Heparinised clotting factor concentrates in patients with Christmas disease and liver disease

Evidence has been sought of activation of the coagulation system in two groups of patients following the infusion of two heparinised clotting factor concentrates. No changes were detected in 13 patients with mild hepatic dysfunction. In six studies on patients with Christmas disease induced abnormalities occurred in only one. Activation of the coagulation mechanism did not occur in another individual who had received the same batch of material.

Cerebral involvement with disseminated intravascular coagulation in intestinal disease

Over a two-and-a-half-year period at the Sheffield Royal Infirmary, six patients developed disseminated intravascular coagulation as a serious complication of intestinal disease. There was clinical evidence of cerebral involvement in all six patients, and small vessel thrombi were demonstrated in the brains of all three cases examined post mortem. Where the true significance of the cerebral disorder was not recognised, this led to delay in the diagnosis with serious risk to the patient. In the single case in which the diagnosis was made early, the intravascular coagulation was completely reversed with heparin therapy.

A reassessment of vascular factors in relation to intravascular coagulation

Sural nerve biopsy was performed in twenty-four diabetic patients, with clinical and electrophysiological evidence of diabetic neuropathy. Material from an autopsy case was also examined. Vessels plugged with fibrin were seen within nerve in nine cases. In three cases fibrin was observed tracking into the vessel wall and in four, older thrombus was observed in vessels. Areas of necrosis in nerve bundles were seen in two of the latter. In two patients there had been a preceding episode of intravascular coagulation. Fibrin deposition within small vessels could well play a part in damaging the diabetic nerve and a disturbance of the balance between deposition and removal by fibrinolysis could explain phasic variation in the symptoms of neuropathy.

Platelet abnormalities in diabetic peripheral neuropathy

Abnormal platelet function has been demonstrated in 20 patients with diabetic peripheral neuropathy. The results are compared to those obtained from 19 matched diabetic patients with no clinical evidence of complications and 20 matched normal control subjects. Platelets from patients with diabetic neuropathy showed an increased sensitivity to the aggregating agents adenosine diphosphate and adrenaline. Spontaneous platelet aggregation was demonstrated in both groups of diabetic patients.

Serial changes in the coagulation system following clotting factor concentrate infusion

Various parameters of the coagulation system have been monitored in patients with Christmas disease following the infusion of clotting factor concentrates. Significant reduction of clotting factor VIII and serum antithrombin III were observed in each of the five studies, whilst the plasma fibrinogen level fell in four subjects. The induced abnormalities were shortlived and there were no clinical sequelae. Further studies are required to assess the effects of similar concentrates in patients with liver disease.

Essential thrombocythaemia and peripheral gangrene

Six patients are described in whom gangrene of one or more toes occurred as the presenting feature of essential thrombocythaemia. Spontaneous platelet aggregation was observed in platelet-rich plasma from four patients and platelet aggregation after the addition of adenosine diphosphate and collagen was highly abnormal in samples from all six. All of the patients described dramatic relief of pain within six hours of ingestion of aspirin and this coincided with disappearance of the spontaneous platelet aggregation and collagen-induced platelet aggregation. Treatment with phosphorus-32 corrected the platelet count and there were no further recurrences of peripheral vascular disease. Platelet function tests performed at the time all gave normal results. It is concluded that essential thrombocythaemia is an important and treatable cause of peripheral vascular disease.

The kidney and intravascular coagulation in myelomatosis

In 15 out of 35 patients with myelomatosis histological examination showed intravascular fibrin within the glomeruli, and this was associated with proliferation of the mesangial complex in 12. The presence of intravascular fibrin and mesangial proliferation was not associated with any specific immunoglobulin abnormality or with the presence or absence of Bence Jones proteinuria. In addition to fibrin being present within glomerular capillaries it was also shown in intertubular capillaries in three cases of myelomatosis with acute tubular necrosis. It is suggested that intraglomerular coagulation and fibrin deposition may contribute to the genesis of renal failure in myelomatosis.

Disseminated intravascular coagulation as a consequence of cerebral damage

Three cases with intracranial lesions developed evidence of disseminated intravascular coagulation which was confirmed at necropsy. The factors engendering this state, including release of potent thromboplastin from neural tissue are discussed and the danger of this intermediary mechanism of disease increasing the mortality of intracranial disease is demonstrated. Careful haematological investigation of all patients with intracranial disease is therefore advised, especially if they manifest evidence of a bleeding tendency.

Postpartum purpura fulminans: successful management with streptokinase

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Disseminated intravascular coagulation with thymoma-associated Cushing's syndrome

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Intravascular coagulation and E. coli septicaemia

Eight patients with E. coli septicaemia had oliguric renal failure which was associated with haematological evidence of intravascular coagulation. Five of these patients also had the characteristic blood picture of microangiopathic haemolytic anaemia. In an attempt to prevent further deposition of fibrin, intravenous heparin was administered to six patients, three of whom recovered fully and three died. The diagnosis of intravascular coagulation was subsequently confirmed by histological examination of necropsy material and it is suggested that some of the complications of E. coli septicaemia may be attributable to disseminated intravascular coagulation.

Acute renal failure in myelomatosis from intravascular coagulation

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