Resolution of possible acquired protein S deficiency after viral suppression in HIV infection

2021 ◽  
Vol 14 (11) ◽  
pp. e244983
Author(s):  
Leigh Cervino ◽  
Jillian Raybould ◽  
Patricia Fulco
Keyword(s):  
Viral Suppression ◽  
Treatment Guidelines ◽  
Protein S ◽  
People Living With Hiv ◽  
Protein S Deficiency ◽  
Anticoagulation Management ◽  
S Deficiency ◽  
Increased Risk ◽  
Undiagnosed Hiv ◽  
Living With Hiv

Current literature suggests an increased risk of venous thromboembolism (VTE) in people living with HIV (PLWH) with poorly controlled viraemia and immunodeficiency. VTE treatment guidelines do not specifically address anticoagulation management in PLWH. We report a case of a 33-year-old woman diagnosed with an unprovoked pulmonary embolism (PE) and deemed protein S deficient. Three years later, she was diagnosed with AIDS. Antiretroviral therapy (ART) was promptly initiated with viral suppression and immune reconstitution within 12 months. Eight years after her initial PE, the patient self-discontinued warfarin. Multiple repeat protein S values were normal. ART without anticoagulation has continued for 3 years with no thrombotic events. This case describes a patient with VTE presumably secondary to undiagnosed HIV with possible consequent acquired protein S deficiency. Additional research is needed to understand the characteristics of PLWH with VTE who may warrant long-term anticoagulation as opposed to shorter courses.

Severe Arterial Cerebral Thrombosis in a Patient with Protein S Deficiency (Moderately Reduced Total and Markedly Reduced Free Protein S): A Family Study

1989 ◽  
Vol 61 (01) ◽  
pp. 144-147 ◽  
Author(s):  
A Girolami ◽  
P Simioni ◽  
A R Lazzaro ◽  
I Cordiano
Keyword(s):  
Arterial Thrombosis ◽  
Protein C ◽  
Protein S ◽  
Protein S Deficiency ◽  
Protein C Deficiency ◽  
Free Protein ◽  
Her Family ◽  
S Deficiency ◽  
Increased Risk ◽  
Patient Reported

SummaryDeficiency of protein S has been associated with an increased risk of thrombotic disease as already shown for protein C deficiency. Deficiencies of any of these two proteins predispose to venous thrombosis but have been only rarely associated with arterial thrombosis.In this study we describe a case of severe cerebral arterial thrombosis in a 44-year old woman with protein S deficiency. The defect was characterized by moderately reduced levels of total and markedly reduced levels of free protein S. C4b-bp level was normal. Protein C, AT III and routine coagulation tests were within the normal limits.In her family two other members showed the same defect. All the affected members had venous thrombotic manifestations, two of them at a relatively young age. No other risk factors for thrombotic episodes were present in the family members. The patient reported was treated with ASA and dipyridamole and so far there were no relapses.

Elevated Levels of Prothrombin Activation Fragment 1+2 in Plasma from Patients with Heterozygous Arg506 to Gin Mutation in the Factor V Gene (APC-Resistance) and/or Inherited Protein S Deficiency

1996 ◽  
Vol 75 (02) ◽  
pp. 270-274 ◽  
Author(s):  
Benget Zöller ◽  
Johan Holm ◽  
Peter Svensson ◽  
Björn Dahlbäck
Keyword(s):  
Plasma Concentration ◽  
Protein C ◽  
Protein S ◽  
Factor V ◽  
Protein S Deficiency ◽  
Apc Resistance ◽  
S Deficiency ◽  
Increased Risk ◽  
Factor V Gene ◽  
V Gene

SummaryInherited resistance to activated protein C (APC-resistance), caused by a point mutation in the factor V gene leading to replacement of Arg(R)506 with a Gin (Q), and inherited protein S deficiency are associated with functional impairment of the protein C anticoagulant system, yielding lifelong hypercoagulability and increased risk of thrombosis. APC-resistance is often an additional genetic risk factor in thrombosis-prone protein S deficient families. The plasma concentration of prothrombin fragment 1+2 (F1+2), which is a marker of hyper-coagulable states, was measured in 205 members of 34 thrombosis-prone families harbouring the Arg506 to Gin mutation (APC-resistance) and/or inherited protein S deficiency. The plasma concentration of F1+2 was significantly higher both in 38 individuals carrying the FV:Q506 mutation in heterozygous state (1.7 ± 0.7 nM; mean ± SD) and in 48 protein S deficient cases (1.9 ± 0.9 nM), than in 100 unaffected relatives (1.3 ±0.5 nM). Warfarin therapy decreased the F1+2 levels, even in those four patients who had combined defects (0.5 ± 0.3 nM). Our results agree with the hypothesis that individuals with APC-resistance or protein S deficiency have an imbalance between pro- and anti-coagulant forces leading to increased thrombin generation and a hypercoagulable state.

Genetic analysis, phenotypic diagnosis, and risk of venous thrombosis in families with inherited deficiencies of protein S

Blood ◽  
2000 ◽  
Vol 95 (6) ◽  
pp. 1935-1941 ◽  
Author(s):  
Michael Makris ◽  
Michael Leach ◽  
Nick J. Beauchamp ◽  
Martina E. Daly ◽  
Peter C. Cooper ◽  
...  
Keyword(s):  
Venous Thrombosis ◽  
Protein S ◽  
Structural Defects ◽  
Protein S Deficiency ◽  
Gene Defect ◽  
Thrombotic Risk ◽  
Free Protein ◽  
First Degree Relatives ◽  
S Deficiency ◽  
Increased Risk

Abstract Protein S deficiency is a recognized risk factor for venous thrombosis. Of all the inherited thrombophilic conditions, it remains the most difficult to diagnose because of phenotypic variability, which can lead to inconclusive results. We have overcome this problem by studying a cohort of patients from a single center where the diagnosis was confirmed at the genetic level. Twenty-eight index patients with protein S deficiency and a PROS1 gene defect were studied, together with 109 first-degree relatives. To avoid selection bias, we confined analysis of total and free protein S levels and thrombotic risk to the patients' relatives. In this group of relatives, a low free protein S level was the most reliable predictor of a PROS1gene defect (sensitivity 97.7%, specificity 100%). First-degree relatives with a PROS1 gene defect had a 5.0-fold higher risk of thrombosis (95% confidence interval, 1.5-16.8) than those with a normal PROS1 gene and no other recognized thrombophilic defect. Although pregnancy/puerperium and immobility/trauma were important precipitating factors for thrombosis, almost half of the events were spontaneous. Relatives with splice-site or major structural defects in the PROS1 gene were more likely to have had a thrombotic event and had significantly lower total and free protein S levels than those relatives having missense mutations. We conclude that persons withPROS1 gene defects and protein S deficiency are at increased risk of thrombosis and that free protein S estimation offers the most reliable way of diagnosing the deficiency.

scholarly journals Deficiency of the natural anticoagulant proteins in women with pregnancy related venous thromboembolism

2009 ◽  
Vol 62 (1-2) ◽  
pp. 53-62 ◽  
Author(s):  
Gorana Mitic ◽  
Ljubica Povazan ◽  
Radmila Lazic ◽  
Dragan Spasic ◽  
Milana Maticki-Sekulic
Keyword(s):  
Venous Thromboembolism ◽  
Protein C ◽  
Protein S ◽  
Single Woman ◽  
Control Group ◽  
Protein S Deficiency ◽  
Clotting Factors ◽  
Protein C Deficiency ◽  
S Deficiency ◽  
Increased Risk

Inherited thrombophilia can be defined as a predisposition to thrombosis caused by heritable defects, such as mutations in genes encoding the natural anticoagulants or clotting factors. Pregnancy related risk of VTE is sixfold increased comparing to non pregnant age matched women. Pregnancy is an independent risk factor for the development of venous thromboembolism and this risk is further increased by the presence of thrombophilia. Aim of the study: The aim of the study was to evaluate the association between deficiency of natural anticoagulants: antithrombin, protein C and protein S and pregnancy related thromboembolism. We have determined the activities of antithrombin, proten C and protein S in 74 women with pregnancy related thrombosis and in 45 healthy women who had at least two uncomplicated pregnancies. Among the women with the history of venous thromboembolism antithrombin deficiency was found in 4 (5.4%), protein C deficiency in 2 (2.7%) and protein S deficiency in 5 (6.76%). The total of 11 (14.6%) women was found to be deficient. Not a single woman in the control group was found to be deficient in natural anticoagulants. Deficiencies of coagulation inhibitors are associated with an increased risk of venous thrombosis during pregnancy and puerperium (p= 0.006). Antithrombin, protein C and protein S deficient women are at higher risk of developing venous thromboembolism during antepartal period (p= 0.0097). Prophylactic treatment with heparin should be recommended from the very beginning of the following pregnancy in women with antithrombin, protein C or protein S deficiency.

scholarly journals Protein S deficiency complicated with repetitive peripheral arterial thrombosis successfully treated by mechanical thrombectomy device with Rotarex system

2017 ◽  
Vol 5 (1) ◽  
pp. 5
Author(s):  
Wei-Sheng Liao ◽  
Wei-Tsung Wu ◽  
Nai-Yu Chi ◽  
Wen-Hsien Lee ◽  
Chun-Yuan Chu ◽  
...  
Keyword(s):  
Arterial Thrombosis ◽  
Mechanical Thrombectomy ◽  
Rare Complication ◽  
Protein S ◽  
Protein S Deficiency ◽  
Catheter Directed Thrombolysis ◽  
S Deficiency ◽  
Increased Risk ◽  
Thrombectomy Device ◽  
Peripheral Arterial

Protein S deficiency is an inherited thrombophilia associated with an increased risk of venous thromboembolism. However, arterial thrombosis is a relative rare complication of protein S deficiency and the prognosis of these patients was worse than those without protein S deficiency in the literature. Herein we reported a 43-year-old male with protein S deficiency experiencing several times acute peripheral arterial thrombosis of left leg. Surgical thrombectomy was performed initially but later endovascular treatment (EVT) was suggested. Although EVT was successfully performed by catheter-directed thrombolysis (CDT), arterial thrombosis still recurred three months later. CDT was tried again but thrombosis could not be treated by this strategy anymore. Therefore, we used mechanical thrombectomy device (Rotarex system) and successfully regained the straight-line blood flow to the foot after the procedure. Peripheral echo showed patent flow after 6 months follow-up. In conclusion, arterial thrombosis is a relative rare complication of protein S deficiency and prognosis was not well in the literature, our case reminds physicians that Rotarex system is a safe and highly efficient device for acute PAOD even in the patients with hypercoagulable state.

scholarly journals A novel rare c. -39C>T mutation in the PROS1 5’UTR causing PS deficiency by creating a new upstream translation initiation codon and inhibiting the production of the natural protein

2020 ◽  
Author(s):  
Sylvie Labrouche-Colomer ◽  
Omar Soukarieh ◽  
Carole Proust ◽  
Christine Mouton ◽  
Yoann Huguenin ◽  
...  
Keyword(s):  
Protein S ◽  
Start Codon ◽  
Molecular Defect ◽  
Protein S Deficiency ◽  
Wild Type ◽  
Rare Mutations ◽  
S Deficiency ◽  
Increased Risk ◽  
Sequencing Strategy ◽  
Translation Initiation Codon

SummaryInherited Protein S deficiency (PSD) (MIM176880) is a rare automosal dominant disorder caused by rare mutations, mainly located in the coding sequence of the structural PROS1 gene, and associated with an increased risk of venous thromboembolism. To identify the molecular defect underlying PSD observed in an extended French pedigree with 7 PSD affected members in who no candidate deleterious PROS1 mutation was detected by Sanger sequencing of PROS1 exons and their flanking intronic regions or via a MLPA approach, a whole genome sequencing strategy was adopted. This led to the identification of a never reported C to T substitution at c.-39 from the natural ATG codon of the PROS1 gene that completely segregates with PSD in the whole family. This substitution ACG->ATG creates a new start codon upstream of the main ATG. We experimentally demonstrated that the variant generates a novel overlapping ORF and inhibits the translation of the wild type protein from the main ORF in HeLa cells. This work describes the first example of 5’UTR PROS1 mutation causing PSD through the creation of an upstream ORF, a mutation that is not predicted to be deleterious by standard annotation softwares.

Abstract 548: Molecular Mechanism Behind Protein S Deficiency in Obese Patients

2017 ◽  
Vol 37 (suppl_1) ◽  
Author(s):  
Vijaya S Pilli
Keyword(s):  
Molecular Mechanism ◽  
Plasma Protein ◽  
Protein S ◽  
Factor Ix ◽  
Negative Regulator ◽  
Liver Protein ◽  
Protein S Deficiency ◽  
S Deficiency ◽  
Increased Risk

Introduction: Protein S is a vitamin K-dependent plasma protein, produced mainly in the liver; Protein S circulates in the blood at a concentration of 450 nM. Protein S is an anticoagulant, serving as a cofactor for APC and TFPI, and as an inhibitor of Factor IX (FIXa). Protein S deficiency causes deep vein thrombosis (DVT), increased risk of inflammation and, because DVT is a complication commonly observed in obese individuals, Protein S deficiency might be associated with obesity. Aim: To identify a correlation between Protein S deficiency and obesity, and identify the probable molecular mechanism behind the Protein S deficiency in the obese subjects. Methods: Immunoblots, ELISA, EMSA, CHIP, aPTT assay, and thrombin generation assay. Results: By ELISA, we measured a decrease in Protein S level in obese mice compared with wild type mice. In obesity, the liver becomes hypoxic, thus, we hypothesized that hypoxia and hypoxia inducible factor 1 alpha (HIF1α) may regulate Protein S expression in obesity. We found that a high fat diet induced HIF1α stability in mice. HIF1α levels were inversely proportional to Protein S levels, suggesting that HIF1α is a negative regulator of Protein S expression. We further identified a putative HIF1α binding site in the Protein S promoter, and, by using in vitro and in vivo assays, we demonstrated that HIF1α binds directly to the Protein S promoter and suppresses transcription. We further confirmed HIF1α-mediated Protein S transcriptional regulation in vivo, Plasma Protein S levels are increased in the liver-specific HIF1α knockout mouse whereas, liver-specific overexpression of HIF1α reduced the concentration of Protein S in the plasma. Conclusion: We conclude that HIF1α regulates Protein S expression in mouse liver and in obesity. Inhibition of HIF1α or intravenous injection of Protein S may reduce the occurrence of DVT in obese individuals.

Molecular basis of protein S deficiency

2007 ◽  
Vol 98 (09) ◽  
pp. 543-556 ◽  
Author(s):  
Pablo Fuentes-Prior ◽  
Begoña Hurtado ◽  
Pablo García de Frutos ◽  
Núria Sala
Keyword(s):  
Tyrosine Kinases ◽  
Protein S ◽  
Protein S Deficiency ◽  
Autosomal Dominant Trait ◽  
Large Deletions ◽  
S Deficiency ◽  
Increased Risk ◽  
Anticoagulant System ◽  
Cellular Components

SummaryProtein S deficiency (PSD) has been the most difficult to study among the classical inherited thrombophilic factors. This is in part due to the peculiar biology of protein S (PS), which has an anticoagulant role but no enzymatic activity,and because it interacts with plasma components that function in both haemostasis and inflammation.Clinically,it also has been difficult to define and standardise valuable assays to determine PS status and implication in thrombosis. Despite these drawbacks, at present heterozygous PS deficiency is well established as an autosomal dominant trait associated with an increased risk of thrombosis from data on familial and population studies. Almost twohundred mutations have been characterised in PROS1, and approximately 30% of them have been characterised in vitro,clarifying the mechanisms leading to PSD. Furthermore, recent studies on the presence of large deletions in PROS1 have increased the number of PSD associated to PROS1 mutations. Finally, the discovery of new functions for PS, both in the anticoagulant system as well as in the interaction with cellular components through receptor tyrosine kinases, is broadening the importance of this molecule in the context of biomedicine.

Free and Total Protein S Antigen Levels on the Risk of Venous Thrombosis: Results From the MEGA Study

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 538-538
Author(s):  
Daniel D. Ribeiro ◽  
Maria Carolina T. Pintao ◽  
Willem M. Lijfering ◽  
Pieter H. Reitsma ◽  
Frits R. Rosendaal
Keyword(s):  
Venous Thrombosis ◽  
Total Protein ◽  
Protein S ◽  
Type I ◽  
Protein S Deficiency ◽  
Blood Draw ◽  
Free Protein ◽  
Type Iii ◽  
S Deficiency ◽  
Increased Risk

Abstract Abstract 538 Context: Conflicting data have been reported on the risk for venous thrombosis in individuals with low total protein S levels (i.e. type I protein S deficiency) and low free protein S levels with normal total protein S levels (i.e. type III protein S deficiency). This may be due to small numbers, wrong cut off level or inclusion of individuals with mild transitory decrements in protein S levels. Most studies that showed that type I and type III protein S deficiency were related with an increased risk for venous thrombosis, have been performed in thrombophilic families, suggesting that these deficiencies are inherited. As the prevalence of inherited type I or type III protein S deficiency is not known, the relevance of these findings within normal populations remain to be established. Objectives: To assess the risk of first venous thrombosis in persons with low levels of free protein S or total protein S in a large population-based case–control study. Design: MEGA study, 4956 consecutive patients aged 18 to 70 years with a first episode of venous thrombosis were included. Age- and sex-matched controls were partners of patients (n=3297) or individuals recruited by random digit dialing (n=3000). DNA was obtained by standard methods and was available for 4485 patients and 4889 control subjects. Citrated plasma was available for 2471 patients and 2940 controls. Molecular basis for protein S deficiency was investigated by analysis of copy number variation of PROS1 and sequencing of individuals with the lowest levels of protein S in attempt to explain the different findings in risk estimates between families and population studies. Statistical analysis: Odds ratios were adjusted for age and sex (matching factors) for levels of free/total protein S and their 95% confidence levels (95% CIs) with the use of logistic regression. The 2.5th-97.5th percentile of both total and free protein S in control subjects that did not use vitamin K antagonists (VKA) at time of blood draw were considered as the reference range. Individuals that used VKA at time of blood draw were excluded when calculating relative risk estimates. Furthermore, a preplanned sensitivity analysis was performed where we excluded estrogen users and pregnant women at time of blood draw. Results: Individuals with low free protein S levels or low total protein S levels (<2.5th percentile) were not at increased risk of venous thrombosis as compared to individuals with protein S levels in the 2.5th-97.5th percentile; odds ratio 0.82 (95% CI, 0.56–1.21) and 0.90 (95% CI, 0.62–1.31) respectively. Excluding all women who used estrogens or were pregnant/puerperic at time of venous thrombosis or at time of blood sampling increased the odds ratios slightly to 1.55 (95% CI, 0.84–2.88) for individuals with low free protein S levels and to 1.28 (95% CI, 0.70–2.35) in individuals with low total protein S levels. We subsequently compared decreasing cut off values of free and total protein S levels on the risk of venous thrombosis as compared to the same reference group. Although numbers became small, it appeared that a free protein S cut off level of < 0.20th or < 0.10th percentile could identify individuals at high risk of venous thrombosis (odds ratios 2.01; 95% CI, 0.57–7.15, and 5.44; 95% CI, 0.61–48.78, respectively). Even extremely low (<0.10th percentile) total protein S levels were not associated with venous thrombosis. Only one patient had a copy number variation of PROS1 in 2270 consecutive samples tested. Currently, we are sequencing the PROS1 gene in all individuals with protein S levels <1st percentile of which results will be available before the ASH conference of 2011. Conclusion: Low free protein S and low total protein S levels could not identify individuals at risk for venous thrombosis in a population based study. Although extremely low free protein S levels were associated with an increased risk for venous thrombosis, numbers were too small to support testing on free protein S in an unselected group of venous thrombosis patients. Disclosures: No relevant conflicts of interest to declare.

PROS1 genotype phenotype relationships in a large cohort of adults with suspicion of inherited quantitative protein S deficiency

2016 ◽  
Vol 115 (03) ◽  
pp. 570-579 ◽  
Author(s):  
Genevieve Plu-Bureau ◽  
Marie Héléne Horellou ◽  
Antoine Rauch ◽  
Pierre Suchon ◽  
Martine Alhenc-Gelas ◽  
...  
Keyword(s):  
Retrospective Cohort ◽  
Protein S ◽  
Type I ◽  
Type Ii ◽  
Protein S Deficiency ◽  
Normal Range ◽  
Established Risk Factor ◽  
S Deficiency ◽  
Increased Risk ◽  
History Of

SummaryInherited protein S deficiency (PSD) is an established risk factor for venous thromboembolism (VTE). However, data are conflicting concerning risk of VTE associated with decreased free PS level (FPS) and information on PROS1 genotype-phenotype relationship is sparse. In a retrospective cohort of 579 patients with inherited type I/III deficiency suspicion, PROS1 genotyping was performed and the effect of genotype on FPS and on VTE risk was investigated. We found 116 (including 65 novel) detrimental mutations (DM) in 222 (type I/III in 194, type II in 28), PS Heerlen in 74, possibly non DM in 38 and no mutation in 245 subjects. Among DMs, type I/IIIDMs only were found in subjects with FPS<30 %. Prevalence of type I/III DM decreased with increasing FPS level. Risk of VT associated with FPS level and genotype was studied in the 467 subjects with personal or family history of thrombosis. Only type I/IIIDM carriers presented with an increased risk of VTE [1.41 (95%CI (1.05–1.89)] compared to subjects with no mutation. Among the group of type I/IIIDM heterozygotes and subjects with no mutation, the optimal FPS cut-off point for identifying subjects at increased VTE risk was searched for. We found that only subjects with FPS<30% and type I/IIIDM presented with an increased risk [1.48 (95%CI 1.08–2.04)]. Our findings confirm the value of a cut-off FPS level for identifying subjects at increased VTE risk far below the lower limit of the normal range and suggest a place for PROS1 genotyping in PSD diagnosis strategy.

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