Association of Reduced Factor VIII with Impaired Platelet Reactivity to Adrenalin and Collagen after Total Thyroidectomy

Conservative management of a rare case of post thyroidectomy tracheal injury with coagulation abnormalities

Background

Tracheal injury is a rare but potentially serious acute complication of endotracheal intubation. Very few cases of tracheal injury associated with coagulation abnormalities have been reported in the literature. We present a rare case of a patient presenting with tracheal injury in combination with coagulation abnormalities following thyroidectomy.

Case presentation

A 58-year-old woman with a history of postoperative chemotherapy for breast cancer, gastric polyps, multiple colonic polyps, esophageal papillary adenomas, and thyroid adenomas presented with dyspnea following 10 ml hemoptysis on the third day after thyroidectomy; she was admitted to the intensive care unit and underwent tracheal intubation for maintaining the airway. Subsequent bronchoscopy revealed a nodular red neoplasm 5-cm from the carina in the trachea obstructing part of the lumen, with a small amount of fresh hemorrhage on the surface. Tracheal injury was considered the preliminary diagnosis. Fiberoptic bronchoscope guided tracheal intubation helped prevent rupture of the tumor, and the cannula was properly inflated to arrest the bleeding while blocking the lower part of the trachea. An emergency surgical evacuation of the cervical hematoma was performed for managing postoperative bleeding. The patient demonstrated persistent pancytopenia despite frequent transfusions. Laboratory examination results revealed abnormal coagulation parameters, anemia, and hepatic dysfunction. Following a multidisciplinary team discussion, pituitrin for hemostasis, tranexamic acid for strengthening hemostasis treatment, and nutritional support and anti-infection treatment were initiated. Endotracheal tube cuff inflation was performed to compress the bleeding site. Complete resolution of the subcutaneous hematoma was observed nine days after the tracheal injury; bronchoscopy revealed residual ecchymosis in the airway hematoma with no evidence of obstruction.

Conclusion

Conservative management of tracheal injury limited to the mucosa or submucosa without significant amount of active bleeding using endotracheal intubation is considered a practical and effective approach. Successful management was ensured by appropriate clinical suspicion, early multidisciplinary team discussion, and prompt diagnosis and interventions.

Changes in haemostasis and thrombosis associated with thyroid disease: Presentation of 2 cases

There is a relationship between thyroid diseases and primary and secondary changes in haemostasis. The most frequent association between them are hypocoagulability states with clinical hypothyroidism and vascular thrombophilia (hypercoagulability and/or hypofibrinolysis) with hyperparathyroidism. However, there are recent studies that have detected changes in haemostasis -primary and secondary- associated with thyroid diseases with normal hormone levels, suggesting other pathogenic mechanisms not yet known. The cases are presented of 2 patients with thyroid disease that required surgery: one multinodular goitre and one papillary carcinoma of the thyroid, both with normal hormone levels. They were shown to have haemostasis disorders during the preoperative work up. These showed a Factor VII deficiency and a Factor XI deficiency along with a thrombotic disease of unknown origin, respectively.

Hemostatic changes in thyroid diseases

Several studies have reported hemostatic abnormalities, both in terms of bleeding or thrombosis, in patients with various thyroid dysfunctions. The aim of this review is to briefly discuss the relationship between thyroid disorders and hemostasis (i.e. primary hemostasis, coagulation factors and fibrinolytic system). From the analysis of the more recent literature data, it appears evident that most of the coagulation abnormalities associated with thyroid disorders are a consequence of a direct action of thyroid hormones on the synthesis of various hemostatic factors or a derangement of immune function. On the whole, these data suggest that a hypercoagulable state is present in hyperthyroid patients, while patients suffering from moderate hypothyroidism are at increased risk of thrombosis contrasting with the bleeding tendency of those presenting severe hypothyroidism.

Acquired von Willebrand disease secondary to hypothyroidism: a rare cause for postextraction hemorrhage

Acquired von Willebrand's Disease (AvWD) is a rare disease with a clinical pattern similar to the congenital disorder that typically presents later in life in patients with no prior history of prolonged bleeding. It has been shown to be related to a number of common medical conditions including lymphoproliferative and myeloproliferative diseases, cardiovascular disease, immunological disorders, neoplasia, drugs, and miscellaneous disorders. We present 2 cases where post- and interoperative hemorrhage were the initial sign of AvWD and a previously undiagnosed hypothyroid condition was the precipitating factor. There are no similar cases reported within the dental literature. We highlight the importance of taking a medical history and bleeding history in all patients about to undergo oral surgery, periodontal surgery, or implant placement. Increased vigilance is suggested when patients, who have been otherwise well, present with abnormal bleeding problems as this may be a manifestation of an underlying undiagnosed disease.

Hyperthyroidism and venous thrombosis: a casual or causal association? A systematic literature review

A kaleidoscope of coagulation disorders have been reported in patients with thyroid dysfunctions. Globally, these disorders involve both primary and secondary hemostasis and range from subclinical laboratory abnormalities to, more rarely, life-threatening hemorrhages or thrombotic events. While overt hypothyroidism appears to be associated with a bleeding tendency, hyperthyroidism emerged to have an increased risk of thrombotic events. In particular, a number of case reports have documented acute venous thrombosis complications in patients with overt hyperthyroidism, especially at cerebral sites. Nevertheless, further observational and intervention studies might be needed to provide a more definitive information on the clinical relevance of this association, along with the potential implication for prevention and treatment of coagulation-fibrinolytic abnormalities in patients with thyroid dysfunction.

The Role Of von Willebrand Factor In Hemorrhagic And Thrombotic Disorders

von Willebrand factor (VWF) is a multimeric plasma protein that mediates platelet adhesion as well as platelet aggregation at sites of vascular injury and acts as a carrier of factor VIII. Although acquired or inherited VWF deficiency is associated with a bleeding tendency, there is increasing evidence that VWF has a pivotal role in thrombogenesis. In fact, while the presence in the plasma of unusually large VWF multimers, due to a congenital or acquired deficiency of a VWF-cleaving metalloprotease, has been implicated in the pathogenesis of thrombotic thrombocytopenic purpura, high plasma levels of VWF have been associated with an increased risk of both arterial and venous thrombosis. The role of VWF in normal and pathological hemostasis is discussed in this review, and important advances in the pathophysiology, diagnosis, and treatment of VWF-associated disorders are also described.

Hypothyroidism and acquired von Willebrand's syndrome: a systematic review

Acquired von Willebrand's syndrome type I is the supposed main underlying cause of bleeding tendency in hypothyroid patients. The purpose of this systematic review was to summarize the published evidence on the association between hypothyroidism and acquired von Willebrand's syndrome. All published clinical epidemiological and interventional studies, case reports and in vitro studies that investigated the association between hypothyroidism and acquired von Willebrand's syndrome were identified by a computer-assisted search of the MEDLINE and EMBASE electronic databases. A quality assessment was performed for clinical epidemiological studies. A total of 41 papers were included. A total of 22 epidemiological in vivo studies, two in vitro studies and 47 case reports were finally analyzed. No high quality in vivo study was identified. Almost all bleeding episodes described in the case reports were mucocutaneous. von Willebrand factor (VWF) antigen value was available for 23 patients: median value 28 U/dL (range: 4-45); VWF activity was available for 24 patients: median value 28.5 U/dL (range: <3-55); factor VIII activity was available for 16 patients: median value 47 U/dL (range: 9-74). Acquired von Willebrand's syndrome may be the main factor responsible for bleeding diathesis in overt hypothyroid patients. Even if bleeding episodes are mainly mild and mucocutaneous, blood transfusion, drug administration or surgical procedure may be required.

Clinical review: Thyroid dysfunction and effects on coagulation and fibrinolysis: a systematic review

CONTEXT

Various changes in the coagulation-fibrinolytic system have been described in patients with an excess or deficiency of thyroid hormones. The purpose of this systematic review is to summarize the effects of hyperthyroidism and hypothyroidism on these systems.

EVIDENCE ACQUISITION

All published case-control or interventional cohort studies that evaluated the effects of hyperthyroidism and hypothyroidism on the coagulation-fibrinolytic system in vivo were identified by a computer-assisted search of the MEDLINE and EMBASE electronic databases. A scoring system was used to divide studies into three quality categories: high, medium, and low quality.

EVIDENCE SYNTHESIS

A total of 36 papers were included. Because in several papers more than one case-control study or both a case-control and intervention study were described, a total of 39 case-control studies and 24 interventional cohort studies were analyzed. No high-quality study was identified. Three (7.7%) case-control and eight (33.3%) cohort studies were of medium quality. A total of 19 tests were investigated in the medium-quality studies. These tests revealed a hypocoagulable state for overt hypothyroidism and a hypercoagulable state for overt hyperthyroidism.

CONCLUSIONS

This analysis confirmed that clinically overt hyperthyroidism and hypothyroidism modify the coagulation-fibrinolytic balance, indicating that thyroid hormone excess or deficit is the probable main pathophysiological mechanism. Patients with overt hypothyroidism and overt hyperthyroidism appear to have an increased risk of bleeding and of thrombosis, respectively.

Acquired von Willebrand syndrome: an update

Acquired von Willebrand syndrome (aVWS) is a rare bleeding disorder with laboratory findings similar to those for congenital von Willebrand disease (VWD). However, unlike congenital VWD, it arises in individuals with no personal or family history of bleeding. aVWS occurs in association with a variety of underlying disorders, most frequently in lymphoproliferative disorders, myeloproliferative disorders, and cardiovascular diseases. Through an analysis of the more recent literature data, the pathophysiology and the clinical, laboratory, and therapeutic aspects of this syndrome are concisely reported in this review.

Effects of levothyroxine treatment on biochemical and hemostasis parameters in patients with hypothyroidism

OBJECTIVE

The aims of the study were to evaluate the disturbances in the coagulation system in patients with overt hypothyroidism (OH), to assess the effects of levothyroxine (LT4) on the coagulation parameters, and to determine whether subclinical hypothyroidism (SH) affects concentrations of coagulation markers and several biochemical parameters, thereby supporting early substitution.

DESIGN

The study included 15 patients with SH (TSH levels 5-10 mU/l), 15 patients with OH and 15 euthyroid controls.

METHODS

Blood urea nitrogen, creatinine, creatine phosphokinase, aspartate aminotransferase, lactate dehydrogenase, total-cholesterol, high density lipoprotein-cholesterol, low density lipoprotein-cholesterol and triglyceride levels, and bleeding time, prothrombin time (PT), activated partial thromboplastin time (APTT), factor VIII activity, von Willebrand factor activity (vWF), platelet count and clotting time were evaluated just before and three months after the maintenance of euthyroidism with LT4 treatment.

RESULTS

Factor VIII and vWF activities were lower in patients with SH than in controls (P < 0.01). Increased bleeding time, PT, APTT and clotting time and decreased factor VIII activity and vWF activity were observed in patients with OH when compared with controls. Bleeding time, PT, APTT and clotting time decreased and factor VIII activity, vWF and platelet count increased after LT4 in patients with OH. Increases in factor VIII activity and vWF (P < 0.01) were detected also in the SH group with treatment.

CONCLUSIONS

OH is associated with significant abnormalities in clotting parameters which are reversed by LT4. In contrast, SH is associated with minor changes in factor VIII activity and vWF which are reversible by LT4. Serum lipids and other measured parameters are not improved by LT4 in patients with TSH < 10 mU/l and these data fail to demonstrate a need to treat such patients.

Hemostasis and thyroid diseases revisited

Several papers have reported various hemostatic abnormalities in patients with thyroid diseases. In this concise review, the traditional associations between hypercoagulable state and hyperthyroidism and between hypocoagulative state and hypothyroidism are critically revised on the basis of more recent literature data. In particular, we analyze the hemostatic balance (primary hemostasis, coagulation factors and fibrinolytic system) in different thyroid disorders. Although most of the studies published so far include limited numbers of patients and their results are sometimes contradictory, we can conclude that hyperthyroidism is generally accompanied by a hypercoagulable state, whereas the hemostatic profile in hypothyroidism and thyroid cancer depends on the severity of the disease.

Acquired von Willebrand's disease

von Willebrand's disease (vWD) is the commonest inherited bleeding disorder in man with an estimated incidence of 1 per thousand of the population. Acquired von Willebrand's disease (AvWD) is rare with less than 70 cases reported. AvWD is usually associated with autoimmune or clonal proliferation disorders and whilst the precise mechanism of acquired deficiency of von Willebrand factor (vWF) is poorly understood, the most likely candidate mechanism(s) are; antibodies inactivate or form a complex with immunologic or functional sites on vWF, or vWF multimers are selectively absorbed by malignant cells. Unlike hereditary vWD, the acquired form of the disease can be exceedingly difficult to manage. We report 4 cases of AvWD diagnosed at our centre over the past 3 yr. There was no evidence of a previous personal or family history of bleeding in any of the patients and AvWD was confirmed by laboratory testing. All 4 patients had a recognised primary medical condition known to be associated with AvWD (Waldenstrom's Macroglobulinaemia in 2 patients, hypothyroidism in 1 patient and monoclonal gammopathy of unknown significance (MGUS) in 1 patient). The acquired haemostatic defect corrected following treatment of the primary condition in 3 patients with the other patient requiring on demand von Willebrand Factor replacement to control spontaneous and surgery induced bleeding.

von Willebrand's disease in the dog and cat

Von Willebrand's disease (vWD) is a bleeding disorder that is recognized commonly in dogs but rarely in cats. This article presents the pathophysiology and clinical features of vWD, including a discussion of inherited and acquired types of vWD. Laboratory evaluation and treatment of vWD are reviewed.

von Willebrand disease in children and adolescents

The term von Willebrand disease includes many bleeding disorders caused by abnormalities of vWF. Frequent or severe bleeding may be indicative of vWD or other bleeding conditions. Primary care practitioners need to be familiar with vWD and evaluate possibly affected individuals with appropriate laboratory studies. Patients with vWD should be educated about their disorder and preventive measures to limit its effect. Medications are available that can treat or prevent bleeding complications for most patients with vWD. Intervention with blood products is occasionally necessary.

Plasma von Willebrand factor antigen concentration and buccal mucosal bleeding time in dogs with experimental hypothyroidism

This study was undertaken to investigate the effects of hypothyroidism on buccal mucosal bleeding time and von Willebrand factor antigen (vWf:Ag) concentrations. Hypothyroidism was induced in 8 adult dogs by administration of iodine 131. Four healthy dogs acted as controls. Measurement of plasma vWf:Ag and serum thyroxine and triiodothyronine concentrations, and buccal mucosal bleeding time were made before induction of hypothyroidism, for 23 weeks after 131I administration, and during 5 weeks of levothyroxine supplementation. No significant changes in buccal mucosal bleeding times were noted during the study. After an insignificant increase in vWf:Ag concentration in hypothyroid dogs, levothyroxine treatment was associated with a significant decrease in vWf:Ag concentration in hypothyroid dogs when compared with controls. Results of this study suggest that hypothyroidism does not induce acquired von Willebrand's disease or significant defects in primary hemostasis.

Primary haemostasis in thyroid disease

OBJECTIVES

There have been reports on a bleeding tendency in hypothyroidism resembling von Willebrand's disease. The aim of the present study was to investigate whether altered primary haemostasis is a general phenomenon in thyroid disease.

DESIGN/SETTING

A total of 10 patients with hyperthyroidism and nine patients with hypothyroidism were studied at diagnosis, and during treatment with carbimazole or L-thyroxine, respectively, when euthyroidism had been achieved.

RESULTS

In untreated hypothyroidism, template bleeding time was prolonged (median 9.3 min, range 3.8-20.0 min) compared to that in controls (median 4.0 min, range 3.0-6.0 min; P < 0.05), whereas maximal agglutination velocity induced by ristocetin was decreased (38% min-1, range 4-52% min-1 vs. 70% min-1, range 60-81% min-1, P < 0.05). The level of von Willebrand factor antigen in plasma from hypothyroid patients was less than half of the value in hyperthyroid patients. This difference disappeared after euthyroidism was achieved.

CONCLUSIONS

We found that changed primary haemostasis is a general feature of hypothyroidism, and that it is resolved after levothyroxine treatment.

Elevated plasma levels of VWF:Ag in hyperthyroidism are mediated through beta-adrenergic receptors

Thyroid dysfunction influences the levels of Von Willebrand factor (VWF:Ag). Plasma VWF:Ag levels in 35 hyperthyroid patients were significantly elevated, which had a positive correlation with both T3 (Triiodothyronine) and T4 (Thyroxine) levels. A follow-up study of seven hyperthyroid patients undergoing anti-thyroid therapy showed that the elevated VWF:Ag levels returned to normal range with the normalization of thyroid function. On the other hand, after administration of 160 mg/day of propranolol, a specific blocker of beta-adrenergic receptors, to five hyperthyroid patients for twenty-eight days, plasma VWF:Ag levels returned to normal range, while T3, T4 levels remained high without significant alteration. These results demonstrated that the elevation of plasma VWF:Ag by thyroid hormone is mediated through beta-adrenergic receptors, which may be useful to further understand the physiological and pathological roles of thyroid hormone in the regulation of VWF:Ag levels.