Acquired von Willebrand's disease associated with gastrointestinal angiodysplasia: a case report

Acquired Factor VIII Inhibitor Presenting as Occult GI Bleeding

An acquired coagulation factor deficiency is characterized by acquired autoantibodies against specific clotting factors in those without diagnosed hemophilia. It is a relatively rare condition with an incidence of approximately one case per million per year. We present a case report of an elderly male who initially presented with an occult GI bleed that was identified with a positive fecal occult blood test result. This is the first case reported to our knowledge of an acquired factor inhibitor deficiency presenting in this manner. We postulate the importance of acquired factor inhibitors in the setting of unexplained anemia given absence of overt clinical symptoms that could contribute to aggravate an established GI bleed, especially in the elderly population.

Concurrent Ruptured Pseudoaneurysm of the Internal Carotid Artery and Cerebral Infarction as an Initial Manifestation of Polycythemia Vera

The most common neurologic manifestations of polycythemia vera (PV) are cerebral infarction and transient ischemic attacks, while cerebral hemorrhage or intracranial dissection has been rarely associated with PV. Here we report the first case of a 59-year-old patient with intracranial supraclinoid internal carotid artery (ICA) dissection causing cerebral infarction and concomitant subarachnoid hemorrhage due to pseudoaneurysm rupture as clinical onset of PV. This case report discusses the possible mechanism and treatment of this extremely rare condition.

Intestinal microvascular malformations and congenital asplenia in an adolescent possibly expanding the phenotype of Ivemark syndrome

Intestinal vascular malformations in children and adolescents are rare but must be considered in the differential diagnosis of gastrointestinal bleeding and chronic anemia. We report a 16-year-old girl who developed chronic iron-deficiency anemia due to recurrent bleeding from multiple angiodysplastic lesions of the stomach, duodenum, and jejunum. The cause of blood loss remained unclear for several years while the girl received numerous blood transfusions. Diagnosis was finally established by capsule endoscopy and double-balloon enteroscopy. Treatment was effectively carried out by argon plasma coagulation. Many systemic vascular malformation syndromes are associated with gastrointestinal lesions. However, as no extraintestinal vascular lesions were present in our patient, diagnosis of a known vascular malformation syndrome seemed unlikely. In addition to the microvascular intestinal malformations, we found a familial congenital asplenia without apparent infectious complications. Thus, the reported case possibly constitutes a so far unpublished variant of the Ivemark syndrome without macrovascular malformations but instead with microvascular malformations. We therefore envison that in times of refined diagnostic techniques the phenotype of the Ivemark syndrome might be expanded by including microvascular malformations.

Anticoagulation of juvenile sheep and goats with heparin, warfarin, and clopidogrel

Little data exist on anticoagulation of young sheep and goats. We tested the effect of heparin, warfarin, and clopidogrel in two sheep and two goats weighing 17-35 kg. Each animal received heparin boluses of 80, 100, and 200 units/kg; goats also received 300, 350, and 400 units/kg. All animals received continuous heparin 40, 60, and 80 units/kg/hour; oral warfarin 0.3, 0.6, and 0.9 mg/kg/day; and oral clopidogrel 75 and 150 mg/day (2.8-3.4 and 5.6-6.9 mg/kg/day). Results were in the form of complete blood counts, activated clotting times (ACT), partial thromboplastin times, prothrombin times, thromboelastograms, and whole-blood lumiaggregometry. After heparin boluses of 200 units/kg, sheep and goats reached mean peak ACTs over 400 seconds. After continuous infusions of 40, 60 and 80 units/kg/hour, sheep and goats exceeded our therapeutic range for ACTs (195-215 seconds for sheep, 155-175 seconds for goats). For warfarin therapy, both sheep and goats required treatment with >0.6 mg/kg/day to achieve INRs over 2.5. Clopidogrel treatment, after 14-17 days of 75-150 mg/day, inhibited sheep platelets by 25-36% and goat platelets by 35-46%. We conclude that young sheep and goats can be safely and effectively anticoagulated with heparin and warfarin, and can also show a modest antiplatelet response to clopidogrel. Doses for each drug were generally higher than those used for humans, and warfarin therapy in sheep may be unpredictable. These results should be useful for developing anticoagulation protocols to test pediatric mechanical circulatory support devices.