Acquired inhibitors in malignant and nonmalignant disease states

Acquired Haemophilia A: A Review of What We Know

Autoantibodies against plasma coagulation factors could be developed by some individuals inducing severe and sometimes fatal bleedings. This clinical entity is called acquired haemophilia. It should be suspected in subjects with acute abnormal bleedings, without personal or familiar history of congenital bleeding disorders with an unexplained prolonged aPTT. It is rare disease, although its incidence may be underestimated due to the low knowledge about it by many specialists, the frequent use of anticoagulant or antiplatelet therapies in the affected population that can mask the diagnosis and, sometimes, a so withering effect that avoid its confirmation. Mortality ranges between 9% and 33% depending on the series in the first 2 months after diagnosis. This mortality is attributed in up to 40% of the cases to infections in the context of immunosuppressive treatments used to eliminate the inhibitor. Factor VIII levels below 1% and high inhibitor titers are conditions of worse response rates. Advanced age, patient's ECOG, and underlying conditions are key prognostic factors for response to treatment and patient survival. To reduce morbidity and mortality in these patients, it is important to have clinical knowledge and access to guidelines to achieve an early diagnosis and to optimize the haemostatic and immunosuppressive treatment. This review aims to contribute to the dissemination of basic concepts on the epidemiology etiopathogenesis, diagnosis, treatment and management of these patients, as well as risk factors to get remission and the longest overall survival to allow individualized care. Especial awareness will be proposed in patients with some underlying conditions like cancer, autoimmune diseases, children, pregnancy or drugs.

Acquired hemophilia in malignancy

Acquired hemophilia is a rare but potentially morbid complication in patients with cancer. It may be seen in patients with hematologic neoplasms (usually lymphoproliferative disorders) or with solid tumors. Although the presence of an underlying malignancy portends a worse outcome, the literature suggests that the usual principles of treatment, including immunosuppression, apply to these patients. However, appropriate consideration should be given to the choice of agents, depending on individual risk factors for complications such as thrombosis and infection.

Acquired hemophilia a in a patient with lumbar disc herniation: a case report and review of the literature

OBJECTIVE

To summarize the clinical manifestations and treatment of acquired hemophilia A in a patient with lumbar disc herniation.

SUMMARY OF BACKGROUND DATA

Acquired hemophilia A is a rare but potentially life-threatening hemorrhagic disorder. It is caused by the development of autoantibodies directed against coagulation factor VIII (F VIII) in adults or elderly patients, who do not have a personal or family history of bleeding episodes. The mortality is high if the diagnosis was missed or delays, especially after a surgery.

METHODS

A case was investigated retrospectively and the relevant literature was reviewed.

RESULTS

A 59-year-old man with a 1-year history of lower back and leg pain was admitted to the hospital. He has no family medical history of hemophilia A and the routine laboratory examination did not find abnormality on blood coagulation function. He underwent decompression by laminectomy and discectomy. Seven hours after operation, it was found that the incision was oozing profusely and hemoglobin was reduced gradually, though platelet count was within the normal range. He was diagnosed with acquired factor VIII (FVIII) deficiency based on a prolonged activated partial-thromboplastin time (61.0 seconds), reduced FVIII activity (4.2%), and FVIII inhibitor (8 BU). After treatment with hemodynamic stabilization and immunosuppression therapies (including transfusion of packed red blood cells, fresh frozen plasma, and cryoprecipitate) and administration of human antihemophilic globulin, corticosteroid, and cyclophosphamide, bleeding was stopped gradually. The clinical and biologic condition of the patient improved, though neurological deficit was left.

CONCLUSION

Surgical operation may be a factor contributing to acquired hemophilia A, which, to our knowledge, has not been reported in the literature. Diagnosis of acquired hemophilia requires clinical acumen and any patient who presents with bleeding and a prolonged activated partial-thromboplastin time should be considered. Initial hemodynamic stabilization followed by treatment with immunosuppressive therapy is straightforward and highly successful.

Postpartum acquired factor VIII inhibitors

The development of factor VIII autoantibodies is a rare but severe complication of pregnancy. Although the natural history of postpartum acquired hemophilia A is usually benign, with a high percentage of spontaneous remissions and a low mortality, its quick recognition is important to control bleeding episodes. Based on an analysis of the literature, this review presents the current knowledge on the pathogenesis, diagnosis, epidemiology, natural history, clinical manifestations, and therapeutic management of postpartum acquired hemophilia A.

Acquired hemophilia A

Acquired hemophilia A is a rare but severe autoimmune bleeding disorder, resulting from the presence of autoantibodies directed against clotting factor VIII. The etiology of the disorder remains obscure, although approximately half of all cases are associated with other underlying conditions. A prompt diagnosis and appropriate management enable effective control of this acquired hemorrhagic disorder: the aims of therapy are to terminate the acute bleeding episode and eliminate or reduce the inhibitor. The recent availability of bypassing agents, first activated prothrombin complex concentrates and then recombinant activated factor VII, has significantly reduced mortality during the acute phase of the disease in patients with high titer inhibitors. On another front, immunosuppressive therapy (corticosteroids and cytotoxic agents, alone or in various combinations) has resulted in long-term inhibitor suppression in up to 70% of the cases. Moreover, new therapeutic strategies (anti-CD20 monoclonal antibody and immune tolerance protocols) are very promising and may further improve the prognosis of acquired hemophilia A.

Acquired coagulation inhibitor-associated bleeding disorders: an update

Acquired blood coagulation inhibitors are circulating immunoglobulins that neutralize the activity of a specific coagulation protein or accelerate its clearance from the plasma, thus causing a bleeding tendency. In this review, we focus on the nonhemophilic inhibitors of coagulation, i.e. the autoantibodies occurring in individuals without a pre-existent coagulation defect, reporting the most recent advances in the pathophysiology, diagnosis and treatment of these rare acquired bleeding disorders.

Acquired Factor VIII Inhibitors: Pathophysiology and Treatment

Hemophilia A is classically caused by a congenital deficiency of factor VIII, but an acquired form due to inhibitors to factor VIII (FVIII) typically presents later in life. Patients who develop such acquired factor VIII inhibitors may present with catastrophic bleeding episodes, despite having no prior history of a bleeding disorder. Though the disorder is rare, it is known to cause significant morbidity and mortality. This review will focus on what is currently known about acquired hemophilia A, its pathogenesis, its associated etiologies, and its treatment.

Acquired hemophilia A: a concise review

Acquired hemophilia A is a rare but severe autoimmune bleeding disorder. It is more frequent in the elderly and results from the presence of autoantibodies directed against clotting factor VIII. In this review, we briefly report on the present state of knowledge regarding acquired hemophilia A, analyzing its epidemiology, pathogenesis, diagnostic, and clinical features. We also describe the main characteristics of this disorder according to its association with different conditions and the most important advances in the treatment of bleeding episodes and the eradication of the autoantibody.

Acquired factor VIII inhibitor presenting as a tongue hematoma

Acquired hemophilia is a rare disorder that has potentially disastrous consequences if not recognized and treated in the setting of acute hemorrhage. We report a case of undiagnosed acquired hemophilia due to factor VIII inhibitor in which a tongue hematoma was the chief manifestation. Diagnosis, acute management, and long-term therapeutic options are reviewed.

Successful treatment of acquired factor VIII inhibitor with cyclosporin

Acquired factor VIII inhibitor causes a rare but life-threatening form of bleeding disorder, owing to the formation of auto-antibodies against FVIII. Treatment modalities include the use of immunosuppressive drugs such as cyclophosphamide and corticosteroids, plasmapheresis and i.v. immunoglobulin. A patient with idiopathic acquired FVIII inhibitor presented with serious bleeding complications resistant to all the above therapeutic modalities. Treatment with cyclosporin, however, resulted in a prompt and complete response. The lack of side-effects and the relatively quick response suggest that cyclosporin may be tried as front line treatment for patients with acquired FVIII inhibitors.

Acquired factor VIII inhibitor in a non-haemophilic boy

We describe the case of a previously healthy 8-year-old non-haemophilic boy who developed a factor VIII inhibitor of unknown origin. The symptoms of this disease were haemorrhages in the muscles of the right thigh, numerous bruises and a large haematoma of the right crus with subsequent tissue necrosis. Activated and non-activated prothrombin complex concentrates were administered in the therapy of the haemorrhages. To eliminate factor VIII inhibitor, the patient was treated first with prednisone, then immunoglobulin G and finally with a combination of prednisone and cycylophosphamide, without any effect. A total spontaneous remission was observed after 15 months from the beginning of the disease.

High-titer acquired factor V inhibitor responsive to corticosteroids and cyclophosphamide in a patient with two malignant tumors

We report a 79-year-old man with two simultaneous malignant tumors (buccal epidermoid carcinoma and prostatic adenocarcinoma) who developed a severe bleeding complication at the site of the buccal tumor as well as a massive cerebral hematoma after a skull trauma. Laboratory findings showed the presence of a high-titer specific factor V inhibitor. The patient failed to respond to intravenous immunoglobulins, but both clinical and laboratory improvement was obtained after treatment with corticosteroids and cyclophosphamide.

Pathophysiology of inhibitors to factor VIII in patients with haemophilia A

The occurrence of factor VIII (FVIII) inhibitors is one of the major complications of the treatment of haemophilia A. We present this review as a description of the major players of the antiFVIII immune response, with particular emphasis on the nature and properties of the different antiFVIII antibodies, their mechanisms of action in inhibiting FVIII activity, their potential neutralization by anti-idiotypic antibodies, and the importance of the T cell in participating in the induction of FVIII inhibitors. We briefly conclude on the avenues that remain to be explored in order to establish efficient therapeutic approaches aimed at eliminating FVIII inhibitors in patients with haemophilia A.

Autoantibodies to factor VIII

Anti-Factor VIII (FVIII) antibodies represent a unique model to study the relationship between natural autoreactivity (natural antibodies to FVIII of healthy individuals) and disease-associated autoimmunity ('spontaneous' FVIII inhibitors of patients with anti-FVIII autoimmune disease) to a single human protein antigen. Although natural and disease-associated anti-FVIII antibodies are not readily distinguished based on the comparison of their isotypic distribution and epitope mapping, available studies of cross-reacting idiotypes suggest that FVIII inhibitors in patient's plasma encompass two populations of anti-FVIII antibodies - some antibodies result from the clonal expansion of B lymphocytes that exist previous to the treatment with FVIII and secrete anti-FVIII antibodies with properties similar to those of natural anti-FVIII antibodies present in healthy individuals, other inhibitors are produced by B cell clones that have undergone affinity-maturation and hypermutation of the V-regions of the antibodies they produce. The implications for the treatment of autoimmune patients with anti-FVIII inhibitors are discussed.

[Acquired hemophilia: current diagnostic and therapeutic approaches]

PURPOSE

Acquired haemophilia is a rare disease, occurring most frequently in elderly patients, caused by the development of autoantibodies against factor VIII.

CURRENT KNOWLEDGE AND KEY POINTS

The disease is characterised by spontaneous haemorrhagic complications which can be fatal in 15-20% of the patients. However spontaneous remission is possible and in fact natural evolution and aetiology are still partly unknown. Acquired haemophilia may arise in association with auto-immune diseases, lymphoproliferative malignancy, pregnancy and also as a drug reaction. The aims of the treatment are first to treat the bleeding which is the most common cause of morbidity and mortality, and second to eliminate the inhibitor by immunosuppression. However no consensus exists for these two parts of the treatment. Bleeding may be controlled by prothrombin complex concentrates, recombinant factor VIIa or porcine factor VIII. The inhibitor is abolished in up 70% of patients using prednisone and cyclophosphamide. Other combinations of prednisone with azathioprine or with cyclophosphamide and vincristine or the use of high-dose immunoglobulin or double-filtration plasmapheresis have also proven effective in some patients.

FUTURE AND PROJECTS

The rare occurrence of the disease, the associated with various diseases, and lack of consensus about treatment, require multicentric prospective studies.

Acquired haemophilia in the elderly is a severe disease: report of five new cases

Acquired haemophilia is a rare but life-threatening bleeding disease that can be observed in males or females at various ages. In the present study, we report on five cases of acquired factor (F) VIII inhibitors diagnosed in the elderly population over a period of 5 years between 1995 and 1999 in our hospital. The median age of the patients at the time of diagnosis was 76.2 years (66-92 years). In all cases, the diagnosis was suggested by mild to severe bleeding with no previous bleeding history. While the absence of associated conditions is frequently reported especially among the elderly, in our series an underlying disease was found in four out of the five cases: kidney tumour (two cases) and autoimmune disease (two cases). The bleeding was controlled in four patients using porcine FVIII (two cases) or recombinant FVIIa (two cases). The inhibitors were completely resolved in two patients (kidney tumour, GoodPasture syndrome) by treatment of the underlying disease. However, three patients died as direct or indirect consequence of having an inhibitor. Our series confirms and extends previous data reporting the complexity and severity of this disorder. Because bleeding is often severe, a prompt and correct diagnosis is required to provide adequate therapeutic options that take the advanced age of the patients into account.

Postpartum acquired hemophilia (factor VIII inhibitors): a case report and review of the literature

Pathologic inhibitors of blood coagulation as a cause of postpartum acquired hemostatic failure are rare. Since 1937, 96 cases of postpartum factor VIII (FVIII) inhibitors, including the current case, have been reported. Suspicion for the diagnosis of this condition is often low. We report a case of postpartum FVIII inhibitor formation in a 24-year-old woman who developed intermittent postpartum bleeding that resulted from the inhibitors she formed to FVIII. A unique form of therapy was used in treatment of her disorder. She did not respond to conventional surgical or medical management of her bleeding until Autoplex T (Baxter Healthcare, Glendale, CA), an activated prothrombin complex concentrate (aPCC) was used. The literature concerning acquired hemophilia is reviewed, and new therapeutic medical advances are emphasized.

Acquired hemophilia successfully treated with oral immunosuppressive therapy

Acquired hemophilia is a rare disorder associated with serious bleeding in nonhemophilic patients. We had a 40-year-old woman who was diagnosed as acquired hemophilia with a factor VIII inhibitor level of 27.5 BU/mL. She was presented with gross hematuria and severe right shoulder pain, and was successfully treated with daily oral cyclophosphamide and prednisone for 2 weeks. After the remission, the doses of prednisone and cyclophosphamide were slowly decreased and she remained in complete remission without further bleeding episodes.

Acute renal failure in acquired haemophilia following the use of high dose intravenous immunoglobulin

High dose intravenous immunoglobulin (IVIG) is a useful form of treatment in patients with acquired haemophilia, a rare bleeding disorder due to auto-antibodies to factor VIII. We describe a patient with acquired haemophilia who developed acute renal failure rapidly after treatment with a high sucrose content IVIG preparation. We speculate that the sucrose content of the preparation was responsible for the renal failure and make recommendations on the use of IVIG in patients with acquired haemophilia.

Acquired hemophilia due to factor VIII inhibitors in 34 patients

BACKGROUND

Acquired hemophilia is a rare disease caused by the development of auto-antibodies against factor VIII.

SUBJECTS AND METHODS

We studied the characteristics and outcomes of 34 patients (19 women and 15 men) with acquired hemophilia from 1980 to 1997.

RESULTS

The mean age of the patients was 61 years (range, 22-93 years). An underlying disease was observed in 18 (53%) patients: 5 patients had cancer, 4 an autoimmune disorder, 2 a dermatologic disorder, 3 asthma, 3 were postpartum, and 1 had an adverse reaction to ampicillin. Factor VIII level was <5% in 30 (90%) patients; factor VIII antibodies were elevated (>10 Bethesda units) in 23 (69%) patients. Bleeding requiring transfusions was reported in 25 (75%) patients. Human factor VIII was given to 14 patients and porcine factor VIII to 5. Six patients received prothrombin complex concentrates and one desmopressin. Several immunosuppressive treatments were used, mainly corticosteroids, cyclophosphamide, and intravenous immunoglobulin. Bleeding stopped in all but one patient within 2 weeks. Most patients achieved complete remission, although two relapses were observed subsequently.

CONCLUSION

This large study helps to clarify the presentation and clinical course of acquired hemophilia. Prospective studies are needed to determine the efficacy of treatment.

Autoimmune coagulation disorders

The spontaneous onset of autoantibodies against circulating factors, including factors II, V, VII, VIII, IX, XI, XII, and XIII, is a phenomenon of unclear causes. It may occur in patients with no underlying disease process or may be antedated by autoimmune diseases and malignancies. The antibodies are almost always IgG and are most commonly directed at F VIII. They generally present with a bleeding diathesis in patients with no history of prior bleeding events. The laboratory abnormalities vary depending on whether the inhibitor involves the intrinsic or extrinsic pathway of coagulation, and the laboratory studies may vary depending on the technique used. Supportive measures are used initially but are generally not completely effective. Supportive measures are followed by blood products, such as recombinant human F VIII, porcine F VIII, or PCC/aPCC. There are limitations to each of these, however. If bleeding is severe and high titers of inhibitors are present, plasma-pheresis may lead to a temporary decrease in the titer but is short-lived. Immunosuppressive therapy should ultimately be attempted to suppress further antibody production. Spontaneous remission may occur with some of the inhibitors, primarily postpartum or drug related, for reasons not fully understood.

Autoimmune C1 inhibitor deficiency: report of eight patients

PURPOSE

In this study, we investigated the clinical and biochemical features and the responses to treatment of eight patients with auto-antibody-mediated C1 inhibitor (C1-INH) deficiency and symptoms of angioedema.

PATIENTS AND METHODS

In addition to the 8 patients with acquired angioedema (AAE), we also studied 36 subjects with hereditary angioedema (HAE), 15 of them treated with C1-INH plasma concentrate, and 26 patients with different autoantibodies in their plasma (10 with systemic lupus erythematosus, 6 with lupus-like anticoagulant, and 10 with chronic liver disease). Functional C1-INH was measured with the reagent kit of Immuno (Vienna, Austria); C1-INH, C4, and C1q antigen were determined by radial immunodiffusion; and autoantibodies to C1-INH were detected by an enzyme-linked immunosorbent assay method.

RESULTS

Four patients with AAE had no other diseases, one had breast cancer, one liver hydatidosis, one Waldenström's disease, and one a benign M component. Functional C1-INH levels were below 30% of normal, and C1q plasma levels were low in seven patients but normal in one. Autoantibodies to C1-INH were detectable in all eight AAE patients but in none of the others. Prophylactic treatment with attenuated androgens was successful in one of four patients, and with antifibrinolytic agents (tranexamic acid) in six of seven patients. Laryngeal attacks in five patients were treated with C1-INH plasma concentrate; two patients had marked clinical and biochemical responses. In three, the symptoms resolved only with high doses, and the biochemical parameters did not significantly increase.

CONCLUSIONS

Our results suggest that patients with autoimmune AAE are clinically and biochemically heterogeneous. They have different responses to treatment that seem to be related to variable C1-INH consumption.

DDAVP in acquired hemophilia A: case report and review of the literature

One patient with an acquired factor VIII inhibitor is reported in which an acute lower intestinal hemorrhage was successfully managed using Desmopressin (DDAVP). The patient initially had a factor VIII level of 10% with a inhibitor titer of 1.9 Bethesda units. Following administration of DDAVP the factor VIII level rose to 86% and there was a decrease in the number and volume of bloody stools. The inhibitor disappeared following treatment with corticosteroids, however the patient ultimately expired due to complications of ischemic colitis. This case and 21 previously reported cases of acquired hemophilia treated with DDAVP are reviewed. The data support a role for DDAVP in the treatment of non life threatening hemorrhage in patients with acquired hemophilia and low titer factor VIII inhibitors (< 5 Bethesda units or factor VIII > or = 5%).