Main clinical manifestations of a bleeding diathesis: an often disregarded aspect of medical and surgical history taking

Platelet Delta (δ)-Storage Pool Deficiency: A Case Series and Review of the Literature

Hereditary platelet delta (δ)-storage pool deficiency is a rare condition in which there are fewer dense granules in platelets disrupting primary hemostasis. It can cause a mild-moderate bleeding tendency with normal coagulation studies; hence, it is an underdiagnosed diagnostic challenge. The authors present three patients with hereditary platelet delta (δ)-storage pool deficiency who had heavy menstrual bleeding, excessive bleeding following surgery, mucocutaneous bleeding, and a bleeding score greater than or equal to 6. These cases reveal the susceptibility of underdiagnosing platelet disorders and the significance of utilizing a bleeding assessment tool to help guide further workup with transmission electron microscopy to visualize the fewer dense granules in platelets. Although bleeding is typically moderate, it can be severe in certain scenarios, like after mucosal surgeries, and can lead to death, highlighting the importance of the condition's recognition and prophylactic treatment.

State of Dental Health and Management Needs of Young Hemophilic Patients: A Case-control Study

Background

In particular, when it comes to systemic diseases like hemophilia, good dental health is crucial to a person's overall health and wellness. Through the means of this study, we aim to assess the prevalence of various dental anomalies in children suffering from hemophilia in comparison to healthy children and assess their treatment needs.

Materials and methods

This was a descriptive, case-control study with 400 subjects, 200 each in the study (hemophilic) and control (nonhemophilic) groups. The subjects' ages ranged from 5 to 15 years. Utilizing the oral hygiene index-simplified (OHI-S), the state of oral hygiene was documented (OHI-S). Using decaying extracted filled tooth (DEFT) and decayed, missing, and filled tooth (DMFT) for the primary and permanent dentition, respectively, teeth afflicted by dental caries and teeth restored/extracted as a result of dental caries were assessed. Statistical Package for the Social Sciences (SPSS) software (version 27.0) was used for statistical analysis.

Results

Hemophilic people had a considerably greater incidence of dental caries. Furthermore, even though their DMFT/DEFT and OHI-S scores were barely poorer than those of healthy people, children with hemophilia had a significantly larger percentage of dental treatment needs across all age categories than the other group.

Conclusion

The percentage of hemophilic children who needed dental treatment across different age groups was significantly higher than the other group, which supports our observations that the dental health status of hemophilic children was poor and treatment requirement was high among them as well. This is true even though the DMFT/DEFT scores and OHI-S scores in hemophilic children were only slightly worse than in healthy individuals.

How to cite this article

Sharma S, Shahi AK, Chandra S, et al. State of Dental Health and Management needs of Young Hemophilic Patients: A Case-control Study. Int J Clin Pediatr Dent 2023;16(2):380-387.

[Step by step - A diagnostic approach to bleeding disorders]

The main symptom of hemorrhagic diathesis is an increased bleeding tendency. Due to the subjectivity of various features of the bleeding history, unclarity of the family history, and an individualization of the extent of diagnostic the evaluation of a suspected bleeding disorder represents a challenging endeavour in hematology. Hemorrhagic diathesis can be divided into the following sub-categories: disorders in primary hemostasis (e. g. von Willebrand disease, different causes of thrombocytopenia), secondary hemostasis (e. g. hemophilia A and B, Vitamin K deficiency) and fibrinolysis, and in connective tissue or vascular formation. This article reviews available diagnostic methods for bleeding disorders, from structured patient history to highly specialized laboratory diagnosis.

[Hematoma in lipedema: from cutaneous origin or defect of coagulation?]

Lipedema is a widespread in concern of etiology partially unknown disease especially in women. In many cases it is accompanied by bleeding complications. Our current work focuses on possible coagulation disorders as potential sources of such bleeding complications. Since only a minority of our patients showed a coagulation defect it is suggestive that the main underlying reason for bleeding in lipedema is of cutaneous origin what may only be forwarded by simultaneously existing coagulation disorders.

Prediction of Ticagrelor and its Active Metabolite in Liver Cirrhosis Populations Using a Physiologically Based Pharmacokinetic Model Involving Pharmacodynamics

Ticagrelor, a P2Y₁₂ receptor antagonist, has been highly recommended for use in acute coronary syndrome. The major active metabolite (AM) is similar to the parent drug, which exhibits antiplatelet activity. The inhibition of platelet aggregation (IPA) is used as an assay to demonstrate the anticoagulant efficacy of ticagrelor. In this study, we developed a physiologically based pharmacokinetic (PBPK) model to predict the pharmacokinetics of ticagrelor and its AM and combined this model with a pharmacodynamics model to reflect potential pharmacodynamic alterations in liver cirrhosis populations. The simulated results obtained using the PBPK model were validated by fold error values, which were all smaller than 2. Comparisons of exposure in different classifications of liver cirrhosis indicated that exposure to ticagrelor increased significantly with an increase in the degree of cirrhosis severity, whereas exposure to AM was decreased. The total concentration of ticagrelor and AM was related to the IPA included in the Sigmoid E_max model. The PBPK model of ticagrelor and AM could predict the pharmacokinetics of all populations, and a combination of PD models was used to extrapolate for predicting unknown scenarios. Liver cirrhosis may result in prolonged IPA, depending on the severity degree of this disease. The combined PBPK model including IPA can reveal changes in pharmacokinetics and pharmacodynamics in populations affected by liver cirrhosis and indicate the risk potential.

My patient is thrombocytopenic! Is (s)he? Why? And what shall I do?

Solving the riddle of a thrombocytopenic patient is a difficult and fascinating task. The spectrum of possible aetiologies is wide, ranging from an in vitro artefact to severe treatment-resistant thrombocytopenic bleeding conditions, or even life-threatening prothrombotic states. Moreover, thrombocytopenia by itself does not protect from thrombosis and sometimes a patient with a low platelet count requires concomitant antithrombotic treatment as well. In order to identify and treat the cause and the effects of the thrombocytopenia, you have to put together several pieces of information, solving a unique jig-jaw puzzle.

The present work is not a textbook article about thrombocytopenia, rather a collection of differential diagnostic thoughts, treatment concepts, and some basic knowledge, that you can retrieve when facing your next thrombocytopenic patient. Enjoy reading it, but most importantly enjoy taking care of patients with a low platelet count. I bet the present work will assist you in this challenging and rewarding clinical task.

Bleeding manifestations in heterozygotes with congenital FVII deficiency: a comparison with unaffected family members during a long observation period

OBJECTIVES

To determine whether heterozygotes with FVII deficiency have a bleeding tendency or not.

PATIENTS AND METHODS

Eighty-four patients (OK) heterozygous for FVII deficiency, at the onset of the study, were paired with unaffected family members and followed for a long period of time (mean 22.6 years) for the occurrence of bleeding. Diagnosis of heterozygosis had to be based on family studies, clotting, immunological assays and genetic analysis.

RESULTS

The mean FVII activity level was 0.51 IU/dl (range 35-65) and 94 IU/dl (range 88-118) in the heterozygotes and in the normal counterparts, respectively. Documented bleeding manifestations occurred in eight heterozygotes and in seven normal subjects. Statistical analysis of the difference was not significant. Bleeding manifestations were easy bruising, bleeding after tooth extractions, menorrhagia, epistaxis with no difference among the two groups. There was no strict correlation between bleeding and FVII activity levels.

CONCLUSIONS

The study indicates that heterozygotes for FVII deficiency show rare bleeding manifestations which are also present in the unaffected family members with normal FVII levels. This indicates that Factor VII activity levels played no role in the occurrence of the bleeding symptoms. Furthermore, FVII levels of around 0.40 IU/dl are capable of assuring a normal hemostasis.

Do hemophiliacs have a higher risk for dental caries than the general population?

OBJECTIVE

The aim of this study was to examine if patients with hemophilia were at increased risk for dental decay as compared to the general population.

MATERIALS AND METHODS

Census sampling was used in this case-control study to recruit cases (patients with hemophilia) and a control group individuals recruited randomly from the general population, which were matched with cases based on gender, age and place of residence. Clinical examinations included dental health and salivary assessments (flow rate, buffer capacity, caries-associated bacteria) and a structured questionnaire which inquired about socioeconomic status and dental health-related behaviors.

RESULTS

In the deciduous dentition, the overall caries experience (dmf) differed statistically significantly (P=0.003) between the hemophiliacs (2.6±2.6) and their matched healthy controls (6.1±2.5). Bivariate analyses did not reveal significant differences between cases and controls regarding salivary functions, except that higher bacteriological counts were found in healthy controls in deciduous dentitions than in patients with hemophilia (P=0.019). Children without hemophilia were from higher socioeconomic status families than hemophiliacs (P=0.004), but such differences were not found for adults (P=0.090). When compared to healthy adults, adult hemophiliacs had more gum bleeding at rest (P<0.001) as well as during their tooth brushing (P=0.007) and they also consumed more soft drinks than controls (P=0.025).

CONCLUSIONS

Better dental health was observed in children with hemophilia as compared to children without it. There were no differences in dental health between adult hemophiliacs and healthy controls from the general population. None of the linear multiple regression models confirmed hemophilia to be an additional caries risk when it was controlled for other caries determinants.

Late postoperative hemorrhage in a patient with undiagnosed COX-1 deficiency after third molar extractions

Oral maxillofacial surgeons direct invasive procedures that often cause significant bleeding. Uncontrolled hemorrhage is a rare, yet serious, complication that can be seen in patients with thrombocytopathy. Platelets have 3 distinct roles in coagulation: initial adhesion, phospholipid externalization, and platelet aggregation.(1) Several types of platelet deficiencies, including defects of adhesion (Bernard-Soulier syndrome), defects of aggregation (Glanzmann thrombasthenia), and disorders of platelet secretion due to a deficiency of adenosine diphosphate (ADP) or cyclooxygenase-1 (COX-1).(2-4) COX has 2 isoforms: COX-1 and COX-2.(5,6) COX-1 is expressed constitutively in most tissues, and COX-2 is induced primarily by inflammatory mediators.(7,8) Although both isoforms are present in platelets, COX-1 is the major isoform that contributes to coagulation, because it is critically important in the formation of thromboxane A2 (TXA2) by way of the arachidonic acid (AA) pathway.(9) AA is a potent inducer of platelet aggregation.(1,3,4) When AA is exposed to an activating agent, such as ADP, it undergoes a series of enzymatic reactions that culminates in the production of TXA2.(10) TXA2 is the predominant product of the COX-1 pathway and is a major metabolite of AA in platelets. TXA2 is necessary for normal platelet function. Therefore, the inhibition of, or a deficiency in, COX-1 will compromise the AA pathway, thereby reducing platelet secretion and altering normal platelet aggregatory function.(1,3) COX-1 deficiencies are usually caused by drug interactions with the enzyme itself. In addition, studies have identified genetic mutations that can result in COX-1 deficiency.(2) We present the hospital course, management, and diagnosis of a patient with an undiagnosed COX-1 deficiency who had had third molars removed in a private office. To our knowledge, this is the first case of COX-1 deficiency diagnosed after exodontia documented in English studies. In addition, we reviewed the published data of this rare disorder that has significant clinical implications.

Bleeding manifestations apparently unrelated to coagulation or other organic disorders: A tentative classification and diagnostic clues

OBJECTIVE

To study the features of bleeding conditions apparently not associated with vascular, platelet, or clotting dysfunctions.

METHOD

Conditions that may meet these criteria are: Münchausen syndrome factitious or fictitious, suicidal or homicidal bleeding, bleeding due to self-punishment, stigmatization, the battered child syndrome, and psychogenic bleeding.

RESULTS

The importance of these variegate conditions is not trivial in clinical practice. Differential diagnosis may be difficult and involve other specialists besides hematologists. Occasionally, invasive procedures are involved.

DISCUSSION

The occurrence of bleeding in patients, without a clotting defect or a systemic disorder and a negative family history for bleeding represents a diagnostic challenge. A careful examination of the physical and psychological status of the patient and an appropriate evaluation of the environment in which bleeding occurs, is always needed.

Rare and Unusual Bleeding Manifestations in Congenital Bleeding Disorders

Epistaxis, superficial and deep hematomas, hemarthrosis, gastrointestinal bleeding, hematuria represent the most frequent hemorrhagic events in congenital coagulation disorders. Occasionally, bleeding manifestations occur in unusual sites or are peculiar. A clotting defect may alter the clinical aspect of skin conditions or infections (hemorrhagic scabies or varicella). Hemobilia may occur as a complication of transjugular liver biopsy in hemophilia or Bernard-Soulier syndrome. Hemarthrosis of small joints of feet and hands occur in patients with hemophilia treated with protease inhibitors. Intramedullary hematomas of long bones have been described in α2-plasmin inhibitor or fibrinogen deficiencies. Spleen fracture with consequent hemoperitoneum has been reported in patients with fibrinogen deficiency. Rectus muscle sheath hematoma may occur in patients with factor VII (FVII)or FX deficiency. Acute or subacute intestinal obstruction may be caused by intramural wall hematomas in hemophilia and von Willebrand (vW)-disease. Physicians should always keep in mind that a congenital hemorrhagic disorder may cause bleeding in any tissue of the body and therefore alter the normal clinical features of a given disease.

Delineating the Hemostaseome as an aid to individualize the analysis of the hereditary basis of thrombotic and bleeding disorders

Next-generation sequencing and genome-wide association studies represent powerful tools to identify genetic variants that confer disease risk within populations. On their own, however, they cannot provide insight into how these variants contribute to individual risk for diseases that exhibit complex inheritance, or alternatively confer health in a given individual. Even in the case of well-characterized variants that confer a significant disease risk, more healthy individuals carry the variant, with no apparent ill effect, than those who manifest disease. Access to low-cost genome sequence data promises to provide an unprecedentedly detailed view of the nature of the hereditary component of complex diseases, but requires the large-scale comparison of sequence data from individuals with and without disease to deliver a clinical calibration. The provision of informatics support remains problematic as there are currently no means to interpret the data generated. Here, we initiate this process, a prerequisite for such a study, by narrowing the focus from an entire genome to that of a single biological system. To this end, we examine the 'Hemostaseome,' and more specifically focus on DNA sequence changes pertaining to those human genes known to impact upon hemostasis and thrombosis that can be analyzed coordinately, and on an individual basis, to interrogate how specific combinations of variants act to confer disease predisposition. As a first step, we delineate known members of the Hemostaseome and explore the nature of the genetic variants that may cause disease in individuals whose hemostatic balance has become shifted toward either a prothrombotic or anticoagulant phenotype.

Acquired Platelet Dysfunction in 109 Patients From a Tertiary Care Referral Hospital

Background: Acquired platelet function defects (PFDs) remain poorly characterized, underrecognized, and therefore understudied. Patients/Methods: Clinical and laboratory records of 109 patients with acquired PFDs diagnosed over 5 years were analyzed. Screening studies (platelet count, prothrombin time, activated partial thromboplastin time, and thrombin time), template bleeding time, platelet factor 3 (PF-3) availability test, light-transmission aggregometry, and further testing as indicated were performed. Results: 64 patients had mild and 26 had major bleeding. In all, 15 were referred for preoperative testing, whereas 4 had thrombotic events. Causes and associations of PFDs were drug-induced (34), idiopathic (34), hematopoietic neoplasms (15; myeloma 4, Waldenstrom macroglobulinemia 2, chronic myeloid leukemia 4, essential thrombocythaemia 3, and primary myelofibrosis and chronic lymphocytic leukemia 1 each), chronic liver disease (4), postcardiac surgery (2), uremia (2), and thalassemia major (7). Miscellaneous disorders comprised the rest. Conclusions: Acquired PFDs span a wide range of disease settings. Systematic, sequential laboratory testing identifies patterns of dysfunction, excludes inherited disorders, and streamlines management.

Hemarthrosis due to a rare cause of hemorrhagic diathesis: Ehlers-Danlos syndrome

The authors report a case of hemarthrosis complicated by severe anemia related to a congenital connective tissue disease: Ehlers-Danlos syndrome. A boy fell down and suffered tumefaction of both knees with bilateral rupture of the rotula tendon. He underwent surgical reinsertion of each tendon on the rotula. He later showed an unexpected ongoing hematic effusion, with severe anemia. He was screened for coagulation disorders with no results. On taking a more detailed history and investigating the patient's phenotypical features, the authors diagnosed Ehlers-Danlos syndrome, hypermobile variant. The hemarthrosis and anemia were thus concluded to be consequences of excessive tissue fragility due to a congenital connective tissue disease.

Evaluation of the oral health situation of a group of Egyptian haemophilic children and their re-evaluation following an oral hygiene and diet education programme

Haemophilic children in Egypt have received minimal dental intervention and their dental needs required assessment. The purpose of this study was to assess the oral health needs of a sample (n = 60) of Egyptian haemophilic children (6-12 years), so as to develop, implement and evaluate an oral hygiene education programme over an 8-month period on the experimental group (n = 30) vs. the control group (n = 30). The oral hygiene index simplified (OHI-S) index was used for baseline data and at the end of the study, while DMFS and defs were used to collect caries experience baseline data on each subject. The results showed that the DMFT and deft were significantly higher than those of the non-haemophilic population in Egypt and also higher than those of haemophilic children in developed countries and that the decayed component represented most of the index values. At phase I, the mean value of the OHI-S of experimental and the control groups was 2.67 +/- 0.45 and 2.53 +/- 0.53, respectively, but the difference was not significant (P > 0.05), both values were in the 'fair' category (1.3-3.0). At phase II, the end of the 8 months follow-up period and after the application of a strict oral care programme in the experimental group, there was a significant decrease from 2.67 to 1.20 (P < 0.001), a shift of values occurred from the 'fair' category to the 'good' category (0.1-1.2) while there was no significant difference in the control group. It can be concluded that professional plaque control, education and access to oral hygiene aids is paramount to improve oral health of these children.

Haematuria in patients with haemophilia and its influence on renal function and proteinuria

To investigate renal function in a group of patients with a history of haemophilia and haematuria. We reviewed 32 medical records of the patients with haemophilia and gross haematuria identified through a computerized haemophilia registry, from January 1993 to December 2004. In all patients but three (two refused to participate and one died) clinical and laboratory tests were performed by the nephrologist. One patient had chronic renal failure because of diabetic nephropathy. In two patients reduced renal function was detected by creatinine clearance measurements, and one of them had Duchenne muscular dystrophy. In four patients minimal proteinuria was diagnosed by the biuret method. Mild reduction in renal function of unknown cause was found in only one of the 29 patients tested.