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Sun YH, Nie WJ, Tian DD, Ye Q. Lupus anticoagulant-hypoprothrombinemia syndrome in children: Three case reports and systematic review of the literature. Lupus 2023; 32:1211-1221. [PMID: 37480550 DOI: 10.1177/09612033231191153] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
OBJECTIVE Children with lupus anticoagulant hypoprothrombinemia syndrome (LAHPS) are characterized by prolonged activated partial thromboplastin time (APTT) and prothrombin time (PT), lupus anticoagulant positivity and low prothrombin (factor II, FII) levels. Bleeding or thrombosis tendencies related to LAHPS in children can occur due to the development of anti-prothrombin antibodies that are usually linked to autoimmune or infectious diseases. METHODS We report three pediatric cases of LAHPS and describe details on their clinical symptoms, laboratory characteristics, treatment. PubMed, Medline, and Web of Science searches were conducted on LAHPS in children between 1960 and 2023; articles in English were included. RESULTS The coagulation profile revealed prolonged PT and APTT, with low prothrombin levels (19.4%, 21.0% and 12.9%, respectively) and positive lupus anticoagulant in 3 pediatric cases. Fifty-nine relevant articles reported 93 pediatric LAHPS cases (mean age: 9 years (0.8-17 years)); 63 females and 30 males, 87 patients presented with minor to severe bleeding diathesis, and 3 patients presented with thrombosis events. Among 48 patients ≥9 years old, 36 had SLE; among 45 patients <9 years, 29 had viral infection. When all patients were divided into two groups based on age, associated disease, and factor II level, Pearson's χ2 tests were performed, p =.00, and there was clinical significance between autoimmune and infectious disease in patients ≥9 years old and <9 years old, and in patients FII level ≤10% and >10%. LAHPS patients with autoimmune disease had a protracted course and needed prolonged treatment with immune-modulating therapy, while those patients with infectious disease resolved spontaneously or needed short-term immune-modulating therapy. CONCLUSION LAHPS caused by autoimmune disease are common in patients ≥9 years old, especially SLE, and FII level ≤10% is often reported in patients caused by autoimmune disease, suggesting that children ≥9 years old diagnosed with LAHPS-related autoimmune disease should pay special attention to the FII level. While LAHPS caused by infectious disease is more frequently observed in patients <9 years, especially viral infection. Early diagnostic investigations are critical to differentiating LAHPS caused by autoimmune or infectious disease, as the prognosis, treatment and outcome are distinct.
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Affiliation(s)
- Yan-Hong Sun
- Department of clinical laboratory, National Clinical Research Center for Child Health, National Children's Regional Medical Center, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wen-Jian Nie
- Department of clinical laboratory, National Clinical Research Center for Child Health, National Children's Regional Medical Center, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dan-Dan Tian
- Department of clinical laboratory, National Clinical Research Center for Child Health, National Children's Regional Medical Center, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qing Ye
- Department of clinical laboratory, National Clinical Research Center for Child Health, National Children's Regional Medical Center, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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2
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Chumsky J, Kahn PJ, Carroll WL, Pierce KA, Hillier K. Lupus anti-coagulant hypoprothrombinemia syndrome across different ages: a case report and review of the literature. Clin Rheumatol 2023:10.1007/s10067-023-06619-3. [PMID: 37157007 DOI: 10.1007/s10067-023-06619-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/13/2023] [Accepted: 04/30/2023] [Indexed: 05/10/2023]
Abstract
Lupus anti-coagulant hypoprothrombinemia syndrome (LAHPS) is a rare condition that can be difficult to treat. It increases the risk of thrombosis and bleeding due to the presence of lupus anti-coagulant and factor II deficiency, respectively. There are a limited number of cases described in the literature. Herein we describe a case of LAHPS with bleeding symptoms as a first clinical manifestation of systemic lupus erythematosus (SLE) in an 8-year-old female. She has had multiple recurrences of her bleeding symptoms, requiring treatment with steroids, cyclophosphamide, mycophenolate mofetil, and rituximab. Her course was later complicated by development of arthritis and lupus nephritis. Her complicated course provides a new perspective on the clinical course and treatment of LAHPS. We also present a comprehensive literature review which demonstrates the difficulty in treating patients with LAHPS with underlying SLE and the variability of the clinical course and management of LAHPS depending on the age at presentation.
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Affiliation(s)
- Jessica Chumsky
- Department of Pediatrics, NYU Langone Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Philip J Kahn
- Department of Pediatrics, Division of Pediatric Rheumatology, Hassenfeld Children's Hospital at NYU Langone Health, NYU Grossman School of Medicine, New York, NY, USA
| | - William L Carroll
- Perlmutter Cancer Center, Departments of Pediatrics and Pathology, NYU Grossman School of Medicine, New York, NY, USA
| | - Kristyn A Pierce
- Department of Pediatrics, Hassenfeld Children's Hospital at NYU Langone Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Kirsty Hillier
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Hassenfeld Children's Hospital at NYU Langone Health, NYU Grossman School of Medicine, 160 E 32Nd St., L3 Medical, New York, NY, 10016, USA.
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3
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Rasmussen KL, Philips M, Tripodi A, Goetze JP. Unexpected, isolated activated partial thromboplastin time prolongation: A practical mini-review. Eur J Haematol 2020; 104:519-525. [PMID: 32049377 DOI: 10.1111/ejh.13394] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/07/2020] [Accepted: 02/07/2020] [Indexed: 01/03/2023]
Abstract
A common inquiry in coagulation laboratories is how to interpret an unexpected, isolated prolonged activated partial thromboplastin time (APTT). In this context, isolated means together with a normal prothrombin time (PT) and/or normal international normalized ratio (INR). This finding may lead to contact with laboratory doctors for further advice on a diagnostic strategy. Occasionally, the need for a diagnostic algorithm can be subacute, where surgery has to be postponed until an explanation for the isolated, prolonged APTT has been established. Activated partial thromboplastin time as a coagulation test was developed to monitor patients with hemophilia. Different APTT reagents display considerable differences in their sensitivity to deficiencies of coagulation factors. An isolated, prolonged APTT is seen in (a) individuals/patients with lupus anticoagulants, (b) patients in treatment with anticoagulants, mainly heparin, and (c) patients with deficiencies of specific coagulation factors. In this tutorial review, we summarize what may cause an isolated prolonged APTT and we present a simple diagnostic algorithm to differentiate between lupus anticoagulants (common) and factor deficiencies (rare). The identification of an isolated prolonged APTT as well as the underlying cause can be of the utmost importance in ensuring the correct therapeutic follow-up.
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Affiliation(s)
| | - Malou Philips
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark
| | - Armando Tripodi
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milano, Italy
| | - Jens Peter Goetze
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark.,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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4
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Murphy CH, Jin J, Zehnder JL. Antiphospholipid Antibodies in Patients With Lupus Anticoagulant Prozone Effect. Am J Clin Pathol 2020; 153:229-234. [PMID: 31598704 DOI: 10.1093/ajcp/aqz151] [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: 11/12/2022] Open
Abstract
OBJECTIVES Lupus anticoagulant (LAC) is typically associated with thrombosis but also rarely with hemorrhage. Some patients exhibit a prozone effect on LAC testing. Antiphosphatidylserine/prothrombin (aPS/PT) antibodies may provide a mechanism for both hemorrhage and prozone effect. Our goal was to evaluate whether antibody specificities, isotypes, and titers were associated with LAC prozone effect, factor II levels, hemorrhage, and thrombosis. METHODS Patients with prozone effect noted on LAC testing were entered into a database over 3 years. Factor II activity and aPS/PT antibody testing were performed when a sufficient residual sample was available. RESULTS All patients with LAC prozone effect and antibody testing were positive for at least 1 class of aPS/PT antibodies. In addition, aPS/PT IgG titers were significantly associated with thrombosis and significantly inversely associated with factor II levels. CONCLUSIONS In prozone effect patients, aPS/PT antibodies are associated with LAC prozone effect as well as thrombosis and decreased factor II levels.
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Affiliation(s)
- Colin H Murphy
- Department of Pathology, School of Medicine, Stanford University, Stanford, CA
| | - Jing Jin
- Stanford Coagulation and Hemostasis Laboratory, Stanford Medical Center, Palo Alto, CA
| | - James L Zehnder
- Department of Pathology, School of Medicine, Stanford University, Stanford, CA
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5
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Fujiwara K, Shimizu J, Tsukahara H, Shimada A. Lupus anticoagulant-hypoprothrombinemia syndrome and immunoglobulin-A vasculitis: a report of Japanese sibling cases and review of the literature. Rheumatol Int 2019; 39:1811-1819. [PMID: 31392497 DOI: 10.1007/s00296-019-04404-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 07/29/2019] [Indexed: 10/26/2022]
Abstract
Lupus anticoagulant-hypoprothrombinemia syndrome (LAHPS) is a rare bleeding disorder caused by antiprothrombin antibodies. LAHPS is associated with systemic lupus erythematosus (SLE) or infections. We describe two Japanese brothers with immunoglobulin-A vasculitis (IgAV) who met the diagnostic criteria of LAHPS. They presented with palpable purpura and abdominal pain, and had a prolonged activated partial thromboplastin time (APTT) and prothrombin deficiency with the presence of lupus anticoagulant. Pediatric LAHPS was reviewed in abstracts from the Japan Medical Abstracts Society that were written in Japanese and PubMed or Web of Science-listed articles in English between 1996 and 2019. Including our cases, pediatric LAHPS has been reported in 40 Japanese and 46 non-Japanese patients. We summarized the clinical and laboratory characteristics of all 86 cases, and found only one Japanese LAHPS case with IgAV, except for our cases. Of the 86 cases, most were associated with infections followed by SLE. The presence of SLE, older age, lower prothrombin levels, severe bleeding symptoms, and positivity of immunoglobulin G anticardiolipin antibodies and anticardiolipin/β2-glycoprotein I antibodies and/or β2-glycoprotein I-dependent anticardiolipin antibodies had higher odds of requiring treatment. Measuring the APTT and prothrombin time (PT) might be required in patients with IgAV when they do not have a typical clinical course or distinctive symptoms. LAHPS should be considered with prolongation of the APTT and/or PT. Additionally, it is important to maintain a balance between the risk of thrombosis and hemorrhage when normalization of the PT and FII levels occurs in LAHPS cases under treatment.
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Affiliation(s)
- Kaori Fujiwara
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Junya Shimizu
- Department of Pediatrics, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | | | - Akira Shimada
- Department of Pediatric Hematology/Oncology, Okayama University Hospital, 2-5-1, Shikatacho, Kitaku, Okayama, 700-8558, Japan.
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Pilania RK, Suri D, Jindal AK, Kumar N, Sharma A, Sharma P, Guleria S, Rawat A, Ahluwalia J, Singh S. Lupus anticoagulant hypoprothrombinemia syndrome associated with systemic lupus erythematosus in children: report of two cases and systematic review of the literature. Rheumatol Int 2018; 38:1933-1940. [PMID: 30099593 DOI: 10.1007/s00296-018-4127-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 08/06/2018] [Indexed: 12/13/2022]
Abstract
We report two children with systemic lupus erythematosus (SLE) having severe bleeding manifestations and lupus anticoagulant hypoprothrombinemia syndrome (LAHPS) along with a review of published cases of childhood SLE and LAHPS. We report clinical and laboratory profile of two children diagnosed with childhood SLE and LAHPS. We also conducted literature search to identify similar published cases and a review was performed. An 8-year-old girl had presented with fever, arthralgia, alopecia, anasarca and bleeding from multiple sites. She was diagnosed to have SLE based on laboratory investigations which showed anemia, thrombocytopenia, low complements, positive anti-nuclear antibody (ANA) and double standard DNA (dsDNA) antibodies. She was also found to have prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT), positive lupus anticoagulant (LA) and low factor II levels. She was diagnosed to have SLE with LAHPS and treated with intravenous methylprednisolone, intravenous immunoglobulin and cyclophosphamide with good outcome. Patient 2 was a 7-year-old-boy who was diagnosed to have SLE when he presented with fever, anasarca, malar rash, arthritis and bleeding from skin and mucosa. Laboratory investigations revealed anemia, proteinuria, low complements, positive ANA and anti-dsDNA titre. Coagulation studies showed deranged PT and aPTT, positive LA and low factor II levels. He was diagnosed to have SLE with LAHPS and was treated with intravenous methylprednisolone and oral mycophenolate mofetil. Review of literature of cases with childhood SLE and LAHPS showed that there are 32 cases have been reported till date which have been summarized. LAHPS is an uncommonly identified cause of bleeding in patients with SLE and must be suspected while evaluating these children.
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Affiliation(s)
- Rakesh Kumar Pilania
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Deepti Suri
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - Ankur Kumar Jindal
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Narender Kumar
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Avinash Sharma
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Praveen Sharma
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sandesh Guleria
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Amit Rawat
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Jasmina Ahluwalia
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
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7
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Gupta A, Mishra P, Pati HP, Tyagi S, Mahapatra M, Seth T, Saxena R. Spectrum of hemostatic disorders in Indian females presenting with bleeding manifestations. Int J Lab Hematol 2018; 40:437-441. [PMID: 29575615 DOI: 10.1111/ijlh.12806] [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: 11/20/2017] [Accepted: 02/16/2018] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Hemostatic disorders are often missed in women with bleeding particularly menorrhagia. Preexisting hemostatic disorders are now known as common risk factor for postpartum hemorrhage and prolonged bleeding in puerperium. Females with bleeding complaints constitute an important population referred to hematology clinic. Hence, we aim to evaluate the type and frequency of hemostatic disorders among females presenting with bleeding in a tertiary care hospital and a basic hemostatic laboratory. METHODS Three-year data were retrospectively analyzed for 200 females with various bleeding complaints. Due to resource constraints, a hemostatic workup was done with prothrombin time, activated partial thromboplastin time, thrombin time, fibrinogen assay, clot solubility test, mixing studies, specific factor assays, platelet function test, and von Willebrand factor antigen level. RESULTS A total of 200 females were investigated to identify the cause of their bleeding. Thirty-five of 200 (17.5%) females were found with an underlying bleeding disorder. Of these 35 females, 65.7% presented with bleeding from more than 1 site. Most common bleeding manifestation was spontaneous bruising in 18 of 35 (51.4%) patients followed by petechiae (48.6%). Inherited bleeding disorders were noted in majority. The most common inherited bleeding disorder identified was von Willebrand disease (VWD) in 34.3% females. Second most common disorder was Glanzmann's thrombasthenia accounting for 22.8%. Rare coagulation factor deficiency, such as factors VII, X, and XIII deficiencies, was noted. Three cases revealed acquired causes of coagulation defects. CONCLUSION Underlying hemostatic defects should be searched for in women with unexplained bleeding complaints. This will not only help in diagnosis but also in proper management for future hemostatic challenges.
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Affiliation(s)
- A Gupta
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - P Mishra
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - H P Pati
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - S Tyagi
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - M Mahapatra
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - T Seth
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - R Saxena
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
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8
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Cetin Gedik K, Siddique S, Aguiar CL. Rituximab use in pediatric lupus anticoagulant hypoprothrombinemia syndrome - report of three cases and review of the literature. Lupus 2018; 27:1190-1197. [PMID: 29320972 DOI: 10.1177/0961203317751853] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Lupus anticoagulant hypoprothrombinemia syndrome (LA-HPS) is a rare condition that may predispose both to thrombosis and bleeding due to positive lupus anticoagulant (LA) and factor II (FII) deficiency. It can be seen in association with infections or systemic lupus erythematosus (SLE) and may require glucocorticoids (GCs) and/or immunosuppressive medications. Pediatric LA-HPS cases in the literature and three cases that received only rituximab (RTX) for LA-HPS (in addition to GCs) at two institutions between January 2010 and June 2017 were analyzed descriptively. Pediatric LA-HPS cases (≤18 years) with bleeding or thrombotic events were included. Information obtained included demographics, presenting symptoms, diagnoses, treatments, pre-/post-treatment prothrombin time (PT)/partial thromboplastin time (PTT)/LA/FII levels, and outcomes. In addition to three LA-HPS cases identified at our institutions, as of June 2017, 37 articles reported 54 pediatric LA-HPS cases (mean age: 8 years (0.9-17 years); female/male: (2:1); viral illness 27 (50%), SLE 20 (37%), and other six (11%)). All cases had a positive LA and FII deficiency (range: 0%-40%). All cases presented with bleeding diathesis and were treated with various regimens, but there was no reported use of RTX. The purpose of this report is to describe the novel use of RTX as a steroid-sparing agent in three pediatric SLE cases and to systematically review the literature on pediatric cases of LA-HPS.
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Affiliation(s)
- K Cetin Gedik
- 1 Department of Pediatric Rheumatology, 25050 Steven and Alexandra Cohen Children's Medical Center , Lake Success, NY, USA
| | - S Siddique
- 2 Department of Pediatric Rheumatology, 25062 Hospital for Special Surgery -Weill Cornell Medical Center, New York, NY, USA
| | - C L Aguiar
- 3 Department of Pediatric Rheumatology, 20666 Children's Hospital of The King's Daughters , Norfolk, VA, USA
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9
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Lupus Anticoagulant-hypoprothrombinemia Syndrome (LAC-HPS) in Children With Systemic Lupus Erythematosus: Report of 3 Cases. J Pediatr Hematol Oncol 2017; 39:e521-e524. [PMID: 28787393 DOI: 10.1097/mph.0000000000000891] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Lupus anticoagulant, also known as lupus antibody, is generally associated with thrombosis rather than bleeding events. Lupus anticoagulant-hypoprothrombinemia syndrome in children is rather rare but can lead to mild to life-threatening bleeding. Here, we report 3 cases of lupus anticoagulant-hypoprothrombinemia syndrome associated with systemic lupus erythematosus. They initially presented with mucocutaneous bleedings, and subsequently developed other symptoms fulfilling the laboratory criteria for systemic lupus erythematosus. Case 2 and 3 had significant epistaxis and intracerebral hemorrhage responded to systemic corticosteroid along with fresh frozen plasma. Three cases demonstrated acquired hypoprothrombinemia with no correction of mixing studies. Case 1 had low factor X level, which has never been reported previously. In all 3 cases, their coagulogram returned to normal level after corticosteroid treatment.
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10
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Foord A, Baca N, Buchbinder D, Mahajerin A. Lupus anticoagulant hypoprothrombinemia syndrome associated with severe thrombocytopenia in a child. Pediatr Blood Cancer 2017; 64. [PMID: 27862892 DOI: 10.1002/pbc.26357] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/07/2016] [Accepted: 10/12/2016] [Indexed: 01/19/2023]
Abstract
Lupus anticoagulant hypoprothrombinemia syndrome (LAHPS) comprises lupus anticoagulant, acquired hypoprothrombinemia, and often mild thrombocytopenia or normal platelets. It is usually associated with autoimmunity or postviral illness. We describe a case of a 10-year-old boy with oral bleeding and severe thrombocytopenia initially suggestive of immune thrombocytopenia. Secondary to bleeding, evaluation demonstrated prolonged coagulation tests and subsequently revealed the presence of lupus anticoagulant and hypoprothrombinemia, along with marked autoimmunity, suggestive of LAHPS. He was treated with intravenous immunoglobulin and hydroxychloroquine. This case report and discussion highlight the diagnostic and therapeutic challenges associated with LAHPS and coincident severe thrombocytopenia.
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Affiliation(s)
- Aimee Foord
- Hematology-Oncology Hospitalist Service, Division of Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Nicole Baca
- Division of Hematology/Oncology, CHOC Children's Hospital, Orange, California
| | - David Buchbinder
- Division of Hematology/Bone Marrow Transplant, CHOC Children's Hospital, Orange, California
| | - Arash Mahajerin
- Division of Hematology, CHOC Children's Hospital, Orange, California
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11
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Matsumoto T, Nogami K, Shima M. A combined approach using global coagulation assays quickly differentiates coagulation disorders with prolonged aPTT and low levels of FVIII activity. Int J Hematol 2016; 105:174-183. [PMID: 27730530 DOI: 10.1007/s12185-016-2108-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 10/03/2016] [Accepted: 10/03/2016] [Indexed: 10/20/2022]
Abstract
Patients with mild/moderate hemophilia (H)A, acquired HA (AHA) and lupus anticoagulants (LA), have prolonged aPTTs with low levels of factor (F)VIII activity, but the differentiation of these disorders is complex and time consuming. We established an approach to quickly differentiate these disorders using comprehensive coagulation tests. Patients' plasmas with mild/moderate HA, AHA, LA without anti-phospholipid syndrome [LA-APS(-)], and LA with APS [LA-APS(+)] were examined using clot waveform analysis (CWA) and thrombin generation test (TGT). Activated protein C (APC) sensitivity was assessed by TGT. CWA revealed similarly prolonged clot times in all groups [NP/mild/moderate HA/AHA/LA-APS(-)/LA-APS(+); 33 ± 1/82 ± 12/116 ± 44/90 ± 29/96 ± 15 s] but significantly different decreased maximal coagulation velocity (3.1 ± 0.1/1.3 ± 0.3/0.9 ± 0.5/1.6 ± 0.3/2.2 ± 0.5). In TGT, AHA group demonstrated severely reduced peak-thrombin levels (362 ± 23/170 ± 27/49 ± 21/158 ± 75/158 ± 99 nM), whilst both LA groups markedly prolonged lag times (4.5 ± 0.3/5.0 ± 0.4/4.7 ± 0.8/12.5 ± 7.7/28.8 ± 11.8 min), suggesting that AHA could be readily identified, but the different LA sub-types failed to be classified. An APC sensitivity demonstrated that 'normalized' APC-induced levels of peak thrombin in LA-APS(+) were significantly lower relative to LA-APS(-) (normalized %inhibition; 5 ± 7/42 ± 39 %). Our studies confirmed that %inhibition by APC was significantly decreased in NP preincubated with purified IgGs from LA-APS(+) compared to LA-APS(-), facilitating differentiation between LA groups. A combined approach using CWA and TGT could be a useful means of differentiating coagulation disorders with prolonged aPTT.
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Affiliation(s)
- Tomoko Matsumoto
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.,Course of Hemophilia Treatment and Pathology, Nara Medical University, Kashihara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.,Course of Hemophilia Treatment and Pathology, Nara Medical University, Kashihara, Japan
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12
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Jin J, Zehnder JL. Prozone Effect in the Diagnosis of Lupus Anticoagulant for the Lupus Anticoagulant-Hypoprothrombinemia Syndrome. Am J Clin Pathol 2016; 146:262-7. [PMID: 27473743 DOI: 10.1093/ajcp/aqw106] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The main clinical sequela of a lupus anticoagulant is increased thrombosis risk. However, bleeding due to lupus anticoagulant-hypoprothrombinemia syndrome is a rare but well-described manifestation of antiphospholipid syndrome. The association of acute acquired hypoprothrombinemia is caused by a lupus anticoagulant's specificity to prothrombin, which results in clearance of prothrombin and bleeding due to hypoprothrombinemia (usually <10% of normal). Severe life-threatening bleeding is most frequently reported in children with systemic lupus erythematosus or in healthy children after viral infection. In such cases, steroid therapy is usually effective in controlling the bleeding problems and improving prothrombin levels. METHODS We report one pediatric patient with a lupus anticoagulant who had acute hemorrhagic diathesis. RESULTS The diagnosis in this case was complicated by the presence of a prozone effect in lupus anticoagulant testing. The prozone effect (also known as hook effect) refers to situations where very high concentrations of antibody mask detection, typically in antigen-antibody reactions, which depend on visualization of agglutination. Decreasing the antibody/antigen ratio results in detectable antigen-antibody complexes. CONCLUSIONS We report for the first time a variation on this theme in a patient with a lupus anticoagulant-type antiphospholipid antibody and hypoprothrombinemia, which corrected with immunosuppression and restoration of normal prothrombin levels.
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Affiliation(s)
- Jing Jin
- From the Department of Special Coagulation, Clinical Laboratory, Stanford Medical Center, Stanford, CA
| | - James L Zehnder
- Department of Pathology, School of Medicine, Stanford University, Stanford, CA.
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13
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Abstract
Inhibitors directed against factor V rarely occur, and the clinical symptoms vary. We herein report the case of a patient who presented with a decreased factor V activity that had decreased to <3 %. We administered vitamin K and 6 units of fresh frozen plasma, but she thereafter developed an intracerebral hemorrhage. It is unclear whether surgery >10 years earlier might have caused the development of a factor V inhibitor. The treatment of acquired factor V inhibitors is mainly the transfusion of platelet concentrates and corticosteroids. Both early detection and the early initiation of the treatment of factor V inhibitor are thus considered to be important.
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Affiliation(s)
- Daisuke Hirai
- Departmant of General Medicine, National Hospital Organization Kyoto Medical Center, Japan
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Hwang YE, Park HK, Yeom JS, Park JS, Park ES, Seo JH, Lim JY, Park CH, Woo HO, Youn HS. Lupus Anticoagulant-hypoprothrombinemia Syndrome that did not Progress to Systemic Lupus Erythematosus: A Case Report. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2015. [DOI: 10.15264/cpho.2015.22.2.155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Young Eun Hwang
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Heung Keun Park
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Jung-Sook Yeom
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ji Sook Park
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Eun Sil Park
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ji-Hyun Seo
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Jae Young Lim
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Chan-Hoo Park
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Hyang-Ok Woo
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Hee-Shang Youn
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
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15
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Moser KA, Puetz J. Challenging hemostasis scenarios in pediatric patients - two case studies. Int J Lab Hematol 2015; 37 Suppl 1:72-7. [DOI: 10.1111/ijlh.12355] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 03/16/2015] [Indexed: 10/23/2022]
Affiliation(s)
- K. A. Moser
- Department of Pathology; Saint Louis University School of Medicine; St. Louis MO USA
| | - J. Puetz
- Department of Pediatrics; Saint Louis University School of Medicine; St. Louis MO USA
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16
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Sarker T, Roy S, Hollon W, Rajpurkar M. Lupus anticoagulant acquired hypoprothrombinemia syndrome in childhood: two distinct patterns and review of the literature. Haemophilia 2015; 21:754-60. [PMID: 25929557 DOI: 10.1111/hae.12669] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2015] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Lupus anticoagulant associated with acquired prothrombin deficiency also known as 'lupus anticoagulant hypoprothrombinemia syndrome' (LAHS) is an entity that is well described in adults and is usually associated with autoimmune conditions (LAHS-AI). However, in children, LAHS has unique features that are distinct from the adult type. AIMS We report two paediatric cases of LAHS, describe their distinct patterns and review the paediatric literature on LAHS. METHODS Case studies on two patients with LAHS were reviewed, details on their presentation, work up and management were extracted. A Medline search was conducted on LAHS in children between 1960 and 2014; Articles in languages other than English were excluded. RESULTS The case studies highlight the differences in the two patterns of childhood LAHS. Additionally the review of the literature reveals that there are 15 case reports and 5 case series that report 25 children with LAHS-AI, 9 case reports and 6 case series report 26 children of LAHS associated with viral infections (LAHS-VI). At presentation, all patients with LAHS-AI had positive laboratory tests for autoimmune diseases, most commonly for systemic lupus erythematosus while these tests were negative in LAHS-VI. All patients with LAHS-AI had a protracted course and needed prolonged treatment with immune-suppressive therapy while patients with LAHS-VI resolved spontaneously or needed short-term immune-modulating therapy. CONCLUSION In childhood, two distinct patterns of LAHS are observed, either associated with infection or autoimmune disease. Initial diagnostic investigations are critical to differentiating these two patterns as the prognosis and outcome for each is distinct.
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Affiliation(s)
- T Sarker
- Division of Hematology/Oncology, Carman and Ann Adams, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA.,Wayne State University, Detroit, MI, USA
| | - S Roy
- Division of Hematology/Oncology, Carman and Ann Adams, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA.,Wayne State University, Detroit, MI, USA
| | - W Hollon
- Wayne State University, Detroit, MI, USA
| | - M Rajpurkar
- Division of Hematology/Oncology, Carman and Ann Adams, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA.,Wayne State University, Detroit, MI, USA
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17
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18
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Mulliez SMN, De Keyser F, Verbist C, Vantilborgh A, Wijns W, Beukinga I, Devreese KMJ. Lupus anticoagulant-hypoprothrombinemia syndrome: report of two cases and review of the literature. Lupus 2014; 24:736-45. [PMID: 25391540 DOI: 10.1177/0961203314558859] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 10/10/2014] [Indexed: 11/16/2022]
Abstract
Lupus anticoagulant-hypoprothrombinemia syndrome (LA-HPS) is a rare acquired disorder caused by prothrombin antibodies. The disease is most common in the pediatric age group (<16 years), and more prevalent in women. There are well-established clinical diseases associated with LA-HPS, most notably systemic lupus erythematosus (SLE) and viral infections. The clinical manifestation of LA-HPS varies greatly in severity and it may cause severe life-threatening bleeding diathesis. LA-HPS is to be suspected when a patient presents with bleeding and a prolonged activated partial thromboplastin and prothrombin time, in combination with a lupus anticoagulant. The diagnosis is confirmed in the laboratory by identification of reduced prothrombin levels. There are no standardized recommendations for treatment of the hemorrhage associated with the syndrome; corticosteroids are used as first-line treatment. This review summarizes what is currently known about the pathogenesis, clinical features, diagnosis, treatment and prognosis of LA-HPS, and presents two case reports.
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Affiliation(s)
- S M N Mulliez
- Coagulation Laboratory, Department of Clinical Chemistry, Microbiology and Immunology, Ghent University Hospital, Ghent, Belgium
| | - F De Keyser
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - C Verbist
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - A Vantilborgh
- Department of Hematology, Ghent University Hospital, Ghent, Belgium
| | - W Wijns
- Department of Hematobiology, Erasme Hospital, Brussels, Belgium
| | - I Beukinga
- Department of Hematobiology, Erasme Hospital, Brussels, Belgium
| | - K M J Devreese
- Coagulation Laboratory, Department of Clinical Chemistry, Microbiology and Immunology, Ghent University Hospital, Ghent, Belgium
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19
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Mauge L, Passeron A, Alhenc-Gelas M, Pouchot J, Darnige L. Activated partial thromboplastin time sensitivity to lupus anticoagulant in a patient with transient arthritis and lupus anticoagulant-hypoprothrombinemia syndrome. Ann Hematol 2014; 94:713-5. [DOI: 10.1007/s00277-014-2245-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 10/26/2014] [Indexed: 11/25/2022]
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20
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Kim JS, Kim MJ, Bae EY, Jeong DC. Pulmonary hemorrhage in pediatric lupus anticoagulant hypoprothrombinemia syndrome. KOREAN JOURNAL OF PEDIATRICS 2014; 57:202-5. [PMID: 24868219 PMCID: PMC4030123 DOI: 10.3345/kjp.2014.57.4.202] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 05/25/2013] [Accepted: 09/13/2013] [Indexed: 11/27/2022]
Abstract
Lupus anticoagulant-hypoprothrombinemia syndrome (LAHPS), a very rare disease that is caused by the presence of antifactor II antibodies, is usually counterbalanced by the prothrombotic effect of lupus anticoagulant (LAC). Patients with LAHPS are treated using fresh frozen plasma, steroids, immunosuppressive agents, and immunoglobulins for managing the disease and controlling hemorrhages. Notably, steroids are the important treatment for treating hypoprothrombinemia and controlling the bleeding. However, some patients suffer from severe, life-threatening hemorrhages, when factor II levels remain very low in spite of treatment with steroids. Here, we report a case of LAHPS in a 15-year-old girl who experienced pulmonary hemorrhage with rapid progression. She was referred to our hospital owing to easy bruising and prolonged bleeding. She was diagnosed with LAHPS that presented with pancytopenia, positive antinuclear antibody, proloned prothrombin time, activated partial thromboplastin time, positive LAC antibody, and factor II deficiency. Her treatment included massive blood transfusion, high-dose methylprednisolone, vitamin K, and immunoglobulin. However, she died due to uncontrolled pulmonary hemorrhage.
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Affiliation(s)
- Ji Soo Kim
- Department of Pediatrics, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Min Jae Kim
- Department of Pediatrics, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - E Young Bae
- Department of Pediatrics, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Dae Chul Jeong
- Department of Pediatrics, The Catholic University of Korea College of Medicine, Seoul, Korea
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21
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Paschal RD, Neff AT. Resolution of Hypoprothrombinemia-Lupus Anticoagulant Syndrome (HLAS) after multidrug therapy with rituximab: a case report and review of the literature. Haemophilia 2012; 19:e62-5. [DOI: 10.1111/hae.12027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2012] [Indexed: 12/25/2022]
Affiliation(s)
- R. D. Paschal
- Division of Hematology and Oncology, Department of Internal Medicine; Vanderbilt University Medical Center; Nashville; TN; USA
| | - A. T. Neff
- Division of Hematology and Oncology, Department of Internal Medicine; Vanderbilt University Medical Center; Nashville; TN; USA
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22
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Mazodier K, Arnaud L, Mathian A, Costedoat-Chalumeau N, Haroche J, Frances C, Harlé JR, Pernod G, Lespessailles E, Gaudin P, Charlanne H, Hachulla E, Niaudet P, Piette JC, Amoura Z. Lupus anticoagulant-hypoprothrombinemia syndrome: report of 8 cases and review of the literature. Medicine (Baltimore) 2012; 91:251-260. [PMID: 22932789 DOI: 10.1097/md.0b013e31826b971f] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The lupus anticoagulant-hypoprothrombinemia syndrome (LAHS)--the association of acquired factor II deficiency and lupus anticoagulant--is a rare disease drastically different from antiphospholipid syndrome in that it may cause predisposition not only to thrombosis but also to severe bleeding. We performed a retrospective study of 8 patients with LAHS referred to 6 French tertiary care centers between January 2003 and February 2011, and a literature review retrieving all related articles published between 1960 and April 2011. Including our 8 new cases, LAHS has been reported in 74 cases. The disease mostly occurs in young adults, with a female to male sex ratio of 1.4. Associated conditions mostly include autoimmune diseases such as systemic lupus erythematosus and infectious diseases. Bleeding is a frequent feature (89% of cases), while arterial and/or venous thrombosis is less common (13%). Factor II level is severely decreased at diagnosis (median value, 11%; range, 1%-40%). LAHS associated with autoimmune diseases is more persistent than LAHS associated with infection, and hemorrhagic complications are more common. Corticosteroids should be considered the first-line treatment, but the thrombotic risk strongly increases during treatment because of the improvement of factor II level. Despite the fact that 50% of patients develop severe bleeding, the mortality rate is <5%, after a median follow-up of 13 months (range, 0.5-252 mo). LAHS associated with autoimmune diseases should be diagnosed and managed carefully because the disease is persistent and severe hemorrhagic complications are common.
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Affiliation(s)
- Karin Mazodier
- From the Service de Médecine Interne (KM, JRH), Hôpital La Conception, Marseille; Service de Médecine Interne (LA, AM, NCC, JH, CF, JCP, ZA), Hôpital Pitié-Salpêtrière and Université Pierre et Marie Curie, Paris; Laboratoire d'Hématologie (GP), CHU de Grenoble, Grenoble; Service de Rhumatologie (EL), CHR d'Orléans, Orléans; Service de Rhumatologie (PG), CHUG Hôpital Sud, Grenoble; Service de Médecine Interne (HC, EH), Hôpital Claude Huriez, Lille; and Service de Néphro-Pédiatrie (PN), Hôpital Necker, Paris; France
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23
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Abstract
Lupus anticoagulants are autoantibodies that are associated with an increased risk of thromboembolic events and adverse pregnancy outcomes. They are identified by a systematic, laboratory-based approach that includes the following steps: 1) prolongation of a phospholipid-dependent screening assay, 2) demonstration of an inhibitory activity by mixing studies with healthy pooled plasma, and 3) documentation that the inhibitory activity is phospholipid dependent. Laboratory testing can be complicated by several variables, however, including preanalytical factors, multiple reagents and testing platforms, and difficulties with interpreting the results. Guidelines have been developed through several professional organizations that build upon the steps listed above and provide guidance to improve the reproducibility of test results. This article reviews the guidelines developed by the Lupus Anticoagulant/Phospholipid Dependent Antibodies Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis and addresses several common issues encountered during testing for these clinically relevant autoantibodies.
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24
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Rochanda L, Del Zoppo GJ, Feinstein DI, Liebman HA. Approach to the treatment, characterization and diagnosis of an acquired auto-antibody directed against factors prothrombin, factor X and factor IX: a case report and review of the literature. Haemophilia 2011; 18:102-7. [PMID: 21707870 DOI: 10.1111/j.1365-2516.2011.02553.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Bleeding disorders secondary to acquired non-inhibitory antibodies directed against vitamin K-dependent coagulation proteins are rare. In this report, the authors describe a patient with a low grade lymphoma who presented with a fatal acquired bleeding manifestation and abnormal hemostatic studies resulting from deficiencies in both prothrombin and factor X. Patient plasma samples were collected and studied for the presence of an acquired inhibitor. Levels of plasma coagulation proteins were measured using immunoassay. Patient anti-prothrombin immunoglobulin G was isolated and binding to prothrombin, prothrombin F1.2, factors IX and X was evaluated using immunoblots and competition immunoassay. Prolongation in the prothrombin time and activated partial thromboplastin time suggested a factor deficiency in the common pathway of coagulation. Functional and antigenic levels of both prothrombin and factor X were decreased. An IgG subtype-4 antibody was isolated from patient plasma using affinity chromatography on prothrombin-sepharose. This antibody was found to bind to a common metal-ion-dependent conformational epitope found on the γ-carboxyglutamic acid (Gla) domain of prothrombin, factor X and factor IX. This report represents the first description of an acquired bleeding disorder resulting from a unique cross-reactive auto-antibody against a common metal-ion-dependent antigenic structure on the Gla-domain of the vitamin K-dependent proteins.
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Affiliation(s)
- L Rochanda
- Division of Hematology, Department of Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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25
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Appert-Flory A, Fischer F, Amiral J, Monpoux F. Lupus Anticoagulant-Hypoprothrombinemia syndrome (HLAS): report of one case in a familial infectious context. Thromb Res 2009; 126:e139-40. [PMID: 20006899 DOI: 10.1016/j.thromres.2009.11.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Revised: 11/10/2009] [Accepted: 11/20/2009] [Indexed: 10/20/2022]
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26
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Abstract
The antiphospholipid syndrome (APS) is an autoimmune disorder presenting with tissue injury in various organs attributed to large or small vessel thrombosis or, in some instances, possible nonthrombotic inflammatory mechanisms, associated with in vitro evidence of antibodies to certain proteins, or proteinphospholipid complexes. Although the pathophysiology, diagnosis, and management of APS may seem clear and straightforward from a distance, closer inspection reveals a more complex, incomplete, and uncertain image. This article reviews the evolution of APS from the first description of lupus anticoagulant to the current criteria used to guide clinical research, critiques laboratory methods used to identify autoantibodies, comments on prognosis and management, and summarizes insights into the pathophysiology of this elusive disorder.
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Affiliation(s)
- Charles Eby
- Department of Pathology and Immunology, Washington University School of Medicine, Campus box 8118, St. Louis, MO 63110, USA.
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27
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White RH, Gosselin RC. Testing for Thrombophilia: Pitfalls, Limitations, and Marginal Impact on Treatment Duration Recommendations. ACTA ACUST UNITED AC 2009; 76:303-13. [DOI: 10.1002/msj.20111] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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28
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Management of a Patient with Lupus Anticoagulant and Antiphospholipid Syndrome for Off-Pump Coronary Artery Bypass Grafting Using the Hepcon® System. Anesth Analg 2009; 108:1116-9. [PMID: 19299773 DOI: 10.1213/ane.0b013e3181994f88] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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29
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Taddio A, Brescia AC, Lepore L, Rose' CD. Steady improvement of prothrombin levels after cyclophosphamide therapy in pediatric lupus anticoagulant hypoprothrombinemia syndrome (LAHPS). Clin Rheumatol 2007; 26:2167-2169. [PMID: 17516128 DOI: 10.1007/s10067-007-0647-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2007] [Revised: 04/30/2007] [Accepted: 05/01/2007] [Indexed: 11/26/2022]
Abstract
Lupus anticoagulant hypoprothrombinemia syndrome (LAHPS) is a rare acquired disorder associated with several different conditions but mostly with systemic lupus erythematosus (SLE). LAHPS probably results from the presence of anti-Factor II antibodies, which usually counterbalance the prothrombotic effect of the lupus anticoagulant (LAC). In fact, Factor II deficiency in SLE is invariably associated with the presence of LAC. No consensus exists for the treatment of LAHPS. Corticosteroids, with or without the addition of vitamin K or blood products, have been a successful first-line treatment. Immunoglobulin (IVIG) treatment has been shown to be effective in the setting of acute bleeding. However, in some patients, conservative treatment is not enough to control bleeding, and the addition of immunosuppressive therapy, usually azathioprine, is needed. In our patients, Factor II deficiency reappeared after tapering steroids. Both children achieved normal Factor II levels with cyclophosphamide. This effect was long-lasting, a phenomenon that has not been documented in children prior to this report.
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Affiliation(s)
- Andrea Taddio
- Department of Sciences of Reproduction and Development, University of Trieste, IRCCS Burlo Garofolo, Istituto per l'Infanzia, via dell'Istria 65/1, Trieste, 34100, Italy
- Division of Rheumatology, A.I. duPont Hospital for Children, Department of Paediatrics, Thomas Jefferson University, 1600 Rockland Road, Wilmington, DE, 19803, USA
| | - AnneMarie C Brescia
- Division of Rheumatology, A.I. duPont Hospital for Children, Department of Paediatrics, Thomas Jefferson University, 1600 Rockland Road, Wilmington, DE, 19803, USA
| | - Loredana Lepore
- Department of Sciences of Reproduction and Development, University of Trieste, IRCCS Burlo Garofolo, Istituto per l'Infanzia, via dell'Istria 65/1, Trieste, 34100, Italy
| | - Carlos D Rose'
- Division of Rheumatology, A.I. duPont Hospital for Children, Department of Paediatrics, Thomas Jefferson University, 1600 Rockland Road, Wilmington, DE, 19803, USA.
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Clauser S, Fischer AM, Darnige L. Quinidine-induced lupus anticoagulant, hypoprothrombinemia, and antiprothrombin antibodies. Am J Hematol 2007; 82:330. [PMID: 16955465 DOI: 10.1002/ajh.20750] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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31
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Lim S, Zuha R, Burt T, Chacko J, Scott R, Mainwaring CJ. Life-threatening bleeding in a patient with a lupus inhibitor and probable acquired factor VII deficiency. Blood Coagul Fibrinolysis 2007; 17:667-71. [PMID: 17102654 DOI: 10.1097/01.mbc.0000252602.17401.7d] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We report the case of a 71-year-old man on warfarin for chronic atrial fibrillation presenting with a massive spontaneous soft tissue bleed. Despite reversing the effects of warfarin with large doses of intravenous vitamin K and fresh frozen plasma, bleeding continued, and his prothrombin time and activated partial thromboplastin time remained prolonged. The prothrombin time and activated partial thromboplastin time failed to correct with 50% normal plasma. Further investigations confirmed a lupus inhibitor with low levels of factors II, V, VII and XI. Factor II, V and XI levels normalized, however, when the patient's plasma was diluted 1:16 in buffer, suggesting the lupus inhibitor may have been interfering with these factor assays causing artefactual low results. Factor VII levels remained consistently low at all dilutions. The patient subsequently died following a massive left haemothorax despite surgical intervention and treatment with activated recombinant factor VII concentrate. We presumed the primary problem was bleeding from a local vascular lesion but the patient was never well enough to undergo confirmatory angiography. This case highlights the fact that patients with lupus inhibitors can develop severe haemorrhagic complications, and illustrates the complexities involved in both the investigation and treatment of abnormal bleeding in these patients.
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Affiliation(s)
- Sean Lim
- Department of Haematology, Royal Bournemouth Hospital, Bournemouth, UK
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32
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Mizumoto H, Maihara T, Hiejima E, Shiota M, Hata A, Seto S, Atsumi T, Koike T, Hata D. Transient antiphospholipid antibodies associated with acute infections in children: a report of three cases and a review of the literature. Eur J Pediatr 2006; 165:484-8. [PMID: 16552544 DOI: 10.1007/s00431-006-0117-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2005] [Revised: 02/13/2006] [Accepted: 02/14/2006] [Indexed: 10/24/2022]
Abstract
We describe two previously healthy children who had multiple ecchymoses several days after acute infection. In both cases, the prothrombin time (PT) and the activated partial thromboplastin time (APTT) were prolonged. Further examinations revealed the presence of lupus anticoagulant (LA), phosphatidylserine-dependent antiprothrombin antibodies (aPS/PT), and low serum complement. In both cases, we confirmed the presence of a serum immune complex. The patients' symptoms improved spontaneously within 1 week, and all laboratory data normalized within several months. We also describe another asymptomatic case positive for LA and aPS/PT presumably associated with cytomegalovirus infection. The prevalence of transient antiphospholipid antibodies associated with viral infections in children must be much higher than we expected. We have to take it into consideration when we see abnormal coagulation results, but the occurrence of significant bleeding symptoms is rare.
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Affiliation(s)
- H Mizumoto
- Department of Pediatrics, Kitano Hospital, Tazuke Kofukai Medical Research Institute, 2-4-20 Ohgimachi, Kita-ku, Osaka, 530-8480, Japan
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33
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Abstract
In cases of suspected non-accidental injury in children, it is vital that a haematologist confirms the presence or absence of a haemostatic disorder so that the child welfare and legal systems can make accurate judgements regarding the cause of isolated injuries. The present paper will discuss commonly used methods for the diagnosis of coagulation disorders in children, and will describe how the investigation of easy bruising and bleeding can be highly problematic. For instance, some frequently used tests for the assessment of haemostasis in children are insensitive, inappropriate, or based on values derived from adult populations. Furthermore, artefact is a frequent problem, and many cases present with a negative family history of bleeding. Therefore, the role played by the haematologist in potential child abuse cases is an essential yet challenging one.
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Affiliation(s)
- Ri Liesner
- Department of Haematology & Oncology and Children's Haemophilia Comprehensive Care Centre, Great Ormond Street Children's Hospital & Institute of Child Health, London, UK
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