Whole-exome sequencing reveals a novel frameshift mutation in a consanguineous family with a hereditary coagulation factor XII deficiency.

BACKGROUND AND AIMS: We aimed to elucidate a hereditary mutation of coagulation factor XII (FXII) in a consanguineous Chinese family. METHODS: Mutations were investigated using Sanger and whole-exome sequencing. FXII (FXII:C) activity and FXII antigen (FXII:Ag) were assessed using clotting assays and ELISA, respectively. Gene variants were annotated and the likelihood that amino acid mutations would affect protein function was predicted using bioinformatics. RESULTS: Activated partial thromboplastin time was prolonged to > 170 s (reference range, 22.3-32.5 s), and FXII:C and FXII:Ag were decreased to 0.3% and 1%, respectively, (normal range for both, 72%-150%) in the proband. Sequencing revealed a homozygous frameshift mutation c.150delC (p.Phe51Serfs*44) site in the F12 gene exon 3. This mutation results in premature termination of the encoded protein translation and the protein is truncated. Bioinformatic findings indicated a novel pathogenic frameshift mutation. CONCLUSION: The c.150delC frameshift mutation p.Phe51Serfs*44 in the F12 gene likely explains the low FXII level and the molecular pathogenesis of an inherited FXII deficiency in a consanguineous family.

At What Point Are Long-Term (>5 Years) Survivors of APL Safe? A Study from the SEER Database.

BACKGROUND: Acute promyelocytic leukemia (APL) is a highly curable cancer, but it is not clear whether it is also necessary to monitor long-term toxicity in "cured" patients who survive for more than five years, which is critical to ensuring maximum survival in APL patients. METHODS: A total of 1952 APL 5-year survivors and 5973 non-APL acute myeloid leukemia (AML) 5-year survivors were included from the Surveillance, Epidemiology, and End Results (SEER) database. The standardized mortality ratio (SMR) was calculated to measure the risk of death. Cumulative mortality is calculated as the incidence of specific causes of death under competing risk events. RESULTS: The SMR of all causes of death in >5-year survivors of APL was higher than that of the general population only at 60-119 months (SMR, 1.41). This was mainly because a significant increase in mortality from AML (SMR, 87.67) and second malignant neoplasms (SMNs) (SMR, 1.56) was found only at 60-119 months. However, there was no higher risk of death from non-cancer-related disease in >5-year survivors of APL than that of the general population (SMR, 0.89). The SMR of all-cause deaths in >5-year survivors of non-APL AML decreased year by year and was no higher than that of the general population until after 216 months. The cumulative incidence of AML-related death, SMN-related death, and non-cancer-related death was significantly lower in APL patients than in non-APL AML patients throughout the follow-up period. CONCLUSIONS: Compared with the general population, the risk of death of patients with APL was higher within 5 to 10 years but not higher over 10 years. Therefore, we believe that long-term survivors of APL are safe after 10 years.

Modified immunosuppressive therapy with porcine antilymphocyte globulin plus delayed cyclosporine A in children with severe aplastic anemia.

Immunosuppressive therapy (IST) with antithymocyte globulin (ATG) and cyclosporine (CsA) is the standard treatment for children with severe aplastic anemia (SAA) with no human leukocyte antigen-matched siblings. Due to the unavailability of horse ATG in China, porcine antilymphocyte globulin (p-ALG), which is less expensive and more effective than rabbit ATG, is widely used. We sought to evaluate the efficacy and safety profile of modified IST with p-ALG plus delayed CsA at day 21 in 50 SAA children. Eighteen SAA patients who progressed from nonsevere aplastic anemia (NSAA) were classified as SAA-II; the other 32 patients were classified as SAA-I. Overall response (OR) rates at 3, 6 and 12 months were 56, 64 and 62%, respectively. The 10-year overall survival (OS) rate and disease-free survival (DFS) rate were 80 and 56%. The OR, OS and DFS rates in the SAA-I group were clearly better than those in the SAA-II group. Death rate from infection within 30 days was 4%. Modified IST with p-ALG plus delayed CsA is a reliable and well-tolerated treatment for children with SAA, and reduces early death due to infection. Modified IST is more suitable for children with SAA-I.

Rituximab as first-line treatment for acquired thrombotic thrombocytopenic purpura.

Objective To investigate the efficacy and safety of rituximab (RTX) as first-line treatment of acquired thrombotic thrombocytopenic purpura (aTTP). Methods Twenty-five patients with acute aTTP and/or severe a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) deficiency were admitted to our centre from April 2009 to March 2015. Fourteen patients received RTX plus standard therapy (plasma exchange and corticosteroids) at acute episodes. Haemoglobin, platelet count, schistocytes, lactate dehydrogenase levels, ADAMTS13 activity and its inhibitors, and the ratio of B lymphocytes in the peripheral blood, were monitored. The number of plasma exchange (PEXs), total plasma volume, remission time, relapse ratio, and adverse effects were recorded. Results The median number of PEXs was 5 (2-17) sessions and median total plasma volume was 168.43 ml/kg (62.86-469.52 ml/kg). Patients achieved haematological remission at a median of 15 days (5-22 days), and the median time of immunological remission was 2 weeks (2-8 weeks) with a median follow-up of 13 months (3-61 months). ADAMTS13 activity significantly increased after 2 weeks. The B lymphocyte percentage in peripheral blood was reduced 1 week after the first dose of RTX infusion compared with before treatment (2.21% ± 5.23% vs 18.47% ± 7.34%, P = 0.000 [the result of statistical software]), and began to gradually increase 9 months later. Severe adverse effects and relapsing TTP were not observed during therapy and follow-up. However, one patient who had sustained immunological remission died of severe pneumonia 7 months later. Conclusion Although our study was limited by its small sample number and it was a non-controlled, clinical trial, it showed potential benefits of RTX therapy for acute aTTP. RTX may be administered as a first-line therapy for lowering patients' relapse rate in the long term. Randomized, controlled trials of RTX for aTTP are required.

Development of acquired factor V inhibitor after treatment with ceftazidime: a case report and review of the literature.

We report the case of a 59-year-old Chinese man who showed an asymptomatic coagulation factor V deficiency pattern after second intravenous treatment with ceftazidime. Normal pooled plasma failed to correct the abnormalities in a mixing test, and the presence of factor V inhibitor was confirmed by the Bethesda method. The coagulopathy was not corrected by transfusion of fresh frozen plasma and prothrombin complex concentrate, but rather by treatment with prednisone and withdrawal of dubious drugs. The findings reported here should prompt clinicians to watch for drug-induced coagulation factor deficiency.

[Clinical study on Rituximab in the treatment of idiopathic thrombotic thrombocytopenic purpura].

OBJECTIVE: To study the efficacy and safety of rituximab (RTX) in the treatment of idiopathic thrombotic thrombocytopenic purpura (ITTP). METHODS: Among 17 ITTP patients, nine cases of the RTX group were administrated with RTX plus plasma exchange (PEX) and steroids. Eight cases of the control group received PEX plus steroids±other immune inhibitors. Patients received RTX 375 mg/m², 1 per week for 4 weeks. The laboratory parameters, including hemogram, LDH, ADAMTS13 activities and its inhibitors, and the ratio of B lymphocytes in peripheral blood were monitored. The number of PEX, total plasma volumes, remission time, relapse ratio and adverse effects in both groups were compared. RESULTS: The median number of PEX/median total plasma volumes in the RTX and control group were 5(2-8)/9.6(4.0-15.4) L and 6(4-9)/11.2(7.5-14.6) L, respectively. Patients in the RTX and control group achieved hematologic remission at the median time of 15(5-20) days and 22(7-36) days, respectively. And the median time of immunological remission in the two groups was 2(2-8) and 2(2-4) weeks, respectively. ADAMTS13 activities increased significantly after 2 weeks in both two groups. There was no relapse in the RTX group, while 4 patients relapsed in the control group. The percentage of B lymphocytes in peripheral blood obviously deduced one week after first dose of RTX infusion compared with the level before treatment [(2.19±5.11)% vs (18.39±7.15)%, P<0.001], and began to gradually increase 9 months later. Severe adverse events were not observed in RTX group during the therapeutic procedure and follow-up, but one patient, who had sustained immunologic remission, died of severe pneumonia 7 months later. CONCLUSION: In the treatment of ITTP, RTX in conjunction with PEX and steroids appeared to be a safe and effective therapy, with fast and sustained remission in hematology and even in immunology, with lower relapse rate and less adverse effects. But patients needed to be paid attention to prevent and treat infectious events in time.

Haematidrosis associated with epilepsy in a girl successfully treated with oxcarbazepine: case report.

The aetiology and pathological mechanisms involved in the development of haematidrosis (bloody sweat) remain unclear. There is no specific treatment for this disorder. This case report describes the clinical manifestations and treatment of a 9-year-old female with haematidrosis associated with epilepsy. The diagnosis of haematidrosis was confirmed by medical personnel who observed the bleeding and were able to rule out other causes of the bloody exudate. The episodes of bleeding were spontaneous, transient, and self-limited. Smears of the bloody exudate contained all of the components of peripheral blood. A skin biopsy taken at one site of the bloody exudate was normal, showing no signs of blood extravasation or bleeding sweat glands. The bleeding events were found to be immediately preceded by tonic seizures. An electroencephalogram indicated cerebral parietooccipital epilepsy, which was characterized by an intermittent medium-high amplitude θ rhythm (5-7 Hz) with a few spikes. The symptoms of both epilepsy and haematidrosis resolved after treatment with the antiepileptic drug 150 mg oxcarbazepine, orally, twice a day, which suggests that the epileptic seizures triggered haematidrosis in this patient.

[Abnormal expression of IL- 23/IL- 17 axis in peripheral blood of 45 patients with primary immune thrombocytopenia].

OBJECTIVE: To investigate the expression of IL- 23/IL- 17 axis in peripheral blood of patients with primary immune thrombocytopenia （ITP） and its clinical significance. METHODS: The real-time quantitative reverse transcription-polymerase chain reaction（RT-PCR）was used to determine the expression of IL-23p19, p40, p35, IL-23R, IL-12Rß1, IL-12Rß2, IL-17A, IL-17F mRNA in the peripheral blood of 45 ITP patients and 30 healthy controls. The correlations between the expression of IL-23 and IL- 17, platelet counts, serum cytokine concentrations of ITP patients were analyzed. Furthermore, nine newly diagnosed ITP patients were followed up during treatment. RESULTS: The gene expressions of IL-23p19, p40, IL-23R, IL-12Rß1, IL-17A, IL-17F in ITP patients were significantly higher than those in healthy controls, the relative expression levels of ITP were 5.58, 2.13, 4.20, 2.45, 4.29, 2.50 times as much as that of healthy controls. And elevated serum IL-23［（198.70±94.56）ng/L vs（50.72±22.97）ng/L, t= 10.06, P<0.001ï¼½, IL-17［（85.25±21.97）ng/L vs（11.39±4.27）ng/L, t=21.94，P<0.001ï¼½levels were also observed in these ITP patients. In addition, the serum IL-23 level in ITP patients was positively correlated with IL-17（r=0.496, P<0.01）, but negatively correlated with the platelet counts（r=-0.408, P<0.01）, and IL-17 level was negatively correlated with platelet counts（r=-0.464, P<0.01）. CONCLUSION: The IL-23/IL- 17 expression in ITP patients was significantly elevated, indicating IL-23/IL-17 play an important role in the pathogenesis of ITP.

Effective treatment with para-aminomethylbenzoic acid for chronic disseminated intravascular coagulation associated with aortic dissection.

Chronic disseminated intravascular coagulation is a rare complication of aortic dissection. Surgical correction or low molecular weight heparin is treatment of choice, but for a severe bleeding problem due to excessive fibrinolysis, para-aminomethylbenzoic acid would be a simple and effective therapeutic approach.

Efficacy and safety of immunosuppressive therapy in the treatment of seronegative hepatitis associated aplastic anemia.

OBJECTIVE: To investigate the clinical characteristics of seronegative hepatitis-associated aplastic anemia (AA) (SNHAA) and hepatitis B virus (HBV) infection complicating AA (HBVAA), and thereby compare the efficacy of immunosuppressive therapy (IST). METHODS: An analysis was conducted on the clinical data of ten patients with SNHAA out of 332 cases of AA from our center at AA diagnosis, and on the efficacy of IST. This was compared to 22 cases of HBVAA at AA onset as well as the associated IST outcomes. RESULTS: Nine patients with SNHAA developed severe aplastic anemia, with a median age of 18 years. After IST, six (60%) of the SNHAA patients achieved complete remission and two achieved partial remission. The patients with HBVAA had a total response rate of 82.3%. The disease recurred in two HBVAA patients. No statistically significant differences were observed in response rate, mortality, and recurrence rate between both groups. As compared with HBVAA, patients with SNHAA had a shorter interval from the acute episode of hepatitis to AA onset (4 months versus 92 months, P=0.00), a quicker response to IST (2.5 months versus 4.5 months, P=0.018), a lower proportion of bone marrow hematopoietic tissues (20.6% versus 23.6%, P=0.03), and lower white blood cell and absolute neutrophil count (0.8 × 10(9)/L versus 1.23 × 10(9)/L and 0.26 × 10(9)/L versus 0.58 × 10(9)/L, P=0.026 and P=0.0009, respectively). No significant liver damage or hepatitis B fulminant infection was observed in either group during the follow-up. CONCLUSION: The prevalence of SNHAA is 3.01%. SNHAA often presents as severe AA and responds to IST quickly. Neither hepatitis prior to AA nor AA complicating HBV infection have been shown to influence the early efficacy of IST and adverse events, and HBV may not be the causative agent of AA.

[The diagnostic value of protein induced by vitamin K absence or antagonist-II in non-infant patients with acquired deficiency of vitamin K-dependent coagulation factors].

OBJECTIVE: To explore the diagnostic value of protein induced by vitamin K absence or antagonist -II(PIVKA-II) in non-infant with acquired deficiency of vitamin K-dependent coagulation factors(ADVKCF). METHODS: PIVKA-II levels were measured by ELISA in 50 patients with ADVKCF on day 0, 3, 7 after vitamin K treatment. Prothrombin time(PT), APTT, FII: C, FVII: C, FIX: C, and FX: C were analyzed simultaneously. Twenty healthy subjects were enrolled as controls. RESULTS: The average level of PIVKA-II in ADVKCF group was (3.83 ± 1.40)µg/L, while (1.30 ± 0.54) µg/L in the control group (P < 0.05). The PIVKA-II levels on day 0 and 3 did not show significant difference [(3.83 ± 1.40) µg/L vs (3.79 ± 0.66) µg/L, P > 0.05], but decreasing significantly on day 7 compared to the control group(P < 0.05). The PIVKA-II level was (3.78 ± 1.30) µg/L in patients receiving plasma transfusion, while (3.91 ± 1.49)µg/L in no-plasma-transfusion group (P > 0.05). Coagulation factors II, VII, IX and X activity which decreased significantly before treatment returned to normal range after one week use of vitamin K, leading to complete correction of prolonged APTT and PT (>100 seconds). CONCLUSIONS: The PIVKA-II level in ADVKCF patients is significantly higher than that of healthy subjects within one week treatment of vitamin K, which is not influenced by plasma transfusion. This study suggests that PIVKA-II is a more sensitive parameter than APTT, PT and the activity of coagulation factor, which could be a valuable factor in the early diagnosis of ADVKCF.

Research on the roles of transcription factors T-bet and GATA-3 in aplastic anemia.

BACKGROUND: Aplastic anemia (AA) is a type of bone marrow hematopoietic system disease. The immune mediated hematopoietic inhibition is recognized as the most common pathogenesis of AA. However, the roles of the T-bet/GATA-3-mediated cell immune disorder in aplastic anemia (AA) is still unknown. METHODS: Experimental samples were obtained from 27 patients with AA, including 15 cases of severe AA (SAA) and 12 cases of immune mediated AA (MAA), and 25 healthy volunteers (control group). The secretory levels of IFN-gamma and IL-4 cytokines were determined by ELISA. The mRNA expression levels of transcription factors T-bet, GATA-3, and FoxP3 were measured in PBMCs by RT-PCR. Th1, Th2, and T lymphocyte subsets were detected in peripheral blood by flow cytometry. RESULTS: Compared to the healthy control group, the expression of T-bet mRNA and the percentage of Th1-type cells in the AA group significantly increased (p < 0.01), while the expression of GATA-3 and FoxP3 mRNA and the percentage of Th2-type cells decreased sharply (p < 0.05, p < 0.01). Compared with MAA, the expression of T-bet mRNA and the percentage of Th1-type cells increased significantly in SAA (p < 0.01); meanwhile, the expression of GATA-3 mRNA and the proportion of Th2-type cells decreased noticeably (p < 0.05, p < 0.01). Particularly, the percentage of CD3+ and CD3+CD8+ T cells in the AA group increased (p < 0.05), while the percentage of CD3+CD4+, CD4+CD25+, and CD4+CD8+ cells decreased (p < 0.05, p < 0.01). CONCLUSIONS: Abnormal expression of the transcription factors T-bet and GATA-3 contributes to the imbalance of Thl/Th2 lymphocytes associated with immune dysfunction, leading to the development and progression of AA.

Valproic acid-associated low fibrinogen and delayed intracranial hemorrhage: case report and mini literature review.

A 41-year-old male had suffered from gradual hearing loss in his right ear for 2 years. Head computed tomography and magnetic resonance imaging scans showed a neoplasm in the cerebellopontine angle region, which was confirmed by the diagnosis of acoustic neurilemmoma by pathological findings after surgery. Following surgery, he routinely received valproic acid (VPA) to prevent seizures. However, the patient presented with hypofibrinogenemia and cerebral hemorrhage after taking VPA for 12 days. The hypofibrinogenemia recurred when VPA was re-administered. After withdrawal of VPA, his fibrinogen concentration rose to normal within several days. As far as we are aware, this is the first case of cerebral hemorrhage due to VPA to have been reported. Herein, as well as reporting on this case, a mini review of the relevant literature is also presented.

Extramedullary plasmacytoma in the presence of multiple myeloma: clinical correlates and prognostic relevance.

OBJECTIVE: We studied the clinical and laboratory features and outcomes of multiple myeloma (MM) with extramedullary plasmocytoma (EP) disease both at diagnosis and during the course of MM. PATIENTS AND METHODS: Forty-two patients of 467 patients with MM were retrospectively analyzed from both the 100th Hospital of the People's Liberation Army and Shanghai Changzheng Hospitals. The clinical characteristics, laboratory parameters, responses, risk factors, and outcomes were analyzed. RESULTS: The median age was 53 years with a male/female sex ratio of 34:8. Twenty-six patients had EP disease at the time of diagnosis, and 16 patients developed EP during the course of the disease. We found that the Durie-Salmon stage, serum lactate dehydrogenase level, beta-2-microglobulin, complete blood counts, albumin, and the type of immunoglobulin (Ig) were not associated with the development of EP disease. Patients who developed EP during the course of MM had a higher ratio of plasmocytes and premature plasmocytes in the bone marrow with lower C-reactive protein level and earlier stage of International Staging System for Lung Cancer at the diagnosis of MM compared with patients who presented with EP at diagnosis. Once the patients developed EP disease, they frequently showed resistance to chemotherapy. With a median follow-up of 30 months, 19 patients were alive. Log-rank univariate analysis showed that patients with EP who had normal C-reactive protein, higher hemoglobin, lower serum lactate dehydrogenase, and stage I of International Staging System for Lung Cancer had longer survival. However, cyclooxygenase multivariate analysis failed to show statistical significance for any factor. CONCLUSIONS: EP disease is the MM end-phase and is not a rare manifestation of MM with a cumulative incidence of 9% of MM. The prognosis is very poor once the diagnosis of EP disease is concurrent with MM.

Clinical study of thalidomide combined with dexamethasone for the treatment of elderly patients with newly diagnosed multiple myeloma.

OBJECTIVE: To investigate the relationship between the efficacy and safety of different doses of thalidomide (Thal) plus dexamethasone (Dex) as the initial therapy in elderly patients with newly diagnosed multiple myeloma (MM). METHODS: Clinical data of 28 elderly patients with newly diagnosed MM who underwent the TD regimen as the initial therapy were analyzed retrospectively. The patients were divided into two groups according to the maximal sustained dose of Thal: lower dose (group A) and higher dose (group B). The overall response rate (ORR), progression free survival (PFS), overall survival (OS), and adverse events (AES) were compared between the two groups. RESULTS: A total of 28 patients were followed up with a median of 18 months. The ORR was 60.1%. The median response time and PFS were 2.0 and 17.0 months, respectively. The mean sustained dose of Thal in group B was significantly higher than group A (292.9 mg v 180.4 mg, P=0.01). There was no significantly difference in ORR (57.1% v 64.3%, P=1.00) and PFS (9.63months v 17.66 months, P=0.73) between groups A and B. During the follow up, only five patients died (<40%) and, therefore, median OS values were not available. It is estimated, however, that the mean survival time in the two groups was 35.6 and 33.4 months (P>0.05), respectively. All of the patients tolerated the treatment well. The incidence of AES in patients with a grading above 3 in group B was significantly higher than in group A (P=0.033). CONCLUSIONS: The TD regimen results in a high response rate and manageable AES as the initial therapy in elderly patients with MM. TD should be considered as the front line regimen for the treatment of elderly patients with MM in areas with financial constraints. The clinical response can be achieved at a low dose Thal with minimal toxicity.

Treatment of vitamin K-dependent coagulation factor deficiency and subarachnoid hemorrhage.

BACKGROUND: In adults, vitamin K-dependent coagulation factor deficiency (VKCFD) increases in the recent years. We treated a VKCFD patient with subarachnoid hemorrhage, with favorable outcomes. METHODS: A 19-year-old male student with VKCFD was treated at our hospital. The initial treatment was injection of a large dose of vitamin K and fresh plasma, and then with oral high dose of vitamin K4. RESULTS: At 4 weeks after admission, the focus of hemorrhage subsided, neurological examination was normal, and the patient was discharged. CONCLUSIONS: VKCFD is rare and its diagnosis should be based on the history of the patient and the results of laboratory examinations. A large dose of vitamin K is the first choice of treatment.

[Pathology, diagnosis and treatment of a patient with hemotidrosis.].

OBJECTIVE: To investigate the pathology, diagnosis and treatment of a patient with hemotidrosis. METHODS: Coagulation tests, coagulation factor activities, von Willebrand factor concentration, bleeding time and platelet aggregation were measured. The bloody exudates from the skin was examined under light microscopy. The involved skin area biopsy was examined histologically. RESULTS: The bloody exudates contained all kinds of normal blood cells mixed with sweat-like fluid, rather than true-sweat. Histopathologic examination showed normal sweat gland structure without blood cells. The patient was successfully treated with propranolol. CONCLUSION: Sympathetic nerve activation in the vasculature might play a role in hemotidrasis, and beta-blockers might be an effective drug for treatment.