concised description of congenital bleeding disorders

1. INHERITED BLEEDING
DISORDERS
DR. BRIJENDRA BAHADUR SINGH
DR. MILI JAIN
DEPARTMENT OF PATHOLOGY , KING GEORGE MEDICAL UNIVERSITY
LUCKNOW

2. • COAGULATION DISORDERS
• PLATELET DISORDERS
• VASCULAR DISORDERS

3. CONGENITAL COAGULOPATHIES
• Von willebrand disease
• Hemophilia
• Rare congenital single- factor deficiencies

4. • A 24-year-old woman presents with heavy vaginal bleeding, fatigue, and
light-headedness. She has a history of menorrhagia since menarche and iron-
deficiency anemia. She had to return to the oral surgeon for suturing after
wisdom tooth extraction at age 16 years. Her family history is remarkable for
a sister with heavy menses. Her father had recurrent nose bleeds as a child
and had several cauterizations as therapy.
CASE 1

5. Work up?

6. • CBC was done , Hb- 6 gm/dl, TLC,DLC & platelet count were within normal
limit
• PT- 13( control 14 seconds), APTT- 44 seconds(control 33 seconds), BT- 14
mins, TT- 17 seconds ( control 16 seconds)
• VWF:RCo assay showed- < 30% of normal
• Platelet aggregation showed decreased aggregation with ristocetin and normal
aggregation with ADP, collagen, epinehprine and arachidonic acid.
• DIAGNOSIS ???????,

8. VON WILLEBRAND DISEASE
• Prof. Erik von Willebrand in 1926
• Most common congenital bleeding disorders
• Approximately 1% of population
• Autosomal dominant except type 3
• Plasma concentration – 0.5 to 1.0 mg/dl

9. • Gene is located on chromosome 12
• Synthesized in the endoplasmic reticulum of endothelial cells and
megakaryocytes
• Stored in cytoplasmic weibel-palade bodies and alpha granules of platelets
• Vwf cleaving protease (ADAMTS-13)
• Primary function is to mediate platelet adhesion to subendotheial collagen
• Protects factor VIII from proteolysis and prolonging its half-life(8-12 hours)

11. PATHOPHYSIOLOGY OF VWD
• Structural or quantitative VWF abnormalities reduces platelet adhesion
• Leads to muco-cutaneous hemorrhages of varying variety
• Severe quantitative vwf deficiency creates in addition factor VIII
deficiency
• When factor VIII levels decrease to < 30% of normal, anatomical soft
tissue bleedings also occurs

12. VWD TYPES AND SUBTYPES
• Type 1 von willebrand disease
• Type 2 von willebrand disease-
• subtype 2A VWD
• subtype 2B VWD
• subtype 2M VWD
• subtype 2N VWD(Normandy variant; autosomal Hemophilia)
• Type 3 von willebrand disease

13. TREATMENT

15. • Subtype 2M VWD
-Decreased platelet receptor binding but normal multimeric pattern
• Subtype 2NVWD
-Autosomal missense mutation impairs its factor VIII binding site resulting
In factor VIII deficiency

16. LABORATORY DIAGNOSIS
• Bleeding time – prolonged
• PT- Normal , APTT- Normal to slightly prolonged in type 1, prolonged-
type 3, normal in type 2
• VWF : Rco assay
• VWF: CB assay
• VWF antigen
• VWF multimers

17. CASE 2
• A 7 years old male presented with joints pain , prolonged bleeding after
trauma, subcutaneous hematomas since the age of 2 years. His father has
similar history of bleeding diathesis.

18. WORK UP

19. • CBC- Normal TLC, DLC and platelet count. Hb- 9.8 g/dl
• Screening tests- PT- 13 seconds( control-14 seconds), APTT- 46 seconds(
control-34 seconds), TT- 16 seconds (control 1 bleeding time- 6 minutes
• Mixing studies were done and normal APTT came after mixing with factor
IX depleted plasma
• Factor VIII assay – 26 iu/dl(45-158 iu/dl)
DIAGNOSIS???????

20. HEMOPHILIA-A
• Second to VWD in prevalence
• Anatomic soft tissue bleeding
• 1 in 10,000 individuals
• 85% are deficient in factor VIII
• FACTOR VIII – 2 chain, 2,85,000 dalton protein translated from X
chromosome
• VIIIa/IXa complex- TENASE COMPLEX

21. • Large size of factor VIII gene i.e 186kb+ various hot spots (Cpg
dinucleotide) predisposes factor VIII gene to mutate.
• Inversions ( Breakpoint is intron 22: other intron 1) associated with severe
hemophilia
• Point mutations associated with mild to moderate hemophilia.

22. • 30% of newly diagnosed cases arise as a result of spontaneous germ line
mutations
• Extreme lyonization- disproportional inactivation of the x chromosome
with the normal gene or spontaneous germline mutation in otherwise
normal allele of a heterozygous female

23. CLINICAL MANIFESTATIONS
• Anatomic bleeds with deep muscle and joint hemorrhages
• Hematomas, wound oozing after trauma or surgery
• Bleeding into CNS, peritoneum, GI tract and kidneys
• Acute joint bleeds (hemarthosis)- quite painful
• Chronic joint bleeds- inflammation, permanent loss of mobility

24. • Severity of hemophilia A symptoms are inversely proportional to factor
VIII activity
• Mild hemophilia- activity levels of 5 % to 30%
• Moderate hemophilia- 1% to 5%
• Severe hemophilia- < 1%

25. LABORATORY DIAGNOSIS
• Screening tests-
PT – normal, PTT- Prolonged, TT- normal, BT- normal
• Factor VIII functional assay:
- One stage method-m/c simple
- Two stage method and chromogenic assay-less subjected to variables.
• Factor VIII Ag:
calculated using radiometric immunoassay and ELISA

26. • Carrier detection- ratio of factor VIII activity to VWF: Ag value
• A reference interval for the VIII:VWF ratio using plasmas from at least 30
women who don’t have factor VIII deficiency
• If the individual being tested is below the lower limit of normal, she is
likely to be a carrier

27. TREATMENT
• Recombinant factor VIII concentrate
• Repeat dosing is done on an 8 to 12 hour schedule
• Second administration uses half the concentration of first dose

28. HEMOPHILIA A AND FACTOR VIII INHIBITORS
• Alloantibody inhibitors of factor VIII arise
in response to treatment in 30% of patients
with severe hemophilia and 3% of those
with moderate hemophilia
• Most factor VIII inhibitors are
immunoglobulin G4, non–complement
fixing, warm-reacting antibodies.
• Bethesda assay is used to quantitate the
inhibitor
Factor VIII assay
<30% >30%
Inhibitor + No inhibitor

29. TREATMENT OF HEMOPHILIA A IN PATIENTS
WITH INHIBITORS
• Low responders(up to 5 bethesda units)- large doses of factor VIII
concentrate
• High responders(> 5 bethesda units)- activated PCC, Autoplex T or FEIBA

30. HEMOPHILIA B
• Christmas disease
• 14% of hemophilia cases in U.S.A.
• In India , incidence nearly equals that of hemophilia A
• Sex linked, markedly heterogeneous disorder involving numerous
mutations
• Mild to severe bleeding manifestations

31. • Determination of female carrier status is less successful
• DNA analysis may be used to to establish carrier status
• PTT – Prolonged, PT- normal, TT- Normal
• Factor IX assay
• Treatment- recombinant or column purified plasma derived factor IX
concentrates

32. TREATMENT
• Calculated initial dose is doubled to compensate for factor IX distribution
in extravascular space
• Inhibitors to factor IX arise in 3 %
• In those patients PCC or rFVIIa are given

33. HEMOPHILIA C
• Rosenthal Syndrome
• Factor XI Deficiency, autosomal dominant
• Mild to moderate bleeding symptoms
• Frequency and severity of bleeding episodes don’t correlate with factor XI levels
• PTT- prolonged, PT- normal, BT- normal
• Plasma infusions

35. FACTOR XIII DEFICIENCY
• Autosomal recessive disorder
• Defective cross linking of fibrin
• Anatomic bleeds and poor wound healing
• Normal PT, APTT, TT, BT- screening
• Clot solubility test

36. PLATELET DISORDERS
QUALITATIVE DISORDERS
• Glanzmann thrombasthenia
• Bernard- Soulier (giant platelet)
syndrome
• Wiskott- Aldrich syndrome
• Hermansky-Pudlak Syndrome
• Chediak higashi syndrome
• Grey platelet syndrome
QUANTITATIVE DISORDERS
• Fechtner syndrome
• Epstein syndrome
• May –Hegglin anamoly
• Fanconi anemia
• TAR syndrome
• Congenital amegakaryocytic thrombocytopenia
• Autosomal dominant thrombocytopenia

37. CASE 3
• 6 Year old male child, Symptomatic since birth
• Prolonged bleeding after circumcision, epistaxis(1-2episode/month) and ecchymotic
patches over extremities
• Born of consanguineous marriage
• No family history of similar illness & No history of blood transfusion.

38. WORK UP?

39. WORK UP
• Platelet count-350x109 /L
• total leucocyte count & red blood cell indices within normal limits
• No platelet clumps on peripheral blood smear(PBS).
• Coagulation screening
Bleeding time - > 15 min
Prothrombin time(PT)- 13.0 sec( control- 14.0 sec)
Activated partial thromboplastin time(APTT)- 26.0 sec ( control – 26 sec)
Clot Retraction(CR) at 2 hour- Not seen.

40. • Lack of platelet aggregation with ADP, collagen, epinephrine and thrombin
and Aggregation seen with Ristocetin.
DIAGNOSIS???

42. GLANZMANN THROMBASTHENIA
• It is named after Eduard Glanzmann , the Swiss pediatrician
• Abnormal in vitro clot retraction and normal platelet count
• Autosomal recessive disorder
• High degree of consanguinity
• Deficiency or abnormality of the platelet membrane GP IIb/IIIa (αIIb/β3)
complex

43. • Failure of binding of fibrinogen to GP IIb/IIIa , reduced or absent platelet
aggregation
• GP IIb/IIIa is coded by ITGA2B and ITGB3 genes on chromosome 17

44. CLINICAL FEATURES
• Rare disorder manifests itself clinically in the neonatal period or infancy,
occasionally with bleeding after circumcision and frequently with epistaxis
and gingival bleeding.
• Hemorrhagic manifestations include petechiae, purpura, menorrhagia,
gastrointestinal bleeding, and hematuria.

45. LABORATORY DIAGNOSIS
• PBS shows lack of platelet clumps and normal platelet count and
morphology
• bleeding time,
• Poor in vitro clot retraction,
• Lack of platelet aggregation in response to all platelet-activating agents
(ADP, collagen, thrombin, and epinephrine)
• Normal aggregation in response to ristocetin

47. • A subdivision of Glanzmann thrombasthenia into cases with absent
(type1) and subnormal (type 2) in vitro clot retraction
• Individuals with type 2 disease have more residual GP IIb/IIIa complexes
(10% to 20% of normal) than those with type 1 disease (0%-5% of
normal)

48. TREATMENT
• Transfusion of normal platelet
• To reduce alloimmunization single- donor platelet apheresis products,HLA
matched donor platelets or ABO- matched donor platelets
• Hormonal therapy ( norethindrone acetate) to control menorrhagia

49. Dr. Jean Bernard

50. BERNARD-SOULIER (GIANT PLATELET) SYNDROME
• 1948, is named after Dr. Jean Bernard and Dr. Jean Pierre Soulier
• Rare disorder of platelet adhesion
• Usually manifested in infancy or childhood
• Ecchymoses, epistaxis, and gingival bleeding
• Autosomal recessive disorder in which the glycoprotein Ib/IX/V (GP
Ib/IX/V) complex is missing from the platelet surface or exhibits abnormal
function

51. • Heterozygotes have about 50% of normal levels of GP Ib, GP V, and GP
IX have normal or near-normal platelet function.
• Homozygotes have a moderate to severe bleeding disorder characterized
by a prolonged bleeding time, enlarged platelets, thrombocytopenia, and
usually decreased platelet survival.

52. • Four glycoproteins are required to form the GP Ib/IX/V complex: GP Ibα,
GP Ibβ, GP IX, and GP V.
• In the complex, these proteins are present in the ratio of 2:2:2:1.
• The gene for GP Ibα is located on chromosome 17, the gene for GP Ibβ is
located on chromosome 22, and the genes for GP IX and GP V are located
on chromosome 3.
• Most frequent forms of BSS involve defects in GP Ibα synthesis or
expression

53. LABORATORY FEATURES
• PBS – Giant platelets
• Normal aggregation responses ADP, epinephrine, collagen, and
arachidonic acid
• No response to ristocetin and have diminished response to thrombin.

55. MAY-HEGGLIN ANAMOLY
• Rare autosomal dominant disorder
• Mutations in the MYH9 gene
• PBS - large platelets and dohle like bodies in neutrophils and occasionally
in monocytes
• Thrombocytopenia is present in about 1/3rd to ½ of cases. Platelet function
in response to platelet-activating agents is usually normal.

57. • Sebastian syndrome- autosomal dominant disorder
Mutation in MYH9 gene
Large platelets, thrombocytopenia and granulocytic inclusions
• Fechtner syndrome- similar abnormalities accompanied by deafness,
cataracts and nephritis
• Epstein syndrome- large platelets , deafness, ocular problems and
glomerular nephritis

58. TAR SYNDROME
• Rare autosomal recessive disorder
• Severe neonatal thrombocytopenia and congenital absence or extreme
hypoplasia of radial bones of the forearms and other orthopedic
abnormalities
• Mutation in RBM8A gene located on chromosome 1q
• Two deletion of RBM8A, two mutation of RBM8A or most commonly
both

60. • Cardiac lesions
• Transient Leukemoid reactions with elevated WBC count in 90% of
patients
• Thrombocytopenia (10,000 to 30,000/cumm)

61. CONGENITAL AMEGAKARYOCYTIC
THROMBOCYTOPENIA
• Autosomal recessive disorder
• Mutation in MPL gene on chromosome 1(1p34) leading to complete loss
of thrombopoietin receptor function
• Platelet count < 20,000/cumm
• At birth, petechiae and frequent physical abnormalities
• Half of the patients develop aplastic anemia in the first year of life and
myelodysplasia and leukemia later in childhood

62. AUTOSOMAL DOMINANT THROMBOCYTOPENIA
• Mutation(s) in the ANKRD26 gene on short arm of chromosome 10
• Incomplete megakaryocytic differentiation – thrombocytopenia
• Approximately 10% of inherited thrombocytopenia

63. DENSE GRANULE DEFICIENCIES
Hermansky-Pudlak Syndrome
• Autosomal recessive disorder
• Tyrosinase-positive occulocutaneous albinism, defective lysosomal
function in a variety of cell types, ceroid-like deposition in the cells of the
reticuloendothelial system,
• Mutations responsible for syndrome are located on chromosome 19
• Swiss cheese platelet

64. CHÉDIAK-HIGASHI SYNDROME
• Rare autosomal recessive disorder
• partial oculocutaneous albinism, frequent pyogenic bacterial infections,
giant lysosomal granules in cells of hematologic and non hematologic
origin, and hemorrhage.
• Mutation in the LYST gene located on chromosome 13

66. • Patients who do not die of bacterial infection develop a lymphohistiocytic
infiltration into the major organs of the body, resulting in organ failure.
• Bleeding episodes vary from mild to moderate but worsen as the platelet
count decreases

67. WISKOTT - ALDRICH SYNDROME
• X-linked recessive disease
• Triad of severe eczema, recurrent infections and thrombocytopenia
• Lack the ability to make anti-polysaccharide antibodies, which results in a
propensity for pneumococcal sepsis.
• Bleeding episodes are typically moderate to severe.
• A milder form without immune deficiency is known as hereditary X-linked
thrombocytopenia

68. • PBS- small platelets
• The platelets show a decreased aggregation response to ADP, collagen, and
epinephrine and lack a secondary wave of aggregation in response to these
agonists. The response to thrombin is normal.
• The most effective treatment for the thrombocytopenia seems to be
splenectomy,
• Platelet transfusions may be needed to treat hemorrhagic episodes.

69. ALPHA – GRANULE DEFICIENCY- GRAY PLATELET
SYNDROME
• Autosomal recessive
• Specific absence of morphologically recognizable α-granules in platelets.
• Mild bleeding tendencies, prolonged bleeding time, moderate
thrombocytopenia, fibrosis of the marrow
• Large platelets - gray appearance on a Wright-stained blood smear
• Plasma levels of platelet factor 4 and α-thromboglobulin are increased.

71. REFERENCES
• RODAK’S Hematology CLINICAL PRINCIPLES AND APPLICATIONS
, Fifth Edition
• DACIE AND LEWIS PRACTICAL HEMATOLOGY , ELEVENTH
EDITION