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Ceglédi A, Dolgos J, Fekete M, Gopcsa L, Várkonyi A, Vilimi B, Mikala G, Bodó I. Delayed spontaneous remission of acquired factor V inhibitor refractory to immunosuppressive therapy with pregnancy-associated improvement. Pathol Oncol Res 2023; 29:1611250. [PMID: 37334173 PMCID: PMC10272408 DOI: 10.3389/pore.2023.1611250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 05/22/2023] [Indexed: 06/20/2023]
Abstract
Introduction: Acquired factor V inhibitor (AFVI) is a rare autoimmune bleeding disorder. The treatment of AFVI is challenging, and patients often require both bleeding control and inhibitor eradication. Methods: We conducted a retrospective analysis of the medical records of a 35-year-old Caucasian woman who presented with severe AFVI-induced bleeding and subsequent immunosuppressive therapy. Results: To provide haemostasis, rFVIIa was given with good efficacy. The patient was treated with various combinations of immunosuppressive regimens over the course of 2.5 years, including plasmapheresis plus immunoglobulins, dexamethasone + rituximab, cyclophosphamide + dexamethasone + rituximab + cyclosporine, cyclosporin + sirolimus + cyclophosphamide + dexamethasone, bortezomib + sirolimus + methylprednisolone, and sirolimus + mycophenolate mofetil. Although these treatment modalities resulted in intermittent partial reversals of AFVI over 2.5 years, eventually the inhibitor became therapy-resistant. However, following the discontinuation of all immunosuppressive therapy, the patient experienced a partial spontaneous remission, which was followed by a pregnancy. During the pregnancy, the FV activity increased to 54% and the coagulation parameters returned to normal levels. The patient underwent Caesarean section without any bleeding complications and delivered a healthy child. Discussion: The use of an activated bypassing agent for bleeding control is effective in patients with severe AFVI. The presented case is unique because the treatment regimens included multiple combinations of immunosuppressive agents. This demonstrates that AFVI patients may undergo spontaneous remission even after multiple courses of ineffective immunosuppressive protocols. Additionally, pregnancy-associated improvement of AFVI is an important finding that warrants further investigation.
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Affiliation(s)
- Andrea Ceglédi
- Departments of Hematology and Stem Cell Transplantation, South Pest Central Hospital, National Institute of Hematology and Infectious Diseases, Saint Ladislaus Campus, Budapest, Hungary
| | - János Dolgos
- Departments of Hematology and Stem Cell Transplantation, South Pest Central Hospital, National Institute of Hematology and Infectious Diseases, Saint Ladislaus Campus, Budapest, Hungary
| | - Mónika Fekete
- Department of Public Health, Semmelweis University, Budapest, Hungary
| | - László Gopcsa
- Departments of Hematology and Stem Cell Transplantation, South Pest Central Hospital, National Institute of Hematology and Infectious Diseases, Saint Ladislaus Campus, Budapest, Hungary
| | - Andrea Várkonyi
- Departments of Hematology and Stem Cell Transplantation, South Pest Central Hospital, National Institute of Hematology and Infectious Diseases, Saint Ladislaus Campus, Budapest, Hungary
| | - Beáta Vilimi
- Departments of Hematology and Stem Cell Transplantation, South Pest Central Hospital, National Institute of Hematology and Infectious Diseases, Saint Ladislaus Campus, Budapest, Hungary
| | - Gábor Mikala
- Departments of Hematology and Stem Cell Transplantation, South Pest Central Hospital, National Institute of Hematology and Infectious Diseases, Saint Ladislaus Campus, Budapest, Hungary
| | - Imre Bodó
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA, United States
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Mima F, Minami R, Asako M, Matsunaga H, Fujita Y, Takimoto Y, Senda S, Nakahara W, Ikeda M, Ueda S. Acquired Factor V Inhibitor Complicated with Immune Thrombocytopenia. Intern Med 2022; 61:91-95. [PMID: 34176833 PMCID: PMC8810259 DOI: 10.2169/internalmedicine.7173-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We herein report a patient with a high bleeding tendency as a result of acquired factor V inhibitor and immune thrombocytopenia (ITP). The administration of prednisolone increased the platelet count, but a fatal bleeding event occurred before platelet levels had sufficiently increased. Factor V is stored in not only plasma but also platelets, and platelet-derived factor V might play a local hemostatic role. Bleeding tendency may be high in rare cases where factor V inhibitor is complicated with severe thrombocytopenia. In such patients, physicians should consider aggressive hemostatic therapy, including plasma exchange, in addition to immunosuppressive therapy.
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Affiliation(s)
- Fuka Mima
- Department of Hematology, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Ryota Minami
- Department of Hematology, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Mizuki Asako
- Department of Hematology, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Hitomi Matsunaga
- Department of Hematology, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Yuri Fujita
- Department of Clinical Laboratory, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Yoshimi Takimoto
- Department of Clinical Laboratory, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Sonoko Senda
- Department of Clinical Laboratory, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Wataru Nakahara
- Department of Hematology, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Mako Ikeda
- Department of Hematology, Hyogo Prefectural Nishinomiya Hospital, Japan
| | - Shuji Ueda
- Department of Hematology, Hyogo Prefectural Nishinomiya Hospital, Japan
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Ichinose A, Osaki T, Souri M. A Review of Coagulation Abnormalities of Autoimmune Acquired Factor V Deficiency with a Focus on Japan. Semin Thromb Hemost 2021; 48:206-218. [PMID: 34942668 DOI: 10.1055/s-0041-1740149] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Coagulation factor V (or FV for the purpose of medical safety) is an essential cofactor of coagulation factor X in the common pathway of coagulation; severe FV deficiency leads to a bleeding tendency. Although both congenital and acquired FV deficiencies are widely recognized, FV deficiency also presents as an autoimmune disorder. A nationwide survey on autoimmune coagulation factor deficiencies (AiCFDs) conducted in Japan by our Japanese Collaborative Research Group identified 24 new patients with autoimmune FV deficiency (AiFVD) in the past 5 years. Furthermore, our extensive literature search confirmed that 177 AiFVD cases have been reported in previous articles published from Japan. Patients with AiFVD in Japan were predominantly men, with age similar to those with other AiCFDs. AiFVD was confirmed as a relatively mild type of bleeding diathesis, associated with lower mortality rate than that for AiFVD and other AiCFDs reported in previous studies. Patients with AiFVD had variable FV inhibitor titers and both neutralizing anti-FV autoantibodies and nonneutralizing counterparts. Although spontaneous resolution occurs in some patients, timely initiation of hemostatic and immunosuppressive therapies helps arrest the bleeding and eliminate anti-FV antibodies, resulting in a high cumulative recovery rate. Immunological anti-FV antibody detection is recommended to avoid missing AiFVD cases for the presence of nonneutralizing anti-FV autoantibodies. Further investigation is necessary to clarify the long-term prognosis and optimal management of AiFVD.
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Affiliation(s)
- Akitada Ichinose
- Department of Molecular Pathobiochemistry and Pathobiology, Yamagata University School of Medicine, Yamagata, Japan.,The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan
| | - Tsukasa Osaki
- Department of Molecular Pathobiochemistry and Pathobiology, Yamagata University School of Medicine, Yamagata, Japan.,The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan.,Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Iida-Nishi, Yamagata, Japan
| | - Masayoshi Souri
- Department of Molecular Pathobiochemistry and Pathobiology, Yamagata University School of Medicine, Yamagata, Japan.,The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan.,Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Iida-Nishi, Yamagata, Japan
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