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Rungjirajittranon T, Suwanawiboon B, Nakkinkun Y, Leelakanok N, Kaokunakorn T, Chinthammitr Y, Owattanapanich W, Ruchutrakool T. First-line immunosuppressive therapies for acquired hemophilia A: A 25-year cohort experience and network meta-analysis. Thromb Res 2024; 241:109067. [PMID: 38970991 DOI: 10.1016/j.thromres.2024.109067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/28/2024] [Accepted: 06/17/2024] [Indexed: 07/08/2024]
Abstract
Acquired hemophilia A (AHA) presents a significant bleeding risk. Management involves bleeding control and immunosuppressive therapy (IST) to eliminate inhibitors. This study, encompassing a retrospective cohort of 76 newly diagnosed AHA patients (1997-2022), evaluated IST outcomes such as complete remission (CR), relapse, and mortality rates, alongside influencing factors. Supplementing these findings, a systematic review and network meta-analysis compared CR and relapse rates across ISTs, sourcing from Embase, Scopus, and ScienceDirect up to November 2023. In our cohort, demarcated by a 20 Bethesda-unit titer threshold, cyclophosphamide plus prednisolone (CP; n = 64) was the predominant initial IST. Lower inhibitor levels significantly correlated with higher CR rates (86.8 % vs 62.2 %; P = .014) and showed an odds ratio of 0.26 for CR (P = .021). Median relapse-free survival (RFS) extended to 37.13 months, significantly enhanced by CP (hazard ratio, 0.24; 95 % confidence interval, 0.10-0.60; P = .002). Our network meta-analysis, including 1476 CR and 636 relapse patients, indicated CP and rituximab-based ISTs significantly outperformed steroid monotherapy in terms of CR and lower relapse rates (risk differences of 0.15 and -0.13/-0.15, respectively; P < .05), without significant differences between CP and rituximab. Moreover, adding rituximab to the front-line treatment did not produce superior outcomes compared to the CP regimen alone, positioning CP as a viable first-line choice, particularly where rituximab is less accessible. The consideration of IST toxicity remains critical in treatment decisions.
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Affiliation(s)
- Tarinee Rungjirajittranon
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Bundarika Suwanawiboon
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Yupa Nakkinkun
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Nattawut Leelakanok
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Burapha University, Chonburi, Thailand
| | - Thanapon Kaokunakorn
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Yingyong Chinthammitr
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Weerapat Owattanapanich
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Theera Ruchutrakool
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
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Hata K, Kato J, Takahashi Y, Saito S, Sakanaka K, Kimura T. Acquired Hemophilia A Diagnosed Based on Gross Hematuria: A Case Report and Literature Review. Case Rep Urol 2024; 2024:2760153. [PMID: 39161780 PMCID: PMC11333134 DOI: 10.1155/2024/2760153] [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: 11/26/2023] [Revised: 07/02/2024] [Accepted: 07/22/2024] [Indexed: 08/21/2024] Open
Abstract
Acquired hemophilia A (AHA) is an acquired bleeding disorder caused by neutralizing antibodies (inhibitors) against Coagulation Factor VIII (FVIII:C), causing sudden hemorrhagic symptoms (i.e., subcutaneous bleeding, intramuscular bleeding, and hematuria). Herein, this study is aimed at presenting a case of AHA diagnosed based on hematuria and reviewing patients who were diagnosed with AHA due to hematuria. A 67-year-old woman was referred to Atsugi City Hospital with painless gross hematuria that began 4 weeks before presentation. Contrast-enhanced computed tomography (eCT) revealed an approximately 2 cm mass in the right renal pelvis, and the patient's activated partial thromboplastin time (APTT) was elevated (61.4 s). The day after the endoscopic biopsy, the patient was in shock due to a large retroperitoneal hematoma. Although her condition stabilized after intravenous radioembolization, she underwent emergency surgeries several times because of rebleeding within the next 3 weeks. At that time, APTT was more prolonged at 106.4 s, and the FVIII:C level was 2%. Mixing tests showed an upwardly convex curve after 2-h incubation, indicating the presence of an inhibitor. Factor VIII inhibitor titer was ≥5.1 Bethesda unit (BU)/mL. A combined product of Plasma-Derived Factors VIIa and X (pd-FVIIa/FX), as second-line hemostatic therapy, as well as cyclophosphamide (CYP), were administered after Recombinant Activated Factor VIIa (rFVIIa) had been ineffective. Following this, the Factor VIII inhibitor titer was undetectable, FVIII:C levels were restored, and APTT decreased to within the normal range. Gross hematuria was significantly alleviated. However, the patient died of cytomegalovirus and fungal infections due to prolonged immunosuppressive therapy. Although AHA diagnosed based on hematuria may have a better prognosis than others, there have been occasional cases with severe outcomes. APTT, detected upon initial hematological testing in patients with hematuria, may be a potential indicator of an existing AHA.
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Affiliation(s)
- Kenichi Hata
- Department of UrologyAtsugi City Hospital, 1-16-36, Mizuhiki, Atsugi City, Kanagawa-ken 243-8588, Japan
| | - Junichiro Kato
- Department of NephrologyAtsugi City Hospital, 1-16-36, Mizuhiki, Atsugi City, Kanagawa-ken 243-8588, Japan
| | - Yusuke Takahashi
- Department of UrologyAtsugi City Hospital, 1-16-36, Mizuhiki, Atsugi City, Kanagawa-ken 243-8588, Japan
| | - Shun Saito
- Department of UrologyAtsugi City Hospital, 1-16-36, Mizuhiki, Atsugi City, Kanagawa-ken 243-8588, Japan
| | - Keigo Sakanaka
- Department of UrologyAtsugi City Hospital, 1-16-36, Mizuhiki, Atsugi City, Kanagawa-ken 243-8588, Japan
| | - Takahiro Kimura
- Department of UrologyJikei University School of Medicine, 3-25-8, Nishishinbashi, Minatoku, Tokyo 105-8461, Japan
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Gao F, Dong C, Du M, Li Z, Song Y, Li G. Retrospective study of the clinical manifestations and efficacy of immunotherapy for patients with acquired hemophilia A. J Int Med Res 2024; 52:3000605241266221. [PMID: 39082241 PMCID: PMC11295235 DOI: 10.1177/03000605241266221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 06/11/2024] [Indexed: 08/04/2024] Open
Abstract
OBJECTIVE Raising awareness of acquired hemophilia A (AHA) and early diagnosis is critical to reduce the associated mortality rate. We aimed to characterize acquired hemophilia in Chinese patients and evaluate the effectiveness of immunotherapy. METHODS The clinical characteristics, laboratory test data, therapeutic approaches, and outcomes of 20 patients with AHA who were admitted to Xi'an Central Hospital between January 2012 and December 2020 were retrospectively studied. RESULTS Nine of the patients (45%) were treated by single glucocorticoid administration; three (15%) with cyclophosphamide (CP) in combination with a glucocorticoid; four individuals (20%) received a combination therapy of rituximab with CP and glucocorticoid or rituximab with CP, vincristine, and a glucocorticoid; three (15%) by injection of human immunoglobulin in combination with a glucocorticoid; and one (5%) with CP alone. Six patients (30%) achieved total remission and 11 (55%) partial remission (PR), but three (15%) did not enter remission, indicating an objective response rate of 85%. CONCLUSION Combination therapy with rituximab or intravenous human immunoglobulin achieves superior results in some patients with AHA. Immunosuppression and the administration of coagulation factors can rapidly control the disease and are efficacious, but >50% of patients only achieved PR. These findings suggest that the complete elimination of inhibitors requires prolonged immunosuppression therapy.
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Affiliation(s)
- Fei Gao
- Xi’an Institute of Hematology, Xi’an Central Hospital Affiliated to Xi’an Jiaotong University, Xi’an, Shaanxi, China
- Department of Hematology, Tianjin Hospital, Tianjin, China
| | - Changhu Dong
- The Second Clinical Medical College, Shaanxi University of Chinese Medicine, Xianyang, Shaanxi, China
| | - Mingzhu Du
- Xi’an Institute of Hematology, Xi’an Central Hospital Affiliated to Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Zhenzhen Li
- Xi’an Institute of Hematology, Xi’an Central Hospital Affiliated to Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Yanping Song
- Xi’an Institute of Hematology, Xi’an Central Hospital Affiliated to Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Guang Li
- Xi’an Institute of Hematology, Xi’an Central Hospital Affiliated to Xi’an Jiaotong University, Xi’an, Shaanxi, China
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Nummi V, Hiltunen L, Szanto T, Poikonen E, Lehtinen AE. Acquired haemophilia A in Finland: A nationwide study of incidence, treatment and outcomes. Haemophilia 2024. [PMID: 38941448 DOI: 10.1111/hae.15037] [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: 11/22/2023] [Revised: 04/10/2024] [Accepted: 04/10/2024] [Indexed: 06/30/2024]
Abstract
INTRODUCTION Acquired haemophilia A (AHA) is a bleeding disorder caused by autoantibody development against factor VIII (FVIII). Studies on AHA have mainly focused on patients treated at specialist centres. AIM To determine the incidence, clinical characteristics and outcomes of AHA in an unselected population-based patient cohort from Finland. METHODS This retrospective observational cohort comprised all cases diagnosed with AHA in Finland between 2006 and 2019. Patients were identified by the two central laboratories performing FVIII antibody testing in Finland, the Finnish Red Cross Blood Service and HUSLAB. Clinical details were collected from all hospitals and healthcare units where patients were treated. This study was performed in conjunction with the AHA in the Nordics study. RESULTS The median incidence of AHA was 0.65 per million per year (range 0.19-1.27). Fifty-five patients were identified, with a median age of 76 years and an even sex ratio (51% women). When diagnosed, all had bleeding symptoms with severe bleeds in 92%. First-line immunosuppressive treatment regimens included steroid monotherapy in 31% of cases, steroids and a cytotoxic agent in 51% and a rituximab-based regimen in 16%. Clinical remission was achieved in 71% of cases, and 15% had relapses. Mortality was 13% for bleeds and 9% for treatment-related infections. Overall survival was 64% for 1 year and 56% for 2 years after diagnosis. CONCLUSIONS In a nationwide population-based cohort study, we discovered a lower incidence of AHA than previously reported. Mortality among patients with AHA was high, calling for the consideration of updated treatment strategies.
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Affiliation(s)
- Vuokko Nummi
- Coagulation Disorders Unit, Department of Hematology, Helsinki University Hospital Comprehensive Cancer Centre, Helsinki University, Helsinki, Finland
- Department of Cardiology, Helsinki University and Helsinki University Hospital, Heart and Lung Center, Helsinki, Finland
| | - Leena Hiltunen
- Department of Haemostasis, Finnish Red Cross Blood Service, Helsinki, Finland
- Hemostasis and Platelet Laboratory, Fimlab Laboratories Oy Ltd, Vantaa, Finland
| | - Timea Szanto
- Coagulation Disorders Unit, Department of Hematology, Helsinki University Hospital Comprehensive Cancer Centre, Helsinki University, Helsinki, Finland
| | - Eira Poikonen
- Coagulation Disorders Unit, Department of Hematology, Helsinki University Hospital Comprehensive Cancer Centre, Helsinki University, Helsinki, Finland
| | - Anna-Elina Lehtinen
- Coagulation Disorders Unit, Department of Hematology, Helsinki University Hospital Comprehensive Cancer Centre, Helsinki University, Helsinki, Finland
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Ruberti A, Kremer Hovinga JA, Nappi F, Vettese A, Bianchi E, Fernandes E, Galfetti E, Monotti R, Paul P, Regazzoni S, Valente D, Rossi D, Stussi G, Gerber B. Acquired haemophilia A in southern Switzerland from 2013 to 2019: a case series. Swiss Med Wkly 2023; 153:40048. [PMID: 37021783 DOI: 10.57187/smw.2023.40048] [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: 04/05/2023] Open
Abstract
AIMS OF THE STUDY: Acquired haemophilia A is a rare disease with an annual incidence of 1.48 per million. Based on clinical observations, we suspect a higher incidence in southern Switzerland, and aimed at providing local epidemiological data, and clinical information regarding diagnosis, treatment and outcome in our region.
METHODS: All adult patients with acquired haemophilia A treated between 2013 and 2019 in our facility were included in the present retrospective analysis.
RESULTS: We treated 11 patients with acquired haemophilia A between 2013 and 2019, resulting in an annual incidence of 4.5 per million (95% confidence interval [CI] 0–9.0). Median delay from first symptoms to diagnosis was 4.5 days, and the median age at diagnosis was 79 years (range 23–87). Possible causative conditions were: pregnancy (n = 1), polyarteritis nodosa (n = 1), myelodysplastic syndrome (n = 1), chronic human immunodeficiency virus (HIV) (n = 1), and HIV postexposure prophylaxis (n = 1). In five patients no underlying or associated condition was identified. Median activated partial thromboplastin time (aPTT)) at baseline was 79 seconds (65–117; ref. value <38 sec), and FVIII:C 2.15% (<1–3.75%). A FVIII:C <1% was present in 4/10 patients. Median FVIII-inhibitor titre was 10.3 BU/ml (2.4–75.0 BU/ml). All patients had bleeding symptoms, 5/10 patients had major bleedings, and 7/10 patients were treated with bypassing agents. All patients received corticosteroids; 7/10 patients received immunosuppressive combination therapy. FVIII levels of ≥50% were achieved after a median of 40 days (8–62). One patient had a severe immunosuppressive therapy-related infection. An 87-years-old woman died for reasons not related to acquired haemophilia A or immunosuppressive therapy.
CONCLUSIONS: Acquired haemophilia A is a rare disease, but manageable despite the advanced patient age and comorbidities. Its incidence in Southern Switzerland is higher than previously suspected.
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Affiliation(s)
- Andrea Ruberti
- Department of Internal Medicine, Ospedale La Carità, Locarno, Switzerland
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Johanna A Kremer Hovinga
- Department of Haematology and Central Haematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Federico Nappi
- Department of Internal Medicine, Ospedale La Carità, Locarno, Switzerland
| | - Aurora Vettese
- Department of Laboratory Medicine EOLAB, Bellinzona, Switzerland
| | - Elena Bianchi
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Eliana Fernandes
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Elena Galfetti
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Rita Monotti
- Department of Internal Medicine, Ospedale La Carità, Locarno, Switzerland
| | - Pamella Paul
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Stefano Regazzoni
- Department of Internal Medicine, Ospedale Civico, Lugano, Switzerland
| | | | - Davide Rossi
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
- Laboratory of Experimental Haematology, Institute of Oncology Research, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Georg Stussi
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Bernhard Gerber
- Department of Laboratory Medicine EOLAB, Bellinzona, Switzerland
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
- University of Zurich, Switzerland
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Acquired Hemophilia A: An Update on the Etiopathogenesis, Diagnosis, and Treatment. Diagnostics (Basel) 2023; 13:diagnostics13030420. [PMID: 36766524 PMCID: PMC9914651 DOI: 10.3390/diagnostics13030420] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/10/2023] [Accepted: 01/20/2023] [Indexed: 01/25/2023] Open
Abstract
Acquired haemophilia A (AHA) is a rare bleeding disorder caused by inhibitory autoantibodies against coagulation factor VIII (FVIII). AHA is a disease that most commonly affects the elderly but has also been observed in children and in the postpartum period. AHA is idiopathic in 50% of cases and is associated with autoimmune diseases, malignancies, and infections in the remaining 50%. Recently, cases of association between AHA, COVID-19 vaccination, and infection have been reported in the literature. For diagnoses, determining FVIII levels is crucial to distinguish the different causes of aPTT prolongation. Treatment of AHA is based on bypassing agents (recombinant factor VIIa, activated prothrombin complex concentrate) and porcine FVIII to control the bleeding and immunosuppressive therapy (corticosteroids, rituximab, cyclophosphamide) to suppress autoantibody production. It is important to start a prophylactic regimen to prevent further bleeding episodes until the inhibitor is negative. Recently, the series of cases reported in the literature suggest that emicizumab may provide effective and safe haemorrhage prophylaxis in the outpatient setting.
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Liu Y, Ruan X, Lei P, Shang B, Zhu Z, Chen S, Wang D, Wang R, Li X, Xue F. Acquired Hemophilia A: A Retrospective Multicenter Analysis of 42 Patients. Clin Appl Thromb Hemost 2023; 29:10760296221151165. [PMID: 36653966 PMCID: PMC9893059 DOI: 10.1177/10760296221151165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Immunosuppressive therapy (IST) for acquired hemophilia A (AHA) results in remission within days to months in 60% to 80% of patients. However, little is known regarding the predictors of response. AIM This study aimed to identify the factors that influence response to treatment. METHODS The data of 42 patients with AHA from three hospitals were retrospectively analyzed. RESULTS All 42 AHA patients received IST; complete treatment data were available for 34 patients. The response rate was 60% among the 5/34 (14.7%) patients who received steroids alone, 70.8% among the 24/34 (70.6%) patients who received steroids plus cyclophosphamide, and 80% among the 5/34 (14.7%) patients who received steroids plus cyclophosphamide and rituximab. Overall, 29/34 (85.3%) patients achieved CR; 4/34 (13.8%) of them relapsed after a median time of 410 (21-1279) days. Adverse events occurred in 14/34 (41.2%) patients: 13/34 (38.2%) had infections and 1/34 (2.9%) developed pancytopenia. In univariate and multivariate Cox regression analyses, FVIII inhibitor titer ≥20 BU/mL was the only significant prognostic factor affecting time to CR. No variable had significant effect on OS. CONCLUSION FVIII inhibitory antibody titer ≥20 BU/mL appears to be an important predictor of time to complete response in patients with acquired hemophilia A treated with immunosuppressive therapy.
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Affiliation(s)
- Yanhui Liu
- Department of Hematology, Hemophilia Comprehensive Care Center, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China,Yanhui Liu, Department of Hematology, Henan Provincial People's Hospital, 7 Weiwu Road, Jinshui District, Zhengzhou 450003, Henan, PR China.
Fei Xue, Department of Hepatobiliary and Pancreatic Surgery, Henan Provincial People's Hospital, 7 Weiwu Road, Jinshui District, Zhengzhou 450003, Henan, PR China.
| | - Xiang Ruan
- Department of Hematology, Hemophilia Comprehensive Care Center, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China
| | - Pingchong Lei
- Department of Hematology, Hemophilia Comprehensive Care Center, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China
| | - Baojun Shang
- Institute of Hematology, Hemophilia Comprehensive Care Center, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China
| | - Zunmin Zhu
- Department of Hematology, Hemophilia Comprehensive Care Center, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China,Institute of Hematology, Hemophilia Comprehensive Care Center, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China
| | - Shengmei Chen
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, PR China
| | - Dao Wang
- Department of Pediatrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, PR China
| | - Ruijuan Wang
- Department of Hematology, Nanyang Central Hospital, Nanyang, Henan Province, PR China
| | - Xiqing Li
- Department of Oncology, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China
| | - Fei Xue
- Department of Hepatobiliary and Pancreatic Surgery, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China
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Lindahl R, Nummi V, Lehtinen A, Szanto T, Hiltunen L, Olsson A, Glenthoej A, Chaireti R, Vaide I, Funding E, Zetterberg E. Acquired Haemophilia A in four north European countries: survey of 181 patients. Br J Haematol 2022; 201:326-333. [PMID: 36541135 DOI: 10.1111/bjh.18611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
Acquired haemophilia A (AHA) is a rare bleeding disorder caused by acquired antibodies against coagulation factor VIII. In the Nordic countries, treatment and outcomes have not been studied in recent times. To collect retrospective data on patients diagnosed with AHA in the Nordic countries between 2006 and 2018 and compare demographic data and clinical outcomes with previously published reports, data were collected by six haemophilia centres: three Swedish, one Finnish, one Danish and one Estonian. The study included 181 patients. Median age at diagnosis was 76 (range 5-99) years, with even gender distribution. Type and severity of bleeding was comparable to that in the large European Acquired Haemophilia Registry study (EACH2). Bleedings were primarily treated with activated prothrombin complex concentrate (aPCC) with a high success rate (91%). For immunosuppressive therapy, corticosteroid monotherapy was used most frequently and this may be the cause of the overall lower clinical remission rate compared to the EACH2 study (57% vs. 72%). Survey data on 181 patients collected from four north European countries showed similar demographic and clinical features as in previous studies on AHA. aPCC was used more frequently than in the EACH2 study and the overall remission rate was lower.
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Affiliation(s)
- Rickard Lindahl
- Department of Haematology, Oncology and Radiation Physics, Coagulation Unit Skåne University Hospital Malmö and Lund University Lund Sweden
| | - Vuokko Nummi
- Coagulation Disorders Unit, Department of Haematology Helsinki University Hospital Comprehensive Cancer Centre, Helsinki University Helsinki Finland
| | - Anna‐Elina Lehtinen
- Coagulation Disorders Unit, Department of Haematology Helsinki University Hospital Comprehensive Cancer Centre, Helsinki University Helsinki Finland
| | - Timea Szanto
- Coagulation Disorders Unit, Department of Haematology Helsinki University Hospital Comprehensive Cancer Centre, Helsinki University Helsinki Finland
| | - Leena Hiltunen
- Department of Haemostasis Finnish Red Cross Blood Service Helsinki Finland
| | - Anna Olsson
- Department of Medicine Region Västra Götaland, Sahlgrenska University Hospital Gothenburg Sweden
| | - Andreas Glenthoej
- Department of Haematology Rigshospitalet Copenhagen Denmark
- Department of Clinical Medicine Copenhagen University Copenhagen Denmark
| | - Roza Chaireti
- Department of Haematology Karolinska University Hospital Stockholm Sweden
| | - Ines Vaide
- Department of Haematology and Oncology Institute of Clinical Medicine, University of Tartu Tartu Estonia
| | - Eva Funding
- Department of Haematology Rigshospitalet Copenhagen Denmark
- Department of Clinical Medicine Copenhagen University Copenhagen Denmark
| | - Eva Zetterberg
- Department of Haematology, Oncology and Radiation Physics, Coagulation Unit Skåne University Hospital Malmö and Lund University Lund Sweden
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Gidaro A, Palmieri G, Donadoni M, Mameli LA, La Cava L, Sanna G, Castro D, Delitala AP, Manetti R, Castelli R. A Diagnostic of Acquired Hemophilia Following PD1/PDL1 Inhibitors in Advanced Melanoma: The Experience of Two Patients and a Literature Review. Diagnostics (Basel) 2022; 12:diagnostics12102559. [PMID: 36292248 PMCID: PMC9600358 DOI: 10.3390/diagnostics12102559] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/11/2022] [Accepted: 10/19/2022] [Indexed: 11/16/2022] Open
Abstract
Acquired hemophilia A (AHA) is a rare bleeding disorder caused by the development of specific autoantibodies against factor VIII (FVIII). Immunotherapy is a recent therapeutic option that targets the patient's self-tolerance against tumor cells. Because therapeutic effects of the immune checkpoint inhibitors (ICIs) are mediated by enhancing the immune response to restore antitumor immunity, autoimmune-related adverse effects can be seen in up to 80% of patients during treatment and after treatment. A rare hematologic ICIs-related adverse event is AHA. Hereafter we report two cases of AHA developed during anti-PD-1 immunotherapy for advanced melanoma: one secondary to treatment with nivolumab and one secondary to pembrolizumab. Both patients were treated with activated FVII (Novoseven®, Novo Nordisk, Bagsværd, Denmark) as hemostatic treatment combined with the eradication of antibodies anti-FVIII obtained with rituximab. In the last few years these drugs have significantly improved the therapeutic armamentarium for the management of AHA. Indeed, while FVIIa has proven to be an effective and safe tool for the treatment of acute bleeding related to FVIII autoantibodies, rituximab is a promising alternative for the autoantibodies' elimination and the restoration of normal hemostasis. Our finding supports the use of this combination even in AHA secondary to ICIs treatment.
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Affiliation(s)
- Antonio Gidaro
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi N° 74, 20157 Milan, Italy
- Correspondence: (A.G.); (R.C.); Tel.: +39-0239042391 (A.G.); +39-079-228446 (R.C.)
| | - Giuseppe Palmieri
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale san Pietro N° 8, 07100 Sassari, Italy
| | - Mattia Donadoni
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi N° 74, 20157 Milan, Italy
| | - Lucia A. Mameli
- Departmental Simple Operative Unit Coagulation, Hemostasis Diseases Hospital S Maria Annunziata, Via Enrico De Nicola N° 14, 07100 Sassari, Italy
| | - Leyla La Cava
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi N° 74, 20157 Milan, Italy
| | - Giuseppe Sanna
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale san Pietro N° 8, 07100 Sassari, Italy
| | - Dante Castro
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale san Pietro N° 8, 07100 Sassari, Italy
| | - Alessandro P. Delitala
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale san Pietro N° 8, 07100 Sassari, Italy
| | - Roberto Manetti
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale san Pietro N° 8, 07100 Sassari, Italy
| | - Roberto Castelli
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale san Pietro N° 8, 07100 Sassari, Italy
- Correspondence: (A.G.); (R.C.); Tel.: +39-0239042391 (A.G.); +39-079-228446 (R.C.)
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Pishko AM, Doshi BS. Acquired Hemophilia A: Current Guidance and Experience from Clinical Practice. J Blood Med 2022; 13:255-265. [PMID: 35592586 PMCID: PMC9112043 DOI: 10.2147/jbm.s284804] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/22/2022] [Indexed: 12/23/2022] Open
Abstract
In acquired hemophilia A (AHA), autoantibodies to coagulation factor VIII (FVIII) neutralize FVIII activity leading to a potentially severe bleeding diathesis that carries a high rate of morbidity and mortality. This disorder is rare and occurs mainly in adults over 60 years of age or in the postpartum period. The diagnosis should be suspected in patients with new-onset bleeding without a personal or family history of bleeding and can be confirmed via specific assays for FVIII inhibitors. Treatment involves both hemostatic therapies to decrease bleeding and immune modulation strategies to re-establish immune tolerance to FVIII. There are limited data on treatment for refractory disease, based mostly on small case series. Registry studies have informed consensus guidelines for optimal hemostatic therapies and initial immunosuppressive therapies. Additional studies are needed to evaluate novel hemostatic agents and develop biomarkers to risk-stratify treatment while limiting adverse events.
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Affiliation(s)
- Allyson M Pishko
- Department of Medicine, Division of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Bhavya S Doshi
- Department of Pediatrics, Division of Hematology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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11
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Shah E, Abro C, Zaidi F, Goel R. Doxycycline-induced acquired haemophilia A. BMJ Case Rep 2021; 14:e244748. [PMID: 34598965 PMCID: PMC8488736 DOI: 10.1136/bcr-2021-244748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2021] [Indexed: 11/04/2022] Open
Abstract
An 80-year-old man with no personal or family history of bleeding, presented to hospital with extensive haematomas and skin bruising after using doxycycline. His basic lab workup was concerning for a coagulopathy with an elevated activated partial thromboplastin time and significant anaemia. Mixing studies and other factor levels were tested that led to the diagnosis of acquired haemophilia A with low factor VIII levels and high factor VIII antibodies. He was started on steroids, but his haemoglobin level continued to drop. Later, during his treatment, he was given multiple therapeutic agents, including cyclophosphamide, rituximab and recombinant factor VII (NovoSeven-R). Gradually factor VIII levels increased and haemoglobin stabilised. The hospital course was complicated by COVID-19 pneumonia leading to acute respiratory distress syndrome; the patient eventually expired due to respiratory failure.
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Affiliation(s)
- Ejaz Shah
- Internal Medicine, HSHS Saint John's Hospital, Springfield, Illinois, USA
| | - Calvin Abro
- Haematology and Oncology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Fawwad Zaidi
- Haematology and Oncology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Ruchika Goel
- Haematology and Oncology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
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12
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Diagnosis and Management of Acquired Hemophilia A: Case Reports and a Literature Review. Case Rep Med 2021; 2021:5554664. [PMID: 34567128 PMCID: PMC8457949 DOI: 10.1155/2021/5554664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/20/2021] [Accepted: 08/26/2021] [Indexed: 11/17/2022] Open
Abstract
Background Acquired hemophilia A (AHA) is a potentially life-threatening autoimmune hemostatic disorder where autoantibodies that disrupt the functions of factor VIII (FVIII) are present in the circulation. The early diagnosis of AHA is difficult since the symptoms of AHA differ from those of congenital hemophilia A. Furthermore, the management of AHA is also more complex due to the presence of autoantibodies against FVIII (FVIII inhibitors). Here, we present three case reports and conduct a literature review of AHA with the aim to increase awareness and knowledge regarding the diagnosis and treatment of AHA. Case Presentations. We present three patients diagnosed with AHA in these case reports. The first patient was a young female, while the second and third patients were middle-aged and elderly males, respectively. All patients presented with a chief complaint of bruises without hemarthrosis and a history of bleeding. Laboratory examinations of the patients revealed isolated prolonged aPTT, normal PT, and the presence of autoantibodies against factor VIII, which are characteristics of AHA. Patients were then treated with corticosteroids to reduce the titer level of autoantibodies and received factor VIII transfusion to stop bleeding. Conclusion AHA can be suspected in patients presenting with symptoms of bruises without hemarthrosis and without the history of bleeding. Isolated aPTT elevation with normal PT should raise high suspicion of AHA. The presence of FVIII inhibitors can help to confirm the diagnosis of AHA. Treatment consists of factor VIII transfusion and corticosteroid therapy. Bypassing agents are recommended as an alternative to FVIII transfusion.
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Abstract
BACKGROUND Acquired haemophilia A is a rare bleeding disorder caused by the development of specific autoantibodies against coagulation factor VIII. Standard treatment, usually steroids alone, or in combination with cyclophosphamide, aims to stop acute bleeds by using haemostatic agents to promote clotting. Rituximab may be an alternative approach to the treatment of acquired haemophilia by eradicating FVIII autoantibodies. This is an update of a previously published Cochrane Review. OBJECTIVES To assess the efficacy and adverse effects of rituximab for treating people with acquired haemophilia A. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's trials registers, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and conference proceedings (January 2021). We also undertook searches of CENTRAL, MEDLINE and online trial registries (January 2021). SELECTION CRITERIA Randomised and quasi-randomised controlled trials of rituximab for people with acquired haemophilia A, with no restrictions on gender, age or ethnicity. DATA COLLECTION AND ANALYSIS No trials matching the selection criteria were eligible for inclusion. MAIN RESULTS No trials matching the selection criteria were eligible for inclusion. AUTHORS' CONCLUSIONS We found no randomised clinical trials of rituximab for acquired haemophilia A. Thus, we are not able to draw any conclusions or make any recommendations on rituximab for eradicating inhibitors in people with acquired haemophilia A based on the highest quality evidence. Given that undertaking randomised controlled trials in this field is a complex task, we suggest that, while planning such trials, clinicians treating the disease continue to base their choices on alternative, lower-quality sources of evidence. In a future update of this review, we plan to appraise and incorporate eligible randomised controlled trials, as well as other high-quality, non-randomised studies.
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Affiliation(s)
- Tracey Remmington
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
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14
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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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15
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Roy AM, Siddiqui A, Venkata A. Undiagnosed Acquired Hemophilia A: Presenting as Recurrent Gastrointestinal Bleeding. Cureus 2020; 12:e10188. [PMID: 33029467 PMCID: PMC7529483 DOI: 10.7759/cureus.10188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Acute gastrointestinal bleeding (GIB) is a frequently encountered medical emergency and it can be life-threatening depending on the etiology and the clinical condition of the patient. The most common causes of GIB are peptic ulcer disease, aspirin-induced gastritis, variceal hemorrhage, esophagitis, neoplasms like gastric cancer. Acquired hemophilia causing acute gastrointestinal bleed is extremely rare and only a few cases are reported worldwide. Acquired hemophilia A (AHA) is a rare disorder caused by the production of autoantibodies that inactivates clotting factor VIII. We present a case of upper gastrointestinal bleed due to AHA which was undiagnosed for two years. A 74-year-old patient with a history of myasthenia gravis, presented with anemia, and GIB. She underwent multiple endoscopies without a clear bleeding source. Coagulation studies showed isolated activated partial thromboplastin time prolongation which was not corrected by mixing study. Factor VIII activity was low and Bethesda titer showed elevated inhibitor levels. Factor Eight Bypassing Agent, recombinant factor VIIa, and steroids were given to control bleeding. Her clinical condition worsened, and she passed away. Elderly patients presenting with an undiagnosed source of GIBs, inconclusive endoscopic studies should be evaluated for acquired coagulopathies, especially in those with a history of autoimmune diseases and malignancies. Prompt diagnosis and treatment are warranted as it carries a high mortality. Part of the case presentation was presented as an abstract at a regional conference
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Affiliation(s)
- Arya Mariam Roy
- Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Aisha Siddiqui
- Internal Medicine, American University of Antigua, New York, USA
| | - Anand Venkata
- Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences, Little Rock, USA
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Acquired Haemophilia A: An Intriguing Disease. Mediterr J Hematol Infect Dis 2020; 12:e2020045. [PMID: 32670523 PMCID: PMC7340240 DOI: 10.4084/mjhid.2020.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/18/2020] [Indexed: 12/31/2022] Open
Abstract
Abstract. Acquired Haemophilia A is a rare acquired bleeding disorder caused by Factor VIII autoantibodies, which neutralise FVIII activity. These inhibitors differ from alloantibodies against FVIII, which can occur in congenital Haemophilia A after repeated exposures to plasma-derived or recombinant FVIII products. In most cases, the disease occurs suddenly in subjects without a personal or familiar history of bleedings, with symptoms that may be mild, moderate, or severe. However, only laboratory alterations are present in ~ 30% of patients. The incidence varies from 1 to 4 cases per million/year; more than 80% of patients are elderly, males and females are similarly affected. There is a small peak of incidence related to pregnancy in young women aged 20–40 years. The disease may be underdiagnosed in the elderly. The diagnostic algorithm is based on an isolated prolonged activated partial thromboplastin time, normal thrombin time, absence of Lupus Anticoagulant, and a mixing test that reveals the presence of an inhibitor: the finding of reduced FVIII activity and the detection of neutralising autoantibodies against FVIII lead to the diagnosis. The disease is idiopathic in 44%–63% of cases, while in the others etiological factors are present. Bleeding prevention and treatment are based on therapeutic tools as by-passing agents, recombinant porcine FVIII concentrate or, in a limited number of cases, FVIII concentrates and desmopressin. As soon as the diagnosis has been made, immunosuppressive therapy must be started to eradicate the inhibitor. Better knowledge of the disease, optimal management of bleeding and eradication of the inhibitor have significantly reduced morbidity and mortality in most patients.
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17
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The management of a patient with pregnancy-acquired hemophilia – a case report. GINECOLOGIA.RO 2020. [DOI: 10.26416/gine.29.3.2020.3764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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18
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Kim SH, Park SJ, Park CI, Choi SU, Kim JH. Spontaneous Retroperitoneal Hemorrhage Caused by Idiopathic Acquired Hemophilia A Misdiagnosed as a Delayed Traumatic Hematoma: A Case Report. JOURNAL OF ACUTE CARE SURGERY 2019. [DOI: 10.17479/jacs.2019.9.2.72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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19
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Sun B, Xue F, Feng Y, Sun J, Yu Z, Hou M, Zhang J, Zeng X, Zhao Y, Lian S, Huang M, Niu T, Cui Z, Wu J, Yang R. Outcome of CARE: a 6‐year national registry of acquired haemophilia A in China. Br J Haematol 2019; 187:653-665. [PMID: 31372978 DOI: 10.1111/bjh.16128] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 05/27/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Boyang Sun
- State Key Laboratory of Experimental Haematology, National Clinical Research Centre for Haematological Disorders Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases TianjinChina
| | - Feng Xue
- State Key Laboratory of Experimental Haematology, National Clinical Research Centre for Haematological Disorders Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases TianjinChina
| | - Ying Feng
- Department of Haematology Second Affiliated Hospital of Guangzhou Medical University GuangzhouChina
| | - Jing Sun
- Nanfang Hospital Nanfang Medical University GuangzhouChina
| | - Ziqiang Yu
- Department of Haematology The First Affiliated Hospital of Soochow University SuzhouChina
| | - Ming Hou
- Department of Haematology Qilu Hospital, Shandong University Jinan ShandongChina
| | - Jingyu Zhang
- Department of Haematology, Key Laboratory of Haematology of Hebei Province The Second Hospital of Hebei Medical University Shijiazhuang HebeiChina
| | - Xiaojing Zeng
- Department of Blood Transfusion The Affiliated Hospital of Guizhou University GuiyangChina
| | - Yongqiang Zhao
- Department of Haematology Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences BeijingChina
| | - Shimei Lian
- Department of Haematology Dalian Municipal Central Hospital, Affiliated Hospital of Dalian Medical University Dalian China
| | - Meijuan Huang
- Fujian Institute of Haematology Fujian Medical University Union Hospital FuzhouChina
| | - Ting Niu
- Department of Haematology West China Hospital, Sichuan University Chengdu SichuanChina
| | - Zhongguang Cui
- The Affiliated Hospital of Qingdao University QingdaoChina
| | - Jingsheng Wu
- Department of Haematology Anhui Provincial Hospital, Anhui Medical University Hefei China
| | - Renchi Yang
- State Key Laboratory of Experimental Haematology, National Clinical Research Centre for Haematological Disorders Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases TianjinChina
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20
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Compartment syndrome of the forearm with life-threatening bleeding after fasciotomy as the presenting sign of postpartum acquired hemophilia A: a case report. Blood Coagul Fibrinolysis 2019; 30:120-126. [PMID: 30864964 DOI: 10.1097/mbc.0000000000000799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
: Acquired hemophilia A (AHA) is a rare bleeding disorder caused by the development of autoantibodies against clotting factor VIII. Although the cause of this disorder remains obscure, it is often linked to malignancies, drug administration, autoimmune diseases and pregnancy. In pregnancy-associated AHA, hemorrhagic symptoms usually present 1-4 months peripartum, however they may occur up to 1-year postpartum. Compartment syndrome of the forearm is also very uncommon complication of AHA but can have devastating consequences. We report a rare case of a compartment syndrome of the forearm in a 30-year-old woman 2.5 months postpartum as the presentation of pregnancy-associated AHA.
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21
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Mizrahi T, Doyon K, Dubé E, Bonnefoy A, Warner M, Cloutier S, Demers C, Castilloux JF, Rivard GE, St-Louis J. Relapse pattern and long-term outcomes in subjects with acquired haemophilia A. Haemophilia 2019; 25:252-257. [PMID: 30694571 DOI: 10.1111/hae.13685] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 11/06/2018] [Accepted: 01/03/2019] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Acquired haemophilia A (AHA) is a rare autoimmune bleeding disorder caused by neutralizing antibodies against factor VIII (FVIII). Despite significant initial morbidity and mortality, most patients achieve remission with immunosuppressive therapy. AIM Long-term follow-up data from the Quebec Reference Centre for Inhibitors (QRCI) were analysed to identify factors predictive of AHA relapse and the influence of relapse on survival. METHODS Criteria used to define AHA were levels of FVIII <0.3 IU/mL and FVIII inhibitor titres ≥0.6 Bethesda Units (BU). Complete remission was defined as FVIII >0.5 IU/mL and/or FVIII inhibitor titres <0.6 BU while not on immunosuppression. RESULTS Between 2000 and 2012, 111 subjects met the inclusion criteria and were followed for a median of 25.6 months. Ninety per cent of them reached remission on immunosuppression in a median time of 45 days. Fourteen patients presented one or more relapses in a median time of 13.4 months. Most relapse episodes were successfully treated. Associated lymphoproliferative syndromes (LPS) were predictive of relapse, whereas FVIII activity and inhibitor titres at initial diagnosis or immunosuppressive regimens were not. The overall survival (OS) was the same, with or without relapse. CONCLUSION Among the recognized potential risk factors for relapse, only LPS was statistically significant. The long-term follow-up of our patients also showed that late or multiple relapses may occur, but that relapse is not associated with a worse OS. Thus, long-term follow-up is important for optimal management of AHA.
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Affiliation(s)
- Terry Mizrahi
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Karine Doyon
- Division of Hematology, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
| | - Evemie Dubé
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Arnaud Bonnefoy
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Margaret Warner
- Division of Hematology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Stéphanie Cloutier
- Hôpital de l'Enfant Jésus, Centre Hospitalier Universitaire de Québec, Quebec City, Quebec, Canada
| | - Christine Demers
- Hôpital de l'Enfant Jésus, Centre Hospitalier Universitaire de Québec, Quebec City, Quebec, Canada
| | - Jean-François Castilloux
- Division of Hematology-Oncology, Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Georges-Etienne Rivard
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada.,Division of Hematology-Oncology, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Jean St-Louis
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada.,Division of Hematology-Oncology, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
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Kumar N, Rajpal S, Ahluwalia J, Bose S, Uppal V, Varma N, Malhotra P, Varma S. Acquired Hemophilia A: Experience of a Tertiary Care Institute from North India. Indian J Hematol Blood Transfus 2018; 34:524-529. [PMID: 30127565 DOI: 10.1007/s12288-017-0873-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 08/31/2017] [Indexed: 10/18/2022] Open
Abstract
Acquired hemophilia A (AHA) is an uncommon bleeding disorder infrequently reported among Indians. The present retrospective data comprises eight cases of AHA over a period of 15 years. The mean age of patients was 59.7 years. The activated partial thromboplastin time was prolonged in all cases and the inhibitor screen showed the presence of inhibitors. Factor VIII: C assay was performed in 7 cases and all cases demonstrated low levels. Lupus anticoagulant was negative. Six patients were managed with steroids and symptomatic supportive care. These patients were followed up for a mean period of 3.5 years (range 1-5 years). Of these, there was one fatality prior to initiation of therapy and one patient continues to have inhibitors.
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Affiliation(s)
- Narender Kumar
- 1Department of Hematology, Postgraduate Institute of Medical Education and Research, Level 5, Research Block A, Sector 12, Chandigarh, 160012 India
| | - Sweta Rajpal
- 1Department of Hematology, Postgraduate Institute of Medical Education and Research, Level 5, Research Block A, Sector 12, Chandigarh, 160012 India
| | - Jasmina Ahluwalia
- 1Department of Hematology, Postgraduate Institute of Medical Education and Research, Level 5, Research Block A, Sector 12, Chandigarh, 160012 India
| | - Sunil Bose
- 1Department of Hematology, Postgraduate Institute of Medical Education and Research, Level 5, Research Block A, Sector 12, Chandigarh, 160012 India
| | - Varun Uppal
- 1Department of Hematology, Postgraduate Institute of Medical Education and Research, Level 5, Research Block A, Sector 12, Chandigarh, 160012 India
| | - Neelam Varma
- 1Department of Hematology, Postgraduate Institute of Medical Education and Research, Level 5, Research Block A, Sector 12, Chandigarh, 160012 India
| | - Pankaj Malhotra
- 2Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012 India
| | - Subhash Varma
- 2Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012 India
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23
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[Acquired hemophilia A associated with chronic myelomonocytic leukemia successfully treated by rituximab and azacitidine]. Rev Med Interne 2018; 39:654-657. [PMID: 29653879 DOI: 10.1016/j.revmed.2018.03.373] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 03/12/2018] [Accepted: 03/14/2018] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Acquired hemophilia A is a factor VIII deficiency related to anti-factor VIII immunoglobulins. We are reporting the case of a patient with acquired hemophilia A related to chronic myelomonocytic leukemia. CASE REPORT A 74-years old woman had a spontaneous calf hematoma with compression syndrome. Coagulation tests revealed an extended partial thromboplastin time and a factor VIII deficiency with circulating factor VIII antibodies. Chronic myelomonocytic leukemia was diagnosed in the same time. Initial management included hemostatic transfusion and steroids and was completed rituximab and azacitidine. Evolution was favorable. CONCLUSION We report a case of acquired hemophilia A complicating a chronic myelomonocytic leukemia. Management with steroids, rituximab and azacitidine was successful. Useful of rituximab during acquired hemophilia is proposed.
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24
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Godaert L, Bartholet S, Colas S, Kanagaratnam L, Fanon JL, Dramé M. Acquired Hemophilia A in Aged People: A Systematic Review of Case Reports and Case Series. Semin Hematol 2018; 55:197-201. [PMID: 30502847 DOI: 10.1053/j.seminhematol.2018.02.004] [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: 08/17/2017] [Revised: 11/22/2017] [Accepted: 02/17/2018] [Indexed: 11/11/2022]
Abstract
Acquired hemophilia A (AHA) is a rare disease that requires urgent management. Currently, there is no consensus regarding optimal management in aged people. This systematic review aimed to describe diagnosis, clinical features, management, and endpoints in population aged 65 years or over with AHA. A literature search up to and including 31 May 2017 was performed in Medline, Embase, and Scopus. The search strategy on article titles comprised the following terms: "acquired" AND ("hemophilia A" OR "haemophilia A"). Filters were applied for age (65 years or older), publication type (case reports and case series), and studies including human beings only. There was no language restriction in the search strategy. Studies with no data on immunosuppressive therapy, and studies in other languages than English or French were excluded. Patient-level and study-level information was extracted. In total, 270 studies were identified by the literature search. After exclusion of duplicates, and studies presenting exclusion criteria, 80 articles including 159 cases were included in the final review. These 159 cases were 76.1 ± 7.2 years old, and were mainly men (64%). There is wide variety in the therapies used to eradicate the Factor VIII autoantibody, and efficacy is difficult to assess. The majority of patients with AHA receive immunosuppressants. Mortality is high, and likely depends on the rapidity of diagnosis and implementation of adequate management and monitoring.
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Affiliation(s)
- Lidvine Godaert
- Department of Geriatrics, University Hospitals of Martinique, Martinique, France.
| | - Seendy Bartholet
- Department of Geriatrics, University Hospitals of Martinique, Martinique, France
| | - Sébastien Colas
- Department of Geriatrics, University Hospitals of Martinique, Martinique, France
| | - Lukshe Kanagaratnam
- Faculty of Medicine, University of Reims Champagne-Ardenne, Reims, France; Department of Research and Public Health, University Hospitals of Reims, Robert Debré Hospital, Reims, France
| | - Jean-Luc Fanon
- Department of Geriatrics, University Hospitals of Martinique, Martinique, France
| | - Moustapha Dramé
- Faculty of Medicine, University of Reims Champagne-Ardenne, Reims, France; Department of Research and Public Health, University Hospitals of Reims, Robert Debré Hospital, Reims, France
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25
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Kruse-Jarres R, Kempton CL, Baudo F, Collins PW, Knoebl P, Leissinger CA, Tiede A, Kessler CM. Acquired hemophilia A: Updated review of evidence and treatment guidance. Am J Hematol 2017; 92:695-705. [PMID: 28470674 DOI: 10.1002/ajh.24777] [Citation(s) in RCA: 234] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 04/24/2017] [Accepted: 04/25/2017] [Indexed: 12/31/2022]
Abstract
Acquired hemophilia A (AHA) is a rare disease resulting from autoantibodies (inhibitors) against endogenous factor VIII (FVIII) that leads to bleeding, which is often spontaneous and severe. AHA tends to occur in elderly patients with comorbidities and is associated with high mortality risk from underlying comorbidities, bleeding, or treatment complications. Treatment, which consists of hemostatic management and eradication of the inhibitors, can be challenging to manage. Few data are available to guide the management of AHA-related bleeding and eradication of the disease-causing antibodies. Endorsed by the Hemostasis and Thrombosis Research Society of North America, an international panel of experts in AHA analyzed key questions, reviewed the literature, weighed the evidence and formed a consensus to update existing guidelines. AHA is likely underdiagnosed and misdiagnosed in real-world clinical practice. Recommendations for the management of AHA are summarized here based on the available data, integrated with the clinical experience of panel participants.
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Affiliation(s)
| | | | - Francesco Baudo
- Thrombosis and Haemostasis Unit; Niguarda Hospital; Milan Italy
| | - Peter W. Collins
- Arthur Bloom Haemophilia Centre, School of Medicine Cardiff University; Cardiff United Kingdom
| | - Paul Knoebl
- Department of Medicine 1, Division of Hematology and Hemostasis; Medical University of Vienna; Vienna Austria
| | | | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation; Hannover Medical School; Hannover Germany
| | - Craig M. Kessler
- Section of Hematology/Oncology; Georgetown University; Washington District of Columbia
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Mo L, Bao GC. Acquired factor VIII deficiency: two case reports and a review of literature. Exp Hematol Oncol 2017; 6:8. [PMID: 28352491 PMCID: PMC5366150 DOI: 10.1186/s40164-017-0068-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 03/18/2017] [Indexed: 12/19/2022] Open
Abstract
Background Acquired factor VIII (FVIII) deficiency, or acquired hemophilia A (AHA), is a rare autoimmune disorder involving antibody-mediated depletion of coagulation FVIII, leading to severe, life-threatening bleeding. The condition is often associated with other autoimmune disorders, and its treatment involves replacement of FVIII and various modes of immunosuppression. Recently, a few noteworthy therapeutic advances have been made. We present two cases of severe AHA in Chinese women. One of these women developed this disorder in the setting of possible parvovirus B19 infection, which has not yet been reported in association with AHA. Other notable features of her case included paradoxical venous thrombosis and possible association with Sjogren’s syndrome and myositis. The other woman failed to respond to usual first-line therapies despite exhibiting a less severe clinical course, illustrating the varied but potentially stubborn behavior of this disorder. Case 1 An 87-year-old woman presented with diffuse ecchymoses, melena, vaginal bleeding. Labs showed hemoglobin (Hgb) nadir of 5.7 mg/dL, elevated partial thromboplastin time (PTT), FVIII level <1%, mixing study consistent with an inhibitor, elevated anti-Sjogren’s-Syndrome-related antigen A antibody, elevated creatinine kinase, and elevated parvovirus IgM and IgG. Imaging of her arm showed diffuse myositis and deep venous thrombosis. After intravenous and oral steroids, her FVIII levels normalized, and her symptoms subsided. Case 2 A 59-year-old woman presented with recurrent ecchymoses and hematomas in her extremities. Labs showed Hgb of 11.7 mg/dL, elevated PTT, FVIII level of 3%, and mixing study consistent with an inhibitor. Despite receiving a long course of steroids, several courses of IVIG, and a few courses of Rituximab, her FVIII level remained critically low. Conclusion The rarity of AHA limits our understanding of this disease and the ability to perform trials to discover optimal therapies. We hope that these case reports and discussion will shed further light on the varied clinical manifestations and natural histories of this disorder to guide better recognition and treatment of AHA.
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Affiliation(s)
- Lan Mo
- Weill Cornell Medicine, New York-Presbyterian Lower Manhattan Hospital, 170 William Street, New York, NY 10038 USA
| | - George C Bao
- Weill Cornell Medicine, New York-Presbyterian Lower Manhattan Hospital, 170 William Street, New York, NY 10038 USA
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Abstract
BACKGROUND Acquired haemophilia A is a rare bleeding disorder caused by the development of specific autoantibodies against coagulation factor VIII. Rituximab may be an alternative approach to the treatment of acquired haemophilia by eradicating FVIII autoantibodies. OBJECTIVES To assess and summarise the efficacy and adverse effects of rituximab for treating people with acquired haemophilia A. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's trials registers, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and conference proceedings.Date of last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group's trials registers: 01 March 2016. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of rituximab for people with acquired hemophilia A, with no restrictions on gender, age or ethnicity. DATA COLLECTION AND ANALYSIS No trials matching the selection criteria were eligible for inclusion. MAIN RESULTS No trials matching the selection criteria were eligible for inclusion. AUTHORS' CONCLUSIONS No randomised clinical trials of rituximab for acquired hemophilia A were found. Thus, based on the highest quality of evidence, we are not able to draw any conclusions or make any recommendations on rituximab for eradicating inhibitors in people with acquired haemophilia A. Given that undertaking randomised controlled trials in this field is a complex task, the authors suggest that, while planning such trials, clinicians treating the disease continue to base their choices on alternative, lower quality sources of evidence. The authors plan, for a future update of this review, to appraise and incorporate any randomised controlled trials, as well as other high-quality non-randomised studies.
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Affiliation(s)
- Yan Zeng
- General Hospital of Chengdu Military RegionDepartment of Hematology270#, Rongdu Da DaoChengduChina610083
| | - Ruiqing Zhou
- Guangzhou First People's Hospital, Guangzhou Medical UniversityDepartment of HematologyPanfu RoadGuangzhouChina510180
| | - Xin Duan
- West China Hospital, Sichuan UniversityDepartment of Orthopaedics SurgeryNo. 37 GuoXueXiang StreetChengduChina610041
| | - Dan Long
- West China Hospital, Sichuan UniversityKey Laboratory of Transplant Engineering and ImmunologyNo. 37, Guo Xue XiangChengduChina610041
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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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