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Athiraman H, Maheshwari M, Polowy C. Bleeding Mystery Unveiled: A Case of Acquired Hemophilia A in the Shadow of Multiple Myeloma. Cureus 2024; 16:e65330. [PMID: 39055971 PMCID: PMC11270631 DOI: 10.7759/cureus.65330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2024] [Indexed: 07/28/2024] Open
Abstract
This case report is of a 50-year-old woman who had a working diagnosis of von Willebrand disease (vWD) due to a history of bleeding complications and continued to experience recurrent bleeding incidents and hematoma. A workup revealed multiple lytic lesions, and a bone marrow biopsy yielded the diagnosis of multiple myeloma. After stem cell transplantation, the patient's factor VIII levels normalized, supporting acquired factor VIII deficiency due to an autoimmune phenomenon. This case highlights the rare occurrence of acquired factor VIII deficiency secondary to multiple myeloma. It also emphasizes the importance of considering secondary causes in patients with a working diagnosis of vWD and recurrent bleeding incidents.
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Affiliation(s)
| | | | - Clayton Polowy
- Hematology and Medical Oncology, Banner Health, Phoenix, USA
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2
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Gray A, Hall AM, Hofmann H, Vick S. Behind the eightball. J Hosp Med 2024; 19:413-416. [PMID: 38558530 DOI: 10.1002/jhm.13346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/15/2024] [Accepted: 03/17/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Adam Gray
- Department of Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Alan M Hall
- Depeartments of Medicine and Pediatrics, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Heather Hofmann
- Department of Medicine, Loma Linda University Health, Loma Linda, California, USA
| | - Sarah Vick
- Department of Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
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3
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Hassan WU, Ahmad M, Abdelazeem B, Koduru U, Kunadi A. Acquired Factor VIII Deficiency in Chronic Myeloid Leukemia: A Case Report. Cureus 2023; 15:e48802. [PMID: 38098897 PMCID: PMC10721210 DOI: 10.7759/cureus.48802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2023] [Indexed: 12/17/2023] Open
Abstract
Factor VIII deficiency is mostly seen in hemophilia A, an X-linked recessive disorder. Patients would have a past medical history of bleeding diathesis or a family history of bleeding disorder. Acquired deficiencies of factor VIII are rare; some cases have been reported in solid malignancies. We present this case of acquired factor VIII deficiency in chronic myeloid leukemia (CML). A 72-year-old man was incidentally found to have leukocytosis at 31,000 and a platelet count of 3.2 million on a routine complete blood count (CBC). Prothrombin time (PT), international normalized ratio (INR), and partial thromboplastin time (PTT) showed an isolated elevation of PTT at 38.1 and a low factor VIII activity level at 39. The patient did not have any history or physical examination suggestive of bleeding diathesis. A bone marrow biopsy confirmed the BCR/ABL mutation, a diagnosis of CML was made, and the patient was started on dasatinib for one month. His PTT normalized after treatment for CML, suggesting a deficiency of factor VIII likely related to CML. The aim of this study is to highlight a case with acquired factor VIII deficiency due to CML and to emphasize the importance of coagulation workup in all newly diagnosed CML patients.
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Affiliation(s)
| | | | | | - Ujwala Koduru
- Internal Medicine, Mclaren Flint Hospital, Flint, USA
| | - Arvind Kunadi
- Internal Medicine, Mclaren Flint Hospital, Flint, USA
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4
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de Bear O, McLean K, Siedel J, Rolston A. Acquired factor VIII inhibitor caused by solid tumor malignancy. Gynecol Oncol Rep 2023; 48:101217. [PMID: 37576357 PMCID: PMC10422097 DOI: 10.1016/j.gore.2023.101217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/23/2023] [Accepted: 05/30/2023] [Indexed: 08/15/2023] Open
Abstract
•Factor VIII inhibitor can be acquired in gynecologic and other malignancies.•The disorder can develop along any timeline of malignancy diagnosis.•Common presentation is uncontrolled bleeding not managed by common interventions.•Treatment requires hemostatic control and an immunosuppressive regimen.
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Affiliation(s)
- Olivia de Bear
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, United States
| | - Karen McLean
- Department of Gynecologic Oncology and Department of Pharmacology & Therapeutics, Roswell Park Comprehensive Cancer Center, Elm & Carlton Streets, Buffalo, NY 14263, United States
| | - Jean Siedel
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, United States
| | - Aimee Rolston
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, United States
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5
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Arslan Davulcu E, Demirci Z, Yılmaz U, Ar MC, Teke HÜ, Karakuş V, Çiftçiler R, Selim C, Yavaşoğlu İ, Durusoy SS, Okan V, Akdeniz A, Yolcu A, Aydoğdu İ, Güney T, Yılmaz AF, Şahin F. Acquired Hemophilia A In Adults: A Multicenter Study from Turkey. Indian J Hematol Blood Transfus 2023; 39:107-115. [PMID: 36699428 PMCID: PMC9868199 DOI: 10.1007/s12288-022-01556-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 07/04/2022] [Indexed: 01/28/2023] Open
Abstract
Acquired hemophilia A (AHA) is a rare disease caused by autoantibodies inhibiting factor VIII (FVIII) activity. Although the conditionis usually idiopathic, there may be other underlying diseases. Treatment consists of two steps: treatment of acute bleeding and immunosuppression. In this multicenter study, we aimed to demonstrate the clinical characteristics, management details, and survival of AHA patients in Turkey. Data was collected from eleven centers in Turkey. aPTT, FVIII, FVIII inhibitor, and hemoglobin (HB) levels, mixing test results, and demographics at diagnosis, treatment information, adverse events, bleeding episodes during follow-up, relapses, and outcome were analyzed. Twenty-nine patients were analyzed (58.6% female). No underlying disorder could be detected in 14 patients. The most prevalent etiologies were pregnancy, malignancy and infections. The median FVIII activity and FVIII inhibitor titer at diagnosis were 0.7% (0.0-29.4%) and 32.6 BU (0.6-135.6 BU) respectively. Bleeding was severe in 44.8% of patients. The HB value was significantly lower in patients with severe bleeding. Most of the patients (n = 25, 86.2%) had only one bleeding episode without relapse, three patients (10.3%) had two bleeding episodes, and one patient had more than three bleedings. 21 (75%) patients received hemostatic therapy. The use of recombinant FVIIa was slightly higher than activated prothrombin complex concentrate (15 versus 10 patients). Immunosuppressive treatment was initiated in 26 (93%) patients. Regimens containing steroid, cyclophosphamide, and rituximab in different combinations were the most preferred. The median follow-up period was 13 months (2-156 months). Median overall survival was 154.97 months. Four and six-year survival were 90.9 ± 0.8% and 77.9 ± 14.1% respectively. This is a unique study that investigated the demographic characteristics, treatment approaches, and patient survival of AHA in Turkey.
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Affiliation(s)
- Eren Arslan Davulcu
- University of Health Sciences Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Hematology Clinic, Istanbul, Turkey
| | - Zühal Demirci
- Hematology Department, Ege Adult Haemophilia and Thrombosis Center, Ege University Medical Faculty, İzmir, Turkey
| | - Umut Yılmaz
- Division of Hematology, Department of Internal Medicine, Istanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Istanbul, Turkey
| | - Muhlis Cem Ar
- Division of Hematology, Department of Internal Medicine, Istanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Istanbul, Turkey
| | - Hava Üsküdar Teke
- Internal Medicine, Hematology Department, Eskişehir Osmangazi University Medical Faculty, Istanbul, Turkey
| | - Volkan Karakuş
- Hematology Clinic, University of Health Sciences Antalya Training and Research Hospital, Istanbul, Turkey
| | - Rafiye Çiftçiler
- Hematology Clinic, Aksaray University Training and Research Hospital, Aksaray, Turkey
| | - Cem Selim
- Internal Medicine Hematology Department, Aydın Adnan Menderes University Medical Faculty, Istanbul, Turkey
| | - İrfan Yavaşoğlu
- Internal Medicine Hematology Department, Aydın Adnan Menderes University Medical Faculty, Istanbul, Turkey
| | | | - Vahap Okan
- Department of Hematology, Gaziantep University School of Medicine, Gaziantep, Turkey
| | - Aydan Akdeniz
- Medical Faculty Hematology Department, Mersin University, Mersin, Turkey
| | - Alkım Yolcu
- Department of Internal Medicine, Faculty of Medicine, Manisa Celal Bayar University, Manisa, Turkey
| | - İsmet Aydoğdu
- Hematology Department, Faculty of Medicine, Manisa Celal Bayar University, Mersin, Turkey
| | - Tekin Güney
- Department of Hematology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Asu Fergün Yılmaz
- Hematology Depertmet, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Fahri Şahin
- Hematology Department, Ege Adult Haemophilia and Thrombosis Center, Ege University Medical Faculty, İzmir, Turkey
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6
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Mingot-Castellano ME, Rodríguez-Martorell FJ, Nuñez-Vázquez RJ, Marco P. Acquired Haemophilia A: A Review of What We Know. J Blood Med 2022; 13:691-710. [PMID: 36447782 PMCID: PMC9701517 DOI: 10.2147/jbm.s342077] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 11/10/2022] [Indexed: 08/31/2023] Open
Abstract
Autoantibodies against plasma coagulation factors could be developed by some individuals inducing severe and sometimes fatal bleedings. This clinical entity is called acquired haemophilia. It should be suspected in subjects with acute abnormal bleedings, without personal or familiar history of congenital bleeding disorders with an unexplained prolonged aPTT. It is rare disease, although its incidence may be underestimated due to the low knowledge about it by many specialists, the frequent use of anticoagulant or antiplatelet therapies in the affected population that can mask the diagnosis and, sometimes, a so withering effect that avoid its confirmation. Mortality ranges between 9% and 33% depending on the series in the first 2 months after diagnosis. This mortality is attributed in up to 40% of the cases to infections in the context of immunosuppressive treatments used to eliminate the inhibitor. Factor VIII levels below 1% and high inhibitor titers are conditions of worse response rates. Advanced age, patient's ECOG, and underlying conditions are key prognostic factors for response to treatment and patient survival. To reduce morbidity and mortality in these patients, it is important to have clinical knowledge and access to guidelines to achieve an early diagnosis and to optimize the haemostatic and immunosuppressive treatment. This review aims to contribute to the dissemination of basic concepts on the epidemiology etiopathogenesis, diagnosis, treatment and management of these patients, as well as risk factors to get remission and the longest overall survival to allow individualized care. Especial awareness will be proposed in patients with some underlying conditions like cancer, autoimmune diseases, children, pregnancy or drugs.
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Affiliation(s)
- María Eva Mingot-Castellano
- Hematology Department, Hospital Universitario Virgen del Rocío. Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| | | | - Ramiro José Nuñez-Vázquez
- Hematology Department, Hospital Universitario Virgen del Rocío. Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| | - Pascual Marco
- General Medicine Department, Universidad Miguel Hernández, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
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7
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Gidaro A, Palmieri G, Donadoni M, Mameli LA, La Cava L, Sanna G, Castro D, Delitala AP, Manetti R, Castelli R. A Diagnostic of Acquired Hemophilia Following PD1/PDL1 Inhibitors in Advanced Melanoma: The Experience of Two Patients and a Literature Review. Diagnostics (Basel) 2022; 12:diagnostics12102559. [PMID: 36292248 PMCID: PMC9600358 DOI: 10.3390/diagnostics12102559] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/11/2022] [Accepted: 10/19/2022] [Indexed: 11/16/2022] Open
Abstract
Acquired hemophilia A (AHA) is a rare bleeding disorder caused by the development of specific autoantibodies against factor VIII (FVIII). Immunotherapy is a recent therapeutic option that targets the patient's self-tolerance against tumor cells. Because therapeutic effects of the immune checkpoint inhibitors (ICIs) are mediated by enhancing the immune response to restore antitumor immunity, autoimmune-related adverse effects can be seen in up to 80% of patients during treatment and after treatment. A rare hematologic ICIs-related adverse event is AHA. Hereafter we report two cases of AHA developed during anti-PD-1 immunotherapy for advanced melanoma: one secondary to treatment with nivolumab and one secondary to pembrolizumab. Both patients were treated with activated FVII (Novoseven®, Novo Nordisk, Bagsværd, Denmark) as hemostatic treatment combined with the eradication of antibodies anti-FVIII obtained with rituximab. In the last few years these drugs have significantly improved the therapeutic armamentarium for the management of AHA. Indeed, while FVIIa has proven to be an effective and safe tool for the treatment of acute bleeding related to FVIII autoantibodies, rituximab is a promising alternative for the autoantibodies' elimination and the restoration of normal hemostasis. Our finding supports the use of this combination even in AHA secondary to ICIs treatment.
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Affiliation(s)
- Antonio Gidaro
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi N° 74, 20157 Milan, Italy
- Correspondence: (A.G.); (R.C.); Tel.: +39-0239042391 (A.G.); +39-079-228446 (R.C.)
| | - Giuseppe Palmieri
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale san Pietro N° 8, 07100 Sassari, Italy
| | - Mattia Donadoni
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi N° 74, 20157 Milan, Italy
| | - Lucia A. Mameli
- Departmental Simple Operative Unit Coagulation, Hemostasis Diseases Hospital S Maria Annunziata, Via Enrico De Nicola N° 14, 07100 Sassari, Italy
| | - Leyla La Cava
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi N° 74, 20157 Milan, Italy
| | - Giuseppe Sanna
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale san Pietro N° 8, 07100 Sassari, Italy
| | - Dante Castro
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale san Pietro N° 8, 07100 Sassari, Italy
| | - Alessandro P. Delitala
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale san Pietro N° 8, 07100 Sassari, Italy
| | - Roberto Manetti
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale san Pietro N° 8, 07100 Sassari, Italy
| | - Roberto Castelli
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale san Pietro N° 8, 07100 Sassari, Italy
- Correspondence: (A.G.); (R.C.); Tel.: +39-0239042391 (A.G.); +39-079-228446 (R.C.)
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8
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K P A, Thakur S, Hanagvadi S, Siva Bharani KSN. "Haemophilia A" - Presenting with oral squamous cell carcinoma diagnosis and management strategies. Oral Oncol 2022; 132:105994. [PMID: 35785746 DOI: 10.1016/j.oraloncology.2022.105994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/16/2022] [Accepted: 06/21/2022] [Indexed: 11/26/2022]
Abstract
Hemophilia is a hereditary disorder of coagulation that results in deficiency of factor VIII (Hemophilia A) or Factor IX (Hemophilia B) with characteristic X linked mode of inheritance, almost exclusively seen in males while females are asymptomatic carriers.The common clinical manifestation in both is prolonged bleeding on trivial trauma, mainly into larger joints or muscles. Life threatening bleeding episodes can result spontaneously or from trauma to the head or internal organs. Replacement of deficient clotting protein, known as Anti Hemophilic Factor (AHF) is the main stay in the treatment of haemophilia. Any Surgical treatment of these patients is to be planned in Institution hospital where comprehensive care is available. The availability of AHF has enabled surgeons to take up surgeries in patients with haemophilia. We discuss PWH with congenital factor VIII deficiency presented with oral squamous cell carcinoma of left side lower jaw with main aim is to provide insight into surgical management and care protocol of these patients.
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Affiliation(s)
- Amith K P
- HCG Cancer Hospital, Banglore, India.
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9
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Daigh LH, Chien MC, Lo CY. Pediatric acquired factor VIII deficiency presenting as hemarthrosis. Pediatr Blood Cancer 2022; 69:e29530. [PMID: 34913591 DOI: 10.1002/pbc.29530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/01/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Leighton H Daigh
- Stanford University School of Medicine, Stanford University, Palo Alto, California, USA
| | - May C Chien
- Department of Pediatrics, Stanford University, Palo Alto, California, USA.,Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Clara Y Lo
- Department of Pediatrics, Stanford University, Palo Alto, California, USA.,Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, California, USA
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10
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Belfeki N, Hamrouni S, Strazzulla A, Diamantis S. Coexistence of Acquired Hemophilia and Antiphospholipid Serology in Monoclonal Gammopathy Patient. Int Med Case Rep J 2021; 14:261-264. [PMID: 33953615 PMCID: PMC8091459 DOI: 10.2147/imcrj.s293931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 03/06/2021] [Indexed: 11/23/2022] Open
Abstract
Acquired hemophilia is a rare coagulopathy with hemorrhage into the skin, muscle, or soft tissues and mucous membranes and caused by inhibitor antibodies, mainly against FVIII. We report a case of acquired hemophilia presenting with diffuse cutaneous hemorrhage and hemothorax. The patient was found to have acquired an FVIII inhibitor and a high titer of anti β2 glycoprotein 1 IgG and IgM, and anticardiolipin IgM in the context of IgA kappa-type monoclonal gammopathy. He received 3 injections of recombinant factor VII (rFVIIa) and blood transfusion. He was started on steroids and oral cyclophosphamide for 6 weeks. Thromboprophylaxis with aspirin at 100 mg/day was started 3 months after discharge. Antiphospholipid antibodies remained positive after 3 months as well as prolonged aPTT, factor VIII raised at 100%, and the inhibitor was not detected. The association between acquired hemophilia and antiphospholipid antibodies is rare and its distinction is mandatory because clinical presentation ranges from massive hemorrhage to thrombosis.
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Affiliation(s)
- Nabil Belfeki
- Department of Internal Medicine, Groupe Hospitalier Sud-Ile de France, Melun, 77000, France
| | - Sarra Hamrouni
- Department of Internal Medicine, Groupe Hospitalier Sud-Ile de France, Melun, 77000, France
| | - Alessio Strazzulla
- Department of Internal Medicine, Groupe Hospitalier Sud-Ile de France, Melun, 77000, France
| | - Sylvain Diamantis
- Department of Internal Medicine, Groupe Hospitalier Sud-Ile de France, Melun, 77000, France
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11
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Esteves Pereira M, Bocksrucker C, Kremer Hovinga JA, Mueller M, Daskalakis M, Mansouri Taleghani B, Nagler M. Immunoadsorption for the Treatment of Acquired Hemophilia: New Observational Data, Systematic Review, and Meta-Analysis. Transfus Med Rev 2021; 35:125-134. [PMID: 33518429 DOI: 10.1016/j.tmrv.2021.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 01/04/2021] [Accepted: 01/04/2021] [Indexed: 12/25/2022]
Abstract
The treatment of patients with acquired hemophilia is challenging due to life-threatening hemorrhages, delayed response, and adverse effects to immunosuppressive agents. Even though immunoadsorption (IA) rapidly removes autoantibodies against factor VIII, this intervention's effectiveness is still a matter of debate. We aimed to study important outcomes of IA as adjunctive treatment in patients with acquired hemophilia. We performed comprehensive literature searches in MEDLINE and EMBASE databases. Clinical and laboratory data of all patients treated in our institution were additionally included. Literature searching yielded 498 records, of which 10 studies describing 106 patients were finally included. The number of patients varied from 1 to 65, and patients' ages ranged between 14 and 89. Treatment criteria in most patients were (1) failed response to immunosuppressive treatment alone, and/or (2) uncontrollable bleeding episodes, and/or (3) high inhibitor titer. Methodological quality was moderate. The number of IA sessions varied from 1 to 24. Within our institution, 12 patients have been treated since 2002; median age was 76 years (range 34-86); median titer of factor VIII inhibitor was 20 Bethesda units (range 3-214). Pooled estimates, modeling a random-effect binominal distribution incorporating the Freeman-Tukey double arcsine transformation, were 86% in case of factor VIII recovery (95% confidence interval 76%-94%), 95% for reduction of factor VIII inhibitor (83%, 100%), and 7% in case of death (0%, 18%). Our data suggest that IA might be a beneficial adjunctive treatment in patients with high-risk acquired hemophilia, but future studies shall confirm this observation.
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Affiliation(s)
- Michael Esteves Pereira
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Christoph Bocksrucker
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johanna Anna Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland; Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Martin Mueller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Michael Daskalakis
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland; Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Behrouz Mansouri Taleghani
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland; Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Michael Nagler
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland; University Institute of Clinical Chemistry, Inselspital University Hospital, Bern, Switzerland.
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12
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Poscente M, Gan CL, Heng DYC, Alimohamed N. Case - Acquired hemophilia A in a patient with metastatic castration-resistant prostate cancer. Can Urol Assoc J 2021; 15:E519-E521. [PMID: 33591907 DOI: 10.5489/cuaj.7089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Michael Poscente
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Chun Loo Gan
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Daniel Y C Heng
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
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13
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Pauls M, Rydz N, Nixon NA, Ezeife D. Paraneoplastic acquired haemophilia A in extensive-stage small cell lung cancer (ES-SCLC) in the era of immunotherapy. BMJ Case Rep 2021; 14:14/1/e236973. [PMID: 33509862 PMCID: PMC7845684 DOI: 10.1136/bcr-2020-236973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Small cell lung cancer (SCLC) is a deadly and rapidly progressive disease that can present with various paraneoplastic syndromes on initial workup. Acquired factor VIII (FVIII) deficiency, also known as acquired haemophilia A (AHA), has been identified as a rare paraneoplastic syndrome in SCLC. Here, we present a 61-year-old woman with a massive gastrointestinal bleed and prolonged activated partial thromboplastin time (PTT) in the emergency department. She was diagnosed with rare paraneoplastic AHA secondary to extensive-stage SCLC (ES-SCLC). She was treated with high-dose steroids and factor bypassing agents, which led to the resolution of bleeding and undetectable FVIII inhibitor levels. She was subsequently treated for ES-SCLC with carboplatin, etoposide and atezolizumab. This case report highlights a rare clinical presentation of paraneoplastic AHA that necessitates prompt recognition in patients with SCLC with ongoing bleeding and elevated PTT.
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Affiliation(s)
| | - Natalia Rydz
- Division of Hematology and Hematologic Malignancies, University of Calgary, Calgary, Canada
| | | | - Doreen Ezeife
- Medical Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Canada
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14
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Taza F, Suleman N, Paz R, Haas C. Acquired Hemophilia A and urothelial carcinoma. J Community Hosp Intern Med Perspect 2021; 11:89-93. [PMID: 33552425 PMCID: PMC7850392 DOI: 10.1080/20009666.2020.1836726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Acquired Hemophilia A (AHA) is a rare entity, resulting from the production of autoantibodies against Factor VIII of the coagulation cascade. These autoantibodies may develop in response to autoimmune conditions, drugs, neoplastic diseases, and pregnancy. Diagnosis involves clinical presentation, mucocutaneous or intramuscular bleeding, and laboratory findings, such as prolonged activated partial thromboplastin time, decreased levels of Factor VIII, and the presence of Factor VIII autoantibodies. The etiology is diverse, with a variety of underlying culprits. Malignancy-associated AHA has been associated with approximately 15% of cases. Urothelial malignancy-mediated AHA is exceedingly rare, with only two previously published reports. The management of AHA includes stabilization and control of bleeding via the use of hemostatic agents, and elimination of the inhibitor with immunosuppressive therapy. Here, we report a case of AHA secondary to urothelial malignancy and review the pathobiology and pathogenesis of Hemophilia A and AHA.
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Affiliation(s)
- Fadi Taza
- Department of Medicine, MedStar Health Internal Medicine Residency Program, Baltimore, MD, USA
| | - Nawar Suleman
- Department of Medicine, MedStar Health Internal Medicine Residency Program, Baltimore, MD, USA
| | - Robert Paz
- Department of Medicine, MedStar Health Hospitalist Program, Baltimore, MD, USA
| | - Christopher Haas
- Department of Medicine, MedStar Health Internal Medicine Residency Program, Baltimore, MD, USA.,Georgetown University Medical Center, Washington, DC, USA
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15
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Sakai T, Azuma Y, Sano A, Sadamoto S, Tochigi N, Nagase D, Iyoda A. Perioperative Bypassing Agent Therapy for Pulmonary Pleomorphic Carcinoma with Acquired Hemophilia. Ann Thorac Cardiovasc Surg 2021; 28:302-306. [PMID: 33473052 PMCID: PMC9433887 DOI: 10.5761/atcs.cr.20-00257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 74-year-old man was admitted with lung cancer, and preoperative blood test showed abnormal activated partial thromboplastin time (APTT). Coagulation factor screening and APTT mixing test achieved a diagnosis of acquired hemophilia A (AHA). Bypassing agent therapy was indicated and lobectomy was successfully performed without bleeding complications. APTT returned to normal after the operation without any additional treatment for AHA. The pathogenesis of AHA is still unknown and there is no evidence for hemostatic strategy for AHA patients requiring surgery. This study supports the importance of hemostatic therapy and suggests that malignancy might cause AHA.
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Affiliation(s)
- Takashi Sakai
- Division of Chest Surgery, Department of Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Yoko Azuma
- Division of Chest Surgery, Department of Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Atsushi Sano
- Division of Chest Surgery, Department of Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Sota Sadamoto
- Department of Surgical Pathology, Toho University School of Medicine, Tokyo, Japan
| | - Naobumi Tochigi
- Department of Surgical Pathology, Toho University School of Medicine, Tokyo, Japan
| | - Daisuke Nagase
- Division of Hematology and Oncology, Department of Internal Medicine, Toho University School of Medicine, Tokyo, Japan
| | - Akira Iyoda
- Division of Chest Surgery, Department of Surgery, Toho University School of Medicine, Tokyo, Japan
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16
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Acquired haemophilia A and late development of secondary autoimmune disorders, evidences from a single-centre observational study. Blood Coagul Fibrinolysis 2020; 31:495-499. [DOI: 10.1097/mbc.0000000000000956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Acquired Hemophilia A Presenting as Massive Postoperative Bleeding in a Patient with Oral Squamous Cell Carcinoma. Case Rep Otolaryngol 2020; 2020:8961785. [PMID: 32953190 PMCID: PMC7487110 DOI: 10.1155/2020/8961785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 05/17/2020] [Accepted: 08/23/2020] [Indexed: 11/27/2022] Open
Abstract
Acquired hemophilia A (AHA) is an extremely rare and serious bleeding disorder caused by autoantibodies against coagulation factor VIII (FVIII). Approximately, 10% of patients with AHA have an underlying malignancy. We report on a 46-year-old man with AHA and advanced oral cancer who presented with massive bleeding after surgery. Preoperative blood coagulation tests showed no abnormalities. He underwent radical tumor resection followed by reconstruction using a free rectus abdominal musculocutaneous flap. Massive subcutaneous hemorrhage developed in his neck and abdomen on the first postoperative day. The hemorrhage remained uncontrolled, despite embolization of the responsible vessels. Subsequent laboratory data showed prolonged activated partial thromboplastin time and decreased FVIII levels. On the basis of his clinical course and the presence of the FVIII inhibitor, we speculated that the patient suffered from AHA. We administered recombinant activated factor VII and prednisolone, after which the spontaneous bleeding stopped and the subcutaneous hemorrhage resolved. A review of the literature identified only three previous documented cases of AHA associated with head and neck cancer. This case indicates that AHA should not be ruled out in patients with uncontrolled postoperative bleeding, while attempting to ensure bleeding control and preventing potentially catastrophic fatal consequences.
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Acquired Haemophilia A: An Intriguing Disease. Mediterr J Hematol Infect Dis 2020; 12:e2020045. [PMID: 32670523 PMCID: PMC7340240 DOI: 10.4084/mjhid.2020.045] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/18/2020] [Indexed: 12/31/2022] Open
Abstract
Abstract. Acquired Haemophilia A is a rare acquired bleeding disorder caused by Factor VIII autoantibodies, which neutralise FVIII activity. These inhibitors differ from alloantibodies against FVIII, which can occur in congenital Haemophilia A after repeated exposures to plasma-derived or recombinant FVIII products. In most cases, the disease occurs suddenly in subjects without a personal or familiar history of bleedings, with symptoms that may be mild, moderate, or severe. However, only laboratory alterations are present in ~ 30% of patients. The incidence varies from 1 to 4 cases per million/year; more than 80% of patients are elderly, males and females are similarly affected. There is a small peak of incidence related to pregnancy in young women aged 20–40 years. The disease may be underdiagnosed in the elderly. The diagnostic algorithm is based on an isolated prolonged activated partial thromboplastin time, normal thrombin time, absence of Lupus Anticoagulant, and a mixing test that reveals the presence of an inhibitor: the finding of reduced FVIII activity and the detection of neutralising autoantibodies against FVIII lead to the diagnosis. The disease is idiopathic in 44%–63% of cases, while in the others etiological factors are present. Bleeding prevention and treatment are based on therapeutic tools as by-passing agents, recombinant porcine FVIII concentrate or, in a limited number of cases, FVIII concentrates and desmopressin. As soon as the diagnosis has been made, immunosuppressive therapy must be started to eradicate the inhibitor. Better knowledge of the disease, optimal management of bleeding and eradication of the inhibitor have significantly reduced morbidity and mortality in most patients.
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Salaj P, Geierová V, Ivanová E, Loužil J, Pohlreichová V, Hrachovinová I, Dulíček P. Identifying risk factors and optimizing standard of care for patients with acquired haemophilia A: Results from a Czech patient cohort. Haemophilia 2020; 26:643-651. [PMID: 32590889 DOI: 10.1111/hae.14084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/22/2020] [Accepted: 06/01/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Acquired haemophilia A (AHA) is a rare autoimmune disorder, characterized by bleeds of varying severity caused by autoantibodies against factor VIII (FVIII). AIM Identify risk factors associated with AHA-related deaths/relapses and assess the effect of increased corticosteroid doses. METHODS AHA patients treated across two specialist centres in the Czech Republic, generally receiving first-line haemostatic therapy with rFVIIa and immunosuppression with corticosteroids/cyclophosphamide, were included. We analysed the association between early death (within 8 weeks of diagnosis [considered disease-related]) and age, malignancy, FVIII levels and bleeding severity. Risk factors associated with reduced 2-year survival and relapse incidence, and the effect of increased corticosteroid doses on early death and remission were also assessed. RESULTS The demographics of the described cohort (n = 66) were similar to other AHA registries. Early death occurred in 20% of cases. Unlike age and malignancy, FVIII levels <1% and severe bleeding were associated significantly with early death (P = .010 and P = .046, respectively). Patients with underlying malignancy or requiring continued haemostatic therapy exhibited significantly decreased 2-year survival compared with those without these risk factors (P = .007 and P = .006, respectively). Patients with an underlying autoimmune disease relapsed significantly more than those without (P = .015). Higher corticosteroid doses were associated with a significantly increased incidence of early deaths (P < .001), but also with early remission (P < .001). CONCLUSION Based on this rather large patient cohort, we were able to evaluate the significance of several risk factors associated with treatment outcomes in AHA and the effect of initial treatment with corticosteroids on survival and time to remission.
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Affiliation(s)
- Peter Salaj
- Institute of Haematology and Blood Transfusion Prague, Prague, Czech Republic
| | - Vera Geierová
- Institute of Haematology and Blood Transfusion Prague, Prague, Czech Republic
| | - Eva Ivanová
- University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Jan Loužil
- Institute of Haematology and Blood Transfusion Prague, Prague, Czech Republic
| | - Viera Pohlreichová
- Institute of Haematology and Blood Transfusion Prague, Prague, Czech Republic
| | - Ingrid Hrachovinová
- Institute of Haematology and Blood Transfusion Prague, Prague, Czech Republic
| | - Petr Dulíček
- University Hospital Hradec Králové, Hradec Králové, Czech Republic
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20
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Lewis A, Joseph J, Pathak N, Baseri B, Luhrs C. Acquired factor VIII deficiency in prostate adenocarcinoma presenting as multiple hematomas and hemarthrosis. SAGE Open Med Case Rep 2020; 8:2050313X20906743. [PMID: 32110407 PMCID: PMC7026807 DOI: 10.1177/2050313x20906743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 01/14/2020] [Indexed: 12/11/2022] Open
Abstract
Acquired hemophilia A or acquired factor VIII deficiency is a rare bleeding disorder due to the presence of autoantibodies to factor VIII. It has been associated with autoimmune conditions, certain medications, and malignancy. It has a high morbidity and mortality, and early diagnosis and treatment is critically important. Acquired hemophilia A usually manifests with soft tissue bleeding, such as epistaxis, genitourinary, or gastrointestinal bleeding and rarely with hemarthrosis. In this case report, we present the management of an uncommon case of acquired hemophilia A in a patient with metastatic prostate adenocarcinoma who presented with both hemarthrosis and soft tissue bleeding. Bleeding was controlled with recombinant factor VIIa, factor VIII bypassing agent, and immunosuppressive therapy with prednisone and rituximab. Chemotherapy with docetaxel was also promptly initiated to address the underlying condition and achieve long-term remission, which is currently ongoing for 10 months.
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Affiliation(s)
- Akeem Lewis
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Joe Joseph
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Nirmal Pathak
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Babak Baseri
- Department of Hematology and Oncology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Carol Luhrs
- Department of Hematology and Oncology, SUNY Downstate Medical Center, Brooklyn, NY, USA
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21
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Pandya D, Hellerslia V, Gettings E. Acquired factor VIII inhibitor in a patient with multiple sclerosis treated with interferon β-1a. J Neuroimmunol 2020; 340:577146. [PMID: 31945592 DOI: 10.1016/j.jneuroim.2020.577146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 01/12/2023]
Abstract
Acquired Factor VIII inhibitor is a rare acquired clotting disorder which has been seen in the setting of particular medications, autoimmune disease, and malignancy. Reports of this disorder in patients receiving immunomodulatory therapies for multiple sclerosis are rare. We present a case of a 48 year-old woman with likely development of acquired Factor VIII inhibitor in the setting of interferon beta monotherapy for multiple sclerosis, and discuss the pathogenesis of this disorder which involves shifts in helper T cell populations and increased production of immunoglobulins.
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Affiliation(s)
- D Pandya
- Temple University Hospital, Department of Neurology, 3401 North Broad Street, Philadelphia, PA 19140, USA.
| | - V Hellerslia
- Temple University Hospital, Department of Pharmacy Practice, Philadelphia, PA 19140, USA
| | - E Gettings
- Temple University Hospital, Department of Neurology, Philadelphia, PA 19140, USA
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22
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Acquired Hemophilia A (FVIII Deficiency) Associated with Papillary Thyroid Cancer: Treatment with Recombinant Porcine FVIII. Case Rep Hematol 2019; 2019:9026121. [PMID: 31559096 PMCID: PMC6735189 DOI: 10.1155/2019/9026121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 08/08/2019] [Indexed: 12/05/2022] Open
Abstract
Acquired hemophilia A (AHA) is a rare autoimmune disorder caused by autoantibodies against Factor VIII (FVIII). It has a high mortality due to bleeding complications. FVIIa-based bypassing agents are the first line of treatment but not always effective. Recombinant porcine (rp) FVIII (Obizur®) was recently approved for rescue treatment but with little evidence-based information regarding efficacy. We report a case of papillary thyroid cancer associated with AHA malignancy that responded to a single dose of rpFVIII after failure to achieve hemostasis with FVIIa-based bypassing products.
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23
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Cuilleron J, Mas P, Kiakouama L, Gaillot-Durand L, Seve P, Devouassoux G. [Acquired hemophilia A revealing lung cancer]. Rev Mal Respir 2018; 35:727-730. [PMID: 30098880 DOI: 10.1016/j.rmr.2017.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 08/24/2017] [Indexed: 11/17/2022]
Abstract
Acquired hemophilia A (AHA) is a rare disease, defined by the production of anti-factor VIII antibodies causing disordered hemostasis. It is idiopathic in 50% of cases, but sometimes associated with solid tumors. We report a case where AHA led to the diagnosis of lung cancer. CASE REPORT An 82-year-old man with spontaneous hematomas on his trunk and extremities, and isolated prolongation of activated partial thromboplastin time was admitted to the emergency room. A severely reduced factor VIII level and a high factor VIII inhibitor title confirmed the diagnosis of AHA. Thoracic computed tomography scan found a suspect lung nodule and biopsy was consistent with a primary lung adenocarcinoma. The patient received recombinant factor VIII, immunosuppressive therapies, and finally lung stereotactic radiotherapy. Thirty months after diagnosis, the patient is in complete remission both from AHA and from his lung cancer. CONCLUSIONS Acquired hemophilia A is a rare but potentially severe disease, which may be idiopathic or linked to a solid tumor. The severity of AHA depends on both the volume of hemorrhage and the presence of associated diseases.
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Affiliation(s)
- J Cuilleron
- Service de pneumologie, hôpital de la Croix-Rousse, hospices civils de Lyon, 103, Grande rue de la Croix-Rousse, 69004 Lyon, France
| | - P Mas
- Service de pneumologie, hôpital de la Croix-Rousse, hospices civils de Lyon, 103, Grande rue de la Croix-Rousse, 69004 Lyon, France
| | - L Kiakouama
- Service de pneumologie, hôpital de la Croix-Rousse, hospices civils de Lyon, 103, Grande rue de la Croix-Rousse, 69004 Lyon, France
| | - L Gaillot-Durand
- Service d'anatomopathologie, hôpital de la Croix-Rousse, hospices civils de Lyon, 69004 Lyon, France
| | - P Seve
- Service de médecine interne, hôpital de la Croix-Rousse, hospices civils de Lyon, 69004 Lyon, France; Université Claude-Bernard, Lyon 1, 69004 Lyon France
| | - G Devouassoux
- Service de pneumologie, hôpital de la Croix-Rousse, hospices civils de Lyon, 103, Grande rue de la Croix-Rousse, 69004 Lyon, France; Université Charles-Mérieux, 69004 Oullins, France.
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24
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Yıldız A, Şahin O, Yayar O, Öztürk ÇP, Afacan Öztürk HB, Maral S, Okutan H, Albayrak M. The rare coexistence of high titer inhibitor development and gastrointestinal stromal tumor in a patient with severe hemophilia: A case report. Transfus Apher Sci 2018; 57:398-400. [DOI: 10.1016/j.transci.2018.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 04/17/2018] [Accepted: 04/24/2018] [Indexed: 01/20/2023]
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25
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Acquired hemophilia with thrombosis in a cancer patient: an unusual presentation. Blood Coagul Fibrinolysis 2017; 29:129-130. [PMID: 29095762 DOI: 10.1097/mbc.0000000000000670] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
: Acquired hemophilia A (AHA) which presents with spontaneous severe intramuscular, mucosal and/or subcutaneous bleeding is a rare bleeding disorder. Even 50% of AHA patients are defined as idiopathic; 10% of cases are related with malignancy. Here, we present a case of AHA in a 43-year-old lady who was diagnosed with malignancy and venous thromboembolism on vena cava 2 years ago. To the best of our knowledge, this is the first report in literature presented with both acquired hemophilia and thrombosis associated with malignancy. A routine workup for malignancy like solid tumors, lymphoproliferative, or myeloproliferative diseases should be performed and followed up for a long time despite clinical improvement for individuals presented with AHA. Moreover, because of warfarin treatment, the diagnosis may be difficult and delayed. Clinicans should rule out AHA in patients who are on warfarin treatment and have abnormal coagulation tests.
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26
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Napolitano M, Siragusa S, Mancuso S, Kessler CM. Acquired haemophilia in cancer: A systematic and critical literature review. Haemophilia 2017; 24:43-56. [PMID: 28960809 DOI: 10.1111/hae.13355] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2017] [Indexed: 12/12/2022]
Abstract
AIM There is a paucity of data on the clinical presentation and management of cancer patients with acquired haemophilia (AH), we here report a systematic literature review on acquired haemophilia in the context of cancer. METHODS Treatment outcomes of AH were defined as complete response (CR), partial response (PR) or no response (NR), based on inhibitor eradication, coagulation factor VIII levels and bleeding control. Reported deaths were either related to cancer or bleeding. RESULTS Overall, 105 cases were collected and analyzed according to classification of cancer and efficacy of treatments for inhibitor and malignancy. The mean age was 68 years for both males (range 37-86 years) and females (range 43-89 years), 39 patients were female subjects and 66 were males. A solid cancer was diagnosed in 60 subjects, while 45 patients suffered a haematological malignancy. Solid cancers affected mainly males; however, the incidence of solid tumours vs haematological malignancies was not statistically significant (P = .09). Not all patients were treated for their underlying cancer, bleeding and/or inhibitor, in two cases outcome is unavailable. CR was reported in 62.1% (64/103) cases, PR in 9.7% (10/103) cases, NR with or without death was reported in 28.1% (29/103) cases. CONCLUSION CR was best achieved when successful and complete elimination of autoantibodies occurred contemporaneously with the successful treatment of the underlying malignancy. In some cases, recurrent autoantibodies were harbingers of relapsed cancer. Type of cancer, inhibitor titer, treatments administered for bleeding control and inhibitor eradication did not significantly affect clinical outcome of analyzed cases.
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Affiliation(s)
- M Napolitano
- Hematology Unit, Thrombosis and Hemostasis Reference Regional Center, Università degli studi di Palermo, Palermo, Italy
| | - S Siragusa
- Hematology Unit, Thrombosis and Hemostasis Reference Regional Center, Università degli studi di Palermo, Palermo, Italy
| | - S Mancuso
- Hematology Unit, Thrombosis and Hemostasis Reference Regional Center, Università degli studi di Palermo, Palermo, Italy
| | - C M Kessler
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
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27
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Franchini M, Vaglio S, Marano G, Mengoli C, Gentili S, Pupella S, Liumbruno GM. Acquired hemophilia A: a review of recent data and new therapeutic options. ACTA ACUST UNITED AC 2017; 22:514-520. [PMID: 28441921 DOI: 10.1080/10245332.2017.1319115] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Acquired hemophilia A (AHA) is a rare, but potentially life-threatening, bleeding disorder caused by an autoantibody against factor VIII that interferes with its coagulant function. METHODS We performed a narrative review focusing on the diagnostic aspects of AHA and on the current treatment strategies with particular regard to new data and therapeutic developments. RESULTS The management of this severe hemorrhagic disorder is based on the control of bleeding with the use of bypassing agents and on the utilization of a variety of immunosuppressant agents with the goal of eliminating the autoantibody permanently. CONCLUSION The optimal management of AHA should be multidisciplinary and requires a close collaboration between physicians from various specialties.
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Affiliation(s)
- Massimo Franchini
- a Italian National Blood Centre, National Institute of Health , Rome , Italy.,b Department of Haematology and Transfusion Medicine , 'Carlo Poma' Hospital , Mantua , Italy
| | - Stefania Vaglio
- a Italian National Blood Centre, National Institute of Health , Rome , Italy.,c Department of Clinical and Molecular Medicine , 'Sapienza' University of Rome , Rome , Italy
| | - Giuseppe Marano
- a Italian National Blood Centre, National Institute of Health , Rome , Italy
| | - Carlo Mengoli
- a Italian National Blood Centre, National Institute of Health , Rome , Italy
| | - Sara Gentili
- a Italian National Blood Centre, National Institute of Health , Rome , Italy
| | - Simonetta Pupella
- a Italian National Blood Centre, National Institute of Health , Rome , Italy
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28
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An extra X does not prevent acquired hemophilia – Pregnancy-associated acquired hemophilia A. Thromb Res 2017; 151 Suppl 1:S82-S85. [DOI: 10.1016/s0049-3848(17)30074-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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29
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Innao V, Allegra A, Morreale R, Russo S, Musolino C. Disappearance of Acquired Hemophilia A after Complete Remission in a Multiple Myeloma Patient. Turk J Haematol 2017; 34:184-185. [PMID: 28077343 PMCID: PMC5440874 DOI: 10.4274/tjh.2016.0146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
| | - Alessandro Allegra
- Messina University Faculty of Medicine, Department of Human Pathology and the Adult Developmental, Division of Hematology, Messina, Italy Phone: 0039 090 2212364 E-mail:
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31
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Franco-Moreno AI, Santero-García M, Cabezón-Gutiérrez L, Martín-Díaz RM, García-Navarro MJ. Acquired hemophilia A in a patient with hepatocellular carcinoma: a case report and literature review. Ann Hematol 2016; 95:2099-2100. [PMID: 27666283 DOI: 10.1007/s00277-016-2825-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 09/11/2016] [Indexed: 12/20/2022]
Affiliation(s)
- A I Franco-Moreno
- Department of Internal Medicine, Torrejón University Hospital, Mateo Inurria, s/n (Soto del Henares), Torrejón de Ardoz, Madrid, 28850, Spain.
| | - M Santero-García
- Department of Haematology, Torrejón University Hospital, Madrid, Spain
| | | | - R M Martín-Díaz
- Department of Internal Medicine, Torrejón University Hospital, Mateo Inurria, s/n (Soto del Henares), Torrejón de Ardoz, Madrid, 28850, Spain
| | - M J García-Navarro
- Department of Internal Medicine, Torrejón University Hospital, Mateo Inurria, s/n (Soto del Henares), Torrejón de Ardoz, Madrid, 28850, Spain
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32
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Okiro JO, Khan AZ, Keane F, Murad F. Aspirin unmasking acquired haemophilia A in a patient with prostate cancer. BMJ Case Rep 2016; 2016:bcr-2016-216890. [PMID: 27609590 DOI: 10.1136/bcr-2016-216890] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 72-year-old man, on treatment for prostate cancer, attended the emergency department with his 2nd episode of spontaneous extensive bruising and haematomas. His first presentation was 2 months prior but this was thought to be because of his aspirin and he improved when aspirin was discontinued. On this occasion aspirin had been restarted 7 days before he developed his symptoms. His blood investigation was significant for a much raised activated partial thromboplastin time (aPTT). On his 3rd day of admission he deteriorated clinically with a drastic drop in his haemoglobin and worsening tense haematomas. Blood investigations confirmed the diagnosis of acquired factor VIII deficiency and he subsequently received treatment with factor VIII inhibitor bypassing activity, steroids and immunosuppresants.
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Affiliation(s)
| | | | - Fergus Keane
- Galway University Hospitals, Galway, Galway, Ireland
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33
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Goto M, Haga N, Yokota K, Takamizawa K, Takedani H. A successful physiotherapy management case of a patient with acquired haemophilia A prior to factor VIII inhibitor eradication. Haemophilia 2016; 22:e228-31. [PMID: 26988340 DOI: 10.1111/hae.12914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2016] [Indexed: 11/30/2022]
Affiliation(s)
- M Goto
- Rehabilitation Center, The University of Tokyo Hospital, Tokyo, Japan
| | - N Haga
- Department of Rehabilitation Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - K Yokota
- Rehabilitation Center, The University of Tokyo Hospital, Tokyo, Japan
| | - K Takamizawa
- Rehabilitation Center, The University of Tokyo Hospital, Tokyo, Japan
| | - H Takedani
- Department of Joint Surgery, Hospital of the Institute of Medical Science, The University of Tokyo, Tokyo, Japan
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34
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Geethakumari PR, Sama A, Caro JG, Yeo CJ, Nagalla S. "The Immune Conundrum": Acquired Hemophilia A, Immune Thrombocytopenia, and Neutropenia in a Patient with Pancreatic Cancer. Case Rep Pancreat Cancer 2016; 2:14-18. [PMID: 30631809 PMCID: PMC6319692 DOI: 10.1089/crpc.2015.29011.prg] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Malignancy-associated bleeding can pose diagnostic dilemmas. We report a unique case of paraneoplastic acquired hemophilia A (AHA), immune thrombocytopenia (ITP), and immune neutropenia in a patient with pancreatic adenocarcinoma. Case Presentation: A 66-year-old male with newly diagnosed pancreatic cancer and normal preoperative hematological evaluation was taken to the operating room for pancreaticoduodenectomy. The operation was aborted due to empyema of the gall bladder, cholangitis, and local extent of disease. Postoperatively, the patient developed bleeding diatheses with mucocutaneous and intra-abdominal bleeding and a prolonged activated partial thromboplastin time. Evaluation revealed high-titer factor VIII inhibitor confirming AHA. Management with bypassing agents such as recombinant activated factor VII, factor VIII inhibitor bypassing activity, and immunosuppression with steroids, cyclophosphamide, and rituximab achieved remission in 2 months. ITP developed after achieving normal factor VIII levels, which was managed with intravenous immunoglobulin. Neutropenia was detected before initiation of chemotherapy and was managed with granulocyte-colony stimulating factor. Conclusion: These unique challenges posed by paraneoplastic hematological syndromes warrant the need for astute clinical judgment and multidisciplinary collaboration for effective management.
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Affiliation(s)
| | - Ashwin Sama
- Department of Medical Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Jaime G Caro
- Department of Hematology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Charles J Yeo
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Srikanth Nagalla
- Department of Hematology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Berczi C, Razso K, Osvath P, Boda Z, Flasko T. Acquired Hemophilia Caused by Ureteral Tumor. Clin Genitourin Cancer 2015; 13:e387-9. [DOI: 10.1016/j.clgc.2015.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/21/2015] [Accepted: 05/29/2015] [Indexed: 10/23/2022]
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Le Cam-Duchez V. Hémophilie A acquise et hémopathies lymphoïdes : revue de la littérature. Rev Med Interne 2015; 36:834-9. [DOI: 10.1016/j.revmed.2015.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 08/24/2015] [Accepted: 09/14/2015] [Indexed: 01/29/2023]
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Kojima M, Ichinose A, Souri M, Osaki T, Kawai H, Amaki J, Numata H, Miyamoto M, Ogiya D, Tsuboi K, Ogawa Y, Ozawa S, Ando K. Successful bypass surgery for esophageal carcinoma under adequate factor XIII/13 replacement therapy in a case of intractable autoimmune hemorrhaphilia due to anti-Factor XIII/13 antibodies. Int J Hematol 2015; 103:341-7. [DOI: 10.1007/s12185-015-1917-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 11/16/2015] [Accepted: 11/18/2015] [Indexed: 11/28/2022]
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Girardi DDM, Silva DRA, Villaça PR, Souza CE, da Fonseca LG, Bastos DA, Hoff PMG. Acquired hemophilia A in a patient with advanced prostate cancer. Autops Case Rep 2015; 5:55-9. [PMID: 26484336 PMCID: PMC4584669 DOI: 10.4322/acr.2015.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 05/15/2015] [Indexed: 11/23/2022]
Abstract
Acquired hemophilia A (AHA) is a rare disorder that results from the presence of autoantibodies against the clotting factor VIII (FVIII) causing hemorrhagic disorders. This entity is mostly associated with autoimmune diseases, pregnancy, the postpartum period, drugs and malignancy. Among the solid cancers, prostate neoplasm is the most common cause of AHA. The management of AHA involves the control of active bleeding and the use of specific therapies to eliminate the inhibitor. The authors describe the case of an 87-year-old man with prostate cancer who developed a bleeding disorder 5 years after the cancer diagnosis. Treatment with prednisone did not reach a satisfactory clinical response, which was only achieved with the association of azathioprine. The patient became asymptomatic with no further bleeding episodes, but developed a fatal sepsis after 3 months of treatment with these immunosuppressive agents.
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Affiliation(s)
- Daniel da Motta Girardi
- Clinical Oncology Department - Instituto do Câncer do Estado de São Paulo, São Paulo/SP - Brazil
| | | | - Paula Ribeiro Villaça
- Hospital das Clinicas - Faculdade de Medicina - Universidade de São Paulo, São Paulo/SP - Brazil
| | - Ciro Eduardo Souza
- Clinical Oncology Department - Instituto do Câncer do Estado de São Paulo, São Paulo/SP - Brazil
| | | | - Diogo Assed Bastos
- Clinical Oncology Department - Instituto do Câncer do Estado de São Paulo, São Paulo/SP - Brazil
| | - Paulo Marcelo Gehm Hoff
- Clinical Oncology Department - Instituto do Câncer do Estado de São Paulo, São Paulo/SP - Brazil
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Acquired inhibitors of clotting factors: AICE recommendations for diagnosis and management. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 13:498-513. [PMID: 26192778 DOI: 10.2450/2015.0141-15] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Mariotti J, Locatelli G, Cirrincione S, Agostinelli E, Corti D, Maggioni A, Falanga A, Rosti A. Eradication of acquired hemophilia associated with indolent non-Hodgkin lymphoma by a disease specific treatment. Leuk Lymphoma 2015; 56:3210-2. [PMID: 25735965 DOI: 10.3109/10428194.2015.1023722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Jacopo Mariotti
- a Hematology/Blood Bank Division , Ospedale Treviglio-Caravaggio , Treviglio , Italy
| | - Giovanni Locatelli
- b Internal Medicine Division , Ospedale Treviglio-Caravaggio , Treviglio , Italy
| | - Sonia Cirrincione
- a Hematology/Blood Bank Division , Ospedale Treviglio-Caravaggio , Treviglio , Italy
| | - Enrica Agostinelli
- a Hematology/Blood Bank Division , Ospedale Treviglio-Caravaggio , Treviglio , Italy
| | - Daniela Corti
- c Department of Anatomic Pathology , Ospedale Treviglio-Caravaggio , Treviglio , Italy
| | - Anna Maggioni
- d Department of Immunohematology and Transfusion Medicine , Hospital Papa Giovanni XXIII , Bergamo , Italy
| | - Anna Falanga
- d Department of Immunohematology and Transfusion Medicine , Hospital Papa Giovanni XXIII , Bergamo , Italy
| | - Alberto Rosti
- a Hematology/Blood Bank Division , Ospedale Treviglio-Caravaggio , Treviglio , Italy
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Acquired inhibitors to factor VIII and fibrinogen in the setting of T-cell large granular lymphocyte leukemia. Blood Coagul Fibrinolysis 2015; 26:211-3. [DOI: 10.1097/mbc.0000000000000209] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mulliez SMN, Vantilborgh A, Devreese KMJ. Acquired hemophilia: a case report and review of the literature. Int J Lab Hematol 2014; 36:398-407. [PMID: 24750687 DOI: 10.1111/ijlh.12210] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Accepted: 02/24/2014] [Indexed: 11/27/2022]
Abstract
Acquired hemophilia A (AHA) is a rare bleeding disorder caused by autoantibodies against clotting factor VIII (FVIII). FVIII autoantibody is characterized as polyclonal immunoglobulin G directed against the FVIII procoagulant activity. This disease occurs most commonly in the elderly population and with preponderance of men in nonpregnancy-related AHA. There are well-established clinical associations with AHA such as malignancy, other autoimmune diseases and pregnancy. However, up to 50% of reported cases remain idiopathic. The clinical manifestation of AHA includes mostly spontaneous hemorrhages into skin, muscles and soft tissues, or mucous membranes. AHA should be suspected when a patient with no previous history of bleeding presents with bleeding and an unexplained prolonged activated partial thromboplastin time. The diagnosis is confirmed in the laboratory by the subsequent identification of reduced FVIII levels and FVIII inhibitor titration. There is a high mortality, making prompt diagnosis and treatment vitally important. The principles of treatment consist in controlling the bleeding and eradicating the inhibitor. Because of the overall high relapse rate (15-33%), it is also recommended to follow up these patients. The review summarizes what is currently known about the epidemiology, pathogenesis, clinical features, diagnosis, treatment and prognosis of AHA and starts with a case report.
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Affiliation(s)
- S M N Mulliez
- Coagulation Laboratory, Department of Clinical Chemistry, Microbiology and Immunology, Ghent University Hospital, Ghent, Belgium
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Yao Q, Zhu X, Liu Y, Zhang F, Yuan T, Xu J, Wang X. Low-dose rituximab in the treatment of acquired haemophilia. ACTA ACUST UNITED AC 2014; 19:483-6. [PMID: 24611711 DOI: 10.1179/1607845414y.0000000152] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE AND IMPORTANCE Acquired haemophilia is a rare hemorrhagic disease caused by inhibitory autoantibodies against coagulation factor VIII. Rituximab has become a popular choice for immunosuppressive therapy in acquired haemophilia, almost with the same schedule of 375 mg/m(2) per week for 4-6 doses. While the effect of low-dose rituximab has seldom been reported. CLINICAL PRESENTATION We report a patient, aged 88 years, who developed acquired haemophilia with severe hemorrhage and elevation of carbohydrate antigen 125 (CA125), but in the absence of a detectable cause. INTERVENTION We prescribed a low-dose rituximab alone (100 mg per week for a total of four infusions) for the patient, different from the conventional usage, but received a similar effect. In addition, the patient was diagnosed with immune thrombocytopenia 22 months after rituximab, while FVIII activity and activated partial thromboplastin time remained within the normal range. After four infusions of low-dose rituximab, the platelet count recovered. CONCLUSION At a follow-up of 34 months, the patient remains in remission without further treatment, suggesting low-dose rituximab seems to be a safe and effective regimen for the elderly patients with acquired haemophilia.
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Barbara DW, McKenzie KM, Parikh SA, Ashrani AA, Pruthi RK, Burkhart HM, Suri RM, Mauermann WJ. Successful Perioperative Management of Severe Bleeding From Undiagnosed Acquired Factor VIII Inhibitors. J Cardiothorac Vasc Anesth 2014; 29:731-4. [PMID: 24462516 DOI: 10.1053/j.jvca.2013.10.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Indexed: 11/11/2022]
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Abstract
There is an increased risk not only of bleeding but also of thrombosis in the cancer patient. The double jeopardy creates an additional problem in their management and requires special attention. This review provides information on pathophysiology in the regulation of hemostasis, leading to bleeding and thrombotic complications. The process is complex with multiple factors being involved. In addition to the pathogenesis, a number of clinical syndromes, diagnostic methods and the management of hemostatic abnormalities in the cancer patient are presented. Potential effects of cancer treatment on these risks magnify the hazards encountered by the managing team. Wherever management is discussed, emphasis is placed on the scientific basis for the rationale of the therapeutic approach.
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Affiliation(s)
- Anaadriana Zakarija
- Division of Hematology/Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611-3008, USA.
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Lambing AY. Unexpected hemorrhage: an unusual and potentially catastrophic clinical challenge. J Am Assoc Nurse Pract 2013; 25:342-50. [PMID: 24170617 DOI: 10.1111/j.1745-7599.2012.00807.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Unexpected bleeding or hemorrhage related to the development of acquired factor VIII inhibitors is an emerging clinical challenge in patients. Symptoms can occur suddenly with bleeding and/or bruising that is excessive relative to the degree of injury or severity of a comorbid condition. Diagnosis is difficult, and bleeding can quickly become life threatening if not treated promptly. This review provides current information, using a patient case scenario, to improve awareness and recognition of patients presenting unexpectedly with excessive bleeding of unknown etiology. DATA SOURCES To complete this review, a search of English-language publications was conducted using Medline and CINAHL databases (1966-2010). CONCLUSIONS Although development of acquired factor VIII inhibitors is rare, its incidence is increasing in many different patient care settings. Improved awareness and recognition is needed to mitigate the significant patient morbidity and mortality that can occur without rapid and timely treatment by experienced hematology specialists. IMPLICATIONS FOR PRACTICE Nurse practitioners, as front-line clinicians treating patients in various therapeutic areas, may be the first healthcare professionals who see patients with this disorder. Increased knowledge and awareness of this rare but potentially catastrophic cause of excessive bleeding can improve prompt treatment and optimize patient outcomes.
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Affiliation(s)
- Angela Y Lambing
- Department of Hematology and Oncology, Hemophilia and Thrombosis Treatment Center, Henry Ford Health System, Detroit, Michigan
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Franchini M, Mannucci PM. Acquired haemophilia A: a 2013 update. Thromb Haemost 2013; 110:1114-20. [PMID: 24008306 DOI: 10.1160/th13-05-0363] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 08/06/2013] [Indexed: 11/05/2022]
Abstract
Acquired haemophilia A (AHA) is a rare but often severe bleeding disorder caused by autoantibodies against coagulation factor VIII (FVIII). AHA occurs more frequently in the elderly and in association with several conditions, such as the post-partum period, malignancies, autoimmune diseases or drug exposure; however, approximately 50% of reported cases are apparently idiopathic. Beside the elimination of the underlying disorder, the therapeutic approach to AHA should be directed toward the control of acute bleed and the eradication of FVIII autoantibody production. In this narrative review, we summarise the current knowledge on the epidemiology, diagnosis and clinical features of AHA, focusing in particular on advances in the management of this challenging bleeding disorder.
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Affiliation(s)
- Massimo Franchini
- Pier Mannuccio Mannucci, MD, Scientific Direction, IRCCS Cà Granda Foundation Maggiore Policlinico Hospital, Via Pace 9, 20122 Milan, Italy, Tel.: +39 02 5503 5414, Fax: +39 02 54 100 125, E-mail:
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Abstract
Acquired inhibitors of coagulation cause a life-threatening disease. Clinically newly occurring hemorrhagic diathesis combined with prolonged activated partial thromboplastin time (aPTT) time is diagnostically indicative and can be confirmed by a positive plasma exchange test. For thrombotic thrombocytopenic purpura and hemolytic uremic syndrome (TTP-HUS) the diagnosis of Coombs negative hemolytic anemia together with thrombocytopenia should lead to the detection of fragmentocytes in peripheral blood smears. Hairy cell leukemia is a rare subgroup of chronic B-cell neoplasia with the clinical signs of pancytopenia and splenomegaly which characteristically stain positive for CD103. The gastrointestinal stromal tumor (GIST) has nothing in common with classical soft tissue sarcoma based on the activating mutation of the KIT or PDGFRA gene (positivity for CD117). In all of these disorders the correct diagnosis has a major influence on patient outcome. For the case of acquired inhibitors of coagulation immunosuppressive therapy and substitution of coagulation factors (e.g. recombinant factor VIIa) or for TTP-HUS the immediate start of plasma exchange are mandatory. For hairy cell leukemia a very effective treatment exists with purine analogs (e.g. cladribine) and for metastatic inoperable GIST with tyrosine kinase inhibitors (e.g. imatinib).
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Affiliation(s)
- L H Lindner
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München, Marchioninistr. 15, 81377, München, Deutschland,
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Miura T, Ban D, Koyama T, Kudo A, Ochiai T, Irie T, Nakamura N, Tanaka S, Arii S. Severe postoperative hemorrhage caused by antibody-mediated coagulation factor deficiencies: report of two cases. Surg Today 2013; 44:976-81. [DOI: 10.1007/s00595-013-0584-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 11/04/2012] [Indexed: 11/30/2022]
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