syndrome is a rare genetic disorder characterized mainly by congenital heart disease, occasional intellectual disability, and varied orthopaedic, rheumatological and haematologic anomalies. Despite potentially serious functional consequences, joint involvement has been rarely studied in the literature. Our objective was to perform a retrospective study evaluating the prevalence and characteristics of joint involvement in Noonan syndrome. METHODS We recorded articular symptoms, including their type and frequency, in patients with Noonan syndrome followed up in French hospitals. Patients were included if the diagnosis was confirmed before the age of 20 based on the van der Burgt criteria or genetic analysis. Data are presented as frequencies or medians (ranges), and patient groups were compared using chi-square or Fisher tests. RESULTS Seventy-one patients were included from 4 centres. The average age was 12.5 years (range: 2-36). Musculoskeletal pain was found in 18 patients (25%) and joint stiffness in 10 (14%) located in the wrists, elbows, ankles, knees and hips, which was usually bilateral. Only one destructive form was described (multiple villonodular synovitis and a giant cell lesion of the jaw). There were no cases of systemic lupus erythaematosus (SLE) or other autoimmune arthritis. Raynaud's phenomenon was observed in 3 patients. Only 50% of joint complaints led to additional exploration. SOS1 mutations (P<0.05) and treatment with growth hormone (GH) (P<0.05) were the only factors significantly related to musculoskeletal pain. Patients treated with GH did not have more SOS1 mutations. Patients experiencing pain were not more likely to experience stiffness, joint hypermobility, or coagulation abnormalities. CONCLUSION Joint manifestations were frequent in Noonan syndrome, predominant in large joints, and rarely explored. Multiple villonodular synovitis is characteristic but rare. Auto-immune disorders were not described in this cohort. A more multidisciplinary approach could be recommended for the early detection of possibly disabling rheumatologic manifestations.
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Affiliation(s)
- Aurore Le Quellec
- Rheumatology department, Center of Autoimmune Rare Diseases (CERAINO), CHU Cavale Blanche, Brest, France
| | - Thomas Edouard
- Endocrinology, bone diseases and genetics unit, hôpital des Enfants, CHU de Toulouse, France
| | | | - Antoine Pouzet
- Pediatric and genetic department, CHU Morvan, Brest, France
| | | | | | | | | | - Alain Saraux
- Rheumatology department, Center of Autoimmune Rare Diseases (CERAINO), CHU Cavale Blanche, Brest, France; Endocrinology, bone diseases and genetics unit, hôpital des Enfants, CHU de Toulouse, France; Pediatric and genetic department, CHU Morvan, Brest, France; Pediatric department, CHU Morvan, Brest, France; Genetic department, CHU de Caen, France; Pediatric and genetic department, CHU de Nantes, France; UMR1227, Inserm, université de Bretagne Occidentale, Brest, France
| | - Valérie Devauchelle-Pensec
- Rheumatology department, Center of Autoimmune Rare Diseases (CERAINO), CHU Cavale Blanche, Brest, France; Endocrinology, bone diseases and genetics unit, hôpital des Enfants, CHU de Toulouse, France; Pediatric and genetic department, CHU Morvan, Brest, France; Pediatric department, CHU Morvan, Brest, France; Genetic department, CHU de Caen, France; Pediatric and genetic department, CHU de Nantes, France; UMR1227, Inserm, université de Bretagne Occidentale, Brest, France.
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