American Journal of Hematology 22:415-419 (1986) A New Case of High-Molecular-Weight Kininogen Inherited Deficiency Jean-Jacques Lefrere, Marie-Helene Horellou, Daniele Gozin, Jacqueline Conard, Jean-Yves Muller, Michael Clark, Jean-Pierre Soulier, and Meyer Samama Laboratoire Central d’Hematologie, H6tel-Dieu (J.J.L., M.-H.H., J.C., M.S.), Centre National de Transfusion Sanguine (D.G., J.-Y M., J.-P.S.), and Service d’Hematologie Pediatrique, H6pital Saint-Louis (M.C.), Paris, France A preoperative hemostasis study discovered a prolonged activated partial thromboplastin time in a 23-year-old Portuguese Caucasian woman without personal or past family history of hemorrhage or thrombosis. This was corrected by pooled plasma that excluded circulating anticoagulant. Activated partial thromboplastin time was prolonged whatever the activator, particularly ellagic acid, and was not corrected by prolonged kaolin incubation. Levels of factors VIII and XI1 were normal; factor XI and prekallikrein levels were either moderately low or normal according to activators and defective reagents used. High-molecular-weight kininogen (HMWK) level assessed by coagulation and immunological method was virtually nil. Fibrinolysis activity was normal before and after veinous occlusion. The programmed operation was performed without any particular preparation and no complication arose. Family investigation found heterozygous HMWK deficiency in the proposita’s father and three of her siblings. Key words: prekallikrein, contact coagulation system INTRODUCTION Between 1974 and 1976, a small number of publications reported cases of a congenital deficiency of a then unknown coagulation factor, the high-molecularweight kininogen (HMWK). It was named after one of the patients suffering from this deficit and factors Fitzgerald [1-31, Williams , Flaujeac [5-71, Reid , and Fujiwara  were described in succession. HMWK takes part in the contact system, the earliest phase of the intrinsic coagulation pathway. In view of its great rarity, we describe here another case of a congenital deficit of HMWK in a 23-year-old woman. METHODS Coagulation assays were performed according to classical techniques [lo]. The study of the contact system was made according to previously described techniques [ll]. The dosage of the complement was performed in Pr. Kazatchkine’s laboratory. Received for publication September 12, 1985; accepted February 6 , 1986. Address reprint requests to Dr J.J. Lefrtre, Centre National de Transfusion Sanguine, 6, Rue A. Cabanel, 75015, Paris, France. 0 1986 Alan R. Liss, Inc. 416 Case Report: Lefrkre et al The immunological dosage of HMWK was realized in Mrs. Steinbuch’s laboratory (C.N. T.S. Orsay). CASE REPORT A 23-year-old white Caucasian (Portuguese) woman, without past surgical or obstetrical history, or of hemorrhage or thrombosis, was referred for ovarian hysterectomy. There was no known family history of hemorrhage or consanguinity. Preoperative hemostasis check-up showed (Table I) a normal bleeding time, a normal platelet count, a normal Quick test, a prolonged APTT, a normal thrombin clotting time, and a normal fibrinogen level. After 1 hr incubation at 37°C of normal plasma with the patient’s plasma, APTT was normalized, thus eliminating the hypothesis of a circulating anticoagulant. There was no difference in APTT with the various reagents used (Table 11) and prolonged incubation with celite did not correct APTT (patient: 48 sec; normal plasma: 32 sec; patient after 15 min incubation: 56 sec; normal plasma after 15 min incubation: 32 sec). The study of the intrinsic coagulation phase factors showed the following: factor VIII 70%, factors IX and XI1 100%, and discordant results for prekallikrein and factor XI activity: APTT studied with platelin activator reagent (General Diagnostics) and Merz Dade XI defective plasma showed 42% factor XI, but studied with C.N.T.S. XI defective plasma, it showed 95% after activation by a cephalin 1/400 and kaolin mixture. APTT studied with Fletcher Trait Immuno defective plasma and APTT reagent after 1 min incubation showed 35% prekallikrein level, but it was estimated at 100% with Fletcher Trait King defective plasma after 30 sec incubation with a cephalin 11400 and kaolin mixture. Immunological assay of prekallikrein was 5 p g / d and chromogenic dosage of prekallikrein with activation by celite was estimated at 70%. Global contact measured by the amydolytic (chromo-kallicrein, Diagnostica Stago) method after activation by dextran sulfate was below 10%.Factor XII activation capacity measured by the amydolytic method (dextran sulfate + exogenous prekallikrein) was 80%. + TABLE I. Patient’s Preowrative Hemostasis Check-Ur, Patient Bleeding time (Ivy’s method) Platelet count Quick test APTT Thrombin clotting time Fibrinogen level 6 min 250. 109/L 100% 47 sec 20 sec 2.5 g/L Normal < 8 min 150. 109/L >75% 28 sec 19 sec 2-4 g/L TABLE 11. Patient’s APTT With the Various ThromboplastinUsed Thromboplastin Platelin + activator (General Diagnostics) Automated APTT (General Diagnostics) CK prest (Diagnostica Stago) Cephamat (Biomerieux) Activator Results reagent Patientheference Celite Silice Kaolin Ellagic acid 78/31 sec 48/33 sec 52/33 sec 49/30 sec 417 Case Report: High-Molecular-Weight Kininogen Deficiency Functional dosage of HMWK by the coagulation method showed very low levels with different defective reagents used: 0.65% with Flaujeac plasma, 1.7% with Fitzgerald (King), less than 5 % with Fitzgerald (Immuno). Immunological assay of HMWK antigen by Laurel1 technique with Behring anti-HMWK antiserum was nil (no detectable precipitate). Full correction of patient plasma APTT was obtained by addition of 30% normal plasma. For added normal plasma concentrations exceeding l o % , we obtained a dose-related linear response. Fibrinolysis study results were almost normal: Euglobulin lysis time before anoxia was 11 hr (normal: 3-10 hr), and was 2 hr after 10 min anoxia by venous occlusion (normal 90 min); FearnleyGallimore test lasted 2 hr before anoxia (normal: 3-10 hr) and 1 hr after 10 min 90 min). We found no abnormality in component factors: CHS0 = anoxia (normal 106%, C3 = 116%, C4 = 87%, B = 107% (normal values = 100 f 20%,results expressed in percentage of a reference pool). A study of the proposita’s family discovered four heterozygous HMWK defect trait carriers (Table 111, Fig. 1); levels were near to 50% of normal values with comparable results between functional and immunological dosages. These patients did not have an impaired global contact activity through their HMWK defect; prekallikrein and factor XI were normal. < < TABLE 111. APTT, Global, Contact Measured by Amydolytic Method After Activation by Dextran Sulfate Functional and Immunological HMWK Dosages in the Proposita’s Family APTT PatientlReference (set) 32/34 29/34 31/34 51/36 35/34 35/36 35/34 31/34 II 12 11I 112 (proposita) 113 114 115 116 Global contact activity (dextran sulfate) (%) 96 99 100 < 10 92 > 100 83 87 HMWK: functional dosage (%) HMWK: immunological dosage (%) 48 103 69 1.7 63 80 84 66 55 100 75 0 50 75 50 50 I Fig. 1. Proposita’s family (proposita denoted by arrow). 418 Case Report: Lefrere et al The scheduled surgical operation was performed without any particular preparation and was not complicated by any hemorrhage. DISCUSSION HMWK is a one-chain a-globulin with a 110,000-dalton molecular weight [ 121. It is transported in plasma complexed with prekallikrein and factor XI, allowing the latter’s binding to negative-charged surfaces [3,13,14]. The patient had no tendency to hemorrhage as seen in factor XI1 defect [ 151, in prekallikrein defect [ 16,171, or in congenital HMWK defects previously described [1,4,6,8,9]. The hereditary transmission of the trait appears to be recessive autosomal since both sexes are affected. Unlike the prekallikrein deficit, prolonged preincubation of patient’s plasma with celite does not normalize APTT. Yet, unlike the prekallikrein deficit, the use of ellagic acid does not correct APTT: It is known that contact phase activation by ellagic acid is possible in cases of the prekallikrein deficit but not of the HMWK deficit. In Fitzgerald [l], Williams , and Fujiwara  plasmas were reported to associate HMWK deficit with low prekallikrein levels. In these patients, decreased prekallikrein level (20 to 40 %) is underestimated. Prekallikrein also appears abnormal under immunological assay since it does not migrate without its binding protein, HMWK. This new case of HMWK congenital deficit (there are fewer than ten mentioned in the world’s publications) was clinically entirely nonsymptomatic, which is the usual case in congenital deficits of contact factors. The biological study pinpointed the close relationship between HMWK and prekallikrein. Prekallikrein, even when present at normal levels, is poorly absorbed by surfaces when its binding protein is absent; on the other hand, heterozygous subjects show normal prekallikrein activation, proving that in congenital deficiencies such as the one reported, the defect only concerns HMWK. The variable impairment of prekallikrein activation is not related to the level of this protein, but to HMWK, which is necessary for its optimal activation. ACKNOWLEDGMENTS We thank Mrs J. Lerable for her valuable technical cooperation. REFERENCES Waldmann R, Abraham JP, Rebuck JW, Caldwell J, Saito H, Ratnoff OD: Fitzgerald factor: A hitherto unrecognized coagulation factor. Lancet i:949-95 1, 1975. 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