Successful use of recombinant factor VIII devoid of von Willebrand factor during multiple teeth extractions in a patient with type 3 von Willebrand disease

We report a 55-year-old patient with type 3 von Willebrand disease who underwent multiple tooth extractions with successful hemostatic management using recombinant factor VIII. The patient was previously misdiagnosed and treated incorrectly then at 53 years old, he was diagnosed with type 3 von Willebrand disease. As he had avoided dental treatments for two decades due to severe bleeding after dental extraction, multiple severe caries and marginal periodontitis were revealed. The patient refused the use of blood products in hemostatic management because he was afraid of blood-borne diseases and development of anti-von Willebrand factor alloantibodies. After close consultation, we therefore decided to use recombinant factor VIII. Four teeth extraction procedures were executed twice. Before extraction, bolus recombinant factor VIII (50 IU/kg) was administered intravenously followed by continuous infusion (5-10 IU/kg per h) for approximately 48 h. The factor VIII:C level increased from about 1 to 20-32% 30 min after bolus infusion. During continuous infusion (10 IU/kg/h), factor VIII:C was maintained at more than 10%. Little bleeding occurred during and after the multiple teeth extractions and during suture removal. On frequent examinations during a 1-year follow-up, neither von Willebrand factor nor factor VIII inhibitors were detected.

Oral surgery with fibrin sealants in patients with bleeding disorders: a case report

Surgical treatment of patients with bleeding disorders requires careful planning. The use of fibrin sealants following a dental extraction in a patient with von Willebrand's disease is presented in this report. A female patient with von Willebrand's disease had an extraction of a maxillary right third molar. After evaluation by the surgeon and the hematologist, the surgery was performed with a topical application of fibrin sealant and systemic administration of antifibrinolytic drugs. Hemostasis was obtained without replacement of plasma clotting factor. New techniques of achieving hemostasis in patients with bleeding disorders using fibrin sealants have been successfully used in oral surgery without replacement of plasma clotting factors or changes in anticoagulant therapy.

[Monoclonal gammopathies]

Monoclonal gammopathies can induce clinical or biological symptoms, independent of any associated hemopathy. Cryoglobulins types I and II are responsible for cutaneous lesions, peripheral neuropathy, and membranoproliferative glomerulopathy. Peripheral neuropathies associated with monoclonal gammopathy are chronic, distal, symmetrical and progressive, in two thirds of the cases the monoclonal component reacts with a neuronal antigen principally myelin associated glycoprotein. POEMS syndrome is characterized by: polyneuropathy, organomegaly, endocrine disorder, monoclonal component, and skin diseases. Deposits of light chains of immunoglobulins are responsible for a glomerulopathy, and sometimes affect other organs (skin, heart). Other manifestations are described: angioneurotic oedema, acquired Willebrand disease, systemic capillary leak syndrome, Fanconi syndrome. Treatment of the gammopathy can control associated affections.

A cognitive therapy conceptualization of panic disorder exacerbated by interferon treatment

This case conference presents a patient with von Willebrand disease, receiving year-long interferon treatment for hepatitis C. She was referred to C-L Psychiatry following a severe exacerbation of panic disorder. Our guest interviewer is Dr. Craig White, a Scottish cognitive therapist. The subsequent discussion outlines the treatment challenges of panic disorder that occurs when a patient is receiving interferon. A literature review evaluates psychological effects of interferon and biological mechanisms by which interferon may exacerbate anxiety and depression. A cognitive therapy conceptualization of interferon-induced exacerbation of panic disorder is proposed.

[Obstetric analgesia and anesthesia with remifentanyl in a patient with von Willebrand disease]

A 30-year-old woman with von Willebrand's disease was admitted in labor. As epidural analgesia was ruled out due to risk of spinal hematoma, a pump for patient-controlled analgesia (PCA) was provided with boluses of remifentanil and set for intravenous infusion of 24 micrograms with a lockout time of 5 minutes. The patient reported analgesia to be satisfactory. Later, because of abnormal fetal positioning, an emergency cesarean was performed with the patient under general anesthesia with remifentanil, with propofol and succinylcholine for induction. A healthy girl was born free of respiratory depression. Von Willebrand's disease is a hemorrhagic disorder of autosomal dominant inheritance due to a quantitative or functional factor VIII deficit. Various subtypes and degrees of severity of abnormal bleeding have been described. It is the most common genetic hemostatic disorder affecting obstetric procedures, and although epidural analgesia has been used with strict hematologic monitoring, that technique carries a risk of hematoma. PCA is useful in patients for whom regional techniques are contraindicated. With adequate fetal and maternal monitoring, remifentanil in PCA is safe and more effective than other opiates for labor pain.

Platelet functional defects in women with unexplained menorrhagia

Menorrhagia is a common clinical problem and is unexplained in more than 50% of women. Although studies suggest that von Willebrand's Disease (VWD) is found in a substantial number of women with unexplained menorrhagia, the prevalence of platelet defects in women with menorrhagia is unknown. To determine the prevalence of platelet and other hemostatic defects, we evaluated women ages 17-55 diagnosed with unexplained menorrhagia. Seventy-four women (52 white, 16 black, six other) were studied. Bleeding time was prolonged in 23 women (31.5%). Maximal percent platelet aggregation was decreased with one or more agonists in 35 (47.3%) women. The most commonly found platelet function defects were reduced aggregation responses to ristocetin in 22 women and to epinephrine in 16 women. Sixteen of 22 women with reduced ristocetin aggregation had von Willebrand ristocetin cofactor (VWF:RCo) and von Willebrand factor antigen (VWF:Ag) > 60%. Platelet ATP release was decreased with one or more agonists in 43 (58.1%) women. Of the black women studied, 11/16 (69%) had abnormal platelet aggregation studies compared with 20/52 white women (39%) (P = 0.06). Black women with menorrhagia had a higher prevalence of decreased platelet aggregation in response to ristocetin and epinephrine than did white women (P = 0.0075, P = 0.02). Ten women (13.5%) had VWF:RCo and/or VWF:Ag < 60%. Using race and blood group specific ranges, 5 (6.8%) women had decreased VWF:RCo, VWF:Ag and/or collagen binding (VWF:CB). Mild factor XI deficiency was found in two women and one woman with mild factor V deficiency and one hemophilia A carrier were identified. We conclude that the prevalence of platelet function defects and other inherited bleeding disorders is substantial in a multiracial US population of women with unexplained menorrhagia.

A protocol for the dental management of von Willebrand's disease, haemophilia A and haemophilia B

A guide for the dental management of the three inherited bleeding disorders, von Willebrand's disease, haemophilia A and haemophilia B, was established jointly by the Institute of Medical and Veterinary Science Transfusion and Haemostasis Unit in conjunction with the Medically Compromised Dental Unit at the Adelaide Dental Hospital. This protocol was subjected to a successful trial for 24 months.

von Willebrand disease and pregnancy

von Willebrand Disease (vWD) affects approximately 1% of Americans and as many as 25% of women referred for evaluation of menorrhagia. We briefly review the history of vWD, its molecular defects, and diagnostic criteria for each subtype of disease. We also address obstetric management of the patient with vWD. While there is a significant increased risk for postpartum hemorrhage, patients with vWD should not be discouraged to undertake pregnancy.

Successful living related liver transplantation from a donor with von Willebrand's disease

We report a successful living related liver transplantation from a donor with von Willebrand's disease. With proper preparation, a substantial liver resection can be performed safely in such patients, and the transplanted liver will function normally.

Two consecutive pregnancies and deliveries in a patient with von Willebrand's disease type 3

Pregnancy and delivery are critical events in women with von Willebrand's disease type 3. Prophylactic treatment for delivery and early postpartum period is recommended. Vaginal delivery is considered safe. However, experience is based on rare case reports. We report the management of two pregnancies and successful deliveries in a woman with von Willebrand's disease type 3.

Antihaemophilic factor deficiency, capillary defect of von Willebrand type, and idiopathic thrombocytopenia occurring in one family

Thrombocytopenia of the type found in idiopathic thrombocytopenic purpura is described in a family with a deficiency of antihaemophilic factor, and a capillary abnormality. The propositus (father) has thrombocytopenia and abnormal platelet morphology, together with a plasma deficiency of antihaemophilic factor, but normal capillaries. His two daughters each are deficient in antihaemophilic factor with normal platelets but abnormal capillaries.

The rate of blood loss from skin punctures during the Ivy bleeding time test

The rate of blood loss from skin punctures during the performance of the Ivy bleeding time test has been measured by a simple technique in normal individuals, in patients without defects of the haemostatic or coagulation system, and in patients with known haemorrhagic disorders.A wide range was found in normal individuals, but repeated tests on a single individual showed a smaller variation. Nearly half of the tests on patients with von Willebrand's disease, thrombocytopenia, ;capillary type' of bleeding, or haemorrhagic renal failure gave abnormally high rates of blood loss. Haemophilic, Christmas disease, and Dinedevan-treated patients gave low volumes and rates of blood loss.A group of patients has been encountered in whom the bleeding time was normal but the rate of blood loss was increased. The majority of these had haemorrhagic symptoms and other evidence of a defective haemostatic or coagulation system. It is suggested that a consideration of the rate of blood loss in those patients with a normal bleeding time gives additional help in interpreting the Ivy test. A high rate may indicate the need for further investigation of the haemostatic and coagulation system.

A USEFUL PHOTOMETRIC TEST FOR THE DIAGNOSIS OF VON WILLEBRAND'S DISEASE

When small amounts of adenosine diphosphate are added to citrated platelet-rich plasma, the consequent modification of platelets leads to a decrease in optical density. In Von Willebrand's disease the optical density at 610 mmu increases instead of decreasing. This finding is used to study the effects of treatment on this disorder.

ANTIHEMOPHILIC FACTOR LEVELS IN BLEEDER SWINE FOLLOWING INFUSIONS OF PLASMA AND SERUM

Swine with a hemophilia-like disease characterized by a long bleeding time and low antihemophilic factor (AHF, factor VIII) level were infused with porcine plasma and porcine serum. Unlike the response of classical hemophiliacs, but similar to that of patients with von Willebrand's disease, the initial postinfusion levels of AHF were sustained with some fluctuation for 24 hr. Serum infusion resulted in a delayed increase in AHF which reached a maximum concentration between the 12th and 24th hr after infusion. Within 75 hr the effects of both the plasma and serum infusions had vanished. No correction of the prolonged bleeding times was observed following the infusions. The AHF levels encountered after the infusion of plasma and serum cannot be accounted for by the AHF activity contained in the infused materials; new AHF synthesis or AHF release from storage are suggested as possible mechanisms.