Screening for paroxysmal nocturnal hemoglobinuria (PNH) in patients presenting with cerebral sinovenous thrombosis (CSVT): Results of a FLAER based flowcytometry study in Indian patients

  • Saniya Sharma
  • Jasmina AhluwaliaEmail author
  • Charu Batra Atreja
  • Manish Modi
  • Manupdesh Singh Sachdeva
  • Narender Kumar
  • Parveen Bose
  • Sunil Kumar Bose
  • Varun Uppal
  • Vivek Lal
  • Neelam Varma


Patients with paroxysmal nocturnal hemoglobinuria (PNH) may present with thrombosis at unusual sites, of which cerebral sinovenous thrombosis (CSVT) is one and screening for PNH is recommended in this condition. Though many patients diagnosed with PNH develop CSVT, it is unclear how many patients with PNH would present for the first time with thrombosis. We analysed the results of screening for PNH by flowcytometry in our patients with CSVT. The laboratory data of patients referred for thrombophilia and PNH testing in CSVT was examined to assess the frequency of PNH at presentation in these patients. FLAER and CD24 on granulocytes and FLAER and CD14 on monocytes respectively were used to screen the leucocytes for PNH by flowcytometry. The data for Protein C, S and Antithrombin deficiency, antiphospholipid antibodies and the Factor V Leiden mutation was examined and circumstantial risk factors were also assessed. Of the 180 cases of CSVT screened by flowcytometry for PNH, not a single case tested positive. Positivity for anti-phospholipid antibodies was the most common thrombophilic risk factor (5%). Pregnancy was the most common circumstantial risk factor. Our data on FLAER based flowcytometry in the North Indian population with CSVT suggests that PNH is not a common risk factor in our patients with thrombosis at this unusual site.


Cerebral sinovenous thrombosis Paroxysmal nocturnal hemoglobinuria FLAER flow cytometry Antiphospholipid antibodies 



The help rendered by Dr Harpreet Virk in data retrieval is gratefully acknowledged.

Compliance with ethical standards

The study was approved by Institute Ethics Committee, Postgraduate Institute of Medical Education and Research, Chandigarh, India (IEC no. INT/IEC/2018/EIC001147).

Conflicts of interest

The authors declare that they have no conflicts of interest to declare.


  1. 1.
    Bousser MG, Ferro JM (2007) Cerebral venous thrombosis: an update. Lancet Neurol 6:162–170CrossRefGoogle Scholar
  2. 2.
    Stam J (2005) Thrombosis of the cerebral veins and sinuses. N Engl J Med 352:1791–1798CrossRefGoogle Scholar
  3. 3.
    Moyo VM, Mukhina GL, Garrett ES, Brodsky RA (2004) Natural history of paroxysmal nocturnal haemoglobinuria using modern diagnostic assays. Br J Haematol 126:133–138CrossRefGoogle Scholar
  4. 4.
    Araten D, Thaler H, Luzzatto L (2005) High incidence of thrombosis in African-American and Latin-American patients with paroxysmal nocturnal haemoglobinuria. Thromb Haemost 93:88–91CrossRefGoogle Scholar
  5. 5.
    Parker CJ (2002) Historical aspects of paroxysmal nocturnal haemoglobinuria: "defining the disease". Br J Haematol 117:3–22CrossRefGoogle Scholar
  6. 6.
    Hillmen P (2000) Implications of recent insights into the pathophysiology of paroxysmal nocturnal haemoglobinuria. Br J Haematol 108:470–479CrossRefGoogle Scholar
  7. 7.
    Hillmen P, Lewis SM, Bessler M, Luzzatto L, Dacie JV (1995) Natural history of paroxysmal nocturnal hemoglobinuria. N Engl J Med 333:1253–1258CrossRefGoogle Scholar
  8. 8.
    Parker C, Omine M, Richards S, Nishimura J, Bessler M, Ware R et al (2005) Diagnosis and management of paroxysmal nocturnal hemoglobinuria. Blood 106:3699–3709CrossRefGoogle Scholar
  9. 9.
    Wiedmer T, Ando B, Sims PJ (1997) Complement C5b-9 stimulated platelet secretion is associated with a Ca2+ initiated activation of cellular protein kinases. J Biol Chem 262:13674–13681Google Scholar
  10. 10.
    Hillmen P, Muus P, Dührsen U, Risitano AM, Schubert J, Luzzatto L et al (2007) Effect of the complement inhibitor Ecluzimab on thromboembolism in patients with paroxysmal nocturnal hemoglobinuria. Blood 110:4123–4128CrossRefGoogle Scholar
  11. 11.
    Borowitz MJ, Craig FE, Digiuseppe JA, Illingworth AJ, Rosse W, Sutherland DR et al (2010) Guidelines for the diagnosis and monitoring of paroxysmal nocturnal hemoglobinuria and related disorders by flow cytometry. Cytometry B Clin Cytom 78:211–230PubMedGoogle Scholar
  12. 12.
    Sutherland DR, Illingworth A, Marinov I, Ortiz F, Andreasen J, Payne D et al (2018) ICCS/ESCCA consensus guidelines to detect GPI-deficient cells in paroxysmal nocturnal hemoglobinuria (PNH) and related disorders part 2: reagent selection and assay optimization for high-sensitivity testing. Cytometry B Clin Cytom 94:23–48CrossRefGoogle Scholar
  13. 13.
    Ahluwalia J, Naseem S, Sachdeva MU, Bose P, Bose SK, Kumar N et al (2014) Paroxysmal Nocturnal Hemoglobinuria is rare cause for thrombosis of the intra-abdominal veins in the ethnic Indian population: results from FLAER-based flowcytometry screening. Eur J Haematol 92:435–443CrossRefGoogle Scholar
  14. 14.
    Garewal G, Das R, Ahluwalia J, Mittal N, Varma S (2003) Prothrombin G20210A is not prevalent in North India. J Thromb Haemost 1:2253–2254CrossRefGoogle Scholar
  15. 15.
    Bertina RM, Koeleman BP, Koster T, Rosendaal FR, Dirven RJ, de Ronde H et al (1994) Mutation in blood coagulation factor V associated with resistance to activated protein C. Nature 369:64–67CrossRefGoogle Scholar
  16. 16.
    Illingworth A, Marinov I, Sutherland DR, Wagner-Ballon O, Del Vecchio L (2018) ICCS/ESCCA consensus guidelines to detect GPI deficient cells in paroxysmal nocturnal hemoglobinuria (PNH) and related disorders part 3: data analysis, reporting and case studies. Cytometry B Clin Cytom 94:49–66CrossRefGoogle Scholar
  17. 17.
    Meppiel E, Crassard I, de Latour RP, de Guibert S, Terriou L, Chabriat H et al (2015) Cerebral venous thrombosis in paroxysmal nocturnal hemoglobinuria. a series of 15 cases and review of the literature. Med Baltim 94:1–8CrossRefGoogle Scholar
  18. 18.
    Misra UK, Kalita J, Bansal V, Nair PP (2008) Paroxysmal nocturnal haemoglobinuria presenting as cerebral venous sinus thrombosis. Transfus Med 18:308–311CrossRefGoogle Scholar
  19. 19.
    Narayan D, Kaul S, Ravishankar K, Suryaprabha T, Bandaru VC, Mridula KR et al (2012) Risk factors, clinical profile, and long-term outcome of 428 patients of cerebral sinus venous thrombosis: insights from Nizam's Institute Venous Stroke Registry, Hyderabad (India). Neurol India 60:154–159CrossRefGoogle Scholar
  20. 20.
    Ferro JM, Canhao P, Stam J, Bousser MG, Barinagarrementeria F (2004) Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke 35:664–670CrossRefGoogle Scholar
  21. 21.
    James AH, Bushnell CD, Jamison MG, Myers ER (2005) Incidence and risk factors for stroke in pregnancy and the puerperium. Obstet Gynecol 106:509 – 516CrossRefGoogle Scholar
  22. 22.
    de Latour RP, Mary JY, Salanoubat C, Terriou L, Etienne G, Mohty M et al (2008) Paroxysmal nocturnal hemoglobinuria: natural history of disease subcategories. Blood 112:3099–3106CrossRefGoogle Scholar
  23. 23.
    Qi X, He C, Han G, Yin Z, Wu F, Zhang Q et al (2013) Prevalence of paroxysmal nocturnal hemoglobinuria in Chinese patients with Budd–Chiari syndrome or portal vein thrombosis. J Gastroenterol Hepatol 28:148–152CrossRefGoogle Scholar
  24. 24.
    Baloda V, Ahluwalia J, Varma N, Chawla YK (2013) Large clones with PNH-type phenotype are not common in patients presenting with intra-abdominal thrombosis–a prospective study. Clin Appl Thromb Hemost 19:562–569CrossRefGoogle Scholar
  25. 25.
    Lee JW, Jang JH, Kim JS, Yoon SS, Lee JH, Kim YK et al (2013) Clinical signs and symptoms associated with increased risk for thrombosis in patients with paroxysmal nocturnal hemoglobinuria from a Korean Registry. Int J Hematol 97:749–757CrossRefGoogle Scholar
  26. 26.
    Madkaikar M, Gupta M, Jijina F, Ghosh K (2009) Paroxysmal nocturnal haemoglobinuria: diagnostic tests, advantages, & limitations. Eur J Haematol 83:503–551CrossRefGoogle Scholar
  27. 27.
    Pai N, Ghosh K, Shetty S (2013) Hereditary thrombophilia in cerebral venous thrombosis: a study from India. Blood Coagul Fibrinolysis 24:540–543CrossRefGoogle Scholar
  28. 28.
    Dentali F, Crowther M, Ageno W (2006) Thrombophilic abnormalities, oral contraceptives, and risk of cerebral vein thrombosis: a meta-analysis. Blood 107:2766–2773CrossRefGoogle Scholar
  29. 29.
    Saposnik G, Barinagarrementeria F, Brown RD Jr, Bushnell CD, Cucchiara B, Cushman M et al (2011) Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 42:1158–1192CrossRefGoogle Scholar
  30. 30.
    Mercier T, Devos T, Mukovnikova M, Boekx N (2017) Diagnosing nocturnal paroxysmal hemoglobinuria: a single-center 4-year experience. Int J Lab Hem 39:329–336CrossRefGoogle Scholar
  31. 31.
    Connors JM (2017) Thrombophilia testing and venous thrombosis. N Engl J Med 377:1177–1187CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Saniya Sharma
    • 1
  • Jasmina Ahluwalia
    • 1
    Email author
  • Charu Batra Atreja
    • 3
  • Manish Modi
    • 2
  • Manupdesh Singh Sachdeva
    • 1
  • Narender Kumar
    • 1
  • Parveen Bose
    • 1
  • Sunil Kumar Bose
    • 1
  • Varun Uppal
    • 1
  • Vivek Lal
    • 2
  • Neelam Varma
    • 1
  1. 1.Department of HematologyPostgraduate Institute of Medical Education and ResearchChandigarhIndia
  2. 2.Department of NeurologyPostgraduate Institute of Medical Education and ResearchChandigarhIndia
  3. 3.Department of PathologyMaharishi Markandeshwar Institute of Medical Sciences & Research ( MMIMSR ), Maharishi Markandeshwar (Deemed to be University) (MMDU)Mullana, AmbalaIndia

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