Hemorrhagic diathesis in a carrier of hemophilia B

Hemorrhagic Diathesis in a Carrier of Hemophilia B

A carrier of hemophilia B was found to have an unusually low factor IX level of 13 per cent. Her history of previous bleeding and the hospital course following elective dental extractions were consistent wtth a mild hemorrhagic diathests. The patient is a member of a large kindred of hemophiliacs. The mean level of factor IX in 12 carriers in this kindred was 42 per cent, wtth a range of 13 to 100 per cent. This patient represents the sixth reported case in which a female carrier of factor IX deficiency was symptomatic.

CRAIG S. KITCHENS, M.D.* JACK LEVIN, M.D.T W. KING SMITH, D.D.S.$ Baltimore, Maryland

Since antiquity, it has been recognized that hemophilic disorders are heritable diseases expressed clinically in males and carried by asymptomatic females [ 11. In 1803, it was demonstrated that hemophilia was transmitted by what is now known as a sex-linked pattern of inheritance [2]. Although it had been long suggested that a female could clinically express hemophilia, Merskey [3] first convincingly demonstrated the existence of a female hemophiliac. We describe an obligate carrier of hemophilia B (Christmas disease or factor IX deficiency) who manifested a moderate hemorrhagic diathesis.

MATERIALS AND METHODS Routine hematologic studies were performed with accepted technics. For coagulation studies, venous blood was cdlected in plastic syringes and transferred to glass tubes containing 3.8 per cent sodium citrate (nine parts blood: one part anticoagulant). Plasma was prepared and either immediately tested or stored at -2O’C. Prothrombin times (PT) by the tnethod of Quick [4], nonactivated partial thromboplastin times (PTT) using From ths Division of Hematology. Department of Medicine, The Johns Hopkins University School of Medicine and Hospital, Baltimore. Maryland. This study was supported in part by Research Grant HL 01601 from the National Heart and Lung Institute. and Training Grant TI AM 5260 from the National Institute of Arthritis, Metabolism and Digestive Diseases. National Institutes of Heatth. Bethesda. Maryland. Requests for reprints should be addressed to Dr. Jack Levin, Hematology Division, The Johns Hopkins Hospital, Battimore, Maryland 21205. Manuscript accepted May 1. 1975. * Present address: University of FkMi College of Medicine, Department of Medicine, Gainesville, Ftorlds 32610. $ Present address: 10 West Broadway, Sel Air, Maryland 21014. t Recipient of a Research Career Development Award (K04 HL 29906) Heart and Lung Institute.

136

January 1976

from the National

Thrombofaxe

(Ortho

thromboplastin

Diagnostics,

Raritan,

N.J.),

and

activated

partial

times (APlT) using Cephaloplastin (Dads Reagents, Miami,

Fla.) were determined within one hour of blood collection. Coagulation factors VIII. IX and XI were measured by the technic of Hardisty and MacPfterson

[S] employing

of these

factors.

Pbsma

plasma

from patients

samples

were

with hereditary

collected

deficiencies

in plastic tubes,

made

platelet-free, and stored in siliconized gbssware for the factor Xl (PTA) assays. Normal levels of coagulation factors in this hboratory are 60 per cent to 2 100 per cent. Fibrinogen

was measured

by the method of Claus

[ 61, fibrinogen degradation products by the ‘hemagglutination munoassay agulants

of Merskey

by the method

was demonstrated

et al. [ 71, and ffre presence of Margolius

and Ratnoff

by the insolubility of phsma

inhibition im-

of circubting [a].

Factor

antico-

XIII activity

clots in 5M urea [9].

CASE REPORT The proposita is a 27 year old white woman. She had no history of neonatal bleeding. Her menses lasted approximately 10 days and required up to 10 pads/day. Recently, menorrhagia had been less severe, in apparent response

The American Journal of Medicine

to oral contraceptives.

Volume 60

At age

15 she underwent

exploratory

HEMORRHAGIC DIATHESIS IN A CARRIER OF HEMOPHILIA B-KITCHENS

laparotomy

ET AL.

for acute abdominal pain, and a ruptured ovar-

ian cyst was

found.

surgery.

days postoperatively,

Four

No excessive

bleeding occurred

at

blood began to ooze

from the incision and continued to do so for three weeks. During

that period, 7 units of whole blood were adminis-

tered until the bleeding stopped. When she became pregnant in 1963,

she sought

tion. A diagnosis

consultation

of factor

and she was instructed

Xl (PTA)

at another

deficiency

institu-

was made

to receive 2 units of fresh

P ;

25

frozen

I .J

plasma at the initiation of labor. Labor and delivery were uncomplicated

and resulted

for hemorrhage.

;g

P

has never been any history

of petechiae, epistaxis,

or bleeding from the urinary or gastrointesti-

She has noted only a slight increase in bruising.

She was first seen at this institution of hemostasis

in 1973 for evaluation

prior to oral surgery.

Physical examination revealed a healthy appearing white woman. There were no mucocutaneous signs of ab-

normal hemostasis. All joints were normal. Examination of the lungs, heart and abdomen revealed no abnormalities. The hemoglobin concentration, white blood cell count, hepatic and renal function tests, and chest roentgenogram were normal. Impacted third molars were demonstrated roentgenographically. On admission, routine coagulation studies were performed. The Lee-White whole blood clotting time, recalcified clotting time, Duke bleeding time, tourniquet qualitative

clot retraction

test and

were normal. The platelet count

was 300,000/mm3. The level of fibrin degradation products was normal. The PT was 15 set (normal 15 to 20 set), PTT 81 set (normal 70 to 90 set), and APTT 45 set (normal 35 to 4.5 set). Fibrinogen concentration was 280 mg/lOO ml. Levels of procoagulant activity of factors VIII and Xl were each 100 per cent. Factor normal,

and circulating anticoagulants

XIII activity was

were not detected.

The initial activity of factor IX was 10 per cent. Eight other determinations surgery

I

, /b-f-

5

IO

I5

27 43

POST-OPERATIVE DAYS

She continued to bleed for three weeks

There

nal tracts.

m/9

/

r

$j

and as a result received a total of 19 units of whole blood. hemarthrosis,

Pre- lnfusm Level

, ! -i 0

in the birth of an apparently

healthy son. Five days postpartum, she began to bleed vaginally. Examination failed to reveal any anatomic reason

i+\,L

of factor

or after discharge

IX were performed

either before

and levels ranged from 8 to 16

per cent, with a mean of 13 per cent. Simultaneous PlTs were either normal or slightly prolonged (range 70 to 110 set). The karyotype of the proposita was determined using accepted technics. A single Barr body was demonstrated in 14 per cent (normal 14 per cent to 40 per cent) of cells obtained from a buccal smear. Karyotype analysis of metaphase figures from cultured lymphocytes consistently revealed 46 chromosomes and an apparently normal female pattern by the G banding technic. Therapy, factor IX levels and the clinical course are shown graphically in Figure 1. The patient was given 2 units of fresh frozen plasma every eight hours during the 24 hour period prior to surgery. After the first 4 units, her factor IX level rose from 10 per cent to 40 per cent. Three impacted third molars were extracted without difficulty, using nerve block anesthesia. The sockets were sutured. There was mild bleeding from all sockets during the 24

fm

kgute 1. Hospital course following dental extractions. Bleeding ceased on postoperative day 9 when the sockets were repacked. hour period following surgery (day 0) but none for the next four days. On day 5, oozing began at the right maxillary site and continued for three days, despite local debridement and repacking of the sockets. During this time, factor IX activity ranged from 20 per cent to 45 per cent. She was retested for evidence of a circulating anticoagulant; none was detected. She received a total of 71 units (approximately 200 ml/unit) of fresh frozen plasma during an 11 day period. Her weight increased from 124 to 129 pounds, and the blood pressure level rose from 100/60 to 140190 mm Hg. The hematocrit value fell from 40 per cent to 23 per cent. With the cessation of plasma therapy and the administration of hydrochlorothiazide (50 mg/day) for three days, the weight and blood pressure returned to normal and the hematocrit value rose to 30 per cent. During the last few days of hospitalization, there was no bleeding. She received no medication except oral ferrous sulfate. Follow-up examinations were within normal limits. The factor IX activity and hematocrit value have returned to their prehospitalization levels. FAMILY STUDIES The patient’s father and son had histories compatible with a bleeding diathesis. The father (individual Ill-l in Figure 2) had bled excessively following dental extractions and on one occasion required hospitalization and blood transfusions. He had experienced occasional traumatic hemarthroses as a youth. Her son (V-l) bled three days after circumcision but has had no other symptoms. Her three male and two female siblings have had no excessive bleeding. A nephew (V-2) has experienced repeated hematomas of the tongue. He bled excessively following dental extraction and required a total of 32 U of whole blood or fresh frozen plasma before hemostasis was achieved. It is of interest that the family had recognized that there was little spontaneous bleeding in affected members, that small lacerations or abrasions did not bleed abnormally, and that postoperative bleeding characteristically began about four days after surgery.

January 1976

The American Journalof Medicine Volume 60

139

HEMORRHAGIC DIATHESIS IN A CARRIER OF HEMOPHILIA B-KITCHENS

0:

MALE CLINICALLY AFFECTED MALE

a=

0:

ET AL.

Figure 2. Pedigree of the proposita. Members of each generation are specified in the text by consecutive enumeration in a counterclockwise direction.

FEMALE

l

‘%%L~FEMALE

* ;INDIVIWAL TESTED FDR FACTOR IX ACTMTY

As the pedigree analysis progressed, it was discovered that this family was related to the majority of factor IXdeficient patients followed at this institution. We had previously considered some of these patients to be unrelated. Figure 2 illustrates the kindred. Thirty-four symptomatic persons are shown (one female and 33 males). Factor IX levels were determined in a total of 40 persons. The mean factor IX level of the 14 persons tested in the symptomatic group was 5 per cent f 6 per cent’ (range 1 to 13 per cent). Conversely, the lowest level observed in an asymptomatic person was 18 per cent (V-24). These data strongly support the historic information provided by the family. The mean factor IX level in eight obligate carriers (daughters of hemophiliacs) was 44 per cent f 25 per cent* (range 13 per cent to 100 per cent). Four probable carriers demonstrated a mean value of 39 per cent f 12 per cent (range 18 per cent to 48 per cent). The 12 obligate and probable carriers had an over-all mean factor IX level of 42 per cent f 22 per cent’ (range 13 per cent to 100 per cent). All the historic and laboratory data are compatible with sex-linked inheritance. A portion of the proposita’s immediate family and their factor IX levels are shown in Figure 3. The proposita was related to the patient (111-13)who provides the substrate for our factor IX assay. Although his plasma had previously been determined to be factor IXl

* f 1 S.D.

140

January

1976

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of

Medicfne

Volume

deficient by comparison with known hemophilia B plasma, we thought it desirable to confirm this family’s deficiency using factor IX-deficient plasma obtained from an unrelated patient. The control curve obtained from the unrelated donor was identical to that usually observed in factor IX assays in our laboratory, and was used to reconfirm the diagnosis of Christmas disease in this family. COMMENTS Hemophilia is the prototype of sex-linked heritable disorders in man [ 10,111. Nearly all symptomatic cases are in males although well documented cases in females with abnormal bleeding have been described [ 12-151. During the 1950’s, it was discovered that carriers of hemophilia had approximately half the procoagulant activity of normal persons [ 161. As technics improved, it was appreciated that there was a Gaussian distribution of procoagulant activity in hemophilia A and B carriers and that the mean activity was 50 per cent of normal [ 171. Veltkamp et al. [18] predicted the probability of carriership for females in families of hemophilia A or B, based on their levels of procoagulant activity and their relationship to hemizygous males. Barrow et al. [ 191 studied 19 mothers of patients with hemophilia B and detected factor IX levels which ranged from 29

60

HEMORRHAGIC

DIATHESIS

IN A CARRIER OF HEMOPHILIA

B-KITCHENS

ET AL.

per cent to 109 per cent (mean of 67 per cent). Simpson and Biggs [20] studied 53 obligate heterozygotes

of hemophilia

B and detected

levels

which

ranged from 11 per cent to 130 per cent (mean of 55 per cent). They also demonstrated a lack of correlation between the heterozygote’s factor IX level and the severity of the diathesis within a given kindred. Kasper et al. [21] recently studied 45 carriers of hemophilia B and found a range of activity from 9 per cent to 90 per cent with a mean of 33 per cent. Carriers of hemophilia A are now being studied by immunologic methods [22]. Presumably, these methods will be used for study of hemophilia B carriers in the future. The possible genetic mechanisms by which females can demonstrate low levels of procoagulant activity apply to both hemophilia A and B [ 13,22,23]. Table I lists the case reports of symptomatic females with congenital deficiencies of factor IX, and the mechanisms that have been implicated. As reported previously [24-271, it must be ascertained that a presumed female patient is indeed a genotypic female and not a mosaic, an example of Turner’s syndrome or other genetic anomaly. Another possibility is that the patient is homozygous for hemophilia as has been reported for hemophilia A [3,12] and hemophilia B [28]. This is very improbable in our case. Detailed pedigree analysis, performed using the Bayesian method according to Chase and Murphy [ 291, demonstrated that the relative odds of the proband being heterozygous rather than homozygous affected were of the order of 100,000 to one. This calculation was based on the assumption that factor IX deficiency is a genetic lethal in males: therefore, the true odds are probably somewhat less. Homozygosity also can be produced by the transmission of the affected X chromosome (from either a carrier mother or a hemophilic father) in association with spontaneous mutation of the other X chromosome. This latter mechanism TABLE

is impossible

I

Symptomatic

Factor IX Activity (% normal)

<;

,/

; 13 c 2 1;

I 13

to disprove

in our patient,

Females with Congenital -__

Deficiency

n

= MALE

u

n=

w

FEMALE

t=DECEASED

/‘= PRDPOSITA

0

CLINICALLY CLINICALLY = AFFECTED =AFFECTED 43 s ;;;;;;:, ACT,V,TY FEMALE MALE Figure 3. Pedigree of the immediate family of the proposita, including the available members of her maternal lineage.

but all children of such a female would either be affected males or carrier females. Rarely, sporadic cases are found in families with normal clinical histories and laboratory studies, as described by Rozman et al. [30]. Their patient was a young girl with a factor IX level of 2 per cent and a severe hemorrhagic diathesis including spontaneous hemarthroses. Recently there have been reports of acquired deficiency of factor IX. This has been observed in association with Sheehan’s syndrome [31], nephrotic syndrome [32] and other diseases [33]. None of these possibilities provide likely explanations for our patient’s factor IX deficiency. It is most probable that our patient is an example of a clinically affected carrier. A few such cases have been reported (Table I). These range from a mild diathesis, such as the case (13 per cent activity) reported by Cook and Douglas [34], to severe bleeding, including spontaneous hemarthroses (5 per cent activity), as described by Lascari et al. [35]. Other symptomatic female carriers have been described by of Factor IX Mechanism

Symptoms Hemarthroses, hematomas Hematomas, hemothorax Postdental extraction bleeding Hemarthroses Postdental extraction bleeding Postdental extraction bleeding Hematomas, hemarthroses Postpartum hemorrhage Hematomas, hemarthroses Postpartum hemorrhage and postdental extraction bleeding

X0 XX

(Turner’s syndrome) (ring)/XO mosaicism Homozygous “Sporadic” Carrier Carrier Carrier Carrier Carrier Carrier

__~

January 1976

The American Journal of Medlclne

Reference ~41 ~271 [281 [301 [341 (351 [361 [371 [391 Present report

Volume 60

141

HEMORRHAGICDIATHESIS IN A CARRIER OF HEMOPHILIAB-KITCHENS ET AL.

Nilehn and Nilsson [ 361 as well as by Clark [37]. The most plausible explanation for variable levels in heterozygotes is provided by the Lyon hypothesis [38], which proposes that all X chromosomes, in excess of one, are genetically inactivated on a random basis in all somatic cells at an early stage of embryogenesis. This mechanism would account for the markedly less than predicted level for a carrier, as observed in the present patient: whereas her sisters, who are also obligate carriers, had levels (43 per cent and 55 per cent) more typical of heterozygotes. This hypothesis also explains the 100 per cent level of factor IX observed in one probable carrier (111-52).Revesz et al. [39] recently reported a most remarkable case. In their family, a carrier of hemophilia B gave birth to monozygous twin girls. One of the pair was asymptomatic with a factor IX level of 15 per cent, whereas the other had a severe diathesis with less than 1 per cent activity. Although the diagnosis in this patient was apparently correct, and seemingly appropriate therapy was rendered, she experienced abnormal bleeding following the technically uncomplicated removal of three impacted molars. She did not bleed from the sites of anesthesia. Her factor IX levels rose appropriately following the initial plasma infusions but did not remain as high as anticipated, considering the volume of plasma administered. Random units of fresh frozen plasma were tested for factor IX activity and all were found to contain normal levels. Others [40,41] also have observed that factor IX levels after infusion of plasma or concentrate are not as predictable as factor VIII levels in patients with hemophilia A following infusion therapy. Although it was impossible

to accurately calculate a plasma half-life from our data, it seemed shorter than the usually reported 18 to 24 hours [42]. It has been the experience of this laboratory that the half-life of infused factor IX, during the first few days of replacement therapy, may be as short as 8 to 12 hours. Therefore, we initially administer plasma or concentrate every 8 hours to control hemorrhage. At no time was bleeding of sufficient magnitude to warrant the use, in this patient, of commercial pooled concentrates, which have a high risk of transmitting hepatitis. It is noteworthy that a moderate hemorrhagic diathesis was present in a patient who initially had a normal clotting time, PT, PTT, bleeding time and platelet count. This series of tests often constitutes the “routine” evaluation of hemostasis that is carried out prior to surgery, biopsy or other invasive procedures. As demonstrated by our patient and reported by others [ 11,431, these screening tests often fail to detect persons with significant hemostatic defects. Our patient’s personal and family history was the most sensitive screening “test” employed and the importance of the clinical history in evaluating possible hemorrhagic disorders is clearly demonstrated in this report.

ACKNOWLEDGMENT We wish to express our appreciation to Dr. D. S. Borgaonkar of The Johns Hopkins Cytogenetics Laboratory for the chromosomal studies and to Dr. Thomas F. Newcomb of the Veteran’s Hospital, Gainesville, Florida, for supplying factor IX-deficient plasma from an unrelated family.

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6.

7.

8. 9.

f42

Rosner F: Hemophilia in the talmud and rabbinic writings. Ann Intern Med 70: 833, 1969. Otto JC: An account of an hemorrhagic disposition existing in certain families. Med Reposit 6: 1, 1803. Merskey C: The occurrence of haemophilia in the human female. Q J Med 20: 299, 1951. Quick AJ: Hemorrhagic Diseases, Philadelphia, Lea & Febiger, 1957, p 379. Hardisty RM, MacPherson JC: A one-stage factor VIII (antihaemophilic globulin) assay and its use on venous and capillary plasma. Thromb Diath Haemorrh 7: 215, 1962. Claus A: Gerrinerungsphysiologische schnellmethods zur bestimmung des fibrinogens. Acta Haematol (Base0 17: 237, 1957. Merskey C, Kleiner 61, Johnson AJ: Quantitative estimation of split products of fibrinogen in human serum, relation to diagnosis and treatment. Blood 28: 1, 1966. Margolius A Jr, Ratnoff OD: A laboratory study of the carrier state in classic hemophilia. J Clin Invest 35: 1316, 1956. Duckert F. Beck EA: Clinical disorders due to the deficiency

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of factor XIII (fibrin stabilizing factor, fibrinase). Semin Hematol 5: 83, 1968. Graham JB: von Willebrand’s disease and hemophilia A. Seminaire sur I’enfance hemophile 1: 14, 1988. Prentice CRM, Ratnoff OD: Genetic disorders in blood coagulation. Semin Hematol 4: 93, 1967. Morita H, Kagami M, Ebata Y, Yoshimura H: The occurrence of homozygous hemophilia in the female. Acta Haematol (Basel) 45: 112. 1971. Whissell DY, Hoag MS, Aggeler PM, Kropatkin M, Garner E: Hemophilia in a woman. Am J Med 38: 119, 1965. Bulloch W, Fildes P: Haemophilia. Treasury of Human Inheritance, vol 1, pt 2 (Pearson K, ed). London, Dulau & Co., 1911, p 169. McBride JA, Hunter J, Pearse E, Sultan Y, Caen JP: Haemophilia in a female. Thromb Diith Haemorrh 26: 205, 1971. Brinkhous KM, Langdell RD, Penick GD, Graham JB. Wagner RH: Newer approaches to the study of hemophilia and hemophilioid states. JAMA 154: 481, 1954. Veftkamp JJ, Hemker HC, Loeliger EA: Detection of hetero-

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quency for X-linked lethal recessives. Hum Hered 23: 19. 1973. Rozman C, Castillo R, Ribas-Mundo M. Suros J: Christmas disease in a girl with female karyotype. Acta Haematol (Basel) 37: 217. 1967. Brown CH Ill, Kvols LK, Hsu TH, Levin J: Factor IX deficiency and bleeding in a patient with Sheehan’s syndrome. Blood 39: 650, 1972. Natelson EA. Lynch EC, Hettig RA, Alfrey CP Jr: Acquired factor IX deficiency in the nephrotic syndrome. Ann Intern Med 73: 373, 1970. Ozsoylu S, Ozer FL: Acquired factor IX deficiency: a report of two cases. Acta Haematol (Basel) 50: 305. 1973. Cook IA, Douglas AS: Demonstrable deficiency of Christmas factor in two sisters. Br Med J 1: 479, 1960. Lascari AD, Hoak JC, Taylor JC: Christmas disease in a girl. Am J Dis Child 117: 585, 1969. Nilehn JE, Nilsson IM: Haemophilia B in a girl. Thromb Diith Haemorrh 7: 552, 1962. Clark KG: Haemophilic women. Lancet 1: 1388, 1973. Lyon MF: Sex chromatin and gene action in the mammal&t X-chromosome. Am J Hum-Genet 14: 135, 1962. Revesz T, Schuler D. Goldschmidt B. Elodi S: Christmas disease in one of a pair of monozygotic twin girls, possibly the effect of Lyonization. J Med Genet 9: 396. 1972. Bggs R: Christmas disease. Treatment of Haemophilii and Other Coagulation Disorders (Biggs R, MacFarlane RG. eds), Philadelphia. F. A. Davis 8 CO., 1966, p 224. Kasper CK: Surgical operation in hemophilia B. Use of factor IX concentrate. Calif Med 113: 4. 1970. Biggs R. Denson KWE: The fate of prothrombin and factors VIII. IX, and X transfused to patients deficient in these factors. Br J Haematol9: 532, 1963. Diamond LK, Porter FS: The inadequacies of routine bleeding and clotting times. N Engl J Med 259: 1025, 1958.

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