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Bhatti MQ, Gonzalez-Fernandez E, Bhatia K, Divani AA, Di Napoli M, Hinduja A, Datta YH. Neurological Complications Associated with Hereditary Bleeding Disorders. Curr Neurol Neurosci Rep 2023; 23:751-767. [PMID: 37864642 DOI: 10.1007/s11910-023-01313-y] [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] [Accepted: 09/15/2023] [Indexed: 10/23/2023]
Abstract
PURPOSE OF REVIEW Hereditary bleeding disorders may have a wide variety of clinical presentations ranging from mild mucosal and joint bleeding to severe central nervous system (CNS) bleeding, of which intracranial hemorrhage (ICH) is the most dreaded complication. In this review, we will discuss the pathophysiology of specific hereditary bleeding disorders, namely, hemophilia A, hemophilia B, and von Willebrand disease (vWD); their clinical manifestations with a particular emphasis on neurological complications; a brief overview of management strategies pertaining to neurological complications; and a review of literature guiding treatment strategies. RECENT FINDINGS ICH is the most significant cause of morbidity and mortality in patients with hemophilia. Adequate control of bleeding with the administration of specific factors or blood products, identification of risk factors for bleeding, and maintaining optimal coagulant activity are essential for appropriately managing CNS bleeding complications in these patients. The administration of specific recombinant factors is tailored to a patient's pharmacokinetics and steady-state levels. During acute bleeding episodes, initial factor activity should be maintained between 80 and 100%. Availability of monoclonal antibody Emicizumab has revolutionized prophylactic therapies in patients with hemophilia. Management of ICH in patients with vWD involves using plasma-derived factor concentrates, recombinant von Willebrand factor, and supportive antifibrinolytic agents individualized to the type and severity of vWD. Hemophilia and vWD are the most common hereditary bleeding disorders that can predispose patients to life-threatening CNS complications-intracranial bleeds, intraspinal bleeding, and peripheral nerve syndromes. Early care coordination with a hematologist can help develop an effective prophylactic regimen to avoid life-threatening bleeding complications in these patients. Further research is needed to evaluate using emicizumab as an on-demand treatment option for acute bleeding episodes in patients with hemophilia.
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Affiliation(s)
| | | | - Kunal Bhatia
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Afshin A Divani
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA.
| | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Sulmona, L'Aquila, Italy
| | - Archana Hinduja
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Yvonne H Datta
- Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, USA
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Abe H, Saito M, Uno K, Koike T, Ichikawa S, Saito M, Kanno T, Hatta W, Asano N, Masamune A. A case of refractory bleeding from duodenal angioectasia with acquired hemophilia A. Clin J Gastroenterol 2023; 16:355-360. [PMID: 37022595 DOI: 10.1007/s12328-023-01790-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 03/23/2023] [Indexed: 04/07/2023]
Abstract
Acquired hemophilia A (AHA) is a coagulation disorder related to the factor VIII inhibitors, which might cause intractable bleeding of gastrointestinal tracts. However, its scarcity makes it difficult to recognize AHA as a pitfall of endoscopic hemostasis failure. An 81-year-old female with a history of endoscopic treatment for colon polyps visited a local hospital with chief compliments of bloody stool and severe anemia. During several examinations for the bleeding origin, esophagogastroduodenoscopy depicted a 5 mm-sized hemorrhagic angioectasia of the duodenum, followed by treatment with argon plasma coagulation. However, hemostasis was not achieved by multiple sessions of endoscopic hemostasis and transcatheter arterial embolization, so blood transfusion was repeatedly done and she was transferred to our hospital. Laboratory data showed severe anemia with coagulation disorder. Based on the results of von Willebrand factor activity, factor VIII activity and factor VIII inhibitor, we diagnosed AHA as a comorbidity. Endoscopic hemostasis was confirmed only after improvement of APTT level and negative for the factor VIII inhibitor by hemostatic bypass treatment with recombinant active factor VII and immunosuppressive therapy with prednisolone and cyclophosphamide. In case of refractory bleeding of gastrointestinal tract, we should suspect of a comorbidity of coagulation disorder like AHA.
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Affiliation(s)
- Hiroko Abe
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Masahiro Saito
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Kaname Uno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Satoshi Ichikawa
- Division of Hematology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Masashi Saito
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Takeshi Kanno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Waku Hatta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Naoki Asano
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
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3
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Osaki T, Souri M, Yokoyama C, Magari Y, Ichinose A. Unmet Need for Reliable Immunological Detection Method for Anti-von Willebrand Factor Autoantibodies. Thromb Haemost 2023; 123:478-481. [PMID: 36539201 DOI: 10.1055/a-2002-2394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Tsukasa Osaki
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Iida-Nishi, Yamagata, Japan.,The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan.,Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Iida-Nishi, Yamagata, Japan
| | - Masayoshi Souri
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Iida-Nishi, Yamagata, Japan.,The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan.,Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Iida-Nishi, Yamagata, Japan
| | - Chikako Yokoyama
- The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan.,Department of Biochemical Engineering, Graduate School of Science and Engineering, Yamagata University, Yonezawa, Japan.,Department of Chemistry and Bioengineering, Graduate School of Engineering, Osaka Metropolitan University, Osaka, Japan
| | | | - Akitada Ichinose
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Iida-Nishi, Yamagata, Japan.,The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan
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4
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Tang Q, Liao J, Xie X. Acquired Hemophilia Associated with Rheumatic Diseases: A Case-Based Systematic Review. J Inflamm Res 2022; 15:4385-4393. [PMID: 35945991 PMCID: PMC9357396 DOI: 10.2147/jir.s369288] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/19/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Qi Tang
- Department of Rheumatology and Immunology, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Jiafen Liao
- Department of Rheumatology and Immunology, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Xi Xie
- Department of Rheumatology and Immunology, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Correspondence: Xi Xie, Department of Rheumatology and Immunology, the Second Xiangya Hospital, Central South University, Changsha, 410011, People’s Republic of China, Tel/Fax +86 0731 8529 5255, Email
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Acquired Haemophilia A: A 15-Year Single-Centre Experience of Demography, Clinical Features and Outcome. J Clin Med 2022; 11:jcm11102721. [PMID: 35628847 PMCID: PMC9144570 DOI: 10.3390/jcm11102721] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/03/2022] [Accepted: 05/04/2022] [Indexed: 01/27/2023] Open
Abstract
Acquired haemophilia A (AHA) is a rare severe bleeding disorder resulting from the production of autoantibodies directed against coagulation factor VIII. At presentation, bleeding events can be severe, and an early diagnosis and treatment are of major importance. The current study aims to analyse the treated patients who have been diagnosed with AHA for a better understanding of our population and treatment outcome. We conducted a retrospective study with 26 patients who had been diagnosed with AHA and who were treated in our hospital between January 2006 and January 2021. The patients ranged in age from 30 to 85 years old: 46.10% were men, 46.10% had no known underlying condition, 27% had an underlying malignancy, 7.60% presented with other diseases: psoriatic arthritis and Paget's disease, and 19.30% presented with AHA during puerperium. All of the patients had bleeding events and were treated with bypass agents for this as well as with immunosuppressive therapy to eradicate the inhibitor. A total of 53.80% of the patients had major bleeding. Sixty-nine percent of the patients achieved complete remission, but 26.90% died during the follow-up, although bleeding was not the cause of death in any of these cases. Our observations underline the importance of clinical suspicion and early referral to centres with experience and laboratory facilities for managing AHA.
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Bowyer A, Gray E, Lowe A, Murphy P, Platton S, Riddell A, Chowdary P, Lester W, Jenkins PV. Laboratory coagulation tests and recombinant porcine factor VIII: A United Kingdom Haemophilia Centre Doctors’ Organisation guideline. Haemophilia 2022; 28:515-519. [DOI: 10.1111/hae.14536] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 02/18/2022] [Accepted: 02/25/2022] [Indexed: 01/19/2023]
Affiliation(s)
- Annette Bowyer
- Department of Coagulation Royal Hallamshire Hospital Sheffield UK
| | - Elaine Gray
- Haemostasis Section National Institute for Biological Standards and Control Potters Bar UK
| | - Anna Lowe
- UK National External Quality Assurance Scheme for Blood Coagulation Sheffield UK
| | - Paul Murphy
- Department of Haematology Newcastle Upon Tyne Hospitals Newcastle upon Tyne UK
| | - Sean Platton
- The Royal London Hospital Haemophilia Centre Barts Health NHS Trust London UK
| | - Anne Riddell
- Katharine Dormandy Haemophilia Centre Royal Free Hospital London UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia Centre Royal Free Hospital London UK
| | - Will Lester
- Haemophilia Unit University Hospitals Birmingham Birmingham UK
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Zafar M, Butler-Manuel W, Newman J, Berliti S, Cowley A. Could a Haematoma Be Due to an Acquired Phenomenon? Cureus 2021; 13:e19792. [PMID: 34909344 PMCID: PMC8653922 DOI: 10.7759/cureus.19792] [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] [Accepted: 11/21/2021] [Indexed: 11/17/2022] Open
Abstract
Acquired hemophilia, as opposed to congenital hemophilia, develops in individuals with no previous history of bleeding disorder with almost similar numbers of males and females affected. It is predominantly a disease of the elderly. It is an autoimmune disorder and occurs when the immune system produces antibodies that mistakenly attack healthy tissue, specifically the clotting factors, in particular clotting factor VIII. As a result, affected individuals develop abnormal uncontrolled bleeding into the muscles, soft tissues, and the skin and it can occur spontaneously during surgery, or following trauma, and potentially cause life-threatening bleeding complications in severe cases. The affected individuals may remain undiagnosed or be misdiagnosed, making it difficult to determine the actual frequency of the disorder in the general population. The clinical presentation should suspect it with confirmation by an abnormal coagulation test. Typical laboratory results with a recent onset of abnormal bleeding and an isolated prolongation of the activated partial thromboplastin time (APTT), especially in the elderly and peri- and post-partum women, should raise eyebrows. We present two cases following different symptomatology and emphasize the clinical challenges for junior medical doctors who receive patients on the front end. We hope to emphasize understanding simple coagulation blood results followed by a meaningful discussion with the hematology team towards appropriate and timely management of the bleeding diathesis. We hope this case series report will help junior medical doctors manage patients appropriately and consult with their hematology colleagues.
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Affiliation(s)
- Mansoor Zafar
- Gastroenterology and Hepatology, Conquest Hospital - East Sussex Healthcare NHS Trust, St. Leonards-on-Sea, GBR
| | - William Butler-Manuel
- Internal Medicine, Conquest Hospital - East Sussex Healthcare NHS Trust, St. Leonards-on-Sea, GBR
| | - Joel Newman
- Internal Medicine and Hematology, Conquest Hospital - East Sussex Healthcare NHS Trust, St. Leonards-on-Sea, GBR
| | - Stefano Berliti
- Internal Medicine and Acute Medicine, Conquest Hospital - East Sussex Healthcare NHS Trust, St. Leonards-on-Sea, GBR
| | - Anna Cowley
- Internal Medicine and Hematology, Conquest Hospital - East Sussex Healthcare NHS Trust, St. Leonards-on-Sea, GBR
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8
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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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9
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[Unclear massive hemorrhage with obstruction of the airways]. HNO 2021; 69:1009-1011. [PMID: 33723671 DOI: 10.1007/s00106-021-01025-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2021] [Indexed: 10/21/2022]
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10
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Khan UZ, Yang X, Masroor M, Aziz A, Yi H, Liu H. Surgery-associated acquired hemophilia A: a report of 2 cases and review of literature. BMC Surg 2020; 20:213. [PMID: 32967658 PMCID: PMC7510307 DOI: 10.1186/s12893-020-00872-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/16/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Acquired Hemophilia A (AHA) is a rare bleeding diathesis in patients with no previous personal or family bleeding history. The diagnosis of this disease often delays due to unfamiliarity of physicians with it, which leads to its high mortality rate. CASE PRESENTATION Two cases (one 12 years old female and another 18 years old male) were admitted for right upper abdominal mass and right upper abdominal pain respectively at different times. Pre-operative diagnosis of both cases was congenital choledochal cyst. They suffered continuous gastrointestinal bleeding (hematemesis and melena) with reduced hemoglobin to 54 g/L and 60 g/L after Roux-en-Y anastomosis respectively. To investigate the exact bleeding site, Digital subtraction angiography (DSA) of case 1 showed contrast overflow at small branch of proper hepatic artery but had unremarkable result for case 2, whereas gastroscopy of both cases showed unremarkable results. Multiple surgeries were also performed for hemostatic purpose but each time no active bleeding site was found. Finally, hematologists consultation was mandated in both cases and they were diagnosed as acquired haemophilia A. However, unfortunately case 1 patient could not survive because of sever hemorrhage and infection while Case 2 of 18 years old male survived after proper haemophilia treatment catalog. CONCLUSION Awareness about surgery associated acquired haemophilia A (SAHA) can facilitate quick diagnosis and lifesaving management because the mortality rate in SAHA is high due to lake of knowledge or late recognition of the disease. Bleeding always occurs at surgical sites and it can occur immediately within few hours after surgery in some cases. Hemorrhage may be severe or even life threatening and it presents a special challenge for diagnosis and treatment in a patient who has just undergone a surgical procedure. The treatment strategies for AHA include resumption of hemostasis with either recombinant porcine factor VIII (rpFVIII) or bypassing agents and immunosuppressive therapy to suppress the production of the factor VIII inhibitor.
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Affiliation(s)
- Umar Zeb Khan
- Department of General Surgery, The Third Xiangya Hospital of Central South University, 138 Tongzipo Rd, Changsha, 410013, China
| | - Xiangwu Yang
- Department of General Surgery, The Third Xiangya Hospital of Central South University, 138 Tongzipo Rd, Changsha, 410013, China
| | - Matiullah Masroor
- Department of General Surgery, The Second Xiangya Hospital of Central South University, 139 Renmin Middle Rd, Changsha, 410011, China
| | - Abdul Aziz
- Molecular Biology Research Center & Center for Medical Genetics, School of Life Sciences, Central South University, Changsha, 410078, China
| | - Hui Yi
- Molecular Biology Research Center & Center for Medical Genetics, School of Life Sciences, Central South University, Changsha, 410078, China
| | - Hai Liu
- Department of General Surgery, The Third Xiangya Hospital of Central South University, 138 Tongzipo Rd, Changsha, 410013, China.
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11
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Arain A, Muhsen IN, Abdelrahim M. Acquired haemophilia as a paraneoplastic manifestation of pancreatic cancer. Ecancermedicalscience 2020; 14:1053. [PMID: 32582368 PMCID: PMC7302889 DOI: 10.3332/ecancer.2020.1053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Indexed: 11/06/2022] Open
Abstract
Acquired haemophilia is a severe haematological disorder characterised by the presence of anti-factor VIII antibodies. Although rare, it can lead to serious bleeding complications. Acquired haemophilia can be seen in patients with malignancies as a paraneoplastic phenomenon. This is a case of a 52-year-old patient who presented with haematuria and retroperitoneal bleeding soon after being diagnosed with pancreatic adenocarcinoma and subsequently was found to have acquired haemophilia. The treatment of underlying malignancy with chemotherapy may accelerate the eradication of anti-factor VIII antibodies.
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Affiliation(s)
- Abeer Arain
- Houston Methodist Cancer Center, Houston Methodist Hospital, Houston, TX 77030, USA.,https://orcid.org/0000-0001-6295-4318
| | - Ibrahim N Muhsen
- Department of Medicine, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Maen Abdelrahim
- Houston Methodist Cancer Center, Houston Methodist Hospital, Houston, TX 77030, USA.,Cockrell Center for Advanced Therapeutic-Phase I program, The Methodist Hospital Research Institute, Houston, TX 77030, USA.,Weill Cornell Medical College, Institute of Academic Medicine, Houston, TX 77030, USA
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12
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Lewis A, Joseph J, Pathak N, Baseri B, Luhrs C. Acquired factor VIII deficiency in prostate adenocarcinoma presenting as multiple hematomas and hemarthrosis. SAGE Open Med Case Rep 2020; 8:2050313X20906743. [PMID: 32110407 PMCID: PMC7026807 DOI: 10.1177/2050313x20906743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 01/14/2020] [Indexed: 12/11/2022] Open
Abstract
Acquired hemophilia A or acquired factor VIII deficiency is a rare bleeding disorder due to the presence of autoantibodies to factor VIII. It has been associated with autoimmune conditions, certain medications, and malignancy. It has a high morbidity and mortality, and early diagnosis and treatment is critically important. Acquired hemophilia A usually manifests with soft tissue bleeding, such as epistaxis, genitourinary, or gastrointestinal bleeding and rarely with hemarthrosis. In this case report, we present the management of an uncommon case of acquired hemophilia A in a patient with metastatic prostate adenocarcinoma who presented with both hemarthrosis and soft tissue bleeding. Bleeding was controlled with recombinant factor VIIa, factor VIII bypassing agent, and immunosuppressive therapy with prednisone and rituximab. Chemotherapy with docetaxel was also promptly initiated to address the underlying condition and achieve long-term remission, which is currently ongoing for 10 months.
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Affiliation(s)
- Akeem Lewis
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Joe Joseph
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Nirmal Pathak
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Babak Baseri
- Department of Hematology and Oncology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Carol Luhrs
- Department of Hematology and Oncology, SUNY Downstate Medical Center, Brooklyn, NY, USA
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13
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Quantification of coagulation factor VIII in human plasma with liquid chromatography tandem mass spectrometry using a selective sample purification with camelid nanobodies. J Pharm Biomed Anal 2019; 175:112781. [PMID: 31398627 DOI: 10.1016/j.jpba.2019.112781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/20/2019] [Accepted: 07/17/2019] [Indexed: 01/26/2023]
Abstract
Patients with hemophilia A are currently diagnosed and monitored by measuring the activity of coagulation factor VIII (FVIII) in plasma mostly with the one-stage clotting assay (OSA). Although the OSA is routinely available in many clinical laboratories, it has in some circumstances relatively low sensitivity and specificity. Therefore, the FVIII activity as a biomarker does not always correlate with the bleeding phenotype. Therefore, we have developed a liquid chromatography tandem mass spectrometry method to quantify the concentration of coagulation FVIII in plasma which would allow us to investigate the relation between FVIII plasma concentration, FVIII activity and bleeding tendency in future studies. LC-MS/MS method was set up by firstly dissociation Von Willebrand factor (VWF) from coagulation factor VIII by triggering the coagulation cascade to occur thus generating active factor VIII (FVIIIa). FVIIIa was then selectively extracted by means of immunoaffinity interaction using anti-FVIII camelid nanobody, after which FVIIIa was eluted, heat denatured and trypsin digested. Finally, a FVIII specific peptide was used as a surrogate for quantification by mass spectrometry. Critical method parameters such as antibody amount, incubation time, sample volume and type of streptavidin 96 well plate were optimized. The method was validated according to European Medicines Agency (EMA) guidelines where an LLOQ of 1 ng/mL was obtained using 50 μL of citrate plasma sample. Within-run and between-run accuracy and precision for quality control (QC) samples, LLOQ (1 ng/mL), QC Low (5 ng/mL), QC Med (150 ng/mL), QC High (300 ng/mL) were within the threshold of 15% relative standard deviation (RSD) and Bias. The selective immunoaffinity method which was used in combination with a highly sensitive mass spectrometer allowed for an unpresented LLOQ of 1 ng/mL utilizing 50 μL plasma sample. This method will be used to investigate the beneficial value of FVIII plasma concentration which may be used in conjunction with FVIII activity for patient diagnosis and dosage optimization.
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14
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Acquired Hemophilia A (FVIII Deficiency) Associated with Papillary Thyroid Cancer: Treatment with Recombinant Porcine FVIII. Case Rep Hematol 2019; 2019:9026121. [PMID: 31559096 PMCID: PMC6735189 DOI: 10.1155/2019/9026121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 08/08/2019] [Indexed: 12/05/2022] Open
Abstract
Acquired hemophilia A (AHA) is a rare autoimmune disorder caused by autoantibodies against Factor VIII (FVIII). It has a high mortality due to bleeding complications. FVIIa-based bypassing agents are the first line of treatment but not always effective. Recombinant porcine (rp) FVIII (Obizur®) was recently approved for rescue treatment but with little evidence-based information regarding efficacy. We report a case of papillary thyroid cancer associated with AHA malignancy that responded to a single dose of rpFVIII after failure to achieve hemostasis with FVIIa-based bypassing products.
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15
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Saito M, Ogasawara R, Izumiyama K, Mori A, Kondo T, Tanaka M, Morioka M, Ieko M. Acquired hemophilia A in solid cancer: Two case reports and review of the literature. World J Clin Cases 2018; 6:781-785. [PMID: 30510943 PMCID: PMC6264993 DOI: 10.12998/wjcc.v6.i14.781] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/21/2018] [Accepted: 10/22/2018] [Indexed: 02/05/2023] Open
Abstract
Acquired hemophilia A (AHA) is a rare, hemorrhagic autoimmune disease, whose pathogenesis involves reduced coagulation factor VIII (FVIII) activity related to the appearance of inhibitors against FVIII. Common etiological factors include autoimmune diseases, malignancy, and pregnancy. We report two cases of AHA in solid cancer. The first case is a 63-year-old man who developed peritoneal and intestinal bleeding after gastrectomy for gastric cancer. He was diagnosed with AHA, and was treated with prednisone, followed by cyclophosphamide. In the second case, a 68-year-old man developed a subcutaneous hemorrhage. He was diagnosed with AHA in hepatocellular carcinoma on CT imaging, and treated with rituximab alone. Hemostasis was achieved for both patients without bypassing agents as the amount of inhibitors was reduced and eradicated. However, both patients died within 1 year due to cancer progression. Successful treatment for AHA in solid cancer can be difficult because treatment of the underlying malignancy is also required.
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Affiliation(s)
- Makoto Saito
- Department of Internal Medicine and Hematology, Aiiku Hospital, Sapporo 0640804, Japan
| | - Reiki Ogasawara
- Department of Internal Medicine and Hematology, Aiiku Hospital, Sapporo 0640804, Japan
| | - Koh Izumiyama
- Department of Internal Medicine and Hematology, Aiiku Hospital, Sapporo 0640804, Japan
| | - Akio Mori
- Department of Internal Medicine and Hematology, Aiiku Hospital, Sapporo 0640804, Japan
| | - Takeshi Kondo
- Department of Internal Medicine and Hematology, Aiiku Hospital, Sapporo 0640804, Japan
| | - Masanori Tanaka
- Department of Internal Medicine and Hematology, Aiiku Hospital, Sapporo 0640804, Japan
| | - Masanobu Morioka
- Department of Internal Medicine and Hematology, Aiiku Hospital, Sapporo 0640804, Japan
| | - Masahiro Ieko
- Department of Internal Medicine, Health Sciences University of Hokkaido, Toubetsu 0610293, Japan
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16
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A high titer of acquired factor V inhibitor in a hemodialysis patient who developed arterial thrombosis. Int J Hematol 2018; 109:214-220. [PMID: 30446942 DOI: 10.1007/s12185-018-2561-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 10/27/2022]
Abstract
An 87-year-old man with diabetes mellitus was admitted to control recurrent bleeding from hemodialysis puncture sites. He was a smoker and had been diagnosed with arteriosclerosis obliterans. His PT and APTT were markedly prolonged, and all coagulation factors were markedly decreased (factor V [FV] activity < 1%) or below the measurement threshold, with the exception of fibrinogen and factor XIII. Neither PT nor APTT were corrected upon mixing with normal plasma. A high titer of FV inhibitor was found at 415 BU/mL, and anti-FV autoantibody was detected by both immunoblot assay and ELISA. Prednisolone administration and plasma exchange partially improved prolonged PT and APTT and decreased the FV inhibitor level. Five months later, he manifested symptoms of severe ischemia in both legs. Angiography revealed diffuse stenosis downstream of both common iliac arteries. Endovascular therapy was repeated four times, the prednisolone dose was reduced, and low-dose antiplatelet therapy was initiated. After the final successful endovascular therapy, arterial thrombosis was detected using ultrasound and angiography. Aspiration thrombectomy and thrombolytic therapy failed to achieve recanalization, and necrosis of the legs worsened. Despite the severe coagulation abnormalities, vascular interventions should have been performed with regular-dose antiplatelet therapy, as the patient exhibited multiple risk factors for atherothrombosis.
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Charlebois J, Rivard GÉ, St-Louis J. Management of acquired hemophilia A: Review of current evidence. Transfus Apher Sci 2018; 57:717-720. [PMID: 30396835 DOI: 10.1016/j.transci.2018.10.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Acquired hemophilia A (AHA) is a rare acquired bleeding disorder caused by autoantibodies against autologous factor VIII (FVIII). It is a disease that most commonly affects the elderly, but it has been described in children and during the post-partum period. It is idiopathic in 50% of cases and is associated with autoimmune disease, malignancy, pregnancy, infection or certain medications in the other 50%. The diagnosis should be suspected in patients with an isolated prolonged aPPT without previous personal or familial bleeding history. Treating the bleeding and eradication of the inhibitor is the mainstay of treatment. The first line of treatment for acute bleeding is the use of bypassing agents. The most commonly used method for eradicating the inhibitor is immunosuppression, namely corticosteroids alone or in combination with cyclophosphamide. This review summarises current knowledge and reviews management options and guidelines.
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Affiliation(s)
- Janie Charlebois
- Division of Hematology/Oncology, Centre Hospitalier Universitaire Sainte-Justine, Department of Pediatrics, Université de Montréal, Montréal, Qc, Canada
| | - Georges-Étienne Rivard
- Division of Hematology/Oncology, Centre Hospitalier Universitaire Sainte-Justine, Department of Pediatrics, Université de Montréal, Montréal, Qc, Canada
| | - Jean St-Louis
- Division of Hematology/Oncology, Hôpital Maisonneuve-Rosemont, Department of Medicine, Université de Montréal, Montréal, Qc, Canada.
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Madeley J, Hodges G, Birchley A. Development of acquired haemophilia A in a patient treated with alemtuzumab for multiple sclerosis. BMJ Case Rep 2018; 2018:bcr-2018-226588. [PMID: 30337289 DOI: 10.1136/bcr-2018-226588] [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] [Indexed: 12/29/2022] Open
Abstract
This case illustrates a 36-year-old man who presented with a factor VIII (FVIII) inhibitor (acquired haemophilia A) with cutaneous bleeding and a significant thigh haematoma. No traditional risk factors for the development of a FVIII inhibitor were identified. However, previous treatment with alemtuzumab for multiple sclerosis was noted in the patient's history. Alemtuzumab is an anti-CD52 monoclonal antibody and is known to be associated with the development of a number of autoimmune conditions, with a delay in onset of these conditions as long as 5 years after the cessation of treatment. To our knowledge, there have only been three previously documented cases of a FVIII inhibitor in the setting of alemtuzumab therapy. This case adds further evidence to the current body of literature suggesting alemtuzumab as a causative agent for the development of an FVIII inhibitor.
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Affiliation(s)
- Jarrett Madeley
- Department of Haematology, Cairns Hospital, Cairns, Queensland, Australia
| | - Georgina Hodges
- Department of Haematology, Townsville Hospital, Townsville, Queensland, Australia
| | - Andrew Birchley
- Department of Haematology, Townsville Hospital, Townsville, Queensland, Australia
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Andreadis P, Kafantari K, Agapidou A, Vakalopoulou S, Vlachaki E. Successful Outcome of Severe Intra-cerebral Bleeding Associated with Acquired Factor V Inhibition: Utilization of Multiple Therapeutic Agents. Balkan Med J 2018; 35:112-115. [PMID: 28903884 PMCID: PMC5820439 DOI: 10.4274/balkanmedj.2017.0158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Acquired coagulation factor inhibitors are antibodies that either inhibit activity or increase the clearance of a clotting factor and lead to an increased risk of bleeding. Most of the time, the disorder is attributed to factor VIII inhibition (acquired haemophilia A); however, other coagulation factors could also be implicated. Case Report: Herein, we report an interesting case of a patient who underwent coronary artery bypass grafting and received antibiotic treatment after surgery with third generation cephalosporin. A month later, he presented with extreme bleeding diathesis and cerebral haemorrhage. Following a thorough clinical and laboratory investigation, an acquired factor V inhibitor was diagnosed. The patient received treatment with corticosteroids, intravenous immunoglobulins, anti-CD20 monoclonal antibodies (rituximab), cyclophosphamide and recombinant factor VIIa. Finally, despite the poor initial prognosis, the patient managed to achieve a full recovery. Conclusion: As there are no clear guidelines on acquired coagulation inhibitor treatment, reports of such cases could offer insight for future therapy choices. The case was unique because the treatment regimen included a combination of multiple therapeutic agents including rituximab.
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Affiliation(s)
- Panagiotis Andreadis
- Clinic of Internal Medicine, Ippokrateio General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Katerina Kafantari
- Clinic of Internal Medicine, Ippokrateio General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Aleka Agapidou
- Clinic of Hematology, Homerton University Hospital, Homerton Row, London
| | - Sofia Vakalopoulou
- Clinic of Internal Medicine, Ippokrateio General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Efthymia Vlachaki
- Clinic of Internal Medicine, Ippokrateio General Hospital of Thessaloniki, Thessaloniki, Greece
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20
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Cui QY, Wu TQ, Shen HS, Chen HF, Yu ZQ, Wang ZY. Refractory lupus nephropathy and acquired Factor VIII and IX deficiencies in a patient with systemic lupus erythematosus treated with rituximab. Haemophilia 2017; 23:e504-e506. [PMID: 28851067 DOI: 10.1111/hae.13232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Q-Y Cui
- Jiangsu Institute of Hematology, Key Lab of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - T-Q Wu
- The Department of Hematology, PLA 100th Hospital, Suzhou, China
| | - H-S Shen
- The Department of Hematology, PLA 100th Hospital, Suzhou, China
| | - H-F Chen
- The Department of Hematology, PLA 100th Hospital, Suzhou, China
| | - Z-Q Yu
- Jiangsu Institute of Hematology, Key Lab of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Z-Y Wang
- Jiangsu Institute of Hematology, Key Lab of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China
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21
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Napolitano M, Siragusa S, Mancuso S, Kessler CM. Acquired haemophilia in cancer: A systematic and critical literature review. Haemophilia 2017; 24:43-56. [PMID: 28960809 DOI: 10.1111/hae.13355] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2017] [Indexed: 12/12/2022]
Abstract
AIM There is a paucity of data on the clinical presentation and management of cancer patients with acquired haemophilia (AH), we here report a systematic literature review on acquired haemophilia in the context of cancer. METHODS Treatment outcomes of AH were defined as complete response (CR), partial response (PR) or no response (NR), based on inhibitor eradication, coagulation factor VIII levels and bleeding control. Reported deaths were either related to cancer or bleeding. RESULTS Overall, 105 cases were collected and analyzed according to classification of cancer and efficacy of treatments for inhibitor and malignancy. The mean age was 68 years for both males (range 37-86 years) and females (range 43-89 years), 39 patients were female subjects and 66 were males. A solid cancer was diagnosed in 60 subjects, while 45 patients suffered a haematological malignancy. Solid cancers affected mainly males; however, the incidence of solid tumours vs haematological malignancies was not statistically significant (P = .09). Not all patients were treated for their underlying cancer, bleeding and/or inhibitor, in two cases outcome is unavailable. CR was reported in 62.1% (64/103) cases, PR in 9.7% (10/103) cases, NR with or without death was reported in 28.1% (29/103) cases. CONCLUSION CR was best achieved when successful and complete elimination of autoantibodies occurred contemporaneously with the successful treatment of the underlying malignancy. In some cases, recurrent autoantibodies were harbingers of relapsed cancer. Type of cancer, inhibitor titer, treatments administered for bleeding control and inhibitor eradication did not significantly affect clinical outcome of analyzed cases.
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Affiliation(s)
- M Napolitano
- Hematology Unit, Thrombosis and Hemostasis Reference Regional Center, Università degli studi di Palermo, Palermo, Italy
| | - S Siragusa
- Hematology Unit, Thrombosis and Hemostasis Reference Regional Center, Università degli studi di Palermo, Palermo, Italy
| | - S Mancuso
- Hematology Unit, Thrombosis and Hemostasis Reference Regional Center, Università degli studi di Palermo, Palermo, Italy
| | - C M Kessler
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
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22
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Ioannou P, Tsagkaraki E, Tsioutis C, Devetzoglou M, Xylouri I, Gikas A, Panagiotakis S. A case of severe unprovoked hemorrhage in an elderly male: a case report. Clin Case Rep 2017; 5:1159-1161. [PMID: 28680617 PMCID: PMC5494408 DOI: 10.1002/ccr3.1029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 05/10/2017] [Indexed: 11/29/2022] Open
Abstract
Acquired hemophilia is a rare but potentially fatal clinical condition requiring clinical suspicion to reach to a diagnosis, especially in elder patients. This diagnosis should be suspected in patients that present with unexplained persistent bleeding from skin, soft tissues, and mucosa and have a prolonged aPTT.
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Affiliation(s)
- Petros Ioannou
- Internal Medicine Department; University Hospital of Heraklion; Heraklion Crete Greece
| | - Emmanouela Tsagkaraki
- Internal Medicine Department; University Hospital of Heraklion; Heraklion Crete Greece
| | - Constantinos Tsioutis
- Internal Medicine Department; University Hospital of Heraklion; Heraklion Crete Greece
| | - Maria Devetzoglou
- Hematology Department; University Hospital of Heraklion; Heraklion Crete Greece
| | - Irene Xylouri
- Hematology Department; University Hospital of Heraklion; Heraklion Crete Greece
| | - Achilleas Gikas
- Internal Medicine Department; University Hospital of Heraklion; Heraklion Crete Greece
| | - Symeon Panagiotakis
- Internal Medicine Department; University Hospital of Heraklion; Heraklion Crete Greece
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23
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Mitchell JL, Wright S, Kazi S, Watson HG, Mutch NJ. Defective α 2 antiplasmin cross-linking and thrombus stability in a case of acquired factor XIII deficiency. Br J Haematol 2017; 178:794-799. [PMID: 28516512 DOI: 10.1111/bjh.14759] [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: 01/25/2017] [Accepted: 03/20/2017] [Indexed: 12/01/2022]
Abstract
Acquired factor XIII (FXIII) deficiency is a rare and life-threatening condition that is often misdiagnosed or missed completely. A 72-year-old woman presented with symptoms of major unprovoked bleeding but routine coagulation screening tests and platelet count were normal. Low activated FXIII (FXIIIa) activity levels and abnormal urea clot stability led to diagnosis of acquired FXIII deficiency. A modified Bethesda inhibitor titre of 1.6 Bethesda units/ml indicated the presence of a FXIII inhibitor. Bleeding responded to a single dose of FXIII concentrate and immunosuppression with prednisolone induced remission. A subsequent relapse was treated with combined prednisolone and Rituximab resulting in a prolonged, ongoing remission. Here we analyse the mechanisms underlying this idiopathic case of acquired FXIII deficiency. Prospective analysis of patient plasma revealed minimal FXIIIa activity and antigen in presentation and relapse samples. Thrombi formed from these samples lysed rapidly and showed an absence of cross-linked α2 AP. Western blotting revealed the presence of FXIII-B, indicating only FXIII-A and FXIII-A2 B2 were affected. FXIII activity and antigen levels normalised on remission. Our data suggest the presence of inhibitor-induced clearance of FXIII from plasma. As a consequence, reduced thrombus stability was evident due to defective α2 AP cross-linking, thereby explaining symptoms of excessive bleeding.
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Affiliation(s)
| | - Sonja Wright
- Department of Haematology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Sajida Kazi
- Department of Haematology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Henry G Watson
- Department of Haematology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Nicola J Mutch
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
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25
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Abstract
Objective: To review published literature evaluating the use of rituximab for treatment of acquired hemophilia. Data Sources: An English-language literature search was conducted using MEDLINE (1966–January 2006). References of identified articles were subsequently reviewed for additional data. Search terms included rituximab, acquired hemophilia, and inhibitors. Data Synthesis: Available data suggest that B-cell depletion by rituximab in patients with acquired hemophilia may contribute to the eradication of inhibitors to coagulation factors. B-cells have been shown to be essential in the development of autoimmunity or an acquired immune response. Beneficial effects of rituximab, after failure of established therapies, have been reported in case reports and one small, open-label trial. Conclusions: Although data are limited, administration of rituximab appears to be an effective option for treatment of patients with acquired hemophilia after established therapies have failed. Patients given rituximab experienced cessation of recurrent bleeding, normalization of factor VIII activity, and eradication of inhibitors. A complete response to rituximab (undetectable inhibitors, normalization of factor levels) generally occurred several weeks to months after initiation of therapy.
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Affiliation(s)
- Joan M Stachnik
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois Medical Center at Chicago, 60612-7229, USA.
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26
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Sheth C, Gill A, Sekhon S. Life-threatening hemorrhage from acquired hemophilia A as a presenting manifestation of prostate cancer. J Community Hosp Intern Med Perspect 2016; 6:32461. [PMID: 27609734 PMCID: PMC5016740 DOI: 10.3402/jchimp.v6.32461] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 07/14/2016] [Accepted: 07/15/2016] [Indexed: 11/21/2022] Open
Abstract
Acquired factor VIII deficiency (acquired hemophilia A) is a rare condition characterized by the acquisition of autoantibodies that affect the clotting activity of factor VIII (fVIII). The most common manifestation in affected patients is a hemorrhagic diathesis. This disorder is associated with autoimmune diseases, pregnancy, postpartum period, drugs, and malignancy. Management of this condition begins with attempts to arrest an acute bleed based on the site and severity of bleeding and inhibitor titer. The next priority is eradication of the fVIII antibodies using immunosuppressive therapies. We report the case of a 66-year-old male who presented with spontaneous right thigh hematoma with prolonged activated partial prothrombin time and normal prothrombin time. Mixing studies confirmed the presence of an inhibitor. Further investigation for the underlying etiology of acquired hemophilia A leads to diagnosis of prostate cancer. Treatment consisted of bypassing agents including activated factor VII and activated prothrombin plasma concentrate to arrest the bleeding. Steroids and cyclophosphamide were added to suppress the fVIII inhibitors. Concomitant treatment of locally advanced prostate cancer with chemotherapy confirmed the eradication of the inhibitors. To our knowledge, this is the first reported case of prostate cancer diagnosed and treated simultaneously with acquired hemophilia A resulting in favorable patient outcome.
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Affiliation(s)
- Chirag Sheth
- Department of Internal Medicine, San Joaquin General Hospital, French Camp, CA, USA;
| | - Amandeep Gill
- Department of Internal Medicine, San Joaquin General Hospital, French Camp, CA, USA
| | - Sumeet Sekhon
- Department of Internal Medicine, San Joaquin General Hospital, French Camp, CA, USA
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27
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Linenberger ML, Price TH. Use of Cellular and Plasma Apheresis in the Critically Ill Patient: Part II: Clinical Indications and Applications. J Intensive Care Med 2016; 20:88-103. [PMID: 15855221 DOI: 10.1177/0885066604273479] [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: 11/16/2022]
Abstract
Apheresis is the process of separating the blood and removing or manipulating a cellular or plasma component for therapeutic benefit. Such procedures may be indicated in the critical care setting as primary or adjunctive therapy for certain hematologic, neurologic, renal, and autoimmune/rheumatologic disorders. In part I of this series, the technical aspects of apheresis were described and the physiologic rationale and clinical considerations were discussed. This review highlights the pathophysiologic basis, specific clinical indications, and treatment parameters for disorders that more commonly require management in the intensive care unit. The choice of plasma or cellular apheresis in these cases is guided by wellaccepted, evidence-based clinical treatment guidelines. For some disorders, such as liver failure, severe sepsis, and multiple-organ dysfunction syndrome, apheresis treatment approaches remain experimental. Ongoing studies are investigating the potential utility of conventional plasma exchange, ex vivo plasma manipulation, and newer technologies for these and other disorders in severely ill patients.
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Affiliation(s)
- Michael L Linenberger
- Apheresis and Cellular Therapy, Seattle Cancer Care Alliance, Seattle, WA 98109, USA.
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28
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See A, Sudirman SR, Huang XY. Spontaneous multilevel airway haemorrhage in acquired haemophilia A. Eur Arch Otorhinolaryngol 2016; 274:2657-2660. [DOI: 10.1007/s00405-016-4251-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 08/05/2016] [Indexed: 11/24/2022]
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29
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Autoimmune acquired factor XIII deficiency due to anti-factor XIII/13 antibodies: A summary of 93 patients. Blood Rev 2016; 31:37-45. [PMID: 27542511 DOI: 10.1016/j.blre.2016.08.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/14/2016] [Accepted: 08/02/2016] [Indexed: 11/22/2022]
Abstract
Autoimmune acquired factor XIII (F13) deficiency or autoimmune hemophilia-like disease (hemorrhaphilia) resulted from the generation of anti-F13 antibodies (AH13) is a severe bleeding disorder that occurs mainly in the elderly. Although rare, the number of patients diagnosed with AH13 has recently increased. To improve understanding of this disease, the author summarized 93 ever reported/diagnosed AH13 cases. About 50% of cases were idiopathic. In the remaining half of the patients, autoimmune diseases and malignancies were the most common underlying diseases. Intramuscular and subcutaneous bleeding were the most frequently reported symptoms. Hemorrhage was the cause of death in 13 patients. In 4 patients, the diagnosis was established after hemorrhagic death. Therefore, physicians/hematologists must raise the awareness of AH13 as a life-threatening disease. Most patients were treated with F13 concentrates to arrest bleeding and with prednisolone and cyclophosphamide to eradicate anti-F13 autoantibodies. AH13 cases tend to become chronic and intractable and require close follow-up over an extended period.
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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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31
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Zeng Y, Zhou R, Duan X, Long D. Rituximab for eradicating inhibitors in people with acquired haemophilia A. Cochrane Database Syst Rev 2015. [DOI: 10.1002/14651858.cd011907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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32
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Acquired inhibitors of clotting factors: AICE recommendations for diagnosis and management. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 13:498-513. [PMID: 26192778 DOI: 10.2450/2015.0141-15] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Tana M, Tana C, Amerio P, Vitullo G, di Giosia P, di Febbo C, Davì G. Severe non-traumatic bleeding, the answer is not in the blood. Intern Emerg Med 2015; 10:461-4. [PMID: 25716205 DOI: 10.1007/s11739-015-1210-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 02/05/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Marco Tana
- Internal Medicine Unit, Department of Medicine and Science of Aging, "G. d'Annunzio" University, Chieti, Italy,
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34
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Ichinose A, Osaki T, Souri M. Clinical features of 32 new Japanese cases with autoimmune haemorrha-philia due to anti-factor XIII antibodies. Haemophilia 2015; 21:653-8. [DOI: 10.1111/hae.12677] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2015] [Indexed: 11/30/2022]
Affiliation(s)
- A. Ichinose
- Department of Molecular Patho-Biochemistry and Patho-Biology; Yamagata University School of Medicine; Yamagata Japan
| | - T. Osaki
- Department of Molecular Patho-Biochemistry and Patho-Biology; Yamagata University School of Medicine; Yamagata Japan
| | - M. Souri
- Department of Molecular Patho-Biochemistry and Patho-Biology; Yamagata University School of Medicine; Yamagata Japan
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O'Connor CR. Systematic review of the presentation of coagulation factor VIII inhibitors in rheumatic diseases: A potential cause of life-threatening hemorrhage. Semin Arthritis Rheum 2015; 44:695-709. [PMID: 25595725 DOI: 10.1016/j.semarthrit.2014.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 11/22/2014] [Accepted: 11/28/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To provide a comprehensive review regarding the clinical presentation of acquired factor VIII (FVIII) inhibitors, also known as "acquired hemophilia," in patients with rheumatic diseases. METHODS A systematic MEDLINE search was conducted to identify English-language articles published from 1993 through January 10, 2012, providing details regarding the clinical presentation, laboratory evaluation, and management of a patient(s) with newly or previously diagnosed autoimmune disease coexistent with an acquired FVIII inhibitor. RESULTS In total, 49 patients fulfilled the criteria for inclusion in the review; the greatest percentage (24.5%) had systemic lupus erythematosus, followed by rheumatoid arthritis (16%). The majority (78%) presented with spontaneous mucocutaneous or muscular bleeding. Prolonged activated partial thromboplastin time (aPTT) was identified in all of the 45 patients for whom results were provided. Five patients presented with an asymptomatic prolonged aPTT, which was attributed to a lupus anticoagulant in two patients, only one of whom actually had a coexisting lupus anticoagulant. Invasive procedures led to serious bleeding in both of these patients, one of whom died as a result. The majority (59%) of patients experienced complete or partial remission of their inhibitors, most (96%) after systemic eradicative therapy. A total of three (6%) patients died as a direct result of FVIII inhibitors. CONCLUSIONS Although acquired FVIII inhibitors are rare in patients with autoimmune diseases, prompt diagnosis is essential to avoid extensive bleeding, which could be life threatening. Treatment requires eradication of the factor inhibitors. Rheumatologists must be able to distinguish acquired FVIII inhibitors from lupus anticoagulants.
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Affiliation(s)
- Carolyn Riester O'Connor
- Division of Rheumatology, Drexel University College of Medicine, 245 N. 15th St, Philadelphia, PA 19102.
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Mulliez SMN, Vantilborgh A, Devreese KMJ. Acquired hemophilia: a case report and review of the literature. Int J Lab Hematol 2014; 36:398-407. [PMID: 24750687 DOI: 10.1111/ijlh.12210] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Accepted: 02/24/2014] [Indexed: 11/27/2022]
Abstract
Acquired hemophilia A (AHA) is a rare bleeding disorder caused by autoantibodies against clotting factor VIII (FVIII). FVIII autoantibody is characterized as polyclonal immunoglobulin G directed against the FVIII procoagulant activity. This disease occurs most commonly in the elderly population and with preponderance of men in nonpregnancy-related AHA. There are well-established clinical associations with AHA such as malignancy, other autoimmune diseases and pregnancy. However, up to 50% of reported cases remain idiopathic. The clinical manifestation of AHA includes mostly spontaneous hemorrhages into skin, muscles and soft tissues, or mucous membranes. AHA should be suspected when a patient with no previous history of bleeding presents with bleeding and an unexplained prolonged activated partial thromboplastin time. The diagnosis is confirmed in the laboratory by the subsequent identification of reduced FVIII levels and FVIII inhibitor titration. There is a high mortality, making prompt diagnosis and treatment vitally important. The principles of treatment consist in controlling the bleeding and eradicating the inhibitor. Because of the overall high relapse rate (15-33%), it is also recommended to follow up these patients. The review summarizes what is currently known about the epidemiology, pathogenesis, clinical features, diagnosis, treatment and prognosis of AHA and starts with a case report.
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Affiliation(s)
- S M N Mulliez
- Coagulation Laboratory, Department of Clinical Chemistry, Microbiology and Immunology, Ghent University Hospital, Ghent, Belgium
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Zeng Y, Zhou R, Duan X, Long D, Yang S. Interventions for treating acute bleeding episodes in people with acquired hemophilia A. Cochrane Database Syst Rev 2014; 2014:CD010761. [PMID: 25165992 PMCID: PMC8078231 DOI: 10.1002/14651858.cd010761.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Acquired hemophilia A is a rare bleeding disorder caused by autoantibodies to coagulation factor VIII (FVIII). In most cases, bleeding episodes are spontaneous and severe at presentation. The optimal hemostatic therapy is controversial. OBJECTIVES To determine the efficacy of hemostatic therapies for acute bleeds in people with acquired hemophilia A; and to compare different forms of therapy for these bleeds. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 4) and MEDLINE (Ovid) (1948 to 30 April 2014). We searched the conference proceedings of the: American Society of Hematology; European Hematology Association; International Society on Thrombosis and Haemostasis (ISTH); and the European Association for Haemophilia and Allied Disorders (EAHAD) (from 2000 to 30 April 2014). In addition to this we searched clinical trials registers. SELECTION CRITERIA All randomised controlled trials and quasi-randomised trials of hemostatic therapies 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 hemostatic therapies for acquired hemophilia A were found. Thus, we are not able to draw any conclusions or make any recommendations on the optimal hemostatic therapies for acquired hemophilia A based on the highest quality of evidence. GIven that carrying out randomized controlled trials in this field is a complex task, the authors suggest that, while planning randomised controlled trials in which patients can be enrolled, clinicians treating the disease continue to base their choices on alternative, lower quality sources of evidence, which hopefully, in the future, will also be appraised and incorporated in a Cochrane Review.
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Affiliation(s)
- Yan Zeng
- Department of Hematology, General Hospital of Chengdu Military Region, 270#, Rongdu Da Dao, Chengdu, Sichuan, China, 610083
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Jentzsch T, Brand-Staufer B, Schäfer FP, Wanner GA, Simmen HP. Illustrated operative management of spontaneous bleeding and compartment syndrome of the lower extremity in a patient with acquired hemophilia A: a case report. J Med Case Rep 2014; 8:132. [PMID: 24886030 PMCID: PMC4109126 DOI: 10.1186/1752-1947-8-132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 02/03/2014] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Spontaneous bleeding resulting in compartment syndrome at the lower adult leg due to acquired hemophilia A is rare. There are no reports on operative management of this entity. CASE PRESENTATION We present a case of atraumatic compartment syndrome of the lower leg due to acquired factor VIII deficiency, in an 83-year-old Caucasian man of European descent. He was treated surgically with a long and complicated postoperative course after presenting to a community hospital with a 2-day history of increasing pain and swelling in his left lower leg without a previous history of trauma. CONCLUSIONS Awareness, prompt diagnosis and effective treatment of compartment syndrome caused by a rare bleeding disorder, which is usually acquired by the elderly, is essential and may spare a patient from surgery or even limb loss, if early administration of recombinant factor VIIa is effective. The course of disease in a patient with operative management of spontaneous bleeding, compartment syndrome and acquired hemophilia A may be prolonged. However, an interdisciplinary approach with meticulous surgical treatment and bleeding management with recombinant factor VIIa as well as inhibitor eradication by immunosuppressive treatment can be successful and expensive.
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Affiliation(s)
- Thorsten Jentzsch
- Division of Trauma Surgery, Department of Surgery, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland.
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McCain S, Gull S, Ahmad J, Carey D. Acquired hemophilia A as a cause of acute upper gastrointestinal hemorrhage. BMJ Case Rep 2014; 2014:bcr-2013-203179. [PMID: 24501339 DOI: 10.1136/bcr-2013-203179] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 71-year-old man presented to the emergency department with his first episode of hematemesis. He was anemic and coagulopathic on admission, and became hemodynamically unstable requiring surgical intervention to control the bleeding. Prior to surgery, he required 100% plasma exchange with human plasma derived prothrombin complex concentrate (Octaplex) as the exchange fluid. At induction of anesthesia, he received tranexamic acid, prothrombin complex concentrate, and platelets. At the time of knife to skin, he was given coagulation factor VIIa intravenously as a bolus. This treatment was on the recommendation of the hematology team who suspected a diagnosis of acquired hemophilia on the basis of his history and coagulation screen. His bleeding was controlled and a diagnosis of acquired hemophilia A was confirmed in the postoperative period. This was managed with immunosuppressive therapy, and at the 2 year follow-up he remains well and is off all treatment.
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Barbara DW, McKenzie KM, Parikh SA, Ashrani AA, Pruthi RK, Burkhart HM, Suri RM, Mauermann WJ. Successful Perioperative Management of Severe Bleeding From Undiagnosed Acquired Factor VIII Inhibitors. J Cardiothorac Vasc Anesth 2014; 29:731-4. [PMID: 24462516 DOI: 10.1053/j.jvca.2013.10.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Indexed: 11/11/2022]
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Ilkhchoui Y, Koshkin E, Windsor JJ, Petersen TR, Charles M, Pack JD. Perioperative management of acquired hemophilia a: a case report and review of literature. Anesth Pain Med 2013; 4:e11906. [PMID: 24660144 PMCID: PMC3961036 DOI: 10.5812/aapm.11906] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 06/15/2013] [Accepted: 06/22/2013] [Indexed: 11/16/2022] Open
Abstract
Introduction: Acquired hemophilia A is a rare bleeding disorder with a high mortality rate. Diagnosis and treatment of this disorder can be very challenging to anesthesiologists because of lack of a personal or familial abnormal bleeding history. Case presentation: We report a 60-year-old woman who presented to the operating room for an urgent fasciotomy. She was initially diagnosed to have compartment syndrome of her left upper extremity secondary to an expanding hematoma after multiple unsuccessful venipuncture attempts. After surgical intervention, she developed recurrent intramuscular hematomas, became severely anemic, and required surgical re-exploration and multiple blood product transfusions. Ultimately, she was found to have an elevated activated partial thromboplastin time (aPTT), very low FVIII activity, and high FVIII inhibitor titers consistent with the diagnosis of acquired hemophilia A. Conclusions: Treatment strategies in acquired hemophilia are based on two major objectives. During the acute stage, effective control of bleeding is critical. The ultimate therapeutic goal during the subacute phase is the elimination of the inhibitors targeting factor VIII. Here, we present this case and will review current literature regarding therapeutic approaches to this rare condition in the operating room setting and postoperative course.
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Affiliation(s)
- Yashar Ilkhchoui
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, University of New Mexico, Albuquerque, USA
- Corresponding author: Yashar Ilkhchoui, Department of Anesthesiology and Critical Care Medicine, School of Medicine, University of New Mexico, Albuquerque, NM, USA. Tel: +1-5052722610, Fax: +1-5052721300, E-mail:
| | - Eugene Koshkin
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, University of New Mexico, Albuquerque, USA
| | - Jimmy J Windsor
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, University of New Mexico, Albuquerque, USA
| | - Timothy R Petersen
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, University of New Mexico, Albuquerque, USA
| | - Matthew Charles
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, University of New Mexico, Albuquerque, USA
| | - Jeffery D Pack
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, University of New Mexico, Albuquerque, USA
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Lambing AY. Unexpected hemorrhage: an unusual and potentially catastrophic clinical challenge. J Am Assoc Nurse Pract 2013; 25:342-50. [PMID: 24170617 DOI: 10.1111/j.1745-7599.2012.00807.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Unexpected bleeding or hemorrhage related to the development of acquired factor VIII inhibitors is an emerging clinical challenge in patients. Symptoms can occur suddenly with bleeding and/or bruising that is excessive relative to the degree of injury or severity of a comorbid condition. Diagnosis is difficult, and bleeding can quickly become life threatening if not treated promptly. This review provides current information, using a patient case scenario, to improve awareness and recognition of patients presenting unexpectedly with excessive bleeding of unknown etiology. DATA SOURCES To complete this review, a search of English-language publications was conducted using Medline and CINAHL databases (1966-2010). CONCLUSIONS Although development of acquired factor VIII inhibitors is rare, its incidence is increasing in many different patient care settings. Improved awareness and recognition is needed to mitigate the significant patient morbidity and mortality that can occur without rapid and timely treatment by experienced hematology specialists. IMPLICATIONS FOR PRACTICE Nurse practitioners, as front-line clinicians treating patients in various therapeutic areas, may be the first healthcare professionals who see patients with this disorder. Increased knowledge and awareness of this rare but potentially catastrophic cause of excessive bleeding can improve prompt treatment and optimize patient outcomes.
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Affiliation(s)
- Angela Y Lambing
- Department of Hematology and Oncology, Hemophilia and Thrombosis Treatment Center, Henry Ford Health System, Detroit, Michigan
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Abstract
Acquired hemophilia is a rare disorder with an estimated annual incidence of 0.2-1 cases per million individuals. The etiology of the disorder remains obscure, although approximately half of all cases are associated with other underlying conditions. In acquired hemophilia, the severe hemorrhagic diathesis is caused by the development of autoantibodies directed against a clotting factor, most commonly factor VIII. These autoantibodies inhibit normal coagulation and lead to bleeding complications, which can be life-threatening in a high percentage of cases. Prompt diagnosis and appropriate management of the disorder enable effective control; the short- and long-term aims of therapy are to terminate the acute bleed and eliminate or reduce the inhibitor, respectively. Immune tolerance therapy has been shown to successfully eradicate or suppress inhibitors in patients with congenital hemophilia A and may be applicable to patients with acquired hemophilia. Here we present preliminary data on the use of immune tolerance therapy in patients with acquired hemophilia and discuss possible treatment strategies.
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Affiliation(s)
- Mario von Depka
- Department of Hematology, Haemostasis and Oncology, Hannover Medical School, Germany.
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Sborov DW, Rodgers GM. How I manage patients with acquired haemophilia A. Br J Haematol 2013; 161:157-65. [DOI: 10.1111/bjh.12228] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Douglas W. Sborov
- Division of Hematology and Oncology; Ohio State University Medical Center; The Arthur G. James Comprehensive Cancer Center; Columbus; OH; USA
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Aggressive fatal case of autoimmune hemorrhaphilia resulting from anti-Factor XIII antibodies. Blood Coagul Fibrinolysis 2013. [DOI: 10.1097/mbc.0b013e328358e8e7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Duodenal tumor presenting as acquired hemophilia in an 88-year-old woman: a clinical case and review of the literature. Case Rep Gastrointest Med 2012; 2012:203801. [PMID: 22966469 PMCID: PMC3432527 DOI: 10.1155/2012/203801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 07/30/2012] [Indexed: 11/17/2022] Open
Abstract
Acquired hemophilia is a rare disease, presenting with severe hemorrhage, we present a case caused by a duodenal tumor, the clinical management, ethical implications, treatment recommendations, and a review of the literature.
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Factor XIII is a key molecule at the intersection of coagulation and fibrinolysis as well as inflammation and infection control. Int J Hematol 2012; 95:362-70. [PMID: 22477542 DOI: 10.1007/s12185-012-1064-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 03/20/2012] [Accepted: 03/20/2012] [Indexed: 10/28/2022]
Abstract
Factor XIII (FXIII) is a transglutaminase consisting of two catalytic A subunits (FXIII-A) and two non-catalytic B subunits (FXIII-B) in plasma. FXIII-B protects FXIII-A from its clearance. FXIII-A is also present as a homodimer inside megakaryocytes/platelets and monocytes/macrophages. Although possible functions of intracellular FXIII-A have been proposed, these remain to be established. Intra- and extra-cellular FXIIIs support platelet adhesion and spreading as well as clot retraction, suggesting that FXIII is important for the stabilization of platelet-fibrin clots. Intra- and extra-cellular FXIIIs also support immobilization and killing of bacteria as well as phagocytosis by macrophages. Thus, FXIII may function in innate immunity. Congenital FXIII deficiency due to defective F13-A genes manifests as a life-long bleeding tendency, abnormal wound healing, and recurrent miscarriage. Although congenital FXIII-B deficiency used to be thought rare, reports of such cases have increased recently. As the bleeding tendency is often mild, patients with FXIII-B deficiency may be overlooked by physicians. Patients with acquired FXIII deficiency, in particular those with autoimmune hemorrhaphilia due to anti-FXIII antibodies, are on the increase, at least in Japan. It is important to diagnose such cases as early as possible, and to treat them with immunosuppression in combination with FXIII replacement therapy as their bleeding symptoms can be life-threatening.
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Riachy MA, Nasr F, Azar R. Acquired haemophilia secondary to ivabradine presenting with acute respiratory distress syndrome. BMJ Case Rep 2012; 2012:bcr.01.2012.5506. [PMID: 22604198 DOI: 10.1136/bcr.01.2012.5506] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The authors present the case of a 72-year-old patient who presented with severe dyspnoea, scant haemoptysis, pronounced desaturation and bilateral haematomas on the upper limbs. Chest radiography showed bilateral infiltrates mainly in the lower lobes. The patient's prothrombin time, and platelet count were normal. However, the activated partial thromboplastin time showed a prolongation that was not reversed on a correction study. Factor VIII (FVIII) levels were very low and evidence of FVIII inhibitor was found. The patient had started taking ivabradine 2 months earlier, and the diagnosis of idiosyncratic acquired haemophilia was established. The patient was treated with volume expansion therapy, high levels of oxygen, multiple transfusions, methylprednisolone, desmopressine and rituximab. On the 3rd day, the patient showed progressive amelioration of his dyspnoea, oxygen needs and chest infiltrates. On the 7th day, the patient was discharged.
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Affiliation(s)
- Moussa Albert Riachy
- Pulmonary and Critical Care Department, Hotel Dieu de France Hospital, Beirut, Lebanon.
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Mogili S, Woodlock T. A large spontaneous abdominal bruise in a 60-year-old woman: a case report. Med Princ Pract 2012; 21:86-8. [PMID: 22024936 DOI: 10.1159/000331808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Accepted: 04/05/2011] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To report a case of severe abdominal bruising successfully diagnosed using systematic hemostatic investigations. CLINICAL PRESENTATION AND INTERVENTION A 60-year-old woman developed a large spontaneous nontraumatic, painless bruise over the right lower abdominal wall. Computed tomographic scan of the abdomen showed a subcutaneous hematoma beneath the site of the obvious bruise diagnosed as a hematoma. Laboratory tests revealed an activated partial thromboplastin time of 53 s and a factor VIII level of <1%, consistent with the diagnosis of acquired hemophilia A. The patient was treated with steroids and immunosuppressants and her factor VIII levels gradually normalized. CONCLUSION This case report showed that whenever there is spontaneous bruising, factor VIII deficiency should be considered as one of the important differential diagnosis.
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Affiliation(s)
- Sujatha Mogili
- Department of Medicine, Unity Health System, 1555 Long Pond Rd., Rochester, NY 14626, USA.
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Gao Y, Liu S, Ma G, Lv L, Su Y. Efficacy of low-dose rituximab in a refractory acquired factor VIII inhibitor case secondary to pemphigus. Acta Haematol 2012; 127:20-2. [PMID: 21996575 DOI: 10.1159/000330951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 07/18/2011] [Indexed: 11/19/2022]
Abstract
Acquired factor VIII (FVIII) inhibitor induces a bleeding disorder caused by specific antibodies to FVIII. The cause of approximately one fifth of cases can be attributed to autoimmune disorders, such as pemphigus. Here, we describe a case of refractory acquired FVIII inhibitor in a patient with primary pemphigus and its successful treatment with low-dose rituximab. Coagulation studies revealed a prolonged activated partial thromboplastin time, which could not be corrected with the mixing test. At the same time, the FVIII activity level was significantly reduced, and the FVIII inhibitor titer was elevated. A treatment regimen with prednisolone/cyclophosphamide followed by prednisolone/cyclosporine was used. The patient temporarily responded but then became resistant to these medicines. However, subsequent treatment with low-dose rituximab achieved considerable clinical and laboratory improvement in the same patient. Follow-up at 6 months revealed a low level of residual FVIII inhibitor activity with normal coagulation functions. No drug-related side effects were detected. In conclusion, our results indicate that low-dose rituximab might be an effective and safe treatment for patients with acquired FVIII inhibitor.
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Affiliation(s)
- Yujuan Gao
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, China
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