750
Clinical and laboratory observations
The Journal of Pediatrics November 1990
Homozygous protein S deficiency in an infant with purpura fulminans Chularatana Mahasandana, MD, Vinai Suvatte, MD, A m p a i w a n Chuansumrit, MD, Richard A. Marlar, PhD, Marilyn J. Manco-Johnson, MD, Linda J. Jacobson, BS, and William E. Hathaway, MD From the Department of Pediatrics, Faculty of Medicine, Siriraj and Ramathibodi Hospitals, Mahidot University, Bangkok, Thailand, and the Department of Pediatrics, University of Colorado School of Medicine, Denver
Protein C, a vitamin K--dependent zymogen, and its cofactor, protein S (also vitamin K dependent), play major roles in the anticoagulant system for limiting thrombus formation.I, 2 Deficiency of either protein C or S is associated with recurrent familial thrombosis. 35 Several reports have described purpura fulminans caused by severe homozygous protein C deficiency in neonates and infants. 6, 7 However, deficiency of protein S has not been reported as a cause of neonatal purpura fulminans. We describe a 2-year-old infant with homozygous protein S deficiency who has had relapsing purpura fulminans since the age of 10 days. A brief account of this patient has been published) METHODS Blood was collected by standard two-syringe technique from a peripheral vein into buffered citrate anticoagulant. Plasma obtained by centrifugation was frozen at - 3 0 ~ C and transported by air in dry ice to the University of Colorado Health Sciences Center Special Coagulation Laboratory, in Denver. Protein C activity and antigen were measured as previously detailed. 9 Total protein S was assayed by immunoelectrophoresis with 0.5% monospecific polyclonal rabbit antihuman protein S antibody. 1~ The lower limit of detection for this assay is 0.1 U / m l based on a normal adult plasma pool containingl.00 U / m l . In addition, immunoelectrophoresis using a radioactive element for total protein S was performed by a modification of the method of Marlar et al. II The isolated IgG fraction of rabbit anti-protein S was radiolabeled, mixed with unlabeled antiprotein S IgG, and used as detailed, m The lower limit of detection for protein S is 0.002 U / m l . Free protein S was
Submitted for publication Oct. 30, 1989; accepted June 19, 1990. Reprint requests: William E. Hathaway, MD, Department of Pediatrics, Box C-222, Universtiy of Colorado Health Sciences Center, 4200 East Ninth Ave., Denver, CO 80262. 9/22/23260
measured by rocket immunoelectrophoresis after the protein S complexed to C4b-binding protein was precipitated by adding polyethylene glycol 8000 at 4 ~ C. 12 The lower limit of detection for free protein S i s 0.10 U / m l . The C4bbinding protein level was measured by rocket immunoelectrophoresis with sheep antihuman C4b-binding protein antibody. Crossed immunoelectrophoresis for free and C4bbound protein S was performed by the method of Comp et al. 12 Other coagulation determinations were obtained by standard methods. CASE REPORT A Thai girl was delivered at a provincial hospital in Thailand at 37 weeks of gestation by cesarean section because of preeclampsia and thick meconium-stained amniotic fluid. 8 She was small for FFP
Fresh frozen plasma
gestational age: birth weight was 1850 gin. The initial physical examination revealed no abnormalities. The infant received oral vitamin K1 prophylaxis at birth, and her postnatal clinical course was uneventful. She was breast fed only and did well until the age of 10 days, when subcutaneous hemorrhage and necrotic skin lesions first developed on the scalp and lower aspect of the abdomen, just above the inguinal area. She was treated by wound dressing and d6bridement without improvement. At the age of 14 days, she was admitted to the local hospital because of progression of the necrotic skin lesions. Heparin was administered intravenously every 6 hours and blood transfusion was given with some improvement. When heparin was discontinued after 24 days in the hospital, the skin hemorrhage and necrosis recurred and required continuation of intravenously administered heparin and intermittent whole blood transfusions for partial control. The infant was transferred to Siriraj Hospital Medical School at the age of 3 months. Physical examination revealed an ill baby with dark blue necrotic areas and bullae on the scalp, lower aspect of the abdomen, and upper aspect of the left thigh. Body temperature was 39 ~ C and weight was 3900 gm. The liver and spleen were not palpable, and the remainder of the examination showed no abnormalities. Results of the initial blood studies are shown in Tables I and
Volume 117 Humber 5
Clinical and laboratory observations
7~1
T a b l e I. Routine hematologic studies V a l u e s during patient's first y e a r Test
At 3 m o
At 6 m o
At 7 m o
At 11 m o
Hematocrit (%) Platelet count (per #1) Xl03 PT (NV 13-15 sec) aPTT (NV 38-50 sec) TT (NV 8-10 sec) Fibrinogen (NV 200-400 mg/dl) FDP (NV negative)
25 235 41.3 88.6 39.1 10 1:80(+)
36 265 17 50 11 ---
34 80 16.8 ---1:2(+)
25 30 38 >180 > 30 10 1:80(+)
+, Positive;PT, prothrombin time; NV, normal value; aPTT, activated partial thromboptastintime; TT, thrombin time; FDP. fibrinogendegradation product.
II. The infant was treated for sepsis and hypofibrinogenemia with antibiotics and cryoprecipitate (1 bag) given every 72 hours. The skin necrosis did not change although the clotting values improved. Vitamin Kl was also given orally, and cereals were added to the diet. In the second week the use of cryoprecipitate (1 bag) was increased to every other day without improvement of the skin lesions. During the third week, cryoprecipitate was given every day and there was a prompt response. The necrotic area began to heal and no new lesions appeared. At the age of 3~/2months, the patient was noted to have abnormal eye movements, and examination revealed endophthalmitis of both eyes, microphthalmos of the right eye, and total blindness. Results of tests for intrauterine infections were negative. Any attempt to decrease the dose of cryoprecipitate to every other day resulted in recurrence of subcutaneous hemorrhage and skin necrosis in the old scars. A search for the cause of thrombosis was attempted during the patient's full recovery. Detailed coagulation studies were performed at the ages of 6 and 7 months after cryoprecipitate infusions were withheld for 72 hours (Table lI). At 6 months the patient seemed fully recovered, but at 7 months she began to have new thrombotic skin lesions. Blood samples from her parents were also obtained at that time. The studies revealed an absence of protein S in the infant's blood; only trace amounts of the free protein S could be detected in her parents' samples. Other studies of the infant at the age of 6 months revealed normal values for antithrombin Ill, plasminogen, and protein C coagulant activity. The infant received a daily dose of cryoprecipitate for 489 months. Oral warfarin treatment was added when she was 8 months of age, and the dose was adjusted to keep the prothrombin time at about two and one-half times normal in an attempt to substitute oral warfarin therapy for cryoprecipitate transfusion. The infant did well until age 11 months, when large, deep ecchymoses and massive tissue necrosis developed on the left thigh after no cryoprecipitate had been given for 5 days, in spite of the continuation of oral warfarin therapy. Blood studies at that time were compatible with disseminated intravascular clotting (Table I). Thrombosis was controlled by cryoprecipitate transfusion every 12 hours for 14 days. The use of cryoprecipitate was gradually reduced to every third day when there was no further progression of the skin necrosis. This thrombotic episode resulted in massive tissue necrosis that required skin grafting. The patient was treated with a daily
oral dose of warfarin and a dose of cryoprecipitate (two bags) every third day until 189 years of age. At that time, fresh frozen plasma, 10 ml/kg, was used instead of cryoprecipitate because cryoprecipitate and FFP were found to contain equal amounts of protein S (1.0 U/ml). At 2 years of age, the patient has a body weight of 10.8 kg, length 80 cm, and head circumference 45 cm; eight teeth have erupted. Although she is permanently blind, she is able to sit up by herself; she stands with support but cannot walk. She can hear, and recognizes her name. A recent MRI study showed mild, diffuse cerebral atrophy. At present the patient is maintained on a regimen of oral warfarin therapy (prothrombin time 17 to 18 seconds [control value 13 to 14 seconds]) and FFP, 10 ml/kg every 96 hours via Hickman catheter, without recurrence of thrombotic lesions. The mother and father are both of pure Thai extraction, 27 years of age, and in good health. There is no family history of thrombotic tendency, blood disease, or consanguinity. On March 9, 1990, the infant was given 10 ml/kg of FFP. Studies of total and free protein S were performed at 2, 4, 6, 8, 12, and 24 hours after transfusion. Protein S amounts, shown to be entirely in the C4b-bound fraction on crossed immunoelectrophoresis, are listed in 'Fable 11. The approximate half-disappearance time was 36 hours. DISCUSSION The association of hereditary thrombotic disease with deficiencies of protein C and protein S is well known. In a review in 1986, C o m p 5' ~3 discussed two patients whom he had previously reported and suggested that they had a double heterozygous or homozygous deficiency of protein S. The two brothers had marked reduction in both total and free protein S (no measurable activity; 13% and 19% antigen, respectively); both had extensive thromboembolic disease, with onset at 14 to 15 years o f age. The parents, like other heterozygotes reported to have protein S deficiency, had intermediate levels. N e o n a t a l purpura fulminans was not seen in these or other reported cases of protein S deficiency. On the other hand, the association of neonatal purpura fulminans with homozygous protein C deficiency has
752
Clinical and laboratory observations
The Journal of Pediatrics November 1990
Table II. Studies of protein C, protein S, antithrombin Ili, and plasminogen Protein C (U/ml)
Normal adult Father Mother Infant At age 3 mo At age 6 mo At age 7 mo Cryoprecipitate FFP Baseline at 72 hr After FFP, 10 ml/kg At 2 hr At 4 hr At 6 hr At 8 hr At 12 hr At 24 hr ND,
Not
Protein S (U/ml) Free antigen
C4b-binding protein (U/ml)
Antithrombin III (U/ml)
Plasminogen (U/ml)
0.5-1.5 0.84 0.78
0.8-1.2 ---
0.76-1.2 ---
Activity
Antigen
Total antigen
0.7-1.3 0.76 0.9
0.7-1.3 1.0 1.0
0.7-l.34 0.7 0.48
0.5-1.5 Trace 0.1
0.23 0.59 0.21 ---
Trace -0.27 ---
0 ND 0 0.85-1.0 1.2 0 0.23 0.22 0.19 0.18 0.17 0.165 0.145
0 0 0 -1.5 0 0 0 0 0 0 0 0
__
0.46
m
0.8
m
1.02
detectable.
been described in at least 12 families. 14 These infants had massive skin necrosis, disseminated intravascular clotting, severe venous thromboembolic disease, and central nervous system lesions with blindness, but most parents of these infants are free of symptoms and may have an autosomal recessive form of the disorder. Our patient had massive skin necrosis beginning in the newborn period and therefore resembled patients with homozygous protein C deficiency. The blindness and changes in both eyes were suggestive of retinal vessel thrombosis in utero. Studies of the protease inhibitors revealed normal levels of antithrombin III and plasminogen. The low levels of protein C at 3 and 7 months of age were due to the occurrence of disseminated intravascular clotting during thrombotic episodes. Protein S activity was never detected in the infant, and the heterozygous range of protein S was noted in the parents. These findings indicate that this infant has severe homozygous protein S deficiency. Protein S is vitamin K dependent; in normal infants less than 3 months of age, the level of all vitamin K-dependent proteins may be physiologically low, especially in those who are breast fed and who received no vitamin K prophylaxis at birth. However, our patient had received vitamin K prophylaxis at birth. Protein S exists in two forms in plasma, as free protein and in a bimolecular, noncovalent complex with the regulatory complement C4b-binding protein. Only free protein S in plasma functions as a cofactor to activated
protein C, and thrombosis may develop in patients who have decreased levels of free protein S. 2, 12, 15 The response to treatment with cryopreeipitate and F F P indicates that both are sources of protein S. Because of the good response to the daily dose of cryoprecipitate, and to avoid blood volume overload, we did not give F F P at the beginning of therapy. Although there are many reports of the effectiveness of warfarin alone in preventing thrombotic episodes in the case of homozygous protein C deficiency, 6, 7 our patient did not respond to warfarin alone even when the prothrombin time was two and one-half times the control values. We were able to control the thrombosis with the combination of orally administered warfarin and cryoprecipitate transfusion. This patient seems to need lifelong replacement of protein S, and the only sources in Thailand are eryoprecipitate and FFP. Protein S concentrate, which may be the ideal product for this patient, is not yet available. REFERENCES
1. Esmon CT. Protein C. Prog Hemost Thromb 1984;7:25-54, 2. Walker FJ. Regulation &activated protein C by protein S: the role of phospholipid in factor Va inactivation. J Biol Chem 1981;256:11128-31. 3. Griffin JH, Evatt B, Zimmerman TS, Kleiss AJ. Deficiency of protein C in congenital thrombotic disease. J Clin Invest 1981;68:1370-3. 4. Bertina RM, Brockmans AW, van der Linden IK, Mertens K.
Volume 117 Number 5
5.
6.
7.
8.
9.
Protein C deficiency in a Dutch family with thrombotic disease. Thromb Haemost 1982;48:1-5. Comp PC, Nixon RR, Cooper R, Esmon CT. Familial protein S deficiency is associated with recurrent thrombosis. J Clin Invest 1984;74:2082-8~ Branson HE, Katz 3, Marble R, Griffin JH. Inherited protein C deficiency and coumarin-responsive chronic relapsing purpura fulminans in a newborn infant. Lancet 1983;2:1165-8. Seligsohn U, Berger A, Abend M, et al. Homozygous protein C deficiency manifested by massive venous thrombosis in the newborn. N Engl J Med 1984;310:55%62. Mahasandana C, Suvatte V, Marlar RA, Manco-Johnson M J, Jacobson L J, Hathaway WE. Neonatal purpura fulminans associated with homozygous protein S deficiency. Lancet 1990;1:61-62. Manco-Johnson MF, Marlar RA, Jacobson L J, Hays T, Warady BA. Severe protein C deficiency in newborn infants. J PEDIATR 1988;113:359-63.
Clinical and laboratory observations
753
l 0. Fair DS, Marlar RA. Biosynthesis and secretion of factor VII, protein C, protein S and the protein C inhibitor from a human hepatoma cell line. Blood 1986;67:64-70. l 1. Marlar RA, Endres-Brooks J, Miller C. Serial studies of protein C and its inhibitor in patients with disseminated intravascular coagulation. Blood 1985;66:59-63. 12. Comp PC, Doray D, Patton D, Esmon CT. An abnormal plasma distribution of protein S occurs in functional protein S deficiency. Blood 1986;67:504-8. 13. Comp PC. Hereditary disorders predisposing to thrombosis. Progr Hemost Thromb 1986;8:71-102. 14. Marlar RA, Montgomery RR, Broekmans AW, et al. Diagnosis and treatment of homozygous protein C deficiency. J P~DIATR 1989;114:528-34. 15. Dahlb~ick B. Inhibition of protein Ca cofactor function of human and bovine protein S by C4b-binding protein. J Biol Chem 1986;261:12022-7.
Association of Henoch-SchOnlein purpura glomerulonephritis with C4B deficiency Bettina H. Ault, MD, F. Bruder S t a p l e t o n , MD, Marian L. Rivas, PhD, F. Bryson W a l d o , MD, Shane Roy III, MD, Robert H. M c L e a n , MD, J i a n g Bin, MD, a n d Robert J. W y a t t , MD From the Department of Pediatrics, University of Tennessee, Memphis, the Department of Pediatrics, University of Alabama, Birmingham, and the Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
Henoch-Sch6nlein purpura is a systemic vasculitic disease that mainly affects children. Although the disease is usually selfdimited with a good eventual outcome, the glomerulonephritis associated with H S P may lead to renal failure. Presently the prognosis for H S P glomerulonephritis can be predicted only by the severity of renal histologic findings and clinical features. 1 Genes for the human complement proteins C2, factor B, and C4 (both C4A and C4B isotypes) are located within the
Supported by a grant from the Le Bonheur Children's Medical Center. Presented at the annual meeting of the Society for Pediatric Research, Anaheim, Calif., May 9, 1990. Submitted for publication March 14, 1990; accepted May 29, 1990. Reprint requests: Robert J. Wyatt, MD, Pediatric Research Laboratories, Room B310, 956 Court Ave., Memphis, TN 38163. 9/22/22773
major histocompatibility complex on human chromosome 6. They are designated class III M H C alleles. Complete deficiency of C2 has been described in three children with H S P 24 " and complete C4 deficiency in one child with HSP. 5 Previously, we found a significant increase in complete deficiencies of either C4A or C4B isotype in children and adults followed in Kentucky who had H S P or a closely related disease, IgA nephropathy. 6 In our study we examined C4 phenotypes in children with H S P from three centers in the southeastern United States. HSP MHC
Henoeh-Schfnlein purpura Major histocompatibility complex
METHODS S u b j e c t s . The diagnosis of H S P was based on the presence of a purpurie rash in the typical lower-extremity distribution, with abdominal pain, arthralgia, or both, during the acute phase of the illness. All patients and control subjects
Clinical and laboratory observations
The Journal of Pediatrics November 1990
Homozygous protein S deficiency in an infant with purpura fulminans Chularatana Mahasandana, MD, Vinai Suvatte, MD, A m p a i w a n Chuansumrit, MD, Richard A. Marlar, PhD, Marilyn J. Manco-Johnson, MD, Linda J. Jacobson, BS, and William E. Hathaway, MD From the Department of Pediatrics, Faculty of Medicine, Siriraj and Ramathibodi Hospitals, Mahidot University, Bangkok, Thailand, and the Department of Pediatrics, University of Colorado School of Medicine, Denver
Protein C, a vitamin K--dependent zymogen, and its cofactor, protein S (also vitamin K dependent), play major roles in the anticoagulant system for limiting thrombus formation.I, 2 Deficiency of either protein C or S is associated with recurrent familial thrombosis. 35 Several reports have described purpura fulminans caused by severe homozygous protein C deficiency in neonates and infants. 6, 7 However, deficiency of protein S has not been reported as a cause of neonatal purpura fulminans. We describe a 2-year-old infant with homozygous protein S deficiency who has had relapsing purpura fulminans since the age of 10 days. A brief account of this patient has been published) METHODS Blood was collected by standard two-syringe technique from a peripheral vein into buffered citrate anticoagulant. Plasma obtained by centrifugation was frozen at - 3 0 ~ C and transported by air in dry ice to the University of Colorado Health Sciences Center Special Coagulation Laboratory, in Denver. Protein C activity and antigen were measured as previously detailed. 9 Total protein S was assayed by immunoelectrophoresis with 0.5% monospecific polyclonal rabbit antihuman protein S antibody. 1~ The lower limit of detection for this assay is 0.1 U / m l based on a normal adult plasma pool containingl.00 U / m l . In addition, immunoelectrophoresis using a radioactive element for total protein S was performed by a modification of the method of Marlar et al. II The isolated IgG fraction of rabbit anti-protein S was radiolabeled, mixed with unlabeled antiprotein S IgG, and used as detailed, m The lower limit of detection for protein S is 0.002 U / m l . Free protein S was
Submitted for publication Oct. 30, 1989; accepted June 19, 1990. Reprint requests: William E. Hathaway, MD, Department of Pediatrics, Box C-222, Universtiy of Colorado Health Sciences Center, 4200 East Ninth Ave., Denver, CO 80262. 9/22/23260
measured by rocket immunoelectrophoresis after the protein S complexed to C4b-binding protein was precipitated by adding polyethylene glycol 8000 at 4 ~ C. 12 The lower limit of detection for free protein S i s 0.10 U / m l . The C4bbinding protein level was measured by rocket immunoelectrophoresis with sheep antihuman C4b-binding protein antibody. Crossed immunoelectrophoresis for free and C4bbound protein S was performed by the method of Comp et al. 12 Other coagulation determinations were obtained by standard methods. CASE REPORT A Thai girl was delivered at a provincial hospital in Thailand at 37 weeks of gestation by cesarean section because of preeclampsia and thick meconium-stained amniotic fluid. 8 She was small for FFP
Fresh frozen plasma
gestational age: birth weight was 1850 gin. The initial physical examination revealed no abnormalities. The infant received oral vitamin K1 prophylaxis at birth, and her postnatal clinical course was uneventful. She was breast fed only and did well until the age of 10 days, when subcutaneous hemorrhage and necrotic skin lesions first developed on the scalp and lower aspect of the abdomen, just above the inguinal area. She was treated by wound dressing and d6bridement without improvement. At the age of 14 days, she was admitted to the local hospital because of progression of the necrotic skin lesions. Heparin was administered intravenously every 6 hours and blood transfusion was given with some improvement. When heparin was discontinued after 24 days in the hospital, the skin hemorrhage and necrosis recurred and required continuation of intravenously administered heparin and intermittent whole blood transfusions for partial control. The infant was transferred to Siriraj Hospital Medical School at the age of 3 months. Physical examination revealed an ill baby with dark blue necrotic areas and bullae on the scalp, lower aspect of the abdomen, and upper aspect of the left thigh. Body temperature was 39 ~ C and weight was 3900 gm. The liver and spleen were not palpable, and the remainder of the examination showed no abnormalities. Results of the initial blood studies are shown in Tables I and
Volume 117 Humber 5
Clinical and laboratory observations
7~1
T a b l e I. Routine hematologic studies V a l u e s during patient's first y e a r Test
At 3 m o
At 6 m o
At 7 m o
At 11 m o
Hematocrit (%) Platelet count (per #1) Xl03 PT (NV 13-15 sec) aPTT (NV 38-50 sec) TT (NV 8-10 sec) Fibrinogen (NV 200-400 mg/dl) FDP (NV negative)
25 235 41.3 88.6 39.1 10 1:80(+)
36 265 17 50 11 ---
34 80 16.8 ---1:2(+)
25 30 38 >180 > 30 10 1:80(+)
+, Positive;PT, prothrombin time; NV, normal value; aPTT, activated partial thromboptastintime; TT, thrombin time; FDP. fibrinogendegradation product.
II. The infant was treated for sepsis and hypofibrinogenemia with antibiotics and cryoprecipitate (1 bag) given every 72 hours. The skin necrosis did not change although the clotting values improved. Vitamin Kl was also given orally, and cereals were added to the diet. In the second week the use of cryoprecipitate (1 bag) was increased to every other day without improvement of the skin lesions. During the third week, cryoprecipitate was given every day and there was a prompt response. The necrotic area began to heal and no new lesions appeared. At the age of 3~/2months, the patient was noted to have abnormal eye movements, and examination revealed endophthalmitis of both eyes, microphthalmos of the right eye, and total blindness. Results of tests for intrauterine infections were negative. Any attempt to decrease the dose of cryoprecipitate to every other day resulted in recurrence of subcutaneous hemorrhage and skin necrosis in the old scars. A search for the cause of thrombosis was attempted during the patient's full recovery. Detailed coagulation studies were performed at the ages of 6 and 7 months after cryoprecipitate infusions were withheld for 72 hours (Table lI). At 6 months the patient seemed fully recovered, but at 7 months she began to have new thrombotic skin lesions. Blood samples from her parents were also obtained at that time. The studies revealed an absence of protein S in the infant's blood; only trace amounts of the free protein S could be detected in her parents' samples. Other studies of the infant at the age of 6 months revealed normal values for antithrombin Ill, plasminogen, and protein C coagulant activity. The infant received a daily dose of cryoprecipitate for 489 months. Oral warfarin treatment was added when she was 8 months of age, and the dose was adjusted to keep the prothrombin time at about two and one-half times normal in an attempt to substitute oral warfarin therapy for cryoprecipitate transfusion. The infant did well until age 11 months, when large, deep ecchymoses and massive tissue necrosis developed on the left thigh after no cryoprecipitate had been given for 5 days, in spite of the continuation of oral warfarin therapy. Blood studies at that time were compatible with disseminated intravascular clotting (Table I). Thrombosis was controlled by cryoprecipitate transfusion every 12 hours for 14 days. The use of cryoprecipitate was gradually reduced to every third day when there was no further progression of the skin necrosis. This thrombotic episode resulted in massive tissue necrosis that required skin grafting. The patient was treated with a daily
oral dose of warfarin and a dose of cryoprecipitate (two bags) every third day until 189 years of age. At that time, fresh frozen plasma, 10 ml/kg, was used instead of cryoprecipitate because cryoprecipitate and FFP were found to contain equal amounts of protein S (1.0 U/ml). At 2 years of age, the patient has a body weight of 10.8 kg, length 80 cm, and head circumference 45 cm; eight teeth have erupted. Although she is permanently blind, she is able to sit up by herself; she stands with support but cannot walk. She can hear, and recognizes her name. A recent MRI study showed mild, diffuse cerebral atrophy. At present the patient is maintained on a regimen of oral warfarin therapy (prothrombin time 17 to 18 seconds [control value 13 to 14 seconds]) and FFP, 10 ml/kg every 96 hours via Hickman catheter, without recurrence of thrombotic lesions. The mother and father are both of pure Thai extraction, 27 years of age, and in good health. There is no family history of thrombotic tendency, blood disease, or consanguinity. On March 9, 1990, the infant was given 10 ml/kg of FFP. Studies of total and free protein S were performed at 2, 4, 6, 8, 12, and 24 hours after transfusion. Protein S amounts, shown to be entirely in the C4b-bound fraction on crossed immunoelectrophoresis, are listed in 'Fable 11. The approximate half-disappearance time was 36 hours. DISCUSSION The association of hereditary thrombotic disease with deficiencies of protein C and protein S is well known. In a review in 1986, C o m p 5' ~3 discussed two patients whom he had previously reported and suggested that they had a double heterozygous or homozygous deficiency of protein S. The two brothers had marked reduction in both total and free protein S (no measurable activity; 13% and 19% antigen, respectively); both had extensive thromboembolic disease, with onset at 14 to 15 years o f age. The parents, like other heterozygotes reported to have protein S deficiency, had intermediate levels. N e o n a t a l purpura fulminans was not seen in these or other reported cases of protein S deficiency. On the other hand, the association of neonatal purpura fulminans with homozygous protein C deficiency has
752
Clinical and laboratory observations
The Journal of Pediatrics November 1990
Table II. Studies of protein C, protein S, antithrombin Ili, and plasminogen Protein C (U/ml)
Normal adult Father Mother Infant At age 3 mo At age 6 mo At age 7 mo Cryoprecipitate FFP Baseline at 72 hr After FFP, 10 ml/kg At 2 hr At 4 hr At 6 hr At 8 hr At 12 hr At 24 hr ND,
Not
Protein S (U/ml) Free antigen
C4b-binding protein (U/ml)
Antithrombin III (U/ml)
Plasminogen (U/ml)
0.5-1.5 0.84 0.78
0.8-1.2 ---
0.76-1.2 ---
Activity
Antigen
Total antigen
0.7-1.3 0.76 0.9
0.7-1.3 1.0 1.0
0.7-l.34 0.7 0.48
0.5-1.5 Trace 0.1
0.23 0.59 0.21 ---
Trace -0.27 ---
0 ND 0 0.85-1.0 1.2 0 0.23 0.22 0.19 0.18 0.17 0.165 0.145
0 0 0 -1.5 0 0 0 0 0 0 0 0
__
0.46
m
0.8
m
1.02
detectable.
been described in at least 12 families. 14 These infants had massive skin necrosis, disseminated intravascular clotting, severe venous thromboembolic disease, and central nervous system lesions with blindness, but most parents of these infants are free of symptoms and may have an autosomal recessive form of the disorder. Our patient had massive skin necrosis beginning in the newborn period and therefore resembled patients with homozygous protein C deficiency. The blindness and changes in both eyes were suggestive of retinal vessel thrombosis in utero. Studies of the protease inhibitors revealed normal levels of antithrombin III and plasminogen. The low levels of protein C at 3 and 7 months of age were due to the occurrence of disseminated intravascular clotting during thrombotic episodes. Protein S activity was never detected in the infant, and the heterozygous range of protein S was noted in the parents. These findings indicate that this infant has severe homozygous protein S deficiency. Protein S is vitamin K dependent; in normal infants less than 3 months of age, the level of all vitamin K-dependent proteins may be physiologically low, especially in those who are breast fed and who received no vitamin K prophylaxis at birth. However, our patient had received vitamin K prophylaxis at birth. Protein S exists in two forms in plasma, as free protein and in a bimolecular, noncovalent complex with the regulatory complement C4b-binding protein. Only free protein S in plasma functions as a cofactor to activated
protein C, and thrombosis may develop in patients who have decreased levels of free protein S. 2, 12, 15 The response to treatment with cryopreeipitate and F F P indicates that both are sources of protein S. Because of the good response to the daily dose of cryoprecipitate, and to avoid blood volume overload, we did not give F F P at the beginning of therapy. Although there are many reports of the effectiveness of warfarin alone in preventing thrombotic episodes in the case of homozygous protein C deficiency, 6, 7 our patient did not respond to warfarin alone even when the prothrombin time was two and one-half times the control values. We were able to control the thrombosis with the combination of orally administered warfarin and cryoprecipitate transfusion. This patient seems to need lifelong replacement of protein S, and the only sources in Thailand are eryoprecipitate and FFP. Protein S concentrate, which may be the ideal product for this patient, is not yet available. REFERENCES
1. Esmon CT. Protein C. Prog Hemost Thromb 1984;7:25-54, 2. Walker FJ. Regulation &activated protein C by protein S: the role of phospholipid in factor Va inactivation. J Biol Chem 1981;256:11128-31. 3. Griffin JH, Evatt B, Zimmerman TS, Kleiss AJ. Deficiency of protein C in congenital thrombotic disease. J Clin Invest 1981;68:1370-3. 4. Bertina RM, Brockmans AW, van der Linden IK, Mertens K.
Volume 117 Number 5
5.
6.
7.
8.
9.
Protein C deficiency in a Dutch family with thrombotic disease. Thromb Haemost 1982;48:1-5. Comp PC, Nixon RR, Cooper R, Esmon CT. Familial protein S deficiency is associated with recurrent thrombosis. J Clin Invest 1984;74:2082-8~ Branson HE, Katz 3, Marble R, Griffin JH. Inherited protein C deficiency and coumarin-responsive chronic relapsing purpura fulminans in a newborn infant. Lancet 1983;2:1165-8. Seligsohn U, Berger A, Abend M, et al. Homozygous protein C deficiency manifested by massive venous thrombosis in the newborn. N Engl J Med 1984;310:55%62. Mahasandana C, Suvatte V, Marlar RA, Manco-Johnson M J, Jacobson L J, Hathaway WE. Neonatal purpura fulminans associated with homozygous protein S deficiency. Lancet 1990;1:61-62. Manco-Johnson MF, Marlar RA, Jacobson L J, Hays T, Warady BA. Severe protein C deficiency in newborn infants. J PEDIATR 1988;113:359-63.
Clinical and laboratory observations
753
l 0. Fair DS, Marlar RA. Biosynthesis and secretion of factor VII, protein C, protein S and the protein C inhibitor from a human hepatoma cell line. Blood 1986;67:64-70. l 1. Marlar RA, Endres-Brooks J, Miller C. Serial studies of protein C and its inhibitor in patients with disseminated intravascular coagulation. Blood 1985;66:59-63. 12. Comp PC, Doray D, Patton D, Esmon CT. An abnormal plasma distribution of protein S occurs in functional protein S deficiency. Blood 1986;67:504-8. 13. Comp PC. Hereditary disorders predisposing to thrombosis. Progr Hemost Thromb 1986;8:71-102. 14. Marlar RA, Montgomery RR, Broekmans AW, et al. Diagnosis and treatment of homozygous protein C deficiency. J P~DIATR 1989;114:528-34. 15. Dahlb~ick B. Inhibition of protein Ca cofactor function of human and bovine protein S by C4b-binding protein. J Biol Chem 1986;261:12022-7.
Association of Henoch-SchOnlein purpura glomerulonephritis with C4B deficiency Bettina H. Ault, MD, F. Bruder S t a p l e t o n , MD, Marian L. Rivas, PhD, F. Bryson W a l d o , MD, Shane Roy III, MD, Robert H. M c L e a n , MD, J i a n g Bin, MD, a n d Robert J. W y a t t , MD From the Department of Pediatrics, University of Tennessee, Memphis, the Department of Pediatrics, University of Alabama, Birmingham, and the Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
Henoch-Sch6nlein purpura is a systemic vasculitic disease that mainly affects children. Although the disease is usually selfdimited with a good eventual outcome, the glomerulonephritis associated with H S P may lead to renal failure. Presently the prognosis for H S P glomerulonephritis can be predicted only by the severity of renal histologic findings and clinical features. 1 Genes for the human complement proteins C2, factor B, and C4 (both C4A and C4B isotypes) are located within the
Supported by a grant from the Le Bonheur Children's Medical Center. Presented at the annual meeting of the Society for Pediatric Research, Anaheim, Calif., May 9, 1990. Submitted for publication March 14, 1990; accepted May 29, 1990. Reprint requests: Robert J. Wyatt, MD, Pediatric Research Laboratories, Room B310, 956 Court Ave., Memphis, TN 38163. 9/22/22773
major histocompatibility complex on human chromosome 6. They are designated class III M H C alleles. Complete deficiency of C2 has been described in three children with H S P 24 " and complete C4 deficiency in one child with HSP. 5 Previously, we found a significant increase in complete deficiencies of either C4A or C4B isotype in children and adults followed in Kentucky who had H S P or a closely related disease, IgA nephropathy. 6 In our study we examined C4 phenotypes in children with H S P from three centers in the southeastern United States. HSP MHC
Henoeh-Schfnlein purpura Major histocompatibility complex
METHODS S u b j e c t s . The diagnosis of H S P was based on the presence of a purpurie rash in the typical lower-extremity distribution, with abdominal pain, arthralgia, or both, during the acute phase of the illness. All patients and control subjects
