Mixing Studies in Patients With Prolonged Activated Partial Thromboplastin Time or Prothrombin Time

Extensive ecchymosis and retroperitoneal hemorrhage due to acquired hemophilia-A following influenza vaccination: A case report

INTRODUCTION

Acquired hemophilia-A (AHA) is a rare but potentially life-threatening impaired coagulation disorder characterized by the development of autoantibodies against clotting factor VIII. Only a few case reports have been experienced with influenza vaccine-triggered AHA. Here, we report a case of severe hemorrhagic disorder due to AHA following influenza vaccine, which was successfully treated.

PATIENT CONCERNS

The patient presented to the emergency department because of several severe, progressively worsening bruises after receiving the influenza vaccination. Consequently, the patient required intubation due to nasal-oral bleeding, which compromised the airway, and retroperitoneal hemorrhage with shock also developed.

DIAGNOSIS

AHA was confirmed through a coagulation factor assay, including coagulation activity and antibody testing, which is possibly triggered by influenza vaccination.

INTERVENTION

Low-dose cyclophosphamide and hydrocortisone were prescribed until activated partial thromboplastin time showed normal levels. Coagulation factor VIIa was administered, and aggressive blood transfusion was carried out concurrently to address the blood loss.

OUTCOMES

The upper airway bleeding subsided and bleeding tendencies had been corrected to normal. The patient was smoothly weaned from the ventilator and recovered from critical illness. She was then discharged on the 19th day.

LESSONS

The activated partial thromboplastin time mixing test can be performed immediately to establish the initial differential diagnosis and treatment plan for severe coagulopathy. AHA may be triggered by vaccination, with the hypothesis of activation of autoantibodies and molecular mimicry; this mechanism should be further studied.

Prolonged coagulation times in severe fever with thrombocytopenia syndrome virus infection, the indicators of heparin-like effect and increased haemorrhagic risk

Prolonged coagulation times, such as activated partial thromboplastin time (APTT) and thrombin time (TT), are common in patients infected with severe fever with thrombocytopenia syndrome virus (SFTSV) and have been confirmed to be related to patient's poor outcome by previous studies. To find out the reason for prolonged coagulation time in patients with SFTSV infection, and whether it predicts haemorrhagic risk or not. Seventy-eight consecutive patients with confirmed SFTSV infection were enrolled in this prospective, single-centre, observational study. Several global and specific coagulation parameters of these patients on admission were detected, and the haemorrhagic events during hospitalization and their outcomes were recorded. Most of the enrolled patients had prolonged APTT (82.1%) and TT (80.8%), normal prothrombin time (83.3%) and intrinsic coagulation factors above haemostatic levels (97.4%). The heparin-like effect was confirmed by a protamine neutralization test and anti-Xa activity detection in most patients. Interestingly, the APTT and TT results were significantly positively correlated with the levels of endothelial markers and viral load, respectively. The APTT was independently associated with the haemorrhage of patients. The prolonged APTT and TT of SFTS patients may mainly be attributed to endogenous heparinoids and are associated with increased haemorrhagic risk.

Isolated Prolongation of Activated Partial Thromboplastin Time: Not Just Bleeding Risk!

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.

"Familial Multiple Coagulation Factor Deficiencies of FXI and FXII in an Asymptomatic Saudi Woman"

Factor XI deficiency (FXI) is the third most common coagulation factor deficiency after hemophilia A and B, ie, in the hierarchy after factors VIII and IX, taking into account von Willebrand's factor deficiency, as bleeding disorders are higher than in hemophilia C. Factor XII deficiency (FXII) is a congenital condition, inherited in the vast majority of cases in an autosomal recessive manner, more often associated with thromboembolic complications. A combination of both factor deficiencies has been found very rarely, and it can be familial multiple coagulation factor deficiency (FMCFD). This study reports the case of a 39-year-old woman from Saudi Arabia who had the combination of FXI and FXII deficiencies, known to be on treatment for hypothyroidism and was referred to a hematology clinic with an incidental finding of prolonged activated partial thromboplastin time (aPTT). Although there was no history of bleeding tendency, her siblings had a family history of an unknown type of bleeding disorder. On physical examination, the patient did not show any bruising, petechiae, or ecchymosis. The aPTT was 69 seconds (27-38) with normal use of other hemostatic agents and was corrected after a 50:50 mixing study. Intrinsic coagulation factors were evaluated, and they revealed severe FXI and moderate FXII deficiencies. Due to a strong family history, the patient was diagnosed with FMCFD. In conclusion, familial combined multiple clotting factor deficiency (FCMFD) is a rare condition that requires attention and reporting. The management strategy in such cases has not been well studied, especially in the long-term symptomatic patient with severe but asymptomatic combined FXI and FXII deficiencies, which is an area for review and further study.

Bleeding After Central Venous Catheter Placement in a Patient With Undiagnosed Acquired Hemophilia A: A Case Report

Acquired hemophilia A is a rare condition caused by autoantibodies against endogenous coagulation factor VIII, which results in spontaneous bleeding. Workup of a patient with difficult hemostasis after removing and placing a central venous catheter led to the diagnosis of acquired hemophilia A.

A 64-year-old man was transferred with an intramuscular right thigh mass. Initial biopsy at an outside facility showed degenerated muscle and coagula and he was transferred for incisional biopsy and definitive treatment. The patient had difficult venous access, and a right internal jugular venous catheter was placed. The catheter insertion site showed slow continuous bleeding. Achieving adequate hemostasis after removing the catheter was difficult, and a hematoma formed after the placement of an infraclavicular axillary venous catheter under ultrasound guidance. Coagulation studies revealed a prolonged activated partial thromboplastin time at 96 seconds. The patient was then diagnosed with acquired hemophilia A by enzyme-linked immunosorbent assay using anti-factor VIII antibodies.

Even if ultrasound-guided central venous catheterization is performed carefully, bleeding may occur in some patients, suggesting the possibility of coagulopathy. Decision-making for performing central venous catheterization requires extensive knowledge of coagulopathies to understand the causes of bleeding complications.

Preparation of Chitosan/Clay Composites for Safe and Effective Hemorrhage Control

Uncontrolled hemorrhage from trauma or surgery can lead to death. In this study, chitosan/kaolin (CSK) and chitosan/montmorillonite (CSMMT) composites were prepared from chitosan (CS), kaolin (K), and montmorillonite (MMT) as raw materials to control bleeding. The physiochemical properties and surface morphology of CSK and CSMMT composites were analyzed by Fourier transform infrared spectrometry (FT-IR), X-ray diffraction (XRD), scanning electron microscopy (SEM), zeta potentials, and X-ray fluorescence (XRF). The hemostatic mechanism was measured in vitro by activated partial thromboplastin time (APTT), prothrombin time (PT), in vitro clotting time, erythrocyte aggregation, and thromboelastogram (TEG). The hemostasis ability was further verified by using tail amputation and arteriovenous injury models in rats. The biocompatibility of CSK and CSMMT was evaluated by in vitro hemolysis, cytotoxicity assays, as well as acute toxicity test and skin irritation tests. The results show that CSK and CSMMT are promising composite materials with excellent biocompatibility and hemostatic properties that can effectively control bleeding.

Evaluation of Novel Tranexamic Acid/Montmorillonite Intercalation Composite, as a New Type of Hemostatic Material

Radiation enteritis-clinically manifested as diarrhea, intestinal bleeding, and so on-is frequently caused when the body is exposed to radiation or radiotherapy because the intestine is radiation-sensitive as an abdominal organ. Therefore, strategies to modulate intestinal hemostasis had inspired an important research trend in the process of preventing and treating radiation enteritis. Based on the structural characteristics of montmorillonite (MMT) and the hemostatic drug tranexamic acid (TXA) which was used clinically to treat enteritis, the tranexamic acid-montmorillonite composite material (TXA-MMT) was prepared through intercalation composite technology. According to the analysis of FTIR, XRD, TG-DTG, SEM, and XRF, the prepared TXA-MMT was verified that tranexamic acid could intercalate into layers of montmorillonite. To evaluate the biocompatibility, two experiments were conducted by in vitro hemolysis and in vitro cytotoxicity experiments and results showed that TXA-MMT exhibited good visible biocompatibility. Activated partial thromboplastin time, prothrombin time, and in vitro clotting time were adopted to determine the hemostatic effect of TXA-MMT. Compared with other groups, TXA-MMT revealed a significant decrease in clotting time variations, APTT, and PT. In addition, to investigate the preventive effect of TXA-MMT by the intervention of radiation enteritis mice, inflammatory factors IL-1β, IL-6, and TNF-α and the content of endotoxin in the serum of mice were detected. It demonstrated that TXA-MMT reduced the levels of these factors. Besides, the expression and the pathological changes of the small intestine tissue of mice were relieved. Our findings suggests that TXA-MMT as a promising intercalation composite has a great potential for application in the field of intestinal hemostasis.

Endothelium, Platelets, and Coagulation Factors as the Three Vital Components for Diagnosing Bleeding Disorders: A Simplified Perspective with Clinical Relevance

Bleeding disorders are a major group of hematological disorders, which are highly prevalent in the world. Excessive bleeding can result in serious consequences including hypoperfusion and cardiac arrest. The body has its selfmechanism to control excessive bleeding which is termed hemostasis. Hemostasis is achieved in two major steps, the formation of the primary and secondary hemostatic plugs. Endothelium, platelets, and coagulation factors are three components involved in hemostasis. Endothelium and platelets have a major role in forming the primary hemostatic plug. Consequently, the first step in investigating a bleeding disorder is platelet count. Despite normal platelet count, abnormality in the primary hemostatic plug may arise due to functional defects of the platelets including adhesion, activation, and aggregation. Von Willebrand disease (VWD) is an endothelial defect and the most prevalent inherited defect in coagulation. Abnormalities in the secondary hemostatic plug are largely due to coagulation factor deficiencies, and, to a lesser extent, the presence of inhibitors. Techniques involving viscoelastics have been aiding in rapid diagnosis and are useful in point-of-care testing. This article discusses the investigation of bleeding disorders from the perspective of the endothelium, platelet, and coagulation factor physiology. These three components should be properly investigated to achieve the definitive diagnosis of bleeding disorders.

The Prevalence of Coagulopathy and Associated Factors Among Adult Type II Diabetes Mellitus Patients Attending the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia

INTRODUCTION

Diabetes mellitus is a heterogeneous disorder of metabolism which results hyperglycemic-related atherothrombotic complications. These complications are the leading cause of death in diabetes mellitus patients. Therefore, this study was aimed to determine the prevalence of coagulopathy and associated factors among adult type II diabetes mellitus patients attending at University of Gondar comprehensive specialized hospital.

METHODS

A facility-based cross-sectional study was conducted among 357 study participants. A questionnaire and a data collection sheet were used to collect the sociodemographic and clinical data, respectively. About 6mL of venous blood samples were collected for coagulation tests and complete blood count. For prolonged coagulation tests, a mixing test was performed. Data were entered into EpiInfo and exported to SPSS for statistical analysis. Then, descriptive statistics were done. A binary and multivariable logistic regression model was used to identify the associated factors. P-value <0.05 was considered as statistically significant.

RESULTS

In this study, 357 study participants were included. Of them, 52.1% (186) and 80.7% (288) were females and urban residences, respectively. The prevalence of coagulopathy was 26.6% (95% CI: 22.1, 31.5%). Out of this, 12.3% and 8.7% showed shortened PT and aPTT, respectively. In addition, the prevalence of prolonged PT and aPTT were 5.6% and 3.9%, respectively. From the prolonged PT and aPTT, the prevalence of factor deficiency was 95% and 92.8%, respectively. Being female (AOR = 2.06; 95% CI: 1.11-3.85%), abnormal BMI (AOR = 1.94; 95% CI: 1.08-3.50), and educational status of high school (AOR = 0.26; 95% CI: 0.10-0.83%) were significantly associated with hypercoagulation.

CONCLUSION

Coagulopathy is an important public health problem among type II diabetes mellitus patients. Being female and having abnormal BMI were associated with hypercoagulation. Therefore, regular monitoring of coagulation parameters is vital to reduce the consequence of coagulopathy.

Could a Haematoma Be Due to an Acquired Phenomenon?

Acquired hemophilia, as opposed to congenital hemophilia, develops in individuals with no previous history of bleeding disorder with almost similar numbers of males and females affected. It is predominantly a disease of the elderly. It is an autoimmune disorder and occurs when the immune system produces antibodies that mistakenly attack healthy tissue, specifically the clotting factors, in particular clotting factor VIII. As a result, affected individuals develop abnormal uncontrolled bleeding into the muscles, soft tissues, and the skin and it can occur spontaneously during surgery, or following trauma, and potentially cause life-threatening bleeding complications in severe cases. The affected individuals may remain undiagnosed or be misdiagnosed, making it difficult to determine the actual frequency of the disorder in the general population. The clinical presentation should suspect it with confirmation by an abnormal coagulation test. Typical laboratory results with a recent onset of abnormal bleeding and an isolated prolongation of the activated partial thromboplastin time (APTT), especially in the elderly and peri- and post-partum women, should raise eyebrows. We present two cases following different symptomatology and emphasize the clinical challenges for junior medical doctors who receive patients on the front end. We hope to emphasize understanding simple coagulation blood results followed by a meaningful discussion with the hematology team towards appropriate and timely management of the bleeding diathesis. We hope this case series report will help junior medical doctors manage patients appropriately and consult with their hematology colleagues.

Current therapeutic approaches in the management of hemophilia-a consensus view by the Romanian Society of Hematology

Hemophilia A (HA) and hemophilia B (HB) are rare disorders, being caused by the total lack or under-expression of two factors from the coagulation cascade coded by genes of the X chromosome. Thus, in hemophilic patients, the blood does not clot properly. This results in spontaneous bleeding episodes after an injury or surgical intervention. A patient-centered regimen is considered optimal. Age, pharmacokinetics, bleeding phenotype, joint status, adherence, physical activity, personal goals are all factors that should be considered when individualizing therapy. In the past 10 years, many innovations in the diagnostic and treatment options were presented as being either approved or in development, thus helping clinicians to improve the standard-of-care for patients with hemophilia. Recombinant factors still remain the standard of care in hemophilia, however they pose a challenge to treatment adherence because they have short half-life, which where the extended half-life (EHL) factors come with the solution, increasing the half-life to 96 hours. Gene therapies have a promising future with proven beneficial effects in clinical trials. We present and critically analyze in the current manuscript the pros and cons of all the major discoveries in the diagnosis and treatment of HA and HB, as well as identify key areas of hemophilia research where improvements are needed.

Unexpected, isolated activated partial thromboplastin time prolongation: A practical mini-review

A common inquiry in coagulation laboratories is how to interpret an unexpected, isolated prolonged activated partial thromboplastin time (APTT). In this context, isolated means together with a normal prothrombin time (PT) and/or normal international normalized ratio (INR). This finding may lead to contact with laboratory doctors for further advice on a diagnostic strategy. Occasionally, the need for a diagnostic algorithm can be subacute, where surgery has to be postponed until an explanation for the isolated, prolonged APTT has been established. Activated partial thromboplastin time as a coagulation test was developed to monitor patients with hemophilia. Different APTT reagents display considerable differences in their sensitivity to deficiencies of coagulation factors. An isolated, prolonged APTT is seen in (a) individuals/patients with lupus anticoagulants, (b) patients in treatment with anticoagulants, mainly heparin, and (c) patients with deficiencies of specific coagulation factors. In this tutorial review, we summarize what may cause an isolated prolonged APTT and we present a simple diagnostic algorithm to differentiate between lupus anticoagulants (common) and factor deficiencies (rare). The identification of an isolated prolonged APTT as well as the underlying cause can be of the utmost importance in ensuring the correct therapeutic follow-up.

Intestinal necrosis caused by acute mesenteric ischemia associated with pregnancy: A case report and literature review

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Acute mesenteric ischemia associated with pregnancy is a rare pathology that is difficult to treat.

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Acute mesenteric ischemia can be caused by a venous thrombosis associated with gestation.

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Acute mesenteric ischemia should be considered in pregnant woman.

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Patient with intense intestinal necrosis, need a intestinal resection which would cause a short bowel syndrome.

Introduction

Mesenteric ischaemia associated with pregnancy is a rare disease with a high mortality rate and its prognosis depends on the time passing between diagnosis and final management.

Presentation of case

A 38-year-old Peruvian woman developed intestinal necrosis during week 35 of her pregnancy because of mesenteric ischaemia associated with her pregnancy.

Discussion

Given the findings of extensive intestinal necrosis, surgical resection was performed, causing short bowel syndrome. Histopathological analysis confirmed that the immediate cause of the patient’s ischaemia was venous thrombosis associated with her gestation.

Conclusion

Acute mesenteric ischaemia should be considered as a possible diagnosis in pregnant woman with risk factors for thrombophilia presenting with abdominal pain.

Coagulation mixing studies: Utility, algorithmic strategies and limitations for lupus anticoagulant testing or follow up of abnormal coagulation tests

Coagulation testing underpins the investigation of hemostasis and/or monitoring of anticoagulation therapy for prevention and/or treatment of thrombosis related pathology. Assessment of coagulation results requires comparison against a normal reference range or interval (NRR/NRI). Results flagged as "abnormal" (ie, above the NRR/NRI for patients not on anticoagulant therapy), typically require further evaluation. eg, follow up or reflexive testing is used to identify the reason for prolongation, especially when supported by clinical context (eg, bleeding). Mixing tests may have utility to help identify the pathway of follow-up testing (ie, towards investigation of factor deficiencies, or else inhibitors), and are also useful for investigation of lupus anticoagulants (LA). In general, mixing tests that "correct" tend to suggest the presence of factor deficiencies, where as those that do not correct suggest the presence of "inhibitors". Various approaches can be used to identify correction/non-correction, and all have strengths and limitations. Furthermore, eventual identification of causal factor deficiencies or even "inhibitors" may (eg, factor VIII or IX deficiencies or inhibitors) or may not (eg, factor XII deficiency) be clinically important. Ultimately, mixing studies performed in view of appropriate clinical scenarios (eg, bleeding patient) and for LA investigations in symptomatic patients will have best utility.