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Kim HJ, Jung YJ, Lee JH, Lee HJ, Maeng CH, Baek SK, Han JJ. Severe acquired hemophilia A associated with COVID-19 vaccination: A case report and literature review. Medicine (Baltimore) 2024; 103:e39166. [PMID: 39093750 PMCID: PMC11296452 DOI: 10.1097/md.0000000000039166] [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: 03/15/2024] [Accepted: 07/11/2024] [Indexed: 08/04/2024] Open
Abstract
RATIONALE Acquired hemophilia A (AHA) is a rare autoimmune disease caused by an antibody that inhibits coagulation factor VIII activity. More than half of patients with AHA cannot identify underlying disorders. The remaining patients are associated with malignancies, autoimmune diseases, skin diseases, infections, and medications. Here, we present a case of 56-year-old Korean man with underlying hypertension, dyslipidemia, and diabetes mellitus who developed AHA following the second dose of BNT162b2 COVID-19 vaccination. PATIENT CONCERNS He presented with a large 20 × 30 cm-sized hematoma along the psoas muscle and intracranial hemorrhage, necessitating intensive care with mechanical ventilation and continuous renal replacement therapy. Laboratory testing demonstrated that activated partial thromboplastin time and prothrombin times were 74.7 seconds (normal range 29-43 seconds) and 17.2 seconds (normal range 12.5-14.7 seconds), respectively. DIAGNOSES Laboratory tests confirmed AHA with undetectable factor VIII activity (<1.5%) and a positive factor VIII antibody with a titer of 8.49 Bethesda units/mL. INTERVENTIONS Recombinant factor VIIa (NovoSeven®) was administered every 2 hours to control the bleeding, alongside immunosuppression with methylprednisolone 1 mg/kg daily and cyclophosphamide 2 mg/kg daily to eliminate the autoantibody. OUTCOMES Despite the treatments, the patient developed sepsis and succumbed 14 weeks after admission. LESSONS This rare case underscores the importance of monitoring for AHA following COVID-19 vaccination. Although the benefits outweigh the risks of vaccination, AHA should be considered in the differential diagnosis of unusual bleeding following the vaccinations. Early diagnosis and management before severe bleeding are critical for successfully controlling life-threatening bleeding.
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Affiliation(s)
- Hong Jun Kim
- Department of Hematology and Medical Oncology, Kyung Hee University, College of Medicine, Seoul, Republic of Korea
| | - Ye Ji Jung
- Department of Hematology and Medical Oncology, Kyung Hee University, College of Medicine, Seoul, Republic of Korea
| | - Jun Ho Lee
- Department of Hematology and Medical Oncology, Kyung Hee University, College of Medicine, Seoul, Republic of Korea
| | - Hyun Jung Lee
- Department of Hematology and Medical Oncology, Kyung Hee University, College of Medicine, Seoul, Republic of Korea
| | - Chi Hoon Maeng
- Department of Hematology and Medical Oncology, Kyung Hee University, College of Medicine, Seoul, Republic of Korea
| | - Sun Kyung Baek
- Department of Hematology and Medical Oncology, Kyung Hee University, College of Medicine, Seoul, Republic of Korea
| | - Jae Joon Han
- Department of Hematology and Medical Oncology, Kyung Hee University, College of Medicine, Seoul, Republic of Korea
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2
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Winn SP, Mohsin F, Peeke S. A Rare Case of Hemophilia: Acquired Factor VIII Deficiency. Cureus 2024; 16:e62407. [PMID: 39011224 PMCID: PMC11248456 DOI: 10.7759/cureus.62407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2024] [Indexed: 07/17/2024] Open
Abstract
Unlike hereditary hemophilia, acquired hemophilia is a rare life-threatening bleeding disorder that occurs in a person who has no personal or family history of bleeding episodes. It usually presents with new-onset subcutaneous/joint/muscle bleeding causing ecchymoses and hematomas, hematuria, GI bleeding, retroperitoneal bleeding, or rarely acute intracranial hemorrhage in elderly individuals. The diagnosis involves assessing prolonged activated partial thromboplastin time (aPTT) and conducting mixing studies after ruling out lupus anticoagulants and interfering substances such as heparins. Management consists of controlling hemostasis using recombinant activated factor VII (rFVIIa) and activated prothrombin complex concentrates (aPCC), along with eradicating autoantibodies against factor VIII from the body system using immunosuppressive therapies. Due to the risk of uncontrolled bleeding in individuals who were previously normal, delayed diagnoses and recurrences are not uncommon, potentially resulting in unfavorable outcomes.
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Affiliation(s)
- Soe P Winn
- Internal Medicine, Maimonides Medical Center, Brooklyn, USA
| | - Fizza Mohsin
- Internal Medicine, Maimonides Medical Center, Brooklyn, USA
| | - Stephen Peeke
- Hematology and Oncology, Maimonides Medical Center, Brooklyn, USA
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3
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Evangelidis N, Kotsiou N, Evangelidis P, Alevizopoulos VI, Dermitzakis I, Chissan S, Vakalopoulou S, Gavriilaki E. Genetics and Epigenetics in Acquired Hemophilia A: From Bench to Bedside. Curr Issues Mol Biol 2024; 46:5147-5160. [PMID: 38920981 PMCID: PMC11201880 DOI: 10.3390/cimb46060309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 05/14/2024] [Accepted: 05/21/2024] [Indexed: 06/27/2024] Open
Abstract
Acquired hemophilia A (AHA) is a bleeding disorder characterized by the immunological inhibition of factor VIII (FVIII) of the hemostatic pathway leading to hemorrhagic events. Different domains of FVIII are the target of autoantibodies (mainly immunoglobulin (Ig) G) leading to the deficiency of FVIII. Several factors have been associated with the activation of the auto-immunity towards FVIII. Emerging evidence implicates CD4+ T cell activation in mediating this autoimmune response, with their involvement like that observed in congenital hemophilia A. Several genes such as HLA II DRB*16, DQB1*0502, and CTLA-4 + 49 are responsible for the pathogenesis of AHA. Epigenetic modifications and mainly long-coding RNAS (lncRNAs) are potentially contributing to the pathogenesis of AHA. The treatment approach of AHA includes the management of acute bleeding events and the administration of immunosuppressive medications. This review aimed to summarize the published data on the genetics and epigenetics of AHA. The severity and the mortality of this disease are creating an emerging need for further research in the field of the genetics and epigenetics of acquired hemorrhagic disorder.
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Affiliation(s)
- Nikolaos Evangelidis
- Hematology Unit-Hemophilia Centre, 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (N.E.); (N.K.); (P.E.); (V.I.A.); (S.C.); (S.V.)
| | - Nikolaos Kotsiou
- Hematology Unit-Hemophilia Centre, 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (N.E.); (N.K.); (P.E.); (V.I.A.); (S.C.); (S.V.)
| | - Paschalis Evangelidis
- Hematology Unit-Hemophilia Centre, 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (N.E.); (N.K.); (P.E.); (V.I.A.); (S.C.); (S.V.)
| | - Vlasios I. Alevizopoulos
- Hematology Unit-Hemophilia Centre, 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (N.E.); (N.K.); (P.E.); (V.I.A.); (S.C.); (S.V.)
| | - Iasonas Dermitzakis
- Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | - Sofia Chissan
- Hematology Unit-Hemophilia Centre, 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (N.E.); (N.K.); (P.E.); (V.I.A.); (S.C.); (S.V.)
| | - Sofia Vakalopoulou
- Hematology Unit-Hemophilia Centre, 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (N.E.); (N.K.); (P.E.); (V.I.A.); (S.C.); (S.V.)
| | - Eleni Gavriilaki
- Hematology Unit-Hemophilia Centre, 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (N.E.); (N.K.); (P.E.); (V.I.A.); (S.C.); (S.V.)
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4
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Bahrini K, Hannachi E. Does SARS-CoV-2vaccination induce acquired autoimmune discords and inflammatory manifestations? Clinics (Sao Paulo) 2023; 78:100257. [PMID: 37499426 PMCID: PMC10413055 DOI: 10.1016/j.clinsp.2023.100257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 07/05/2023] [Indexed: 07/29/2023] Open
Affiliation(s)
- Khadija Bahrini
- Research Unit UR17DN05, Military Hospital of Tunis, Tunis El-Manar University, Tunis, Tunisia.
| | - Emna Hannachi
- Laboratoire de Parasitologie Médicale, Biotechnologies et Biomolécules; LR11-IPT06; Institut Pasteur de Tunis, Université Tunis El-Manar, Tunis-Belvédère, Tunisia
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5
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Konstantinov K, Dolladille C, Gillet B, Alexandre J, Aouba A, Deshayes S, Repesse Y. Drug-associated acquired hemophilia A: an analysis based on 185 cases from the WHO pharmacovigilance database. Haemophilia 2023; 29:186-192. [PMID: 36367755 DOI: 10.1111/hae.14692] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/21/2022] [Accepted: 10/27/2022] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Acquired hemophilia A (AHA) is a rare autoimmune hemorrhagic disease occurring in several underlying conditions. Drug-associated AHA (D-AHA) is poorly addressed nowadays. AIM This work aims to identify and characterize which drugs are associated with AHA using the WHO global database of reported potential effects of medicinal products (VigiBase). METHODS First, we realized a disproportionality analysis using the information component (IC) to identify D-AHA in VigiBase. IC compares observed- and expected-values in order to find associations between drugs and adverse drug reactions (ADRs) using disproportionate Bayesian reporting. IC025 is the lower end of a 95% credibility interval for the IC. Then, we collected cases of drugs significantly associated with AHA from July 2004 to November 2021. RESULTS 14 drugs with IC025 > 0 were identified representing a total of 185 cases. D-AHA occurred more frequently in men (59%) than women (41%). The median (min-max) age at onset was 75 years (8-98). The median [Q1-Q3] time to onset of D-AHA from the start of the suspected drug was 30 days [9.5-73.75] and 10% of cases resulted in a fatality. The drugs associated with the highest IC025 (IC025 > 2) were Clopidogrel, Alemtuzumab, Omalizumab. This study retrieved for the first time three usually used drugs (3/14) that exhibit a significant pharmacovigilance signal for D-AHA. CONCLUSION This worldwide pharmaco-epidemiologic study updates the list of the drugs associated with AHA. The clinician should be aware of these possible severe ADR, which might require larger epidemiological and pathophysiologic studies.
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Affiliation(s)
| | - Charles Dolladille
- UNICAEN, EA4650 SEILIRM, CHU de Caen Normandie, Normandie University, Caen, France.,Department of Pharmacology, CHU de Caen Normandie, Caen, France
| | | | - Joachim Alexandre
- UNICAEN, EA4650 SEILIRM, CHU de Caen Normandie, Normandie University, Caen, France.,Department of Pharmacology, CHU de Caen Normandie, Caen, France
| | - Achille Aouba
- Department of Internal Medicine, UNICAEN, CHU de Caen Normandie, Normandie University, Caen, France
| | - Samuel Deshayes
- Department of Internal Medicine, UNICAEN, CHU de Caen Normandie, Normandie University, Caen, France
| | - Yohann Repesse
- Haematology Laboratory, CHU Caen Normandie, Caen, France.,Unicaen, Inserm, Physiopathology and Imaging of Neurological Disorders (PhIND), Normandie University, Caen, France
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6
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Gidaro A, Palmieri G, Donadoni M, Mameli LA, La Cava L, Sanna G, Castro D, Delitala AP, Manetti R, Castelli R. A Diagnostic of Acquired Hemophilia Following PD1/PDL1 Inhibitors in Advanced Melanoma: The Experience of Two Patients and a Literature Review. Diagnostics (Basel) 2022; 12:diagnostics12102559. [PMID: 36292248 PMCID: PMC9600358 DOI: 10.3390/diagnostics12102559] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/11/2022] [Accepted: 10/19/2022] [Indexed: 11/16/2022] Open
Abstract
Acquired hemophilia A (AHA) is a rare bleeding disorder caused by the development of specific autoantibodies against factor VIII (FVIII). Immunotherapy is a recent therapeutic option that targets the patient's self-tolerance against tumor cells. Because therapeutic effects of the immune checkpoint inhibitors (ICIs) are mediated by enhancing the immune response to restore antitumor immunity, autoimmune-related adverse effects can be seen in up to 80% of patients during treatment and after treatment. A rare hematologic ICIs-related adverse event is AHA. Hereafter we report two cases of AHA developed during anti-PD-1 immunotherapy for advanced melanoma: one secondary to treatment with nivolumab and one secondary to pembrolizumab. Both patients were treated with activated FVII (Novoseven®, Novo Nordisk, Bagsværd, Denmark) as hemostatic treatment combined with the eradication of antibodies anti-FVIII obtained with rituximab. In the last few years these drugs have significantly improved the therapeutic armamentarium for the management of AHA. Indeed, while FVIIa has proven to be an effective and safe tool for the treatment of acute bleeding related to FVIII autoantibodies, rituximab is a promising alternative for the autoantibodies' elimination and the restoration of normal hemostasis. Our finding supports the use of this combination even in AHA secondary to ICIs treatment.
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Affiliation(s)
- Antonio Gidaro
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi N° 74, 20157 Milan, Italy
- Correspondence: (A.G.); (R.C.); Tel.: +39-0239042391 (A.G.); +39-079-228446 (R.C.)
| | - Giuseppe Palmieri
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale san Pietro N° 8, 07100 Sassari, Italy
| | - Mattia Donadoni
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi N° 74, 20157 Milan, Italy
| | - Lucia A. Mameli
- Departmental Simple Operative Unit Coagulation, Hemostasis Diseases Hospital S Maria Annunziata, Via Enrico De Nicola N° 14, 07100 Sassari, Italy
| | - Leyla La Cava
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, Via G.B. Grassi N° 74, 20157 Milan, Italy
| | - Giuseppe Sanna
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale san Pietro N° 8, 07100 Sassari, Italy
| | - Dante Castro
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale san Pietro N° 8, 07100 Sassari, Italy
| | - Alessandro P. Delitala
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale san Pietro N° 8, 07100 Sassari, Italy
| | - Roberto Manetti
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale san Pietro N° 8, 07100 Sassari, Italy
| | - Roberto Castelli
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale san Pietro N° 8, 07100 Sassari, Italy
- Correspondence: (A.G.); (R.C.); Tel.: +39-0239042391 (A.G.); +39-079-228446 (R.C.)
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7
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Duminuco A, Calagna M, Markovic U, Esposito B, Grasso S, Riccobene C, Di Raimondo F, Giuffrida G. Acquired hemophilia A following COVID-19 vaccination - The importance of prompt diagnosis: A case report. Transfus Apher Sci 2022; 62:103577. [PMID: 36151008 PMCID: PMC9465488 DOI: 10.1016/j.transci.2022.103577] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 08/31/2022] [Accepted: 09/07/2022] [Indexed: 11/17/2022]
Abstract
Acquired hemophilia A (AHA) is a rare coagulopathy characterized by hemorrhagic manifestations. It has been linked to various conditions, including autoimmune disorders, drugs, tumors, lymphoproliferative disorders, and infections. We present a case of AHA in a 71-year-old male patient with cutaneous hematoma occurring 8 days after vaccination for COVID-19. This report aims to highlight the risk of FVIII inhibitor development following an immune stimulus, thus improving our knowledge regarding possible vaccination-related adverse events. Furthermore, we underline how the potential risk of not recognizing disease manifestations promptly, together with specific coagulation alterations, could significantly affect the patient's outcome. Adequate management plans and the diffusion of shared guidelines are of fundamental importance in order to prevent the development of life-threatening complications and initiate appropriate treatment as soon as possible. DATA AVAILABILITY: All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.
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Affiliation(s)
- Andrea Duminuco
- Division of Hematology with BMT, A.O.U. Policlinico "G.Rodolico-San Marco", Via S. Sofia 78, 95123 Catania, Italy.
| | - Marianna Calagna
- Division of Hematology with BMT, A.O.U. Policlinico "G.Rodolico-San Marco", Via S. Sofia 78, 95123 Catania, Italy
| | - Uros Markovic
- Division of Hematology with BMT, A.O.U. Policlinico "G.Rodolico-San Marco", Via S. Sofia 78, 95123 Catania, Italy; Division of Hematology with BMT, Istituto Oncologico del Mediterraneo, Viagrande, Italy; Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Messina, Italy
| | - Benedetta Esposito
- Division of Hematology with BMT, A.O.U. Policlinico "G.Rodolico-San Marco", Via S. Sofia 78, 95123 Catania, Italy
| | - Stephanie Grasso
- Division of Hematology with BMT, A.O.U. Policlinico "G.Rodolico-San Marco", Via S. Sofia 78, 95123 Catania, Italy
| | - Carla Riccobene
- Division of Hematology with BMT, A.O.U. Policlinico "G.Rodolico-San Marco", Via S. Sofia 78, 95123 Catania, Italy
| | - Francesco Di Raimondo
- Division of Hematology with BMT, A.O.U. Policlinico "G.Rodolico-San Marco", Via S. Sofia 78, 95123 Catania, Italy
| | - Gaetano Giuffrida
- Division of Hematology with BMT, A.O.U. Policlinico "G.Rodolico-San Marco", Via S. Sofia 78, 95123 Catania, Italy
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8
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Tang Q, Liao J, Xie X. Acquired Hemophilia Associated with Rheumatic Diseases: A Case-Based Systematic Review. J Inflamm Res 2022; 15:4385-4393. [PMID: 35945991 PMCID: PMC9357396 DOI: 10.2147/jir.s369288] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/19/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Qi Tang
- Department of Rheumatology and Immunology, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Jiafen Liao
- Department of Rheumatology and Immunology, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Xi Xie
- Department of Rheumatology and Immunology, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Correspondence: Xi Xie, Department of Rheumatology and Immunology, the Second Xiangya Hospital, Central South University, Changsha, 410011, People’s Republic of China, Tel/Fax +86 0731 8529 5255, Email
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9
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Pishko AM, Doshi BS. Acquired Hemophilia A: Current Guidance and Experience from Clinical Practice. J Blood Med 2022; 13:255-265. [PMID: 35592586 PMCID: PMC9112043 DOI: 10.2147/jbm.s284804] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/22/2022] [Indexed: 12/23/2022] Open
Abstract
In acquired hemophilia A (AHA), autoantibodies to coagulation factor VIII (FVIII) neutralize FVIII activity leading to a potentially severe bleeding diathesis that carries a high rate of morbidity and mortality. This disorder is rare and occurs mainly in adults over 60 years of age or in the postpartum period. The diagnosis should be suspected in patients with new-onset bleeding without a personal or family history of bleeding and can be confirmed via specific assays for FVIII inhibitors. Treatment involves both hemostatic therapies to decrease bleeding and immune modulation strategies to re-establish immune tolerance to FVIII. There are limited data on treatment for refractory disease, based mostly on small case series. Registry studies have informed consensus guidelines for optimal hemostatic therapies and initial immunosuppressive therapies. Additional studies are needed to evaluate novel hemostatic agents and develop biomarkers to risk-stratify treatment while limiting adverse events.
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Affiliation(s)
- Allyson M Pishko
- Department of Medicine, Division of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Bhavya S Doshi
- Department of Pediatrics, Division of Hematology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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10
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Al Hennawi H, Al Masri MK, Bakir M, Albarazi M, Jazaeri F, Almasri TN, Shoura SJ, Barakeh ARR, Taftafa A, Khan MK, Zaleski HI. Acquired Hemophilia A Post-COVID-19 Vaccination: A Case Report and Review. Cureus 2022; 14:e21909. [PMID: 35265430 PMCID: PMC8898568 DOI: 10.7759/cureus.21909] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2022] [Indexed: 11/13/2022] Open
Abstract
Acquired hemophilia A (AHA) is an inhibitory coagulopathy that represents a rare variant of hemorrhagic syndromes. We present a case of idiopathic AHA in a 75-year-old male patient with a cutaneous hematoma that could be attributed to a recent COVID-19 vaccination. The aim of this report is to raise awareness of a possible association between AHA and COVID-19 vaccination and to review similar reported cases and management plans to prevent the development of possible morbidity and debilitating complications. This case illustrates an exceptionally rare side effect of the COVID-19 vaccination. The advantages of obtaining the COVID-19 vaccine outweigh the risks.
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Affiliation(s)
- Hussam Al Hennawi
- College of Medicine, Alfaisal University College of Medicine, Riyadh, SAU
| | | | - Mohamad Bakir
- College of Medicine, Alfaisal University College of Medicine, Riyadh, SAU
| | - Mohieddin Albarazi
- College of Medicine, Alfaisal University College of Medicine, Riyadh, SAU
| | - Feras Jazaeri
- College of Medicine, Alfaisal University College of Medicine, Riyadh, SAU
| | - Talal N Almasri
- College of Medicine, Alfaisal University College of Medicine, Riyadh, SAU
| | - Sami J Shoura
- Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, USA
| | | | | | - Muhammad K Khan
- College of Medicine, Dow University of Health Sciences, Civil Hospital Karachi, Karachi, PAK
| | - Henry I Zaleski
- Hematology and Oncology, Houston Methodist Hospital, Houston, USA
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11
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Soliman DS, Al Battah A, Al Faridi D, Ibrahim F. Acquired Hemophilia A Developed Post COVID-19 Vaccine: An Extremely Rare Complication. J Med Cases 2022; 13:1-4. [PMID: 35211227 PMCID: PMC8827248 DOI: 10.14740/jmc3827] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/26/2021] [Indexed: 01/29/2023] Open
Abstract
Acquired hemophilia A (AHA) is a rare autoimmune bleeding disorder caused by circulating autoantibodies (inhibitor) directed against coagulation factor VIII (FVIII). We report a 39-year-old single female who presented to emergency department with sudden onset gross hematuria 10 days following her first dose of Pfizer-BioNTech severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA (coronavirus disease 2019 (COVID-19)) vaccine. Coagulation profile revealed isolated prolongation of the activated partial thromboplastin time due to FVIII deficiency with normal von Willebrand factor and activity. Mixing study revealed time-dependent inhibitor pattern that was successively identified as directed against FVIII using the Nijmegen-modified Bethesda assay. FVIII inhibitor in a titer of 17.2 Bethesda Units/mL was detected. While thrombosis is a frequent complication of severe COVID-19 infection, on the other hand, bleeding is rare in the setting of COVID-19 infection/vaccination with no anticoagulants. Till date, a couple of cases of acquired hemophilia developed after receiving mRNA derived COVID-19 vaccines (Pfizer-BioNTech SARS-CoV-2 mRNA vaccine and Moderna mRNA vaccines) had been reported. It is important to raise the awareness about this rare side effect that might be directly induced by the mRNA COVID-19 vaccine or that the vaccine could have triggered it in a genetically predisposed individual. We recommend considering screening for an inhibitor (by mixing study) in cases with otherwise unexplained onset hemorrhagic disorder and/or isolated activated partial thromboplastin time prolongation.
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Affiliation(s)
- Dina Sameh Soliman
- Department of Laboratory Medicine and Pathology, Hamad Medical Corporation, Doha, Qatar.,Department of Laboratory Medicine and Pathology, Weill Cornell Medicine, Doha, Qatar.,Department of Clinical Pathology, National Cancer Institute, Cairo, Egypt
| | - Afaf Al Battah
- Department of Hematology and Medical Oncology, National Centre for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Dekra Al Faridi
- Department of Laboratory Medicine and Pathology, Hamad Medical Corporation, Doha, Qatar
| | - Feryal Ibrahim
- Department of Laboratory Medicine and Pathology, Hamad Medical Corporation, Doha, Qatar
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12
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Al-Ali D, Elshafeey A, Mushannen M, Kawas H, Shafiq A, Mhaimeed N, Mhaimeed O, Mhaimeed N, Zeghlache R, Salameh M, Paul P, Homssi M, Mohammed I, Narangoli A, Yagan L, Khanjar B, Laws S, Elshazly MB, Zakaria D. Cardiovascular and haematological events post COVID-19 vaccination: A systematic review. J Cell Mol Med 2021; 26:636-653. [PMID: 34967105 PMCID: PMC8817142 DOI: 10.1111/jcmm.17137] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 12/05/2021] [Accepted: 12/09/2021] [Indexed: 12/15/2022] Open
Abstract
Since COVID‐19 took a strong hold around the globe causing considerable morbidity and mortality, a lot of effort was dedicated to manufacturing effective vaccines against SARS‐CoV‐2. Many questions have since been raised surrounding the safety of the vaccines, and a lot of media attention to certain side effects. This caused a state of vaccine hesitancy that may prove problematic in the global effort to control the virus. This review was undertaken with the aim of putting together all the reported cardiovascular and haematological events post COVID‐19 vaccination in published literature and to suggest possible mechanisms to explain these rare phenomena.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Lina Yagan
- Weill Cornell Medicine Qatar, Doha, Qatar
| | | | - Sa'ad Laws
- Weill Cornell Medicine Qatar, Doha, Qatar
| | - Mohamed B Elshazly
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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13
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Osaki T, Souri M, Ichinose A. Important roles of the human leukocyte antigen class I and II molecules and their associated genes in the autoimmune coagulation factor XIII deficiency via whole-exome sequencing analysis. PLoS One 2021; 16:e0257322. [PMID: 34506591 PMCID: PMC8432773 DOI: 10.1371/journal.pone.0257322] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 08/30/2021] [Indexed: 11/19/2022] Open
Abstract
Autoimmune coagulation factor XIII deficiency is a bleeding disorder caused by the formation of autoantibodies against the coagulation factor XIII (FXIII); however, the molecular mechanism underlying this process is unknown. Therefore, in the present study, we aimed to elucidate this mechanism by performing whole-exome sequencing analysis of 20 cases of autoimmune FXIII deficiency. We identified approximately 21,788–23,916 variants in each case. In addition to their ability to activate T cells, present antigens, and immune tolerance, the candidate alleles were further narrowed down according to their allelic frequencies and the magnitude of damage caused by the substitution of amino acids. After selecting 44 candidate alleles, we investigated whether they were associated with the FXIII inhibitory titers and/or the anti-FXIII autoantibodies. We found that two polymorphisms whose variant allele frequencies were significantly lower in the patients tended to decrease FXIII inhibitory titers as the number of variant alleles increased. We also found that five polymorphisms whose variant allele frequencies were significantly higher in the patients tended to increase the levels of the anti-FXIII autoantibodies as the number of variant alleles increased. All of these polymorphisms were found in the human leukocyte antigen (HLA) class I and II molecules and their associated genes. In particular, the HLA class II molecule and its associated genes were found to be involved in the presentation of foreign antigens as well as the negative regulation of the proliferation of T-cells and the release of cytokines. Polymorphisms in the HLA class II molecules and the cytotoxic T lymphocyte antigen 4 have been reported to be associated with the development of autoantibodies in acquired hemophilia A. Therefore, we hypothesized that these polymorphisms may be associated with the development of autoantibodies in autoimmune FXIII deficiency.
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Affiliation(s)
- Tsukasa Osaki
- Japanese Collaborative Research Group on Autoimmune Coagulation Factor Deficiencies (JCRG supported by the Japanese Ministry of Health, Labor and Welfare), Yamagata, Japan
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan
- Department of Public Health and Hygiene, Yamagata University Faculty of Medicine, Yamagata, Japan
- * E-mail:
| | - Masayoshi Souri
- Japanese Collaborative Research Group on Autoimmune Coagulation Factor Deficiencies (JCRG supported by the Japanese Ministry of Health, Labor and Welfare), Yamagata, Japan
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan
- Department of Public Health and Hygiene, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Akitada Ichinose
- Japanese Collaborative Research Group on Autoimmune Coagulation Factor Deficiencies (JCRG supported by the Japanese Ministry of Health, Labor and Welfare), Yamagata, Japan
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan
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14
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Cameron H, Perez Botero J. Recognition of the unique bleeding pattern and laboratory findings in acquired haemophilia A facilitates prompt treatment of a life-threatening disorder. BMJ Case Rep 2021; 14:14/8/e244238. [PMID: 34344656 PMCID: PMC8336148 DOI: 10.1136/bcr-2021-244238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Acquired haemophilia A (AHA) is an uncommon but severe acquired bleeding disorder caused by the development of antibodies against clotting factor VIII, impairing secondary haemostasis. It is more common in older individuals and characteristically presents with spontaneous soft tissue bleeding that can rapidly become life-threatening. Definitive treatment requires immunosuppression to eradicate anti-FVIII antibodies, while providing haemostatic support to manage bleeding. Transfusions of fresh frozen plasma or cryoprecipitate, typically used to treat severe bleeding, are ineffective in patients with AHA. Instead, highly specialised clotting factor concentrates are required. While the appearance and extent of the soft tissue bleeding and the markedly prolonged activated partial thromboplastin time are characteristic, lack of familiarity with this disease process can lead to significant treatment delays. We report the clinical course and management of a 65-year-old woman who presented with severe anaemia of unclear aetiology with unrecognised soft tissue bleeding who was subsequently diagnosed with AHA.
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Affiliation(s)
- Hunter Cameron
- School of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Juliana Perez Botero
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA .,Versiti, Milwaukee, Wisconsin, USA
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15
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Radwi M, Farsi S. A case report of acquired hemophilia following COVID-19 vaccine. J Thromb Haemost 2021; 19:1515-1518. [PMID: 33783953 PMCID: PMC8250362 DOI: 10.1111/jth.15291] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 03/07/2021] [Indexed: 01/14/2023]
Abstract
Acquires hemophilia A (AHA) is rare bleeding condition commonly associated with malignancy, autoimmune disease, or pregnancy. We report a case of a 69-year-old gentleman who developed bleeding symptoms after receiving COVID-19 vaccine. Laboratory testing showed isolated prolongation of the activated partial thromboplastin time, and normal von Willebrand factor. Further testing confirmed the presence of factor VIII inhibitor. To date, no cases of AHA have been reported after exposure to COVID-19 vaccine. There have been two cases of AHA following seasonal flu and H1N1 vaccination, as well as two cases of AHA following COVID-19 infection. We present a summary of these cases and review of literature of autoimmune reactions following vaccination.
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Affiliation(s)
- Mansoor Radwi
- Department of Hematology, College of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Sara Farsi
- Department of Anesthesia and Critical Care, King AbdulAziz University Hospital, King Abdulaziz University, Jeddah, Saudi Arabia
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Ghafouri S, Rettig M, Kahlon KS. An 89-Year-Old Man with COVID-19-Associated Coagulopathy Presenting with a Prolonged Partial Thromboplastin Time, Lupus Anticoagulant, and a High Titer of Factor VIII Inhibitor. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e926728. [PMID: 33122620 PMCID: PMC7610155 DOI: 10.12659/ajcr.926728] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patient: Male, 89-year-old Final Diagnosis: Acquired hemophilia A • COVID-19 Symptoms: Bleeding • hypoxia Medication: — Clinical Procedure: — Specialty: Hematology
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Affiliation(s)
- Sanaz Ghafouri
- Departmernt of Hematology Oncology, University of California Los Angeles (UCLA) Medical Center, Los Angeles, CA, USA
| | - Matthew Rettig
- Departmernt of Hematology Oncology, University of California Los Angeles (UCLA) Medical Center, Los Angeles, CA, USA.,Departmernt of Hematology and Oncology, Veterans Affairs of Greater Los Angeles Health Care System, Los Angeles, CA, USA
| | - Kanwarpal S Kahlon
- Departmernt of Hematology Oncology, University of California Los Angeles (UCLA) Medical Center, Los Angeles, CA, USA
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17
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Aslam HM, Chong T, Park J, Nicolosi T, Shah R. Pulmonary Embolism in Acquired Hemophilia A: A Rare Complication With Factor VIII Inhibitor Bypassing Activity Therapy. Cureus 2020; 12:e9152. [PMID: 32789089 PMCID: PMC7417320 DOI: 10.7759/cureus.9152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Acquired hemophilia A (AHA) is an uncommon complication caused by autoantibodies against Factor VIII. The main concern with these patients is hemorrhage, which is often treated with Factor VIII inhibitor bypassing activity (FEIBA). On rare occasions, treatment with FEIBA can result in thromboembolism, a potentially fatal complication. This unfortunate situation occurred in our patient, a 64-year-old female who was treated with FEIBA after being diagnosed with AHA. After initiating FEIBA, she developed clinical signs and symptoms of pulmonary embolism, which was ultimately responsible for her acute death. While pulmonary embolism may be a rare complication of FEIBA treatment, clinicians should be aware of its possibility, especially as the complete safety profile for this treatment is not well known.
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Involvement of antifactor VIII autoantibodies specificity in the outcome of inhibitor eradication therapies in acquired hemophilia a patients. Blood Coagul Fibrinolysis 2019; 30:127-132. [PMID: 30958453 DOI: 10.1097/mbc.0000000000000804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
: We hypothesized that inhibitor specificity may predict the outcome of antifactor VIII autoantibodies eradication treatment in acquired hemophilia A. Our objective was to analyze the association between factor VIII domains recognized by inhibitors and outcome of the immunosuppressive therapies (ISTs) in a prospective, observational study. 16 patients were recruited. Inhibitor specificities were assessed at diagnosis and throughout the study. Their association with IST outcome was addressed. First-line IST succeeded in 56% of patients. Inhibitors reacted mainly with light chain domains (69%) and/or the A2 domain (44%). 31% inhibitors recognized more than one domain. Significantly, the number of patients whose inhibitors recognized the light chain was significantly higher in the group of those who did not reach complete remission after first line IST when compared with those who did [6/7 (85.7%) vs. 4/9 (44.4%), P < 0.05]. Therefore, inhibitor specificity could predict the success of IST in acquired hemophilia A.
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Kaur K, Kalla A. A case of acquired hemophilia A in an elderly female. J Community Hosp Intern Med Perspect 2018; 8:237-240. [PMID: 30181835 PMCID: PMC6116292 DOI: 10.1080/20009666.2018.1487246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 05/30/2018] [Indexed: 11/04/2022] Open
Abstract
Acquired Hemophilia A (AHA) is a bleeding diathesis related to the development of factor VIII inhibitor, which can frequently go undetected. It commonly manifests as spontaneous mucosal bleeds without any known history of a bleeding disorder, but has the potential to cause life threatening bleeding especially in elderly patients with underlying comorbidities. Here we describe a case of AHA in a 78 year old female presenting with spontaneous mucocutaneous bleeding as tongue hematoma and recurrent gastrointestinal (GI) bleeding. Underlying etiology remained unclear in this case. While she did not require any reversal agents to control bleeding, the patient received steroids and rituximab as inhibitor eradication therapy.
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Affiliation(s)
- Kiranveer Kaur
- Department of Internal Medicine, Saint Agnes Hospital, Baltimore, MD, USA
| | - Abhishek Kalla
- Department of Hematology and Oncology, Saint Agnes Hospital, Baltimore, MD, USA
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20
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Hemofilia adquirida: epidemiología, clínica, diagnóstico y tratamiento. Med Clin (Barc) 2017; 148:314-322. [DOI: 10.1016/j.medcli.2016.11.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 11/04/2016] [Accepted: 11/08/2016] [Indexed: 11/20/2022]
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Mo L, Bao GC. Acquired factor VIII deficiency: two case reports and a review of literature. Exp Hematol Oncol 2017; 6:8. [PMID: 28352491 PMCID: PMC5366150 DOI: 10.1186/s40164-017-0068-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 03/18/2017] [Indexed: 12/19/2022] Open
Abstract
Background Acquired factor VIII (FVIII) deficiency, or acquired hemophilia A (AHA), is a rare autoimmune disorder involving antibody-mediated depletion of coagulation FVIII, leading to severe, life-threatening bleeding. The condition is often associated with other autoimmune disorders, and its treatment involves replacement of FVIII and various modes of immunosuppression. Recently, a few noteworthy therapeutic advances have been made. We present two cases of severe AHA in Chinese women. One of these women developed this disorder in the setting of possible parvovirus B19 infection, which has not yet been reported in association with AHA. Other notable features of her case included paradoxical venous thrombosis and possible association with Sjogren’s syndrome and myositis. The other woman failed to respond to usual first-line therapies despite exhibiting a less severe clinical course, illustrating the varied but potentially stubborn behavior of this disorder. Case 1 An 87-year-old woman presented with diffuse ecchymoses, melena, vaginal bleeding. Labs showed hemoglobin (Hgb) nadir of 5.7 mg/dL, elevated partial thromboplastin time (PTT), FVIII level <1%, mixing study consistent with an inhibitor, elevated anti-Sjogren’s-Syndrome-related antigen A antibody, elevated creatinine kinase, and elevated parvovirus IgM and IgG. Imaging of her arm showed diffuse myositis and deep venous thrombosis. After intravenous and oral steroids, her FVIII levels normalized, and her symptoms subsided. Case 2 A 59-year-old woman presented with recurrent ecchymoses and hematomas in her extremities. Labs showed Hgb of 11.7 mg/dL, elevated PTT, FVIII level of 3%, and mixing study consistent with an inhibitor. Despite receiving a long course of steroids, several courses of IVIG, and a few courses of Rituximab, her FVIII level remained critically low. Conclusion The rarity of AHA limits our understanding of this disease and the ability to perform trials to discover optimal therapies. We hope that these case reports and discussion will shed further light on the varied clinical manifestations and natural histories of this disorder to guide better recognition and treatment of AHA.
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Affiliation(s)
- Lan Mo
- Weill Cornell Medicine, New York-Presbyterian Lower Manhattan Hospital, 170 William Street, New York, NY 10038 USA
| | - George C Bao
- Weill Cornell Medicine, New York-Presbyterian Lower Manhattan Hospital, 170 William Street, New York, NY 10038 USA
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22
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Le Cam-Duchez V. Hémophilie A acquise et hémopathies lymphoïdes : revue de la littérature. Rev Med Interne 2015; 36:834-9. [DOI: 10.1016/j.revmed.2015.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 08/24/2015] [Accepted: 09/14/2015] [Indexed: 01/29/2023]
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An Acquired Factor VIII Inhibitor in a Patient with HIV and HCV: A Case Presentation and Literature Review. Case Rep Hematol 2013; 2013:628513. [PMID: 24198984 PMCID: PMC3806160 DOI: 10.1155/2013/628513] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 08/29/2013] [Indexed: 12/01/2022] Open
Abstract
Introduction. Despite its low incidence, acquired factor VIII inhibitor is the most common autoantibody affecting the clotting cascade. The exact mechanism of acquisition remains unclear, but postpartum patients, those with autoimmune conditions or malignancies, and those with exposure to particular drugs appear most susceptible. There have been several case reports describing acquired FVIII inhibitors in patients receiving interferon alpha for HCV treatment and in patients being treated for HIV. To our knowledge, this is the first case of a patient with HCV and HIV who was not actively receiving treatment for either condition. Case Presentation. A 57-year-old Caucasian male with a history of HIV and HCV was admitted to our hospital for a several day history of progressively worsening right thigh bruising and generalized weakness. CTA of the abdominal arteries revealed large bilateral retroperitoneal hematomas. Laboratory studies revealed the presence of a high titer FVIII inhibitor. Conclusion. Our case of a very rare condition highlights the importance of recognizing and understanding the diagnosis of acquired FVIII inhibitor. Laboratory research and clinical data on the role of newer agents are needed in order to better characterize disease pathogenesis, disease associations, genetic markers, and optimal disease management.
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Long term outcome of patients with acquired haemophilia – A monocentre interim analysis of 82 patients. ATHEROSCLEROSIS SUPP 2013; 14:223-8. [DOI: 10.1016/j.atherosclerosissup.2012.10.033] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Zeitler H, Ulrich-Merzenich G, Panek D, Goldmann G, Vidovic N, Brackmann HH, Oldenburg J. Extracorporeal Treatment for the Acute und Long-Term Outcome of Patients with Life-Threatening Acquired Hemophilia. ACTA ACUST UNITED AC 2012; 39:264-270. [PMID: 22969696 DOI: 10.1159/000341913] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 07/18/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVES: In acquired hemophilia (AH), autoantibodies (inhibitors) impede blood coagulation factors leading to severe bleedings. Cornerstones of a successful treatment are the control of bleeding and an eradication of autoantibodies. The present study is an update of our previous documentation of the treatment of high-titer AH patients with severe life-threatening bleeding undergoing the modified Bonn-Malmö-Protocol (MBMP). METHODS: 64 AH patients were treated by a standard combination protocol (MBMP) consisting of antibody depletion through immunoadsorption, i.v. immunoglobulin, immunosuppression, and high-dose FVIII substitution. They underwent a long-term follow-up. RESULTS: Primary study endpoints loss of detection of the activity of the inhibitor and FVIII recovery ? 5% were reached in a median time of 3 days (95% CI: 2.6-3.4 days), the median time of FVIII substitution was 13 days (95% CI 10.6-15.3 days), and the median time of immunoadsorption was 16 days (95% CI 13-18.9 days). In 5 patients the AH occurred as paraneoplastic syndrome, and partial remission was achieved. Relapses without bleeding event occurred only in second-line MBMP. Those responded excellently to short time treatment. Overall patients remained in remission over a median follow-up time of 8 years. Conclusion: Except for paraneoplastic AH, MBMP-treated patients have a remarkable prognosis which is confirmed by long-term follow-up with a complete response rate of 93% (53/57) in the first year post MBMP and 100% during long-term follow-up. These outcome in life-threatening AH is unique and until now not achievable via other treatment schedules. In life-threatening bleedings physicians should take into account MBMP as a first line treatment.
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Affiliation(s)
- Heike Zeitler
- Internal Medical Clinic I, Center of Extracorporeal Therapy and Autoimmunity (CETA), Germany
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Katsuyama T, Sada KE, Katayama A, Hinamoto N, Wakabayashi H, Kawabata T, Makino H. Acquired haemophilia in a patient with Castleman's disease: a case report. Haemophilia 2012; 18:e360-e362. [PMID: 22630343 DOI: 10.1111/j.1365-2516.2012.02850.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2012] [Indexed: 06/01/2023]
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