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Chin CS, Liang SJ. Extensive ecchymosis and retroperitoneal hemorrhage due to acquired hemophilia-A following influenza vaccination: A case report. Medicine (Baltimore) 2024; 103:e38300. [PMID: 38787989 PMCID: PMC11124756 DOI: 10.1097/md.0000000000038300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/29/2024] [Indexed: 05/26/2024] Open
Abstract
INTRODUCTION Acquired hemophilia-A (AHA) is a rare but potentially life-threatening impaired coagulation disorder characterized by the development of autoantibodies against clotting factor VIII. Only a few case reports have been experienced with influenza vaccine-triggered AHA. Here, we report a case of severe hemorrhagic disorder due to AHA following influenza vaccine, which was successfully treated. PATIENT CONCERNS The patient presented to the emergency department because of several severe, progressively worsening bruises after receiving the influenza vaccination. Consequently, the patient required intubation due to nasal-oral bleeding, which compromised the airway, and retroperitoneal hemorrhage with shock also developed. DIAGNOSIS AHA was confirmed through a coagulation factor assay, including coagulation activity and antibody testing, which is possibly triggered by influenza vaccination. INTERVENTION Low-dose cyclophosphamide and hydrocortisone were prescribed until activated partial thromboplastin time showed normal levels. Coagulation factor VIIa was administered, and aggressive blood transfusion was carried out concurrently to address the blood loss. OUTCOMES The upper airway bleeding subsided and bleeding tendencies had been corrected to normal. The patient was smoothly weaned from the ventilator and recovered from critical illness. She was then discharged on the 19th day. LESSONS The activated partial thromboplastin time mixing test can be performed immediately to establish the initial differential diagnosis and treatment plan for severe coagulopathy. AHA may be triggered by vaccination, with the hypothesis of activation of autoantibodies and molecular mimicry; this mechanism should be further studied.
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Affiliation(s)
- Chi Sheuan Chin
- Department of Internal Medicine, China Medical University Hospital, China Medical University Hospital, Taichung City, Taiwan
| | - Shinn-Jye Liang
- Division of Pulmonary and Critical Care, Department of Internal Medicine, China Medical University Hospital, Taichung City, Taiwan
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2
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Irsara C, Griesmacher A, Loacker L, Feistritzer C, Überbacher CA, Amiral J. Anti-Thrombin IgA in a Patient with Multiple Myeloma Leading to In Vitro Interference in Multiple Coagulation Tests and Confounding Diagnosis. Hamostaseologie 2024. [PMID: 38428837 DOI: 10.1055/a-2211-6841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND We report the case of a 59-year-old multiple myeloma patient in whom an anti-human thrombin IgA antibody led to prolonged in vitro coagulation times, suggesting inhibitors to all intrinsic coagulation factors in the absence of spontaneous bleeding. METHODS Routine and extensive special coagulation tests, in vivo bleeding time, and specific antibody testing were performed. RESULTS Although the patient did not suffer from spontaneous bleeding and had a normal in vivo bleeding time, the anti-human thrombin IgA autoantibody affected all coagulation assays involving human thrombin in vitro, mimicking inhibitors to intrinsic coagulation factors. As the IgA paraprotein and the IgA antibody virtually disappeared after autologous stem cell transplantation, the coagulation tests also largely normalized. CONCLUSION Antibodies to human thrombin may interfere with all coagulation assays involving thrombin, imitating a severe coagulopathy. However, in vivo they do not necessarily lead to strongly increased bleeding tendency. Complex and ambiguous coagulation abnormalities should be evaluated and treated in an interdisciplinary setting, including a highly specialized coagulation laboratory, from the beginning.
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Affiliation(s)
- Christian Irsara
- Central Institute of Medical and Chemical Laboratory Diagnostics (ZIMCL), University Hospital of Innsbruck, Innsbruck, Austria
| | - Andrea Griesmacher
- Central Institute of Medical and Chemical Laboratory Diagnostics (ZIMCL), University Hospital of Innsbruck, Innsbruck, Austria
| | - Lorin Loacker
- Central Institute of Medical and Chemical Laboratory Diagnostics (ZIMCL), University Hospital of Innsbruck, Innsbruck, Austria
| | - Clemens Feistritzer
- Department of Internal Medicine V, Hematology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Jean Amiral
- Scientific-Hemostasis Consulting, Franconville, France
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3
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Kempton CL, Payne AB, Fedewa SA. Race, ethnicity, and immune tolerance induction in hemophilia A in the United States. Res Pract Thromb Haemost 2023; 7:102251. [PMID: 38193063 PMCID: PMC10772873 DOI: 10.1016/j.rpth.2023.102251] [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: 06/14/2023] [Revised: 10/20/2023] [Accepted: 10/26/2023] [Indexed: 01/10/2024] Open
Abstract
Background In racially diverse communities, treatment of chronic diseases can vary across racial and ethnic groups. Objectives To examine healthcare disparities in hemophilia care in the United States by evaluating receipt of immune tolerance induction (ITI) among different racial and ethnic groups. Methods In this cross-sectional study, people with severe hemophilia A with an inhibitor who entered the Center for Disease Control and Prevention Community Counts registry between 2013 and 2017, were aged ≥5 years at study entry, and had a history of an inhibitor (n = 614) were included. The proportion of participants receiving ITI was examined according to race and ethnicity in bivariable analysis and multivariable analysis adjusting for demographic and clinical covariates. Unadjusted and adjusted prevalence ratios and corresponding 95% CIs were computed. Results Among 614 participants included in the study, 56.4% were non-Hispanic (NH) White, 19.7% were NH Black, 18.4% were Hispanic, and 4.9% were Asian. ITI was received by 85.2% of participants. On bivariable analysis, ITI treatment did not vary by race or ethnicity. On multivariable analysis, NH Black and Hispanic participants were significantly less likely to receive ITI compared to NH White participants (adjusted prevalence ratio, 0.91 [95% CI, 0.84-0.99] and 0.84 [95% CI, 0.75-0.93], respectively). Conclusion Although the role of ITI may evolve with growing use of emicizumab and the introduction of new hemophilia treatment products, understanding characteristics that influence care, particularly race and ethnicity, where physician bias and patient mistrust can occur, will remain relevant and applicable to other complex therapies, including gene therapy.
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Affiliation(s)
- Christine L. Kempton
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
- Hemophilia of Georgia Center for Bleeding & Clotting Disorders of Emory, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Amanda B. Payne
- National Center on Birth Defects and Developmental Disabilities, Center for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Stacey A. Fedewa
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
- Hemophilia of Georgia Center for Bleeding & Clotting Disorders of Emory, Emory University School of Medicine, Atlanta, Georgia, USA
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Shen MC, Chou SC, Chiou SS, Lin PC, Chen YC, Lin HY, Lee YC, Huang CE, Weng TF, Huang TH, Chung CY, Chen JS, Chen SH, Cheng SN, Hsiao CC, Huang YM, Chen SH, Yu YB, Lin SC, Lin CY, Peng CT, Wang JD. Efficacy, safety and cost of emicizumab prophylaxis in haemophilia A patients with inhibitors: A nationwide observational study in Taiwan. Haemophilia 2023; 29:1499-1508. [PMID: 37819166 DOI: 10.1111/hae.14880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/26/2023] [Accepted: 09/26/2023] [Indexed: 10/13/2023]
Abstract
INTRODUCTION Emicizumab mimicking the cofactor function of activated factor VIII (FVIII) restores haemostasis. METHODS This nationwide observational study aimed to retrospectively investigate efficacy, safety, and cost in 1 year before and up to 3 years after emicizumab prophylaxis for haemophilia A (HA) patients with FVIII inhibitors. RESULTS AND DISCUSSION A total of 39 severe HA patients with a median age of 23.0 years were enrolled. The median historical peak FVIII inhibitor titre was 174.2 BU/mL with an interquartile range of 56.5-578.8 BU/mL. The median annualized bleeding rate reduced from 24 to 0 events in the first year after emicizumab prophylaxis (p < .01) and sustained in the second and third years. The median annualized joint bleeding rate reduced to 0 and maintained up to 3 years (p < .01). Twenty-seven patients (69.2%) had target joints before emicizumab prophylaxis and only seven patients (17.9%) of them had target joints after prophylaxis. Medical costs, including cost of haemostatic therapy, frequency of outpatient department visits, emergency room visits and hospital admission, were significantly reduced after emicizumab prophylaxis (p < .01). FVIII inhibitor titre decreased after emicizumab prophylaxis. Overall, three (7.7%) patients experienced 202 grade 1 drug-related adverse events after emicizumab prophylaxis. No serious adverse events were reported during emicizumab prophylaxis period. The adherence to emicizumab prophylaxis was 100% up to 3 years. CONCLUSIONS HA patients with FVIII inhibitors treated with emicizumab prophylaxis resulted in a significant reduction in treated bleeds and associated costs. No new safety events were observed.
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Affiliation(s)
- Ming-Ching Shen
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Sheng-Chieh Chou
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shyh-Shin Chiou
- Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Pei-Chin Lin
- Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yeu-Chin Chen
- Hemophilia Care and Research Center, Tri-Service General Hospital, Taipei, Taiwan
- Division of Hematology/Oncology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hsuan-Yu Lin
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Yang-Cheng Lee
- Division of Hematology and Oncology, Departments of Internal Medicine, Tainan Municipal Hospital, Tainan, Taiwan
| | - Cih-En Huang
- Division of Hematology and Oncology, Department of Medicine, Chang Gung Memorial Hospital at Chiayi, Chiayi, Taiwan
| | - Te-Fu Weng
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Ting-Huan Huang
- Division of Pediatric Hematology/Oncology, Hsinchu Mackay Memorial Hospital, Hsinchu, Taiwan
| | - Chih-Yuan Chung
- Department of Medical Oncology, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Jiann-Shiuh Chen
- Division of Hematology and Oncology, Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Shu-Huey Chen
- Department of Pediatrics, Shuang Ho Hospital, Ministry of Health and Welfare, Taipei Medical University, New Taipei, Taiwan
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Shin-Nan Cheng
- Haemophilia Care and Research Center, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Department of Paediatrics, Tung's Taichung Metrohabor Hospital, Taichung, Taiwan
| | - Chih-Cheng Hsiao
- Division of Pediatric Hematology/Oncology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yen-Min Huang
- Division of Hematology and Oncology, Department of Internal Medicine, Hemophilia and Thrombosis Treatment Center, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Shih-Hsiang Chen
- Division of Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yuan-Bin Yu
- Division of Hematology and Oncology, Far-East Memorial Hospital, New Taipei City, Taiwan
| | - Shih-Chiang Lin
- Division of Hematology and Oncology, Far-East Memorial Hospital, New Taipei City, Taiwan
| | - Ching-Yeh Lin
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Ching-Tien Peng
- Division of Pediatric Haematology and Oncology, China Medical University Children's Hospital, China Medical University, Taichung, Taiwan
| | - Jiaan-Der Wang
- Center for Rare Disease and Hemophilia, Department of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung City, Taiwan
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5
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Shima M, Amano K, Ogawa Y, Yoneyama K, Ozaki R, Kobayashi R, Sakaida E, Saito M, Okamura T, Ito T, Hattori N, Higasa S, Suzuki N, Seki Y, Nogami K. A prospective, multicenter, open-label phase III study of emicizumab prophylaxis in patients with acquired hemophilia A. J Thromb Haemost 2023; 21:534-545. [PMID: 36696195 DOI: 10.1016/j.jtha.2022.10.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/09/2022] [Accepted: 10/05/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Emicizumab is a bispecific antibody that mimics the cofactor function of activated factor (F) VIII. It prevents bleeds in patients with congenital hemophilia A regardless of the inhibitor status; however, no prospective clinical studies have been conducted for emicizumab in patients with acquired hemophilia A (PwAHA). OBJECTIVES To describe the primary analysis results from a prospective, multicenter, open-label phase III study evaluating the efficacy, safety, and pharmacokinetics of emicizumab in PwAHA (AGEHA; JapicCTI-205151). METHODS Emicizumab was administered subcutaneously at 6 mg/kg on day 1 and 3 mg/kg on day 2, followed by 1.5 mg/kg once weekly from day 8 onward. Predefined criteria for the completion of dosing included FVIII activity of >50 IU/dL. RESULTS By the cutoff date (April 23, 2021), 12 patients on immunosuppressive therapy were enrolled, and 11 of them (91.7%) completed emicizumab treatment. The mean trough plasma emicizumab concentration rapidly reached a steady state (1 week), achieving the efficacious level that was established in patients with congenital hemophilia A (>30 μg/mL). Before first emicizumab administration, 7 patients (58.3%) experienced 77 major bleeds. During emicizumab treatment, no major bleeds occurred in any patient. Neither death due to bleeding or infection nor any study treatment-related serious adverse event was reported. One asymptomatic, nonserious deep vein thrombosis was discovered with no laboratory findings indicating any trend toward hypercoagulation. CONCLUSION These results suggest that emicizumab prophylaxis with the tested dosing regimen and completion criteria may have a favorable benefit-risk profile in PwAHA.
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Affiliation(s)
- Midori Shima
- Thrombosis and Hemostasis Research Center, Nara Medical University, Kashihara, Japan; Department of Pediatrics, Nara Medical University, Kashihara, Japan.
| | - Kagehiro Amano
- Department of Laboratory Medicine, Tokyo Medical University Hospital, Tokyo, Japan
| | - Yoshiyuki Ogawa
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | | | | | | | - Emiko Sakaida
- Department of Hematology, Chiba University Hospital, Chiba, Japan
| | - Makoto Saito
- Blood Disorders Center, Aiiku Hospital, Sapporo, Japan
| | - Takashi Okamura
- Department of Hematology, St. Mary's Hospital, Kurume, Japan
| | - Toshihiro Ito
- Department of Infectious Diseases, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Norimichi Hattori
- Division of Hematology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Satoshi Higasa
- Department of Hematology, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Nobuaki Suzuki
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Yoshinobu Seki
- Department of Hematology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Minami-uonuma, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
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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.
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7
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Simon B, Ceglédi A, Dolgos J, Farkas P, Gaddh M, Hankó L, Horváth R, Kaposi A, Magyar L, Masszi T, Szederjesi A, Wohner N, Bodó I. Combined immunosuppression for acquired hemophilia A: CyDRi is a highly effective low-toxicity regimen. Blood 2022; 140:1983-1992. [PMID: 35930747 PMCID: PMC10653022 DOI: 10.1182/blood.2022016873] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/25/2022] [Indexed: 11/20/2022] Open
Abstract
Acquired hemophilia A (AHA) is a rare severe autoimmune bleeding disorder with significant morbidity and mortality. Although critical for disease control, there is no consensus for the best immunosuppressive regimen. Most authors use steroids first line, followed by other agents for steroid failures. Upfront combined regimens offer the advantage of reduced steroid exposure and toxicity as well as increased efficacy. We retrospectively analyzed data from 32 patients with AHA treated on an identical such institutional protocol: cyclophosphamide 1000 mg on days 1 and 22, dexamethasone 40 mg on days 1, 8, 15, and 22, and rituximab 100 mg on days 1, 8, 15, and 22 (the regimen was termed CyDRi). All patients received at least 1 cycle of CyDRi. If necessary, CyDRi was repeated until remission, no sooner than day 43 of the previous cycle. Bleeding control was rapidly achieved. The median time for bleeding control was 15.5 days (range, 0-429 days; interquartile range, 2.5-29.5 days). Thirty-one (96.8%) of 32 patients achieved durable complete remission (CR); 29 (90.6%) of 32 patients were alive at last follow-up, all of them in CR. The median time to reach first CR was 77 days (range, 19-939 days; interquartile range, 31-115 days). Toxicity and side effects were acceptable and milder than those of commonly used, prolonged steroid therapies. In conclusion, the CyDRi regimen produced markedly higher CR rates and overall survival than currently used sequential regimens. Taken together, CyDRi proved to be an attractive option for the immunosuppression of elderly patients with AHA.
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Affiliation(s)
- Barbara Simon
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | - Andrea Ceglédi
- Department of Hematology and Stem Cell Transplantation, South-Pest Central Hospital, National Institute of Hematology and Infectious Disease, St. László Campus, Budapest, Hungary
| | - János Dolgos
- Department of Hematology and Stem Cell Transplantation, South-Pest Central Hospital, National Institute of Hematology and Infectious Disease, St. László Campus, Budapest, Hungary
| | - Péter Farkas
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | - Manila Gaddh
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA
| | - László Hankó
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | - Robert Horváth
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | | | - Lászlóné Magyar
- Department of Hematology and Stem Cell Transplantation, South-Pest Central Hospital, National Institute of Hematology and Infectious Disease, St. László Campus, Budapest, Hungary
| | - Tamás Masszi
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | - Attila Szederjesi
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | - Nikolett Wohner
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | - Imre Bodó
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA
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8
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Than PA, Davis CR, Rennert RC, Morrison SD, Findlay MW, Kay MA, Gurtner GC. Selective Microvascular Tissue Transfection Using Minicircle DNA for Systemic Delivery of Human Coagulation Factor IX in a Rat Model Using a Therapeutic Flap. Plast Reconstr Surg 2022; 149:117-129. [PMID: 34757962 DOI: 10.1097/prs.0000000000008630] [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: 11/25/2022]
Abstract
BACKGROUND Gene therapy is a promising treatment for protein deficiency disorders such as hemophilia B. However, low tissue selectivity and efficacy are limitations of systemic vector delivery. The authors hypothesized that selective transfection of rat superficial inferior epigastric artery flaps could provide systemic delivery of coagulation factor IX, preventing the need for systemic vector administration. METHODS Minicircle DNA containing green fluorescent protein, firefly luciferase, and human coagulation factor IX was created. Vector constructs were validated by transfecting adipose-derived stromal cells isolated from Wistar rat superficial inferior epigastric artery flaps and evaluating transgene expression by fluorescence microscopy, bioluminescence, and enzyme-linked immunosorbent assay. Minicircle DNA luciferase (10 and 30 μg) was injected into murine (wild-type, C57/BL/6) inguinal fat pads (n = 3) and followed by in vivo bioluminescence imaging for 60 days. Wistar rat superficial inferior epigastric artery flaps were transfected with minicircle DNA human coagulation factor IX (n = 9) with plasma and tissue transgene expression measured by enzyme-linked immunosorbent assay at 2 and 4 weeks. RESULTS Transfected adipose-derived stromal cells expressed green fluorescent protein for 30 days, luciferase for 43 days, and human coagulation factor IX (21.9 ± 1.2 ng/ml) for 28 days in vitro. In vivo murine studies demonstrated dose-dependence between minicircle DNA delivery and protein expression. Ex vivo rat superficial inferior epigastric artery flap transfection with minicircle DNA human coagulation factor IX showed systemic transgene expression at 2 (266.6 ± 23.4 ng/ml) and 4 weeks (290.1 ± 17.1 ng/ml) compared to control tissue (p < 0.0001). CONCLUSIONS Rat superficial inferior epigastric artery flap transfection using minicircle DNA human coagulation factor IX resulted in systemic transgene detection, suggesting that selective flap or angiosome-based tissue transfection may be explored as a treatment for systemic protein deficiency disorders such as hemophilia B.
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Affiliation(s)
- Peter A Than
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine
| | - Christopher R Davis
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine
| | - Robert C Rennert
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine
| | - Shane D Morrison
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine
| | - Michael W Findlay
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine
| | - Mark A Kay
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine
| | - Geoffrey C Gurtner
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine
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9
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Matsuoka A, Sasaki Y, Kubodera A, Hayashi K, Shimizu R, Toriihara A, Nakamura A, Furukawa K, Tanaka H. Acquired Hemophilia A Presenting with Infectious Aortic Aneurysms Due to an Underlying Helicobacter cinaedi Infection. Intern Med 2021; 60:3947-3952. [PMID: 34121015 PMCID: PMC8758458 DOI: 10.2169/internalmedicine.7517-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Acquired hemophilia A (AHA) is a bleeding disorder caused by the acquired appearance of inhibitor for factor VIII. Approximately half of all patients with AHA have some type of underlying disease. We herein report the case of a 72-year-old Japanese man with AHA who presented with infectious aortic aneurysms due to an underlying Helicobacter cinaedi infection. To our knowledge, this is the first report of AHA triggered by a bacterial infection; however, there may be similar cases that remain undiagnosed because this pathogen is difficult to identify. Clinicians should consider the possibility of H. cinaedi as a causative pathogen in patients presenting with a fever of unknown origin.
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Affiliation(s)
- Anna Matsuoka
- Department of Internal Medicine, Asahi General Hospital, Japan
| | - Yuya Sasaki
- Department of Internal Medicine, Asahi General Hospital, Japan
| | - Ai Kubodera
- Department of Hematology, Asahi General Hospital, Japan
| | | | - Ryo Shimizu
- Department of Hematology, Asahi General Hospital, Japan
| | | | - Akira Nakamura
- Department of Infectious Disease, Asahi General Hospital, Japan
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10
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Unexplained hemorrhagic syndrome? Consider acquired hemophilia A or B. Blood Rev 2021; 53:100907. [PMID: 34776294 DOI: 10.1016/j.blre.2021.100907] [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: 09/24/2021] [Revised: 10/29/2021] [Accepted: 11/01/2021] [Indexed: 11/02/2022]
Abstract
There is a dire need to develop an algorithm to improve the recognition of acquired hemophilia A and B (AHA and AHB) in clinical practice. Initial and intensive care unit (ICU) management of the disorder is particular and represents a challenge for the internist/hematologist and the ICU physician. A delay in the proper treatment of bleeding episodes can lead to a life-threatening event. Expert advice should be sought as soon as possible. Succesful resolution involves accurate diagnosis, bleeding control with hemostatic and immunotherapy, and eradication of the autoantibodies to improve overall survival. Current treatment guidelines are based on the literature in the form of cases and observational studies due to a lack of randomized controlled trials. AH can be triggered by many pathologies, presenting as a paraneoplastic syndrome in case of malignancies or as surgical associated acquired hemophilia (SAHA). We have reviewed the literature from 2015 to 2021 regarding the new case reports to further assess if there is an improvement in the clinical approach.
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11
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Lei B, Liang C, Feng H. Congenital hemophilia A with low activity of factor XII: a case report and literature review. Ital J Pediatr 2021; 47:204. [PMID: 34635150 PMCID: PMC8503991 DOI: 10.1186/s13052-021-01137-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Congenital hemophilia A is a recessive inherited hemorrhagic disorder. According to the activity of functional coagulation factors, the severity of hemophilia A is divided into three levels: mild, moderate and severe. The first bleeding episode in severe and moderate congenital hemophilia A occurs mostly in early childhood and mainly involves soft tissue and joint bleeds. At present, there are limited reports on severe congenital hemophilia A with low factor XII (FXII) activity during the neonatal period. CASE PRESENTATION A 13-day-old neonate was admitted to the hospital with hematoma near the joints of both upper arms. Coagulation tests showed he had low activity of factor VIII (FVIII) and FXII. He was diagnosed with congenital hemophilia A and treated with human coagulation factor VIII (recombinant FVIII). Although the hematoma became smaller, FVIII activity was only increased to a certain extent and FXII activity decreased gradually. Unfortunately, the child responded poorly to recombinant human coagulation factor VIII and his guardian rejected prophylactic inhibitors and genetic testing and refused further treatment. Three months later, the child developed intracranial hemorrhage (ICH) due to low FVIII activity. CONCLUSIONS In hemophilia A, the presence of FVIII inhibitors, drug concentration and testing are three important aspects that must be considered when FVIII activity does not reach the desired level. Early positive disease treatment and prophylaxis can decrease the frequency of bleeding and improve quality of life. We recommend that pregnant women with a family history of hemophilia A undergo early prenatal and neonatal genetic testing.
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Affiliation(s)
- Baoyu Lei
- Department of Neonatology, Maoming People's Hospital, Weimin Road, Maonan District, Maoming, 525000, Guangdong, China
| | - Chuang Liang
- Department of Neonatology, Maoming People's Hospital, Weimin Road, Maonan District, Maoming, 525000, Guangdong, China
| | - Haiyan Feng
- Department of Neonatology, Maoming People's Hospital, Weimin Road, Maonan District, Maoming, 525000, Guangdong, China.
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Abstract
Acquired hemophilia A is a potentially severe bleeding disorder caused by antibodies against the patient's own factor VIII. Acquired hemophilia A is rare. It is most commonly diagnosed in older individuals; about one-half of cases of acquired hemophilia are associated with underlying conditions, including autoimmune disease, cancer, and pregnancy. The diagnosis of acquired hemophilia A can be suspect with an isolated activated partial thromboplastin time elevation, and confirmed with demonstration of reduced factor VIII activity and the presence of a specific factor VIII inhibitor. Treatment of acquired hemophilia A involves control of bleeding, and eradication of the inhibitor.
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Affiliation(s)
- Menaka Pai
- McMaster University, Hamilton, Canada; Hamilton Health Sciences, Hamilton, Canada; Hamilton Regional Laboratory Medicine Program, Hamilton, Canada.
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Abstract
BACKGROUND Acquired haemophilia A is a rare bleeding disorder caused by the development of specific autoantibodies against coagulation factor VIII. Standard treatment, usually steroids alone, or in combination with cyclophosphamide, aims to stop acute bleeds by using haemostatic agents to promote clotting. Rituximab may be an alternative approach to the treatment of acquired haemophilia by eradicating FVIII autoantibodies. This is an update of a previously published Cochrane Review. OBJECTIVES To assess the efficacy and adverse effects of rituximab for treating people with acquired haemophilia A. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's trials registers, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and conference proceedings (January 2021). We also undertook searches of CENTRAL, MEDLINE and online trial registries (January 2021). SELECTION CRITERIA Randomised and quasi-randomised controlled trials of rituximab for people with acquired haemophilia A, with no restrictions on gender, age or ethnicity. DATA COLLECTION AND ANALYSIS No trials matching the selection criteria were eligible for inclusion. MAIN RESULTS No trials matching the selection criteria were eligible for inclusion. AUTHORS' CONCLUSIONS We found no randomised clinical trials of rituximab for acquired haemophilia A. Thus, we are not able to draw any conclusions or make any recommendations on rituximab for eradicating inhibitors in people with acquired haemophilia A based on the highest quality evidence. Given that undertaking randomised controlled trials in this field is a complex task, we suggest that, while planning such trials, clinicians treating the disease continue to base their choices on alternative, lower-quality sources of evidence. In a future update of this review, we plan to appraise and incorporate eligible randomised controlled trials, as well as other high-quality, non-randomised studies.
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Affiliation(s)
- Tracey Remmington
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
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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.
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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
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15
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Transplacental hemophilia A and prophylactic treatment with intravenous immunoglobulin and recombinant factor VIIa in the newborn period: a case report. Blood Coagul Fibrinolysis 2021; 32:151-154. [PMID: 33196507 DOI: 10.1097/mbc.0000000000000978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acquired hemophilia due to inhibitor antibodies to factor VIII (FVIII) is a very rare entity in neonatal period. Maternal IgG antibodies may cross the placenta and can cause life-threatening hemorrhages in newborns. Here, we represent a newborn who diagnosed as a transplacental acquired hemophilia A. A very high titer of inhibitor level (320 Nijmegen-Bethesda unit) was detected in plasma due to transplasental transfer in this case. According to the best of our knowledge the baby had the highest inhibitor level in neonatal period in the literature. Bleeding complications including intracranial hemorrhage secondary to this condition were reported before. Therefore, to prevent possible life complications, prophylactic recombinant FVIIa was administered in the presenting case and any bleeding event was not observed during follow-up. In conclusion, using prophylactic recombinant FVIIa in newborns is a safe choice for transplacental acquired hemophilia A.
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Dewarrat N, Gavillet M, Angelillo-Scherrer A, Naveiras O, Grandoni F, Tsakiris DA, Alberio L, Blum S. Acquired haemophilia A in the postpartum and risk of relapse in subsequent pregnancies: A systematic literature review. Haemophilia 2021; 27:199-210. [PMID: 33550699 DOI: 10.1111/hae.14233] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 12/05/2020] [Accepted: 12/09/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND About 1%-5% of acquired haemophilia A cases affect mothers in the postpartum setting. AIMS This study delineates the characteristics of this disease, specific to the postpartum setting, notably relapse in subsequent pregnancies. METHODS Report of two cases and literature study (1946-2019), yielding 73 articles describing 174 cases (total 176 cases). RESULTS Patients were aged 29.9 years (17-41) and 69% primigravidae. Diagnosis was made at a median of 60 days after delivery (range 0-308). Bleeding types were obstetrical (43.4%), cutaneous (41.3%), and muscular (36.7%). In >90% of the cases, FVIII at diagnosis was <1% (range 0%-8%). FVIII inhibitor was documented in 75.4% cases (median titre of 20 BU/ml, range 1-621). Haemostatic treatment was necessary in 57.1% using fresh frozen plasma (16%), factor concentrate (27.6%) and/or bypassing agents (37.4%). Immunosuppressive treatment was administered in 90.8%, mostly steroids (85.3%), alone or combined with immunosuppressants (27%). Rituximab was used mostly as a second line treatment. Only 24 patients (13.6%) had documented subsequent pregnancies and 6 (22.2%) suffered haemophilia recurrence during pregnancy. CONCLUSION This study allows better definition of: (1) clinical and laboratory characteristics of postpartum acquired haemophilia, (2) response to therapy, and (3) the risk of relapse for subsequent pregnancies.
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Affiliation(s)
- Natacha Dewarrat
- Service and Central Laboratory of Haematology, Department of Oncology and Department of Laboratories and Pathology, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Mathilde Gavillet
- Service and Central Laboratory of Haematology, Department of Oncology and Department of Laboratories and Pathology, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Anne Angelillo-Scherrer
- Department of Haematology and Central Haematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Olaia Naveiras
- Service and Central Laboratory of Haematology, Department of Oncology and Department of Laboratories and Pathology, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Francesco Grandoni
- Service and Central Laboratory of Haematology, Department of Oncology and Department of Laboratories and Pathology, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | | | - Lorenzo Alberio
- Service and Central Laboratory of Haematology, Department of Oncology and Department of Laboratories and Pathology, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Sabine Blum
- Service and Central Laboratory of Haematology, Department of Oncology and Department of Laboratories and Pathology, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
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17
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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.
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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
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18
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Shimonishi N, Ogiwara K, Oda Y, Kawabe T, Emmi M, Shima M, Nogami K. Inhibitor Index in the Clot Waveform Analysis-Based Mixing Test Differentiates among Hemophilia A without and with Inhibitors, and Lupus Anticoagulant. Thromb Haemost 2021; 121:792-799. [PMID: 33412612 DOI: 10.1055/s-0040-1721776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND The mixing test is used to identify the pathway to follow-up testing and is also useful for the investigation of lupus anticoagulant (LA) positivity. "To completely correct" indicates clotting factor deficiency, while "to not correct" indicates the presence of a clotting factor inhibitor including LA. "Index of circulation anticoagulant" and/or "percent correction" is used to interpret the results of mixing studies, but it does not accurately differentiate factor inhibitors from LA. AIM To precisely differentiate hemophilia A (HA), HA with inhibitor (HA-inh), and LA using the clot waveform analysis (CWA)-based mixing test. METHODS Plasma samples from HA, LA, and HA-inh including acquired HA were incubated with normal plasma in 9:1, 1:1, and 1:9 mix ratios. From activated partial thromboplastin time CWA at 0-minute (immediately) and 12-minute incubation, the ratios of CWA parameters at 12 minutes/0 minute (inhibitor index) were assessed. RESULTS The inhibitor index values of CWA parameters obtained using the mixing test in a 1:1 ratio demonstrated a significant difference between HA-inh and LA but could not differentiate LA from HA-inh completely. Plasmas used for the mixing tests in 9:1 and 1:9 ratios were able to fully distinguish between HA-inh (>0.5 BU/mL) and LA. These indices significantly correlated with inhibitor titer below 40 BU/mL (r > 0.90), possibly estimating FVIII inhibitor titer from the inhibitor index. Plasmas in HA and LA could be distinguished by mixing in a 1:1 ratio at 0 minute (immediately). CONCLUSION The inhibitor index from CWA-based mixing tests with a 12-minute incubation could differentiate among HA, HA-inh, and LA quickly.
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Affiliation(s)
- Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Yukio Oda
- SEKISUI MEDICAL CO., LTD., Tokyo, Japan
| | | | - Mari Emmi
- SEKISUI MEDICAL CO., LTD., Tokyo, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Beny K, du Sartz de Vigneulles B, Chamouard V, Guilloux R, Gay V, Negrier C, Dussart C. Patients' Perception of the Impact of Innovation on Hemophilia Care Management Organization: A Qualitative Study Protocol (INNOVHEMO Study). Patient Prefer Adherence 2021; 15:1807-1815. [PMID: 34434044 PMCID: PMC8380624 DOI: 10.2147/ppa.s322531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/21/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND New therapies provide a favorable evolution in the care management of persons with hemophilia. However, the impact of these new therapies on patient care organization remains to be determined. A qualitative study will be implemented to analyze patients' perception regarding the impact of innovation on the organization of their care management. Secondary objectives will include refining specific factors related to persons with hemophilia (barriers or facilitators, especially the place of treatment) to consider within an organizational impact analysis. PATIENTS AND METHODS Semi-structured individual interviews will be conducted via videoconferencing or by phone by two researchers using an interview guide. Participants will be recruited from the Rhône-Alpes region, in France. Physicians from two hemophilia treatment centers will identify eligible patients. Moreover, a call for volunteers will be launched by the Rhône-Alpes committee of the French hemophilia association. Interviews will be conducted with adult patients, adolescent patients or parents of a minor with hemophilia regularly treated prophylactically or on demand. Data analysis will be performed with NVivo® software. Each interview will be analyzed by two researchers using an inductive content analytic method. DISCUSSION The INNOVHEMO study is an original study analyzing the way patients perceive the impact of an innovation on their care management organization. The resulting patient-specific factors, identified as barriers or facilitators, will need to be integrated into a more comprehensive analysis of the impact of innovation on care management organization.
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Affiliation(s)
- Karen Beny
- EA 4129 Laboratory P2S (Health Systemic Process), University of Lyon, University Claude Bernard Lyon 1, Lyon, France
- Central Pharmacy, Hospices Civils de Lyon, Lyon, France
- Correspondence: Karen Beny Central Pharmacy, Hospices Civils de Lyon, 57 rue Francisque Darcieux, CS 60004, 69563 Saint Genis Laval Cedex, Lyon, FranceTel +33 4 78 86 66 92Fax +33 4 72 67 88 74 Email
| | | | - Valerie Chamouard
- Reference center on hemophilia and other constitutional hemorrhagic diseases, Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon, France
- Pharmacy, Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon, France
| | - Ronald Guilloux
- Laboratory S2HEP, University of Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Valérie Gay
- Hemophilia Care Center, Centre hospitalier Métropole Savoie, Chambéry, France
| | - Claude Negrier
- Reference center on hemophilia and other constitutional hemorrhagic diseases, Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon, France
| | - Claude Dussart
- EA 4129 Laboratory P2S (Health Systemic Process), University of Lyon, University Claude Bernard Lyon 1, Lyon, France
- Central Pharmacy, Hospices Civils de Lyon, Lyon, France
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20
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Abdul-Halim NA, Ng HJ. Bullous pemphigoid is a common associated disorder with acquired haemophilia A. Int J Hematol 2021; 113:58-62. [PMID: 32949372 DOI: 10.1007/s12185-020-03002-9] [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] [Received: 06/24/2020] [Revised: 08/31/2020] [Accepted: 09/02/2020] [Indexed: 10/23/2022]
Abstract
Although the estimated incidence of acquired haemophilia A (AHA) in Singapore is similar to those reported in the literature, we have observed differences in the frequency of their associated diseases, particularly bullous pemphigoid (BP). We investigated the actual incidence of BP among our AHA cohort, their clinical characteristics and treatment outcomes. 6 out of 37 (16%) patients with AHA had BP, making it the most common underlying disorder in our cohort. The median age at diagnosis of AHA was 76 years old with a female preponderance. Most patients had their AHA diagnosed after BP with the median time between BP to AHA diagnosis being 107.5 days. Initial haemostasis was achieved, and factor VIII inhibitor was eliminated in all patients with a median time of disappearance being 52 days. Two patients had recurrence of their factor VIII inhibitor during the tapering of their immunosuppression. There was no relationship between the relapse of BP and AHA. This study suggests that BP is a common association with AHA. These patients respond well to bypassing agent and immunosuppression. However, they have a higher recurrence of factor VIII inhibitor and should be monitored closely for relapse during the tapering period of their immunosuppression.
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Affiliation(s)
- Nurul Aidah Abdul-Halim
- Department of Haematology, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore.
| | - Heng Joo Ng
- Department of Haematology, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore
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21
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Acquired haemophilia A and late development of secondary autoimmune disorders, evidences from a single-centre observational study. Blood Coagul Fibrinolysis 2020; 31:495-499. [DOI: 10.1097/mbc.0000000000000956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Kim HK, Peral C, Rubio-Rodríguez D, Rubio-Terrés C. Cost of patients with hemophilia A treated with standard half-life or extended half-life FVIII in Spain. Expert Rev Pharmacoecon Outcomes Res 2020; 21:315-320. [PMID: 32597317 DOI: 10.1080/14737167.2020.1789457] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND In a real-world analysis (RWA) conducted in the United States (US), median international units (IUs) of extended half-life (EHL) recombinant coagulation factor VIII (rFVIII) dispensed were 10% to 45% greater than standard half-life (SHL) rFVIII. The mean IUs of each rFVIII dispensed quarterly were obtained from two databases (N = 776). METHODS A probabilistic model in a 1-year time horizon was used in order to analyze the cost comparison of SHL and EHL rFVIII products in Spain. In this analysis, mean IUs were those of the RWA, and frequency of use and prices for each rFVIII were obtained from sales estimates based on Spanish sources (IQVIA; €, 2019). RESULTS Data showed an average annual savings per patient of €11,227 for SHL rFVIII versus EHL rFVIII products, with a savings probability of 75.5%. The results were stable in the sensitivity analyses. Not switching treatment from SHL to EHL rFVIII resulted in greater savings per patient (€53,078), with a savings probability of 99.9%. Considering the frequency of rFVIII dispensation in the US, annual savings per patient would increase to €16,350 in Spain, with a savings probability of 79.9%. CONCLUSIONS According to this model, use of SHL rFVIII versus EHL rFVIII products could lead to savings for the Spanish National Health System.
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Affiliation(s)
| | - Carmen Peral
- Pfizer, S.L.U., Health Economics & Outcomes Research Department, Madrid, Spain
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Acquired Haemophilia A: An Intriguing Disease. Mediterr J Hematol Infect Dis 2020; 12:e2020045. [PMID: 32670523 PMCID: PMC7340240 DOI: 10.4084/mjhid.2020.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/18/2020] [Indexed: 12/31/2022] Open
Abstract
Abstract. Acquired Haemophilia A is a rare acquired bleeding disorder caused by Factor VIII autoantibodies, which neutralise FVIII activity. These inhibitors differ from alloantibodies against FVIII, which can occur in congenital Haemophilia A after repeated exposures to plasma-derived or recombinant FVIII products. In most cases, the disease occurs suddenly in subjects without a personal or familiar history of bleedings, with symptoms that may be mild, moderate, or severe. However, only laboratory alterations are present in ~ 30% of patients. The incidence varies from 1 to 4 cases per million/year; more than 80% of patients are elderly, males and females are similarly affected. There is a small peak of incidence related to pregnancy in young women aged 20–40 years. The disease may be underdiagnosed in the elderly. The diagnostic algorithm is based on an isolated prolonged activated partial thromboplastin time, normal thrombin time, absence of Lupus Anticoagulant, and a mixing test that reveals the presence of an inhibitor: the finding of reduced FVIII activity and the detection of neutralising autoantibodies against FVIII lead to the diagnosis. The disease is idiopathic in 44%–63% of cases, while in the others etiological factors are present. Bleeding prevention and treatment are based on therapeutic tools as by-passing agents, recombinant porcine FVIII concentrate or, in a limited number of cases, FVIII concentrates and desmopressin. As soon as the diagnosis has been made, immunosuppressive therapy must be started to eradicate the inhibitor. Better knowledge of the disease, optimal management of bleeding and eradication of the inhibitor have significantly reduced morbidity and mortality in most patients.
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Tiede A, Collins P, Knoebl P, Teitel J, Kessler C, Shima M, Di Minno G, d'Oiron R, Salaj P, Jiménez-Yuste V, Huth-Kühne A, Giangrande P. International recommendations on the diagnosis and treatment of acquired hemophilia A. Haematologica 2020; 105:1791-1801. [PMID: 32381574 PMCID: PMC7327664 DOI: 10.3324/haematol.2019.230771] [Citation(s) in RCA: 163] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 04/07/2020] [Indexed: 12/18/2022] Open
Abstract
Acquired hemophilia A (AHA), a rare bleeding disorder caused by neutralizing autoantibodies against coagulation factor VIII (FVIII), occurs in both men and women without a previous history of bleeding. Patients typically present with an isolated prolonged activated partial thromboplastin time due to FVIII deficiency. Neutralizing antibodies (inhibitors) are detected using the Nijmegen-modified Bethesda assay. Approximately 10% of patients do not present with bleeding and, therefore, a prolonged activated partial thromboplastin time should never be ignored prior to invasive procedures. Control of acute bleeding and prevention of injuries that may provoke bleeding are top priorities in patients with AHA. We recommend treatment with bypassing agents, including recombinant activated factor VII, activated prothrombin complex concentrate, or recombinant porcine FVIII in bleeding patients. Autoantibody eradication can be achieved with immunosuppressive therapy, including corticosteroids, cyclophosphamide and rituximab, or combinations thereof. The median time to remission is 5 weeks, with considerable interindividual variation. FVIII activity at presentation, inhibitor titer and autoantibody isotype are prognostic markers for remission and survival. Comparative clinical studies to support treatment recommendations for AHA do not exist; therefore, we provide practical consensus guidance based on recent registry findings and the authors' clinical experience in treating patients with AHA.
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Affiliation(s)
- Andreas Tiede
- Hannover Medical School, Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover, Germany
| | - Peter Collins
- Arthur Bloom Haemophilia Centre, University Hospital of Wales School of Medicine, Cardiff University, Cardiff, UK
| | - Paul Knoebl
- Department of Medicine 1, Division of Hematology and Hemostasis, Medical University of Vienna, Vienna, Austria
| | - Jerome Teitel
- Division of Hematology and Oncology, St. Michael's Hospital, Toronto, and Department of Medicine, University of Toronto, Toronto, Canada
| | - Craig Kessler
- Georgetown University Hospital, Lombardi Cancer Center, Division of Hematology/Oncology, Washington, DC, USA
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Nara, Japan
| | - Giovanni Di Minno
- Regional Reference Center for Coagulation Disorders, Federico II University Hospital, Naples, Italy
| | - Roseline d'Oiron
- Centre de Référence de l'Hémophilie et des Maladies Hémorragiques Constitutionnelles Rares, Hôpitaux Universitaires Paris Sud, Hôpital Bicêtre APHP, Le Kremlin-Bicêtre, France
| | - Peter Salaj
- Institute of Hematology and Blood Transfusion, Prague, Czech Republic
| | - Victor Jiménez-Yuste
- Hematology Department, La Paz University Hospital, Autonoma University, Madrid, Spain
| | - Angela Huth-Kühne
- SRH Kurpfalzkrankenhaus Heidelberg GmbH and Hemophilia Center, Heidelberg, Germany
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Mixing-based inhibitor screening in haemophilia A: challenges in interpretation. Blood Coagul Fibrinolysis 2019; 30:401-408. [PMID: 31644446 DOI: 10.1097/mbc.0000000000000863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Inhibitor development in haemophilia A patients is a dreaded complication of factor VIII (FVIII) replacement therapy. With increasing use of FVIII replacement therapy, there is an imperative need for cost-effective and standardized screening. To evaluate the efficacy of mixing-based inhibitor screening (MBIS) in the detection of FVIII inhibitors and to assess the best cut-off values for MBIS. Forty inhibitor positive and 40 inhibitor negative haemophilia A patients, diagnosed by standard criteria, with detailed clinical, haematological and on-demand treatment records were included. MBIS was evaluated in all 80 cases and a classical Bethesda assay and Nijmegen modification of Bethesda assay (NBA) were used as gold standards for inhibitor diagnosis. Classical Bethesda assay missed eight cases, most with low titres, which were confirmed by NBA. A systematic analysis of cut-offs for MBIS using a receiver operating characteristic curve fixed the cut-off at more than 5 s. MBIS detected 36 out of 40 inhibitor positive haemophilia A patients with a sensitivity, specificity, PPV and NPV of 90.0, 95, 94.7, 90.5%, respectively, whereas at the conventional cut-off of more than 10 s, MBIS detected only 25 of 40 cases with a low sensitivity of 62.5%. The likelihood ratio of a positive test was 11. The false-negative haemophilia A patients had low titres from 1.6 to 4.2 BU/ml. MBIS at a cut-off of 5 s can be considered as an effective screening test in low-resource situations. In clinical situations and in cases with clinical evidence of inhibitors we recommend that a direct NBA should be done.
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Tiede A, Giangrande P, Teitel J, Amano K, Benson G, Nemes L, Jiménez-Yuste V, d'Oiron R, Benchikh El Fegoun S, Kessler CM. Clinical evaluation of bleeds and response to haemostatic treatment in patients with acquired haemophilia: A global expert consensus statement. Haemophilia 2019; 25:969-978. [PMID: 31517435 DOI: 10.1111/hae.13844] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/30/2019] [Accepted: 08/19/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Acquired haemophilia (AH) is a rare bleeding disorder with significant morbidity and mortality. Most patients initially present to physicians without experience of the disease, delaying diagnosis and potentially worsening outcomes. Existing guidance in AH is limited to clinical opinion of few experts and does not address monitoring bleeds in specific anatomical locations. AIM Derive consensus from a large sample of experts around the world in monitoring bleeding patients with AH. METHODS Using the Delphi methodology, a structured survey, designed to derive consensus on how to monitor bleeding patients with AH, was developed by a steering committee for completion by a group of haematologists with an interest in AH. Consensus was defined as ≥75% agreement with a given survey statement. After three rounds of survey refinement, a final list of consensus statements was compiled. RESULTS Thirty-six global specialists in AH participated. The participants spanned 20 countries and had treated a median of 12.0 (range, 1-50) patients with AH within the preceding 5 years. Consensus was achieved in all items after three survey rounds. In addition to statements on general management of bleeding patients, consensus statements in the following areas were presented: urinary tract, gastrointestinal tract, muscles, skin, joints, nose, pharynx, mouth, intracranial and postpartum. CONCLUSIONS Here, we present consensus statements derived from a broad sample of global specialists to address monitoring of location-specific bleeds and evaluating efficacy of bleeding treatment in patients with AH. These statements could be applied in practice by treating physicians and validated by individual population surveys.
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Affiliation(s)
| | | | - Jerome Teitel
- St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | - Roseline d'Oiron
- Centre de Référence de l'Hémophilie et des Maladies Hémorragiques Constitutionnelles rares, Hôpitaux Universitaires Paris Sud-APHP-Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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Lee A. Emergency management of patients with bleeding disorders: Practical points for the emergency physician. Transfus Apher Sci 2019; 58:553-562. [PMID: 31416711 DOI: 10.1016/j.transci.2019.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Emergency department (ED) physicians are often the first point of contact for patients who present with bleeding symptoms. Work up and management of bleeding in the emergency room can be a daunting task as it requires: (1) accurate diagnosis of the bleeding cause, of which there is long list of common and rare etiologies (2); appropriate investigations and interpretation of the results; and (3) timely management of bleeding symptoms to prevent limb- or life-threatening complications. Crucial to the management of a bleeding patient is a thorough yet focused history exploring bleeding symptoms, medications/drugs (anticoagulants, antiplatelets), mechanism of trauma/injury, personal and family history of diagnosed bleeding disorders or bleeding symptoms and recognizing acuity and severity of bleeding that requires immediate intervention. Physical examination should focus on signs of mucocutaneous versus deep tissue or joint bleeding and assessing for structural lesions that may contribute to bleeding symptoms in patients with known bleeding diathesis. In patients with diagnosed bleeding disorders, emergency care cards will usually outline the initial treatment (e.g. clotting factor replacement, DDAVP) which should be administered before pursuing investigations/imaging studies. Special attention must be paid to the patient with recurrent or unexplained bleeding, or unexplained coagulation studies. There should be a low threshold to consult hematology in these cases and involvement of hematology early in managing patients with bleeding disorders to improve outcomes. This paper is directed toward emergency physicians, pediatricians, and general internists and will highlight key concepts in the primary care and work up of diagnosed and undiagnosed bleeding disorders requiring urgent treatment.
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Affiliation(s)
- Adrienne Lee
- Departments of Medicine, Cumming School of Medicine, University of Calgary and the Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health Services, 1403-29th Street NW, Calgary, AB T2N 2T9, Canada.
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Kageyama Y, Matsumoto T, Tawara I, Wada H, Katayama N. Life-Threatening Tongue and Retropharyngeal Hemorrhage in a Patient with Hemophilia A with Inhibitors. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:1022-1026. [PMID: 31303639 PMCID: PMC6647615 DOI: 10.12659/ajcr.916151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Patient: Male, 71 Final Diagnosis: Hemophilia A Symptoms: Dysarthria • dysphagia • dyspnea Medication: — Clinical Procedure: Cricothyrotomy • tracheotomy Specialty: Hematology
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Affiliation(s)
- Yuki Kageyama
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Takeshi Matsumoto
- Department of Transfusion Medicine and Cell Therapy, Mie University Hospital, Tsu, Mie, Japan
| | - Isao Tawara
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Hideo Wada
- Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Naoyuki Katayama
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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29
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Denny N, Scott M, Hay C, Thachil J. Expecting the unexpected: Acquired haemophilia A in a patient with homozygous factor V deficiency. Haemophilia 2019; 25:e101-e103. [PMID: 30690823 DOI: 10.1111/hae.13669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/14/2018] [Accepted: 11/20/2018] [Indexed: 06/09/2023]
Affiliation(s)
- Nicholas Denny
- Department of Haematology, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Martin Scott
- Department of Haematology, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Charles Hay
- Department of Haematology, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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Abstract
Hemophilia A, also known as factor VIII deficiency, is a rare disorder caused by an insufficient level of factor VIII, an essential clotting protein. Hemophilia A can be inherited or acquired. Inherited hemophilia A is caused by a mutation to the factor VIII gene on the X chromosome, which is commonly passed down from parents to children. However, in about one-third of cases, the cause is a spontaneous mutation in that gene. Acquired hemophilia A is due to an autoantibody to factor VIII, which is termed an inhibitor. This rare disorder can cause life-threatening bleeding complications. Management relies on a rapid and accurate diagnosis, control of bleeding episodes, and eradication of the inhibitor by immunosuppression therapy. Most treatment strategies are centered around anecdotal reports or small case series. This case report summarizes the successful treatment of a patient with acquired hemophilia A and major bleeding following a surgical procedure, with the use of desmopressin, recombinant factor VIIa, repeated doses of recombinant factor VIII, rituximab, and prednisone.
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Affiliation(s)
- Mark Shen
- Department of Pharmacy, NYU Winthrop Hospital, Mineola, NY, USA
| | - Shan Wang
- Department of Pharmacy, NYU Winthrop Hospital, Mineola, NY, USA
| | - Julia Sessa
- Department of Pharmacy, St. Joseph's Hospital Health Center, Syracuse, NY, USA
| | - Adel Hanna
- Surgical Intensive Care Unit Attending Physician, Department of Surgery, NYU Winthrop Hospital, Mineola, NY, USA
| | | | - Fahd Ali
- Surgical Intensive Care Unit Attending Physician, Department of Surgery, NYU Winthrop Hospital, Mineola, NY, USA
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31
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Preijers T, Laros-vanGorkom BA, Mathôt RA, Cnossen MH. Pharmacokinetic-guided dosing of factor VIII concentrate in a morbidly obese severe haemophilia A patient undergoing orthopaedic surgery. BMJ Case Rep 2019; 12:12/1/bcr-2018-226812. [PMID: 30642854 DOI: 10.1136/bcr-2018-226812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
A 58-year-old morbidly obese male (body mass index: 38 kg/m2) with severe haemophilia A underwent total knee replacement surgery. Perioperatively, factor VIII (FVIII) levels were measured daily and maximum a posteriori (MAP) Bayesian estimation was used to calculate the individual pharmacokinetic (PK) parameters and doses required to obtain prescribed FVIII target levels. In the MAP Bayesian procedure, a population PK model was used in which PK parameters were normalised using body weight. In this specific case, ideal body weight was used to scale the PK parameters instead of actual body weight. Except for the preoperative FVIII level, adequate FVIII levels were achieved during the 10-day perioperative period. During follow-up visits, the knee prosthesis was reported to function adequately.
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Affiliation(s)
- Tim Preijers
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Ron Aa Mathôt
- Hospital Pharmacy-Clinical Pharmacology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Marjon H Cnossen
- Department of Paediatric Haematology, Erasmus University Medical Center, Sophia Childrens Hospital Rotterdam, Rotterdam, The Netherlands
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Dhir A, Tempe DK. Anemia and Patient Blood Management in Cardiac Surgery—Literature Review and Current Evidence. J Cardiothorac Vasc Anesth 2018; 32:2726-2742. [DOI: 10.1053/j.jvca.2017.11.043] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Indexed: 12/24/2022]
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Andreadis P, Kafantari K, Agapidou A, Vakalopoulou S, Vlachaki E. Successful Outcome of Severe Intra-cerebral Bleeding Associated with Acquired Factor V Inhibition: Utilization of Multiple Therapeutic Agents. Balkan Med J 2018; 35:112-115. [PMID: 28903884 PMCID: PMC5820439 DOI: 10.4274/balkanmedj.2017.0158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Acquired coagulation factor inhibitors are antibodies that either inhibit activity or increase the clearance of a clotting factor and lead to an increased risk of bleeding. Most of the time, the disorder is attributed to factor VIII inhibition (acquired haemophilia A); however, other coagulation factors could also be implicated. Case Report: Herein, we report an interesting case of a patient who underwent coronary artery bypass grafting and received antibiotic treatment after surgery with third generation cephalosporin. A month later, he presented with extreme bleeding diathesis and cerebral haemorrhage. Following a thorough clinical and laboratory investigation, an acquired factor V inhibitor was diagnosed. The patient received treatment with corticosteroids, intravenous immunoglobulins, anti-CD20 monoclonal antibodies (rituximab), cyclophosphamide and recombinant factor VIIa. Finally, despite the poor initial prognosis, the patient managed to achieve a full recovery. Conclusion: As there are no clear guidelines on acquired coagulation inhibitor treatment, reports of such cases could offer insight for future therapy choices. The case was unique because the treatment regimen included a combination of multiple therapeutic agents including rituximab.
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Affiliation(s)
- Panagiotis Andreadis
- Clinic of Internal Medicine, Ippokrateio General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Katerina Kafantari
- Clinic of Internal Medicine, Ippokrateio General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Aleka Agapidou
- Clinic of Hematology, Homerton University Hospital, Homerton Row, London
| | - Sofia Vakalopoulou
- Clinic of Internal Medicine, Ippokrateio General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Efthymia Vlachaki
- Clinic of Internal Medicine, Ippokrateio General Hospital of Thessaloniki, Thessaloniki, Greece
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35
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Dolan G, Benson G, Duffy A, Hermans C, Jiménez-Yuste V, Lambert T, Ljung R, Morfini M, Zupančić Šalek S. Haemophilia B: Where are we now and what does the future hold? Blood Rev 2018; 32:52-60. [DOI: 10.1016/j.blre.2017.08.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 08/08/2017] [Accepted: 08/15/2017] [Indexed: 01/19/2023]
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36
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Wool GD, Chapel D, Treml A, Miller JL. Therapeutic plasma exchange as part of multimodal treatment of acquired hemophilia in a patient with concurrent acute intracerebral bleed and pulmonary embolism. Transfusion 2017; 57:1827-1832. [PMID: 28436106 DOI: 10.1111/trf.14132] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 03/07/2017] [Accepted: 03/08/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Autoantibodies against Factor VIII (FVIII) define the rare but life-threatening bleeding disorder acquired hemophilia A (AHA). Correction of FVIII deficiency and eradication of the factor inhibitor are the ultimate therapeutic goals in this disorder. Bypassing agents such as recombinant factor VIIa (rFVIIa) or FVIII inhibitor bypassing agent are often used to control coagulopathy before the inhibitor is eradicated. Bypassing agents carry a risk of thrombosis, however. CASE REPORT We report a patient with newly diagnosed AHA and thalamic bleed who additionally had active atrial fibrillation and developed a segmental pulmonary embolism, limiting tolerable rFVIIa dosage. This patient with very-high-risk brain bleed and concurrent thrombosis on bypass agent represented a significant management dilemma for which we successfully utilized therapeutic plasma exchange (TPE) to reduce the inhibitor titer. RESULTS FVIII inhibitor was undetectable and FVIII level was above the lower limit of normal within 12.5 days from starting TPE. While the patient ultimately died 24 days from admission for reasons unrelated to bleeding, his intracerebral hemorrhage was unchanged in size and no other bleeding morbidity was observed. CONCLUSION This patient achieved eradication of FVIII inhibitor and did not have bleed expansion while receiving multimodal therapy including corticosteroids, rituximab, and TPE. We discuss the periprocedural risks of TPE in an acquired hemophilia patient and our multiteam management of that risk.
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Affiliation(s)
- Geoffrey D Wool
- Department of Pathology, University of Chicago, Chicago, Illinois
| | - David Chapel
- Department of Pathology, University of Chicago, Chicago, Illinois
| | - Angela Treml
- Department of Pathology, University of Chicago, Chicago, Illinois
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37
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Batty P, Austin SK, Khair K, Millar CM, Palmer B, Rangarajan S, Stümpel JP, Thanigaikumar M, Yee TT, Hart DP. Treatment burden, haemostatic strategies and real world inhibitor screening practice in non-severe haemophilia A. Br J Haematol 2017; 176:796-804. [PMID: 28198996 DOI: 10.1111/bjh.14543] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/03/2016] [Indexed: 12/11/2022]
Abstract
Inhibitor formation in non-severe haemophilia A is a life-long risk and associated with morbidity and mortality. There is a paucity of data to understand real-world inhibitor screening practice. We evaluated the treatment burden, haemostatic strategies, F8 genotyping and inhibitor screening practices in non-severe haemophilia A in seven London haemophilia centres. In the 2-year study period, 44% (377/853) patients received at least one haemostatic treatment. Seventy-nine percent of those treated (296/377) received factor VIII (FVIII) concentrate. F8 genotype was known in 88% (331/377) of individuals. Eighteen per cent (58/331) had 'high-risk' F8 genotypes. In patients with 'standard-risk' F8 genotypes treated on-demand with FVIII concentrate, 51·3% episodes (243/474) were screened within 1 year. However, poor screening compliance was observed after 'high-risk' treatment episodes. In patients with 'standard-risk' F8 genotypes, 12·3% (28/227) of treatment episodes were screened in the subsequent 6 weeks after surgery or a bleed requiring ≥5 exposure days. Similarly, in the context of 'high-risk' F8 genotypes after any FVIII exposure, only 13·6% (12/88) of episodes were screened within 6 weeks. Further study is required to assess optimal practice of inhibitor screening in non-severe haemophilia A to inform subsequent clinical decisions and provide more robust prevalence data to further understand the underlying immunological mechanism.
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Affiliation(s)
- Paul Batty
- The Royal London Hospital Haemophilia Centre, QMUL, Barts and The London School of Medicine and Dentistry, London, UK
| | - Steve K Austin
- St George's Healthcare NHS Trust, Haemophilia Centre, London, UK.,The Centre for Haemostasis and Thrombosis, St Thomas' Hospital, London, UK
| | - Kate Khair
- Great Ormond Street Haemophilia Centre, London, UK
| | | | - Ben Palmer
- The United Kingdom National Haemophilia Database, Manchester, UK
| | - Savita Rangarajan
- The Centre for Haemostasis and Thrombosis, St Thomas' Hospital, London, UK
| | - Jan-Phillip Stümpel
- The Royal London Hospital Haemophilia Centre, QMUL, Barts and The London School of Medicine and Dentistry, London, UK
| | | | - Thynn T Yee
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Daniel P Hart
- The Royal London Hospital Haemophilia Centre, QMUL, Barts and The London School of Medicine and Dentistry, London, UK
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38
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Hvas AM, Poulsen LH. Inhibitor screening in non-severe haemophilia patients; a major challenge. Br J Haematol 2017; 176:683-685. [PMID: 28182257 DOI: 10.1111/bjh.14546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 11/29/2016] [Indexed: 01/06/2023]
Affiliation(s)
- Anne-Mette Hvas
- Centre for Haemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Lone H Poulsen
- Centre for Haemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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39
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Liu J, Wang H, Shang G, Wang L, Zhao H, Liu H. Acquired hemophilia A in a patient treated by Ginkgo-dipyridamolum. Clin Case Rep 2017; 5:119-122. [PMID: 28174634 PMCID: PMC5290506 DOI: 10.1002/ccr3.712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Revised: 08/02/2016] [Accepted: 08/28/2016] [Indexed: 11/09/2022] Open
Abstract
Acquired hemophilia A might be caused by Ginkgo‐dipyridamolum especially by Ginkgo, and it was successfully treated with hemostasis and immune‐suppression therapy including methylprednisolone and cyclophosphamide.
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Affiliation(s)
- Jinbo Liu
- Department of Vascular Medicine Peking University Shougang Hospital Beijing China
| | - Hongyu Wang
- Department of Vascular Medicine Peking University Shougang Hospital Beijing China
| | - Guangyun Shang
- Department of Vascular Medicine Peking University Shougang Hospital Beijing China
| | - Lichun Wang
- Department of Vascular Medicine Peking University Shougang Hospital Beijing China
| | - Hongwei Zhao
- Department of Vascular Medicine Peking University Shougang Hospital Beijing China
| | - Huan Liu
- Department of Vascular Medicine Peking University Shougang Hospital Beijing China
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41
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McMullen S, Buckley B, Hall E, Kendter J, Johnston K. Budget Impact Analysis of Prolonged Half-Life Recombinant FVIII Therapy for Hemophilia in the United States. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:93-99. [PMID: 28212975 DOI: 10.1016/j.jval.2016.09.2396] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 09/02/2016] [Accepted: 09/03/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND Hemophilia A is a factor VIII deficiency, associated with spontaneous, recurrent bleeding episodes. This may lead to comorbidities such as arthropathy and joint replacement, which contribute to morbidity and increased health care expenditure. Recombinant factor VIII Fc fusion protein (rFVIIIFc), a prolonged half-life factor therapy, requires fewer infusions, resulting in reduced treatment burden. OBJECTIVE Use a budget impact analysis to assess the potential economic impact of introducing rFVIIIFc to a formulary from the perspective of a private payer in the United States. METHODS The budget impact model was developed to estimate the potential economic impact of adding rFVIIIFc to a private payer formulary across a 2-year time period. The eligible patient population consisted of inhibitor-free adults with severe hemophilia A, receiving recombinant-based episodic or prophylaxis treatment regimens. Patients were assumed to switch from conventional recombinant factor treatment to rFVIIIFc. Only medication costs were included in the model. RESULTS The introduction of rFVIIIFc is estimated to have a budget impact of 1.4% ($0.12 per member per month) across 2 years for a private payer population of 1,000,000 (estimated 19.7 individuals receiving treatment for hemophilia A). The introduction of rFVIIIFc is estimated to prevent 124 bleeds across 2 years at a cost of $1891 per bleed avoided. CONCLUSIONS Hemophilia A is a rare disease with a low prevalence; therefore, the overall cost to society of introducing rFVIIIFc is small. Considerations for comprehensively assessing the budget impact of introducing rFVIIIFc should include episodic and prophylaxis regimens, bleed avoidance, and annual factor consumption required under alternative scenarios.
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42
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Sudheesh KM, Bharani KSNS, Kiran HY, Hanagavadi S. "Antihemophilic factor is not the only answer for all factor VIII deficiencies." Case report of odontogenic infection in a patient with hemophilia A, complicated by factor VIII inhibitors, and managed by transfusion of antihemophilic factor and factor VIII inhibitor bypass activity. Indian J Dent 2016; 7:149-152. [PMID: 27795652 PMCID: PMC5015568 DOI: 10.4103/0975-962x.186700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Dental extraction in hemophiliacs with acquired inhibitors is always a risky procedure, which often presents a lot of problems associated with bleeding. A known case of hemophilia A complicated with factor VIII inhibitors and having odontogenic infection was successfully managed by transfusion of factor VIII inhibitor bypass activity (FEIBA) and antihemophilic factor. Past medical history was significant for multiple factor VIII transfusions. Bethesda assay done to identify inhibitors revealed low titer factor VIII inhibitors. Extraction of the involved tooth was done after transfusion of FEIBA with low-dose protocols. Minimal bleeding was noted after extraction which was controlled by local measures. FEIBA was proven to be highly effective, and no side effects of the product were observed.
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Affiliation(s)
- K M Sudheesh
- Department of Oral and Maxillofacial Surgery, College of Dental Sciences, Davangere, Karnataka, India
| | - K S N Siva Bharani
- Department of Oral and Maxillofacial Surgery, College of Dental Sciences, Davangere, Karnataka, India
| | - H Y Kiran
- Department of Oral and Maxillofacial Surgery, College of Dental Sciences, Davangere, Karnataka, India
| | - Suresh Hanagavadi
- Department of Pathology, J J M Medical College, Davangere, Karnataka, India
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43
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Losos M, Scrape S, Joshi S, Shmookler A, Chen J. The tipping point: The critical role of therapeutic apheresis in a case of refractory acquired hemophilia. J Clin Apher 2016; 32:564-566. [PMID: 27646211 DOI: 10.1002/jca.21509] [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: 07/08/2016] [Revised: 09/03/2016] [Accepted: 09/06/2016] [Indexed: 01/06/2023]
Abstract
Acquired hemophilia A (AHA) is a rare autoimmune disorder that leads to factor VIII (FVIII) deficiency via autoantibody formation. Standard treatment options include FVIII bypassing factors and immunosuppression. However, the role of therapeutic plasma exchange (TPE) is not clear in the treatment of AHA. We present a case of idiopathic AHA in a 66 year old female with severe bleeding and a FVIII inhibitor of 17.6 Bethesda units (BU). She failed to respond to standard treatment including maximum dose of recombinant FVIIa (rFVIIa), rituximab, and other immunosuppressive agents. Her FVIII inhibitor rapidly increased to 140 BU and FVIII was below 5%. TPE was initiated 3 weeks after admission and her bleeding stabilized after the first treatment and completely stopped after three treatments. Repeat testing revealed increased FVIII to 15% and FVIII inhibitor decreased to 2.0 BU. After an additional TPE treatment, her FVIII increased to 27% and FVIII inhibitor decreased to 0.6 BU and she was discharged without bleeding 40 days after admission. In this case, TPE played a critical role in reducing FVIII inhibitor, which resulted in a recovery of FVIII activity and hemostasis. Therefore, TPE should be initiated early in AHA patients with bleeding and high titer of FVIII inhibitor.
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Affiliation(s)
- Michael Losos
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA
| | - Scott Scrape
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sarita Joshi
- Department of Hematology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Aaron Shmookler
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jian Chen
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Tabriznia-Tabrizi S, Gholampour M, Mansouritorghabeh H. A close insight to factor VIII inhibitor in the congenital hemophilia A. Expert Rev Hematol 2016; 9:903-13. [PMID: 27367203 DOI: 10.1080/17474086.2016.1208554] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Hemophilia A (HA) has an X-linked pattern of inheritance and is the most common of the hemorrhagic disorders. HA is caused by a decreased or deficiency of the functional clotting factor VIII (FVIII) and effects 1 in 5000-10,000 male births. The common treatment for hemophilia is replacement therapy by plasma-derived or recombinant FVIII. Approximately 20-30% of people with a severe type of HA develop an inhibitor and this phenomenon is the main challenge in the management of these patients. Genetic factors and environmental determinants contribute to inhibitor development. Here, the roles of various genetic and environmental factors such as the type of FVIII concentrate used, the number of exposure days, and peak treatment time will be discussed in detail. It seems this information is helpful for hematologists. AREAS COVERED A literature review was done in January 2016 on PubMed and Scopus using the following keywords:' h(a)emophilia A & factor VIII inhibitor', 'h(a)emophilia A & factor VIII alloantibody', 'h(a)emophilia A & inhibitor'. There was no time limitation; however, there was an English language limitation placed on the articles selected. Expert commentary: Influential genetic and environmental factors in developing inhibitors have been discussed. Most of the risk factors are related to previously untreated patients with hemophili.
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Affiliation(s)
| | - Marzie Gholampour
- a Haematology , Mashhad University of Medical sciences (MUMS) , Mashhad , Iran
| | - Hassan Mansouritorghabeh
- b Allergy Research Center, Ghaem hospital, School of Medicine , Mashhad University of Medical Sciences , Mashhad , Iran
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Windyga J, Stefanska-Windyga E, Odnoczko E, Baran B, Czubak G. Activated prothrombin complex concentrate in combination with tranexamic acid: a single centre experience for the treatment of mucosal bleeding and dental extraction in haemophilia patients with inhibitors. Haemophilia 2016; 22:e465-8. [DOI: 10.1111/hae.13035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2016] [Indexed: 11/29/2022]
Affiliation(s)
- J. Windyga
- Department of Disorders of Hemostasis and Internal Medicine; Institute of Hematology and Transfusion Medicine; Warsaw Poland
- Laboratory of Hemostasis and Metabolic Diseases; Institute of Hematology and Transfusion Medicine; Warsaw Poland
| | - E. Stefanska-Windyga
- Outpatient Clinic for Patients with Coagulation Disorders; Institute of Hematology and Transfusion Medicine; Warsaw Poland
| | - E. Odnoczko
- Laboratory of Hemostasis and Metabolic Diseases; Institute of Hematology and Transfusion Medicine; Warsaw Poland
| | - B. Baran
- Laboratory of Hemostasis and Metabolic Diseases; Institute of Hematology and Transfusion Medicine; Warsaw Poland
| | - G. Czubak
- Outpatient Clinic for Patients with Coagulation Disorders; Institute of Hematology and Transfusion Medicine; Warsaw Poland
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Abstract
BACKGROUND Acquired haemophilia A is a rare bleeding disorder caused by the development of specific autoantibodies against coagulation factor VIII. Rituximab may be an alternative approach to the treatment of acquired haemophilia by eradicating FVIII autoantibodies. OBJECTIVES To assess and summarise the efficacy and adverse effects of rituximab for treating people with acquired haemophilia A. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's trials registers, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and conference proceedings.Date of last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group's trials registers: 01 March 2016. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of rituximab for people with acquired hemophilia A, with no restrictions on gender, age or ethnicity. DATA COLLECTION AND ANALYSIS No trials matching the selection criteria were eligible for inclusion. MAIN RESULTS No trials matching the selection criteria were eligible for inclusion. AUTHORS' CONCLUSIONS No randomised clinical trials of rituximab for acquired hemophilia A were found. Thus, based on the highest quality of evidence, we are not able to draw any conclusions or make any recommendations on rituximab for eradicating inhibitors in people with acquired haemophilia A. Given that undertaking randomised controlled trials in this field is a complex task, the authors suggest that, while planning such trials, clinicians treating the disease continue to base their choices on alternative, lower quality sources of evidence. The authors plan, for a future update of this review, to appraise and incorporate any randomised controlled trials, as well as other high-quality non-randomised studies.
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Affiliation(s)
- Yan Zeng
- General Hospital of Chengdu Military RegionDepartment of Hematology270#, Rongdu Da DaoChengduChina610083
| | - Ruiqing Zhou
- Guangzhou First People's Hospital, Guangzhou Medical UniversityDepartment of HematologyPanfu RoadGuangzhouChina510180
| | - Xin Duan
- West China Hospital, Sichuan UniversityDepartment of Orthopaedics SurgeryNo. 37 GuoXueXiang StreetChengduChina610041
| | - Dan Long
- West China Hospital, Sichuan UniversityKey Laboratory of Transplant Engineering and ImmunologyNo. 37, Guo Xue XiangChengduChina610041
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Yoo KY, Joo SC, Choi YM. Long-term course of anti-factor VIII antibody in patients with hemophilia A at a single center. Blood Res 2016; 51:37-43. [PMID: 27104190 PMCID: PMC4828527 DOI: 10.5045/br.2016.51.1.37] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 01/29/2016] [Accepted: 02/04/2016] [Indexed: 11/17/2022] Open
Abstract
Background Immune tolerance induction (ITI) can reduce inhibitors against factor VIII concentrates by 70-80%. In this study, we elucidated the characteristics of inhibitors and attempted to determine the proper indications and timing for ITI. Methods Subjects included hemophilia A patients registered at the Korea Hemophilia Foundation from 1991 through 2014. Inhibitors were classified as persistent and transient. Patients were classified into groups according to peak inhibitor titer: low (<2 BU/mL), moderate (2 to <5 BU/mL), high (5 to <10 BU/mL), and very high titer (≥10 BU/mL). Results Overall, 350 (21.4%) of 1,634 hemophilia A patients developed inhibitors at least once. Of these, 100 (6.1%) and 250 (15.3%) patients developed persistent and transient inhibitors, respectively. For transient inhibitors, the median peak titer was 1.0 BU/mL, persistent for median of 11.0 months (10.0, 8.0, 13.0, and 19.0 months in the low, moderate, high, and very high titer transient inhibitor groups, respectively). Overall, 95.8% (215), 72.2% (17), 52.4% (21), and 21.7% (97) of patients in the low, moderate, high, and very high titer groups became inhibitor-negative spontaneously, without ITI. Conclusion Given the spontaneous disappearance of inhibitors and high cost of ITI, it is worthwhile to postpone ITI for 11 months unless the peak inhibitor titer is greater than 10 BU/mL.
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McDonald R, Patel AP, Horrocks C. A rare and life-threatening cause of epistaxis. BMJ Case Rep 2015; 2015:bcr-2015-213528. [PMID: 26698214 DOI: 10.1136/bcr-2015-213528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Epistaxis is a potentially life-threatening condition that can compromise a patient's airway, breathing and circulation. Early recognition of underlying bleeding diatheses that are amenable to medical therapy is imperative in order for timely treatment and to reduce morbidity. We present a case in which acquired haemophilia was diagnosed in an 83-year-old man presenting with seemingly uncomplicated epistaxis. The patient suffered multisite haemorrhages and haemodynamic compromise before definitive management with monoclonal antibody therapy. The case highlights the difficulties in managing this rare condition. It also emphasises the importance of clotting assay analysis in patients who present with epistaxis in the absence of an underlying anticoagulant.
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Affiliation(s)
- Rory McDonald
- Department of ENT, Head & Neck Surgery, Peterborough City Hospital, Peterborough, UK
| | - Anant Piyush Patel
- Department of ENT, Head & Neck Surgery, Peterborough City Hospital, Peterborough, UK
| | - Claudine Horrocks
- Department of ENT, Head & Neck Surgery, Peterborough City Hospital, Peterborough, UK
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Torticollis in a haemophilic infant with inhibitor: a case of spinal epidural haematoma. Blood Coagul Fibrinolysis 2015; 27:576-9. [PMID: 26650462 DOI: 10.1097/mbc.0000000000000465] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Central nervous system bleeding, which can be a life-threatening complication, is seen in 2.7% of patients with haemophilia. Spinal epidural haematomas represent about one-tenth of such cases. Here, we report on a 10-month-old boy with severe haemophilia A, who presented with torticollis. Although administration of factor VIII at a dose of 50 U/kg, the patient developed flaccid paralysis of the upper extremities. Factor VIII inhibitor screen was positive. Magnetic resonance imaging of the spine revealed spinal epidural haematomas, extending from C-1 to the cauda equina. Treatment was continued with recombinant activated factor VIIa without surgery. After 1 month, complete neurological recovery was achieved and fully resolved haematomas were detected on spinal MRI. A prompt radiological evaluation of the cervical spine with MRI should be made in patients with haemophilia presenting with torticollis. In addition, in the case of life-threatening bleeding in patients with haemophilia, the possibility of an inhibitor should be kept in mind.
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50
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Goto S, Ookawara S, Ueda Y, Ito K, Miyazawa H, Kitano T, Shindo M, Kaku Y, Hirai K, Hoshino T, Ashizawa M, Mori H, Yoshida I, Tabei K. Effectiveness of plasma exchange for acquired type A hemophilia. CEN Case Rep 2015; 4:196-199. [DOI: 10.1007/s13730-015-0168-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 01/15/2015] [Indexed: 11/28/2022] Open
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