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Gabe C, Ziza KC, Durazzo N, Pagani FM, Oliveira VB, Conrado MCAV, Dezan MR, Mendrone A, Villaça PR, Dinardo CL, Rocha V. Detection of alloimmunization in Glanzmann Thrombasthenia and Bernard-Soulier Syndrome: Data from a Brazilian Center. Hematol Transfus Cell Ther 2023; 45 Suppl 2:S101-S107. [PMID: 36114116 PMCID: PMC10433308 DOI: 10.1016/j.htct.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 04/28/2022] [Accepted: 06/13/2022] [Indexed: 10/17/2022] Open
Abstract
INTRODUCTION The Glanzmann Thrombasthenia (GT) and Bernard-Soulier Syndrome (BSS) are rare hereditary disorders of platelet function. Their treatment often requires platelet transfusion, which can lead to the development of alloantibodies. OBJECTIVE In this study, we aim to develop a strategy for alloantibody detection and to describe the frequency of alloimmunization in a patient population from a single center in southeastern Brazil. METHODS Samples from patients with GT or BSS were tested using the Platelet Immunofluorescence Test (PIFT). If a positive result was obtained, a confirmatory step using the Monoclonal Antibody Immobilization of Platelet Antigens (MAIPA) and Luminex bead-based platelet assay (PAKLx) was executed. MAIN RESULTS Among 11 patients with GT, we detected the presence of alloantibodies in 5 using PIFT, with confirmation through MAIPA and PAKLx in 2 (1 anti-HLA and 1 anti-HPA), resulting in a frequency of 18.1%. Among 4 patients with BSS, PIFT was positive in 3, with confirmation by MAIPA and PAKLx in 1 (anti-HLA), showing a frequency of 25%. The two patients with anti-HLA antibodies exhibited a panel reactive antibody (PRA-HLA) testing greater than 97%. CONCLUSION Our study highlights the importance of identifying platelet alloimmunization in this patient population. The proposed algorithm for platelet alloantibodies detection allows resource optimization.
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Affiliation(s)
- Caroline Gabe
- Faculdade de Medicina da Universidade de São Paulo (FM USP), São Paulo, SP, Brazil.
| | - Karen Chinoca Ziza
- Faculdade de Medicina da Universidade de São Paulo (FM USP), São Paulo, SP, Brazil
| | - Natália Durazzo
- Instituto de Medicina Tropical da da Universidade de São Paulo (IMT USP), São Paulo, SP, Brazil
| | - Flavia M Pagani
- Fundação Pró-Sangue Hemocentro de São Paulo, São Paulo, SP, Brazil
| | | | | | - Marcia R Dezan
- Fundação Pró-Sangue Hemocentro de São Paulo, São Paulo, SP, Brazil
| | - Alfredo Mendrone
- Fundação Pró-Sangue Hemocentro de São Paulo, São Paulo, SP, Brazil
| | | | - Carla Luana Dinardo
- Instituto de Medicina Tropical da da Universidade de São Paulo (IMT USP), São Paulo, SP, Brazil; Fundação Pró-Sangue Hemocentro de São Paulo, São Paulo, SP, Brazil
| | - Vanderson Rocha
- Faculdade de Medicina da Universidade de São Paulo (FM USP), São Paulo, SP, Brazil; Fundação Pró-Sangue Hemocentro de São Paulo, São Paulo, SP, Brazil; Churchill Hospital, NHS BT, Oxford University, Oxford, United Kingdom
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Mathews N, Rivard GE, Bonnefoy A. Glanzmann Thrombasthenia: Perspectives from Clinical Practice on Accurate Diagnosis and Optimal Treatment Strategies. J Blood Med 2021; 12:449-463. [PMID: 34149292 PMCID: PMC8205616 DOI: 10.2147/jbm.s271744] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/20/2021] [Indexed: 01/27/2023] Open
Abstract
Glanzmann thrombasthenia (GT) is a rare autosomal recessive disorder of fibrinogen-mediated platelet aggregation due to a quantitative or qualitative deficit of the αIIbβ3 integrin at the platelet surface membrane resulting from mutation(s) in ITGA2B and/or ITGB3. Patients tend to present in early childhood with easy bruising and mucocutaneous bleeding. The diagnostic process requires consideration of more common disorders of haemostasis and coagulation prior to confirming the disorder with platelet light transmission aggregation, flow cytometry of CD41 and CD61 expression, and/or exon sequencing of ITGA2B and ITGB3. Antifibrinolytic therapy, recombinant activated factor VII, and platelet transfusions are the mainstay of therapy, although the latter may trigger formation of anti-platelet antibodies in GT patients and inadvertent platelet-refractory disease. The management of these patients therefore remains complex, particularly in the context of trauma, labour and delivery, and perioperative care. Bone marrow transplantation remains the sole curative option, although the venue of gene therapy is being increasingly explored as a future alternative for definitive treatment of GT.
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Affiliation(s)
- Natalie Mathews
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Georges-Etienne Rivard
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, H3T 1C5, Canada
| | - Arnaud Bonnefoy
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, H3T 1C5, Canada
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Padate B, Mansukhani D, Jijina F, Khodaiji S. Acquired Glanzmann thrombasthenia: a rare disorder. J Hematop 2020. [DOI: 10.1007/s12308-020-00421-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Mutreja D, Sharma RK, Purohit A, Aggarwal M, Saxena R. Evaluation of platelet surface glycoproteins in patients with Glanzmann thrombasthenia: Association with bleeding symptoms. Indian J Med Res 2018; 145:629-634. [PMID: 28948953 PMCID: PMC5644297 DOI: 10.4103/ijmr.ijmr_718_14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background & objectives: Glanzmann thrombasthenia (GT) is a rare, inherited autosomal recessive disorder characterized by qualitative or quantitative deficiency of integrin αIIbβ3 [glycoprotein IIb (GPIIb)/IIIa, CD41/CD61] diagnosed by absent or reduced platelet aggregation to physiological agonists, namely, collagen, adenosine-di-phosphate, epinephrine and arachidonic acid. The objective of this study was to quantitate platelet surface GPs, classify GT patients and relate the results with the severity of bleeding and platelet aggregation studies. Methods: Fifty one patients of GT diagnosed by platelet aggregation studies were evaluated for the expression of CD41, CD61, CD42a and CD42b on platelet surface by flow cytometry. The association between the clinical phenotype based on bleeding score and GT subtype on flow cytometric evaluation was assessed. Results: Twenty four (47%) patients of GT were classified as type I (as CD41/CD61 were virtually absent, <5%), six (11.8%) patients as type II (5-20% CD41/CD61) and 21 (41.2%) as type III or GT variants as they had near normal levels of CD41 and CD61. Type III GT patients had significantly lower numbers of severe bleeders (P=0.034), but the severity of bleeding did not vary significantly in type I and II GT patients. In all GT patients, mean CD41 expression was found to be lower than mean CD61 expression (P=0.002). Interpretation & conclusions: Type I GT was found most common in our patients and with lowered mean CD41 expression in comparison with CD61. Type III GT patients had significantly lower numbers of severe bleeders, but the severity of bleeding did not vary significantly in type I and II GT patients.
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Affiliation(s)
- Deepti Mutreja
- Department of Haematology, All India Institute of Medical Sciences, New Delhi, India
| | - Rahul Kumar Sharma
- Department of Haematology, All India Institute of Medical Sciences, New Delhi, India
| | - Abhishek Purohit
- Department of Haematology, All India Institute of Medical Sciences, New Delhi, India
| | - Mukul Aggarwal
- Department of Haematology, All India Institute of Medical Sciences, New Delhi, India
| | - Renu Saxena
- Department of Haematology, All India Institute of Medical Sciences, New Delhi, India
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Nurden AT. Acquired Antibodies to αIIbβ3 in Glanzmann Thrombasthenia: From Transfusion and Pregnancy to Bone Marrow Transplants and Beyond. Transfus Med Rev 2018; 32:S0887-7963(18)30037-3. [PMID: 29884513 DOI: 10.1016/j.tmrv.2018.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 05/14/2018] [Accepted: 05/20/2018] [Indexed: 11/23/2022]
Abstract
Patients with the inherited bleeding disorder Glanzmann thrombasthenia (GT) possess platelets that lack αIIbβ3 integrin and fail to aggregate, and have moderate to severe mucocutaneous bleeding. Many become refractory to platelet transfusions due to the formation of isoantibodies to αIIbβ3 with the rapid elimination of donor platelets and/or a block of function. Epitope characterization has shown isoantibodies to be polyclonal and to recognize different epitopes on the integrin with β3 a major site and αvβ3 on endothelial and vascular cells a newly recognized target. Pregnancy in GT can also lead to isoantibody formation when fetal cells with β3 integrins pass into the circulation of a mother lacking them; a consequence is neonatal thrombocytopenia and a high risk of mortality. Antibody removal prior to donor transfusions can provide transient relief, but all evidence points to recombinant FVIIa as the first choice for GT patients either to stop bleeding or as prophylaxis. Promoting thrombin generation by rFVIIa favors GT platelet interaction with fibrin, and the risk of deep vein thrombosis also associated with prolonged immobilization and catheter use requires surveillance. Although having a high risk, allogeneic bone marrow transplantation associated with different stem cell sources and conditioning regimens has proved successful in many cases of severe GT with antibodies, and often, the associated conditioning and immunosuppressive therapy leads to loss of isoantibody production. Animal models of gene therapy for GT show promising results, but isoantibody production can be stimulated and CRISPR/Cas9 technology has yet to be applied. Up-to-date consensus protocols for dealing with isoantibodies in GT are urgently required, and networks providing patient care should be expanded.
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Affiliation(s)
- Alan T Nurden
- Institut de Rhythmologie et de Modélisation Cardiaque, Plateforme Technologique d'Innovation Biomédicale, Hôpital Xavier Arnozan, Pessac, France.
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Fiore M, d'Oiron R, Pillois X, Alessi MC. Anti-α IIb β 3 immunization in Glanzmann thrombasthenia: review of literature and treatment recommendations. Br J Haematol 2018; 181:173-182. [PMID: 29611179 DOI: 10.1111/bjh.15087] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Glanzmann thrombasthenia (GT) is caused by inherited defects of the αIIb β3 platelet glycoprotein. This bleeding disorder can be treated with platelet transfusion therapy, but some patients will be immunized and begin to form anti-human leucocyte antigen (HLA) and/or anti-αIIb β3 antibodies. These antibodies can bind and interfere with the function of the transfused platelets, rendering treatment ineffective. However, platelet transfusion refractoriness attributable to HLA antibodies may be managed by the selection of compatible donors, although they are not always readily available, particularly in an emergency. Thus, anti-αIIb β3 antibodies represent one of the most severe complications in GT. Both genetic and environmental factors may contribute to the risk of anti-αIIb β3 development, but the underlying pathogenic mechanisms are still unknown. This review will summarize the current knowledge of the risk factors for development of anti-αIIb β3 antibodies in patients with GT and discuss how these findings may influence the clinical management of patients.
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Affiliation(s)
- Mathieu Fiore
- Laboratory of Haematology, Reference Centre for Platelet Disorders, University Hospital of Bordeaux, Pessac, France
| | - Roseline d'Oiron
- Centre for Haemophilia and Rare Congenital Disorders, University Hospital Paris-Sud, AP-HP, Bicêtre Hospital, Kremlin-Bicêtre, France
| | - Xavier Pillois
- Laboratory of Haematology, Reference Centre for Platelet Disorders, University Hospital of Bordeaux, Pessac, France.,Cardiovascular Adaptation to Ischaemia, Inserm U1034, Pessac, France
| | - Marie-Christine Alessi
- Laboratory of Haematology, University Hospital of La Timone, French Reference Centre for Rare Platelet Disorders, Marseille, France
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Chitlur M, Rajpurkar M, Recht M, Tarantino MD, Yee DL, Cooper DL, Gunawardena S. Recognition and management of platelet-refractory bleeding in patients with Glanzmann's thrombasthenia and other severe platelet function disorders. Int J Gen Med 2017; 10:95-99. [PMID: 28435309 PMCID: PMC5388206 DOI: 10.2147/ijgm.s128953] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Patients with rare qualitative platelet disorders or platelet function disorders (PFDs) may present to the hospital physician with severe bleeding episodes or excessive surgical bleeding. Although standard treatment consists of platelet transfusions, repeated transfusions may result in the development of antiplatelet antibodies (APA) or clinical refractoriness, rendering further platelet therapy ineffective. In such settings, an approved treatment option for patients with Glanzmann’s thrombasthenia (GT), one of the well-known rare PFDs, is recombinant activated coagulation factor VII (rFVIIa). Data regarding the efficacy of rFVIIa in patients with GT and platelet refractoriness are available from a large patient registry, an international survey, and multiple case reports and demonstrate efficacy in patients with and without refractoriness or APA. This article reviews the rFVIIa clinical data in patients with GT and platelet refractoriness and discusses clinical implications relevant to the hospital-based physician. Because uncontrolled bleeding can be life-threatening, hospital physicians should be alert to the signs of platelet refractoriness, be able to recognize continued internal or external bleeding, and know how to adapt treatment regimens for the effective management of bleeding. The management of patients who receive rFVIIa should occur in consultation with a hematologist with experience in PFDs, and patients with suspected platelet refractoriness should be referred to such a hematologist as early as possible. A critical unmet need is the development of a definition of an adequate response to platelet transfusion, which would facilitate early recognition of platelet refractoriness in patients with PFDs who exhibit a normal platelet count.
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Affiliation(s)
- Meera Chitlur
- Carman and Ann Adams Department of Pediatrics, Wayne State University and Children's Hospital of Michigan, Detroit, MI, USA
| | - Madhvi Rajpurkar
- Carman and Ann Adams Department of Pediatrics, Wayne State University and Children's Hospital of Michigan, Detroit, MI, USA
| | - Michael Recht
- Oregon Health and Science University, Portland, OR, USA
| | | | - Donald L Yee
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - David L Cooper
- Clinical Development, Medical and Regulatory Affairs, Novo Nordisk Inc., Plainsboro, NJ, USA
| | - Sriya Gunawardena
- Clinical Development, Medical and Regulatory Affairs, Novo Nordisk Inc., Plainsboro, NJ, USA
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Muhammed S, Dalal S, Adhikari K, Mathai SS. Glanzmann thrombasthenia in a child manifesting after dengue infection. Med J Armed Forces India 2016; 72:S176-S177. [DOI: 10.1016/j.mjafi.2016.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 05/13/2016] [Indexed: 11/29/2022] Open
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Haran M, Schattner A, Mate A, Starobin D, Haran G, Shtalrid M. Can a rare form of myasthenia gravis shed additional light on disease mechanisms? Clin Neurol Neurosurg 2012; 115:562-6. [PMID: 22854280 DOI: 10.1016/j.clineuro.2012.06.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 06/26/2012] [Accepted: 06/30/2012] [Indexed: 02/04/2023]
Abstract
A healthy 43-year-old physician developed gradually progressive and fluctuating fatigable muscle weakness involving ocular, limb, bulbar and respiratory muscles, with episodic acute respiratory failure, eventually necessitating intermittent non-invasive respiratory support (NIV). A mild short episode occurred 15 years earlier with complete resolution. Electromyography (EMG) studies and acetylcholine receptor (AchR) antibodies were repeatedly non-diagnostic. The diagnosis of myasthenia gravis (MG) was finally confirmed by direct measurement of diaphragmatic strength using magnetic nerve stimulation providing clear cut evidence of significant fatigable weakness and the demonstration of muscle-specific kinase (MuSK) serum antibodies using a novel cell-based assay. The cluster of several atypical features and lack of response to commonly used treatment modalities prompted a search for a unifying mechanism and better understanding of the underlying pathophysiology. Review of the literature suggested a possible impairment of excitation-contraction coupling with malfunction of a signaling protein downstream to the AchR, without an accompanying impairment of electrical transmission. This postulated mechanism, resulting in a disturbance of calcium signaling, explained the unusual features in this patient's illness and led to treatment with salbutamol and ephedrine and to significant symptomatic improvement not achieved by any other treatment.
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Affiliation(s)
- Michal Haran
- Hematology Institute, Kaplan Medical Center, Rehovot, Hebrew University Hadassah Medical School, Jerusalem, Israel
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Wiwanitkit V. Glanzmann′s thrombasthenia and molecular mimicry. INDIAN JOURNAL OF HUMAN GENETICS 2010; 16:43. [PMID: 20838493 PMCID: PMC2927795 DOI: 10.4103/0971-6866.64942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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