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Santoro RC, Molinari AC, Leotta M, Martini T. Isolated Prolongation of Activated Partial Thromboplastin Time: Not Just Bleeding Risk! MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1169. [PMID: 37374373 DOI: 10.3390/medicina59061169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023]
Abstract
Activated partial thromboplastin time (aPTT) is a fundamental screening test for coagulation disturbances. An increased aPTT ratio is quite common in clinical practice. How the detection of prolonged activated aPTT with a normal prothrombin time is interpreted is therefore very important. In daily practice, the detection of this abnormality often leads to delayed surgery and emotional stress for patients and their families and may be associated with increased costs due to re-testing and coagulation factor assessment. An isolated, prolonged aPTT is seen in (a) patients with congenital or acquired deficiencies of specific coagulation factors, (b) patients receiving treatment with anticoagulants, mainly heparin, and (c) individuals/patients with circulating anticoagulants. We summarize here what may cause an isolated prolonged aPTT and evaluate the preanalytical interferences. The identification of the cause of an isolated prolonged aPTT is of the utmost importance in ensuring the correct diagnostic workup and therapeutic choices.
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Affiliation(s)
- Rita Carlotta Santoro
- Hemostasis and Thrombosis Unit, Azienda Ospedaliera Pugliese-Ciaccio, 88100 Catanzaro, Italy
| | | | - Marzia Leotta
- Hemostasis and Thrombosis Unit, Azienda Ospedaliera Pugliese-Ciaccio, 88100 Catanzaro, Italy
| | - Tiziano Martini
- Immuno-Haematology and Transfusion Medicine, Center for Congenital Bleeding Disorders, Cesena General Hospital, 47521 Cesena, Italy
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Ruberti A, Kremer Hovinga JA, Nappi F, Vettese A, Bianchi E, Fernandes E, Galfetti E, Monotti R, Paul P, Regazzoni S, Valente D, Rossi D, Stussi G, Gerber B. Acquired haemophilia A in southern Switzerland from 2013 to 2019: a case series. Swiss Med Wkly 2023; 153:40048. [PMID: 37021783 DOI: 10.57187/smw.2023.40048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
AIMS OF THE STUDY: Acquired haemophilia A is a rare disease with an annual incidence of 1.48 per million. Based on clinical observations, we suspect a higher incidence in southern Switzerland, and aimed at providing local epidemiological data, and clinical information regarding diagnosis, treatment and outcome in our region.
METHODS: All adult patients with acquired haemophilia A treated between 2013 and 2019 in our facility were included in the present retrospective analysis.
RESULTS: We treated 11 patients with acquired haemophilia A between 2013 and 2019, resulting in an annual incidence of 4.5 per million (95% confidence interval [CI] 0–9.0). Median delay from first symptoms to diagnosis was 4.5 days, and the median age at diagnosis was 79 years (range 23–87). Possible causative conditions were: pregnancy (n = 1), polyarteritis nodosa (n = 1), myelodysplastic syndrome (n = 1), chronic human immunodeficiency virus (HIV) (n = 1), and HIV postexposure prophylaxis (n = 1). In five patients no underlying or associated condition was identified. Median activated partial thromboplastin time (aPTT)) at baseline was 79 seconds (65–117; ref. value <38 sec), and FVIII:C 2.15% (<1–3.75%). A FVIII:C <1% was present in 4/10 patients. Median FVIII-inhibitor titre was 10.3 BU/ml (2.4–75.0 BU/ml). All patients had bleeding symptoms, 5/10 patients had major bleedings, and 7/10 patients were treated with bypassing agents. All patients received corticosteroids; 7/10 patients received immunosuppressive combination therapy. FVIII levels of ≥50% were achieved after a median of 40 days (8–62). One patient had a severe immunosuppressive therapy-related infection. An 87-years-old woman died for reasons not related to acquired haemophilia A or immunosuppressive therapy.
CONCLUSIONS: Acquired haemophilia A is a rare disease, but manageable despite the advanced patient age and comorbidities. Its incidence in Southern Switzerland is higher than previously suspected.
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Affiliation(s)
- Andrea Ruberti
- Department of Internal Medicine, Ospedale La Carità, Locarno, Switzerland
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Johanna A Kremer Hovinga
- Department of Haematology and Central Haematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Federico Nappi
- Department of Internal Medicine, Ospedale La Carità, Locarno, Switzerland
| | - Aurora Vettese
- Department of Laboratory Medicine EOLAB, Bellinzona, Switzerland
| | - Elena Bianchi
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Eliana Fernandes
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Elena Galfetti
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Rita Monotti
- Department of Internal Medicine, Ospedale La Carità, Locarno, Switzerland
| | - Pamella Paul
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Stefano Regazzoni
- Department of Internal Medicine, Ospedale Civico, Lugano, Switzerland
| | | | - Davide Rossi
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
- Laboratory of Experimental Haematology, Institute of Oncology Research, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Georg Stussi
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Bernhard Gerber
- Department of Laboratory Medicine EOLAB, Bellinzona, Switzerland
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
- University of Zurich, Switzerland
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Perioperative diagnosis and impact of acquired von Willebrand syndrome in infants with congenital heart disease. Blood 2023; 141:102-110. [PMID: 36054926 DOI: 10.1182/blood.2022015699] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 07/06/2022] [Accepted: 08/11/2022] [Indexed: 01/28/2023] Open
Abstract
Acquired von Willebrand syndrome (aVWS) has been reported in patients with congenital heart diseases associated with shear stress caused by significant blood flow gradients. Its etiology and impact on intraoperative bleeding during pediatric cardiac surgery have not been systematically studied. This single-center, prospective, observational study investigated appropriate diagnostic tools of aVWS compared with multimer analysis as diagnostic criterion standard and aimed to clarify the role of aVWS in intraoperative hemorrhage. A total of 65 newborns and infants aged 0 to 12 months scheduled for cardiac surgery at our tertiary referral center from March 2018 to July 2019 were included in the analysis. The glycoprotein Ib M assay (GPIbM)/von Willebrand factor antigen (VWF:Ag) ratio provided the best predictability of aVWS (area under the receiver operating characteristic curve [AUC], 0.81 [95% CI, 0.75-0.86]), followed by VWF collagen binding assay/VWF:Ag ratio (AUC, 0.70 [0.63-0.77]) and peak systolic echocardiographic gradients (AUC, 0.69 [0.62-0.76]). A cutoff value of 0.83 was proposed for the GPIbM/VWF:Ag ratio. Intraoperative high-molecular-weight multimer ratios were inversely correlated with cardiopulmonary bypass (CPB) time (r = -0.57) and aortic cross-clamp time (r = -0.54). Patients with intraoperative aVWS received significantly more fresh frozen plasma (P = .016) and fibrinogen concentrate (P = .011) than those without. The amounts of other administered blood components and chest closure times did not differ significantly. CPB appears to trigger aVWS in pediatric cardiac surgery. The GPIbM/VWF:Ag ratio is a reliable test that can be included in routine intraoperative laboratory workup. Our data provide the basis for further studies in larger patient cohorts to achieve definitive clarification of the effects of aVWS and its potential treatment on intraoperative bleeding.
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Hirsiger JR, Martinez M, Tsakiris DA, Cittone MG, Graf L, Oldenburg J, Pezeshkpoor B, Recher M, Mueller J, Gerber B, Berger CT. Investigating potential mechanisms underlying FVIII inhibition in acquired hemophilia A associated with mRNA COVID-19 vaccines. J Thromb Haemost 2022; 20:1015-1018. [PMID: 35108443 PMCID: PMC9303467 DOI: 10.1111/jth.15665] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/22/2022] [Accepted: 01/31/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Julia R Hirsiger
- Translational Immunology, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Maria Martinez
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | | | - Micol G Cittone
- Clinic of Hematology, Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland
| | - Lukas Graf
- Hemophilia and Hemostasis Center, Centre for Laboratory Medicine, St. Gallen, Switzerland
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
| | - Behnaz Pezeshkpoor
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
| | - Mike Recher
- Immunodeficiency, Department of Biomedicine, University of Basel, Basel, Switzerland
- University Center for Immunology, University Hospital Basel, Basel, Switzerland
| | - Jens Mueller
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Christoph T Berger
- Translational Immunology, Department of Biomedicine, University of Basel, Basel, Switzerland
- University Center for Immunology, University Hospital Basel, Basel, Switzerland
- Immunization Clinic, Medical Outpatient Clinic, University Hospital Basel, Basel, Switzerland
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Khalife R, Duffett L, Wang TF, Tinmouth A. Déclenchement soudain de règles abondantes chez une femme de 34 ans. CMAJ 2021; 193:E1643-E1646. [PMID: 34697103 PMCID: PMC8562987 DOI: 10.1503/cmaj.210169-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Roy Khalife
- Département de médecine de l'Université d'Ottawa, Hôpital d'Ottawa et Institut de recherche de l'Hôpital d'Ottawa, Ottawa, Ont.
| | - Lisa Duffett
- Département de médecine de l'Université d'Ottawa, Hôpital d'Ottawa et Institut de recherche de l'Hôpital d'Ottawa, Ottawa, Ont
| | - Tzu-Fei Wang
- Département de médecine de l'Université d'Ottawa, Hôpital d'Ottawa et Institut de recherche de l'Hôpital d'Ottawa, Ottawa, Ont
| | - Alan Tinmouth
- Département de médecine de l'Université d'Ottawa, Hôpital d'Ottawa et Institut de recherche de l'Hôpital d'Ottawa, Ottawa, Ont
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Khalife R, Duffett L, Wang TF, Tinmouth A. New onset of acute heavy menstrual bleeding in a 34-year-old woman. CMAJ 2021; 193:E1173-E1176. [PMID: 34344772 PMCID: PMC8354654 DOI: 10.1503/cmaj.210169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Roy Khalife
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Ont.
| | - Lisa Duffett
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Ont
| | - Tzu-Fei Wang
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Ont
| | - Alan Tinmouth
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Ont
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Korsten P, Wallbach M, Binder C. Type 2A von Willebrand disease and systemic sclerosis: Vonicog alfa reduced gastrointestinal bleeding. Res Pract Thromb Haemost 2020; 4:1230-1234. [PMID: 33134789 PMCID: PMC7590322 DOI: 10.1002/rth2.12426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 12/28/2022] Open
Abstract
Von Willebrand disease (VWD) is a bleeding disorder caused by qualitative or quantitative defects of von Willebrand factor (VWF). This case report of a patient with systemic sclerosis and gastrointestinal bleeding from angiodysplasias seeks to address the key clinical question of a useful diagnostic and therapeutic approach in this setting. The extent of vascular malformations and the frequency of bleeding episodes were unusually severe, and we reached a diagnosis of inherited type 2A VWD. After an insufficient effect of treatment with factor VIII (FVIII)/VWF, prophylactic administration of vonicog alfa, a recombinant VWF preparation without FVIII, was initiated. This therapy led to a substantial reduction of transfusion requirements and the improvement of angiodysplasias. In refractory gastrointestinal bleeding, hemostaseological evaluation is crucial, as inherited disorders of hemostasis may go unnoticed, especially in patients with underlying autoimmune diseases, where complications may be ascribed to the underlying disease.
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Affiliation(s)
- Peter Korsten
- Department of Nephrology and RheumatologyUniversity Medical Center GöttingenGöttingenGermany
| | - Manuel Wallbach
- Department of Nephrology and RheumatologyUniversity Medical Center GöttingenGöttingenGermany
| | - Claudia Binder
- Department of Hematology and Medical OncologyUniversity Medical Center GöttingenGöttingenGermany
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