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Thromb Haemost 2022; 122(09): 1479-1485
DOI: 10.1055/a-1777-6881
Coagulation and Fibrinolysis

The Lesson Learned from the New c.2547-1G > T Mutation Combined with p.R854Q: When a Type 2N Mutation Reveals a Quantitative von Willebrand Factor Defect

Alessandra Casonato
1   Department of Medicine, University of Padua Medical School, Padua, Italy
,
Maria Rita Cozzi
2   Immunopathology and Cancer Biomarkers, Centro di Riferimento Oncologico, Aviano, Italy
,
Silvia Ferrari
1   Department of Medicine, University of Padua Medical School, Padua, Italy
,
Beatrice Rubin
1   Department of Medicine, University of Padua Medical School, Padua, Italy
,
Lisa Gianesello
1   Department of Medicine, University of Padua Medical School, Padua, Italy
,
Luigi De Marco
3   Department of Translational Research, Stem Cell Unit, Centro di Riferimento Oncologico, Aviano, Italy
4   Department of Molecular and Experimental Medicine, SCRIPPS, Research Institute, La Jolla, California, United States
,
Viviana Daidone
1   Department of Medicine, University of Padua Medical School, Padua, Italy
› Author Affiliations Funding This work was supported by a grant from the MURST (ex 60% 2020).
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Abstract

Type 2N is a rare von Willebrand disease (VWD) variant involving an impairment in the factor VIII (FVIII) carrier function of von Willebrand factor (VWF). It has a phenotype that mimics hemophilia A, and FVIII binding to VWF (VWF:FVIIIB) is tested to differentiate between the two disorders. Type 2N VWF defects may also be associated with quantitative VWF mutations (type 2N/type 1), further complicating the identification of cases. We report on a new quantitative VWF mutation (c.2547–1G > T) revealed by a p.R854Q type 2N mutation acting as homozygous despite being carried as a heterozygous defect. The proband had near-normal VWF levels (initially ruling out a defective VWF synthesis) and slightly reduced FVIII levels, while a VWF:FVIIIB test showed significantly reduced binding. Routine tests on type 2N homozygotes or heterozygotes combined with quantitative VWF defects in our cohort showed reduced FVIII levels in both groups, but it was only in the former that the FVIII/VWF antigen (VWF:Ag) ratio was always significantly reduced. The two tests are therefore not enough to identify all forms of type 2N VWD. While relatives of type 2N homozygotes usually have normal FVIII levels and FVIII/VWF:Ag ratios, relatives of type 2N/type 1 may have high FVIII/VWF:Ag ratios, but their VWF:FVIIIB and/or VWF:FVIIIB/VWF:Ag ratios are always low. Measuring FVIII and VWF levels may therefore suggest type 2N VWD in patients carrying type 2N mutations alone, but not in type 2N combined with quantitative VWF defects. The VWF:FVIIIB test should consequently be included when exploring VWF function, whatever VWD patient's phenotype.

Keywords

von Willebrand factor - type 2N von Willebrand disease - FVIII carrier function - VWF:FVIIIB - type 2N VWF mutations

Author Contributions

A.C. designed the research and wrote the paper; M.R.C. performed the hemostatic tests; S.F., B.R., and L.G. performed the hemostatic tests and genetic analysis; L.D.M. analyzed and discussed the results; V.D. conducted the genetic analysis, analyzed the data, and discussed the results.




Publication History

Received: 25 November 2021

Accepted: 18 February 2022

Accepted Manuscript online:
21 February 2022

Article published online:
13 June 2022

© 2022. Thieme. All rights reserved.

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  • References

  • 1 Sadler JE. Biochemistry and genetics of von Willebrand factor. Annu Rev Biochem 1998; 67: 395-424
    CrossrefPubMedGoogle Scholar
  • 2 Fay PJ, Coumans JV, Walker FJ. von Willebrand factor mediates protection of factor VIII from activated protein C-catalyzed inactivation. J Biol Chem 1991; 266 (04) 2172-2177
    CrossrefPubMedGoogle Scholar
  • 3 Lenting PJ, VAN Schooten CJ, Denis CV. Clearance mechanisms of von Willebrand factor and factor VIII. J Thromb Haemost 2007; 5 (07) 1353-1360
    CrossrefPubMedGoogle Scholar
  • 4 Jorieux S, Magallon T, Mazurier C. Evidence that NH2-terminal but not COOH-terminal moiety of plasma von Willebrand factor binds to factor VIII. Thromb Res 1987; 48 (02) 205-210
    CrossrefPubMedGoogle Scholar
  • 5 Foster PA, Fulcher CA, Marti T, Titani K, Zimmerman TS. A major factor VIII binding domain resides within the amino-terminal 272 amino acid residues of von Willebrand factor. J Biol Chem 1987; 262 (18) 8443-8446
    CrossrefPubMedGoogle Scholar
  • 6 Wise RJ, Dorner AJ, Krane M, Pittman DD, Kaufman RJ. The role of von Willebrand factor multimers and propeptide cleavage in binding and stabilization of factor VIII. J Biol Chem 1991; 266 (32) 21948-21955
    CrossrefPubMedGoogle Scholar
  • 7 Casonato A, Sartorello F, Cattini MG. et al. An Arg760Cys mutation in the consensus sequence of the von Willebrand factor propeptide cleavage site is responsible for a new von Willebrand disease variant. Blood 2003; 101 (01) 151-156
    CrossrefPubMedGoogle Scholar
  • 8 Piétu G, Ribba AS, Meulien P, Meyer D. Localization within the 106 N-terminal amino acids of von Willebrand factor (vWF) of the epitope corresponding to a monoclonal antibody which inhibits vWF binding to factor VIII. Biochem Biophys Res Commun 1989; 163 (01) 618-626
    CrossrefPubMedGoogle Scholar
  • 9 Chiu P-L, Bou-Assaf GM, Chhabra ES. et al. Mapping the interaction between factor VIII and von Willebrand factor by electron microscopy and mass spectrometry. Blood 2015; 126 (08) 935-938
    CrossrefPubMedGoogle Scholar
  • 10 Pipe SW, Montgomery RR, Pratt KP, Lenting PJ, Lillicrap D. Life in the shadow of a dominant partner: the FVIII-VWF association and its clinical implications for hemophilia A. Blood 2016; 128 (16) 2007-2016
    CrossrefPubMedGoogle Scholar
  • 11 Casonato A, Galletta E, Sarolo L, Daidone V. Type 2N von Willebrand disease: characterization and diagnostic difficulties. Haemophilia 2018; 24 (01) 134-140
    CrossrefPubMedGoogle Scholar
  • 12 Goodeve AC. The genetic basis of von Willebrand disease. Blood Rev 2010; 24 (03) 123-134
    CrossrefPubMedGoogle Scholar
  • 13 Nishino M, Girma J-P, Rothschild C, Fressinaud E, Meyer D. New variant of von Willebrand disease with defective binding to factor VIII. Blood 1989; 74 (05) 1591-1599
    CrossrefPubMedGoogle Scholar
  • 14 Mazurier C, Dieval J, Jorieux S, Delobel J, Goudemand M. A new von Willebrand factor (vWF) defect in a patient with factor VIII (FVIII) deficiency but with normal levels and multimeric patterns of both plasma and platelet vWF. Characterization of abnormal vWF/FVIII interaction. Blood 1990; 75 (01) 20-26
    CrossrefPubMedGoogle Scholar
  • 15 Gaucher C, Jorieux S, Mercier B, Oufkir D, Mazurier C. The “Normandy” variant of von Willebrand disease: characterization of a point mutation in the von Willebrand factor gene. Blood 1991; 77 (09) 1937-1941
    CrossrefPubMedGoogle Scholar
  • 16 Casonato A, Gaucher C, Pontara E. et al. Type 2N von Willebrand disease due to Arg91Gln substitution and a cytosine deletion in exon 18 of the von Willebrand factor gene. Br J Haematol 1998; 103 (01) 39-41
    CrossrefPubMedGoogle Scholar
  • 17 Jorieux S, Gaucher C, Goudemand J, Mazurier C. A novel mutation in the D3 domain of von Willebrand factor markedly decreases its ability to bind factor VIII and affects its multimerization. Blood 1998; 92 (12) 4663-4670
    CrossrefPubMedGoogle Scholar
  • 18 Hilbert L, Jorieux S, Proulle V. et al; INSERM Network on Molecular Abnormalities in von Willebrand Disease. Two novel mutations, Q1053H and C1060R, located in the D3 domain of von Willebrand factor, are responsible for decreased FVIII-binding capacity. Br J Haematol 2003; 120 (04) 627-632
    CrossrefPubMedGoogle Scholar
  • 19 Casonato A, Pontara E, Sartorello F. et al. Identifying carriers of type 2N von Willebrand disease: procedures and significance. Clin Appl Thromb Hemost 2007; 13 (02) 194-200
    CrossrefPubMedGoogle Scholar
  • 20 Casonato A, Pontara E, Sartorello F, Gemmati D, Cattini MG, Girolami A. Combined hemophilia A and type 2 von Willebrand's disease: defect of both factor VIII level and factor VIII binding capacity of von Willebrand factor. Haematologica 2001; 86 (10) 1110-1111
    PubMedGoogle Scholar
  • 21 Pontara E, Gresele P, Cattini MG. et al. Spontaneous hemarthrosis in combined Glanzmann thrombasthenia and type 2N von Willebrand disease. Blood Coagul Fibrinolysis 2014; 25 (04) 401-404
    CrossrefPubMedGoogle Scholar
  • 22 Mazurier C. von Willebrand disease masquerading as haemophilia A. Thromb Haemost 1992; 67 (04) 391-396
    Article in Thieme ConnectPubMedGoogle Scholar
  • 23 Galletta E, Daidone V, Zanon E, Casonato S. Type 3 von Willebrand disease mistaken for moderate haemophilia A: a lesson still to be learned. Haemophilia 2018; 24 (03) e154-e157
    CrossrefPubMedGoogle Scholar
  • 24 Casonato A, Pontara E, Zerbinati P, Zucchetto A, Girolami A. The evaluation of factor VIII binding activity of von Willebrand factor by means of an ELISA method: significance and practical implications. Am J Clin Pathol 1998; 109 (03) 347-352
    CrossrefPubMedGoogle Scholar
  • 25 Casonato A, De Marco L, Mazzucato M. et al. A new congenital platelet abnormality characterized by spontaneous platelet aggregation, enhanced von Willebrand factor platelet interaction, and the presence of all von Willebrand factor multimers in plasma. Blood 1989; 74 (06) 2028-2033
    CrossrefPubMedGoogle Scholar
  • 26 Casonato A, Galletta E, Galvanin F, Daidone V. Von Willebrand disease type Vicenza: in search of a classification for the archetype of reduced von Willebrand factor survival. eJHaem 2021; 2: 340-348
    CrossrefPubMedGoogle Scholar
  • 27 Casonato A, Pontara E, Sartorello F. et al. Reduced von Willebrand factor survival in type Vicenza von Willebrand disease. Blood 2002; 99 (01) 180-184
    CrossrefPubMedGoogle Scholar
  • 28 Favaloro EJ, Mohammed S, Koutts J. Identification and prevalence of von Willebrand disease type 2N (Normandy) in Australia. Blood Coagul Fibrinolysis 2009; 20 (08) 706-714
    CrossrefPubMedGoogle Scholar
  • 29 Seidizadeh O, Peyvandi F, Mannucci PM. Von Willebrand disease type 2N: An update. J Thromb Haemost 2021; 19 (04) 909-916
    CrossrefPubMedGoogle Scholar
  • 30 Bellissimo DB, Christopherson PA, Flood VH. et al. VWF mutations and new sequence variations identified in healthy controls are more frequent in the African-American population. Blood 2012; 119 (09) 2135-2140
    CrossrefPubMedGoogle Scholar
  • 31 Eikenboom J, Federici AB, Dirven RJ. et al; MCMDM-1VWD Study Group. VWF propeptide and ratios between VWF, VWF propeptide, and FVIII in the characterization of type 1 von Willebrand disease. Blood 2013; 121 (12) 2336-2339
    CrossrefPubMedGoogle Scholar
  • 32 James PD, Connell NT, Ameer B. et al. ASH ISTH NHF WFH 2021 Guidelines on the diagnosis of von Willebrand disease. Blood Adv 2021; 5: 280-300
    CrossrefPubMedGoogle Scholar
  • 33 Tuddenham EG, Lane RS, Rotblat F. et al. Response to infusions of polyelectrolyte fractionated human factor VIII concentrate in human haemophilia A and von Willebrand's disease. Br J Haematol 1982; 52 (02) 259-267
    CrossrefPubMedGoogle Scholar
  • 34 Mazurier C, Gaucher C, Jorieux S, Goudemand M. Collaborative Group. Biological effect of desmopressin in eight patients with type 2N ('Normandy') von Willebrand disease. Br J Haematol 1994; 88 (04) 849-854
    CrossrefPubMedGoogle Scholar