A Novel 3-Base Pair 1834–1836 AAG-Deletion (Lys570Del) Mutation In Factor XIII A Subunit Associated with Factor XIII Deficiency

Abstract Abstract 1412 Factor XIII is a transglutaminase that cross-links proteins in plasma, vascular matrix, endothelial cells, platelets and monocytes, and plays a role in atherosclerosis, wound healing, and inflammation. Plasma FXIII molecule is a hetero-tetramer consisting of two catalytic A-subunits and two B-subunits that act as carrier molecules. The gene encoding FXIII A subunit comprises of 15 exons spanning 160 kb and the mature protein contains 731 amino acids. FXIII deficiency is a rare autosomal recessive disorder affecting ∼1 in 1–3 million people. It is characterized by bleeding, impaired wound repair and spontaneous abortions. We report studies from a family where two children son (13 yrs) and daughter (11 yrs) have had a lifelong bleeding tendency and spontaneous intracranial hemorrhages. Both parents were asymptomatic and there was no consanguinity. The results of routine laboratory tests, prothrombin time and activated partial thromboplastin time were normal in all subjects. The plasma FXIII activity by a commercially available chromogenic assay was 5% in the son and <3% in the daughter (normal range 57–192%). The FXIII activity in the father and mother were 198% and 74%, respectively. We have identified a novel deletion mutation, which has not been reported so far in FXIII deficiency. Leukocyte RNA was isolated from the buffy-coat and cDNA was obtained by reverse-transcription PCR using SuperScript First-Strand Synthesis System. The amplified products were cloned in pGEM-T vector (Promega) and sequenced on an automated gene-sequencer. Both children and the father have a novel 3 bp AAG-deletion position 1834–1836 nt in FXIII A chain. This mutation causes a lysine 570 deletion in the ß-barrel 1 of Factor XIII A subunit and has not been reported so far. It may lead to protein misfolding resulting in an unstable protein, and low levels of FXIII. The second major change detected in the two siblings was a A/T substitution at position 737 nt causing Tyr204Phe substitution in the two siblings; this was present in the mother in a heterozygous condition. This mutation has been previously reported in FXIII deficiency and linked to increased risk of haemorrhagic stroke in young women and of miscarriages. The compound heterozygosity for Lys570Del and Tyr204Phe substitution observed in both children is the likely cause of Factor XIII deficiency leading to lifelong bleeding condition. In addition to above, the father had Val34Leu polymorphism, previously reported to be associated with resistance to myocardial infarction. This polymorphism is present in ∼20% of white European, 40% of Pima Native American and 13% of South Asian populations. The mother also had a known A/C polymorphism at 1119 nt position for a synonymous Pro332Pro change. We also found 3 other variations in FXIII A chain in this family. The daughter has Glu216Gly and Asp267Asn change in the protein corresponding to alterations at nucleotide 773 (A/G) and 925 (A/G), respectively. The son and mother had a substitution at 1442 nt (T/C) leading to a Leu439Pro change. These variations, Glu216Gly, Asp267Asn and Leu439Pro found in the two children (Leu439Pro also in mother) are present in the catalytic core domain of the Factor XIII A chain. All of the polymorphisms or mutations reported in this study were heterozygous in the studied subjects. FXIII gene mutations and polymorphisms result in a high level of heterogeneity of disease presentation. Other point mutations in the FXIII A catalytic core as well as mutations in ß-barrel 1 region have been described in association with a hemorrhagic state in FXIII deficiency. Our study documents a new 3-bp 1834–1836 nt AAG-deletion (Lys570Del) in association with FXIII deficiency. We suggest that compound heterozygosity for Lys570Del and Tyr204Phe is the cause of FXIII deficiency in our patients. Further structure-function studies will aid in understanding the impact of these amino acid substitutions or deletions on FXIII function and on the associated bleeding diathesis. Disclosures: No relevant conflicts of interest to declare.

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A Novel Nonsense Mutation of F13A1 Gene Causing Inherited Factor XIII Deficiency in a Chinese Han Family

Blood ◽

10.1182/blood.v118.21.4661.4661 ◽

2011 ◽

Vol 118 (21) ◽

pp. 4661-4661

Author(s):

Dawei Wang ◽

Liang Tang ◽

Wei Shi ◽

Heng Mei ◽

Rui Yang ◽

...

Keyword(s):

Nonsense Mutation ◽

Factor Xiii ◽

Family Members ◽

Coagulation Factor ◽

Maternal Grandmother ◽

Chinese Han ◽

Factor Xiii Deficiency ◽

Fxiii Activity ◽

Fxiii Deficiency

Abstract Abstract 4661 Introduction: Coagulation factor XIII (FXIII) is a protransglutaminase that has a major role in the final stage of blood coagulation process by forming cross-links between γ-glutamyl and ε-lysine residues of fibrin chains. The plasma FXIII (pFXIII) circulates in plasma as a heterotetramer (FXIII-A2B2) consisting of two catalytic A subunits (FXIII-A2) and two carrier B subunits (FXIII-B2). Inherited FXIII deficiency is a rare autosomal recessive disease with lifelong bleeding. Most cases of FXIII deficiency are heterogeneous due to mutations in the F13A gene. Currently, more than 100 mutations have been reported. Aim: To identify the genetic defect of inherited coagulation factor XIII (FXIII) deficiency in a Chinese Han family. Methods and Results: A 13 year-old patient complained of poor wound healing after operation and had a history of an excessive bleeding from the umbilical cord stump after her birth. The routine laboratory tests are normal. Her bleeding time is more than 15 minutes and fibrin clot was solubilized very quickly in 5mol/L urea, and became insoluble when normal plasma was mixed with her plasma in vitro. Her plasma FXIII activity was zero with the amine incorporation assay and plasma FXIII antigen was also near zero by one-step sandwich ELISA method, the plasma FXIIIA antigen was zero using an indirect competitive ELISA assay. The plasma FXIIIA antigen, FXIII activity and antigen were assayed in all available family members. The testing results of patient’s grandfather and maternal grandmother were within normal range. But the other pedigree members’ results were lower in different level compare with normal ranges. All members of her family had normal coagulation test. All the exons of F13A gene as well as F13B gene and their flanking regions were amplified by PCR for direct sequencing to identify the mutations in the proband. Direct DNA sequencing of all purified amplification products from the patient’s F13A gene demonstrated a homozygous nonsense mutation in exon8 (C to A transversion at nucleotide 98531 which caused Cys327X). And the patient didn’t have the Val34Leu polymorphism. In the pedigree except of the proband, the Cys327X mutation was found in the heterozygous state in all investigated members except for her grandfather and maternal grandmother. A family study revealed that the mutation was inherited from both parents. The identified mutation was validated by PCR-RFLP technique in the family members and healthy people. Restriction enzyme analysis of amplified exon 8 DNA fragment confirmed that the patient was homozygous for this mutation. Then the quantitative RT-PCR method was used for studying the mRNA expression level of mutant FXIIIA. And the results indicated that F13A mRNA transcripts in heterozygous mutant were reduced by 25% when compared to transcripts in wild-type one, while the homozygous mutant level of F13A mRNA transcript was nearly zero relative to the normal transcript. Conclusion: We have identified a novel Cys327X nonsense mutation in human FXIIIA gene which we have not found in the FXIII database (www.f13-database.de) or in previous publications.And the identified nonsense mutation is causative for severe factor XIII deficiency with a bleeding disorder. Further, in vitro expression studies of the factor XIII mutation is required to confirm their pathological mechanism. Disclosures: No relevant conflicts of interest to declare.

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Fatal Bleeding Caused by Congenital Factor XIII Deficiency and Development of An Inhibitor in a Hispanic Male

Blood ◽

10.1182/blood.v112.11.4515.4515 ◽

2008 ◽

Vol 112 (11) ◽

pp. 4515-4515

Author(s):

Filipe R. Lorenzo ◽

Derrick Haslem ◽

Josef T. Prchal ◽

Charles Greenberg

Keyword(s):

Factor Xiii ◽

Factor Xiiia ◽

Bleeding Complications ◽

Factor Xiii Deficiency ◽

Catalytic Core ◽

Fatal Bleeding ◽

Plasma Factor ◽

A Chain ◽

Hispanic Male ◽

Congenital Factor

Abstract We report a case of fatal bleeding in a patient with mild congenital Factor XIII deficiency who also developed an inhibitor that interfered with fibrin stabilization. Plasma Factor XIII circulates as a tetramer composed of two A-chain and two B-chains and is bound to fibrinogen. After thrombin cleaves the A-chain at Arg 37, the B-chain dissociate producing Factor XIIIa. Factor XIIIa catalyzes covalent linkages between the fibrin molecules aligned in the fibrin clot. Factor XIIIa makes the fibrin resistant to disruption by urea and plasmin. Factor XIIIa levels greater than 1 % are needed to covalently stabilize a clot. We studied a 39 year old Hispanic male that presented with altered mental status, headache and a large left frontal parietal hemorrhage. Ultimately, he became non-responsive and was intubated. He had no major bleeding history but did have frequent nosebleeds. Routine blood counts and coagulation laboratory tests were normal. However, a qualitative Factor XIII assay was abnormal and the clot dissolved in 5M Urea. Furthermore, a 1:1 mixing study did not correct the defect suggesting the presence of an inhibitor. A small dose of cryoprecipitate was administered to the patient and this corrected the clot stability defect. Four days later, the defect recurred and 150 ml of cryoprecipitate was administered and despite correction of the fibrin stabilizing abnormality the patient died. Two of his sisters had a history of repeated hemorrhagic miscarriages in Mexico a finding consistent with congenital Factor XIII deficiency. DNA sequencing of the factor XIII a-chain gene was performed from the propositus’ mononuclear cells. A reverse transcription was done using an oligo(dT) 12–18 primer followed by nested PCR amplification and a heterozygous missense mutation was observed at codon 35 (G226T; Val35Leu). This mutation was than confirmed in propositus’ platelet cDNA. The Val35Leu substitution is close to the thrombin cleavage site, the G226T substitution is in the catalytic core domain. This case demonstrates that in some cases of Factor XIII deficiency there is residual Factor XIIIa activity in the mutant molecule that can prevent serious bleeding. However, patients may develop autoantibodies that further interfere with Factor XIII function and may suffer serious bleeding complications. Additional cases of Factor XIII deficiency may exist in patients that have mild bleeding problems.

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Establishment of an International Registry of Patients with Inherited FXIII Deficiency.

Blood ◽

10.1182/blood.v110.11.2149.2149 ◽

2007 ◽

Vol 110 (11) ◽

pp. 2149-2149

Author(s):

Vytautas Ivaskevicius ◽

Rainer Seitz ◽

Hans P. Kohler ◽

Laszlo Muszbek ◽

Robert A.S. Ariens ◽

...

Keyword(s):

Factor Xiii ◽

Working Party ◽

Splice Site Mutation ◽

Autosomal Recessive Disorder ◽

Bleeding Tendency ◽

Site Mutation ◽

Impaired Wound Healing ◽

Thrombosis Research ◽

The Impact ◽

Fxiii Deficiency

Abstract Inherited factor XIII (FXIII) deficiency is a rare autosomal recessive disorder affecting approximately one out of one to three million people. FXIII deficiency is characterized by a lifelong bleeding tendency, impaired wound healing and spontaneous abortions in females. In 1993, the European Thrombosis Research Organization (ETRO) Working Party on FXIII initiated a Europe-wide questionnaire on inherited FXIII deficiency. Since 2005, the registry has been endorsed by the Factor XIII Subcommittee of the Scientific and Standardization committee (SSC) of the ISTH. The analysis of 104 European patients demonstrated that the most common bleeding symptoms were subcutaneous bleeding (57%) followed by delayed umbilical cord bleeding (56%), muscle hematoma (49%), hemorrhage after surgery (40%), hemarthrosis (36%), and intracerebral bleeding (34%). Prophylactic treatment was initiated in about 70% of all patients. FXIII-B subunit-deficient patients had a milder phenotype than patients with FXIII-A subunit deficiency.The most frequent mutation affecting the F13A gene was a splice site mutation in intron 5 (IVS5-1G>A).This mutation was found in eight (17%) of 46 analyzed families.The haplotype analysis of patients carrying the IVS5-1A allele was consistent with a founder effect. Recently, we created a new FXIII database website (http://www.f13-database.de) with information about FXIII proteins, genes, mutations and polymorphisms. This website also includes a new questionnaire. Information provided by this questionnaire will allow better understanding of the differences of diagnostic and treatment possibilities in various parts of the world, and it will help to understand the impact of reduced FXIII activity in heterozygous relatives and finally, it will generally increase our knowledge on this rare disease. We hope that our initiative to establish a new international FXIII registry will be actively supported by the community involved in caring for FXIII deficient patients.

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Novel Missense Mutations Associated with FXIII Deficiency and Bleeding.

Blood ◽

10.1182/blood.v114.22.4201.4201 ◽

2009 ◽

Vol 114 (22) ◽

pp. 4201-4201

Author(s):

Edward Park ◽

Leiqian Tai ◽

Peggy Nakagawa ◽

Loan Hsieh ◽

Diane J. Nugent

Keyword(s):

Amino Acid ◽

Missense Mutation ◽

Factor Xiii ◽

Missense Mutations ◽

Novel Mutations ◽

Factor Xiii Deficiency ◽

Catalytic Core ◽

Subunit A ◽

Exon 10 ◽

Fxiii Deficiency

Abstract Abstract 4201 Introduction Factor XIII deficient patients may present at any age, with a variety of bleeding symptoms, poor wound healing, and in females, frequent miscarriages. Factor XIII (FXIII) is a transglutaminase enzyme that was first discovered as a clotting protein in the coagulation cascade, but it is now understood that it cross-links proteins in the plasma, vascular matrix, endothelial cells, platelets and monocytes. In addition to maintaining normal hemostasis, FXIII plays a role in atherosclerosis, wound healing, inflammation, and pregnancy. FXIII circulates in plasma as a tetramer protein (FXIII-A2B2) held together by non-covalent bonds. FXIII has two catalytic A subunits (FXIII-A2) of 83kd and two non-catalytic B subunits or carrier subunits (FXIII-B2) of 79kd. Mutations have been identified in almost every exon of the FXIIIA subunit and often are unique to a particular cohort or family with Factor XIII deficiency. Our center has been characterizing patients with FXIII deficiency and has an IRB approved study to characterize bleeding phenotype in relation to genotype or mutational analysis. As part of this effort, we have identified 3 novel missense mutations, which we have not found in the FXIII database (<www.f13-database.de>) or in previous publications. Methods After obtaining informed consent, venous blood was collected in EDTA tubes for DNA isolation, PCR and ultimately DNA sequencing. DNA was isolated using QIAamp DNA Blood Midi Kit (Qiagen, Germantown, MD). Customary PCR was used to amplify the 15 exons for subunit A and the 12 exons for subunit B, using sequence specific primers based on previous publication and created to initiate outside of the encoding sequence. The nucleotide sequencing of amplified products was obtained via ABI 3730 DNA Analyzer (UCLA Sequencing and Genotyping Core). Results All three novel mutations were found in three, separate, unrelated individuals, with FXIII deficiency diagnosed early in life with a moderate to severe bleeding. Using the methods described above, the DNA sequencing and analysis for all exons for both the A and B subunits revealed three novel mutations, two on exon 12 subunit A and one on exon 10 subunit A. Patient 1 has a novel missense mutation in exon 10 at the 427 amino acid position, changing the aspartic acid into an asparagine (Asp427Asn) in the catalytic core. Patient 2 and 3 each had a unique mutation in exon 12. Exon 12 covers the transition from the catalytic core region and the Barrel 1 region of the FXIIIA molecule thus including portions of each functional region. Patient 2: An exon 12 missense mutation in aa 501 resulting in a change from glycine to an arginine (Gly501Arg) still in the catalytic core region. Patient 3 also had a mutation in exon 12 but in position 576 resulting in an amino acid change from threonine to methionine (Thr576Met) now in the Barrel 1 region. Patient 2 also had a missense mutation that has been previously reported in exon 3 (Arg77His) in the β-sandwich region. Three new missense mutations have been identified in patients with severe Factor XIII deficiency and a bleeding disorder. Previous reports of other point mutations in the FXIIIA catalytic core and barrel 1 regions have also been described in association with a hemorrhagic state in deficient patients. Ongoing protein expression studies will aid in our understanding of how these single amino acid substitutions result in such a serious bleeding diathesis. Disclosures: No relevant conflicts of interest to declare.

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Patient-centered approach to managing factor XIII deficiency

BMJ Case Reports ◽

10.1136/bcr-2020-241501 ◽

2021 ◽

Vol 14 (9) ◽

pp. e241501

Author(s):

Varun Iyengar ◽

Caitlin Montcrieff ◽

Salley Pels

Keyword(s):

Factor Xiii ◽

Blood Clot ◽

Pharmacokinetic Data ◽

Patient Centered ◽

Factor Xiii Deficiency ◽

Improved Outcomes ◽

Individualise Therapy ◽

A Subunit ◽

Patients Experience ◽

Fxiii Activity

Factor XIII (FXIII) is a thrombin-activated protransglutaminase that plays a key role in blood clot formation. Congenital FXIII A-subunit deficiency represents a rare bleeding disorder that affects one in 2–3 million individuals worldwide and is treated with recombinant FXIII (rFXIII). However, due to the rarity of the disease, clinicians are often left to weigh individual variation in FXIII activity and/or symptoms to optimally guide dosing. Cases often become further complicated when patients experience refractory bleeding, which can be difficult to treat. This report describes an approach to rFXIII dosing in two patients who required deviation from standard protocols to maintain therapeutic FXIII troughs. We highlight limitations in our understanding of FXIII deficiency management, while also providing an example of the application of pharmacokinetic data to individualise therapy for improved outcomes. Finally, the case reminds us of the importance of patient-centered, cost-conscious care and multidisplinary teamwork in complex cases.

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MEASUREMENT OF FACTOR XIII ACTIVITY IN HUMAN PLATELET HOMOGENATE BY A NEW UV-KINETIC METHOD

10.1055/s-0038-1644647 ◽

1987 ◽

Author(s):

J Polgár ◽

Y Hidasi ◽

A Toth ◽

L Muszbek

Keyword(s):

Factor Xiii ◽

Human Platelet ◽

Kinetic Method ◽

Kinetic Assay ◽

A Subunit ◽

Incorporation Assay ◽

Diagnostic Importance ◽

Fxiii Activity ◽

Fxiii Deficiency

Factor XIII (FXIIl) of blood coagulation is a zymogen which is converted into an active transglutaminase during the clotting process. Earlier methods used for its determination are cumbersome, laborious, and not suitable for routine laboratory measurements.Most recently we have designed a new simple UV-kinetic assay for the determination of FXIII in the plasma (Muszbek et al., Clin. Chem., 3JL, 35, 1985). The assay is performed on def:j.b-rinated plasma in which FXIII is activated by thrombin and Ca2+. Acetylateddephosphorylated (AD)β-casein and ethylamine are used as substrates and the ammonia released during thereaction is continuously monitored by a NADPH dependent indicator reaction at 340 nm. As the enzymatically active a subunit of FXIII is also present in platelets and monocytes/macrophages we attempted to adapt the above method for the measurement of cellular FXIII activity. Experiments were carried out on Lubrol extract of washed sonicated platelets. It was found that the small amount of fibrinogen present in platelets does not need to be removed and in the blank hirudin used for preventing activation of plasma FXIII should be replaced by EGTA. The concentration of substrates and activators were optimized. The methodwas found linear at least up-to 40 U/l enzyme activity. It had a good reproducibility (optimal conditionvariance was less than 3%) and correlated well with the most commonly used fluorescent amine (dansylcadaverine) incorporation assay. The method was adapted to a centrifugal fast analyser (Baker, Centrifichem). In addition to congenital FXIII deficiency the determination of FXIII in platelets by this new methodmight have a diagnostic importance in haemopoietic diseases with diminished or accelerated platelet production.

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FXIII Protein Inhibitor against the FXIII-A Subunit in an 8-Year-Old Boy with Inherited Severe Factor XIII Deficiency Complicated by Multiple Intracerebral Cavernomas

10.1055/s-0040-1721583 ◽

2020 ◽

Author(s):

S. Horneff ◽

G. Goldmann ◽

A. Kerstan ◽

C. Klein ◽

N. Marquardt ◽

...

Keyword(s):

Factor Xiii ◽

Protein Inhibitor ◽

Factor Xiii Deficiency ◽

A Subunit

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Factor XIII Deficiency and Intracranial Bleed: Surgical Management and Prophylaxis with Cryoprecipitate

Journal of Pediatric Neurology ◽

10.1055/s-0041-1731026 ◽

2021 ◽

Author(s):

Sunil V. Furtado ◽

Pranoy Hegde ◽

Rasmi Palassery ◽

B. P. Karunakara

Keyword(s):

Factor Xiii ◽

Perioperative Management ◽

Severe Headache ◽

Resonance Imaging ◽

Factor Xiii Deficiency ◽

Limb Weakness ◽

High Propensity ◽

Intracranial Bleed ◽

The Brain ◽

Fxiii Deficiency

AbstractFactor XIII (FXIII) deficiency is a rare bleeding disorder with affected patients having high propensity for intracranial hemorrhage. A 12-year-old girl presented with severe headache, limb weakness, and rapidly worsening sensorium over 4 days. Magnetic resonance imaging of the brain and computed tomography (CT) of the head showed intraparenchymal bleed. Patient had normal coagulation profile and abnormal FXIII level. The perioperative management included cryoprecipitate transfusion to bring the FXIII value to 74%. She underwent craniotomy and evacuation of the hematoma. Postoperatively, she received prophylaxis against rebleed with cryoprecipitate. In the absence of FXIII concentrate, correction of FXIII deficiency is possible with cryoprecipitate in emergent situations.

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Acquired Factor XIII Deficiency in a Patient with Metastatic Lung Cancer

Clinical Oncology Research and Reports ◽

10.31579/2693-4787/028 ◽

2022 ◽

Vol 3 (1) ◽

pp. 01-03

Author(s):

Ana Sofia Mendes ◽

Marco Dias ◽

Sara Morais ◽

Raque Romão ◽

Bernardo Teixeira ◽

...

Keyword(s):

Lung Cancer ◽

Neutralizing Antibodies ◽

Factor Xiii ◽

Process Analysis ◽

Clinical Report ◽

Bleeding Tendency ◽

Metastatic Nsclc ◽

Immune Mediated ◽

Clinical Records ◽

Fxiii Deficiency

Acquired factor XIII (FXIII) deficiency can result in life-long bleeding tendency and can be caused by enhanced consumption, impaired synthesis, or as an immune-mediated process. The latter can be related with solid neoplasms, through neutralizing or non-neutralizing antibodies. The relationship between FXIII activity and non-small cell lung cancer (NSCLC) is not well established. This case report is about a patient with NSCLC and acquired FXIII deficiency. Materials and Methods: Clinical records were obtained through the electronic process analysis, and the confidentiality of the patient was always assured. Results and Discussion: A 70-year-old male with no relevant past medical history and a recently diagnosed metastatic NSCLC was admitted for priapism. Five days later, a he developed a bleeding disorder, with slightly elevated coagulation times and normal fibrinogen levels and platelets count. FXIII level was found to be decreased (0.24 IU/mL) and FXIII plasma mixing studies did not confirm the presence of a neutralizing inhibitor. The FXIII level correction with standard plasma mixing studies was in favour of a non-neutralizing antibody. Despite treatment, haemorrhage control was not achieved and the patient died. Conclusion: This clinical report describes a rare case of a patient with metastatic NSCLC presenting a severe haemorrhagic event caused by FXIII deficiency immune-mediated by non-neutralizing antibodies and subsequent increased clearance.

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