39 research outputs found
Protein methylation as a marker of aspartate damage in glucose-6-phosphate dehydrogenase-deficient erythrocytes
The 'Mediterranean' variant of glucose-6-phosphate dehydrogenase (G6PD) deficiency is due to the C563CT point mutation, leading to replacement of Ser with Phe at position 188, resulting in acute haemolysis triggered by oxidants. Previous work has shown increased formation of altered aspartate residues in membrane proteins during cell ageing and in response to oxidative stress in normal erythrocytes. These abnormal residues are specifically recognized by the repair enzyme L-isoaspartate (d-aspartate) protein O-methyltransferase (PCMT; EC 2.1.1.77). The aim of this work was to study the possible involvement of protein aspartate damage in the mechanism linking the G6PD defect and erythrocyte injury, through oxidative stress. Patients affected by G6PD deficiency (Mediterranean variant) were selected. In situ methylation assays were performed by incubating intact erythrocytes in the presence of methyl-labelled methionine. Altered aspartate residues were detected in membrane proteins by methyl ester quantification. We present here evidence that, in G6PD-deficient erythrocytes, damaged residues are significantly increased in membrane proteins, in parallel with the decay of pyruvate kinase activity, used as a cell age marker. Erythrocytes from patients were subjected to oxidative stress in vitro, by treatment with t-butylhydroperoxide, monitored by a rise in concentration of both methaemoglobin and thiobarbituric acid-reactive substances. L-Isoaspartate residues increased dramatically in G6PD-deficient erythrocytes in response to such treatment, compared with baseline conditions. The increased susceptibility of G6PD-deficient erythrocytes to membrane protein aspartate damage in response to oxidative stress suggests the involvement of protein deamidation/isomerization in the mechanisms of cell injury and haemolysis
Budd-Chiari syndrome in a paroxysmal nocturnal hemoglobinuria patient with previous cerebral venous thrombosis
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare
clonal stem cell disorder characterized by intravascular
hemolytic anemia that results from the clonal expansion of
hematopoietic stem cells harboring somatic mutations in an
X-linked gene, termed PIG-A (phosphatidylinositol glycan
class A). PIG-A mutations block glycosylphosphatidylinositol (GPI) anchor biosynthesis, resulting in a deficiency
or absence of all GPI-anchored proteins on the cell surface.
CD55 and CD59 are GPI-anchored complement regulatory
proteins. Their absence on PNH red cells is responsible for
the complement-mediated intravascular hemolysis, leading
to the release of free hemoglobin, which contributes to many
of the clinical manifestations of PNH including fatigue,
pain, esophageal spasm and possibly serious thrombotic
episodes [1]. Allogeneic hematopoietic stem cell transplantation is the only curative therapy for PNH. The
complement inhibitor eculizumab, a humanized monoclonal
antibody against C5, that inhibits terminal complement
activation, recently approved in the US, has been shown to
reduce hemolysis, decrease the erythrocyte transfusion
requirements and the risk for thrombosis, and to improve
quality of life of PNH patients [2, 3]. Major morbidity and
mortality with PNH are often ascribed to the development of
venous thromboembolism (VTE) [1–6], and several patients
have recurrent thromboses [7]. VTE in PNH patients occur
mostly at unusual sites. Data from a recent review report
hepatic vein thrombosis, leading to Budd-Chiari syndrome
(BCS), as the most frequent (40.7%) thrombotic complication, accounting for the majority of deaths [8], followed by
cerebral vein and sinus thromboses, superior sagittal sinus
being the most frequently involved site [8]. Inherited
thrombophilia may increase the risk of serious thromboembolic events in PNH patients [9]. In patients experiencing
VTE, early anti-thrombotic therapy (heparin, thrombolysis)
aimed to limit the extension of thrombosis, or to dissolve
formed thrombi, should improve the prognosis of this severe
complication. PNH patients suffering from VTE should be
treated with anticoagulant drugs indefinitely [1]. Thrombocytopenia often complicates PNH, and this issue must be
addressed when an anticoagulation management plan is
formulated [1]. Recurrent, life-threatening thrombosis
merits consideration for bone marrow transplantation
(BMT) [1]. Over the past few years significant advances in
other therapeutic approaches, such as transjugular intrahepatic portosystemic shunt (TIPS), have contributed to the
improvement of survival in this setting [8].
We report the case of a 29-year-old woman, R. D. The
family history was negative for VTE and cardiovascular
disease. She was a non-smoker. And had been slightly
overweight since childhood. When she was 19 years old, an
isolated moderate thrombocytopaenia (50,000/mmc) was
detected although in the absence of bleeding. As idiopathic
thrombocytopaenia was diagnosed, she was treated with
long-term steroids, with an improvement in the platelet
count (120,000/mmc). At the age of 27, while on oral
contraceptives for 3 months, she experienced a sudden
occurrence of headache and visual loss, followed by seizures and coma. A computed tomography (CT scan)
showed multiple cerebral venous thromboses. Screenings
A. Tufano (&) N. Macarone Palmieri E. Cimino
A. M. Cerbone
Regional Reference Centre for Coagulation Disorders,
Department of Clinical and Experimental Medicine,
Federico II University of Naples, Via S. Pansini, 5,
80131 Naples, Italy
e-mail: [email protected]
F. Alfinito
Division of Hematology, Federico II University of Naples,
Via S. Pansini, 5, 80131 Naples, Italy
123
Intern Emerg Med (2009) 4:75–77
DOI 10.1007/s11739-008-0182-7for congenital (antithrombin, protein C, protein S, factor V
Leiden, prothrombin G20210A mutation, C677T MTHFR
variant) and acquired (Lupus anticoagulant, antiphospholipid antibodies) thrombophilic abnormalities were negative.
At that time, according to the available clinical records,
she did not receive anticoagulant drugs, and symptoms
improved after diuretics and steroid administration.
Two years later, when she was 29 years of age, the
patient was admitted to our hospital for recurrent abdominal pain, fever and pancytopaenia (WBC 4,000/mmc; Hb
9 g/dl; platelets 61,000/mmc). Steroid treatment had been
withdrawn some weeks before the admission. Laboratory
testing confirmed anaemia (9.8 g/dl) and a low platelet
count (60,000/mmc), and also showed an increased LDH
(1605 IU/L) ALP (137 IU/L) and cGT (112 IU/L) levels
and reduced haptoglobin. An abdominal CT scan showed
hepatic and splenic enlargement with ascites and signs of
hepatic outflow obstruction, consistent with a Budd-Chiari
syndrome (Fig. 1). Lupus anticoagulant and antiphospholipid antibodies were still negative. Homocysteine levels
were normal. Cytofluorimetric investigation of peripheral
blood cell immunophenotype showed abnormalities of
complement regulatory proteins, consistent with the diagnosis of PNH [10]: 80% of red blood cells were CD59
deficient, 90% of granulocytes lacked CD 68b and 95% of
monocytes did not show CD14 on cell membrane. Almost
all hemopoesis was clonal. Bone marrow aspirate showed
dysplastic features.
Because of the thrombocytopenia, and while the patient
was under evaluation for BMT, treatment with oral anticoagulants was delayed, and therapy with full-dose
enoxaparin (100 IU/Kg bid) was started. Progressive
splenic enlargement and bone marrow failure resulted in
further reduction of the platelet count over the following
three months (30,000/mmc); therefore, heparin dosage was
reduced to 100 IU/Kg/d in order to avoid hemorrhagic
complications. Six months later she experienced recurrent
abdominal pain and ascites, compatible with a recurrence
of the Budd-Chiari syndrome, and fatal hepatic failure. Her
severe clinical condition hampered surgical or radiologic
therapeutic approaches.
Another PNH patient with a history of cerebral venous
thrombosis and Budd-Chiari syndrome is described in a
case-report published in 2005 [11]. The authors present the
case of a 26-year-old man with a previous diagnosis of
apparently idiopathic cerebral vein thrombosis, who
developed hepatic venous thrombosis, and who had laboratory tests suggestive of PNH 9 months later. This patient
underwent a TIPS, but experienced 1 month later an episode of stent blockage treated with balloon dilatation and
restenting.
In conclusion, our case report highlights that PNH
should be considered in patients with venous thrombosis at
unusual sites, especially if associated with haemocromocytometric abnormalities. Antithrombotic treatment in this
setting is mandatory, but a careful risk-to-benefit ratio
evaluation should be taken into account. A TIPS procedure
may be a useful therapeutic option for PNH patients with
Budd-Chiari syndrome, but caution is needed to prevent
stent occlusion