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Ohara F, Suzuki A, Suzuki N, Kanematsu T, Okamoto S, Tamura S, Kiyoi H, Matsushita T, Katsumi A. Newly diagnosed multiple myeloma with bleeding and coagulation abnormalities caused by a thrombin-inhibiting substance. Int J Hematol 2024:10.1007/s12185-024-03849-2. [PMID: 39292377 DOI: 10.1007/s12185-024-03849-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 09/04/2024] [Accepted: 09/09/2024] [Indexed: 09/19/2024]
Abstract
Approximately 7% of patients with newly diagnosed multiple myeloma (MM) experience bleeding complications with varying causes, but few reports have described these complications. Here we report the case of a patient with newly diagnosed MM who presented with a bleeding tendency and various coagulation abnormalities. Chromogenic assays, thrombin time, and reptilase time revealed the presence of a thrombin-inhibiting substance that inhibited release of fibrinopeptide A from fibrinogen. The coagulation abnormalities improved after treatment with daratumumab, lenalidomide, and dexamethasone. As the thrombin inhibition mechanism remains unclear, no previous studies have reported recent treatment outcomes in older patients producing thrombin-inhibiting substances, which can hinder clinical treatment. Therefore, we believe that the diagnosis and the treatment course of this case provide valuable information. Moreover, such case reports provide significant insights into the pathophysiology of bleeding complications associated with MM.
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Affiliation(s)
- Fumiya Ohara
- Department of Hematology, National Center for Geriatrics and Gerontology, 7-430 Morioka-Cho, Obu, Aichi, 474-8511, Japan
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Atsuo Suzuki
- Department of Medical Technique, Nagoya University Hospital, Nagoya, Japan
| | - Nobuaki Suzuki
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Takeshi Kanematsu
- Department of Clinical Laboratory, Nagoya University Hospital, Nagoya, Japan
| | - Shuichi Okamoto
- Department of Clinical Laboratory, Nagoya University Hospital, Nagoya, Japan
- Division of Cellular and Genetic Sciences, Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shogo Tamura
- Department of Clinical Laboratory Science, Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Hitoshi Kiyoi
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tadashi Matsushita
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
- Department of Clinical Laboratory, Nagoya University Hospital, Nagoya, Japan
| | - Akira Katsumi
- Department of Hematology, National Center for Geriatrics and Gerontology, 7-430 Morioka-Cho, Obu, Aichi, 474-8511, Japan.
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2
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Banday AZ, Nisar R, Patra PK, Ahmad I, Gupta A. Basic Investigations in Pediatric Rheumatology. Indian J Pediatr 2024; 91:927-933. [PMID: 37676468 DOI: 10.1007/s12098-023-04821-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/03/2023] [Indexed: 09/08/2023]
Abstract
The spectrum of pediatric rheumatological disorders is diverse and they are important differential diagnoses in a variety of clinical scenarios. Basic investigations not only provide supporting evidence for the diagnosis of a rheumatological illness but also help in exclusion of other diseases as well as for monitoring the activity of disease. Among these, complete blood count, biochemical assays including tests for inflammatory response, urine analysis, and various autoantibodies are often used. In addition, depending on the clinical features, imaging and tissue biopsies are used to confirm the diagnosis.
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Affiliation(s)
- Aaqib Zaffar Banday
- Department of Pediatrics, Government Medical College (GMC), Srinagar, Jammu and Kashmir, 190018, India.
| | - Rahila Nisar
- Department of Microbiology, Government Medical College (GMC), Baramulla, India
| | - Pratap Kumar Patra
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Patna, India
| | - Imtiyaz Ahmad
- Department of Pediatrics, Government Medical College (GMC), Srinagar, Jammu and Kashmir, 190018, India
| | - Anju Gupta
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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3
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Wang B, Tang N, Zhang C. Lupus Anticoagulant-Hypoprothrombinemia Syndrome: Literature Review and Description of Local Case in a 3-Year-Old Chinese Girl. Semin Thromb Hemost 2024; 50:592-604. [PMID: 38395068 DOI: 10.1055/s-0044-1779739] [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: 02/25/2024]
Abstract
Lupus anticoagulant-hypoprothrombinemia syndrome (LAHPS) is a rare, acquired coagulopathy syndrome. Here, we aim to summarize the clinical features of LAHPS to improve the understanding of the disease. The clinical data of 52 patients with LAHPS retrieved through PubMed from 2019 to 2023, supplemented with a local case of a child with LAHPS, were retrospectively analyzed, and the clinical characteristics were summarized. 56.6% of LAHPS patients were female, the median age at onset was 13.0 years (range, 1.2-85 years), and the median activity of factor II was 18.0% (range, 0.1-69%). 64.2% of LAHPS patients experienced hemorrhage, with 29.4% having multisite hemorrhage and 20.6% experiencing both nonsevere and severe hemorrhage. Most of the reported cases were secondary to autoimmune diseases (60.6%), followed by infections (33.3%). Corticosteroids were administered to 79.3% of patients with hemorrhage, and 90.6% of patients with LAHPS showed improvement. In conclusion, LAHPS is most commonly observed in female patients, particularly those under 18 years of age. LAHPS is characterized by hemorrhage, occurring at various sites and with varying degrees of severity, but the majority of patients improve with appropriate treatment and management.
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Affiliation(s)
- Bin Wang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ning Tang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chi Zhang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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4
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Devreese KMJ. Noncriteria antiphospholipid antibodies in antiphospholipid syndrome. Int J Lab Hematol 2024; 46 Suppl 1:34-42. [PMID: 38584293 DOI: 10.1111/ijlh.14268] [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: 01/26/2024] [Accepted: 02/28/2024] [Indexed: 04/09/2024]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease characterized by thrombotic manifestations and/or obstetric complications in patients with persistently positive antiphospholipid antibodies (aPL). aPL are a heterogeneous group of autoantibodies, but only lupus anticoagulant, anticardiolipin (aCL), and antibeta2-glycoprotein I antibodies (aβ2GPI) IgG or IgM are included as laboratory classification criteria. Seronegative APS patients are usually defined as patients with the clinical symptoms of APS but who test negative for aPL. The negativity to classic aPL criteria does not exclude the presence of other aPL. Several noncriteria aPL have been identified. Some noncriteria aPL are well studied, such as IgA aCL and aβ2GPI, the antiphosphatidylserine-prothrombin (aPS/PT) antibodies, and the antibodies against the domain I of beta2-glycoprotein I (aDI), both latter groups receiving more attention for their role in thrombotic events and pregnancy complications. Other noncriteria aPL that have been studied are antibodies against annexin V, prothrombin, phosphatidylethanolamine, phosphatidic acid, phosphatidylserine, phosphatidylinositol, vimentin-cardiolipin complex, anti-protein S/protein C. Measurement of some of these noncriteria aPL (aPS/PT, aDI) is useful in the laboratory work-out of APS in specific situations. We have to differentiate between patients who are positive for noncriteria aPL only, and patients who have both criteria and noncriteria aPL to enable us to study their role in the diagnosis or risk stratification of APS. The research on noncriteria aPL is continually developing as the clinical relevance of these antibodies is not yet fully clarified.
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Affiliation(s)
- Katrien M J Devreese
- Coagulation Laboratory, Ghent University Hospital, Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
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5
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Yamada K, Nakajima Y, Ogiwara K, Sakai T, Fukuda K, Nogami K. ROTEM could be useful for lupus anticoagulant hypoprothrombinemia syndrome. Pediatr Int 2024; 66:e15773. [PMID: 38863279 DOI: 10.1111/ped.15773] [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: 11/23/2023] [Revised: 01/29/2024] [Accepted: 03/25/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Lupus anticoagulant-hypoprothrombinemia syndrome (LAHPS) is a rare disease caused by acquired factor II (FII) deficiency and lupus anticoagulant. Patients with LAHPS typically present with thrombosis and bleeding. However, little information is available on the evaluation of coagulation potential in patients with LAHPS. We examined global coagulation potentials in patients with LAHPS during the clinical course in this study. METHODS Coagulation potentials in two pediatric patients with LAHPS were assessed by measuring clotting time (CT) and clot formation time using Ca2+-triggered rotational thromboelastometry (ROTEM), CT and maximum coagulation velocity using clot waveform analysis (CWA), and lag time and peak thrombin using the thrombin generation assay (TGA). The day of admission was defined as day 0. RESULTS In case 1, the bleeding symptoms disappeared by day 5. However, the TGA and CWA results were markedly lower than normal, although FII activity (FII:C) returned to within the normal range by day 14. In contrast, ROTEM revealed a recovery to near-normal levels (day 14). All coagulation parameters (day 80) were within normal ranges. In case 2, coagulation potential was severely depressed until day 12, although FII:C returned to normal levels. Bleeding symptoms disappeared on day 19, and the ROTEM data revealed that the parameters were close to the normal range. The coagulation parameters in all assays were normalized on day 75. CONCLUSIONS Recovery of coagulation potential in patients with LAHPS was slower than the recovery of FII:C. Moreover, ROTEM appeared to be clinically useful for assessing coagulation potential in patients with LAHPS.
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Affiliation(s)
- Koyo Yamada
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Pediatrics, Kokuho Central Hospital, Tawaramoto, Nara, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Toshiyuki Sakai
- Pediatrics, Kokuho Central Hospital, Tawaramoto, Nara, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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6
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Sun YH, Nie WJ, Tian DD, Ye Q. Lupus anticoagulant-hypoprothrombinemia syndrome in children: Three case reports and systematic review of the literature. Lupus 2023; 32:1211-1221. [PMID: 37480550 DOI: 10.1177/09612033231191153] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
OBJECTIVE Children with lupus anticoagulant hypoprothrombinemia syndrome (LAHPS) are characterized by prolonged activated partial thromboplastin time (APTT) and prothrombin time (PT), lupus anticoagulant positivity and low prothrombin (factor II, FII) levels. Bleeding or thrombosis tendencies related to LAHPS in children can occur due to the development of anti-prothrombin antibodies that are usually linked to autoimmune or infectious diseases. METHODS We report three pediatric cases of LAHPS and describe details on their clinical symptoms, laboratory characteristics, treatment. PubMed, Medline, and Web of Science searches were conducted on LAHPS in children between 1960 and 2023; articles in English were included. RESULTS The coagulation profile revealed prolonged PT and APTT, with low prothrombin levels (19.4%, 21.0% and 12.9%, respectively) and positive lupus anticoagulant in 3 pediatric cases. Fifty-nine relevant articles reported 93 pediatric LAHPS cases (mean age: 9 years (0.8-17 years)); 63 females and 30 males, 87 patients presented with minor to severe bleeding diathesis, and 3 patients presented with thrombosis events. Among 48 patients ≥9 years old, 36 had SLE; among 45 patients <9 years, 29 had viral infection. When all patients were divided into two groups based on age, associated disease, and factor II level, Pearson's χ2 tests were performed, p =.00, and there was clinical significance between autoimmune and infectious disease in patients ≥9 years old and <9 years old, and in patients FII level ≤10% and >10%. LAHPS patients with autoimmune disease had a protracted course and needed prolonged treatment with immune-modulating therapy, while those patients with infectious disease resolved spontaneously or needed short-term immune-modulating therapy. CONCLUSION LAHPS caused by autoimmune disease are common in patients ≥9 years old, especially SLE, and FII level ≤10% is often reported in patients caused by autoimmune disease, suggesting that children ≥9 years old diagnosed with LAHPS-related autoimmune disease should pay special attention to the FII level. While LAHPS caused by infectious disease is more frequently observed in patients <9 years, especially viral infection. Early diagnostic investigations are critical to differentiating LAHPS caused by autoimmune or infectious disease, as the prognosis, treatment and outcome are distinct.
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Affiliation(s)
- Yan-Hong Sun
- Department of clinical laboratory, National Clinical Research Center for Child Health, National Children's Regional Medical Center, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wen-Jian Nie
- Department of clinical laboratory, National Clinical Research Center for Child Health, National Children's Regional Medical Center, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dan-Dan Tian
- Department of clinical laboratory, National Clinical Research Center for Child Health, National Children's Regional Medical Center, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qing Ye
- Department of clinical laboratory, National Clinical Research Center for Child Health, National Children's Regional Medical Center, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Nusrat S, Tewari S, Khan O. Successful treatment of lupus anticoagulant hypoprothrombinemia syndrome with rituximab. Thromb J 2023; 21:77. [PMID: 37461027 DOI: 10.1186/s12959-023-00517-z] [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: 05/31/2023] [Accepted: 06/24/2023] [Indexed: 07/20/2023] Open
Abstract
Lupus anticoagulant-hypoprothrombinemia syndrome (LAHPS) is a rare acquired bleeding disorder secondary to development of antibodies against prothrombin protein, in the presence of antiphospholipid antibodies. We describe the case of a 13-year-old girl who presented with severe menorrhagia and symptomatic anemia. Labs indicated anemia, thrombocytopenia, elevated PT and aPTT, high-titer inhibitor on mixing studies, positive ANA and anti-dsDNA antibodies, along with a triple-positive antiphospholipid antibody panel. Given additional systemic manifestations, systemic lupus erythematosus was diagnosed. High dose steroids and hydroxychloroquine subsequently started. Her clinical course was complicated by femoral deep venous thrombosis and post renal biopsy retroperitoneal hematoma. Further workup revealed low prothrombin level and the diagnosis of lupus anticoagulant hypoprothrombinemia syndrome. In view of suboptimal response to initial immunosuppressive therapy, rituximab was added to her regimen, leading to an improvement in clinical symptoms and resolution of hypoprothrombinemia. She remains recurrence free 5 years from the event.
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Affiliation(s)
- Sanober Nusrat
- Hematology-Oncology Section, Department of Medicine, University of Oklahoma Health Sciences Center, 800 NE 10th Street, Oklahoma City, OK, 73104, USA.
| | | | - Osman Khan
- Pediatric Hematology-Oncology Section, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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8
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Santoro RC, Molinari AC, Leotta M, Martini T. Isolated Prolongation of Activated Partial Thromboplastin Time: Not Just Bleeding Risk! MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1169. [PMID: 37374373 DOI: 10.3390/medicina59061169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023]
Abstract
Activated partial thromboplastin time (aPTT) is a fundamental screening test for coagulation disturbances. An increased aPTT ratio is quite common in clinical practice. How the detection of prolonged activated aPTT with a normal prothrombin time is interpreted is therefore very important. In daily practice, the detection of this abnormality often leads to delayed surgery and emotional stress for patients and their families and may be associated with increased costs due to re-testing and coagulation factor assessment. An isolated, prolonged aPTT is seen in (a) patients with congenital or acquired deficiencies of specific coagulation factors, (b) patients receiving treatment with anticoagulants, mainly heparin, and (c) individuals/patients with circulating anticoagulants. We summarize here what may cause an isolated prolonged aPTT and evaluate the preanalytical interferences. The identification of the cause of an isolated prolonged aPTT is of the utmost importance in ensuring the correct diagnostic workup and therapeutic choices.
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Affiliation(s)
- Rita Carlotta Santoro
- Hemostasis and Thrombosis Unit, Azienda Ospedaliera Pugliese-Ciaccio, 88100 Catanzaro, Italy
| | | | - Marzia Leotta
- Hemostasis and Thrombosis Unit, Azienda Ospedaliera Pugliese-Ciaccio, 88100 Catanzaro, Italy
| | - Tiziano Martini
- Immuno-Haematology and Transfusion Medicine, Center for Congenital Bleeding Disorders, Cesena General Hospital, 47521 Cesena, Italy
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Lipari A, Sorrentino S, Tamburini C, Castaman G, Prisco D, De Candia E. Bleeding and thrombotic events in a patient with lupus anticoagulant-associated hypoprothrombinemia and antiphospholipid antibody syndromes: managing hemostasis between Scylla and Charybdis. Intern Emerg Med 2023; 18:1233-1238. [PMID: 37165299 DOI: 10.1007/s11739-023-03292-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/22/2023] [Indexed: 05/12/2023]
Affiliation(s)
- Alice Lipari
- Malattie Emorragiche e Trombotiche, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Roma, Italy
| | - Silvia Sorrentino
- Malattie Emorragiche e Trombotiche, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Roma, Italy
| | - Carlo Tamburini
- SOD Medicina Interna Interdisciplinare, AOU Careggi, Firenze, Italy
| | - Giancarlo Castaman
- Dipartimento di Oncologia, AOU Careggi, Centro di Malattie Emorragiche e Trombotiche, Firenze, Italy
| | - Domenico Prisco
- SOD Medicina Interna Interdisciplinare, AOU Careggi, Firenze, Italy
- Dipartimento di Medicina Sperimentale e Clinica, Università di Firenze, Firenze, Italy
| | - Erica De Candia
- Malattie Emorragiche e Trombotiche, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Roma, Italy.
- Dipartimento di Medicina e Chirurgia Traslazionale, Universita Cattolica del Sacro Cuore, Roma, Italy.
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10
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Pérez ML, Laso RV, Velasco-Rodríguez D, Martín-Herrero S, Alfonzo IM, García-Raso A, Llamas-Sillero P. Lupus anticoagulant-hypoprothrombinemia syndrome: A cerebral bleeding case report as systemic lupus erythematosus debut. REUMATOLOGIA CLINICA 2023; 19:223-227. [PMID: 37061283 DOI: 10.1016/j.reumae.2022.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/23/2022] [Indexed: 04/17/2023]
Abstract
Lupus anticoagulant-hypoprothrombinaemia syndrome (LAHPS) is a rare disorder caused by the presence of lupus anticoagulant (LA) and acquired prothrombin deficiency, which may present with severe haemorrhagic manifestations. LAHPS is usually associated with systemic lupus erythematosus (SLE), or infections and it is more frequent in the paediatric population and female gender. We describe a 42-year-old man with thrombotic antiphospholipid syndrome (APS) on chronic anticoagulation treatment with acenocoumarol who presented with spontaneous intracranial bleeding, prolongation of prothrombin time (PT), activated partial thromboplastin time (APTT) and low factor II levels (after optimal anticoagulation reversal) as a debut of SLE.
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Affiliation(s)
- Miriam Lopez Pérez
- Department of Hematology, Hospital Universitario Fundación Jiménez Díaz, Hospitales Quirón Públicos, IIS-FJD, Madrid, Spain.
| | - Rosa Vidal Laso
- Department of Hematology, Hospital Universitario Fundación Jiménez Díaz, Hospitales Quirón Públicos, IIS-FJD, Madrid, Spain
| | - Diego Velasco-Rodríguez
- Department of Hematology, Hospital Universitario Fundación Jiménez Díaz, Hospitales Quirón Públicos, IIS-FJD, Madrid, Spain
| | - Sara Martín-Herrero
- Department of Hematology, Hospital Universitario Fundación Jiménez Díaz, Hospitales Quirón Públicos, IIS-FJD, Madrid, Spain
| | - Inés Martinez Alfonzo
- Department of Hematology, Hospital Universitario Fundación Jiménez Díaz, Hospitales Quirón Públicos, IIS-FJD, Madrid, Spain
| | - Aránzazu García-Raso
- Department of Hematology, Hospital Universitario Fundación Jiménez Díaz, Hospitales Quirón Públicos, IIS-FJD, Madrid, Spain
| | - Pilar Llamas-Sillero
- Department of Hematology, Hospital Universitario Fundación Jiménez Díaz, Hospitales Quirón Públicos, IIS-FJD, Madrid, Spain
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11
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Acedo N, Alonso A, Feijoó ES, García C, Ortiz AM, Alegre A. Lupus anticoagulant hypoprothrombinemia syndrome: A case report. Clin Case Rep 2023; 11:e7071. [PMID: 37038533 PMCID: PMC10082346 DOI: 10.1002/ccr3.7071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/31/2023] [Accepted: 02/21/2023] [Indexed: 04/12/2023] Open
Abstract
Lupus anticoagulant hypoprothrombinemia syndrome (LAHPS) is a rare entity associated with an increased risk of hemorrhage. Corticosteroids have been used in its treatment with favorable results. We present the case of a 54-year-old female patient with a personal history of Lupus diagnosed with LAHPS following an episode of cerebellar hemorrhage.
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Affiliation(s)
- Natalia Acedo
- Hematology DepartmentHospital Universitario de La PrincesaMadridSpain
| | - Alejandro Alonso
- Hematology DepartmentHospital Universitario de La PrincesaMadridSpain
| | | | - Cristina García
- Hematology DepartmentHospital Universitario de La PrincesaMadridSpain
| | - Ana M. Ortiz
- Rheumatology DepartmentHospital Universitario de La PrincesaMadridSpain
| | - Adrián Alegre
- Hematology DepartmentHospital Universitario de La PrincesaMadridSpain
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12
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Monti M, Martini T, Pengo V, Poletti G, Pedrazzi P, Biasoli C, Giovacchini M, Fasano T. Association between Severe Acute Respiratory Syndrome Coronavirus 2Infection (Coronavirus Disease 2019) and Lupus Anticoagulant-Hypoprothrombinemia Syndrome: A Case Report and Literature Assessment. Semin Thromb Hemost 2023. [PMID: 36807282 DOI: 10.1055/s-0043-1762577] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Affiliation(s)
- Marta Monti
- Clinical Pathology Unit, Hub Laboratory, AUSL della Romagna, Cesena, Italy
| | - Tiziano Martini
- Immuno-Haematology and Transfusion Medicine, Center for Congenital Bleeding Disorders, Cesena General Hospital, Cesena, Italy
| | - Vittorio Pengo
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padova, Padova, Italy.,Arianna Foundation on Anticoagulation, Bologna, Italy
| | - Giovanni Poletti
- Clinical Pathology Unit, Hub Laboratory, AUSL della Romagna, Cesena, Italy
| | - Paola Pedrazzi
- Immuno-Haematology and Transfusion Medicine, Center for Congenital Bleeding Disorders, Cesena General Hospital, Cesena, Italy
| | - Chiara Biasoli
- Immuno-Haematology and Transfusion Medicine, Center for Congenital Bleeding Disorders, Cesena General Hospital, Cesena, Italy
| | | | - Tommaso Fasano
- Clinical Pathology Unit, Hub Laboratory, AUSL della Romagna, Cesena, Italy
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13
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Davidson S. Assays to Monitor Bivalirudin. Methods Mol Biol 2023; 2663:369-380. [PMID: 37204724 DOI: 10.1007/978-1-0716-3175-1_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Bivalirudin (Angiomax, Angiox) is a parenteral direct thrombin inhibitor (DTI) that is used for patients with heparin-induced thrombocytopenia (HIT), where heparin cannot be used due to the risk of thrombosis. Bivalirudin is also licensed for use in cardiology procedures (e.g., percutaneous transluminal coronary angioplasty; PTCA). Bivalirudin is a synthetic analogue of hirudin found in the saliva of the medicinal leech and has a relatively short half-life of ~25 min. Several assays can be used to monitor bivalirudin; these include the activated partial thromboplastin time (APTT), activated clotting time (ACT), ecarin clotting time (ECT), an ecarin-based chromogenic assay, thrombin time (TT), the dilute TT, and the prothrombinase-induced clotting time (PiCT). Drug concentrations can also be measured using liquid chromatography tandem mass spectrometry (LC/MS) and clotting or chromogenic-based assays with specific drug calibrators and controls.
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Affiliation(s)
- Simon Davidson
- Division of Medicine, University College London, London, UK
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14
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Jin Y, Cheng Y, Mi J, Xu J. A rare case of schizophrenia coexistence with antiphospholipid syndrome, β-thalassemia, and monoclonal gammopathy of undetermined significance. Front Psychiatry 2023; 14:1178247. [PMID: 37091711 PMCID: PMC10117972 DOI: 10.3389/fpsyt.2023.1178247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/21/2023] [Indexed: 04/25/2023] Open
Abstract
A patient with schizophrenia who was treated with chlorpromazine developed lupus anticoagulant (LA) and antiphospholipid syndrome (APS). On protein electrophoresis, a monoclonal immunoglobulin A peak was seen in this patient, defining a condition of monoclonal gammopathy of undetermined significance. Additionally, β-thalassemia was diagnosed with the CD41-42 genotype. This condition is extremely rare, particularly in patients with schizophrenia and APS. We present a case of a patient with schizophrenia and secondary APS who had a positive LA, a significantly prolonged activated partial thromboplastin time, endogenous coagulation factor deficiency and inhibitor, no bleeding, and an unexpected finding of β-thalassemia and monoclonal IgA. Following that, a literature review on the disorders was presented.
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Affiliation(s)
- Yingming Jin
- Department of Hematology and Oncology, Ningbo No.2 Hospital, Ningbo, China
| | - Yiquan Cheng
- Department of Hematology and Oncology, Ningbo No.2 Hospital, Ningbo, China
| | - Jifeng Mi
- Department of Laboratory Medicine, Ningbo No.2 Hospital, Ningbo, China
| | - Jianfen Xu
- Department of Hematology and Oncology, Ningbo No.2 Hospital, Ningbo, China
- *Correspondence: Jianfen Xu,
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15
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ORIHIME study: real-world treatment patterns and clinical outcomes of 338 patients with acquired hemophilia A from a Japanese administrative database. Int J Hematol 2023; 117:44-55. [PMID: 36331704 PMCID: PMC9813148 DOI: 10.1007/s12185-022-03467-w] [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] [Received: 07/22/2022] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Acquired hemophilia A (AHA) is a rare disorder, and clinical practices for treating AHA have not been fully clarified in Japan. OBJECTIVES This study aims to investigate the epidemiology of AHA and real-world treatment practices in Japan. PATIENTS/METHODS This observational study was based on a health administrative database of hospitalized patients diagnosed with AHA who were treated with immunosuppressants. RESULTS The study included 214 males and 124 females (mean age 75.7 years). The most frequently used bypassing agent was recombinant activated factor VII. The predominant choice of immunosuppressant for first-line treatment was steroid monotherapy. Median days from the index date to the start of rehabilitation was 65.0 for cardiovascular, 35.5 for respiratory and 23.0 for locomotor. The proportion of patients with an activities of daily living (ADL) score < 70 points was high at both first admission and final discharge (47.4% and 38.8%). The percentage of deaths during hospitalization was 18.6%. CONCLUSIONS This study clarified the treatment patterns and clinical outcomes of AHA in a large population in Japan. This was the first study showing ADL score distribution and time to rehabilitation. Further investigation is needed to develop better clinical practices for treatment of AHA.
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16
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Islabão AG, Trindade VC, da Mota LMH, Andrade DCO, Silva CA. Managing Antiphospholipid Syndrome in Children and Adolescents: Current and Future Prospects. Paediatr Drugs 2022; 24:13-27. [PMID: 34904182 PMCID: PMC8667978 DOI: 10.1007/s40272-021-00484-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 11/28/2022]
Abstract
Pediatric antiphospholipid syndrome (APS) is a rare acquired multisystem autoimmune thromboinflammatory condition characterized by thrombotic and non-thrombotic clinical manifestations. APS in children and adolescents typically presents with large-vessel thrombosis, thrombotic microangiopathy, and, rarely, obstetric morbidity. Non-thrombotic clinical manifestations are frequently seen in pediatric APS and may be present even before the vascular thrombotic events occur. We review insights into the pathogenesis of APS and discuss potential targets for therapy. The identification of multiple immunologic abnormalities in patients with APS reveals molecular targets for current or future treatment. Management strategies, especially for APS in adolescents, require screening for additional prothrombotic risk factors and consideration of counseling regarding contraceptive strategies, lifestyle recommendations, treatment adherence, and mental health issues associated with this autoimmune thrombophilia. The main goal of therapy in pediatric APS is the prevention of thrombosis. The management of acute thrombosis events in children and adolescents is the same as for primary APS, which involves isolated occurrences, and secondary APS, which is seen in association with another autoimmune disease, e.g., systemic lupus erythematosus. A pediatric hematologist should be consulted so other differential thrombophilic conditions can be eliminated. Therapy includes unfractionated heparin or low-molecular-weight heparin followed by vitamin K antagonists. Treatment of catastrophic APS involves triple therapy (anticoagulation, intravenous corticosteroid pulse therapy, and plasma exchange) and may include intravenous immunoglobulin for children and adolescents with this condition. New drugs such as eculizumab and sirolimus seem to be promising drugs for APS.
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Affiliation(s)
- Aline Garcia Islabão
- Pediatric Rheumatology Unit, Hospital da Criança de Brasília Jose Alencar, Brasília, DF Brazil ,Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade de Brasília, Brasília, DF Brazil
| | - Vitor Cavalcanti Trindade
- Faculdade de Medicina, Children and Adolescent Institute, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647-Cerqueira César, São Paulo, SP 05403-000 Brazil
| | - Licia Maria Henrique da Mota
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade de Brasília, Brasília, DF Brazil ,Rheumatology Unit, Hospital Universitário de Brasília, Universidade de Brasília, Brasília, Brazil
| | | | - Clovis Artur Silva
- Faculdade de Medicina, Children and Adolescent Institute, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647-Cerqueira César, São Paulo, SP, 05403-000, Brazil. .,Rheumatology Division, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil.
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17
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Miloš M, Marijančević D, Kozmar A, Anić B, Coen Herak D. Dramatically prolonged coagulation screening tests in a patient with positive lupus anticoagulant and monoclonal immunoglobulin M without bleeding manifestations. Clin Chim Acta 2021; 525:6-11. [PMID: 34896061 DOI: 10.1016/j.cca.2021.11.027] [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: 11/05/2021] [Revised: 11/26/2021] [Accepted: 11/27/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Concomitant presence of lupus anticoagulant (LA) and monoclonal immunoglobulin in the same patient is uncommon and the influence of this finding on coagulation results is still unknown. CASE REPORT We present a patient with a diagnosis of systemic lupus erythematosus (SLE) and secondary antiphospholipid syndrome (APS) with permanently positive LA who presented with accidental finding of newly discovered monoclonal IgM in a high concentration and dramatically prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT), without bleeding manifestations. CONCLUSION Concomitant presence of extremely prolonged PT and aPTT with unusual coagulation reaction kinetics, consistent LA ratio over the follow-up period and normalization of coagulation screening results with decreasing monoclonal IgM concentration elicited suspicion that PT and aPTT prolongation could be attributed to M-protein with antiphospholipid specificity. Low LA-sensitive aPTT reagent Actin FS demonstrated exceptional sensitivity, whereas human placental thromboplastin in contrast to recombinant reagents showed significantly lower sensitivity to monoclonal IgM with antiphospholipid specificity. Changes in the activity of SLE observed during the follow-up period were inversely related to monoclonal IgM concentration, while the presence of secondary APS was consistent. Described analytical interference on PT and aPTT without bleeding manifestation should point towards suspicion of previously unidentified monoclonal IgM with antiphospholipid sensitivity.
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Affiliation(s)
- Marija Miloš
- Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Zagreb, Croatia; Faculty of Pharmacy, University of Mostar, Bosnia & Herzegovina.
| | - Domagoj Marijančević
- Laboratory of Endocrinology, Department of Oncology and Nuclear Medicine, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Ana Kozmar
- Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Branimir Anić
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia; University of Zagreb School of Medicine, Zagreb, Croatia
| | - Désirée Coen Herak
- Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Zagreb, Croatia
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18
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Moore GW, Jones PO, Platton S, Hussain N, White D, Thomas W, Rigano J, Pouplard C, Gray E, Devreese KMJ. International multicenter, multiplatform study to validate Taipan snake venom time as a lupus anticoagulant screening test with ecarin time as the confirmatory test: Communication from the ISTH SSC Subcommittee on Lupus Anticoagulant/Antiphospholipid Antibodies. J Thromb Haemost 2021; 19:3177-3192. [PMID: 34192404 DOI: 10.1111/jth.15438] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/08/2021] [Accepted: 06/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lupus anticoagulant (LA) assays are compromised in anticoagulated patients, and existing strategies to overcome the interferences have limitations. The prothrombin-activating Taipan snake venom time (TSVT) screening test and ecarin time (ET) confirmatory test are innately insensitive to vitamin K antagonists (VKA) and direct factor Xa inhibitors (DFXaI). OBJECTIVES Validate standardized TSVT/ET reagents for LA detection, in a multicenter, multiplatform study. PATIENTS/METHODS Six centers from four countries analyzed samples with TSVT/ET from 81 nonanticoagulated patients with LA, patients with established antiphospholipid syndrome (APS), and proven persistent LA who were either not anticoagulated (n = 120) or were anticoagulated with VKAs (n = 180) or DFXaIs (n = 71). Additionally, 339 nonanticoagulated LA-negative patients, and 575 anticoagulated non-APS patients (172 VKA, 403 DFXaI) were tested. Anticoagulant spiking experiments were performed and 112 samples containing potential interferences (i.e., direct thrombin inhibitors) were tested. Results were evaluated against locally derived cutoffs. Imprecision was evaluated. RESULTS Cutoffs were remarkably similar despite use of different analyzers and donor populations. Cutoffs for TSVT ratio, ET ratio, percent correction, and normalized TSVT ratio/ET ratio ranged between 1.08 and 1.10, 1.09 and 1.12, 9.3% and 14.8%, and 1.10 and 1.15, respectively. Coefficients of variation for TSVT and ET ratios were ≤5.0%. TSVT/ET exhibited sensitivity, specificity, and negative and positive predictive values of 78.2%/95.0%/86.3%/91.5%, respectively, with established APS as the LA-positive population, and 86.9%/95.0%/76.8%/97.4%, respectively, with triple-positive APS. Interference was seen with direct thrombin inhibitors, unfractionated heparin, and low molecular weight heparins, but not VKAs or DFXaIs. CONCLUSIONS TSVT/ET are validated for LA detection in nonanticoagulated patients and those on VKAs or DFXaIs.
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Affiliation(s)
- Gary W Moore
- Department of Haemostasis and Thrombosis, Viapath Analytics, Guy's & St. Thomas' Hospitals, London, UK
- Specialist Haemostasis Unit, Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Faculty of Science and Technology, Middlesex University, London, UK
| | - Paul O Jones
- Department of Haemostasis and Thrombosis, Viapath Analytics, Guy's & St. Thomas' Hospitals, London, UK
| | - Sean Platton
- The Royal London Hospital Haemophilia Centre, Barts Health NHS Trust, London, UK
| | - Nadia Hussain
- Clinical Biochemistry Department, Barts Health NHS Trust, London, UK
| | - Danielle White
- Specialist Haemostasis Unit, Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Will Thomas
- Specialist Haemostasis Unit, Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Joseph Rigano
- Haematology Department, Alfred Health, Melbourne, Vic., Australia
| | - Claire Pouplard
- Department of Hemostasis, University Hospital of Tours, University of Tours, Tours, France
| | - Elaine Gray
- Haemostasis Section, The National Institute for Biological Standards and Control, Potters Bar, UK
| | - Katrien M J Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
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19
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Wada H, Ichinose A, Shiraki K, Shimpo H, Shimaoka M. Coagulation factor V inhibitors, a review of the case report literature. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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20
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Llorente-Chávez A, Plascencia-Félix JF, Merayo-Chalico J. Lupus anticoagulant-hypoprothrombinaemia syndrome: subdural haematoma as an unusual and initial manifestation. Mod Rheumatol Case Rep 2021; 5:306-309. [PMID: 33970809 DOI: 10.1080/24725625.2021.1920139] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
We describe the case of a 50-year-old woman with a history of SLE and APS that presented with a spontaneous subdural haematoma, prolonged aPTT, PT and INR and positive LA. The activity of the coagulation factors II, VIII, IX and XI was extremely low, and anti-prothrombin antibody IgG was positive. LAHS was established, with inhibition of the intrinsic pathway, as an acquired haemophilia. The patient received corticosteroids and cyclophosphamide as treatment. To the best of our knowledge, this is one of the few reports of spontaneous intracranial bleeding, an unusual and initial manifestation of LAHS in an adult patient.HighlightsLAHS is characterised by the presence of LA and hypoprothrombinaemia caused by anti-prothrombin antibodies.Prolonged aPTT and INR, and positive LA are important laboratory findings that help the suspicion of LAHS.Intracranial bleeding is an unusual manifestation of LAHS associated with low factor II activity.Corticosteroids are the first-line treatment of LAHS.The prognosis of LAHS is good with adequate treatment, with a reported mortality of 5%.
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Affiliation(s)
- Amaya Llorente-Chávez
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Javier Merayo-Chalico
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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21
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A Chinese Boy With Lupus Anticoagulant-hypoprothrombinemia Syndrome: A Case Report and Review of the Literature. J Pediatr Hematol Oncol 2021; 43:e445-e447. [PMID: 32287097 DOI: 10.1097/mph.0000000000001805] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 03/19/2020] [Indexed: 11/26/2022]
Abstract
We herein report an unusual case of lupus with bleeding diathesis in a Chinese adolescent boy. In the presence of lupus anticoagulant and hypoprothrombinemia, the diagnosis of lupus anticoagulant-hypoprothrombinemia syndrome was made. He responded promptly to immunosuppressive agents and achieved disease remission.
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22
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Cohen H, Efthymiou M, Devreese KMJ. Monitoring of anticoagulation in thrombotic antiphospholipid syndrome. J Thromb Haemost 2021; 19:892-908. [PMID: 33325604 DOI: 10.1111/jth.15217] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 12/07/2020] [Accepted: 12/09/2020] [Indexed: 12/23/2022]
Abstract
Anticoagulation is central to the management of thrombotic antiphospholipid syndrome (APS). The standard anticoagulant treatment for thrombotic APS is life-long warfarin or an alternative vitamin K antagonist. The role of direct oral anticoagulants for thrombotic APS is not established due to the lack of definitive evidence and has recently been addressed in international guidance. Other anticoagulant options include low molecular weight heparin, unfractionated heparin, and fondaparinux. In APS patients, lupus anticoagulant can affect phospholipid-dependent coagulation monitoring tests, so that they may not reflect true anticoagulation intensity. Accurate assessment of anticoagulation intensity is essential, to optimize anticoagulant dosing and facilitate thrombus resolution; minimize the risk of recurrent thrombosis or bleeding; inform assessment of whether recurrent thrombosis is related to breakthrough thrombosis while on therapeutic anticoagulation, subtherapeutic anticoagulation, non-adherence, or spurious results; and guide the management of bleeding. Knowledge of anticoagulant intensity also informs assessment and comparison of anticoagulation regimens in clinical studies. Considerations regarding anticoagulation dosing and/or monitoring of thrombotic APS patients underpin appropriate management in special situations, notably APS-related severe renal impairment, which can occur in APS or APS/systemic lupus erythematosus-related nephropathy or catastrophic APS; and APS-related thrombocytopenia. Anticoagulant dosing and monitoring in thrombotic APS patients also require consideration in anticoagulant-refractory APS and during pregnancy. In this review, we summarize the tests generally used in monitoring anticoagulant therapy, use of the main anticoagulants considered for thrombotic APS, lupus anticoagulant effects on anticoagulation monitoring tests, and strategies for appropriate anticoagulant monitoring in thrombotic APS.
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Affiliation(s)
- Hannah Cohen
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Maria Efthymiou
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - Katrien M J Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, Department of Diagnostic Sciences, Ghent University Hospital, Ghent University, Ghent, Belgium
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23
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Sakamoto A, Ogura M, Hattori A, Tada K, Horikawa R, Nakadate H, Matsumoto K, Nogami K, Ieko M, Ishiguro A. Lupus anticoagulant hypoprothrombinemia syndrome associated with bilateral adrenal haemorrhage in a child: early diagnosis and intervention. Thromb J 2021; 19:19. [PMID: 33731125 PMCID: PMC7968225 DOI: 10.1186/s12959-021-00271-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 03/09/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Lupus anticoagulant-hypoprothrombinemia syndrome (LAHPS) is characterized by bleeding and thrombosis in patients with autoimmune diseases or infections. Paediatric LAHPS exhibits various degrees of bleeding, ranging from mild to severe; however, adrenal haemorrhage due to LAHPS and its long-term clinical course have not been sufficiently described. CASE PRESENTATION A 9-year-old boy presented with prolonged abdominal pain and abnormal coagulation screening tests. The laboratory tests showed prolonged activated partial thromboplastin time and subsequently revealed the presence of lupus anticoagulant, anti-nuclear antibodies, and hypoprothrombinemia, leading to diagnosis of LAHPS. An enhanced computed tomogram demonstrated nodular lesions in the adrenal glands bilaterally, suggestive of adrenal haemorrhage. Laboratory and clinical manifestations exhibited life-threatening adrenal insufficiency that required hydrocortisone administration. The patient developed systemic lupus erythematosus, diagnosed 12 months later. CONCLUSIONS This patient with LAHPS developed rare adrenal failure due to adrenal haemorrhage, a life-threatening event that should be recognized and treated early. In our case, renal dysfunction was also observed when systemic lupus erythematosus was diagnosed 1 year after LAHPS. Our case emphasizes that early recognition of adrenal failure and careful long-term observation is required in patients with autoantibodies.
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Affiliation(s)
- Atsushi Sakamoto
- Center for Postgraduate Education and Training, National Center for Child Health and Development, NCCHD, Tokyo, Japan. .,Children's Cancer Center, National Center for Child Health and Development, Setagaya-ku, Tokyo, 157-8535, Japan.
| | - Masao Ogura
- Division of Nephrology and Rheumatology, NCCHD, Tokyo, Japan
| | - Atsushi Hattori
- Division of Endocrinology and Metabolism, NCCHD, Tokyo, Japan
| | - Kinji Tada
- Center for Postgraduate Education and Training, National Center for Child Health and Development, NCCHD, Tokyo, Japan
| | - Reiko Horikawa
- Division of Endocrinology and Metabolism, NCCHD, Tokyo, Japan
| | | | - Kimikazu Matsumoto
- Children's Cancer Center, National Center for Child Health and Development, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Masahiro Ieko
- Department of Internal Medicine, School of Dentistry, Health Sciences University of Hokkaido, Ishikari-Tobetsu, Hokkaido, Japan
| | - Akira Ishiguro
- Center for Postgraduate Education and Training, National Center for Child Health and Development, NCCHD, Tokyo, Japan.,Division of Hematology, NCCHD, Tokyo, Japan
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24
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Vandamme S, Desclée E, Ver Elst K, Weekx S, Maes P, Van Brusselen D, Vermeiren S. Lupus anticoagulant hypoprothrombinaemia syndrome: An instructive paediatric case. J Paediatr Child Health 2021; 57:443-444. [PMID: 32281176 DOI: 10.1111/jpc.14889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 02/18/2020] [Accepted: 03/13/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Sarah Vandamme
- Laboratory of Haematology, GZA Hospitals Antwerp, Antwerp, Belgium.,Laboratory of Haematology, University Hospital Antwerp, Edegem, Belgium
| | - Emilie Desclée
- Department of Paediatrics, GZA Hospitals Antwerp, Antwerpen, Belgium.,Department of Paediatrics, University Hospital Antwerp, Edegem, Belgium
| | | | - Steven Weekx
- Laboratory of Haematology, GZA Hospitals Antwerp, Antwerp, Belgium
| | - Philip Maes
- Department of Paediatrics, University Hospital Antwerp, Edegem, Belgium
| | - Daan Van Brusselen
- Department of Paediatrics, GZA Hospitals Antwerp, Antwerpen, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Sigrid Vermeiren
- Laboratory of Haematology, GZA Hospitals Antwerp, Antwerp, Belgium
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25
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Keikhaei B, Saadati N, Mahmoudian-Sani MR, Varnaseri M. A maternal death due to the intracerebral hemorrhage caused by antiphospholipid syndrome: a case report. Clin Rheumatol 2021; 40:3329-3333. [PMID: 33392889 DOI: 10.1007/s10067-020-05559-6] [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: 05/11/2020] [Revised: 11/26/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by the presence of antiphospholipid antibodies in patients with arterial or venous thrombosis or pregnancy complications. This paper reports a case of a 31-year-old woman who died after she underwent C-section for intrauterine fetal death (IUFD) at the 25th week of gestation. The patient was complaining of pelvic pressure, swelling in the lower limbs, and pain in the groin, one big toe, and both wrists. She had low platelet count, liver abnormalities, and proteinuria. After IUFD, she complained of flank pain and headache. After discharge from the hospital, the patient had constant headaches and 5 days later woke up with hemiplegia. CT scan showed cerebral hemorrhage in the right hemisphere and thrombosis in the left hemisphere. The LA and APS tests were positive. The main cause of death was hemorrhage and infarction in the brain.
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Affiliation(s)
- Bijan Keikhaei
- Thalassemia and Hemoglobinopathy Research Center, Research Institute of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Najmieh Saadati
- Fertility, Infertility and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Mohammad-Reza Mahmoudian-Sani
- Thalassemia and Hemoglobinopathy Research Center, Research Institute of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mehran Varnaseri
- Infectious Diseases Department, Razi Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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26
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Thomas M, Jain S, Muthusamy K, Bernice TS, Pansuriya H, Punnen A, Kumar S. A rare treatable and under recognized cause of recurrent convexity subarachnoid hemorrhage: Lupus anticoagulant hypoprothombinemia syndrome. Ann Indian Acad Neurol 2021; 24:986-989. [PMID: 35359554 PMCID: PMC8965963 DOI: 10.4103/aian.aian_804_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 08/21/2020] [Accepted: 09/28/2020] [Indexed: 11/11/2022] Open
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27
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Punnen KA, Kumar TS, Geevar T. Lupus cofactor phenomenon in a child with systemic lupus erythematosus with lupus anticoagulant–Hypoprothrombinemia syndrome. INDIAN JOURNAL OF RHEUMATOLOGY 2021. [DOI: 10.4103/injr.injr_41_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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28
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Acquired Factor XI Deficiency with Lupus Anticoagulant in a Pregnant Woman Diagnosed by the Eruptions and Pain in Fingers. Case Rep Obstet Gynecol 2020; 2020:8854676. [PMID: 33489393 PMCID: PMC7803157 DOI: 10.1155/2020/8854676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 12/10/2020] [Accepted: 12/15/2020] [Indexed: 12/17/2022] Open
Abstract
We report a case of acquired factor XI deficiency with lupus anticoagulant (LA) in a 28-year-old primigravida who presented with finger pain and eruptions on her palms and fingers during the 3rd trimester of pregnancy. The patient complained of pain and reddening of the fingers at 30 weeks of gestation. She was referred to our tertiary center with a diagnosis of preeclampsia and suspected collagen disease at 35 weeks of gestation. Erythema was seen on the fingers and palms, and she presented with pain and cryesthesia on the fingers. Laboratory investigations revealed an activated partial thromboplastin time of 51 s (normal, 23–40 s), although it was normal during the 30th and 34th gestational weeks, LA with an anticardiolipin-beta2-glycoprotein I complex antibody, and low level of clotting XI activity (25 U/mL). On week 37 day 0 of gestation, the patient presented with severe hypertension. An urgent Cesarean section was performed after transfusion of two units of fresh frozen plasma. There was no excessive bleeding during the surgery or the postpartum period. The symptoms on her fingers and palms gradually improved after surgery. Our case indicates that dermatoses of pregnancy may become a starting point for the diagnosis of autoimmune diseases and coagulation abnormalities. When a patient presents with an atypical symptom, as in our case, the possibility of various diseases should be considered.
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29
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Pengo V, Zardo L, Cattini MG, Bison E, Pontara E, Altinier S, Cheng C, Denas G. Prothrombin Is Responsible for the Lupus Cofactor Phenomenon in a Patient with Lupus Anticoagulant/Hypoprothrombinemia Syndrome. TH OPEN 2020; 4:e40-e44. [PMID: 32159072 PMCID: PMC7062548 DOI: 10.1055/s-0040-1705091] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/22/2020] [Indexed: 11/16/2022] Open
Abstract
Lupus anticoagulant is a misnomer as it is commonly associated with thromboembolic events. In few cases, the name retains its literal meaning when it characterizes patients with a bleeding disorder. We describe a patient with lupus anticoagulant, hypoprothrombinemia, and major bleeding (lupus anticoagulant/hypoprothrombinemia syndrome). Immunological studies revealed a huge amount of circulating monoclonal immunoglobulin M lambda (IgMλ) antiphosphatidylserine/prothrombin antibodies (14,400 U/mL). Affinity purified monoclonal antibodies (440 U/mL) prolonged the coagulation time of normal plasma by 12.2 seconds (diluted Russell viper venom time) and 25.5 seconds (silica clotting time). The original patient's plasma mixed 1:1 with normal plasma showed a marked prolongation of coagulation times (lupus cofactor) from a ratio of 2.94 to 5.23 in diluted Russel viper venom time and from 2.30 to 3.00 using the silica clotting time. Human prothrombin added to original patient's plasma caused a marked prolongation of coagulation times in diluted Russell viper venom test thus unequivocally explaining the lupus cofactor phenomenon. In conclusion, we have shown that lupus anticoagulant/hypoprothrombinemia syndrome is attributable to monoclonal IgMλ antibodies directed to phosphatidylserine/prothrombin and that prothrombin is the protein responsible for the observed lupus cofactor phenomenon.
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Affiliation(s)
- Vittorio Pengo
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padova, Italy
| | - Lorena Zardo
- Castelfranco Veneto General Hospital - ULSS 2 Treviso, Treviso, Italy
| | - Maria Grazia Cattini
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padova, Italy
| | - Elisa Bison
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padova, Italy
| | - Elena Pontara
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padova, Italy
| | - Sara Altinier
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
| | - Chunyan Cheng
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padova, Italy
| | - Gentian Denas
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padova, Italy
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A case report of severe bleeding due to lupus anticoagulant hypoprothrombinemia syndrome. J Thromb Thrombolysis 2020; 49:334-336. [DOI: 10.1007/s11239-019-01955-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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31
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Madison JA, Zuo Y, Knight JS. Pediatric antiphospholipid syndrome. Eur J Rheumatol 2020; 7:S3-S12. [PMID: 31804173 PMCID: PMC7004270 DOI: 10.5152/eurjrheum.2019.19160] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 10/01/2019] [Indexed: 12/12/2022] Open
Abstract
Despite its potential to cause significant morbidity in children, pediatric antiphospholipid syndrome (APS) is an understudied condition. In this review, we will cover what is known about pediatric APS epidemiology and how the clinician might approach the diagnosis of pediatric APS. We will highlight similarities and differences with the adult disease, both for primary APS and in the context of lupus. Clinical manifestations beyond thrombosis, especially neurologic and hematologic in nature, will be discussed. We will also consider what unique implications antiphospholipid antibody-positivity may have for children with lupus and for neonates born to mothers with APS. The approach to treatment will be covered, including the unique impact of APS medications on children as compared with adults. Finally, the importance of future mechanistic research is emphasized as physicians endeavor to provide the personalized care that children with APS clearly deserve.
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Affiliation(s)
- Jacqueline A. Madison
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Yu Zuo
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason S. Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Murphy CH, Jin J, Zehnder JL. Antiphospholipid Antibodies in Patients With Lupus Anticoagulant Prozone Effect. Am J Clin Pathol 2020; 153:229-234. [PMID: 31598704 DOI: 10.1093/ajcp/aqz151] [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] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Lupus anticoagulant (LAC) is typically associated with thrombosis but also rarely with hemorrhage. Some patients exhibit a prozone effect on LAC testing. Antiphosphatidylserine/prothrombin (aPS/PT) antibodies may provide a mechanism for both hemorrhage and prozone effect. Our goal was to evaluate whether antibody specificities, isotypes, and titers were associated with LAC prozone effect, factor II levels, hemorrhage, and thrombosis. METHODS Patients with prozone effect noted on LAC testing were entered into a database over 3 years. Factor II activity and aPS/PT antibody testing were performed when a sufficient residual sample was available. RESULTS All patients with LAC prozone effect and antibody testing were positive for at least 1 class of aPS/PT antibodies. In addition, aPS/PT IgG titers were significantly associated with thrombosis and significantly inversely associated with factor II levels. CONCLUSIONS In prozone effect patients, aPS/PT antibodies are associated with LAC prozone effect as well as thrombosis and decreased factor II levels.
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Affiliation(s)
- Colin H Murphy
- Department of Pathology, School of Medicine, Stanford University, Stanford, CA
| | - Jing Jin
- Stanford Coagulation and Hemostasis Laboratory, Stanford Medical Center, Palo Alto, CA
| | - James L Zehnder
- Department of Pathology, School of Medicine, Stanford University, Stanford, CA
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Kim JW, Kim TW, Ryu KH, Park SG, Jeong CY, Park DH. Anaesthetic considerations for patients with antiphospholipid syndrome undergoing non-cardiac surgery. J Int Med Res 2020; 48:300060519896889. [PMID: 31937174 PMCID: PMC7113712 DOI: 10.1177/0300060519896889] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 12/02/2019] [Indexed: 12/30/2022] Open
Abstract
Antiphospholipid syndrome (APS) is an acquired thrombotic autoimmune disorder that is clinically characterized by the development of thrombosis and obstetric morbidities in patients with antiphospholipid antibodies. Due to hypercoagulability, the focus of management is anticoagulation for the prevention of thrombosis and its recurrence. When such patients undergo surgery, however, the underlying risk of thrombosis increases as a result of anticoagulant withdrawal, immobilization, and/or intimal injury. Conversely, there is also an increased risk of bleeding due to thrombocytopaenia, possible disseminated intravascular coagulation, or progression to catastrophic APS, as a result of excessive anticoagulation, surgery, and infection. Measures for appropriate perioperative anticoagulation are discussed in this review, as well as anaesthetic considerations for preventing perioperative complications in patients with APS undergoing non-cardiac surgery.
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Affiliation(s)
- Jae Won Kim
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| | - Tae Woo Kim
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| | - Keon Hee Ryu
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| | - Sun Gyoo Park
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| | - Chang Young Jeong
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| | - Dong Ho Park
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
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Menegatti M, Biguzzi E, Peyvandi F. Management of rare acquired bleeding disorders. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:80-87. [PMID: 31808848 PMCID: PMC6913473 DOI: 10.1182/hematology.2019000066] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Autoantibodies toward clotting factors may develop in people suffering from autoimmune or neoplastic diseases, after drug intake or even in subjects without apparent conditions. They are more commonly directed against factor VIII (FVIII) or von Willebrand factor leading to acquired hemophilia A or acquired von Willebrand syndrome, respectively. Rarely, autoantibodies develop against other clotting factors, such as fibrinogen, FII, FV, FVII, FX, FXI, and FXIII. The clinical picture of an acquired bleeding disorder includes a wide spectrum of clinical manifestations ranging from minimal or no bleeding to life-threatening events. Patients with no previous personal or family history of bleeding may have sudden-onset hemorrhagic manifestations, sometimes fatal, especially if an early diagnosis is not made. On the other hand, some patients may not have hemorrhagic symptoms at onset, and their diagnosis can therefore be delayed. The laboratory diagnostic assessment is performed by screening coagulation tests followed by specific factor-level measurement and inhibitor-titrating assays. An early diagnosis of acquired coagulopathies is mandatory for starting the appropriate treatment aimed at both controlling the acute bleeding episode mainly using the bypassing agents, and eradicating the anticlotting factor autoantibody, using immunosuppressive treatment. Therefore, prompt intervention by an expert and a specialized center is needed for immediate recognition and treatment of the disease.
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Affiliation(s)
- Marzia Menegatti
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy; and
| | - Eugenia Biguzzi
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy; and
| | - Flora Peyvandi
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy; and
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Fujiwara K, Shimizu J, Tsukahara H, Shimada A. Lupus anticoagulant-hypoprothrombinemia syndrome and immunoglobulin-A vasculitis: a report of Japanese sibling cases and review of the literature. Rheumatol Int 2019; 39:1811-1819. [PMID: 31392497 DOI: 10.1007/s00296-019-04404-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 07/29/2019] [Indexed: 10/26/2022]
Abstract
Lupus anticoagulant-hypoprothrombinemia syndrome (LAHPS) is a rare bleeding disorder caused by antiprothrombin antibodies. LAHPS is associated with systemic lupus erythematosus (SLE) or infections. We describe two Japanese brothers with immunoglobulin-A vasculitis (IgAV) who met the diagnostic criteria of LAHPS. They presented with palpable purpura and abdominal pain, and had a prolonged activated partial thromboplastin time (APTT) and prothrombin deficiency with the presence of lupus anticoagulant. Pediatric LAHPS was reviewed in abstracts from the Japan Medical Abstracts Society that were written in Japanese and PubMed or Web of Science-listed articles in English between 1996 and 2019. Including our cases, pediatric LAHPS has been reported in 40 Japanese and 46 non-Japanese patients. We summarized the clinical and laboratory characteristics of all 86 cases, and found only one Japanese LAHPS case with IgAV, except for our cases. Of the 86 cases, most were associated with infections followed by SLE. The presence of SLE, older age, lower prothrombin levels, severe bleeding symptoms, and positivity of immunoglobulin G anticardiolipin antibodies and anticardiolipin/β2-glycoprotein I antibodies and/or β2-glycoprotein I-dependent anticardiolipin antibodies had higher odds of requiring treatment. Measuring the APTT and prothrombin time (PT) might be required in patients with IgAV when they do not have a typical clinical course or distinctive symptoms. LAHPS should be considered with prolongation of the APTT and/or PT. Additionally, it is important to maintain a balance between the risk of thrombosis and hemorrhage when normalization of the PT and FII levels occurs in LAHPS cases under treatment.
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Affiliation(s)
- Kaori Fujiwara
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Junya Shimizu
- Department of Pediatrics, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | | | - Akira Shimada
- Department of Pediatric Hematology/Oncology, Okayama University Hospital, 2-5-1, Shikatacho, Kitaku, Okayama, 700-8558, Japan.
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Lupus anticoagulant-hypoprothrombinemia syndrome and similar diseases: experiences at a single center in Japan. Int J Hematol 2019; 110:197-204. [PMID: 31165409 DOI: 10.1007/s12185-019-02674-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 05/16/2019] [Accepted: 05/21/2019] [Indexed: 12/16/2022]
Abstract
Patients with lupus anticoagulant (LA), a thrombotic risk factor, along with decreased prothrombin (FII) activity are classified as lupus anticoagulant-hypoprothrombinemia syndrome (LAHPS) and occasionally show bleeding symptoms, although this is not essential for diagnosis. We treated 20 cases of LAHPS over a 3-year period. Median FII activity was 20.9% and the anti-prothrombin antibody (anti-II Ab), shown by ELISA findings, was detected in 55%. Bleeding symptoms were observed in 20%, although that finding was not correlated with FII activity or anti-FII Ab quantity. We also observed 21 LA cases with decreased activity of coagulation factors other than FII, which we have designated LAHPS-like syndrome (LLS). Among LLS patients, anti-FII Ab and bleeding symptoms were seen in 47.6% and 14.3%, respectively. Our findings suggest that bleeding in LAHPS and LLS cannot be explained only by FII activity decreased by anti-FII Ab. Low FVIII activity and the anti-FVIII antibody (anti-FVIII Ab) were detected in some LAHPS and LLS patients, making it difficult to distinguish those from acquired hemophilia A cases. Detection of anti-FVIII Ab quantity by ELISA may be useful for accurate determination, as that was not performed in our LAHPS or LLS patients.
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37
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Kumano O, Ieko M. Determining the cut-off value of the APTT mixing test for factor VIII inhibitor: reply. Clin Chem Lab Med 2019; 57:e91-e93. [DOI: 10.1515/cclm-2019-0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 02/12/2019] [Indexed: 11/15/2022]
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38
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Fatal pulmonary embolism and pulmonary hemorrhage in lupus anticoagulant hypoprothrombinemia syndrome: a case report and review of literature. Blood Coagul Fibrinolysis 2018; 29:708-713. [PMID: 30300149 DOI: 10.1097/mbc.0000000000000776] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
: Lupus anticoagulant hypoprothrombinemia syndrome (LAHS) is a rare disorder characterized by development of lupus anticoagulant and antiprothrombin antibodies. The most common clinical manifestation is bleeding. Clinical management can be challenging due to the subtle balance between the bleeding and thrombotic tendencies. We report a novel case of LAHS in which the patient experienced the sequence of hemorrhage-thrombosis-hemorrhage before eventually dying of fatal pulmonary embolism and pulmonary hemorrhage. Specifically, she presented with multiple gastrointestinal bleeding episodes, followed by multifocal subdural hematomas, pulmonary embolism after normalization of prothrombin activity levels with immunosuppression, and finally with fatal pulmonary hemorrhage after enoxaparin treatment for pulmonary embolism. This case illustrates the importance of recognizing early minor bleeding episodes, and detecting specific antiprothrombin antibodies, in the diagnosis of LAHS. Furthermore, it highlights the complex challenge of normalizing prothrombin activity levels while at the same time preventing medical complications.
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39
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Pilania RK, Suri D, Jindal AK, Kumar N, Sharma A, Sharma P, Guleria S, Rawat A, Ahluwalia J, Singh S. Lupus anticoagulant hypoprothrombinemia syndrome associated with systemic lupus erythematosus in children: report of two cases and systematic review of the literature. Rheumatol Int 2018; 38:1933-1940. [PMID: 30099593 DOI: 10.1007/s00296-018-4127-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 08/06/2018] [Indexed: 12/13/2022]
Abstract
We report two children with systemic lupus erythematosus (SLE) having severe bleeding manifestations and lupus anticoagulant hypoprothrombinemia syndrome (LAHPS) along with a review of published cases of childhood SLE and LAHPS. We report clinical and laboratory profile of two children diagnosed with childhood SLE and LAHPS. We also conducted literature search to identify similar published cases and a review was performed. An 8-year-old girl had presented with fever, arthralgia, alopecia, anasarca and bleeding from multiple sites. She was diagnosed to have SLE based on laboratory investigations which showed anemia, thrombocytopenia, low complements, positive anti-nuclear antibody (ANA) and double standard DNA (dsDNA) antibodies. She was also found to have prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT), positive lupus anticoagulant (LA) and low factor II levels. She was diagnosed to have SLE with LAHPS and treated with intravenous methylprednisolone, intravenous immunoglobulin and cyclophosphamide with good outcome. Patient 2 was a 7-year-old-boy who was diagnosed to have SLE when he presented with fever, anasarca, malar rash, arthritis and bleeding from skin and mucosa. Laboratory investigations revealed anemia, proteinuria, low complements, positive ANA and anti-dsDNA titre. Coagulation studies showed deranged PT and aPTT, positive LA and low factor II levels. He was diagnosed to have SLE with LAHPS and was treated with intravenous methylprednisolone and oral mycophenolate mofetil. Review of literature of cases with childhood SLE and LAHPS showed that there are 32 cases have been reported till date which have been summarized. LAHPS is an uncommonly identified cause of bleeding in patients with SLE and must be suspected while evaluating these children.
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Affiliation(s)
- Rakesh Kumar Pilania
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Deepti Suri
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - Ankur Kumar Jindal
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Narender Kumar
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Avinash Sharma
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Praveen Sharma
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sandesh Guleria
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Amit Rawat
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Jasmina Ahluwalia
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
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40
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Lupus Anticoagulant-Hypoprothrombinemia Syndrome. Indian J Pediatr 2018; 85:392-393. [PMID: 29139061 DOI: 10.1007/s12098-017-2524-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 10/04/2017] [Indexed: 10/18/2022]
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41
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Lupus anticoagulant - hypoprothrombinemia syndrome: a rare cause of intracranial bleeding. Blood Coagul Fibrinolysis 2018; 28:416-418. [PMID: 28009646 DOI: 10.1097/mbc.0000000000000615] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: We report a 14-year-old girl who presented with subdural hematoma and a deranged coagulation profile suggestive of an inhibitor. Investigations revealed prothrombin deficiency along with positivity for antiphospholipid antibodies, which improved with steroid therapy. Bleeding diathesis in children and adolescents commonly results from thrombocytopenia, platelet function disorders, or coagulation factor deficiency; whereas bleeding because of coagulation factor inhibitors are extremely rare in this age group. This case also highlights the uncommon presentation of antiphospholipid antibody syndrome, as they often present with thrombosis or pregnancy complications rather than bleeding.
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42
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Cetin Gedik K, Siddique S, Aguiar CL. Rituximab use in pediatric lupus anticoagulant hypoprothrombinemia syndrome - report of three cases and review of the literature. Lupus 2018; 27:1190-1197. [PMID: 29320972 DOI: 10.1177/0961203317751853] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Lupus anticoagulant hypoprothrombinemia syndrome (LA-HPS) is a rare condition that may predispose both to thrombosis and bleeding due to positive lupus anticoagulant (LA) and factor II (FII) deficiency. It can be seen in association with infections or systemic lupus erythematosus (SLE) and may require glucocorticoids (GCs) and/or immunosuppressive medications. Pediatric LA-HPS cases in the literature and three cases that received only rituximab (RTX) for LA-HPS (in addition to GCs) at two institutions between January 2010 and June 2017 were analyzed descriptively. Pediatric LA-HPS cases (≤18 years) with bleeding or thrombotic events were included. Information obtained included demographics, presenting symptoms, diagnoses, treatments, pre-/post-treatment prothrombin time (PT)/partial thromboplastin time (PTT)/LA/FII levels, and outcomes. In addition to three LA-HPS cases identified at our institutions, as of June 2017, 37 articles reported 54 pediatric LA-HPS cases (mean age: 8 years (0.9-17 years); female/male: (2:1); viral illness 27 (50%), SLE 20 (37%), and other six (11%)). All cases had a positive LA and FII deficiency (range: 0%-40%). All cases presented with bleeding diathesis and were treated with various regimens, but there was no reported use of RTX. The purpose of this report is to describe the novel use of RTX as a steroid-sparing agent in three pediatric SLE cases and to systematically review the literature on pediatric cases of LA-HPS.
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Affiliation(s)
- K Cetin Gedik
- 1 Department of Pediatric Rheumatology, 25050 Steven and Alexandra Cohen Children's Medical Center , Lake Success, NY, USA
| | - S Siddique
- 2 Department of Pediatric Rheumatology, 25062 Hospital for Special Surgery -Weill Cornell Medical Center, New York, NY, USA
| | - C L Aguiar
- 3 Department of Pediatric Rheumatology, 20666 Children's Hospital of The King's Daughters , Norfolk, VA, USA
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43
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Foord A, Baca N, Buchbinder D, Mahajerin A. Lupus anticoagulant hypoprothrombinemia syndrome associated with severe thrombocytopenia in a child. Pediatr Blood Cancer 2017; 64. [PMID: 27862892 DOI: 10.1002/pbc.26357] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/07/2016] [Accepted: 10/12/2016] [Indexed: 01/19/2023]
Abstract
Lupus anticoagulant hypoprothrombinemia syndrome (LAHPS) comprises lupus anticoagulant, acquired hypoprothrombinemia, and often mild thrombocytopenia or normal platelets. It is usually associated with autoimmunity or postviral illness. We describe a case of a 10-year-old boy with oral bleeding and severe thrombocytopenia initially suggestive of immune thrombocytopenia. Secondary to bleeding, evaluation demonstrated prolonged coagulation tests and subsequently revealed the presence of lupus anticoagulant and hypoprothrombinemia, along with marked autoimmunity, suggestive of LAHPS. He was treated with intravenous immunoglobulin and hydroxychloroquine. This case report and discussion highlight the diagnostic and therapeutic challenges associated with LAHPS and coincident severe thrombocytopenia.
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Affiliation(s)
- Aimee Foord
- Hematology-Oncology Hospitalist Service, Division of Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Nicole Baca
- Division of Hematology/Oncology, CHOC Children's Hospital, Orange, California
| | - David Buchbinder
- Division of Hematology/Bone Marrow Transplant, CHOC Children's Hospital, Orange, California
| | - Arash Mahajerin
- Division of Hematology, CHOC Children's Hospital, Orange, California
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44
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Bel Feki N, Zayet S, Ben Ghorbel I, Houman MH. Lupus anticoagulant-hypoprothrombinemia syndrome presenting with co-existing cerebral venous thrombosis and subdural hemorrhage. JOURNAL DES MALADIES VASCULAIRES 2016; 41:403-406. [PMID: 27743753 DOI: 10.1016/j.jmv.2016.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 07/22/2016] [Indexed: 05/25/2023]
Abstract
The lupus anticoagulant-hypoprothrombinemia syndrome (LA-HPS) - the association of acquired factor II deficiency and lupus anticoagulant - is a rare disease that may cause a predisposition not only to thrombosis but also to severe bleeding. We are reporting on a 36-year-old female patient presenting with co-existing cerebral venous thrombosis and subdural hemorrhage. The coagulation screening showed a prolonged prothrombin time (PT), activated partial thromboplastin time (aPTT), and a normal fibrinogen level and platelet count. Evaluation of the clotting factors revealed decreased levels of factors II (37%). Factors V, VIII, IX and XI were normal. Lupus anticoagulant (LA) was demonstrated by the Dilute Russell's Viper Venom Test (DRVVT). Immunological work-up was positive for IgG type anticardiolipines antibodies (aCL). Successful management consisted first of oral prednisone (60mg/d). Thus, anticoagulation was introduced once factor II had stabilized.
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Affiliation(s)
- N Bel Feki
- Service de médecine interne, CHU La Rabta, Tunis, Tunisia.
| | - S Zayet
- Service des maladies infectieuses, CHU La Rabta, Tunis, Tunisia
| | - I Ben Ghorbel
- Service de médecine interne, CHU La Rabta, Tunis, Tunisia
| | - M-H Houman
- Service de médecine interne, CHU La Rabta, Tunis, Tunisia
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45
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Fatal hemorrhage due to a spontaneous factor V inhibitor with lupus anticoagulant properties. Blood Coagul Fibrinolysis 2016; 28:407-410. [PMID: 27676645 DOI: 10.1097/mbc.0000000000000603] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
: Factor V inhibitors are rare and have varied clinical presentations. We report on a 76-year-old female admitted to the hospital for pneumonia and treated with multiple antibiotics. Her baseline prothrombin time was 15.6 s and the activated partial thromboplastin time was 35 s. On admission day 10, she developed arm weakness and brain imaging showed a subdural hematoma. The prothrombin time was now 59.1 s with an activated partial thromboplastin time of more than 160 s and a normal thrombin time. A mixing study did not correct the clotting times and coagulation factor assays showed a nonspecific inhibition pattern. Only factor V activity remained low with serial dilutions, however, and a 70 Bethesda Unit inhibitor was identified. Aggressive supportive care was initiated but the patient succumbed to the effects of the intracranial hemorrhage. Factor V inhibitors may display lupus anticoagulant properties and may cause catastrophic bleeding. Our case illustrates that these inhibitors can arise quickly and supports an association with antibiotics.
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Kumano O, Ieko M, Naito S, Yoshida M, Takahashi N, Suzuki T, Komiyama Y. New formulas for mixing test to discriminate between lupus anticoagulant and acquired hemophilia A. Thromb Res 2016; 143:53-7. [PMID: 27182981 DOI: 10.1016/j.thromres.2016.05.004] [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] [Received: 12/25/2015] [Revised: 04/27/2016] [Accepted: 05/04/2016] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Lupus anticoagulant (LA) is an antibody that interferes with in vitro coagulation reactions. The mixing test is considered useful for LA diagnosis and is also recommended to differentiate between acquired hemophilia A (AHA) and factor deficiency. However, there has been little study to differentiate between LA and AHA. Our aims are to investigate whether we can differentiate LA and AHA by the mixing test and to establish new formulas for the mixing test to differentiate these samples clearly. MATERIALS AND METHODS We examined 27 LA-positive, 29 coagulation factor deficient, 24 unfractionated heparin and 48 AHA samples. Index of circulating anticoagulant (ICA) values, calculated from the clotting times without incubation and after 2h incubation, were defined as ICA immediate (ICAi) and ICA delayed (ICAd) respectively. ICAd/ICAi and ICAd-ICAi were also calculated to compare the sensitivity and specificity. RESULTS ICAd/ICAi and ICAd-ICAi for AHA samples were significantly higher than those of the other sample groups. The sensitivities to AHA in ICAi, ICAd, ICAd/ICAi and ICAd-ICAi were 66.7%, 81.3%, 93.8% and 91.7% respectively, while the specificities for AHA were 45.0%, 66.3%, 85.0% and 98.8% respectively. ICAd/ICAi and ICAd-ICAi showed high sensitivity and specificity. CONCLUSIONS ICAd/ICAi and ICAd-ICAi were useful for LA and AHA diagnosis, because these could differentiate between LA and AHA samples. These new formulas can contribute to the rapid diagnosis and treatment of LA and AHA.
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Affiliation(s)
- Osamu Kumano
- Department of Internal Medicine, School of Dentistry, Health Sciences University of Hokkaido, Ishikari-Tobetsu, Hokkaido, Japan; Hemostasis Product Engineering, Sysmex Corporation, Kobe, Hyogo, Japan
| | - Masahiro Ieko
- Department of Internal Medicine, School of Dentistry, Health Sciences University of Hokkaido, Ishikari-Tobetsu, Hokkaido, Japan.
| | - Sumiyoshi Naito
- Department of Clinical Laboratory, School of Dentistry, Health Sciences University of Hokkaido, Ishikari-Tobetsu, Hokkaido, Japan
| | - Mika Yoshida
- Department of Clinical Laboratory, School of Dentistry, Health Sciences University of Hokkaido, Ishikari-Tobetsu, Hokkaido, Japan
| | - Nobuhiko Takahashi
- Department of Internal Medicine, School of Dentistry, Health Sciences University of Hokkaido, Ishikari-Tobetsu, Hokkaido, Japan
| | - Takeshi Suzuki
- Department of Internal Medicine, School of Dentistry, Health Sciences University of Hokkaido, Ishikari-Tobetsu, Hokkaido, Japan; Hemostasis Product Engineering, Sysmex Corporation, Kobe, Hyogo, Japan
| | - Yutaka Komiyama
- Hemostasis Product Engineering, Sysmex Corporation, Kobe, Hyogo, Japan
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Hwang YE, Park HK, Yeom JS, Park JS, Park ES, Seo JH, Lim JY, Park CH, Woo HO, Youn HS. Lupus Anticoagulant-hypoprothrombinemia Syndrome that did not Progress to Systemic Lupus Erythematosus: A Case Report. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2015. [DOI: 10.15264/cpho.2015.22.2.155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Young Eun Hwang
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Heung Keun Park
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Jung-Sook Yeom
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ji Sook Park
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Eun Sil Park
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ji-Hyun Seo
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Jae Young Lim
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Chan-Hoo Park
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Hyang-Ok Woo
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Hee-Shang Youn
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
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Carreño-Tarragona G, Morales E, Jiménez-Herrero MC, Cortés-Fornieles E, Gutierrez E, Praga M. Lupus anticoagulant-hypoprothrombinemia syndrome: A rare association in systemic lupus erythematosus. Nefrologia 2015; 36:186-8. [PMID: 26306946 DOI: 10.1016/j.nefro.2015.05.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 05/25/2015] [Indexed: 10/23/2022] Open
Affiliation(s)
| | - Enrique Morales
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, España.
| | | | | | - Eduardo Gutierrez
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Manuel Praga
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, España
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