Increasing levels of von Willebrand factor and factor VIII with age in patients affected by von Willebrand disease: REPLY from original authors Biguzzi et al

Scrub Typhus Combined With Septic Shock Disseminated Intravascular Coagulation and Significant Hyperfibrinolysis: A Case Report and Review of the Literature

Introduction: Scrub typhus is an acute infectious disease caused by Orientia tsutsugamushi, whose pathophysiology is characterized by systemic small-vessel vasculitis. Its high misdiagnosis rate stems from its nonspecific clinical features. If not diagnosed and treated in time, patients may rapidly progress to multiorgan dysfunction syndrome (MODS) or even disseminated intravascular coagulation (DIC), posing a severe threat to life. Case Presentation: The patient was a 68-year-old male with "recurrent fever and dry cough for six days." He was admitted to the hospital with a diagnosis of scrub typhus. After admission, he developed severe acute respiratory distress syndrome (ARDS), MODS, septic shock, DIC with thrombocytopenia, hypofibrinogenemia, significant hyperfibrinolysis, and myocardial depression. The patient improved following treatment with doxycycline, moxifloxacin, renal replacement therapy, blood transfusion, antifibrinolysis, invasive mechanical ventilation, and other supportive therapies. The patient's coagulation profile in DIC caused by scrub typhus demonstrated significant hyperfibrinolysis, differing from that of garden-variety sepsis, and no similar cases were identified in a search of medical literature/databases. Conclusion: The fibrinolytic system in DIC caused by scrub typhus is excessively active, and antifibrinolytic therapy may benefit such patients. Further research on the distinct coagulation abnormalities in scrub typhus-associated DIC would be highly valuable compared to sepsis-associated DIC.

Knee replacement surgery in a patient with acquired von Willebrand disease: a case study with recommendations for patient management

Introduction and importance

Acquired von Willebrand disease (AvWD) is a rare underdiagnosed bleeding disorder caused by alterations in the levels of the major blood-clotting protein von Willebrand factor (vWF). The clinical and laboratory parameters of AvWD are similar to congenital vWD, but it is found in individuals with no positive family history with no underlying genetic basis. The disease remains multifactorial and incompletely understood. Proposed mechanisms include the development of autoantibodies to vWF, absorption of high molecular weight vWF multimers that impair normal function, shear stress induced vWF cleavage and increased proteolysis.The aetiology of the disease is variable, the most common being hematoproliferation, lymophoproliferation, myeloproliferation and autoimmune and cardiovascular disorders. Consensus and protocols for AvWD patients that require major surgery are currently lacking. Patients with AvWD can experience thrombotic events during surgery as a result of therapeutic interactions with pro-thrombotic risk factors.

Case presentation

Here, the authors report a patient with AvWD requiring a knee prosthesis implantation due to chronic pain, limited range of motion and functional impairment. The patient had a high risk of bleeding during surgery and was at risk of thrombosis due to age and obesity.

Clinical discussion

Perioperative care required a collaborative approach and the management of bleeding. The patient was administered vWF concentrate Willfact lacking Factor VIII to prevent haemorrhage and to minimize the risk of thrombosis.

Conclusion

The treatment was effective and well-tolerated. The authors use this information to provide recommendations for AvWD patients for whom major surgery is indicated.