Multilineage hemopoietic stem cell defects in Budd Chiari syndrome

BACKGROUND/AIMS

Erythropoietin-independent endogenous growth of erythroid colony from bone marrow cells has been shown in many patients with Budd Chiari syndrome in earlier studies. In another report, increased megakaryocyte colony growth has also been documented in this disease. However, defects in granulocyte-macrophage cell lines in Budd Chiari syndrome have yet to be reported in the literature.

METHODS

Both in vitro erythroid and granulocyte-macrophage colony cultures from peripheral blood mononuclear cells with and without erythropoietin or granulocyte-macrophage colony stimulating factor, respectively, were studied in 32 patients with Budd Chiari syndrome, along with 20 normal healthy controls and ten patient controls with portal hypertension (five patients each with noncirrhotic portal fibrosis and liver cirrhosis). In 18 patients the occlusion was only in the inferior vena cava, in five patients only in hepatic veins, and in nine patients both inferior vena cava and hepatic veins were blocked.

RESULT

Endogenous erythroid or granulocyte-macrophage colony growth was not observed in any of the normal healthy controls or in patient controls with portal hypertension. However, 22 of the 32 (68.8%) patients showed endogenous erythroid colony growth. Moreover, four of them also showed endogenous growth of granulocyte-macrophage colony, not previously reported in Budd Chiari syndrome.

CONCLUSION

It may be inferred that stem cell defects affecting all three hemopoietic cell lines (erythroid, megakaryocyte and granulocyte-macrophage) occur in Budd Chiari syndrome, which may be the primary defect responsible for the pro-thrombotic state causing venous thrombosis in them.

Platelet ultra-structure study in Budd-Chiari syndrome

Morphologic characteristics of circulating platelets were studied in 20 patients with primary Budd-Chiari syndrome (BCS) without any known etiology, using transmission electron microscopy (TEM). Significant platelet ultrastructural changes were observed in all the patients (in 10-->90% platelets) as compared to 20 normal healthy controls (in up to 4% of their platelets). The prominent changes in the platelets were paucity or absence of alpha granules, hypertrophy of the open canalicular systems (OCS) and clumping and fusion of the granules and other organelles in the centre of platelets. Some other changes observed in platelets were dilated channels of OCS, pseudopodial protrusion of cytoplasm and presence of prominent masses of glycogen particles. Platelets from 20 normal controls processed along with the patients' platelets showed only a few such abnormalities. Most of these changes observed in patients' platelets were akin to the changes observed in platelets undergoing activation. Assay of plasma beta-thromboglobulin showed significantly higher levels in all the patients (p < 0.001) further confirming on-going in vivo platelet activation with morphologic changes most likely reflecting the thrombotic process present in BCS patients.

Asymptomatic visceral leishmaniasis in a child with acute lymphoblastic leukaemia

Visceral leishmaniasis was detected incidentally in a patient with acute lymphoblastic leukaemia in remission, during maintenance therapy. Absence of fever, a normal haemogram, normal serum globulins, a negative serology and testicular involvement were the hallmarks of the case. Treatment with sodium stibogluconate (20 mg/kg for 55 days) failed. Subsequent therapy with pentamidine resulted in complete parasite clearance. Prolonged therapy with pentavalent antimony compounds or a higher dose of second line drugs such as pentamidine are recommended for complete clearance.

Lupus anticoagulant and anticardiolipin antibodies in systemic lupus erythematosus

BACKGROUND

Lupus anticoagulant and anticardiolipin antibodies are antiphospholipid antibodies which have been independently associated with a high incidence of thrombotic diseases. However, the importance of their combined occurrence has not yet been examined.

METHODS

We investigated 70 patients with systemic lupus erythematosus for the presence of anticardiolipin antibodies paying particular attention to a history of thrombosis and abortion. Lupus anticoagulant was detected using the kaolin clotting time, its mixing tests with normal plasma and the inosithin neutralization test. Anticardiolipin antibodies were detected using the ELISA technique.

RESULTS

Lupus anticoagulant was detected in 11 patients (16%) and anticardiolipin antibodies in 13 (19%). Six patients were positive for both lupus anticoagulant and anticardiolipin antibodies. These patients had a higher incidence of thrombosis or recurrent abortion (5 of 6) compared to those with lupus anticoagulant (2 of 5) or anticardiolipin antibodies alone (1 of 7). The amount of inosithin required to neutralize lupus anticoagulant was greater [mean (SD) 27.5 (20.5) micrograms] in patients with both lupus anticoagulant and anticardiolipin antibodies than in patients with lupus anticoagulant alone [mean (SD) 4.0 (5.4) micrograms].

CONCLUSION

The presence of lupus anticoagulant is associated with thrombosis and recurrent abortion which are more frequent when both lupus anticoagulant and anticardiolipin antibodies are present and these patients probably have more severe disease as the amount of inosithin required to neutralize the lupus anticoagulant was greater.

Prognostic role of screening tests of haemostasis and underlying diseases in acute disseminated intra-vascular coagulation in adults

The significance of precipitating causes of acute disseminated intra-vascular coagulation (DIC) and the severity of derangement of haemostasis based on laboratory investigations carried out initially were evaluated in 98 patients and was related to the fatal outcome in them. It was seen that septicaemia was the commonest precipitating cause. Survival was better in patients in whom DIC was precipitated by obstetric causes compared with those with septicaemia (P < 0.01). Death was also more frequently associated in patients with higher prothrombin time (PPT) ratio (> 1.5) and/or higher activated partial thromboplastin time (APTT) ratio (> 2.5) as compared to their lower values (P < 0.01 each). Death occurred in all the seventeen patients in whom septicaemia was present along with PPT ratio of > 1.5. It is concluded that deranged haemostasis and presence of septicaemia both independent of each other, contribute to the fatal outcome in acute DIC. Combination of both is associated with poorest prognosis.

Platelet function disorders in north India

BACKGROUND

Platelet function disorders are a fairly common cause of bleeding manifestations. Although their relative types and incidence are well documented, data from India are lacking.

METHODS

Between 1970 and 1991, we studied the clinical and laboratory features of 144 north Indian patients who presented to our hospital with a bleeding diathesis in whom coagulation disorders, von Willebrand's disease and a history of drug ingestion were absent.

RESULTS

Isolated platelet factor 3 availability defect was the commonest (56 cases) followed by the thrombasthenias (49 cases), arachidonic acid pathway defect (26 cases), storage pool disease (8 cases) and the Bernard-Soulier syndrome (3 cases). Isolated platelet factor 3 deficiency was rare (2 cases). Two varieties of thrombasthenia were seen--the classical Glanzmann's (13 cases) and thrombopathic (36 cases). The latter was characterized by absent or sub-normal platelet aggregation with agonists along with a reduced (to less than 50% of normal) total platelet factor 3 content. This has not been reported from western countries. Patients with classical Glanzmann's thrombopathic thrombasthenia with absent platelet aggregation and isolated platelet factor 3 deficiency were severe bleeders. Their family history suggested an autosomal recessive transmission in Glanzmann's and thrombopathic thrombasthenia and a possible autosomal dominant transmission in isolated platelet factor 3 availability defect and isolated platelet factor 3 deficiency.

CONCLUSION

The frequency of various types of platelet function disorders in Indians is similar to that in western populations except that the incidence of thrombopathic thrombasthenias is higher in India.

Inosithin neutralization test to measure lupus anticoagulants

The inosithin neutralization test was performed in 14 patients in whom lupus anticoagulant was detected. To test its specificity, it was also performed in 10 patients with severe hemophilia and in three patients with Factor VIII inhibitors. Prolonged kaolin clotting time was corrected by adding varying amounts of inosithin (Asolectin, 0.19 to 100 micrograms), a soybean-derived phospholipid, in all patients with lupus anticoagulant but not in patients with hemophilia or in two patients with Factor VIII inhibitors. In one patient, both Factor VIII inhibitors and lupus anticoagulant were present. The concentration of lupus anticoagulant in a patient was expressed as the amount of inosithin (measured in micrograms) required to normalize the prolonged kaolin clotting time. This amount correlated significantly with the occurrence of thrombosis and/or recurrent abortion. The inosithin neutralization test is useful to measure lupus anticoagulant.

Efficacy of intrathecal methotrexate with and without cranial radiotherapy in preventing central nervous system relapses in acute lymphocytic leukemia

Introduction of CNS chemoprophylaxis was a major milestone in the development of current therapy for acute lymphocytic leukemia. However, controversies are still existing for ideal form of CNS chemoprophylaxis. The present study was conducted to determine the efficacy of intrathecal methotrexate (IT-MTX) with and without cranial radiotherapy in preventing CNS relapses in Indian children. CNS chemoprophylaxis comprising of six injections of intrathecal methotrexate (12 mg/M2) was administered alone or along with cranial radiotherapy (2000 GY) in 76 children each after successful induction remission. Cranial radiotherapy (RT) with intrathecal methotrexate (IT-MTX) was observed to be more effective as CNS relapses were seen in 11.8% of children as compared to 16.8% of children receiving IT-MTX alone. IT-MTX along with cranial RT delayed the occurrence of CNS relapses and prolonged the event free survival periods.

Evaluation of four coagulation tests to detect plasma lupus anticoagulants

Lupus anticoagulant was detected in 205 newly diagnosed, untreated patients with systemic lupus erythematosus by the following tests: kaolin clotting time, activated partial thromboplastin time, plasma prothrombin time, and, in the last 99 patients, by dilute Russell's viper venom time. In 10 patients, lupus anticoagulant was detected by kaolin clotting time prolongation, corrected by inosithin but not by normal plasma; 12 and 6 of them had prolonged activated partial thromboplastin time and partial plasma prothrombin time, respectively. Only 10 patients had a history of recurrent abortions and/or thrombosis, nine of whom had lupus anticoagulant as shown by the kaolin clotting time test. Of the 99 patients studied by all four tests, 9 showed lupus anticoagulant by both kaolin clotting time and dilute Russell's viper venom time; 7 had a history of abortion and/or thrombosis. The dilute Russell's viper venom time test is easy to perform and not affected by inhibitors to factor VIII or IX. It is recommended as a primary screening test for lupus anticoagulant detection in a hospital clinical laboratory.

A clinico-haematologic profile of paroxysmal nocturnal haemoglobinuria

Clinico-haematological parameters in sixteen patients of paroxysmal nocturnal haemoglobinuria (PNH) are presented. Their modes of presentation included recurrent episodes of cola-coloured urine (6/16), refractory anaemia (9/16) and predominant thrombotic manifestations (1/16). Laboratory investigations revealed the presence of anaemia (16/16), reticulocytosis (14/16), thrombocytopenia (11/16), leucopenia (5/16) and cellular bone marrow (14/16). Two patients had hypoplastic bone marrow initially but subsequently developed PNH. The patients were treated with haematinics, prednisolone (16/16) and oxymethalone (2). Prednisone was effective in suppressing haemolytic episodes. Oxymethalone given to the 2 patients with hypoplastic bone marrow resulted in amelioration of anaemia in one but no effect in the other patient.

Effect of calcium channel blocker (diltiazem) on platelet aggregation

Platelet aggregation with collagen, ADP and sodium arachidonate was significantly inhibited by 0.48 and 0.24 mg/ml of diltiazem but no significant effect occurred with 0.024 mg/ml of diltiazem. It is suggested that the antiplatelet property of diltiazem may be utilized in clinical setting and diltiazem may be tried synergistically with other antiplatelet drugs.

Congenital factor XIII deficiency: two case reports

Two patients with factor XIII deficiency, presenting with bleeding disorder since birth, are reported. The condition is rare and is likely to be missed unless clot solubility in 5 M urea is performed as a screening test in all patients with bleeding disorders. A correct diagnosis is essential as prophylactic management is practicable in this disorder.

Lupus anticoagulants in systemic lupus erythematosus: prevalence and clinical associations

The prevalence of lupus anticoagulant (LAC) and its relation with reported clinical associations has been determined in 55 patients with systemic lupus erythematosus (SLE) from northern India who were studied prospectively. Kaolin clotting time was used to screen for LAC, which was detected in seven (13%) of the patients. Significant associations were found between LAC and thrombotic events, onset of disease at an early age, and disease of shorter duration. No statistically significant association could be found between LAC and recurrent abortions, pulmonary hypertension, thrombocytopenia, and neurological manifestations. It is concluded that LAC is a useful marker for a subset of patients with SLE at risk of thromboembolic events.

Evaluation of factors predisposing to arterial thrombosis in coronary artery disease

Estimation of antithrombin III, alpha 2 macroglobulin and alpha 1 antitrypsin in patients with stable and unstable angina and acute myocardial infarction (15 cases each) were carried out. Twenty age, sex and weight matched healthy subjects were included as controls. Mean platelet factor 4(PF4) levels measured in 10 cases of each subgroup were significantly elevated in myocardial infarction (MI) (48.4 +/- 15.16 ng/ml) and III unstable angina patients (44.7 +/- 15.9 ng/ml) as compared to controls (25.42 +/- 12.47 ng/ml; P less than 0.01). Mean antithrombin III (AT III) levels were markedly reduced in all patients with MI (39.65 +/- 12.8% of normal pooled plasma) and unstable angina (37.9 +/- 16.6% of normal pooled plasma) and in 9 patients with stable angina. Alpha I antitrypsin and alpha 2 macroglobulin levels in these cases showed no significant difference compared to normals. Reduced AT III in coronary artery disease suggests a prethrombotic tendency in these patients. Raised PF4 levels in acute phase of the disease suggests heightened platelet activation.

Cord blood red-cell enzymes and reduced glutathione in Indian neonates, normal and with pathologic jaundice

Red-cell enzymes and reduced glutathione (GSH) were assayed on cord blood in 307 Indian neonates. On follow-up, 20 of them developed pathologic jaundice. Of these, six had red-cell enzyme/GSH deficiency, seven had associated non-enzymatic causes of jaundice, and in the remaining seven the cause could not be diagnosed. In 41 other neonates, there was enzyme/GSH deficiency without pathologic jaundice. The degree of enzyme deficiency had no relation with jaundice. Red-cell enzyme/GSH deficiency state in neonates was associated with pathologic jaundice more frequently (six of 47; 12.8%) than in the absence of such deficiency (14 of 260; 5.4%). None of the jaundiced patients had very high levels of bilirubin nor needed exchange blood transfusion. There was no reduction in haemoglobin level in the enzyme/GSH deficient group with jaundice in comparison with non-deficient jaundiced neonates or normal subjects. The incidence of red-cell enzyme/GSH deficiency appears to be high in Indian neonates; however, the majority of them do not precipitate pathologic jaundice.

Evaluation of a micromethod for detection of G-6-PD deficiency

A simple and inexpensive micromethod based on methaemoglobin reduction technique (MRT) for screening of glucose-6 phosphate dehydrogenase deficiency has been studied using reagent-impregnated curvettes incubated in a makeshift waterbath. The cuvettes shelf life has been tested upto nine months. As the test can be done with finger prick blood, it promises to be more acceptable in the field. The sensitivity of this is similar to classical MRT.

Coagulation abnormalities in systemic lupus erythematosus

Coagulation profile was studied in 55 patients of systemic lupus erythematosus (SLE). Abnormal kaolin clotting time (KCT) was observed in fewer patients (12.9%) as compared to abnormal Russel's viper venom time (RVVT, 20.4%) or activated partial thromboplastin time (APTT, 32.7%). Prolonged prothrombin time (PT), observed in 7.3 per cent patients was not found to be a sensitive test for lupus anticoagulant (LAC). The correction of RVVT and KCT on addition of inosithin suggested a deficiency of platelet lipid factor in these patients. The initial value of uncorrected KCT in patient's plasma did not correlate with the amount of inosithin required for neutralisation. Occurrence of thromboembolic events was significantly associated with prolonged KCT. No other clinical feature showed significant association with any coagulation abnormality.

Platelet function in type I (insulin dependent) diabetes without vascular disease

In 10 patients of type I diabetes who were free from clinically apparent vascular disease, platelet functions were studied prior to control, and 10 days and 3 months after strict metabolic control. Platelet hyperactivity, seen as significant shortening of latent period and increase in rate and degree of aggregation, present in patients in the initial uncontrolled state, but absent at the subsequent two periods did not correlate with glycosylation of haemoglobin. Thus control of diabetes mellitus, capable of reversing platelet hyperactivity, is reflected by blood sugar levels, and not by the glycosylation status of haemoglobin.

Disseminated intravascular coagulation in post-dysenteric haemolytic uraemic syndrome

Coagulation studies were carried out in 14 children with haemolytic uraemic syndrome that followed acute dysentery. Stool cultures showed Shigella dysenteriae in 3 cases and were sterile in the remainder. Prolongation of the prothrombin time, activated partial thromboplastin time and thrombin time and raised levels of fibrinogen degradation products were found in 12 cases, indicating the presence of disseminated intravascular coagulation. Renal histologic examination showed cortical necrosis in 7 cases, which was extensive in 5 and patchy in 2. Disseminated intravascular coagulation may have a role in the pathogenesis of haemolytic uraemic syndrome associated with acute dysentery.

Vitamin B12, folate, and iron studies in homozygous beta thalassemia

The efficacy of serum folate (SF), red blood cell folate (RCF), and serum B12 in diagnosing folate and B12 deficiency, and the effect of iron overload on hemoglobin, were studied in 157 cases of homozygous beta thalassemia (HBT). The patients had lower SF compared with normal subjects (NS) (P less than 0.001) and higher RCF than their parents (P less than 0.001) and NS (P less than 0.001). Forty percent of patients had both low SF (less than 3 ng/mL) and high RCF (greater than 600 ng/mL). Homozygous beta thalassemia patients are known to have folate deficiency. Yet, both folate and B12 deficiency status were similar in the authors' patients and NS. These deficiencies apparently were less in patients compared with their parents, who shared the same nutritional milieu (P less than 0.001). Mean hemoglobin in patients with iron overload (transferrin saturation, TS greater than 50%) was lower than in those without (P less than 0.005). The following is concluded: (1) diagnosis of folate and B12 deficiency based on SF, RCF and serum B12 is vitiated in HBT and needs a therapeutic trial; (2) iron overload of a magnitude indicated by TS greater than 50% can aggravate anemia in HBT.

A study of serum ferritin in beta thalassemia. Iron deficiency and overload

Serum ferritin, serum iron, and unsaturated iron binding capacity were studied in 64 patients with beta homozygous thalassemia (BHT), 120 patients with beta heterozygous thalassemia, and 46 normal subjects. Incidence of iron overload seen in 32 BHT cases was similar in untransfused and transfused cases. Among heterozygotes, iron stores were depleted in 24 (20%), mostly females (70.8%). Only male heterozygotes but not normals were iron deficient. In 18 (75%) heterozygotes with depleted iron stores, transferrin saturation (TS) was normal. It was also normal in 8 (25%) BHT patients and 5 (100%) heterozygotes with iron overload. In 13 (35.1%) BHT patients, it was raised in the absence of iron overload. It was concluded that iron deficiency in heterozygotes is of greater magnitude, especially in females, than hitherto known in India. Transferrin saturation is not a good indicator of either iron depletion or overload. Iron supplementation is recommended in heterozygous beta thalassemia in infants, children, and expectant mothers in geographic areas with high incidence of iron deficiency.