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Taylor SR, Connors JM, Venkataraman V. Hyperfibrinolysis during the treatment of rhabdomyosarcoma. Res Pract Thromb Haemost 2024; 8:102467. [PMID: 39040518 PMCID: PMC11260833 DOI: 10.1016/j.rpth.2024.102467] [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: 03/05/2024] [Revised: 05/22/2024] [Accepted: 05/23/2024] [Indexed: 07/24/2024] Open
Abstract
Background Coagulopathies are frequently observed in alveolar rhabdomyosarcoma (ARMS), with disseminated intravascular coagulation (DIC) being the most common presentation. However, hyperfibrinolysis represents a distinct but often overlapping and potentially life-threatening subset of coagulation disorders that requires specific diagnostic and management approaches. Key Clinical Question How can clinicians identify hyperfibrinolysis and what are the implications for management? Clinical Approach This case report describes a 25-year-old man with metastatic ARMS arising from the prostate who developed persistent gross hematuria one week after initiating chemotherapy. A comprehensive coagulation workup was performed, including assessment of platelet count, prothrombin time, activated partial thromboplastin time, fibrinogen, D-dimer, and fibrin degradation products. Management included repletion of fibrinogen and the use of anti-fibrinolytic agents. Conclusion Recognizing hyperfibrinolysis in ARMS patients is crucial for appropriate management. Clinicians should maintain a high index of suspicion for hyperfibrinolysis in ARMS patients presenting with severe coagulation abnormalities, particularly those with prostatic involvement or undergoing chemotherapy. In cases of primary hyperfibrinolysis, antifibrinolytic agents may be considered, whereas they are generally contraindicated in DIC.
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Affiliation(s)
- Samuel R. Taylor
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean M. Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vinayak Venkataraman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Ghansah H, Orbán-Kálmándi R, Debreceni IB, Katona É, Rejtő L, Váróczy L, Lóczi L, de Laat B, Huskens D, Kappelmayer J, Bagoly Z. Low factor XIII levels and altered fibrinolysis in patients with multiple myeloma. Thromb Res 2024; 234:12-20. [PMID: 38134612 DOI: 10.1016/j.thromres.2023.12.004] [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: 07/24/2023] [Revised: 11/13/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Acquired factor FXIII (FXIII) deficiency can be immune- or non-immune mediated and may cause severe bleeding symptoms. The incidence of acquired FXIII deficiency and its etiology in patients with multiple myeloma (MM) are poorly understood. OBJECTIVES To assess FXIII levels and the balance of fibrinolysis in newly diagnosed, untreated MM and monoclonal gammopathy of undetermined significance (MGUS) patients. METHODS FXIII activity, mixing studies, FXIII-A2B2 antigen, total FXIII-B antigen were measured in platelet-poor plasma from 17 untreated MM patients, 33 untreated MGUS patients, and 30 age and sex-matched healthy controls. Besides routine laboratory measurements, the balance of coagulation and fibrinolysis was evaluated using quantitative fibrin monomer (FM) test, thrombin-antithrombin assay, α2-antiplasmin activity, plasmin-α2-antiplasmin (PAP) complex, D-dimer, plasmin generation assay, clot lysis assay, and ClotPro-TPA test. RESULTS FXIII-A2B2 levels were significantly lower in MM patients compared to controls [median (IQR):14.6 (11.2-19.4) vs. 21.8 (17.1-26.4) mg/L, p = 0.0015], whereas total FXIII-B did not differ between groups. Decrease in FXIII activity was parallel to the decrease in FXIII-A2B2. An immune-mediated inhibitory mechanism was ruled out. Free/total FXIII-B was significantly higher in MM patients compared to MGUS and healthy controls, suggesting an etiology of FXIII-A consumption. In MM and MGUS patients, FM, D-dimer, and PAP complex were significantly elevated compared to controls, indicating hypercoagulability and ongoing fibrinolysis. CONCLUSIONS Low FXIII levels due to consumption were observed in MM patients at diagnosis. Hypercoagulability and ongoing fibrinolysis were detected in MM and MGUS, indicating that a disturbed hemostasis balance is already present in the latter benign condition.
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Affiliation(s)
- Harriet Ghansah
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary; Kálmán Laki Doctoral School, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Rita Orbán-Kálmándi
- Department of Laboratory Medicine, Faculty of Medicine, Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary
| | - Ildikó Beke Debreceni
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Éva Katona
- Department of Laboratory Medicine, Faculty of Medicine, Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary
| | - László Rejtő
- Department of Hematology, Jósa András Teaching Hospital, Nyíregyháza, Hungary
| | - László Váróczy
- Department of Internal Medicine, Division of Hematology, University of Debrecen, Debrecen, Hungary
| | - Linda Lóczi
- Department of Laboratory Medicine, Faculty of Medicine, Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary
| | - Bas de Laat
- Synapse Research Institute, Maastricht, the Netherlands
| | - Dana Huskens
- Synapse Research Institute, Maastricht, the Netherlands
| | - János Kappelmayer
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zsuzsa Bagoly
- Department of Laboratory Medicine, Faculty of Medicine, Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary; Hungarian Research Network (HUN-REN-DE) Cerebrovascular Research Group, Debrecen, Hungary.
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Dang Y, Zhang Y, Jian M, Luo P, Anwar N, Ma Y, Zhang D, Wang X. Advances of Blood Coagulation Factor XIII in Bone Healing. TISSUE ENGINEERING. PART B, REVIEWS 2023; 29:591-604. [PMID: 37166415 DOI: 10.1089/ten.teb.2023.0016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
The biologic process of bone healing is complicated, involving a variety of cells, cytokines, and growth factors. As a result of bone damage, the activation of a clotting cascade leads to hematoma with a high osteogenic potential in the initial stages of healing. A major factor involved in this course of events is clotting factor XIII (FXIII), which can regulate bone defect repair in different ways during various stages of healing. Autografts and allografts often have defects in clinical practice, making the development of advanced materials that support bone regeneration a critical requirement. Few studies, however, have examined the promotion of bone healing by FXIII in combination with biomaterials, in particular, its effect on blood coagulation and osteogenesis. Therefore, we mainly summarized the role of FXIII in promoting bone regeneration by regulating the extracellular matrix and type I collagen, bone-related cells, angiogenesis, and platelets, and described the research progress of FXIII = related biomaterials on osteogenesis. This review provides a reference for investigators to explore the mechanism by which FXIII promotes bone healing and the combination of FXIII with biomaterials to achieve targeted bone tissue repair.
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Affiliation(s)
- Yi Dang
- Department of Orthopaedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yi Zhang
- Department of Hygiene Toxicology, School of Public Health, Zunyi Medical University, Zunyi, China
| | - Minghui Jian
- Department of Hygiene Toxicology, School of Public Health, Zunyi Medical University, Zunyi, China
| | - Peng Luo
- Department of Orthopaedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Nadia Anwar
- Department of Orthopaedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yaping Ma
- Department of Orthopaedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Dingmei Zhang
- Department of Orthopaedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Center for Tissue Engineering, The Fourth Military Medical University, Xian, China
| | - Xin Wang
- Department of Orthopaedic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- School of Mechanical, Medical and Process Engineering, Center for Biomedical Technologies, Queensland University of Technology, Brisbane, Queensland, Australia
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Cuntz F, Deubzer HE, Schulte JH, Nimtz-Talaska A, Eggert A, Holzhauer S. Hemostatic Management in an Infant With Neuroblastoma and Severe Hemophilia B With Extended Half-life Recombinant Factor IX Fusion Protein. J Pediatr Hematol Oncol 2022; 44:e246-e249. [PMID: 33661164 DOI: 10.1097/mph.0000000000002109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 01/08/2021] [Indexed: 11/25/2022]
Abstract
In the rare co-occurrence of childhood cancer and severe hemophilia, hemostatic management is of paramount therapeutic importance. We present the case of an 11-month-old boy with severe congenital hemophilia B, who was diagnosed with metastatic high-risk neuroblastoma. He consequently developed paraneoplastic coagulopathy with life-threatening tumor hemorrhage and intracranial hemorrhage, showing central nervous system relapse. Management consisted of factor IX replacement with extended half-life factor IX fusion protein, adjusted to bleeding risk. Additional interventions included factor XIII, fibrinogen, fresh frozen plasma, tranexamic acid, and platelet transfusions. The half-life of factor IX products was markedly reduced requiring close factor IX monitoring and adequate replacement. This intensified treatment allowed chemotherapy, autologous stem cell transplantation, and GD2 antibody immune therapy without bleeding or thrombosis.
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Affiliation(s)
- Franziska Cuntz
- Department of Pediatric Hematology and Oncology, Charité University Medicine
| | - Hedwig E Deubzer
- Department of Pediatric Hematology and Oncology, Charité University Medicine
- Experimental and Clinical Research Center (ECRC), Charité and Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association, Berlin
| | - Johannes H Schulte
- Department of Pediatric Hematology and Oncology, Charité University Medicine
| | | | - Angelika Eggert
- Department of Pediatric Hematology and Oncology, Charité University Medicine
| | - Susanne Holzhauer
- Department of Pediatric Hematology and Oncology, Charité University Medicine
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Luo Y, Li B, Li J, Zhang Y, Deng M, Hu C, Yan W, Zhou Z, Zhang G. Coagulation Factor XIII Subunit A Is a Biomarker for Curative Effects and Prognosis in Malignant Solid Tumors, Especially Non-small Cell Lung Cancer. Front Oncol 2021; 11:719085. [PMID: 34976787 PMCID: PMC8714639 DOI: 10.3389/fonc.2021.719085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 11/23/2021] [Indexed: 11/24/2022] Open
Abstract
Background The expression of coagulant factor XIII subunit A (FXIII-A) is significantly increased in some types of cancer cells and tumor-associated macrophages (TAMs). However, few studies on plasma FXIII-A in cancer patients have been conducted and have shown contradictory results, so the relationship of plasma FXIII-A with the progression and prognosis of malignant tumors is still unknown. This study explored the association of plasma FXIII-A with a curative effect and the prognosis of patients with malignant solid tumors. Methods We monitored plasma FXIII-A before and during systemic therapy and assessed its relationship with the curative effect and prognosis of malignant solid tumors, especially non-small cell lung carcinoma (NSCLC), by propensity-adjusted, multivariable logistic regression analysis and survival curve, in a prospective study of 1147 patients with different types of malignant solid tumors. The influencing factors of plasma FXIII-A were also analyzed. Results We found that D-dimer (D2) = 1 mg/L was the inflection point for the association between FXIII-A and D2: FXIII-A was significantly negatively correlated with D2 (r = -0.39, p < 0.01) and FDP (r = -0.40, p < 0.01) in D2 > 1 mg/L but uncorrelated with D2 or FDP in D2 ≤ 1 mg/L, which provided a method to find a more realistic plasma FXIII-A level. Plasma FXIII-A was positively correlated with age, platelets, lymphocytes, monocytes and carcinoembryonic antigen (CEA). It was found for the first time that plasma FXIII-A was abnormally significantly increased (FXIII-A > 150%) in post-therapy patients, especially in NSCLC and lung metastasis patients, and the incidence of FXIII-A > 150% in lung adenocarcinoma was 16 times higher than that in lung squamous carcinoma. FXIII-A > 150% proved to be an independent risk factor for disease progression in NSCLC patients (OR=5.74, 95% CI: 1.20-27.60, p = 0.029), predicting poor efficacy. The marked decrease in plasma FXIII-A (FXIII-A < 40%) was related to coagulation disorders and poor prognosis with a short survival time (median survival time of 4 months). Conclusions Plasma FXIII-A has the potential to be a real-time biomarker with bidirectional indicator effects to assess curative effects and prognosis in malignant solid tumors, especially NSCLC.
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Affiliation(s)
- Yujiao Luo
- Department of Hematology, Section of Hemostasis and Thrombosis, Institute of Molecular Hematology, The Second XiangYa Hospital, Central South University, Changsha, China
| | - Bin Li
- National Clinical Research Center for Geriatric Disorders, Department of Geriatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Ji Li
- Department of Hematology, Section of Hemostasis and Thrombosis, Institute of Molecular Hematology, The Second XiangYa Hospital, Central South University, Changsha, China
| | - Yang Zhang
- Department of Oncology, The Second XiangYa Hospital, Central South University, Changsha, China
| | - Mingyang Deng
- Department of Hematology, Section of Hemostasis and Thrombosis, Institute of Molecular Hematology, The Second XiangYa Hospital, Central South University, Changsha, China
| | - Chunhong Hu
- Department of Oncology, The Second XiangYa Hospital, Central South University, Changsha, China
| | - Wenzhe Yan
- Department of Hematology, Section of Hemostasis and Thrombosis, Institute of Molecular Hematology, The Second XiangYa Hospital, Central South University, Changsha, China
| | - Zhiguang Zhou
- Department of Metabolism and Endocrinology, The Second XiangYa Hospital, Central South University, Changsha, China
- *Correspondence: Guangsen Zhang, ; Zhiguang Zhou,
| | - Guangsen Zhang
- Department of Hematology, Section of Hemostasis and Thrombosis, Institute of Molecular Hematology, The Second XiangYa Hospital, Central South University, Changsha, China
- *Correspondence: Guangsen Zhang, ; Zhiguang Zhou,
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Feugray G, Buchbinder N, Buchonnet G, Fenneteau O, Billoir P, Le Cam Duchez V. Acquired factor XIII deficiency in a child with pure erythroid leukemia. Pediatr Blood Cancer 2021; 68:e28890. [PMID: 33484080 DOI: 10.1002/pbc.28890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/14/2020] [Accepted: 12/18/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Guillaume Feugray
- Vascular Hemostasis Unit, Normandie Université, UNIROUEN, Inserm U1096, Rouen University Hospital, Rouen, France
| | - Nimrod Buchbinder
- Pediatric Hematology and Oncology Unit, Rouen University Hospital, Rouen, France
| | | | - Odile Fenneteau
- Biological Hematology, Robert Debré Hospital, AP-HP, Paris, France
| | - Paul Billoir
- Vascular Hemostasis Unit, Normandie Université, UNIROUEN, Inserm U1096, Rouen University Hospital, Rouen, France
| | - Véronique Le Cam Duchez
- Vascular Hemostasis Unit, Normandie Université, UNIROUEN, Inserm U1096, Rouen University Hospital, Rouen, France
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Luo D, Chelales EM, Beard MM, Kasireddy N, Khismatullin DB. Drop-of-blood acoustic tweezing technique for integrative turbidimetric and elastometric measurement of blood coagulation. Anal Bioanal Chem 2021; 413:3369-3379. [PMID: 33796930 PMCID: PMC8016159 DOI: 10.1007/s00216-021-03278-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 02/25/2021] [Accepted: 03/04/2021] [Indexed: 12/19/2022]
Abstract
Many patients develop coagulation abnormalities due to chronic and hereditary disorders, infectious disease, blood loss, extracorporeal circulation, and oral anticoagulant misuse. These abnormalities lead to bleeding or thrombotic complications, the risk of which is assessed by coagulation analysis. Current coagulation tests pose safety concerns for neonates and small children due to large sample volume requirement and may be unreliable for patients with coagulopathy. This study introduces a containerless drop-of-blood method for coagulation analysis, termed "integrated quasi-static acoustic tweezing thromboelastometry" (i-QATT™), that addresses these needs. In i-QATT™, a single drop of blood is forced to levitate and deform by the acoustic radiation force. Coagulation-induced changes in drop turbidity and firmness are measured simultaneously at different instants. The parameters describing early, intermediate, and late stages of the coagulation process are evaluated from the resulting graphical outputs. i-QATT™ rapidly (<10 min) detected hyper- and hypo-coagulable states and identified single deficiency in coagulation factors VII, VIII, IX, X, and XIII. The linear relationship (r2 > 0.9) was established between fibrinogen concentration and two i-QATT™ parameters: maximum clot firmness and maximum fibrin level. Factor XIII activity was uniquely measured by the fibrin network formation time (r2 = 0.9). Reaction time, fibrin formation rate, and time to firm clot formation were linearly correlated with heparin concentration (r2 > 0.7). tPA-induced hyperfibrinolysis was detected in the clot firmness output at 10 min. i-QATT™ provides comprehensive coagulation analysis in point-of-care or laboratory settings, well suited to the needs of neonatal and pediatric patients and adult patients with anemia or blood collection issues.
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Affiliation(s)
- Daishen Luo
- Department of Biomedical Engineering and Tulane Institute for Integrative Engineering for Health and Medicine, Tulane University, 6823 St. Charles Avenue 500 Lindy Boggs Center, New Orleans, LA, 70118, USA
| | - Erika M Chelales
- Department of Biomedical Engineering and Tulane Institute for Integrative Engineering for Health and Medicine, Tulane University, 6823 St. Charles Avenue 500 Lindy Boggs Center, New Orleans, LA, 70118, USA
| | - Millicent M Beard
- Department of Biomedical Engineering and Tulane Institute for Integrative Engineering for Health and Medicine, Tulane University, 6823 St. Charles Avenue 500 Lindy Boggs Center, New Orleans, LA, 70118, USA
| | - Nithya Kasireddy
- Department of Biomedical Engineering and Tulane Institute for Integrative Engineering for Health and Medicine, Tulane University, 6823 St. Charles Avenue 500 Lindy Boggs Center, New Orleans, LA, 70118, USA
| | - Damir B Khismatullin
- Department of Biomedical Engineering and Tulane Institute for Integrative Engineering for Health and Medicine, Tulane University, 6823 St. Charles Avenue 500 Lindy Boggs Center, New Orleans, LA, 70118, USA.
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Wang YZ, Tan BY, Li L, Li ZJ. [Reduction of FXIII during myelosuppression in acute leukemia after chemotherapy and adverse relation with bleeding events]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:59-63. [PMID: 32023756 PMCID: PMC7357909 DOI: 10.3760/cma.j.issn.0253-2727.2020.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Indexed: 11/10/2022]
Abstract
Objective: To explore the relationship between plasma coagulation factor XIII (FXIII) and bleeding events. Methods: A total of 55 cases of acute leukemia (AL) at the myelosuppression phase after chemotherapy hospitalized in our hospital from August 2017 to March 2018 were enrolled, with 35 normal controls. The concentration of plasma coagulation factor XIII (FXIII) was detected by ELISA to determine the relationship between the plasma FXIII levels in AL patients at the myelosuppression phase after chemotherapy with bleeding events. Results: The level of FXIII in AL patients at the myelosuppression phase after chemotherapy was significantly lower than that in controls (P<0.001) . The level of FXIII was inversely related with the bleeding severity (the Spearman correlation coefficient -0.761) . Given the diagnosis cut-off point of FXIII concentration as 103.9 μg/L, the sensitivity of diagnosing bleeding in AL patients at the myelosuppression phase after chemotherapy was 0.939, and the specificity 0.909. Conclusion: AL patients at the myelosuppression phase after chemotherapy had low level of plasma FXIII, and patients with lower plasma FXIII associated with higher incidence and severity of bleeding. FXIII level was an independent influencing factor of bleeding in AL patients at the myelosuppression phase after chemotherapy.
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Affiliation(s)
- Y Z Wang
- Department of Hematology, First Hospital of Lanzhou University, Lanzhou 730000, China
| | - B Y Tan
- Department of Laboratory, First Hospital of Lanzhou University, Lanzhou 730000, China
| | - L Li
- Department of Laboratory, First Hospital of Lanzhou University, Lanzhou 730000, China
| | - Z J Li
- Department of Hematology, First Hospital of Lanzhou University, Lanzhou 730000, China
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Wang Y, Wang L, Xi Y, Li Z. Bleeding with negative coagulation screening test as initial presentation of chronic myelogenous leukemia managed by fresh frozen plasma: A case report. Medicine (Baltimore) 2019; 98:e16984. [PMID: 31464946 PMCID: PMC6736460 DOI: 10.1097/md.0000000000016984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Chronic myelogenous leukemia (CML), a clonal disorder of pluripotent stem cell, rarely presents with bleeding in chronic phase due to the function preservation of the platelets. Factor (F) XIII deficiency, an extremely rare hemorrhagic disease, can cause fatal bleeding, which has been previously described in autoimmune disorders and leukemias. PATIENT CONCERNS A 38-year-old woman with a 20-day history of spontaneous subcutaneous hemorrhage visited our hospital, who presented with intracranial hemorrhage, hematuria, and delayed hematoma after a bone marrow puncture. Initial management included cytogenetics analysis, molecular analysis, and coagulation evaluation. DIAGNOSIS Bone marrow puncture, cytogenetics, and molecular analysis indicated the diagnosis of CML. With the normal results of clotting screening tests and platelet counting, as well as the relief of bleeding after infusion of fresh frozen plasma (FFP), acquired rare bleeding disorder probably associated with factor XIII (FXIII) deficiency. INTERVENTIONS Management with anti-hyperleukocytosis and chemotherapy, hydration, alkalization, diuresis, uric acid-lowering, molecular targeted drugs, and freshly frozen plasma transfusion therapy resolved the bleeding diathesis. OUTCOMES The patient survived from the initial bleeding, however, she died. Twenty six months later due to the progression of CML. LESSONS CML can initially present as unusual bleeding, possibly related to FXIII defect. It is essential to screen coagulopathy including FXIII activity and to supplement plasma for CML patients who present initially as bleeding, which cannot be deciphered by the routine clotting screening test.
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Abstract
Acquired factor XIII (FXIII) deficiency is a rare bleeding disorder that can manifest with spontaneous or delayed life-threatening hemorrhage. Causes of acquired deficiency include immune-mediated inhibition, as well as non-immune FXIII hyperconsumption or hyposynthesis. The occurrence of acquired FXIII deficiency can be idiopathic or may be associated with comorbidities, such as malignancies or autoimmune disorders. Recognition of acquired FXIII deficiency and its underlying cause is imperative, as treatment options vary depending on the etiology. Diagnosis requires quantitative FXIII testing in addition to supplemental inhibitor studies if the clinical situation suggests an immune-mediated pathophysiology. Treatment may involve FXIII replacement, antifibrinolytic administration, and/or inhibitor eradication. However, treatment targets and thresholds are undefined in acquired FXIII deficiency. This review will focus on the clinical characteristics, diagnostic issues and therapeutic options for both immune and non-immune acquired FXIII deficiency. Cases are described to illustrate the clinical features of acquired FXIII deficiency.
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Affiliation(s)
- Matthew Tak Sheng Yan
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Natalia Rydz
- Division of Hematology and Hematologic Malignancies, Foothills Medical Centre, Calgary, AB, Canada
| | - Dawn Goodyear
- Division of Hematology and Hematologic Malignancies, Foothills Medical Centre, Calgary, AB, Canada
| | - Michelle Sholzberg
- St. Michael's Hospital, Room 2-007G Core Lab, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
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11
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Abstract
Objective: To provide a comprehensive literature review on roles of coagulation factor XIII (FXIII) in coagulation, wound healing, neoplasm, bone metabolism, and pregnancy. Data Sources: All articles in PubMed with key words Coagulation factor XIII, wound, leukemia, tumor, bone, and pregnancy with published date from 2001 to 2016 were included in the study. Frequently cited publications before 2000 were also included. Study Selection: We reviewed the role of FXIII in biologic processes as documented in clinical, animal, and in vitro studies. Results: FXIII, a member of the transglutaminase (TG) family, plays key roles in various biological processes. Besides its well-known function in coagulation, the cross-linking of small molecules catalyzed by FXIII has been found in studies to help promote wound healing, improve bone metabolism, and prevent miscarriages. The study has also shown that FXIII concentration level differs in the blood of patients with leukemia and solid tumors and offers promises as a diagnostic indicator. Conclusions: FXIII has many more biologic functions besides being known as coagulation factor. The TG activity of FXIII contributes to several processes, including wound healing, bone extracellular matrix stabilization, and the interaction between embryo and decidua of uterus. Further research is needed to elucidate the link between FXIII and leukemia and solid tumors.
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Affiliation(s)
- Da-Yu Shi
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Shu-Jie Wang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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12
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Naderi M, Dorgalaleh A, Tabibian S, Alizadeh S, Eshghi P, Solaimani G. Current understanding in diagnosis and management of factor XIII deficiency. IRANIAN JOURNAL OF PEDIATRIC HEMATOLOGY AND ONCOLOGY 2013; 3:164-72. [PMID: 24575291 PMCID: PMC3915454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 10/28/2013] [Indexed: 11/19/2022]
Abstract
Factor XIII or "fibrin-stabilizing factor," is a transglutaminase circulates in the blood circulation as a hetero tetramer with two catalytic A subunits and two carrier B subunits. This important coagulation factor has a crucial role in clotting cascade and produces strong covalent bonds between soluble formed fibrin monomers during coagulation. This stable cross linked fibrin strands are resistanttodegradationby thefibrinolyticsystem that enablesthe bodyto stoppotential bleeding episodes. In the absence or severe decrease of factor XIII, although the clot is formed, but is rapidly degraded by the fibrinolytic system, and delayed bleedingoccurs.Factor XIII deficiency is an extremely rare bleeding disorder with estimated incidence of 1/2-3000, 000 in the general population. Presumptive diagnosis of factor XIII deficiency was by clot solubility test in 5M urea or 1% monochloroacetic acid environments. In patients with abnormal screening clot solubility test, the disease can be confirmedbymore specifictestssuch as quantitative factor XIII activity assay andFXIIIAgassay.After diagnosis of disease all patients with severe factor XIII deficiency(<1 U/dl) shouldreceive prophylactic substitution therapywith fresh frozen plasma (FFP) and cryoprecipitate as traditional choices or purified concentrateof blood coagulation factor XIII (Fibrogammin P) inorder to control severe and life-threatening clinical complications of factor XIII deficiency.
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Affiliation(s)
- M Naderi
- Genetic Researcher Center in Non-Communicable Disease, Zahedan University of Medical sciences
| | - A Dorgalaleh
- Hematology Department, Allied Medical School, Tehran University of Medical Sciences, Tehran, Iran
| | - Sh Tabibian
- Hematology Department, Allied Medical School, Tehran University of Medical Sciences, Tehran, Iran
| | - Sh Alizadeh
- Hematology Department, Allied Medical School, Tehran University of Medical Sciences, Tehran, Iran
| | - P Eshghi
- Pediatric Congenital Hematologic Disorders Research Center, Zahedan University of Medical sciences
| | - Gh Solaimani
- Genetic Researcher Center in Non-Communicable Disease, Zahedan University of Medical sciences
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