Clinical Pathological Conference

1. Clinical Pathological Conference • Elizabeth Ross, M.D. • Chief Resident • Department of Medicine • October 12th, 2007

2. Chief Complaint • A 46 year old Dominican woman presents with 3 months of increasing abdominal distention and one month of diffuse epigastric pain

3. History of Present Illness • 2-3 years prior to admission: patient first noticed easy bruisability, she was diagnosed with “anemia” and iron supplementation was started. • 3 months pta: she noticed abdominal distention and was started on a “water pill”. • 1-2 months pta: Her abdominal distention progressed, she felt like she looked pregnant. • 2-3 weeks pta: unrelenting diffuse epigastric pain and discomfort.

4. HPI, continued • Her pain persisted so she sought medical attention and was admitted to an outside hospital • Imaging and lab studies revealed abnormal LFTs and portal and splenic vein thrombosis • She was started on a heparin drip and transferred to Bellevue • Repeat imaging confirmed IVC and hepatic vein thrombosis and also showed portal and splenic vein thrombosis

5. Additonal History Past Medical History: As above Past Surg History: Tuboligation 15 years ago Medications: iron, multivitamin On transfer: heparin drip Allergies: none Family History: Denies history of: clotting disorders, bleeding disorders, malignancy Social History: Born in Dominican Republic, has lived in the US for 10 years, no recent travel. Ten pack-year tobacco history, quit 9 years ago. No etoh, no illicit drug use. Lives with husband. Worked as HHA until four months ago.

6. Review of Symptoms • Monthly, regular menstruation since menarche, with heavy bleeding

7. Physical Exam • General: well-developed woman with apparent ascites, moaning in pain, appears stated age, mildly jaundice • Vital signs: BP 127/82, HR 108 and regular, RR 18, Temp 97.6, SpO2 97% room air • HEENT: oropharynx dry, mild scleral icterus • Lymph: no cervical, axillary or inguinal lymphadenopathy • Neck: supple, no jugular venous distension • Pulmonary: clear to auscultation bilaterally

8. Physical Exam, continued • Heart: tachycardic, regular rhythm, normal heart sounds, no murmurs • Abdominal: Distended, diffusely tender, shifting dullness present, fluid wave present, no masses palpable • Extremities: trace lower extremity edema bilaterally, 2+ peripheral pulses • Skin: no rashes • Rectal: guaiac negative • Neuro: Alert and oriented to person, place and time • Asterixis present

9. Hematology 11.7 9.3 59 MCV 85 (80-100) 34.9 MPV 9.9 (7.4-10.4) • Differential - wnl INR 1.67, PT 21, PTT 66 HIT Antibody – Positive Thrombin Time 133.6 (21.5 –29.9) RVVT – No Inhibitor Detected

10. Chemistry 130 95 13 90 Ca 8.0 4.6 26 0.5 Mg 1.7 Phos 2.0

11. Chemistry/Serology 311 129 6.8 6.0 193 4.3 3.0 LDH – 783 (110-225) ANA – positive Hep Bs Ab – positive Hep Bs Ag – negative Hep Bc Ab – positive Hep C Ab – negative

12. Urinalysis: • orange colored, clear; no glucose, moderate (2+) bilirubin, no ketones, Specific gravity 1.048, trace blood, trace protein, pH 6.5, Urobilinogen 4.0 eu/dL (0-2), no nitrite, trace leukocyte esterase, WBC 0-2, RBC 0-2

13. EKG, sinus tachycardia

14. Abd/Pelvic CT with contrast • Hepatic vein, portal vein, splenic vein and IVC thromboses • … A diagnostic procedure was performed

15. Student Discussants • Marty Wolf – Paroxysmal Nocturnal Hematuria • Leo Drozhinin – Anti-phospholipid Antibody Syndrome • Marci Cherit – Autoimmune Hepatitis • Cristobal Gao – Gastric Cancer

16. Abdominal/pelvic CT with IV contrast Dr. Kay Cho

31. Faculty Discussant Dr. Mitchell Charap

32. A DIAGNOSTIC PROCEDURE WAS PERFORMED

33. Hematologist/Hematopathologist Dr. David Araten

34. Patient 75% 88% FLOW CYTOMETRY WBC Normal 99% 68% RBC CD 59

35. Flow Analysis of Red Cells Normal Control Patient # Events CD59 Expression

36. Flow Analysis of Red Cells Patient Normal Control 65% 25% 10% # Events CD59 Expression

37. Flow Analysis of Red Cells Normal Control Patient 65% 25% 10% # Events PNH II PNH III CD59 Expression

38. Paroxysmal Nocturnal Hemoglobinuria

39. More Typical PNH Patient PNH III

40. CD55 CD59 CD14 CD48 CD87 TFPI stemcell lymphocyte CD55 CD59 CD48 CD52 CD87 monocytes platelets redcell neutrophil CD55 CD59 CD55 CD59 CD66 CD24 CD16 CD55 CD59 acetylcholinesterase

41. C3b C3 C4 C3 C2 GPI C5 C5b Eculizumab C3b Eculizumab Classical pathway C5 convertase C4b C2a C5 Bb C3b C3b Alternative Pathway C5 convertase Bb C3b C3b X Alternative Pathway C3 convertase CD55 X C4b C2a Classical Pathway C3 convertase CD59 X C5b C6 C1r/C1s C8 GPI Classical pathway C7 C1q Antibody C9 Membrane Attack Complex (MAC)

42. Immune Lysis Test Two populations of cells Rosse 1974

43. Immune Lysis Test Three populations of cells Rosse 1974

44. Immune Lysis Test PNH II PNH III Three populations of cells Rosse 1974

45. Loss of all GPI-linked proteins CD48 CD55 CD59 GPI-linked protein O=C N trans- membrane protein GPI Extracellular Intracellular

46. in frame deletion deletion insertion missense mutation insertion/deletion inherited mutation insertion/duplication Acquired Somatic Mutations in PIG-A (Xp22.1) in PNH patients L a r g e d e l e t i o n d e l 7 3 5 b p d e l e x o n s 3 - 4 - 5 . * Null mutations * * * * * * * * * * * * 1 716 849 982 1189 1452 * * * * * * H * * * * * * * * * * * 4 6 5 3 2 1 Ava I 50 bp polymorphism non coding region coding region TM, Transmembrane domain (nt 1246-1326, aa 415-442) GlcNAc transferase homologous region (nt 912-1185, aa 304-395) H: Hot spot reported by Mortazavi et al 2003 changes very close to each other, presumably nonsense mutation * splice site mutation resulting from a single mutational event From Luzzatto & Nafa 2000

47. Marked Geographical Disparity • High rates of thrombosis reported in the United States, Europe and India • Much lower rates in Mexico, Japan, China, and Thailand

48. Ethnicity as a Risk Factor for Thrombosis and Death Araten et al 2005

49. Wrap-Up Dr. Elizabeth Ross

50. Final Diagnosis: Paroxysmal Nocturnal Hemoglobinuria -with granulocyte and erythrocyte clone size greater than 50%