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Elkattawy S, Alyacoub R, Singh KS, Fichadiya H, Kessler W. Prothrombin G20210A Gene Mutation-Induced Recurrent Deep Vein Thrombosis and Pulmonary Embolism: Case Report and Literature Review. J Investig Med High Impact Case Rep 2022; 10:23247096211058486. [PMID: 35426321 PMCID: PMC9016586 DOI: 10.1177/23247096211058486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Inherited thrombophilia is an important cause of venous thrombosis. The Factor V
Leiden (FVL) is the most commonly encountered mutation, followed by the
prothrombin G20210A gene mutation (PTM). The typical venous thrombotic events
(VTEs) associated with PTM mutations are deep vein thrombosis (DVT) and
pulmonary embolisms (PE). The PTM is inherited in an autosomal dominant pattern
with variable penetrance. While heterozygous PTM mutations are more frequent and
well documented in the literature, rare cases of homozygous PTM mutations are
also reported. In this report, we discuss a 56-year-old male with a past medical
history of homozygous prothrombin gene mutation (G20210A) who presented with an
unprovoked DVT of the right lower extremity involving both the proximal and
distal veins associated with multiple bilateral PEs. This case is unique in
terms of the homozygous PTM inheritance, the age at which the patient presented
(usually presentation is earlier in life), and the fact that he had a recurrence
of both DVT and PE simultaneously.
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Affiliation(s)
- Sherif Elkattawy
- Rutgers New Jersey Medical School/Trinitas Regional Medical Center, Elizabeth, USA
| | - Ramez Alyacoub
- Rutgers New Jersey Medical School/Trinitas Regional Medical Center, Elizabeth, USA
| | | | - Hardik Fichadiya
- Rutgers New Jersey Medical School/Trinitas Regional Medical Center, Elizabeth, USA
| | - William Kessler
- Rutgers New Jersey Medical School/Trinitas Regional Medical Center, Elizabeth, USA
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Kenet G, Kurnik K, Gelas MA, Finckh U, Junker R, Heller C, Zieger B, Knöfler R, Holzhauer S, Mesters R, Krümpel A, Klostermeier UC, Limperger V, Nowak-Göttl U. Role of protein S deficiency in children with venous thromboembolism. Thromb Haemost 2017; 113:426-33. [DOI: 10.1160/th14-06-0533] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 08/28/2014] [Indexed: 11/05/2022]
Abstract
SummaryVenous thromboembolism [TE] is a multifactorial disease, and protein S deficiency [PSD] constitutes a major risk factor. In the present study the prevalence of PSD and the clinical presentation at TE onset in a cohort of children is reported. In 367 unselected paediatric patients with TE (age 0.1–18 years) recruited between July 1996 and December 2013, a comprehensive thrombophilia screening was performed along with recording of anamnestic data. Thirty of 367 paediatric patients (8.2 %) derived from 27 families had PSD. Mean age at first TE onset was 14.5 years (range 0.1 to 18). Thrombotic locations were cerebral veins (n=8), calf vein TE (n=3) deep veins (DVT) of the leg (n=12), DVT & pulmonary embolism (n=5) and intra-cardiac veins (n=1) or purpura fulminans (n=1). PSD co-occurred with the factor 5 mutation at rs6025 or the homozygous factor 2 susceptibility variant at rs1799963 in one case each. The Heerlen polymorphism detected in five children presented with milder PSD. In 18 patients (60 %) a concomitant risk factor for TE was identified. A second TE event within primarily healthy siblings occurred in three of 27 PSD families (11.0 %). In this cohort of children with symptomatic TE, the prevalence of PSD adjusted for family status was 7.4 %. Given its clinical implication for patients and family members, thrombophilia testing should be performed and the benefit of medical or educational interventions should be evaluated in this high-risk population.
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Limperger V, Kenet G, Goldenberg NA, Heller C, Holzhauer S, Junker R, Klostermeier UC, Knoefler R, Kurnik K, Krümpel A, Mesters R, Stach M, Young G, Nowak-Göttl U. Impact of high-risk thrombophilia status on recurrence among children with a first non-central-venous-catheter-associated VTE: an observational multicentre cohort study. Br J Haematol 2016; 175:133-40. [PMID: 27329967 DOI: 10.1111/bjh.14192] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/15/2016] [Indexed: 11/30/2022]
Abstract
Deficiency of antithrombin (AT), protein C (PC) or protein S (PS) constitutes a major risk factor for venous thromboembolism (VTE). Individuals at high risk for recurrence who benefit from screening need to be identified. The primary study objective was to determine the individual recurrence risk among children with a first non-central-venous-catheter-associated VTE with respect to their thrombophilia status and to evaluate if the clinical presentation at first VTE onset differs between children with AT, PC or PS deficiency versus no thrombophilia. We calculated the absolute risk of VTE recurrence and event-free-survival adjusted for thrombophilia, age, sex and positive family VTE history in 161 consecutively enrolled paediatric VTE patients. The presence of a deficiency relative to no thrombophilia was evaluated as a potential predictor of recurrence. Predictors for recurrence were AT deficiency (hazard ratio/95% CI: 6·5/2·46-17·2) and female gender (2·6/1·1-6·35). The annual recurrence rates (95% CIs) were 5·4% (2·6-10) in AT-deficient children, 1·3% (0·3-3·8) in patients with PC deficiency, 0·7% (0·08-2·4) in the PS-deficient cohort and 0·9% (0·4-1·8) in patients with no thrombophilia. Positive family VTE history or combined thrombophilias did not predict recurrence. Given the overall annual incidence rate of recurrence of 1·5% we suggest screening for AT deficiency in children with VTE.
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Affiliation(s)
- Verena Limperger
- Institute of Clinical Chemistry, University Hospital Kiel, Kiel, Germany
| | - Gili Kenet
- Thrombosis Unit, National Haemophilia Centre, Tel Hashomer and the Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Neil A Goldenberg
- All Children's Hospital Johns Hopkins Medicine and All Children's Research Institute, St. Petersburg, FL, USA.,Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Susanne Holzhauer
- Department of Paediatric Haematology/Oncology, Charité, Berlin, Germany
| | - Ralf Junker
- Institute of Clinical Chemistry, University Hospital Kiel, Kiel, Germany
| | | | - Ralf Knoefler
- Department of Paediatric Haemostaseology, Dresden, Germany
| | - Karin Kurnik
- Department of Paediatrics, University Children Hospital Munich, Munich, Germany
| | - Anne Krümpel
- Department of Paediatric Haematology/Oncology, University Children Hospital Münster, Münster, Germany
| | - Rolf Mesters
- Department of Medicine/Haematology & Oncology, Univ. Hospital Münster, Münster, Germany
| | - Michael Stach
- IT Service Centre, University Hospital of Münster, Münster, Germany
| | - Guy Young
- Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ulrike Nowak-Göttl
- Institute of Clinical Chemistry, University Hospital Kiel, Kiel, Germany. .,Department of Paediatric Haematology/Oncology, University Children Hospital Münster, Münster, Germany.
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Yoon U, Kwok L, Flessenkaemper I. Bilateral Superficial Femoral Artery Thrombosis in a 15-Year-Old Caucasian Male with Homozygous Prothrombin G20210A Genotype and Associated Antiphospholipid Syndrome. Int J Angiol 2015; 25:e100-e105. [PMID: 28031668 DOI: 10.1055/s-0035-1548557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Prothrombin mutation was usually associated with other well-established predisposing factors for venous thrombosis such as antiphospholipid antibodies. Recently, even isolated prothrombin gene mutation G20210A has been reported to present severe or unusual vein thrombosis. Less clear is the role of prothrombin mutation in the formation of arterial thrombosis. We present a case of a 15-year-old healthy White male with acute bilateral femoral artery thrombosis. The patient presented with increasing left leg pain for about 1 week. He was a physically very active teenager with a new onset of leg pain aggravated by exercise. Physical examination revealed a pale and cold left foot with dorsal foot necrosis (2 × 2 cm) that started 2 days ago. In addition, he complained of moderate rest pain. No symptoms were noticed on the right lower extremity. The ankle brachial index was 0.3 on the left and 0.6 on the right. Duplex sonography showed bilateral superficial femoral artery thrombosis, which was confirmed by angiography. Subsequently, he undergoes left superficial femoral and popliteal artery lysis with rt-PA (Actilyse boehringer ingelheim, Ingelheim am Rhein, Germany) and full heparinization. Treatment was discontinued after 24 hours with no significant improvement of symptoms. Full anticoagulation with Coumadin (Bristol-Myers Squibb Company, New York, NY) and alprostadil (Prostavasin UCB, Brussels, Belgium) infusion for 2 weeks was initiated and eventually patient's symptoms improved. Laboratory testing revealed a homozygous prothrombin G20210A mutation and antiphospholipid syndrome. Homozygous prothrombin G20210A mutation in conjunction with antiphospholipid syndrome is a rare combination of coagulation disorder. Early intervention with full anticoagulation and subsequent lifelong anticoagulation should be considered in treatment strategy.
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Affiliation(s)
- Uzung Yoon
- Department of Surgery, Hofstra North Shore-Long Island Jewish School of Medicine, Manhasset, New York
| | - LaiLai Kwok
- Lincoln Memorial University, DeBusk College of Osteopathic Medicine, Harrogate, Tennessee
| | - Ingo Flessenkaemper
- Helios Klinikum Emil von Behring, Chairman of Vascular and Endovascular Surgery, Berlin, Germany
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Sdogou T, Kossiva L, Kakleas K, Platokouki H, Tentolouri T, Georgouli H, Karayianni C, Karavanaki K. Deep vein thrombosis and pulmonary embolism in a child with diabetic ketoacidosis and protein s deficiency: a case report. Horm Res Paediatr 2013; 79:114-8. [PMID: 23306559 DOI: 10.1159/000343813] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 09/25/2012] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Diabetic ketoacidosis (DKA) is considered a hypercoagulable state, which may be exacerbated in patients with thrombophilia and lead to thrombosis. CASE REPORT We report on a 5.5-year-old boy, who was admitted to the pediatric department with DKA due to newly diagnosed type 1 diabetes. Low-grade fever was reported for 6 days prior to admission and continued during DKA management, with negative septic screening. After DKA management, the child developed symptoms of iliofemoral deep vein thrombosis (DVT). A family history of protein S (PS) deficiency was revealed. He was initially treated intravenously with antibiotics and unfractionated heparin, which, after 2 days, was switched to low-molecular-weight heparin and vitamin K antagonist (VKA) due to poor anticoagulant response. On the 6th day of anticoagulant treatment, the patient presented with pulmonary embolism (PE); he continued with VKA and antibiotics, with significant clinical improvement. Prolonged fever was attributed to DVT and PE. The patient was discharged on oral anticoagulants and insulin. CONCLUSION We report on a child with congenital PS deficiency and DKA who developed DVT and PE despite anticoagulant treatment. It is important in children presenting with DKA to seek thoroughly for a medical history of thrombophilia and to start early thromboprophylaxis in such cases in order to prevent a possible thrombosis.
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Affiliation(s)
- Triantafyllia Sdogou
- 2nd Department of Pediatrics, 'P&A Kyriakou' Children's Hospital, Athens University, Athens, Greece
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Abstract
Hypercoagulable states can be inherited or acquired. Inherited hypercoagulable states can be caused by a loss of function of natural anticoagulant pathways or a gain of function in procoagulant pathways. Acquired hypercoagulable risk factors include a prior history of thrombosis, obesity, pregnancy, cancer and its treatment, antiphospholipid antibody syndrome, heparin-induced thrombocytopenia, and myeloproliferative disorders. Inherited hypercoagulable states combine with acquired risk factors to establish the intrinsic risk of venous thromboembolism for each individual. Venous thromboembolism occurs when the risk exceeds a critical threshold. Often a triggering factor, such as surgery, pregnancy, or estrogen therapy, is required to increase the risk above this critical threshold.
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Affiliation(s)
- Julia A M Anderson
- Department of Clinical and Laboratory Hematology, Royal Infirmary of Edinburgh, Scotland EH16 4SA, UK
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7
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Abstract
Hypercoagulable states can be inherited or acquired. Inherited hypercoagulable states can be caused by a loss of function of natural anticoagulant pathways or a gain of function in procoagulant pathways. Acquired hypercoagulable risk factors include a prior history of thrombosis, obesity, pregnancy, cancer and its treatment, antiphospholipid antibody syndrome, heparin-induced thrombocytopenia, and myeloproliferative disorders. Inherited hypercoagulable states combine with acquired risk factors to establish the intrinsic risk of venous thromboembolism for each individual. Venous thromboembolism occurs when the risk exceeds a critical threshold. Often a triggering factor, such as surgery, pregnancy, or estrogen therapy, is required to increase the risk above this critical threshold.
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Affiliation(s)
- Julia A M Anderson
- Department of Clinical and Laboratory Hematology, Royal Infirmary of Edinburgh, Scotland EH16 4SA, UK
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8
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Sofi F, Marcucci R, Abbate R, Gensini GF, Prisco D. Lipoprotein (a) and venous thromboembolism in adults: a meta-analysis. Am J Med 2007; 120:728-33. [PMID: 17679133 DOI: 10.1016/j.amjmed.2007.01.029] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2006] [Revised: 01/03/2007] [Accepted: 01/05/2007] [Indexed: 11/23/2022]
Abstract
BACKGROUND Lipoprotein (a) [Lp(a)], a low-density lipoprotein particle linked to apolipoprotein (a), has been recently demonstrated to be an independent risk factor for arterial vascular diseases. However, despite increasing evidence of the association between high Lp(a) and arterial thrombotic diseases, few and conflicting results on the association between high Lp(a) levels and venous thromboembolism have been obtained. The aim of this article is to systematically examine the published data on the association between high Lp(a) levels and venous thromboembolism. METHODS A systematic search of all publications listed in the electronic databases (Medline, EMBASE, Web of Science, and The Cochrane Library) up to November 2006, using keywords in combination both as MeSH terms and text words, was conducted. RESULTS Six case-control studies were included, incorporating 1826 cases of venous thromboembolism and 1074 controls. The summary odds ratios of included case-control studies under a fixed-effects model showed a statistically significant association between Lp(a) levels >300 mg/L and venous thromboembolism: 1.87, 95% confidence interval (CI), 1.51-2.30; P <.0001. Furthermore, a random-effects model, which accounts for the interstudy variation, yielded a similar estimate of increased risk (odds ratio [OR] 1.77; 95% CI, 1.14-2.75; P=.01). CONCLUSIONS The present meta-analysis shows a significant association between high Lp(a) levels and the occurrence of venous thromboembolism in adults. Indeed, the detection of Lp(a) could be of clinical relevance for venous thromboembolism, especially among patients with absence of traditional and thrombophilic risk factors.
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Affiliation(s)
- Francesco Sofi
- Department of Medical and Surgical Critical Care, Thrombosis Centre, University of Florence, Italy.
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Bosler D, Mattson J, Crisan D. Phenotypic Heterogeneity in Patients with Homozygous Prothrombin 20210AA Genotype. A paper from the 2005 William Beaumont Hospital Symposium on Molecular Pathology. J Mol Diagn 2006; 8:420-5. [PMID: 16931580 PMCID: PMC1867627 DOI: 10.2353/jmoldx.2006.060014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Venous thromboembolic events (VTEs) affect an estimated 1 in 1000 people annually, resulting in approximately 50,000 deaths, with prevalence increasing with age. The genetic contributors to thrombosis have been described and further explored within the last 15 years as molecular diagnostic techniques have become more widely used. The prothrombin G20210A mutation is the second most common inherited thrombotic risk factor after factor V Leiden. Generally present in less than 5% of the population, the mutation's prevalence varies greatly with ethnicity. The G20210A mutation confers a mildly increased thrombotic risk that is compounded by the presence of other risk factors. One striking characteristic of the G20210A mutation is the phenotypic heterogeneity of the rare homozygous cases. Forty percent of the reported homozygous cases are asymptomatic. Many of the symptomatic patients have additional risk factors that might compound the thrombotic risk. We present here a review of the literature for the homozygous prothrombin G20210A mutation and describe additional cases that exemplify the heterogeneous nature of this entity.
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Affiliation(s)
- David Bosler
- Department of Clinical Pathology, William Beaumont Hospital, 3601 W. 13 Mile Rd., Royal Oak, MI 48073, USA
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Klein L, Bhardwaj V, Gebara B. Cerebral venous sinus thrombosis in a neonate with homozygous prothrombin G20210A genotype. J Perinatol 2004; 24:797-9. [PMID: 15558004 DOI: 10.1038/sj.jp.7211187] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We describe a 7-day-old infant who presented with extensive cerebral venous sinus thrombosis (CVST) and was found to be homozygous for the prothrombin G20210A gene mutation. No other known risk factors for thrombosis were identified.
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Affiliation(s)
- Lisa Klein
- William Beaumont Hospital, Pediatrics, Royal Oak, MI 48073, USA
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Thornburg CD, Lattimore KA, Pipe SW. Tricuspid valve thrombus and pulmonary embolus in an infant with homozygous thermolabile methylenetetrahydrofolate reductase and heterozygous prothrombin G20210A variant. J Perinatol 2003; 23:513-5. [PMID: 13679943 DOI: 10.1038/sj.jp.7210951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We describe an unusual and interesting case of a full-term infant presenting at 7 days of life with HSV pneumonitis and a tricuspid valve thrombus ultimately requiring extracorporeal membrane oxygenation. The infant subsequently developed a pulmonary embolus. The infant was found to be heterozygous for the prothrombin G20210A mutation and homozygous for the methylenetetrahydrofolate reductase C667T mutation. The patient was treated with low molecular weight heparin for a total of 3 months and has not had a recurrent thrombosis. This case illustrates that a combination of congenital and acquired thrombophilic risk factors can contribute to a significant thrombotic event.
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Affiliation(s)
- Courtney D Thornburg
- Department of Pediatrics and Communicable Diseases, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA
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Young G, Manco-Johnson M, Gill JC, Dimichele DM, Tarantino MD, Abshire T, Nugent DJ. Clinical manifestations of the prothrombin G20210A mutation in children: a pediatric coagulation consortium study. J Thromb Haemost 2003; 1:958-62. [PMID: 12871361 DOI: 10.1046/j.1538-7836.2003.00116.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The prothrombin G20210A mutation is a common risk factor for thrombosis which increases the risk of deep vein thrombosis, stroke, and fetal loss. There are few publications of its clinical manifestations in children. Our objective was to determine the clinical manifestations of the prothrombin mutation in children. Via survey of pediatric hematologists, we collected data on children with thrombosis and the prothrombin mutation. Thirty-eight patients with a thrombotic event were identified as having the prothrombin mutation. Children with arterial thrombosis were younger, less than half had additional risk factors present at the time of the event, and had a high frequency of central nervous system thrombosis. Children with venous thrombosis were older, almost always had additional risk factors present, and had thrombosis occur most often in the extremities, although there were also a significant number of events in the central venous and cerebral circulation. There was a striking predilection for central nervous system events as 30% of all the events and 67% of the arterial events occurred there. In all, 14/38 children (37%) had central nervous system thrombosis. Unlike factor V Leiden and deficiencies of proteins C and S which cause venous thromboembolism, the prothrombin mutation in children is often associated with arterial thrombosis and with central nervous system events. In children with the prothrombin mutation and venous thrombosis, other risk factors are usually present. Therefore, children with arterial or venous thrombosis of any location should be evaluated for the presence of the prothrombin mutation.
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Affiliation(s)
- G Young
- Children's Hospital of Orange County, Orange, California 92868, USA.
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14
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Abstract
Acquired and inherited prothrombotic risk factors increase the risk of thrombosis in children. This review is based on "milestone" pediatric reports and new literature data (January 2001-February 2002) on the presence of acquired and inherited prothrombotic risk factors, imaging methods, and treatment modalities in pediatric thromboembolism. After confirming clinically suspected thromboembolism with suitable imaging methods, pediatric patients should be screened for common gene mutations (factor V G1691A, prothrombin G20210A and MTHFR C677T genotypes), rare genetic deficiencies (protein C, protein S, antithrombin, and plasminogen), and new candidates for genetic thrombophilia causing elevated levels of lipoprotein(a), and homocysteine, and probable genetic risk factors (elevations in fibrinogen, factor IX, and factor VIIIC, and decreases in factor XII). Data interpretation is based on age-dependent reference ranges or the identification of causative gene mutations/polymorphisms with respect to individual ethnic backgrounds. Pediatric treatment protocols for acute thromboembolism, including thrombolytic and anticoagulant therapy, are mainly adapted from adult patient protocols.
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Affiliation(s)
- Ulrike Nowak-Göttl
- Department of Pediatric Hematology/Oncology, University of Münster, Germany.
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