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Mouliou DS. C-Reactive Protein: Pathophysiology, Diagnosis, False Test Results and a Novel Diagnostic Algorithm for Clinicians. Diseases 2023; 11:132. [PMID: 37873776 PMCID: PMC10594506 DOI: 10.3390/diseases11040132] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/15/2023] [Accepted: 09/19/2023] [Indexed: 10/25/2023] Open
Abstract
The current literature provides a body of evidence on C-Reactive Protein (CRP) and its potential role in inflammation. However, most pieces of evidence are sparse and controversial. This critical state-of-the-art monography provides all the crucial data on the potential biochemical properties of the protein, along with further evidence on its potential pathobiology, both for its pentameric and monomeric forms, including information for its ligands as well as the possible function of autoantibodies against the protein. Furthermore, the current evidence on its potential utility as a biomarker of various diseases is presented, of all cardiovascular, respiratory, hepatobiliary, gastrointestinal, pancreatic, renal, gynecological, andrological, dental, oral, otorhinolaryngological, ophthalmological, dermatological, musculoskeletal, neurological, mental, splenic, thyroid conditions, as well as infections, autoimmune-supposed conditions and neoplasms, including other possible factors that have been linked with elevated concentrations of that protein. Moreover, data on molecular diagnostics on CRP are discussed, and possible etiologies of false test results are highlighted. Additionally, this review evaluates all current pieces of evidence on CRP and systemic inflammation, and highlights future goals. Finally, a novel diagnostic algorithm to carefully assess the CRP level for a precise diagnosis of a medical condition is illustrated.
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Shah S, Tseng M, Durojaiye A. A Rare Case of Acquired Factor VIII Deficiency in an Elderly Male With a History of Rheumatoid Arthritis. Cureus 2023; 15:e44169. [PMID: 37753049 PMCID: PMC10519439 DOI: 10.7759/cureus.44169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 09/28/2023] Open
Abstract
Acquired hemophilia A (AHA) or factor VIII (FVIII) deficiency is caused by autoantibodies targeting FVIII in the blood coagulation pathway; it is a rare condition making it challenging to diagnose. A timely diagnosis is crucial, without which there is a risk of catastrophic bleeding. We report a case of a patient with a history of duodenal arteriovenous malformations, previously on apixaban, who presented with four days of melena. On admission he was found to have a hemoglobin of 5.7 and elevated partial thromboplastin time (PTT), promoting further workup showing FVIII levels of <1%, with a mixing study that failed to correct suggesting the presence of inhibitors against FVIII. Other characteristics of this patient's cases included controlled rheumatoid arthritis without detectable rheumatoid factor or increased erythrocyte sedimentation rate (ESR). The patient was initially treated with prednisone and intravenous immunoglobulins, but an insufficient response prompted the initiation of recombinant factor VII, rituximab, and cyclophosphamide during hospitalization.
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Affiliation(s)
- Shubhangi Shah
- Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, USA
| | - Michael Tseng
- Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, USA
| | - Ashimiyu Durojaiye
- Hematology and Medical Oncology, Virginia Commonwealth University School of Medicine, Richmond, USA
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Heo HJ, Kim YY, Lee JH, Cho HG, Kim G. Severe pancytopenia and coagulopathy discovered during anesthesia after pre-anesthetic evaluation - A report of two cases. Anesth Pain Med (Seoul) 2023; 18:92-96. [PMID: 36746908 PMCID: PMC9902639 DOI: 10.17085/apm.22236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/04/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Pre-anesthetic evaluation is an important aspect of perioperative patient management. However, anesthesiologists often encounter challenges during anesthesia due toconditions that are not detected during pre-anesthetic evaluations. CASE Case 1 involved a 74-year-old female patient scheduled for cranioplasty and meningioma excision. Severe pancytopenia was detected during anesthesia. Cranioplasty was onlyperformed, the surgery was terminated, and drug-induced pancytopenia was diagnosed andtreated. The pre-anesthetic test results were normal, except for anemia. Case 2 involved a71-year-old male patient who discovered large ecchymosis during general anesthesia preparation in the operating room for choledochal cyst surgery. Surgery was canceled to evaluatethe bleeding tendency, and acquired coagulation factor VIII deficiency was diagnosed andtreated. The pre-anesthetic tests were normal, except for prolongation of the activated partial thromboplastin time. CONCLUSIONS Abrupt hematologic and hemostatic changes may occur during anesthesiaeven though pre-anesthetic evaluation findings are normal.
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Affiliation(s)
- Hyun Joo Heo
- Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Yu Yil Kim
- Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, Jeonju, Korea,Corresponding author Yu Yil Kim, M.D. Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, 365 Seowon-ro, Wansan-gu, Jeonju 54987, Korea Tel: 82-63-230-1591 Fax: 82-63-230-8919 E-mail:
| | - Ji Hye Lee
- Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Hyung Gu Cho
- Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Geonbo Kim
- Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, Jeonju, Korea
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Tang Q, Liao J, Xie X. Acquired Hemophilia Associated with Rheumatic Diseases: A Case-Based Systematic Review. J Inflamm Res 2022; 15:4385-4393. [PMID: 35945991 PMCID: PMC9357396 DOI: 10.2147/jir.s369288] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/19/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Qi Tang
- Department of Rheumatology and Immunology, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Jiafen Liao
- Department of Rheumatology and Immunology, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Xi Xie
- Department of Rheumatology and Immunology, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Correspondence: Xi Xie, Department of Rheumatology and Immunology, the Second Xiangya Hospital, Central South University, Changsha, 410011, People’s Republic of China, Tel/Fax +86 0731 8529 5255, Email
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Marques Dias JI, Ferreira MA, Grilo A, Reis AI. Acquired haemophilia A associated to autoimmune thyroiditis and pangastritis. BMJ Case Rep 2022; 15:e248701. [PMID: 35396240 PMCID: PMC8995960 DOI: 10.1136/bcr-2021-248701] [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] [Accepted: 03/21/2022] [Indexed: 11/04/2022] Open
Abstract
Acquired haemophilia A is a rare condition defined by the presence of coagulation inhibitors, which are autoantibodies directed against factor VIII that interfere with its activity. We report a case of a 69-year-old woman that presented with knee haemarthrosis followed by spontaneous retroperitoneal haematoma. On coagulation studies, she presented normal prothrombin time with prolonged activated partial thromboplastin time non-correcting on mixture test, low titers of factor VIII and was detected factor VIII inhibitor that led to diagnosis of acquired haemophilia A. She was managed with supportive measures to control haemorrhage and immunosuppressive therapy to eradicate inhibitors, initially with corticosteroids, with partial transitory response, after which she developed new spontaneous haematomas. Rituximab was started at that time, with a good outcome. The additional aetiological study identified autoimmune thyroiditis and autoimmune pangastritis, an association rarely described in literature.
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Affiliation(s)
| | | | - Ana Grilo
- Internal Medicine, Hospital Beatriz Angelo, Loures, Lisboa, Portugal
| | - Ana Isabel Reis
- Internal Medicine, Hospital Beatriz Angelo, Loures, Lisboa, Portugal
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Acquired Factor VIII Deficiency Presenting as Gross Hematuria in a Hispanic, Pregnant Patient with Previously Undiagnosed Connective Tissue Disease. Case Rep Rheumatol 2021; 2021:3666270. [PMID: 34840848 PMCID: PMC8612772 DOI: 10.1155/2021/3666270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 10/18/2021] [Accepted: 11/01/2021] [Indexed: 11/17/2022] Open
Abstract
Acquired factor VIII deficiency is a bleeding disorder caused by the presence of autoantibodies against clotting factor VIII. We report a case of a 24-year-old pregnant woman who presented with gross hematuria secondary to acquired factor VIII deficiency in the presence of a previously undiagnosed connective tissue disease. This article includes a literature review of pregnancy-related cases of acquired factor VIII deficiency. We also reviewed various therapeutic approaches for the management of the acquired factor inhibitor which include achieving hemostasis and elimination of the inhibitor via immunosuppressive agents. This case report describes the rare presentation of acquired factor VIII deficiency related to pregnancy and highlights the importance of considering a factor VIII inhibitor in the differential diagnosis of patients who present with bleeding and prolonged PTT during the peripartum and postpartum periods.
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Cameron H, Perez Botero J. Recognition of the unique bleeding pattern and laboratory findings in acquired haemophilia A facilitates prompt treatment of a life-threatening disorder. BMJ Case Rep 2021; 14:14/8/e244238. [PMID: 34344656 PMCID: PMC8336148 DOI: 10.1136/bcr-2021-244238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Acquired haemophilia A (AHA) is an uncommon but severe acquired bleeding disorder caused by the development of antibodies against clotting factor VIII, impairing secondary haemostasis. It is more common in older individuals and characteristically presents with spontaneous soft tissue bleeding that can rapidly become life-threatening. Definitive treatment requires immunosuppression to eradicate anti-FVIII antibodies, while providing haemostatic support to manage bleeding. Transfusions of fresh frozen plasma or cryoprecipitate, typically used to treat severe bleeding, are ineffective in patients with AHA. Instead, highly specialised clotting factor concentrates are required. While the appearance and extent of the soft tissue bleeding and the markedly prolonged activated partial thromboplastin time are characteristic, lack of familiarity with this disease process can lead to significant treatment delays. We report the clinical course and management of a 65-year-old woman who presented with severe anaemia of unclear aetiology with unrecognised soft tissue bleeding who was subsequently diagnosed with AHA.
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Affiliation(s)
- Hunter Cameron
- School of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Juliana Perez Botero
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA .,Versiti, Milwaukee, Wisconsin, USA
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Cao XY, Li MT, Zhang X, Zhao Y, Zeng XF, Zhang FC, Hou Y, Zhu LX. Characteristics of Acquired Inhibitors to Factor VIII and Von Willebrand Factor Secondary to Systemic Lupus Erythematosus: Experiences From a Chinese Tertiary Medical Center. J Clin Rheumatol 2021; 27:201-205. [PMID: 31815811 PMCID: PMC8300847 DOI: 10.1097/rhu.0000000000001284] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Because acquired hemophilia (AH) is a rare entity in systemic lupus erythematosus (SLE), we aimed to investigate the clinical features of SLE-related AH in Chinese patients. METHODS This is a medical records review study carried out at a large tertiary care hospital in China from years 1986 to 2018. We searched the case database in Peking Union Medical College Hospital using the International Classification of Diseases. The clinical data on SLE-related AH patients were collected. RESULTS A total of 9282 SLE patients had been hospitalized. Six female SLE-related AH patients were identified. Four patients had acquired hemophilia A (AHA), and 2 patients had acquired von Willebrand syndrome. Their mean age was 33.67 ± 13.77 years. Five patients had active disease. The mean SLE disease activity index measured at the time of diagnosis of AH was 10.50 ± 5.28. The average level of activated partial thromboplastin time was 86.5 seconds. Coexistence of secondary antiphospholipid syndrome and AHA was found in one case, and pulmonary embolism was observed 3 years later. After immunosuppressive therapy and symptomatic treatment, an overall remission rate of 83.3% was achieved. CONCLUSIONS The frequency of SLE-related AH was low. The development of AH in SLE patients frequently occurs with active disease. The AH could be the first clinical presentation of SLE. Secondary antiphospholipid syndrome and AHA could appear in the same SLE patient. Early and aggressive treatment contributes to a favorable prognosis.
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Affiliation(s)
- Xiao-Yu Cao
- From the Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Graduate School of Peking Union Medical College, Beijing
| | - Meng-Tao Li
- From the Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Graduate School of Peking Union Medical College, Beijing
| | - Xuan Zhang
- From the Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Graduate School of Peking Union Medical College, Beijing
| | - Yan Zhao
- From the Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Graduate School of Peking Union Medical College, Beijing
| | - Xiao-Feng Zeng
- From the Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Graduate School of Peking Union Medical College, Beijing
| | - Feng-Chun Zhang
- From the Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Graduate School of Peking Union Medical College, Beijing
| | - Yong Hou
- From the Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Graduate School of Peking Union Medical College, Beijing
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Li YC, Wang R, Xu H, Ding LP, Ge WH. Anticoagulation Resumption in a Patient With Mechanical Heart Valves, Antithrombin Deficiency, and Hemorrhagic Transformation Following Thrombectomy After Ischemic Stroke. Front Pharmacol 2020; 11:549253. [PMID: 33390937 PMCID: PMC7772403 DOI: 10.3389/fphar.2020.549253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 10/16/2020] [Indexed: 11/26/2022] Open
Abstract
Anticoagulation is essential for patients undergoing mechanical heart valve replacement; however, the timing to reinitiate the anticoagulant could be a dilemma that imposes increased risk for bleeding events in patients suffering from the life-threatening hemorrhagic transformation (HT) after ischemic stroke. Such a situation was presented in this case report. A 71-year-old woman was transferred directly to the Neurocritical Care Unit because of a HT that occurred following the mechanical thrombectomy for ischemic stroke. Since she had a history of prosthetic metallic valve replacement, how the anticoagulating therapy could balance the hemorrhagic and thrombotic risks was carefully evaluated. On day 6 after the onset of hemorrhage transformation, the laboratory results of coagulation and fibrinolysis strongly suggested thrombosis as well as antithrombin deficiency. The short-acting and titratable anticoagulant argatroban was immediately initiated at low dose, and thrombosis was temporarily terminated. On day 3 of anticoagulation resumption, argatroban was discontinued for one dose when the prothrombin time and activated partial thromboplastin time significantly prolonged after argatroban infusion. Aortic valve thrombosis was detected the next day. The anticoagulation was then strengthened by dose adjustment to keep mitral valve intact, to stabilize the aortic valve thrombosis, and to decrease the aortic flow rate. The intravenous argatroban was transited to oral warfarin before the patient was discharged. This study is the first report of administering argatroban and titrating to its appropriate dose in the patient with valve thrombosis, antithrombin deficiency, and HT after mechanical thrombectomy for acute ischemic stroke. Notably, the fluctuations argatroban brings to the coagulation test results might not be interpreted as increased bleeding risk. This case also suggested that the reported timing (day 6 to day 14 after hemorrhage) of anticoagulant resumption in primary intracerebral hemorrhage with mechanical valves might be late for some patients with HT.
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Affiliation(s)
- Yi-Chen Li
- Department of Pharmacy, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China.,Department of Neurosurgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
| | - Rong Wang
- Department of Neurosurgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
| | - Hang Xu
- Department of Pharmacy, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China.,Department of Cardio-Thoracic Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
| | - Lan-Ping Ding
- Department of Pharmacy, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China.,Department of Neurosurgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China.,Department of Pharmacy, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wei-Hong Ge
- Department of Pharmacy, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
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Cinotti E, Trovato E, Fimiani M, Rubegni P. Acquired a haemophilia: a case report. J Eur Acad Dermatol Venereol 2017; 32:e106-e107. [PMID: 28924993 DOI: 10.1111/jdv.14592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- E Cinotti
- Department of Medical, Surgical, and Neurological Science, Dermatology Section, University of Siena, S Maria alle Scotte Hospital, Siena, Italy
| | - E Trovato
- Department of Medical, Surgical, and Neurological Science, Dermatology Section, University of Siena, S Maria alle Scotte Hospital, Siena, Italy
| | - M Fimiani
- Department of Medical, Surgical, and Neurological Science, Dermatology Section, University of Siena, S Maria alle Scotte Hospital, Siena, Italy
| | - P Rubegni
- Department of Medical, Surgical, and Neurological Science, Dermatology Section, University of Siena, S Maria alle Scotte Hospital, Siena, Italy
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