Acquired factor VIII deficiency in prostate adenocarcinoma presenting as multiple hematomas and hemarthrosis

Review of Potential Barriers to Effective Hemostatic Management of Acquired Hemophilia A by Non-Hemophilia Experts in the United States

Acquired hemophilia A (AHA) is an ultra-rare autoimmune disorder caused by autoantibodies against factor VIII. It often presents with life-threatening bleeding to non-hemophilia experts, who have limited awareness of this condition. This review evaluated hemostatic management and identified barriers to optimal management of AHA by non-hemophilia experts in the United States through a literature review. AHA case reports published by non-hemophilia experts from January 2016 through November 2021 in non-hematology journals were critically reviewed for a chronology of clinical course and management, consultation with a hemophilia expert, referencing of available AHA recommendations, discussion of all hemostatic options, and bleed control outcomes; 24 case reports representing 24 patients were identified. Twelve patients had an apparent delay in diagnosis, 17 cases did not seek expert consultation, and 15 did not reference the 2009 International AHA Recommendations, including six in whom hemostatic treatment was not consistent with the recommendations. Of the 17 articles published after the 2017 AHA Guidance, eight did not reference them. Of the five articles published after the 2020 International Recommendations for AHA, three did not reference them. Overall, 14 articles did not discuss all available hemostatic treatment options. Four patients died. Our findings reveal variability in hemostatic management of AHA by non-hemophilia experts in the United States. Lack of AHA awareness remains a primary barrier for optimal management of AHA among non-hemophilia experts. Increasing education about existing AHA guidelines, including available therapies and access to expert care at hemophilia treatment centers, may help improve the outcomes of patients with AHA.

"Accessory After the Factors": A Rare Case of an Acquired Factor VIII Inhibitor in a 75-Year-Old Man on Rivaroxaban

Direct oral anticoagulants (DOACs) are used to treat several conditions such as non-valvular atrial fibrillation, deep vein thrombosis, and pulmonary embolism. DOACs and other anticoagulants block crucial steps in the coagulation cascade and ultimately prevent clot formation. Generally, individuals initiated on an anticoagulant are predisposed to or have a propensity to form clots. Patients with hemophilia are given anticoagulants only in very rare cases. In this report, we discuss the case of a 75-year-old man with a history of atrial fibrillation managed on rivaroxaban; he presented to the emergency department with fatigue, easy bleeding, symptomatic anemia, and significantly elevated partial thromboplastin time (PTT) with an undiagnosed acquired factor VIII inhibitor. Reports of DOAC use and concomitant factor inhibitor autoimmunization, as seen in this case, are scarcely explored in the existing literature. While DOACs are popular anticoagulants, their variable effects on both prothrombin time (PT) and PTT make it difficult to detect superimposed bleeding disorders. In patients with severe anemia or significant elevations in PT or PTT, an expedited workup, including factor assays, may be a reasonable option as evidenced by this case.

An incidental latent adult hemophilia case found after a tonsillectomy

Severe bleeding after a tonsillectomy may cause airway obstruction and be life-threatening. We report post-tonsillectomy bleeding in a 32-year-old patient with hemophilia A, who had not been aware of his disease for more than 30 years. He underwent tonsillectomy for recurrent tonsillitis. He denied episodes of bleeding tendency. The preoperative workup was normal, including platelet count, prothrombin time, and activated partial thromboplastin time. The surgery itself was uneventful, but severe bleeding from the inferior pole of the tonsillar bed developed 7 days after surgery. Emergency hemostasis was performed under general anesthesia in the operating room. The patient then remembered several episodes of bleeding tendency. Coagulation tests revealed a mild lack of coagulation factor VIII to 35%, and a diagnosis of hemophilia A was made. Hemophilia might only be found after surgery and can cause life-threatening complications. However, latent hemophilia detected after a tonsillectomy in a 32-year-old adult is very rare. A careful history of bleeding tendency is important to achieve a diagnosis of coagulopathy, perform a safer surgery, and prevent postoperative complications.