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Alvarado Y, Yao X, Jumper C, Hardwicke F, D'Cunha N, Cobos E. Acquired Hemophilia: A Case Report of 2 Patients With Acquired Factor VIII Inhibitor Treated With Rituximab Plus a Short Course of Steroid and Review of the Literature. Clin Appl Thromb Hemost 2016; 13:443-8. [PMID: 17911199 DOI: 10.1177/1076029607303777] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Acquired hemophilia is an unusual disorder in which nonhemophiliac patients develop autoantibodies (inhibitor) against the factor VIII coagulation protein. Factor VIII inhibitor leads to life-threatening bleeding disorders classically described as new onset of diffuse bruising and prolonged partial thromboplastin time in elderly patients. Treatment is focused in the control of the acute bleeding episode and the long-term suppression of the autoantibody. Several immunosuppressive combinations have been described; however, these treatments are also associated with serious side effects that are difficult to tolerate, especially in older and debilitated patients. New treatment modalities explore the elimination of the autoantibody production by targeting B-cells with rituximab, an anti CD-20 monoclonal antibody that has shown success in a multitude of autoimmune processes. This report presents 2 patients successfully treated with rituximab and a short tapering course of steroids and focuses our discussion in the analysis of different treatment approaches available for these patients' population.
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Affiliation(s)
- Yesid Alvarado
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas 79403, USA
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Acquired hemophilia possibly induced by etanercept in a patient with rheumatoid arthritis. Joint Bone Spine 2015; 82:200-2. [PMID: 25617259 DOI: 10.1016/j.jbspin.2014.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2014] [Indexed: 11/21/2022]
Abstract
A 47-year-old woman with rheumatoid arthritis (RA) treated successively with infliximab, abatacept, and etanercept spontaneously developed subcutaneous bruises and a noncompressive hematoma 11 months after starting etanercept therapy (50mg/week). Her prothrombin time was normal but her activated partial thromboplastin time was increased to 2.48 (normal range, 0.85-1.17). She had a circulating anticoagulant (Rosner index, 45; normal,<13) due to an anti-factor VIII antibody in a titer of 45 Bethesda units. Her factor VIII level was less than 1% (normal range, 55-150). The etanercept and leflunomide were stopped and prednisone was given in a daily dosage of 1mg/kg, in combination with rituximab, two 1-g doses at an interval of 2 weeks. After 5 months, persistence of the anti-factor VIII antibody prompted the initiation of azathioprine therapy, 2mg/kg/d. A remission was achieved 9 months after the diagnosis of acquired hemophilia and was sustained at last follow-up after 3 years. This new case of acquired hemophilia in a patient with RA may reflect a simple association or an inducing role of etanercept.
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de Vitry A, Valois A, Weinborn M, Dupuy-de Fonclare AL, Cuny JF, Barbaud A, Schmutz JL. [Acquired haemophilia A: two cases]. Ann Dermatol Venereol 2014; 141:441-5. [PMID: 24951143 DOI: 10.1016/j.annder.2014.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 02/17/2014] [Accepted: 03/03/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Acquired haemophilia A (AH) is an uncommon bleeding disorder that presents as multiple, disseminated spontaneous subcutaneous bleeds. Diagnosis may be made on the basis of prolonged activated partial thromboplastin time (aPTT). The severity of the disease is associated with the low risk of haemoglobin levels and with potential links with other diseases. OBSERVATIONS Two men were hospitalized for extensive and spontaneous subcutaneous hematoma. In both cases, the International Normalized Ratio (INR) was normal, but aPTT was 3 times higher than normal. Autoantibodies against coagulation factor VIII confirmed the diagnosis of AH. The patients received immunomodulatory treatment. In one patient, diffuse large B-cell lymphoma was discovered one year after successful treatment of AH. DISCUSSION AH may be revealed by areas of bruising, subutaneous haematomas mimicking erythema nodosum, and muscle pain. APTT results alone can prompt the biologist to screen for factor VIII inhibitors. Aside from the risk of fatal bleeding, in half of all cases, the prognosis is determined by associated disorders such as blood dyscrasias, solid tumours, autoimmune diseases, use of certain medicines and pregnancy. After treatment for bleeding complications, therapy focuses on restoring the coagulation time. The aim of immunomodulatory therapy is to stem production of autoantibodies against coagulation factor VIII. CONCLUSION AH must be considered rapidly in order to reduce the risk of bleeding emergencies and to screen for potential related diseases.
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Affiliation(s)
- A de Vitry
- Service de dermatologie, batiment Philippe-Canton, CHU, 6, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France.
| | - A Valois
- Service de dermatologie, hôpital d'instruction des armées Legouest, 27, avenue de Plantières, 57070 Metz, France
| | - M Weinborn
- Service de dermatologie, batiment Philippe-Canton, CHU, 6, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
| | - A-L Dupuy-de Fonclare
- Service de dermatologie, hôpital d'instruction des armées Legouest, 27, avenue de Plantières, 57070 Metz, France
| | - J-F Cuny
- Service de dermatologie, batiment Philippe-Canton, CHU, 6, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
| | - A Barbaud
- Service de dermatologie, batiment Philippe-Canton, CHU, 6, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
| | - J-L Schmutz
- Service de dermatologie, batiment Philippe-Canton, CHU, 6, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
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Borg JY, Guillet B, Le Cam-Duchez V, Goudemand J, Lévesque H. Outcome of acquired haemophilia in France: the prospective SACHA (Surveillance des Auto antiCorps au cours de l'Hémophilie Acquise) registry. Haemophilia 2013; 19:564-70. [PMID: 23574453 DOI: 10.1111/hae.12138] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2013] [Indexed: 01/24/2023]
Abstract
Although extremely rare, acquired haemophilia A (AHA) can cause severe bleeding, which may be fatal. The underlying causes of autoantibody development are not fully understood. Treatment goals are bleeding control and autoantibody eradication. At the time of our study, there was no consensus on a standard treatment strategy for AHA. Previous data were mainly retrospective or from single-centre cohorts. We conducted a prospective, controlled, registry-based study of patients with AHA in France. The prospective French registry (Surveillance des Auto antiCorps au cours de l'Hémophilie Acquise [SACHA]) collected data on prevalence, clinical course, disease associations and outcomes for haemostatic treatment and autoantibody eradication in 82 patients with a 1-year follow-up. Similar to earlier studies, the prevalence of AHA was higher in the elderly, with two thirds of patients aged >70 years. Around half of AHA cases were associated with underlying disease, most commonly autoimmune disease and cancer in younger and older patients respectively. Haemostatic treatment was initially administered to 46% of patients. Complete resolution or improvement of initial bleeding occurred in 22/27 (81%) rFVIIa-treated patients and in all six cases receiving pd-aPCC. The majority of patients (94%) received immunosuppressive therapy, with complete remission at 3 months in 61% (36/59) and in 98% (50/51) at 1 year. Overall mortality was 33%: secondary to bleeding in only three patients but to sepsis in 10. Bypassing agents were effective at controlling bleeding in patients with AHA. Immunosuppressive therapy should be used early but with caution, particularly in elderly patients.
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Affiliation(s)
- J Y Borg
- Haematology Laboratory, Rouen University Hospital and INSERM CIC-CRB 0204, Rouen, France
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Hémophilie A acquise précédant l’apparition d’un cancer : quelles explorations et quelle surveillance ? Rev Med Interne 2009; 30:630-3. [DOI: 10.1016/j.revmed.2008.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Revised: 07/25/2008] [Accepted: 09/03/2008] [Indexed: 11/19/2022]
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Millet A, Decaux O, Bareau B, Guillet B, Cazalets C, Perlat A, Jego P, Grosbois B. Efficacité du rituximab dans les hémophilies acquises: à propos de deux cas et revue de la littérature. Rev Med Interne 2007; 28:862-5. [PMID: 17707554 DOI: 10.1016/j.revmed.2007.06.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2007] [Accepted: 06/25/2007] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Acquired hemophilia due to an inhibitor of factor VIII is a rare clinical situation. EXEGESIS Rituximab is now used in the treatment of acquired hemophilia. We report two cases of acquired hemophilia treated by rituximab with efficiency. CONCLUSION Rituximab appears to be a first line immunosuppressive therapy in acquired hemophilia, especially in post-partum hemophilia.
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Affiliation(s)
- A Millet
- Service de médecine interne, département de médecine de l'adulte, hôpital Sud, 16, boulevard de Bulgarie, 35203 Rennes cedex 02, France
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Lévesque H, Borg JY. [Biotherapy and acquired haemophilia: a place not yet defined]. Rev Med Interne 2007; 28:810-2. [PMID: 17959277 DOI: 10.1016/j.revmed.2007.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2007] [Accepted: 10/02/2007] [Indexed: 10/22/2022]
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Gay V, Jacquemin S, Lecomte C, Raffenot D. À propos de trois cas d'hémophilie acquise. Rev Med Interne 2006. [DOI: 10.1016/j.revmed.2006.10.225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Roth B, El Mouden M. [Diagnosis and management of a haemorrhagic emergency revealing an acquired haemophilia]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2005; 24:60-3. [PMID: 15661466 DOI: 10.1016/j.annfar.2004.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2004] [Accepted: 11/05/2004] [Indexed: 11/21/2022]
Abstract
We relate the case of a 22-year-old woman, without any particular medical history, apart from a previous full-term pregnancy with no complication, for whom the discovery of prolongated APTT (Activated Partial Thromboplastin Time) postponed an emergency operation in spite of intracystic ovarian haemorrhage. The complementary check-up revealed the existence of an autoantibody antifactor VIII (antithromboplastinogen), showing acquired postpartum haemophilia.
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Affiliation(s)
- B Roth
- Service de réanimation polyvalente, centre hospitalier de Calais, 11, quai du Commerce, 62107 Calais, France
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Kaloyannidis P, Sakellari I, Fassas A, Fragia T, Vakalopoulou S, Kartsios C, Garypidou B, Kimiskidis V, Anagnostopoulos A. Acquired hemophilia-A in a patient with multiple sclerosis treated with autologous hematopoietic stem cell transplantation and interferon beta-1a. Bone Marrow Transplant 2004; 34:187-8. [PMID: 15195073 DOI: 10.1038/sj.bmt.1704550] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
UNLABELLED The many causes of hemarthrosis include acquired hemophilia due to production of autoantibodies to factor VIII. We report two very different cases. CASE 1: This woman experienced onset of juvenile idiopathic arthritis at 8 years of age. Her first child was born when she was 28-years-old. Three months after delivery, vaginal bleeding and recurrent hemarthrosis led to a diagnosis of acquired hemophilia (isolated APTT prolongation, 1% VIIIc activity, and 58 U of anti-factor VIII antibody). Treatment included glucocorticoid therapy, prothrombin complex, and intravenous immunoglobulins. She achieved a full recovery within a year. CASE 2: In this 84-year-old woman, spontaneous recurrent hemarthrosis with hematomas revealed idiopathic acquired hemophilia. Treatment included prothrombin complex, factor VIII concentrates, and intravenous immunoglobulins, followed by cyclophosphamide and glucocorticoid therapy. Recovery was complete within a year. The diagnosis, etiology, prognosis, and treatment of acquired hemophilia are discussed. CONCLUSION Although rare, acquired hemophilia should be considered among the causes of hemarthrosis, particularly as a favorable outcome can be expected with early diagnosis and appropriate treatment.
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Affiliation(s)
- Daniel Wendling
- Rheumatology Department, Jean Minjoz Teaching Hospital, 25030 Besançon, France.
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Laporte F, Cestac P, Favre V, DeRoch XS, Khatibi S, Bonnet E, Massip P, Sie P, Bellon B. Traitement d’une hémophilie acquise chez un patient septique. Rev Med Interne 2003; 24:692-5. [PMID: 14550523 DOI: 10.1016/s0248-8663(03)00253-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Acquired haemophilia is a rare bleeding diathesis caused by auto-immune depletion of factor VIII. It is characterised by spontaneous haemorrhagic syndrome, which can be fatal sometimes. EXEGESIS A 71 year-old man presents in a dysimmunitary context (rheumatoid arthritis complicates by an acquired haemophilia) a septicemia with a methicillin resistant staphylococcus aureus. At the time of the hospitalization, the patient is febrile (39 degrees C). The activated partial thromboplastin time is very much increased, the level of factor VIII is lowered by 7% and the title of the inhibitor to factor VIII amounts to 140 Bethesda unities. An haematoma of the right root thigh is also noted. In that case, the concomitant presence of septicemia makes difficult the use of immunosuppressive therapy usually recommended to decrease auto-antibody's level. For the management of the septicemia, an adapted antibiotherapy (vancomycin then teicoplanin) is organized to J1. To control haemorrhagic risk, immunoglobulins are prescribed from d12 to d16, without immediate results. Then prednisone is introduced. We observe a very fast decrease of the anticoagulant circulating title with a neat improvement of the clinical state, allowing so to realize a draining puncture of the psoas. This invasive investigation required the use of prothrombinic complex concentrates ((Feiba) in the dose of 80 UI/kg two to three times a day). Biopsy does not show infection source. CONCLUSION The infection delayed the prescription of immunosuppressive therapy and the surgery. Use of corticoids, following 5 days of intravenous polyvalent immunoglobulin, was the good choice. After 7 weeks of hospitalization the patient has recovered a normal haemostasis results, and a good general state.
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Affiliation(s)
- F Laporte
- Service pharmacie, hôpital Purpan, CHU Toulouse, place Baylac, 31059 Toulouse cedex, France
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Da Mata L, Costecalde M, François J, Carpentier L, Wiel E. [Autoantibodies and anti-factor VIII and Chlamydia pneumoniae infection]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2002; 21:606-9. [PMID: 12192696 DOI: 10.1016/s0750-7658(02)00686-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
We report the case of a 64-year-old man without hemorrhagic history experiencing epistaxis. The standard hemostasis assessment including prothrombin index, activated partial thromboplastin time (APTT) and platelet count found an isolated abnormal APTT (105 sec vs 33 sec). Therefore, coagulation factors were explored. An acquired factor VIII deficiency (5%) with anti-FVIII antibody (4.5 Bethesda unit.mL-1) was recognised. This anti-FVIII antibody was related to a Chlamydia pneumoniae pulmonary infection. Treatment consisted of: i) Four successive anterior packing and activated factor VII infusion (Novoseven); ii) steroids injection and bi-antibiotherapy. The time course of the epistaxis was favourable under treatment.
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Affiliation(s)
- L Da Mata
- Département d'anesthésie-réanimation chirurgicale II, hôpital Claude-Huriez, rue Michel Polonowski, CHRU de Lille, 59037 Lille, France
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