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Garg A, Gupta G, Gupta R, Mishra RK. Converging pathways: acquired von Willebrand disease in systemic lupus erythematosus with antiphospholipid antibodies presenting with persistent menstrual bleeding. BMJ Case Rep 2024; 17:e260824. [PMID: 39231562 DOI: 10.1136/bcr-2024-260824] [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] [Indexed: 09/06/2024] Open
Abstract
We present a case of a woman in her 20s with inadequately treated systemic lupus erythematosus (SLE). She presented with heavy menstrual bleeding, along with nasal and gum bleeding worsening over 3 months. There was no bleeding history in her family, childhood, dental procedures or childbirth. Evaluation ruled out structural causes, revealing prolonged activated partial thromboplastin time (incomplete correction on mixing studies), normal prothrombin time, moderate thrombocytopenia, and lupus anticoagulant and anti-phosphatidylserine/prothrombin antibody positivity twice, 12 weeks apart. Further evaluation showed very low von Willebrand factor (vWF) levels (<5%). She was treated with pulse methylprednisolone for 3 days, resulting in complete symptom resolution and improvement in vWF levels to 130%. The absence of bleeding history, family history, presence of very low vWF and its response to corticosteroids led to a diagnosis of acquired vWF syndrome as the cause of mucosal bleeding in an SLE patient with concomitant positive antiphospholipid antibody. She was discharged on hydroxychloroquine, mycophenolate mofetil and tapering oral corticosteroids.
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Affiliation(s)
- Ankush Garg
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Gaurav Gupta
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ranjan Gupta
- Department of Rheumatology, All India Institute of Medical Sciences, New Delhi, India
| | - Ritesh Kumar Mishra
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
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Jaouen S, Mingant F, Pan-Petesch B, Lippert E, Jeanpierre E, Galinat H. A rare case of acquired von Willebrand syndrome type 2B: diagnosis, treatment, and underlying pathophysiology. Res Pract Thromb Haemost 2024; 8:102516. [PMID: 39228434 PMCID: PMC11369413 DOI: 10.1016/j.rpth.2024.102516] [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] [Received: 04/05/2024] [Revised: 06/14/2024] [Accepted: 06/18/2024] [Indexed: 09/05/2024] Open
Abstract
Background Acquired von Willebrand syndrome (AVWS) is a rare bleeding disorder that usually mimics type 1 or 2A von Willebrand disease (VWD). Key Clinical Question Can AVWS mimic the phenotype of type 2B VWD? Clinical Approach A 64-year-old male patient presented with thrombocytopenia, normal routine hemostasis results, and normal VWF antigen and factor VIII levels but reduced von Willebrand factor (VWF) activity (31 IU/dL). The ristocetin-induced platelet aggregation test showed paradoxical aggregation at low doses of ristocetin, suggesting type 2B VWD, but no deleterious sequence variation was found in either the VWF or GP1BA genes, compatible with AVWS. Serum protein electrophoresis revealed a monoclonal immunoglobulin G antibody. Conclusion This AVWS with a 2B phenotype VWD was probably related to a monoclonal immunoglobulin G antibody causing a VWF conformational change, resulting in increased affinity to platelet glycoprotein-Ib. In the event of surgery or bleeding, treatment with vonicog alfa seems to be the best option for this patient.
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Affiliation(s)
- Simon Jaouen
- Hematology Laboratory, Brest University Hospital, Brest, France
| | - Fanny Mingant
- Hematology Laboratory, Brest University Hospital, Brest, France
| | | | - Eric Lippert
- Hematology Laboratory, Brest University Hospital, Brest, France
| | | | - Hubert Galinat
- Hematology Laboratory, Brest University Hospital, Brest, France
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Alamin AA. Thrombocytopenia and Bleeding in Chronic Kidney Disease: A Case of Acquired Von Willebrand Syndrome. Cureus 2024; 16:e65834. [PMID: 39219970 PMCID: PMC11363469 DOI: 10.7759/cureus.65834] [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: 07/31/2024] [Indexed: 09/04/2024] Open
Abstract
Acquired von Willebrand disease is a rare condition with laboratory findings similar to the inherited type, which can be autosomal dominant or recessive. This case describes a rather rare clinical situation of a 65-year-old man with stage 4 chronic kidney disease who also had acquired von Willebrand syndrome (AvWS) with thrombocytopenia and bleeding. The patient had a complaint of easy fatigability, easy bruising, and prolonged bleeding from small cuts. The patient's initial laboratory workup included thrombocytopenia, which on further evaluation established the diagnosis of AvWS due to chronic kidney disease. More specific examination revealed reduced activity of the von Willebrand factor. The patient was managed with desmopressin and von Willebrand factor concentrates and there was a transient rise in platelet count and relief of symptoms of bleeding. This case underlines the importance of AvWS in any differential diagnosis of thrombocytopenia in patients with chronic kidney disease. This report aims to provide recommendations for early identification and management of AvWS to improve the outcome.
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Affiliation(s)
- Amin A Alamin
- Pathology, College of Medicine, Taif University, Taif, SAU
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Reardon B, Pasalic L, Favaloro EJ. The Intriguing Relationships of von Willebrand Factor, ADAMTS13 and Cardiac Disease. J Cardiovasc Dev Dis 2021; 8:jcdd8090115. [PMID: 34564132 PMCID: PMC8468839 DOI: 10.3390/jcdd8090115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/07/2021] [Accepted: 09/13/2021] [Indexed: 12/26/2022] Open
Abstract
von Willebrand factor (VWF) is an adhesive protein involved in primary hemostasis and facilitates platelet adhesion to sites of vascular injury, thereby promoting thrombus formation. VWF exists in plasma as multimers of increasing size, with the largest (high molecular weight; HMW) expressing the greatest functional activity. A deficiency of VWF is associated with a bleeding disorder called von Willebrand disease (VWD), whereas an excess of VWF, in particular the HMW forms, is associated with thrombosis. ADAMTS13 (a disintegrin and metalloproteinase with thrombospondin type 1 motif-13), also known as VWF-cleaving protease, functions to moderate the activity of VWF by cleaving multimers of VWF and limiting the expression of the largest multimers of VWF. A deficiency of ADAMTS13 is therefore associated with an excess of (HMW forms of) VWF, and thus thrombosis. Indeed, any disturbance of the VWF/ADAMTS13 ratio or ‘axis’ may be associated with pathophysiological processes, including prothrombotic tendency. However, both thrombosis or bleeding may be associated with such disturbances, depending on the presenting events. This review evaluates the relationship of VWF and ADAMTS13 with cardiac disease, including cardiac failure, and associated pathophysiology.
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Affiliation(s)
- Benjamin Reardon
- Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital, Westmead, NSW 2145, Australia; (B.R.); (L.P.)
| | - Leonardo Pasalic
- Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital, Westmead, NSW 2145, Australia; (B.R.); (L.P.)
- NSW Health Pathology, Westmead, NSW 2145, Australia
- Westmead Clinical School, University of Sydney, Westmead, NSW 2145, Australia
- Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Emmanuel J. Favaloro
- Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital, Westmead, NSW 2145, Australia; (B.R.); (L.P.)
- NSW Health Pathology, Westmead, NSW 2145, Australia
- Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW 2145, Australia
- School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW 2650, Australia
- Correspondence: ; Tel.: +61-2-8890-6618
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Hattori N, Kuroda M, Katano H, Takuma T, Ito T, Arai N, Yanai R, Sekizuka T, Ishii S, Miura Y, Tokunaga T, Watanabe H, Nomura N, Eguchi J, Hasegawa H, Nakamaki T, Wakita T, Niki Y. Candidatus Mycoplasma haemohominis in Human, Japan. Emerg Infect Dis 2021; 26:11-19. [PMID: 31855136 PMCID: PMC6924906 DOI: 10.3201/eid2601.190983] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Hemotropic mycoplasmas are common pathogens in animals, but it remains unclear what role these pathogens play in human infections. We report clinical and biologic characterization of Candidatus Mycoplasma haemohominis infection in a 42-year-old man in Japan. The patient had severe hemophagocytic syndrome 1 month after an accidental needlestick injury. Metagenomic deep sequencing identified Candidatus M. haemohominis and determined its draft genome for an isolate from serum of the patient. A high copy number of the Candidatus M. haemohominis genome was detected in serum and bone marrow samples. Electron microscopy examination showed morphologic characteristics of Candidatus M. haemohominis. Levofloxacin monotherapy induced resistance caused by a gyrase A gene mutation in the quinolone resistance–determining region, but a combination treatment with moxifloxacin and minocycline was effective. We identified Candidatus M. haemohominis in a patient who had life-threatening symptoms related to multiple organ infection. Human infection with this mycoplasma might occur more frequently than has been generally recognized.
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Laurente RM, Mohammed GDF. Asymptomatic Severe Acquired von Willebrand's Syndrome in Association With a Glioblastoma Multiforme: A Case Report. Cureus 2020; 12:e11667. [PMID: 33391905 PMCID: PMC7769738 DOI: 10.7759/cureus.11667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
To our knowledge, this is the first reported case of a severe acquired von Willebrand’s Syndrome (avWS) in association with a Glioblastoma Multiforme (GBM). We report a case of a 70-year-old male who presented to the hospital with neurologic findings secondary to a thalamic mass and subsequent hydrocephalus but without any prior history of any bleeding diathesis. A biopsy and septum pellucidotomy was considered and coagulation parameters from pre-operative chemistry returned deranged. Further investigations for bleeding disorders have been performed and an avWS was diagnosed due to the low levels of factor VIII, vWF:Ag, and vWF:RiCoF. The patient responded to a single dose of IVIG and hence the contemplated procedure has been performed. Subsequently, a histopathologic diagnosis of a GBM was made and unfortunately no further treatment was pursued due to the patient's poor response to the initial surgical intervention.
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Affiliation(s)
- Raphael M Laurente
- Neurological Surgery, Salford Royal NHS Foundation Trust, Manchester, GBR
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Thromboelastometry as a diagnostic tool in mild bleeding disorders: A prospective cohort study. Eur J Anaesthesiol 2019; 36:457-465. [PMID: 30950901 DOI: 10.1097/eja.0000000000000985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Major guidelines emphasise the potential of visco-elastic methods to overcome the limitations of conventional laboratory assays in the peri-operative setting. Their sensitivity regarding mild bleeding disorders (MBDs), the most common bleeding disorders in the general population, is however unknown. OBJECTIVE The aim of this study was to investigate the sensitivity of thromboelastometry for diagnosis of MBD. DESIGN A single-centre prospective cohort study. SETTING Haematology outpatient unit of a tertiary general hospital in Central Switzerland. PATIENTS All consecutive patients referred over a 32-month period with a suspected bleeding disorder were included and thromboelastometry was conducted using a ROTEM delta (EXTEM, INTEM and FIBTEM). Diagnostic work-up was performed according to current guidelines including the ISTH bleeding assessment tool (ISTH BAT). MAIN OUTCOME MEASURES Distribution of clotting time (CT) and maximum clot firmness (MCF) results in relation to the presence of MBD. RESULTS Two hundred and seventeen patients were assessed; the median [IQR] age was 39 years [28 to 57]; 151 patients were women (70%). MBD was diagnosed in 97 patients (45%), no MBD was found in 100 patients (46%) and a systemic disorder recognised in 20 patients (9%). Presence of MBD was not associated with a significant difference in thromboelastometry variables (0.2 s in CT EXTEM, 95% CI -2.3 to 2.7; -0.2 mm in MCF EXTEM, 95% CI -1.8 to 1.5; -0.7 s in CT INTEM, 95% CI -12.6 to 11.2; 0.6 mm in MCF INTEM, 95% CI -1.2 to 1.3; 0.8 mm in MCF FIBTEM, 95% CI -1.6 to 1.4) and most results were within the established reference ranges. CONCLUSION Our data did not support the use of thromboelastometry as a diagnostic tool in patients with MBD.
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Bowyer AE, Goodfellow KJ, Seidel H, Westhofen P, Stufano F, Goodeve A, Kitchen S, Makris M. Evaluation of a semi-automated von Willebrand factor multimer assay, the Hydragel 5 von Willebrand multimer, by two European Centers. Res Pract Thromb Haemost 2018; 2:790-799. [PMID: 30349898 PMCID: PMC6178608 DOI: 10.1002/rth2.12141] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 06/14/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The phenotypic diagnosis of von Willebrand disease (VWD) is a multistep process with classification dependent on the quantification of von Willebrand factor (VWF) multimeric structure. VWF multimer analysis is a technically challenging, lengthy and non-standardised assay, usually performed in specialist laboratories. Recently, a new semi-automated multimer assay, the Hydragel 5 von Willebrand multimers (H5VWM) has become available. OBJECTIVES This study, performed in two European centres, compared existing in-house multimer assays to the H5VWM in individuals with and without VWD. RESULTS Overall agreement of 91.1% was observed in 74 individuals with normal VWF levels, 57 patients grouped as type 1 VWD, 33 type 2A, 16 type 2B, 28 type 2M, 11 type 2N. Patients tested following Desmopressin or VWF concentrate, with thrombotic thrombocytopenic purpura and acquired von Willebrand syndrome were also evaluated. Many of the discrepancies between methods were in patients with genetic mutations linked to more than one type of VWD including p.R1374C/H and p.R1315C. Quantifiable multimer results were available within one working day. Densitometry improved the interpretation of the multimers with slight structural variations that were not apparent by visual inspection of the in-house method. CONCLUSIONS 5VWM was a rapid, sensitive, standardised assay which used existing technology and could be included as an initial screen of VWF multimers in a VWD diagnostic algorithm in conjunction with traditional multimer analysis.
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Affiliation(s)
- Annette E. Bowyer
- Department of CoagulationSheffield Haemophilia and Thrombosis CentreSheffieldUK
| | - Karen J. Goodfellow
- Department of CoagulationSheffield Haemophilia and Thrombosis CentreSheffieldUK
| | - Holger Seidel
- Centrum für Blutgerinnungsstörungen und TransfusionsmedizinBonnGermany
| | - Philipp Westhofen
- Centrum für Blutgerinnungsstörungen und TransfusionsmedizinBonnGermany
| | - Francesca Stufano
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico and Luigi Villa FoundationMilanItaly
| | - Anne Goodeve
- Department of Infection, Immunity and Cardiovascular DiseaseUniversity of Sheffield Medical SchoolSheffieldUK
| | - Stephen Kitchen
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico and Luigi Villa FoundationMilanItaly
| | - Michael Makris
- Department of CoagulationSheffield Haemophilia and Thrombosis CentreSheffieldUK
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Kalbhenn J, Schlagenhauf A, Rosenfelder S, Schmutz A, Zieger B. Acquired von Willebrand syndrome and impaired platelet function during venovenous extracorporeal membrane oxygenation: Rapid onset and fast recovery. J Heart Lung Transplant 2018; 37:985-991. [PMID: 29650295 DOI: 10.1016/j.healun.2018.03.013] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 02/18/2018] [Accepted: 03/14/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Bleeding contributes to the high mortality of venovenous extracorporeal membrane oxygenation (vvECMO). The development of acquired von Willebrand syndrome (AVWS) has been identified as relevant pathology during ECMO. This study was performed to determine the onset of AVWS after implantation and the recovery of von Willebrand factor (VWF) parameters after explantation of ECMO in a large cohort of patients. METHODS VWF parameters of 59 patients treated with vvECMO at a university ECMO center were obtained before ECMO implantation, during therapy, and after explantation. In a subgroup of patients, light transmission aggregometry of platelets and flow-cytometric quantification of platelet granule secretion were performed. RESULTS All patients developed severe AVWS hours after implantation of vvECMO. After explantation, AVWS recovered within 3 hours in 60%, within 6 hours in 86%, and in all patients within 1 day. Aggregometry showed hypoaggregability of platelets after stimulation with ADP, ristocetin, collagen, and epinephrine. Flow-cytometric platelet analyses revealed severely reduced expression of CD62 and CD63. CONCLUSIONS All patients during vvECMO support rapidly develop AVWS and platelet dysfunction, resulting in severe impairment of coagulation. After explantation, AVWS overwhelmingly recovers within hours, resulting in a hypercoagulative state. These findings augment the need for novel extracorporeal technologies with reduced shear stress, and shift the emphasis for intense anti-coagulation during ECMO instead to a time-point after explantation.
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Affiliation(s)
- Johannes Kalbhenn
- Department of Anesthesiology and Critical Care, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Axel Schlagenhauf
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Simone Rosenfelder
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Axel Schmutz
- Department of Anesthesiology and Critical Care, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Barbara Zieger
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Heilmann C, Trummer G, Beyersdorf F, Brehm K, Berchtold-Herz M, Schelling J, Geisen U, Zieger B. Acquired Von Willebrand syndrome in patients on long-term support with HeartMate II. Eur J Cardiothorac Surg 2017; 51:587-590. [PMID: 28082469 DOI: 10.1093/ejcts/ezw348] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 08/19/2016] [Indexed: 01/15/2023] Open
Abstract
Objectives Impaired binding of Von Willebrand factor (VWF) to platelets and to collagen due to acquired Von Willebrand syndrome (AVWS) is associated with support from a ventricular assist device (VAD) and can contribute to bleeding tendencies in patients with VADs. The onset of AVWS has been shown to occur immediately after VAD implantation. Our aim was to determine long-term data on AVWS in VAD patients. Methods We analysed 278 data sets of 74 patients on HeartMate II (HMII) support for 3-80 months after implantation (11.2 ± 12.1, median 6.3 months.). Ristocetin cofactor activity (VWF:RCo), collagen binding capacity (VWF:CB), VWF antigen (VWF:Ag) and the ratios of VWF:RCo/VWF:Ag and VWF:CB/VWF:Ag were determined. Further, the presence of high molecular weight (HMW) multimers of VWF was investigated. Results Abnormally low values of VWF:RCo/VWF:Ag and VWF:CB/VWF:Ag were found in 69% and 97% of blood samples, respectively. Only ten of 181 multimer analyses showed a normal pattern, and HMW multimers were present in both specimens in only one of the 74 patients. No significant changes in these parameters were observed over time. The VWF:CB/VWF:Ag ratio correlated with the multimer patterns, whereas the VWF:RCo/VWF:Ag ratio seemed to be less sensitive for AVWS. Conclusions Our data indicate that AVWS is a typical phenomenon in patients with VAD support and that there are no time-dependent changes in these parameters apparent in most patients on long-term support with HMII.
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Affiliation(s)
- Claudia Heilmann
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Georg Trummer
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Kerstin Brehm
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Michael Berchtold-Herz
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Johannes Schelling
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich Geisen
- Institute for Clinical Chemistry and Laboratory Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Is Extracorporeal CO2 Removal Really “Safe” and “Less” Invasive? Observation of Blood Injury and Coagulation Impairment during ECCO2R. ASAIO J 2017; 63:666-671. [DOI: 10.1097/mat.0000000000000544] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Aluganti Narasimhulu C, Nandave M, Bonilla D, Singaravelu J, Sai-Sudhakar CB, Parthasarathy S. Circulating platelet aggregates damage endothelial cells in culture. J Surg Res 2017; 213:90-99. [PMID: 28601338 DOI: 10.1016/j.jss.2017.02.011] [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: 09/26/2016] [Revised: 12/02/2016] [Accepted: 02/14/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Presence of circulating endothelial cells (CECs) in systemic circulation may be an indicator of endothelial damage and/or denudation, and the body's response to repair and revascularization. Thus, we hypothesized that aggregated platelets (AgPlts) can disrupt/denude the endothelium and contribute to the presence of CEC and EC-derived particles (ECDP). METHODS Endothelial cells were grown in glass tubes and tagged with/without 0.5 μm fluorescent beads. These glass tubes were connected to a mini-pump variable-flow system to study the effect of circulating AgPlts on the endothelium. ECs in glass tube were exposed to medium alone, nonaggregated platelets (NAgPlts), AgPlts, and 90 micron polystyrene beads at a flow rate of 20 mL/min for various intervals. Collected effluents were cultured for 72 h to analyze the growth potential of dislodged but intact ECs. Endothelial damage was assessed by real time polymerase chain reaction (RT-PCR) for inflammatory genes and Western blot analysis for von Willebrand factor. RESULTS AND CONCLUSION No ECs and ECDP were observed in effluents collected after injecting medium alone and NAgPlts, whereas AgPlts and Polybeads drastically dislodged ECs, releasing ECs and ECDP in effluents as the time increased. Effluents collected when endothelial cell damage was seen showed increased presence of von Willebrand factor as compared to control effluents. Furthermore, we analyzed the presence of ECs and ECDPs in heart failure subjects, as well as animal plasma samples. Our study demonstrates that circulating AgPlts denude the endothelium and release ECs and ECDP. Direct mechanical disruption and shear stress caused by circulating AgPlts could be the underlying mechanism of the observed endothelium damage.
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Affiliation(s)
| | - Mukesh Nandave
- Department of Pharmacology, SPP School of Pharmacy and Technology Management, SVKM's NMIMS, Mumbai, India
| | - Diana Bonilla
- Division of Cardiothoracic Surgery, The Ohio State University Medical Center, Columbus, Ohio
| | - Janani Singaravelu
- Division of Cardiothoracic Surgery, The Ohio State University Medical Center, Columbus, Ohio
| | | | - Sampath Parthasarathy
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, Florida.
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Fidalgo T, Ferreira G, Oliveira AC, Silva Pinto C, Martinho P, Mendes MJ, Duarte M, Salvado R, Ribeiro ML. Acquired von Willebrand syndrome in haematologic malignancies - how the clinical-laboratory correlation improves a challenging diagnosis - a case series. Haemophilia 2017; 23:e361-e365. [PMID: 28497886 DOI: 10.1111/hae.13243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2017] [Indexed: 11/26/2022]
Affiliation(s)
- T Fidalgo
- Serviço de Hematologia Clínica, Centro Hospitalar Universitãrio de Coimbra, Coimbra, Portugal
| | - G Ferreira
- Serviço de Hematologia Clínica, Centro Hospitalar Universitãrio de Coimbra, Coimbra, Portugal
| | - A C Oliveira
- Serviço de Hematologia Clínica, Centro Hospitalar Universitãrio de Coimbra, Coimbra, Portugal
| | - C Silva Pinto
- Serviço de Hematologia Clínica, Centro Hospitalar Universitãrio de Coimbra, Coimbra, Portugal
| | - P Martinho
- Serviço de Hematologia Clínica, Centro Hospitalar Universitãrio de Coimbra, Coimbra, Portugal
| | - M J Mendes
- Serviço de Hematologia Clínica, Centro Hospitalar Universitãrio de Coimbra, Coimbra, Portugal
| | - M Duarte
- Serviço de Hematologia Clínica, Centro Hospitalar Universitãrio de Coimbra, Coimbra, Portugal
| | - R Salvado
- Serviço de Hematologia Clínica, Centro Hospitalar Universitãrio de Coimbra, Coimbra, Portugal
| | - M L Ribeiro
- Serviço de Hematologia Clínica, Centro Hospitalar Universitãrio de Coimbra, Coimbra, Portugal
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15
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RicoRios N, Bowles L, Ayling RM. Multiple myeloma and acquired von Willebrand disease: a combined cause of preanalytical interference causing gel formation? Ann Clin Biochem 2017; 55:181-184. [PMID: 28490182 DOI: 10.1177/0004563217710488] [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: 11/15/2022]
Abstract
We report a patient with acquired von Willebrand disease, associated with multiple myeloma. At one stage in his illness, we were unable to analyse a sample sent in a serum separator tube, due to the presence of a gel within the separated serum layer. We suggest this was due to anomalous position of the gel because of the density of the sample caused by its high total protein concentration, exacerbated by fibrin strand formation because of inhibition of appropriate fibrin clot formation secondary to clotting disorder.
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Affiliation(s)
- Natividad RicoRios
- 1 Department of Clinical Biochemistry, Barts Health NHS Trust, London, UK
| | - Louise Bowles
- 2 Department of Haematology, Barts Health NHS Trust, London, UK
| | - Ruth M Ayling
- 1 Department of Clinical Biochemistry, Barts Health NHS Trust, London, UK
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Jennes E, Guggenberger D, Zotz R, Thompson L, Brümmendorf TH, Koschmieder S, Jost E. Perioperative intravenous immunoglobulin treatment in a patient with severe acquired von Willebrand syndrome: case report and review of the literature. Clin Case Rep 2017; 5:664-670. [PMID: 28469872 PMCID: PMC5412814 DOI: 10.1002/ccr3.890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 12/23/2016] [Accepted: 01/04/2017] [Indexed: 02/02/2023] Open
Abstract
Acquired von Willebrand syndrome may be related to plasma cell dyscrasia and can cause severe bleeding complications. Treatment, for example, with intravenous immunoglobulins may be indicated in selected cases. Physicians treating plasma cell dyscrasia have to be aware of bleeding complications in these patients, and clarification is necessary.
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Affiliation(s)
- Eva Jennes
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation Medical Faculty RWTH Aachen University Aachen Germany
| | | | - Rainer Zotz
- Institute for Laboratory Medicine, Blood Coagulation and Transfusion Medicine (LBT) Düsseldorf Germany
| | - Lora Thompson
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation Medical Faculty RWTH Aachen University Aachen Germany
| | - Tim H Brümmendorf
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation Medical Faculty RWTH Aachen University Aachen Germany
| | - Steffen Koschmieder
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation Medical Faculty RWTH Aachen University Aachen Germany
| | - Edgar Jost
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation Medical Faculty RWTH Aachen University Aachen Germany
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Di Sabatino A, Ambaglio C, Aronico N, Ghidelli N, Lenti MV, Gamba G, Corazza GR. Acquired von Willebrand syndrome in inflammatory bowel disease. Haemophilia 2017; 23:e231-e233. [PMID: 28314057 DOI: 10.1111/hae.13209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2017] [Indexed: 01/30/2023]
Affiliation(s)
- A Di Sabatino
- Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - C Ambaglio
- Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - N Aronico
- Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - N Ghidelli
- Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - M V Lenti
- Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - G Gamba
- Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - G R Corazza
- Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
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Charles M, Fontoura R, Sugalski G. Early recognition of intraventricular hemorrhage in the setting of thrombocytosis in the emergency department. Open Access Emerg Med 2016; 8:29-33. [PMID: 27307770 PMCID: PMC4886302 DOI: 10.2147/oaem.s98440] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Thrombocytosis is frequently encountered as an incidental laboratory finding since isolated thrombocytosis is often asymptomatic. Even though thrombocytosis is benign and self-limiting in most cases, it can at times result in thrombosis or hemorrhage. The most common type of thrombocytosis is reactive (secondary) thrombocytosis and can be due to infections, trauma, surgery, or occult malignancy. Since thrombocytosis is a known risk factor for thrombosis, it is commonly a concern for ischemic stroke and myocardial infarction. Much less common are hemorrhagic events associated with thrombocytosis. Studies have shown that when hemorrhage is present in patients with thrombocytosis, it is most often seen in the setting of chronic myelogenous leukemia and essential thrombocythemia. In essential thrombocythemia, the overall risk of bleeding and thrombosis is 0.33% per patient-year and 6.6% per patient-year, respectively. In the general population, the risk of bleeding and thrombosis is 0% and 1.2%, respectively. The present study is a case report of an 83-year-old man who presented to the emergency department with hypertension and headache, who was then found to have significant thrombocytosis (platelets >1,000×10(9)/L) and acute right intraventricular hemorrhage without any signs of neurological deficits, or evidence of vascular malformations or mass. We present this case report for review and discussion of some of the challenges and considerations associated with the management of such patients.
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Affiliation(s)
- Marvinia Charles
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Romy Fontoura
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Gregory Sugalski
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
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19
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Distinct mechanisms account for acquired von Willebrand syndrome in plasma cell dyscrasias. Ann Hematol 2016; 95:945-57. [PMID: 27040683 DOI: 10.1007/s00277-016-2650-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 03/18/2016] [Indexed: 02/01/2023]
Abstract
Acquired von Willebrand syndrome (AVWS) is a rare bleeding disorder that may cause life-threatening hemorrhages in patients with plasma cell dyscrasias (PCDs). Early diagnosis and treatment require a thorough understanding of its underlying pathophysiology. Two patients with IgG MGUS presented with dramatically decreased plasma von Willebrand factor (VWF) and a severe type-1 pattern on multimer analysis. A prompt response to intravenous immunoglobulins (IVIG), but not to VWF/FVIII, was consistent with accelerated immunologic clearance of plasma VWF. Another IgG MGUS patient showed a type-2 pattern and a less pronounced response to IVIG, suggesting that additional mechanism(s) contributed to AVWS evolution. In a patient with Waldenström's macroglobulinemia and severe depletion of plasma VWF, multimer analysis indicated association of the IgM paraprotein with VWF before, but not after plasmapheresis, resulting in destruction of the agarose gel and a characteristically distorted band structure of VWF multimers. A type-2 pattern with highly abnormal VWF triplets and laboratory evidence of excessive fibrinolytic activity suggested that plasmin-mediated VWF degradation contributed to AVWS in a patient with multiple myeloma (MM) and AL amyloidosis. Finally, in a patient with IgG MM, maximally prolonged PFA-100® closure times and a specific defect in ristocetin-induced platelet agglutination, both of which resolved after remission induction, indicated interference of the paraprotein with VWF binding to platelet GPIb. Importantly, in none of the six patients, circulating autoantibodies to VWF were detected by a specific in-house ELISA. In summary, when evaluating PCD patients with severe bleeding symptoms, AVWS due to various pathogenic mechanisms should be considered.
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Acquired Von Willebrand's Syndrome in Systemic Lupus Erythematosus. Case Rep Hematol 2014; 2014:208597. [PMID: 25544909 PMCID: PMC4273461 DOI: 10.1155/2014/208597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 11/13/2014] [Indexed: 01/13/2023] Open
Abstract
Acquired von Willebrand syndrome (AVWS) is an uncommon, underdiagnosed, and heterogeneous disease which is increasingly recognized as a cause of bleeding diatheses. Systemic lupus erythematosus (SLE) is an infrequent cause of AVWS. Herein, we report a case of AVWS diagnosed during the initial presentation of SLE in a previously healthy young man with no family history of bleeding diathesis who presented with worsening epistaxis, gastrointestinal bleeding, and anasarca. He was found to have severe anemia and prolonged activated partial thromboplastin time (aPTT) with severely decreased levels of von Willebrand factor (VWF) measurements in addition to markedly decreased factor VIII levels. Further evaluation revealed nephrotic syndrome and interstitial lung disease due to SLE. He initially received combination therapy with intravenous immunoglobulin (IVIG) and von Willebrand factor/factor VIII concentrates without significant improvement. Treatment with steroids, cyclophosphamide, and rituximab was followed by clinical improvement evidenced by cessation of bleeding. The short follow-up did not allow us to definitely prove the therapeutic effect of immunosuppressive treatment on AVWS in SLE patients. This case adds to the literature supporting the relationship between AVWS and SLE and highlights the importance of combination therapy in the treatment of severe AVWS as well as the role of IVIG, cyclophosphamide, and rituximab in AVWS associated with SLE.
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ADAMTS13 content and VWF multimer and triplet structure in commercially available VWF/FVIII concentrates. Biologicals 2014; 43:117-22. [PMID: 25498752 DOI: 10.1016/j.biologicals.2014.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 10/23/2014] [Accepted: 11/13/2014] [Indexed: 11/21/2022] Open
Abstract
ADAMTS13 is a metalloproteinase that cleaves von Willebrand factor (VWF) into smaller multimers in vivo. This cleavage creates both the typical multimeric size distribution and the characteristic triplet band distribution of VWF. Here we analysed ADAMTS13 content, VWF multimeric size distribution and VWF triplet structure in five commercial VWF/factor VIII (FVIII) concentrates. The relative distribution of ADAMTS13 activity values corresponded well to the ADAMTS13 antigen values for all examined concentrates except Haemate HS®, which had markedly higher ADAMTS13 antigen/activity ratio, with Fanhdi® and Haemate HS® displaying the most intense ADAMTS13 signal. Interestingly, ADAMTS13 levels did not correlate with the high molecular weight multimer content of the concentrates, but did correlate with VWF triplet distribution. Densitometric quantification showed that Wilate®, Immunate® and Willfact® displayed human plasma-like VWF triplet distribution, whereas Fanhdi® and Haemate HS® showed enhanced content of the faster migrating triplet band, which corresponded well to their higher ADAMTS13 content. In summary, Immunate®, Willfact® and Wilate® had lower levels of ADAMTS13 antigen and activity and exhibited a plasma-like VWF triplet structure. Fanhdi® and Haemate HS® had higher ADAMTS13 content and an altered triplet structure. The possible impact of these observations on function and clinical efficacy of VWF/FVIII concentrates is discussed.
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Kalbhenn J, Schmidt R, Nakamura L, Schelling J, Rosenfelder S, Zieger B. Early diagnosis of acquired von Willebrand Syndrome (AVWS) is elementary for clinical practice in patients treated with ECMO therapy. J Atheroscler Thromb 2014; 22:265-71. [PMID: 25186021 DOI: 10.5551/jat.27268] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIMS Acquired Von Willebrand syndrome (AVWS) is an acquired bleeding disorder that has been reported to aggravate bleeding complications in patients with ventricular assist devices or aortic stenosis. AVWS is characterized by the loss of the high-molecular-weight (HMW) multimers of Von Willebrand factor (VWF) with consequent impaired VWF binding to platelets and collagen. The aim of this study was to investigate the development of AVWS in patients treated with veno-venous ECMO (extracorporeal membrane oxygenation) support. METHODS We examined the presence of AVWS in adult patients receiving ECMO support (n=18) and control subjects treated without ECMO support (n=18). The diagnosis of AVWS was made based on the ratio of collagen-binding capacity to VWF-antigen (VWF:CB/VWF:Ag) and a VWF multimeric analysis. In addition, bleeding episodes were monitored. RESULTS All patients supported with ECMO developed AVWS. AVWS was identified in the early period after ECMO implantation, i.e. within 24 hours after ECMO implantation. In 17 patients, the VWF:CB/VWF:Ag ratio was significantly reduced and HMW multimers were severely missing, and 17 of the 18 patients developed bleeding complications and required transfusions of blood, FFP and/or platelet concentrates.In addition, nine patients without an ECMO device were investigated (prior to ECMO implantation: n=2, after ECMO explantation: n=7). CONCLUSIONS In this study, all patients treated with ECMO support developed AVWS, and AVWS was detectable within 24 hours after ECMO implantation. However, the AVWS was reversible after ECMO explantation. Making an early diagnosis of AVWS and providing appropriate treatment may reduce the incidence of life-threatening bleeding.
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Affiliation(s)
- Johannes Kalbhenn
- Department of Anaesthesiology and Critical Care Medicine, Freiburg University Medical Center
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Cugno M, Tedeschi A, Siboni SM, Stufano F, Depetri F, Franchi F, Griffini S, Peyvandi F. Salvage therapy with high dose Intravenous Immunoglobulins in acquired Von Willebrand Syndrome and unresponsive severe intestinal bleeding. Exp Hematol Oncol 2014; 3:15. [PMID: 24926417 PMCID: PMC4055248 DOI: 10.1186/2162-3619-3-15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 05/15/2014] [Indexed: 11/23/2022] Open
Abstract
A 91-year-old woman affected with acquired Von Willebrand (VW) syndrome and intestinal angiodysplasias presented with severe gastrointestinal bleeding (hemoglobin 5 g/dl). Despite replacement therapy with VW factor/factor VIII concentrate qid, bleeding did not stop (eleven packed red blood cell units were transfused over three days). High circulating levels of anti-VW factor immunoglobulin M were documented immunoenzimatically. Heart ultrasound showed abnormalities of the mitral and aortic valves with severe flow alterations. When intravenous immunoglobulins were added to therapy, prompt clinical and laboratory responses occurred: complete cessation of bleeding, raise in hemoglobin, VW factor antigen, VW ristocetin cofactor and factor VIII levels as well as progressive reduction of the anti-VWF autoantibody levels.
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Affiliation(s)
- Massimo Cugno
- Department of Pathophysiology and Transplantation, University of Milan, Milano, Italy ; Medicina Interna, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Alberto Tedeschi
- Unità Operativa di Allergologia e Immunologia Clinica, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Simona Maria Siboni
- Department of Pathophysiology and Transplantation, University of Milan, Milano, Italy ; Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, and Luigi Villa Foundation, Milan, Italy
| | - Francesca Stufano
- Department of Pathophysiology and Transplantation, University of Milan, Milano, Italy ; Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, and Luigi Villa Foundation, Milan, Italy
| | - Federica Depetri
- Department of Pathophysiology and Transplantation, University of Milan, Milano, Italy ; Medicina Interna, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Franca Franchi
- Department of Pathophysiology and Transplantation, University of Milan, Milano, Italy ; Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, and Luigi Villa Foundation, Milan, Italy
| | - Samantha Griffini
- Department of Pathophysiology and Transplantation, University of Milan, Milano, Italy ; Medicina Interna, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Flora Peyvandi
- Department of Pathophysiology and Transplantation, University of Milan, Milano, Italy ; Medicina Interna, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy ; Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, and Luigi Villa Foundation, Milan, Italy
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Chu SK, McCormick Z, Hwang S, Sliwa JA, Rydberg L. Outcomes of Acute Inpatient Rehabilitation of Patients With Left Ventricular Assist Devices. PM R 2014; 6:1008-12. [DOI: 10.1016/j.pmrj.2014.05.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 04/03/2014] [Accepted: 05/03/2014] [Indexed: 01/31/2023]
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Stulak JM, Lee D, Haft JW, Romano MA, Cowger JA, Park SJ, Aaronson KD, Pagani FD. Gastrointestinal bleeding and subsequent risk of thromboembolic events during support with a left ventricular assist device. J Heart Lung Transplant 2014; 33:60-4. [DOI: 10.1016/j.healun.2013.07.020] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Revised: 07/24/2013] [Accepted: 07/31/2013] [Indexed: 11/16/2022] Open
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Abstract
Acquired von Willebrand syndrome (AVWS) is a rare bleeding disorder that is characterized by structural or functional alterations in von Willebrand factor (VWF) caused by a range of lymphoproliferative, myeloproliferative, cardiovascular, autoimmune, and other disorders. The pathogenic mechanisms responsible for the VWF abnormalities depend on the underlying condition, but include clearance due to binding of paraproteins, inhibition of VWF, adsorption to the surface of platelets, increased fluid shear stress, and resultant proteolysis or, more rarely, decreased synthesis. The diagnosis and treatment of AVWS are complicated by the need for multiple laboratory tests and the management of bleeding risk in a typically elderly population with serious underlying conditions that predispose towards thrombosis. Recently developed diagnostic algorithms, based on standard laboratory assays, may assist clinicians with the diagnostic workup and help differentiate between AVWS and von Willebrand disease (VWD) types 1 and 2. AVWS should be considered in all patients with new-onset bleeding whenever laboratory findings suggest VWD, particularly in the presence of an AVWS-associated disorder. AVWS testing is also recommended prior to surgery or an intervention with a high risk of bleeding in any individual with an AVWS-associated disorder. Treatment of the underlying condition using immunosuppressants, surgery, or chemotherapy, can lead to remission of AVWS in some individuals and should always be considered. Strategies to prevent and/or treat bleeding episodes should also be in place, including the use of VWF-containing factor VIII concentrates, desmopressin and tranexamic acid. Treatment success will depend largely on the underlying pathogenesis of the disorder.
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Affiliation(s)
- Andreas Tiede
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany.
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27
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Pasotti F, Martini G, Caimi L, Ricotta D. von Willebrand Factor multimers profiling with a semi-automated system. Electrophoresis 2013; 34:818-24. [DOI: 10.1002/elps.201200538] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 10/31/2012] [Accepted: 10/31/2012] [Indexed: 11/08/2022]
Affiliation(s)
- Fabio Pasotti
- Department of Diagnostics; Spedali Civili of Brescia; Brescia; Italy
| | - Giuliana Martini
- Department of Diagnostics; Spedali Civili of Brescia; Brescia; Italy
| | - Luigi Caimi
- Department of Biomedical Sciences and Biotechnologies; Faculty of Medicine; University of Brescia; Brescia; Italy
| | - Doris Ricotta
- Department of Biomedical Sciences and Biotechnologies; Faculty of Medicine; University of Brescia; Brescia; Italy
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28
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Weiss DR, Eiche C, Hupke C, Schellerer VS, Keller AK, Strasser EF, Ringwald J, Zimmermann R, Eckstein R. The structure of the von Willebrand factor is not altered in patients with colorectal carcinoma. Colorectal Dis 2012; 14:1500-6. [PMID: 22507880 DOI: 10.1111/j.1463-1318.2012.03049.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIM Elevated levels of von Willebrand factor (VWF) are often observed in many diseases including colorectal cancer, but this finding is not definite. The aim of our study was to examine the change in VWF multimer distribution in patients with colorectal cancer. METHOD We randomly selected nine patients from each of the four Union for International Cancer Control (UICC) stages of colon cancer. VWF antigen (VWF:Ag), VWF-cleaving protease ADAMTS-13 level and factor VIII activity (FVIII:C) were determined. The multimer distribution of VWF was visualized using electrophoretic multimer analysis. RESULTS The VWF multimer structure was normal with no difference between the four UICC stages. There was no significant increase in VWF:Ag and FVIII:C levels in the more advanced UICC stages. There was no significant difference in the ADAMTS-13 level according to the UICC stage. CONCLUSION There was no change in the VWF multimer distribution to indicate acquired von Willebrand disease.
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Affiliation(s)
- D R Weiss
- Department of Transfusion Medicine and Haemostaseology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany.
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29
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Wiegand G, Hofbeck M, Zenker M, Budde U, Rauch R. Bleeding diathesis in Noonan syndrome: is acquired von Willebrand syndrome the clue? Thromb Res 2012; 130:e251-4. [PMID: 22985731 DOI: 10.1016/j.thromres.2012.08.314] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Revised: 08/10/2012] [Accepted: 08/28/2012] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Noonan syndrome (NS) is characterized by dysmorphic facies, short stature and congenital heart defects. Various haemostatic disorders have been described in NS patients, but not all were related to bleeding, which itself is present in up to 65%. Several subgroups of NS - especially those with PTPN11 mutation - are associated with pulmonary stenosis. As it is known that some heart defects are prone to a shear stress related destruction of the von Willebrand factor as an important haemostatic component, we aimed to find out, whether the pulmonary stenosis could be responsible for such a mechanism in NS patients. PATIENTS, METHODS AND RESULTS We investigated the haemostatic system in 15 children with genetically proven NS (14 with PTPN11, one with SOS1 mutation). Platelet count, basic coagulation parameters, fibrinogen and antithrombin were normal in all patients, none had a relevant reduction of coagulation factor activities. Five patients had pulmonary valve stenosis with systolic gradients>60 mmHg. In three of them a deficiency of the high molecular weight multimers and a pathologic collagen-binding capacity were detected, suggesting acquired von Willebrand syndrome. Nine of our patients indicated a relevant bleeding diathesis and complained of easy bruising, three reported spontaneous gum bleeding. IN CONCLUSION the destruction of the von Willebrand factor could explain the bleeding in some of the NS patients with pulmonary valve stenosis. Our finding is of clinical relevance since most of these patients require either interventional cardiac catheterization or open heart surgery which may be complicated by the haemorrhagic tendency.
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Affiliation(s)
- Gesa Wiegand
- Department of Pediatric Cardiology, University Children´s Hospital, Hoppe-Seyler-Str. 1, 72076 Tuebingen, Germany.
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Colella MP, Duarte GC, Marques JFC, De Paula EV. Haemostatic management of extreme challenges to haemostasis in acquired von Willebrand syndrome. Haemophilia 2012; 18:e188-91. [PMID: 22356103 DOI: 10.1111/j.1365-2516.2012.02769.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- M P Colella
- Hematology and Hemotherapy Center, University of Campinas, Campinas, SP, Brazil.
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Acquired von Willebrand syndrome in patients with extracorporeal life support (ECLS). Intensive Care Med 2011; 38:62-8. [PMID: 21965100 DOI: 10.1007/s00134-011-2370-6] [Citation(s) in RCA: 159] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 07/25/2011] [Indexed: 12/12/2022]
Abstract
PURPOSE Extracorporeal life support (ECLS) is used for patients with refractory heart failure with or without respiratory failure. This temporary support is provided by blood pumps which are connected to large vessels. Bleeding episodes are a typical complication in patients with ECLS. Recently, several studies illustrated that acquired von Willebrand syndrome (AVWS) can contribute to bleeding tendencies in patients with long-term ventricular assist devices (VAD). AVWS is characterized by loss of the high molecular weight (HMW) multimers of von Willebrand factor (VWF) as a result of high shear stress and leads to impaired binding of VWF to platelets and to subendothelial matrix. Since ECLS and VAD share several features, we investigated patients with ECLS for AVWS. METHODS We analyzed 32 patients with ECLS and 19 of them without support. To diagnose AVWS, ratios of ristocetin cofactor activity (VWF:RCo) and collagen binding capacity (VWF:CB) to VWF antigen (VWF:Ag) were employed in conjunction with multimeric analysis. RESULTS Reduced VWF:RCo/VWF:Ag ratios were identified in 28 ECLS patients. Furthermore, VWF:CB/VWF:Ag ratios were decreased in 31 patients. HMW multimers of VWF were missing in the same 31 patients. Thus, 31 of 32 ECLS patients presented with AVWS. Twenty-two of the 32 patients suffered from bleeding complications. Without support, AVWS was not detectable in any analyzed patient. CONCLUSION Our data indicate that AVWS is a typical disorder in patients with ECLS. We hypothesize that AVWS could contribute to aggravation of bleeding tendencies in ECLS patients.
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Shetty S, Kasatkar P, Ghosh K. Pathophysiology of acquired von Willebrand disease: a concise review. Eur J Haematol 2011; 87:99-106. [PMID: 21535159 DOI: 10.1111/j.1600-0609.2011.01636.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Acquired von Willebrand disease (AVWD) is a rare, underdiagnosed hemorrhagic disorder, which is similar to congenital VWD with regard to the clinical and laboratory parameters; however, it is found in individuals with no positive family history and has no genetic basis. The etiology is varied, the commonest being hematoproliferative disorders and cardiovascular disorders. Other disorders associated with AVWD are autoimmune disorders such as systematic lupus erythematosus, hypothyroidism, and neoplasia, or it may also be drug induced. In quite a few cases, the etiology is unknown. The pathogenic mechanisms are different in different underlying disorders or they may be overlapping among these disorders. Some of the proposed mechanisms include the development of autoantibodies, selective absorption of high molecular weight von Willebrand factor (VWF) multimers, non-selective absorption of VWF, mechanical destruction of VWF under high shear stress, and increased proteolysis. This report presents a concise review of the pathophysiological mechanisms of AVWD in these various underlying conditions.
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Affiliation(s)
- Shrimati Shetty
- National Institute of Immunohaematology (ICMR), KEM Hospital, Parel, Mumbai, India.
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Djunic I, Elezovic I, Ilic V, Tomin D, Suvajdzic-Vukovic N, Bila J, Antic D, Vidovic A, Milosevic-Jovcic N. Acquired von Willebrand syndrome in multiple myeloma. ACTA ACUST UNITED AC 2011; 16:209-12. [PMID: 21756536 DOI: 10.1179/102453311x12953015767617] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Acquired von Willebrand syndrome (AvWS) is an uncommon complication of multiple myeloma (MM), and it is believed to be connected with paraprotein. The aim of this study was to determine the incidence of AvWS in patients with MM, and estimate the role of paraprotein in its occurrence. The study included 40 patients with MM. The plasma level of paraprotein, platelet adhesion on glass pearls, plasma von Willebrand factor antigen concentration, and ristocetin-induced platelet aggregation (RIPA) were measured initially. Absence of RIPA was found in six patients with MM (15%); however, all six of them had normal levels of von Willebrand factor antigen. Paraprotein was isolated from the serum of these patients. Platelet aggregation was measured in six healthy donors before and after addition of the isolated paraprotein. RIPA was significantly decreased in healthy donors in the presence of paraprotein (P<0·001). The same test was repeated with added human immunoglobulins for intravenous use without any change in RIPA. A significant negative correlation between plasma paraprotein level and RIPA was found (P<0·001). These investigations have shown that paraprotein is associated with AvWS in patients with MM.
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Affiliation(s)
- Irena Djunic
- Clinic for Haematology, Clinical Center of Serbia, Belgrade, Serbia.
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35
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Leimkühler K, Bach F, Kuhlmann S, Feidicker B, Heim MU, Susemihl C, Schmidt B, Mertzlufft F. [Acquired von Willebrand's disease type 2A following arteriovenous fistula for haemodialysis?]. Hamostaseologie 2011; 31:118-22. [PMID: 21152674 DOI: 10.5482/ha-1129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Acquired von Willebrand's disease (aVWD) is considered to be an underestimated cause of unexplained bleeding. Adsorption of von Willebrand factor (VWF) to tumour cells or hydroxyethyl starch and elimination of VWF by autoantibodies as well as shear stress-induced mechanical alteration of VWF with concomitant cleavage by enzymes may lead to an acquired deficiency of VWF and a bleeding disorder. We report a 39-year-old woman who developed spontaneous bleeding five years after surgical creation of an arteriovenous fistula (AVF) for haemodialysis treatment. AVWD type 2A was diagnosed after successful renal transplantation. One year after surgical closure of the AVF, the aVWD could not be verified again. Thus, the aVWD may have developed because of altered blood flow and shear stress inside the arteriovenous fistula.
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Affiliation(s)
- K Leimkühler
- Klinik für Anästhesiologie, Intensiv-, Notfall-, Transfusionsmedizin und Schmerztherapie, Evangelisches Krankenhaus Bielefeld.
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36
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Acquired Von Willebrand syndrome is an early-onset problem in ventricular assist device patients. Eur J Cardiothorac Surg 2011; 40:1328-33; discussion 1233. [PMID: 21515067 DOI: 10.1016/j.ejcts.2011.03.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Revised: 02/10/2011] [Accepted: 03/02/2011] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Acquired Von Willebrand syndrome (AVWS) can contribute to bleeding complications in patients with ventricular assist devices (VADs). AVWS results from shear stress, which causes unfolding of the high-molecular-weight (HMW) multimers of Von Willebrand factor (VWF) with subsequent cleavage. Loss of the HMW multimers of VWF is the leading finding in AVWS. In consequence, binding of VWF to collagen and to platelets is impaired. The onset of AVWS after VAD implantation is not yet determined. We examined VAD patients for presence of an AVWS in the early, intermediate, and late phase after VAD implantation. METHODS Patients with a biventricular Thoratec-PVAD(®) (BVAD, n = 6) or a left-ventricular HeartMateII(®) (HMII, n = 11) were analyzed prior to VAD implantation and after 1, 3, 14, 30, and 60 days. Diagnosis of AVWS based on VWF:ristocetin cofactor activity/VWF:VWF antigen (VWF:RCo/VWF:Ag), collagen-binding capacity:VWF antigen (VWF:CB/VWF:Ag), and multimeric analysis. In addition, we analyzed the number of bleeding episodes, which required surgical intervention. RESULTS No patient had an AVWS prior to VAD implantation. An AVWS was identified already in the very early postoperative period, that is, in almost all patients on the first day and in all patients on the third day. The AVWS was also detected in the majority of patients in the further course. Nine of all 17 patients suffered bleeding complications and required a total of 25 interventions due to hemorrhages. Forty percent of re-interventions were carried out within the first 10 days after implantation; five of these were necessary within the first 24h. CONCLUSION The AVWS is present already in the early postoperative phase after VAD implantation. Therefore, reduced shear stress has to be an important feature of newly developed assist devices in the future.
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Pruthi RK. Hypertrophic obstructive cardiomyopathy, acquired von Willebrand syndrome, and gastrointestinal bleeding. Mayo Clin Proc 2011; 86:181-2. [PMID: 21364110 PMCID: PMC3046936 DOI: 10.4065/mcp.2011.0023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Rajiv K. Pruthi
- Address correspondence to Rajiv K. Pruthi, MBBS, Division of Hematopathology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ()
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Crow S, Chen D, Milano C, Thomas W, Joyce L, Piacentino V, Sharma R, Wu J, Arepally G, Bowles D, Rogers J, Villamizar-Ortiz N. Acquired von Willebrand syndrome in continuous-flow ventricular assist device recipients. Ann Thorac Surg 2010; 90:1263-9; discussion 1269. [PMID: 20868825 DOI: 10.1016/j.athoracsur.2010.04.099] [Citation(s) in RCA: 265] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Revised: 04/19/2010] [Accepted: 04/23/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Bleeding is a major cause of morbidity in recipients of continuous-flow left ventricular assist devices (CF-LVAD). A better understanding of the impact of CF-LVAD support on the hemostatic profile is necessary to establish better strategies for anticoagulation therapy and risk assessment for bleeding complications. A prospective multicenter study was conducted to characterize von Willebrand factor (vWF) profiles in patients undergoing CF-LVAD implantation. METHODS Blood samples were collected before and after CF-LVAD implantation from 37 patients between July 2008 and April 2009 at Duke University and the University of Minnesota. Blood samples were analyzed for vWF, platelet and collagen-binding ability. The presence of high-molecular-weight (HMW) vWF multimers were detected through gel electrophoresis, and deficiency was graded on a scale of 0 (normal) to 3 (severe loss). RESULTS All 37 patients exhibited significant loss of HMW vWF multimers within 30 days of CF-LVAD implantation. Ten of the 37 patients experienced bleeding complications after CF-LVAD placement. CONCLUSIONS All CF-LVAD recipients had acquired von Willebrand syndrome after LVAD placement, demonstrated by reduced or absent HMW vWF multimer levels. However, not all recipients had bleeding complications. These findings suggest that loss of HMW vWF multimers alone cannot predict bleeding risk. Further refinement of laboratory techniques and a larger follow-up is required to identify risk factors for bleeding in CF-LVAD recipients.
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Affiliation(s)
- Sheri Crow
- Division of Pediatric Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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Hanratty JM, Cowan CG. Acquired von Willebrand disease secondary to hypothyroidism: a rare cause for postextraction hemorrhage. ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY, AND ENDODONTICS 2010; 110:337-40. [PMID: 20656531 DOI: 10.1016/j.tripleo.2010.04.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 04/09/2010] [Accepted: 04/10/2010] [Indexed: 11/20/2022]
Abstract
Acquired von Willebrand's Disease (AvWD) is a rare disease with a clinical pattern similar to the congenital disorder that typically presents later in life in patients with no prior history of prolonged bleeding. It has been shown to be related to a number of common medical conditions including lymphoproliferative and myeloproliferative diseases, cardiovascular disease, immunological disorders, neoplasia, drugs, and miscellaneous disorders. We present 2 cases where post- and interoperative hemorrhage were the initial sign of AvWD and a previously undiagnosed hypothyroid condition was the precipitating factor. There are no similar cases reported within the dental literature. We highlight the importance of taking a medical history and bleeding history in all patients about to undergo oral surgery, periodontal surgery, or implant placement. Increased vigilance is suggested when patients, who have been otherwise well, present with abnormal bleeding problems as this may be a manifestation of an underlying undiagnosed disease.
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Affiliation(s)
- John M Hanratty
- Department of Oral Surgery, School of Dentistry, Royal Victoria Hospital, Belfast, Northern Ireland.
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40
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Ojeda-Uribe M, Caron C, Itzhar-Baikian N, Debliquis A. Bortezomib effectiveness in one patient with acquired von Willebrand syndrome associated to monoclonal gammopathy of undetermined significance. Am J Hematol 2010; 85:396. [PMID: 20425807 DOI: 10.1002/ajh.21692] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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41
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Successful imatinib mesylate therapy for acquired von Willebrand syndrome in chronic myelogenous leukemia. Leuk Res 2009; 33:1723-4. [DOI: 10.1016/j.leukres.2009.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Revised: 05/14/2009] [Accepted: 05/16/2009] [Indexed: 11/21/2022]
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Affiliation(s)
- Adam Cuker
- Clinical Pathological Conference Series, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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43
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Nageswara Rao AA, Rodriguez V, Long ME, Winters JL, Nichols WL, Pruthi RK. Transient neonatal acquired von Willebrand syndrome due to transplacental transfer of maternal monoclonal antibodies. Pediatr Blood Cancer 2009; 53:655-7. [PMID: 19459202 DOI: 10.1002/pbc.22084] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Although typically a disorder of adults, acquired von Willebrand syndrome (AVWS) is increasingly being recognized in the pediatric population in association with congenital cardiac diseases, certain neoplasia, and hypothyroidism. Transplacental transfer of maternal immunoglobulin G (IgG) antibodies as a cause of neonatal disorders in infants born to mothers with autoimmune conditions has been reported. We describe the diagnosis and peripartum clinical management of AVWS due to monoclonal gammopathy of undetermined significance (MGUS) and the first reported case of transient neonatal AVWS due to transplacental transfer of maternal IgG antibodies.
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Mayerhofer M, Haushofer A, Kyrle PA, Chott A, Müllner C, Quehenberger P, Worel N, Traby L, Eichinger S. Mechanisms underlying acquired von Willebrand syndrome associated with an IgM paraprotein. Eur J Clin Invest 2009; 39:833-6. [PMID: 19572993 DOI: 10.1111/j.1365-2362.2009.02177.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Acquired von Willebrand (vW) syndrome is a rare bleeding disorder which is frequently associated with immunological, malignant or cardiovascular disorders. The underlying pathomechanisms, particularly in patients with IgM monoclonal gammopathies, often remain unknown. We report a patient with indolent small B-cell lymphoma (immunocytoma) and plasmacytic differentiation with an IgM kappa paraprotein who was admitted with retroperitoneal haematoma. Medical history and coagulation testing were consistent with acquired vW syndrome. vW immunohistochemistry showed normal cytoplasmic labelling of endothelial cells and megakaryocytes, whereas the lymphomatous infiltrate was negative. Acquired vW syndrome due to adsorption of vW factor on malignant cells was thus excluded. In the multimeric analysis, all multimers were present similar to that in type 1 vW syndrome, but the triplet structures were blurred. The bands on serum immunofixation electrophoresis were also atypically broadened, which suggested complex formation between the IgM and vW factor. Immunoprecipitation studies showed that the 176-kDa proteolytic fragment of vW factor co-precipitated with the IgM paraprotein in the patient but not in the controls, suggesting a specific interaction between vW factor and the paraprotein in the patient. The patient required surgery and was successfully managed by chemotherapy consisting of rituximab and fludarabin as well as plasma exchange.
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Affiliation(s)
- M Mayerhofer
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, Vienna, Austria
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Kozek-Langenecker SA. Influence of fluid therapy on the haemostatic system of intensive care patients. Best Pract Res Clin Anaesthesiol 2009; 23:225-36. [PMID: 19653441 DOI: 10.1016/j.bpa.2008.11.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Haemostatic alterations associated with the use of fluids are related to non-specific dilutional effects and colloid-specific effects, such as acquired von Willebrand syndrome, inhibition of platelet function and fibrin polymerization. Judging by currently available evidence, dextran, hetastarch and pentastarch have a more pronounced impact than tetrastarch, gelatin and albumin. In patients with hypocoagulability, tetrastarch appears to be a suitable volume expander due to its high safety index and volume efficacy. Gelatins have lower inhibitory effects on clot strength compared with tetrastarch, but their volume efficacy is also lower. Dextrans are potent anticoagulants with a high risk for adverse reactions. Albumin has negligible effects on haemostasis, but low volume efficacy and costs limit the use of a blood product as a routine volume replacement fluid. To avoid potential acidosis-induced changes in haemostasis, plasma-adapted carrier solutions may be used instead of saline-based solutions.
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Affiliation(s)
- Sibylle A Kozek-Langenecker
- Department of Anaesthesiology, General Intensive Care and Pain Management, Vienna Medical University, Währinger Gürtel 18-20, 1090 Vienna, Austria.
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ALVAREZ MT, JIMENEZ-YUSTE V, GRACIA J, QUINTANA M, HERNANDEZ-NAVARRO F. Acquired von Willebrand syndrome. Haemophilia 2008; 14:856-8. [DOI: 10.1111/j.1365-2516.2008.01764.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Manfredi E, van Zaane B, Gerdes VEA, Brandjes DPM, Squizzato A. Hypothyroidism and acquired von Willebrand's syndrome: a systematic review. Haemophilia 2008; 14:423-33. [PMID: 18218015 DOI: 10.1111/j.1365-2516.2007.01642.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Acquired von Willebrand's syndrome type I is the supposed main underlying cause of bleeding tendency in hypothyroid patients. The purpose of this systematic review was to summarize the published evidence on the association between hypothyroidism and acquired von Willebrand's syndrome. All published clinical epidemiological and interventional studies, case reports and in vitro studies that investigated the association between hypothyroidism and acquired von Willebrand's syndrome were identified by a computer-assisted search of the MEDLINE and EMBASE electronic databases. A quality assessment was performed for clinical epidemiological studies. A total of 41 papers were included. A total of 22 epidemiological in vivo studies, two in vitro studies and 47 case reports were finally analyzed. No high quality in vivo study was identified. Almost all bleeding episodes described in the case reports were mucocutaneous. von Willebrand factor (VWF) antigen value was available for 23 patients: median value 28 U/dL (range: 4-45); VWF activity was available for 24 patients: median value 28.5 U/dL (range: <3-55); factor VIII activity was available for 16 patients: median value 47 U/dL (range: 9-74). Acquired von Willebrand's syndrome may be the main factor responsible for bleeding diathesis in overt hypothyroid patients. Even if bleeding episodes are mainly mild and mucocutaneous, blood transfusion, drug administration or surgical procedure may be required.
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Affiliation(s)
- E Manfredi
- Department of Clinical Medicine, University of Insubria, Varese, Italy
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Sucker C, Scharf RE, Zotz RB. Use of Recombinant Factor VIIa in Inherited and Acquired von Willebrand Disease. Clin Appl Thromb Hemost 2007; 15:27-31. [DOI: 10.1177/1076029607310920] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Recombinant factor VIIa (rFVIIa) is increasingly used outside the labeled indications for the treatment of life-threatening bleeding episodes after failure of respective standard therapy. In this article, the authors focus on the use of the agent in patients with inherited or acquired von Willebrand disease (vWD). Although the current experience is sparse, published cases indicate the high efficacy of rFVIIa for the treatment of patients refractory to conventional treatment. The agent may be used in patients with congenital vWD complicated by alloantibodies directed against substituted von Willebrand factor or in the presence of concomitant hemostatic defects as well as acquired vWD with hitherto limited therapeutic options. Controlled clinical studies are necessary to define the use of rFVIIa in this clinical setting.
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Affiliation(s)
- Christoph Sucker
- Department of Hemostasis and Transfusion Medicine, Heinrich Heine University Medical Center, Düsseldorf, Germany
| | - Rüdiger E. Scharf
- Department of Hemostasis and Transfusion Medicine, Heinrich Heine University Medical Center, Düsseldorf, Germany
| | - Rainer B. Zotz
- Department of Hemostasis and Transfusion Medicine, Heinrich Heine University Medical Center, Düsseldorf, Germany, -duesseldorf.de
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KOZEK-LANGENECKER SIBYLLEA, SCHARBERT GISELA. Effects of hydroxyethyl starches on hemostasis. ACTA ACUST UNITED AC 2007. [DOI: 10.1111/j.1778-428x.2007.00074.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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