The History of Factor XIII Deficiency

Despite the early discovery of factor XIII (FXIII) in 1944, the diagnosis of FXIII deficiency was not made until 1960, after all the other coagulation factor deficiencies, most likely due to the normality of routine coagulation testing in FXIII deficiency. Although the first case was detected by the clot solubility test and this test has long since been used to detect FXIII deficiency, the test is no longer recommended by experts. Over the past 60 years, knowledge about FXIII deficiency has expanded considerably, between 1992, when the first variant was identified, and 2022, 197 mutations have been reported. Almost all missense mutations have a similar effect on FXIII, leading to instability and faster degradation of mutant FXIII protein. Therapeutic options have evolved from historical fresh frozen plasma (FFP), old plasma, whole blood, and cryoprecipitate, to plasma-derived and recombinant FXIII concentrates, respectively available since 1993 and 2012. These concentrate products were respectively approved by the Food and Drug Administration in 2011 and 2013. This historical review covers various aspects of FXIII related disorders, including the discovery of the FXIII, associated disorders, molecular basis, diagnosis, and treatment of FXIII deficiency.

A case of anti-NPX-2 antibody-positive dermatomyositis resulting in massive haemothorax with acquired factor XIII deficiency

Autoimmune diseases, including dermatomyositis, can be complicated by an acquired autoimmune coagulation factor XIII deficiency, which sometimes results in fatal bleeding. Here, we report the case of a young woman with anti-NPX-2 antibody-positive dermatomyositis who developed massive haemothorax with acquired factor XIII deficiency during treatment, including plasma exchange therapy. Emergency transcatheter arterial embolisation was performed and coagulation factor XIII concentrates (Fibrogammin P® 240 U/day for 5 days) were supplemented. Subsequently, the patient was discharged and managed with oral prednisolone and tacrolimus. Coagulation system test results were followed up regularly and remained within normal limits and the patient progressed without recurrence of bleeding symptoms. Coagulation factor XIII deficiency cannot be assessed without measuring coagulation factor XIII activity because common coagulation-fibrinolytic system test results are not abnormal. The measurement of factor XIII activity should be performed when autoimmune diseases are complicated by unexplained bleeding.

Evaluation of the association of factor XIII at hospital arrival and outcomes in a cohort of severely injured patients

BACKGROUND

Severe traumatic bleeding depletes coagulation factor XIII (FXIII) and fibrinogen. However, the role of FXIII level in bleeding-related outcomes is unknown.

OBJECTIVES

To evaluate the association between FXIII levels at hospital arrival and critical administration threshold (≥3 red blood cell units in 1 hour within the first 24 hours), bleeding-related outcomes, death, and baseline characteristics.

METHODS

A retrospective cohort study was conducted in severely injured adult patients (Injury Severity Score of ≥22 or ≥2 red blood cell units transfused in 24 hours) admitted to a level 1 trauma center. Clinical and laboratory data were collected. Baseline FXIII antigen levels were measured in banked patient plasma. Multivariable logistic and linear regression models were used to estimate the association between FXIII levels, outcomes, and baseline characteristics.

RESULTS

Three hundred sixty-four of 1730 subjects admitted during a 2-year period were analyzed. Median age was 44 years (IQR, 27-62 years), and median Injury Severity Score was 29 (IQR, 22-34). FXIII levels were not associated with critical administration threshold (odds ratio [OR], 1.06; 95% CI, 0.97-1.17) or death (OR, 0.98; 95% CI, 0.90-1.07). FXIII was associated with major bleeding (OR, 1.10; 95% CI, 1.02-1.2) and massive transfusion (OR, 1.25; 95% CI, 1.08-1.44). Lower baseline FXIII levels were associated with arrival from a referring hospital (FXIII level, -0.07 U/mL; 95% CI, -0.11 to -0.03), hemoglobin (FXIII level, -0.05 U/mL; 95% CI, -0.07 to -0.03), fibrinogen level (FXIII level, -0.05 U/mL; 95% CI, -0.08 to -0.02), and platelet count (FXIII level, -0.02 U/mL; 95% CI, -0.04 to -0.008).

CONCLUSIONS

Baseline FXIII levels in severely injured patients were inconsistently associated with bleeding-related outcomes and mortality. However, their association with major bleeding warrants further investigation of the role of FXIII in massively transfused patients with trauma.

Abnormally Prolonged Bleeding After an Arthroscopic Knee Reconstruction Because of an Inherited Factor XIII Deficiency: A Case Report

CASE

An 18-year-old man developed ecchymosis after arthroscopic anterior cruciate ligament reconstruction with semitendinosus graft and meniscal repair. The results of routine coagulation studies were normal, but factor assays showed a reduction in factor XIII levels. The bleeding symptoms were dramatically improved after administration of cryoprecipitate.

CONCLUSION

Factor XIII deficiency is one of the rare clotting factor deficiencies that can be present at birth or be manifested later in life. Clinical awareness of factor XIII deficiency is essential so that appropriate testing and treatment can be achieved.

Factor XIII deficiency with intracranial haemorrhage

A 5-year-old girl presented to paediatric emergency with fever and seizures for a short duration. At first, meningitis was suspected and management was started empirically. There was no improvement in the clinical condition of the patient and investigations revealed spontaneous intracranial haemorrhage (ICH) secondary to factor XIII deficiency. The child was transfused cryoprecipitate and managed conservatively for ICH. She became asymptomatic and was kept on monthly cryoprecipitate transfusions. This case report summarises factor XIII deficiency in ICH which was not suspected initially, but diagnosed later on after CT scan head and factor XIII assay. This report also highlights events occurring during its management.

Successful Management of a Patient with Autoimmune Hemorrhaphilia due to Anti-Factor XIII/13 Antibodies Complicated by Pulmonary Thromboembolism

Autoimmune hemophilia-like disease (hemorrhaphilia) due to anti-factor XIII (FXIII) antibodies (AH13) is a very rare, life-threatening bleeding disorder. A 77-year-old woman developed macrohematuria and a right renal pelvic hematoma. The coagulation times were not prolonged, but FXIII activity and antigen levels were severely and moderately reduced to 9 and 29% of normal values, respectively. Accordingly, the FXIII-specific activity turned out to be low. FXIII inhibitor and anti-FXIII-A subunit autoantibodies were detected by a 1:1 crossmixing test and immunoblot and immunochromatographic assays. She was therefore diagnosed with "definite AH13" and treated with plasma-derived FXIII concentrates to arrest the hemorrhage. In addition to a highly compressed inferior vena cava by a huge renal pelvic hematoma, deep vein thrombosis (DVT) and pulmonary thromboembolism (PE) were identified by systemic computed tomography. The patient was immediately started on anticoagulation therapy with low-dose heparin. Emboli disappeared quickly, probably because under-crosslinked thrombi caused by severe FXIII deficiency are vulnerable to fibrinolysis. After about 1.5 years, anti-FXIII-A subunit autoantibodies still remained despite the use of rituximab, steroid pulse therapy, oral prednisolone, and oral cyclophosphamide treatments. In conclusion, an extremely rare AH13 case complicated by DVT and PE was successfully managed by balancing anticoagulation therapy with hemostatic therapy.

Advances in the treatment of bleeding disorders

Historically, the bleeding episodes in subjects with coagulation disorders were treated with substitution therapy, initially with whole blood and fresh frozen plasma, and more recently with specific factor concentrate. Currently, patients with hemophilia have the possibility of choosing different effective and safe treatments, including novel extended half-life and alternative hemostatic drugs. The availability of novel extended half-life products could probably overcome current prophylaxis limitations, particularly in hemophilia B patients, by reducing the frequency of injections, achieving a higher trough level, and improving the quality of life of the patients. In addition, subcutaneous administration of alternative therapeutics would simplify prophylaxis in patients with hemophilia A and B with and without inhibitors. Regarding von Willebrand disease, a recombinant von Willebrand factor was recently developed to control bleeding episodes in patients with this disease, in addition to available von Willebrand factor/factor VIII concentrates. The management of patients affected by rare bleeding disorders (RBDs) is still a challenge, owing to the limited number of specific products, which are mainly available only in countries with high resources. Some improvements have recently been achieved by the production of new recombinant factor (F) XIII A subunit-derived and FX plasma-derived products for the treatment of patients affected by FXIII and FX deficiency. In addition, the development of novel alternative therapeutics, such as anti-tissue factor pathway inhibitor, ALN-AT3, and ACE910, for patients with hemophilia might also have a role in the treatment of patients affected by RBDs.

[Diagnosis and treatment of acquired factor XIII/13 deficiencies: for all doctors treating the MHLW's designated intractable diseases]

Coagulation factor XIII (FXIII/13) comprises a hetero-tetramer formed by two catalytic A subunits and two carrier B subunits. Inherited/congenital FXIII/13 deficiency is a rare hemorrhagic disease, leading to severe bleeding and recurrent miscarriages. By contrast, acquired FXIII/13 deficiency is common, and is characterized by a secondary decrease in FXIII/13 resulting from its hypo-synthesis and/or hyper-consumption due to primary diseases. Autoimmune hemorrhaphilia--a severe bleeding disorder that occurs mainly in the elderly--results from the generation of anti-FXIII/13 antibodies (AH13). Although this disease is still rare, the number of patients diagnosed with AH13 has recently increased. To improve understanding of this disease, we conducted a nation-wide survey on AH13. We found approximately 50% of cases to be idiopathic. In the remaining half, autoimmune diseases and malignancies were the most common underlying disorders. Intramuscular and subcutaneous bleeding were the most frequently reported symptoms. AH13 patients with intracranial, intra-peritoneal, or retroperitoneal bleeding (s) were prone to hemorrhagic death. Therefore, physicians/hematologists must raise awareness of AH13 as a life-threatening disease. Most patients were treated with FXIII/13 concentrates to arrest bleeding and with prednisolone and cyclophosphamide to eradicate anti-FXIII/13 autoantibodies. AH13 became a 'designated intractable disease of Japan,' and 'Board Certified Hematologists' can now be qualified as designated doctors.

Factor XIII deficiency (fibrin stabilizing factor)

Factor XIII deficiency (fibrin stabilizing Factor or FSF) is a rare coagulation defect. The only patient believed to have this disorder in Hawai'i is presented in this report.

Congenital factor XIII deficiency in Switzerland: from the worldwide first case in 1960 to its molecular characterisation in 2005

Coagulation factor XIII (FXIII) has a major role in the final stage of blood coagulation, is important for wound healing and maintaining pregnancy. Severe congenital FXIII deficiency is a rare disorder with 1 patient in 1-3 million. Untreated, it causes bleeding events, with intracranial haemorrhage being the major cause of death, impaired wound healing, and abortion. FXIII deficiency was traditionally diagnosed using the clot solubility test, but quantitative FXIII activity and antigen assays are preferred today. Treatment consists of replacement therapy with FXIII concentrates administered every 4-6 weeks. The molecular-genetic causes of FXIII deficiency are mutations in the genes coding for the FXIII A- and B-subunits. More than 60 mutations distributed throughout the FXIII A-subunit gene have been identified so far and 4 mutations in the FXIII B-subunit gene. The first case of congenital FXIII deficiency was reported in Switzerland in 1960. In Switzerland we observed a disproportionately high incidence, which can be explained in part by a founder effect. In this article, we summarise general facts on severe congenital FXIII deficiency, and we characterise all FXIII deficient patients living in Switzerland, including the first case described in 1960 who is a member of a large family originating from the canton of Uri.

[Congenital factor XIII deficiency required high-dose factor XIII concentrate in late pregnancy]

Congenital factor XIII (FXIII) deficiency is a rare congenital hemorrhagic disorder. Since FXIII is an essential factor in pregnancy, pregnant patients with congenital FXIII deficiency should receive adequate replacement of FXIII concentrate. We report here on a 19-year-old pregnant woman with congenital FXIII deficiency. Despite regular replacement of FXIII concentrate, FXIII activity decreased rapidly after 32 weeks of gestation and she had to receive a high-dose of FXIII concentrate until delivery. Careful monitoring of FXIII activity is needed in patients with congenital FXIII deficiency, because FXIII activity may decrease rapidly in late pregnancy.

Immunoadsorption for coagulation factor inhibitors: a retrospective critical appraisal of 10 consecutive cases from a single institution

Immunoadsorption is occasionally used as an adjuvant measure in the treatment of subjects with coagulation factor inhibitors. We reviewed our recent 3-year period experience with this procedure in 10 subjects. Immunoadsorption was used in the context of an immune tolerance protocol for 3 subjects with severe congenital deficiency in factor VIII, IX, and XIII; it was effective in lowering the level of inhibitor but immune tolerance was not achieved. It allowed successful use of porcine factor VIII in 4 cases of acquired hemophilia and in one case of inhibitor in mild hemophilia A. This therapeutic approach seems to be more useful in acquired hemophilia than in severe congenital factor deficiencies with inhibitors.

Factor XIII deficiency mistaken for battered child syndrome: case of "correct" test ordering negated by a commonly accepted qualitative test with limited negative predictive value

We report herein a case of Factor XIII deficiency that remained undiagnosed until 2 years of age. Part of the delay in diagnosis was a consequence of testing that was performed on a blood sample obtained after plasma transfusion therapy for a life-threatening bleeding episode. Due to insufficient family follow-up after discharge from the hospital, the diagnosis was delayed 1 year until the child was rehospitalized and a pre-transfusion plasma sample was tested. The commonly accepted approach of using only a qualitative test for the diagnosis of factor XIII deficiency is challenged by this case report.

[Clinical course and management of severe congenital factor XIII deficiency]

Severe homozygous factor XIII deficiency was first described in Switzerland, in 1961. At present 14 patients are known here. Nine are of Swiss origin, the others are immigrants from eastern Europe. A 27-year-old woman with many haemorrhages during childhood immigrated to Switzerland and went through four episodes of haemorrhagic corpus luteum cyst rupture with life-threatening blood loss into the abdomen and three haemorrhages into the retroperitoneal muscles causing sensomotoric palsies, before the diagnosis was established. A monthly prophylactic replacement therapy of 500 IE factor XIII concentrate was started. Since then no signs of haemorrhage occurred. For the last trimester of pregnancy treatment intervals were shortened and dosage increased. Haemorrhage from the umbilical cord for weeks, subcutaneous haematomas, intracranial haemorrhage, muscle haemorrhage and wound bleeding with impaired wound healing as well as tendency to marked scar formation are characteristic for severe homozygous factor XIII deficiency. Without replacement therapy women suffer from obligate abortion. Diagnosis is made by the solubility of fibrin clots in urea (5 mol/l) or monochloroacetic acid (1-2%). For confirmation and monitoring of replacement therapy a quantitative incorporation assay is used. Replacement therapy is necessary in case of haemorrhage, injury, and surgery. Because of the high risk of intracranial haemorrhage prophylaxis is strongly recommended.

Studies on the role of adhesive proteins in maintaining pregnancy

It is well known that maternal fibrinogen (Fg) and factor X III are essential for maintaining early pregnancy. We studied their role by analysis of clinical reports and immunohistochemical investigation.

METHODS

(1) We analyzed the pregnancy cases of congenital afibrinogenemia and congenital factor X III deficiency. (2) Immunohistochemical staining of Fg, subunit A of factor X III (X IIIA) and fibronectin (Fn) were performed in the human implantation site, placenta, and endometrial cells cultured in serum-free medium.

RESULTS

(1) Afibrinogenemia needed to be administrated Fg from 4 weeks' gestation (4 wG), and factor X III deficiency needed factor X III concentrate from 5 wG, in order to prevent abortion. (2) Implantation tissues: Fg, cellular X IIIA and Fn were present at the decidual stroma around invasive cytotrophoblasts at 5 wG. X IIIA-positive cells coincided with LN-5-positive macrophages. Placenta: Fg, cellular X IIIA and Fn were present in the decidual layer. Endometrial culture cells: Fn was secreted by spindle-like shaped cells. X IIIA was secreted by round-shaped cells.

CONCLUSION

Maternal Fg and factor X III are essential just after 4-5 wG, and in that period they and Fn are present abundantly in decidual stroma around invasive cytotrophoblasts. It is concluded that when cytotrophoblasts invade endometrium maternal Fg, factor X III and Fn are concerned with cytotrophoblasts' anchoring as adhesive proteins.

[Experiences with the Port-A-Cath system in children]

In a retrospective study (1987-1997) the complications of a totally implantable venous access device (Port-A-Cath, Fa. Pharmacia, Germany) were analysed in 91 children with 99 implants. All but 2 of these children had malignant diseases. Their age ranged from 0.1 to 18.1 (median 6) years. Overall implant time was 171.2 years (62,488 days), averaging 1.63 years (595 days) per device. 11 complications were registered, i.e. infections (6), occlusions (4) and disconnection (1), resulting in an overall infection rate of 0.06 and a total occlusion rate of 0.04. The overall complication rate was thus 0.11, which compares favourably with other studies. With careful handling, the Port-a-Cath device is very reliable and involves few complications.

[Is the use of factor XIII for delayed wound healing in patients with head-neck tumors of value?]

BACKGROUND

Factor XIII is known to play an important role in wound healing. In patients with head and neck carcinomas there is an accumulation of risk factors for factor XIII deficiency such as chronic liver disease, extensive tissue lesions, and high intraoperative blood loss.

METHOD

Serum levels of factor XIII in 22 patients who had undergone tumor surgery for head and neck carcinoma were measured preoperatively and daily up to 1 week following surgery. Factor XIII was measured with the Berichrome assay as part of our routine laboratory studies. The results were correlated with preoperative pseudocholinesterase (PChe). Factor XIII was substituted for 3 days in 8 patients with persistent wound healing problems that did not improve after two weeks of conservative treatment.

RESULTS

We found that PChe levels are a predictor for the development of factor XIII levels during this period. In patients (n = 14) with normal PChe, factor XIII levels reached 86% of the preoperative values 1 week after operation (group 1). In patients (n = 8) with low PChe, the levels reached only 65% (group 2). The rate of wound healing problems was higher in group 2 (6/8) than in group 1 (2/14). In 6 patients treated with factor XIII, the wounds healed within 3 to 7 days. In two cases revision operation was necessary.

CONCLUSION

We conclude that the therapy with factor XIII may be successful in patients with wound healing problems. Further studies will be necessary to find out whether prophylactic substitution of factor XIII in patients with low preoperative pseudocholinesterase levels is useful.

SD Plasma in TTP and coagulation factor deficiencies for which no concentrates are available

Clinical studies of SD-Plasma (SDP) have included treatment of patients with both the acute and chronic relapsing (CRTTP) forms of TTP and replacement of coagulation factors in patients with congenital deficiencies. With the infusion of SDP in 6 patients with CRTTP, platelet counts rose, LDH values dropped, hemoglobin levels remained constant, and the patients continued in good health. In an FFP-controlled study in acute TTP, 16 patients were exchanged with SDP and 10 with FFP. There was no difference between the two groups in patient survival; relapse or remission rate; incidence of treatment resistance; or in per patient total volume infused, number of treatments, average volume per treatment, or number of relapses. Finally, 48 coagulation factor-deficient patients received SDP for surgical prophylaxis, active bleeding and routine prophylaxis for Factor XIII deficiency. The expected levels of the deficient factors were achieved, and the treating physicians concluded that there was control of bleeding.

Factor XIII deficiency: pathogenic mechanisms and clinical significance

Congenital factor XIII deficiency is a rare disease, but has provided valuable information on the physiological role of factor XIII and the benefit of factor XIII replacement therapy. It could be shown that not only homozygous patients but also heterozygotes are at risk for bleeding complications. Acquired factor XIII deficiency, however, is much more common, and preliminary studies suggest a lack of factor XIII to be an important feature of various diseases. In acute states and severe hemorrhages, replacement therapy with factor XIII concentrates is recommended. Recent progress in assay methods and future clinical studies should help to evaluate the therapeutic potential of factor XIII.

Claw toes correction and factor XIII deficiency--a case report

A 26-year-old male presented with claw toes and Factor XIII deficiency. Correction for his deformity was undertaken. Pre, intra and post-operative transfusions of plasma and blood prevented any haemorrhagic complications.

Pharmacokinetics and tolerability of factor XIII concentrates prepared from human placenta or plasma: a crossover randomised study

The pharmacokinetics and tolerability of factor XIII (FXIII) from plasma were compared with those of FXIII from placenta in a randomised, double-blind, crossover study involving 13 patients with congenital FXIII deficiency. Both FXIII activity and FXIII antigen were monitored. No difference was seen in the mean half-lives of the two preparations (9.3 days and 9.1 days for plasma and placenta FXIII activity, respectively). Response was similar for both preparations, but was slightly greater for FXIII from plasma (1.6 ormula: see text] vs 1.5 [formula: see text]). Similar results were found for recovery (65% vs 60%). The area under the data completed by extrapolation was significantly higher for FXIII from plasma. No differences between preparations in terms of efficacy or tolerability were observed. It can be concluded that treatment with FXIII concentrate from plasma is as efficient as with FXIII concentrate from placenta in terms of recovery and half-life. Both preparations were equivalent in terms of safety during the observation period. With the administration of monthly injections of approximately 30 U/kg serious bleeding events were prevented and no other serious adverse events occurred.

Factor XIII: inherited and acquired deficiency

Factor XIII (XIII), an enzyme found in plasma (present as a pro-enzyme), platelets and monocytes, is essential for normal haemostasis. It may also have a role to play in the processes of wound healing and tissue repair. Inherited XIII deficiency results in a life-long, severe bleeding diathesis which, if untreated, carries a very high risk of death in early life from intracranial bleeding. XIII is a zymogen requiring thrombin and calcium for activation. In plasma, XIII has two subunits: the 'a' subunit, which is the active enzyme, and the 'b' subunit which is a carrier protein. Activated XIII modifies the structure of clot by covalently crosslinking fibrin through an epsilon (gamma-glutamyl)lysine link. It also crosslinks other proteins, including fibronectin and alpha-2-plasmin inhibitor (alpha-2PI), into the clot through the same link. Clot modified by XIII is physically stronger, relatively more resistant to fibrinolysis and may be a more suitable medium for the ingrowth of fibroblasts. Inheritance of factor XIII is autosomal recessive. The majority of patients with the inherited defect show no XIII activity and absence of 'a' subunit protein in plasma, platelets and monocytes. At the molecular level, the defect is not a major gene rearrangement or deletion, but most likely a single point mutation which may be different in each family. Because of the severity of the bleeding diathesis, prophylaxis is desirable and has been shown to be very effective as the in vivo half-life of plasma XIII is long, and low plasma levels are sufficient for haemostasis. Acquired inhibitors have been reported in only two cases with inherited XIII deficiency. Acquired XIII deficiency has been described in a variety of diseases and bleeding has been controlled by therapy with large doses of XIII in such conditions as Henoch-Schönlein purpura, various forms of colitis, erosive gastritis and some forms of leukaemia. Large dose XIII therapy has also been used in an endeavour to promote wound healing after surgery and bone union in non-healing fractures. The use of XIII in these conditions remains controversial. Very rarely a bleeding diathesis results from the development of a specific inhibitor to XIII arising de novo, often as a complication in the course of a disease or in association with long-term drug therapy. The bleeding diathesis in these patients is difficult to treat.

Acquired plasma factor XIII deficiencies

Coagulation factor XIII (FXIII) is of paramount importance in the process of fibrin stabilization, which is the final step of the coagulation cascade. The clinical significance of defective fibrin stabilization is highlighted by the severe hemorrhagic manifestations of congenital FXIII deficiency. In this paper we review the pathophysiology, clinical presentation and therapy of acquired plasma FXIII deficiencies, caused by specific inhibitors or associated with other clinical conditions. For acquired severe FXIII deficiency caused by factor-specific inhibitors, the need for prompt diagnosis and treatment is emphasized by the high hemorrhagic risk and mortality. For moderate reduction of FXIII secondary to other conditions, we discuss the relative importance of FXIII reduction in the development of clinical symptoms and the role of substitution treatment.

Hereditary factor XIII deficiency

Twelve cases of hereditary factor XIII (FX III) deficiency diagnosed over five years (1986-1990) at Christian Medical College and Hospital, Vellore are presented here. Although all the cases had a history of umbilical cord bleeding and subsequent frequent bleeding episodes, diagnosis was considerably delayed. All but two patients required transfusions for bleeding episodes. Ten patients had a history of consanguinity in parents. Clinical features and family history are described in detail here. The ease of performing the Urea solubility test and problems in it's interpretation are highlighted. The role of prophylactic transfusion is also discussed.

[Factor XIII deficiency as the cause of postoperative hemorrhage]

A 38-years-old woman is presented with recurrent postoperative bleedings. The coagulation analysis revealed a factor XIII deficiency. The treatment consisted in transfusions of factor XIII concentrates.

Hemorrhagic disorder due to an isoniazid-associated acquired factor XIII inhibitor in a patient with Waldenström's macroglobulinemia

A case is described of a 75-year-old woman with a history of pulmonary tuberculosis and Waldenström's macroglobulinemia who developed an inhibitor of coagulation factor XIII while taking isoniazid. The patient presented with a subcutaneous hematoma of the abdominal wall that extended from the xiphoid process to the symphysis pubis and measured 20 cm in diameter. Results of routine coagulation studies were normal with the exception of an increased solubility of the patient's plasma clot in 5M urea consistent with a deficiency of factor XIII activity. Persistence of the deficiency following a 1:2 dilution of the patient's plasma in normal plasma indicated the presence of an inhibitor. A sample of the patient's plasma was depleted of IgG by streptococcal protein G adsorption. The IgG-depleted plasma did not inhibit factor XIII activity, indicating that the inhibitory activity was not attributable to the underlying IgM paraprotein. The patient's purified IgG, on the other hand, inhibited factor XIII activity and the inhibitory activity could be neutralized by anti-IgG antibody. The patient's IgG also inhibited factor XIII-mediated incorporation of fluorescent monodansylcadaverine into casein. Binding of the patient's IgG to factor XIII concentrate was demonstrated by enzyme-linked immunosorbent assay and the IgG that bound to the factor XIII was demonstrated to be polyclonal. Isoniazid was discontinued after the patient was admitted to the hospital. Cryoprecipitate infusion controlled bleeding and reduced the inhibitor titer by 50%. Treatment with cyclophosphamide and prednisone, followed by extracorporeal immunoadsorption over a staphylococcal protein A column, did not reduce the inhibitor titer further. Plasma exchange therapy reduced the inhibitor titer to undetectable levels but failed to restore factor XIII activity. Infusions of factor XIII concentrate reproducibly restored factor XIII activity and were not associated with an anamnestic rise in the inhibitor titer. This represents the seventh reported case of an acquired inhibitor to factor XIII associated with the ingestion of isoniazid.

[Fibrin-stabilizing factor and its significance in the surgical treatment of patients with obstructive jaundice]

The fibrin-stabilizing factor (XIII factor of the hemostasis system) was studied in 101 patients with unresolved mechanical jaundice. It was first shown that this disease is characterized by a statistically significant decrease of the FSF to 56-68%. The decrease of the XIII factor is prognostically unfavourable and points to the development of hepatic insufficiency. The experience has shown that in critical patients with the content of FSF lower than 30% it is expedient to perform decompressive procedures such as cholecystostomy, percutaneous transhepatic cholangiostomy, endoscopic papillotomy etc. as well as transfusion of fresh frozen plasma and hemosorption if there is no contraindications. In patients with FSF lower than 50% before operation it is sufficient to perform hemosorption and transfusion of fresh frozen plasma.

[Substitution of F XIII concentrate in ulcerative colitis]

A 33 years old female with ulcerative colitis was admitted with an acute exacerbation of the disease characterised by haematochezia, diarrhoea (10 stools/die) and anaemia (haemoglobin 6.5 g/dl). Therapy with 5-ASA and corticosteroids for six weeks failed to decrease the activity of the disease. Since deficiency of coagulation factor XIII (activity 60%, subunit A 56%) was present, in addition, concentrates of factor XIII (Fibrogammin HS, Behring, F.R.G.) 1250 U/die were given for ten days. The substitution resulted in an immediate increase of reduced F XIII activity (164%) and F XIII subunit A (333%) as well as in a marked improvement of symptoms.

Inherited factor XIII deficiency

A new observation of inherited factor XIII deficiency is described. The patient had presented in the past with an umbilical haemorrhage, a cerebral haemorrhage, multiple haematomas with delayed onset after minimal trauma, and episodes of spontaneous haemarthrosis. The biological diagnosis was made at the age of 7 years. The child had undetectable transamidating activity and factor XIII a chains, while the level of b chains was reduced. The values observed in the parents were intermediate between those of the patient and those of normal plasma. Heated factor VIII concentrates were found to contain only low amounts of factor XIII, and were thus unsuitable for the prophylactic therapy of this rare disease. The patient was successfully treated with monthly injections of a factor XIII concentrate.

Intracranial hemorrhage in congenital deficiency of factor XIII

We describe a male infant with congenital deficiency of coagulation Factor XIII who presented in the immediate postnatal period with umbilical stump bleeding and suffered a severe intracranial hemorrhage at 2 months of age. Factor XIII, also known as "fibrin-stabilizing factor," is a transpeptidase that produces strong covalent bonds between soluble fibrin monomers formed during coagulation. Presumptive diagnosis of Factor XIII deficiency was made with a clot solubility screening test, and confirmation was accomplished by demonstrating the absence of cross-linked fibrin chains by electrophoresis. This patient had received replacement therapy for 2 years, initially with intravenous fresh frozen plasma, and recently with Fibrogammin (Hoechst-Roussel Pharmaceuticals), a European Factor XIII concentrate soon to be available in the United States. Factor XIII deficiency is associated with a high incidence of life-threatening complications, notably intracranial hemorrhage. In light of the long half-life of this factor and the relatively low risk associated with new Factor XIII concentrates, such as Fibrogammin, prophylactic life-long replacement therapy should be considered for patients with severe Factor XIII deficiency.

Activity of blood coagulation factor XIII as a prognostic indicator in patients with Henoch-Schönlein purpura. Efficacy of factor XIII substitution

Determination of coagulation Factor XIII (F XIII)-related parameters in 21 patients with Henoch-Schönlein purpura documented a significant decrease of F XIII activity as well as of the F XIII-related antigenic determinants. Subgroup analysis with regard to the clinical symptoms showed an even further decrease of these parameters in patients with gastrointestinal complications. Stimulated by these findings a substitution therapy with a F XIII concentrate was initiated in those patients whose F XIII activity in plasma remained low and who developed severe abdominal pain accompanied by persisting gastrointestinal bleeding. This therapeutic approach not only corrected the laboratory data, but more important led to a cessation of pain and bleeding. A rapid decrease of F XIII levels after transfusion below 40 U/ml was indicative of relapse of abdominal symptoms, while increasing values were associated with the recovery of the patients.

IN CONCLUSION

F XIII activity determinations appear to have a predictive value in patients with Henoch-Schönlein purpura, and the administration of F XIII concentrates may contribute to the improvement of gastrointestinal complications.

Successful pregnancy in a woman with congenital factor XIII deficiency treated with substitutive therapy. Report of a second case

A syndrome of marked fetal wastage is associated with congenital factor XIII deficiency in adult women. A previously unreported case of a woman with factor XIII deficiency is described, in which substitutive treatment with normal plasma or placental factor XIII concentrate permitted two normal pregnancies. Factor XIII activity was maintained above 1-2% with intermittent infusion of 300 ml to 450 ml of plasma every 14 days or of 500 units of concentrate every 21 days. This case confirms the only other case so far reported in which factor XIII substitutive therapy was able to permit a normal pregnancy in a woman with factor XIII deficiency and seems to suggest factor XIII to be involved in the process of annidation.

Neonatal factor XIII deficiency

We describe a patient diagnosed in the neonatal period as having factor XIII deficiency who presented with persistent umbilical bleeding. Factor XIII deficiency is the only coagulation factor deficiency that cannot be detected by classical hemostatic tests, and a rapid diagnosis is vital during the first decade of life. A newborn presenting with persistent umbilical stump bleeding should be screened for factor XIII deficiency when routine coagulation tests prove normal.

The half life of factor XIII in the management of inherited deficiency

Following the injection of a large dose of factor XIII concentrate the in vivo half life of factor XIII was estimated in a patient with inherited deficiency. Factor XIII activity and enzyme concentration were measured quantitatively, and a qualitative assessment of the crosslinking of fibrin was also made for upto 6 weeks after the injection. The half life was found to be about 9--10 days. This is longer than most previous reports suggest. An explantation for this finding is offered. The relevance of the long half life of factor XIII to the prophylactic treatment of patients with inherited deficiency is demonstrated.

Factor XIII deficiency in antibiotic-associated pseudomembranous colitis and its treatment with factor XIII concentrate

The plasma factor XIII in a 5-year-old girl with antibiotic-associated pseudomembranous colitis decreased to 30%, although her bleeding time and other coagulation factors were normal. Factor XIII concentrate was able to control the severe hemorrhagic diarrhea and improve the laboratory data.