1
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Wei L, Tang Y, Wu Z, Xu P, Mo M. A case of congenital afibrinogenemia with multiple thrombotic and hemorrhagic disorders. Clin Case Rep 2022; 10:e6395. [PMID: 36276905 PMCID: PMC9582684 DOI: 10.1002/ccr3.6395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/04/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022] Open
Abstract
This is a case of congenital afibrinogenemia with multiple thrombotic and hemorrhagic events. His fibrinogen concentration was negatively correlated with thrombin time and prothrombin time and abnormally negatively correlated with plasma D-dimer levels. The individualized standard for fibrinogen concentration may help to balance thrombotic and hemorrhagic events for this disease.
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Affiliation(s)
- Lijian Wei
- Department of Neurologythe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Yuting Tang
- Department of Neurologythe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Zhuohua Wu
- Department of Neurologythe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Pingyi Xu
- Department of Neurologythe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Mingshu Mo
- Department of Neurologythe First Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
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2
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Hadjali-Saichi S, de Mazancourt P, Tapon-Bretaudière J, Mirault T, Guenounou K, Frigaa I, Fischer AM, Chafa O, Helley D. Clinical, biological, and genetic features in an afibrinogenemia patient series in Algeria. Haemophilia 2022; 28:822-831. [PMID: 35488806 PMCID: PMC9540330 DOI: 10.1111/hae.14579] [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: 01/12/2022] [Revised: 04/14/2022] [Accepted: 04/19/2022] [Indexed: 11/28/2022]
Abstract
Introduction The incidence of afibrinogenemia had not been previously reported in Algeria. Afibrinogenemia patients are prone to both haemorrhagic and thrombotic complications. Predictive markers of thrombosis in afibrinogenemia patients are not existent. Aims and methods Clinical and biological data from 46 afibrinogenemia patients are reported. Biological investigations included routine tests, genetics analysis and thrombin generation. Results FGA mutations (four novel and four previously described) and FGB mutations (seven mutations; five novels) were homozygous in all but one family as a result of 28 consanguineous marriages out of 30 discrete families. Incidence of afibrinogenemia in Algeria is at least 3 per million births. Umbilical bleeding was reported in 39/46 cases and was the main discovery circumstance. We also report post trauma or post‐surgery (3/46) bleeding and spontaneous deep vein thrombosis (DVT) in adulthood (1/46), as discovery circumstances. The median age (10.5‐year‐old) of the population reported here explains why there are few hemarthrosis and obstetrical or gynaecological complications in this series. Thrombotic events were reported in seven patients (four spontaneous). Endogenous Thrombin Potential was significantly increased in thrombosis‐prone patients compared to afibrinogenemic patients with and without personal or familial history (1118 vs. 744 and 817 nM IIa × min, respectively). Conclusion The incidence of afibrinogenemia in Algeria is the consequence of consanguineous marriage in families carrying private mutations. The thrombin generation test (TGT) could identify, among afibrinogenemic patients, those presenting a thrombotic risk.
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Affiliation(s)
- Soraya Hadjali-Saichi
- Center for Hemobiology-Blood Transfusion, Mustapha University Hospital, Faculty of Medicine of Algiers, Algiers, Algeria
| | - Philippe de Mazancourt
- Laboratory of molecular biology and UVSQ, UMR 1179, Ambroise Paré Hospital, Boulogne-Billancourt, France
| | | | - Tristan Mirault
- Vascular Medicine department, European Georges Pompidou Hospital, Paris, France
| | - Kahina Guenounou
- Center for Hemobiology-Blood Transfusion, Mustapha University Hospital, Faculty of Medicine of Algiers, Algiers, Algeria
| | - Issam Frigaa
- Center for Hemobiology-Blood Transfusion, Mustapha University Hospital, Faculty of Medicine of Algiers, Algiers, Algeria
| | - Anne-Marie Fischer
- Hematology department, European Georges Pompidou Hospital, Paris University, and UMR-S 970, Paris, France
| | - Ouerdia Chafa
- Center for Hemobiology-Blood Transfusion, Mustapha University Hospital, Faculty of Medicine of Algiers, Algiers, Algeria
| | - Dominique Helley
- Hematology department, European Georges Pompidou Hospital, Paris University, and UMR-S 970, Paris, France
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3
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Hiramatsu D, Ogihara Y, Matsumoto T, Sato K, Takasaki A, Kurita T, Okamoto R, Wada H, Dohi K. Endovascular Treatment for Lower-extremity Arterial Thrombosis in a Patient with Congenital Afibrinogenemia and a History of Bleeding Complications. Intern Med 2022; 61:361-364. [PMID: 34334565 PMCID: PMC8866793 DOI: 10.2169/internalmedicine.7542-21] [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] [Indexed: 11/06/2022] Open
Abstract
Congenital afibrinogenemia is a rare autosomal recessive blood disorder that accompanies thrombotic complications and is associated with bleeding tendency. The management of these opposing complications remains a challenge. Endovascular treatment (EVT) for peripheral arterial thrombosis has not been described in previous studies. A 57-year-old man with congenital afibrinogenemia developed back pain and left lower leg pain. The cause of the pain was confirmed to be renal infarction and lower extremity arterial thrombosis by Doppler ultrasound and contrast-enhanced computed tomography. He was treated with EVT for the lower extremity arterial thrombosis, leading to an excellent short-term improvement without bleeding.
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Affiliation(s)
- Daisuke Hiramatsu
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Yoshito Ogihara
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Takeshi Matsumoto
- Department of Transfusion Medicine and Cell Therapy, Mie University Hospital, Japan
| | - Kei Sato
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Akihiro Takasaki
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Tairo Kurita
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Ryuji Okamoto
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Hideo Wada
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Japan; Associated Department with Mie Graduate School of Medicine, Japan
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
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4
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Congenital dysfibrinogenemia in major surgery: A description of four cases and review of the literature. Clin Chim Acta 2022; 528:1-5. [DOI: 10.1016/j.cca.2022.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/12/2022] [Accepted: 01/16/2022] [Indexed: 12/13/2022]
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5
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Simurda T, Asselta R, Zolkova J, Brunclikova M, Dobrotova M, Kolkova Z, Loderer D, Skornova I, Hudecek J, Lasabova Z, Stasko J, Kubisz P. Congenital Afibrinogenemia and Hypofibrinogenemia: Laboratory and Genetic Testing in Rare Bleeding Disorders with Life-Threatening Clinical Manifestations and Challenging Management. Diagnostics (Basel) 2021; 11:2140. [PMID: 34829490 PMCID: PMC8622093 DOI: 10.3390/diagnostics11112140] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/10/2021] [Accepted: 11/15/2021] [Indexed: 12/19/2022] Open
Abstract
Congenital fibrinogen disorders are rare pathologies of the hemostasis, comprising quantitative (afibrinogenemia, hypofibrinogenemia) and qualitative (dysfibrinogenemia and hypodysfibrinogenemia) disorders. The clinical phenotype is highly heterogeneous, being associated with bleeding, thrombosis, or absence of symptoms. Afibrinogenemia and hypofibrinogenemia are the consequence of mutations in the homozygous, heterozygous, or compound heterozygous state in one of three genes encoding the fibrinogen chains, which can affect the synthesis, assembly, intracellular processing, stability, or secretion of fibrinogen. In addition to standard coagulation tests depending on the formation of fibrin, diagnostics also includes global coagulation assays, which are effective in monitoring the management of replacement therapy. Genetic testing is a key point for confirming the clinical diagnosis. The identification of the precise genetic mutations of congenital fibrinogen disorders is of value to permit early testing of other at risk persons and better understand the correlation between clinical phenotype and genotype. Management of patients with afibrinogenemia is particularly challenging since there are no data from evidence-based medicine studies. Fibrinogen concentrate is used to treat bleeding, whereas for the treatment of thrombotic complications, administered low-molecular-weight heparin is most often. This review deals with updated information about afibrinogenemia and hypofibrinogenemia, contributing to the early diagnosis and effective treatment of these disorders.
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Affiliation(s)
- Tomas Simurda
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (J.Z.); (M.B.); (M.D.); (I.S.); (J.H.); (J.S.); (P.K.)
| | - Rosanna Asselta
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy;
- Humanitas Clinical and Research Center IRCCS, 20089 Rozzano, Italy
| | - Jana Zolkova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (J.Z.); (M.B.); (M.D.); (I.S.); (J.H.); (J.S.); (P.K.)
| | - Monika Brunclikova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (J.Z.); (M.B.); (M.D.); (I.S.); (J.H.); (J.S.); (P.K.)
| | - Miroslava Dobrotova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (J.Z.); (M.B.); (M.D.); (I.S.); (J.H.); (J.S.); (P.K.)
| | - Zuzana Kolkova
- Biomedical Center Martin, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, 03601 Martin, Slovakia; (Z.K.); (D.L.)
| | - Dusan Loderer
- Biomedical Center Martin, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, 03601 Martin, Slovakia; (Z.K.); (D.L.)
| | - Ingrid Skornova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (J.Z.); (M.B.); (M.D.); (I.S.); (J.H.); (J.S.); (P.K.)
| | - Jan Hudecek
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (J.Z.); (M.B.); (M.D.); (I.S.); (J.H.); (J.S.); (P.K.)
| | - Zora Lasabova
- Department of Molecular Biology and Genomics, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, 03601 Martin, Slovakia;
| | - Jan Stasko
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (J.Z.); (M.B.); (M.D.); (I.S.); (J.H.); (J.S.); (P.K.)
| | - Peter Kubisz
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (J.Z.); (M.B.); (M.D.); (I.S.); (J.H.); (J.S.); (P.K.)
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6
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Casini A, Neerman-Arbez M, de Moerloose P. Heterogeneity of congenital afibrinogenemia, from epidemiology to clinical consequences and management. Blood Rev 2020; 48:100793. [PMID: 33419567 DOI: 10.1016/j.blre.2020.100793] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 11/06/2020] [Accepted: 12/06/2020] [Indexed: 12/17/2022]
Abstract
Fibrinogen is a complex protein playing a major role in coagulation. Congenital afibrinogenemia, characterized by the complete absence of fibrinogen, is associated with major hemostatic defects. Even though the clinical course is unpredictable and can be completely different among patients, severe bleeding is the prominent symptom. Patients are also at increased risk of thrombosis and sometimes suffer from spontaneous spleen rupture, bone cysts and defective wound healing. Due to the relative rarity of afibrinogenemia, there are no evidence-based strategies for helping physicians in care of these patients. Fibrinogen supplementation is the keystone to prevent or treat bleeding events. In addition, fibrinogen, a pleiotropic protein with numerous physiological roles in immunity, angiogenesis and tissue repair, is involved in many diseases. Indeed, depletion of fibrinogen in animal models of infections, tumors and neurological diseases has an effect on the clinical course. The consequences for patients with afibrinogenemia still need to be investigated.
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Affiliation(s)
- Alessandro Casini
- Division of Angiology and Hemostasis, University Hospitals of Geneva, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland.
| | - Marguerite Neerman-Arbez
- Department of Genetic Medicine and Development, Faculty of Medicine, University of Geneva, 1 Rue Michel Servet, 1211 Geneva, Switzerland.
| | - Philippe de Moerloose
- Faculty of Medicine, University of Geneva, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland.
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Caimi G, Raso S, Napolitano M, Hopps E, Lo Presti R, Siragusa S. Haemorheological profile in congenital afibrinogenemia and in congenital dysfibrinogenemia: A clinical case report. Clin Hemorheol Microcirc 2020; 73:523-530. [DOI: 10.3233/ch-180542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- G. Caimi
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Università degli Studi di Palermo, Palermo, Italy
| | - S. Raso
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Università degli Studi di Palermo, Palermo, Italy
| | - M. Napolitano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Università degli Studi di Palermo, Palermo, Italy
| | - E. Hopps
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Università degli Studi di Palermo, Palermo, Italy
| | - R. Lo Presti
- Department of Psychology, Educational Science and Human Movement, Università degli Studi di Palermo, Palermo, Italy
| | - S. Siragusa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Università degli Studi di Palermo, Palermo, Italy
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8
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Shapiro A. The use of prophylaxis in the treatment of rare bleeding disorders. Thromb Res 2019; 196:590-602. [PMID: 31420204 DOI: 10.1016/j.thromres.2019.07.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 07/02/2019] [Accepted: 07/16/2019] [Indexed: 12/15/2022]
Abstract
Rare bleeding disorders (RBDs) are a heterogeneous group of coagulation factor deficiencies that include fibrinogen, prothrombin, α2-antiplasmin, plasminogen activator inhibitor-1, and factors II, V, V/VIII, VII, X, XI and XIII. The incidence varies based upon the disorder and typically ranges from 1 in 500,000 to 1 per million population. Symptoms vary with the disorder and residual level of the clotting factor, and can range from relatively minor such as epistaxis, to life threatening, such as intracranial hemorrhage. Rapid treatment of bleeding episodes in individuals with severe bleeding phenotypes is essential to preserve life or limb and to prevent long-term sequelae; therapeutic options depend on the deficiency and range from plasma-derived (eg, fresh frozen plasma, prothrombin complex concentrates, factor X concentrate) to highly purified and recombinant single factor concentrates. The rarity of these disorders limits the feasibility of conventional prospective clinical trials; instead, clinicians rely upon registries, published case reports/series and experience to guide treatment. In some disorders, long-term prophylactic therapy is administered in response to the bleeding phenotype in an individual patient or based on the known natural history and severity of the deficiency. Intermittent prophylaxis, surrounding surgery, pregnancy, labor, and menstruation may be required to prevent or control excessive bleeding. This review summarizes therapeutic options, guidelines, recommendations and observations from the published literature for long-term, surgical, gynecological, and obstetric prophylaxis in deficiencies of fibrinogen; prothrombin; factors II, V, V/VIII, VII, X, XI and XIII; combined vitamin-K dependent factors; α2-antiplasmin; and plasminogen activator inhibitor 1. Platelet disorders including Glanzmann's thrombasthenia and Bernard-Soulier syndrome are also addressed.
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Affiliation(s)
- Amy Shapiro
- Indiana Hemophilia & Thrombosis Center, 8326 Naab Rd., Indianapolis, IN 46260, USA.
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9
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Skaadel H, Bruserud Ø. Thrombotic complications in adult patients with severe single coagulation factor or platelet defects – an overview. Expert Rev Hematol 2019; 12:119-128. [DOI: 10.1080/17474086.2019.1570126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Hanne Skaadel
- Section for Hematology, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Øystein Bruserud
- Section for Hematology, Department of Clinical Science, University of Bergen, Bergen, Norway
- Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen, Norway
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10
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Girolami A, Ferrari S, Cosi E, Santarossa C, Randi ML. Vitamin K-Dependent Coagulation Factors That May be Responsible for Both Bleeding and Thrombosis (FII, FVII, and FIX). Clin Appl Thromb Hemost 2018; 24:42S-47S. [PMID: 30428703 PMCID: PMC6714837 DOI: 10.1177/1076029618811109] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Vitamin K-dependent clotting factors are commonly divided into prohemorrhagic
(FII, FVII, FIX, and FX) and antithrombotic (protein C and protein S).
Furthermore, another protein (protein Z) does not seem strictly correlated with
blood clotting. As a consequence of this assumption, vitamin K-dependent defects
were considered as hemorrhagic or thrombotic disorders. Recent clinical
observations, and especially, recent advances in molecular biology
investigations, have demonstrated that this was incorrect. In 2009, it was
demonstrated that the mutation Arg338Leu in exon 8 of FIX was associated with
the appearance of a thrombophilic state and venous thrombosis. The defect was
characterized by a 10-fold increased activity in FIX activity, while FIX antigen
was only slightly increased (FIX Padua). On the other hand, it was noted on
clinical grounds that the thrombosis, mainly venous, was present in about 2% to
3% of patients with FVII deficiency. It was subsequently demonstrated that 2
mutations in FVII, namely, Arg304Gln and Ala294Val, were particularly affected.
Both these mutations are type 2 defects, namely, they show low activity but
normal or near-normal FVII antigen. More recently, in 2011-2012, it was noted
that prothrombin defects due to mutations of Arg596 to Leu, Gln, or Trp in exon
15 cause the appearance of a dysprothrombinemia that shows no bleeding tendency
but instead a prothrombotic state with venous thrombosis. On the contrary, no
abnormality of protein C or protein S has been shown to be associated with
bleeding rather than with thrombosis. These studies have considerably widened
the spectrum and significance of blood coagulation studies.
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Affiliation(s)
- Antonio Girolami
- Department of Medicine, University of Padua Medical School, Padua, Italy
| | - Silvia Ferrari
- Department of Medicine, University of Padua Medical School, Padua, Italy
| | - Elisabetta Cosi
- Department of Medicine, University of Padua Medical School, Padua, Italy
| | - Claudia Santarossa
- Department of Medicine, University of Padua Medical School, Padua, Italy
| | - Maria Luigia Randi
- Department of Medicine, University of Padua Medical School, Padua, Italy
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Le Quellec S, Desjonqueres A, Rugeri L, Desmurs Clavel H, Farhat F, Mechtouff L, Dargaud Y. Combined life-threatening thromboses and hemorrhages in a patient with afibrinogenemia and antithrombin deficiency. Thromb J 2018; 16:6. [PMID: 29636644 PMCID: PMC5883424 DOI: 10.1186/s12959-018-0162-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 01/04/2018] [Indexed: 11/10/2022] Open
Abstract
Background Patients with congenital afibrinogenemia suffer from spontaneous recurrent severe bleeding. While fibrinogen concentrates are known to effectively treat bleeding episodes, thrombotic complications often occur upon replacement therapy, rendering clinical management highly challenging. Case Presentation We hereby report a case of combined afibrinogenemia and congenital antithrombin deficiency manifested by recurrent life-threatening bleeding, as well as spontaneous severe arterial occlusion, such as acute coronary syndrome and stroke, and venous thromboses like pulmonary embolism. Secondary fibrinogen prophylaxis is recommended following any initial life-threatening bleeding episode in patients with afibrinogenemia, yet the high associated risk of thrombosis illustrates the complexity of choosing the most effective prophylaxis strategy combining fibrinogen concentrate with antithrombotic agent for optimal protection against the risk of both severe bleeding and thrombosis. For our patient, the thrombin generation assay objectively confirmed her prothrombotic tendency. Conclusion This case may help us better understand the pathophysiology of arterial thrombosis in afibrinogenemia, while highlighting the difficulty of managing such complications.
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Affiliation(s)
- S Le Quellec
- 1Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, 28, avenue Doyen J. Lepine, Bron, F-69500 Lyon, France
| | - A Desjonqueres
- 1Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, 28, avenue Doyen J. Lepine, Bron, F-69500 Lyon, France
| | - L Rugeri
- 1Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, 28, avenue Doyen J. Lepine, Bron, F-69500 Lyon, France
| | - H Desmurs Clavel
- 2Service de Médecine Interne, Hôpital Edouard Herriot, Lyon, France
| | - F Farhat
- 3Service de Chirurgie Cardiaque, Hôpital Cardiologique Louis Pradel, Lyon, France
| | - L Mechtouff
- Service Neuro-Vasculaire, Hôpital Neurologique Wertheimer, Lyon, France
| | - Y Dargaud
- 1Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, 28, avenue Doyen J. Lepine, Bron, F-69500 Lyon, France
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Nagler M, Alberio L, Peter-Salonen K, von Tengg-Kobligk H, Lottaz D, Neerman-Arbez M, Lämmle B, Kremer Hovinga JA. Thromboembolism in patients with congenital afibrinogenaemia. Thromb Haemost 2017; 116:722-32. [DOI: 10.1160/th16-02-0082] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 06/02/2016] [Indexed: 11/05/2022]
Abstract
SummaryFrequent arterial and venous thromboembolism in patients with congenital afibrinogenaemia (CA) is neither understood nor is a safe and effective treatment established. It was our objective to report on the clinical observations and laboratory data contributing to the understanding of the frequency, physiopathology, prognosis and treatment of CA. We observed the long-term clinical course and laboratory data in a cohort of four patients with CA and thromboembolic complications, and conducted a systematic review retrieving all available data. Four patients with CA developed recurrent and extensive arterial and venous thromboembolism (TE) from an age of 25–51 years. In two patients, a treatment strategy targeting at maintaining constantly measurable fibrinogen (Fbg) levels (≥0.5 g/l) either by regular Fbg replacement or by orthotopic liver transplantation resulted in long-term remissions. Radiological imaging documented resolved arterial thrombi after 6–12 months. In contrast, recurrent thromboembolic events were observed in two other patients with infrequent Fbg replacement. A systematic review of the literature revealed 48 reports of TE in patients with CA (median age at first event 31 years), and a favourable outcome in most patients with frequent application of Fbg, aimed at constantly measurable trough levels. Present data suggests that patients with CA are at high risk of arterial and venous thromboembolic events, probably caused by thrombin excess owing to lack of thrombin scavenging by Fbg/fibrin. Regular low-dose Fbg replacement might be a safe and effective treatment option in patients with CA and thromboembolic complications.Note: Preliminary data of this report were presented as oral presentation at the XXV Congress of the International Society on Thrombosis and Haemostasis, June 20th to 25th, Toronto, Canada.Supplementary Material to this article is available online at www.thrombosis-online.com.
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Stanciakova L, Kubisz P, Dobrotova M, Stasko J. Congenital afibrinogenemia: from etiopathogenesis to challenging clinical management. Expert Rev Hematol 2017; 9:639-48. [PMID: 27291795 DOI: 10.1080/17474086.2016.1200967] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Congenital afibrinogenemia belongs to the group of autosomal recessive bleeding disorders and represents the absolute deficiency of fibrinogen detected by an antigenic test. This can lead to severe clinical manifestations of the disorder. Therefore, it is very important to take afibrinogenemia into account in the process of the differential diagnostics of the patients. AREAS COVERED The authors provide a summary of currently available literature about afibrinogenemia. They collected the information from the scientific journals dedicated to thrombosis and hemostasis and searched world-wide databases. Expert commentary: The most frequent clinical manifestation of this disorder is mucosal bleeding, but musculoskeletal bleeding pattern, gynecologic and obstetric issues, spontaneous bleeding, episodes provoked by minor injury or any other intervention, and even paradoxical thromboembolic events have been published. Afibrinogenemia is the consequence of mutations of the homozygous or compound heterozygous type in gene FGA, FGB or FGG encoding fibrinogen. Pregnant women with a family history, or with a history of consanguinity ought to be properly counselled. However, primary prophylaxis of bleeding events is not suggested. The article deals with actual information about afibrinogenemia contributing to its early diagnosis and effective treatment, which in many cases requires multidisciplinary approach.
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Affiliation(s)
- Lucia Stanciakova
- a National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology , Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital , Martin , Slovakia
| | - Peter Kubisz
- a National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology , Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital , Martin , Slovakia
| | - Miroslava Dobrotova
- a National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology , Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital , Martin , Slovakia
| | - Jan Stasko
- a National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology , Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital , Martin , Slovakia
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14
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Korte W, Poon MC, Iorio A, Makris M. Thrombosis in Inherited Fibrinogen Disorders. Transfus Med Hemother 2017; 44:70-76. [PMID: 28503122 DOI: 10.1159/000452864] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 10/26/2016] [Indexed: 12/17/2022] Open
Abstract
Although inherited fibrinogen disorders (IFD) are primarily considered to be bleeding disorders, they are associated with a higher thrombotic complication risk than defects in other clotting factors. Managing IFD patients with thrombosis is challenging as anticoagulant treatment may exacerbate the underlying bleeding risk which can be life-threatening. Due to the low prevalence of IFD, there is little information on pathophysiology or optimal treatment of thrombosis in these patients. We searched the literature for cases of thrombosis among IFD patients and identified a total of 128 patient reports. In approximately half of the cases, thromboses were spontaneous, while in the others trauma, surgery, and parturition contributed to the risk. The true mechanism(s) of thrombosis in IFD patients remain to be elucidated. A variety of anticoagulant treatments have been used in the treatment or prevention of thrombosis, sometimes with concurrent fibrinogen replacement therapy. There is no definite evidence that fibrinogen supplementation increases the risk of thrombosis, and it may potentially be effective in the treatment and prevention of both thrombosis and hemorrhage in IFD patients.
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Affiliation(s)
- Wolfgang Korte
- Center for Laboratory Medicine; and Hemostasis and Hemophilia Center St. Gallen, Switzerland
| | - Man-Chiu Poon
- Department of Medicine, Pediatrics and Oncology, University of Calgary, Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Hospital, Calgary, AB, Canada
| | - Alfonso Iorio
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Michael Makris
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK.,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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15
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Ozker E, Atalay F, Gulmez O, Saritas B. Treating a Patient of Dysfibrinogenemia with Acute Thromboembolism by Rivaroxaban and Cilostazol. Indian J Hematol Blood Transfus 2016; 33:431-433. [PMID: 28824252 DOI: 10.1007/s12288-016-0751-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 11/15/2016] [Indexed: 11/28/2022] Open
Abstract
Congenital dysfibrinogenemia is a rare autosomal recessive bleeding disorder, which is characterized by the absence of functional fibrinogen. Patients may have bleeding and paradoxical arterial and venous thrombotic problems from early childhood. The optimal antithrombotic therapy in these patients hasn't been determined yet. In this report we present a dysfibrogenemic patient, who has suffered recurrent arterial thrombosis under aspirin treatment. Intravenous fibrinogen concentrates (fc) along with reduced doses of rivaroxaban (10 mg daily), cilostazol (50 mg bid) and aspirin (100 mg daily) were given as antithrombotic treatment. The pain and the cyanosis clinically recovered within 6 weeks. This is, to our knowledge, the first time in which a new oral anticoagulant, rivaroxaban and cilostazol combination was used in a dysfibrinogenemic patient with thrombotic episodes. We determined the type, the dosage and the duration of antithrombotic treatment according to the clinical progress of the symptoms. Rivaroxaban, cilostazol and fibrinogen concentrate replacement; combination may represent a useful alternative for the antithrombotic treatment in dysfibrinogenemic patients.
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Affiliation(s)
- Emre Ozker
- Department of Cardiovascular Surgery, Baskent University Istanbul Hospital, Oymaci Sk, No:7, Altunizade, 34662 Istanbul, Turkey
| | - Figen Atalay
- Department of Hematology, Baskent University Istanbul Hospital, Istanbul, Turkey
| | - Oyku Gulmez
- Department of Cardiology, Baskent University Istanbul Hospital, Istanbul, Turkey
| | - Bulent Saritas
- Department of Cardiovascular Surgery, Baskent University Istanbul Hospital, Oymaci Sk, No:7, Altunizade, 34662 Istanbul, Turkey
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16
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Casini A, de Moerloose P. Can the phenotype of inherited fibrinogen disorders be predicted? Haemophilia 2016; 22:667-75. [PMID: 27293018 DOI: 10.1111/hae.12967] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2016] [Indexed: 12/17/2022]
Abstract
Congenital fibrinogen disorders are rare diseases affecting either the quantity (afibrinogenaemia and hypofibrinogenaemia) or the quality (dysfibrinogenaemia) or both (hypodysfibrinogenaemia) of fibrinogen. In addition to bleeding, unexpected thrombosis, spontaneous spleen ruptures, painful bone cysts and intrahepatic inclusions can complicate the clinical course of patients with quantitative fibrinogen disorders. Clinical manifestations of dysfibrinogenaemia include absence of symptoms, major bleeding or thrombosis as well as systemic amyloidosis. Although the diagnosis of any type of congenital fibrinogen disorders is usually not too difficult with the help of conventional laboratory tests completed by genetic studies, the correlation between all available tests and the clinical manifestations is more problematic in many cases. Improving accuracy of diagnosis, performing genotype, analysing function of fibrinogen variants and carefully investigating the personal and familial histories may lead to a better assessment of patients' phenotype and therefore help in identifying patients at increased risk of adverse clinical outcomes. This review provides an update of various tests (conventional and global assays, molecular testing, fibrin clot analysis) and clinical features, which may help to better predict the phenotype of the different types of congenital fibrinogen disorders.
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Affiliation(s)
- A Casini
- Division of Angiology and Haemostasis, University Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | - P de Moerloose
- Division of Angiology and Haemostasis, University Hospitals and Faculty of Medicine, Geneva, Switzerland
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17
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Berens C, Rühl H, Ivaškevičius V, Oldenburg J, Hertfelder HJ, Pötzsch B. Recurrent VTE in a heterozygote of the fibrinogen Aα IVS4+1G>T and Aα p.Arg168Ter mutation. Thromb Haemost 2016; 115:1073-5. [PMID: 26763372 DOI: 10.1160/th15-10-0818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 12/07/2015] [Indexed: 12/17/2022]
Affiliation(s)
| | - Heiko Rühl
- Heiko Rühl, MD, Institute of Experimental Haematology and Transfusion Medicine, University of Bonn, Sigmund-Freud-Str. 25, D-53105 Bonn, Germany, Tel.: +49 228 287 16725, Fax: +49 228 287 14783, E-mail:
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18
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Yakovleva EV, Surin VL, Selivanova DS, Sergeeva AM, Gonсharova MV, Demidova EY, Soboleva NP, Makhinya SA, Dezhenkova AV, Likhacheva EA, Zozulya NI. [Hereditary afibrinogenemia: A literature review and clinical observations]. TERAPEVT ARKH 2016. [PMID: 28635887 DOI: 10.17116/terarkh20168812120-125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Afibrinogenemia is a rare congenital coagulopathy that leads to life-threatening bleeding. In afibrinogenemia, plasma fibrinogen levels are less than 0.1 g/L. The clinical manifestations of the disease can be both bleeding and thromboses of different localizations, which is determined by the multifunctional role of fibrinogen in hemostasis. The described cases demonstrate different clinical phenotypes of the disease. In both cases the diagnosis was confirmed by genetic examinations that revealed homozygous mutations in the fibrinogen A genes. The nature of the mutations assumes consanguineous marriages, as confirmed by the results of a genealogical analysis. Fibrinogen preparations are promising in treating afibrinogenemia in Russia.
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Affiliation(s)
- E V Yakovleva
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - V L Surin
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - D S Selivanova
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - A M Sergeeva
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - M V Gonсharova
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - E Yu Demidova
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - N P Soboleva
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - S A Makhinya
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - A V Dezhenkova
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - E A Likhacheva
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - N I Zozulya
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
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19
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20
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Casini A, de Moerloose P. Factor concentrates for rare congenital coagulation disorders: where are we now? Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2016.1108188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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21
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Gallastegui N, Kimble EL, Harrington TJ. Resolution of fibrinogen deficiency in a patient with congenital afibrinogenemia after liver transplantation. Haemophilia 2015; 22:e48-51. [DOI: 10.1111/hae.12802] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2015] [Indexed: 11/28/2022]
Affiliation(s)
- N. Gallastegui
- Department of Medicine; University of Miami Miller School of Medicine/Jackson Memorial Hospital; Miami FL USA
| | - E. L. Kimble
- Department of Medicine; University of Miami Miller School of Medicine/Jackson Memorial Hospital; Miami FL USA
| | - T. J. Harrington
- Department of Medicine; University of Miami Miller School of Medicine/Jackson Memorial Hospital; Miami FL USA
- Division of Hematology/Oncology; Department of Medicine; Hemophilia Treatment Center; University of Miami Miller School of Medicine/Sylvester Comprehensive Cancer Center; Miami FL USA
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