Danazol Treatment for Paroxysmal Nocturnal Hemoglobinuria

Case Report

Masahiro MURAKAWA,Tsunefumi SHIBUYA, Mine HARADA, Takashi OKAMURA, Yoshinobu ASANO, Hideki OKAMURA and Yoshiyuki NlHO

Danazol was administered to two patients with paroxysmal nocturnal hemoglobinuria (PNH)with a dramatic effect on the hematological findings. The patients, 31- and 41-year-old females, were initially diagnosed as having aplastic anemia, and were initially treated with anabolic steroid and immunosuppressive therapy, respectively. Sugar water and Hamtests turned positive at the start of danazol therapy in the former patient and after two months in the latter patient. This drug produced a dramatic improvement in the hemoglobin level and the platelet count and showedfew side effects in the patients. Apossible mechanismof action of danazol for PNHis briefly discussed. Key words: Hemolytic anemia, Aplastic anemia, Hematopoiesis, Therapy

Danazol, a synthetic androgen with a reduced effective (10), the usefulness of this therapy has not virilizing effect, is administered for the treatment of been established. Recently, we experienced two cases endometriosis. Ahn et al (1) introduced this drug as of PNHin which danazol produced a dramatic an effective agent for the treatment of immune effect for the recovery from severe anemia. Danazol thrombocytopenic purpura (ITP), and it has also also had fewer side effects such as virilization and been reported to be useful in the treatment of skin complications than anabolic steroids and gave autoimmune hemolytic anemia (AIHA)even when encouraging results. Weherein report two cases of corticosteroids were ineffective (2). Furthermore, PNHsuccessfully treated with danazol. manyreports have described the effects of this agent CASE REPORT in patients with aplastic anemia (AA) (3), pure red cell aplasia (PRCA) (4) and myelodysplastic Case 1 (I.G.) syndrome (MDS) (5, 6). Paroxysmal nocturnal A 31-year-old Japanese womanwas admitted to hemoglobinuria (PNH) is a primary disorder of bone a local hospital on July 23, 1988, because of marrow hemopoietic cells characterized by an headache and transient left hemiparesis. At the age unusual susceptibility to the hemolytic action of of 27, dysfunctional genital bleeding had developed complement (7, 8). Pancytopenia and intravascular and she was diagnosed to have aplastic anemia (AA) hemolysis followed by hemoglobinuria and sub- on the basis of hematological and bone marrow sequent renal damage in the course are sometimes findings at a local hospital. Fluoxymesterone and difficult to control. Therapeutic trials of cortico- prednisolone (PSL) had produced some effects, but steroids and anabolic steroids for PNHhave not the patient had refused treatment with anabolic always been satisfactory (9). Although the ad- steroids and had been given blood transfusions ministration of danazol has been reported to be alone. From the First Department of Internal Medicine, Faculty of Medicine, Kyushu University, Fukuoka Received for publication August 14, 1989; Accepted for publication June 5, 1990 Reprint requests should be addressed to Tsunefumi Shibuya, MD,First Department of Internal Medicine, Faculty of Medicine, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812, Japan

Jpn J Med Vol 29, No 4 (July, August 1990) 417 Murakawa et al

At admission to a local hospital, Hb was 6.0 g/dl, on August 13, and she was discharged and followed RBC 1.63xlO12/l, Ht 19.7%, MCV 121 fl, MCH up in our outpatient clinic. In October 1988, the dose 36.8 pg, MCHC30.5% and PNH was diagnosed on of danazol was reduced to 200 mg/day because of the basis of positive sugar water and Hamtests. She amenorrhea and appearance of facial acne. The was transfused with 7 units of washed red blood cells hemoglobin level gradually increased from for two days, and then was referred to our depart- November 1988 (Fig. 1). On May 9, 1989, hemato- ment for further examination and for control of the logical findings were as follows; Hb 15.0 g/dl, RBC disease on August 8, 1988. At admission to our 4.51X1012/l, Ht 47.1%, MCV 104 fl, MCH 33.3 department, hematological findings just after pg, MCHC 31.8%, reticulocytes 1.9%, WBC transfusion were as follows (Table 1); Hb 7.7 g/dl, 2.7xlO9/l, and platelets 61x 109/L NCCof the RBC 2.21x1012/l, Ht 24.0%, MCV 109 fl, MCH bone marrow was 321 x 109/l with 36%erythroid 34.8 pg, MCHC32.1%, reticulocytes 2.3%, WBC series. In addition, the serum haptoglobin level 1.9x 109/l and platelets 38 x 109/l. Sugar water and recovered to 103 mg/dl. The remission has thereafter Hamtests were positive. Serum haptoglobin level been maintained for more than 12 months with a was less than 10 mg/dl. Bone marrow aspiration dose of only 100 mg/day of danazol. Liver func- showed a nucleated cell count (NCC) of 15 x 199/1 tion did not deteriorate during the course. with 26.0% erythroid series, and bone marrow Case 2 (S.T.) biopsy also showed highly hypoplastic marrow. A 41-year-old Japanese woman visited a Danazol, at a dose of 400 mg/day, was started physician on March 8, 1988, complaining of palpita-

Table 1. Laboratory findings of patient 1 at admission.

Peripheral Blood Blood Chemistry WBC 1 9x lO9/l T.bil. 0.7 mg/dl St. 3% LDH 526 IU/1 Seg. 51% BUN 9 mg/dl Mo. 4% Creat. 0.7 mg/dl Lym. 42% Iron 99 ^g/ml RBC 2.21 x lO12/l TIBC 253 /ug/m\ Hb 7.7 g/dl Ferritin 67.8 ng/ml Hct 24.0% Haptoglobin < 10 mg/dl Reticulocyte 2. 3 % Platelet 38 x l09/l Serology Sugar water test (+ ) CRP (-) Ham test (+) CH50 41 CH50-U C3 74 mg/dl Bone Marrow C4 31 mg/dl NCC 15 X 10V1 Coombs test (-) M/E ratio 0.68 Cold agglutinin test (-) Macro-Poly. 2.0% Macro-Orth. 1.2% Urine Examination Norm-Poly. 18.4% Occult blood (-) Norm-Orth. 4.4% Protein (-) Neu-Myelo. 3. 6% Urobilinogen (N) Neu-Meta. 2.0% Hemoglobin (-) Neu-Stab. 4.4% Casts (-) Neu-Seg. 7.6% Hemosiderin (-) Monocyte 1.2% Lymphocyte 55.2% Stool Examination Megakaryocyte (-) Occult blood (-) K aryotype 46XX Eggs (-)

418 Jpn J Med Vol 29, No 4 (July, August 1990) Danazol for PNH

I.G. PNH

m400mg

Jul. Aug. Sep. Oct. Nov. Dec. Jan. Feb. Mar. '88 '89 Fig. 1. Clinical course of patient 1. Arrows show RBCtransfusions. tion. Severe pancytopenia was found and she was erythroid series. At this time, both sugar water and referred to our hospital immediately. Hamtests turned positive. Thereafter, the Hb level On admission, hematological findings revealed reached a plateau level of approximately 8 g/dl and marked pancytopenia (Table 2); Hb 4.1 g/dl, RBC the platelet count was then maintained at approxi- 1.05X 1012/l, Ht ll.2%, MCV 106 fl, MCH 39 pg, mately 50 X 109/l, as shown in Fig. 2. All symptoms MCHC 36.6%, reticulocytes 2.6%, WBC 2.6x due to pancytopenia were alleviated, although facial 109/l and platelets 22 x 109/l. Bone marrow aspira- acne and amenorrhea appeared after two months. tion showed a NCC of 43 x 109/l with 24% erythroid Liver function was not affected by the agent. series, and bone marrow biopsy also showed markedly decreased hemopoiesis. Neither sugar DISCUSSION water test nor Hamtest was positive at this time. Danazol is well knownto be effective in some She was diagnosed as having AAand two courses patients with chronic ITP who have failed to of pulse-therapy with methylprednisolone were ad- respond to prednisolone (PSL), immunosuppres- ministered without effect. On May 14, 1988, ad- sants and splenectomy (1 1-15). The mechanisms of ministration of cyclosporin A (Cy-A) at a dose of the effect of danazol for ITP have been explained 280 mg/day was started. The frequency of blood in terms of enhancement of thrombopoiesis (15), transfusions was decreased thereafter and the suppression of anti-platelet auto-antibody produc- leukocyte and platelet counts increased. tion (16, 17), and impairment of clearance of On September 6, 1988, Cy-A was stopped for immunoglobulin-bound platelets by macrophages economic reasons and danazol at a dose of 400 (18). mg/day was started. In two weeks, the hemoglobin A clinical trial of danazol for the treatment of level started to rise with a dramatic increase of autoimmune hemolytic anemia (AIHA) with an reticulocytes to more than 10.0% in the peripheral evaluable effect was reported by Ahn et al (2). In blood. On November 15, 1988, hematological that study, the reduction of the dose of cortico- findings were as follows; Hb 9.1 g/dl, RBC steroids became possible with concomitant ad- 2.39xlO12/l, Ht 29.0%, MCV 121 fl, MCH 38.1 ministration of danazol. It was speculated that pg, MCHC 31.4%, reticulocytes 9.6%, WBC danazol worked by blocking the binding of IgG and 3.1xl09/l, and platelets 58x l09/l. NCC of the C3 to erythrocytes. marrow increased up to 431 x lO9/l with 60.8% With respect to the effect of danazol for AAand

Jpn J Med Vol 29, No 4 (July, August 1990) 419 Murakawa et al

Table 2. Laboratory findings of patient 2 at admission.

Peripheral Blood Blood Chemistry WBC 2.6x lO9/l T.bil. 1.4 mg/dl St. 1% D.bil. 0.2 mg/dl Seg. 56% LDH 593 IU/1 Mo. 2% BUN 20 mg/dl Lym. 41% Creat. 0.8 mg/dl RBC 1.05 x l012/l Iron 318 /ig/ml Hb 4.1 g/dl TIBC 345 ptg/m\ Hct 1 1.2% Haptoglobin <10 mg/dl Reticulocyte 2. 6% Platelet 22 x lO9/l Serology Sugar water test (-) CRP (-) Ham test (-) CH50 37 CH50-U C3 66 mg/dl Bone Marrow C4 26 mg/dl NCC 43 x 109/l Coombs test (-) M/E ratio 2.02 Cold agglutinin test (-) Proerythroblast 0.4% Macro-Poly. 0.4% Urine Examination Norm-Baso. 3.2% Occult blood (-) Norm-Poly. 12.8% Protein (-) Norm-Orth. 7. 2% Urobilinogen (N) Myeroblast 0. 8% Casts (-) Neu-Promyelo. 2. 8% Hemosiderin (-) Neu-Myelo. 1 3.2% Neu-Meta. 8.4% Stool Examination Neu-Stab. 5.2% Occult blood (-) Neu-Seg. 16. 8% Eggs (-) Eo-Meta. 0.4% Eo-Seg. 0.8% Monocyte 0.8% Lymphocyte 25. 2% Plasma cell 1.6% Megakaryocyte 6.25 x 106/l K aryotype 46XX

S.T. A.A. --PNH

Hb (g/dl)10 9

Platelets

xiO9/I)'li U IIU iiii il iiU 400mg

^.-# .--\ \/ U 1

"V ./à"- Mar. Apr. May Jun. Jul. Aug. Sep. Oct. Nov. Dec. Jan. Feb. Mar. 88 '89 Fig. 2. Clinical course of patient 2. Small arrows show RBCtransfusions and large arrows showplatelet transfusions. 420 Jpn J Med Vol 29, No 4 (July, August 1990) Danazol for PNH

MDS,in which a decrease of hemopoietic stem cells Ahn YS, Harrington WJ, Mylvaganam R, Ayub J, Pall LM. Danazol therapy for autoimmune hemolytic or ineffective hemopoiesis is thought to be the main anemia. Ann Int Med 102: 298, 1985. cause of pancytopenia, only a few papers have been Nakamura K, Yoshimitsu K, Ootsuka H, Nakano H, reported (3, 5, 6). Danazol may act as a direct Nagata Y. Long-term danazol treatment for an stimulator of hemopoiesis in such cases, in the same adolescent girl with aplastic anemia. Asia-Oceania J wayas anabolic hormones (19). Onthe other hand, Obst Gynecol 12: 365, 1986. Lippman SM, Durie BGM, Garewal HS, Giordano G, MDSis sometimes accompanied by immunethrom- Greenberg BR. Efficacy of danazol in pure red cell bocytopenia or hemolysis (5) and hence it is probable aplasia. Am J Hematol 23: 373, 1986. that danazol exerts its beneficial effect through Cines DB, Cassileth PA, Kiss JE. Danazol therapy in mechanisms similar to those in ITP and AIHA. myelodysplasia. Ann Int Med 103: 58, 1985. The present two cases indicate the usefulness of Kornberg A, Yona R, Iuklea S, Kaufman S. Danazol danazol for the treatment of PNH, as has been and myelodysplastic syndrome(Letter). AnnInt Med 104: 446, 1986. previously reported (10). PNH is a disorder of blood Rosse WF, Dacie JV. Immunelysis of normal human cells with increased susceptibility to complement- and paroxysmal nocturnal hemoglobinuria (PNH) red mediated lysis, and the PNH cells presumably arise blood cells. J Clin Invest 45: 736, 1966. from a clonal mutation of a hemopoietic stem cell. Aster RH, Enright E. A platelet and granulocyte This fact has been demonstrated by the single membrane defect in paroxysmal nocturnal hemoglobinuria; usefulness for the detection of platelet glucose-6-phosphate dehydrogenase (G-6-PD) iso- antibodies. J Clin Invest 48: 1199, 1969. enzyme in patients who were heterozygous at Firkin F, Goldberg H, Firkin BG. Glucocorticoid G-6-PDlocus (20). The two cases reported here management of paroxysmal nocturnal hemoglobinuria. showed marked bone marrow hypoplasia and Aust Ann Med 17: 127, 1968. negative results in Ham and sugar water tests Harrington WJ, Ahn YS, Cohen JJ, Ayub J, Pall LM. Treatment of paroxysmal nocturnal hemoglobinuria initially, and thus a diagnosis of AAwas made at with danazol. Blood (Abstr.) 64: 86a, 1984. presentation. In patient 1, PNHappeared to occur McVerry BA, Auger M, Bellingham AJ. The use of in the course of AA, as many patients with PNH danazol in the management of chronic immune throm- have a prior history of AA(21). In patient 2, danazol bocytopenic purpura. Br J Haematol 61: 145, 1985. was initially administered for the treatment of AA, Mazzucconi MG, Francesconi M, Falcione E, et al. Danazol therapy in refractory chronic immune throm- and subsequently PNHdeveloped. It is not sur- bocytopenic purpura. Acta Haematol 77: 45, 1987. prising that PNHshould arise from a defective clone West SG, Johnson SC. Danazol for the treatment of in the marrowof AA.As the bone marrowbecame refractory autoimmunethrombocytopeniain systemic hyperplastic and the Hamtest turned positive with lupus erythematosus. Ann Int Med 108: 703, 1988. danazol treatment, it is probable that the agent Dan K, Nomura T. Evaluation of the danazol therapy in chronic refractory idiopathic thrombocytopenic accelerated the proliferation of an abnormal clone purpura. Jpn J Clin Hematol 27: 1705, 1986 (in with increased susceptibility to complement. It is also Japanese). probable, however, that not only overproduction of Suzuki H, KojimaT, Sano M, Saito H, Kawamoto M. hemopoietic cells but also suppression of their Effects of danazol on idiopathic thrombocytopenic purpura. Jpn J Clin Hematol 26: 709, 1985 (in complement- and macrophage-mediated lysis may Japanese). have produced the subsequent increase of blood cells Michakski JP, McCombs CC, Roubinian JR, Talal N. in the peripheral blood. Further studies to define the Effect of androgen therapy on survival and suppressor clinical effects of danazol on PHN clones, and cell activity in aged NZB/NZWFl hybrid mice. Clin particularly on the immune system, are therefore Exp Immunol 52: 229, 1983. necessary. Agnello V, Pariser K, Gell J, Gelfand J, Nuran R, Turksoy RN. Preliminary observation on danazol REFERENCES therapy of systemic lupus erythematosus: Effects on DNAantibodies, thrombocytopenia and complement. 1) Ahn YS, Harrington WJ, Simon SR, Mylvaganam R, J Rheumatol 10: 682, 1983. Pall LM, So AG. Danazol for the treatment of Schreiber AD, Chien P, Tomaski A, Cines DB. Effect idiopathic thrombocytopenia purpura. N Engl J Med of danazol in immunethrombocytopenic purpura. N 308: 1396, 1983. Engl J Med 316: 503, 1987.

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Kennedy BJ, Gilberstein S. Increased erythropoiesis origin of abnormal red cells. Blood 36: 145, 1970. induced by androgenic-hormone therapy. N Engl J Med 21) Lewis SM, Dacie JV. The aplastic anaemia-paroxysmal 256: 719, 1957. nocturnal haemoglobinuria syndrome. Br J Haematol Oni SB, Osunkoga BO, Luzzato L. Paroxysmal 13: 236, 1967. nocturnal hemoglobinuria. Evidence for monoclonal

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