1
|
Ragavan N, Jayaraman D, Suman FR, Pandian N, Scott JX. Successful management of an adolescent male with acquired hemophilia-A with intracranial bleeding using emicizumab. Pediatr Blood Cancer 2024; 71:e31083. [PMID: 38753381 DOI: 10.1002/pbc.31083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 04/30/2024] [Accepted: 05/03/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Niranjan Ragavan
- Department of Pediatrics, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Dhaarani Jayaraman
- Department of Pediatric Hematology & Oncology, FNB Pediatric Hemato-Oncology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Febe Renjitha Suman
- Department of Pathology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Nidarshana Pandian
- Department of Pediatrics, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Julius Xavier Scott
- Department of Pediatric Hematology & Oncology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| |
Collapse
|
2
|
Almomen AM, Alzahrani HA, AlSaeed HH, AlAseri Z, Mady AF, Owaidah T. Saudi expert consensus on acquired hemophilia A diagnosis and management. J Taibah Univ Med Sci 2024; 19:566-574. [PMID: 38736896 PMCID: PMC11087233 DOI: 10.1016/j.jtumed.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 03/05/2024] [Accepted: 04/16/2024] [Indexed: 05/14/2024] Open
Abstract
Objectives Acquired hemophilia affects approximately one in 1 million people. Timely diagnosis is key to appropriate disease management and the prevention of life-threatening complications. Patients with this condition may initially be seen by inexperienced physicians and remain underdiagnosed for several years. This consensus statement is aimed at providing guidelines for all practitioners in the Kingdom of Saudi Arabia (KSA) to diagnose and manage acquired hemophilia A. Methods This consensus statement reflects the opinions drafted by a group of hematology specialists, who used an explicit systematic process to identify areas of agreement and disagreement. Results This consensus statement provides a guide for all practitioners in the KSA regarding the diagnosis of clinical presentation, relevance, characteristics of bleeding symptoms, and case management; it additionally provides guidance for non-specialists. All management aspects, including diagnosis and treatment modalities, are discussed. Conclusions Patients with acquired hemophilia may initially be seen by physicians who lack appropriate expertise in diagnosing and managing this condition. This consensus statement from the premier experts on the disease in the KSA provides details for diagnosing and managing acquired hemophilia.
Collapse
Affiliation(s)
| | - Hazza A. Alzahrani
- Adult Hematology/HSCT, Oncology Centre, King Faisal Specialist Hospital and Research Center, Riyadh, KSA
| | - Hussein H. AlSaeed
- Department of Hematology, Qatif Central Hospital, Qatif Health Network, East Cluster Ministry of Health, KSA
| | - Zohair AlAseri
- Departments of Emergency Medicine and Critical Care, College of Medicine, King Saud University, Riyadh, KSA
- Department of Clinical Sciences, College of Medicine and Riyadh Hospital, Dar Al Uloom University, Riyadh, KSA
- Therapeutic Deputyship, Ministry of Health, Riyadh, KSA
| | - Ahmed F. Mady
- ICU, King Saud Medical City, Riyadh, KSA
- Department of Anesthesiology and ICU, Tanta University Hospital, Egypt
| | - Tarek Owaidah
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, KSA
- Alfaisal University, Riyadh, KSA
| |
Collapse
|
3
|
Giordano L, Cacciola R, Barone P, Vecchio V, Nasso ME, Alvaro ME, Gangemi S, Cacciola E, Allegra A. Autoimmune Diseases and Plasma Cells Dyscrasias: Pathogenetic, Molecular and Prognostic Correlations. Diagnostics (Basel) 2024; 14:1135. [PMID: 38893662 PMCID: PMC11171610 DOI: 10.3390/diagnostics14111135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 05/23/2024] [Accepted: 05/27/2024] [Indexed: 06/21/2024] Open
Abstract
Multiple myeloma and monoclonal gammopathy of undetermined significance are plasma cell dyscrasias characterized by monoclonal proliferation of pathological plasma cells with uncontrolled production of immunoglobulins. Autoimmune pathologies are conditions in which T and B lymphocytes develop a tendency to activate towards self-antigens in the absence of exogenous triggers. The aim of our review is to show the possible correlations between the two pathological aspects. Molecular studies have shown how different cytokines that either cause inflammation or control the immune system play a part in the growth of immunotolerance conditions that make it easier for the development of neoplastic malignancies. Uncontrolled immune activation resulting in chronic inflammation is also known to be at the basis of the evolution toward neoplastic pathologies, as well as multiple myeloma. Another point is the impact that myeloma-specific therapies have on the course of concomitant autoimmune diseases. Indeed, cases have been observed of patients suffering from multiple myeloma treated with daratumumab and bortezomib who also benefited from their autoimmune condition or patients under treatment with immunomodulators in which there has been an arising or worsening of autoimmunity conditions. The role of bone marrow transplantation in the course of concomitant autoimmune diseases remains under analysis.
Collapse
Affiliation(s)
- Laura Giordano
- Hematology Unit, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, Via Consolare Valeria, 98125 Messina, Italy; (L.G.); (P.B.); (V.V.); (M.E.N.); (M.E.A.)
| | - Rossella Cacciola
- Hemostasis/Hematology Unit, Department of Experimental and Clinical Medicine, University of Catania, 95123 Catania, Italy;
| | - Paola Barone
- Hematology Unit, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, Via Consolare Valeria, 98125 Messina, Italy; (L.G.); (P.B.); (V.V.); (M.E.N.); (M.E.A.)
| | - Veronica Vecchio
- Hematology Unit, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, Via Consolare Valeria, 98125 Messina, Italy; (L.G.); (P.B.); (V.V.); (M.E.N.); (M.E.A.)
| | - Maria Elisa Nasso
- Hematology Unit, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, Via Consolare Valeria, 98125 Messina, Italy; (L.G.); (P.B.); (V.V.); (M.E.N.); (M.E.A.)
| | - Maria Eugenia Alvaro
- Hematology Unit, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, Via Consolare Valeria, 98125 Messina, Italy; (L.G.); (P.B.); (V.V.); (M.E.N.); (M.E.A.)
| | - Sebastiano Gangemi
- School and Operative Unit of Allergy and Clinical Immunology, Department and Experimental Medicine, University of Messina, 98125 Messina, Italy;
| | - Emma Cacciola
- Department of Medical and Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95123 Catania, Italy;
| | - Alessandro Allegra
- Hematology Unit, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, Via Consolare Valeria, 98125 Messina, Italy; (L.G.); (P.B.); (V.V.); (M.E.N.); (M.E.A.)
| |
Collapse
|
4
|
Yu D, Xue F, Liu X, Chen Y, Fu R, Sun T, Dai X, Ju M, Dong H, Yang R, Liu W, Zhang L. Acquired hemophilia A: a single-center study of 165 patients. Res Pract Thromb Haemost 2024; 8:102318. [PMID: 38433975 PMCID: PMC10907205 DOI: 10.1016/j.rpth.2024.102318] [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] [Received: 07/19/2023] [Revised: 01/04/2024] [Accepted: 01/05/2024] [Indexed: 03/05/2024] Open
Abstract
Background Acquired hemophilia A (AHA) is a rare hemorrhagic disorder caused by factor (F)VIII inhibitors. The diagnosis and management of AHA remains challenging because of its rarity and heterogeneity. Objectives To analyze the characteristics of AHA to enhance our understanding of this disease and identify effective treatment strategies. To analyze the characteristics of AHA to enhance our understanding of this disease and identify effective treatment strategies. Methods Clinical features of 165 patients with AHA from a single center between July 1997 and December 2021 were retrospectively analyzed. Results The median age of patients at diagnosis was 45 years. The median time to diagnosis was 30 days. All 165 patients experienced bleeding, with a median bleeding score (BS) of 4 (range, 2-12). Hemostatic therapy was administered to 129 (78.2%) patients. Bleeding control was achieved in 80.0% of patients who received prothrombin complex concentrate and in 92.3% of patients who were treated with recombinant activated FVII. Of the 163 patients who received immunosuppressive therapy, 80 (49.1%) received rituximab-based therapy with a 93.3% complete remission (CR) rate, 50 (30.7%) received steroids plus cyclophosphamide with an 85.0% CR rate, and 22 (13.5%) received steroids alone with an 82.4% CR rate. Six cases relapsed after a median duration of 330 days. Immunosuppressive therapy-related adverse events were reported in 17 patients. Seven deaths were recorded. FVIII inhibitor titer of ≥15 BU/mL and BS of ≥6 were identified as significantly poor prognostic factors for CR. Conclusion Immunosuppressive therapies yield remarkably high response rates, with a CR rate exceeding 80%; notably, the regimen containing rituximab exhibits a CR rate of approximately 90%. FVIII inhibitor titer of ≥5 BU/mL and BS of ≥6 were poor predictors of CR in patients with AHA.
Collapse
Affiliation(s)
- Dandan Yu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Feng Xue
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Xiaofan Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Yunfei Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Rongfeng Fu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Ting Sun
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Xinyue Dai
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Mankai Ju
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Huan Dong
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Wei Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| |
Collapse
|
5
|
Kanitthamniyom C, Siladech P, Polpichai N, McCullough M, Saowapa S. Combined life-threatening internal organ bleeding and postpartum hemorrhage associated with acquired hemophilia A. Clin Case Rep 2024; 12:e8399. [PMID: 38173887 PMCID: PMC10761610 DOI: 10.1002/ccr3.8399] [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] [Received: 10/18/2023] [Revised: 12/06/2023] [Accepted: 12/14/2023] [Indexed: 01/05/2024] Open
Abstract
Key Clinical Message Acquired hemophilia A (AHA) can present as life-threatening bleeding during the postpartum period. Prompt treatment allows patients with AHA to achieve complete remission and have normal subsequent pregnancies. Abstract Acquired hemophilia A (AHA) is a rare bleeding disorder caused by the production of autoantibodies against factor VIII (FVIII). AHA can present with severe bleeding, especially in postpartum patient. We report a 38-year-old woman who presented in an emergency department with severe postpartum hemorrhage 2 weeks after cesarean section. Her investigation showed an isolated prolongation of partial thromboplastin time (PTT), low factor VIII assay and a factor VIII inhibitor test, resulting in abnormal Bethesda units which consistent with AHA. This case report highlights the importance of early diagnosis and treatment of AHA. With timely and appropriate management, most patients can achieve a good outcome.
Collapse
Affiliation(s)
| | | | - Natchaya Polpichai
- Department of Internal Medicine Louis A Weiss Memorial HospitalMahidol UniversityBangkokThailand
| | - Maireigh McCullough
- Internal Medicine DepartmentTexas Tech University Health Sciences CenterLubbockTexasUSA
| | - Sakditad Saowapa
- Internal Medicine DepartmentTexas Tech University Health Sciences CenterLubbockTexasUSA
| |
Collapse
|
6
|
Kaltsas A, Zachariou A, Kratiras Z, Sofikitis N, Chrisofos M. Diagnostic Challenges and Management of Acquired Hemophilia A Presenting as Gross Hematuria: A Case Report. Cureus 2023; 15:e51426. [PMID: 38174197 PMCID: PMC10762498 DOI: 10.7759/cureus.51426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2023] [Indexed: 01/05/2024] Open
Abstract
Acquired hemophilia A (AHA) is a rare autoimmune disorder marked by autoantibodies against coagulation factor VIII, leading to bleeding complications. This case report explores a unique presentation of AHA, initially manifested as gross hematuria, a symptom often encountered in healthcare settings with a broad range of differential diagnoses. The background of this study highlights the rarity of AHA and its diverse clinical presentations. The case involves a 62-year-old man with no history of bleeding disorders, presenting with gross hematuria and later developing severe anemia and ecchymoses. Methods employed in the evaluation included urological assessments such as cystoscopy and computed tomography, alongside hematological investigations, which later revealed a prolonged activated partial thromboplastin time (aPTT) and a critically low factor VIII level, indicative of AHA. Results showed a lack of early recognition of coagulation abnormalities, underscoring the need for comprehensive initial assessments in cases of unexplained hematuria. The patient's management at a specialized Hemophilia Center involved inhibitor eradication therapy and management of acute bleeding episodes, resulting in significant clinical improvement. The conclusions drawn from this case emphasize the importance of considering rare conditions like AHA in the differential diagnosis of hematuria and the necessity for a broad diagnostic approach. It advocates for heightened awareness and early coagulation studies in unexplained cases of hematuria to prevent delayed diagnoses and improve patient outcomes. This case contributes to the understanding of AHA's clinical variability and the critical nature of early and comprehensive diagnostic approaches in hematuria evaluation.
Collapse
Affiliation(s)
- Aris Kaltsas
- Third Department of Urology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, GRC
| | | | - Zisis Kratiras
- Third Department of Urology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, GRC
| | | | - Michael Chrisofos
- Third Department of Urology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, GRC
| |
Collapse
|
7
|
Marino R. Acquired Hemophilia A: Bleeding Pattern and Hemostatic Therapeutic Strategies. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1739. [PMID: 37893457 PMCID: PMC10608116 DOI: 10.3390/medicina59101739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/20/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023]
Abstract
Acquired Hemophilia A (AHA) is a rare autoimmune disorder characterized by the onset of a sudden and unexpected bleeding episode in a patient with no personal or family history of bleeding diathesis, and with a typical laboratory feature, i.e., a prolonged activated partial thromboplastin time that is not otherwise explained. This bleeding disorder is caused by autoantibodies directed against the coagulation factor VIII (FVIII). AHA is idiopathic in 50% of cases and is secondary to well-defined diseases in the remaining 50%. AHA affects elderly patients although it has also been observed in the post-partum period. Bleeding manifestations are heterogeneous, ranging from mild to life-threatening bleeds involving limbs and organs. Severe bleeding with a significant decrease in hemoglobin levels must be promptly and adequately treated in order to avoid a worsening of the hemorrhages and their complications. According to international recommendations, the bypass agents (i.e., activated prothrombin complex concentrate and activated recombinant factor VII) and the replacement therapy with recombinant porcine FVIII are considered as the first-line therapy for bleeding control, due to their proven clinical efficacy. Plasma-derived or recombinant FVIII concentrates could be used as second-line treatments. Emicizumab may represent a valid and interesting therapeutic option for prophylaxis of bleeding recurrences.
Collapse
Affiliation(s)
- Renato Marino
- Hemophilia and Thrombosis Centre, University Hospital of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| |
Collapse
|
8
|
Jahangiri OS, Wurzer MP, Malik M. An Unusual Case of Bleeding: Acquired Hemophilia A. Cureus 2023; 15:e45577. [PMID: 37736240 PMCID: PMC10509382 DOI: 10.7759/cureus.45577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2023] [Indexed: 09/23/2023] Open
Abstract
Acquired hemophilia A (AHA) is a bleeding disorder, autoimmune in nature, in which the body produces IgG antibody inhibitors that attack coagulation factor VIII, causing deficiency. It is largely seen in the elderly, but most cases are idiopathic. Cases of acquired hemophilia A can occur in the presence of neutrophilia, infection, acute physiological stress, medication effect, tissue necrosis, various inflammatory disorders, and/or malignancy, which presents a formidable challenge with clinical workup. This case illustrates the potential for a masked bleeding disorder in a complex elderly male patient and the value of a thorough history-taking and workup. Although rare, acquired hemophilia recognition is essential for appropriate therapies to be started as early as possible and for cases to not easily be confused for another bleeding disorder in an acute care setting after ruling out other acute/common causes of similarly presenting symptoms.
Collapse
Affiliation(s)
- Omeed S Jahangiri
- Department of Clinical Medicine/Internal Medicine, Burrell College of Osteopathic Medicine, Las Cruces, USA
| | - Michael P Wurzer
- Department of Clinical Medicine/Internal Medicine, Burrell College of Osteopathic Medicine, Las Cruces, USA
| | - Mohammad Malik
- Department of Clinical Medicine/Internal Medicine, Burrell College of Osteopathic Medicine, Las Cruces, USA
| |
Collapse
|
9
|
Tedeschi R. Acquired haemophilia A in an elderly patient: A case report of functional recovery through physiotherapy. Int J Surg Case Rep 2023; 110:108769. [PMID: 37666165 PMCID: PMC10510055 DOI: 10.1016/j.ijscr.2023.108769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 08/28/2023] [Accepted: 08/28/2023] [Indexed: 09/06/2023] Open
Abstract
INTRODUCTION Acquired haemophilia-A, although uncommon in elderly patients, poses significant clinical challenges, especially when associated with profound musculoskeletal complications. The potential mimicry of hematomas as tumors further complicates the diagnostic process. CASE PRESENTATION An 85-year-old male, with a remote history of hypertension, benign prostatic hyperplasia, and right inguinal hernia, presented with acute pain in the left lower limb, functional limitation, and deep hematomas in the ileopsoas and axillary region. Initial suspicions of a sarcomatous lesion in the ileopsoas, based on radiological findings, were refuted following histopathological examinations, which confirmed the presence of necrotic hemorrhagic tissue. The patient underwent a one-month physical therapy regimen, targeting lower extremity muscles, especially around the hip joint. CLINICAL DISCUSSION The severity of the presentation and the involvement of vital muscles like the ileopsoas and quadriceps underscored the importance of comprehensive rehabilitation. Consistent therapeutic interventions, targeting muscle strength and joint function, demonstrated marked improvement as evidenced by the HJHS, HAL, and FISH scores. The multidisciplinary approach, entailing hematological, rehabilitative, and supportive measures, was paramount in ensuring holistic patient recovery. CONCLUSIONS Acquired haemophilia-A in the elderly necessitates an integrative care approach, encompassing accurate diagnosis and tailored therapeutic interventions. This case emphasizes the transformative potential of dedicated physiotherapy in managing the musculoskeletal implications of this bleeding disorder, underscoring the value of early intervention and comprehensive care.
Collapse
Affiliation(s)
- Roberto Tedeschi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
| |
Collapse
|
10
|
Amu-Hernández LA, Marzo-Alonso C, Tugues-Peiró A, Vicente-Pascual EP, Monteagudo-Aguilar P. A Case Report of Idiopathic Acquired Hemophilia Type A. Cureus 2023; 15:e38634. [PMID: 37284359 PMCID: PMC10241219 DOI: 10.7759/cureus.38634] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2023] [Indexed: 06/08/2023] Open
Abstract
Acquired hemophilia A (AHA) is a rare hemorrhagic coagulopathy caused by the presence of autoantibodies that inhibit the activity of factor VIII (FVIII). Its diagnosis requires a high index of suspicion. It should be suspected in the presence of extensive hematomas or intense mucosal bleeding in patients with no history of previous trauma or hemorrhagic symptoms. We present two clinical cases of AHA, with different presentations and therapeutic management based on immunosuppression and hemostatic control through bypass agents such as activated recombinant FVII (rFVIIa; Novoseven®) and activated prothrombin complex concentrate (aPCC; Feiba®). The first case was an idiopathic AHA that presented with extensive subcutaneous hematomas with inhibitor titer >40 Bethesda units/ml (BU/mL), prolonged activated partial thromboplastin time (aPTT), and FVIII of 0.8%. In contrast, the second case involved a patient with a history of autoimmune disease, who presented with epistaxis and inhibitor titer of 10.8 BU/ml and FVIII of 5.3%.
Collapse
Affiliation(s)
- Liz A Amu-Hernández
- Hematology and Hemostasis, Arnau de Vilanova University Hospital, Lleida, ESP
| | | | - Albert Tugues-Peiró
- Thrombosis and Hemostasis Unit, Arnau de Vilanova University Hospital, Lleida, ESP
| | | | | |
Collapse
|
11
|
Chebbi D, Marzouk S, Krichen I, El Ahmer I, Snoussi M, Dammak C, Frikha F, Salah RB, Kallel C, Bahloul Z. Acquired hemophilia A in a patient with adult-onset Still's disease: Successful treatment with steroids. Clin Case Rep 2023; 11:e7105. [PMID: 36937636 PMCID: PMC10014520 DOI: 10.1002/ccr3.7105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/11/2023] [Accepted: 03/01/2023] [Indexed: 03/17/2023] Open
Abstract
Acquired hemophilia A (AHA) is a potentially life-threatening hemorrhagic disorder with many etiologies. We report the first case in the literature describing the association of AHA with adult-onset Still's disease (AOSD).
Collapse
Affiliation(s)
- Donia Chebbi
- Department of Internal MedicineHedi Chaker University HospitalSfaxTunisia
| | - Sameh Marzouk
- Department of Internal MedicineHedi Chaker University HospitalSfaxTunisia
| | - Imen Krichen
- Department of HematologyHabib Bourguiba University HospitalSfaxTunisia
| | - Ikram El Ahmer
- Department of HematologyHabib Bourguiba University HospitalSfaxTunisia
| | - Mouna Snoussi
- Department of Internal MedicineHedi Chaker University HospitalSfaxTunisia
| | - Chifa Dammak
- Department of Internal MedicineHedi Chaker University HospitalSfaxTunisia
| | - Faten Frikha
- Department of Internal MedicineHedi Chaker University HospitalSfaxTunisia
| | - Raida Ben Salah
- Department of Internal MedicineHedi Chaker University HospitalSfaxTunisia
| | - Choumous Kallel
- Department of HematologyHabib Bourguiba University HospitalSfaxTunisia
| | - Zouhir Bahloul
- Department of Internal MedicineHedi Chaker University HospitalSfaxTunisia
| |
Collapse
|
12
|
Ejaz A, O’Doherty C, Sharpley FA, Curry N, Shapiro S, Desborough MJR. Acquired haemophilia A diagnosed during pregnancy. Obstet Med 2023; 16:56-58. [PMID: 37139513 PMCID: PMC10150309 DOI: 10.1177/1753495x211049987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/28/2021] [Accepted: 09/08/2021] [Indexed: 11/16/2022] Open
Abstract
Pregnancy-associated haemophilia A is an uncommon, acquired bleeding disorder which usually presents post-partum; very rarely it may present during pregnancy. No consensus guidelines exist on the management of this condition in pregnancy and very few cases have been reported in the literature. Here we describe the case of a woman presenting with acquired haemophilia A during pregnancy and outline the management of her bleeding disorder. We contrast her case with that of two other women, presenting to the same tertiary referral centre, with acquired haemophilia A presenting post-partum. These cases highlight the heterogeneous management of this condition and how it may be successfully managed in pregnancy.
Collapse
Affiliation(s)
- Ayesha Ejaz
- Oxford Haemophilia and Thrombosis
Centre, Oxford, UK
| | | | | | - Nicola Curry
- Oxford Haemophilia and Thrombosis
Centre, Oxford, UK
- NIHR Oxford Biomedical Research Centre,
Oxford, UK
| | - Susan Shapiro
- Oxford Haemophilia and Thrombosis
Centre, Oxford, UK
- NIHR Oxford Biomedical Research Centre,
Oxford, UK
| | - Michael J R Desborough
- NIHR Oxford Biomedical Research Centre,
Oxford, UK
- Department of Haematology, John Radcliffe Hospital, Oxford UK
| |
Collapse
|
13
|
Sucker C, Schmitt U, Litmathe J. [Acquired inhibitory body hemophilia : A life-threatening reason for the tendency of hematoma-genesis.]. Wien Med Wochenschr 2023; 173:54-56. [PMID: 34338901 DOI: 10.1007/s10354-021-00866-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/21/2021] [Indexed: 01/28/2023]
Abstract
Here, we report a rare case of acquired hemophilia which was diagnosed months after development of spontaneous hematoma. Clinical symptoms, diagnosis, and treatment are briefly summarized. Acquired hemophilia is a rare potentially life-threatening acquired bleeding disorders which should be considered in patients with acquired spontaneous hematoma.
Collapse
Affiliation(s)
- Christoph Sucker
- COAGUMED Gerinnungszentrum Berlin, Tauentzienstraße 7 b/c, 10789, Berlin, Deutschland. .,Medizinische Hochschule Brandenburg Theodor Fontane, Brandenburg an der Havel, Deutschland.
| | - Ursula Schmitt
- COAGUMED Gerinnungszentrum Berlin, Tauentzienstraße 7 b/c, 10789, Berlin, Deutschland
| | - Jens Litmathe
- Klinik für Akut- und Notfallmediziner, Evangelisches Krankenhaus Wesel, Wesel, Deutschland
| |
Collapse
|
14
|
Franchini M, Cappello E, Valdiserra G, Bonaso M, Moretti U, Focosi D, Tuccori M. Investigating a Signal of Acquired Hemophilia Associated with COVID-19 Vaccination: A Systematic Case Review. Semin Thromb Hemost 2023; 49:15-26. [PMID: 36055265 DOI: 10.1055/s-0042-1754389] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Acquired hemophilia A (AHA), a rare but life-threatening disorder, most commonly occurs in older people and during pregnancy. During the coronavirus disease 2019 (COVID-19) vaccination campaign, an unexpected number of newly diagnosed AHA patients have been identified in clinical practice that were temporally related to COVID-19 vaccination. We present the result of a signal detection analysis aimed at exploring a possible association between COVID-19 immunization and occurrence of AHA. A disproportionality analysis on the World Health Organization (WHO) database was performed to investigate the presence of a signal of risk for AHA associated with COVID-19 vaccines. Reports of AHA associated with any COVID-19 vaccine included in the WHO database were then integrated with those available on the Food and Drug Administration Vaccine Adverse Events Reporting System and those published in the medical literature. The WHO database included 146 reports of AHA. The information component (IC) was significant for the association of AHA with all COVID-19 vaccines (IC025: 1.1) and with the vaccine product BNT162b2 (IC025: 1.6). After duplicate exclusion, 96 unique cases of AHA following COVID-19 vaccines have been reviewed. Median time to diagnosis was 18 days and 40% of cases documented the occurrence after the second dose. Overall, in 57% of the investigated cases, a preexisting condition predisposing to AHA was excluded. About 22% of cases occurred in subjects with age ≤65 years and there was no case associated with pregnancy. Mortality was 11%. Although we cannot exclude that the unexpected frequency of AHA diagnosis can be explained by a detection bias, the signal for COVID-19 vaccine-related AHA is robust and deserves further investigations.
Collapse
Affiliation(s)
- Massimo Franchini
- Division of Transfusion Medicine, Carlo Poma Hospital, Mantua, Italy
| | - Emiliano Cappello
- Unit of Pharmacology and Pharmacovigilance, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giulia Valdiserra
- Unit of Pharmacology and Pharmacovigilance, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Marco Bonaso
- Unit of Pharmacology and Pharmacovigilance, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Ugo Moretti
- Section of Pharmacology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy
| | - Marco Tuccori
- Unit of Pharmacology and Pharmacovigilance, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.,Unit of Adverse Drug Reaction Monitoring, University Hospital of Pisa, Pisa, Italy
| |
Collapse
|
15
|
Acquired Hemophilia A: An Update on the Etiopathogenesis, Diagnosis, and Treatment. Diagnostics (Basel) 2023; 13:diagnostics13030420. [PMID: 36766524 PMCID: PMC9914651 DOI: 10.3390/diagnostics13030420] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/10/2023] [Accepted: 01/20/2023] [Indexed: 01/25/2023] Open
Abstract
Acquired haemophilia A (AHA) is a rare bleeding disorder caused by inhibitory autoantibodies against coagulation factor VIII (FVIII). AHA is a disease that most commonly affects the elderly but has also been observed in children and in the postpartum period. AHA is idiopathic in 50% of cases and is associated with autoimmune diseases, malignancies, and infections in the remaining 50%. Recently, cases of association between AHA, COVID-19 vaccination, and infection have been reported in the literature. For diagnoses, determining FVIII levels is crucial to distinguish the different causes of aPTT prolongation. Treatment of AHA is based on bypassing agents (recombinant factor VIIa, activated prothrombin complex concentrate) and porcine FVIII to control the bleeding and immunosuppressive therapy (corticosteroids, rituximab, cyclophosphamide) to suppress autoantibody production. It is important to start a prophylactic regimen to prevent further bleeding episodes until the inhibitor is negative. Recently, the series of cases reported in the literature suggest that emicizumab may provide effective and safe haemorrhage prophylaxis in the outpatient setting.
Collapse
|
16
|
Liu Y, Ruan X, Lei P, Shang B, Zhu Z, Chen S, Wang D, Wang R, Li X, Xue F. Acquired Hemophilia A: A Retrospective Multicenter Analysis of 42 Patients. Clin Appl Thromb Hemost 2023; 29:10760296221151165. [PMID: 36653966 PMCID: PMC9893059 DOI: 10.1177/10760296221151165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Immunosuppressive therapy (IST) for acquired hemophilia A (AHA) results in remission within days to months in 60% to 80% of patients. However, little is known regarding the predictors of response. AIM This study aimed to identify the factors that influence response to treatment. METHODS The data of 42 patients with AHA from three hospitals were retrospectively analyzed. RESULTS All 42 AHA patients received IST; complete treatment data were available for 34 patients. The response rate was 60% among the 5/34 (14.7%) patients who received steroids alone, 70.8% among the 24/34 (70.6%) patients who received steroids plus cyclophosphamide, and 80% among the 5/34 (14.7%) patients who received steroids plus cyclophosphamide and rituximab. Overall, 29/34 (85.3%) patients achieved CR; 4/34 (13.8%) of them relapsed after a median time of 410 (21-1279) days. Adverse events occurred in 14/34 (41.2%) patients: 13/34 (38.2%) had infections and 1/34 (2.9%) developed pancytopenia. In univariate and multivariate Cox regression analyses, FVIII inhibitor titer ≥20 BU/mL was the only significant prognostic factor affecting time to CR. No variable had significant effect on OS. CONCLUSION FVIII inhibitory antibody titer ≥20 BU/mL appears to be an important predictor of time to complete response in patients with acquired hemophilia A treated with immunosuppressive therapy.
Collapse
Affiliation(s)
- Yanhui Liu
- Department of Hematology, Hemophilia Comprehensive Care Center, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China,Yanhui Liu, Department of Hematology, Henan Provincial People's Hospital, 7 Weiwu Road, Jinshui District, Zhengzhou 450003, Henan, PR China.
Fei Xue, Department of Hepatobiliary and Pancreatic Surgery, Henan Provincial People's Hospital, 7 Weiwu Road, Jinshui District, Zhengzhou 450003, Henan, PR China.
| | - Xiang Ruan
- Department of Hematology, Hemophilia Comprehensive Care Center, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China
| | - Pingchong Lei
- Department of Hematology, Hemophilia Comprehensive Care Center, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China
| | - Baojun Shang
- Institute of Hematology, Hemophilia Comprehensive Care Center, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China
| | - Zunmin Zhu
- Department of Hematology, Hemophilia Comprehensive Care Center, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China,Institute of Hematology, Hemophilia Comprehensive Care Center, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China
| | - Shengmei Chen
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, PR China
| | - Dao Wang
- Department of Pediatrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, PR China
| | - Ruijuan Wang
- Department of Hematology, Nanyang Central Hospital, Nanyang, Henan Province, PR China
| | - Xiqing Li
- Department of Oncology, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China
| | - Fei Xue
- Department of Hepatobiliary and Pancreatic Surgery, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China
| |
Collapse
|
17
|
Surenkov AA, Orel EB, Zozulya NI, Dvirnyk VN. Features of clinical and laboratory diagnosis of rare coagulopathy – acquired hemophilia. RUSSIAN JOURNAL OF HEMATOLOGY AND TRANSFUSIOLOGY 2022. [DOI: 10.35754/0234-5730-2022-67-4-535-550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Introduction. The formation of circulating autoantibodies capable of inhibiting factors of the blood coagulation system is accompanied by the occurrence of spontaneous and/or post-traumatic bleeding in patients without a history of previous disorders of the hemostasis system. One of the reasons for the development of such conditions is acquired hemophilia.Aim – to present algorithms for laboratory diagnosis of acquired hemophilia.Main findings. Primary diagnosis and control of therapy of the disease are carried out based on the results of coagulation studies, the decoding and interpretation of which often causes difficulties due to the low awareness of doctors about the algorithms for laboratory diagnosis and tactics for managing patients. In acquired hemophilia there is no direct relationship between the results of laboratory tests and the clinical manifestations of the disease, which is determined by the kinetics of the interaction of autoantibodies with blood coagulation factor (F) VIII. There is a «false» in vitro decrease in the activity of factors of the internal pathway (FIX, FXI and FXII), associated with the effect of a rapid inhibitor in high titers. An important laboratory task is the determination of lupus anticoagulant, which makes it difficult to timely diagnose and verify the diagnosis.
Collapse
Affiliation(s)
| | - E. B. Orel
- National Medical Research Center for Hematology
| | | | | |
Collapse
|
18
|
Mingot-Castellano ME, Rodríguez-Martorell FJ, Nuñez-Vázquez RJ, Marco P. Acquired Haemophilia A: A Review of What We Know. J Blood Med 2022; 13:691-710. [PMID: 36447782 PMCID: PMC9701517 DOI: 10.2147/jbm.s342077] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 11/10/2022] [Indexed: 08/31/2023] Open
Abstract
Autoantibodies against plasma coagulation factors could be developed by some individuals inducing severe and sometimes fatal bleedings. This clinical entity is called acquired haemophilia. It should be suspected in subjects with acute abnormal bleedings, without personal or familiar history of congenital bleeding disorders with an unexplained prolonged aPTT. It is rare disease, although its incidence may be underestimated due to the low knowledge about it by many specialists, the frequent use of anticoagulant or antiplatelet therapies in the affected population that can mask the diagnosis and, sometimes, a so withering effect that avoid its confirmation. Mortality ranges between 9% and 33% depending on the series in the first 2 months after diagnosis. This mortality is attributed in up to 40% of the cases to infections in the context of immunosuppressive treatments used to eliminate the inhibitor. Factor VIII levels below 1% and high inhibitor titers are conditions of worse response rates. Advanced age, patient's ECOG, and underlying conditions are key prognostic factors for response to treatment and patient survival. To reduce morbidity and mortality in these patients, it is important to have clinical knowledge and access to guidelines to achieve an early diagnosis and to optimize the haemostatic and immunosuppressive treatment. This review aims to contribute to the dissemination of basic concepts on the epidemiology etiopathogenesis, diagnosis, treatment and management of these patients, as well as risk factors to get remission and the longest overall survival to allow individualized care. Especial awareness will be proposed in patients with some underlying conditions like cancer, autoimmune diseases, children, pregnancy or drugs.
Collapse
Affiliation(s)
- María Eva Mingot-Castellano
- Hematology Department, Hospital Universitario Virgen del Rocío. Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| | | | - Ramiro José Nuñez-Vázquez
- Hematology Department, Hospital Universitario Virgen del Rocío. Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| | - Pascual Marco
- General Medicine Department, Universidad Miguel Hernández, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| |
Collapse
|
19
|
Dulcetti A, Bruscia C, Malena DM, Benvenuto R, Martocchia A, Sentimentale A, Tafaro L, March MR, Martelletti P. Acquired Hemophilia in an Elderly Patient with Non-Small Cell Lung Cancer: a Case Report. SN COMPREHENSIVE CLINICAL MEDICINE 2022; 5:7. [PMID: 36466121 PMCID: PMC9684743 DOI: 10.1007/s42399-022-01330-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/25/2022] [Indexed: 06/17/2023]
Abstract
Acquired hemophilia A (AHA) is a rare autoimmune disease caused by autoantibodies against coagulation factor VIII and characterized by spontaneous hemorrhage in patients with no previous family or personal history of bleeding. We report here a case of AHA that occurred in the Department of Medicina D'Urgenza in Sant'Andrea Hospital in a patient with previous diagnosis of NSLC. The aim of this article is to allow a more comprehensive knowledge of AHA that both for the rarity and the poor literature is underdiagnosed; for all these reasons, it is important that different specialists, like emergency specialists, experts in internal medicine, hematologists, and oncologists, acquire a more complete knowledge of the clinical and laboratory features of this disease, allowing an early diagnosis crucial for the evolution of the coagulopathy.
Collapse
Affiliation(s)
- Antonio Dulcetti
- UOC Medicina d’Urgenza, Azienda Ospedaliera-Universitaria Sant’Andrea, Università Degli Studi Di Roma La Sapienza, Via di Grottarossa, 1035, Rome, 00189 Italy
| | - C. Bruscia
- UOC Medicina d’Urgenza, Azienda Ospedaliera-Universitaria Sant’Andrea, Università Degli Studi Di Roma La Sapienza, Via di Grottarossa, 1035, Rome, 00189 Italy
| | - D. M. Malena
- UOC Medicina d’Urgenza, Azienda Ospedaliera-Universitaria Sant’Andrea, Università Degli Studi Di Roma La Sapienza, Via di Grottarossa, 1035, Rome, 00189 Italy
| | - R. Benvenuto
- UOC Medicina d’Urgenza, Azienda Ospedaliera-Universitaria Sant’Andrea, Università Degli Studi Di Roma La Sapienza, Via di Grottarossa, 1035, Rome, 00189 Italy
| | - A. Martocchia
- UOC Medicina d’Urgenza, Azienda Ospedaliera-Universitaria Sant’Andrea, Università Degli Studi Di Roma La Sapienza, Via di Grottarossa, 1035, Rome, 00189 Italy
| | - A. Sentimentale
- UOC Medicina d’Urgenza, Azienda Ospedaliera-Universitaria Sant’Andrea, Università Degli Studi Di Roma La Sapienza, Via di Grottarossa, 1035, Rome, 00189 Italy
| | - L. Tafaro
- UOC Medicina d’Urgenza, Azienda Ospedaliera-Universitaria Sant’Andrea, Università Degli Studi Di Roma La Sapienza, Via di Grottarossa, 1035, Rome, 00189 Italy
| | - M. Rocchietti March
- UOC Medicina d’Urgenza, Azienda Ospedaliera-Universitaria Sant’Andrea, Università Degli Studi Di Roma La Sapienza, Via di Grottarossa, 1035, Rome, 00189 Italy
| | - P. Martelletti
- UOC Medicina d’Urgenza, Azienda Ospedaliera-Universitaria Sant’Andrea, Università Degli Studi Di Roma La Sapienza, Via di Grottarossa, 1035, Rome, 00189 Italy
| |
Collapse
|
20
|
Corpus luteum hemorrhage with acquired hemophilia A: a case report and literature review. BMC Womens Health 2022; 22:418. [PMID: 36221134 PMCID: PMC9552471 DOI: 10.1186/s12905-022-02000-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/05/2022] [Indexed: 11/05/2022] Open
Abstract
Background The rupture of the corpus luteum (CL) may occur at all stages of a woman’s reproductive life. Bleeding of the ruptured CL varies from self-limiting hemorrhage to massive hemoperitoneum, causing the shock and subsequent emergency surgery. But hemoperitoneum secondary to ruptured CL is a rare complication and situation for women with bleeding disorders. Case presentation We here describe a case of severe CL hemorrhage with factor VIII deficiency. We chose conservative management instead of surgery for the abnormal hemostatic condition. With blood product and factor concentrate support, conservative management was successful in avoiding surgery in the episode of bleeding. Conclusion Gynecologist should be alert for the patients with abnormal hemostatic condition. Selective patients presenting with CL hemoperitoneum association with bleeding disorders may undergo conservative management and avoid the risk of surgery.
Collapse
|
21
|
Cives TL, Docampo MF, Fernández MTF, Señarís DM, Carmona AH, Pérez-Rodríguez A, Solano MDCGDC, Fernández MFL. Challenging treatment for refractory acquired haemophilia A complicated with severe severe acute respiratory coronavirus 2 infection. Blood Coagul Fibrinolysis 2022; 33:342-347. [PMID: 35834710 DOI: 10.1097/mbc.0000000000001149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Immunosuppressive treatment and bypassing agents are used to treat acquired haemophilia A (AHA). On the other hand, COVID-19 infection induces a hypercoagulable state. Managing bleeding, risk of thrombosis, bypassing agents, active infection and immunosuppressive treatment can be challenging. A 72-year-old man was diagnosed with acquired hemophilia A. He received steroids, rituximab and recombinant activated factor VII (rFVIIa). He developed severe SARS-CoV-2 infection. Due to thrombotic risk, he received low-molecular-weight heparin (LMWH) and developed an iliopsoas hematoma. Because of the risk of thrombosis, treatment with recombinant porcine FVIII (rpFVIII) was requested. Tocilizumab was administered for treatment of SARS-CoV-2 infection and unexpected improvement of FVIII levels was noted. Concluding, rpFVIII treatment was well tolerated and effective, easy to monitor and to administer. Tocilizumab may play a role as immunosuppressive treatment for AHA. The role of LMWH remains to be established in patients with coagulopathies.
Collapse
Affiliation(s)
- Tamara Lado Cives
- Complexo Hospitalario Universitario de A Coruña, Hospital Materno Infantil, A Coruña, Spain
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Mingot-Castellano ME, García Candel F, Benítez Hidalgo O, Marco A, Navarro GAM, Pérez-Montes R, Donas GG, Canaro M, Paloma MJ, Asenjo B, Calle-Gordo VM, González NP, González RR, Caparrón Miranda IS, París LQ, Herrero S, Nuñez R. Activated Prothrombin Complex Concentrate to Treat Bleeding Events in Acquired Hemophilia A: Bahas Study. Eur J Haematol 2022; 109:686-695. [PMID: 36029160 DOI: 10.1111/ejh.13853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Activated prothrombin complex concentrate (aPCC) is a bypassing agent indicated to treat bleeds in patients with acquired hemophilia A (AHA). Nevertheless, its efficacy and safety in the real-world setting has not often been addressed. METHODS We report the experience of Spanish reference centers for coagulation disorders and from acquired haemophilia Spanish Registry (AHASR), from August 2012 to February 2021. Follow-up period of 30 days after aPCC withdrawal. RESULTS Thirty patients with a median age of 70 years old, suffering from 51 bleeds treated with aPCC were finally evaluated. As first line treatment, aPCC stopped bleed in 13 of 14 (92.9%) cases. aPCC as second line after recombinant factor VIIa failure, stopped bleeding in the all cases. In 17 patients aPCC was used far from initial bleed control as prophylaxis of rebleeding with 94% effectiveness. No thromboembolic episodes was communicated. One patient developed hypofibrinogenemia, which did not prevent aPCC from halting bleeding. No other serious adverse events possibly or probably associated with aPCC were reported. CONCLUSIONS this data support aPCC as haemostatic treatment in AHA with high effectiveness and excellent safety profile in acute bleeds and as extended use to prevent rebleedings, even in anging people with high cardiovascular risk. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- María Eva Mingot-Castellano
- Hematology Department, Hospital Universitario Virgen del Rocio, Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain.,Hematology Department, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | | | - Ana Marco
- Hematology Department, Hospital General de Alicante4, Alicante, Spain
| | | | | | - Gloria García Donas
- Hematology Department, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Mariana Canaro
- Hematology Department, Hospital Son Espases, Palma de Mallorca, Spain
| | - María José Paloma
- Hematology Department, Hospital Universitario Virgen del Camino, Pamplona, Spain
| | - Beatríz Asenjo
- Hematology Department, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | | | | | | | | | - Laura Quintana París
- Hematology Department, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | - Sonia Herrero
- Hematology Department, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | - Ramiro Nuñez
- Hematology Department, Hospital Universitario Virgen del Rocio, Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| |
Collapse
|
23
|
Zattera C, Luly S, Cipriano A, Rizzelli GML, Cecconi N, Santini M. An unexpected turn of events: A rare case of Acquired Haemophilia A after a violin spider bite. EMERGENCY CARE JOURNAL 2022. [DOI: 10.4081/ecj.2022.10457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We report an interesting clinical case of Acquired Haemophilia A (AHA) after a probable Loxosceles rufescens spider bite in a 73- year-old woman, admitted to an Emergency Department (ED) of Central Italy during April 2019. AHA is a rare disease, whose acute clinical manifestations are not widely known by most ED physicians; its prompt recognition and treatment are crucial to avoid fatal bleeding. In particular, the development of AHA after a violin spider bite (another rare and poorly characterized clinical condition) has never been described. Therefore, our case report could provide useful insight into the understanding and treatment of such unusual and possibly life-threatening conditions.
Collapse
|
24
|
Fragner M, Imbo B, Hobson J, Roberts JC, Rajasekhar A, Tarantino MD, Morell J, Kelkar AH. Time is Blood: The Impact of Diagnostic Delays on Acquired Hemophilia A. Cureus 2022; 14:e22048. [PMID: 35340501 PMCID: PMC8915674 DOI: 10.7759/cureus.22048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 02/07/2023] Open
|
25
|
Gicart M, De Weweire A, Demulder A, De Wilde V. Acquired hemophilia A revealed by spontaneous bleeding in an 80-year-old man: a marginal diagnosis? Acta Clin Belg 2022; 77:93-95. [PMID: 32459605 DOI: 10.1080/17843286.2020.1768735] [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: 10/24/2022]
Abstract
This case report illustrates the difficulty associated with diagnosing acquired hemophilia A by reviewing the case of an 80-year-old man admitted to the hospital for anemia. A prolonged activated partial thromboplastin time (aPTT) was not noticed until the patient developed a severe hemorrhagic syndrome.
Collapse
Affiliation(s)
- Marie Gicart
- Department of Hematology, Hôpital Erasme, Université Libre De Bruxelles, Brussels, Belgium
| | - Anne De Weweire
- Department of Hematology, Centre Hospitalier EpiCURA, Baudour, Belgium
| | - Anne Demulder
- Laboratory of Hematology LHUB-ULB ULB, Université Libre De Bruxelles, Brussels, Belgium
| | - Virginie De Wilde
- Department of Hematology, Hôpital Erasme, Université Libre De Bruxelles, Brussels, Belgium
| |
Collapse
|
26
|
Miatech JL, Kantamani D, Stagg MP. Management of Acquired Factor VIII Inhibitors With NovoSeven and Obizur. Cureus 2021; 13:e19145. [PMID: 34868780 PMCID: PMC8629688 DOI: 10.7759/cureus.19145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2021] [Indexed: 11/23/2022] Open
Abstract
Acquired hemophilia A (AHA) is a rare hemorrhagic disorder caused by the production of autoantibodies against coagulation factor VIII (FVIII). AHA is associated with significant morbidity and mortality primarily as a result of bleeding. Although many disorders are associated with the development of these inhibitors, up to 50% of cases remain idiopathic. The approach to therapy involves an initial strategy often to control acute bleeding episodes followed by definitive treatment to eradicate the inhibitor with immunosuppressive agents. We present the case of a 63-year-old Caucasian male hospitalized for severe Covid-19 who developed bleeding due to an acquired FVIII inhibitor that had never been treated definitively. Our case presentation focuses on in-hospital management of this patient's acute bleeding episodes with by-passing agents and recombinant porcine factor VIII.
Collapse
Affiliation(s)
- Jennifer L Miatech
- Internal Medicine Residency Program, Baton Rouge General, Baton Rouge, USA
| | | | - M Patrick Stagg
- Internal Medicine Residency Program, Baton Rouge General, Baton Rouge, USA
| |
Collapse
|
27
|
Puccetti L, Bacchiarri F, Calzoni P, Santoni A, Bocchia M. A fatal unsuspected case of acquired A hemophilia. Misleading role of therapy with acetylsalicylic acid? Intern Emerg Med 2021; 16:2339-2340. [PMID: 34100213 PMCID: PMC8183321 DOI: 10.1007/s11739-021-02760-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/10/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Luca Puccetti
- Hemathology Unit/Coagulative Disorders, "Santa Maria Alle Scotte" University Teaching Hospital of Siena, University of Siena, Siena, Italy.
| | - Francesca Bacchiarri
- Hemathology Unit/Coagulative Disorders, "Santa Maria Alle Scotte" University Teaching Hospital of Siena, University of Siena, Siena, Italy
| | - Paola Calzoni
- Coagulative Disorders Laboratory Unit, Santa Maria Alle Scotte University Teaching Hospital of Siena, Siena, Italy
| | - Adele Santoni
- Hemathology Unit/Coagulative Disorders, "Santa Maria Alle Scotte" University Teaching Hospital of Siena, University of Siena, Siena, Italy
| | - Monica Bocchia
- Hemathology Unit/Coagulative Disorders, "Santa Maria Alle Scotte" University Teaching Hospital of Siena, University of Siena, Siena, Italy
| |
Collapse
|
28
|
Management of acquired hemophilia A: results from the Spanish registry. Blood Adv 2021; 5:3821-3829. [PMID: 34521101 DOI: 10.1182/bloodadvances.2021004626] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/21/2021] [Indexed: 02/07/2023] Open
Abstract
The Spanish Acquired Hemophilia A (AHA) Registry is intended to update the status of AHA in Spain. One hundred and fifty-four patients were included and retrospectively followed for a median of 12 months. Patients were predominantly male (56.3%), with median age at diagnosis of 74 years. AHA was more frequently idiopathic (44.1%) and autoimmune disorder-associated (31.7%). Thirty-four percent of patients were on antithrombotic therapy at diagnosis. Hemostatic treatment was used in 70% of patients. Recombinant activated factor VII was more frequently infused (60.3% vs 20.6% activated prothrombin complex concentrate). Only 1 patient did not achieve control of hemorrhage. Complete remission (CR) was achieved by 84.2% of cases after immunosuppressive therapy. Steroids alone were less efficient than the other strategies (68.2% vs 87.2%, P = .049), whereas no differences existed among these (steroids/cyclophosphamide, 88.5%, vs steroids/calcineurin inhibitors, 81.2%, vs rituximab-based regimens, 87.5%). Female sex and high inhibitor levels influenced CR negatively. Thirty-six deaths (23.8%) were reported. Main causes of death were infection (15 patients, 9.9%) and hemorrhage (5 patients, 3.3%). All hemorrhage-related and half the infection-related deaths occurred within 2 months of diagnosis. Prior antithrombotic therapy was inversely associated with survival, irrespective of age. Median age of nonsurvivors was significantly higher (79 vs 73 years in survivors). Patients dying of infection were older than the other nonsurvivors (85 vs 78 years). In summary, fatal infection in the first months is common in our series. Antithrombotic therapy is associated with mortality. Particular care should be taken to avoid misdiagnosis.
Collapse
|
29
|
Shah E, Abro C, Zaidi F, Goel R. Doxycycline-induced acquired haemophilia A. BMJ Case Rep 2021; 14:e244748. [PMID: 34598965 PMCID: PMC8488736 DOI: 10.1136/bcr-2021-244748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2021] [Indexed: 11/04/2022] Open
Abstract
An 80-year-old man with no personal or family history of bleeding, presented to hospital with extensive haematomas and skin bruising after using doxycycline. His basic lab workup was concerning for a coagulopathy with an elevated activated partial thromboplastin time and significant anaemia. Mixing studies and other factor levels were tested that led to the diagnosis of acquired haemophilia A with low factor VIII levels and high factor VIII antibodies. He was started on steroids, but his haemoglobin level continued to drop. Later, during his treatment, he was given multiple therapeutic agents, including cyclophosphamide, rituximab and recombinant factor VII (NovoSeven-R). Gradually factor VIII levels increased and haemoglobin stabilised. The hospital course was complicated by COVID-19 pneumonia leading to acute respiratory distress syndrome; the patient eventually expired due to respiratory failure.
Collapse
Affiliation(s)
- Ejaz Shah
- Internal Medicine, HSHS Saint John's Hospital, Springfield, Illinois, USA
| | - Calvin Abro
- Haematology and Oncology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Fawwad Zaidi
- Haematology and Oncology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Ruchika Goel
- Haematology and Oncology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| |
Collapse
|
30
|
Singh S. Factor XIII deficiency: Lessons from two patients with unusual bleeding. THE NATIONAL MEDICAL JOURNAL OF INDIA 2021; 34:276-278. [PMID: 35593251 DOI: 10.25259/nmji_140_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Suvir Singh
- Department of Clinical Haematology and Bone Marrow Transplantation, Dayanand Medical College, Ludhiana, Punjab, India
| |
Collapse
|
31
|
Porrazzo M, Baldacci E, Ferretti A, De Luca ML, Barone F, Serrao A, Aprile SM, Capria S, Minotti C, Martelli M, Mazzucconi MG, Chistolini A, Santoro C. Single centre experience on Acquired Haemophilia A patients: Diagnosis, clinical management and analysis of factors predictive of response and outcome. Haemophilia 2021; 27:e667-e674. [PMID: 34382302 DOI: 10.1111/hae.14395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 08/01/2021] [Accepted: 08/02/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Acquired Haemophilia A (AHA) patients show a high response rate to immunosuppressive therapy (IST) but few information about predictors of response and outcome are reported. AIMS We describe a large single-centre AHA cohort, investigating prognostic variables for the 'best response' (BR), time to BR (TTBR) and overall survival (OS). METHODS A total of 61 patients were included, collecting data from clinical charts. RESULTS A progressive increase in diagnoses, from 1978 to 2019, was observed. Fifty/56 patients (89%) underwent haemostatic therapy (rFVIIa 46%, aPCC 34%) with no significant differences in the response (rFVIIa 92.3% vs aPCC 100%) and no thromboembolic events. Sixty/61 patients underwent first-line IST with an initial response rate of 58.4%. The 12-months OS was 85%, the bleeding associated mortality rate 3% (2/61). The response rates at last observation were: CR 64%, PR 8%. We evaluated the influence of age, gender, associated conditions, IST, haemoglobin levels, FVIII:C, inhibitor titre on BR, TTBR and OS: post-partum AHA achieved the BR after a longer time than AHA related to other aetiologies or idiopathic (p = .05); in univariate analysis female sex (p = .03) and the achievement of BR (p = .001) had a positive impact on the OS while AHA secondary to neoplasms showed a shorter survival (p = .04); only the BR achievement remained significant in multivariate analysis (p = .02). CONCLUSIONS Our data on response and survival confirmed those from the main registries. Post-partum AHA and BR achievement were significantly associated to a longer TTBR and a longer OS, respectively. Other predictors of outcome deserve to be explored in prospective studies.
Collapse
Affiliation(s)
- Marika Porrazzo
- Haematology, Department of Translational and Precision Medicine, 'Sapienza' University, Rome, Italy
| | - Erminia Baldacci
- Haematology, Department of Translational and Precision Medicine, 'Sapienza' University, Rome, Italy
| | - Antonietta Ferretti
- Haematology, Department of Translational and Precision Medicine, 'Sapienza' University, Rome, Italy
| | - Maria Lucia De Luca
- Haematology, Department of Translational and Precision Medicine, 'Sapienza' University, Rome, Italy
| | - Francesco Barone
- Haematology, Department of Translational and Precision Medicine, 'Sapienza' University, Rome, Italy
| | - Alessandra Serrao
- Haematology, Department of Translational and Precision Medicine, 'Sapienza' University, Rome, Italy
| | - Simona Michela Aprile
- Haematology, Department of Translational and Precision Medicine, 'Sapienza' University, Rome, Italy
| | - Saveria Capria
- Haematology, Department of Translational and Precision Medicine, 'Sapienza' University, Rome, Italy
| | - Clara Minotti
- Haematology, Department of Translational and Precision Medicine, 'Sapienza' University, Rome, Italy
| | - Maurizio Martelli
- Haematology, Department of Translational and Precision Medicine, 'Sapienza' University, Rome, Italy
| | | | - Antonio Chistolini
- Haematology, Department of Translational and Precision Medicine, 'Sapienza' University, Rome, Italy
| | - Cristina Santoro
- Haematology, Department of Translational and Precision Medicine, 'Sapienza' University, Rome, Italy
| |
Collapse
|
32
|
Wang SJ. [How I diagnose and treat acquired hemophilia A]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:193-198. [PMID: 33910303 PMCID: PMC8081944 DOI: 10.3760/cma.j.issn.0253-2727.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- S J Wang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences, Beijing 100730, China
| |
Collapse
|
33
|
Fernández-Oliveira C, Rotea-Salvo S, Fernández-Docampo M, González-Piñeiro S, Martín-Herranz I. Treatment of high-risk bleeding with susoctocog alfa in a patient with acquired haemophilia A and a nosocomial severe acute respiratory syndrome coronavirus 2 infection. Eur J Hosp Pharm 2021; 30:177-179. [PMID: 34011555 PMCID: PMC10176986 DOI: 10.1136/ejhpharm-2021-002805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/26/2021] [Indexed: 11/03/2022] Open
Abstract
We report the case of a man in his early 70s with idiopathic acquired haemophilia A and persistent high-titre type II inhibitors on immunosuppressive treatment to eradicate the inhibitor. As complications, he had a nosocomial severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, which caused severe pneumonia and an explosive inflammatory reaction that required tocilizumab and remdesivir treatment, and a high-risk retroperitoneal haematoma. Recombinant porcine factor VIII, susoctocog alfa, was requested from the Pharmacy Service in view of the extreme risk of thromboembolism resulting from the concomitant inflammatory storm caused by SARS-CoV-2. Improvement in the SARS-CoV-2 infection made it possible to complete the immunosuppressive treatment with rituximab. The patient was discharged with mycophenolate mofetil as immunosuppressive treatment after 89 days in hospital and 22 days of treatment with susoctocog alfa. His SARS-CoV-2 infection resolved and the haematoma evolved favourably.
Collapse
|
34
|
Emicizumab for the treatment of acquired hemophilia A. Blood 2021; 137:410-419. [PMID: 32766881 DOI: 10.1182/blood.2020006315] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/14/2020] [Indexed: 02/07/2023] Open
Abstract
Acquired hemophilia A (AHA) is a severe bleeding disorder caused by inhibiting autoantibodies to coagulation factor VIII (FVIII). For hemostatic treatment, bypassing agents and human or porcine FVIII are currently standard of care. Emicizumab is a bispecific, FVIII-mimetic therapeutic antibody that reduced the annualized bleeding rates in congenital hemophiliacs. Here, we report on 6 male and 6 female patients with AHA treated with emicizumab (all data medians and interquartile range), age 74 (64-80) years, initial FVIII <1%; inhibitor titer 22.3 Bethesda units (BU)/mL (range, 3-2000). Eight patients had severe bleeding. Emicizumab was started, 3 mg/kg subcutaneously, weekly for 2 to 3 doses, followed by 1.5 mg/kg every 3 weeks to keep the lowest effective FVIII levels. For FVIII monitoring, chromogenic assays with human and bovine reagents were used. All patients received immunosuppression with steroids and/or rituximab. After the first dose of emicizumab, activated partial thromboplastin time normalized in 1 to 3 days, FVIII (human reagents) exceeded 10% after 11 (7.5-12) days. Hemostatic efficacy was obtained and bypassing therapy stopped after 1.5 (1-4) days. FVIII (bovine reagents) exceeded 50%, indicating complete remission after 115 (67-185) days, and emicizumab was stopped after 31 (15-79) days. A median of 5 injections (range, 3-9) were given. No patient died of bleeding or thromboembolism, and no breakthrough bleeding was observed after the first dose of emicizumab. In conclusion, emicizumab seems to be an effective hemostatic therapy for AHA, with the advantages of subcutaneous therapy, good hemostatic efficacy, early discharge, and reduction of immunosuppression and adverse events.
Collapse
|
35
|
Yamamoto M, Shindo M, Sumi C, Igarashi S, Saito T, Tsukada N, Toki Y, Hatayama M, Inamura J, Sato K, Mizukami Y, Torimoto Y, Okumura T. Acquired hemophilia A associated with Epstein-Barr-virus-associated T/natural killer-cell lymphoproliferative disease: A case report. Medicine (Baltimore) 2021; 100:e25518. [PMID: 33879690 PMCID: PMC8078394 DOI: 10.1097/md.0000000000025518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/14/2021] [Accepted: 03/25/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Acquired hemophilia A (AHA) is a rare bleeding disorder caused by autoantibodies against factor VIII (FVIII). Hematological malignancies, especially lymphoid malignancies, are known to be underlying causes of AHA; however, thus far, there is no report of AHA associated with Epstein-Barr-virus-associated T/natural killer-cell lymphoproliferative disease (EBV-T/NK-LPD). Here, we present a case of AHA that developed during treatment for EBV-T/NK-LPD. HISTORY A 69-year-old man visited our hospital because of general fatigue. Blood examination showed pancytopenia, and computed tomography revealed whole-body lymphadenopathy, but there were no findings indicating hematological malignancy from bone marrow aspiration and cervical lymph node biopsy. The level of EBV DNA in peripheral blood was extremely high, and he was diagnosed with EBV-T/NK-LPD. EBV-T/NK-LPD improved with prednisolone (PSL) administration. Seventeen months after starting treatment, the patient complained of back and right leg pain. At that time, he had been treated with low-dose PSL, and EBV-T/NK-LPD was well controlled. Imaging revealed hematoma of the right iliopsoas muscle. Prolonged activated partial thromboplastin time (APTT) was the only abnormal finding in a screening coagulation test. FVIII coagulant activity was below detection limit, and FVIII inhibitor level was increased. From these results, he was diagnosed with AHA.A higher dose of PSL was administered, and, after 1 month of treatment, FVIII activity gradually increased, and FVIII inhibitor level became undetectable. APTT also normalized, and complete remission was achieved and maintained for 13 months with low-dose PSL. During treatment, EBV-T/NK-LPD was well controlled. CONCLUSION It is speculated that proliferating lymphocytes interfere with normal immune functions and that abnormal autoantibodies are produced from those lymphocytes in patients with LPD. Therefore, we speculate that EBV-infected and proliferating monoclonal NK cells might have modulated the immune system and produced autoantibodies against FVIII, thus causing AHA in this patient with EBV-T/NK-LPD.
Collapse
Affiliation(s)
- Masayo Yamamoto
- Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University
| | - Motohiro Shindo
- Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University
| | - Chihiro Sumi
- Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University
| | - Sho Igarashi
- Department of Hematology/Oncology, Asahikawa-Kosei General Hospital
| | - Takeshi Saito
- Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University
| | - Nodoka Tsukada
- Department of Hematology/Oncology, Asahikawa-Kosei General Hospital
| | - Yasumichi Toki
- Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University
| | - Mayumi Hatayama
- Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University
| | - Junki Inamura
- Department of Hematology/Oncology, Asahikawa-Kosei General Hospital
| | - Kazuya Sato
- Department of Hematology/Oncology, Asahikawa-Kosei General Hospital
| | - Yusuke Mizukami
- Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University
| | - Yoshihiro Torimoto
- Oncology Center, Asahikawa Medical University Hospital, Asahikawa, Japan
| | - Toshikatsu Okumura
- Department of Medicine, Division of Gastroenterology and Hematology/Oncology, Asahikawa Medical University
| |
Collapse
|
36
|
Barcellini W, Giannotta JA, Fattizzo B. Autoimmune Complications in Hematologic Neoplasms. Cancers (Basel) 2021; 13:cancers13071532. [PMID: 33810369 PMCID: PMC8037071 DOI: 10.3390/cancers13071532] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/22/2021] [Accepted: 03/24/2021] [Indexed: 12/14/2022] Open
Abstract
Autoimmune cytopenias (AICy) and autoimmune diseases (AID) can complicate both lymphoid and myeloid neoplasms, and often represent a diagnostic and therapeutic challenge. While autoimmune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP) are well known, other rarer AICy (autoimmune neutropenia, aplastic anemia, and pure red cell aplasia) and AID (systemic lupus erythematosus, rheumatoid arthritis, vasculitis, thyroiditis, and others) are poorly recognized. This review analyses the available literature of the last 30 years regarding the occurrence of AICy/AID in different onco-hematologic conditions. The latter include chronic lymphocytic leukemia (CLL), lymphomas, multiple myeloma, myelodysplastic syndromes (MDS), chronic myelomonocytic leukemia (CMML), myeloproliferative neoplasms, and acute leukemias. On the whole, AICy are observed in up to 10% of CLL and with higher frequencies in certain subtypes of non-Hodgkin lymphoma, whilst they occur in less than 1% of low-risk MDS and CMML. AID are described in up to 30% of myeloid and lymphoid patients, including immune-mediated hemostatic disorders (acquired hemophilia, thrombotic thrombocytopenic purpura, and anti-phospholipid syndrome) that may be severe and fatal. Additionally, AICy/AID are found in about 10% of patients receiving hematopoietic stem cell transplant or treatment with new checkpoint inhibitors. Besides the diagnostic difficulties, these AICy/AID may complicate the clinical management of already immunocompromised patients.
Collapse
Affiliation(s)
- Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (J.A.G.); (B.F.)
- Correspondence: ; Tel.: +39-025-503-3256
| | - Juri Alessandro Giannotta
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (J.A.G.); (B.F.)
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (J.A.G.); (B.F.)
- Department of Oncology and Oncohematology, University of Milan, 20122 Milan, Italy
| |
Collapse
|
37
|
Bleeding and response to hemostatic therapy in acquired hemophilia A: results from the GTH-AH 01/2010 study. Blood 2021; 136:279-287. [PMID: 32268359 DOI: 10.1182/blood.2019003639] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 03/25/2020] [Indexed: 12/17/2022] Open
Abstract
Acquired hemophilia A (AHA) is due to autoantibodies against coagulation factor VIII (FVIII) and most often presents with unexpected bleeding. In contrast to congenital hemophilia, the patient's residual FVIII activity does not seem to correlate with the risk of bleeding as suggested from previous studies. Risk factors for bleeding have not been described. We used data from the prospective GTH-AH 01/2010 study to assess the risk of bleeding and the efficacy of hemostatic therapy. FVIII activity was measured at baseline and weekly thereafter. Bleeding events were assessed by treating physicians. A total of 289 bleeds were recorded in 102 patients. There were 141 new bleeds observed starting after day 1 in 59% of the patients, with a mean rate of 0.13 bleed per patient-week in weeks 1 to 12, or 0.27 bleed per patient-week before achieving partial remission. Weekly measured FVIII activity was significantly associated with the bleeding rate, but only achieving FVIII activity ≥50% abolished the risk of bleeding. A good World Health Organization performance status assessed at baseline (score 0 vs higher) was associated with a lower bleeding rate. Hemostatic treatment was reportedly effective in 96% of bleeds. Thus, the risk of new bleeds after a first diagnosis of AHA remains high until partial remission is achieved, and weekly measured FVIII activity may aid in assessing the individual risk of bleeding. These results will help to define future strategies for prophylaxis of bleeding in AHA.
Collapse
|
38
|
Brand A, De Angelis V, Vuk T, Garraud O, Lozano M, Politis D. Review of indications for immunoglobulin (IG) use: Narrowing the gap between supply and demand. Transfus Clin Biol 2021; 28:96-122. [DOI: 10.1016/j.tracli.2020.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
39
|
Giuffrida G, Markovic U, Parisi M, Nicolosi D, Calafiore V. Acquired hemophilia in a 7-year-old girl successfully treated with recombinant FVIIA and steroids: A case report. Clin Case Rep 2021; 9:638-643. [PMID: 33598217 PMCID: PMC7869384 DOI: 10.1002/ccr3.3588] [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] [Received: 06/22/2020] [Revised: 10/19/2020] [Accepted: 10/30/2020] [Indexed: 01/19/2023] Open
Abstract
Acquired hemophilia should be evaluated in pediatric patients with bleeding and isolated prolonged aPTT. Immunosuppressive treatment should be initiated even in minor bleedings. Bypassing agents like rFVIIa can be used in children with success.
Collapse
Affiliation(s)
- Gaetano Giuffrida
- Division of HematologyAOU “Policlinico ‐ Vittorio Emanuele”CataniaItaly
| | - Uros Markovic
- Division of HematologyAOU “Policlinico ‐ Vittorio Emanuele”CataniaItaly
- Department of General Surgery and Medical‐Surgical Specialties, Hematology SectionUniversity of CataniaCataniaItaly
| | - Marina Parisi
- Division of HematologyAOU “Policlinico ‐ Vittorio Emanuele”CataniaItaly
| | - Daniela Nicolosi
- Division of HematologyAOU “Policlinico ‐ Vittorio Emanuele”CataniaItaly
| | - Valeria Calafiore
- Division of HematologyAOU “Policlinico ‐ Vittorio Emanuele”CataniaItaly
| |
Collapse
|
40
|
Sakai T, Azuma Y, Sano A, Sadamoto S, Tochigi N, Nagase D, Iyoda A. Perioperative Bypassing Agent Therapy for Pulmonary Pleomorphic Carcinoma with Acquired Hemophilia. Ann Thorac Cardiovasc Surg 2021; 28:302-306. [PMID: 33473052 PMCID: PMC9433887 DOI: 10.5761/atcs.cr.20-00257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 74-year-old man was admitted with lung cancer, and preoperative blood test showed abnormal activated partial thromboplastin time (APTT). Coagulation factor screening and APTT mixing test achieved a diagnosis of acquired hemophilia A (AHA). Bypassing agent therapy was indicated and lobectomy was successfully performed without bleeding complications. APTT returned to normal after the operation without any additional treatment for AHA. The pathogenesis of AHA is still unknown and there is no evidence for hemostatic strategy for AHA patients requiring surgery. This study supports the importance of hemostatic therapy and suggests that malignancy might cause AHA.
Collapse
Affiliation(s)
- Takashi Sakai
- Division of Chest Surgery, Department of Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Yoko Azuma
- Division of Chest Surgery, Department of Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Atsushi Sano
- Division of Chest Surgery, Department of Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Sota Sadamoto
- Department of Surgical Pathology, Toho University School of Medicine, Tokyo, Japan
| | - Naobumi Tochigi
- Department of Surgical Pathology, Toho University School of Medicine, Tokyo, Japan
| | - Daisuke Nagase
- Division of Hematology and Oncology, Department of Internal Medicine, Toho University School of Medicine, Tokyo, Japan
| | - Akira Iyoda
- Division of Chest Surgery, Department of Surgery, Toho University School of Medicine, Tokyo, Japan
| |
Collapse
|
41
|
Rossio R, Cassin R, Lecchi A, La Marca S, Femia EA, Novembrino C, Siboni SM, Noto A, Reda G, Peyvandi F. Acquired hemophilia A and delta storage pool deficiency in a patient with indolent non-Hodgkin lymphoma. Platelets 2021; 33:168-170. [PMID: 33426985 DOI: 10.1080/09537104.2020.1869928] [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: 10/22/2022]
Abstract
B-cell lymphoproliferative diseases may be associated with acquired hemostasis disorders, such as acquired hemophilia A (AHA) caused by autoantibodies that neutralize factor VIII activity, and δ-storage pool deficiency, an abnormality of platelet function due to defective dense granules and impaired secretion. We describe the case of a 67-year-old man in whom these two acquired bleeding disorders were concomitantly present as the first clinical manifestation of an indolent non-Hodgkin lymphoma. Immunosuppressive therapy with prednisone was initially started to eradicate anti-FVIII antibodies, subsequently boosted with cyclophosphamide and rituximab, these medications being also chosen to treat the associated indolent lymphoma. Bleeding symptoms were first tackled with limited benefit by using rFVIIa and then rescued using recombinant porcine FVIII. After a 6 month's follow-up lymphoma and AHA were in remission and platelet function was improved. This case underlines the need of multiple and complex diagnostic and therapeutic approaches to rare acquired bleeding disorders associated with lymphoproliferative diseases.
Collapse
Affiliation(s)
- Raffaella Rossio
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ramona Cassin
- Hematology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Lecchi
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia La Marca
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Eti Alessandra Femia
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Cristina Novembrino
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Simona M Siboni
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandro Noto
- Hematology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gianluigi Reda
- Hematology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Flora Peyvandi
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
| |
Collapse
|
42
|
Guillet B, Aouba A, Borel-Derlon A, Borg JY, Schved JF, Schneid H, Lévesque H. Adaptation of recombinant activated factor VII in the treatment of acquired haemophilia A: Results from a prospective study (ACQUI-7) in France. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2020.100021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
43
|
[Hematoma in lipedema: from cutaneous origin or defect of coagulation?]. Wien Med Wochenschr 2020; 171:48-52. [PMID: 33301076 DOI: 10.1007/s10354-020-00792-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/12/2020] [Indexed: 10/22/2022]
Abstract
Lipedema is a widespread in concern of etiology partially unknown disease especially in women. In many cases it is accompanied by bleeding complications. Our current work focuses on possible coagulation disorders as potential sources of such bleeding complications. Since only a minority of our patients showed a coagulation defect it is suggestive that the main underlying reason for bleeding in lipedema is of cutaneous origin what may only be forwarded by simultaneously existing coagulation disorders.
Collapse
|
44
|
Development of Acquired Hemophilia A After Treatment of Bronchial Asthma with Benralizumab. Indian J Hematol Blood Transfus 2020; 37:509-510. [PMID: 34267478 DOI: 10.1007/s12288-020-01371-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 10/13/2020] [Indexed: 10/23/2022] Open
|
45
|
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] [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.
Collapse
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.
| |
Collapse
|
46
|
Franchini M, Marano G, Cruciani M, Mengoli C, Pati I, Masiello F, Veropalumbo E, Pupella S, Vaglio S, Liumbruno GM. Advances in managing rare acquired bleeding disorders. Expert Rev Hematol 2020; 13:599-606. [PMID: 32286895 DOI: 10.1080/17474086.2020.1756259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Rare acquired bleeding disorders include a wide spectrum of coagulopathies characterized by spontaneous or post-trauma and post-surgery hemorrhages in patients without a previous personal or family history of bleeding. AREAS COVERED This review, based on a Medline/PubMed search during the last 20 years, will focus mainly on rare acquired bleeding disorders caused by autoantibodies against coagulation factors, including autoantibodies against factor VIII (acquired hemophilia A), von Willebrand factor (acquired von Willebrand syndrome) and other coagulation factors (factors V, X, XI, and XIII). The pathogenic, laboratory, and clinical features of these rare hemorrhagic conditions will be discussed, with particular attention to their management. EXPERT OPINION The treatment of rare acquired bleeding disorders includes the control of bleeding and the elimination of the autoantibody and of the underlying disease, when present. As the bleeding clinical phenotype is often severe, the management of affected patients is particularly challenging. Thus, while an early diagnosis of the acquired coagulopathy is essential to start the most appropriate treatment and to improve patients' outcomes, the support of specialized centers is equally important to provide a correct management of such complicated cases.
Collapse
Affiliation(s)
- Massimo Franchini
- Italian National Blood Centre, National Institute of Health , Rome, Italy.,Department of Hematology and Transfusion Medicine, Carlo Poma Hospital , Mantua, Italy
| | - Giuseppe Marano
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Mario Cruciani
- Italian National Blood Centre, National Institute of Health , Rome, Italy.,Infection Control Committee and Antibiotic Stewardship Programme, AULSS9 Scaligera , Verona, Italy
| | - Carlo Mengoli
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Ilaria Pati
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Francesca Masiello
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Eva Veropalumbo
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Simonetta Pupella
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Stefania Vaglio
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | | |
Collapse
|
47
|
Al Mahmasani L, Finianos A, Bou-Fakhredin R, Elias J, Taher A. Acquired hemophilia A: when an overlooked autoimmune disorder causes significant bleeding. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1740682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Layal Al Mahmasani
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Antoine Finianos
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rayan Bou-Fakhredin
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Joseph Elias
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali Taher
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| |
Collapse
|
48
|
Kietaibl AT, Kietaibl S. New Hemostatic Agents: Perioperative Anesthetic Considerations. Curr Pharm Des 2020; 25:2158-2164. [PMID: 31298165 DOI: 10.2174/1381612825666190708183127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/23/2019] [Indexed: 11/22/2022]
Abstract
AIM Pharmacologic agents with procoagulant effects and antidotes against antithrombotic drugs play an important role in the prevention and management of perioperative coagulopathic bleeding. The aim of this narrative review is knowledge transfer from new and renewed hemostatic agents to anesthesiologists and other physicians involved in perioperative medicine. METHODS The literature search was performed on PubMed and the Summaries of Product Characteristics of 6 pharmacologic agents of interest: fibrinogen concentrate, vonicog alfa, susoctocog alfa, idarucizumab, andexanet alfa, and argatroban. RESULTS AND DISCUSSION This review highlights renewed interest in fibrinogen concentrate, an old prohemostatic drug, in correcting hypofibrinogenemia which is a leading pathomechanism of perioperative bleeding. This review describes clinically relevant aspects for brand new recombinant prohemostatic drugs for their use in critical clinical situations: vonicog alfa for the prevention and correction of bleeding in von Willebrand syndrome, and susoctocog alfa in acquired hemophilia A. Clinical experience and increasing evidence broadened the field of applications of the old antithrombotic drug argatroban to heparin resistance. New antidotes against new antithrombotic agents revolutionized the safety of chronic antithrombotic therapy in the emergency situations of acute and trauma surgery. Information on dosing and handling of new hemostatic drugs is summarized. CONCLUSION New and potent hemostatic agents exist for perioperative use and may enrich the armamentarium of anesthesiologists. Implementation into clinical practice requires their availability and user knowledge. Sustainability of these new drugs depends on post-licensing research, cost-effectiveness, and clinical experience.
Collapse
Affiliation(s)
| | - Sibylle Kietaibl
- Sigmund Freud Private University and Department of Anesthesia and Intensive Care, Evangelical Hospital Vienna, Vienna, Austria
| |
Collapse
|
49
|
|
50
|
Ye N, Liu Z, Xu G, Wang X, Wu F, Xu X, Wu W. Inhibitor eradication and bleeding management of acquired hemophilia A: a single center experience in China. ACTA ACUST UNITED AC 2020; 24:631-636. [PMID: 31514689 DOI: 10.1080/16078454.2019.1663028] [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: 10/26/2022]
Abstract
Objectives: Acquired hemophilia A (AHA) is a rare disease resulting from autoantibodies against coagulation factor VIII that leads to spontaneous bleeding. This study reports the clinical characteristics and treatment outcomes of a relatively sizable cohort of patients with AHA. Methods: We retrospectively analyzed the characteristics and outcomes of 42 patients with AHA diagnosed in our center from January 2014 through December 2018. Results: The FVIII activity (FVIII: C) was significantly suppressed (median 1.5%; interquartile range [IQR]: 0.9-3.5) by FVIII inhibitor (median 8 BU/mL; IQR: 4.0-16.0). Bypassing agents, PCC or FVIIa, were used in 14 patients for bleeding control without any adverse reaction; and most patients (90.5%, 38/42) were placed on immunosuppressive regimen, corticosteroid alone or in combination with cyclophosphamide. Patients treated with corticosteroids alone had a lower median inhibitor titer (8 BU/mL) than those treated with combination corticosteroids of cyclophosphamide (16 BU/mL) (p < 0.001). 97.4% (37/38) patients achieved complete remission (CR) after immunosuppression therapy, and the median time to CR in patients treated with corticosteroids alone was shorter than those with combination corticosteroids of cyclophosphamide (median 40 days; IQR: 31-65 vs. 51 days; IQR: 38-83, p = 0.301). 10 (26.3%) patients relapsed thereafter and were placed on combined corticosteroid and cyclophosphamide treatment, which yielded second remission in 8 patients (80%). Two patients died, one from uncontrolled post-surgical retroperitoneal hemorrhage and one from sepsis complicating corticosteroid therapy. Conclusion: The corticosteroid achieves a satisfactory outcome, particularly with low inhibitors titers; and combination of cyclophosphamide will facilitate remission in sever patients with high titers of inhibitors.
Collapse
Affiliation(s)
- Naifang Ye
- Department of Clinical Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine , Shanghai , People's Republic of China.,Department of Clinical Laboratory Medicine, The Second Affiliated Hospital of Anhui Medical University, Anhui Medical University , Hefei , People's Republic of China
| | - Zhenzhen Liu
- Department of Clinical Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine , Shanghai , People's Republic of China
| | - Guanqun Xu
- Department of Clinical Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine , Shanghai , People's Republic of China
| | - Xuefeng Wang
- Department of Clinical Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine , Shanghai , People's Republic of China
| | - Fang Wu
- Department of Geriatrics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine , Shanghai , People's Republic of China
| | - Xiaoqian Xu
- Department of Hematology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine , Shanghai , People's Republic of China
| | - Wenman Wu
- Department of Clinical Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine , Shanghai , People's Republic of China.,Faculty of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine , Shanghai , People's Republic of China
| |
Collapse
|