Acquired hemophilia in an elderly person / Hemofilia adquirida en un anciano

Abstract Acquired hemophilia is a rare but highly fatal hemostatic disorder that occurs predominantly in elderly people. It is a disorder secondary to the development of specific autoantibodies directed against coagulation factor VIII. It is characterized by potentially fatal gastrointestinal, pulmonary, retroperitoneal, soft tissue or intracranial hemorrhages, so it requires early diagnoses and effective treatments. The present case is of a 78-year-old man with sudden onset gastrointestinal hemorrhage associated with ecchymosis and hematomas in soft tissues, with the complication of a laryngeal hematoma. He had a prolonged partial thromboplastin time (PTT), elevated factor VIII levels and elevated factor VIII inhibitorst. (Acta Med Colomb 2019; 44. DOI:https://doi.org/10.36104/amc.2019.1207).

Resumen La hemofilia adquirida es un trastorno hemostásico poco frecuente pero altamente fatal que se presenta predominantemente en personas ancianas. Es un trastorno secundario al desarrollo de autoanticuerpos específicos dirigidos contra el factor de coagulación VIII. Se caracterizan por debutar hemorragias potencialmente fatales a nivel gastrointestinal, pulmonar, retroperitoneal, de tejidos blandos o intracraneal, por lo que requiere diagnósticos tempranos y tratamientos eficaces para su tratamiento. El presente caso es de un hombre de 78 años con hemorragia gastrointestinal asociado a equimosis y hematomas de aparición súbita en tejidos blandos y como complicación presenta hematoma laríngeo, con tiempo parcial de protrombina (PTT) prolongado, niveles de factor VIII elevados y niveles de inhibidor de factor VIII elevados. (Acta Med Colomb 2019; 44. DOI:https://doi.org/10.36104/amc.2019.1207).

Caracterização da resposta imune in situ nas lesões de hanseníase indeterminada / Characterization of the in situ immune response in indeterminate leprosy

A forma indeterminada é a fase inicial da hanseníase, que se caracteriza histologicamente pelo infiltrado inflamatório leve, não granulomatoso, de linfócitos e histiócitos ao redor de vasos, anexos e nervos. No local de entrada do M. leprae, as células apresentadoras de antígeno do tipo células dendríticas são as primeiras a encontrar o bacilo. Este, no interior de células dendríticas, desencadeia a produção local de citocinas e quimiocinas, que resultam em proliferação de linfócitos T helper 1 ou T helper 2, assim definindo uma resposta imune celular ou humoral, respectivamente. As lesões tuberculoides mostram predominância das citocinas de padrão Th1 como IL-2, TNF-alfa, IFN-y, IL-12 e IL-18, enquanto que nas lesões virchowianas predominam citocinas de padrão Th2, como IL-4, IL-5, IL-10 e TGF-beta. Na pele, as principais células dendríticas são células dendríticas mieloides, células de Langerhans e alguns dendrócitos dérmicos. São identificadas respectivamente pela expressão imuno-histoquímica de S100, CD1a e Fator XIIIa. Células de Langerhans e dendrócitos dérmicos Fator XIIIa positivos estão aumentados em quantidade nas lesões tuberculoides quando comparadas com lesões virchowianas. Os objetivos do presente estudo foram: 1) caracterizar a inflamação "in situ" na hanseníase indeterminada através da quantificação das marcações imuno-histoquímicas de: CD57, CD4, CD8, CD1a, S100, FXIIIa, CD68, Foxp3, CD123, IL-1, IL-2r, IL-4, IL-6, IL-8, IL-10, IL-12, IL-18, IFN-, TNF-alfa, TGF-beta, iNOS, granzima B, receptor Toll-like 2/4, e antígeno BCG, 2) comparar o perfil fenotípico e citocínico das lesões na hanseníase indeterminada entre grupos de reação de Mitsuda positiva e negativa, a fim de investigar se existem padrões que possam prever para qual forma a doença evoluiria, e 3) revisar a histopatologia da forma indeterminada através da análise semiquantitativa das alterações vistas à coloração de hematoxilina/eosina. Foram selecionadas 15 lesões de pacientes...

The indeterminate form is the initial stage of leprosy, which is characterized histologically by mild inflammatory infiltrate, non granulomatous, with lymphocytes and histiocytes around vessels, nerves and adnexals. When M. leprae enter the host, antigen-presenting cells of dendritic type are the first cells to find the bacillus. Once inside dendritic cells, the bacillus elicits local production of cytokines and chemokines, which result in proliferation of T lymphocytes helper 1 or T helper 2, thereby defining a cellular or humoral immune response, respectively. The tuberculoid lesions show predominance of Th1 cytokines such as IL-2, TNF-alfa, IFN-y, IL-12 and IL-18, whereas in the lepromatous lesions predominate cytokines of Th2 pattern such as IL-4, IL-5 IL-10 and TGF-beta. In the skin, main dendritic cells are myeloid dendritic cells, Langerhans cells, and some dermal dendrocytes. They are identified respectively by immunohistochemical expression of S100, CD1a and Factor XIIIa. Langerhans cells and dermal dendrocytes Factor XIIIa positive are increased in number in tuberculoid lesions compared with lepromatous lesions. The objectives of this study were: 1) to characterize "in situ" inflammation in indeterminate leprosy through the quantification of immunohistochemical markers: CD57, CD4, CD8, CD1a, S100, FXIIIa, CD68, Foxp3, CD123, IL-1, IL-2r, IL-4, IL-6, IL-8, IL-10, IL-12, IL-18, IFN-y, TNF-alfa, TGF-beta, iNOS, granzyme B, Toll-like receptor 2/4, and BCG antigen, 2) compare the phenotypic and cytokinic profile of indeterminate leprosy lesions between positive and negative Mitsuda reaction groups in order to investigate if there are patterns that can predict which way the disease may evolve, and 3 ) review the histopathology of the indetermate form by semi-quantitative analysis of changes seen in hematoxylin / eosin. Fifteen lesions of patients with indeterminate leprosy were selected. There was used control groups of Factor...

Enhancing effect of porcine coagulation factor VIII A1 and A3 domains on secretion of post-translationally spliced human/porcine hybrid coagulation factor VIII / 生理学报

Low levels of coagulation factor VIII (fVIII) protein expression caused by its inefficient secretion and the over-sized fVIII gene affect the transgene-based gene therapy for hemophilia A adversely. Our previous study demonstrated that intein-mediated protein trans-splicing for delivery of the fVIII gene with a dual-vector system could improve secretion of post-translationally spliced fVIII by light chain in cis. In this study, a human/porcine hybrid fVIII (HP-fVIII) containing replaced A1 and A3 domains of porcine fVIII was investigated for secretion and activity of the spliced HP-fVIII after intein-based dual-vector delivery of the HP-fVIII gene. A pair of expression plasmids comprising intein-fused HP-fVIII heavy and light chains were constructed and transiently co-transfected into COS-7 cells. The spliced HP-fVIII and bio-activity in culture media were quantitatively analyzed by ELISA and Coatest method respectively. The intracellular splicing of HP-fVIII was detected by Western blotting. The results showed that in the culture supernatant of cells co-transfected with HP-fVIII, the amount and activity of spliced HP-fVIII were significantly higher than those of spliced hfVIII secreted from the cells co-transfected with human fVIII [(184+/-34 ng/mL) vs (48+/-12) ng/mL, P<0.01; (1.18+/-0.22) IU/mL vs (0.31+/-0.10) IU/mL, P<0.01], demonstrating the dramatically enhancing effect of porcine A1 and A3 domains on the secretion of intein-spliced HP-fVIII. The spliced HP-fVIII protein and its activity were also detected in the supernatant from combined cells separately transfected with intein-fused HP-fVIII heavy and light chain genes, indicating that the intein-mediated HP-fVIII splicing was independent of cellular mechanism and could occur outside the cell after the secretion of precursor proteins. Additionally, an intracellularly spliced HP-fVIII band was found with a molecular weight similar to human fVIII protein, confirming the HP-fVIII splicing. These results provided experimental basis for ongoing study using intein-based dual adeno-associated virus (AAV) vector to transfer HP-fVIII gene in animal models.

Comparação dos métodos molecular (PCR-RFLP)e coagulométrico para a detecção de fator V Leiden/resistência à proteína C ativada / Comparison of the methods molecular (PCR-RFLP) and coagulométrico for the detention of factor V Leiden/resistance to activated protein C

A proteína C (PC) é um anticoagulante natural, cuja ação consiste em clivar os fatores Va e VIIIa e, desta forma, limita a formação da trombina. O fator V Leiden (F V Leiden) é resultante da mutação G1691A no gene do fator V e leva a resistência à ação da proteína C ativada (rPCA). A detecção de Fator V Leiden é usualmente feita por método molecular, através da reação em cadeia dapolimerase e polimorfismo de restrição (PCR-RFLP). Esta técnica é bastante complexa e não está, ainda, ao alcance dos laboratórios de menor porte. No entanto, a rPCA pode ser avaliada por método coagulométrico, accessível a todos os laboratórios. O objetivo do presenteestudo foi avaliar a eficácia do método coagulométrico para detecção da resistência hereditária à proteína C ativada, comparando-se os resultados obtidos por esse método e pela detecção de Fator V Leiden por PCR-RFLP. Os participantes deste estudo foram selecionadosdentre indivíduos portadores de mutação de importância em trombofilia, porém assintomáticos, pertencentes a famílias de pacientes que já sofreram evento trombótico (portadores de mutações de importância em trombofilia). O primeiro grupo (grupo I) foi composto por não-portadores da mutação G1691A (n=57) e o segundo (grupo II) por portadores da mutação G1691A (no gene do FV)em heterozigose (n=25). O teste molecular foi feito por reação em cadeia da polimerase, seguida da digestão com endonucleases de restrição (PCR-RFLP) e o método coagulométrico, utilizando-se o conjunto diagnósticoCOATEST APC RESISTANCE V da CHROMOGENIX.Os resultados obtidos demonstraram uma grande concordância entre a identificação do FV Leiden por PCR e detecção de rPCA por método coagulométrico utilizando plasma deficiente em FV. Todos os portadores da mutação G1691A (no gene do FV) apresentaram resistência à proteína Cativada e essa resistência não foi observada entre os não-portadores. Esses resultados permitem concluir que o teste coagulométrico com diluição em plasma deficiente em FV,...

Relation between clinical severity of haemophilia and the factor inhibitor

Alloantibodies occuring in haemophilia as a side effect of repeated treatment represents a severe complication. The antibody binds to a specific epitope within the factor molecule in a time dependent manner. If the alloantibody is present in excess, factor coagulant activity will be inactivated. Our study was conducted on 34 haemophilic patient and 10 control healthy children. All cases and control were subjected to the following: full history taking; complete clinical examination, laboratory investigation of Hb%, RBCs, WBCs, platelets counts, bleeding, coagulation, prothrombin and partial thromboplastin time. And assay of levels of FVIII and FIX, FVIII inhibitor level and FIX inhibitor.71% of haemophilia A were mild and 29% were moderate, 90% of haemophilia B were mild and 10% moderate. An inhibitor was detected in 16 cases [66.6%] out of 24 cases of hemophilia A, and 9 cases [90%] out of 10 cases of haemophilia B. These inhibitors were detected 2-11 years after the diagnosis. There was non significant correlation between inhibitor level in heamophiliaA to age, Hb% and FVIII% but there was negative correlation V.H.S [R< 0.001] to residual FVIII%. Also there was no correlation between inhibitor level in haemophilia B to age, Hb% and FVIII% but there was negative correlation V.H.S [R< 0.001] to residual FIX%. So we can conclude that development of inhibitor to FVIII and FIX although predominantly develop in severe heamophiliacs, they do occasionally appear in mild and moderate disease. Many of them are of low-level and perhaps transient. So we recommend to screen these patients at intervals for the inhibitor. The development of the inhibitor depends on the immunogenecity of the replacement therapy and also on a genetic predisposition