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Familial antithrombin III deficiency, which is inherited by autosomal dominant transmission, is now well recognized as a cause of recurrent venous thromboembolism. Many such families have now been described, but few came from Asia. This report details a Chinese kindred with three members living in Sydney, two of whom are affected.
Three patients with familial antithrombin III (ATIII) deficiency, who also have histories of thromboembolism, were treated with oxymetholone in combination with warfarin. Thrombolysis was observed in one patient with acute thrombosis of inferior vena cava during the oxymetholone and warfarin therapy. No further thromboembolic episodes occurred in these patients after initiation of warfarin with or without oxymetholone. The levels of plasma ATIII, alpha 1-antitrypsin, plasminogen and Cl-inactivator were significantly increased in all patients after the introduction of oxymetholone therapy. This suggests that oxymetholone augments anticoagulant and fibinolytic activity. Hence we consider that oxymetholone in combination with warfarin may be possible thrombolytic therapy in patients with familial ATIII deficiency.
Antithrombin III (ATIII) deficiency is inherited as an autosomal dominant trait. Three types of ATIII deficiency are recognized clinically. The prevalence of ATIII deficiency is uncertain; it has been estimated to occur in between one in 2,000 and one in 20,000 subjects. ATIII deficiency is found in between 4 and 6 percent of young patients with venous thrombosis, similar to but slightly lower than the prevalence of protein C and protein S deficiency in young subjects with thrombosis. The chances of finding a deficiency is increased if there is a history of familial or recurrent venous thrombosis. Cross-sectional reports in the literature are that between 30 and 80 percent of carriers have thrombosis. Thrombosis is uncommon in the first decade, but the risk rises sharply between the ages of 15 and 30. The major clinical manifestations of ATIII deficiency are young age at onset, idiopathic thrombosis, family history, and recurrent venous thromboembolism. Pregnancy and surgery are predisposing factors. Approaches to prophylaxis and treatment are discussed.
Two teenage brothers with recurrent thromboembolic disease were found to have antithrombin III deficiency. A family study spanning four generations revealed a total of 10 members with antithrombin III deficiency. Five of the 10 affected family members have had thrombotic problems. Antithrombin III deficiency was documented by coagulation assays measuring heparin cofactor, anti-Factor Xa, and progressive antithrombin activity; the level of antithrombin III antigenic material measured by immunoelectrophoresis was low in subjects with abnormal coagulation assays. The clinical features which may lead one to suspect the hereditary hypercoagulable condition of antithrombin III deficiency are reviewed.
Long-term warfarin therapy was changed to subcutaneous heparin to cover a planned pregnancy in a patient with congenital antithrombin III (AT III) deficiency. Satisfactory anticoagulation was easily maintained in spite of low levels of biologically active AT III. Delivery and the puerperium were covered by a reduced dose of heparin and alternate day infusions of AT III concentrate. A mean dose of 0.77 U/kg of AT III concentrate produced a rise of 1% in AT III and the half-life was of the order of 24 h, with no evidence of increased consumption during labour and delivery. Pregnancy and labour were uncomplicated and resulted in delivery of a healthy female infant. The importance of early and adequate anticoagulation during pregnancy is emphasized.
We investigated two thrombophilic families with the "classical" type of antithrombin III deficiency, i.e., with a low antithrombin III level measured both by immunochemical and functional methods. We obtained different antithrombin III patterns in the plasma of the affected members of the two families with the modified two dimensional immunoelectrophoresis method (heparin in agarose). In one family, the electrophoretic mobility of the antithrombin III is identical with that of normal antithrombin III. In the other, the antithrombin III displayed a decreased electrophoretic mobility in the heparinized agarose gel. The relatively low affinity of this antithrombin III to heparin could be directly proved by the heparin-agarose affinity chromatography, too. These two different antithrombin III patterns were observed by other investigators at different families as well. On the basis of our simultaneous observations of these two families we propose a classification of the inherited congenital antithrombin III deficiencies.
Congenital deficiency of antithrombin III, the main physiological inhibitor of blood coagulation, enhances recurrent venous thromboses, usually in the mesenteric network. Two such cases are reported.
Antithrombin III levels were studied in relation to the occurrence of thromboembolism in 48 patients with various degrees of proteinuria. Nine of these patients had clinical signs of thrombosis, including four with renal vein thrombosis. In eight of these nine patients, antithrombin III concentrations were below 70 per cent. There was a significant negative correlation between the antithrombin III concentration and the urinary protein excreation (P less than 0.001). Antithrombin III was found in the urine of 32 of 42 patients. There was a significant correlation between the renal clearance and the degree of antithrombin III serum deficiency (P less that 0.001). The clearance and serum level of albumin closely paralleled these changes. We conclude that thrombosis in patients with severe proteinuria is associated with a deficiency of antithrombin III due to urinary excretion of this protein.
3 individuals from 2 unrelated families with recurrent thromboses and quantitative deficiencies of antithrombin III (AT-III) were treated with danazol, 600 mg daily for 4 months. Significant increases of AT-III (p less than 0.025) measured as heparin cofactor activity were noted in 1 female and 1 male patient. Failure to augment levels in the other male patient may have been due to poor absorption of the drug following small bowel resection for mesenteric infarction. Side effects of estrogen deficiency necessitated dosage reduction in the female patient. The 2 males experienced no adverse side effects except for prolongation of the prothrombin time in 1 who was receiving oral anticoagulants. We conclude that danazol causes a significant increase in some individuals with familial AT-III deficiency. Additional studies are necessary to determine whether this form of therapy may prove to be a suitable alternative to long-term anticoagulation and to assess the long-term clinical benefits in individuals with recurrent thrombosis.
Severe acquired antithrombin III (AT III) deficiency was observed in a patient with severe pre-eclamptic toxaemia. Plasma AT III concentration of 0.25 U/ml was found in both functional and immunological assays. The patient was treated with human AT III concentrate as a result of the development of progressive disseminated intravascular coagulation (DIC), the further deterioration of renal function, the risk for thromboembolic complications and the possible adverse effects of heparin therapy. The selective correction of AT III activity resulted in a rapid disappearance of coagulation abnormalities. The patient underwent uncomplicated caesarian section. This observation indicates that acquired severe AT III deficiency may occur as an early feature of DIC in severe pre-eclamptic toxaemia.
Using polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP) and DNA sequencing, the molecular basis of hereditary type Ia antithrombin III (AT III) deficiency was disclosed in two families. One mutation was a change from T to A in the codon of TTA for Leu 140 forming a stop codon of TAA, which was confirmed by mutated primer-mediated PCR-HindIII digestion. The application of this method demonstrated that all four affected members had the mutant allele in a heterozygous state and that none of unaffected subjects had this mutation. Another mutation in the second family was a change from C to T in the codon of CGA for Arg 197 also forming a stop codon of TGA, which was confirmed by PCR-HaeIII digestion. Based on these, it was concluded that the two new nonsense mutations in the AT III gene in a heterozygous state are the molecular basis of hereditary type Ia AT III deficiency.
The incidence of thromboembolic complications (TE) during pregnancy in women with congenital antithrombin III (AT) deficiency has retrospectively been estimated to be about 70%. 8 women with congenital AT deficiency were studied during 9 pregnancies. Subcutaneous or intravenous heparin in doses to prolong the activated partial thromboplastin time (APTT) was given during pregnancy as prophylaxis or therapeutic treatment. During delivery and abortion the AT level was brought to normal by infusion of AT concentrate and the heparin was reduced or withdrawn. Four pregnancies were uncomplicated with regard to TE and resulted in 4 healthy children. Five pregnancies were terminated by induced or spontaneous abortion. 1 woman had TE during heparin prophylaxis and 2 women had TE before the prophylaxis was started. 1 of the latter suffered from a new TE during continued heparing treatment. Insufficient prolongation of APTT was registered at the time of TE in both women with TE during heparin treatment.
A patient with congenital antithrombin III deficiency and a history of thromboembolic events prior to pregnancy was successfully treated with subcutaneous heparin alone throughout two pregnancies. Although adjuvant antithrombin III infusions may have a role in the treatment of this disorder, especially in the peripartum period, there is no evidence that this approach is superior to heparin therapy alone. We present this case as further evidence that heparin therapy alone appears to be a safe and effective treatment for pregnant patients with this rare but serious disorder.
A young man with antithrombin III (AT-III) deficiency sustained a cerebellar venous infarct and recovered following treatment with AT-III concentrate. A family study showed that other members were affected. AT-III deficiency in this family was found to be due to a new variant AT-III TRURO 1. Young patients with strokes should be screened for thrombophilia.
Congenital deficiency of antithrombin III is a disease inherited as an autosomal dominant which predisposes to thromboembolism. Pregnancy and the postpartum period constitute a major additional risk factor for thromboembolism in deficient women. However, pregnancy may be envisaged without risk since there has been an improvement in knowledge concerning the physiology of the AT III molecule, its exact role in coagulation, the application of accurate laboratory tests which measure the deficiency, and especially the programming of pregnancy under cover of preventive treatment consisting of the perfusion of AT III concentrate in association with heparin. The treatment is restricting and costly but is, nevertheless, the only one to recreate conditions that are similar to physiological conditions, and its effect is therefore more certain.
OBJECTIVE: To describe two cases of inherited antithrombin III (AT-III) deficiency presenting at less than or equal to 28 days of age, and to review other neonatal reports. RESEARCH DESIGN: Clinical descriptions of two patients and literature review of known references to the neonatal presentation of this disorder. SETTING: Academic neonatal intensive care unit. PATIENTS: Case reports--two patients with thrombosis and family history of AT-III deficiency. Literature review--neonatal patients with thrombosis and diagnosis of AT-III deficiency or parental diagnosis of AT-III deficiency or diagnosis of AT-III deficiency alone. SELECTION PROCEDURES: Random observation (case reports) and literature search for cases of AT-III deficiency diagnosed in the neonatal period or presenting with thrombosis and a positive family history of the disorder. INTERVENTIONS: Fresh frozen plasma, heparin, and AT-III concentrate were employed in the current case reports. The cases from the literature used combinations of the above or no intervention. MEASUREMENTS/MAIN RESULTS: Twenty-three cases, including the current reports, of suspected or proved AT-III deficiency were found, with at least 11 cases of thrombosis and at least 10 deaths. CONCLUSIONS: Significant morbidity and mortality from inherited AT-III deficiency can occur in the neonatal period, and the incidence of affected neonatal patients is probably underestimated. Careful family history, early recognition, diagnosis, and specific treatment are important for management of this disorder.
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A 25-year-old Oriental woman with nephrotic syndrome was admitted to the United States Naval Hospital in Okinawa. She had acute aortic thrombosis, which was managed initially with bilateral femoral thrombectomy and calf fasciotomies. In the early postoperative period, increasing doses of heparin were required to maintain adequate anticoagulation. Hematologic evaluation revealed a deficiency of antithrombin III (AT-III). Such a deficiency has been recognized as occurring in nephrotic syndrome, most probably due to urinary loss of this serum protein. Five prior cases of acute aortic thrombosis have been described in the nephrotic syndrome, but only three reports of acute aortic thrombosis have been attributed to documented AT-III deficiency. Acute thrombosis due to AT-III deficiency may be confirmed by measuring decreased serum levels of this protein. Treatment is initiated with fresh frozen plasma and heparin, with subsequent utilization of oral warfarin.