Acquired Hemophilia in an Elderly Patient with Carcinoma of the Ampulla of Vater

Unexplained hemorrhagic syndrome? Consider acquired hemophilia A or B

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.

Unforeseen encounter of acquired hemophilia A in a preoperative case of periampullary carcinoma: A case report

INTRODUCTION

Acquired hemophilia A (AHA) is a rare disorder characterized by development of antibodies against factor VIII, which can present as paraneoplastic syndrome in various malignancies like periampullary cancer, cancer of lung, prostate, gastrointestinal stromal tumour and non malignant cases like pregnancy, autoimmune disease and medication.

CASE PRESENTATION

We report a case of elderly man presented with paraneoplastic AHA in periampullary carcinoma in preoperative period which was diagnose by mixing study and inhibitor assay and managed with bypass agents like recombinant factor VII, FEIBA and immunosuppresion to eliminate inhibitor with help of steroid, cyclophosphamide and emicizumab. Patient underwent Whipple's pancreaticoduodenectomy after which coagulation study became normal in immediate postoperative period. Patient was discharged and followed up with chemotherapy.

CLINICAL DISCUSSION

Periampullary carcinoma presenting as AHA is rare and rarer in pre-operative settings. The usual mode of presentation is bleeding after biopsy and from minor surgical scars. The pathogenesis is yet to be delineated. It is managed by factor VIII administration and immunosuppressive therapy.

CONCLUSION

High index suspicion should be there to diagnose AHA as a paraneoplastic manifestation and elective surgery should be delayed till normalization of coagulation parameters.