Spinal epidural haematoma in a patient with haemophilia-B

Spontaneous spinal epidural haematoma is rare. A case of haemophilia-B presenting with cervical spinal cord compression due to epidural haematoma, is reported. This is the second case in literature, to our knowledge, of intraspinal epidural haematoma in a patient with haemophilia-B. The importance of early diagnosis, especially with magnetic resonance imaging and surgical intervention, when deemed necessary, are emphasized.

The kinetics of antibodies against hepatitis C virus may predict viral clearance in exposed hemophiliacs

Several studies have reported the spontaneous loss of hepatitis C virus (HCV) antibodies in HCV-exposed persons. However, the relationship between seroreversion and spontaneous virus clearance has yet to be precisely determined in a single homogeneous population of untreated immunocompetent patients. In this study, 32 human immunodeficiency virus-seronegative hemophiliacs who had been exposed to HCV were followed for a mean duration of 141 months; 22 remained chronic carriers (68.8%). All but 1 of the nonviremic patients (90.0%) showed partial (8 cases) or complete (2 cases) seroreversion. In contrast, all but 1 of the viremic patients (95.1%) had a stable serologic profile when analyzed by a recombinant immunoblot assay. The results indicate that any HCV antibody-positive immunocompetent patient with no detectable serum HCV RNA and normal alanine aminotransferase values and whose serial samples show a progressive decrease in the level of HCV antibodies present may be considered as having a resolved infection.

IgE-mediated allergy and desensitization to factor IX in hemophilia B

BACKGROUND

We describe two patients with factor IX deficiency and high levels of inhibitors to factor IX who developed anaphylaxis to factor IX.

OBJECTIVE

The aim of this study was to develop a skin test, RAST, and desensitization protocol for factor IX allergy.

METHODS

The patients were evaluated by skin test and RAST to factor IX. They also underwent desensitization to factor IX.

RESULTS

Both patients had positive skin test and RAST reactions to factor IX. Control subjects had negative reactions. Both patients were successfully desensitized to factor IX by using two different desensitization protocols. The patients' skin test and RAST reactions to factor IX converted to negative after desensitization.

CONCLUSIONS

IgE-mediated reactions to factor IX do occur and may be diagnosed with the use of skin test and RAST. Patients with this type of reaction may be successfully desensitized to factor IX.

Therapy for chronic hepatitis B and C infection in haemophilia

Haemophiliacs, until recently, have been at risk of hepatitis B and C infection. Substantial numbers of patients remain persistently infected. Several lines of evidence suggest that these diseases will cause considerable morbidity unless therapy can successfully reduce viraemia and prevent disease progression. Cessation of viral replication may prevent progression to hepatic fibrosis.

Mononeuropathy multiplex in hemophilia: an electrophysiologic assessment

Single nerve lesion or mononeuropathy caused by extrinsic compression of hematoma or hemarthrosis is consistently reported for hemophilic patients. To study the manifestation of peripheral nerve lesions, an extensive nerve conduction study of peripheral nerves and specific nerves in correlation with clinical involvement was carried out on 126 hemophilic patients. We found 24 patients with 34 peripheral nerve lesions. The frequency of nerve lesion positively correlated with the severity of hemophilia (p < 0.01) and increasing age (p < 0.05). Nerve lesions occurred more commonly in lower extremities than in upper extremities. The femoral nerve was most commonly involved. Seven patients were identified to have mononeuropathy multiplex with 2 or more nerve lesions involving more than one extremity. All of these patients had chronic condition. Our findings suggest that mononeuropathy multiplex may occur in hemophilic patients.

Implantable venous access devices in children with hemophilia: a report of low infection rates

OBJECTIVE

The objective of this study was to define the efficacy and complications of implantable venous access devices (IVADs) in children with hemophilia.

STUDY DESIGN

Records were reviewed on all patients with congenital blood coagulation disorders monitored at two children's hospitals in whom one or more central venous catheters had been placed.

RESULTS

Since 1989 external and implantable central venous catheters have been inserted to enhance venous access for regular factor concentrate infusion in 45 patients with hemophilia ranging in age from 8 months to 19.5 years (median 7.4 years); 37 patients had factor VIII deficiency and 8 factor IX deficiency. Hemorrhagic complications of catheter placement were infrequent and minor. In the 41 patients having one or more IVADs in place for a median of 31 months, only six episodes of bacteremia occurred in 5 patients during 44,070 days of follow-up. The overall rate of bacteremia complicating IVADs in these patients was 0.14 episodes per 1000 catheter days. Other catheter-related complications were uncommon. Catheters are still in place in 33 patients for a median of 32 months.

CONCLUSION

The low risk of infection and other complications associated with the use of IVADs makes the use of these devices attractive in the treatment of patients with hemophilia who require frequent venous access for factor concentrate infusions.

Activated recombinant human coagulation factor VII therapy for intracranial hemorrhage in patients with hemophilia A or B with inhibitors. Results of the novoseven emergency-use program

Activated recombinant human coagulation factor VII (rFVIIa) is a promising new therapeutic agent for patients with hemophilia A or B with inhibitors who experience serious bleeding episodes or who need coverage during surgical procedures. This open-label, uncontrolled, emergency-use study evaluated the efficacy and safety of rFVIIa in 11 hemophiliac patients and 1 FVII-deficient patient with life-threatening intracranial hemorrhage previously unresponsive to one or more alternative therapies. rFVIIa effectively controlled intracranial hemorrhage in 10 of the 12 patients. Patients with hemophilia A or B received an average of 96.9 rFVIIa injections over 14.7 days with a mean total administration of 153.3 mg, corresponding to 8.1 mg/kg. Most reported adverse events were considered to be unrelated to rFVIIa therapy. These findings suggest that rFVIIa is an effective and well-tolerated therapeutic option in the management of central nervous system bleeding in patients with hemophilia A or B with inhibitors.

Human factor IX corrects the bleeding diathesis of mice with hemophilia B

Mice with hemophilia B have been engineered using gene targeting techniques. These animals exhibit severe factor IX deficiency and a clinical phenotype that mirrors the human disease. We have bred the founder animals onto two different strains of mice, C57B1/6 and CD-1, and have sought to determine whether adenoviral vectors expressing human factor IX could correct the bleeding diathesis of mice with hemophilia B. Initial experiments showed that purified plasma-derived human factor IX added to murine factor IX-deficient plasma resulted in complete correction of the activated partial thromboplastin time (aPTT), and that injection of 10(11) particles of an adenoviral vector expressing human factor IX resulted in normalization of a modified aPTT in mouse plasma. As an additional method of assessing the function of human factor IX in the murine coagulation system, bleeding times were performed in normal, hemophilic, and adenoviral-treated hemophilic mice. By two different bleeding-time techniques, the treated hemophilic mice gave values identical to normal littermate controls, whereas the untreated hemophilic mice exhibited heavy blood loss and prolonged bleeding. There was a marked difference in antibody formation in the two strains of mice; 100% of the hemophilic CD-1 mice formed antibodies to human factor IX, but none of the C57B1/6 mice did. These data suggest that the C57B1/6 hemophilic mice will be more useful for gene transfer studies, while the CD-1 hemophilic mice may be of greater utility in studying the development of inhibitors.

[Hemophiliacs with HIV. Slower progression of the infection among younger patients and at higher dosages of factor concentrates]

HIV disease progression and the effect of replacement therapy with clotting factor concentrates (CFCs) were studied in 100 Swedish haemophiliacs, mean age at seroconversion 29 years (range, 4-72). On average 16 years after seroconversion, 67 per cent of the patients had CD4+ cell counts of < 200 x 10(6)/l, 50 per cent had developed AIDS, and 58 per cent had died. HIV disease progression was significantly slower in those aged less than 28 (median age) at seroconversion (P = 0.004). Moreover, mortality was inversely correlated to total annual CFC consumption after adjustment for age and HIV-related therapy, i.e., Pneumocystis carinii prophylaxis and antiretroviral drugs (P = 0.014), but unrelated to the purity of the CFCs used. After adjustment for age, annual CFC consumption and HIV-therapy, prophylactic replacement therapy was not associated with significantly better survival than on-demand treatment. It is concluded that in HIV-positive haemophiliacs replacement therapy may have a beneficial effect on the immune system, and that CFC purity and the regimen (prophylaxis vs on-demand) would seem to be factors of minor importance.

Hamstring release for fixed knee flexion contracture in hemophilia

Sixteen hamstring tenotomies and posterior capsulotomies were assessed retrospectively in 10 patients with hemophilia. The average age of the patients was 17 years (range, 16-24 years). The main indication for surgery was a fixed knee flexion contracture of 30 degrees to 45 degrees, associated with repeated hemarthroses, and failure of conservative treatment after 6 months. A posterior transverse capsulotomy and a Z shaped hamstring tenotomy were performed. The postoperative treatment consisted of repeated stretching exercises for a 6-month period. An average decrease of 25 degrees in the amount of fixed knee flexion contracture was obtained (range, 10 degrees-40 degrees). Followup for an average of 9.5 years showed 11 good, four fair, and one poor result regarding their joint scores. It is concluded that hamstring release is an effective surgical procedure for fixed knee flexion contracture in hemophilia. It seems to reduce the incidence of hemarthrosis relating to such a deformity.

Arthroscopy for chronic hemophilic synovitis of the knee

Between 1988 and 1995, 32 knee joints (29 patients) with hemophilic arthropathy underwent arthroscopy. The spectrum of procedures ranged from resection of fibrous plicae to synovectomy. Technical difficulties appeared in cases of scarred fixed patella, pronounced posterior tibia subluxation, and severe fibrous ankylosis. All operations done between 1988 and 1991 (23 operations; 21 patients) were reviewed retrospectively. The mean age of the patients in this series was 30 years and the mean followup was 5 years. On subjective evaluation, 13 operations achieved a definite improvement, five showed slight improvement, and two had no improvement (three operations were excluded). Arthroscopic surgery, as a relatively low risk technique, combined with early functional rehabilitation, can be used to achieve satisfactory results in patients with hemophilic arthropathy.

Orthopaedic surgery in hemophilic patients with human immunodeficiency virus

Patients registered at the author's hemophilia center between 1982 and 1994 were studied to establish whether major orthopaedic surgical procedures accelerate the fall of CD4 lymphocyte counts of patients with hemophilia who are infected with the human immunodeficiency virus, and whether patients who had surgery had different rates of development of acquired immune deficiency syndrome or death when compared with patients who did not have surgery. The patients were divided into four groups: Group 1, 22 patients who were human immunodeficiency virus positive undergoing orthopaedic surgery; Group 2, 89 patients who were human immunodeficiency virus positive not undergoing orthopaedic surgery; Group 3, 18 patients who were human immunodeficiency virus negative undergoing orthopaedic surgery; and Group 4, 135 patients who were human immunodeficiency virus negative not undergoing orthopaedic surgery. There was no significant difference between the rates of decline of CD4 lymphocyte counts for patients who were human immunodeficiency virus positive who underwent surgery when compared with human immunodeficiency virus positive patients who did not undergo surgery, nor was there any significant difference between the two human immunodeficiency virus negative groups. There were no significant differences in the rate of development of acquired immune deficiency syndrome or mortality rates between patients who had surgery and those who did not.

Intraarticular dexamethasone in advanced chronic synovitis in hemophilia

From 1988 to 1966, 34 patients with advanced chronic hemophilic synovitis (25 Grade III and nine Grade IV) were treated with intraarticular injections of long acting dexamethasone (sodium phosphate of dexamethasone plus acetate of dexamethasone) in cycles of three injections with 3-week intervals between each injection with 6-month rest intervals between cycles for as many as three cycles, depending on the evolution of each case. All patients had chronic severe synovitis, axial deformity, muscular atrophy, and diminution of range of movement. There were 31 knees, two ankles, and two shoulders. Subjective and objective evaluations were done grouping the results in good, fair, and poor according to grade of patient satisfaction, presence of synovitis and pain, range of movement, and limitation of activities of daily living. In the subjective results there were 19 good results, 12 fair results, and four poor results, and in the objective evaluation there were 22 good results, nine fair results, and four poor results at an average followup of 1.5 years. The use of intraarticular dexamethasone as an alternative in the short to medium term for treatment of advanced chronic hemophilic synovitis with pain and limitation of function before doing an invasive surgical treatment is proposed.

Radioactive synoviorthesis in patients with hemophilia with factor inhibitor

In nine patients with hemophilia and factor inhibitor (six with hemophilia A; three with hemophilia B), 19 joints were treated with radioactive synoviorthesis using Au-198. Ages ranged from 3 to 40 years. Synoviorthesis was performed when the antibody titer was low (< 10 Bethesda units), thus making hemostasis possible by factor administration for 2 to 4 days. On five occasions, radioactive synoviorthesis was performed simultaneously with tolerance induction according to the Malmö protocol. A bleeding free interval of more than 6 months was obtained in 11 joints, six of which remained bleeding free for more than a year. At long term followup (range, 18-182 months) five joints were rated good, one joint was fair, and 11 joints were poor. Although the results are inferior to those for patients with hemophilia without inhibitor, radioactive synoviorthesis should be considered because of its ease of performance and the definite decrease in joint bleeding frequency that it brings about. This is of particular interest in patients with hemophilia caused by factor inhibitor who otherwise are difficult to treat.

Interferon therapy for Japanese hemophiliacs with chronic hepatitis C

Eight Japanese hemophiliacs with chronic hepatitis C (CHC) received interferon (IFN) therapy and four of them (50%) responded completely. Non-responders included 3 double-infected patients: 1 with hepatitis B virus (HBV) and 2 with human immunodeficiency virus-1 (HIV-1). In one of the patients with HIV-1 double infection, the absolute number of CD4+ lymphocytes decreased during IFN therapy. These findings suggest that hemophiliac patients with CHC can respond well to IFN therapy, but in patients who are double-infected with HBV and HIV-1, the indication of IFN therapy should be considered seriously.

Chemical synoviorthesis for hemophilic synovitis

For many years, Rifampicin has been used empirically for the treatment of hemophilic chronic synovitis with encouraging results. A study was performed in which Rifampicin was shown to reduce the inflammation of joints affected by hemophilic synovitis. A clinical study was performed on 48 hemophilic patients (48 joints). Seventeen elbows, eight knees, and 23 ankles were treated. The mean age of the patients was 6 years (range, 4-23 years) and the mean followup was 29 months (range, 24-53 months). Overall, 40 excellent results and eight good results were obtained. The average number of weekly injections of Rifampicin was 3.06 (range, 1-10 injections). Eight patients experienced pain on the first injection, which subsided gradually with the subsequent procedures. Synoviorthesis with Rifampicin seems to be a good method for the treatment of hemophilic synovitis, especially in small joints (elbows and ankles) and in younger children.

Treatment of considerations in patients with compartment syndrome and an inherited bleeding disorder

In addition to consultation with an experienced hematologist, the following are recommendations regarding compartment syndrome in a patient with an inherited bleeding disorder. Von Willebrand's Disease. Humate-P (rich in von Willebrand factor) is the replacement therapy of choice for surgical procedures in patients with von Willebrand's disease. In general, in the perioperative period, factor VIII levels between 50% and 100% are ideal with a gradual tapering to maintain levels at 50% for approximately 2 weeks. Adjuncts to therapy are DDAVP and EACA. Hemophilia A. During the initial evaluation and with measurement of compartment pressures, factor VIII replacement to levels in the range of 40% to 60% of normal is appropriate replacement therapy. For fasciotomy, however, factor VIII levels greater than 50% to 100% are required. In patients who have developed antibodies to factor VIII, a number of options are available. With low titers of factor VIII inhibitor, higher doses of factor VIII may be successful in overriding the inhibitor. In patients with higher titers of inhibitor, activated factor VII or porcine factor VIII is recommended. Hemophilia B. Highly purified factor IX replacement aimed at keeping factor levels between 50% and 100% in the perioperative period, followed by maintenance at 50% for approximately 2 weeks, is optimal management. Treatment Algorithm: The Figure outlines an algorithm to aid in the diagnosis and treatment of compartment syndrome in the patient with an inherited bleeding disorder. In a suspected case of compartment syndrome due to a soft-tissue hemorrhage or injury, factor replacement as outlined above should be initiated. Unequivocal clinical findings in the normal patient usually would be an indication to proceed to fasciotomy without obtaining compartment pressures. In the patient with an inherited bleeding disorder, however, factor replacement and subsequent normalization of the clotting cascade may help lowe compartment pressures. Therefore, we advocate obtaining initial pressures even with clinical findings of an acute compartment syndrome. At our institution, we advocate using an automated handheld pressure monitor (Stryker, Ontario, Canada) or the needle injection technique as described by Whitesides et al. In interpreting the obtained pressures, we choose to use the guidelines as described by Heppenstall et al. Briefly, Heppenstall et al determined that the pressure threshold at which cellular damage occurred was related more closely to the difference between the mean arterial blood pressure and compartment pressure than with the absolute compartment pressure alone; this measurement is called delta P. If delta P is > 30 mm Hg, then one should continue factor replacements and perform serial clinical and pressure examinations. Pressures should be taken every hour for 2 hours total. If the patient worsens in either respect, then the physician should enter the other limb of the algorithm for delta P < 30 mm Hg. For the patient with a delta P < 30 mm Hg, the amount of time since onset of symptoms must be considered. Since the patient may improve with adequate factor replacement, a delta P < 30 mm Hg mercury does not dictate automatic fasciotomy. An adequate time trial of replacement therapy may be attempted. In patients whose pressures do not begin normalizing, we advocate proceeding to fasciotomy. Patients who begin to normalize pressures during a 2-hour trial can be followed with serial clinical and pressure examinations. Any worsening in either scenario is an indication for fasciotomy; otherwise, observation and factor replacement may be continued. After initial decompression, staples may be placed in both wound edges with an elastic vascular loop woven between the two edges in a "shoelace" pattern. Then while waiting for closure, the loops can be gradually tightened at the bedside. Definitive closure should be attempted around the fifth postoperative day. All closure techniques should be pre

Nephrotic syndrome associated with hypocomplementemia in a 4-year-old boy with hemophilia B

PURPOSE

The case of a 4-year-old boy with hemophilia B with inhibitor who developed nephrotic syndrome is described. The possible association between factor IX therapy and nephrotic syndrome in patients with hemophilia B is discussed.

PATIENT AND METHODS

A chart review of a 4-year-old boy with hemophilia B and an inhibitor who developed nephrotic syndrome with transient hypocomplementemia was performed. In addition, a literature search was undertaken to determine the prevalence of this association and possible etiologic factors.

RESULTS

Although the nephrotic syndrome was resistant to steroid therapy and Bebulin (Osterreichisches Institut für Haemoderivate Ges.M.B.H., Subsidiary of Immuno AG, Vienna, Austria) infusions were continued, the edema resolved and proteinuria decreased. Seven month later, proteinuria, accompanied by transient hypocomplementemia, increased again. A rise in factor IX inhibitor level was observed. The patient received no immunosuppressive therapy, and exhibited a continuous decrease in urinary protein excretion over the following months.

DISCUSSION

A discussion about possible differential diagnoses and a review of the literature are presented.

A multicenter controlled, randomized, open trial of interferon alpha2b treatment of anti-human immunodeficiency virus-negative hemophilic patients with chronic hepatitis C. Hepatitis Study Group of the Association of Italian Hemophilia Centers

There is limited information about the long-term efficacy of prolonged therapy (more than 6 months) with interferon alpha in hemophilic patients with chronic hepatitis C who are not coinfected with the human immunodeficiency virus (HIV-1). One hundred and seven hemophiliacs were randomly assigned to 3 million U of interferon alpha2b three times weekly for 12 months or no therapy. The patients were followed up for at least 12 months posttreatment. Response was assessed by both serial alanine aminotransferase (ALT) levels and hepatitis C virus (HCV)-RNA measured by reverse transcribed polymerase chain reaction (RT-PCR) method. Before treatment, serum levels of HCV-RNA were measured quantitatively by second-generation branched-DNA assay and the HCV genotype was determined by RT-PCR. Serum HGV-RNA, a marker of infection with the hepatitis G virus, was also measured by RT-PCR. Normalization of ALT was sustained and serum HCV-RNA was cleared in 6 of 45 treated patients, compared with none of the 50 untreated controls (13% v 0% P < .01). Low pretreatment viremia was the only feature that was associated with an increased likelihood of sustained response (P < .01). This study shows that multitransfused hemophiliacs with chronic hepatitis C not coinfected with HIV-1 respond at low rates to prolonged interferon therapy.