Simultaneous Occurrence of Human Antibodies Directed against Fibrinogen, Thrombin, and Factor V Following Exposure to Bovine Thrombin: Effects on Blood Coagulation, Protein C Activation and Platelet Function

Summary

We describe a patient with severe epistaxis, prolonged coagulation tests and decreased plasma factor V following exposure to bovine topical thrombin. Patient IgG, but not normal IgG, showed binding to immobilized thrombin (bovine > human) and fibrinogen, and to factor V by Western blotting; the binding to thrombin was inhibited by hirudin fragment 54-65. Electron microscopy of rotary shadowed preparations showed complexes with IgG molecules attached near the ends of trinodular fibrinogen molecules. Patient IgG inhibited procoagulant, anticoagulant and cell-stimulating functions of thrombin demonstrated by inhibition of fibrinogen clotting, protein C activation and platelet aggregation; thrombin hydrolysis of S-2238 was not inhibited. The results suggest that the antibody is targeted against anion-binding exosite and not catalytic site of thrombin. Antifibrinogen antibodies have not been reported in patients exposed to bovine thrombin. There is a pressing need to re-evaluate the role of bovine thrombin as a therapeutic agent.

• References

• 1 Strieker RB, Lane PK, Leffert JD, Rodgers GM, Shuman MA, Corash L. Development of antithrombin antibodies following surgery in patient with prosthetic cardiac valves. Blood 1988; 72: 1375-1380
• 2 Flaherty MJ, Handerson R, Wener MH. Iatrogenic immunization with bovine thrombin:a mechanism of prolonged thrombin times after surgery. Ann Int Med 1989; 111: 631-634
• 3 Lawson JH, Pennell BJ, Olson JD, Mann KG. Isolation and characterization of an acquired antithrombin antibody. Blood 1990; 76: 2249-2257
• 4 Zehnder JL, Leung LLK. Development of antibodies to thrombin and factor V with recurrent bleeding in a patient exposed to topical bovine thrombin. Blood 1990; 76: 2011-2016
• 5 Sié P, Bezeaud A, Dupouy D, Archipoff G, Freyssinet JM, Dagoujon JM, Serre G, Guillin MC, Boneu B. An acquired antithrombin antibody directed toward the catalytic center of the enzyme. J Clin Invest 1991; 88: 290-296
• 6 Rapaport SI, Zivelin A, Minow RA, Hunter CS, Donnelly K. Clinical significance of antibodies to bovine and human thrombin and factor V after surgical use of bovine thrombin. Am J Clin Path 1992; 97: 84-91
• 7 Costa JM, Fiessinger JN, Capron L, Aiach M. Partial characterization of an autoantibody recognizing the secondary binding site(s) of thrombin in a patient with recurrent spontaneous arterial thrombosis. Thromb Haemost 1992; 67: 193-199
• 8 Nichols WL, Daniels TM, Fisher PK, Owen WG, Pineda AA, Mann KG. Antibodies to bovine thrombin and coagulation factor V associated with surgical use of topical bovine thrombin or fibrin “GLUE”:a frequent finding. Blood 1993; 82: 59a
• 9 Amaud E, Lafay M, Gaussem P, Picard V, Perrus MJ, Aiach M. An autoantibody directed against human thrombin anion binding exosite in a patient with arterial thrombosis:effects on platelets, endothelial cells and protein C activation. Blood 1994; 84: 1843-1850
• 10 LaSpada AR, Skalhegg BS, Henderson R, Schmer G, Pierce R, Chandler W. Brief report:Fatal hemorrhage in a patient with an acquired inhibitor of human thrombin. New Eng J Med 1995; 333: 494-497
• 11 Laemmli UK. Cleavage of structural proteins during the assembly of the head of bacteriophage T4. Nature 1970; 227: 680-685
• 12 De LaCadena RA, Wyshock EG, Kunapuli SP, Schultze RL, Miller M, Walz DA, Colman RW. Platelet thrombospondin interaction with human high and low molecular weight kininogens. Thromb Haemost 1994; 72: 125-131
• 13 Stubbs MT, Bode W. A player of many parts: the spot light falls on thrombin’s structure. Thromb Res 1993; 69: 01-58
• 14 Krstenansky JL, Mao SJT. Antithrombin properties of C-terminus of hirudin using synthetic unsulfated N^α-acetyl-hirudin_45-65 . FEBS Lett 1987; 211: 10-16
• 15 Veklich YI, Gorkun OV, Medved LV, Nieuwenhuizen W, Weisel JW. Carboxyl terminal portions of the α chains of fibrinogen and fibrin:localization by electron microscopy and the effects of isolated αc fragments on polymerization. J Biol Chem 1993; 268: 13577-13585
• 16 Suzuki S, Sakuragawa N. A study on the properties of commercial thrombin preparations. Thromb Res 1989; 53: 271-277
• 17 Doolittle RF. The structure and evolution of vertebrate fibrinogen. Ann NY Acad Sc 1984; 408: 13-26
• 18 Hoots WK, Carrell NA, Wagner RH, Cooper HA, Mc DonaghJ. A naturally occurring antibody that inhibits fibrin polymerization. New Eng J Med 1981; 304: 857-861
• 19 Galanakis DK, Ginzler EM, Fikrig SM. Monoclonal IgG anticoagulants delaying fibrin aggregation in two patients with systemic lupus erythematosus (SLE). Blood 1978; 52: 1037-1046
• 20 Marciniak E, Greenwood MF. Acquired coagulation inhibitor delaying fibrinopeptide release. Blood 1979; 53: 81-91
• 21 Ghosh S, McEvoy P, McVerry BA. Idiopathic autoantibody that inhibits fibrin monomer polymerization. Br J Haematol 1983; 53: 65-72
• 22 Pirkle H, Theodore I. Thrombin like enzymes from snake venoms. In: Handbook of Natural Toxins, vol 5. Tu AT. (ed). W. B. Saunders; Philadelphia, PA: 1991. pp 225-252
• 23 Fenton JW II. Thrombin specificity. Ann NY Acad Sci 1981; 405: 469-495
• 24 Butkowski RJ, Elion J, Downing MR, Mann KG. Primary structure of human prothrombin 2 and α-thrombin. J Biol Chem 1977; 252: 4942-4953
• 25 Vu TKH, Hung DT, Wheaton VI, Coughlin SR. Molecular cloning of functional thrombin receptor reveals a novel proteolytic mechanism of receptor activation. Cell 1991; 64: 1057-1068
• 26 Coughlin SR. Thrombin receptor structure and function. Thromb Haemost 1993; 70: 184-187