Haematologica 2002; 87:(02)ELT08
[Medline] [prev] [index] [next]A prolonged activated partisl thromboplastin time in a patient with a low grade malignant non-Hodgkin's lymphoma - a case report
Hans-Joachim G. Siemens, Peter Gerke1, Jürgen Steinhoff1, Angela Roth-Isigkeit2, Klaus Wagner2, Sabine Brückner2
Departments of Internal Medicine I1 and II and Anesthesiology2, Medical University of Lübeck, Ratzeburger Allee 160, D-23538 Lübeck, Germany
Correspondence: Dr. H.J. Siemens, Hematology Laboratory, 2nd Department of Internal Medicine, Medical University of Lübeck, Krögen 6, D - 24306 Plön, Germany . Tel.: international +49.452250449. Fax: international +49. 452250482. E-mail: hj.siemens@gmx.de
AbstractA 55-year-old female patient with anemia, thrombocytopenia, splenomegaly and a tentative diagnosis of a non-Hodgkin's lymphoma (NHL) was referred for further diagnosis. Four weeks prior, global coagulation tests had been normal. In 1990 she had received an allogenic renal transplant. Laboratory tests were essentially normal on admission except for a prolonged PT and APTT. The TT was normal. Furthermore, antibodies due to a recent EBV infection were found. More specific coagulation tests revealed a normal bleeding time and platelet count, but profoundly reduced factor activities for factors II, V, VII, VIII, IX, X, XI and XII. However, factor XIII was measured to be normal. Inhibitors were only found against factor IX (28.8 BU/mL) but not against factors VIII or XII. The kaolin clotting time and the dRVV test revealed negative results for lupus anticoagulants. In a lupus-sensitive APTT assay, a prolonged clotting time was measured and in a dilutional assay with standardized human plasma, normal values for APTT were determined. Anti-cardiolipin antibodies were negative. No bleeding complications occurred during abdominal lymph node extirpation. Palliative chemotherapy (CT) with mitoxantrone, leukeran, and prednisolone was started. After 2 weeks, the PT rose and after 4 weeks, i. e. 2 courses of CT, it was normal. The spleen returned to its normal size. In conclusion, we detected an inhibitor due to an NHL (or a recent EBV infection) with strong alterations of the coagulation system in vitro, yet without any in vivo bleeding tendency. A lupus anticoagulant could not be detected. Only an anti-phosphatidylserine antibody was weakly positive. Measurement of the prothrombin time (PT) and the activated partial thromboplastin time (APTT) forms part of the basal screening tests in every routine laboratory which deals with primary coagulation tests. Both tests are usually ordered to recognize disturbances in coagulation, or else to measure the effect of anticoagulation therapy. The differential diagnosis of a prolonged PT and a prolonged APTT includes a number of conditions, which are given in (Table 1).
The most frequent reason for a pathologic test result is the use of anticoagulatory drugs in the patient. All other potential causes have to be analyzed in a haematology laboratory capable of special testing. If the PT or the APTT is prolonged, all relevant single factors are determined after the exclusion of a possible anticoagulant therapy. However, if both tests are prolonged at the same time, for cost effectiveness, the global test with the greater deviation from the internal laboratory standard is analyzed further. This is done in order to avoid a whole battery of factor analyses, since most of the time, only one or a few factors are involved, e.g. in the diagnosis of a hemophilia or a hepatogenic coagulopathy. If, however, both tests reveal highly pathologic values, a number of or even all possible factor activities have to be determined. After the relevant factor has been found, further tests to reveal the underlying cause for the factor deficit are carried out. We here present the case of a Caucasian female patient with a rare differential diagnosis of a pathologically prolonged PT and APTT, i. e. both global tests and show the therapeutic consequences.
Materials and Methods
Presentation of the Case. A 55-year-old female Caucasian patient was referred to our hospital for further diagnosis. For approximately one month she had been suffering from weakness and fatigue and increasing pain in the left upper quadrant. A month prior to this admission, a tentative diagnosis of a non-Hodgkin's-lymphoma had been made in another hospital based on a splenomegaly, anemia, thrombocytopenia and scattered lymphocyte nests in the bone marrow. Constitutional "B" symptoms1 were not present. Global coagulation tests at that time had been normal (PTTa-Reagenz' and Neoplastin plus' on a BM Coasys 110' compound, Roche Diagnostics, Mannheim, Germany).
Concerning the past medical history, the following important facts should be mentioned. In 1971, the patient was first diagnosed with chronic renal failure due to primary bilateral renal atrophy and arterial hypertension. Between 1986 and 1990 the patient was on dialysis due to terminal renal failure. In 1990 she received an allogenic renal transplant. Since then she has been on cyclosporine A and prednisolone, and initially also on azathioprine for immunosuppression. She has had two steroid sensitive rejections.
On admission, the patient (height 160 cm, weight 63 kg, BMI 25) was in a reduced general condition. The skin and mucous membranes were pale and the thyroid gland was enlarged. Pathologically enlarged lymph nodes were not palpable; the liver could be palpated 1 cm and the spleen approximately 4 cm below the costal arch. In the left lower abdomen the painless renal transplant was located. A thrombosed Cimino shunt was present on the right forearm. The skin was free of bleeding symptoms such as hematomas, petechiae or suggillations. The temperature was 36.8 °C. All other physical findings were normal.Methods of Coagulation Tests:Multiple blood samples were obtained by single venous punctures in the cubital or forearm region with careful use of a tourniquet. The blood was directly drawn into Sarstedt Monovettes' (Nümbrecht, Germany), containing 0.106 mol/L of sodium citrate solution without buffer. Necessary i.-v.-drugs interfering with coagulation, such as factor concentrates were neither given in the same arm nor at the same time. Other drugs with known influence on the coagulatory system were not administered. Global tests were done frequently, other factor concentrations were analyzed several times during the diagnostic and therapy regimen. Every parameter was thus measured at least 3 times on 3 different days from newly obtained blood samples. The samples were centrifuged (3,000g for global tests, 10,000g for LA as platelet poor plasma with less than 10 platelets per nL) in the laboratory within one hour after withdrawal and the plasma obtained was either analyzed directly or deep frozen at -72° C for later analysis of special tests. All global tests were immediately carried out on a BCS automatic coagulation analyzer from Dade-Behring (DB), Marburg, Germany. Individual factor analyses were performed using an ACL 3000 analyzer from Instrumentation Laboratory, Milan, Italy. For the determination of the PT, the dilute PT, and the corresponding individual factors, InnovinTM (DB) reagent was used. For the measurement of the APTT and the individual factor analyses, Actin FSTM (DB) was used. The measurement of single factors was carried out in a single-phase-preparation in diluted plasma (1:5) using factor deficient plasma made by DB. Only factor XIII was determined with a chromogenic test (Berichrom, DB) using a BCS on which global tests were performed as well. Antithrombin (AT III) was determined on the BCS using an adapted CoatestTM by Chromogenix, Mölndal, Sweden. The determinations of the inhibitors were done according to the Nijmegen modification of the Bethesda method.2 The assays for lupus anticoagulants were performed following public recommendations.3 The dRVV (dilute Russell's viper venom test) screening and confirmation test came from American Diagnostica, Pfungstadt, Germany, the Textarin time and the Ecarin /Textarin ratio test from Diagnostica Stago, Asniere sur Seine, France. The kaolin clotting time (KCT) was performed as an internal laboratory test according to a publication by Exner.4 A ratio of greater than 1.2 was considered pathological. Anti-Xa-activing was determined with a CoatestTM by Chromogenix. Antibodies against cardiolipin, phosphatidylserine and beta2-glycoprotein I were assayed with an ELISA test from Imtec, Berlin, Germany. All measurements, were performed following the recommendations of the ECAT assay procedures.5 Commercially available kits were assayed according the manufacturers rules.
Results
General Laboratory Findings: Serum electrolytes, cholinesterase, liver enzymes except for glutamyl transferase (48 U/L), lipase and TSH were normal. Increased levels were found for creatinine (133 mmol/L), LDH (332 U/L), alkaline phosphatase (462 U/L), bilirubin (24.5 mmol/L) and ferritin (295 mg/L). C-reactive protein (73 mg/L) and beta2-microglobulin (9.2 mg/L; normal < 2.2 mg/L). The blood count revealed a microcytic anemia (Hgb 98 g/L, MCV 74.7 fL) and a slight thrombocytopenia of 146/nL. Controls during the further course revealed platelet values as low as 44/nL. The differential showed a regular pattern and a normal leukocyte count. The lymphocyte typing revealed normal values for CD4, CD8 and CD19 positive cells. A leukemic wash out of B-lymphocytes could therefore not be demonstrated. Monoclonal immunoglobulins responsible for the inhibitory effects on coagulation tests could not be found. Serologic screening for hepatitis A, B and C was negative. There was no evidence for cytomegaly-pp65-antigen and Epstein-Barr virus DNA. In the EBV immunoblot, IgG antibodies against membrane antigen, early-antigen and virus capside antigen p23 were found, IgM antibodies against membrane antigen were slightly positive. These titer constellations are indicative of a recent infection.
Coagulation Test Results. Global coagulation tests were pathologic: the PT value was prolonged with 54 sec (s) (equals an INR of 5.9) and APTT was measured to be 53s (normal 25-35s). Thrombin time at normal with 18 sec as was the AT III concentration. The fibrinogen concentration was high, being 13.2 g/L. The bleeding time according to Ivy6 was normal at 1 minute and 51 sec. The number of platelets and their function were inconspicuous. On the other hand, all activities for individual coagulation factors were clearly reduced (see Table 2), except for factor XIII which showed an activity of 140%. An inhibitor against factor VIII and XII was not found, but factor IX revealed a relevant titer of 28.8 BU/mL. Anticardiolipin antibodies were not found, only antibodies against phosphatidylserine were detected. The kaolin clotting time (KCT) was measured on several occasions and never prolonged. The other lupus-sensitive assays were inconspicuous as to the presence of a lupus anticoagulant. Mixing studies showed a shortening of time in the preparation with standard human plasma (SHP) as a direct hint to the presence of an inhibitor. The 1:8-dilutions of the factors IX, XI and XII showed higher activities compared to undiluted samples. This strongly suggested the presence of an inhibiting agent against the partial prothrombin complex. For further details see Table 2.
Other diagnostic procedures. The abdominal ultrasound screening showed a homogeneous liver structure with a liver size in the upper normal range. A hypodense area was identified in the liver hilus region with a size of 48 mm x 16 mm. The biliary tract was unremarkable, the spleen seemed not homogeneous in structure and was significantly enlarged (170 mm x 71 mm). The abdominal CT scan confirmed these ultrasonographic findings and also showed extensive lymphomas in the liver hilus region as well as in the caval and aorto-caval area. The CT scan of the head, neck and thorax region showed no evidence of tumor growth.
Medical course. Since there was strong evidence of a lymphoma, the retrieval of pathologically altered lymphatic tissue for histological diagnosis and planning of therapeutic approach had highest priority. Since pathologic tissue could only be suspected in the abdominal and retroperitoneal regions, the coagulatory situation had to be improved first. Surprisingly, the patient had not noticed any bleeding tendency, despite her extremely prolonged PT and APTT. Oral and intravenous administration of vitamin K (Koller test) did not change the laboratory analysis of coagulatory parameters. After the detection of a relevant specific inhibitor against factor IX of 28.8 BU/L, we gave 2,400 IE of factor IX concentrate (ImmunineTM, Baxter, Unterschleissheim). The recovery of factor IX was only 8%. The PT and the APTT stayed essentially unchanged. After administration of 2,000 IE of prothrombin complex concentrate (PPSB, Prothromplex STIM 4TM, Baxter, Unterschleissheim, Germany), and a subsequent reduction of the PT to 40s, a mini-laparotomy was carried out to obtain lymph node material from the hepato-duodenal ligament for histological examination. No bleeding complications occurred. The microscopic findings showed a massive infiltration of a low malignant non-Hodgkin's-lymphoma of the monocytoid type (marginal zone lymphoma, stage ps IV M+, according to the Ann Arbor classification). Due to the massive enlargement of the spleen, we assumed a primary splenic form. The patient, however, refused to undergo a splenectomy. Therefore, we began palliative chemotherapy according to the MCP protocol (mitoxantrone, leukeran and prednisolone). After two weeks of therapy, the PT value had already decreased to 15s, and after four weeks the PT value lay within the normal range as did all factor activities. Ultrasound screening showed that the longitudinal diameter of the spleen decreased from 22 to 14.7 cm during the same time span. The patient received a total of seven cycles of chemotherapy which she tolerated well.
Discussion
After allograft transplantation, patients usually receive an immuno-suppressive regimen for many years to prevent rejection of the organ. Therefore, patients are at a 50 to 100-fold increased risk of developing a malignoma7 of which the incidence is currently given at 6% (4-8%).8 The most frequent tumors are lymphomas, carcinomas and Kaposi's sarcoma. These tumors develop after 22 months (Kaposi sarcoma) at the earliest. However, the mean time for tumor development is approximately 113 months. In our patient, NHL was diagnosed approximately 90 months after transplantation. A probably recent EBV infection was also present. This infection was suspected to be the cause of the lympho-proliferative disease.9 Due to ultrasonographic and laboratory findings, a massive involvement of the liver seemed unlikely. Hepatic insufficiency could not account for the pathologic coagulation tests. However, a hepatogenic coagulopathy was supported by the reduced single factor activities and the low platelet count as found in at least 50% of patients with a hepatic insufficiency.10 On the other hand, the thrombocytopenia could also be explained by the bone marrow infiltration of the B-cell-lymphoma which had been diagnosed earlier. Factor VIII:C activity was reduced. Since it is usually elevated in a hepatogenic coagulopathy (acute or chronic),11 this was another argument against a hepatic cause of our findings.
Another differential diagnosis for a pathologically prolonged APTT is the detection of an inhibitor against the activity of an individual coagulation factor. Acquired inhibitors, which mostly act against factor VIII:C are also found in non-hemophilic patients. In a review, Hultin12 mentioned an investigation by Green and Lechner which showed that in 46% of all 215 patients with an inhibitor, no other disease as the cause of this inhibitor was found.13 Eighteen percent of patients suffered from auto-immune diseases, 7.3% were female patients in the post-partum period and 6.3% of patients suffered from malignomas; including lympho-proliferative diseases. eighty-seven percent of patients with a known inhibitor required transfusions and 22% died as a direct consequence of the inhibitor. In our patient, we were able to identify an inhibitor against factor IX. This is considered an extremely rare finding.14 Usually the cessation of the bleeding episode is attempted with the administration of high doses of the relevant factor. The only other available therapy is the application of recombinant factor VIIa concentrate. In our patient, we also tried to give factor IX concentrate and PPSB before the lymph node extirpation procedure to improve the coagulatory situation. However, this was not successful. Nonetheless, an increased bleeding tendency, neither before, during, nor after the lymph node extirpation was noticed. This finding was supported by the normal bleeding time.
An anticoagulant which prolongs the APTT and possibly the PT, but does not inactivate a single coagulation factor is called lupus-anticoagulant (LA).15 As initially suspected, an LA is not only found in patients with SLE,16 but also in other patients such as those with autoimmune diseases or malignomas.17 These antibodies are directed against phospholipid-dependent coagulation processes and thus prolong coagulation times in vitro.18 To be distinguished, these are better characterized anticardiolipin-antibodies which are directed against specific phospholipids such as cardiolipin or beta2-glycoprotein I. Patients with these antibodies tend to suffer from thromboembolic complications.19 In our patient we neither found clinical nor Doppler-ultrasonographic signs of a thromboembolic event. The tests that we carried out were negative for antiphospholipid antibodies, i. e. for the KCT, the dRVV-test, the plasma exchange and the anti-cardiolipin antibodies, but positive for antibodies against phosphatidylserin. Only the lupus sensitive APTT was prolonged, but the routine not lupus sensitive APTT had already been prolonged initially (seeTable 2). All tests were chosen and carried out according to the recommendations of the SSCC4,20 so that a antiphospholipid antibody could be excluded.
So far only few reports have been published on the clinical features of patients with a splenic marginal cell lymphoma, (SMCL). Different autoimmune phenomena have thus been described.21-23 Among others, there was a patient with a lupus anticoagulant and with anti-cardiolipin antibodies.21 As in our patient these antibodies disappeared after chemotherapy. Other authors have suspected that the lymphoma possibly produced immunoglobulins with the above-mentioned features. In our patient, the concentrations for all immunoglobulins lay within the normal range.
In conclusion, we assume that in our patient an inhibitor against factor IX in combination with a non-factor specific inhibitor produced by the lymphoma cells was detected in the coagulation laboratory. This factor either alone or in combination with further lymphoma cell products influenced both global tests of coagulation.Acknowledgments
We would like to thank Professor Monika Barthels of the Medical School of Hannover, Germany for extensive discussions during the treatment of our patient. Furthermore, we gratefully acknowledge the efficient laboratory work carried out by Mrs. Alexandra Jurat and Mrs. Delia Guttau. We would also like to thank Mrs. Andrea Champagne, Pittsburg, Kansas, USA for proof-reading this paper.
References