1
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Perioperative diagnosis and impact of acquired von Willebrand syndrome in infants with congenital heart disease. Blood 2023; 141:102-110. [PMID: 36054926 DOI: 10.1182/blood.2022015699] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 07/06/2022] [Accepted: 08/11/2022] [Indexed: 01/28/2023] Open
Abstract
Acquired von Willebrand syndrome (aVWS) has been reported in patients with congenital heart diseases associated with shear stress caused by significant blood flow gradients. Its etiology and impact on intraoperative bleeding during pediatric cardiac surgery have not been systematically studied. This single-center, prospective, observational study investigated appropriate diagnostic tools of aVWS compared with multimer analysis as diagnostic criterion standard and aimed to clarify the role of aVWS in intraoperative hemorrhage. A total of 65 newborns and infants aged 0 to 12 months scheduled for cardiac surgery at our tertiary referral center from March 2018 to July 2019 were included in the analysis. The glycoprotein Ib M assay (GPIbM)/von Willebrand factor antigen (VWF:Ag) ratio provided the best predictability of aVWS (area under the receiver operating characteristic curve [AUC], 0.81 [95% CI, 0.75-0.86]), followed by VWF collagen binding assay/VWF:Ag ratio (AUC, 0.70 [0.63-0.77]) and peak systolic echocardiographic gradients (AUC, 0.69 [0.62-0.76]). A cutoff value of 0.83 was proposed for the GPIbM/VWF:Ag ratio. Intraoperative high-molecular-weight multimer ratios were inversely correlated with cardiopulmonary bypass (CPB) time (r = -0.57) and aortic cross-clamp time (r = -0.54). Patients with intraoperative aVWS received significantly more fresh frozen plasma (P = .016) and fibrinogen concentrate (P = .011) than those without. The amounts of other administered blood components and chest closure times did not differ significantly. CPB appears to trigger aVWS in pediatric cardiac surgery. The GPIbM/VWF:Ag ratio is a reliable test that can be included in routine intraoperative laboratory workup. Our data provide the basis for further studies in larger patient cohorts to achieve definitive clarification of the effects of aVWS and its potential treatment on intraoperative bleeding.
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2
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Wang S, Hu Q, Chen Y, Hu X, Tang N, Zhang A, Liu A. Case report: A case of acquired von Willebrand syndrome as onset clinical presentation of systemic lupus erythematosus manifested as epistaxis and pulmonary hemorrhage. Front Pediatr 2022; 10:1013764. [PMID: 36204663 PMCID: PMC9530141 DOI: 10.3389/fped.2022.1013764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 09/02/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Acquired von Willebrand syndrome (AVWS) is a less common bleeding disorder, primarily manifested as mild to moderate mucocutaneous bleeding and laboratory tests are similar to hereditary von Willebrand disease (VWD). AVWS is secondary to other diseases, and systemic lupus erythematosus (SLE) is a relatively rare cause. CASE PRESENTATION We report a case of AVWS as onset clinical presentation of SLE manifested as epistaxis and pulmonary hemorrhage. A 13-year-old male child presented to the hospital with a six-month history of recurrent epistaxis and a one-month history of anemia. Routine blood tests demonstrated severe normocytic anemia and normal platelet count. Von Willebrand test revealed a significantly lower level. High-resolution chest computed tomography (CT) showed patchy ground glass opacities consistent with hemorrhagic changes. After ruling out the family history, the patient was diagnosed with AVWS. Additional tests confirmed positive antinuclear and anti-Sm antibodies. The underlying SLE was diagnosed and treated with methylprednisolone with disease recovery. CONCLUSION We recommend screening for bleeding disorders in patients with recurrent epistaxis. AVWS should be considered when laboratory findings suggest hereditary von Willebrand disease without a personal or familial history of bleeding. In addition, the underlying disease should be explored.
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Affiliation(s)
- Songmi Wang
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qun Hu
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yaxian Chen
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiufen Hu
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ning Tang
- Department of Clinical Laboratory, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ai Zhang
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Aiguo Liu
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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3
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Pikta M, Banys V, Szanto T, Joutsi-Korhonen L, Vaide I, Varik M, Lehtinen AE, Giangrande P, Laane E. Von Willebrand Factor Multimeric Assay in Acquired von Willebrand Disease Diagnosis: A Report of Experience from North Estonia Medical Centre. J Lab Physicians 2021; 13:195-201. [PMID: 34602781 PMCID: PMC8478502 DOI: 10.1055/s-0041-1730818] [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] [Indexed: 01/12/2023] Open
Abstract
Objectives
Acquired von Willebrand syndrome (AVWS) is a rare and frequently underdiagnosed bleeding disorder with an unknown prevalence. The diagnosis of AVWS is made based on laboratory investigations and the presence of clinical symptoms. Evaluation and management of affected patients are complex due to the need for multiple laboratory assays.
Materials and Methods
Here, we describe the clinical and laboratory data of seven patients with a diagnosis of AVWS. All patients met the criteria for AVWS based on laboratory findings, bleeding symptoms, and the absence of any previous history of a bleeding disorder.
Results
In all cases, the laboratory findings, lack of bleeding anamnesis, and family history suggested the presence of AVWS. Von Willebrand factor multimeric analysis showed decreased high-molecular weight (HMW) multimers in six cases. Patients with lower HMW multimers experienced more severe bleeding complications.
Conclusions
The diagnosis of AVWS is complex and requires extensive laboratory evaluation. Interdisciplinary collaboration and complex laboratory evaluations are of paramount importance for the early recognition of AVWS and optimal AVWS diagnosis as well as successful clinical management.
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Affiliation(s)
- Marika Pikta
- Department of Health Technologies, Tallinn University of Technology, Tallinn, Estonia.,Department of Laboratory Medicine, North Estonia Medical Centre, Tallinn, Estonia
| | - Valdas Banys
- Department of Physiology, Biochemistry, Microbiology and Laboratory Medicine, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania
| | - Timea Szanto
- Research Program Unit of Systems Oncology, Helsinki University Hospital, Unit of Coagulation Disorders, Helsinki, Finland
| | - Lotta Joutsi-Korhonen
- Department of Clinical Chemistry, Unit of Coagulation Disorders, HUSLAB Laboratory Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ines Vaide
- Hemato-Oncology Clinic, Institute of Clinical Medicine, Tartu University, Tartu, Estonia
| | - Mirja Varik
- Hematology Department, North Estonia Medical Centre, Tallinn, Estonia
| | - Anna-Elina Lehtinen
- Department of Hematology, Unit of Coagulation Disorders, Helsinki University Hospital Comprehensive Cancer Center and University of Helsinki, Helsinki, Finland
| | - Paul Giangrande
- Green Templeton College, University of Oxford, Oxford, United Kingdom
| | - Edward Laane
- Hemato-Oncology Clinic, Institute of Clinical Medicine, Tartu University, Tartu, Estonia
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4
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Franchini M, Mannucci PM. Acquired von Willebrand syndrome: focused for hematologists. Haematologica 2020; 105:2032-2037. [PMID: 32554559 PMCID: PMC7395262 DOI: 10.3324/haematol.2020.255117] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 05/27/2020] [Indexed: 12/16/2022] Open
Abstract
The acquired von Willebrand syndrome (AvWS) is a rare bleeding disorder with laboratory findings similar to those of inherited von Willebrand disease. However, unlike the inherited disease, AvWS occurs in persons with no personal and family history of bleeding and is often associated with a variety of underlying diseases, most frequently lymphoproliferative, myeloproliferative and cardiovascular disorders. After the presentation of a typical case, in this narrative review we discuss the more recent data on the pathophysiology, clinical, laboratory and therapeutic aspects of this acquired bleeding syndrome. We chose to focus particularly on those aspects of greater interest for the hematologist.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantua
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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5
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Franchini M, Marano G, Cruciani M, Mengoli C, Pati I, Masiello F, Veropalumbo E, Pupella S, Vaglio S, Liumbruno GM. Advances in managing rare acquired bleeding disorders. Expert Rev Hematol 2020; 13:599-606. [PMID: 32286895 DOI: 10.1080/17474086.2020.1756259] [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: 12/14/2022]
Abstract
INTRODUCTION Rare acquired bleeding disorders include a wide spectrum of coagulopathies characterized by spontaneous or post-trauma and post-surgery hemorrhages in patients without a previous personal or family history of bleeding. AREAS COVERED This review, based on a Medline/PubMed search during the last 20 years, will focus mainly on rare acquired bleeding disorders caused by autoantibodies against coagulation factors, including autoantibodies against factor VIII (acquired hemophilia A), von Willebrand factor (acquired von Willebrand syndrome) and other coagulation factors (factors V, X, XI, and XIII). The pathogenic, laboratory, and clinical features of these rare hemorrhagic conditions will be discussed, with particular attention to their management. EXPERT OPINION The treatment of rare acquired bleeding disorders includes the control of bleeding and the elimination of the autoantibody and of the underlying disease, when present. As the bleeding clinical phenotype is often severe, the management of affected patients is particularly challenging. Thus, while an early diagnosis of the acquired coagulopathy is essential to start the most appropriate treatment and to improve patients' outcomes, the support of specialized centers is equally important to provide a correct management of such complicated cases.
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Affiliation(s)
- Massimo Franchini
- Italian National Blood Centre, National Institute of Health , Rome, Italy.,Department of Hematology and Transfusion Medicine, Carlo Poma Hospital , Mantua, Italy
| | - Giuseppe Marano
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Mario Cruciani
- Italian National Blood Centre, National Institute of Health , Rome, Italy.,Infection Control Committee and Antibiotic Stewardship Programme, AULSS9 Scaligera , Verona, Italy
| | - Carlo Mengoli
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Ilaria Pati
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Francesca Masiello
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Eva Veropalumbo
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Simonetta Pupella
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Stefania Vaglio
- Italian National Blood Centre, National Institute of Health , Rome, Italy
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6
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Sacco M, Ranalli P, Lancellotti S, Petrucci G, Dragani A, Rocca B, De Cristofaro R. Increased von Willebrand factor levels in polycythemia vera and phenotypic differences with essential thrombocythemia. Res Pract Thromb Haemost 2020; 4:413-421. [PMID: 32211575 PMCID: PMC7086469 DOI: 10.1002/rth2.12315] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 01/13/2020] [Accepted: 01/17/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Acquired von Willebrand factor (VWF) deficiency was described in Philadelphia-negative myeloproliferative neoplasms, especially in essential thrombocythemia (ET). VWF phenotype in contemporary patients with polycythemia vera (PV) remains less explored. OBJECTIVES To characterize the VWF phenotype in PV and to compare VWF phenotype in PV with matched healthy subjects and ET patients. PATIENTS/METHODS We studied 48 PV patients, treated according to current recommendations (hematocrit ≤ 45%, on low-dose aspirin prophylaxis); 48 healthy and 41 subjects with ET, all sex, age, and blood group matched. We measured VWF antigen, activity, multimeric pattern, ADAMTS-13, and factor VIII (FVIII) antigen. RESULTS In patients with PV, VWF antigen and activity were significantly higher than in healthy subjects (antigen: 119[96-137] vs 93[79-107] IU/dL; activity: 114[95-128] vs 90[79-107] IU/dL, respectively, medians and interquartile, P < 0.01), with normal multimeric distribution. ADAMTS-13 levels were similar between patients with PV and healthy subjects. FVIII levels were higher in PV than in healthy subjects (141[119-169] versus 98[88-123] IU/dL, respectively, P < 0.01). By multivariable analysis, JAK2-p.V617F allelic burden, erythrocyte count, and male sex significantly predicted VWF antigen and activity levels. As compared to patients with ET, patients with PV showed similar VWF antigen levels but approximately 40% higher activity (79[49-104] vs 112[93-125] IU/dL, respectively, P < 0.01). CONCLUSIONS Patients with PV show increased VWF and FVIII levels, predicted by JAK2-p.V617F burden and erythrocyte count. At variance with ET, acquired VWF defect was not observed in PV. High VWF/FVIII levels may sustain the thrombotic diathesis of PV and may be investigated as biomarkers for risk stratification.
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Affiliation(s)
- Monica Sacco
- Servizio Malattie Emorragiche e TromboticheFondazione Policlinico Universitario “A. Gemelli” IRCCSRomaItaly
| | - Paola Ranalli
- Dipartimento di Medicina Interna e Chirurgia TraslazionaleFacoltà di Medicina e Chirurgia “A. Gemelli”Università Cattolica del Sacro CuoreRomaItaly
| | | | - Giovanna Petrucci
- Istituto di FarmacologiaFacoltà di Medicina e Chirurgia “A. Gemelli”Università Cattolica del S. Cuore and Fondazione Policlinico Universitario “A. Gemelli” IRCCSRomeItaly
| | - Alfredo Dragani
- Dipartimento di Medicina Interna e Chirurgia TraslazionaleFacoltà di Medicina e Chirurgia “A. Gemelli”Università Cattolica del Sacro CuoreRomaItaly
| | - Bianca Rocca
- Istituto di FarmacologiaFacoltà di Medicina e Chirurgia “A. Gemelli”Università Cattolica del S. Cuore and Fondazione Policlinico Universitario “A. Gemelli” IRCCSRomeItaly
| | - Raimondo De Cristofaro
- Servizio Malattie Emorragiche e TromboticheFondazione Policlinico Universitario “A. Gemelli” IRCCSRomaItaly
- Dipartimento di EmatologiaOspedale S. SpiritoPescaraItaly
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7
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Matsunaga Y, Ishimura M, Nagata H, Uike K, Kinjo T, Ochiai M, Yamamura K, Takada H, Tanoue Y, Hayakawa M, Matsumoto M, Hara T, Ohga S. Thrombotic microangiopathy in a very young infant with mitral valvuloplasty. Pediatr Neonatol 2018. [PMID: 29523490 DOI: 10.1016/j.pedneo.2018.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Thrombotic microangiopathies (TMA) are microvascular occlusive disorders characterized by systemic or intrarenal platelet aggregation, thrombocytopenia, and red cell fragmentation. Post-operative TMA mostly occurs in adult patients with cardiovascular surgery, with the distinct pathophysiology from classical thrombotic thrombocytopenic purpura (TTP) although the exact pathophysiology remains unclear. CASE PRESENTATION A one-month-old infant developed TMA after the initial surgery of double outlet right ventricle. ADAM metallopeptidase with thrombospondin type 1 motif 13 (ADAMTS13) activity was sustained (64%) with the undetectable inhibitor. Von Willebrand factor (VWF) multimer analyses showed absent high-molecular weight multimers. Echocardiography disclosed severe mitral regurgitation. The mitral valve repair 32 days after the initial valvuloplasty led to prompt resolution of TMA. These suggested that TMA occurred in association with valvulopathy-triggered turbulent shear flow, mechanical hemolysis and endothelial damage. The consumption of large VWF multimers might account for the vascular high shear stress shown in Heyde syndrome. CONCLUSION The youngest case of post-operative TMA underscores the critical coagulopathy after the first surgical intervention for congenital heart disease.
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Affiliation(s)
- Yuka Matsunaga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Masataka Ishimura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan.
| | - Hazumu Nagata
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Kiyoshi Uike
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Tadamune Kinjo
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Masayuki Ochiai
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Kenichiro Yamamura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Hidetoshi Takada
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan; Department of Perinatal and Pediatric Medicine, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Yoshihisa Tanoue
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Masaki Hayakawa
- Department of Blood Transfusion Medicine, Nara Medical University, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Japan
| | | | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
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8
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Pelland-Marcotte MC, Humpl T, James PD, Rand ML, Bouskill V, Reyes JT, Bowman ML, Carcao MD. Idiopathic pulmonary arterial hypertension - a unrecognized cause of high-shear high-flow haemostatic defects (otherwise referred to as acquired von Willebrand syndrome) in children. Br J Haematol 2018; 183:267-275. [PMID: 30141279 DOI: 10.1111/bjh.15530] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 06/21/2018] [Indexed: 02/06/2023]
Abstract
Acquired von Willebrand syndrome (AVWS) is reported in high-flow high-shear congenital cardiac disorders. We hypothesized that the narrowed pulmonary vasculature in idiopathic pulmonary arterial hypertension (IPAH) may induce AVWS. We conducted a cross-sectional evaluation of children with IPAH. Patients with bleeding symptoms and/or laboratory abnormalities (thrombocytopenia, anomalies in coagulation screening tests) were tested in-depth for haemostatic defects. Fourteen children were followed with IPAH of which 8 were eligible. Four children exhibited abnormal bleeding scores (International Society on Thrombosis and Haemostasis Bleeding Assessment Tool: 3-5). All 8 patients showed very prolonged platelet function analyser (PFA)-100 closure times. Six children demonstrated either mild thrombocytopenia or low-normal von Willebrand factor (VWF) antigen (VWF:Ag) or VWF activity [mean (range), in iu/dl: VWF:Ag: 70 (61-91); VWF activity: 57 (34-70)]. Average VWF collagen binding capacity (VWF:CB) was 64 iu/dl (range: 53-123 iu/dl), with low-normal VWF activity/VWF:Ag or VWF:CB/VWF:Ag ratios occurring in five patients. All children had normal multimers distribution patterns. One patient underwent a lung transplantation, with normalization of haemostatic abnormalities post-surgery. Overall, 8 out of 14 children with IPAH had mild to moderate bleeding symptoms and/or laboratory abnormalities in keeping with AVWS. Normalization of the haemostatic defects following lung transplantation and lack of family history of bleeding attests to the acquired nature of their defects.
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Affiliation(s)
- Marie-Claude Pelland-Marcotte
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Tilman Humpl
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Paula D James
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Margaret L Rand
- Division of Haematology/Oncology, Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Departments of Laboratory Medicine & Pathobiology, Biochemistry and Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Vanessa Bouskill
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.,Department of Nursing, The Hospital for Sick Children, Toronto, ON, Canada
| | - Janette T Reyes
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.,Department of Nursing, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mackenzie L Bowman
- Department of Medicine, Queen's University, Kingston, ON, Canada.,Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Manuel D Carcao
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
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9
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Tanaka H, Nagai Y, Kuwabara C, Shimizu R, Umeki A, Yamamoto T. Acquired von Willebrand Syndrome due to Aortic Valve Stenosis in a Case with Antiphospholipid Antibody. Intern Med 2018; 57:1641-1644. [PMID: 29321442 PMCID: PMC6028691 DOI: 10.2169/internalmedicine.9860-17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Acquired von Willebrand syndrome (AVWS) is a bleeding disorder caused by an acquired deficiency of von Willebrand factor (vWF). Some patients with AVWS show a low bleeding tendency and are diagnosed by the presence of a mild prolongation of activated partial thromboplastin time (APTT) preoperatively. Another cause of APTT prolongation is the presence of antiphospholipid antibody (aPL). We experienced a case of AVWS due to aortic valve stenosis in a patient with aPL in whom aortic valve replacement surgery was successful with vWF replacement. In patients with AVWS-associated disorders who are identified based on APTT prolongation at the preoperative examination, both vWF and aPL screening tests must be performed.
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Affiliation(s)
| | - Yurie Nagai
- Department of Hematology, Asahi General Hospital, Japan
| | | | - Ryo Shimizu
- Department of Hematology, Asahi General Hospital, Japan
| | - Akihide Umeki
- Department of Cardiovascular Surgery, Asahi General Hospital, Japan
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10
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Sugase T, Akimoto T, Kimura T, Yagisawa T, Kusano E, Nagata D. Acquired von Willebrand Syndrome Complicating Nephrotic Syndrome: A Case of a Patient With Membranous Nephropathy. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2018; 11:1179547618763371. [PMID: 29568223 PMCID: PMC5858607 DOI: 10.1177/1179547618763371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 02/14/2018] [Indexed: 01/28/2023]
Abstract
Acquired von Willebrand syndrome (AVWS) is a rare clinical entity presenting with heterogeneous hemorrhagic manifestations, although some subsets of patients with AVWS may be asymptomatic until they are exposed to major trauma, an invasive procedure, or surgery. We herein report one such case in a 73-year-old male patient with nephrotic syndrome with a prolonged active partial thromboplastin time. We initially did not deal with this distinct abnormal clotting profile seriously, but persistent bleeding after a retroperitoneoscopic-assisted renal biopsy that allowed us to ascribe his nephrotic syndrome to membranous nephropathy fortuitously led to the discovery of concurrent AVWS. We feel that an accurate and prompt diagnosis as well as awareness of the disease remain a challenge for physicians and therefore strongly recommend the further accumulation of experiences similar to our own in a prospective manner. This report underscores the pitfalls associated with determining the bleeding risk, including an insufficient assessment and improper weighting of an abnormal clotting profile prior to the invasive procedure. Several management concerns that emerged in the current case are also discussed.
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Affiliation(s)
- Taro Sugase
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Takaaki Kimura
- Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Shimotsuke, Japan
| | - Takashi Yagisawa
- Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Shimotsuke, Japan
| | - Eiji Kusano
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
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11
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Topf HG, Weiss D, Lischetzki G, Strasser E, Rascher W, Rauh M. Evaluation of a modified thromboelastography assay for the screening of von Willebrand disease. Thromb Haemost 2017; 105:1091-9. [DOI: 10.1160/th10-12-0782] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Accepted: 03/05/2011] [Indexed: 01/15/2023]
Abstract
SummaryThromboelastography (TEG) has been shown to be a valuable point-of-care device for the rapid diagnosis of various bleeding disorders. However, TEG has thus far not been used for the screening for von Willebrand disease (VWD). We evaluated the performance of a modified TEG assay for the laboratory screening of VWD. Three hundred twenty-eight patients (148 male, 180 female, median age 8.4 years, range 0.1 – 72.7 years) were included in the study. The diagnosis and classification of patients was based on personal and familial case history, von Willebrand factor antigen, ristocetin cofactor levels, collagen binding assay, factor VIII coagulant activity and multimer analysis. The ratio of clot strength after preincubation with ristocetin, and without ristocetin, represents the component of clot strength that is formed by cross-linked fibrin fibres and is dependent on the agglutinated platelet fraction. The decrease of the maximum amplitude is a function of the ristocetin concentration and provides a diagnostic parameter able to differentiate between healthy individuals and patients having VWD. Based on a preliminary cut-off value of 25% for the area under the curve (AUC) ratio, the sensitivity varied from 53% to 100% for the different VWD patient groups. The test is suitable for use as a screening test using whole blood and has the additional benefit of being suitable as a point of care test. It appears also useful for monitoring responses to desmopressin (DDAVP) and infusion therapy.
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12
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Acquired von Willebrand Syndrome in IgM Monoclonal Gammopathy as the Presentation of Lymphoplasmacytic Lymphoma. Case Rep Hematol 2017; 2017:9862620. [PMID: 28695028 PMCID: PMC5485300 DOI: 10.1155/2017/9862620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 05/07/2017] [Indexed: 01/19/2023] Open
Abstract
Acquired von Willebrand syndrome (AVWS) is an increasingly recognized entity with numerous potential underlying etiologies. Most commonly implicated are lymphoproliferative, myeloproliferative, cardiovascular, and autoimmune disorders. Unlike inherited von Willebrand disease (vWD), AVWS tends to present at an older age and without a family history of vWD. Treatment is directed at the underlying etiology if one is uncovered, as well as treatment and prevention of bleeding. Here, we present a rare case of AVWS secondary to Waldenström macroglobulinemia which went unrecognized for several years but resolved promptly with treatment. The potential mechanisms of AVWS secondary to monoclonal gammopathies are discussed as well as strategies to treat and prevent bleeding in these patients.
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13
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Rottenstreich A, Kleinstern G, Krichevsky S, Varon D, Lavie D, Kalish Y. Factors related to the development of acquired von Willebrand syndrome in patients with essential thrombocythemia and polycythemia vera. Eur J Intern Med 2017; 41:49-54. [PMID: 27919526 DOI: 10.1016/j.ejim.2016.11.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 11/15/2016] [Accepted: 11/21/2016] [Indexed: 02/01/2023]
Abstract
OBJECTIVE We characterized acquired von Willebrand syndrome (AVWS) among essential thrombocythemia (ET) and polycythemia vera (PV) patients. METHODS A review of patients with ET or PV evaluated for AVWS. RESULTS Of 116 patients with ET, 64 (55%) developed AVWS; of 57 with PV, 28 (49%) developed AVWS. Median platelet counts of ET and PV patients who developed AVWS were 920×109/L and 679×109/L, respectively (P=0.01). Of patients who developed AVWS, 69.5% had platelet counts below 1000×109/L. Bleeding was more common in patients with AVWS, among both ET and PV patients (P<0.001). VWF:RCo levels and VWF:RCo/VWF:Ag ratio were lower among JAK2 V617F positive- vs. JAK2 V617F negative- ET patients (P=0.02 and P=0.002, respectively); whereas VWF:Ag levels were comparable (P=0.96). ET patients harboring the JAK2 V617F mutation were more likely to develop AVWS than were calreticulin-positive patients (70.3% vs. 45.7%, P=0.02), despite lower platelet counts (median 773 vs. 920×109/L, P=0.05). In multivariable analysis, younger age (P=0.002), platelet count (P<0.001), hemoglobin level (P=0.01) and JAK2 V617F mutation (P=0.01) independently predicted the development of AVWS among ET patients; whereas only platelet count predicted its development among PV patients (P<0.001). CONCLUSION Among ET and PV patients, AVWS was common and associated with higher bleeding rates and higher platelet count; nonetheless, most AVWS patients had platelet counts under 1000×109/L. Thus, AVWS screening should be included in routine assessment of ET and PV patients. Among ET patients, JAK2 V617F was a main driver for the development of AVWS.
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Affiliation(s)
- A Rottenstreich
- Hematology Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - G Kleinstern
- Braun School of Public Health and Community Medicine, Faculty of Medicine of the Hebrew University and Hadassah, Jerusalem, Israel; Health Sciences Research, Mayo Clinic, Rochester, MN
| | - S Krichevsky
- Hematology Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - D Varon
- Hematology Department, Sourasky Medical Center, Tel Aviv, Israel
| | - D Lavie
- Hematology Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Y Kalish
- Hematology Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Acquired von Willebrand Syndrome Associated to Secondary IgM MGUS Emerging after Autologous Stem Cell Transplantation for AL Amyloidosis. Mediterr J Hematol Infect Dis 2017; 9:e2017034. [PMID: 28512563 PMCID: PMC5419196 DOI: 10.4084/mjhid.2017.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 04/10/2017] [Indexed: 12/18/2022] Open
Abstract
Acquired von Willebrand syndrome (AVWS) is a rare hemorrhagic disorder that occurs in patients with no prior personal or family history of bleeding. Here, we describe a case of AVWS occurring after autologous stem cell transplantation (ASCT). Interestingly, AVWS developed after bortezomib-based induction and conditioning regimens. Recent evidence suggests that the proximity of the bortezomib therapy to the collection of stem cells with consequent depletion of regulatory T cells after the conditioning regimen could explain some of the unusual autoimmune complications reported in patients receiving bortezomib prior to ASCT. In addition, this patient developed a secondary MGUS post-ASCT, which may have also contributed to the AVWS. To the best of our knowledge, this is the first case of post-ASCT AVWS reported. Prospective data is needed to better elucidate the mechanisms by which these unusual complications occur in patients receiving bortezomib prior to ASCT.
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15
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Komeno Y, Shibuya N, Uryu H, Yamada H, Toda T, Shibasaki M, Kunishima S, Iihara K, Ryu T. Splenic Marginal Zone Lymphoma with Acquired von Willebrand Syndrome Diagnosed via Splenic Bleeding. Intern Med 2017; 56:557-562. [PMID: 28250305 PMCID: PMC5399210 DOI: 10.2169/internalmedicine.56.7258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
An 85-year-old woman underwent emergent splenectomy due to left abdominal pain and active bleeding in a massively enlarged spleen. The histological diagnosis was splenic marginal zone lymphoma (SMZL). A prolonged activated partial thromboplastin time (APTT) was noted, and additional tests led to the diagnosis of type 2A-like acquired von Willebrand syndrome (AVWS). An APTT cross mixing test ruled out the presence of inhibitors. She received eight courses of rituximab monotherapy. The coagulation data showed no improvement, possibly because the lymphoma showed a poor response to the treatment. AVWS rarely causes bleeding in solid organs. This is the first case of SMZL with AVWS diagnosed via splenic bleeding.
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Affiliation(s)
- Yukiko Komeno
- Department of Hematology, Japan Community Healthcare Organization (JCHO) Tokyo Yamate Medical Center, Japan
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Vaglio S, Prisco D, Biancofiore G, Rafanelli D, Antonioli P, Lisanti M, Andreani L, Basso L, Velati C, Grazzini G, Liumbruno GM. Recommendations for the implementation of a Patient Blood Management programme. Application to elective major orthopaedic surgery in adults. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 14:23-65. [PMID: 26710356 PMCID: PMC4731340 DOI: 10.2450/2015.0172-15] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Stefania Vaglio
- Italian National Blood Centre, National Institute of Health, Rome, Italy
- Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gianni Biancofiore
- Liver Transplant Anaesthesia and Critical Care, University Hospital Pisana, Pisa, Italy
| | - Daniela Rafanelli
- Immunohaematology and Transfusion Unit, Pistoia 3 Local Health Authority, Pistoia, Italy
| | - Paola Antonioli
- Department of Infection Prevention Control and Risk Management, Ferrara University Hospital, Ferrara, Italy
| | - Michele Lisanti
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Lorenzo Andreani
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Leonardo Basso
- Orthopaedics and Trauma Ward, Cottolengo Hospital, Turin, Italy
| | - Claudio Velati
- Transfusion Medicine and Immunohaematology Department of Bologna Metropolitan Area, Bologna, Italy, on behalf of Italian Society of Transfusion Medicine and Immunohaematology (SIMTI); Italian Society of Italian Society of Orthopaedics and Traumatology (SIOT); Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Therapy (S.I.A.A.R.T.I.); Italian Society for the Study of Haemostasis and Thrombosis (SISET), and the National Association of Hospital Medical Directors (ANMDO) working group
| | - Giuliano Grazzini
- Italian National Blood Centre, National Institute of Health, Rome, Italy
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Bowyer AE, Guy S, Shepherd MF, Sampson BM, Kitchen S, Makris M. Von Willebrand factor activity assay errors. Haemophilia 2015; 22:e74-6. [DOI: 10.1111/hae.12862] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2015] [Indexed: 01/16/2023]
Affiliation(s)
- A. E. Bowyer
- Coagulation laboratory; Sheffield Haemophilia and Thrombosis Centre; Royal Hallamshire Hospital; Sheffield UK
| | - S. Guy
- Coagulation laboratory; Sheffield Haemophilia and Thrombosis Centre; Royal Hallamshire Hospital; Sheffield UK
| | - M. F. Shepherd
- Coagulation laboratory; Sheffield Haemophilia and Thrombosis Centre; Royal Hallamshire Hospital; Sheffield UK
| | - B. M. Sampson
- Coagulation laboratory; Sheffield Haemophilia and Thrombosis Centre; Royal Hallamshire Hospital; Sheffield UK
| | - S. Kitchen
- Coagulation laboratory; Sheffield Haemophilia and Thrombosis Centre; Royal Hallamshire Hospital; Sheffield UK
| | - M. Makris
- Coagulation laboratory; Sheffield Haemophilia and Thrombosis Centre; Royal Hallamshire Hospital; Sheffield UK
- Department of Cardiovascular Science; University Sheffield; Sheffield UK
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Christopher KL, Stafeeva K, Erlanger MS. Spontaneous iris bleeding during cataract surgery in a patient with thrombocytopenia. Digit J Ophthalmol 2015; 21:1-7. [PMID: 27330466 PMCID: PMC4902647 DOI: 10.5693/djo.02.2015.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 91-year old man with a history of senile cataract and chronic lymphocytic leukemia (CLL), with a platelet count of 75,000/μL, presented for phacoemulsification and intraocular lens implantation in the left eye. A paracentesis made at the beginning of the procedure caused a small but not unusual amount of anterior chamber decompression. Spontaneous bleeding subsequently occurred from multiple sights on the iris surface. The bleeding was stopped by injecting hyaluronic acid into the anterior chamber to increase intraocular pressure. The remainder of the procedure was performed without complication, and resulting visual acuity improved from 20/70 preoperatively to 20/20(-2) with refraction 1 week postoperatively. In previously reported cases of intraocular bleeding during cataract surgery in thrombocytopenic patients, platelet counts were all ≤55,000/μL.
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Affiliation(s)
- Karen L. Christopher
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora, Colorado
| | - Ksenia Stafeeva
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora, Colorado
| | - Michael S. Erlanger
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora, Colorado
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Mital A, Prejzner W, Świątkowska-Stodulska R, Hellmann A. Factors predisposing to acquired von Willebrand syndrome during the course of polycythemia vera - retrospective analysis of 142 consecutive cases. Thromb Res 2015; 136:754-7. [PMID: 26269222 DOI: 10.1016/j.thromres.2015.07.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 07/27/2015] [Accepted: 07/28/2015] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The aim of this study was to verify if PV patients with and without avWS differ in terms of their baseline clinical parameters. MATERIAL AND METHODS The study included 142 consecutive patients with PV. avWS was diagnosed on the basis of abnormally low levels of von Willebrand factor and other routine tests. Patients with and without concomitant avWS were compared in terms of their demographic characteristics, present and past medical histories and laboratory parameters. RESULTS Concomitant avWS was found in 17 PV patients (12.0%). Individuals with avWS have been diagnosed with PV at significantly younger age than those without, and significantly less often were in remission at the time of testing for bleeding disorders. Most of them (58.8%) presented with typical signs of bleeding disorder. Moreover, they showed significantly higher erythrocyte, leukocyte and platelet counts, abnormalities of coagulation profile corresponding to defects of primary hemostasis and abnormal values of all parameters used in the routine diagnosis of avWS. CONCLUSIONS Even every tenth patient with PV may develop avWS. Young age at diagnosis of PV and poor response to previous treatment of this condition are potential risk factors of avWS that should be considered during history taking. Sings of bleeding disorder observed in a person with PV necessitate evaluation for avWS.
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Affiliation(s)
- Andrzej Mital
- Department of Hematology and Transplantology, Medical University of Gdansk, Gdansk, Poland.
| | - Witold Prejzner
- Department of Hematology and Transplantology, Medical University of Gdansk, Gdansk, Poland
| | | | - Andrzej Hellmann
- Department of Hematology and Transplantology, Medical University of Gdansk, Gdansk, Poland
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Early severe preeclampsia with marked platelet dysfunction in association with essential thrombocytemia: case report and discussion. Blood Coagul Fibrinolysis 2015. [PMID: 26196190 DOI: 10.1097/mbc.0000000000000352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Essential thrombocytemia--a classic myeloproliferative neoplasm characterized by persistent thrombocytosis--may associate both thrombotic and hemorrhagic events, as well as platelet dysfunction. Of all myeloproliferative neoplasms, essential thrombocytemia is more likely to be associated with pregnancy, because of a higher comparative incidence in younger patients. This association significantly increases the risk of pregnancy loss and of various pregnancy complications. We present a case of early severe preeclampsia with a critical and unusual evolution and life-threatening complications.
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Kruse-Jarres R. Acquired bleeding disorders in the elderly. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:231-236. [PMID: 26637727 DOI: 10.1182/asheducation-2015.1.231] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The hemostatic balance changes with advancing age which may be due to factors such as platelet activation, increase of certain clotting factor proteins, slowing of the fibrinolytic system, and modification of the endothelium and blood flow. Generally, this predisposes the elderly to thrombosis rather than bleeding. It often necessitates antiplatelet or anticoagulation therapy, which can cause significant bleeding problems in an aging population. Additionally, changing renal function, modification in immune regulation, and a multitude of other disease processes, can give rise to acquired bleeding disorders. Bleeding can prove difficult to treat in a dynamic environment and in a population that may have underlying thrombotic risk factors.This article discusses some specific challenges of acquired bleeding arising in the elderly. The use of anticoagulation and nonsteroidal anti-inflammatory medications is prevalent in the treatment of the elderly and predisposes them to increased bleeding risk as their physiology changes. When prescribing and monitoring these therapies, it is exceedingly important to weigh thrombotic versus bleeding risks. There are additional rare acquired bleeding disorders that predominantly affect the elderly. One of them is acquired hemophilia, which is an autoimmune disorder arising from antibodies against factor VIII. The treatment challenge rests in the use of hemostatic agents in a population that is already at increased risk for thrombotic complications. Another rare disorder of intensifying interest, acquired von Willebrand syndrome, has a multitude of etiologic mechanisms. Understanding the underlying pathophysiology is essential in making a treatment decision for this disorder.
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Affiliation(s)
- Rebecca Kruse-Jarres
- Washington Center for Bleeding Disorders at Bloodworks Northwest and University of Washington, Seattle, WA
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22
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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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23
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Franchi F, Biguzzi E, Stufano F, Siboni SM, Baronciani L, Peyvandi F. A two-step approach (Enzyme-linked immunosorbent assay and confirmation assay) to detect antibodies against von Willebrand factor in patients with Acquired von Willebrand Syndrome. Thromb Res 2014; 134:1316-22. [PMID: 25300810 DOI: 10.1016/j.thromres.2014.09.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 08/26/2014] [Accepted: 09/20/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acquired von Willebrand Syndrome is a rare bleeding disorder, which arises in individuals with no personal or family history of bleeding, associated with lymphoproliferative and myeloproliferative disorders or other diseases. AIM To develop a two-step approach assay to detect autoantibodies against VWF and to verify their prevalence in AVWS. METHODS AVWS definition: negative personal or family history of bleeding diathesis, VWF below normal range and recent history of bleeding manifestations. Twenty-three consecutive patients affected by AVWS were enrolled. An ELISA assay (first step) using recombinant VWF protein immobilized on plates and sheep/goat polyclonal anti-human IgG or IgM labelled with peroxidase was developed. A group of 40 healthy subjects was tested to calculate the floating cut point value. A confirmation assay (with addition of purified VWF vs buffer) was performed (second step). RESULTS Twenty-one patients (93%) had an associated disease, two patients had idiopathic AVWS. Anti-VWF autoantibodies were detected in 9 patients (39%). Of these, eight (89%) had VWF:RCo levels <10%, but none of them resulted positive using Bethesda assay (neutralizing antibodies). The confirmation test confirmed the positive results obtained with ELISA and resulted negative in those patients with negative results and in the controls. CONCLUSION With the present two-step approach assay nine out of 23 (39%) patients affected with AVWS resulted positive for anti-VWF autoantibodies. This ELISA assay might be used as an additional confirmation tool in the diagnostic procedure in patients affected by AVWS or in the follow-up of congenital and acquired patients exposed to replacement therapy.
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Affiliation(s)
- Franca Franchi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.
| | - Eugenia Biguzzi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Italy
| | - Francesca Stufano
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Italy
| | - Simona M Siboni
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Italy
| | - Luciano Baronciani
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Italy
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Italy; Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Acquired von Willebrand syndrome: von Willebrand factor propeptide to von Willebrand factor antigen ratio predicts remission status. Blood 2014; 124:e1-3. [PMID: 24951428 DOI: 10.1182/blood-2014-02-557132] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
We investigated a case of acquired von Willebrand syndrome (AVWS) secondary to a nonneutralizing anti-von Willebrand factor (VWF) antibody associated with an autoimmune disorder. At diagnosis, VWF activity (VWF:Act), antigen (VWF:Ag), multimers, and factor VIII coagulant activity were virtually absent. VWF propeptide (VWFpp) was elevated with an infinitely high VWFpp to VWF:Ag ratio (VWFpp:Ag) consistent with rapid VWF clearance. Immunosuppressive treatment resulted in phenotypic remission 1 with normalization of VWF/factor VIII levels and multimer pattern. However, VWFpp:Ag remained elevated (∼2× normal), consistent with ongoing VWF clearance by the remaining anti-VWF antibody still present by enzyme-linked immunosorbent assay. This suggests that increased VWF secretion was compensating for the incomplete remission state. Relapse occurred when VWFpp:Ag was again infinitely high, with associated decreased VWFpp but unchanged anti-VWF titers; switching the balance to favor VWF clearance over secretion. Complete remission with undetectable anti-VWF occurred only when VWFpp:Ag was normal. This case of relapsing-remitting AVWS demonstrates the use of VWFpp:Ag for predicting remission status.
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Acquired von Willebrand disease and multiple myeloma: a case report of a breast cancer survivor. Blood Coagul Fibrinolysis 2014; 25:890-3. [PMID: 24911454 DOI: 10.1097/mbc.0000000000000149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Acquired von Willebrand disease (aVWD) is rare disease and is associated with a variety of underlying diseases. We report a case of aVWD in the setting of multiple myeloma. The patient was a 63-year-old female with breast cancer in remission who was admitted for symptomatic anemia. She was diagnosed with multiple myeloma. She also had subcutaneous bleeding before admission. Laboratory studies revealed isolated prolongation of the activated partial thromboplastin time, which corrected in a mixing study. Her factor VIII activity, von Willebrand factor (VWF) Ag, and VWF activity were low. VWF multimer study confirmed the patient had aVWD. The treatment of aVWD is discussed in this article, including the treatment of underlying diseases, and acute management in emergent situations. An intriguing question in this case is whether the patient's multiple myeloma is a chemotherapy-induced hematological malignancy or a second primary malignancy.
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Stockschlaeder M, Schneppenheim R, Budde U. Update on von Willebrand factor multimers: focus on high-molecular-weight multimers and their role in hemostasis. Blood Coagul Fibrinolysis 2014; 25:206-16. [PMID: 24448155 PMCID: PMC3969155 DOI: 10.1097/mbc.0000000000000065] [Citation(s) in RCA: 141] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 11/27/2013] [Accepted: 12/04/2013] [Indexed: 12/16/2022]
Abstract
Normal hemostasis requires von Willebrand factor (VWF) to support platelet adhesion and aggregation at sites of vascular injury. VWF is a multimeric glycoprotein built from identical subunits that contain binding sites for both platelet glycoprotein receptors and collagen. The adhesive activity of VWF depends on the size of its multimers, which range from 500 to over 10 000 kDa. There is good evidence that the high-molecular-weight multimers (HMWM), which are 5000-10 000 kDa, are the most effective in supporting interaction with collagen and platelet receptors and in facilitating wound healing under conditions of shear stress. Thus, these HMWM of VWF are of particular clinical interest. The unusually large multimers of VWF are, under normal conditions, cleaved by the plasma metalloproteinase ADAMTS13 to smaller, less adhesive multimers. A reduction or lack of HMWM, owing to a multimerization defect of VWF or to an increased susceptibility of VWF for ADAMTS13, leads to a functionally impaired VWF and the particular type 2A of von Willebrand disease. This review considers the biology and function of VWF multimers with a particular focus on the characterization of HMWM - their production, storage, release, degradation, and role in normal physiology. Evidence from basic research and the study of clinical diseases and their management highlight a pivotal role for the HMWM of VWF in hemostasis.
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Affiliation(s)
| | - Reinhard Schneppenheim
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf
| | - Ulrich Budde
- Department of Hemostaseology, Medilys Laborgesellschaft, Hamburg, Germany
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27
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Acquired von Willebrand syndrome associated with monoclonal gammopathy of undetermined significance. Ann Hematol 2013; 93:1427-8. [DOI: 10.1007/s00277-013-1982-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 11/28/2013] [Indexed: 10/25/2022]
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Hernández-Gilsoul T, Atisha-Fregoso Y, Vargas-Ruíz AG, Rivero-Sigarroa E, Dominguez-Cherit G, Namendys-Silva SA. Pulmonary hypertension secondary to hyperviscosity in a patient with rheumatoid arthritis and acquired von Willebrand disease: a case report. J Med Case Rep 2013; 7:232. [PMID: 24088343 PMCID: PMC4015717 DOI: 10.1186/1752-1947-7-232] [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: 05/29/2013] [Accepted: 08/20/2013] [Indexed: 01/04/2023] Open
Abstract
Introduction Acquired von Willebrand disease is initiated by autoantibodies and hyperviscosity syndrome caused by a massive polyclonal hypergammaglobulinemia. Acquired von Willebrand disease associated with autoimmune disease in addition to pulmonary hypertension during emergency room presentation is a rare condition. To the best of our knowledge, this is the second case reported in the literature treated with success; the first one was reported in 1987. Case presentation A 28-year-old mestizo man with a 3-year history of inflammatory arthritis was admitted to our hospital. An overlap of rheumatoid arthritis with systemic lupus erythematosus was suspected; therefore methotrexate was initiated, and later changed to leflunomide because of liver toxicity. Prothrombin time, international normalized ratio and activated partial thromboplastin times were normal (11/10.4 seconds; 1.2; 31.1/26.9 seconds, respectively), von Willebrand factor activity was observed with low ristocetin cofactor at 33.6UI/dL, high von Willebrand factor antigen >200UI/dL, and a low von Willebrand factor: ristocetin cofactor to von Willebrand factor antigen ratio. He was admitted to the emergency room with a 24-hour evolution of progressive dyspnea, cough, thoracic pain, and palpitations, 104 beats/min, 60/40 mmHg, temperature of 38°C, pulse oximetric saturation 88% and 30 breaths/minute. Cold, pale and mottled skin was also observed. He was then transferred to the intensive care unit. The placement of a pulmonary artery catheter was made. The initial patterns showed a precapillary pulmonary hypertension; acute pulmonary embolism was the first choice for diagnosis. Pulmonary angiography was conducted, and when no clot was discovered, pulmonary artery hypertension associated with connective tissue disease was considered. Serum protein electrophoresis confirmed the presence of a massive polyclonal hypergammaglobulinemia, and no paraproteinemia or monoclonal cell population was found from the electrophoretic pattern of the patient’s plasma. Hypergammaglobulinemia was the cause of hyperviscosity syndrome associated with autoantibodies. Three sessions of plasma exchange therapy were made, and clinical improvement was observed. He was then discharged from the intensive care unit and hospital, respectively. He is now attended by an external consult and has no respiratory symptomatology. Conclusions Hyperviscosity syndrome with pulmonary arterial hypertension presentation in a patient with acquired von Willebrand disease in an autoimmune context is a rare condition that can be treated successfully with plasmapheresis and critical care support.
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Affiliation(s)
- Thierry Hernández-Gilsoul
- Department of Critical Care Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, México.
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Kasatkar P, Ghosh K, Shetty S. An atypical manifestation of acquired von Willebrand syndrome (AVWS) associated with systemic lupus erythematosus (SLE). Ann Hematol 2013; 93:173-5. [DOI: 10.1007/s00277-013-1767-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 04/17/2013] [Indexed: 10/26/2022]
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31
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Franchini M, Mannucci PM. Von Willebrand disease-associated angiodysplasia: a few answers, still many questions. Br J Haematol 2013; 161:177-82. [PMID: 23432086 DOI: 10.1111/bjh.12272] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The association between angiodysplasia and von Willebrand disease (VWD) has been known for more than 40 years. Bleeding in the gastrointestinal tract associated with angiodysplasia worsens the clinical course of this inherited haemorrhagic disorder and management may become difficult and challenging. Angiodysplasia associated with acquired defects or dysfunctions of von Willebrand factor (VWF) has also been reported in a variety of conditions such as monoclonal gammopathies, Heyde syndrome and in carriers of ventricular assist devices. The most recent advances concerning the mechanistic, clinical and therapeutic aspects of VWD-associated angiodysplasia are summarized in this review, together with the limitations of our knowledge that warrant further research in the frame of international cooperation.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Haematology, Carlo Poma Hospital, Mantova, Italy
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32
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Acquired von Willebrand syndrome in a patient with monoclonal gammopathy of undetermined significance. Blood Coagul Fibrinolysis 2012; 24:430-2. [PMID: 23249617 DOI: 10.1097/mbc.0b013e32835bfdde] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acquired von Willebrand syndrome (AVWS) is a rare bleeding disorder that typically presents as mucocutaneous bleeding in individuals with no personal or family history of bleeding disorder. Here we present a case in which a patient presented with profound epistaxis and was found to have AVWS in the setting of monoclonal gammopathy of undetermined significance (MGUS).
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Bharati KP, Prashanth UR. Von Willebrand disease: an overview. Indian J Pharm Sci 2012; 73:7-16. [PMID: 22131616 PMCID: PMC3224412 DOI: 10.4103/0250-474x.89751] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Revised: 01/10/2011] [Accepted: 01/15/2011] [Indexed: 12/05/2022] Open
Abstract
Most commonly inherited bleeding disorder, first described in Aland Islands by Erik von Willebrand. It occurs as a result of decrease in plasma levels or defect in von Willebrand factor which is a large multimeric glycoprotein. Monomers of this glycoprotein undergo N-glycosylation to form dimers which get arranged to give multimers. Binding with plasma proteins (especially factor VIII) is the main function of von Willebrand factor. The disease is of two forms: Inherited and acquired forms. Inherited forms are of three major types. They are type 1, type 2, and type 3; in which type 2 is sub-divided into 2A, 2B, 2M, 2N. Type 1 is more prevalent than all other types. Mucocutaneous bleeding is mild in type 1 whereas it is mild to moderate in types 2A, 2B, and 2M. Type 2N has similar symptoms of haemophilia. The pathophysiology of each type depends on the qualitative or quantitative defects in von Willebrand factor. The diagnosis is based on von Willebrand factor antigen, von Willebrand factor activity assay, FVIII coagulant activity and some other additional tests. Results should be analyzed within the context of blood group. von Willebrand factor multimer analysis is essential for typing and sub typing the disease. The management of the disease involves replacement therapy, non-replacement therapy and other therapies that include antifibrinolytics and topical agents.
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Affiliation(s)
- K Pavani Bharati
- Department of Pharmacy Practice, JNTUK, Vizianagaram - 535 003, India
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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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35
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Boudreaux MK. Inherited platelet disorders. J Vet Emerg Crit Care (San Antonio) 2012; 22:30-41. [PMID: 22316339 DOI: 10.1111/j.1476-4431.2011.00702.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 11/22/2011] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To present the latest information on inherited platelet disorders in domestic animals. DATA SOURCES Research articles and reviews spanning 40 years available on PubMed. HUMAN DATA SYNTHESIS Information regarding inherited platelet disorders in people is plentiful and often descriptions of human conditions have led to the identification of similar disorders in veterinary species. There are exceptions, however, in which specific inherited platelet disorders were first described in animals with subsequent identification in people. VETERINARY DATA SYNTHESIS Many inherited platelet disorders have been documented in animals at the functional and molecular level and that information is presented in this review. CONCLUSIONS Much progress has been made in the past 20 years in the characterization of inherited platelet disorders in animals at the functional, biochemical, and molecular level. The study of inherited platelet disorders has greatly enhanced the understanding of platelet physiology and has led in some instances to the development of platelet inhibitory medications. Characterization of inherited disorders at the molecular level greatly facilitates diagnosis and identification of affected and heterozygous animals thus avoiding propagation of the defect by breeders. When used with available functional and biochemical diagnostic tests, it significantly enhances the quality of care and case management.
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Affiliation(s)
- Mary K Boudreaux
- From the Department of Pathobiology, College of Veterinary Medicine, Auburn University, AL 36849-5519, USA.
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36
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Muzaffar J, Katragadda L, Haider S, Javed A, Anaissie E, Usmani S. Rituximab and intravenous immunoglobulin (IVIG) for the management of acquired factor VIII inhibitor in multiple myeloma: case report and review of literature. Int J Hematol 2011; 95:102-6. [DOI: 10.1007/s12185-011-0968-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Revised: 11/05/2011] [Accepted: 11/09/2011] [Indexed: 10/14/2022]
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Biondo F, Matturro A, Santoro C, Leporace A, D'Elia G, Baldacci E, Pignoloni P, Pulsoni A, Foà R, Mazzucconi M. Remission of acquired von Willebrand syndrome after successful treatment of gastric MALT lymphoma. Haemophilia 2011; 18:e34-5. [PMID: 22059776 DOI: 10.1111/j.1365-2516.2011.02681.x] [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: 01/23/2023]
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38
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Voisin S, Hamidou M, Lefrançois A, Sigaud M, Mahé B, Trossaërt M. Acquired von Willebrand syndrome associated with monoclonal gammopathy: a single-center study of 36 patients. Medicine (Baltimore) 2011; 90:404-411. [PMID: 22033454 DOI: 10.1097/md.0b013e3182397166] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
In this single-center retrospective study, we evaluated the accuracy of laboratory tests in diagnosing acquired von Willebrand syndrome associated with lymphoproliferative disorders in 36 consecutive patients diagnosed at the University Hospital of Nantes, France. We also compared hemostatic treatments in the following groups: 21 patients with Waldenström macroglobulinemia (WM), 14 with monoclonal gammopathy of undetermined significance (MGUS) (10 with IgG-MGUS and 4 with IgM-MGUS), and 1 with IgA multiple myeloma (IgA-MM). The diagnosis was made in 18 (50%) patients during systematic screening, in 6 (17%) during active mild hemorrhage, and in 12 (33%) during an active, severe bleed. Of the laboratory tests studied, only closure times measured on the Platelet Function Analyzer (PFA)-100 device reliably diagnosed the hemostatic problem. There was no relationship between the factor VIII activity (FVIII:C) or von Willebrand factor activity (VWF:RCo) levels and the previous history of hemorrhage described by patients.We studied hemostatic treatment in most patients: IgG-MGUS patients responded well to high-dose intravenous immunoglobulin (IVIg) infusions (1 g/kg per d), although patients with IgM-MGUS did not. Desmopressin infusions were effective in 3 patients with IgG-MGUS and 2 patients with IgM-MGUS when the baseline values were above 10 IU/dL, but levels soon returned to the baseline. The 7 WM patients had a good response to desmopressin. These results confirm the efficacy of IVIg in IgG-MGUS patients and the prominent role of closure time in the diagnosis of acquired von Willebrand syndrome.
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Affiliation(s)
- Sophie Voisin
- From Laboratoire Hématologie (SV), Centre Hospitalier Universitaire, Hôpital Rangueil, Toulouse; Médecine Interne (MH), Hôtel Dieu, Centre Hospitalier Universitaire, Nantes; Centre Régional de Traitement de l'Hémophilie (AL, MS, MT), Centre Hospitalier Universitaire, Nantes; and Hématologie Clinique (BM), Hôtel Dieu, Centre Hospitalier Universitaire, Nantes; France
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Petros S. [Management of bleeding disorders in intensive care medicine]. Med Klin Intensivmed Notfmed 2011; 106:177-82. [PMID: 22037560 DOI: 10.1007/s00063-011-0017-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Accepted: 09/09/2011] [Indexed: 11/24/2022]
Abstract
Bleeding disorders are frequent in intensive care medicine, the most common form being acquired. Trauma, gastrointestinal bleeding, liver failure, hematologic malignancies, and adverse drug reactions play an important role. Moderate to severe hereditary bleeding disorders are usually known prior to the acute disease state, while mild hereditary forms may manifest for the first time in association with the acute stress condition. Generally, proper history taking and structured observation are decisive in order to conduct an appropriate diagnostic workup and initiate logical hemostatic management. One cannot always wait for laboratory results during continuous blood loss or conditions such as hypothermia and acidosis. In such cases, pathophysiological extrapolation of expected hemostatic disturbances is essential for timely hemostatic management.
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Affiliation(s)
- S Petros
- Interdisziplinäre Internistische Intensivmedizin, Universitätsklinikum Leipzig AöR, Liebigstrasse 20, Leipzig, Germany.
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Sokkary NA, Dietrich JE, Venkateswaran L. Idiopathic pulmonary hypertension causing acquired von Willebrand disease and menorrhagia. J Pediatr Adolesc Gynecol 2011; 24:e107-9. [PMID: 21715195 DOI: 10.1016/j.jpag.2011.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Revised: 04/12/2011] [Accepted: 04/20/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND Von Willebrand disease (VWD) maybe inherited or acquired; both etiologies can be associated with heavy menstrual bleeding. Pulmonary arterial hypertension may result in acquired VWD due to the destruction of high molecular weight von Willebrand multimers. We report a case of menorrhagia due to acquired VWD in a patient with idiopathic pulmonary hypertension. CASE An adolescent female with known idiopathic pulmonary hypertension developed acquired VWD. Her primary disease necessitates the use of platelet inhibitors and intermittent anticoagulation. At menarche she also developed menorrhagia due to acquired VWD. She is currently controlled with stimate and progesterone-only therapy. VWD in a patient with idiopathic pulmonary hypertension causing menorrhagia. Although VWD and menorrhagia are commonly linked, the treatment and disease process in a patient with idiopathic pulmonary arterial hypertension is incredibly complex.
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Affiliation(s)
- Nancy A Sokkary
- Department of Pediatric and Adolescent Gynecology, Baylor College of Medicine, Houston, TX, USA.
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41
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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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42
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Unusual Autoimmune Nonhematologic Complications in Chronic Lymphocytic Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2011; 11 Suppl 1:S10-3. [DOI: 10.1016/j.clml.2011.02.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 02/08/2011] [Accepted: 02/22/2011] [Indexed: 11/21/2022]
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43
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Onimoe G, Grooms L, Perdue K, Ruymann F. Acquired von Willebrand Syndrome in congenital heart disease: does it promote an increased bleeding risk? Br J Haematol 2011; 155:622-4. [PMID: 21569008 DOI: 10.1111/j.1365-2141.2011.08732.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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44
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Ueda M, Kawamura N, Tateishi T, Shigeto H, Ohyagi Y, Kira JI. [A case of chronic inflammatory demyelinating polyradiculoneuropathy concomitant with acquired von Willebrand syndrome]. Rinsho Shinkeigaku 2011; 51:334-337. [PMID: 21706830 DOI: 10.5692/clinicalneurol.51.334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
We report a case of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) concomitant with acquired von Willebrand syndrome. A 33-year-old man developed motor and sensory polyneuropathy with electrophysiological conduction slowing. At this time, M-protein was absent He was diagnosed with CIDP and received intravenous immunoglobulin and subsequent oral corticosteroids, which resulted in almost complete remission for over 10 years. At the age of 44, he presented with chronic anemia. Laboratory tests and colonoscopy revealed that he had acquired von Willebrand syndrome with monoclonal gammopathy of undetermined significance (IgG lambda type) and colon cancer. Bleeding symptoms were.resolved with intravenous immunoglobulin, but not with supplementation of factor VIII. Shortly after successful excision of the cancer, CIDP and acquired von Willebrand syndrome simultaneously recurred. Intravenous immunoglobulin produced rapid improvement of both neurological and hematological abnormalities. Concurring CIDP and acquired von Willebrand syndrome in the present case may indicate that the conditions have a partly common immunological background including monoclonal gammopathy and a potential common autoantibody-mediated mechanism. Alternatively, dysfunction of von Willebrand factor may increase blood-nerve barrier permeability, inducing the recurrence of CIDP.
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Affiliation(s)
- Maki Ueda
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University
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45
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Höög CM, Broström O, Lindahl TL, Hillarp A, Lärfars G, Sjöqvist U. Bleeding from gastrointestinal angioectasias is not related to bleeding disorders - a case control study. BMC Gastroenterol 2010; 10:113. [PMID: 20920209 PMCID: PMC2955688 DOI: 10.1186/1471-230x-10-113] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Accepted: 09/28/2010] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Angioectasias in the gastrointestinal tract can be found in up to 3% of the population. They are typically asymptomatic but may sometimes result in severe bleeding. The reasons for why some patients bleed from their angioectasias are not fully understood but it has been reported that it may be explained by an acquired von Willebrand syndrome (AVWS). This condition has similar laboratory findings to congenital von Willebrand disease with selective loss of large von Willebrand multimers. The aim of this study was to find out if AVWS or any other bleeding disorder was more common in patients with bleeding from angioectasias than in a control group. METHODS We compared bleeding tests and coagulation parameters, including von Willebrand multimers, from a group of 23 patients with anemia caused by bleeding from angioectasias, with the results from a control group lacking angioectasias. RESULTS No significant differences between the two groups were found in coagulation parameters, bleeding time or von Willebrand multimer levels. CONCLUSION These results do not support a need for routine bleeding tests in cases of bleeding from angioectasias and do not show an overall increased risk of AVWS among these patients.
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Affiliation(s)
- Charlotte M Höög
- Department of Medicine, Karolinska Institutet, Stockholm Söder Hospital, Stockholm, Sweden
| | - Olle Broström
- Department of Medicine, Karolinska Institutet, Stockholm Söder Hospital, Stockholm, Sweden
| | - Tomas L Lindahl
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Andreas Hillarp
- Department of Clinical Chemistry, Malmö University Hospital, Malmö, Sweden
| | - Gerd Lärfars
- Department of Medicine, Karolinska Institutet, Stockholm Söder Hospital, Stockholm, Sweden
| | - Urban Sjöqvist
- Department of Medicine, Karolinska Institutet, Stockholm Söder Hospital, Stockholm, Sweden
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46
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Torres R, Fedoriw Y. Laboratory testing for von Willebrand disease: toward a mechanism-based classification. Clin Lab Med 2009; 29:193-228. [PMID: 19665675 DOI: 10.1016/j.cll.2009.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The heterogeneity of von Willebrand disease reflects the varied roles of von Willebrand factor in coagulation. Significant challenges remain in the detection, classification, and determination of bleeding risk in disorders related to von Willebrand factor. A clearer understanding of the specific disease mechanisms is essential to the development of improved methods for prognosis and management in this and other conditions with abnormalities of the von Willebrand factor system.
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Affiliation(s)
- Richard Torres
- Department of Laboratory Medicine, Yale School of Medicine, 333 Cedar Street, P.O. Box 208035, New Haven, CT 06520-8035, USA.
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47
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Vanderschueren S, Mylle M, Dierickx D, Delforge M, Verhamme P, Peerlinck K, Meersseman W, Knockaert DC. Monoclonal gammopathy of undetermined significance: significant beyond hematology. Mayo Clin Proc 2009; 84:842-5. [PMID: 19720783 PMCID: PMC2735435 DOI: 10.4065/84.9.842] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
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48
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Vanderschueren S, Mylle M, Dierickx D, Delforge M, Verhamme P, Peerlinck K, Meersseman W, Knockaert DC. Monoclonal gammopathy of undetermined significance: significant beyond hematology. Mayo Clin Proc 2009; 84:842-5. [PMID: 19720783 PMCID: PMC2735435 DOI: 10.1016/s0025-6196(11)60495-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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49
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Abstract
Unexpectedly high rates of venous thromboembolic events (VTE) concurrent with the introduction of highly effective immune modulating drugs thalidomide and lenolidomide for treatment of multiple myeloma have focused attention on the incidence and underlying pathophysiology of VTE in patients with plasma cell dyscrasias, and on thromboprophylaxis approaches. While bleeding complications are relatively uncommon in patients with lymphoproliferative disorders, acquired von Willebrand syndrome, typically occurring in patients with monoclonal gammopathy of unknown significance, and acquired coagulopathies associated with primary amyloidosis can present with haemorrhagic complications and both are challenging to manage. This review highlights these important haemostasis-related complications of plasma cell dyscrasias and provides an overview of other uncommon bleeding and thrombotic events that can affect diagnostic and therapeutic management of clonal plasma cell disorders. Due to the infrequency of most of these haemostasis complications, available information is typically based on retrospective cases or series.
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Affiliation(s)
- Charles Eby
- Department of Pathology & Immunology and Medicine, Washington University School of Medicine, St Louis, MO 63110, USA.
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50
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Pakk H, Kim IH, Park SH, Lee DS, Park SY, Cho HI, Kim HK. Acquired von Willebrand Syndrome Associated with Amyloidosis. THE KOREAN JOURNAL OF HEMATOLOGY 2009. [DOI: 10.5045/kjh.2009.44.4.310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Hyewon Pakk
- Department of Laboratory Medicine, College of Medicine, Seoul National University, Seoul, Korea
| | - In-Ho Kim
- Department of Internal Medicine, College of Medicine, Seoul National University, Seoul, Korea
| | - Sung-Hye Park
- Department of Pathology, College of Medicine, Seoul National University, Seoul, Korea
| | - Dong-Soon Lee
- Department of Laboratory Medicine, College of Medicine, Seoul National University, Seoul, Korea
| | - Seon-Yang Park
- Department of Internal Medicine, College of Medicine, Seoul National University, Seoul, Korea
| | - Han-Ik Cho
- Department of Laboratory Medicine, College of Medicine, Seoul National University, Seoul, Korea
| | - Hyun Kyung Kim
- Department of Laboratory Medicine, College of Medicine, Seoul National University, Seoul, Korea
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