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Kanitthamniyom C, Siladech P, Polpichai N, McCullough M, Saowapa S. Combined life-threatening internal organ bleeding and postpartum hemorrhage associated with acquired hemophilia A. Clin Case Rep 2024; 12:e8399. [PMID: 38173887 PMCID: PMC10761610 DOI: 10.1002/ccr3.8399] [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: 10/18/2023] [Revised: 12/06/2023] [Accepted: 12/14/2023] [Indexed: 01/05/2024] Open
Abstract
Key Clinical Message Acquired hemophilia A (AHA) can present as life-threatening bleeding during the postpartum period. Prompt treatment allows patients with AHA to achieve complete remission and have normal subsequent pregnancies. Abstract Acquired hemophilia A (AHA) is a rare bleeding disorder caused by the production of autoantibodies against factor VIII (FVIII). AHA can present with severe bleeding, especially in postpartum patient. We report a 38-year-old woman who presented in an emergency department with severe postpartum hemorrhage 2 weeks after cesarean section. Her investigation showed an isolated prolongation of partial thromboplastin time (PTT), low factor VIII assay and a factor VIII inhibitor test, resulting in abnormal Bethesda units which consistent with AHA. This case report highlights the importance of early diagnosis and treatment of AHA. With timely and appropriate management, most patients can achieve a good outcome.
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Affiliation(s)
| | | | - Natchaya Polpichai
- Department of Internal Medicine Louis A Weiss Memorial HospitalMahidol UniversityBangkokThailand
| | - Maireigh McCullough
- Internal Medicine DepartmentTexas Tech University Health Sciences CenterLubbockTexasUSA
| | - Sakditad Saowapa
- Internal Medicine DepartmentTexas Tech University Health Sciences CenterLubbockTexasUSA
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2
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Lim CC, Ling SW, Vijayan KV, Lee MJ, Devesayaham PR. Acquired Hemophilia A: Rare Cause of Upper Airway Hematoma and a Literature Review. Indian J Otolaryngol Head Neck Surg 2023; 75:3886-3888. [PMID: 37974717 PMCID: PMC10645700 DOI: 10.1007/s12070-023-03943-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/06/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Acquired hemophilia A (AHA) is a rare blood disorder with high morbidity and even mortality as severe bleeding can occur in up to 90% of affected patients. Unlike congenital hemophilia which presents with intra-articular bleeding, acquired hemophilia causes bleeding into the skin, muscle, mucous membranes and soft tissues. CASE PRESENTATION We report an unusual case of upper airway hematoma in a 61-year-old man who presented with acute onset dysphagia and shortness of breath. There were bruises on his neck and blood clots on the floor of mouth when he was examined. Endoscopic examination revealed an extensive laryngeal hematoma. A prolonged activated partial thromboplastin time (APTT) prompted us to investigate for factor VIII deficiency leading to the diagnosis of AHA. He recovered completely after a treatment regime instituted by the hematology team without suffering any grave debilitating events. CONCLUSION AHA with laryngeal hematoma is a rare condition with only a handful of cases reported. Although a life-threatening disease, it is easily reversed with early recognition and administration of medical therapy involving the hematology team.
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Affiliation(s)
- Chee Chean Lim
- Department of Otorhinolaryngology, Faculty of Medicine, University of Malaya, Kuala Lumpur, 50603 Malaysia
| | - Siew Wei Ling
- Department of Otorhinolaryngology, Hospital Raja Permaisuri Bainun, Jalan Raja Ashman Shah, Ipoh, Perak, 30450 Malaysia
| | - Kumareysh Vijay Vijayan
- Department of Otorhinolaryngology, Hospital Raja Permaisuri Bainun, Jalan Raja Ashman Shah, Ipoh, Perak, 30450 Malaysia
| | - Ming Jun Lee
- Department of Otorhinolaryngology, Hospital Raja Permaisuri Bainun, Jalan Raja Ashman Shah, Ipoh, Perak, 30450 Malaysia
| | - Philip Rajan Devesayaham
- Department of Otorhinolaryngology, Hospital Raja Permaisuri Bainun, Jalan Raja Ashman Shah, Ipoh, Perak, 30450 Malaysia
- Clinical Research Centre (CRC) HRPB Ipoh, Hospital Raja Permaisuri Bainun, Ministry of Health Malaysia, Ipoh, Malaysia
- School of Medicine, Faculty of Health and Medical Sciences, Taylor’s University, Subang Jaya, Malaysia
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3
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Tang Q, Liao J, Xie X. Acquired Hemophilia Associated with Rheumatic Diseases: A Case-Based Systematic Review. J Inflamm Res 2022; 15:4385-4393. [PMID: 35945991 PMCID: PMC9357396 DOI: 10.2147/jir.s369288] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/19/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Qi Tang
- Department of Rheumatology and Immunology, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Jiafen Liao
- Department of Rheumatology and Immunology, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Xi Xie
- Department of Rheumatology and Immunology, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Correspondence: Xi Xie, Department of Rheumatology and Immunology, the Second Xiangya Hospital, Central South University, Changsha, 410011, People’s Republic of China, Tel/Fax +86 0731 8529 5255, Email
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Teitel J, Ackery AD. Just the facts: how do I recognize, diagnose and treat acquired (autoimmune) hemophilia? CAN J EMERG MED 2022; 24:477-479. [PMID: 35861916 DOI: 10.1007/s43678-022-00344-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 06/07/2022] [Indexed: 11/02/2022]
Affiliation(s)
- Jerome Teitel
- Department of Medicine, Division of Hematology and Oncology, University of Toronto, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
| | - Alun D Ackery
- Department of Medicine, Department of Emergency Medicine, St. Michael's Hospital, University of Toronto, Unity Health Toronto, Toronto, Canada
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Acquired Haemophilia A: A 15-Year Single-Centre Experience of Demography, Clinical Features and Outcome. J Clin Med 2022; 11:jcm11102721. [PMID: 35628847 PMCID: PMC9144570 DOI: 10.3390/jcm11102721] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/03/2022] [Accepted: 05/04/2022] [Indexed: 01/27/2023] Open
Abstract
Acquired haemophilia A (AHA) is a rare severe bleeding disorder resulting from the production of autoantibodies directed against coagulation factor VIII. At presentation, bleeding events can be severe, and an early diagnosis and treatment are of major importance. The current study aims to analyse the treated patients who have been diagnosed with AHA for a better understanding of our population and treatment outcome. We conducted a retrospective study with 26 patients who had been diagnosed with AHA and who were treated in our hospital between January 2006 and January 2021. The patients ranged in age from 30 to 85 years old: 46.10% were men, 46.10% had no known underlying condition, 27% had an underlying malignancy, 7.60% presented with other diseases: psoriatic arthritis and Paget's disease, and 19.30% presented with AHA during puerperium. All of the patients had bleeding events and were treated with bypass agents for this as well as with immunosuppressive therapy to eradicate the inhibitor. A total of 53.80% of the patients had major bleeding. Sixty-nine percent of the patients achieved complete remission, but 26.90% died during the follow-up, although bleeding was not the cause of death in any of these cases. Our observations underline the importance of clinical suspicion and early referral to centres with experience and laboratory facilities for managing AHA.
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Abstract
Acquired hemophilia A is a potentially severe bleeding disorder caused by antibodies against the patient's own factor VIII. Acquired hemophilia A is rare. It is most commonly diagnosed in older individuals; about one-half of cases of acquired hemophilia are associated with underlying conditions, including autoimmune disease, cancer, and pregnancy. The diagnosis of acquired hemophilia A can be suspect with an isolated activated partial thromboplastin time elevation, and confirmed with demonstration of reduced factor VIII activity and the presence of a specific factor VIII inhibitor. Treatment of acquired hemophilia A involves control of bleeding, and eradication of the inhibitor.
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Affiliation(s)
- Menaka Pai
- McMaster University, Hamilton, Canada; Hamilton Health Sciences, Hamilton, Canada; Hamilton Regional Laboratory Medicine Program, Hamilton, Canada.
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Measurement of coagulation factor antibody levels is useful for diagnosis and determining therapeutic efficacy in hemorrhagic patients with autoantibodies to coagulation factor VIII and factor V: results from a single center in Japan. Int J Hematol 2021; 115:11-20. [PMID: 34476734 DOI: 10.1007/s12185-021-03212-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/26/2021] [Accepted: 08/26/2021] [Indexed: 10/20/2022]
Abstract
Coagulation factor inhibitors (CFIs) sometimes cause fatal bleeding conditions. Determination of an inhibitor titer (INH-titer) using the Bethesda method is essential for diagnosing diseases associated with CFIs and examining the effects of immunosuppressive therapy. We reviewed 17 cases with CFIs (acquired hemophilia A, n = 11; FV inhibitor, n = 6) to examine the usefulness of determining quantities of an autoantibody to a coagulation factor (CF-IgG) by ELISA for diagnosis and therapeutic efficacy, as compared with INH-titer. One patient with an INH-titer and no evidence of CF-IgG was lupus anticoagulant (LA)-positive, and thus the positive INH-titer may have been a false positive caused by LA. Although INH-titer alone was insufficient to correctly identify patients with CFI, determination of CF-IgG appeared to be useful. In addition, even after INH-titer disappearance, hemorrhagic conditions recurred when CF-IgG was detected. These findings suggest that the presence of a clearance antibody against the coagulation factor might reduce the activity of that coagulation factor even after disappearance of the corresponding neutralizing antibody. Although the diagnosis and therapeutic efficacy can also be determined by INH-titer disappearance and improvement of corresponding coagulation factor activity, determination of CF-IgG by ELISA can improve the accuracy of these assessments.
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Abstract
BACKGROUND Acquired haemophilia A is a rare bleeding disorder caused by the development of specific autoantibodies against coagulation factor VIII. Standard treatment, usually steroids alone, or in combination with cyclophosphamide, aims to stop acute bleeds by using haemostatic agents to promote clotting. Rituximab may be an alternative approach to the treatment of acquired haemophilia by eradicating FVIII autoantibodies. This is an update of a previously published Cochrane Review. OBJECTIVES To assess the efficacy and adverse effects of rituximab for treating people with acquired haemophilia A. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's trials registers, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and conference proceedings (January 2021). We also undertook searches of CENTRAL, MEDLINE and online trial registries (January 2021). SELECTION CRITERIA Randomised and quasi-randomised controlled trials of rituximab for people with acquired haemophilia A, with no restrictions on gender, age or ethnicity. DATA COLLECTION AND ANALYSIS No trials matching the selection criteria were eligible for inclusion. MAIN RESULTS No trials matching the selection criteria were eligible for inclusion. AUTHORS' CONCLUSIONS We found no randomised clinical trials of rituximab for acquired haemophilia A. Thus, we are not able to draw any conclusions or make any recommendations on rituximab for eradicating inhibitors in people with acquired haemophilia A based on the highest quality evidence. Given that undertaking randomised controlled trials in this field is a complex task, we suggest that, while planning such trials, clinicians treating the disease continue to base their choices on alternative, lower-quality sources of evidence. In a future update of this review, we plan to appraise and incorporate eligible randomised controlled trials, as well as other high-quality, non-randomised studies.
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Affiliation(s)
- Tracey Remmington
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
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Wang KY, Shah P, Roarke DT, Shakil SA. Severe acquired haemophilia associated with asymptomatic SARS-CoV-2 infection. BMJ Case Rep 2021; 14:14/7/e242884. [PMID: 34285024 PMCID: PMC8292732 DOI: 10.1136/bcr-2021-242884] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
A 65-year-old man presented with symptoms of severe subcutaneous bleeding in his arm, which led to compartment syndrome requiring fasciotomy and massive blood transfusion protocol. Medical history was significant for history of autoimmune thyroid disease. Workup revealed elevated partial thromboplastin time, decreased factor VIII levels and elevated factor VIII inhibitor levels. He was worked up for causes of acquired haemophilia A and was found to have an elevated SARS-CoV-2 antibody level. Given his negative workup for other secondary aetiologies, we suspect that the cause of his haemophilia A was from his SARS-CoV-2 infection, which has been observed previously in various case reports.
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Affiliation(s)
- Kevin Y Wang
- Department of Internal Medicine, NSLIJ Health System, New Hyde Park, New York, USA
| | - Pratik Shah
- Department of Internal Medicine, NSLIJ Health System, New Hyde Park, New York, USA
| | - Dennis T Roarke
- Department of Internal Medicine, Northwell Health, New Hyde Park, New York, USA
| | - Shams A Shakil
- Department of Hematology Oncology, Northwell Health, New Hyde Park, New York, USA
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10
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Autoimmune- and complement-mediated hematologic condition recrudescence following SARS-CoV-2 vaccination. Blood Adv 2021; 5:2794-2798. [PMID: 34255033 PMCID: PMC8276576 DOI: 10.1182/bloodadvances.2021004957] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/20/2021] [Indexed: 12/22/2022] Open
Abstract
Severe exacerbation of underlying hematologic conditions can occur within 1 to 4 days after dose 2 of a 2-dose SARS-CoV-2 vaccine series. A mild exacerbation after dose 1 and/or a history of vaccine-related adverse events may portend a more serious event after dose 2.
A variety of autoimmune disorders have been reported after viral illnesses and specific vaccinations. Cases of de novo immune thrombocytopenia (ITP) have been reported after SARS-CoV-2 vaccination, although its effect on preexisting ITP has not been well characterized. In addition, although COVID-19 has been associated with complement dysregulation, the effect of SARS-CoV-2 vaccination on preexisting complementopathies is poorly understood. We sought to better understand SARS-CoV-2 vaccine-induced recurrence of autoimmune- and complement-mediated hematologic conditions. Three illustrative cases were identified at the University of Washington Medical Center and the Seattle Cancer Care Alliance from January through March 2021. We describe the recrudescence of 2 autoimmune conditions (ITP and acquired von Willebrand Disease [AvWD]/acquired hemophilia A) and 1 complementopathy (paroxysmal nocturnal hemoglobinuria [PNH]). We report the first known case of AvWD/acquired hemophilia A, and describe the first PNH exacerbation in the absence of complement inhibition after SARS-CoV-2 vaccination. Although SARS-CoV-2 vaccine-induced ITP is a known concern, our case clearly depicts how thrombocytopenia in the setting of preexisting ITP can sequentially worsen with each vaccine dose. Based on our experiences and these examples, we provide considerations for how to monitor and assess risk in patients with underlying autoimmune- and complement-mediated hematologic conditions.
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11
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Acquired haemophilia A and late development of secondary autoimmune disorders, evidences from a single-centre observational study. Blood Coagul Fibrinolysis 2020; 31:495-499. [DOI: 10.1097/mbc.0000000000000956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Tiede A, Collins P, Knoebl P, Teitel J, Kessler C, Shima M, Di Minno G, d'Oiron R, Salaj P, Jiménez-Yuste V, Huth-Kühne A, Giangrande P. International recommendations on the diagnosis and treatment of acquired hemophilia A. Haematologica 2020; 105:1791-1801. [PMID: 32381574 PMCID: PMC7327664 DOI: 10.3324/haematol.2019.230771] [Citation(s) in RCA: 163] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 04/07/2020] [Indexed: 12/18/2022] Open
Abstract
Acquired hemophilia A (AHA), a rare bleeding disorder caused by neutralizing autoantibodies against coagulation factor VIII (FVIII), occurs in both men and women without a previous history of bleeding. Patients typically present with an isolated prolonged activated partial thromboplastin time due to FVIII deficiency. Neutralizing antibodies (inhibitors) are detected using the Nijmegen-modified Bethesda assay. Approximately 10% of patients do not present with bleeding and, therefore, a prolonged activated partial thromboplastin time should never be ignored prior to invasive procedures. Control of acute bleeding and prevention of injuries that may provoke bleeding are top priorities in patients with AHA. We recommend treatment with bypassing agents, including recombinant activated factor VII, activated prothrombin complex concentrate, or recombinant porcine FVIII in bleeding patients. Autoantibody eradication can be achieved with immunosuppressive therapy, including corticosteroids, cyclophosphamide and rituximab, or combinations thereof. The median time to remission is 5 weeks, with considerable interindividual variation. FVIII activity at presentation, inhibitor titer and autoantibody isotype are prognostic markers for remission and survival. Comparative clinical studies to support treatment recommendations for AHA do not exist; therefore, we provide practical consensus guidance based on recent registry findings and the authors' clinical experience in treating patients with AHA.
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Affiliation(s)
- Andreas Tiede
- Hannover Medical School, Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover, Germany
| | - Peter Collins
- Arthur Bloom Haemophilia Centre, University Hospital of Wales School of Medicine, Cardiff University, Cardiff, UK
| | - Paul Knoebl
- Department of Medicine 1, Division of Hematology and Hemostasis, Medical University of Vienna, Vienna, Austria
| | - Jerome Teitel
- Division of Hematology and Oncology, St. Michael's Hospital, Toronto, and Department of Medicine, University of Toronto, Toronto, Canada
| | - Craig Kessler
- Georgetown University Hospital, Lombardi Cancer Center, Division of Hematology/Oncology, Washington, DC, USA
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Nara, Japan
| | - Giovanni Di Minno
- Regional Reference Center for Coagulation Disorders, Federico II University Hospital, Naples, Italy
| | - Roseline d'Oiron
- Centre de Référence de l'Hémophilie et des Maladies Hémorragiques Constitutionnelles Rares, Hôpitaux Universitaires Paris Sud, Hôpital Bicêtre APHP, Le Kremlin-Bicêtre, France
| | - Peter Salaj
- Institute of Hematology and Blood Transfusion, Prague, Czech Republic
| | - Victor Jiménez-Yuste
- Hematology Department, La Paz University Hospital, Autonoma University, Madrid, Spain
| | - Angela Huth-Kühne
- SRH Kurpfalzkrankenhaus Heidelberg GmbH and Hemophilia Center, Heidelberg, Germany
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Al Mahmasani L, Finianos A, Bou-Fakhredin R, Elias J, Taher A. Acquired hemophilia A: when an overlooked autoimmune disorder causes significant bleeding. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1740682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Layal Al Mahmasani
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Antoine Finianos
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rayan Bou-Fakhredin
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Joseph Elias
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali Taher
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Theron A, Burcheri S, Vacheret F, Hillaire-Buys D, Sauguet P, Schved JF, Faillie JL, Biron-Andreani C. Iatrogenic acquired factor V inhibitors: A case report and review of the French pharmacovigilance database. Thromb Res 2017; 157:154-156. [PMID: 28755628 DOI: 10.1016/j.thromres.2017.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 06/02/2017] [Accepted: 06/07/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Alexandre Theron
- Department of Laboratory Haematology, University Hospital of Montpellier, France
| | - Sara Burcheri
- Department of Clinical Haematology, Hospital of Perpignan, France
| | | | | | - Pauline Sauguet
- Department of Laboratory Haematology, University Hospital of Montpellier, France
| | - Jean-François Schved
- Department of Laboratory Haematology, University Hospital of Montpellier, France
| | - Jean-Luc Faillie
- Department of Pharmacology, University Hospital of Montpellier, France
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16
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See A, Sudirman SR, Huang XY. Spontaneous multilevel airway haemorrhage in acquired haemophilia A. Eur Arch Otorhinolaryngol 2016; 274:2657-2660. [DOI: 10.1007/s00405-016-4251-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 08/05/2016] [Indexed: 11/24/2022]
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Abstract
BACKGROUND Acquired haemophilia A is a rare bleeding disorder caused by the development of specific autoantibodies against coagulation factor VIII. Rituximab may be an alternative approach to the treatment of acquired haemophilia by eradicating FVIII autoantibodies. OBJECTIVES To assess and summarise the efficacy and adverse effects of rituximab for treating people with acquired haemophilia A. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's trials registers, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and conference proceedings.Date of last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group's trials registers: 01 March 2016. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of rituximab for people with acquired hemophilia A, with no restrictions on gender, age or ethnicity. DATA COLLECTION AND ANALYSIS No trials matching the selection criteria were eligible for inclusion. MAIN RESULTS No trials matching the selection criteria were eligible for inclusion. AUTHORS' CONCLUSIONS No randomised clinical trials of rituximab for acquired hemophilia A were found. Thus, based on the highest quality of evidence, we are not able to draw any conclusions or make any recommendations on rituximab for eradicating inhibitors in people with acquired haemophilia A. Given that undertaking randomised controlled trials in this field is a complex task, the authors suggest that, while planning such trials, clinicians treating the disease continue to base their choices on alternative, lower quality sources of evidence. The authors plan, for a future update of this review, to appraise and incorporate any randomised controlled trials, as well as other high-quality non-randomised studies.
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Affiliation(s)
- Yan Zeng
- General Hospital of Chengdu Military RegionDepartment of Hematology270#, Rongdu Da DaoChengduChina610083
| | - Ruiqing Zhou
- Guangzhou First People's Hospital, Guangzhou Medical UniversityDepartment of HematologyPanfu RoadGuangzhouChina510180
| | - Xin Duan
- West China Hospital, Sichuan UniversityDepartment of Orthopaedics SurgeryNo. 37 GuoXueXiang StreetChengduChina610041
| | - Dan Long
- West China Hospital, Sichuan UniversityKey Laboratory of Transplant Engineering and ImmunologyNo. 37, Guo Xue XiangChengduChina610041
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Alvarado Y, Yao X, Jumper C, Hardwicke F, D'Cunha N, Cobos E. Acquired Hemophilia: A Case Report of 2 Patients With Acquired Factor VIII Inhibitor Treated With Rituximab Plus a Short Course of Steroid and Review of the Literature. Clin Appl Thromb Hemost 2016; 13:443-8. [PMID: 17911199 DOI: 10.1177/1076029607303777] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Acquired hemophilia is an unusual disorder in which nonhemophiliac patients develop autoantibodies (inhibitor) against the factor VIII coagulation protein. Factor VIII inhibitor leads to life-threatening bleeding disorders classically described as new onset of diffuse bruising and prolonged partial thromboplastin time in elderly patients. Treatment is focused in the control of the acute bleeding episode and the long-term suppression of the autoantibody. Several immunosuppressive combinations have been described; however, these treatments are also associated with serious side effects that are difficult to tolerate, especially in older and debilitated patients. New treatment modalities explore the elimination of the autoantibody production by targeting B-cells with rituximab, an anti CD-20 monoclonal antibody that has shown success in a multitude of autoimmune processes. This report presents 2 patients successfully treated with rituximab and a short tapering course of steroids and focuses our discussion in the analysis of different treatment approaches available for these patients' population.
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Affiliation(s)
- Yesid Alvarado
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas 79403, USA
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19
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Paudel R, Dominguez LW, Dogra P, Suman S, Badin S, Wasserman C. A Hematological Menace: Multiple Venous Thrombosis Complicated by Acquired Factor VIII Deficiency. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:214-8. [PMID: 27040655 PMCID: PMC4824342 DOI: 10.12659/ajcr.895316] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patient: Male, 21 Final Diagnosis: Acquired Factor VIII Deficiency Symptoms: Abdominal hematoma • DVT • life threatening bleeding Medication: — Clinical Procedure: Life saving medical therapy Specialty: Hematology
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Affiliation(s)
- Robin Paudel
- Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - Luis W Dominguez
- Department of Internal Medicine, Jersey City Medical Center, Jersey City, NJ, USA
| | - Prerna Dogra
- Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - Saurav Suman
- Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - Simon Badin
- Department of Medicine, Jersey City Medical Center, Jersey City, NJ, USA
| | - Carrie Wasserman
- Department of Medicine, Jersey City Medical Center, Jersey City, NJ, USA
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20
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A subset of high-titer anti-factor VIII A2 domain antibodies is responsive to treatment with factor VIII. Blood 2016; 127:2028-34. [PMID: 26825708 DOI: 10.1182/blood-2015-09-670034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 01/20/2016] [Indexed: 11/20/2022] Open
Abstract
The primary B-cell epitopes of factor VIII (fVIII) are in the A2 and C2 domains. Within the C2 domain, antibody epitope and kinetics are more important than inhibitor titer in predicting pathogenicity in a murine bleeding model. To investigate this within the A2 domain, the pathogenicity of a diverse panel of antihuman fVIII A2 domain monoclonal antibodies (MAbs) was tested in the murine model. MAbs were injected into hemophilia A mice, followed by injection of human B domain-deleted fVIII. Blood loss after a 4-mm tail snip was measured. The following anti-A2 MAbs were tested: high-titer type 1 inhibitors 4A4, 2-76, and 1D4; 2-54, a high-titer type 2 inhibitor; B94, a type 2 inhibitor; and noninhibitory MAbs GMA-012, 4C7, and B25. All high-titer type 1 MAbs produced blood loss that was significantly greater than control mice, whereas all non-inhibitory MAbs produced blood loss that was similar to control. The type 2 MAbs were not pathogenic despite 2-54 having an inhibitor titer of 34 000 BU/mg immunoglobulin G. In addition, a patient with a high-titer type 2 anti-A2 inhibitor who is responsive to fVIII is reported. The discrepancy between inhibitor titer and bleeding phenotype combined with similar findings in the C2 domain stress the importance of inhibitor properties not detected in the standard Bethesda assay in predicting response to fVIII therapy.
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Le Cam-Duchez V. Hémophilie A acquise et hémopathies lymphoïdes : revue de la littérature. Rev Med Interne 2015; 36:834-9. [DOI: 10.1016/j.revmed.2015.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 08/24/2015] [Accepted: 09/14/2015] [Indexed: 01/29/2023]
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Zeng Y, Zhou R, Duan X, Long D. Rituximab for eradicating inhibitors in people with acquired haemophilia A. Cochrane Database Syst Rev 2015. [DOI: 10.1002/14651858.cd011907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Grahammer F, Fischer KG. Successful immunoadsorption of life-threatening bleeding in factor VIII inhibitor disease, but no long-term remission with anti-CD20 treatment. BMJ Case Rep 2015; 2015:bcr-2015-210034. [PMID: 26323976 DOI: 10.1136/bcr-2015-210034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 62-year-old man and a 64-year-old woman presented to our institution with acquired haemophilia A. They both developed life-threatening bleeding. Immunoadsorption using protein A columns was used to rapidly lower factor VIII inhibitor levels. Immunosuppression with steroids and the anti-CD20 antibody, rituximab, was instituted. Yet their effects were either partial or complicated by an early relapse. Repetitive cyclophosphamide administration led to a sustained immunological response. While immunoadsorption appears effective and safe to lower factor VIII inhibitor levels, it seems that further preferably randomised controlled trials are needed to establish the value of rituximab versus the standard immunosuppressive regime comprising cyclophosphamide.
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Affiliation(s)
- Florian Grahammer
- Renal Division, University Medical Center Freiburg, Freiburg, Germany
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Acquired inhibitors of clotting factors: AICE recommendations for diagnosis and management. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 13:498-513. [PMID: 26192778 DOI: 10.2450/2015.0141-15] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Abstract
Acquired hemophilia A is a rare autoimmune disorder caused by an autoantibody (inhibitor) to factor VIII (FVIII) that interferes with its coagulant function and predisposes to severe, potentially life-threatening hemorrhage. Disease management focuses on controlling bleeding, primarily with the use of bypassing therapy and recombinant porcine FVIII, and permanently eradicating the autoantibody using various immunosuppressants. Treatment challenges include delayed diagnosis, difficulty achieving hemostasis and durable remissions, and complications associated with the use of hemostatic and immunosuppressive therapy in a primarily older patient population.
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Affiliation(s)
- Maissaa Janbain
- Louisiana Center for Bleeding and Clotting Disorders, Tulane University Medical Center, New Orleans, LA, USA
| | - Cindy A Leissinger
- Louisiana Center for Bleeding and Clotting Disorders, Tulane University Medical Center, New Orleans, LA, USA
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Kannan MS, Raj Kumar TR, Subramanian S. Acquired factor VIII inhibitor syndrome: A rare cause of hematuria. Indian J Urol 2015; 31:73-4. [PMID: 25624582 PMCID: PMC4300578 DOI: 10.4103/0970-1591.139551] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 50-year-old woman presented with gross hematuria for 1 month. Clinical examinations, laboratory investigations, ultrasound and contrast computed tomography were normal, except anemia. Cystoscopy revealed bloody efflux from the right side. Retrograde pyelogram showed filling defect in the renal pelvis and biopsy was inconclusive. Renal angiogram was normal. She developed ecchymosis on the right thigh and arm with elevated activated partial thromboplastin time. The partial thromboplastin time correction study and Bethesda study confirmed the presence of acquired factor VIII inhibitor (acquired hemophilia). With flexible ureterorenoscopy, the mass in the renal pelvis was removed and its histopathology revealed clotted blood. The patient was subsequently managed with steroids and Factor eight inhibitor bypass activity.
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27
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de Vitry A, Valois A, Weinborn M, Dupuy-de Fonclare AL, Cuny JF, Barbaud A, Schmutz JL. [Acquired haemophilia A: two cases]. Ann Dermatol Venereol 2014; 141:441-5. [PMID: 24951143 DOI: 10.1016/j.annder.2014.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 02/17/2014] [Accepted: 03/03/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Acquired haemophilia A (AH) is an uncommon bleeding disorder that presents as multiple, disseminated spontaneous subcutaneous bleeds. Diagnosis may be made on the basis of prolonged activated partial thromboplastin time (aPTT). The severity of the disease is associated with the low risk of haemoglobin levels and with potential links with other diseases. OBSERVATIONS Two men were hospitalized for extensive and spontaneous subcutaneous hematoma. In both cases, the International Normalized Ratio (INR) was normal, but aPTT was 3 times higher than normal. Autoantibodies against coagulation factor VIII confirmed the diagnosis of AH. The patients received immunomodulatory treatment. In one patient, diffuse large B-cell lymphoma was discovered one year after successful treatment of AH. DISCUSSION AH may be revealed by areas of bruising, subutaneous haematomas mimicking erythema nodosum, and muscle pain. APTT results alone can prompt the biologist to screen for factor VIII inhibitors. Aside from the risk of fatal bleeding, in half of all cases, the prognosis is determined by associated disorders such as blood dyscrasias, solid tumours, autoimmune diseases, use of certain medicines and pregnancy. After treatment for bleeding complications, therapy focuses on restoring the coagulation time. The aim of immunomodulatory therapy is to stem production of autoantibodies against coagulation factor VIII. CONCLUSION AH must be considered rapidly in order to reduce the risk of bleeding emergencies and to screen for potential related diseases.
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Affiliation(s)
- A de Vitry
- Service de dermatologie, batiment Philippe-Canton, CHU, 6, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France.
| | - A Valois
- Service de dermatologie, hôpital d'instruction des armées Legouest, 27, avenue de Plantières, 57070 Metz, France
| | - M Weinborn
- Service de dermatologie, batiment Philippe-Canton, CHU, 6, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
| | - A-L Dupuy-de Fonclare
- Service de dermatologie, hôpital d'instruction des armées Legouest, 27, avenue de Plantières, 57070 Metz, France
| | - J-F Cuny
- Service de dermatologie, batiment Philippe-Canton, CHU, 6, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
| | - A Barbaud
- Service de dermatologie, batiment Philippe-Canton, CHU, 6, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
| | - J-L Schmutz
- Service de dermatologie, batiment Philippe-Canton, CHU, 6, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
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Abstract
Currently, recombinant activated factor VII (rFVIIa) (NovoSeven) is indicated for the treatment of spontaneous and surgical bleeding in congenital haemophilia A and B patients with inhibitors to factors VIII (FVIII) and IX (FIX) >5 Bethesda units (BU) worldwide, and in patients with acquired haemophilia, congenital FVII deficiency and Glanzmann's thrombasthenia in Europe. Until April 2003, almost three-quarters of a milion doses of rFVIIa have been administered proving its efficacy and excellent safety record. According to results from initial clinical trials and a large number of case reports, the rFVIIa may be effective not only in treating haemophilia patients but also in treatment of bleeding in patients on oral anticoagulation or heparin, patients with liver diseases, von Willebrand disease (vWD), thrombocytopenia, various platelet defects, congenital or acquired deficiency of FVII, and in subjects without any pre-existing coagulopathy with diffuse life-threatening bleeding triggered by surgery or trauma. This review will briefly summarize rFVIIa mode of action in haemostasis, the current clinical experience with rFVIIa and focus on the alternative use of rFVIIa in patients at the high risk of bleeding in both spontaneous cases and clinical trials reports.
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Affiliation(s)
- Peter Kubisz
- Department of Hematology and Blood Transfusion, Jessenius Medical School of Comenius University, Martin, Slovakia.
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Borg JY, Guillet B, Le Cam-Duchez V, Goudemand J, Lévesque H. Outcome of acquired haemophilia in France: the prospective SACHA (Surveillance des Auto antiCorps au cours de l'Hémophilie Acquise) registry. Haemophilia 2013; 19:564-70. [PMID: 23574453 DOI: 10.1111/hae.12138] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2013] [Indexed: 01/24/2023]
Abstract
Although extremely rare, acquired haemophilia A (AHA) can cause severe bleeding, which may be fatal. The underlying causes of autoantibody development are not fully understood. Treatment goals are bleeding control and autoantibody eradication. At the time of our study, there was no consensus on a standard treatment strategy for AHA. Previous data were mainly retrospective or from single-centre cohorts. We conducted a prospective, controlled, registry-based study of patients with AHA in France. The prospective French registry (Surveillance des Auto antiCorps au cours de l'Hémophilie Acquise [SACHA]) collected data on prevalence, clinical course, disease associations and outcomes for haemostatic treatment and autoantibody eradication in 82 patients with a 1-year follow-up. Similar to earlier studies, the prevalence of AHA was higher in the elderly, with two thirds of patients aged >70 years. Around half of AHA cases were associated with underlying disease, most commonly autoimmune disease and cancer in younger and older patients respectively. Haemostatic treatment was initially administered to 46% of patients. Complete resolution or improvement of initial bleeding occurred in 22/27 (81%) rFVIIa-treated patients and in all six cases receiving pd-aPCC. The majority of patients (94%) received immunosuppressive therapy, with complete remission at 3 months in 61% (36/59) and in 98% (50/51) at 1 year. Overall mortality was 33%: secondary to bleeding in only three patients but to sepsis in 10. Bypassing agents were effective at controlling bleeding in patients with AHA. Immunosuppressive therapy should be used early but with caution, particularly in elderly patients.
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Affiliation(s)
- J Y Borg
- Haematology Laboratory, Rouen University Hospital and INSERM CIC-CRB 0204, Rouen, France
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Abstract
Acquired hemophilia is a rare but potentially morbid complication in patients with cancer. It may be seen in patients with hematologic neoplasms (usually lymphoproliferative disorders) or with solid tumors. Although the presence of an underlying malignancy portends a worse outcome, the literature suggests that the usual principles of treatment, including immunosuppression, apply to these patients. However, appropriate consideration should be given to the choice of agents, depending on individual risk factors for complications such as thrombosis and infection.
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Affiliation(s)
- Brandi N Reeves
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, NC, USA
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Duodenal tumor presenting as acquired hemophilia in an 88-year-old woman: a clinical case and review of the literature. Case Rep Gastrointest Med 2012; 2012:203801. [PMID: 22966469 PMCID: PMC3432527 DOI: 10.1155/2012/203801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 07/30/2012] [Indexed: 11/17/2022] Open
Abstract
Acquired hemophilia is a rare disease, presenting with severe hemorrhage, we present a case caused by a duodenal tumor, the clinical management, ethical implications, treatment recommendations, and a review of the literature.
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32
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Tengborn L, Baudo F, Huth-Kühne A, Knoebl P, Lévesque H, Marco P, Pellegrini F, Nemes L, Collins P. Pregnancy-associated acquired haemophilia A: results from the European Acquired Haemophilia (EACH2) registry. BJOG 2012; 119:1529-37. [DOI: 10.1111/j.1471-0528.2012.03469.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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33
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Knoebl P, Marco P, Baudo F, Collins P, Huth-Kühne A, Nemes L, Pellegrini F, Tengborn L, Lévesque H. Demographic and clinical data in acquired hemophilia A: results from the European Acquired Haemophilia Registry (EACH2). J Thromb Haemost 2012; 10:622-31. [PMID: 22321904 DOI: 10.1111/j.1538-7836.2012.04654.x] [Citation(s) in RCA: 322] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acquired hemophilia A (AHA) is a rare autoimmune disease caused by autoantibodies against coagulation factor VIII and characterized by spontaneous hemorrhage in patients with no previous family or personal history of bleeding. Although data on several AHA cohorts have been collected, limited information is available on the optimal management of AHA. OBJECTIVES The European Acquired Hemophilia Registry (EACH2) was established to generate a prospective, large-scale, pan-European database on demographics, diagnosis, underlying disorders, bleeding characteristics, treatment and outcome of AHA patients. RESULTS Five hundred and one (266 male, 235 female) patients from 117 centers and 13 European countries were included in the registry between 2003 and 2008. In 467 cases, hemostasis investigations and AHA diagnosis were triggered by a bleeding event. At diagnosis, patients were a median of 73.9 years. AHA was idiopathic in 51.9%; malignancy or autoimmune diseases were associated with 11.8% and 11.6% of cases. Fifty-seven per cent of the non-pregnancy-related cases were male. Four hundred and seventy-four bleeding episodes were reported at presentation, and hemostatic therapy initiated in 70.5% of patients. Delayed diagnosis significantly impacted treatment initiation in 33.5%. Four hundred and seventy-seven patients underwent immunosuppression, and 72.6% achieved complete remission. CONCLUSIONS Representing the largest collection of consecutive AHA cases to date, EACH2 facilitates the analysis of a variety of open questions in AHA.
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Affiliation(s)
- P Knoebl
- Division of Hematology and Hemostasis, Department of Medicine 1, Medical University of Vienna, Vienna, Austria.
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Hwang HW, Kong JH, Yu DW, Kim WT, Kim HS, Lee CI. A patient with acquired hemophilia A induced by clopidogrel. THE KOREAN JOURNAL OF HEMATOLOGY 2012; 47:80-2. [PMID: 22479283 PMCID: PMC3317479 DOI: 10.5045/kjh.2012.47.1.80] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 09/20/2011] [Accepted: 02/20/2012] [Indexed: 11/29/2022]
Abstract
Acquired hemophilia A (AHA) is a rare bleeding disorder caused by autoantibodies against factor VIII (FVIII). Treatment with clopidogrel is a cause of AHA, but its clinical course is unknown. Recently, we treated a 65-year-old man who was hospitalized for cerebellar infarction and had a prolonged activated partial thromboplastin time (aPTT) with soft tissue oozing after 3 weeks of clopidogrel use. We terminated clopidogrel administration and transfused the patient with fresh frozen plasma. However, the aPTT increased up to 98.8 seconds, and the FVIII and FVIII inhibitor levels were <1% and 5.4 Bethesda units/mL, respectively. Clopidogrel-associated AHA was considered, and we began steroid treatment. Two months later, FVIII, FVIII inhibitor, and aPTT values were normalized. No further bleeding or aPTT prolongation has been reported during the 2-year follow-up period. AHA should be considered in patients taking clopidogrel and experiencing bleeding, unless the platelet count and coagulation screen are normal.
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Affiliation(s)
- Hye Won Hwang
- Division of Hematology-Oncology, Department of Medicine, Wonju Christian Hospital, Yonsei University College of Medicine, Wonju, Korea
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Abstract
Acquired haemophilia A is an auto-immune disease caused by an inhibitory antibody to factor VIII. The pattern of bleeding varies but patients remain at risk of life threatening bleeding until the inhibitor has been eradicated. The cornerstones of management are; rapid and accurate diagnosis, control of bleeding, investigation for an underlying cause and eradication of the inhibitor by immunosuppression. Patients should always be managed jointly with a specialist centre even if they present without significant bleeding. Despite an extensive literature, few controlled data are available and treatment guidelines are based on expert opinion. To treat bleeds recombinant factor VIIa and activated prothrombin complex concentrate are equally efficacious but both are superior to factor VIII or desmopressin. Immunosuppression should be started as soon as the diagnosis is made. Commonly used regimens are steroids alone or combined with cytotoxic agents. Rituximab is being used more widely but current evidence does not suggest that it improves outcomes or reduces side effects.
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Affiliation(s)
- P W Collins
- Arthur Bloom Haemophilia Centre, School of Medicine, Cardiff University, Heath Park, Cardiff, UK
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36
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Micic D, Williams EC, Medow JE. Cerebellar hemorrhage as a first presentation of acquired Hemophilia A. Neurocrit Care 2010; 15:170-4. [DOI: 10.1007/s12028-010-9489-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Kim HJ, Lee WS, Lee YJ, Jun HS, Seo SK, Joo YD. Acquired factor VIII deficiency after consuming the dried gallbladder of a cobra, Naja naja. THE KOREAN JOURNAL OF HEMATOLOGY 2010; 45:205-7. [PMID: 21120211 PMCID: PMC2983047 DOI: 10.5045/kjh.2010.45.3.205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 07/29/2010] [Accepted: 09/02/2010] [Indexed: 11/25/2022]
Abstract
Acquired factor VIII deficiency is very rare, often fatal. It is associated with pregnancy, autoimmune diseases, malignancy, and drugs, although no underlying cause is found in 50%. A 49-year-old male was referred with right shoulder bruising. The coagulation test showed a prolonged activated partial thromboplastin time. The factor VIII level was less than 1%, and the factor VIII inhibitor antibody titer was 246 Bethesda units/mL. The findings were compatible with acquired factor VIII deficiency. He had consumed the dried gallbladder of a cobra, Naja naja, for two weeks, it contained venom. After the initial treatment with factor VIII, he did not take supplemental coagulation factor VIII. The patient was readmitted with left forearm swelling. He lost consciousness suddenly and brain computed tomography (CT) revealed a subdural hematoma. Despite administering recombinant factor VII, his bleeding was not controlled and he died.
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Affiliation(s)
- Hyun Ju Kim
- Department of Hemato-Oncology, Busan Paik Hospital Inje University, Busan, Korea
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Phadke G, Gupta D, Botdorf J, Misra M. Acquired factor VIII inhibitor in a nonhemophilia patient on hemodialysis: challenges in management. Hemodial Int 2010; 14 Suppl 1:S38-41. [PMID: 21040418 DOI: 10.1111/j.1542-4758.2010.00489.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
It is well known that the uremic milieu predisposes patients to an increased risk of bleeding. We report a case of a patient on hemodialysis who developed recurrent unexplained bleeding episodes. His renal failure was secondary to systemic lupus erythematosus. Further investigations revealed that his bleeding was secondary to the development of acquired inhibitors to factor VIII: C following a flare up of his systemic lupus erythematosus. Management issues related to recurrent bleeding in this situation are discussed and reviewed.
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Affiliation(s)
- Gautam Phadke
- Division of Nephrology, University Health Sciences Center, University of Missouri at Columbia, Columbia, MO 65212, USA
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Yadava RK, Fernando MU, Watson DK. Acquired haemophilia in a newly diagnosed elderly diabetic. Age Ageing 2010; 39:660-1. [PMID: 20634550 DOI: 10.1093/ageing/afq087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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40
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Consensus recommendations for the diagnosis and treatment of acquired hemophilia A. BMC Res Notes 2010; 3:161. [PMID: 20529258 PMCID: PMC2896368 DOI: 10.1186/1756-0500-3-161] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Accepted: 06/07/2010] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Acquired hemophilia A (AHA) is a rare bleeding disorder caused by an autoantibody to coagulation factor (F) VIII. It is characterized by soft tissue bleeding in patients without a personal or family history of bleeding. Bleeding is variable, ranging from acute, life-threatening hemorrhage, with 9-22% mortality, to mild bleeding that requires no treatment. AHA usually presents to clinicians without prior experience of the disease, therefore diagnosis is frequently delayed and bleeds under treated. METHODS Structured literature searches were used to support expert opinion in the development of recommendations for the management of patients with AHA. RESULTS Immediate consultation with a hemophilia center experienced in the management of inhibitors is essential to ensure accurate diagnosis and appropriate treatment. The laboratory finding of prolonged activated partial thromboplastin time with normal prothrombin time is typical of AHA, and the diagnosis should be considered even in the absence of bleeding. The FVIII level and autoantibody titer are not reliable predictors of bleeding risk or response to treatment. Most patients with AHA are elderly; comorbidities and underlying conditions found in 50% of patients often influence the clinical picture. Initial treatment involves the control of acute bleeding with bypassing agents. Immunosuppressive treatment to eradicate the FVIII inhibitor should be started as soon as the diagnosis is confirmed to reduce the time the patient is at risk of bleeding. CONCLUSIONS These recommendations aim to increase awareness of this disorder among clinicians in a wide range of specialties and provide practical advice on diagnosis and treatment.
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41
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Acute renal failure as a complication of acquired hemophilia due to autoantibody to factor VIII. Clin Exp Nephrol 2009; 14:85-9. [PMID: 19826896 DOI: 10.1007/s10157-009-0226-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2008] [Accepted: 08/25/2009] [Indexed: 10/20/2022]
Abstract
A 53-year-old Japanese woman, without any specific medical or family history, was admitted to our hospital for acute renal failure with macrohematuria. Routine blood analysis, including blood coagulation test, revealed azotemia accompanied by prolonged activated partial thromboplastin time (aPTT). Computed tomography revealed bilateral kidney swelling with dilatation of the renal pelvis. An extensive coagulation analysis revealed that the concentration of factor VIII had decreased to 1.8% and the level of factor VIII inhibitor was markedly elevated to 19 BU/ml. The final diagnosis was acquired hemophilia induced by autoantibodies against factor VIII, which was complicated by postrenal acute renal failure due to the obstruction of urinary tracts by renal bleeding and clots. The patient was treated with a combination of prednisolone at a dose of 50 mg/day (1 mg/kg body weight) and cyclophosphamide. The levels of factor VIII inhibitor decreased gradually, and the activity of factor VIII was improved after treatment. The levels of aPTT and concentrations of factor VIII and factor VIII inhibitor were monitored during the subsequent follow-ups.
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42
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Collins PW, Percy CL. Advances in the understanding of acquired haemophilia A: implications for clinical practice. Br J Haematol 2009; 148:183-94. [PMID: 19814739 DOI: 10.1111/j.1365-2141.2009.07915.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Acquired haemophilia A is an auto-immune disease caused by an inhibitory antibody to factor VIII. Patients with an acquired factor VIII inhibitor are at risk of life- and limb-threatening bleeding until the inhibitor has been eradicated. Management relies on rapid and accurate diagnosis, control of bleeding episodes, investigation for a precipitating cause and eradication of the inhibitor by immunosuppression. Patients should always be managed jointly with a specialist centre even if they present without overt bleeding. Despite an extensive literature, few controlled data are available and management guidelines are predominantly based on case reports, retrospective cohorts and expert opinion. This paper reviews the current literature on incidence, pathogenesis, diagnosis, haemostatic therapy and inhibitor eradication strategies. Potential future developments are discussed.
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Affiliation(s)
- Peter W Collins
- Arthur Bloom Haemophilia Centre, University Hospital of Wales and School of Medicine, Cardiff University, UK.
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43
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Huth-Kühne A, Baudo F, Collins P, Ingerslev J, Kessler CM, Lévesque H, Castellano MEM, Shima M, St-Louis J. International recommendations on the diagnosis and treatment of patients with acquired hemophilia A. Haematologica 2009; 94:566-75. [PMID: 19336751 DOI: 10.3324/haematol.2008.001743] [Citation(s) in RCA: 296] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Acquired hemophilia A (AHA) is a rare bleeding disorder characterized by autoantibodies directed against circulating coagulation factor (F) VIII. Typically, patients with no prior history of a bleeding disorder present with spontaneous bleeding and an isolated prolonged aPTT. AHA may, however, present without any bleeding symptoms, therefore an isolated prolonged aPTT should always be investigated further irrespective of the clinical findings. Control of acute bleeding is the first priority, and we recommend first-line therapy with bypassing agents such as recombinant activated FVII or activated prothrombin complex concentrate. Once the diagnosis has been achieved, immediate autoantibody eradication to reduce subsequent bleeding risk should be performed. We recommend initial treatment with corticosteroids or combination therapy with corticosteroids and cyclophosphamide and suggest second-line therapy with rituximab if first-line therapy fails or is contraindicated. In contrast to congenital hemophilia, no comparative studies exist to support treatment recommendations for patients with AHA, therefore treatment guidance must rely on the expertise and clinical experience of specialists in the field. The aim of this document is to provide a set of international practice guidelines based on our collective clinical experience in treating patients with AHA and contribute to improved care for this patient group.
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Affiliation(s)
- Angela Huth-Kühne
- SRH Kurpfalzkrankenhaus and Hemophilia Center Heidelberg gGmbH Bonhoefferstrasse 5, 69123 Heidelberg.
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Cretel E, Jean R, Chiche L, Durand JM. Successful treatment with rituximab in an elderly patient with acquired factor VIII inhibitor. Geriatr Gerontol Int 2009; 9:197-9. [DOI: 10.1111/j.1447-0594.2008.00491.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Acquired hemophilia a in a patient with lumbar disc herniation: a case report and review of the literature. Spine (Phila Pa 1976) 2009; 34:E305-8. [PMID: 19365240 DOI: 10.1097/brs.0b013e31819740d6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To summarize the clinical manifestations and treatment of acquired hemophilia A in a patient with lumbar disc herniation. SUMMARY OF BACKGROUND DATA Acquired hemophilia A is a rare but potentially life-threatening hemorrhagic disorder. It is caused by the development of autoantibodies directed against coagulation factor VIII (F VIII) in adults or elderly patients, who do not have a personal or family history of bleeding episodes. The mortality is high if the diagnosis was missed or delays, especially after a surgery. METHODS A case was investigated retrospectively and the relevant literature was reviewed. RESULTS A 59-year-old man with a 1-year history of lower back and leg pain was admitted to the hospital. He has no family medical history of hemophilia A and the routine laboratory examination did not find abnormality on blood coagulation function. He underwent decompression by laminectomy and discectomy. Seven hours after operation, it was found that the incision was oozing profusely and hemoglobin was reduced gradually, though platelet count was within the normal range. He was diagnosed with acquired factor VIII (FVIII) deficiency based on a prolonged activated partial-thromboplastin time (61.0 seconds), reduced FVIII activity (4.2%), and FVIII inhibitor (8 BU). After treatment with hemodynamic stabilization and immunosuppression therapies (including transfusion of packed red blood cells, fresh frozen plasma, and cryoprecipitate) and administration of human antihemophilic globulin, corticosteroid, and cyclophosphamide, bleeding was stopped gradually. The clinical and biologic condition of the patient improved, though neurological deficit was left. CONCLUSION Surgical operation may be a factor contributing to acquired hemophilia A, which, to our knowledge, has not been reported in the literature. Diagnosis of acquired hemophilia requires clinical acumen and any patient who presents with bleeding and a prolonged activated partial-thromboplastin time should be considered. Initial hemodynamic stabilization followed by treatment with immunosuppressive therapy is straightforward and highly successful.
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Meeks SL, Healey JF, Parker ET, Barrow RT, Lollar P. Non-classical anti-factor VIII C2 domain antibodies are pathogenic in a murine in vivo bleeding model. J Thromb Haemost 2009; 7:658-64. [PMID: 19187078 PMCID: PMC2897237 DOI: 10.1111/j.1538-7836.2009.03299.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The pathogenicity of anti-human factor (F) VIII monoclonal antibodies (MAbs) was tested in a murine bleeding model. METHODS MAbs were injected into the tail veins of hemophilia A mice to a peak plasma concentration of 60 nm, followed by injection of human B domain-deleted FVIII at 180 U kg(-1), producing peak plasma concentrations of approximately 2 nm. At 2 h, blood loss following a 4-mm tail snip was measured. The following MAbs were tested: (i) 4A4, a type I anti-A2 FVIII inhibitor, (ii) I54 and 1B5, classical type I anti-C2 inhibitors, (iii) 2-77 and B45, non-classical type II anti-C2 inhibitors, and (iv) 2-117, a non-classical anti-C2 MAb with inhibitory activity less than 0.4 Bethesda Units per mg IgG. RESULTS All MAbs except 2-117 produced similar amounts of blood loss that were significantly greater than control mice injected with FVIII alone. Increasing the dose of FVIII to 360 U kg(-1) overcame the bleeding diathesis produced by the type II MAbs 2-77 and B45, but not the type I antibodies, 4A4, I54, and 1B5. These results were consistent with the in vitro Bethesda assay in which 4A4 completely inhibited both 1 U mL(-1) and 3 U mL(-1) FVIII, while there was 40% residual activity at saturating concentrations of 2-77 at either concentration of FVIII. CONCLUSIONS For patients with an inhibitor response dominated by non-classical anti-C2 antibodies both the in vivo and in vitro results suggest that treatment with high-dose FVIII rather than bypassing agents may be warranted.
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Affiliation(s)
- S L Meeks
- Department of Pediatrics, Aflac Cancer Center and Blood Disorders Service, Children's Healthcare of Atlanta, Emory University, Atlanta, GA 30322, USA
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Franchini M, Lippi G, Manzato F, Vescovi PP. Thyroid-associated autoimmune coagulation disorders. J Thromb Thrombolysis 2009; 29:87-91. [DOI: 10.1007/s11239-009-0327-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Accepted: 02/25/2009] [Indexed: 01/08/2023]
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Pillai A, Gautam M, Williamson H, Martlew V, Nash J, Thachil J. Multisystem failure due to three coexisting autoimmune diseases. Intern Med 2009; 48:837-42. [PMID: 19443981 DOI: 10.2169/internalmedicine.48.1957] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Systemic lupus erythematosis (SLE) is a potentially fatal, autoimmune disease, which can affect different organs and can present with protean clinical manifestations. It may be associated with many other autoimmune conditions and two rare such conditions are myelofibrosis and acquired haemophilia. Autoimmune myelofibrosis is a bone marrow disorder characterized by pancytopenia, which can occur in conjunction with the presenting features, or an exacerbation of previously established SLE. Acquired haemophilia is another rare disorder of haemostasis, which can be life threatening without prompt and appropriate treatment. The management of these different conditions in itself poses a difficult problem but when the three conditions present simultaneously in the same individual, the accurate diagnosis and indeed the appropriate management becomes extremely challenging. This report describes a young woman who presented with pancytopenia secondary to myelofibrosis and panserositis with no identifiable precipitating factors. Her condition deteriorated rapidly and she required intensive care support for respiratory failure and renal impairment. A presumed diagnosis of SLE was considered and treatment was initiated which improved and stabilised her condition. However, she developed bleeding complications from acquired haemophilia which required further specialist intervention. Multidisciplinary management of the patient helped in the resolution of the complications and stabilisation of her autoimmune conditions. This report should make physicians aware of the rare presentations of SLE and its complex management.
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Affiliation(s)
- Arvind Pillai
- Department of Haematology, Royal Liverpool University Hospital, Liverpool, UK
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Lee N, Yoon SH, Lim W, Kim MH, Kim HJ, Kim SK, Park JS, Seol YM, Song MK, Choi YJ, Chung JS, Cho GJ. Post-operative Bleeding due to Acquired Hemophilia Successfully Treated with Recombinant Factor VIIa: Case Report. THE KOREAN JOURNAL OF HEMATOLOGY 2009. [DOI: 10.5045/kjh.2009.44.3.163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Naria Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Korea
| | - Seong Hoon Yoon
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Korea
| | - Won Lim
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Korea
| | - Mi Hyun Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Korea
| | - Hyo Jeong Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Korea
| | - Seon Kyeong Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Korea
| | - Jin Sup Park
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Korea
| | - Young Mi Seol
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Korea
| | - Moo Kon Song
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Korea
| | - Young Jin Choi
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Korea
| | - Joo Seop Chung
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Korea
| | - Goon Jae Cho
- Department of Internal Medicine, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Korea
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MASHIKO R, YAMAMOTO T, SATO M, NOGUCHI S, MATSUMURA A. Acquired Hemophilia First Manifesting as Life-Threatening Intracranial Hemorrhage -Case Report-. Neurol Med Chir (Tokyo) 2009; 49:93-5. [DOI: 10.2176/nmc.49.93] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Ryota MASHIKO
- Department of Neurosurgery, Kitaibaraki Municipal General Hospital
| | - Tetsuya YAMAMOTO
- Department of Neurosurgery, Graduate School of Comprehensive Human Sciences, University of Tsukuba
| | - Masayuki SATO
- Department of Neurosurgery, Kitaibaraki Municipal General Hospital
| | - Shozo NOGUCHI
- Department of Neurosurgery, Kitaibaraki Municipal General Hospital
| | - Akira MATSUMURA
- Department of Neurosurgery, Graduate School of Comprehensive Human Sciences, University of Tsukuba
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