CASE REPORTS

Management of Neonatal resistance of factor V () Fulminans with towards inhibition by activated PC is the most common genetic risk factor for hereditary Severe Deficiency (1). Homozygosity or compound heterozygo- Krishna Sen sity for PC mutations, producing an absolute Angshumoy Roy* deficiency of PC anticoagulant activity are exceedingly rare, found in only ~1/2,50,000 newborns(2). However, the complete lack of Neonatal purpura fulminans is a life- plasma PC activity in these patients results in threatening clinical entity characterized by exten- sive subcutaneous and disseminated neonatal purpura fulminans, a devastating intravascular usually manifesting thrombotic disorder of the newborn, shortly after birth. We report an autosomal recessive characterized by sudden onset of widespread form of the disease in a neonate who was diagnosed purpuric lesions progressing to gangrenous with compound heterozygosity for mutations in his , accompanied with disseminated protein C gene as the molecular basis of his disorder. intravascular coagulation (DIC) and shock. Keywords: Protein C, Purpura fulminans. An acquired form, usually recognized in older infants as a post-meningococcal syndrome is also caused by decreased levels Protein C (PC) is a vitamin K-dependent and activity of PC(3). serine protease anticoagulant that plays an essential role in regulating coagulation by Here, we describe a neonate with purpura degrading activated factors V and VIII in fulminans who was diagnosed with compound plasma. Mutations affecting proteins in the PC heterozygosity for PC mutations as the cause pathway (proteins C and S, factors V and VIII) of his hereditary thrombophilia. are the most common genetic predisposing Case Report factors for venous thromboembolism in adults. Whereas, heterozygous mutations in the PC The patient is a male newborn who was gene (PROC; OMIM: 176860) confer an ~five- delivered at term by cesarean section and fold increased risk for , a referred to our Center on the second day of his point mutation in the factor V gene producing life with a single gangrenous lesion on his scrotal area. The neonate weighed 2435g at From the Department of Pediatric Medicine, Park birth and had no apparent congenital Children’s Center for Treatment and Research, malformations; he is the first offspring of non- 4 Gorky Terrace, Kolkata 700 019, India and *Departments of Pathology and Molecular and consanguineous parents who were childless Human Genetics, Baylor College of Medicine, One for 11 years. Maternal history for recurrent Baylor Plaza, Houston, TX 77030, USA miscarriages or antenatal TORCH infections Correspondence to: Krishna Sen, Department of and family history for thromboembolic events Pediatric Medicine, Park Children’s Center for were negative. The newborn had received Treatment and Research, 4 Gorky Terrace, vitamin K prophylaxis at birth. Kolkata 700 019, India. E-mail: [email protected] Within the next 72 hours, purpuric lesions Manuscript received: October 13, 2005; appeared over the perineal region, the flexor Initial review completed: December 12, 2005; surface of the right thigh and the right lower Revision accepted: February 6, 2006. quadrant of his abdomen. The lesions soon

INDIAN PEDIATRICS 542 VOLUME 43__JUNE 17, 2006 CASE REPORTS enlarged and vesiculated, forming hemorr- that excluded as the hagic bullae with subsequent necrosis and cause of his acute renal failure. Over the next black eschar formation. The margins of the 2 days, the urine output increased and the lesions became erythematous and indurated. A hematuria subsided. complete blood count examination (CBC) Clinically, the cutaneous thrombotic revealed moderate with manifestations culminating in DIC with normal values for hematocrit and total and sudden onset in a newborn was strikingly differential leukocyte counts (Table I). The similar to neonatal purpura fulminans. In the patient received 2 units of absence of signs of generalized septicemia in (FFP) immediately and was started on a course this patient, a deficiency of the anticoagulant of intravenous vancomycin and ceftazidime. factors, protein C and remained the On the twelfth day of life, the patient leading differential diagnoses in the etio- developed hematuria and marked oliguria and pathogenesis of the disorder. We assessed started to ooze blood from the umbilical stump endogenous plasma PC activity in this patient and the lesions. A repeat CBC was using a chromogenic assay (Berichrom significant for severe thrombocytopenia protein C; Dade-Behring GmbH, Marburg, (~16,000/mL) which, along with grossly Germany); whereas normal levels vary elevated fibrin degradation product (FDP) between 0.8-1.3 IU/mL, PC activity in the levels, high levels of D-dimers (>10, 000 ng/ patient was in the undetectable range (Table I). mL) and markedly decreased plasma With a provisional diagnosis of purpura levels (Table I) confirmed a fulminans due to PC deficiency, we began laboratory diagnosis of DIC. fresh frozen plasma (FFP) transfusion at 15 The patient was immediately treated with 2 mL/kg every 12 hours. The skin lesions and units of concentrate that reversed the general condition of the patient started to thrombocytopenia (>1,60,000/mL) and the improve rapidly. After three weeks of FFP manifestations. We performed an transfusion, we shifted to low molecular urgent color doppler study of the renal vessels weight at 1 mg/kg for three days

TABLE I–Laboratory Test Values in the Patient for Evaluation of .

72 h 12th day 16th day 14 days after Reference FFP transfusion values

Platelets (× µL) 90 16 – 524 100-300* APTT, sec – NC – 28.3 35-52** PT (INR) – – – 1.06 0.9-2.7** Fibrinogen (mg/dL) – 50 – – 95-245** D-Dimer (µg/mL) – 10 – – <0.5*** Protein C Clotting activity (%) (96 h after FFP treatment) – – ND – 80-130 – not measured; NC: not coagulable; ND: not detectable, *(11) ** (13) ***(14).

INDIAN PEDIATRICS 543 VOLUME 43__JUNE 17, 2006 CASE REPORTS following which, oral anticoagulation with perception and bilateral vitreous hemorrhage, was instituted, gradually titrating the as an ocular complication of the initial episode dose to 0.3 mg/kg so as to maintain the of DIC. Imaging studies (USG, CT) have ruled international normalized ratio (INR) at ~ 2.5 out any other intra-abdominal or cerebral following the recommendations of the thrombotic events. International Committee on Thrombosis and Hemostasis(4). Discussion We obtained informed consent from the PC deficiency is predominantly inherited parents to analyze the PROC gene in the patient in an autosomal dominant manner with hetero- and his parents. Amplification of all nine exons zygous carriers often remaining asympto- and direct sequencing of the amplicons matic until later in life when they become revealed that the patient was a compound highly susceptible to venous thrombo- heterozygote for two missense alleles: a embolism. Autosomal recessive PC deficiency 6245C>T mutation in exon 7 inherited from the is less common, caused by homozygous or father and an 8752C>T mutation in exon 9 compound heterozygous mutations in PROC, from the mother, both alleles numbered and usually leads to a more severe form of the according to Foster et al.,(5). The paternal disease with onset of thrombotic mani- allele is predicted to cause an R178W festations at birth(4). The PC mutation data- alteration within the activation peptide of PC. base (PROC database: http://www.xs4all.nl/ The maternal allele is predicted to cause an ~reitsma/Prot_C_home.htm - version 1.2.1, A346V change in the serine protease domain updated 1998), an excellent repository of PC of the mature protein. Significantly, both the mutations identified worldwide, together with R178 and A346 residues are highly conserved recent studies report only 65 symptomatic amino acids in mammalian PC species; cases with recessive inheritance, 34 of them mutations in these residues have been being compound heterozygotes(7-10). previously reported to co-segregate with This study reports a case with the classic familial type I PC deficiency, in which, there is manifestations of neonatal purpura fulminans a quantitative reduction in plasma PC antigen caused by compound heterozygous mutations levels secondary to defective production, in the PROC gene. Since adults with hetero- folding or secretion of the protein(6,7). Our zygous PC deficiency are often asymptomatic, results therefore confirm that the purpura our results emphasize that even in the absence fulminans in our patient is due to a type I PC of parental history of familial thromboembolic deficiency resulting from compound hetero- events, an autosomal recessive PC deficiency zygous mutations in his PROC gene. should always be sought as an explanation for The patient was discharged after the thrombotic disorders in the newborn with cutaneous lesions healed and his INR is manifestations of DIC. Genotyping of currently being monitored fortnightly on an suspected patients for PROC mutations outpatient basis. Although warfarin-induced provides an unambiguous molecular skin necrosis has been previously reported in confirmation of a clinical diagnosis. Detection patients undergoing oral coumarin therapy, of mutations is also useful in the management our patient has tolerated the low-dose therapy and prognosis of autosomal recessive PC very well. However, at ~3 months of age, the deficiency. These patients require long-term infant was diagnosed with diminished light oral anticoagulation which, if well tolerated,

INDIAN PEDIATRICS 544 VOLUME 43__JUNE 17, 2006 CASE REPORTS can be adequate for them to remain free of Party on Homozygous of coagulopathy throughout life(4). Finally, the Subcommittee on Protein C and Protein S, genetic analysis is essential in the risk International Committee on Thrombosis and Haemostasis. J Pediatr 1989; 114: 528-534. assessment for affected couples planning to conceive and for prenatal testing of the fetus 5. Foster DC, Yoshitake S, Davie EW. The during a subsequent pregnancy. nucleotide sequence of the gene for human protein C. Proc Natl Acad Sci U S A 1985; 82: Contributors: The patient was under the 4673-4677. management of KS. AR was involved in the genetic 6. Poort SR, Pabinger-Fasching I, Mannhalter C, analysis and in the drafting of the manuscript. Reitsma PH, Bertina RM. Twelve novel and Funding: None. two recurrent mutations in 14 Austrian Competing Interests: None. families with hereditary protein C deficiency. Blood Coagul Fibrinolysis 1993; 4: 273-280. REFERENCES 7. Alhenc-Gelas M, Gandrille S, Aubry ML, 1. Seligsohn U, Lubetsky A. Genetic suscepti- Aiach M. Thirty-three novel mutations in the bility to venous thrombosis. N Engl J Med protein C gene. French INSERM network on 2001; 344: 1222-1231. molecular abnormalities responsible for 2. Rosendaal FR. Venous thrombosis: A multi- protein C and protein S. Thromb Haemost. causal disease. Lancet 1999; 353: 1167-1173. 2000; 83: 86-92. 3. Brandtzaeg P, Sandset PM, Joo GB, Ovstebo 8. Millar DS, Johansen B, Berntorp E, Minford R, Abildgaard U, Kierulf P. The quantitative A, Bolton-Maggs P, Wensley R, et al. association of plasma endotoxin, anti- Molecular genetic analysis of severe protein C thrombin, protein C, extrinsic pathway deficiency. Hum Genet 2000; 106: 646-653. inhibitor and fibrinopeptide A in systemic 9. Ablin AR, Kushner JH, Murphy A, Zippin C. . Thromb Res 1989; Platelet enumeration in the neonatal period. 55: 459-470. Pediatrics 1961; 28: 822-824. 4. Marlar RA, Montgomery RR, Broekmans 10. Manco-Johnson MJ. Development of hemo- AW. Diagnosis and treatment of homozygous stasis in the fetus. Thromb Res 2005; 115 protein C deficiency. Report of the Working Suppl 1: 55-63.

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