Paroxysmal Nocturnal Hemoglobinuria
NORD is very grateful to Charles J. Parker, MD, Professor of Medicine, Division of Hematology and Hematologic Malignancies, University of Utah School of Medicine, for assistance in the preparation of this report.
Synonyms of Paroxysmal Nocturnal Hemoglobinuria
- Marchiafava-Micheli syndrome
- No subdivisions found.
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disorder in which red blood cells break apart prematurely. It is an acquired hematopoietic stem cell disorder. Hematopoietic stem cells are created in the bone marrow, the spongy center of the long bones of the body. These cells grow and eventually develop into red blood cells, white blood cells and platelets. Some hematopoietic stem cells in individuals with PNH are defective and consequently develop into defective blood cells. These defective blood cells, especially red blood cells, are extremely susceptible to premature destruction by a person's own immune system.
The classic finding is the premature destruction of red blood cells (hemolysis), resulting in repeated episodes of hemoglobin in the urine (hemoglobinuria). Hemoglobin is the red, iron-rich, oxygen-containing pigment of the blood. Individuals with hemoglobinuria may exhibit dark-colored or bloody urine. This finding is most prominent in the morning, after the urine has concentrated overnight during sleep. However, hemolysis in individuals with PNH is a constant process, it does not occur only at night. Blood in the urine may not always be visible to the eye.
In addition to hemolysis, individuals with PNH are also susceptible to developing repeated, potentially life-threatening blood clots (thromboses). Affected individuals also have some degree of underlying bone marrow dysfunction. Severe bone marrow dysfunction potentially results in low levels of red and white blood cells and platelets (pancytopenia). The specific symptoms of PNH vary greatly from one person to another and affected individuals usually do not exhibit all of the symptoms potentially associated with the disorder.
The symptoms of PNH occur because of the production of defective blood cells or low levels of blood cells due to bone marrow dysfunction. The specific symptoms and progression of the disorder vary greatly from one person to another. Some individuals may have mild symptoms that remain stable for many years; others may have serious symptoms that can progress to cause life-threatening complications.
It is important to note that affected individuals may not have all of the symptoms discussed below. Affected individuals should talk to their physician and medical team about their specific case, associated symptoms and overall prognosis.
The premature destruction of red blood cells (hemolysis) is the primary clinical finding associated with PNH. Hemolysis may result in blood in the urine, although many individuals with hemolysis present without visible blood in the urine. When hemolysis occurs, a red blood cell's outer wall (membrane) breaks down (lysis) releasing hemoglobin. Hemoglobin is excreted from the body in the urine, resulting in the dark-colored or bloody urine (hemoglobinuria) that is characteristic of this disorder. Hemolysis is ongoing, but may worsen during periods of infection or stress. This may be referred to as a hemolytic episode. The premature destruction of red blood cells may result in low levels of circulating red blood cells (hemolytic anemia), especially if there is underlying bone marrow dysfunction.
Chronic hemolysis is central to all the symptoms and physical findings associated with PNH. Mild hemolysis can cause fatigue, irregular heartbeats, headaches, chest pain and difficulty breathing when exercising. If hemolysis is severe, additional symptoms can develop including disabling fatigue, difficulty swallowing (dysphagia) and painful muscle contractions that affect the abdomen, the esophagus (esophageal spasms) and, in men, can cause erectile dysfunction and impotence. Chronic hemolysis can also lead to the development of blood clots and end-stage organ damage. For example, some affected individuals may develop kidney (renal) insufficiency and, although rare, can potentially develop kidney failure.
Approximately 40 percent of individuals with PNH may develop blood clots, especially in the veins (venous thrombosis). The exact reason individuals with PNH develop blood clots is not fully understood. In addition to red blood cells, defective hematopoietic stem cells may also produce defective platelets. Researchers believe that these defective platelets are abnormally prone to forming blood clots. Chronic hemolysis can contribute to the development of blood clots. Blood clots can be carried via the bloodstream to various areas of the body, potentially resulting in life-threatening complications. Blood clots may reduce or cut off blood flow to various organs, especially the stomach, liver, and brain. The specific symptoms associated with venous thrombosis depend upon the specific area of the body affected. For example, blood clots affecting the liver may result in jaundice, abdominal pain, or, potentially, a condition known as Budd-Chiari syndrome (for more information, see the Related Disorders section below). Blood clots affecting the stomach may result in a sharp pain in the stomach or a bloated or full feeling. Blood clots affecting cerebral veins may cause symptoms such as headaches or increased intracranial pressure. Blood clots in the lungs can result in shortness of breath, difficulty breathing, and palpitations. In rare cases, blood clots may form in the arteries. Blood clots can potentially cause life-threatening complications by cutting off blood flow to vital organs.
Most individuals with PNH have some degree of bone marrow dysfunction. Individuals with mild bone marrow dysfunction may not have any symptoms or only mild symptoms. Individuals with severe bone marrow dysfunction may have low levels of red and white blood cells or platelets (pancytopenia). Red blood cells deliver oxygen to the body, white blood cells help in fighting off infections and platelets allow the body to form clots to stop bleeding. A low level of circulating red blood cells is known as anemia. A low level of white blood cells is known as leukopenia. A low level of platelets is known as thrombocytopenia.
Individuals with anemia may experience tiredness, increased need for sleep, weakness, lightheadedness, dizziness, irritability, headaches, pale skin color, difficulty breathing (dyspnea), and cardiac symptoms. Individuals with leukopenia have an increased risk of contracting bacterial and fungal infections. Individuals with thrombocytopenia are more susceptible to excessive bruising following minimal injury and spontaneous bleeding from the mucous membranes, especially those of the gums and nose. Women may develop increased menstrual blood loss (menorrhagia).
Many individuals with PNH may simultaneously have another, closely-related disorder known as acquired aplastic anemia. To a lesser extent, some individuals may have myelodysplasia. Although the exact relationship among these disorders is unknown, researchers now believe that PNH arises from autoimmune bone marrow failure, which occurs in most cases of acquired aplastic anemia and some cases of myelodysplasia. In rare cases, PNH may eventually develop into acute leukemia. The reason for this change is unknown. (For more information on these disorders, see the Related Disorders section below.)
Two factors are necessary for the development of PNH: an acquired somatic mutation of the PIG-A gene, which affects hematopoietic stem cells creating defective "PNH" blood cells, and a predisposition to the multiplication and expansion of these defective stem cells. Most likely, PNH arises in the setting of autoimmune bone marrow failure, as occurs in most cases of acquired aplastic anemia. Researchers believe that defective PNH stem cells survive the misguided attack by the immune system and multiply, while healthy stem cells are destroyed, resulting in the development of PNH. The reason that defective cells survive while healthy cells are destroyed is not known.
The mutation in the PIG-A gene is a somatic mutation, which means that it occurs after conception; it is not inherited and is not passed on to children. This mutation occurs randomly, for no apparent reason (sporadically). In PNH, this mutation occurs in a single hematopoietic stem cell (clonal disorder), which then multiplies and expands. The reason why PNH cells expand and multiply is not fully understood. Researchers believe that other factors such as secondary mutations or immune factors may be necessary for PNH cells to expand and multiply. Therefore, although the PIG-A mutation is necessary for the development of PNH, it presence alone is not sufficient to cause the disorder.
The PIG-A gene produces a protein that is essential to the creation (biosynthesis) of glycosyl phosphatidylinositol (GPI) anchors. These anchors allow some proteins to attach to a cell's membrane. These proteins are called GPI-anchored proteins. In cells with a PIG-A gene mutation, the GPI anchors are not formed, and, consequently, GPI-anchored proteins cannot attach to the cell's membranes. Some of these GPI-anchored proteins serve to protect cells from the immune system. Consequently, a lack of these surface proteins renders "PNH" blood cells extremely susceptible to destruction by a part of the immune system known as the complement system. Blood cells are the only cells in the body that are affected in PNH. Red blood cells are particularly sensitive to premature destruction by the complement system.
The complement system is a complex group of proteins that work together to fight infection in the body. These proteins respond to bacteria, viruses or other foreign substances in the body. They work with white blood cells to destroy foreign material in the body. In individuals with PNH, the complement system mistakenly destroys "PNH" blood cells due to the lack of GPI-anchored proteins that normally protect blood cells from the activity of the immune system.
PNH is believed to affect males and females in equal numbers, although some studies show a slight female preponderance. The prevalence is estimated to be between 0.5-1.5 per million people in the general population. The disorder has been described in many racial groups and has been identified in all areas of the world. The disorder may occur with greater frequency in individuals of Southeast Asia or the Far East who experience greater rates of aplastic anemia. The disorder can affect any age group. The median age at diagnosis is during the 30s.
PNH was first reported in the medical literature in the latter half of the 19th century. The disorder was termed paroxysmal nocturnal hemoglobinuria because of the mistaken belief that hemolysis and subsequent hemoglobinuria occurred in only in intermittent episodes (paroxysmally) and with greater frequency during the night (nocturnal). However, while hemoglobinuria may appear paroxysmally, hemolysis is ongoing both during the day and at night.
Symptoms of the following disorders can be similar to those of PNH. Comparisons may be useful for a differential diagnosis.
PNH and acquired aplastic anemia are closely related disorders, while PNH can also occur in association with some forms of myelodysplasia such as refractory anemia. Individuals with PNH may have acquired aplastic anemia or myelodysplasia at the same time. Researchers believe that PNH may arise out of autoimmune bone marrow failure, which causes most cases of acquired aplastic anemia and some cases of myelodysplasia.
Acquired aplastic anemia is a rare disorder caused by profound, almost complete bone marrow failure. Bone marrow is the spongy substance found in the center of the long bones of the body. The bone marrow produces specialized cells (hematopoietic stem cells) that grow and eventually develop into red blood cells (erythrocytes), white blood cells (leukocytes), and platelets. In acquired aplastic anemia, an almost complete absence of hematopoietic stem cells eventually results in low levels of red and white blood cells and platelets (pancytopenia). Specific symptoms associated with acquired aplastic anemia may vary, but include fatigue, chronic infections, dizziness, weakness, headaches, and episodes of excessive bleeding. Most cases of acquired aplastic anemia occur for unknown reasons (idiopathic), although researchers now believe that most of these cases result from the immune system mistakenly targeting the bone marrow (autoimmunity). (For more information on this disorder, choose "acquired aplastic anemia" as your search term in the Rare Disease Database.)
Myelodysplastic syndrome (myelodysplasia) is a rare group of blood disorders that occur as a result of improper development of blood cells within the bone marrow. The three main types of blood cells (i.e., red blood cells, white blood cells and platelets) are affected. Red blood cells deliver oxygen to the body, white blood cells help fight infections, and platelets assist in clotting to stop blood loss. These improperly developed blood cells fail to develop normally and enter the bloodstream. As a result, individuals with MDS have abnormally low blood cell levels (low blood counts). General symptoms associated with MDS include fatigue, dizziness, weakness, bruising and bleeding, frequent infections, and headaches. In some cases, MDS may progress to life-threatening failure of the bone marrow or develop into an acute leukemia. The exact cause of MDS is unknown, but in approximately 50 percent of cases acquired (somatic) genetic abnormalities can be identified in the bone marrow cells. There are no certain environmental risk factors. (For more information on this disorder, choose "myelodsyplastic syndromes" as your search term in the Rare Disease Database.)
Rarely, individuals with PNH may eventually develop leukemia, which is a form of cancer affecting the bone marrow and blood. It is characterized by the uncontrolled accumulation of blood cells. Acute forms of leukemia often result in low levels of red and white blood cells and platelets (pancytopenia).
Paroxysmal cold hemoglobinuria is a rare autoimmune hemolytic disorder characterized by the premature destruction of healthy red blood cells (hemolysis) minutes to hours after exposure to cold. Autoimmune diseases occur when the body's natural defenses against invading organisms mistakenly destroy healthy tissue for unknown reasons. Normally, red blood cells have a life span of approximately 120 days. In an individual affected with paroxysmal cold hemoglobinuria, the red blood cells are destroyed prematurely and suddenly by an antibody mediated process upon exposure to temperatures of 10 to 15 degrees Centigrade and below. (For more information on this disorder, choose "paroxysmal cold hemoglobinuria" as your search term in the Rare Disease Database.)
The following disorders may be associated with PNH as secondary characteristics. They are not necessary for a differential diagnosis:
Budd-Chiari syndrome is a rare disorder characterized by narrowing and obstruction (occlusion) of the veins of the liver (hepatic veins). In individuals with PNH, blood clots (thromboses) block the hepatic veins. Symptoms associated with Budd Chiari syndrome include pain in the upper right part of the abdomen, an abnormally large liver (hepatomegaly), and/or accumulation of fluid (ascites) in the space between the two layers of the membrane that lines the stomach (peritoneal cavity) . Additional findings that may be associated with the disorder include nausea, vomiting, and/or an abnormally large spleen (splenomegaly). The severity of the disorder varies from case to case, depending upon the site and number of affected veins. In some cases, if the major hepatic veins are involved, high blood pressure in the veins carrying blood from the gastrointestinal (GI) tract back to the heart through the liver (portal hypertension) may be present. (For more information on this disorder, choose "Budd-Chiari" as your search term in the Rare Disease Database.)
A diagnosis of PNH may be suspected in individuals who have symptoms of intravascular hemolysis (e.g., hemoglobinuria, abnormally high serum LDH concentration) with no known cause. A diagnosis may be made based upon a thorough clinical evaluation, a detailed patient history, and a variety of specialized tests. The main diagnostic test for individuals with suspected PNH is flow cytometry, a blood test that can identify PNH cells (blood cells that are missing GPI-anchored proteins).
The treatment of PNH is directed at the specific symptoms that are present in each individual and includes a variety of different therapeutic options.
On March 16, 2007, the U.S. Food and Drug Administration (FDA) approved the orphan drug eculizumab (Soliris®) as a treatment for PNH. This is the first drug to be approved for this disorder. Soliris does not cure PNH but halts the breakdown of red blood cells and can reduce the risk of thrombosis and improve overall quality of life. Soliris works by blocking the complement system of the body that inadvertently destroys blood cells. Because it blocks part of the body's natural immune system, Soliris increases the risk of meningococcal infections. Therefore, patients must be vaccinated with a meningococcal vaccine at least two weeks prior to receiving the first dose of Soliris. For additional information about the drug, contact:
Alexion Pharmaceuticals, Inc.
352 Knotter Dr.
Cheshire, CT 06410
Phone: (203) 272-ALXN
Fax: (203) 271-8190
On January 29, 2009 Canada's national healthcare regulatory agency, Health Canada, approved the use of Soliris® (eculizumab) for the treatment of all patients in Canada with paroxysmal nocturnal hemoglobinuria (PNH).
Additional treatment for PNH is symptomatic and supportive and varies depending upon the individual's age, general health, presence of associated disorders, severity of PNH and degree of underlying bone marrow failure.
Some individuals with PNH receive folic acid (folate) supplements to insure that the supply of folate is adequate as demand increases when the bone marrow attempts to compensate for the hemolytic anemia of PNH by augmenting red blood cell production (erythropoiesis) in the bone marrow. Supplemental iron should be give to individuals with iron-deficiency, which can occur because of red blood cell destruction and the consequent loss of iron in the urine.
Some physicians suggest that individuals exhibiting symptoms of hemolysis should receive treatment with steroids such as prednisone because it is believed that such treatment slows the rate of destruction of red blood cells. However, treatment with steroids such as prednisone is controversial because steroid therapy is not beneficial to everyone and carries the potential for serious side effects, especially if the therapy is continued for a long duration.
The administration of drugs that block the formation of blood clots (anticoagulation therapy) may be prescribed. Some individuals may be placed on long-term anticoagulant therapy. Use of blood thinners must be strictly managed because of the risk of excessive bleeding due to low platelet numbers in some individuals.
Individuals with Budd-Chiari syndrome may be treated by thrombolytic therapy, in which certain drugs are used to breakdown or dissolve blood clots. Such treatment requires experience in managing the potential side-effects these drugs as the risk of adverse events (particularly bleeding) is substantial.
The only curative therapy for individuals with PNH is bone marrow transplantation. However, because of the risk of morbidity and mortality, it is reserved for individuals with serious complications such as severe bone marrow failure or repeated, life-threatening blood clot formation. The specific form of bone marrow transplantation used most often in treating PNH is an allogeneic bone marrow transplant. During an allogeneic bone marrow transplant, an affected individual's bone marrow is destroyed usually by chemotherapy or radiation and replaced with healthy marrow obtained from a donor. The donor marrow is transplanted intravenously into the body where it travels to the bone marrow where it eventually begins producing new blood cells. The best match for a bone marrow transplant is an identical twin or sibling with an identical HLA type. However, in many cases, a search for an unrelated, matched donor is necessary. Bone marrow transplantation can cure underlying bone marrow dysfunction and can eliminate the defective PNH stem cells.
Individuals with PNH who have severe bone marrow failure may also be treated with immunosuppressive therapy. Individuals with acquired aplastic anemia have responded favorably to this form of treatment, in which certain drugs are used to suppress the activity of the immune system. This form of treatment may be beneficial in cases of PNH that are dominated by bone marrow failure. While the immunosuppressive therapy can restore bone marrow function, it does not eradicate the PNH clone. The two most commonly used immunosuppressive agents, given alone or in combination, are antithymocyte globulin (ATG) and cyclosporin.
Some individuals with PNH with low blood cell counts may receive treatment with blood transfusions. This treatment consists of giving red blood cell transfusions to correct anemia, platelet transfusions to treat or prevent serious bleeding, and antibiotics to treat or prevent infections. Affected individuals who are eligible for a bone marrow transplant should not, if possible, receive blood transfusions because blood transfusions reduce the chances of a successful transplant.
Some individuals with PNH may receive treatment with manmade (synthetic) growth factors. Growth factors are proteins normally found in the body that stimulate the bone marrow to produce blood cells. Erythropoietin (EPO) is a growth factor produced by the kidneys that stimulates the bone marrow to create red blood cells. Epogen®, Procrit®, and Aranesp® are forms of erythropoietin. Therapy with red blood cell growth factors may lessen the need for blood transfusions. Individuals with PNH who have low levels of white blood cells may receive growth factors such as granulocyte-colony stimulating factor (G-CSF) that stimulate the bone marrow to make white blood cells.
Some individuals with PNH may receive treatment with androgens, which are male hormones that stimulate the bone marrow to produce red blood cells. Androgen therapy, such as danazole, may help to improve the symptoms of anemia.
Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.
For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:
Toll-free: (800) 411-1222
TTY: (866) 411-1010
For information about clinical trials sponsored by private sources, in the main, contact:
Contact for additional information about paroxysmal nocturnal hemoglobinuria:
Charles J. Parker, MD
Professor of Medicine
Division of Hematology and Hematologic Malignancies
University of Utah School of Medicine
Organizations related to Paroxysmal Nocturnal Hemoglobinuria
Please note that some of these organizations may provide information concerning certain conditions potentially associated with this disorder.
Parker CJ, Ware RE. Paroxysmal Nocturnal Hemoglobinuria. In: Wintrobes Clinical Hematology, 12th ed. Greer JP, Foerster J, Rodgers GM, et al., eds. 2009 Lippincott, Williams & Wilkins. Philadelphia, PA. pp. 998-1020.
Parker CJ. Paroxysmal Nocturnal Hemoglobinuria. NORD Guide to Rare Disorders. Lippincott Williams & Wilkins. Philadelphia, PA. 2003:389-390.
Hill A, Rother RP, Arnold L, et al. Eculizumab prevents intravascular hemolysis in patients with paroxysmal nocturnal hemoglobinuria and unmasks low level extravascular hemolysis occurring through C3 opsonization. Haematologica. 2010;95:567-573
Brodsky RA. How I treat paroxysmal nocturnal hemoglobinuria. Blood. 2009;113:6522-6527.
Brodsky RA. Advances in the diagnosis and therapy of paroxysmal nocturnal hemoglobinuria. Blood Rev. 2008;22:65-74.
Hillmen P, Young NS, Schubert J, et al. The complement inhibitor eculizumab in paroxysmal nocturnal hemoglobinuria. N Engl J Med. 2006;355:1233-1243.
Hill A, Richards SJ, Hillmen P. Recent developments in the understanding and management of paroxysmal nocturnal hemoglobinuria. Br J Haematol. 2007;137:181-192.
Parker C, Omine M, Richards S, et al. Diagnosis and management of paroxysmal nocturnal hemoglobinuria. Blood. 2005;106:3699-3709.
Meyers G, Parker CJ. Management issues in paroxysmal nocturnal hemoglobinuria. Int J Hematol. 2003;77:125-132.
FROM THE INTERNET
Rosse WF. Paroxysmal Nocturnal Hemoglobinuria. Orphanet encyclopedia, December 2004. Available at: http://www.orpha.net/data/patho/GB/uk-PNH.pdf Accessed: November 3, 2010.
Genetics Home Reference. Paroxysmal Nocturnal Hemoglobinuria. May 7, 2007. Available at: http://ghr.nlm.nih.gov/condition/paroxysmal-nocturnal-hemoglobinuria Accessed: November 3, 2010.
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