Ospedale S. Eugenio – Cattedra di Ematologia Università Tor Vergata CASE REPORT Luca Maurillo Ospedale S. Eugenio – Cattedra di Ematologia Università Tor Vergata

CLINICAL HISTORY Twenty years old male Asthenia, fever, dark urine No organomegaly Pancytopenia: WBC 2970/ml (Neutrophils 35%) Hgb 6.9 g/dL MCV 110 fl Plts 28.000 /ml Reticulocytes 110.000 mL

CLINICAL HISTORY Hyperbilirubinemia 2,39 mg/dL Conjugated 0,32 Non conjugated 2,07 LDH 4000 U/L Iron 117 mg/dl Ferritin 379 ng/mL

DIFFERENTIAL DIAGNOSIS HEMOLYTIC ANEMIA (PARVOVIRUS B19 INFECTION?) PNH MDS

CLINICAL HISTORY Radiological examinations: Chest RX ray normal TB CT scan normal Abdominal echography normal EGDS normal Bone marrow aspirate Erythroid hyperplasia, dyserythropoiesis Blasts < 5% Bone marrow biopsy: No fibrosis Additional tests: Cytogenetics 46xy Autoimmunity negative Immunohematological tests negative EPO in the serum 2040 mU/mL Folate/Vit.B12 normal

CLINICAL HISTORY Additional tests: Parvovirus B19 negative Cell colture abnormal growth with a “MDS-like” pattern Ham Test positive (+) G6PD normal PK normal Erythrocyte membrane electrophoresis Abnormal increase of spectrin dimers (38%, normal value 10%) PNH phenotype negative

Red Cell membrane defect CLINICAL DIAGNOSIS MDS RA subtype Red Cell membrane defect

THERAPY Suggested: AlloSCT (HLA compatible sibling donor available) Patient refusal Given: Transfusion, 2-4 RPC per months Amifostin: no response EPO: no response (as expected)

FOLLOW-UP WBC and Plts normalization Transfusional requirement: unmodified Persistence of dark urine Episodic abdominal pain Renal hypertrophy with renal function normal Splenomegaly Normal ferritin levels

Re-Evaluation Same results as the presentation, but emergence of PNH clone as demonstrated by flow cytometry

Negative control Positive control M1 M2 R3 Negative control Positive control 90% 82%

WHO SHOULD BE SCREENED FOR PNH? Patients with hemoglobinuria Patients with Coombs-negative intravascular hemolysis (high serum LDH), especially pts. with concurrent iron deficiency Patients with aplastic anemia (screen at diagnosis and once yearly even in the absence of evidence of intravascular hemolysis) Patients with refractory anemia – MDS (recommended even in the absence of hemolysis) Patients with venous thrombosis involving unusual sites Patients with episodic dysphagia or abdominal pain with evidence of intravascular hemolysis Parker et al. Blood 2005

PNH AND MDS MDS/PNH 4/40 pts (10%) MDS/PNH; cut-off 1% (CD55-, CD59-) PNH cells detected only in RA-MDS patients normocellular o hypercellular marrow on clot section morfologic displasia on bone marrow smears granulocytes CD59- ranged from 16-95% erythrocytes CD59- ranged from 13-22% (PNH 35-80%) Ham test mild in contrast with Classic PNH cytogenetic analysis: 1 trisomy 8, 3 normal karyotype PIG-A mutations in granulocytes MDS/PNH resembles AA/PNH (low PNH erythrocytes) Does MDS predispose to PNH creating conditions favourable to the genesis of PNH clone? Iwanago et al. Br J Hem 1998

PNH AND MDS Cut-off 1% (cells CD15+CD16-CD66b-) Pathology PNH clone % 115 Aplastic Anemia 22 39 MDS 23 28 BMT pts 0 18 cancer pts 0 13 LGL 0 20 renal allografts 0 21 healthy participants 0 Dunn and al Ann Int Med,1999

PNH AND MDS Cut-off 0.003% (cells CD11b/Gly-A+CD55-CD59-) MDS subtype N°pts PNH clone % RA 119 17* RARS 4 0 RAEB 33 0 RAEB-t 8 0 * Percentage PNH-type granulocytes <1% in 17/21 (81%) PNH+ patients Wang et al. Blood 2002

PNH AND MDS Wang et al. Blood 2002