Treatment of bleeding in acquired hemophilia A with the proper administration of recombinant activated factor VII: single-center study of 7 cases

Gastric ulcer bleeding in acquired hemophilia A patient and persistent inhibitor successfully treated with endoscopic methods of hemostasis

ABSTRACT: Acquired hemophilia A (AHA) is extremely rare, life-threatening bleeding disorder caused by sudden development of autoantibodies against coagulation factor VIII. Invasive procedures in AHA patients with persistent inhibitor, resistant to eradication therapies, pose an extreme threat of life due to uncontrolled bleeding poorly respond to surgical methods of hemostasis and bypassing agents. We report a case of idiopathic AHA 71-year-old patient with persistent high-titer inhibitor (104 BU) resistant to immunosuppressive treatment and immune tolerance induction. The patient was admitted with severe bleeding gastric ulcer complicated by gastric mucosal lacerations (Mallory-Weiss tears). Repeated endoscopic treatment with injection therapy and argon plasma coagulation were applied resulting in bleeding arrest. As bypassing agent recombinant active factor VII (rFVIIa) was applied with an average dose of 91.26 µg/kg (administering cumulatively of 134 doses during 14 days) and the total dose of 855.82 mg. In conclusion, gastric ulcer bleeding in AHA patient with persistent inhibitor can be successfully arrested with the use of endoscopic hemostasis methods and proper doses of rFVIIa.

Acquired hemophilia A in solid cancer: Two case reports and review of the literature

Acquired hemophilia A (AHA) is a rare, hemorrhagic autoimmune disease, whose pathogenesis involves reduced coagulation factor VIII (FVIII) activity related to the appearance of inhibitors against FVIII. Common etiological factors include autoimmune diseases, malignancy, and pregnancy. We report two cases of AHA in solid cancer. The first case is a 63-year-old man who developed peritoneal and intestinal bleeding after gastrectomy for gastric cancer. He was diagnosed with AHA, and was treated with prednisone, followed by cyclophosphamide. In the second case, a 68-year-old man developed a subcutaneous hemorrhage. He was diagnosed with AHA in hepatocellular carcinoma on CT imaging, and treated with rituximab alone. Hemostasis was achieved for both patients without bypassing agents as the amount of inhibitors was reduced and eradicated. However, both patients died within 1 year due to cancer progression. Successful treatment for AHA in solid cancer can be difficult because treatment of the underlying malignancy is also required.

Acquired hemophilia A developing cerebral infarction 36 days after the frequent administration of bypass hemostatic agents

A 74-years-old male who was a smoker and received treatment for hypertension, dyslipidemia, peripheral arterial disease and idiopathic interstitial pneumonia complained of subcutaneous hemorrhage of the right lower thigh. Marked anemia (hemoglobin 5.5 g/dL) and prolonged activated partial thromboplastin time (≥130 seconds) were noted. The factor VIII activity level was reduced to 1.2%, and the factor VIII inhibitor titer was 285.3 BU/mL, a diagnosis of acquired hemophilia A (AHA) was made. Then, hematomas of 5 intra-muscles were recurred. Hemostasis became difficult despite frequent and high-dose administration of recombinant human coagulation factor VIIa (total: 18 days, 305 mg). Hemostasis was achieved by switching to activated prothrombin complex concentrate (for 3 days, 18,000 units), however, cerebral infarction occurred after 36 days. After the frequent administration of bypass hemostatic agents on elderly AHA patients with several risk factors for ischemic stroke, the risk of subsequent thrombotic events may persist for 1 month.