Acquired factor VIII inhibitor as presentation of chronic myelogenous leukemia during interferon-alpha therapy

Case Report: Effective management of adalimumab-induced acquired hemophilia A with the CyDRI protocol

Introduction

Acquired Hemophilia A (AHA) is a rare autoimmune disorder characterized by the emergence of inhibitors that specifically target coagulation Factor VIII, frequently resulting in severe bleeding episodes.

Methods

We conducted a retrospective analysis of the medical records of a 68-year-old male patient who presented with adalimumab-induced AHA.

Results

The patient received adalimumab, a tumor necrosis factor inhibitor antibody, as part of his treatment for rheumatoid arthritis. The patient's clinical journey, characterized by intense bleeding and coagulopathy, was effectively managed with the application of recombinant Factor VIIa (rFVIIa) and the CyDRi protocol.

Discussion

The case emphasizes the importance of prompt coagulation assessment in patients with bleeding symptoms receiving disease-modifying therapy for rheumatoid arthritis that includes adalimumab therapy, considering the rare yet life-threatening nature of AHA. Additionally, this report provides an extensive review of the existing literature on drug-induced AHA, with a special emphasis on cases linked to immunomodulatory medications. Through this two-pronged approach, our report aims to enhance understanding and awareness of this severe complication among healthcare providers, promoting timely diagnosis and intervention.

Bleeding with negative coagulation screening test as initial presentation of chronic myelogenous leukemia managed by fresh frozen plasma: A case report

INTRODUCTION

Chronic myelogenous leukemia (CML), a clonal disorder of pluripotent stem cell, rarely presents with bleeding in chronic phase due to the function preservation of the platelets. Factor (F) XIII deficiency, an extremely rare hemorrhagic disease, can cause fatal bleeding, which has been previously described in autoimmune disorders and leukemias.

PATIENT CONCERNS

A 38-year-old woman with a 20-day history of spontaneous subcutaneous hemorrhage visited our hospital, who presented with intracranial hemorrhage, hematuria, and delayed hematoma after a bone marrow puncture. Initial management included cytogenetics analysis, molecular analysis, and coagulation evaluation.

DIAGNOSIS

Bone marrow puncture, cytogenetics, and molecular analysis indicated the diagnosis of CML. With the normal results of clotting screening tests and platelet counting, as well as the relief of bleeding after infusion of fresh frozen plasma (FFP), acquired rare bleeding disorder probably associated with factor XIII (FXIII) deficiency.

INTERVENTIONS

Management with anti-hyperleukocytosis and chemotherapy, hydration, alkalization, diuresis, uric acid-lowering, molecular targeted drugs, and freshly frozen plasma transfusion therapy resolved the bleeding diathesis.

OUTCOMES

The patient survived from the initial bleeding, however, she died. Twenty six months later due to the progression of CML.

LESSONS

CML can initially present as unusual bleeding, possibly related to FXIII defect. It is essential to screen coagulopathy including FXIII activity and to supplement plasma for CML patients who present initially as bleeding, which cannot be deciphered by the routine clotting screening test.