Spectrum of Inherited Bleeding Disorders in Indians

Diagnostic Challenges in Children With Congenital Bleeding Disorders: A Developing Country Perspective

OBJECTIVES

To assess the frequency and characteristics of children with inherited bleeding disorders that were initially misdiagnosed, leading to inappropriate disease management.

METHODS

This study was conducted at the Haematology/Pathology Department of Fauji Foundation Hospital, Rawalpindi, Pakistan, from August 2014 to August 2018. Children who were diagnosed with an inherited bleeding disorder but did not respond to initial therapy were reevaluated.

RESULTS

In total, 62 children were diagnosed with a bleeding disorder. Of these, 27 were diagnosed with an inherited bleeding disorder and 35 with an acquired bleeding disorder. Of the 27 children with inherited bleeding disorders, 18% (n = 5) were misdiagnosed and treated inappropriately. The median age of the misdiagnosed patients was 9 years (range, 5-13 years). Three patients with Bernard-Soulier syndrome had been misdiagnosed as having immune thrombocytopenic purpura, 1 patient with von Willebrand disease had been misdiagnosed as having hemophilia A, and 1 patient with haemophilia B had been misdiagnosed as having hemophilia A.

CONCLUSIONS

There are chances of misdiagnosis and improper or invasive management if comprehensive laboratory evaluation and a thorough clinical evaluation are not performed in children with congenital bleeding disorders.

Inherited Bleeding Disorders in North Indian Children: 14 years' Experience from a Tertiary Care Center

Inherited bleeding disorders are not uncommon in pediatric practice: most of them being chronic, require lifelong replacement therapy. To frame a management policy, it is essential to assess the load and pattern of bleeding disorders in the local population. However, there is paucity of data reporting the clinical spectrum of coagulation and platelet function disorders in Indian children. Hence to find out the exact burden and clinico-investigational profile of these patients we conducted this study. In this retrospective case review, detailed clinical information was extracted from case records in 426 children with a suspected diagnosis of hereditary bleeding disorder registered in the Pediatric Hematology clinic of a tertiary referral centre over a period of 14 years (1998-2011) and pooled for analysis. In our cohort prevalence of hemophilia A, hemophilia B, platelet function disorders, von Willebrand disease and other rare factor deficiencies were 72%, 11%, 7%, 4% and 4% respectively. Common clinical spectrum included skin bleeds, arthropathy, mucosal bleeds. 10% had deeper tissue bleeding and 16% received replacement therapy at the first visit. Nearly 3/4th of cases were lost for follow up after the initial visit. Hemophilia A was the commonest inherited bleeding disorder in our population. Skin bleeds and arthropathy were common clinical presentations. Factor replacement therapy was restricted to a minority. There is an urgent need for establishing centres of excellence with administrative commitment for factor replacement therapy for comprehensive management of such children in resource-limited countries.

Inherited Bleeding Disorders-Experience of a Not-for-Profit Organization in Pakistan

Patient registry is a powerful tool for planning health care and setting groundwork for research. This survey reports a detailed registry of inherited bleeding disorders (IBD) and their management at a not-for-profit organization in a developing country to form the basis for planning development and research. We reviewed medical records of patients with IBD from 8 hemophilia treatment centers of Fatimid Foundation located in various cities. Information collected included sociodemographic data, diagnostic tests, severity of hemophilia A and B, number of bleeding episodes per year, site and frequency of hemarthrosis, and seropositivity for viral diseases. We analyzed 1497 patients from November 1, 2015, to April 30, 2016. There were 1296 (87%) males and 201 (13%) females with a mean age of 24.5 (11) years (range, 6 months to 65 years). Hemophilia A constituted the bulk of IBD (848, 57%) followed by von Willebrand disease (172, 11%), hemophilia B (144, 10%), platelet function defect (106, 7%), and rare bleeding disorders (70, 5%). Mucocutaneous bleeding (1144, 76%) and hemarthrosis (1035 patients, 69%) were the main complications. There were 1026 (69%) patients who received only blood components for treatment of any bleeding episode while the remaining 464 (31%) were on combination therapy (blood components and factor concentrate). Seroreactivity for hepatitis C was frequent (28%), while hepatitis B (1%) and human immunodeficiency virus (0.01%) were less commonly seen. This study was an important step toward a patient registry in a hemophilia treatment center in Pakistan. Hemophilia A is the most common bleeding disorder and hepatitis C is the most frequent treatment-related complication.

Clinical profile of patients with rare inherited coagulation disorders: a retrospective analysis of 67 patients from northern India

Introduction

Inherited bleeding disorders are characterized by the absence or reduced level of clotting factors, and the clinical manifestations vary according to the type and magnitude of the deficient factor.

Aim

To study the clinical presentation of the rare inherited coagulation factor disorders in a tertiary care hospital and to compare the data from those reported in other populations.

Methods

Sixty-seven patients, who presented to the Department of Hematology, All India Institute of Medical Sciences, New Delhi, were evaluated retrospectively from 2005 to 2011. The tests performed included platelet count, prothrombin time (PT), activated partial thromboplastin time (aPTT), thrombin time (TT), factors assay and clot solubility test in 5 M urea. Factor XI assays were aPTT based while factors V, VII and X assays were PT based.

Results

Male to female ratio was 2:1. The median age of onset of the first episode of bleeding was at 6 months (range, from birth to 20 years) whereas the median age of presentation to our hospital was 9 years (range, 2 months to 54 years). The most common deficient factor was factor X (43%), followed by factor XIII (27%) and factor VII (10%).

Conclusion

There is a wide gap between the initial manifestation of the bleeding disorders and first presentation to the tertiary care hospital for assessment and treatment. Factor X deficiency is the most common among these rare coagulation disorders in our population, whereas factor VII deficiency is more common in Iranian and North American population.

Congenital bleeding disorders in Karachi, Pakistan

OBJECTIVE

To determine the frequency of inherited bleeding disorders, its complications, and treatment modalities available for its treatment.

DESIGN

Cross-sectional study.

PATIENTS AND METHODS

Patients with a history of bleeding tendency were tested for confirmation of the diagnosis. History and clinical findings were recorded. Laboratory analysis included prothrombin time (PT), activated partial thromboplastin time (APTT), bleeding time (BT), and fibrinogen assay. Patients with prolonged APTT were tested for factors VIII (FVIII) and IX (FIX). If FVIII was low, von Willebrand factor: antigen (vWF:Ag) and von Willebrand factor:ristocetin cofactor (vWF:RCo) were performed. When PT and APTT both were prolonged, FV, FX, and FII were tested. Platelet aggregation studies were done when there was isolated prolonged BT. Urea clot solubility test was done when all coagulation tests were normal. All patients with hemophilia A and B were evaluated for inhibitors.

RESULTS

Of the 376 patients, inherited bleeding disorder was diagnosed in 318 (85%) cases. Median age of patients was 16.4 years. Hemophilia A was the commonest inherited bleeding disorder that was observed in 140 (37.2%) followed by vWD 68 (18.0%), platelet function disorders 48 (12.8%), and hemophilia B in 33 (8.8%) cases. We also found rare congenital factor deficiencies in 13 (3.4%), low VWF in 11 (3.0%) participants and 5 (1.3%) in female hemophilia carriers. Hemarthrosis was the most frequent symptom in hemophilia A and B (79.7%) involving knee joint. Inhibitor was detected in 21 (15%) cases. Fresh frozen plasma/cryoprecipitate were the most common modality of treatment. In 58 patients, no abnormality was detected in coagulation profile.

CONCLUSION

Hemophilia A and vWD are the most common congenital bleeding disorders in this study. Hemarthrosis involving knee joint was the most common complication. Inhibitor was detected in a significant number of patients. Plasma is still the most common modality of treatment.

Clinical features and types of von Willebrand disease in Karachi

This study was conducted on patients with a history of congenital bleeding disorders or with suspected bleeding tendencies. Laboratory analysis revealed Von Willebrand disease (VWD) in 68 (21.3%) of 318 participants with male to female ratio of 0.8: 1 (31 to 37) and median age 17 years (range 2-45 years). Type 3 being the most frequent, 35 (51.4%) of 68, type 2, 20 (29.4%) of 68, and lastly type 1, 13 (19.1%) of 68. A total of 55.8% patients with VWD presented with mucocutaneous bleeding. Menorrhagia was the most common presentation of female patients. Von Willebrand disease (21.3%) was the second common bleeding disorder and the most common coagulation defect among females with menorrhagia. However, the frequency in the study was quite low when compared to the western world. Similarly, low frequency of VWD type 1 might be due to the fact that only symptomatic patients visited us. Further studies are needed as there is limited information on VWD in the developing countries. This will help in the development of expertise for the accurate diagnosis & proper management.

An experience of single centre at C S M Medical University, Lucknow, for the prevalence of hemophilia in Uttar Pradesh

OBJECTIVE

To evaluate the incidence of hereditary bleeding disorders, registered at our centre from all over Uttar Pradesh over an extended period of 10 years.

MATERIAL AND METHODS

A complete coagulation profile of 240 cases conducted, followed by clinical history of the patient. The frequency and type of bleeding, age of onset, treatment taken, consanguinity and the blood transfusion if any, are little information collected from the patient.

RESULTS

The complete scenario of bleeders indicated maximum number (92%) of hemophilia 'A' from northern UP as compared from other zones (76.5% ± 3). Contrarily, hemophilia 'B' registered maximum from eastern zone (26%) and minimum from the northern zone (8%). The age diversity at diagnosis ranged between 1-32 years. The reasons for difference are all speculative. Definite cause needs extensive research.

CONCLUSIONS

The study showed that elderly patients with hemophilia had significantly more impairments in physical functioning and depression than younger ones.

Inherited platelet function disorders versus other inherited bleeding disorders: an Indian overview

Inherited deficiencies of plasma proteins involved in blood coagulation generally lead to lifelong bleeding disorders, whose severity is directly proportional to the degree of factor deficiency. Platelet and other coagulation factors play an important role in the haemostasis mechanism. We attempted to study the prevalence of inherited platelet function disorders (PFDs) and correlate with other coagulation factor disorders in the Indian population. Patients with PFDs and other coagulation factor disorders who presented at our hospital during the 5 year period (from January, 2001 to December, 2005) were the subjects of the study. A total of 1576 patients were diagnosed to have congenital bleeding disorders including PFDs, von Willebrand disease, haemophilia A and B and rare coagulation disorder cases. Haemophilia A (HA) was the most common and was seen in 52.31% of the patients followed by total PFDs seen in 27.77% of the patients. Based on severity of the disease, the results of PFDs were highly significant when compared to haemophilia and von Willebrand disease (VWD) (p=0.000). Severity was found higher in HA (77.8%) followed by HB (69.6%) and was found lower for PF3 availability defect (9.0%). It has been concluded that the prevalence of PFDs is relatively low as compared to coagulation factors related disorder and also it has been established that type-1 VWD is relatively less frequent in India as compared to the West.