Acquired factor V inhibitor in a critically ill patient

Delayed spontaneous remission of acquired factor V inhibitor refractory to immunosuppressive therapy with pregnancy-associated improvement

Introduction: Acquired factor V inhibitor (AFVI) is a rare autoimmune bleeding disorder. The treatment of AFVI is challenging, and patients often require both bleeding control and inhibitor eradication. Methods: We conducted a retrospective analysis of the medical records of a 35-year-old Caucasian woman who presented with severe AFVI-induced bleeding and subsequent immunosuppressive therapy. Results: To provide haemostasis, rFVIIa was given with good efficacy. The patient was treated with various combinations of immunosuppressive regimens over the course of 2.5 years, including plasmapheresis plus immunoglobulins, dexamethasone + rituximab, cyclophosphamide + dexamethasone + rituximab + cyclosporine, cyclosporin + sirolimus + cyclophosphamide + dexamethasone, bortezomib + sirolimus + methylprednisolone, and sirolimus + mycophenolate mofetil. Although these treatment modalities resulted in intermittent partial reversals of AFVI over 2.5 years, eventually the inhibitor became therapy-resistant. However, following the discontinuation of all immunosuppressive therapy, the patient experienced a partial spontaneous remission, which was followed by a pregnancy. During the pregnancy, the FV activity increased to 54% and the coagulation parameters returned to normal levels. The patient underwent Caesarean section without any bleeding complications and delivered a healthy child. Discussion: The use of an activated bypassing agent for bleeding control is effective in patients with severe AFVI. The presented case is unique because the treatment regimens included multiple combinations of immunosuppressive agents. This demonstrates that AFVI patients may undergo spontaneous remission even after multiple courses of ineffective immunosuppressive protocols. Additionally, pregnancy-associated improvement of AFVI is an important finding that warrants further investigation.

Plasma Exchange as an Initial Treatment for Severe Bleeding Induced by Acquired Factor V Deficiency: A Case Report and Mini Literature Review

Acquired factor V deficiency (AFVD) is a rare autoimmune bleeding disorder. Unlike acquired hemophilia, bypass therapies with recombinant activated factor VII and activated prothrombin complex concentrates are ineffective for severe bleeding due to AFVD. Although several treatment strategies have been attempted, a standard of care for severe hemorrhage induced by AFVD is lacking. Herein, we report a case of AFVD with severe bleeding that responded to plasma exchange (PE) combined with immunosuppression. We also reviewed previously reported AFVD cases with severe hemorrhage and suggest that PE may be an effective initial treatment for AFVD-induced severe hemorrhage.

Acquired factor V inhibitors after allogeneic hematopoietic stem cell transplantation in a dog

Objective

Describe the clinical course and management of a dog that underwent hematopoietic stem cell transplantation (HSCT) for treatment of B‐cell lymphoma and developed acquired circulating factor V (FV) inhibitors.

Case Summary

An 8‐year‐old male castrated Briard dog diagnosed with lymphoma (IVb, B‐cell) presented for allogeneic HSCT. Despite multiple platelet, fresh frozen plasma, and red blood cell transfusions prolonged recovery and clinical bleeding occurred. Circulating acquired FV inhibitors were identified and hemorrhage subsequently was managed by immunosuppression. The dog was discharged when clinical resolution of bleeding was achieved.

New or Unique Information Provided

This case report describes a dog undergoing curative intent treatment for lymphoma, and subsequently acquiring factor inhibition, and was successfully managed. Specific coagulation screening to assess for coagulation factor deficiencies or inhibitors is essential in the diagnosis and treatment of patients with refractory bleeding or only transient response to blood transfusion.

Acquired factor V inhibitor after liver transplantation

Acquired inhibitors against coagulation factor V (FV) occur rarely, the clinical symptoms vary to a great extent, from asymptomatic laboratory abnormalities to life-threatening bleeding. Coagulation factor V (FV) is a plasma-cofactor mostly existing in the plasma, and approximately 20-25% (Tracy et al. (1982), Kane (2006)) of FV exist in platelet granules. Patients' reaction is the prolonging of prothrombin time (PT) and activated partial thromboplastin time (APTT), but there is no exact reason, and that can not be corrected after normal plasma transfusion (Morris and Curris (2009), Lucia and Aguilar (2005)). We report here a case of the occurrence of FV inhibitors after orthotopic liver transplantation (OLT). With gastrointestinal bleeding, patient's haemostatic response was not achieved after using fresh frozenplasma (FFP), platelet concentrates (PC), prothrombin complex concentrates (PCC) or recombinant activated FVII (rFVIIa). After using high-dose intravenous immunoglobulin (IVIg) and change of immunosuppressant from tacrolimus (FK506) to cyclosporine, the bleeding stopped and better laboratory examination results was achieved thereafter.

Acquired factor V inhibitor in a woman following aortic aneurysm surgery

A 67-year-old woman with nephrotic syndrome as a complication of membranous glomerulonephritis associated with chronic active hepatitis B virus infection developed factor V inhibitor following emergency aortic aneurysm surgery followed by massive blood transfusions and haemodialysis. On the second postoperative day, prothrombin time and activated partial thromboplastin time increased and were unresponsive to fresh frozen plasma. Epistaxis and urethral bleeding were observed, followed by mucosal mouth bleeding. A very low factor V activity less than 5% was found and a factor V inhibitor was detected at 7.76 Bethesda Units. Treatment with corticosteroids was successful. In this patient, several conditions known to predispose to the generation of factor V inhibitor occurred simultaneously. Four months later, factor V inhibitor (225 Bethesda Units) recurred and the patient died of intracerebral haemorrhage.

Successful management of a possible antibiotic-related acquired factor V inhibitor: a case report and review of the literature

Acquired factor inhibitors are rare. We report a case of an elderly male who presented with a bleeding diathesis associated with an elevated prothrombin time and an activated partial thromboplastin time. Work-up revealed undetectable factor V activity and a factor V inhibitor level of >50 Bethesda units. The inhibitor may have been triggered by antibiotics. With a multimodality approach using steroids, platelet transfusions, intravenous immunoglobulin, factor VIII inhibitor bypass activity agent and cyclophosphamide, we successfully eliminated the inhibitor and controlled the bleeding.

Acquired factor V inhibitors: a systematic review

The occurrence of an inhibitor against coagulation factor V (FV) is a rare but challenging condition, which may span from asymptomatic laboratory abnormalities to potentially life-threatening bleeding. The onset of FV inhibitors has been associated most frequently in the past with the patients' exposure to topical bovine thrombin administered during surgery procedures. However, since this preparation is no longer used, in this systematic review we have only focused on non-bovine thrombin-related FV inhibitor cases.