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

2. 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 /ml
Reticulocytes mL

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

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

5. 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 mU/mL
Folate/Vit.B12 normal

7. 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

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

9. 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)

10. 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

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

12. Negative control Positive controlM1 M2 R3
Negative control
Positive control
90%
82%

13. 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

14. 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

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

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

17. PNH AND MDS
Wang et al. Blood 2002