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Warkentin TE. Limb Ischemic Necrosis Secondary to Microvascular Thrombosis: A Brief Historical Review. Semin Thromb Hemost 2024. [PMID: 38688305 DOI: 10.1055/s-0044-1786356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Ischemic limb injury can be broadly classified into arterial (absent pulses) and venous/microvascular (detectable pulses); the latter can be divided into two overlapping disorders-venous limb gangrene (VLG) and symmetrical peripheral gangrene (SPG). Both VLG and SPG feature predominant acral (distal) extremity ischemic necrosis, although in some instances, concomitant nonacral ischemia/skin necrosis occurs. Historically, for coagulopathic disorders with prominent nonacral ischemic necrosis, clinician-scientists implicated depletion of natural anticoagulants, especially involving the protein C (PC) system. This historical review traces the recognition of natural anticoagulant depletion as a key feature of nonacral ischemic syndromes, such as classic warfarin-induced skin necrosis, neonatal purpura fulminans (PF), and meningococcemia-associated PF. However, only after several decades was it recognized that natural anticoagulant depletion is also a key feature of predominantly acral ischemic microthrombosis syndromes-VLG and SPG-even when accompanying nonacral thrombosis is not present. These acquired acral limb ischemic syndromes typically involve the triad of (a) disseminated intravascular coagulation, (b) natural anticoagulant depletion, and (c) a localizing explanation for microthrombosis occurring in one or more limbs, either deep vein thrombosis (helping to explain VLG) or circulatory shock (helping to explain SPG). In most cases of VLG or SPG there are one or more events that exacerbate natural anticoagulant depletion, such as warfarin therapy (e.g., warfarin-associated VLG complicating heparin-induced thrombocytopenia or cancer hypercoagulability) or acute ischemic hepatitis ("shock liver") as a proximate factor predisposing to severe depletion of hepatically synthesized natural anticoagulants (PC, antithrombin) in the setting of circulatory shock.
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Affiliation(s)
- Theodore E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Service of Benign Hematology, Hamilton Health Sciences, Hamilton General Hospital, Hamilton, Ontario, Canada
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Abbaker MM, Edupuganti S, Elmukashfi ST, Elsheikh TAE. Neonatal Purpura Fulminans in a Patient With Arterial Thrombosis and Congenital Renal Agenesis. Cureus 2024; 16:e52503. [PMID: 38371013 PMCID: PMC10874227 DOI: 10.7759/cureus.52503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/20/2024] Open
Abstract
Neonatal purpura fulminans (PF) is an uncommon skin disorder characterized by acute disseminated intravascular coagulation, tissue necrosis, and small vessel thrombosis. Here, we present a case of a seven-day-old male who was admitted to the Neonatal Intensive Care (NICU) Unit at Gaafar Ibn Auf Tertiary Hospital, in January 2023. He presented with black bullous lesions on the plantar surface of the left foot, deep bluish discoloration over the right buttock and right lower abdomen, and gangrenous changes in the right foot with clear demarcation. Birth history was not significant other than mild pallor and icterus. His blood workup was consistent with severe anemia, thrombocytopenia, elevated prothrombin time, and partial thromboplastin time with decreased protein C and S levels; blood culture yielded no growth. A Doppler ultrasound scan of lower extremities confirmed distal occlusion of the right dorsalis pedis artery. The abdominal ultrasound revealed a free left renal bed and left-sided renal agenesis. We came to a diagnosis of neonatal PF and started administering blood and fresh frozen plasma and subcutaneous heparin injections, but unfortunately, the patient eventually passed away. Hence, we decided to report this case to emphasize the significance of the clinical picture in assisting with early diagnosis, despite limited access to genetic testing. We also want to highlight the importance of a "high index of suspicion" that might be mandatory for better outcomes.
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3
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Palevski D, Ben-David G, Weinberger Y, Haj Daood R, Fernández JA, Budnik I, Levy-Mendelovich S, Kenet G, Nisgav Y, Weinberger D, Griffin JH, Livnat T. 3K3A-Activated Protein C Prevents Microglia Activation, Inhibits NLRP3 Inflammasome and Limits Ocular Inflammation. Int J Mol Sci 2022; 23:ijms232214196. [PMID: 36430674 PMCID: PMC9694680 DOI: 10.3390/ijms232214196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/07/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022] Open
Abstract
3K3A-Activated Protein C (APC) is a recombinant variant of the physiological anticoagulant APC with pleiotropic cytoprotective properties albeit without the bleeding risks. The anti-inflammatory activities of 3K3A-APC were demonstrated in multiple preclinical injury models, including various neurological disorders. We determined the ability of 3K3A-APC to inhibit ocular inflammation in a murine model of lipopolysaccharide (LPS)-induced uveitis. Leukocyte recruitment, microglia activation, NLRP3 inflammasome and IL-1β levels were assessed using flow cytometry, retinal cryosection histology, retinal flatmount immunohistochemistry and vascular imaging, with and without 3K3A-APC treatment. LPS triggered robust inflammatory cell recruitment in the posterior chamber. The 3K3A-APC treatment significantly decreased leukocyte numbers and inhibited leukocyte extravasation from blood vessels into the retinal parenchyma to a level similar to controls. Resident microglia, which underwent an inflammatory transition following LPS injection, remained quiescent in eyes treated with 3K3A-APC. An inflammation-associated increase in retinal thickness, observed in LPS-injected eyes, was diminished by 3K3A-APC treatment, suggesting its clinical relevancy. Finally, 3K3A-APC treatment inhibited inflammasome activation, determined by lower levels of NLRP3 and its downstream effector IL-1β. Our results highlight the anti-inflammatory properties of 3K3A-APC in ocular inflammation and suggest its potential use as a novel treatment for retinal diseases associated with inflammation.
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Affiliation(s)
- Dahlia Palevski
- Rabin Medical Center, Ophthalmology Department and Laboratory of Eye Research, Felsenstein Medical Research Center, Petah-Tikva 49100, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Gil Ben-David
- Rabin Medical Center, Ophthalmology Department and Laboratory of Eye Research, Felsenstein Medical Research Center, Petah-Tikva 49100, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Yehonatan Weinberger
- Rabin Medical Center, Ophthalmology Department and Laboratory of Eye Research, Felsenstein Medical Research Center, Petah-Tikva 49100, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Rabeei Haj Daood
- Rabin Medical Center, Ophthalmology Department and Laboratory of Eye Research, Felsenstein Medical Research Center, Petah-Tikva 49100, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - José A. Fernández
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA 92037, USA
| | - Ivan Budnik
- Sheba Medical Center, The Amalia Biron Thrombosis Research Institute, Tel-Hashomer 52621, Israel
| | - Sarina Levy-Mendelovich
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
- Sheba Medical Center, The Amalia Biron Thrombosis Research Institute, Tel-Hashomer 52621, Israel
| | - Gili Kenet
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
- Sheba Medical Center, The Amalia Biron Thrombosis Research Institute, Tel-Hashomer 52621, Israel
| | - Yael Nisgav
- Rabin Medical Center, Ophthalmology Department and Laboratory of Eye Research, Felsenstein Medical Research Center, Petah-Tikva 49100, Israel
| | - Dov Weinberger
- Rabin Medical Center, Ophthalmology Department and Laboratory of Eye Research, Felsenstein Medical Research Center, Petah-Tikva 49100, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - John H. Griffin
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA 92037, USA
| | - Tami Livnat
- Rabin Medical Center, Ophthalmology Department and Laboratory of Eye Research, Felsenstein Medical Research Center, Petah-Tikva 49100, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
- Sheba Medical Center, The Amalia Biron Thrombosis Research Institute, Tel-Hashomer 52621, Israel
- Correspondence:
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Minford A, Brandão LR, Othman M, Male C, Abdul-Kadir R, Monagle P, Mumford AD, Adcock D, Dahlbäck B, Miljic P, DeSancho MT, Teruya J. Diagnosis and management of severe congenital protein C deficiency (SCPCD): Communication from the SSC of the ISTH. J Thromb Haemost 2022; 20:1735-1743. [PMID: 35570324 DOI: 10.1111/jth.15732] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 02/04/2023]
Abstract
Severe congenital protein C deficiency (SCPCD) is rare and there is currently substantial variation in the management of this condition. A joint project by three Scientific and Standardization Committees of the ISTH: Plasma Coagulation Inhibitors, Pediatric/Neonatal Thrombosis and Hemostasis, and Women's Health Issues in Thrombosis and Hemostasis, was developed to review the current evidence and help guide on diagnosis and management of SCPCD. We provide a summary of the clinical presentations, differential diagnoses, appropriate investigations to confirm the diagnosis, approaches for management of the acute situation, and options for long-term management including subsequent pregnancies. We finally provide a set of recommendations to help in this regard.
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Affiliation(s)
- Adrian Minford
- Department of Paediatrics, Bradford Royal Infirmary, West Yorkshire, UK
| | - Leonardo R Brandão
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Maha Othman
- School of Medicine, Queen's University, Kingston, ON, Canada
- School of Baccalaureate Nursing, St. Lawrence College, Kingston, ON, Canada
| | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - Rezan Abdul-Kadir
- Katharine Dormandy Haemophilia and Thrombosis Centre and Department of Obstetrics and Gynaecology, The Royal Free NHS Foundation Hospital, London, London, UK
- Institute for Women's Health, University College London, London, UK
| | - Paul Monagle
- Kids Cancer Centre, Department of Haematology, Sydney Children's Hospital, Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Dorothy Adcock
- Laboratory Corporation of America, Burlington, North Carolina, USA
| | - Björn Dahlbäck
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Predrag Miljic
- Faculty of Medicine, Clinic of Hematology, Clinical Center of Serbia, University in Belgrade, Belgrade, Serbia
| | - Maria T DeSancho
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Jun Teruya
- Departments of Pathology & Immunology, Pediatrics, and Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
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Inoue K, Arakawa Y, Noguchi J, Irikura T, Watakabe M, Hiraki T, Honda M, Mitani Y, Mori M, Fukuoka K, Oshima K, Kawashima H, Kurihara J, Koh K. Successful perioperative management using prothrombin complex concentrates in patients with severe congenital protein C deficiency. Pediatr Blood Cancer 2022; 69:e29380. [PMID: 34665512 DOI: 10.1002/pbc.29380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 08/21/2021] [Accepted: 09/16/2021] [Indexed: 11/09/2022]
Abstract
Perioperative management of severe congenital protein C deficiency remains unestablished. This deficiency is often treated with anticoagulants, such as warfarin. Although anticoagulants need to be perioperatively discontinued, there are few methods for the management of such patients. We adopted a method for administering prothrombin complex concentrates (PCC), which includes intermittent administration of inactive protein C (PPSB-HT), and examined its outcome as a perioperative management approach for severe congenital protein C deficiency. Three patients underwent our perioperative management six times. We monitored activity levels of protein C, factor IX, and so forth. These patients could be perioperatively managed with PCC treatment.
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Affiliation(s)
- Kyohei Inoue
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Yuki Arakawa
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Jun Noguchi
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Tomoya Irikura
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Mai Watakabe
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Takamasa Hiraki
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Mamoru Honda
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Yuichi Mitani
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Makiko Mori
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Kohei Fukuoka
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Koichi Oshima
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Hiroshi Kawashima
- Department of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Jun Kurihara
- Department of Neurosurgery, Saitama Children's Medical Center, Saitama, Japan
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
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6
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Thau A, Saffren B, Anderst JD, Carpenter SL, Levin AV. A review on clotting disorders and retinal hemorrhages: Can they mimic abuse? CHILD ABUSE & NEGLECT 2021; 118:105070. [PMID: 34049052 DOI: 10.1016/j.chiabu.2021.105070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 03/12/2021] [Accepted: 04/07/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND The characteristic findings of abusive head trauma (AHT) include retinal hemorrhages (RH). RH have many etiologies in childhood, which should be considered in the differential diagnosis of possible child abuse. The relationship between RH and thrombophilia in children is not well established. OBJECTIVE In this literature review, we sought to assess whether retinal findings in pediatric patients with thrombophilia could mimic those of AHT. METHODS A literature search was performed to identify all cases of thrombophilia in children less than 18 years old with ocular manifestations. Disorders of thrombophilia including protein C and S deficiency, factor V Leiden (FVL), prothrombin variant, MTHFR mutation, hyperhomocysteinemia, elevated factor VIII, and elevated lipoprotein (a) were considered. All cases of pediatric thrombophilia with retinal examination or intraocular bleeding were included. If provided, descriptions of the RH were reviewed. RESULTS Our initial search yielded 514 results. Forty-three articles met our inclusion criteria. We identified 3 children with RH within the AHT usual age range (<5 years old), ages 5 weeks and 7 weeks old, in the setting of thrombophilia. One child had ocular findings that could potentially mimic abuse. No other indicators of abuse were present in this case. CONCLUSIONS Based on previous reports, thrombophilia alone has not been shown to clearly mimic abusive head trauma. In reported cases of thrombophilia with RH, the clinical picture and ophthalmic findings are usually distinct from abuse.
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Affiliation(s)
- Avrey Thau
- Thomas Jefferson University, Philadelphia, PA, USA; Department of Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Philadelphia, PA, USA
| | - Brooke Saffren
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - James D Anderst
- Division of Child Adversity and Resilience, Children's Mercy Hospital, Kansas City, MO, USA
| | - Shannon L Carpenter
- Department of Hematology, Oncology, and Bone Marrow Transplantation, Children's Mercy Hospital, Kansas City, MO, USA
| | - Alex V Levin
- Thomas Jefferson University, Philadelphia, PA, USA; Department of Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Philadelphia, PA, USA.
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7
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Pöschl J, Behnisch W, Beedgen B, Kuss N. Case Report: Successful Long-Term Management of a Low-Birth Weight Preterm Infant With Compound Heterozygous Protein C Deficiency With Subcutaneous Protein C Concentrate Up to Adolescence. Front Pediatr 2021; 9:591052. [PMID: 34650936 PMCID: PMC8506145 DOI: 10.3389/fped.2021.591052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/25/2021] [Indexed: 12/18/2022] Open
Abstract
Homozygous/compound heterozygous forms of congenital protein C deficiency are often associated with severe antenatal and postnatal thrombotic or hemorrhagic complications. Protein C deficiency frequently leads to severe adverse outcomes like blindness and neurodevelopmental delay in children and may even lead to death. The most widely used long-term postnatal treatment consists of oral anticoagulation with vitamin K antagonists (e.g., warfarin), which is supplemented with protein C concentrate in acute phases. Subcutaneous infusions have been described in infants mostly from 2 months of age after severe postnatal thrombosis, but not in newborns or premature infants without thromboembolism. We report the first case of a compound heterozygous protein C-deficient preterm infant, born at 31+5 weeks of gestation to parents with heterozygous protein C deficiency (protein C activity 0.9% at birth). We focus on both prenatal and perinatal management including antithrombotic treatment during pregnancy, the cesarean section, and continuous postnatal intravenous and consecutive subcutaneous therapy with protein C concentrate followed by a change of therapy to direct oral anticoagulants (DOACs) (apixaban). We report successful home treatment with subcutaneous protein C concentrate substitution overnight (target protein C activity >25%) without complication up to 12.5 years of age. We propose that early planned cesarean section at 32 or preferably 34 weeks of gestation limits potential maternal side effects of anticoagulation with vitamin K antagonists and reduces fetal thromboembolic complications during late pregnancy. Intravenously administered protein C and early switch to subcutaneous infusions (reaching about 3 kg body weight) resulted in sufficient protein C activity and has guaranteed an excellent quality of life without any history of thrombosis for 13 years now. In older children with protein C deficiency, as in our case, DOACs could be a new therapeutic option.
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Affiliation(s)
- Johannes Pöschl
- Department of Neonatology, Heidelberg University Children's Hospital, Heidelberg, Germany
| | - Wolfgang Behnisch
- Department of Pediatric Oncology, Hematology and Immunology, Heidelberg University Children's Hospital, Heidelberg, Germany
| | - Bernd Beedgen
- Department of Neonatology, Heidelberg University Children's Hospital, Heidelberg, Germany
| | - Navina Kuss
- Department of Neonatology, Heidelberg University Children's Hospital, Heidelberg, Germany
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Barg AA, Dardik R, Levin C, Koren A, Levy-Mendelovich S, Pode-Shakked B, Kenet G. Severe Protein C Deficiency due to Novel Biallelic Variants in PROC and Their Phenotype Correlation. Acta Haematol 2020; 144:327-331. [PMID: 32980846 DOI: 10.1159/000509968] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/07/2020] [Indexed: 01/21/2023]
Abstract
Severe protein C deficiency due to biallelic PROC mutations is an extremely rare thrombophilia, most commonly presenting during the neonatal period as purpura fulminans. Despite treatment, severe morbidity and mortality are frequent. The current study reports 3 unrelated patients harboring novel homozygous PROC mutations and their clinical phenotypes. We discuss how the cytoprotective activity of protein C and its role in the stabilization of endothelial barriers may account for the unique symptoms of this thrombophilia.
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Affiliation(s)
- Assaf A Barg
- Israeli National Hemophilia Center and Thrombosis Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Rima Dardik
- Israeli National Hemophilia Center and Thrombosis Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Carina Levin
- Pediatric Hematology Unit, Emek Medical Center, Afula, Israel
- The Ruth and Baruch Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ariel Koren
- Pediatric Hematology Unit, Emek Medical Center, Afula, Israel
- The Ruth and Baruch Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Sarina Levy-Mendelovich
- Israeli National Hemophilia Center and Thrombosis Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Talpiot Medical Leadership Program, Sheba Medical Center, Tel Hashomer, Israel
| | - Ben Pode-Shakked
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute for Rare Diseases, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
- Talpiot Medical Leadership Program, Sheba Medical Center, Tel Hashomer, Israel
| | - Gili Kenet
- Israeli National Hemophilia Center and Thrombosis Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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9
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Ghassemi F, Abdi F, Esfahani M. Ophthalmic manifestations of congenital protein C deficiency: a case report and mini review. BMC Ophthalmol 2020; 20:282. [PMID: 32660449 PMCID: PMC7358193 DOI: 10.1186/s12886-020-01424-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 04/06/2020] [Indexed: 11/16/2022] Open
Abstract
Background Homozygous protein C (PC) deficiency is a potentially fatal disease with ocular blinding presentation or sequela. Case presentation A 5 month-old boy was presented for evaluation of leukocoria. He had a history of frequent bruises and PC deficiency, treated with warfarin. His intraocular pressure was normal. In the left eye leukoma with anterior segment dysgenesis, shallow anterior chamber, and cataract were observed. Fundus was not visible. B-scan revealed a closed funnel retinal detachment. His right eye had a normal anterior segment and a thin retina with anomalous retinal vascular branching at equator and peripheral retina. A fibrovascular tuft on the optic nerve head with induced traction on superior arcade was visible. Total loss of a and b wave of both were appreciated in electroretinography (ERG). Fluorescein angiography (FA) showed very severe leakage at the junction of the vascularized and non-vascularized retina and optic nerve head. Favorable outcome was achieved with lasering of avascular retina in the right eye. Conclusion The potential for protein C deficiency should be assessed in all infants with leukocoria, anterior segment dysgenesis, retinal detachment and retinal dysplasia. Early diagnosis could save the child’s life and vision.
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Affiliation(s)
- Fariba Ghassemi
- Eye research center, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin Square, Tehran, IR, Iran. .,Retina & Vitreous Service, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, IR, Iran. .,Department of Ophthalmology, Farabi Hospital Medical University Hospital, Tehran University of Medical Sciences, Tehran, IR, Iran.
| | - Fatemeh Abdi
- Eye research center, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin Square, Tehran, IR, Iran.,Department of Ophthalmology, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, IR, Iran
| | - Mandana Esfahani
- Eye research center, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin Square, Tehran, IR, Iran
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10
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Activated protein C induces suppression and regression of choroidal neovascularization- A murine model. Exp Eye Res 2019; 186:107695. [PMID: 31201804 DOI: 10.1016/j.exer.2019.107695] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/27/2019] [Accepted: 06/11/2019] [Indexed: 02/04/2023]
Abstract
Activated protein C (APC) exerts diverse cell signaling pathways which results in multiple distinct cytoprotective actions. These include anti-apoptotic and anti-inflammatory activities and stabilization of endothelial and epithelial barriers. We studied the ability of APC to inhibit the leakage and the growth of newly formed as well as pre-existing choroidal neovascularization (CNV) and examined the ability of APC to stabilize the Retinal Pigmented Epithelium (RPE). We explored the contribution of Tie2 receptor to the protective effects of APC. CNV was induced by laser photocoagulation in C57BL/6J mice. APC was injected intravitreally immediately or 7 days after CNV induction. Neovascularization was evaluated on RPE-choroidal flatmounts using FITC-dextran perfusion and CD31 immunofluorescence. CNV leakage was measured by fluorescein angiography (FA). The ability of APC to stabilize the RPE barrier was evaluated in-vitro by dextran permeability and zonula occludens 1 (ZO1) immunostaining. Tie2 blocking was induced in-vivo by intraperitoneal injection of Tie2 kinase inhibitor and in-vitro by incubation with anti Tie2 antibodies. APC treatment dramatically inhibited the generation of newly formed CNV leakage sites and reversed leakage in 85% of the pre-existing CNV leaking sites. In RPE cell culture, APC induced translocation of ZO1 to the cell membrane, accompanied by reduction in permeability of the monolayer. Inhibition of Tie2 significantly decreased APC protective activities in both the mouse model and the RPE cell culture. Our results show that APC treatment significantly inhibits the leakage and growth of newly formed, as well as pre-existing CNV, and its protective activities are partially mediated via the Tie2 receptor. The data suggest that APC should be further investigated as a possible effective treatment for CNV.
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11
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Griffin JH, Fernández JA, Lyden PD, Zlokovic BV. Activated protein C promotes neuroprotection: mechanisms and translation to the clinic. Thromb Res 2017; 141 Suppl 2:S62-4. [PMID: 27207428 DOI: 10.1016/s0049-3848(16)30368-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Activated protein C (APC) is a plasma serine protease that is capable of antithrombotic, anti-inflammatory, anti-apoptotic, and cell-signaling activities. Animal injury studies show that recombinant APC and some of its mutants are remarkably therapeutic for a wide range of injuries. In particular, for neurologic injuries, APC reduces damage caused by ischemia/reperfusion in the brain, by acute brain trauma, and by chronic neurodegenerative conditions. For these neuroprotective effects, APC requires endothelial cell protein C receptor. APC activates cell signaling networks with alterations in gene expression profiles by activating protease activated receptors 1 and 3. To minimize APC-induced bleeding risk, APC variants were engineered to lack > 90% anticoagulant activity but retain normal cell signaling. The neuroprotective APC mutant, 3K3A-APC which has Lys191-193 mutated to Ala191-193, is very neuroprotective and it is currently in clinical trials for ischemic stroke.
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Affiliation(s)
- John H Griffin
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA, USA; Department of Medicine, Division of Hematology/Oncology, University of California San Diego, San Diego, CA, USA.
| | - José A Fernández
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA, USA
| | - Patrick D Lyden
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Berislav V Zlokovic
- Department of Neurosurgery, University of Southern California, Keck School of Medicine, Los Angeles, CA; Department of Neurosurgery, Zilkha Neurogenetic Institute, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
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12
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New HV, Berryman J, Bolton-Maggs PHB, Cantwell C, Chalmers EA, Davies T, Gottstein R, Kelleher A, Kumar S, Morley SL, Stanworth SJ. Guidelines on transfusion for fetuses, neonates and older children. Br J Haematol 2016; 175:784-828. [DOI: 10.1111/bjh.14233] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Helen V. New
- NHS Blood and Transplant; London UK
- Imperial College Healthcare NHS Trust; London UK
| | | | | | | | | | | | - Ruth Gottstein
- St. Mary's Hospital; Manchester/University of Manchester; Manchester UK
| | | | - Sailesh Kumar
- Mater Research Institute; University of Queensland; Brisbane Australia
| | - Sarah L. Morley
- Addenbrookes Hospital/NHS Blood and Transplant; Cambridge UK
| | - Simon J. Stanworth
- Oxford University Hospitals NHS Trust/NHS Blood and Transplant; Oxford UK
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13
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Hereditary protein C deficiency in a Saudi neonate with bilateral adrenal gland haemorrhages: A rare case report. J Taibah Univ Med Sci 2016. [DOI: 10.1016/j.jtumed.2016.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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14
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Fruchtman Y, Strauss T, Rubinstein M, Ben Harush M, Revel-Vilk S, Kapelushmik J, Paret G, Kenet G. Skin Necrosis and Purpura Fulminans in Children With and Without Thrombophilia--A Tertiary Center's Experience. Pediatr Hematol Oncol 2016; 32:505-10. [PMID: 26436558 DOI: 10.3109/08880018.2015.1068896] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Purpura fulminans (PF) is a very rare clinicopathologic skin disorder comprising dermal microvascular thrombosis associated with perivascular hemorrhage of multiple origins. It may occur as the presenting symptom of severe congenital deficiency of protein C (PC) or protein S (PS) during the newborn period, or later in life following oral anticoagulant therapy with vitamin K antagonists, or of sepsis that may be associated with disseminated intravascular coagulation. Treatment consists of anticoagulants and PC concentrates during acute episodes. We report our experience in the diagnosis and management of pediatric PF. The medical records of the 6 children aged 2-16 years (median: 5 years) who presented with PF to our tertiary care center between 1996 and 2013 were studied. The thrombophilia workup revealed either the presence of congenital homozygous PC deficiency, prothrombotic polymorphisms (factor V Leiden and FIIG20210A heterozygosity), acquired PC/PS deficiency, or no discernible thrombophilia. The skin necrosis resolved following conservative fresh-frozen plasma/anticoagulant therapy in 2 cases, whereas 3 children required interventional plastic surgery. The sixth case, a 10-year-old child with severe PC deficiency, heterozygous factor V Leiden, and FIIG20210A, received recombinant activated PC. PF in childhood is rare and has multiple etiologies. Understanding of the variable pathogenesis and risk factors will facilitate diagnosis and appropriate clinical management.
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Affiliation(s)
- Yariv Fruchtman
- a Department of Pediatric Emergency Care and Pediatric Hematology Unit , Soroka Medical Center , Beer-Sheba , Israel , affiliated to the Ben Gurion University of the Negev , Beer Sheva , Israel.,b Thrombosis Unit, National Hemophilia Center , Safra Children's Hospital, Sheba Medical Center , Tel Hashomer, Israel
| | - Tzipora Strauss
- b Thrombosis Unit, National Hemophilia Center , Safra Children's Hospital, Sheba Medical Center , Tel Hashomer, Israel.,c Department of Neonatology , Safra Children's Hospital, Sheba Medical Center , Tel Hashomer, Israel
| | - Marina Rubinstein
- d Department of Critical Care, Safra Children's Hospital , Sheba Medical Center , Tel Hashomer , Israel , affiliated to the Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Miriam Ben Harush
- a Department of Pediatric Emergency Care and Pediatric Hematology Unit , Soroka Medical Center , Beer-Sheba , Israel , affiliated to the Ben Gurion University of the Negev , Beer Sheva , Israel
| | - Shoshana Revel-Vilk
- e Department of Pediatric Hematology/Oncology , Hadassah Hebrew University Medical Center , Jerusalem , Jerusalem , Israel
| | - Joseph Kapelushmik
- a Department of Pediatric Emergency Care and Pediatric Hematology Unit , Soroka Medical Center , Beer-Sheba , Israel , affiliated to the Ben Gurion University of the Negev , Beer Sheva , Israel
| | - Gideon Paret
- d Department of Critical Care, Safra Children's Hospital , Sheba Medical Center , Tel Hashomer , Israel , affiliated to the Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Gili Kenet
- b Thrombosis Unit, National Hemophilia Center , Safra Children's Hospital, Sheba Medical Center , Tel Hashomer, Israel
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15
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Abstract
The protein C anticoagulant pathway is critical for controlling microvascular thrombosis and is initiated when thrombin binds to thrombomodulin (TM) on the surface of the endothelium. Protein C activation is augmented by an endothelial cell protein C receptor (EPCR). EPCR is shed from the vasculature by inflammatory mediators and thrombin. EPCR binds to activated neutrophils in a process that involves proteinase 3 and Mac-1 and appears to inhibit leukocyte extravasation. EPCR can undergo translocation from the plasma membrane to the nucleus where it re-directs gene expression. During translocation, EPCR can carry activated protein C (APC) to the nucleus, possibly accounting for the ability of APC to modulate inflammatory mediator responses in the endothelium. TNF-α and other inflammatory mediators can down-regulate EPCR and TM. Inhibition of protein C pathway function increases cytokine elaboration, endothelial cell injury and leukocyte extravasation in response to endotoxin and infusion of APC reverses these processes. In vitro, APC has been reported to inhibit TNF-α elaboration from monocytes and to block leukocyte adhesion to selectins. Since thrombin can elicit many inflammatory responses in microvascular endothelium, loss of control of microvascular thrombin generation due to impaired protein C pathway function probably contributes to microvascular dysfunction in sepsis.
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Affiliation(s)
- Charles T. Esmon
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation; Departments of Pathology, and Biochemistry & Molecular Biology, University of Oklahoma Health Sciences Center, , Howard Hughes Medical Institute, Oklahoma City, Oklahoma, USA
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16
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Shah R, Ferreira P, Karmali S, Le D. Severe Congenital Protein C Deficiency: Practical Aspects of Management. Pediatr Blood Cancer 2016; 63:1488-90. [PMID: 27138381 DOI: 10.1002/pbc.25997] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 03/10/2016] [Accepted: 03/11/2016] [Indexed: 11/11/2022]
Abstract
Subcutaneous (SC) protein C (PC) was used in a child with purpura fulminans secondary to severe congenital PC deficiency. For maintenance, PC 80-120 IU/kg, given over 60-90 min SC Q48hr, has been successful as a home therapy for more than 3 years. The treatment was monitored by measuring trough PC chromogenic activity (target ≥15%) and D-dimer levels. No change in clinical course was appreciated after discontinuing enoxaparin (and leaving the patient on prophylactic PC replacement alone). A significant discrepancy between clotting-based and chromogenic-based PC activity is shown.
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Affiliation(s)
- Ravi Shah
- Pediatric Hematology, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Patrick Ferreira
- Medical Genetics, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Shelina Karmali
- Pediatric Hematology, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Doan Le
- Pediatric Hematology, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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17
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Punzalan RC, Gottschall JL. Use and Future Investigations of Recombinant and Plasma-Derived Coagulation and Anticoagulant Products in the Neonate. Transfus Med Rev 2016; 30:189-96. [PMID: 27576087 DOI: 10.1016/j.tmrv.2016.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 07/18/2016] [Indexed: 12/27/2022]
Abstract
Although congenital bleeding disorders can manifest in the newborn period, the most common causes of bleeding and thrombosis in neonates are acquired conditions. Factor concentrates are used for specific diagnoses (hemophilia with inhibitors, specific factor deficiency, von Willebrand disease) and approved indications, and increasingly for off-label indications (bleeding in surgery cardiopulmonary bypass, extracorporeal membrane oxygenation). We will review the approved indications for factor products in the neonate and discuss the evidence and rationale for off-label use of factor products in management of bleeding and thrombosis in the neonate.
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Affiliation(s)
- Rowena C Punzalan
- BloodCenter of Wisconsin, Milwaukee, WI; Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.
| | - Jerome L Gottschall
- BloodCenter of Wisconsin, Milwaukee, WI; Department of Pathology, Medical College of Wisconsin, Milwaukee, WI
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18
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Manco-Johnson MJ, Bomgaars L, Palascak J, Shapiro A, Geil J, Fritsch S, Pavlova BG, Gelmont D. Efficacy and safety of protein C concentrate to treat purpura fulminans and thromboembolic events in severe congenital protein C deficiency. Thromb Haemost 2016; 116:58-68. [PMID: 27052576 DOI: 10.1160/th15-10-0786] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 03/27/2016] [Indexed: 11/05/2022]
Abstract
Severe congenital protein C (PC) deficiency (SCPCD) is associated with disseminated intravascular coagulation (DIC), purpura fulminans (PF), and vascular thromboembolic events (TE), often leading to organ failure and death. PC replacement therapy offers a safe, effective treatment for thromboembolic complications of SCPCD and secondary prophylaxis for recurrent DIC, PF, and TEs. A prospective, multi-centre, open-label, phase 2/3 study was conducted to demonstrate the safety and efficacy of protein C concentrate for treatment of PF and acute TEs. Fifteen enrolled patients with SCPCD received protein C concentrate; 11 received treatment for acute TEs (PF, 18 events; PF and other coumarin-related vascular thromboembolic events [coumarin-induced skin necrosis; CISN], 1 event; venous thrombosis, 5 events). Pre-defined efficacy criteria for treatment of acute TEs were compared with a historical control arm (i. e. patients receiving conventional therapy without protein C replacement). PF/CISN was demonstrated by pre-defined primary and secondary efficacy ratings. Primary ratings of protein C concentrate-treated episodes were significantly higher (p=0.0032) than in the historical control. For 19 PF/CISN episodes in 11 patients, 94.7 % of treatments were rated effective and 5.3 % effective with complications (not related to protein C concentrate). In a secondary efficacy rating, all treatments were rated effective (68.4 % excellent; 21.1 % good; 10.5 % fair). For 5/24 vascular thrombosis episodes, 80 % of treatments were rated excellent and 20 % were rated good. No treatment-related adverse events or serious adverse events occurred. In conclusion, protein C concentrate provides an efficacious, safe treatment for PF, CISN, and other TEs in SCPCD patients.
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Affiliation(s)
| | | | | | | | | | | | | | - David Gelmont
- David Gelmont, BioTherapeutics Clinical Research, Baxalta US Inc., One Baxter Way, Westlake Village, CA 91362-3811, USA, Tel.: +1 805 372 3352, Fax: +1 805 372 3492, E-mail:
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19
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Lim MS, Shin JE, Lee SM, Eun HS, Park MS, Park KI, Namgung R, Lee KA, Lee JS. Diagnosis of Severe Protein C Deficiency Confirmed by Presence of Rare PROCGene Mutation. NEONATAL MEDICINE 2016. [DOI: 10.5385/nm.2016.23.4.233] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Myung Seop Lim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Eun Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Soon Min Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Ho Sun Eun
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Min Soo Park
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Kook In Park
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Ran Namgung
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung A Lee
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Sung Lee
- Department of Clinical Genetics, Yonsei University College of Medicine, Seoul, Korea
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20
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Abstract
Homozygous protein C deficiency is an extremely rare condition presenting in the neonatal period with purpura fulminans, with very high rates of morbidity and mortality. Optimal treatment for this condition is highly complex, poorly understood, and often limited by cost and product supply. We report a child who presented 2 days after birth with purpura fulminans and severe prenatal eye damage, but no cerebral lesions. He was treated with novel multimodal therapy culminating in liver transplant at 3 years of age. The patient is now 12 years of age, well, with blindness as his only long-term deficit.
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21
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Limperger V, Klostermeier UC, Kenet G, Holzhauer S, Alhenc Gelas M, Finckh U, Junker R, Heller C, Zieger B, Kurnik K, Knöfler R, Mesters R, Halimeh S, Nowak-Göttl U. Clinical and laboratory characteristics of children with venous thromboembolism and protein C-deficiency: an observational Israeli-German cohort study. Br J Haematol 2014; 167:385-93. [DOI: 10.1111/bjh.13039] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 06/13/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Verena Limperger
- Institute of Clinical Chemistry; University Hospital of Kiel & Lübeck; Lübeck Germany
| | | | - Gili Kenet
- Thrombosis Unit; National Haemophilia Centre; Tel Hashomer and the Sackler Medical School; Tel Aviv University; Tel-Hashomer Israel
| | - Susanne Holzhauer
- Department of Paediatric Haematology/Oncology; Charité- Charité - Universitaetsmedizin Berlin; Berlin Germany
| | - Martine Alhenc Gelas
- Service d'hématologie biologique; AP-HP, Hôpital Europeen Georges Pompidou; Paris France
| | - Ulrich Finckh
- Medizinisches Versorgungszentrum Eberhard & Partner; Dortmund Germany
| | - Ralf Junker
- Institute of Clinical Chemistry; University Hospital of Kiel & Lübeck; Lübeck Germany
| | - Christine Heller
- University Hospital; Department of Paediatric Hemostaseology; Frankfurt Germany
| | - Barbara Zieger
- Department Paediatrics; University Children Hospital Freiburg; Freiburg Germany
| | - Karin Kurnik
- Department of Paediatrics; University Children Hospital Munich; Munich Germany
| | - Ralf Knöfler
- Department of Paediatric Hemostaseology; University Hospital Dresden; Dresden Germany
| | - Rolf Mesters
- Department of Medicine/Haematology & Oncology; University Hospital of Münster; Münster Germany
| | - Susan Halimeh
- Coagulation Centre Rhine-Ruhr; Duisburg Germany
- University Children Hospital; Münster Germany
| | - Ulrike Nowak-Göttl
- University Children Hospital; Münster Germany
- Centre of Thrombosis and Haemostasis; Department of Clinical Chemistry; University Hospital of Kiel & Lübeck; Kiel Germany
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22
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Minford A, Behnisch W, Brons P, David M, Gomez Gomez N, Hertfelder HJ, Kruempel A, Kurnik K, Mathias M, Molines Honrubia A, Monagle P, Morgan M, Nowak-Göttl U, Olivieri M. Subcutaneous protein C concentrate in the management of severe protein C deficiency - experience from 12 centres. Br J Haematol 2014; 164:414-21. [DOI: 10.1111/bjh.12640] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 09/30/2013] [Indexed: 12/30/2022]
Affiliation(s)
- Adrian Minford
- Department of Paediatrics; Bradford Royal Infirmary; Bradford UK
| | - Wolfgang Behnisch
- Department of Paediatric Haematology and Oncology; University Hospital of Heidelberg; Heidelberg Germany
| | - Paul Brons
- Department of Paediatric Haematology-Oncology; Radboud University Nijmegen Medical Centre; Nijmegen The Netherlands
| | - Michele David
- Division of Hematology; CHU Ste. Justine; Montreal QC Canada
| | | | - Hans-Joerg Hertfelder
- Institute of Experimental Haematology and Transfusion Medicine; University Hospital Bonn; Bonn Germany
| | - Anne Kruempel
- Department of Paediatric Haematology and Oncology; Children's University Hospital; Münster Germany
| | - Karin Kurnik
- Paediatric Haemophilia and Blood Coagulation Centre; Dr von Haunersches Kinderspital; University of Munich; Munich Germany
| | - Mary Mathias
- Haemophilia Comprehensive Care Centre; Great Ormond Street Hospital; London UK
| | - Antonio Molines Honrubia
- Haematology and Haemotherapy Department; Hospital Universitario Materno Infantil de Canarias; Las Palmas de Gran Canaria Spain
| | - Paul Monagle
- Department of Haematology; The Royal Children's Hospital; Department of Paediatrics; University of Melbourne; Melbourne Vic. Australia
| | - Mary Morgan
- Department of Paediatric Haematology-Oncology; University Hospital Southampton; Southampton UK
| | - Ulrike Nowak-Göttl
- Thrombosis and Haemostasis Treatment Centre; Institute of Clinical Chemistry; University Hospital Schleswig-Holstein; Kiel Germany
| | - Martin Olivieri
- Paediatric Haemophilia and Blood Coagulation Centre; Dr von Haunersches Kinderspital; University of Munich; Munich Germany
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23
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Hypercoagulability in a newborn with concomitant homozygous factor V Leiden and severe homozygous protein C deficiency type 1. Blood Coagul Fibrinolysis 2013; 24:777-9. [PMID: 24056294 DOI: 10.1097/mbc.0b013e328364194b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This is a case report of a female newborn presented with skin necrotic lesions 1 week after delivery. Laboratory investigations revealed severe homozygous protein C deficiency associated with homozygous factor V Leiden, although her pregnancy and perinatal periods were otherwise uneventful, with negative family history of thrombotic or bleeding disorders. Patient stabilization was established by supportive measures and long-term administration of fresh frozen plasma and warfarin.
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24
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Abstract
Neonatal stroke is a diverse clinical entity. Terminology and aetiology described in the literature are very varied. While numerous risk factors are cited, only few case-control studies have investigated them in a systematic fashion. This equipoise extends to the investigational and management profile of perinatal stroke too. Controversy persists about the suitability of detailed haematological thrombophilia workup in the neonatal period. This case-based review details the variable clinical presentation in term and preterm neonates, discusses the current literature, ascertains the respective roles of various imaging modalities, explores relevant new neuroprotective interventions and proposes a systematic approach to clinical and neuroimaging workup. Long-term follow-up is important as many infants suffer neuro-disability, which might need early intervention strategies.
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Affiliation(s)
- Arvind Sehgal
- Monash Newborn, Monash Children's, Melbourne, Australia.
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25
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Frommhold D, Tschada J, Braach N, Buschmann K, Doerner A, Pflaum J, Stahl MS, Wang H, Koch L, Sperandio M, Bierhaus A, Isermann B, Poeschl J. Protein C concentrate controls leukocyte recruitment during inflammation and improves survival during endotoxemia after efficient in vivo activation. THE AMERICAN JOURNAL OF PATHOLOGY 2011; 179:2637-50. [PMID: 21907691 DOI: 10.1016/j.ajpath.2011.07.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Revised: 06/18/2011] [Accepted: 07/13/2011] [Indexed: 01/13/2023]
Abstract
Anti-inflammatory properties of protein C (PC) concentrate are poorly studied compared to activated protein C, although PC is suggested to be safer in clinical use. We investigated how PC interferes with the leukocyte recruitment cascade during acute inflammation and its efficacy during murine endotoxemia. We found that similar to activated protein infusion, intravenous PC application reduced leukocyte recruitment in inflamed tissues in a dose- and time-dependent manner. During both tumor necrosis factor-α induced and trauma-induced inflammation of the cremaster muscle, intravital microscopy revealed that leukocyte adhesion and transmigration, but not rolling, were profoundly inhibited by 100 U/kg PC. Moreover, PC blocked leukocyte emigration into the bronchoalveolar space during lipopolysaccharide (LPS) induced acute lung injury. PC was efficiently activated in a murine endotoxemia model, which reduced leukocyte infiltration of organs and strongly improved survival (75% versus 25% of control mice). Dependent on the inflammatory model, PC provoked a significant inhibition of leukocyte recruitment as early as 1 hour after administration. PC-induced inhibition of leukocyte recruitment during acute inflammation critically involves thrombomodulin-mediated PC activation, subsequent endothelial PC receptor and protease-activated receptor-1-dependent signaling, and down-regulation of intercellular adhesion molecule 1 leading to reduced endothelial inflammatory response. We conclude that during acute inflammation and sepsis, PC is a fast acting and effective therapeutic approach to block leukocyte recruitment and improve survival.
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Affiliation(s)
- David Frommhold
- Department of Neonatology, University Children's Hospital, Heidelberg, Germany.
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26
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Knoebl PN. Severe congenital protein C deficiency: the use of protein C concentrates (human) as replacement therapy for life-threatening blood-clotting complications. Biologics 2011; 2:285-96. [PMID: 19707361 PMCID: PMC2721356 DOI: 10.2147/btt.s1954] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The protein C pathway has an important function in regulating and modulating blood coagulation and ensuring patency of the microcirculation. Protein C deficiency leads to macro- and microvascular thrombosis. Congenital severe protein C deficiency is a life-threatening state with neonatal purpura fulminans and pronounced coagulopathy. Patients with heterozygous protein C deficiency have an increased risk for thromboembolic events or experience coumarin-induced skin necrosis during initiation of coumarin therapy. Replacement with protein C concentrates is an established therapy of congenital protein C deficiency, resulting in rapid resolving of coagulopathy and thrombosis without reasonable side effects. This article summarizes the current knowledge on protein C replacement therapy in congenital protein C deficiency.
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Affiliation(s)
- Paul N Knoebl
- Department of Medicine 1, Division Hematology and Hemostasis, Medical University of Vienna, Vienna, Austria
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27
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Abstract
The mechanisms of vascular control of thrombotic events remain unclear. The vasculature possesses essential anticoagulant factors that regulate coagulation. Because the endothelium-to-blood ratios are much higher in the microcirculation, it is likely that stasis contributes to thrombotic risk, due in large part to failure to rapidly access the microcirculation and to gain access to this highly anticoagulant environment. Inflammation can potentiate thrombosis in part through downregulation of the vascular anticoagulants, a process that appears to be exacerbated in aging, a well-known risk factor for thrombosis. Surgery and trauma, two major risk factors for thrombosis, result in the release of a variety of cellular components that trigger coagulation through separate mechanisms.
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Affiliation(s)
- Charles T Esmon
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, 73104, USA.
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28
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de Kort EHM, Vrancken SLAG, van Heijst AFJ, Binkhorst M, Cuppen MPJM, Brons PPT. Long-term subcutaneous protein C replacement in neonatal severe protein C deficiency. Pediatrics 2011; 127:e1338-42. [PMID: 21482600 DOI: 10.1542/peds.2009-2913] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
We describe here the case of a boy who presented 2 days after birth with purpura fulminans on his feet and scalp. Laboratory investigations revealed signs of disseminated intravascular coagulation. An underlying coagulation disorder was suspected, and therapy with recombinant tissue plasminogen activator, fresh-frozen plasma, and unfractionated heparin was started. On the basis of plasma protein C activity and antigen levels of 0.02 and 0.03 IU/mL, respectively, after administration of fresh-frozen plasma, a diagnosis of severe protein C deficiency was established, and therapy with intravenous protein C concentrate (Ceprotin [Baxter, Deerfield, IL]) was started. Because of difficulties with venous access, we switched to subcutaneous administration after 6 weeks. The precise dosing schedule for subcutaneously administered protein C concentrate is unknown. In the literature, a trough level of protein C activity at >0.25 IU/mL is recommended to prevent recurrent thrombosis. During 1 year of follow-up our patient frequently had protein C activity levels at <0.25 IU/mL. Clinically, however, there was no recurrent thrombosis, and we kept the dosage unchanged. This report highlights 2 important points: (1) subcutaneously administered protein C concentrate is effective in treating severe protein C deficiency; and (2) in accordance with previous studies, after the acute phase trough levels of protein C activity at >0.25 IU/mL may not be necessary to prevent recurrent thrombosis. However, further research on the dosing, efficacy, and safety of protein C concentrate for prophylaxis and treatment of severe protein C deficiency is needed.
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Affiliation(s)
- Ellen H M de Kort
- Department of Pediatrics, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, Netherlands
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29
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Kroiss S, Albisetti M. Use of human protein C concentrates in the treatment of patients with severe congenital protein C deficiency. Biologics 2010; 4:51-60. [PMID: 20376174 PMCID: PMC2846144 DOI: 10.2147/btt.s3014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2010] [Indexed: 01/19/2023]
Abstract
Protein C is one of the major inhibitors of the coagulation system that downregulate thrombin generation. Severe congenital protein C deficiency leads to a hypercoagulability state that usually presents at birth with purpura fulminans and/or severe venous and arterial thrombosis. Recurrent thrombotic events are commonly seen. From the 1990’s, several virus-inactivated human protein C concentrates have been developed. These concentrates currently constitute the therapy of choice for the treatment and prevention of clinical manifestations of severe congenital protein C deficiency. This review summarizes the available information on the use of human protein C concentrates in patients with severe congenital protein C deficiency.
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Affiliation(s)
- Sabine Kroiss
- Division of Hematology, University Children's Hospital, Zurich, Switzerland
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30
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31
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Kienast A, Nowak- Göttl U, Krümpel A, Harms E, Rellensmann G, Kurnik K, Hörnig- Franz I. Neonatale Purpura fulminans. Monatsschr Kinderheilkd 2009. [DOI: 10.1007/s00112-009-2022-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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32
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Abstract
Severe protein C deficiency (i.e. protein C activity <1 IU dL(-1)) is a rare autosomal recessive disorder that usually presents in the neonatal period with purpura fulminans (PF) and severe disseminated intravascular coagulation (DIC), often with concomitant venous thromboembolism (VTE). Recurrent thrombotic episodes (PF, DIC, or VTE) are common. Homozygotes and compound heterozygotes often possess a similar phenotype of severe protein C deficiency. Mild (i.e. simple heterozygous) protein C deficiency, by contrast, is often asymptomatic but may involve recurrent VTE episodes, most often triggered by clinical risk factors. The coagulopathy in protein C deficiency is caused by impaired inactivation of factors Va and VIIIa by activated protein C after the propagation phase of coagulation activation. Mutational analysis of symptomatic patients shows a wide range of genetic mutations. Management of acute thrombotic events in severe protein C deficiency typically requires replacement with protein C concentrate while maintaining therapeutic anticoagulation; protein C replacement is also used for prevention of these complications around surgery. Long-term management in severe protein C deficiency involves anticoagulation with or without a protein C replacement regimen. Although many patients with severe protein C deficiency are born with evidence of in utero thrombosis and experience multiple further events, intensive treatment and monitoring can enable these individuals to thrive. Further research is needed to better delineate optimal preventive and therapeutic strategies.
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Affiliation(s)
- N A Goldenberg
- Hemophilia & Thrombosis Center, Department of Pediatrics, University of Colorado Denver and The Children's Hospital, Aurora, CO, USA
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Raffini L, Thornburg C. Testing children for inherited thrombophilia: more questions than answers. Br J Haematol 2009; 147:277-88. [PMID: 19656153 DOI: 10.1111/j.1365-2141.2009.07820.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Thrombotic events in children have become an increasingly common problem, particularly in paediatric tertiary care hospitals. The prevalence of inherited thrombophilia in children who develop thrombosis varies substantially depending on the population. Children who develop thrombosis, as well as those who have not but have a positive family history, are frequently tested for inherited thrombophilia. The clinical utility of performing such tests has been questioned, in both adults and children. This review will examine the practise of testing for inherited thrombophilia in children, focusing on the rationale for testing and highlighting areas in which more evidence is needed prior to making strong recommendations. Future studies, many of which are currently being performed or proposed, are necessary to address many of the unanswered questions.
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Affiliation(s)
- Leslie Raffini
- Division of Hematology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104-4399, USA.
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Abstract
Inflammation shifts the hemostatic mechanisms in favor of thrombosis. Multiple mechanisms are at play including up regulation of tissue factor leading to the initiation of clotting, amplification of the clotting process by augmenting exposure of cellular coagulant phospholipids, inhibition of fibrinolysis by elevating plasminogen activator inhibitor 1 (PAI-1) and decreases in natural anticoagulant pathways, particularly targeted toward down regulation of the protein C anticoagulant pathway through multiple mechanisms. The decreased function of the natural anticoagulant pathways may be particularly problematic because these appear to play a role in dampening inflammatory responses. The protein C anticoagulant pathway provides a useful model for the impact of inflammation on coagulation. This pathway plays a major role in preventing microvascular thrombosis. The pathway is initiated when thrombin binds to thrombomodulin (TM) on the surface of the endothelium. An endothelial cell protein C receptor (EPCR) augments protein C activation by the thrombin-TM complex more than 10-fold in vivo. EPCR is shed from the endothelium by inflammatory mediators and thrombin. EPCR binds to activated neutrophils in a process that involves proteinase 3 and Mac-1 and appears to inhibit leukocyte extravisation. EPCR can undergo translocation from the plasma membrane to the nucleus where it redirects gene expression. During translocation it can carry activated protein C (APC) to the nucleus, possibly accounting for the ability of APC to modulate inflammatory mediator responses in the endothelium. TNF alpha and other inflammatory mediators can down-regulate EPCR and TM and IL-6 can depress levels of protein S in experimental animals. Inhibition of protein C pathway function increases cytokine elaboration, endothelial cell injury and leukocyte extravisation in response to endotoxin, processes that are decreased by infusion of APC. In vitro, APC inhibits TNF alpha elaboration from monocytes and to block leukocyte adhesion to selectins. Since thrombin can elicit many inflammatory responses in microvascular endothelium, loss of control of microvascular thrombin generation due to impaired protein C pathway function probably contributes to microvascular dysfunction in sepsis.
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Affiliation(s)
- Charles T Esmon
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Department of Pathology, University of Oklahoma Health Sciences Center, Howard Hughes Medical Institute, Oklahoma City, OK 73104, USA.
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35
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Erupciones inflamatorias y purpúricas. DERMATOLOGÍA NEONATAL 2009. [PMCID: PMC7161408 DOI: 10.1016/b978-84-8086-390-2.50019-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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36
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Manco-Johnson MJ, Hacker MR, Jacobson LJ, Hay WW. Pharmacokinetics of protein C and antithrombin in the fetal lamb: a model to predict human neonatal replacement dosing. Neonatology 2009; 95:279-85. [PMID: 19039246 PMCID: PMC3701438 DOI: 10.1159/000178025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2007] [Accepted: 05/19/2008] [Indexed: 11/19/2022]
Abstract
BACKGROUND The preterm infant is at risk for consumptive coagulopathy and thrombosis due to late maturation of coagulation regulatory proteins. Replacement proteins are available, but neonatal pharmacokinetic data are lacking. OBJECTIVE The objective was to determine the pharmacokinetic properties of antithrombin (AT) and protein C (PC) in order to provide data for estimating doses in human infants. METHODS A catheterized ovine model was used to determine pharmacokinetic properties of AT and PC, including plasma recovery, volume of distribution (V(d)), clearance (Cl) and half-life (t((1/2))), in the fetal lamb relative to the ewe. RESULTS AT studies showed statistically significant differences between ewes and fetuses in recovery (p < 0.0001), V(d) (p = 0.0002) and Cl (p < 0.0001). The AT t((1/2)) was significantly shortened among fetuses (5.55 h, 95% CI: 4.01-7.08) compared to ewes (18.7 h, 95% CI: 11.6-25.8). PC recovery (p < 0.0001), V(d) (p < 0.0001) and Cl (p = 0.004) differed significantly between ewes and singleton fetuses as did the t((1/2)): 3.86 h (95% CI: 3.35-4.36) and 11.9 h (95% CI: 10.9-12.9) in the singletons and ewes, respectively. All PC parameters were significantly different for twins compared to ewes. CONCLUSIONS AT and PC show decreased recovery and t((1/2)) in the fetal lamb. These data can be used to estimate dosing for human neonates in comparison with human adult dosing recommendations.
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Roach ES, Golomb MR, Adams R, Biller J, Daniels S, Deveber G, Ferriero D, Jones BV, Kirkham FJ, Scott RM, Smith ER. Management of Stroke in Infants and Children. Stroke 2008; 39:2644-91. [PMID: 18635845 DOI: 10.1161/strokeaha.108.189696] [Citation(s) in RCA: 743] [Impact Index Per Article: 46.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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38
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Abstract
With improved pediatric survival from serious underlying illnesses, greater use of invasive vascular procedures and devices, and a growing awareness that vascular events occur among the young, venous thromboembolism (VTE) increasingly is recognized as a critical pediatric concern. This review provides background on etiology and epidemiology in this disorder, followed by an in-depth discussion of approaches to the clinical characterization, diagnostic evaluation, and management of pediatric VTE. Prognostic indicators and long-term outcomes are considered, with emphasis on available evidence underlying current knowledge and key questions for further investigation.
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Affiliation(s)
- Neil A Goldenberg
- Mountain States Regional Hemophilia and Thrombosis Center, P.O. Box 6507, Mail-Stop F-416, Aurora, CO 80045-0507, USA.
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39
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Severe congenital protein C deficiency: description of a new mutation and prophylactic protein C therapy and in vivo pharmacokinetics. J Pediatr Hematol Oncol 2008; 30:166-71. [PMID: 18376272 DOI: 10.1097/mph.0b013e31815d8943] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Severe congenital protein C deficiency is a rare life-threatening disorder that presents with purpura fulminans, disseminated intravascular coagulation, and thrombotic complications during the neonatal period. Affected children require acute replacement therapy with fresh frozen plasma or protein C concentrate, for example, Ceprotin (Baxter AG, Vienna). Long-term management and outcome is dependent on effective anticoagulation with warfarin, low-molecular weight heparin, or protein C concentrate. We describe the successful use of intravenous protein C concentrate for thrombotic prophylaxis in 2 sisters with severe type I protein C deficiency. Individualized long-term prophylactic regimens were developed based on clinical response. In vivo pharmacokinetic analyses of protein C concentrate were performed in each patient. Analysis of the protein C gene coding sequences identified 2 mutations in both patients, the previously described Arg169 to Trp mutation, and a novel mutation that changes Cys17 into a stop codon.
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40
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Baselga E, Torrelo A. Inflammatory and Purpuric Eruptions. NEONATAL DERMATOLOGY 2008. [PMCID: PMC7315339 DOI: 10.1016/b978-1-4160-3432-2.50022-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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41
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Dreyfus M, Ladouzi A, Chambost H, Gruel Y, Tardy B, Ffrench P, Bridey F, Tellier Z. Treatment of inherited protein C deficiency by replacement therapy with the French purified plasma-derived protein C concentrate (PROTEXEL®). Vox Sang 2007; 93:233-40. [PMID: 17845261 DOI: 10.1111/j.1423-0410.2007.00953.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES A multicentre retrospective study was performed to assess the efficacy/safety of a French purified plasma-derived protein C (PC) concentrate in inherited PC deficiency. MATERIALS AND METHODS Nine patients were enrolled, five children aged < 5 weeks, among whom four with a severe deficiency were homozygous, and four patients < 37 years with PC levels ranging 14-25%, including one compound heterozygous. RESULTS Thirty replacement therapy courses were recorded with mean PC dosages ranging between 24-90 IU/kg/day for prophylactic courses and 51-209 IU/kg/day for treatment courses. Recoveries varied between 0.8 and 1.12% IU/kg in preventive situations and between 1.09 and 1.91% IU/kg for treatment courses; 23 treatment courses were performed in patients aged 1 day to 18 years, 19 out of 23 treatments resulted in complete recovery with no sequelae. Treatment efficacy was difficult to assess in four out of 23 cases because the thrombotic event was not confirmed in one case and due to late treatment initiation in the three other cases. Seven prophylactic treatments were used either in association of vitamin K antagonists or to prevent thrombotic events due to vitamin K antagonist introduction or withdrawal. The safety assessed during 914 infusions was excellent. No abnormal bleeding was reported, including with high doses, during surgery, with heparin therapy. CONCLUSIONS Replacement therapy with this French PC concentrate is safe and effective in patients with inherited PC deficiency.
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Affiliation(s)
- M Dreyfus
- Bicêtre Hospital, Assistance Publique-Hopitaux de Paris, Paris XI University, Le Kremlin Bicêtre, France.
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42
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Nguyen TC, Carcillo JA. Bench-to-bedside review: thrombocytopenia-associated multiple organ failure--a newly appreciated syndrome in the critically ill. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2007; 10:235. [PMID: 17096864 PMCID: PMC1794442 DOI: 10.1186/cc5064] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
New onset thrombocytopenia and multiple organ failure (TAMOF) presages poor outcome in critical illness. Patients who resolve thrombocytopenia by day 14 are more likely to survive than those who do not. Patients with TAMOF have a spectrum of microangiopathic disorders that includes thrombotic thrombocytopenic purpura (TTP), disseminated intravascular coagulation (DIC) and secondary thrombotic microanigiopathy (TMA). Activated protein C is effective in resolving fibrin-mediated thrombosis (DIC); however, daily plasma exchange is the therapy of choice for removing ADAMTS 13 inhibitors and replenishing ADAMTS 13 activity which in turn resolves platelet: von Willebrand Factor mediated thrombosis (TTP/secondary TMA).
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Affiliation(s)
- Trung C Nguyen
- Texas Children's Hospital, 6621 Fannin St MC2-3450, Houston, TX 770330, USA
| | - Joseph A Carcillo
- Division CCM, 6th Floor, Children's Hospital of Pittsburgh, 3705 5th Avenue, Pittsburgh PA 15213, USA
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Alhenc-Gelas M, Aiach M. Anomalies constitutionnelles de la coagulation prédisposant à la thrombose. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/s1155-1984(07)46642-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Dahabreh Z, Dimitriou R, Chalidis B, Giannoudis PV. Coagulopathy and the role of recombinant human activated protein C in sepsis and following polytrauma. Expert Opin Drug Saf 2005; 5:67-82. [PMID: 16370957 DOI: 10.1517/14740338.5.1.67] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Recombinant human activated protein C (rhAPC) also known as drotrecogin alfa (activated) has known antithrombotic, anti-inflammatory, and profibrinolytic properties in severe sepsis. Treatment with rhAPC (Xigris) has been shown to reduce mortality in patients with severe sepsis. The lack of any trials of rhAPC in trauma patients means that a definitive recommendation regarding its use in the polytraumatised patient, in whom severe head trauma or other contraindications for the use of rhAPC have been excluded remains controversial at present. This article describes the current evidence of its efficacy and safety in severe sepsis with relation to surgery and trauma.
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Affiliation(s)
- Ziad Dahabreh
- St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
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45
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Iqbal O, Messmore H, Fareed J, Ahmad S, Hoppensteadt D, Hazar S, Tobu M, Aziz S, Wehrmacher W. Antithrombotic agents in the treatment of severe sepsis. Expert Opin Emerg Drugs 2005; 7:111-39. [PMID: 15989540 DOI: 10.1517/14728214.7.1.111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Sepsis, a systemic inflammatory syndrome, is a response to infection and when associated with multiple organ dysfunction is termed severe sepsis. It remains a leading cause of mortality in the critically ill. The response to the invading microorganisms may be considered as a balance between a pro-inflammatory and an anti-inflammatory reaction. While an inadequate pro-inflammatory reaction and a strong anti-inflammatory response could lead to overwhelming infection and the death of the patient, a strong and uncontrolled pro-inflammatory response, manifested by the release of pro-inflammatory mediators may lead to microvascular thrombosis and multiple organ failure. Endotoxin triggers sepsis via the release of various mediators such as tumour necrosis factor-alpha and interleukin-1 (IL-1). These cytokines activate the complement and coagulation systems, release adhesion molecules, prostaglandins, leukotrienes, reactive oxygen species and nitric oxide. Other mediators involved in the sepsis syndrome include IL-1, -6 and -8; arachidonic acid metabolites; platelet activating factor; histamine; bradykinin; angiotensin; complement components and vasoactive intestinal peptide. These pro-inflammatory responses are counteracted by IL-10. Most of the trials targeting the different mediators of the pro-inflammatory response have failed due to a lack of correct definition of sepsis. Understanding the exact pathophysiology of the disease will enable more advanced treatment options. Targeting the coagulation system with various anticoagulant agents including, activated protein C, and tissue factor pathway inhibitor (TFPI) is a rational approach. Many clinical trials have been conducted to evaluate these agents in severe sepsis. While trials on antithrombin and TFPI were not so successful, the double-blind, placebo-controlled, Phase III trial of recombinant human activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) was successful, creating a significant decrease in mortality when compared to the placebo group. A better understanding of the pathophysiologic mechanism of severe sepsis will provide better treatment options, and combination antithrombotic treatment may provide a multipronged approach for the treatment of severe sepsis.
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Affiliation(s)
- Omer Iqbal
- Loyola University Medical Center, Maywood, Illinois 60153, USA
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46
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Park UC, Choung HK, Kim SJ, Yu YS. Bilateral Retinal Dysplasia and Secondary Glaucoma Associated with Homozygous Protein C Deficiency. KOREAN JOURNAL OF OPHTHALMOLOGY 2005; 19:112-5. [PMID: 15988926 DOI: 10.3341/kjo.2005.19.2.112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Protein C deficiency is an autosomal recessive disorder, which predisposes the patient to potentially blinding and widespread lethal thromboembolic complications, especially in the homozygous type. We here report the first Korean case of ophthalmic involvement and its surgical treatment in homozygous protein C deficiency. METHODS A 3.4kg, full term girl was born by normal delivery but showed bilateral leukocoria on day 2. Laboratory results disclosed a very low protein C activity level (10%) in the patient and moderately decreased levels in the other family members. Ophthalmic examination showed bilateral corneal opacity and shallow anterior chamber. B-scan ultrasonography which showed intravitreal mass lesions without microphthalmos and a funnel-shaped retinal detachment suggested bilateral retinal dysplasia. RESULTS As the eyes were under progression of secondary glaucoma, bilateral lensectomies were performed at 2 months old and corneal opacity was regressed to some degree. However, at 14 months old, the left eye showed moderate corneal opacity with a band keratopathy. CONCLUSIONS Although visual outcome was very poor after surgery, we could impede or slow down the progression of secondary glaucoma and save the eyeballs in the infant with homozygous protein C deficiency.
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Affiliation(s)
- Un Chul Park
- Department of Ophthalmology, Seoul National University Children's Hospital, Seoul, Korea
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47
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Abstract
Human protein C is a serine protease that circulates in the blood as an inactive zymogen. It is converted to its active form by interaction with thrombomodulin on the endothelial wall. Activated protein C has a significant role in maintaining haemostasis, and is a major mechanism of controlling microvascular thrombosis. Recent reports describe the use of drotrecogin alfa (recombinant activated protein C) in severe sepsis, a condition relevant to emergency medicine. This review describes the physiology of the protein C pathway and its importance in sepsis. It will also focus on the use of drotrecogin alfa in sepsis, and its use in the ED.
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Affiliation(s)
- Adam M McLeay
- The Tweed Hospital, Tweed Heads, New South Wales, Australia.
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48
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Tazbir J. Sepsis and the Role of Activated Protein C. Crit Care Nurse 2004. [DOI: 10.4037/ccn2004.24.6.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Janice Tazbir
- Janice Tazbir has been a critical care nurse for 19 years, mostly at the University of Chicago Hospitals, Chicago, Ill. She has been a professor at Purdue University Calumet, Hammond, Ind, for 6 years. Her areas of teaching include advanced medical/surgical and critical care nursing
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49
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Journeycake JM, Manco-Johnson MJ. Thrombosis during infancy and childhood: what we know and what we do not know. Hematol Oncol Clin North Am 2004; 18:1315-38, viii-ix. [PMID: 15511618 DOI: 10.1016/j.hoc.2004.07.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Despite underlying illnesses, children have a greater chance to survive and are expected to live 6 to 8 decades following an episode of venous or arterial thrombosis. The disproportionate benefits of preventing thrombosis and its sequelae in pediatric patients are evident. Therefore, it is necessary to develop appropriate strategies for diagnosis and management of thromboembolic events in children and to understand their acute and long-term effects. There still are many unanswered questions and clinical trials are being designed to help study these important issues.
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Affiliation(s)
- Janna M Journeycake
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas TX, 75390-9063, USA.
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50
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Abstract
Children born with severe homozygous protein C deficiency do not survive beyond the neonatal period unless they receive protein C replacement. Protein C concentrate (Baxter Biosciences, Vienna) is usually given intravenously via a central venous catheter The authors describe 2 children in whom protein C concentrate was successfully administered by subcutaneous infusion after they had had recurrent central line infections. Alternate daily doses of 250-350 IU/kg resulted in trough protein C levels of > 25 IU/dL. In the follow-up period of 1-2 years neither child has had a thrombotic episode or purpuric skin lesions, and infusions are managed in the home by their parents.
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Affiliation(s)
- M Mathias
- Great Ormond Street Hospital for Children NHS Trust, London, UK.
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