Middle Cerebral Arterial Thrombosis in a Patient with Hypofibrinogenemia, 5 Days After rFVIIa and FFP Infusion

Genetic Analysis of Afibrinogenemia and Hypofibrinogenemia: Novel Mutations in the FGB Gene in the Turkish Population

INTRODUCTION

Congenital afibrinogenemia is a rare autosomal recessive disorder characterized by bleeding that varies from mild to severe and by complete absence or extremely low levels of plasma and platelet fibrinogen. Hypofibrinogenemia is characterized by fibrinogen levels <1.5 g/L.

OBJECTIVE

In this study, we analyzed fibrinogen beta chain gene mutations in Turkish afibrinogenemia and hypofibrinogenemia patients.

METHODS

We evaluated 20 afibrinogenemia and hypofibrinogenemia patients and 80 healthy controls. We have sequenced all exons of the FGB gene using the DNA isolated from the peripheral blood samples of patients and controls.

RESULTS AND CONCLUSION

We found a nonsense mutation in exon 4 at nucleotide 630 that encoded serine amino acid, and in the same exon a missense mutation of T to C at nucleotide 647, resulting in a transition from leucine to proline (p.L198P) in a child with hypofibrinogenemia. These mutations have been shown for the first time in the same patient of Turkish descent. Furthermore, there was a novel heterozygous guanine-to-adenine nucleotide change in exon 3. This caused the change of arginine amino acid to threonine amino acid at position 136 (p.A136T) in a protein, which has not been described in the literature before.

Successful Long Term Eradication of Factor VIII Inhibitor in Patients with Acquired Haemophilia A in Saudi Arabia

Acquired haemophilia A is a serious and potentially fatal bleeding disorder. Diagnosis is difficult and maybe delayed due to its rarity. The high mortality rate and the complex nature of treatment necessitate patient management at a haemophilia centre, where the required expertise and resources are available. Prompt diagnosis is crucial and early initiation of therapy could be life saving. Management includes initial control of bleeding followed by an approach to eradicate the coagulation factor inhibitor. In this paper we describe our local experience with acquired haemophilia A, which resulted in the successful control of major bleeding at presentation and eradication of inhibitors.

Fibrinogen replacement therapy for congenital fibrinogen deficiency

This review of published studies was conducted to derive data on patients with congenital fibrinogen deficiency (CFD), including dosing of fibrinogen replacement therapy, outcome, and adverse events, either temporally related or distant to fibrinogen replacement, in order to assist clinicians in developing treatment plans for patients with CFD. A systematic review was performed of case reports identified by a MEDLINE search between 1961 and 2010. Eligible studies included subjects with a diagnosis of CFD who received fibrinogen replacement. An attempt was made to extract dose, frequency, duration, hemostatic efficacy and adverse events such as thrombosis or allergic reactions. Reported thrombotic events distant from fibrinogen replacement were also recorded. From 104 papers reviewed, a total of 50 cases were identified: afibrinogenemia (35), hypofibrinogenemia (6), and dysfibrinogenemia (9). Fibrinogen replacement therapy was generally effective in preventing or treating bleeding in doses adequate to achieve and maintain fibrinogen activity above 50-100 mg dL(-1) (non-surgical and obstetric use) or 100-200 mg dL(-1) (surgical prophylaxis). Increased fibrinogen clearance was observed with massive hemorrhage, major surgery, and advanced pregnancy. Obstetric outcomes were optimized when fibrinogen replacement was initiated prior to conception. Uncontrolled hemorrhage, allergic reactions and antibody formation were rare events. However, thromboses, both related and unrelated to fibrinogen replacement, occurred in 15 of 50 (30%) patients overall, and in eight of 12 (67%) adult non-obstetric patients with afibrinogenemia. Published fibrinogen replacement regimens are presented for 50 CFD patients. Fibrinogen replacement therapy requires careful monitoring of fibrinogen levels. Afibrinogenemia is associated with thromboembolic complications with or without treatment.

A review of long-term prophylaxis in the rare inherited coagulation factor deficiencies

The rare inherited coagulation factor deficiencies (deficiencies of factors I, II, V, VII, XI, XIII, combined FV + FVII deficiency, combined deficiency of the vitamin K dependent factors and von Willebrand disease type 3) have an aggregate prevalence of approximately 1:100,000. They may cause recurrent life or function threatening haemorrhage. In this article we review the available literature on long-term prophylaxis and, where possible, make recommendations on this important area.

[Medical-surgical management of traumatic cardiac rupture: Relevance of recombinant activated factor VII]

The mortality rate from cardiac rupture by blunt chest injury is high. In multiple trauma patient, haemorrhage is a major cause of death. Regardless of aetiology, the management of massive bleeding requires immediate surgery with simultaneous stabilization of haemostasis and maintenance of normovolaemia. A pharmacological approach to reduce blood transfusion consists on the use of recombinant activated factor VII (rFVIIa). We report our experience with rFVIIa to control the haemorrhage in a blunt heart trauma with coagulopathy. The surgical exploration found a right haemothorax related to a pericardium rupture with two open wounds of the heart. The atrial and ventricular ruptures were repaired without cardiopulmonary bypass. The use of two consecutive doses (100 microg/kg) of rFVIIa during, and after surgery, reduced the need of transfusion. After this episode, the patient developed a transient cardiac dysfunction, and then was discharged from hospital. The use of rFVIIa reduced probably the need of blood transfusion in this case of blunt heart trauma. This treatment should be envisaged in similar cases after the failure of standard therapy to control the bleeding.

Feasibility of IA Thrombolysis for Acute Ischemic Stroke Among Anticoagulated Patients

BACKGROUND AND PURPOSE

Limited information exists regarding thrombolysis among anticoagulated acute stroke patients. We present data from three consecutive patients, on active warfarin therapy, treated with intra-arterial reteplase.

CASES

All patients were screened for the presence of intracranial hemorrhage. Warfarin was reversed with fresh frozen plasma in all patients and cerebral angiography and intra-arterial administration of reteplase was performed. Computed tomographic scans were performed to detect any subsequent intracranial hemorrhage. Ages ranged from 58 to 79 years with initial National Institutes of Health Stroke Scale scores ranging from 12 to 17. Baseline international normalized ratios (INRs) were 1.99-2.25. None of the patients suffered from intracranial hemorrhage following thrombolysis, and two of the patients experienced early neurological improvement.

CONCLUSION

Low dose, intra-arterial reteplase following acute reversal of elevated INR is feasible and may offer a potential treatment for patients suffering with acute ischemic stroke while receiving active warfarin treatment.