Jaundice and antibodies directed against factors 8 and 9 in patients treated for haemophilia or Christmas disease in the United Kingdom

Retinal surgery complicated by a spontaneously acquired factor VIII inhibitor

We studied a factor VIII inhibitor spontaneously occurring in an otherwise healthy patient who underwent retinal reattachment. The clotting defect first manifested itself as a delayed hemorrhagic choroidal detachment. His bleeding diathesis was successfully managed by infusion of factor VIII concentrate, prednisone, and cyclophosphamide. Surgical procedures in patients with severe bleeding disorders present a difficult therapeutic problem which can be effectively managed by the close cooperation of the surgeon, hematologist, coagulation laboratory, and blood bank.

Commercial factor VIII associated hepatitis, 1974-75, in the United Kingdom: a retrospective survey

A retrospective survey of transfusion hepatitis associated with a brand of commercial Factor VIII was carried out in 24 Haemophilia Centres from January 1974 until December 1975. Of 371 patients who were transfused with this product, and were followed up, 78 cases of hepatitis affecting 66 patients were found (17.7%). Two types of hepatitis were observed: hepatitis B and non-B hepatitis, the latter with an incubation period of between 8 and 60 days. Twelve patients contracted two types of hepatitis, non-B followed by hepatitis B. Only one patient died after contracting hepatitis B. Four of the suspect batches of concentrate were found to be positive for HBsAg by radioimmunoassay. There was evidence that the presence of hepatitis B surface antibody in a patient's serum prior to exposure was associated with immunity to hepatitis B. Evidence was presented suggesting that the non-B hepatitis observed was not due to hepatitis A. The factors affecting the incidence of transfusion hepatitis in haemophiliacs were discussed.

Antibody to hepatitis B surface antigen in haemophiliacs on long-term therapy with Scottish factor VIII

Thirty-five patients with haemophilia A were studied clinically and serologically between 1971-2 and 1975-6 for evidence of hepatitis B infection. One patient suffered from clinical hepatitis B, and a further eight patients showed antibody responses to hepatitis B surface antigen (HBsAg) consistent with exposure to HBsAg during this period. No evidence for HBsAg exposure was found in 14 patients, while the remaining 12 patients had high titres of antibody to HBsAg at both times and no inferences could be drawn about HBsAg exposure. All patients had received exclusively replacement factor VIII material prepared locally from HBsAg-screened voluntary Scottish blood donations. From the details of the therapy given we calculated that the rate of HBsAg seroconversion in these patients represented about 0.3 HBsAg-containing donations/1000 donations.

Immune complexes and abnormal liver function in haemophilia

Abnormal 125I-Clq-binding activity was found in the sera of 94% of 55 haemophiliacs. Sera from 66% of these patients inhibited macrophage uptake of labelled aggregated human IgG in a competitive radiobioassay. These results suggest that large molecular weight immune complexes are present in these sera. Analysis of the precipitates obtained directly from the sera by addition of 4% polyethylene glycol showed either a mixture of IgG and IgM or IgM alone. There was poor correlation between the radiobioassay results and the Clq-binding activities in the whole group of 55 patients, suggesting a heterogeneous population of complexes. Nevertheless, a significant correlation was found between Clq-binding activities and the radiobioassay results in seven patients with antibodies to factor VIII, suggesting a homogeneous population of complexes. There was poor correlation between the level of immune complexes and the amount of replacement therapy the patient had received in the previous six months. Abnormal liver function tests were found in 55% of the patients studied but there was poor correlation between these abnormal levels and the Clq binding activities and radiobioassay results. Only two patients had clinical evidence of liver disease.

Haemophilia treatment in the United Kingdom from 1969 to 1974

A study has been made by the Haemophilia Centre Directors of the United Kingdom and Northern Ireland. From 1969 to 1974 2600 patients with haemophilia A and 388 with haemophilia B attended Haemophilia Centres for treatment. Of these patients, 71 are known to have died in the survey period. A record is presented of the amounts and types of therapeutic materials used each year during this time. The incidenceof jaundice and anti-factor VIII and anti-factor IX antibodies was recorded.

Hepatitis-B: a review

The recent literature on various aspects of hepatitis-B is reviewed with emphasis on the interrelationships of viral structure, antigenic components, and host immune response in acute, chronic, and asymptomatic carrier states of the infection. The mode of replication and mechanisms of transmission are discussed. Special attention is paid to potential non-parenteral routes of spread. The role of hepatitis-B in associated immune complex diseases and in hepatoma is outlined. A guide to the interpretation of serologic tests for hepatitis-B associated antigen and antibody patterns is presented in relation to the clinical stage and prognosis of the infection. Therapy, except in conceptual terms, is not covered but a summary of the current status of active and passive immunization is given. The unresolved question of the infectivity of carrier medical staff for their patient contacts, and the reverse, is discussed.

The prevalence of hepatitis-B antigen (HB S Ag) and its antibody (Anti-HB S) among London hemophiliacs and blood donors from London and two tropical areas

The prevalence of hepatitis-B antigen (HB s AG) and its antibody (anti-HBs) among 49 London hemophiliacs was compared with that among women attending an antenatal clinic and healthy blood donors from London and from two parts of the tropics (Mauritius and Zambia). The prevalence of HBsAG and anti-HBs was low in antenatal patients, London blood donors and blood donors from Mauritius. However, a high proportion of hemophiliacs (59%) were anti-HBs positive, this being comparable with Zambian blood donors (53%), although anti-HBs titers in hemophiliacs were much higher (GMT 1:342) than in Zambian blood donors (GMT 1:36). In contrast, HBsAG was detected in 29 of 250 (12%) Zambian donors but in only 3 of 49 (6%) hemophiliacs. Clinically overt hepatitis occurred in only two hemophiliacs. However, the presence of HBsAG-specific IgM in 7 of 29 (24%) anti-HBs-positive hemophiliacs suggests that a proportion of these patients recently experienced subclinical infection by hepatitis-B virus, Anti-HBs-positive hemophiliacs received a significantly higher number of- cryoprecipitate units than did those without anti-HBs(P less than 0.01). Five of seven hemophiliacs with high titers of anti-HBs (greater than 1:4,096) showed a decline in titer after 1972 which may have been associated with the introduction of screening of cryoprecipitate for HBsAG.

Carcinoma of the ampulla of Vater in a haemophiliac patient

A 42-year-old haemophiliac who presented with a cholestatic jaundice and repeated gastro-intestinal haemorrhage is described. The bleeding was initially thought to be due to the severity of the haemophilia itself rather than from any local cause and the jaundice thought to be due to a serum hepatitis. The correct diagnosis of ampullary carcinoma was eventually made after numerous barium studies, fibre-optic endoscopy and two laparotomies. A carcinoma was discovered at a second endoscopy some 12 months after initial presentation. Attention is brought to the rare association of ampullary carcinoma and haemophilia, and to the difficulties involved in diagnosis.

Evaluation of prophylactic replacement therapy in haemophilia B

Prophylaxis replacement therapy has been assessed for a period of 12 months in 10 patients with severe haemophilia B showing a high incidence of spontaneous bleeding episodes. Two different schedules of administration of a freeze-dried factor IX concentrate were randomly evaluated: according to scheme A, 7.5 U/kg were administrated biweekly, whereas scheme B was based on the weekly infusion of 15 U/kg. On prophylaxis the frequency of bleeding episodes was significantly reduced (P less than 0.005) when compared with that observed in one-year period preceding the trial. Biweekly infusions were superior to weekly infusion (P less than 0.01), and the benefit appeared to be related to the higher number of days in which measurable levels of factor IX were attained in plasma. Range of motion, which was redeced at the start of the trial in 26 joints, was found to have improved in 23. Favourable changes of the joint radiological picture were observed in 6 cases. Hepatitis and factor IX inhibitors did not develop during the trial period. Side effects were rare and mild.

An outbreak of hepatitis associated with intravenous injection of factor-VIII concentrate

An outbreak of jaundice associated with three out of four batches of a commercial brand of freeze-dried factor-VIII concentrate occurred at the Bournemouth haemophilia centre between April and June, 1974. Seven cases of non-B hepatitis and four of hepatitis B occurred within 6 months of the first use of this product. Two patients contracted both types of hepatitis; thus nine patients became ill out of a total of twenty regularly seen at the centre, eighteen of whom received commercial factor-VIII concentrate.

Asymptomatic liver disease in haemophiliacs

The incidence of jaundice and of abnormal liver function tests has been assessed in 91 multitransfused patients with severe haemophilia A and B. Tests of hepatocyte function were within the normal range in the majority of patients. On the contrary, tests of biliary cell function, liver cell damage, and bromsulphthalein retention gave high rates of abnormal values, which tended to increase with age. Hepatitis B surface antigen was present in 8% and the corresponding antibody in 66% of the cases; 18% had a history of jaundice. All patients were asymptomatic and only a minority showed clinical signs of liver involvement. These data suggest that in haemophilacs repeated and prolonged contact with the agent(s) responsible for post-transfusion hepatitis may cause chronic liver damage not associated with overt illness.