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| VON WILLEBRAND DISEASE, TYPE 3; VWD3 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| VON WILLEBRAND DISEASE, TYPE III VWD, TYPE 3 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Phenotype Gene Relationships | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Clinical Synopsis | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| A number sign (#) is used with this entry because von Willebrand disease (VWD) type 3 is caused by homozygous or compound heterozygous mutation in the gene encoding von Willebrand factor (VWF; 613160), which maps to chromosome 12p13. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Description | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Von Willebrand disease is a bleeding disorder resulting from a defect in platelet aggregation due to defects in the von Willebrand factor protein. Type 3 von Willebrand disease, which is inherited as an autosomal recessive disorder, is associated with a severe quantitative defect or virtual absence of VWF in plasma, a prolonged bleeding time, and more severe bleeding tendencies compared to the other types of VWD. Type 3 accounts for about 1% of patients with VWD. Bleeding usually starts in infancy and can include epistaxis, recurrent mucocutaneous bleeding, bleeding after surgery, and hemarthroses. Since VWF also serves as a carrier protein for coagulation factor VIII (F8; 300841), affected individuals also have very low levels of plasma F8, resembling hemophilia A (306700) (summaries by Zhang et al., (1992, 1993); reviews by Sadler et al., 2006 and Lillicrap, 2009). For a general description and a classification of the types of von Willebrand disease, see VWD type 1 (193400). | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Clinical Features | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Von Willebrand (1926, 1931) discovered a hemorrhagic condition in persons living on the Aland Islands in the Sea of Bothnia between Sweden and Finland and called it 'pseudohemophilia.' (See 300600 for another Aland Island disease.) The main difference from classic hemophilia was prolonged bleeding time. Major clinical problems were gastrointestinal, urinary, and uterine bleeding; hemarthroses were rare, but present. Nyman et al. (1981) followed up on the kindred originally reported by von Willebrand (1926). Zhang et al. (1993) described patients descended from the original family reported by von Willebrand (1926). Only heterozygotes were found surviving. The proposita was a 5-year-old girl, who later bled to death during her fourth menstrual period. She had a normal coagulation time, but the bleeding time was prolonged, despite a normal platelet count. All but 1 of her 11 sibs had bleeding symptoms, as did both of her parents, who were third cousins, and many members of her family on both sides. Four of the proband's sisters had died of uncontrolled bleeding in early childhood; 3 died from gastrointestinal bleeding and 1 from bleeding after she bit her tongue in a fall. The predominant symptoms were bleeding from mucous membranes, such as from the nose, the gingivae after tooth extractions, the uterus, and the gastrointestinal tract. In contrast to hemophilia, hemarthroses seemed to be rare. All 5 of the girls who died from uncontrolled bleeding were probably homozygotes. Zimmerman et al. (1979) studied the factor VIII abnormalities in patients with severe recessive von Willebrand disease from 8 families. In 5 families, the parents were first or second cousins. Heterozygous parents had normal to moderately decreased factor VIII-related antigen. A qualitative abnormality of the trace quantities of factor VIII-related antigen was demonstrated in 5 of 6 patients, with absence or relative decrease of the larger, less anodal forms. In addition, 5 different patterns were observed, each suggesting a different molecular abnormality. The findings indicated that severe von Willebrand disease is allelic to the dominant forms of the disorders, with different mutations responsible for the defect. Berliner et al. (1986) observed a relatively high incidence of severe autosomal recessive VWD type 3 in Israel, especially among Arabs. In 15 obligate carriers of type 3 disease, mean levels of factor VIII clotting activity, of von Willebrand factor, and of ristocetin cofactor were significantly higher than the corresponding mean values in 31 symptomatic and 12 asymptomatic VWD type 1 patients, and in turn lower than the values observed in 30 healthy subjects. Ristocetin cofactor was the best criterion for discrimination of type 3 carriers, normals, and type 1 patients. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Other Features | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Sramek et al. (2004) studied atherosclerotic lesions in the carotid and femoral arteries of 47 individuals with type 3 VWD and 84 healthy controls and found no difference in intima-media thickness, proportion with atherosclerotic plaques, or thickness of plaques. There was no effect of VWF treatment on intima-media or plaque thickness in VWD patients. Sramek et al. (2004) concluded that VWF does not play a substantial role in human atherogenesis. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Inheritance | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Von Willebrand disease is inherited as an autosomal recessive trait (Lillicrap, 2009). Autosomal recessive inheritance of VWD was described by several authors, including Veltkamp and van Tilburg (1974), Holmberg (1974), Sultan et al. (1975), Ruggeri et al. (1976), and Ingram (1978). Sultan et al. (1975) noted that the phenotype can be as severe as that observed in hemophilia. Many of the patients were born of consanguineous parents. In some instances, heterozygous parents showed minor laboratory abnormalities in the absence of clinical features of the disorder. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Clinical Management | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| In a review of VWD, James and Lillicrap (2008) noted that VWD type 3 is associated with the development of anti-VWF alloantibodies after exposure to therapeutic VWF concentrates, representing an important issue in the clinical management of this subtype. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Population Genetics | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Lillicrap (2009) stated that VWD type 3 varies in incidence from frequencies of 1 per 500,000 to 1 per million in many Western countries, to figures as high as 6 per million in countries where consanguineous marriages are more frequent. Sutherland et al. (2009) identified a recurrent 8.6-kb deletion of exons 4 and 5 of the VWF gene (613160.0038) in Caucasian British patients with VWD type 3 and VWD type 1 (193400). The deletion was not found in VWD patients of Asian origin, and haplotype analysis confirmed a founder effect in the white British population. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Molecular Genetics | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Ngo et al. (1988) studied the genomic DNA from 10 affected persons from 6 families with severe von Willebrand disease, characterized by undetectable or trace quantities of VWF in plasma and tissue stores. Four patients from 1 family showed complete homozygous deletion of the VWF gene. Gene dosage analysis was consistent with heterozygous deletion in both of the asymptomatic parents and in 4 asymptomatic sibs. A second family had complete heterozygous deletion of the VWF gene in the proband and in 1 asymptomatic parent, suggesting that a different type of genetic abnormality was inherited from the other parent, consistent with compound heterozygosity. Alloantibodies to VWF after treatment developed only in the kindred with homozygous deletions. In a patient with severe type 3 von Willebrand disease, Peake et al. (1990) found a homozygous 2.3-kb deletion in the VWF gene which included exon 42; a novel 182-bp insertion was found between the breakpoints. The patient had an alloantibody inhibitor to VWF. The insertion was detected by PCR amplification both in the patient's DNA and in his carrier relatives. In patients with VWD type 3, Zhang et al. (1992, 1992, 1992) identified homozygous or compound heterozygous mutations in the VWF gene (see, e.g., 613160.0015-613160.0017). Some heterozygous family members had a less severe phenotype, consistent with VWD type 1. Zhang et al. (1993) found that the original family with VWD reported by von Willebrand (1926) carried a common 1-bp deletion in the VWF gene (613160.0021). Eikenboom et al. (1998) reviewed families with recessive VWD type 3 from northern Italy. Several mutations located throughout the gene were identified, indicating diverse molecular defects (see, e.g., C2362F, 613160.0034). | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Genotype/Phenotype Correlations | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Shelton-Inloes et al. (1987) found a correlation between the development of alloantibodies to VWF and the nature of the genetic lesion in VWD. Alloantibodies to VWF have been described only in the severe type 3 disease. Shelton-Inloes et al. (1987) studied 19 patients with severe recessive VWD type 3 by Southern blotting with probes encompassing the full 9 kb of the VWF cDNA. Two presumably unrelated patients with type 3 who had large deletions within the VWF gene were the only ones among those studied who developed inhibitory alloantibodies to VWF. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| See Also: | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Veltkamp and Van Tilburg (1973); Wise et al. (1993) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| REFERENCES | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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