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Deficient tissue plasminogen activator release and normal tissue plasminogen activator inhibitor in a patient with recurrent deep vein thrombosis
BRIEF CLINICAL OBSERVATIONS 1. Rundles RW: Chronic myelogenous leukemia. In: Williams WJ, et al. Hematology, 3rd ed. New York: McGraw-Hill, 1983; 200-201. 2. Maldonado N, Haddock J, Perez-Santiago E: Autoimmune hemolytic anemia in chronic granulocytic leukemia. Blood 1967; 30: 518-521. 3.Videbaek A: Auto-immune hemolytic anemia in some malignant systemic diseases. Acta Med Stand 1962; 171: 463-476. 4. Cline M, Berlin N: Patterns of anemia in chronic myelocytic leukemia. Cancer 1963; 16: 624-632. 5. Pengelly CDR. Wilkinson JF: The frequency and mechanism of haemolysis in the leukaemias. reticuloses and myeloproliferative diseases. Br J Haematol 1962; 8: 343-357. 6. Rowley JD. Testa JR: Chromosome abnormalities in malignant hematologic diseases. Adv Cancer Res 1982; 36: 103-148. Submitted
August 3, 1989, and accepted in revised form September 7, 1989
(NOTE: This work was supported kins Leukemia Fund.)
in part by the Per-
DEFICIENT TISSUE PLASMINOGEN ACTIVATOR RELEASE AND NORMAL TISSUE PLASMINOGEN ACTIVATOR INHIBITOR IN A PATIENT WITH RECURRENT DEEP VEIN THROMBOSIS Venous thrombosis may be caused by several interacting factors, such as stasis of the blood, hypercoagulability, or deficient fibrinolysis [l]. Recent studies in patients with idiopathic deep venous thrombosis have shown that deficient fibrinolysis is increasingly diagnosed as the underlying mechanism for the propensity for the development of abnormal thrombosis [2]. In principle, defective fibrinolysis might be due to (1) a decreased synthesis of vessel wall tissue plasminogen activator (t-PA) or defective release of activators, or both; or (2) inactivation of t-PA by inhibitors. In this report, we describe a patient who presented with recurrent spontaneous deep vein thrombosis and no known organic disorders commonly associated with hypercoagulability. Laboratory determinations of the fibrinolytic response demonstrated low values for both t-PA activity and t-PA antigen concentration, and normal concentrations of t-PA inhibitor (t-PAD. A 21-year-old black man presented with a five-day history of fever, right lower extremity pain, and edema. His medical history was significant for three previous hospitalizations since age 17 for recurrent episodes of deep femoral system venous thrombosis complicated on one occasion by the onset of pul-
monary embolus. He had no family history of thrombotic disorders and no known risk factors associated with a hypercoagulable state. Extensive search to demonstrate an underlying malignancy was undertaken twice with negative results. Computed tomography of the abdomen revealed complete occlusion of the inferior vena cava and iliac veins with development of collateral circulation in the superficial venous system of the pelvis and abdomen. During his most recent hospitalization in February 1989, he was initially treated with sodium heparin in a continuous infusion at an average dose of 1,400 units/hour for 10 days, and long-term oral anticoagulation with warfarin at 7.5 mg/day was resumed. In addition, a therapeutic trial with stano~0101, 12 mglday, was begun in an attempt to enhance plasminogen activator release [3]; however, the patient was lost to follow-up for several months and exhibited poor compliance with his prescribed medications. On admission, the hemoglobin level was 10.7 g/dL, the hematocrit was 34 volume %, the white blood cell count was 6,500/ PL (69 polymorphonuclear leukocytes, two bands, 26 lymphocytes, three monocytes), and the platelet count was 36O,OOO/pL. Blood from the antecubital vein was collected into O.l-volume trisodium citrate (final concentration 0.01 mL), after a 12-hour fast. For the coagulation and fibrinolytic studies, the heparin infusion was temporarily discontinued and the titrated blood was immediately cooled on ice. Platelet-poor plasma obtained by centrifugation at 4°C for 15 minutes at 3,000 G was quick-frozen in aliquots and stored at -7O”C, until
used. The venous occlusion test was carried out with a sphygmomanometer pressure at the midpoint between systolic and diastolic blood pressure for 20 minutes [4]. Blood samples were obtained before and at the end of venous occlusion from the occluded arm. All assays were performed in duplicate and the results are shown in Table I. A distinct abnormality was noted in the expected enhancement of the t-PA activity and antigen after 20 minutes of venous occlusion; in addition, the t-PA1 activity was determined not to be increased and similar to that measured in normal individuals. Various abnormalities of the blood coagulation and fibrinolytic system have been identified in persons with thromboembolic disease. Since the initial reports of subjects with congenital deficiencies of antithrombin-III, protein C, or protein S, a significant number of families with these disorders have been described. Dysfunctional molecules of antithrombin-III, fibrinogen, and protein C have also been reported as predisposing to venous or arterial thrombosis [5]. Disturbances in the fibrinolytic system are also considered to play an important role in the development of thromboembolic diseases. Thus, increased fibrinolysis inhibition or decreased vein wall fibrinolysis activity has been found in patients with venous thrombosis [l]. This system is activated by various agents, an important one being the t-PA localized to the vessel wall where it is synthesized and stored. The activator is continuously released from the endothelial cells into the bloodstream and its baseline concentration is now measured
TABLE I Coagulation Assay and Effect of Venous Occlusion (VO) on Fibrinolytic Parameters Patient Before VO After Vd Prothrombin time (seconds) Activated partial thromboplastin time (seconds) Antithrombin-Ill activity (%) Protein C activity (%) Protein C antigen (U/mL) Protein S antigen (U/mL) Plasminogen activity(%) t-PA activity (IU/mL) t-PA antigen (ng/mL) t-PA inhibitor activity (IU/mL)
12.8 30.3 113 130 1.23 1.12 113 0.07 3.7 2.3
0:9 4.2
Control Subjects (n = 18) Before VO After VO (range) 10.5-13.0 29.1-38.6
-
82-115 61-132 0.67-1.40 0.67-1.25 80-120 0.02-0.09 1.3-8.5 0.4-3.0
x 0.33-0.73 3.5-25 -
-PA = tissue plasminogen activator.
February
1990
The American
Journal
qf Medicine
Volume
88
199
utilizing acidified diluted plasma Progress in the methodology for samples exposed to solubilized fi- the evaluation of the various circubrin. After venous occlusion for 10 lating proteins that initiate and into 20 minutes, normal individuals hibit the fibrinolytic process has will exhibit a two- to three-fold in- provided a theoretic basis to excrease in both t-PA functional ac- plain our clinical observations activity and antigen concentration cording to three possible interac[6]. Recently, several groups have tions: (1) a feedback mechanism reported evidence for the existence that aims to maintain minimal fibrinolytic activity in testing plasof a rapidly acting inhibitor of t-PA (t-PAI) demonstrable in acidified ma by stimulating t-PA production plasma samples. ‘and release to compensate for high Clinical studies in patients with t-PA1 levels, (2) a similar but redeep venous thrombosis have dem- verse mechanism whereby continuonstrated high concentrations of ously released t-PA in larger than plasma t-PA1 in which circulating normal amounts is compensated t-PA/t-PA1 complexes produce an for by increased t-PA1 production; overall decrease in t-PA functional or (3) a longer half-life in the circuactivity. In general, venous occlu- lation of the t-PA/t-PA1 complex sion in these patients releases ade- compared to that of free t-PA. Furquate circulating t-PA antigen, but ther elucidation of the deficient fiis associated with persistently high brinolytic responses in similar pat-PA1 levels (independent from tients may lead to a better underveno-occlusion) and impaired fi- standing of the prethrombotic brinolysis [2]. Our patient, how- state and the critical factors inever, showed an unusual and dif- volved during its progression to ferent response to veno-occlusion clinically detectable intravascular characterized both by poor t-PA thrombosis. functional activity and antigen release and by normal t-PA1 plasma concentration. These observations BRUCE LATHAM, M.D. will be extended to include studies ERNEST~ A. KUFOY, M.D. in family members and repeated tO’NEILL BARRETT, Jr., M.D. PA release determinations to asM. FRANCISCO GONZALEZ, M.D. sess intrapatient variability in relaUniversity of South Carolina tionship to inflammatory states [7] School of Medicine or environmental factors [8]. Columbia, South Carolina
200
February
1990
The American
Journal
of Medicine
Volume
88
ACKNOWLEDGMENT We wish to thank Mrs. Hume Fulmer for her secretarial assistance in the preparation of this manuscript.
1. Wiman B. Llunberg B. Chmielewska J, et al: The role of the fibrinolytic system in deep vein thrombosis. J Lab Clin Med 1985; 105: 265-270. 2. Nilsson IM. Ljungner H. Tengborn L: Two different mechanisms in patients with venous thrombosis and defective fibrinolysis: low concentration of plasminogen activator or increased concentration of plasminogen activator inhibitor. Br Med J 1985; 290: 1453. 3. Mannucci PM, Kluft C. Traas OW, Seveso P, D’Angelo A: Congenital plasminogen deficiency associated with venous thromboembolism: therapeutic trial with stanozolol. Br J Haematol 1986; 63: 753759. 4. Staider M, Havert J, Kruithof EKO. Bachmann F: Release of vascular plasminogen activator (V-PA) after venous stasis: electrophoretic-zymographic analysls of face and complexed V-PA. Br J Haematol 1985; 61: 169-176. 5. Rodgers GM, Shuman MA: Congenital thrombotic disorders. Am J Haematol 1986; 21: 919-930. 6. Knshnamurti C, Tan DB, Barr CF, Alving BM: Plasminogen activator Inhibitor activities in a reference population. Am J Clin Pathol 1988; 89: 747-752. 7. Juhan-Vague I, Aillaud MF, DeCock F, et al: The fast-acting inhibitor of tissue-type plasminogen actlvator is an acute phase reactant protein. In: Davidson JF, Donati MB, Coccheri S, eds. Progress in flbrinolysis. Edinburgh: Churchill Livingstone, 1985: 146149. 8. Vague PU, Juhan-Vogue I, Aillaud MF, eta/:Correlation between blood fibrinolytic activity, PA inhibitor level, plasma insulin level and relative body weight in normal and obese subjects. Metabolism 1986; 35: 25D-253. Submitted
June 8, 1989, and accepted in revised form September 13. 1989
August 3, 1989, and accepted in revised form September 7, 1989
(NOTE: This work was supported kins Leukemia Fund.)
in part by the Per-
DEFICIENT TISSUE PLASMINOGEN ACTIVATOR RELEASE AND NORMAL TISSUE PLASMINOGEN ACTIVATOR INHIBITOR IN A PATIENT WITH RECURRENT DEEP VEIN THROMBOSIS Venous thrombosis may be caused by several interacting factors, such as stasis of the blood, hypercoagulability, or deficient fibrinolysis [l]. Recent studies in patients with idiopathic deep venous thrombosis have shown that deficient fibrinolysis is increasingly diagnosed as the underlying mechanism for the propensity for the development of abnormal thrombosis [2]. In principle, defective fibrinolysis might be due to (1) a decreased synthesis of vessel wall tissue plasminogen activator (t-PA) or defective release of activators, or both; or (2) inactivation of t-PA by inhibitors. In this report, we describe a patient who presented with recurrent spontaneous deep vein thrombosis and no known organic disorders commonly associated with hypercoagulability. Laboratory determinations of the fibrinolytic response demonstrated low values for both t-PA activity and t-PA antigen concentration, and normal concentrations of t-PA inhibitor (t-PAD. A 21-year-old black man presented with a five-day history of fever, right lower extremity pain, and edema. His medical history was significant for three previous hospitalizations since age 17 for recurrent episodes of deep femoral system venous thrombosis complicated on one occasion by the onset of pul-
monary embolus. He had no family history of thrombotic disorders and no known risk factors associated with a hypercoagulable state. Extensive search to demonstrate an underlying malignancy was undertaken twice with negative results. Computed tomography of the abdomen revealed complete occlusion of the inferior vena cava and iliac veins with development of collateral circulation in the superficial venous system of the pelvis and abdomen. During his most recent hospitalization in February 1989, he was initially treated with sodium heparin in a continuous infusion at an average dose of 1,400 units/hour for 10 days, and long-term oral anticoagulation with warfarin at 7.5 mg/day was resumed. In addition, a therapeutic trial with stano~0101, 12 mglday, was begun in an attempt to enhance plasminogen activator release [3]; however, the patient was lost to follow-up for several months and exhibited poor compliance with his prescribed medications. On admission, the hemoglobin level was 10.7 g/dL, the hematocrit was 34 volume %, the white blood cell count was 6,500/ PL (69 polymorphonuclear leukocytes, two bands, 26 lymphocytes, three monocytes), and the platelet count was 36O,OOO/pL. Blood from the antecubital vein was collected into O.l-volume trisodium citrate (final concentration 0.01 mL), after a 12-hour fast. For the coagulation and fibrinolytic studies, the heparin infusion was temporarily discontinued and the titrated blood was immediately cooled on ice. Platelet-poor plasma obtained by centrifugation at 4°C for 15 minutes at 3,000 G was quick-frozen in aliquots and stored at -7O”C, until
used. The venous occlusion test was carried out with a sphygmomanometer pressure at the midpoint between systolic and diastolic blood pressure for 20 minutes [4]. Blood samples were obtained before and at the end of venous occlusion from the occluded arm. All assays were performed in duplicate and the results are shown in Table I. A distinct abnormality was noted in the expected enhancement of the t-PA activity and antigen after 20 minutes of venous occlusion; in addition, the t-PA1 activity was determined not to be increased and similar to that measured in normal individuals. Various abnormalities of the blood coagulation and fibrinolytic system have been identified in persons with thromboembolic disease. Since the initial reports of subjects with congenital deficiencies of antithrombin-III, protein C, or protein S, a significant number of families with these disorders have been described. Dysfunctional molecules of antithrombin-III, fibrinogen, and protein C have also been reported as predisposing to venous or arterial thrombosis [5]. Disturbances in the fibrinolytic system are also considered to play an important role in the development of thromboembolic diseases. Thus, increased fibrinolysis inhibition or decreased vein wall fibrinolysis activity has been found in patients with venous thrombosis [l]. This system is activated by various agents, an important one being the t-PA localized to the vessel wall where it is synthesized and stored. The activator is continuously released from the endothelial cells into the bloodstream and its baseline concentration is now measured
TABLE I Coagulation Assay and Effect of Venous Occlusion (VO) on Fibrinolytic Parameters Patient Before VO After Vd Prothrombin time (seconds) Activated partial thromboplastin time (seconds) Antithrombin-Ill activity (%) Protein C activity (%) Protein C antigen (U/mL) Protein S antigen (U/mL) Plasminogen activity(%) t-PA activity (IU/mL) t-PA antigen (ng/mL) t-PA inhibitor activity (IU/mL)
12.8 30.3 113 130 1.23 1.12 113 0.07 3.7 2.3
0:9 4.2
Control Subjects (n = 18) Before VO After VO (range) 10.5-13.0 29.1-38.6
-
82-115 61-132 0.67-1.40 0.67-1.25 80-120 0.02-0.09 1.3-8.5 0.4-3.0
x 0.33-0.73 3.5-25 -
-PA = tissue plasminogen activator.
February
1990
The American
Journal
qf Medicine
Volume
88
199
utilizing acidified diluted plasma Progress in the methodology for samples exposed to solubilized fi- the evaluation of the various circubrin. After venous occlusion for 10 lating proteins that initiate and into 20 minutes, normal individuals hibit the fibrinolytic process has will exhibit a two- to three-fold in- provided a theoretic basis to excrease in both t-PA functional ac- plain our clinical observations activity and antigen concentration cording to three possible interac[6]. Recently, several groups have tions: (1) a feedback mechanism reported evidence for the existence that aims to maintain minimal fibrinolytic activity in testing plasof a rapidly acting inhibitor of t-PA (t-PAI) demonstrable in acidified ma by stimulating t-PA production plasma samples. ‘and release to compensate for high Clinical studies in patients with t-PA1 levels, (2) a similar but redeep venous thrombosis have dem- verse mechanism whereby continuonstrated high concentrations of ously released t-PA in larger than plasma t-PA1 in which circulating normal amounts is compensated t-PA/t-PA1 complexes produce an for by increased t-PA1 production; overall decrease in t-PA functional or (3) a longer half-life in the circuactivity. In general, venous occlu- lation of the t-PA/t-PA1 complex sion in these patients releases ade- compared to that of free t-PA. Furquate circulating t-PA antigen, but ther elucidation of the deficient fiis associated with persistently high brinolytic responses in similar pat-PA1 levels (independent from tients may lead to a better underveno-occlusion) and impaired fi- standing of the prethrombotic brinolysis [2]. Our patient, how- state and the critical factors inever, showed an unusual and dif- volved during its progression to ferent response to veno-occlusion clinically detectable intravascular characterized both by poor t-PA thrombosis. functional activity and antigen release and by normal t-PA1 plasma concentration. These observations BRUCE LATHAM, M.D. will be extended to include studies ERNEST~ A. KUFOY, M.D. in family members and repeated tO’NEILL BARRETT, Jr., M.D. PA release determinations to asM. FRANCISCO GONZALEZ, M.D. sess intrapatient variability in relaUniversity of South Carolina tionship to inflammatory states [7] School of Medicine or environmental factors [8]. Columbia, South Carolina
200
February
1990
The American
Journal
of Medicine
Volume
88
ACKNOWLEDGMENT We wish to thank Mrs. Hume Fulmer for her secretarial assistance in the preparation of this manuscript.
1. Wiman B. Llunberg B. Chmielewska J, et al: The role of the fibrinolytic system in deep vein thrombosis. J Lab Clin Med 1985; 105: 265-270. 2. Nilsson IM. Ljungner H. Tengborn L: Two different mechanisms in patients with venous thrombosis and defective fibrinolysis: low concentration of plasminogen activator or increased concentration of plasminogen activator inhibitor. Br Med J 1985; 290: 1453. 3. Mannucci PM, Kluft C. Traas OW, Seveso P, D’Angelo A: Congenital plasminogen deficiency associated with venous thromboembolism: therapeutic trial with stanozolol. Br J Haematol 1986; 63: 753759. 4. Staider M, Havert J, Kruithof EKO. Bachmann F: Release of vascular plasminogen activator (V-PA) after venous stasis: electrophoretic-zymographic analysls of face and complexed V-PA. Br J Haematol 1985; 61: 169-176. 5. Rodgers GM, Shuman MA: Congenital thrombotic disorders. Am J Haematol 1986; 21: 919-930. 6. Knshnamurti C, Tan DB, Barr CF, Alving BM: Plasminogen activator Inhibitor activities in a reference population. Am J Clin Pathol 1988; 89: 747-752. 7. Juhan-Vague I, Aillaud MF, DeCock F, et al: The fast-acting inhibitor of tissue-type plasminogen actlvator is an acute phase reactant protein. In: Davidson JF, Donati MB, Coccheri S, eds. Progress in flbrinolysis. Edinburgh: Churchill Livingstone, 1985: 146149. 8. Vague PU, Juhan-Vogue I, Aillaud MF, eta/:Correlation between blood fibrinolytic activity, PA inhibitor level, plasma insulin level and relative body weight in normal and obese subjects. Metabolism 1986; 35: 25D-253. Submitted
June 8, 1989, and accepted in revised form September 13. 1989