Type II protein C deficiency in a 16-year-old girl with central retinal vein occlusion

A review on clotting disorders and retinal hemorrhages: Can they mimic abuse?

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.

Combined CRVO with CRAO in a patient with protein C deficiency

PURPOSE

To study the underlying factors in a young patient having central retinal venous obstruction with central retinal arterial obstruction and its effects on visual outcome.

METHODS

A 33-year-old man presented with a complaint of sudden loss of vision in his right eye. A complete ophthalmic evaluation with fundus angiography showed combined central retinal venous obstruction with central retinal arterial obstruction. Detailed investigations revealed reduced (20%) functional assay of protein C suggestive of the diagnosis of severe Type II protein C deficiency with Factor V Leiden mutation. This ocular event was the first sign of the underlying disorder.

RESULTS

The ophthalmic event rapidly progressed to no perception of light. Anticoagulant therapy was started to prevent life-threatening systemic complications. Despite antiglaucoma medications, intraocular pressure was high and cyclocryotherapy was advised.

CONCLUSION

Retinal vascular disorders in the younger population have different underlying risk factors than in the older age group. Clinical presentation, severity, and management also depend on causative factors. Combined retinal artery and vein occlusion is very uncommon. Combined cases have mostly been attributed to rheological causes like thrombophilia, vessel wall inflammation, and mechanical compression. Protein C deficiency has mainly been linked to vein occlusions and there is no reference to protein C deficiency as a cause of combined central retinal venous obstruction and central retinal arterial obstruction. Combined cases usually present with severe visual loss and have rapid progression. Young patients having such presentation should be thoroughly evaluated to diagnose underlying factors and initiate appropriate management at the earliest.

[A case of non-occulsive mesentery ischemia with pulmonary embolism due to protein C deficiency]

Protein C is an important physiological anticoagulant factor. Protein C deficiency has been linked to venous thrombosis at unusual sites, including the cerebral and mesenteric veins. Hereditary protein C deficiency is inherited primarily as an autosomal dominant trait with incomplete penetrance. Protein C and S deficiencies are known to increase the risk of venous thrombosis and pulmonary thromboembolism. Testing for protein C levels and function is necessary for the detection of both type I and type II protein C deficiency. In this article, we report a case of pulmonary embolism and mesentery ischemia due to type 1 protein C deficiency.