Clinical practice: the bleeding child. Part II: disorders of secondary hemostasis and fibrinolysis

Delta Storage Pool Deficiency: A Pediatric Case Report and Review of the Literature

Platelet storage deficiencies are a heterogeneous group of bleeding disorders of variable severity caused by decreased number or content of platelet granules. We present the case of a 10-year-old patient with no personal history of previous bleeding who was admitted to the emergency department due to menorrhagia and mucocutaneous pallor. Common disorders of primary and secondary hemostasis were ruled out. Subsequently, a study of electron microscopy of platelets was performed, which reported the presence of alpha granules with a decreased number of dense granules. Currently, the patient receives treatment with tranexamic acid during menstrual periods, supplementation with ferrous sulfate, and oral contraceptives, achieving control of bleeding episodes.

Valsalva purpura on the face of a 7-year-old child

Valsalva purpura refers to purpura resulting from performing the Valsalva maneuver, a forced expiratory effort against a closed glottis. There are limited reported cases of Valsalva purpura in children, specifically on the cheeks. We present the case of a 7-year-old child who developed Valsalva purpura on his cheeks after performing the Valsalva maneuver during deep breathing exercises by holding his breath underwater during his swimming sessions. This article overviews the relationship between the Valsalva maneuver, purpura, and similar cases.

How to use a coagulation screen

A coagulation screen is an important screening test when investigating a child who presents with easy bruising or bleeding. Interpretation of a coagulation screen can be challenging for clinicians. Evolution of the haemostasis system during childhood means normal ranges vary with age and needs to be interpreted alongside the clinical information. It is essential to consider preanalytical variables when interpreting a coagulation screen, and the reason for the investigation must always be considered. It is important that the sample is taken under optimal conditions, including sample technique, use of the correct bottle and prompt transport to the laboratory. An abnormal coagulation screen may indicate an underlying congenital bleeding disorder or an acquired bleeding disorder, or may be due to sampling error. Limitations of the coagulation screen are essential to be aware of, as some children with normal coagulation screen results may have bleeding disorders. Conversely, an abnormal coagulation screen does not always indicate a bleeding disorder.

Dry Socket Etiology, Diagnosis, and Clinical Treatment Techniques

Dry socket, also termed fibrinolytic osteitis or alveolar osteitis, is a complication of tooth exodontia. A dry socket lesion is a post-extraction socket that exhibits exposed bone that is not covered by a blood clot or healing epithelium and exists inside or around the perimeter of the socket or alveolus for days after the extraction procedure. This article describes dry socket lesions; reviews the basic clinical techniques of treating different manifestations of dry socket lesions; and shows how microscope level loupe magnification of 6× to 8× or greater, combined with co-axial illumination or a dental operating microscope, facilitate more precise treatment of dry socket lesions. The author examines the scientific validity of the proposed causes of dry socket lesions (such as bacteria, inflammation, fibrinolysis, or traumatic extractions) and the scientific validity of different terminologies used to describe dry socket lesions. This article also presents an alternative model of what causes dry socket lesions, based on evidence from dental literature. Although the clinical techniques for treating dry socket lesions seem empirically correct, more evidence is required to determine the causes of dry socket lesions.

Hemarthrosis subtalar, a rare diagnosis

Type B hemophilia usually affects patients with a family history of this disease and has a typical clinical picture. However, in the present case it appeared in a patient outside the typical age with no family history of hematologic malignancies and with an unusual clinical picture.

A Review of Hormonal Contraception and Venous Thromboembolism in Adolescents

BACKGROUND

The number of adolescents who are prescribed hormonal contraception (HC) for contraceptive and noncontraceptive indications is increasing. Approximately 1 of 4 female adolescents will use some form of HC by age 19 years. Venous thromboembolism (VTE) is a rare, but life-threatening complication associated with HC use. Although adolescents aged 15 to 19 years have the lowest absolute HC-associated VTE risk, they still account for 5.9% of HC-associated VTE. The absolute HC-associated VTE risk for those younger than 15 years of age is not well described.

OBJECTIVE

The objectives of this report are to describe the current literature regarding HC-associated VTE in adolescents, to review the coagulation cascade and in vivo coagulation, to highlight differences between the adolescent and adult coagulation profiles, to discuss coagulation profile changes related to HC use, and to identify knowledge deficits for future study.

CONCLUSION

The mechanisms and confounding variables that lead to HC-associated VTE in all adolescents are not well understood because many large HC studies exclude female adolescents younger than 18 years of age. Because of the paucity of data in this age group, observational studies and randomized controlled trials of VTE risk in adolescents on varying forms of HC are needed. Studies should include female adolescents across the entire adolescent age span (12-21 years) to better understand HC-associated VTE risk in this population.

First-Step Results of Children Presenting with Bleeding Symptoms or Abnormal Coagulation Tests in an Outpatient Clinic

Objective:

Mild bleeding symptoms are commonly seen in the general population. The aim of this study was to determine the final clinical and laboratory features of children referred for a first evaluation with a suspected bleeding disorder in the pediatric outpatient clinic of İstanbul University.

Materials and Methods:

The medical records of 26,737 outpatients who were admitted to the Division of Ambulatory Pediatrics between 31 October 2011 and 31 October 2012 were evaluated retrospectively. Ninety-nine patients were initially diagnosed as having probable bleeding disorders and were followed up. The symptoms of bleeding in addition to coagulation tests were analyzed.

Results:

Of the 99 patients, 52 (52.5%) were male and 47 were female, and the mean age of the entire study group was 9.1±4.1 years (minimum-maximum: 2-18 years). Major bleeding symptoms were epistaxis in 36 patients (36.4%), easy bruising in 32 (32.3%), and menorrhagia in 6 (6.1%). After initial tests ordered by the pediatrician, 36 of 99 patients (36.4%) were diagnosed as having bleeding disorders that included von Willebrand disease in 12 (12.1%), hemophilia A or B in 9 (9.1%), and other rare factor deficiencies in 9 (9.1%). Six patients (6.1%) were found to have combined deficiencies. Seven of 36 patients had a family history of bleeding.

Conclusion:

Among the patients referred for bleeding disorders, 36.4% were diagnosed with a bleeding disorder with the help of primary screening tests ordered in the outpatient clinic.

Duodenal haematoma following endoscopy as a marker of coagulopathy

BACKGROUND

Intramural duodenal haematomas (IDHs) are a rare complication of endoscopic biopsy but can cause significant morbidity and mortality, including duodenal obstruction, hospitalization and needing intravenous feeding. They are extremely uncommon in those with normal haematology.

OBJECTIVE

To describe the occurrence of IDHs following endoscopic biopsy in our institution.

MATERIALS AND METHODS

We identified three patients who developed a post biopsy IDH during an 18-month period (2010-2012) in a retrospective search of our hospital pathology and imaging databases.

RESULTS

All three children had complex medical problems and presented with gastrointestinal symptoms including severe abdominal pain, reflux, poor feeding and abnormal gut transit time. All underwent normal upper GI endoscopy with duodenal biopsy. Following endoscopy, they presented with intermittent GI obstruction with severe abdominal pain, distension and bilious vomiting or symptoms of pancreatitis, had imaging features of IDH and were managed conservatively making a full recovery. Initial haematology including platelet counts were normal, but two children were subsequently found to have platelet dysfunction and the third to have an unclassified coagulopathy.

CONCLUSION

IDHs may be the presenting factor in children with unsuspected bleeding problems. We present these findings to raise awareness of the imaging features and clinical impact of these cases because better understanding of these risk factors may help to avoid these complications in children in the future.

Rare bleeding disorders in children: identification and primary care management

Bleeding symptoms are common in healthy children but occasionally may indicate an underlying congenital or acquired bleeding diathesis. The rare bleeding disorders (RBDs) comprise inherited deficiencies of coagulation factors I (congenital fibrinogen deficiencies), II, V, VII, X, XI, and XIII and combined factor deficiencies, most notably of factors V and VIII and of vitamin K-dependent factors. These disorders often manifest during childhood and may present with recurrent or even serious or life-threatening bleeding episodes, particularly during the neonatal period. Accordingly, primary care and other nonhematologist pediatric providers should be familiar with the clinical presentation and initial evaluation of these rare disorders. Bleeding manifestations generally vary within the same RBD and may be indistinguishable from 1 RBD to another or from other more common bleeding disorders. Serious bleeding events such as intracranial hemorrhage may be heralded by less serious bleeding symptoms. The results of initial coagulation studies, especially prothrombin time and activated partial thromboplastin time, are often helpful in narrowing down the potential factor deficiency, with factor XIII deficiency being an exception. Consultation with a hematologist is advised to facilitate accurate diagnosis and to ensure proper management and follow-up. The approach to bleeding episodes and invasive procedures is individualized and depends on the severity, frequency, and, in the case of procedures, likelihood of bleeding. Prophylaxis may be appropriate in children with recurrent serious bleeding and specifically after life-threatening bleeding episodes. When available, specific purified plasma-derived or recombinant factor concentrates, rather than fresh frozen plasma or cryoprecipitate, are the treatment of choice.

Lupus anticoagulants in two children--bleeding due to nonphospholipid-dependent antiprothrombin antibodies

We describe two children with significant bleeding: one with multiple ecchymoses and the other with scrotal bleeding. In both patients, the activated partial thromboplastin time (APTT) was prolonged, with positivity for lupus anticoagulants (LA). However, the Owren prothrombin time (PT), usually insensitive for LA, was also prolonged. The presence of LA is associated with diverse clinical manifestations, with most patients being asymptomatic while others present venous or arterial thrombosis. Bleeding in conjunction with LA is rare and it is unusual to see prolongation of the Owren PT assay due to LA. An extended laboratory investigation of one of the patient's plasma revealed not only LA but also a specific nonphospholipid-dependent antiprothrombin antibody causing an acquired hypoprothrombinemia.

CONCLUSION

It is likely that the low prothrombin activity and not the LA caused the bleeding. The bleeding signs and symptoms in both patients subsided when the PT was normalized, although the prolonged APTT and the LA remained.