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Montague SJ, Price J, Pennycott K, Pavey NJ, Martin EM, Thirlwell I, Kemble S, Monteiro C, Redmond-Motteram L, Lawson N, Reynolds K, Fratter C, Bignell P, Groenheide A, Huskens D, de Laat B, Pike JA, Poulter NS, Thomas SG, Lowe GC, Lancashire J, Harrison P, Morgan NV. Comprehensive functional characterization of a novel ANO6 variant in a new patient with Scott syndrome. J Thromb Haemost 2024:S1538-7836(24)00127-2. [PMID: 38492852 DOI: 10.1016/j.jtha.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 02/09/2024] [Accepted: 02/29/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Scott syndrome is a mild platelet-type bleeding disorder, first described in 1979, with only 3 unrelated families identified through defective phosphatidylserine (PS) exposure and confirmed by sequencing. The syndrome is distinguished by impaired surface exposure of procoagulant PS on platelets after stimulation. To date, platelet function and thrombin generation in this condition have not been extensively characterized. OBJECTIVES Genetic and functional studies were undertaken in a consanguineous family with a history of excessive bleeding of unknown cause. METHODS A targeted gene panel of known bleeding and platelet genes was used to identify possible genetic variants. Platelet phenotyping, flow adhesion, flow cytometry, whole blood and platelet-rich plasma thrombin generation, and specialized extracellular vesicle measurements were performed. RESULTS We detected a novel homozygous frameshift variant, c.1943del (p.Arg648Hisfs∗23), in ANO6 encoding Anoctamin 6, in a patient with a bleeding history but interestingly with normal ANO6 expression. Phenotyping of the patient's platelets confirmed the absence of PS expression and procoagulant activity but also revealed other defects including reduced platelet δ granules, reduced ristocetin-mediated aggregation and secretion, and reduced P-selectin expression after stimulation. PS was absent on spread platelets, and thrombi formed over collagen at 1500/s. Reduced thrombin generation was observed in platelet-rich plasma and confirmed in whole blood using a new thrombin generation assay. CONCLUSION We present a comprehensive report of a patient with Scott syndrome with a novel frameshift variant in AN06, which is associated with no platelet PS exposure and markedly reduced thrombin generation in whole blood, explaining the significant bleeding phenotype observed.
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Affiliation(s)
- Samantha J Montague
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Joshua Price
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Katherine Pennycott
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Natasha J Pavey
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Eleyna M Martin
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Isaac Thirlwell
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Samuel Kemble
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Catarina Monteiro
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Lily Redmond-Motteram
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Natalie Lawson
- Haemophilia Unit, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, United Kingdom
| | - Katherine Reynolds
- Haemophilia Unit, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, United Kingdom
| | - Carl Fratter
- Oxford Genetics Laboratories, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Patricia Bignell
- Oxford Genetics Laboratories, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | | | - Dana Huskens
- Synapse Research Institute, Maastricht, the Netherlands
| | - Bas de Laat
- Synapse Research Institute, Maastricht, the Netherlands
| | - Jeremy A Pike
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Centre of Membrane Proteins and Receptors, Universities of Birmingham and Nottingham, the Midlands, United Kingdom
| | - Natalie S Poulter
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Centre of Membrane Proteins and Receptors, Universities of Birmingham and Nottingham, the Midlands, United Kingdom
| | - Steven G Thomas
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Centre of Membrane Proteins and Receptors, Universities of Birmingham and Nottingham, the Midlands, United Kingdom
| | - Gillian C Lowe
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Comprehensive Care Haemophilia Centre, University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Jonathan Lancashire
- Haemophilia Unit, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, United Kingdom
| | - Paul Harrison
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Neil V Morgan
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.
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2
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O'Mahony B, Dunn AL, Leavitt AD, Peyvandi F, Ozelo MC, Mahlangu J, Peerlinck K, Wang JD, Lowe GC, Tan CW, Giermasz A, Tran H, Khoo TL, Cockrell E, Pepperell D, Chambost H, López Fernández MF, Kazmi R, Majerus E, Skinner MW, Klamroth R, Quinn J, Yu H, Wong WY, Robinson TM, Pipe SW. Health-related quality of life following valoctocogene roxaparvovec gene therapy for severe hemophilia A in the phase 3 trial GENEr8-1. J Thromb Haemost 2023; 21:3450-3462. [PMID: 37678546 DOI: 10.1016/j.jtha.2023.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 08/11/2023] [Accepted: 08/27/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Severe hemophilia A (HA) negatively impacts health-related quality of life (HRQOL). OBJECTIVES We aimed to analyze HRQOL in adult men with severe HA without inhibitors after valoctocogene roxaparvovec gene transfer in the phase 3 trial GENEr8-1. METHODS Participant-reported outcomes were the hemophilia-specific quality of life questionnaire for adults (Haemo-QOL-A), the EQ-5D-5L instrument, the Hemophilia Activities List (HAL), and the Work Productivity and Activity Impairment Questionnaire: Hemophilia Specific (WPAI+CIQ:HS). Participants completed the questionnaires at baseline and through 104 weeks postinfusion with 6 × 1013 vg/kg of valoctocogene roxaparvovec. Scores were analyzed per participant characteristics and outcomes. RESULTS For 132 HIV-negative participants, mean change from baseline in Haemo-QOL-A Total Score met the anchor-based clinically important difference (CID: 5.5) by week 12; the mean (SD) increase was 7.0 (12.6) at week 104. At week 104, improvement in Consequences of Bleeding, Treatment Concern, Worry, and Role Functioning domain scores exceeded the CID (6). EQ-5D-5L Utility Index scores improved above the CID at week 52, but not at week 104. EQ-5D-5L visual analog scale and HAL scores increased from baseline to week 104. Participants reported less activity and work impairment at week 104 than baseline. Participants with problem joints had lower mean baseline Haemo-QOL-A Total and domain scores than those without them, but improved over 104 weeks, except for 11 participants with ≥3 problem joints. Participants with 0 bleeds during the baseline prophylaxis period reported Haemo-QOL-A score improvements above the CID, including in the Consequences of Bleeding domain. CONCLUSION Valoctocogene roxaparvovec provided clinically meaningful HRQOL improvement for men with severe HA.
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Affiliation(s)
- Brian O'Mahony
- Irish Haemophilia Society, Dublin, Ireland; Trinity College, Dublin, Ireland.
| | - Amy L Dunn
- The Division of Hematology, Oncology, and BMT at Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Andrew D Leavitt
- University of California San Francisco, San Francisco, California, USA
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy; Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Margareth C Ozelo
- Hemocentro UNICAMP, Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Johnny Mahlangu
- Hemophilia Comprehensive Care Center, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand and NHLS, Johannesburg, South Africa
| | - Kathelijne Peerlinck
- Department of Vascular Medicine and Haemostasis and Haemophilia Centre, University Hospitals Leuven, Leuven, Belgium
| | - Jiaan-Der Wang
- Center for Rare Disease and Hemophilia, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Gillian C Lowe
- West Midlands Comprehensive Care Haemophilia Centre, Queen Elizabeth Hospital, Birmingham, UK
| | - Chee Wee Tan
- Department of Haematology, Royal Adelaide Hospital, Adelaide, South Australia, Australia; University of Adelaide, Adelaide, South Australia, Australia
| | - Adam Giermasz
- Hemophilia Treatment Center, University of California Davis, Sacramento, California, USA
| | - Huyen Tran
- Haemostasis & Thrombosis Unit, Haemophilia Treatment Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Teh-Liane Khoo
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Erin Cockrell
- Pediatric Hematology Oncology, Saint Joseph's Children's Hospital, Tampa, Florida, USA
| | - Dominic Pepperell
- Department of Haematology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Hervé Chambost
- AP-HM, Department of Pediatric Hematology Oncology, Children Hospital La Timone & Aix Marseille University, INSERM, INRA, C2VN, Marseille, France
| | | | - Rashid Kazmi
- Department of Haematology, Southampton University Hospital, Southampton, UK
| | - Elaine Majerus
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Mark W Skinner
- Institute for Policy Advancement Ltd, Washington, DC, USA; McMaster University, Hamilton, Ontario, Canada
| | - Robert Klamroth
- Comprehensive Care Haemophilia Treatment Center, Vivantes Klinikum im Friedrichshain, Berlin, Germany; Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Germany
| | | | - Hua Yu
- BioMarin Pharmaceutical Inc, Novato, California, USA
| | - Wing Yen Wong
- BioMarin Pharmaceutical Inc, Novato, California, USA
| | | | - Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
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3
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Kemble S, Dalby A, Lowe GC, Nicolson PLR, Watson SP, Senis Y, Thomas SG, Harrison P. Analysis of preplatelets and their barbell platelet derivatives by imaging flow cytometry. Blood Adv 2022; 6:2932-2946. [PMID: 35042240 PMCID: PMC9092408 DOI: 10.1182/bloodadvances.2021006073] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/21/2021] [Indexed: 11/20/2022] Open
Abstract
Circulating large "preplatelets" undergo fission via barbell platelet intermediates into two smaller, mature platelets. In this study, we determine whether preplatelets and/or barbells are equivalent to reticulated/immature platelets by using ImageStream flow cytometry and super-resolution microscopy. Immature platelets, preplatelets, and barbells were quantified in healthy and thrombocytopenic mice, healthy human volunteers, and patients with immune thrombocytopenia or undergoing chemotherapy. Preplatelets and barbells were 1.9% ± 0.18%/1.7% ± 0.48% (n = 6) and 3.3% ± 1.6%/0.5% ± 0.27% (n = 12) of total platelet counts in murine and human whole blood, respectively. Both preplatelets and barbells exhibited high expression of major histocompatibility complex class I with high thiazole orange and Mitotracker fluorescence. Tracking dye experiments confirmed that preplatelets transform into barbells and undergo fission ex vivo to increase platelet counts, with dependence on the cytoskeleton and normal mitochondrial respiration. Samples from antibody-induced thrombocytopenia in mice and patients with immune thrombocytopenia had increased levels of both preplatelets and barbells correlating with immature platelet levels. Furthermore, barbells were absent after chemotherapy in patients. In mice, in vivo biotinylation confirmed that barbells, but not all large platelets, were immature. This study demonstrates that a subpopulation of large platelets are immature preplatelets that can transform into barbells and undergo fission during maturation.
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Affiliation(s)
| | - Amanda Dalby
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
- Centre of Membrane Proteins and Receptors (COMPARE), University of Birmingham and University of Nottingham, Midlands, United Kingdom
| | - Gillian C. Lowe
- West Midlands Haemophilia Comprehensive Care Centre, University Hospitals Birmingham Foundation Trust, Birmingham, United Kingdom; and
| | - Phillip L. R. Nicolson
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
- West Midlands Haemophilia Comprehensive Care Centre, University Hospitals Birmingham Foundation Trust, Birmingham, United Kingdom; and
| | - Steve P. Watson
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
- Centre of Membrane Proteins and Receptors (COMPARE), University of Birmingham and University of Nottingham, Midlands, United Kingdom
| | - Yotis Senis
- Institut National de la Santé et de la Recherche Médicale, Etablissement Français du Sang Grand Est, Unité Mixte de Recherche-S 1255, Fédération de Médecine Translationnelle de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Steven G. Thomas
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
- Centre of Membrane Proteins and Receptors (COMPARE), University of Birmingham and University of Nottingham, Midlands, United Kingdom
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4
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Montague SJ, Smith CW, Lodwick CS, Stoneley C, Roberts M, Lowe GC, Lester WA, Watson SP, Nicolson PLR. Anti-platelet factor 4 immunoglobulin G levels in vaccine-induced immune thrombocytopenia and thrombosis: Persistent positivity through 7 months. Res Pract Thromb Haemost 2022; 6:e12707. [PMID: 35515079 PMCID: PMC9066380 DOI: 10.1002/rth2.12707] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/10/2022] [Accepted: 03/18/2022] [Indexed: 12/31/2022] Open
Abstract
Background Anti-platelet factor 4 (PF4) antibodies that activate platelets via FcγRIIA drive the pathophysiology of vaccine-induced immune thrombocytopenia and thrombosis (VITT). Evolution of these antibodies and their ability to activate platelets after initial treatment remains unknown. Objectives To assess how clinical and platelet parameters, anti-PF4 antibody levels, and patient serum reactivity changes during follow-up after VITT presentation. Methods We describe cases of seven discharged VITT patients that were followed from diagnosis up to 280 days (range 199-280) after vaccination. We measured anti-PF4 antibodies and PF4 levels in patient serum during follow-up and tested the ability of patient serum to activate healthy donor platelets and patient platelets over time. Results Anti-PF4 immunoglobulin G antibody levels are very high at diagnosis (0.9-2.6 OD) and remain relatively high (>1.0 OD) in all patients, except one treated with rituximab, at 7 months post vaccination. All patients were on direct oral anticoagulants throughout follow-up and no patients had recurrent thrombosis. Patients' platelets during follow-up have normal FcγRIIA levels and responsiveness to platelet agonists. Patient diagnostic serum strongly activated control platelets, either alone or with PF4. Most follow-up serum alone was weaker at stimulating donor and patient platelets. However, follow-up serum beyond 150 days still strongly activated platelets with PF4 addition in three patients. Patient serum PF4 levels were lower than controls at diagnosis but returned within normal range by day 50. Conclusions Explanations for reduced platelet activation during follow-up, despite similar total anti-PF4 antibody levels, remains unclear. Clinical implications of persistent anti-PF4 antibodies in VITT require further study.
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Affiliation(s)
- Samantha J Montague
- Institute of Cardiovascular Sciences College of Medical and Dental Sciences University of Birmingham Birmingham UK
| | - Christopher W Smith
- Institute of Cardiovascular Sciences College of Medical and Dental Sciences University of Birmingham Birmingham UK
| | - Clare S Lodwick
- Department of Haematology Worcester Acute Hospitals NHS Trust Worcester UK
| | - Charlotte Stoneley
- Department of Blood Sciences University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - Matthew Roberts
- Department of Blood Sciences University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - Gillian C Lowe
- Comprehensive Care Haemophilia Centre University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - William A Lester
- Comprehensive Care Haemophilia Centre University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - Steve P Watson
- Institute of Cardiovascular Sciences College of Medical and Dental Sciences University of Birmingham Birmingham UK
| | - Phillip L R Nicolson
- Institute of Cardiovascular Sciences College of Medical and Dental Sciences University of Birmingham Birmingham UK.,Comprehensive Care Haemophilia Centre University Hospitals Birmingham NHS Foundation Trust Birmingham UK
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5
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Desborough MJR, Obaji S, Lowe GC, Doree C, Thomas W. Management of surgery, menorrhagia and child-birth for patients with unclassified bleeding disorders: a systematic review of cohort studies. Blood Coagul Fibrinolysis 2021; 32:366-372. [PMID: 33973892 DOI: 10.1097/mbc.0000000000001045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Unclassified bleeding disorders account for 2.6% of all new bleeding disorder registrations in the UK. The management of the bleeding phenotype associated with these disorders is poorly described. Systematic review and meta-analysis to determine the bleeding rates associated with tranexamic acid, desmopressin, platelet transfusion, plasma transfusion and recombinant activated factor VII, for patients with unclassified bleeding disorders undergoing surgery, childbirth or with menorrhagia. We searched for randomized controlled trials in MEDLINE, Embase, The Cochrane Central Register of Controlled Trials, PubMed, ISI Web of Science and the Transfusion Evidence Library from inception to 24 February 2020. Wherever appropriate, data were pooled using the metaprop function of STATA. Two studies with 157 participants with unclassified bleeding disorders were identified. The pooled risk of minor bleeding for patients undergoing surgery treated with peri-operative tranexamic acid was 11% (95% confidence interval 3--20%; n = 52; I2 = 0%); the risk for desmopressin and tranexamic acid in combination was 3% (95% confidence interval 0--7%; n = 71; I2 = 0%). There were no instances of major bleeding. In one procedure, 1 of 71 (1.4%), treated with a combination of desmopressin and tranexamic acid, the patient had a line-related deep vein thrombosis. There were too few patients treated to prevent postpartum haemorrhage or for menorrhagia to draw conclusions. The GRADE quality of evidence was very low suggesting considerable uncertainty over the results. However, both tranexamic acid, and the combination of tranexamic and desmopressin have high rates of haemostatic efficacy and have few adverse events. PROTOCOL REGISTRATION PROSPERO CRD42020169727.
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Affiliation(s)
- Michael J R Desborough
- Haemostasis and Thrombosis Centre, Guy's and St Thomas' NHS Foundation Trust, London
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust
- Radcliffe Department of Medicine, University of Oxford, Oxford
| | - Samya Obaji
- Cardiff Haemophilia Centre, University Hospital of Wales
| | - Gillian C Lowe
- Comprehensive Care Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood and Transplant, Oxford
| | - Will Thomas
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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6
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Nicolson PL, Desborough MJ, Hart D, Biss TT, Lowe GC, Toh CH. A HaemSTAR is born; a trainee-led, UK-wide research network in haematology. Clin Med (Lond) 2019; 19:532-533. [PMID: 31732603 DOI: 10.7861/clinmed.2019-0313] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Phillip Lr Nicolson
- HaemSTAR, NIHR Haematology Clinical Research Network, University of Birmingham, Birmingham, UK and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Michael Jr Desborough
- HaemSTAR, NIHR Haematology Clinical Research Network and NIHR Oxford Bioresource, Oxford, UK
| | - Daniel Hart
- NIHR Haematology Clinical Research Network and Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Tina T Biss
- NIHR Haematology Clinical Research Network and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Gillian C Lowe
- NIHR Haematology Clinical Research Network and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Cheng-Hock Toh
- NIHR Haematology Clinical Research Network and Royal Liverpool University Hospital, Liverpool, UK
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7
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Abstract
Patients with mild bleeding disorders are under-recognized and frequently present to general physicians. The underlying reasons for bleeding are multifactorial. There is little evidence to guide diagnostic and management decision making in patients with mild bleeding disorders. This article outlines different types of mild bleeding disorders, with a particular focus on bleeding associated with low levels of von Willebrand factor and mild platelet defects. It gives practical, evidence-based advice on the investigation and management of patients with a suspected or known mild bleeding disorder, considering the scenarios of an acute bleed, stable outpatient, peri-surgical management and thrombosis. Patients with a mild bleeding disorder have variable bleeding because of the interplay of genetic and environmental factors. The clinical history remains of utmost importance in their general management. Liaison with a specialist centre, multidisciplinary assessment and a careful judgement of the balance of risk in each individual circumstance is required to safely manage these patients.
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Affiliation(s)
- H K Hussein
- Specialty Registrar in Clinical Haematology, Department of Clinical Haematology, Queen Elizabeth Hospital, Birmingham
| | - Plr Nicolson
- Specialty Registrar in Clinical Haematology and BHF Clinical Research Training Fellow, Department of Clinical Haematology, Queen Elizabeth Hospital, Birmingham, and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT
| | - K Fordwor
- Core Medical Trainee, Department of Medicine, Chelsea and Westminster Hospital, London
| | - G C Lowe
- Consultant Haematologist, Department of Clinical Haematology, Queen Elizabeth Hospital, Birmingham
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8
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Khan AO, Maclachlan A, Lowe GC, Nicolson PLR, Ghaithi RA, Thomas SG, Watson SP, Pike JA, Morgan NV. High-throughput platelet spreading analysis: a tool for the diagnosis of platelet-based bleeding disorders. Haematologica 2019; 105:e124-e128. [PMID: 31221775 DOI: 10.3324/haematol.2019.225912] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Abdullah O Khan
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham
| | - Annabel Maclachlan
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham
| | - Gillian C Lowe
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham
| | - Phillip L R Nicolson
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham
| | - Rashid Al Ghaithi
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham
| | - Steven G Thomas
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham.,Centre of Membrane and Protein and Receptors (COMPARE), University of Birmingham and University of Nottingham, Midlands, UK
| | - Steve P Watson
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham.,Centre of Membrane and Protein and Receptors (COMPARE), University of Birmingham and University of Nottingham, Midlands, UK
| | - Jeremy A Pike
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham.,Centre of Membrane and Protein and Receptors (COMPARE), University of Birmingham and University of Nottingham, Midlands, UK
| | - Neil V Morgan
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham
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9
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Lowe GC, Fickowska R, Al Ghaithi R, Maclachlan A, Harrison P, Lester W, Watson SP, Myers B, Clark J, Morgan NV. Investigation of the contribution of an underlying platelet defect in women with unexplained heavy menstrual bleeding. Platelets 2018; 30:56-65. [PMID: 30520671 PMCID: PMC6406209 DOI: 10.1080/09537104.2018.1543865] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Heavy menstrual bleeding (HMB) is often undiagnosed in women and can cause discomfort and distress. A haemostatic cause for excessive bleeding is often not routinely investigated and can lead to hysterectomy at an early age. A prospective cohort study was carried out to determine whether certain patients with unexplained HMB have an underlying platelet function defect (PFD). The Genotyping and Phenotyping of Platelets (GAPP) study recruited 175 women with HMB and 44 unrelated volunteers from 25 Haemophilia Centres across the UK, and a tertiary gynaecology service. Bleeding history was assessed using the International Society on Thrombosis and Haemostasis Bleeding Assessment Tool (ISTH-BAT). Platelet count, platelet size, haemoglobin and mean corpuscular volume were measured in whole blood using the Sysmex XN-1000 Haematology Analyzer. Platelet function testing using lumiaggregometry and flow cytometry was performed in patients included in this study. A PFD was identified in 47% (82/175) of patients with HMB. Cutaneous bleeding was the most frequent additional bleeding symptom (89% in PFD and 83% with no PFD). Whole blood platelet count was significantly lower (P < 0.0001) between the PFD group and no PFD group. The prevalence of anaemia did not differ between patients and healthy volunteers. Clinical evaluation alone is insufficient to determine presence of an underlying PFD in patients with HMB. Platelet function tests may be considered and clinical guidelines may include them in their algorithms. An appropriate diagnosis and subsequent tailored management of HMB may prevent unnecessary surgery and help manage future haemostatic challenges.
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Affiliation(s)
- Gillian C Lowe
- a Comprehensive Care Haemophilia Centre , University Hospital Birmingham NHS Foundation Trust , Birmingham , UK
| | - Roksana Fickowska
- b Institute of Cardiovascular Sciences, College of Medical and Dental Sciences , University of Birmingham , Birmingham , UK
| | - Rashid Al Ghaithi
- c Institute of Inflammation and Ageing, College of Medical and Dental Sciences , University of Birmingham , Birmingham , UK
| | - Annabel Maclachlan
- b Institute of Cardiovascular Sciences, College of Medical and Dental Sciences , University of Birmingham , Birmingham , UK
| | - Paul Harrison
- c Institute of Inflammation and Ageing, College of Medical and Dental Sciences , University of Birmingham , Birmingham , UK
| | - Will Lester
- a Comprehensive Care Haemophilia Centre , University Hospital Birmingham NHS Foundation Trust , Birmingham , UK
| | - Steve P Watson
- b Institute of Cardiovascular Sciences, College of Medical and Dental Sciences , University of Birmingham , Birmingham , UK
| | - Bethan Myers
- d Department of Haematology , Lincoln County Hospital , Lincoln , UK.,e Haemostasis & Thrombosis Unit, Leicester Royal Infirmary , University Hospitals Of Leicester NHS Trust , Leicester , UK
| | - Justin Clark
- f Department of Gynaecology , Birmingham Women's and Children's NHS Foundation Trust , Birmingham , UK
| | - Neil V Morgan
- b Institute of Cardiovascular Sciences, College of Medical and Dental Sciences , University of Birmingham , Birmingham , UK
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10
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Johnson B, Doak R, Allsup D, Astwood E, Evans G, Grimley C, James B, Myers B, Stokley S, Thachil J, Wilde J, Williams M, Makris M, Lowe GC, Wallis Y, Daly ME, Morgan NV. A comprehensive targeted next-generation sequencing panel for genetic diagnosis of patients with suspected inherited thrombocytopenia. Res Pract Thromb Haemost 2018; 2:640-652. [PMID: 30349881 PMCID: PMC6178765 DOI: 10.1002/rth2.12151] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 08/20/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Inherited thrombocytopenias (ITs) are a heterogeneous group of disorders characterized by low platelet counts and often disproportionate bleeding with over 30 genes currently implicated. Previously the UK-GAPP study using whole exome sequencing (WES) identified a pathogenic variant in 19 of 47 (40%) patients of which 71% had variants in genes known to cause IT. AIMS To employ a targeted next-generation sequencing platform to improve efficiency of diagnostic testing and reduce overall costs. METHODS We have developed an IT-specific gene panel as a pre-screen for patients prior to WES using the Agilent SureSelectQXT transposon-based enrichment system. RESULTS Thirty-one patients were analyzed using the panel-based sequencing, of which; 10% (3/31) were identified with a classified pathogenic variant, 16% (5/31) were identified with a likely pathogenic variant, 51% (16/31) were identified with variants of unknown significance, and 23% (7/31) were identified with either no variant or a benign variant. DISCUSSION AND CONCLUSION Although requiring further clarification of the impact of the genetic variations, the application of an IT-specific next generation sequencing panel is an viable method of pre-screening patients for variants in known IT-causing genes prior to WES. With an added benefit of distinguishing IT from idiopathic thrombocytopenic purpura (ITP) and the potential to identify variants in genes known to have a predisposition to hematological malignancies, it could become a critical step in improving patient clinical management.
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Affiliation(s)
- Ben Johnson
- Institute of Cardiovascular SciencesCollege of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
| | - Rachel Doak
- West Midlands Regional Genetics LaboratoryBirmingham Women's HospitalBirminghamUK
| | - David Allsup
- Hull York Medical SchoolUniversity of HullHullUK
| | - Emma Astwood
- Nottingham Haemophilia CentreNottingham University HospitalNottinghamUK
| | - Gillian Evans
- Kent Haemophilia CentreKent & Canterbury HospitalCanterburyUK
| | - Charlotte Grimley
- Nottingham Haemophilia CentreNottingham University HospitalNottinghamUK
| | - Beki James
- Regional Centre for Paediatric HaematologyLeeds Children's HospitalLeedsUK
| | - Bethan Myers
- Department of HaematologyLincoln County HospitalLincolnUK
| | - Simone Stokley
- Nottingham Haemophilia CentreNottingham University HospitalNottinghamUK
| | - Jecko Thachil
- Department of HaematologyManchester Royal InfirmaryManchesterUK
| | - Jonathan Wilde
- Comprehensive Care Haemophilia CentreUniversity Hospitals NHS Foundation TrustBirminghamUK
| | - Mike Williams
- Department of HaematologyBirmingham Children's HospitalBirminghamUK
| | - Mike Makris
- Department of Infection, Immunity and Cardiovascular ScienceUniversity of Sheffield Medical SchoolUniversity of SheffieldSheffieldUK
| | - Gillian C. Lowe
- Comprehensive Care Haemophilia CentreUniversity Hospitals NHS Foundation TrustBirminghamUK
| | - Yvonne Wallis
- West Midlands Regional Genetics LaboratoryBirmingham Women's HospitalBirminghamUK
| | - Martina E. Daly
- Department of Infection, Immunity and Cardiovascular ScienceUniversity of Sheffield Medical SchoolUniversity of SheffieldSheffieldUK
| | - Neil V. Morgan
- Institute of Cardiovascular SciencesCollege of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
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Nisar SP, Lordkipanidzé M, Jones ML, Dawood BB, Murden S, Cunningham MR, Mumford AD, Wilde JT, Watson SP, Lowe GC, Mundell SJ. A novel thromboxane A2 receptor N42S variant results in reduced surface expression and platelet dysfunction. Thromb Haemost 2017; 111:923-32. [DOI: 10.1160/th13-08-0672] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 12/19/2013] [Indexed: 11/05/2022]
Abstract
SummaryA small number of thromboxane receptor variants have been described in patients with a bleeding history that result in platelet dysfunction. We have identified a patient with a history of significant bleeding, who expresses a novel heterozygous thromboxane receptor variant that predicts an asparagine to serine substitution (N42S). This asparagine is conserved across all class A GPCRs, suggesting a vital role for receptor structure and function. We investigated the functional consequences of the TP receptor heterozygous N42S substitution by performing platelet function studies on platelet-rich plasma taken from the patient and healthy controls. We investigated the N42S mutation by expressing the wild-type (WT) and mutant receptor in human embryonic kidney (HEK) cells. Aggregation studies showed an ablation of arachidonic acid responses in the patient, whilst there was right-ward shift of the U46619 concentration response curve (CRC). Thromboxane generation was unaffected. Calcium mobilisation studies in cells lines showed a rightward shift of the U46619 CRC in N42S–expressing cells compared to WT. Radioligand binding studies revealed a reduction in BMax in platelets taken from the patient and in N42S–expressing cells, whilst cell studies confirmed poor surface expression. We have identified a novel thromboxane receptor variant, N42S, which results in platelet dysfunction due to reduced surface expression. It is associated with a significant bleeding history in the patient in whom it was identified. This is the first description of a naturally occurring variant that results in the substitution of this highly conserved residue and confirms the importance of this residue for correct GPCR function.
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Watson SP, Daly ME, Harrison P, Lowe GC, Paterson A, Rivera J, Warner TD, Morgan NV. ISTH Advanced Training Course on platelet bleeding disorders: How should they be investigated? St. Anne's College, Oxford, 6-9th September 2016. Platelets 2016; 27:719-721. [PMID: 27841701 DOI: 10.1080/09537104.2016.1256726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Steve P Watson
- a Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham , Birmingham , UK
| | - Martina E Daly
- b Department of Infection , Immunity and Cardiovascular Disease, University of Sheffield , Sheffield , UK
| | - Paul Harrison
- c Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham , Birmingham , UK
| | - Gillian C Lowe
- a Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham , Birmingham , UK.,d Haemophilia Comprehensive Care Centre, University Hospital Birmingham , Edgbaston , Birmingham , UK
| | - Andrew Paterson
- e Program in Genetics & Genomic Biology , The Hospital for Sick Children Research Institute , Toronto , Ontario , Canada
| | - Jose Rivera
- f Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia , IMIB-Arrixaca, CIBERER, Murcia 30003 , Spain
| | - Tim D Warner
- g The William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London , London , UK
| | - Neil V Morgan
- a Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham , Birmingham , UK
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13
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Johnson B, Lowe GC, Futterer J, Lordkipanidzé M, MacDonald D, Simpson MA, Sanchez-Guiú I, Drake S, Bem D, Leo V, Fletcher SJ, Dawood B, Rivera J, Allsup D, Biss T, Bolton-Maggs PH, Collins P, Curry N, Grimley C, James B, Makris M, Motwani J, Pavord S, Talks K, Thachil J, Wilde J, Williams M, Harrison P, Gissen P, Mundell S, Mumford A, Daly ME, Watson SP, Morgan NV. Whole exome sequencing identifies genetic variants in inherited thrombocytopenia with secondary qualitative function defects. Haematologica 2016; 101:1170-1179. [PMID: 27479822 DOI: 10.3324/haematol.2016.146316] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 06/10/2016] [Indexed: 12/11/2022] Open
Abstract
Inherited thrombocytopenias are a heterogeneous group of disorders characterized by abnormally low platelet counts which can be associated with abnormal bleeding. Next-generation sequencing has previously been employed in these disorders for the confirmation of suspected genetic abnormalities, and more recently in the discovery of novel disease-causing genes. However its full potential has not yet been exploited. Over the past 6 years we have sequenced the exomes from 55 patients, including 37 index cases and 18 additional family members, all of whom were recruited to the UK Genotyping and Phenotyping of Platelets study. All patients had inherited or sustained thrombocytopenia of unknown etiology with platelet counts varying from 11×109/L to 186×109/L. Of the 51 patients phenotypically tested, 37 (73%), had an additional secondary qualitative platelet defect. Using whole exome sequencing analysis we have identified "pathogenic" or "likely pathogenic" variants in 46% (17/37) of our index patients with thrombocytopenia. In addition, we report variants of uncertain significance in 12 index cases, including novel candidate genetic variants in previously unreported genes in four index cases. These results demonstrate that whole exome sequencing is an efficient method for elucidating potential pathogenic genetic variants in inherited thrombocytopenia. Whole exome sequencing also has the added benefit of discovering potentially pathogenic genetic variants for further study in novel genes not previously implicated in inherited thrombocytopenia.
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Affiliation(s)
- Ben Johnson
- Institute for Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Gillian C Lowe
- Institute for Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Jane Futterer
- Institute for Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Marie Lordkipanidzé
- Institute for Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, UK
| | - David MacDonald
- Institute for Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Michael A Simpson
- Division of Genetics and Molecular Medicine, King's College, London, UK
| | - Isabel Sanchez-Guiú
- Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, Murcia, Spain
| | - Sian Drake
- Institute for Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Danai Bem
- Institute for Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Vincenzo Leo
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield Medical School, University of Sheffield, UK
| | - Sarah J Fletcher
- Institute for Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Ban Dawood
- Institute for Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, UK
| | - José Rivera
- Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, Murcia, Spain
| | - David Allsup
- Hull Haemophilia Treatment Centre, Hull and East Yorkshire Hospitals NHS Trust, Castle Hill Hospital, Hull, UK
| | - Tina Biss
- Department of Haematology, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | | | - Peter Collins
- Arthur Bloom Haemophilia Centre, School of Medicine, Cardiff University, UK
| | - Nicola Curry
- Oxford Haemophilia & Thrombosis Centre, Churchill Hospital, Oxford, UK
| | | | - Beki James
- Regional Centre for Paediatric Haematology, Leeds Children's Hospital, UK
| | - Mike Makris
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield Medical School, University of Sheffield, UK
| | | | - Sue Pavord
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, UK
| | - Katherine Talks
- Department of Haematology, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Jonathan Wilde
- Adult Haemophilia Centre, Queen Elizabeth Hospital, Birmingham, UK
| | - Mike Williams
- Department of Haematology, Birmingham Children's Hospital, UK
| | - Paul Harrison
- School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Paul Gissen
- Medical Research Council, Laboratory for Molecular Cell Biology, University College London, UK
| | - Stuart Mundell
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, UK
| | - Andrew Mumford
- School of Cellular and Molecular Medicine, University of Bristol, UK
| | - Martina E Daly
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield Medical School, University of Sheffield, UK
| | - Steve P Watson
- Institute for Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Neil V Morgan
- Institute for Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, UK
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Fletcher SJ, Johnson B, Lowe GC, Bem D, Drake S, Lordkipanidzé M, Guiú IS, Dawood B, Rivera J, Simpson MA, Daly ME, Motwani J, Collins PW, Watson SP, Morgan NV. SLFN14 mutations underlie thrombocytopenia with excessive bleeding and platelet secretion defects. J Clin Invest 2015; 125:3600-5. [PMID: 26280575 DOI: 10.1172/jci80347] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 07/08/2015] [Indexed: 01/08/2023] Open
Abstract
Inherited thrombocytopenias are a group of disorders that are characterized by a low platelet count and are sometimes associated with excessive bleeding that ranges from mild to severe. We evaluated 36 unrelated patients and 17 family members displaying thrombocytopenia that were recruited to the UK Genotyping and Phenotyping of Platelets (GAPP) study. All patients had a history of excessive bleeding of unknown etiology. We performed platelet phenotyping and whole-exome sequencing (WES) on all patients and identified mutations in schlafen 14 (SLFN14) in 12 patients from 3 unrelated families. Patients harboring SLFN14 mutations displayed an analogous phenotype that consisted of moderate thrombocytopenia, enlarged platelets, decreased ATP secretion, and a dominant inheritance pattern. Three heterozygous missense mutations were identified in affected family members and predicted to encode substitutions (K218E, K219N, and V220D) within an ATPase-AAA-4, GTP/ATP-binding region of SLFN14. Endogenous SLFN14 expression was reduced in platelets from all patients, and mutant SLFN14 expression was markedly decreased compared with that of WT SLFN14 when overexpressed in transfected cells. Electron microscopy revealed a reduced number of dense granules in affected patients platelets, correlating with a decreased ATP secretion observed in lumiaggregometry studies. These results identify SLFN14 mutations as cause for an inherited thrombocytopenia with excessive bleeding, outlining a fundamental role for SLFN14 in platelet formation and function.
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15
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Leo VC, Morgan NV, Bem D, Jones ML, Lowe GC, Lordkipanidzé M, Drake S, Simpson MA, Gissen P, Mumford A, Watson SP, Daly ME. Use of next-generation sequencing and candidate gene analysis to identify underlying defects in patients with inherited platelet function disorders. J Thromb Haemost 2015; 13:643-50. [PMID: 25556537 PMCID: PMC4383639 DOI: 10.1111/jth.12836] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 12/14/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Inherited platelet function disorders (PFDs) are heterogeneous, and identification of the underlying genetic defects is difficult when based solely on phenotypic and clinical features of the patient. OBJECTIVE To analyze 329 genes regulating platelet function, number, and size in order to identify candidate gene defects in patients with PFDs. PATIENTS/METHODS Targeted analysis of candidate PFD genes was undertaken after next-generation sequencing of exomic DNA from 18 unrelated index cases with PFDs who were recruited into the UK Genotyping and Phenotyping of Platelets (GAPP) study and diagnosed with platelet abnormalities affecting either Gi signaling (n = 12) or secretion (n = 6). The potential pathogenicity of candidate gene defects was assessed using computational predictive algorithms. RESULTS Analysis of the 329 candidate PFD genes identified 63 candidate defects, affecting 40 genes, among index cases with Gi signaling abnormalities, while 53 defects, within 49 genes, were identified among patients with secretion abnormalities. Homozygous gene defects were more commonly associated with secretion abnormalities. Functional annotation analysis identified distinct gene clusters in the two patient subgroups. Thirteen genes with significant annotation enrichment for 'intracellular signaling' harbored 16 of the candidate gene defects identified in nine index cases with Gi signaling abnormalities. Four gene clusters, representing 14 genes, with significantly associated gene ontology annotations were identified among the cases with secretion abnormalities, the most significant association being with 'establishment of protein localization.' CONCLUSION Our findings demonstrate the genetic complexity of PFDs and highlight plausible candidate genes for targeted analysis in patients with platelet secretion and Gi signaling abnormalities.
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Affiliation(s)
- V C Leo
- Department of Cardiovascular Science, University of Sheffield Medical School, University of Sheffield, Sheffield, UK
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16
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Bailey CH, Andersen LK, Lowe GC, Pittelkow MR, Bostwick JM, Davis MDP. A population-based study of the incidence of delusional infestation in Olmsted County, Minnesota, 1976-2010. Br J Dermatol 2015; 170:1130-5. [PMID: 24472115 DOI: 10.1111/bjd.12848] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Delusional infestation (DI) is a well-recognized clinical entity but there is a paucity of reliable data concerning its epidemiology. Knowledge of the epidemiology is fundamental to an understanding of any disease and its implications. Epidemiology is most accurately assessed using population-based studies, which are most generalizable to the wider population in the U.S. and worldwide. To our knowledge, no population-based study of the epidemiology (particularly incidence) of DI has been reported to date. OBJECTIVES To determine the incidence of delusional infestation (DI) using a population-based study. METHODS Medical records of Olmsted County residents were reviewed using the resources of the Rochester Epidemiology Project to confirm the patient's status as a true incident case of DI and to gather demographic information. Patients with a first-time diagnosis of DI or synonymous conditions between 1 January 1976 and 31 December 2010 were considered incident cases. RESULTS Of 470 identified possible diagnoses, 64 were true incident cases of DI in this population-based study. The age- and sex-adjusted incidence was 1·9 [95% confidence interval (CI) 1·5-2·4] per 100 000 person-years. Mean age at diagnosis was 61·4 years (range 9-92 years). The incidence of DI increased over the four decades from 1·6 (95% CI 0·6-2·6) per 100 000 person-years in 1976-1985 to 2·6 (95% CI 1·4-3·8) per 100 000 person-years in 2006-2010. CONCLUSIONS Our data indicate that DI is a rare disease, with incidence increasing across the life span, especially after the age of 40 years.
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Affiliation(s)
- C H Bailey
- Mayo Medical School, Mayo Clinic College of Medicine, Rochester, MN, U.S.A
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17
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Jones ML, Norman JE, Morgan NV, Mundell SJ, Lordkipanidzé M, Lowe GC, Daly ME, Simpson MA, Drake S, Watson SP, Mumford AD. Diversity and impact of rare variants in genes encoding the platelet G protein-coupled receptors. Thromb Haemost 2015; 113:826-37. [PMID: 25567036 PMCID: PMC4510585 DOI: 10.1160/th14-08-0679] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 11/13/2014] [Indexed: 12/20/2022]
Abstract
Platelet responses to activating agonists are influenced by common population variants within or near G protein-coupled receptor (GPCR) genes that affect receptor activity. However, the impact of rare GPCR gene variants is unknown. We describe the rare single nucleotide variants (SNVs) in the coding and splice regions of 18 GPCR genes in 7,595 exomes from the 1,000-genomes and Exome Sequencing Project databases and in 31 cases with inherited platelet function disorders (IPFDs). In the population databases, the GPCR gene target regions contained 740 SNVs (318 synonymous, 410 missense, 7 stop gain and 6 splice region) of which 70 % had global minor allele frequency (MAF) < 0.05 %. Functional annotation using six computational algorithms, experimental evidence and structural data identified 156/740 (21 %) SNVs as potentially damaging to GPCR function, most commonly in regions encoding the transmembrane and C-terminal intracellular receptor domains. In 31 index cases with IPFDs (Gi-pathway defect n=15; secretion defect n=11; thromboxane pathway defect n=3 and complex defect n=2) there were 256 SNVs in the target regions of 15 stimulatory platelet GPCRs (34 unique; 12 with MAF< 1 % and 22 with MAF≥ 1 %). These included rare variants predicting R122H, P258T and V207A substitutions in the P2Y12 receptor that were annotated as potentially damaging, but only partially explained the platelet function defects in each case. Our data highlight that potentially damaging variants in platelet GPCR genes have low individual frequencies, but are collectively abundant in the population. Potentially damaging variants are also present in pedigrees with IPFDs and may contribute to complex laboratory phenotypes.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Andrew D Mumford
- Dr. A. D. Mumford, University of Bristol, Level 7 Bristol Royal Infirmary, Bristol, BS2 8HW, United Kingdom, Tel.: +44 117 3423152, Fax: +44 117 3424036, E-mail
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Srikantharajah M, Mahendra P, Vydianath B, Lowe GC. Kikuchi-Fujimoto disease: a rare but important differential diagnosis for lymphadenopathy. BMJ Case Rep 2014; 2014:bcr-2014-205470. [PMID: 25199195 DOI: 10.1136/bcr-2014-205470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 23-year-old man presented with a 6-week history of fevers, cervical lymphadenopathy and fatigue. A CT of the neck, chest, abdomen and pelvis showed left cervical lymphadenopathy, enlarged lymph nodes in the axilla and groin and hepatomegaly. A left cervical excisional lymph node biopsy was undertaken and the histopathological findings were consistent with Kikuchi-Fujimoto disease. He was treated with high-dose prednisolone for 1 week, which was then tapered. Generalised arthralgia and daily episodes of malaise were experienced for a subsequent 2 months following the cessation of corticosteroids. The condition lasted 4 months from the onset of symptoms. This case report highlights the importance of including Kikuchi-Fujimoto disease as a differential diagnosis for lymphadenopathy. Kikuchi-Fujimoto disease has commonly been mistaken for tuberculosis and lymphoma, and unnecessary exposure to agents used to treat these conditions can be avoided by prompt histological diagnosis.
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Affiliation(s)
| | - Prem Mahendra
- Department of Haematology, Centre of Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - Bindu Vydianath
- Department of Histopathology, Queen Elizabeth Hospital, Birmingham, UK
| | - Gillian C Lowe
- Department of Haematology, Centre of Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK
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Moss RC, Lowe GC, Frampton CA, Revell P. A nurse-led randomised controlled trial of a structured educational programme for patients starting warfarin therapy. J Res Nurs 2014. [DOI: 10.1177/1744987113515261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Aim To investigate the effect of a randomised controlled trial of a nurse-led structured educational programme compared to standard care on patient knowledge when starting anticoagulant therapy with warfarin. Methods 45 patients commencing warfarin during an inpatient admission were randomised into either a control group receiving ‘usual’ care, or an experimental group with structured counselling and provision of an educational video. Identical questionnaires assessing knowledge of anticoagulation therapy were applied at discharge and again 3 months later. Results Patients receiving a structured educational approach had significantly better knowledge about their therapy both at hospital discharge and at 3 months post discharge ( p = <0.001 and p = 0.038 respectively). Secondary outcomes measured also showed a higher level of patient satisfaction ( p = 0.017) and time in target INR range (56.7% versus 48.1%) in the educational arm. Conclusions A formal and structured nurse-led educational package at the initiation of anticoagulant treatment with warfarin treatment improves patient knowledge.
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Affiliation(s)
- RC Moss
- Haematology Specialist Registrar, Department of Haematology, Gloucestershire Royal Hospital, UK
| | - GC Lowe
- Haematology Specialist Registrar, Department of Haematology, Stafford Hospital, UK
| | - CA Frampton
- Clinical Nurse Specialist in Anticoagulation, Department of Haematology, Stafford Hospital, UK
| | - P Revell
- Haematology Consultant, Department of Haematology, Stafford Hospital, UK
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20
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Dovlatova N, Lordkipanidzé M, Lowe GC, Dawood B, May J, Heptinstall S, Watson SP, Fox SC. Evaluation of a whole blood remote platelet function test for the diagnosis of mild bleeding disorders. J Thromb Haemost 2014; 12:660-5. [PMID: 24618131 PMCID: PMC4405765 DOI: 10.1111/jth.12555] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 02/23/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Mild platelet function disorders (PFDs) are complex and difficult to diagnose. The current gold standard test, light transmission aggregometry (LTA), including lumi-aggregometry, is time and labour intensive and blood samples must be processed within a limited time after venepuncture. Furthermore, many subjects with suspected PFDs do not show a platelet abnormality on LTA. OBJECTIVE To assess the diagnostic potential of an easy-to-use remote platelet function test (RPFT) as a diagnostic pre-test for suspected PFDs. METHODS A remote platelet function test was compared with lumi-aggregometry in participants recruited to the Genotyping and Phenotyping of Platelets Study (GAPP, ISRCTN 77951167). For the RPFT, whole blood was stimulated with platelet agonists, stabilized with PAMFix and returned to the central laboratory for analysis of P-selectin and CD63 by flow cytometry. RESULTS For the 61 study participants (42 index cases and 19 relatives) there was a good agreement between lumi-aggregometry and the RPFT, with diagnosis being concordant in 84% of cases (κ = 0.668, P < 0.0001). According to both tests, 29 participants were identified to have a deficiency in platelet function and 22 participants appeared normal. There were four participants where lumi-aggregometry revealed a defect but the RPFT did not, and six participants where the RPFT detected an abnormal platelet response that was not identified by lumi-aggregometry. CONCLUSION This study suggests that the RPFT could be an easy-to-use pre-test to select which participants with bleeding disorders would benefit from extensive platelet phenotyping. Further development and evaluation of the test are warranted in a wider population of patients with excessive bleeding and could provide informative screening tests for PFDs.
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Affiliation(s)
- N Dovlatova
- Cardiovascular Medicine, University of Nottingham, Queens Medical Centre, Nottingham, UK; Centre for Cardiovascular Sciences, Birmingham Platelet Group, University of Birmingham, Birmingham, UK
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21
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Patel YM, Lordkipanidzé M, Lowe GC, Nisar SP, Garner K, Stockley J, Daly ME, Mitchell M, Watson SP, Austin SK, Mundell SJ. A novel mutation in the P2Y12 receptor and a function-reducing polymorphism in protease-activated receptor 1 in a patient with chronic bleeding. J Thromb Haemost 2014; 12:716-25. [PMID: 24612435 DOI: 10.1111/jth.12539] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 01/27/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND The study of patients with bleeding problems is a powerful approach in determining the function and regulation of important proteins in human platelets. We have identified a patient with a chronic bleeding disorder expressing a homozygous P2RY(12) mutation, predicting an arginine to cysteine (R122C) substitution in the G-protein-coupled P2Y(12) receptor. This mutation is found within the DRY motif, which is a highly conserved region in G-protein-coupled receptors (GPCRs) that is speculated to play a critical role in regulating receptor conformational states. OBJECTIVES To determine the functional consequences of the R122C substitution for P2Y(12) function. PATIENT/METHODS We performed a detailed phenotypic analysis of an index case and affected family members. An analysis of the variant R122C P2Y(12) stably expressed in cells was also performed. RESULTS ADP-stimulated platelet aggregation was reduced as a result of a significant impairment of P2Y(12) activity in the patient and family members. Cell surface R122C P2Y(12) expression was reduced both in cell lines and in platelets; in cell lines, this was as a consequence of agonist-independent internalization followed by subsequent receptor trafficking to lysosomes. Strikingly, members of this family also showed reduced thrombin-induced platelet activation, owing to an intronic polymorphism in the F2R gene, which encodes protease-activated receptor 1 (PAR-1), that has been shown to be associated with reduced PAR-1 receptor activity. CONCLUSIONS Our study is the first to demonstrate a patient with deficits in two stimulatory GPCR pathways that regulate platelet activity, further indicating that bleeding disorders constitute a complex trait.
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Affiliation(s)
- Y M Patel
- Department of Cardiology, Cardiovascular Division, King's College London, The Rayne Institute, St Thomas' Hospital, London, UK
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Daly ME, Leo VC, Lowe GC, Watson SP, Morgan NV. What is the role of genetic testing in the investigation of patients with suspected platelet function disorders? Br J Haematol 2014; 165:193-203. [DOI: 10.1111/bjh.12751] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Martina E. Daly
- Department of Cardiovascular Science; University of Sheffield Medical School; University of Sheffield; Sheffield UK
| | - Vincenzo C. Leo
- Department of Cardiovascular Science; University of Sheffield Medical School; University of Sheffield; Sheffield UK
| | - Gillian C. Lowe
- Centre for Cardiovascular Sciences; School of Clinical and Experimental Medicine; College of Medical and Dental Sciences; University of Birmingham; Birmingham UK
| | - Steve P. Watson
- Centre for Cardiovascular Sciences; School of Clinical and Experimental Medicine; College of Medical and Dental Sciences; University of Birmingham; Birmingham UK
| | - Neil V. Morgan
- Centre for Cardiovascular Sciences; School of Clinical and Experimental Medicine; College of Medical and Dental Sciences; University of Birmingham; Birmingham UK
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Stockley J, Morgan NV, Bem D, Lowe GC, Lordkipanidzé M, Dawood B, Simpson MA, Macfarlane K, Horner K, Leo VC, Talks K, Motwani J, Wilde JT, Collins PW, Makris M, Watson SP, Daly ME. Enrichment of FLI1 and RUNX1 mutations in families with excessive bleeding and platelet dense granule secretion defects. Blood 2013; 122:4090-3. [PMID: 24100448 PMCID: PMC3862284 DOI: 10.1182/blood-2013-06-506873] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 09/18/2013] [Indexed: 11/20/2022] Open
Abstract
We analyzed candidate platelet function disorder genes in 13 index cases with a history of excessive bleeding in association with a significant reduction in dense granule secretion and impaired aggregation to a panel of platelet agonists. Five of the index cases also had mild thrombocytopenia. Heterozygous alterations in FLI1 and RUNX1, encoding Friend leukemia integration 1 and RUNT-related transcription factor 1, respectively, which have a fundamental role in megakaryocytopoeisis, were identified in 6 patients, 4 of whom had mild thrombocytopenia. Two FLI1 alterations predicting p.Arg337Trp and p.Tyr343Cys substitutions in the FLI1 DNA-binding domain abolished transcriptional activity of FLI1. A 4-bp deletion in FLI1, and 2 splicing alterations and a nonsense variation in RUNX1, which were predicted to cause haploinsufficiency of either FLI1 or RUNX1, were also identified. Our findings suggest that alterations in FLI1 and RUNX1 may be common in patients with platelet dense granule secretion defects and mild thrombocytopenia.
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Affiliation(s)
- Jacqueline Stockley
- Department of Cardiovascular Science, University of Sheffield Medical School, University of Sheffield, Sheffield, United Kingdom
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Lowe GC, Lordkipanidzé M, Watson SP. Utility of the ISTH bleeding assessment tool in predicting platelet defects in participants with suspected inherited platelet function disorders. J Thromb Haemost 2013; 11:1663-8. [PMID: 23809206 PMCID: PMC3773236 DOI: 10.1111/jth.12332] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 06/29/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND The ISTH bleeding assessment tool (ISTH-BAT) was developed to record bleeding symptoms and to aid diagnosis in patients with a possible bleeding disorder. OBJECTIVES To investigate the utility of the ISTH-BAT in predicting functional defects in platelet activation in participants with suspected inherited platelet function disorders. PATIENTS/METHODS Participants with clinical evidence of excessive bleeding and suspected inherited platelet function disorders and healthy volunteers were recruited to the Genotyping and Phenotyping of Platelets study (GAPP; ISRCTN 77951167). The ISTH-BAT questionnaire was applied by a trained investigator prior to lumiaggregometry. RESULTS One hundred participants were included (79 with suspected inherited platelet function disorders, and 21 healthy volunteers). The ISTH-BAT score in participants with suspected inherited platelet function disorders (median 12; interquartile range [IQR] 8-16) was significantly higher than in healthy volunteers (median 0; IQR 0-0). There was no difference between participants with suspected inherited platelet function disorders with a platelet defect detected by lumiaggregometry (median 11; IQR 8-16) and those with normal platelet function (median 12; IQR 8-14) (P > 0.05). The ISTH-BAT score was not associated with a demonstrable platelet defect on platelet function testing (area under the receiver operating characteristic curve = 0.501 [95% confidence interval 0.372-0.630, P = 0.98] and odds ratio 1.01 [95% confidence interval 0.93-1.09, P = 0.91]). CONCLUSIONS The ISTH-BAT is a powerful tool for documenting lifelong bleeding history. However, the score obtained is not predictive of the presence of a platelet defect on lumiaggregometry in patients with suspected inherited platelet function disorders.
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Affiliation(s)
- G C Lowe
- Centre for Cardiovascular Sciences, Institute of Biomedical Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
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Abstract
The majority of patients with platelet function disorders (PFDs) have normal platelet counts and mild day-to-day bleeding symptoms, but are at risk of major hemorrhage at times of trauma, surgery, or childbirth. This group is challenging to investigate, because the assays are often time-intensive and labour-intensive, and interpretation is difficult, especially in patients with mild disorders. In addition, interuser variability in performance of the assays, including the currently accepted gold standard, light transmission aggregometry, makes the results difficult to compare between laboratories. Furthermore, a similar pattern of mucocutaneous bleeding is seen in disorders in other components of the hemostatic pathway, including type 1 von Willebrand disease (VWD). We have undertaken an extensive investigation of patients with clinically diagnosed excessive bleeding, using a genotyping and platelet phenotyping approach based on lumi-aggregometry, and other specialist tests of platelet function, in combination with Sanger and next-generation sequencing (NGS). We found a functional defect in ~ 60% of patients, the majority being associated with feedback pathways of platelet activation. Function-disrupting mutations were identified in known and novel genes, and coinheritance with other genetic disorders of hemostasis, including type 1 VWD, was shown. A significant number of mutations are heterozygous and unlikely to cause extensive bleeding in isolation, consistent with incomplete penetrance of inheritance of bleeding disorders and a multifactorial etiology for excessive bleeding in many patients. Mucocutaneous bleeding is a complex trait, and this has important implications for NGS in the assessment of a PFD.
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Affiliation(s)
- S P Watson
- Centre for Cardiovascular Sciences, Institute of Biomedical Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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Lordkipanidzé M, Lowe GC, Watson SP. Simultaneous measurement of ATP release and LTA does not potentiate platelet aggregation to epinephrine. Thromb Haemost 2013; 110:199-201. [PMID: 23636351 DOI: 10.1160/th13-02-0123] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 04/20/2013] [Indexed: 01/25/2023]
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Lowe GC, Sánchez Guiu I, Chapman O, Rivera J, Lordkipanidzé M, Dovlatova N, Wilde J, Watson SP, Morgan NV. Microsatellite markers as a rapid approach for autozygosity mapping in Hermansky-Pudlak syndrome: identification of the second HPS7 mutation in a patient presenting late in life. Thromb Haemost 2013; 109:766-8. [PMID: 23364359 DOI: 10.1160/th12-11-0876] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 01/17/2013] [Indexed: 11/05/2022]
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Abstract
The initial appearance of subacute cutaneous lupus erythematosus (SCLE) skin lesions in conjunction with Ro/SS-A autoantibodies occurring as an adverse reaction to hydrochlorothiazide [i.e. drug-induced SCLE (DI-SCLE)] was first reported in 1985. Over the past decade an increasing number of drugs in different classes has been implicated as triggers for DI-SCLE. The management of DI-SCLE can be especially challenging in patients taking multiple medications capable of triggering DI-SCLE. Our objectives were to review the published English language literature on DI-SCLE and use the resulting summary data pool to address questions surrounding drug-induced SCLE and to develop guidelines that might be of value to clinicians in the diagnosis and management of DI-SCLE. A systematic review of the Medline/PubMed-cited literature on DI-SCLE up to August 2009 was performed. Our data collection and analysis strategies were prospectively designed to answer a series of questions related to the clinical, prognostic and pathogenetic significance of DI-SCLE. One hundred and seventeen cases of DI-SCLE were identified and reviewed. White women made up the large majority of cases, and the mean overall age was 58·0 years. Triggering drugs fell into a number of different classes, highlighted by antihypertensives and antifungals. Time intervals ('incubation period') between drug exposure and appearance of DI-SCLE varied greatly and were drug class dependent. Most cases of DI-SCLE spontaneously resolved within weeks of drug withdrawal. Ro/SS-A autoantibodies were present in 80% of the cases in which such data were reported and most remained positive after resolution of SCLE skin disease activity. No significant differences in the clinical, histopathological or immunopathological features between DI-SCLE and idiopathic SCLE were detected. There is now adequate published experience to suggest that DI-SCLE does not differ clinically, histopathologically or immunologically from idiopathic SCLE. It should be recognized as a distinct clinical constellation differing clinically and immunologically from the classical form of drug-induced systemic lupus erythematosus.
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Affiliation(s)
- G C Lowe
- University of Utah School of Medicine, Salt Lake City, USA
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