Acquired factor V inhibitor with erythema and eosinophilia in a patient with end-stage renal disease

Autoimmune factor V deficiency (AiFVD) is a rare bleeding disorder caused by factor V inhibitors. In this report, we present the case of an 89-year-old man who developed bleeding tendency during surgery to create arteriovenous fistula for hemodialysis. The bleeding tendency developed with prolongation of activated partial thromboplastin and prothrombin time, following drug-induced eruption and eosinophilia. Significant reduction in coagulation factor activity and inhibitory pattern in cross-mixing tests suggested the presence of inhibitors to coagulation factors. Subsequently, we detected a factor V inhibitor and anti-factor V autoantibodies was confirmed using enzyme-linked immunosorbent assay with purified human plasma factor V. Thus, the patient was 'definitely diagnosed' with AiFVD in accordance with the diagnostic criteria enacted by the Japanese Ministry of Health, Labor, and Welfare. The bleeding tendency improved after initiating oral prednisolone 50 mg (1 mg/kg) followed by normalization of activated partial thromboplastin time and prothrombin time at the 34th day. After improving the coagulation system prolongation, the inhibitor and autoantibodies has been eradicated. Since it is suggested that drug-induced immune response can cause AiFVD, AiFVD should be considered in patients who undergo hemodialysis and develop failure of hemostasis and drug-induced eruption.

Acquired Factor V Deficiency Associated with CFPM Administration

BACKGROUND

Acquired factor V deficiency (AFVD) caused by Factor V (FV) inhibition is a rare event, characterized by prolonged prothrombin time and activated partial thromboplastin time. To date, various factors were reported as triggers for developing FV inhibitor. Clinical symptoms range from asymptomatic to life-threatening bleeding. Case Report and Conclusions: Here, we report an 84-year-old Japanese male on hemodialysis due to renal failure who developed subcutaneous hemorrhage after administration of cefepime (CFPM) to treat bacteremia. Deficient FV activity (< 1.0%) was identified and AFVD with FV inhibitor titer of 9 BU/mL was diagnosed. Although the patient had multiple risks for developing FV inhibitor, CFPM was thought to be the major culprit in this case. After the diagnosis, oral prednisolone (30 mg/day) was initiated, but the patient died of respiratory/cardiac failure, unrelated to AFVD.

Acquired factor V inhibitor after exposure to topical human thrombin related to an otorhinolaryngological procedure

Acquired factor V (FV) inhibitors occur rarely and classically develop after exposure to bovine thrombin. The clinical presentation is variable, ranging from asymptomatic with incidental laboratory abnormalities to significant bleeding. With the development of human-derived thrombin agents, bovine thrombin is less frequently used. We report a case of an acquired FV inhibitor that developed in a patient after exposure to human thrombin used as a hemostatic agent during an otorhinolaryngology surgical procedure. Our review of the literature revealed only one prior reported case of FV inhibitor after exposure to human thrombin. Hematologists and surgeons should be aware of this rare, but potentially life-threatening, complication in the postprocedural setting.

[Development of asymptomatic acquired factor V inhibitor after the administration of antibiotics]

Acquired factor V (FV) inhibitor is a rare coagulation disorder, the causes and clinical symptoms of which are known to vary widely. Acquired FV inhibitor mostly occurs with exposure to fibrin glues during surgical procedures. We experienced a case with asymptomatic acquired FV inhibitor caused by antibiotic therapy for aspiration pneumonia.A man in his eighties had been treated for chronic atrial fibrillation, cerebral infarction and spinal canal stenosis. He was admitted after antibiotic therapy for aspiration pneumonia in a previous hospital. On admission, the screening test for blood coagulation revealed extreme prolongation of both prothrombin time (PT) and activated partial thromboplastin time (APTT). Vitamin K was administered intravenously after cessation of warfarin, but neither PT nor APTT showed any improvement. Subsequently, a cross mixing test was performed and showed an inhibitor pattern. Furthermore, a high titer of FV inhibitor was detected by the Bethesda method and an acquired FV inhibitor was thus diagnosed. Despite the presence of FV inhibitor, the patient showed no bleeding symptoms. Eight months later, both PT and APTT had diminished to normal clotting time values without immunosuppressive therapies.

Bovine thrombin induces an acquired coagulopathy in sensitized patients undergoing revision spinal surgery: a report of two cases

STUDY DESIGN

A report of two cases is presented.

OBJECTIVE

To raise awareness of bovine thrombin-induced factor V deficiency.

SUMMARY OF BACKGROUND DATA

Bovine thrombin is a frequently used hemostatic agent in spinal surgery. Current preparations contain clotting factors in addition to thrombin, particularly factor V, which are immunogenic. Re-exposure of sensitized patients to bovine thrombin products during subsequent surgery may lead to the formation of antibodies that cross-react with human clotting factors, most commonly against factor V. Hemorrhagic complications have been reported in nonspinal patients due to a bovine thrombin-induced factor V deficiency.

METHODS

Two spinal cases are reported, and the literature is reviewed.

RESULTS

In the cases outlined, both patients underwent revision spinal surgery, with re-exposure to bovine thrombin. Both patients developed abnormal coagulation profiles, with an acquired factor V deficiency. No hemorrhagic complications occurred; however, second-stage surgery was delayed in one patient and not undertaken in the other. In both patients, the coagulopathy resolved spontaneously.

CONCLUSIONS

Bovine thrombin-induced coagulopathy is well recognized in cardiac surgery but has not been reported in spinal surgical patients. Data available from cardiac surgical patients suggests that those who are sensitized to two or more bovine clotting factors are at greatest risk of hemorrhagic complications. The cases we present demonstrate that this phenomenon occurs in spinal surgical patients and serve to raise awareness of the potential danger of bovine thrombin in sensitized patients.

Acquired FV inhibitors: a needless iatrogenic complication of bovine thrombin exposure

BACKGROUND

FV inhibitors are a largely preventable iatrogenic coagulopathy in which the frequency is increasing in clinical practice.

STUDY DESIGN AND METHODS

Three cases associated with our institution are reported. A systematic review of the MEDLINE database was performed, and reference lists were reviewed to identify relevant publications.

RESULTS

One hundred twenty-six cases of FV inhibitors have been reported in the world's literature. Eighty-seven have been reported in the last decade, of which two thirds are due to exposure to bovine thrombin. Bovine thrombin-associated FV antibodies develop in 40 to 66 percent of cardiac surgery patients and in 20 percent of neurosurgery patients. Thirty-three percent of reported patients developed bleeding complications. Inhibitors persisted on average 2.3 months. Standard coagulation assays do not reliably predict clinical manifestations. Multimodality therapy, including immunosuppression, is useful for treatment of symptomatic patients.

CONCLUSIONS

FV inhibitors are a common complication of bovine thrombin exposure that can have devastating clinical consequences. Transfusion medicine specialists and hematologists can play a critical role in reducing the incidence of FV inhibitors by educating the medical community about safer alternative fibrin sealants.

Modulation of an acquired coagulation factor V inhibitor with intravenous immune globulin

PURPOSE

We report that treatment of an immune mediated postoperative Factor V (FV) deficiency with intravenous immune globulin (IVIg) resulted in serological and clinical disappearance of the inhibitor.

PATIENTS AND METHODS

A 9-year-old girl was exposed to bovine thrombin during cardiovascular surgery and subsequently developed severe, refractory hemorrhage caused by acquired FV deficiency (FV activity < 5%). Despite blood product transfusions, hemorrhage continued, and the patient was given IVIg, 400 mg/kg daily, for 9 day.

RESULTS

Prolonged clotting times immediately trended toward normal, and the hemorrhage ceased by the fifth IVIg treatment day, concomitant with increasing plasma FV activity and disappearance of human FV inhibitor activity. The patient's plasma initially had a much higher inhibitor titer against bovine FV (122-215 Bethesda units) than against human FV (3-4 Bethesda units). Circulating antibodies (IgM and IgG) to bovine and human thrombin and FV were detected by enzyme-linked immunosorbent assay (ELISA). After completion of IVIg treatment, IgG antibodies to bovine FV and thrombin persisted, as did high-titer inhibition of bovine FV, whereas the subpopulation of IgG and IgM antibodies reactive with human FV were undetectable.

CONCLUSIONS

The inhibitor likely developed from a heterogenetic immune response to bovine FV contaminating the topical thrombin preparation used during surgery. To our knowledge, this is the first demonstration of immunological clearance of an acquired FV antibody associated with the use of IVIg. The data suggest an antiidiotypic mechanism of IVIg in modulating clearance of antihuman FV antibodies.

Redo cardiac surgery: late bleeding complications from topical thrombin-induced factor V deficiency

Bovine thrombin-induced factor V deficiency was though to be a very rare acquired coagulopathy, with only three documented cases. We report a series of nine patients seen during a period of 32 months; these patients had normal preoperative coagulation profiles, and this unique coagulopathy developed 1 to 2 weeks after cardiovascular operations. The coagulopathy was characterized by a markedly elevated prothrombin time (40.9 +/- 5.8 seconds), an elevated activated partial thromboplastin time (96.3 +/- 12.2 seconds), a study positive for lupus anticoagulation (9/9), and markedly decreased levels of factor V (0.09 +/- 0.03 U/ml) and factor XI (0.04 +/- 0.02 U/ml), respectively. All patients had been exposed to commercially available bovine thrombin during prior cardiovascular or vascular operations and received a second bovine thrombin challenge during the latest procedure. Coagulopathic bleeding developed in four of the nine patients. Bleeding was unrelated to absolute fall in factor V level, but cessation of hemorrhage appeared to correlate with improvement in factor V level. Treatment with vitamin K, fresh frozen plasma, and platelet infusion were all unsuccessful in altering prothrombin time or factor V levels. Intravenous gamma globulin was used in three patients, two of whom were bleeding. All three patients showed a transient increase in factor V levels. Bleeding stopped in one of the two patients; the other continued to bleed and subsequently died. The third patient was treated prophylactically to increase factor V levels in preparation for flap reconstruction of his sternum. His factor V level increased from 0.26 to 0.49 U/ml, and he underwent the procedure without incident. Bovine thrombin-induced factor V deficiency may have been previously unrecognized. This deficiency should be suspected in patients who have undergone redo cardiovascular operations and in whom marked elevations in their prothrombin time occur 7 to 10 days after exposure to bovine thrombin. The resulting coagulopathy, although usually self-limited, has the potential to produce devastating bleeding complications. Intravenous gamma globulin (1 gm/kg during each of 2 days) has been used to increase factor V levels transiently but its role in therapy of this coagulopathy requires further investigation.