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Ichinose A, Osaki T, Souri M. Diagnosis and Treatment of Autoimmune Acquired Coagulation Factor Deficiencies: An Evidence-Based Review of Japanese Practice. Semin Thromb Hemost 2024. [PMID: 38866039 DOI: 10.1055/s-0044-1787188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
Among the acquired coagulation factor deficiencies, autoimmune coagulation factor deficiencies (AiCFD) are rare and result from autoantibody production against coagulation factors. In Japan, a nationwide survey on AiCFD has been conducted since 2009. Autoimmune factor XIII, factor VIII, von Willebrand factor, factor V, and factor X deficiencies (AiF13D, AiF8D, AiVWFD, AiF5D, and AiF10D, respectively) have been enacted as "designated intractable disease-282." The incidence of AiF8D, AiF13D, and AiF5D was 1.83, 0.044, and 0.038 per million people/year, respectively, whereas that of AiVWFD and AiF10D was not calculable owing to the small number of patients. AiF13D and AiF8D were often idiopathic, whereas AiVWFD was often associated with plasma cell neoplasms. Epistaxis was a characteristic symptom of AiVWFD, intramuscular bleeding was frequent in AiF13D and AiF8D, and subcutaneous bleeding (purpura) was frequent in AiF13D and AiF10D, although none were specific to any one disease. Differential diagnosis cannot be made based on bleeding symptoms alone; therefore, rapid and accurate testing is mandatory. Definitive diagnosis of AiCFD necessitates identifying the presence of coagulation factor "inhibitors" and/or "autoantibodies." Therefore, these tests should be performed upon unexplained severe acquired coagulation factor deficiencies. The mainstay of treatment for AiCFD was hemostatic therapy and autoantibody eradication therapy, which included the replacement of coagulation factors or "bypass" agents and administration of immunosuppressants. The rate of hemorrhagic death was high in AiF13D (13%), followed by AiF5D (7%) and Ai10D (5%); therefore, early diagnosis and optimal treatment are essential for AiCFDs. Given the unknown long-term prognosis, "intractable disease platform registries" have begun to accumulate in Japan.
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Affiliation(s)
- Akitada Ichinose
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan
- The Japanese Collaborative Research Group on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare, Yamagata University School of Medicine, Yamagata, Japan
| | - Tsukasa Osaki
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan
- The Japanese Collaborative Research Group on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare, Yamagata University School of Medicine, Yamagata, Japan
- Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Yamagata, Japan
| | - Masayoshi Souri
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan
- The Japanese Collaborative Research Group on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare, Yamagata University School of Medicine, Yamagata, Japan
- Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Yamagata, Japan
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Ogawa Y, Ichinose A, Yanagisawa K, Souri M, Osaki T, Kanaya S, Handa H. Retrospectively diagnosed autoimmune VWF deficiency in a patient with repeated hemorrhagic events after two common colds. Int J Hematol 2024:10.1007/s12185-024-03782-4. [PMID: 38761278 DOI: 10.1007/s12185-024-03782-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/18/2024] [Accepted: 04/19/2024] [Indexed: 05/20/2024]
Abstract
Autoimmune von Willebrand factor (VWF) deficiency (AiVWFD) caused by anti-VWF autoantibodies is a rare bleeding disorder, whereas "non-immune" acquired von Willebrand syndrome (AVWS) caused by other etiologies is more common. Therefore, only 40 patients with AiVWFD have been identified in Japan through an ongoing nationwide survey on autoimmune coagulation factor deficiencies. This may be due to the inability to efficiently detect anti-VWF antibodies, as anti-VWF antibody testing is not routine. An 80-year-old Japanese woman developed AVWS and experienced bleeding after two separate common colds. She took the same cold medicine each time and recovered spontaneously after discontinuation of the medicine. Severe VWF deficiency normalized each time. Initial immunological tests did not detect anti-VWF autoantibodies, and thus a diagnosis of "non-immune" AVWS of unknown origin was made. However, after 6 years, new ELISA assays using purified VWF proteins detected free anti-VWF autoantibodies, which led to a retrospective diagnosis of AiVWFD. It is probable that the cold medicine (and/or cold virus infection) induced the autoantibodies, as the recurrence and normalization of the same coagulation abnormality and the clinical course (including drug administration and discontinuation) were completely synchronized. If AiVWFD is suspected, highly sensitive autoantibody tests should be performed.
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Affiliation(s)
- Yoshiyuki Ogawa
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
- The Japanese Collaborative Research Group (JCRG) On Autoimmune Acquired Coagulation Factor Deficiencies Supported By the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan
| | - Akitada Ichinose
- The Japanese Collaborative Research Group (JCRG) On Autoimmune Acquired Coagulation Factor Deficiencies Supported By the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan.
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata, 990-9585, Japan.
| | - Kunio Yanagisawa
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Masayoshi Souri
- The Japanese Collaborative Research Group (JCRG) On Autoimmune Acquired Coagulation Factor Deficiencies Supported By the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata, 990-9585, Japan
- Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Yamagata, Japan
| | - Tsukasa Osaki
- The Japanese Collaborative Research Group (JCRG) On Autoimmune Acquired Coagulation Factor Deficiencies Supported By the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata, 990-9585, Japan
- Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Yamagata, Japan
| | - Shuhei Kanaya
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hiroshi Handa
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
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Takahashi M, Morita Y, Hayashi T, Higashihara T, Kawasaki K, Sato S, Yokose S, Sasaki S, Funakoshi K, Sasaki T, Zhou D, Ichinose A, Ohtsuka H, Ishibasi Y, Hatao F, Shimizu K, Isono N, Sasaki N, Kozai Y, Okada H, Chikasawa Y. A case of acquired hemophilia A after pancreaticoduodenectomy for distal cholangiocarcinoma. Biomed Rep 2023; 19:61. [PMID: 37614988 PMCID: PMC10442756 DOI: 10.3892/br.2023.1643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/17/2023] [Indexed: 08/25/2023] Open
Abstract
Acquired hemophilia A (AHA) is a rare disease that results from factor VIII inhibitors causing abnormal coagulation, and certain cases may develop after highly invasive surgery. The present case study reports on a 68-year-old male patient who developed AHA after undergoing a subtotal stomach-preserving pancreatoduodenectomy for distal cholangiocarcinoma. The patient experienced complications after surgery, requiring reoperation on postoperative day (PD) 5 due to rupture of the Braun's enterostomy. On PD 6, angiography was performed after bleeding was detected in the jejunal limb, but hemostasis occurred spontaneously during the examination. Bleeding was observed again on PD 8 and direct surgical ligation was performed. On PD 14, bleeding recurred in the jejunal limb and angiography was performed to embolize the periphery of the second jejunal artery. During the procedure, the prothrombin time was normal, but only the activated partial thromboplastin time was prolonged. A close examination of the coagulation system revealed a decrease in factor VIII levels and the presence of factor VIII inhibitors, resulting in the diagnosis of AHA. Administration of steroids was initiated on PD 15 and, in addition to daily blood transfusions, activated prothrombin complex concentrate was administered to achieve hemostasis. The patient was discharged from the intensive care unit on PD 36 but later developed an intractable labial fistula due to suture failure at the gastrojejunostomy site. As the use of factor VIII inhibitors continued despite the administration of steroids, cyclophosphamide (CPA) pulse therapy was added at PD 58. However, CPA was ineffective and the administration of rituximab was initiated on PD 98. After 12 courses of rituximab, the patient tested negative for factor VIII inhibitors on PD 219. On PD 289, labial fistula closure was performed with continuous replacement of factor VIII and the patient was discharged on PD 342.
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Affiliation(s)
- Makoto Takahashi
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Yasuhiro Morita
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Tatsuya Hayashi
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Taku Higashihara
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Keishi Kawasaki
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Shunsuke Sato
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Shota Yokose
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Shu Sasaki
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Kaoruko Funakoshi
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Takayoshi Sasaki
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Daren Zhou
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Akinori Ichinose
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Hideo Ohtsuka
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Yuji Ishibasi
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Fumihiko Hatao
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Keiki Shimizu
- Department of Critical Care and Emergency Medicine, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Nobuo Isono
- Department of Plastic Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Naomi Sasaki
- Department of Nursing, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Yasuji Kozai
- Department of Hematology, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Haruka Okada
- Department of Pathology, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Yushi Chikasawa
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo 183-8524, Japan
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Shoji-Asahina A, Nakatani E, Imaichi Y, Ohata E, Oshima M, Miyakoshi A, Miyake H, Ichikawa Y, Dote H, Ubukata N, Funaki D, Urano T. Risk factors, treatment and survival rates of late-onset acquired haemophilia A: A cohort study from the Shizuoka Kokuho Database. Haemophilia 2023; 29:799-808. [PMID: 37096498 DOI: 10.1111/hae.14793] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 03/01/2023] [Accepted: 04/12/2023] [Indexed: 04/26/2023]
Abstract
INTRODUCTION Acquired haemophilia A (AHA) is a rare disease. The risk factors have yet to be studied. AIM We aimed to identify risk factors for late-onset AHA in Japan. METHODS A population-based cohort study was conducted using data from the Shizuoka Kokuho Database. The study population was defined as individuals aged ≥60 years. Cause-specific Cox regression analysis was performed to calculate hazard ratios. RESULTS Of 1,160,934 registrants, there were 34 patients with newly diagnosed AHA. The mean follow-up period was 5.6 years, and the incidence of AHA was 5.21 per million person-years. Myocardial infarction, diabetes mellitus, solid tumors, antimicrobial agents, phenytoin and anti-dementia drugs, which showed significant differences in the univariate analysis, were excluded from the multivariable analysis because of the small number of cases. Multivariable regression analysis showed that the presence of Alzheimer's disease (hazard ratio [HR]:4.28, 95% confidence interval [CI]:1.67-10.97) and rheumatic disease (HR:4.65, 95% CI:1.79-12.12) increased the risk of AHA development. CONCLUSION We found that comorbid Alzheimer's disease is a risk factor of AHA incidence in the general population. Our findings provide insight into the etiology of AHA, and the proof of the coexistence of Alzheimer's disease may support the recent notion that Alzheimer disease is an autoimmune disease.
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Affiliation(s)
- Aya Shoji-Asahina
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
- Department of Clinical Laboratory, Japanese Red Cross Shizuoka Hospital, Aoi-ku, Shizuoka, Japan
| | - Eiji Nakatani
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Yutaro Imaichi
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Emi Ohata
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Michiko Oshima
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Akinori Miyakoshi
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Hiromu Miyake
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Yoshikazu Ichikawa
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Hisashi Dote
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Nanako Ubukata
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Daito Funaki
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Tetsumei Urano
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
- Department of Medical Physiology, Hamamatsu University School of Medicine, Higashi-ku, Hamamatsu, Japan
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Abe H, Saito M, Uno K, Koike T, Ichikawa S, Saito M, Kanno T, Hatta W, Asano N, Masamune A. A case of refractory bleeding from duodenal angioectasia with acquired hemophilia A. Clin J Gastroenterol 2023; 16:355-360. [PMID: 37022595 DOI: 10.1007/s12328-023-01790-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 03/23/2023] [Indexed: 04/07/2023]
Abstract
Acquired hemophilia A (AHA) is a coagulation disorder related to the factor VIII inhibitors, which might cause intractable bleeding of gastrointestinal tracts. However, its scarcity makes it difficult to recognize AHA as a pitfall of endoscopic hemostasis failure. An 81-year-old female with a history of endoscopic treatment for colon polyps visited a local hospital with chief compliments of bloody stool and severe anemia. During several examinations for the bleeding origin, esophagogastroduodenoscopy depicted a 5 mm-sized hemorrhagic angioectasia of the duodenum, followed by treatment with argon plasma coagulation. However, hemostasis was not achieved by multiple sessions of endoscopic hemostasis and transcatheter arterial embolization, so blood transfusion was repeatedly done and she was transferred to our hospital. Laboratory data showed severe anemia with coagulation disorder. Based on the results of von Willebrand factor activity, factor VIII activity and factor VIII inhibitor, we diagnosed AHA as a comorbidity. Endoscopic hemostasis was confirmed only after improvement of APTT level and negative for the factor VIII inhibitor by hemostatic bypass treatment with recombinant active factor VII and immunosuppressive therapy with prednisolone and cyclophosphamide. In case of refractory bleeding of gastrointestinal tract, we should suspect of a comorbidity of coagulation disorder like AHA.
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Affiliation(s)
- Hiroko Abe
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Masahiro Saito
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Kaname Uno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Satoshi Ichikawa
- Division of Hematology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Masashi Saito
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Takeshi Kanno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Waku Hatta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Naoki Asano
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
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Osaki T, Souri M, Yokoyama C, Magari Y, Ichinose A. Unmet Need for Reliable Immunological Detection Method for Anti-von Willebrand Factor Autoantibodies. Thromb Haemost 2023; 123:478-481. [PMID: 36539201 DOI: 10.1055/a-2002-2394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Tsukasa Osaki
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Iida-Nishi, Yamagata, Japan.,The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan.,Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Iida-Nishi, Yamagata, Japan
| | - Masayoshi Souri
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Iida-Nishi, Yamagata, Japan.,The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan.,Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Iida-Nishi, Yamagata, Japan
| | - Chikako Yokoyama
- The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan.,Department of Biochemical Engineering, Graduate School of Science and Engineering, Yamagata University, Yonezawa, Japan.,Department of Chemistry and Bioengineering, Graduate School of Engineering, Osaka Metropolitan University, Osaka, Japan
| | | | - Akitada Ichinose
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Iida-Nishi, Yamagata, Japan.,The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan
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ORIHIME study: real-world treatment patterns and clinical outcomes of 338 patients with acquired hemophilia A from a Japanese administrative database. Int J Hematol 2023; 117:44-55. [PMID: 36331704 PMCID: PMC9813148 DOI: 10.1007/s12185-022-03467-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Acquired hemophilia A (AHA) is a rare disorder, and clinical practices for treating AHA have not been fully clarified in Japan. OBJECTIVES This study aims to investigate the epidemiology of AHA and real-world treatment practices in Japan. PATIENTS/METHODS This observational study was based on a health administrative database of hospitalized patients diagnosed with AHA who were treated with immunosuppressants. RESULTS The study included 214 males and 124 females (mean age 75.7 years). The most frequently used bypassing agent was recombinant activated factor VII. The predominant choice of immunosuppressant for first-line treatment was steroid monotherapy. Median days from the index date to the start of rehabilitation was 65.0 for cardiovascular, 35.5 for respiratory and 23.0 for locomotor. The proportion of patients with an activities of daily living (ADL) score < 70 points was high at both first admission and final discharge (47.4% and 38.8%). The percentage of deaths during hospitalization was 18.6%. CONCLUSIONS This study clarified the treatment patterns and clinical outcomes of AHA in a large population in Japan. This was the first study showing ADL score distribution and time to rehabilitation. Further investigation is needed to develop better clinical practices for treatment of AHA.
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Nardella J, Comitangelo D, Marino R, Malcangi G, Barratta MD, Sabba C, Perrone A. Acquired Hemophilia A After SARS-CoV-2 Infection: A Case Report. J Med Cases 2022; 13:197-201. [PMID: 35655623 PMCID: PMC9119369 DOI: 10.14740/jmc3921] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/14/2022] [Indexed: 11/17/2022] Open
Abstract
Acquired hemophilia A is a rare autoimmune coagulation disorder associated to the development of neutralizing antibodies directed towards coagulation factor VIII, known as factor VIII inhibitors, in subjects with previous normal clotting system homeostasis and personal and family history negative for bleeding episodes. This condition, although variable in severity and clinical presentation, may lead to severe and life-threatening hemorrhages which can be either spontaneous or associated with traumatic events and invasive procedures. Here we report the case of a 53-year-old woman who was admitted to our Internal Medicine Unit "Cesare Frugoni", Policlinico di Bari, in July 2021, and diagnosed with acquired hemophilia A. We aim to raise awareness about this rare condition, its clinical presentation and therapeutic management options in order to obtain a quick diagnosis and an effective therapeutic intervention.
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Affiliation(s)
- Jennifer Nardella
- DIM - Interdisciplinary Department of Medicine, Internal Medicine Unit “Cesare Frugoni”, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
| | - Domenico Comitangelo
- DIM - Interdisciplinary Department of Medicine, Internal Medicine Unit “Cesare Frugoni”, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
| | - Renato Marino
- Hemophilia and Transfusion Center, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
| | - Giuseppe Malcangi
- Hemophilia and Transfusion Center, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
| | - Marco Damiano Barratta
- DIM - Interdisciplinary Department of Medicine, Internal Medicine Unit “Cesare Frugoni”, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
| | - Carlo Sabba
- DIM - Interdisciplinary Department of Medicine, Internal Medicine Unit “Cesare Frugoni”, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
| | - Antonio Perrone
- DIM - Interdisciplinary Department of Medicine, Internal Medicine Unit “Cesare Frugoni”, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
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Wang LY, Shen Y, Zeng HQ, Zhang Y, Lou SF, Deng JC, Luo Y. Feasibility of therapeutic plasma exchange-based combination therapy in the treatment of acquired hemophilia A: A retrospective 6 case series. Medicine (Baltimore) 2021; 100:e26587. [PMID: 34398013 PMCID: PMC8294921 DOI: 10.1097/md.0000000000026587] [Citation(s) in RCA: 1] [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] [Received: 10/20/2020] [Accepted: 06/17/2021] [Indexed: 01/04/2023] Open
Abstract
Poor availability and a lack of affordability of bypassing agents (recombinant activated factor VII and activated prothrombin complex concentrate) in west China prompted us to investigate an alternative cost-effective combination therapy. We aimed to explore the feasibility of therapeutic plasma exchange (TPE)-based combination therapy in the treatment of acquired hemophilia A (AHA).We retrospectively investigated the clinical features of AHA in 6 patients who were treated with a combination of TPE, corticosteroids, and rituximab in our department for 9 years between January, 2011 and December, 2019.We examined 1 male and 5 female patients. The median age at diagnosis of AHA was 51 years (18-66 years). In all patients, FVIII activity levels were low (median: 1.5%; 1-3%), FVIII inhibitor titers were high (median: 24.5 BU/mL; 13.2-48.6 BU/mL), and activated partial thromboplastin time was markedly prolonged (median: 99.4 s; 60.9-110.1 s). They underwent 2 to 8 cycles of plasma exchange and were given varying combinations of dexamethasone, methylprednisolone, prednisone, and rituximab. After TPE bleeding gradually stopped, and activated partial thromboplastin time decreased. After 3 months of treatment, FVIII inhibitors completely disappeared.TPE when combined with corticosteroids and rituximab, as adjunctive immunosuppressive agents, may be an effective and reliable treatment for AHA. When there is no alternative, intensive first-line treatment including TPE may be lifesaving.
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Schep SJ, Dijk WEM, Beckers EAM, Meijer K, Coppens M, Eikenboom J, Leebeek FWG, Vulpen LFD, Fischer KF, Schutgens REG. Treatment of acquired hemophilia A, a balancing act: results from a 27-year Dutch cohort study. Am J Hematol 2021; 96:51-59. [PMID: 32974947 PMCID: PMC7756759 DOI: 10.1002/ajh.26009] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 12/22/2022]
Abstract
Acquired hemophilia A (AHA) is a severe auto-immune bleeding disorder. Treatment of AHA is burdensome and optimal management is still unresolved. Therefore a retrospective nationwide multi-center cohort study (1992-2018) was performed to evaluate clinical presentation and treatment efficacy and safety of AHA in the Netherlands. Multivariate logistic and Cox regression analysis was used to study independent associations between patient characteristics and clinical outcomes. A total of 143 patients (median age 73 years; 52.4% male) were included with a median follow-up of 16.8 months (IQR 3.6-41.5 months). First-line immunosuppressive treatment was mostly steroid monotherapy (67.6%), steroids/cyclophosphamide (11.9%) and steroids/rituximab (11.9%), with success rates of 35.2%, 80.0% and 66.7% respectively, P < .05. Eventually 75% of patients achieved complete remission (CR). A high anti-FVIII antibody titer, severe bleeding and steroid monotherapy were associated with lower CR rates. Infections, the most important adverse event, occurred significantly more often with steroid combination therapy compared to steroids alone (38.7% vs 10.6%; P = .001). Overall mortality was 38.2%, mostly due to infections (19.2%) compared to 7.7% fatal bleeds. Advanced age, underlying malignancy and ICU admission were predictors for mortality. This study showed that AHA is characterized by significant disease-related and treatment-related morbidity and mortality. A high anti-FVIII titer, severe bleeding and steroid monotherapy were associated with a lower CR rate. The efficacy of steroid combination therapies however, was overshadowed by higher infection rates and infections represented the most important cause of death. The challenging and delicate balance between treatment effectivity and safety requires ongoing monitoring of AHA and further identification of prognostic markers.
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Affiliation(s)
- Sarah J. Schep
- Van Creveldkliniek University Medical Center Utrecht, University Utrecht Utrecht The Netherlands
| | - Wobke E. M. Dijk
- Van Creveldkliniek University Medical Center Utrecht, University Utrecht Utrecht The Netherlands
| | - Erik A. M. Beckers
- Department of Internal Medicine/Hematology Maastricht University Medical Center +, part of the Nijmegen/Eindhoven/Maastricht Haemophilia Treatment Center (HTC) Maastricht The Netherlands
| | - Karina Meijer
- Department of Hematology University Medical Center Groningen, University of Groningen Groningen The Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine Amsterdam University Medical Centers, University of Amsterdam Amsterdam The Netherlands
| | - Jeroen Eikenboom
- Division of Thrombosis and Hemostasis, Department of Internal Medicine Leiden University Medical Center, part of the Leiden/The Hague HTC Leiden The Netherlands
| | - Frank W. G. Leebeek
- Department of Hematology Erasmus MC, University Medical Center Rotterdam Rotterdam The Netherlands
| | - Lize F. D. Vulpen
- Van Creveldkliniek University Medical Center Utrecht, University Utrecht Utrecht The Netherlands
| | - Kathelijn F. Fischer
- Van Creveldkliniek University Medical Center Utrecht, University Utrecht Utrecht The Netherlands
| | - Roger E. G. Schutgens
- Van Creveldkliniek University Medical Center Utrecht, University Utrecht Utrecht The Netherlands
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11
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Nakakubo Y, Yamamoto K, Fujita M. Atypical Presenting Symptoms of Acute Onset Acquired Haemophilia with Eosinophilic Fasciitis. Eur J Case Rep Intern Med 2020; 7:001722. [PMID: 32908832 DOI: 10.12890/2020_001722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 05/25/2020] [Indexed: 11/05/2022] Open
Abstract
Acquired haemophilia is a bleeding disorder caused by antibodies against coagulation factors. Some cases are associated with autoimmune diseases. However, no cases of acquired haemophilia with eosinophilic fasciitis have been previously reported. Herein we describe the case of a patient with eosinophilic fasciitis associated with acquired haemophilia. LEARNING POINTS Eosinophilic fasciitis is one of the underlying diseases of acquired haemophilia.The underlying disease of acquired haemophilia should be investigated thoroughly and systematically to optimize therapeutic strategies.This is the first report of acquired haemophilia in association with eosinophilic fasciitis.
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Affiliation(s)
- Yuto Nakakubo
- Department of Clinical Immunology and Rheumatology, The Tazuke-Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Kazuyo Yamamoto
- Department of Hematology, The Tazuke-Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Masaaki Fujita
- Department of Clinical Immunology and Rheumatology, The Tazuke-Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan.,Department of Clinical Immunology and Rheumatology, Kansai Electric Power Hospital, Osaka, Japan
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12
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Takeyama M, Nogami K, Matsumoto T, Noguchi-Sasaki M, Kitazawa T, Shima M. An anti-factor IXa/factor X bispecific antibody, emicizumab, improves ex vivo coagulant potentials in plasma from patients with acquired hemophilia A. J Thromb Haemost 2020; 18:825-833. [PMID: 31984625 DOI: 10.1111/jth.14746] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/31/2019] [Accepted: 01/17/2020] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Acquired hemophilia A (AHA) is caused by autoantibodies against factor (F)VIII, and is characterized by severe, spontaneous bleeding, which can be life-threatening. Emicizumab, an anti-FIXa/FX bispecific antibody, significantly reduces bleeding events in congenital hemophilia A (HA) with and without inhibitors. The known pathophysiological mechanisms and current preclinical data in HA suggest that emicizumab could provide effective treatment for AHA, but the coagulation activities of emicizumab in these patients remain unknown. AIM To evaluate the coagulant effects of emicizumab in plasma from AHA patients. METHODS AND RESULTS Tissue factor-triggered thrombin generation assays using normal plasma preincubated with anti-FVIII monoclonal antibodies recognizing different epitopes demonstrated that 20 µg/mL emicizumab recovered the depressed peak levels of thrombin generation to 46% to 72%. Further studies were devised, therefore, to simulate the clinical course in AHA patients, including during the acute phase for severe bleeding requiring FVIII-bypassing therapy, and during the subacute/chronic phase with less bleeding. Various concentrations of emicizumab were used to represent the potential changes in plasma levels based on the half-life of the antibody (~30 days). The ex vivo addition of emicizumab to plasma samples from AHA patients (n = 16) increased peak thrombin in all cases, irrespective of the inhibitor epitope specificity. Thrombin generation at 20 and 100 µg/mL emicizumab was restored to (median) 43.9% and 92.2%, respectively. Differences were evident in some cases, however, and recovery rates appeared likely to be greater in patients with type 2 inhibitor than those with type 1. CONCLUSION Emicizumab improved ex vivo coagulation potential in plasma from AHA patients.
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Affiliation(s)
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Tomoko Matsumoto
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
- Tenri School of Medical Technology, Tenri, Japan
| | | | | | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
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13
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Ogawa Y, Yanagisawa K, Naito C, Uchiumi H, Ishizaki T, Shimizu H, Gohda F, Ieko M, Ichinose A, Handa H. Overshoot of FVIII activity in patients with acquired hemophilia A who achieve complete remission. Int J Hematol 2020; 111:544-549. [PMID: 31939075 DOI: 10.1007/s12185-020-02823-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 12/28/2019] [Accepted: 01/07/2020] [Indexed: 10/25/2022]
Abstract
Acquired hemophilia A (AHA) is a rare, life-threatening bleeding disorder caused by autoantibodies against coagulation factor VIII (FVIII). Immunosuppressive therapy for AHA aims to arrest bleeding by eliminating FVIII inhibitors. Factor VIII activity overshoot after complete remission (CR) has been reported anecdotally, but details remain unclear. We retrospectively analyzed data from 17 patients with AHA who achieved CR under immunosuppressive therapy between 2009 and 2019 at Gunma University Hospital. FVIII activity overshoot was defined as ≥ 150%. All 17 patients had low FVIII activity (median 2.1%; range < 1.0-8.9%) due to FVIII inhibition (median 14.7 BU/mL; range 2.0-234.0) and all achieved CR within a median of 39 (range 19-173) days. Overshoot occurred in 11 (64.7%) patients and maximal FVIII activity reached > 200% in six of them. The median duration from CR to overshoot was 13 (range 0-154) days. The FVIII overshoot was transient (72.7%) or persistent (27.3%). Venous thromboembolism developed as a complication of overshoot in one patient due to iliac vein compression by a massive hematoma. Overshoot of FVIII activity after CR occurs more frequently than previously expected in patients with AHA.
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Affiliation(s)
- Yoshiyuki Ogawa
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan. .,The Japanese Collaborative Research Group (JCRG) on Acquired Coagulopathies Supported by the Japanese Ministry of Health, Labour and Welfare, Yamagata, Japan.
| | - Kunio Yanagisawa
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Chiaki Naito
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hideki Uchiumi
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan.,Hidaka-Kai Shirane Clinic, Numata, Japan
| | - Takuma Ishizaki
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hiroaki Shimizu
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Fumito Gohda
- Department of Internal Medicine, National Hospital Organization Takasaki General Medical Center, Takasaki, Japan
| | - Masahiro Ieko
- The Japanese Collaborative Research Group (JCRG) on Acquired Coagulopathies Supported by the Japanese Ministry of Health, Labour and Welfare, Yamagata, Japan.,Department of Internal Medicine, School of Dentistry, Health Sciences University of Hokkaido, Ishikari-Tonetsu, Japan
| | - Akitada Ichinose
- The Japanese Collaborative Research Group (JCRG) on Acquired Coagulopathies Supported by the Japanese Ministry of Health, Labour and Welfare, Yamagata, Japan.,Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan
| | - Hiroshi Handa
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
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14
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Abdalkader AF, Salih AAM, Ibraheem EK. Patient profile, clinical characteristics and treatment response in acquired haemophilia A: A retrospective analysis of a single-centre experience over a 3-year period. Haemophilia 2019; 26:e1-e4. [PMID: 31742825 DOI: 10.1111/hae.13869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 10/08/2019] [Accepted: 10/09/2019] [Indexed: 11/28/2022]
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15
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Mihara M, Ogawa Y, Nagasaka M, Kobayashi N, Shimizu H, Shinozawa K, Fukutake K, Inoue M, Murakami M, Handa H. Successful Management of Acquired Factor V Inhibitor by Monitoring Factor V Activity, Antigen, and Inhibitor Values during Immunosuppressive Therapy. Acta Haematol 2019; 143:486-490. [PMID: 31563916 DOI: 10.1159/000502730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 08/15/2019] [Indexed: 11/19/2022]
Abstract
Acquired factor V inhibitor (AFVI) results from the formation of autoantibodies to coagulation factor V (FV), and the clinical phenotype can range from asymptomatic laboratory abnormalities to life-threatening bleeds. We describe a 74-year-old man who developed AFVI along with a massive subcutaneous hematoma. He was initially treated with prednisolone (PSL), but AFVI recurred when the dose was reduced after a short period. We subsequently increased the PSL dose and added cyclophosphamide (CY), which resulted in a complete response. We then gradually tapered PSL and stopped CY, and the patient has since remained free of recurrent AFVI symptoms. We monitored FV activity, antigen concentrations, and inhibitor titers of this patient throughout the clinical course. The ratio of FV activity to antigen concentration was low at diagnosis and gradually increased along with the patient's improvement. This ratio might be a useful parameter for evaluating the effects of immunosuppressive therapy in patients with AFVI.
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Affiliation(s)
- Masahiro Mihara
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
- Department of Internal Medicine, Kiboukan Hospital, Takasaki, Japan
| | - Yoshiyuki Ogawa
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan,
| | - Motoo Nagasaka
- Department of Internal Medicine, Kiboukan Hospital, Takasaki, Japan
| | - Nobuhiko Kobayashi
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hiroaki Shimizu
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
- Department of Internal Medicine, Kiboukan Hospital, Takasaki, Japan
| | - Keiko Shinozawa
- Department of Molecular Genetics of Coagulation Disorders, Tokyo Medical University, Tokyo, Japan
| | - Katsuyuki Fukutake
- Department of Molecular Genetics of Coagulation Disorders, Tokyo Medical University, Tokyo, Japan
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Madoka Inoue
- Department of Clinical Laboratory, Gunma University Hospital, Maebashi, Japan
| | - Masami Murakami
- Department of Clinical Laboratory Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hiroshi Handa
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
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16
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A Case of a Patient Who Is Diagnosed with Mild Acquired Hemophilia A after Tooth Extraction Died of Acute Subdural Hematoma due to Head Injury. Case Rep Dent 2019; 2018:7185263. [PMID: 30627455 PMCID: PMC6304843 DOI: 10.1155/2018/7185263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/12/2018] [Accepted: 11/25/2018] [Indexed: 11/20/2022] Open
Abstract
Background Acquired hemophilia A (AHA) is a rare disorder which results from the presence of autoantibodies against blood coagulation factor VIII. The initial diagnosis is based on the detection of an isolated prolongation of the activated partial thromboplastin time (aPTT) with negative personal and family history of bleeding disorder. Definitive diagnosis is the identification of reduced FVIII levels with evidence of FVIII neutralizing activity. Case report We report a case of a 93-year-old female who was diagnosed as AHA after tooth extraction at her home clinic. Prolongation of aPTT and a reduction in factor VIII activity levels were observed with the presence of factor VIII inhibitor. AHA condition is mild. However, acute subdural hematoma of this patient occurred due to an unexpected accident in our hospital. Hematoma was gradually increased and the patient died 13 days after admission. Discussion Although AHA is mild, intracranial bleeding is a life-threatening condition. We also should pay attention to the presence of AHA patients when we extract teeth.
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17
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Kadohira Y, Yamada S, Hayashi T, Morishita E, Asakura H, Ichinose A. A discrepancy between prothrombin time and Normotest (Hepaplastintest) results is useful for diagnosis of acquired factor V inhibitors. Int J Hematol 2018; 108:145-150. [PMID: 29611057 DOI: 10.1007/s12185-018-2453-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/27/2018] [Accepted: 03/28/2018] [Indexed: 11/27/2022]
Abstract
Acquired coagulation factor inhibitors are rare. Among them, coagulation factor V (FV) inhibitor is particularly uncommon and presents with variable clinical manifestations. Certain acquired FV inhibitor patients have only mild bleeding or, in select cases, no symptoms at all, leading to spontaneous recovery. Others have life-threatening bleeding that requires medical attention. Thus, a prompt decision regarding diagnosis and clinical intervention is crucial for such patients. In five acquired FV inhibitor cases treated in our facility, each patient had a malignancy as an underlying disease and all unexpectedly showed prolongation of both prothrombin time (PT) and activated partial thromboplastin time (APTT). They all also displayed a discrepancy between PT and Normotest (Hepaplastintest, HPT) results. All but one patient experienced no bleeding at the time of diagnosis and achieved spontaneous recovery in 1-3 weeks. The patient with bleeding symptoms received plasma exchanges and a platelet transfusion. Useful markers in diagnosing the presence of an acquired FV inhibitor were a sudden prolongation of PT and APTT, and a discrepancy between the PT/APTT and HPT assays. Spontaneous recovery can be expected for patients with only minor bleeding.
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Affiliation(s)
- Yasuko Kadohira
- Department of Hematology, Kanazawa University Hospital, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Shinya Yamada
- Department of Hematology, Kanazawa University Hospital, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Tomoe Hayashi
- Department of Hematology, Kanazawa University Hospital, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Eriko Morishita
- Department of Hematology, Kanazawa University Hospital, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
- Japanese Collaborative Research Group on Autoimmune Haemorrhaphilia Supported by the Japanese Ministry of Health, Labor and Welfare, Yamagata, Japan
| | - Akitada Ichinose
- Japanese Collaborative Research Group on Autoimmune Haemorrhaphilia Supported by the Japanese Ministry of Health, Labor and Welfare, Yamagata, Japan
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School, Yamagata, Japan
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18
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Bastida JM, Cano-Mozo MT, Lopez-Cadenas F, Vallejo VE, Merchán S, Santos-Montón C, González-Calle D, Carrillo J, Martín AA, Torres-Hernández JA, González M, Martín-Herrero F, Pabón P, González-Porras JR. Hemorrhagic pericardial effusion as the debut of acquired hemophilia in a chronic lymphocytic leukemia patient: A case report, and a review of acquired hemophilia A-related hematological malignancies. Medicine (Baltimore) 2017; 96:e8669. [PMID: 29381944 PMCID: PMC5708943 DOI: 10.1097/md.0000000000008669] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Acquired hemophilia A (AHA) is a rare bleeding disease caused by autoantibodies against factor VIII. Spontaneous bleeding symptoms usually affect the skin and muscle, while pericardial effusion is an extremely rare manifestation. In the elderly, anticoagulant treatment is frequent and bleeding symptoms are usually associated with this. CLINICAL FINDINGS We report a hemorrhagic pericardial effusion as the AHA debut in a patient with untreated chronic lymphocytic leukemia and anticoagulated with apixaban for atrial fibrillation and chronic arterial ischemia. The patient was treated with recombinant activated factor VII to control the active bleeding and corticosteroids and cyclophosphamide to eradicate the inhibitor. In addition, a briefly review of hematological malignancies associated to acquired hemophilia was performed. PARTICULARITIES:: a) anticoagulant treatment may confuse the suspicion of AHA and its diagnosis; b) hemorrhagic pericardial effusion is an extremely rare presentation; c) bypassing agents raise the risk of thromboembolism; d) hematological malignancies rarely cause AHA (<20% of cases). CONCLUSION A multidisciplinary team is needed to diagnose and manage AHA effectively. The use of anticoagulants may lead to the misdiagnosis of clinical symptoms. Chronic lymphocytic leukemia is one of the main causes of hematological malignancies associated. The specific treatment of CLL is still recommended in the event of active disease.
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Affiliation(s)
- José María Bastida
- Department of Hematology, Hospital Universitario de Salamanca-IBSAL, Salamanca
| | | | - Felix Lopez-Cadenas
- Department of Hematology, Hospital Universitario de Salamanca-IBSAL, Salamanca
| | | | - Soraya Merchán
- Department of Cardiology, Hospital Universitario de Salamanca-IBSAL, Salamanca
| | | | | | - Javier Carrillo
- Department of Hematology, Hospital Universitario de Salamanca-IBSAL, Salamanca
| | - Ana Africa Martín
- Department of Hematology, Hospital Universitario de Salamanca-IBSAL, Salamanca
| | | | - Marcos González
- Department of Hematology, Hospital Universitario de Salamanca-IBSAL, Salamanca
| | | | - Pedro Pabón
- Department of Cardiology, Hospital Universitario de Salamanca-IBSAL, Salamanca
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