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Takahashi M, Morita Y, Hayashi T, Higashihara T, Kawasaki K, Sato S, Yokose S, Sasaki S, Funakoshi K, Sasaki T, Zhou D, Ichinose A, Ohtsuka H, Ishibasi Y, Hatao F, Shimizu K, Isono N, Sasaki N, Kozai Y, Okada H, Chikasawa Y. A case of acquired hemophilia A after pancreaticoduodenectomy for distal cholangiocarcinoma. Biomed Rep 2023; 19:61. [PMID: 37614988 PMCID: PMC10442756 DOI: 10.3892/br.2023.1643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/17/2023] [Indexed: 08/25/2023] Open
Abstract
Acquired hemophilia A (AHA) is a rare disease that results from factor VIII inhibitors causing abnormal coagulation, and certain cases may develop after highly invasive surgery. The present case study reports on a 68-year-old male patient who developed AHA after undergoing a subtotal stomach-preserving pancreatoduodenectomy for distal cholangiocarcinoma. The patient experienced complications after surgery, requiring reoperation on postoperative day (PD) 5 due to rupture of the Braun's enterostomy. On PD 6, angiography was performed after bleeding was detected in the jejunal limb, but hemostasis occurred spontaneously during the examination. Bleeding was observed again on PD 8 and direct surgical ligation was performed. On PD 14, bleeding recurred in the jejunal limb and angiography was performed to embolize the periphery of the second jejunal artery. During the procedure, the prothrombin time was normal, but only the activated partial thromboplastin time was prolonged. A close examination of the coagulation system revealed a decrease in factor VIII levels and the presence of factor VIII inhibitors, resulting in the diagnosis of AHA. Administration of steroids was initiated on PD 15 and, in addition to daily blood transfusions, activated prothrombin complex concentrate was administered to achieve hemostasis. The patient was discharged from the intensive care unit on PD 36 but later developed an intractable labial fistula due to suture failure at the gastrojejunostomy site. As the use of factor VIII inhibitors continued despite the administration of steroids, cyclophosphamide (CPA) pulse therapy was added at PD 58. However, CPA was ineffective and the administration of rituximab was initiated on PD 98. After 12 courses of rituximab, the patient tested negative for factor VIII inhibitors on PD 219. On PD 289, labial fistula closure was performed with continuous replacement of factor VIII and the patient was discharged on PD 342.
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Affiliation(s)
- Makoto Takahashi
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Yasuhiro Morita
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Tatsuya Hayashi
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Taku Higashihara
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Keishi Kawasaki
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Shunsuke Sato
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Shota Yokose
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Shu Sasaki
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Kaoruko Funakoshi
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Takayoshi Sasaki
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Daren Zhou
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Akinori Ichinose
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Hideo Ohtsuka
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Yuji Ishibasi
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Fumihiko Hatao
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Keiki Shimizu
- Department of Critical Care and Emergency Medicine, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Nobuo Isono
- Department of Plastic Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Naomi Sasaki
- Department of Nursing, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Yasuji Kozai
- Department of Hematology, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Haruka Okada
- Department of Pathology, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Yushi Chikasawa
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo 183-8524, Japan
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Shoji-Asahina A, Nakatani E, Imaichi Y, Ohata E, Oshima M, Miyakoshi A, Miyake H, Ichikawa Y, Dote H, Ubukata N, Funaki D, Urano T. Risk factors, treatment and survival rates of late-onset acquired haemophilia A: A cohort study from the Shizuoka Kokuho Database. Haemophilia 2023; 29:799-808. [PMID: 37096498 DOI: 10.1111/hae.14793] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 03/01/2023] [Accepted: 04/12/2023] [Indexed: 04/26/2023]
Abstract
INTRODUCTION Acquired haemophilia A (AHA) is a rare disease. The risk factors have yet to be studied. AIM We aimed to identify risk factors for late-onset AHA in Japan. METHODS A population-based cohort study was conducted using data from the Shizuoka Kokuho Database. The study population was defined as individuals aged ≥60 years. Cause-specific Cox regression analysis was performed to calculate hazard ratios. RESULTS Of 1,160,934 registrants, there were 34 patients with newly diagnosed AHA. The mean follow-up period was 5.6 years, and the incidence of AHA was 5.21 per million person-years. Myocardial infarction, diabetes mellitus, solid tumors, antimicrobial agents, phenytoin and anti-dementia drugs, which showed significant differences in the univariate analysis, were excluded from the multivariable analysis because of the small number of cases. Multivariable regression analysis showed that the presence of Alzheimer's disease (hazard ratio [HR]:4.28, 95% confidence interval [CI]:1.67-10.97) and rheumatic disease (HR:4.65, 95% CI:1.79-12.12) increased the risk of AHA development. CONCLUSION We found that comorbid Alzheimer's disease is a risk factor of AHA incidence in the general population. Our findings provide insight into the etiology of AHA, and the proof of the coexistence of Alzheimer's disease may support the recent notion that Alzheimer disease is an autoimmune disease.
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Affiliation(s)
- Aya Shoji-Asahina
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
- Department of Clinical Laboratory, Japanese Red Cross Shizuoka Hospital, Aoi-ku, Shizuoka, Japan
| | - Eiji Nakatani
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Yutaro Imaichi
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Emi Ohata
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Michiko Oshima
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Akinori Miyakoshi
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Hiromu Miyake
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Yoshikazu Ichikawa
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Hisashi Dote
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Nanako Ubukata
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Daito Funaki
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
| | - Tetsumei Urano
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Aoi-ku, Shizuoka, Japan
- Department of Medical Physiology, Hamamatsu University School of Medicine, Higashi-ku, Hamamatsu, Japan
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Liu Y, Ruan X, Lei P, Shang B, Zhu Z, Chen S, Wang D, Wang R, Li X, Xue F. Acquired Hemophilia A: A Retrospective Multicenter Analysis of 42 Patients. Clin Appl Thromb Hemost 2023; 29:10760296221151165. [PMID: 36653966 PMCID: PMC9893059 DOI: 10.1177/10760296221151165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Immunosuppressive therapy (IST) for acquired hemophilia A (AHA) results in remission within days to months in 60% to 80% of patients. However, little is known regarding the predictors of response. AIM This study aimed to identify the factors that influence response to treatment. METHODS The data of 42 patients with AHA from three hospitals were retrospectively analyzed. RESULTS All 42 AHA patients received IST; complete treatment data were available for 34 patients. The response rate was 60% among the 5/34 (14.7%) patients who received steroids alone, 70.8% among the 24/34 (70.6%) patients who received steroids plus cyclophosphamide, and 80% among the 5/34 (14.7%) patients who received steroids plus cyclophosphamide and rituximab. Overall, 29/34 (85.3%) patients achieved CR; 4/34 (13.8%) of them relapsed after a median time of 410 (21-1279) days. Adverse events occurred in 14/34 (41.2%) patients: 13/34 (38.2%) had infections and 1/34 (2.9%) developed pancytopenia. In univariate and multivariate Cox regression analyses, FVIII inhibitor titer ≥20 BU/mL was the only significant prognostic factor affecting time to CR. No variable had significant effect on OS. CONCLUSION FVIII inhibitory antibody titer ≥20 BU/mL appears to be an important predictor of time to complete response in patients with acquired hemophilia A treated with immunosuppressive therapy.
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Affiliation(s)
- Yanhui Liu
- Department of Hematology, Hemophilia Comprehensive Care Center, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China,Yanhui Liu, Department of Hematology, Henan Provincial People's Hospital, 7 Weiwu Road, Jinshui District, Zhengzhou 450003, Henan, PR China.
Fei Xue, Department of Hepatobiliary and Pancreatic Surgery, Henan Provincial People's Hospital, 7 Weiwu Road, Jinshui District, Zhengzhou 450003, Henan, PR China.
| | - Xiang Ruan
- Department of Hematology, Hemophilia Comprehensive Care Center, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China
| | - Pingchong Lei
- Department of Hematology, Hemophilia Comprehensive Care Center, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China
| | - Baojun Shang
- Institute of Hematology, Hemophilia Comprehensive Care Center, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China
| | - Zunmin Zhu
- Department of Hematology, Hemophilia Comprehensive Care Center, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China,Institute of Hematology, Hemophilia Comprehensive Care Center, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China
| | - Shengmei Chen
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, PR China
| | - Dao Wang
- Department of Pediatrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, PR China
| | - Ruijuan Wang
- Department of Hematology, Nanyang Central Hospital, Nanyang, Henan Province, PR China
| | - Xiqing Li
- Department of Oncology, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China
| | - Fei Xue
- Department of Hepatobiliary and Pancreatic Surgery, Henan Provincial People's Hospital, People's Hospital of Henan University, Zhengzhou, Henan Province, PR China
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Ogawa Y, Amano K, Matsuo-Tezuka Y, Okada N, Murakami Y, Nakamura T, Yamaguchi-Suita H, Nogami K. ORIHIME study: real-world treatment patterns and clinical outcomes of 338 patients with acquired hemophilia A from a Japanese administrative database. Int J Hematol 2023; 117:44-55. [PMID: 36331704 DOI: 10.1007/s12185-022-03467-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Acquired hemophilia A (AHA) is a rare disorder, and clinical practices for treating AHA have not been fully clarified in Japan. OBJECTIVES This study aims to investigate the epidemiology of AHA and real-world treatment practices in Japan. PATIENTS/METHODS This observational study was based on a health administrative database of hospitalized patients diagnosed with AHA who were treated with immunosuppressants. RESULTS The study included 214 males and 124 females (mean age 75.7 years). The most frequently used bypassing agent was recombinant activated factor VII. The predominant choice of immunosuppressant for first-line treatment was steroid monotherapy. Median days from the index date to the start of rehabilitation was 65.0 for cardiovascular, 35.5 for respiratory and 23.0 for locomotor. The proportion of patients with an activities of daily living (ADL) score < 70 points was high at both first admission and final discharge (47.4% and 38.8%). The percentage of deaths during hospitalization was 18.6%. CONCLUSIONS This study clarified the treatment patterns and clinical outcomes of AHA in a large population in Japan. This was the first study showing ADL score distribution and time to rehabilitation. Further investigation is needed to develop better clinical practices for treatment of AHA.
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Gutierrez N, Park J, Leighton T. "Accessory After the Factors": A Rare Case of an Acquired Factor VIII Inhibitor in a 75-Year-Old Man on Rivaroxaban. Cureus 2021; 13:e18597. [PMID: 34765360 PMCID: PMC8572517 DOI: 10.7759/cureus.18597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 11/05/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are used to treat several conditions such as non-valvular atrial fibrillation, deep vein thrombosis, and pulmonary embolism. DOACs and other anticoagulants block crucial steps in the coagulation cascade and ultimately prevent clot formation. Generally, individuals initiated on an anticoagulant are predisposed to or have a propensity to form clots. Patients with hemophilia are given anticoagulants only in very rare cases. In this report, we discuss the case of a 75-year-old man with a history of atrial fibrillation managed on rivaroxaban; he presented to the emergency department with fatigue, easy bleeding, symptomatic anemia, and significantly elevated partial thromboplastin time (PTT) with an undiagnosed acquired factor VIII inhibitor. Reports of DOAC use and concomitant factor inhibitor autoimmunization, as seen in this case, are scarcely explored in the existing literature. While DOACs are popular anticoagulants, their variable effects on both prothrombin time (PT) and PTT make it difficult to detect superimposed bleeding disorders. In patients with severe anemia or significant elevations in PT or PTT, an expedited workup, including factor assays, may be a reasonable option as evidenced by this case.
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Affiliation(s)
- Nikolas Gutierrez
- Dermatology, 1st Marine Division, 1st Combat Engineer Battalion, Camp Pendleton, USA
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Abstract
An 80-year-old man with no personal or family history of bleeding, presented to hospital with extensive haematomas and skin bruising after using doxycycline. His basic lab workup was concerning for a coagulopathy with an elevated activated partial thromboplastin time and significant anaemia. Mixing studies and other factor levels were tested that led to the diagnosis of acquired haemophilia A with low factor VIII levels and high factor VIII antibodies. He was started on steroids, but his haemoglobin level continued to drop. Later, during his treatment, he was given multiple therapeutic agents, including cyclophosphamide, rituximab and recombinant factor VII (NovoSeven-R). Gradually factor VIII levels increased and haemoglobin stabilised. The hospital course was complicated by COVID-19 pneumonia leading to acute respiratory distress syndrome; the patient eventually expired due to respiratory failure.
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Affiliation(s)
- Ejaz Shah
- Internal Medicine, HSHS Saint John's Hospital, Springfield, Illinois, USA
| | - Calvin Abro
- Haematology and Oncology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Fawwad Zaidi
- Haematology and Oncology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Ruchika Goel
- Haematology and Oncology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
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Aynalem M, Shiferaw E, Gelaw Y, Enawgaw B. Coagulopathy and its associated factors among patients with a bleeding diathesis at the University of Gondar Specialized Referral Hospital, Northwest Ethiopia. Thromb J 2021; 19:36. [PMID: 34074308 PMCID: PMC8170961 DOI: 10.1186/s12959-021-00287-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 05/14/2021] [Indexed: 12/03/2022] Open
Abstract
Background Coagulopathy is the major cause of mortality and morbidity throughout the world. Globally, about 26–45% of healthy people have a history of bleeding symptoms, which may be a result of thrombocytopenia, factor deficiency, or pathological inhibitory. Objective To assess coagulopathy and its associated factors among patients with bleeding diathesis at the University of Gondar Specialized Referral Hospital from January to May 2020. Method A cross-sectional study was conducted on 384 study participants with bleeding diathesis recruited by using a convenient sampling technique. Socio-demographic and clinical characteristics were collected by using questioners. Then 6 ml venous blood was collected with a needle and syringe method. About 3 ml blood was transferred to EDTA test tube for platelet count and 2.7 ml blood was transferred to a test tube containing 0.3 ml of 3.2% sodium citrated anticoagulant for coagulation test. For those study participants with prolonged coagulation tests, a mixing test was done. Blood film and stool examination were also done for malaria and intestinal parasite identification, respectively. The data were entered into EPI-Info version 3.5.3 and then transferred to SPSS version-20 for analysis. Descriptive statistics were summarized as percentages, means, and standard deviations. Bivariate and multivariate logistic regression was used to identify the associated factors, and a P-value less than 0.05 was considered statistically significant. Results In this study, the prevalence of coagulopathy was 253/384 (65.9%; 95% CI: 61.16, 70.64). From them, 21.3% (54/253), 51.4% (130/253), and 27.3% (69/253) had only thrombocytopenia, only prolonged coagulation test, and mixed abnormality, respectively. Among participants with prolonged coagulation time, the prevalence of factor deficiency was 21.1% (42/199). Cardiac disease (AOR = 4.80; 95% CI: 2.65, 23.1), and other chronic diseases (AOR = 8.1; 95% CI: 1.84, 35.58) were significantly associated with coagulopathy. Conclusion In this study, coagulopathy due to inhibitory was a public health problem. The participants with cardiac and other chronic diseases were at high risk for coagulopathy. Therefore, mixing tests could be done for all prolonged coagulation tests and it could be considered as a routine laboratory test.
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Affiliation(s)
- Melak Aynalem
- Department of Hematology and Immunohematology, School of Medical Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, P.O. Box 196, Gondar, Ethiopia.
| | - Elias Shiferaw
- Department of Hematology and Immunohematology, School of Medical Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, P.O. Box 196, Gondar, Ethiopia
| | - Yemataw Gelaw
- Department of Hematology and Immunohematology, School of Medical Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, P.O. Box 196, Gondar, Ethiopia
| | - Bamlaku Enawgaw
- Department of Hematology and Immunohematology, School of Medical Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, P.O. Box 196, Gondar, Ethiopia
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Dewarrat N, Gavillet M, Angelillo-Scherrer A, Naveiras O, Grandoni F, Tsakiris DA, Alberio L, Blum S. Acquired haemophilia A in the postpartum and risk of relapse in subsequent pregnancies: A systematic literature review. Haemophilia 2021; 27:199-210. [PMID: 33550699 DOI: 10.1111/hae.14233] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 12/05/2020] [Accepted: 12/09/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND About 1%-5% of acquired haemophilia A cases affect mothers in the postpartum setting. AIMS This study delineates the characteristics of this disease, specific to the postpartum setting, notably relapse in subsequent pregnancies. METHODS Report of two cases and literature study (1946-2019), yielding 73 articles describing 174 cases (total 176 cases). RESULTS Patients were aged 29.9 years (17-41) and 69% primigravidae. Diagnosis was made at a median of 60 days after delivery (range 0-308). Bleeding types were obstetrical (43.4%), cutaneous (41.3%), and muscular (36.7%). In >90% of the cases, FVIII at diagnosis was <1% (range 0%-8%). FVIII inhibitor was documented in 75.4% cases (median titre of 20 BU/ml, range 1-621). Haemostatic treatment was necessary in 57.1% using fresh frozen plasma (16%), factor concentrate (27.6%) and/or bypassing agents (37.4%). Immunosuppressive treatment was administered in 90.8%, mostly steroids (85.3%), alone or combined with immunosuppressants (27%). Rituximab was used mostly as a second line treatment. Only 24 patients (13.6%) had documented subsequent pregnancies and 6 (22.2%) suffered haemophilia recurrence during pregnancy. CONCLUSION This study allows better definition of: (1) clinical and laboratory characteristics of postpartum acquired haemophilia, (2) response to therapy, and (3) the risk of relapse for subsequent pregnancies.
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Affiliation(s)
- Natacha Dewarrat
- Service and Central Laboratory of Haematology, Department of Oncology and Department of Laboratories and Pathology, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Mathilde Gavillet
- Service and Central Laboratory of Haematology, Department of Oncology and Department of Laboratories and Pathology, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Anne Angelillo-Scherrer
- Department of Haematology and Central Haematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Olaia Naveiras
- Service and Central Laboratory of Haematology, Department of Oncology and Department of Laboratories and Pathology, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Francesco Grandoni
- Service and Central Laboratory of Haematology, Department of Oncology and Department of Laboratories and Pathology, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | | | - Lorenzo Alberio
- Service and Central Laboratory of Haematology, Department of Oncology and Department of Laboratories and Pathology, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Sabine Blum
- Service and Central Laboratory of Haematology, Department of Oncology and Department of Laboratories and Pathology, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
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Pauls M, Rydz N, Nixon NA, Ezeife D. Paraneoplastic acquired haemophilia A in extensive-stage small cell lung cancer (ES-SCLC) in the era of immunotherapy. BMJ Case Rep 2021; 14:14/1/e236973. [PMID: 33509862 PMCID: PMC7845684 DOI: 10.1136/bcr-2020-236973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Small cell lung cancer (SCLC) is a deadly and rapidly progressive disease that can present with various paraneoplastic syndromes on initial workup. Acquired factor VIII (FVIII) deficiency, also known as acquired haemophilia A (AHA), has been identified as a rare paraneoplastic syndrome in SCLC. Here, we present a 61-year-old woman with a massive gastrointestinal bleed and prolonged activated partial thromboplastin time (PTT) in the emergency department. She was diagnosed with rare paraneoplastic AHA secondary to extensive-stage SCLC (ES-SCLC). She was treated with high-dose steroids and factor bypassing agents, which led to the resolution of bleeding and undetectable FVIII inhibitor levels. She was subsequently treated for ES-SCLC with carboplatin, etoposide and atezolizumab. This case report highlights a rare clinical presentation of paraneoplastic AHA that necessitates prompt recognition in patients with SCLC with ongoing bleeding and elevated PTT.
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Affiliation(s)
| | - Natalia Rydz
- Division of Hematology and Hematologic Malignancies, University of Calgary, Calgary, Canada
| | | | - Doreen Ezeife
- Medical Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Canada
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Sakai T, Azuma Y, Sano A, Sadamoto S, Tochigi N, Nagase D, Iyoda A. Perioperative Bypassing Agent Therapy for Pulmonary Pleomorphic Carcinoma with Acquired Hemophilia. Ann Thorac Cardiovasc Surg 2021; 28:302-306. [PMID: 33473052 PMCID: PMC9433887 DOI: 10.5761/atcs.cr.20-00257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 74-year-old man was admitted with lung cancer, and preoperative blood test showed abnormal activated partial thromboplastin time (APTT). Coagulation factor screening and APTT mixing test achieved a diagnosis of acquired hemophilia A (AHA). Bypassing agent therapy was indicated and lobectomy was successfully performed without bleeding complications. APTT returned to normal after the operation without any additional treatment for AHA. The pathogenesis of AHA is still unknown and there is no evidence for hemostatic strategy for AHA patients requiring surgery. This study supports the importance of hemostatic therapy and suggests that malignancy might cause AHA.
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Affiliation(s)
- Takashi Sakai
- Division of Chest Surgery, Department of Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Yoko Azuma
- Division of Chest Surgery, Department of Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Atsushi Sano
- Division of Chest Surgery, Department of Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Sota Sadamoto
- Department of Surgical Pathology, Toho University School of Medicine, Tokyo, Japan
| | - Naobumi Tochigi
- Department of Surgical Pathology, Toho University School of Medicine, Tokyo, Japan
| | - Daisuke Nagase
- Division of Hematology and Oncology, Department of Internal Medicine, Toho University School of Medicine, Tokyo, Japan
| | - Akira Iyoda
- Division of Chest Surgery, Department of Surgery, Toho University School of Medicine, Tokyo, Japan
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Franchini M, Marano G, Cruciani M, Mengoli C, Pati I, Masiello F, Veropalumbo E, Pupella S, Vaglio S, Liumbruno GM. Advances in managing rare acquired bleeding disorders. Expert Rev Hematol 2020; 13:599-606. [PMID: 32286895 DOI: 10.1080/17474086.2020.1756259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Rare acquired bleeding disorders include a wide spectrum of coagulopathies characterized by spontaneous or post-trauma and post-surgery hemorrhages in patients without a previous personal or family history of bleeding. AREAS COVERED This review, based on a Medline/PubMed search during the last 20 years, will focus mainly on rare acquired bleeding disorders caused by autoantibodies against coagulation factors, including autoantibodies against factor VIII (acquired hemophilia A), von Willebrand factor (acquired von Willebrand syndrome) and other coagulation factors (factors V, X, XI, and XIII). The pathogenic, laboratory, and clinical features of these rare hemorrhagic conditions will be discussed, with particular attention to their management. EXPERT OPINION The treatment of rare acquired bleeding disorders includes the control of bleeding and the elimination of the autoantibody and of the underlying disease, when present. As the bleeding clinical phenotype is often severe, the management of affected patients is particularly challenging. Thus, while an early diagnosis of the acquired coagulopathy is essential to start the most appropriate treatment and to improve patients' outcomes, the support of specialized centers is equally important to provide a correct management of such complicated cases.
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Affiliation(s)
- Massimo Franchini
- Italian National Blood Centre, National Institute of Health , Rome, Italy.,Department of Hematology and Transfusion Medicine, Carlo Poma Hospital , Mantua, Italy
| | - Giuseppe Marano
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Mario Cruciani
- Italian National Blood Centre, National Institute of Health , Rome, Italy.,Infection Control Committee and Antibiotic Stewardship Programme, AULSS9 Scaligera , Verona, Italy
| | - Carlo Mengoli
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Ilaria Pati
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Francesca Masiello
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Eva Veropalumbo
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Simonetta Pupella
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Stefania Vaglio
- Italian National Blood Centre, National Institute of Health , Rome, Italy
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Türkantoz H, Königs C, Knöbl P, Klamroth R, Holstein K, Huth-Kühne A, Heinz J, Eichler H, Tiede A. Cross-reacting inhibitors against recombinant porcine factor VIII in acquired hemophilia A: Data from the GTH-AH 01/2010 Study. J Thromb Haemost 2020; 18:36-43. [PMID: 31448877 DOI: 10.1111/jth.14618] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/22/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Recombinant porcine factor VIII (rpFVIII, OBI-1, susoctocog alfa) is used for the treatment of acute bleeds in patients with acquired hemophilia A (AHA). Inhibitors in AHA can sometimes cross-react with rpFVIII. OBJECTIVES To assess the frequency, strength, and determinants of cross-reactivity. PATIENTS/METHODS Baseline samples from 70 patients of the prospective, observational cohort study GTH-AH 01/2010 were assessed for anti-human FVIII and anti-rpFVIII inhibitors using modified Nijmegen-Bethesda assays, as well as anti-human FVIII domain reactivity using enzyme-linked immunoassay (ELISA). RESULTS Anti-human FVIII inhibitors were present in all samples ranging between 0.7 and 3891 Bethesda Units (BU)/mL. Inhibitors from 31 of 70 patients (44%) partially inhibited rpFVIII with anti-rpFVIII titers ranging between 0.5 and 471 BU/mL. Anti-rpFVIII titers were ≤5 BU in most patients. Patients with cross-reacting inhibitors, as compared to patients without, had significantly higher anti-human FVIII titers (27.8 versus 5.4 BU/mL) and lower baseline FVIII activity (<1 versus 2.6 IU/dL). The ratio between anti-rpFVIII to anti-human titers was highest for inhibitors involving the C1 domain. Cross-reactivity was very rare, if inhibitors reacted only with the C2 domain of FVIII (6%). An anti-human FVIII titer of >100 BU/mL predicted cross-reactivity with 97% likelihood, whereas an anti-human FVIII titer of <3.8 BU/mL predicted absent cross-reactivity with 90% likelihood. CONCLUSION Cross-reacting inhibitors should be considered when choosing a treatment for bleeding patients with AHA. Cross-reactivity is frequent in patients with anti-human FVIII titers of >100 BU/mL.
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Affiliation(s)
- Halet Türkantoz
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Christoph Königs
- Department of Pediatrics, Clinical and Molecular Hemostasis, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Paul Knöbl
- Hematology and Hemostasis, Vienna Medical University, Vienna, Austria
| | - Robert Klamroth
- Internal Medicine, Vivantes Clinic Friedrichshain, Berlin, Germany
| | - Katharina Holstein
- Hematology and Clinical Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Angela Huth-Kühne
- Hemophilia Care Center, SRH Kurpfalzkrankenhaus Heidelberg, Heidelberg, Germany
| | - Jürgen Heinz
- Hematology and Oncology, Freiburg University Hospital, Freiburg, Germany
| | - Hermann Eichler
- Institute of Clinical Hemostaseology and Transfusion Medicine, Saarland University and Saarland University Hospital, Homburg/Saar, Germany
| | - Andreas Tiede
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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Uzunov A, Secată D, Munteanu O, Oproiu A, Cîrstoiu MM. The management of a patient with pregnancy-acquired hemophilia – a case report. Ginecologia ro 2020; 3:8. [DOI: 10.26416/gine.29.3.2020.3764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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14
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Sun B, Xue F, Feng Y, Sun J, Yu Z, Hou M, Zhang J, Zeng X, Zhao Y, Lian S, Huang M, Niu T, Cui Z, Wu J, Yang R. Outcome of CARE: a 6‐year national registry of acquired haemophilia A in China. Br J Haematol 2019; 187:653-665. [PMID: 31372978 DOI: 10.1111/bjh.16128] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 05/27/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Boyang Sun
- State Key Laboratory of Experimental Haematology, National Clinical Research Centre for Haematological Disorders Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases TianjinChina
| | - Feng Xue
- State Key Laboratory of Experimental Haematology, National Clinical Research Centre for Haematological Disorders Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases TianjinChina
| | - Ying Feng
- Department of Haematology Second Affiliated Hospital of Guangzhou Medical University GuangzhouChina
| | - Jing Sun
- Nanfang Hospital Nanfang Medical University GuangzhouChina
| | - Ziqiang Yu
- Department of Haematology The First Affiliated Hospital of Soochow University SuzhouChina
| | - Ming Hou
- Department of Haematology Qilu Hospital, Shandong University Jinan ShandongChina
| | - Jingyu Zhang
- Department of Haematology, Key Laboratory of Haematology of Hebei Province The Second Hospital of Hebei Medical University Shijiazhuang HebeiChina
| | - Xiaojing Zeng
- Department of Blood Transfusion The Affiliated Hospital of Guizhou University GuiyangChina
| | - Yongqiang Zhao
- Department of Haematology Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences BeijingChina
| | - Shimei Lian
- Department of Haematology Dalian Municipal Central Hospital, Affiliated Hospital of Dalian Medical University Dalian China
| | - Meijuan Huang
- Fujian Institute of Haematology Fujian Medical University Union Hospital FuzhouChina
| | - Ting Niu
- Department of Haematology West China Hospital, Sichuan University Chengdu SichuanChina
| | - Zhongguang Cui
- The Affiliated Hospital of Qingdao University QingdaoChina
| | - Jingsheng Wu
- Department of Haematology Anhui Provincial Hospital, Anhui Medical University Hefei China
| | - Renchi Yang
- State Key Laboratory of Experimental Haematology, National Clinical Research Centre for Haematological Disorders Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases TianjinChina
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15
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Abstract
RATIONALE Acquired hemophilia A is a rare hemorrhagic disease in which the body produces specific antibodies that attack factor VIII, resulting in bleeding that is mainly mucocutaneous and associated with soft tissue and the gastrointestinal system. Approximately 50% of this disease derives from basic diseases, such as autoimmune diseases, cancer, and pregnancy. PATIENT CONCERNS We report a 35-year-old postpartum female with acquired hemophilia A who initially presented with pleural hemorrhage. DIAGNOSES In this patient activated prothrombin time (PT) and activated partial thromboplastin time (APTT) were found, and the factor VIII activity was 12.6%, furthermore Bethesda assay showed a FVIII antibody titer of 7.4 Bethesda units (BUs). INTERVENTIONS The treatment requires a 2-pronged approach: treatment of the bleeding and elimination of the inhibitor. OUTCOMES After hemostatic agents were used and inhibitors were eradicated, the patient achieved complete remission without relapse. LESSONS It is essential to recognize the development of disease earlier in pregnant woman.
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Affiliation(s)
| | - Hangping Ge
- Department of Hematology, First Affiliated Hospital of Zhejiang, Chinese Medical University, Hangzhou, China
| | - Pingping Hu
- Department of Hematology, First Affiliated Hospital of Zhejiang, Chinese Medical University, Hangzhou, China
| | - Ni Zhu
- Department of Hematology, First Affiliated Hospital of Zhejiang, Chinese Medical University, Hangzhou, China
| | - Junfa Chen
- Department of Hematology, First Affiliated Hospital of Zhejiang, Chinese Medical University, Hangzhou, China
| | - Jianping Shen
- Department of Hematology, First Affiliated Hospital of Zhejiang, Chinese Medical University, Hangzhou, China
| | - Yu Zhang
- Department of Hematology, First Affiliated Hospital of Zhejiang, Chinese Medical University, Hangzhou, China
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Strazzulla A, Chakvetadze C, Picque M, Cassard B, Hernandez F, De Pontfarcy A, Flateau C, Danneels P, Belfeki N, Diamantis S. Evolution of haemostatic parameters and risk of bleeding during treatment with cefazolin. Eur J Clin Microbiol Infect Dis 2018; 38:177-183. [PMID: 30414092 DOI: 10.1007/s10096-018-3412-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 10/24/2018] [Indexed: 11/30/2022]
Abstract
In 2017, five cases of severe haemorrhages during treatment with cefazolin occurred in France. The aim of this study was to assess the risk of haemorrhage related to treatment with cefazolin by evaluating haemostatic parameters and bleeding events. A retrospective study was conducted from January 2016 to December 2017. Two populations were analysed: (i) overall population, which included all patients treated with cefazolin during this period and (ii) coagulation study population, which included all patients treated with cefazolin with available coagulation parameters (activated partial thromboplastin time (aPTT) and international normalised ratio (INR) at baseline and at the end of treatment or EoT). Values of either aPTT or INR at baseline and at EoT were compared. Cases of severe haemorrhages were reported and correlated with values of aPTT and INR. Overall, 132 patients received cefazolin and 59/132 (45%) were included in the coagulation study group. A significant increase of median aPTT was observed from baseline to EoT (39.5 and 44.3 sec; p = 0.004, respectively). Overall, severe haemorrhage occurred in 7/132 (5%) patients. Coagulation parameters were available in three of them, and no correlation was observed between bleeding events and aPTT increase. This study showed that bleeding is probably more frequent than ever reported before during cefazolin treatment. The significant increase of aPTT observed during cefazolin treatment was not correlated with risk of haemorrhage. Further studies are needed to explore the possible physio-pathological pathways behind the modification of haemostatic parameters and risk of haemorrhage.
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Affiliation(s)
- Alessio Strazzulla
- Infectious Diseases Unit, Centre Hospitalier Sud Ile de France, Melun, France.
| | | | - Marie Picque
- Medical Biology Laboratory, Centre Hospitalier Sud Ile de France, Melun, France
| | - Bruno Cassard
- Pharmacy, "Marc Jaquet", Centre Hospitalier Sud Ile de France, Melun, France
| | - Fabien Hernandez
- Pharmacy, "Marc Jaquet", Centre Hospitalier Sud Ile de France, Melun, France
| | - Astrid De Pontfarcy
- Infectious Diseases Unit, Centre Hospitalier Sud Ile de France, Melun, France
| | - Clara Flateau
- Infectious Diseases Unit, Centre Hospitalier Sud Ile de France, Melun, France
| | - Pierre Danneels
- Infectious Diseases Unit, Centre Hospitalier Sud Ile de France, Melun, France
| | - Nabil Belfeki
- Infectious Diseases Unit, Centre Hospitalier Sud Ile de France, Melun, France
| | - Sylvain Diamantis
- Infectious Diseases Unit, Centre Hospitalier Sud Ile de France, Melun, France
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17
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Napolitano M, Siragusa S, Mancuso S, Kessler CM. Acquired haemophilia in cancer: A systematic and critical literature review. Haemophilia 2017; 24:43-56. [PMID: 28960809 DOI: 10.1111/hae.13355] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2017] [Indexed: 12/12/2022]
Abstract
AIM There is a paucity of data on the clinical presentation and management of cancer patients with acquired haemophilia (AH), we here report a systematic literature review on acquired haemophilia in the context of cancer. METHODS Treatment outcomes of AH were defined as complete response (CR), partial response (PR) or no response (NR), based on inhibitor eradication, coagulation factor VIII levels and bleeding control. Reported deaths were either related to cancer or bleeding. RESULTS Overall, 105 cases were collected and analyzed according to classification of cancer and efficacy of treatments for inhibitor and malignancy. The mean age was 68 years for both males (range 37-86 years) and females (range 43-89 years), 39 patients were female subjects and 66 were males. A solid cancer was diagnosed in 60 subjects, while 45 patients suffered a haematological malignancy. Solid cancers affected mainly males; however, the incidence of solid tumours vs haematological malignancies was not statistically significant (P = .09). Not all patients were treated for their underlying cancer, bleeding and/or inhibitor, in two cases outcome is unavailable. CR was reported in 62.1% (64/103) cases, PR in 9.7% (10/103) cases, NR with or without death was reported in 28.1% (29/103) cases. CONCLUSION CR was best achieved when successful and complete elimination of autoantibodies occurred contemporaneously with the successful treatment of the underlying malignancy. In some cases, recurrent autoantibodies were harbingers of relapsed cancer. Type of cancer, inhibitor titer, treatments administered for bleeding control and inhibitor eradication did not significantly affect clinical outcome of analyzed cases.
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Affiliation(s)
- M Napolitano
- Hematology Unit, Thrombosis and Hemostasis Reference Regional Center, Università degli studi di Palermo, Palermo, Italy
| | - S Siragusa
- Hematology Unit, Thrombosis and Hemostasis Reference Regional Center, Università degli studi di Palermo, Palermo, Italy
| | - S Mancuso
- Hematology Unit, Thrombosis and Hemostasis Reference Regional Center, Università degli studi di Palermo, Palermo, Italy
| | - C M Kessler
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
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19
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Perez EE, Orange JS, Bonilla F, Chinen J, Chinn IK, Dorsey M, El-Gamal Y, Harville TO, Hossny E, Mazer B, Nelson R, Secord E, Jordan SC, Stiehm ER, Vo AA, Ballow M. Update on the use of immunoglobulin in human disease: A review of evidence. J Allergy Clin Immunol 2016; 139:S1-S46. [PMID: 28041678 DOI: 10.1016/j.jaci.2016.09.023] [Citation(s) in RCA: 365] [Impact Index Per Article: 45.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 09/12/2016] [Accepted: 09/23/2016] [Indexed: 12/20/2022]
Abstract
Human immunoglobulin preparations for intravenous or subcutaneous administration are the cornerstone of treatment in patients with primary immunodeficiency diseases affecting the humoral immune system. Intravenous preparations have a number of important uses in the treatment of other diseases in humans as well, some for which acceptable treatment alternatives do not exist. We provide an update of the evidence-based guideline on immunoglobulin therapy, last published in 2006. Given the potential risks and inherent scarcity of human immunoglobulin, careful consideration of its indications and administration is warranted.
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Affiliation(s)
- Elena E Perez
- Allergy Associates of the Palm Beaches, North Palm Beach, Fla.
| | - Jordan S Orange
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Francisco Bonilla
- Department of Pediatrics, Clinical Immunology Program, Children's Hospital Boston and Harvard Medical School, Boston, Mass
| | - Javier Chinen
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Ivan K Chinn
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Morna Dorsey
- Department of Pediatrics, Allergy, Immunology and BMT Division, Benioff Children's Hospital and University of California, San Francisco, Calif
| | - Yehia El-Gamal
- Department of Pediatrics, Pediatric Allergy and Immunology Unit, Children's Hospital and Ain Shams University, Cairo, Egypt
| | - Terry O Harville
- Departments of Pathology and Laboratory Services and Pediatrics, University of Arkansas, Little Rock, Ark
| | - Elham Hossny
- Department of Pediatrics, Pediatric Allergy and Immunology Unit, Children's Hospital and Ain Shams University, Cairo, Egypt
| | - Bruce Mazer
- Department of Pediatrics, Allergy and Immunology, Montreal Children's Hospital and McGill University, Montreal, Quebec, Canada
| | - Robert Nelson
- Department of Medicine and Pediatrics, Division of Hematology and Oncology and Stem Cell Transplantation, Riley Hospital, Indiana University School of Medicine and the IU Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Elizabeth Secord
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, Mich
| | - Stanley C Jordan
- Nephrology & Transplant Immunology, Kidney Transplant Program, David Geffen School of Medicine at UCLA and Cedars-Sinai Medical Center, Los Angeles, Calif
| | - E Richard Stiehm
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Ashley A Vo
- Transplant Immunotherapy Program, Comprehensive Transplant Center, Kidney Transplant Program, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Mark Ballow
- Department of Pediatrics, Division of Allergy & Immunology, University of South Florida, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg, Fla
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20
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Sheth C, Gill A, Sekhon S. Life-threatening hemorrhage from acquired hemophilia A as a presenting manifestation of prostate cancer. J Community Hosp Intern Med Perspect 2016; 6:32461. [PMID: 27609734 PMCID: PMC5016740 DOI: 10.3402/jchimp.v6.32461] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 07/14/2016] [Accepted: 07/15/2016] [Indexed: 11/21/2022] Open
Abstract
Acquired factor VIII deficiency (acquired hemophilia A) is a rare condition characterized by the acquisition of autoantibodies that affect the clotting activity of factor VIII (fVIII). The most common manifestation in affected patients is a hemorrhagic diathesis. This disorder is associated with autoimmune diseases, pregnancy, postpartum period, drugs, and malignancy. Management of this condition begins with attempts to arrest an acute bleed based on the site and severity of bleeding and inhibitor titer. The next priority is eradication of the fVIII antibodies using immunosuppressive therapies. We report the case of a 66-year-old male who presented with spontaneous right thigh hematoma with prolonged activated partial prothrombin time and normal prothrombin time. Mixing studies confirmed the presence of an inhibitor. Further investigation for the underlying etiology of acquired hemophilia A leads to diagnosis of prostate cancer. Treatment consisted of bypassing agents including activated factor VII and activated prothrombin plasma concentrate to arrest the bleeding. Steroids and cyclophosphamide were added to suppress the fVIII inhibitors. Concomitant treatment of locally advanced prostate cancer with chemotherapy confirmed the eradication of the inhibitors. To our knowledge, this is the first reported case of prostate cancer diagnosed and treated simultaneously with acquired hemophilia A resulting in favorable patient outcome.
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Affiliation(s)
- Chirag Sheth
- Department of Internal Medicine, San Joaquin General Hospital, French Camp, CA, USA;
| | - Amandeep Gill
- Department of Internal Medicine, San Joaquin General Hospital, French Camp, CA, USA
| | - Sumeet Sekhon
- Department of Internal Medicine, San Joaquin General Hospital, French Camp, CA, USA
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Hosier GW, Mason RJ, Sue Robinson K, Bailly GG. Acquired hemophilia A: A rare cause of gross hematuria. Can Urol Assoc J 2015; 9:E905-7. [PMID: 26834904 DOI: 10.5489/cuaj.3306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Acquired hemophilia A is a rare condition caused by spontaneous development of factor VIII inhibitor. This condition most commonly presents with multiple hemorrhagic symptoms and isolated hematuria is exceedingly rare. Early diagnosis is important, as this condition carries a high mortality rate (13-22%). We present a case of an 82-year-old man with isolated hematuria caused by a factor VIII inhibitor who was successfully treated with recombinant activated factor VII concentrate, as well as prednisone and cyclophosphamide.
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Affiliation(s)
| | | | - K Sue Robinson
- Department of Hematology, Dalhousie University, Halifax, NS, Canada
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Le Cam-Duchez V. Hémophilie A acquise et hémopathies lymphoïdes : revue de la littérature. Rev Med Interne 2015; 36:834-9. [DOI: 10.1016/j.revmed.2015.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 08/24/2015] [Accepted: 09/14/2015] [Indexed: 01/29/2023]
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Porru M, Mameli A, Cianchetti EM, Musu M, Montisci R, Finco G, Marongiu F. Acquired factor VIII inhibitor and subsequent development of non-Hodgkin's lymphoma: a case report and review of the literature. Blood Coagul Fibrinolysis 2015; 26:967-71. [PMID: 26517066 DOI: 10.1097/MBC.0000000000000370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acquired hemophilia A (AHA) is a rare disorder caused by the development of factor VIII autoantibodies. It can induce acute and major hemorrhages in patients with negative personal and family history of bleeding. AHA is frequently associated with hematologic malignancies. This study describes the first case of AHA in a patient who developed a mantle cell lymphoma after a year and half of complete remission. It also provides an example of an initial wrong approach in terms of diagnosis and treatment, as well as of a very long course of the disease. Further, a review of AHA-associated lymphomas from 1974 to 2014 is also presented.Clinical and laboratory staff should be alert to the possibility of such an event when the medical history of patients is enriched with new symptoms or signs. A follow-up of at least 2 years might therefore be required.
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Okamura T, Komatsu M, Ito A, Ito T, Suga T, Arakura N, Sakai H, Tanaka E. A case of acquired hemophilia A diagnosed after percutaneous endoscopic gastrostomy. Clin J Gastroenterol 2015; 8:290-3. [PMID: 26345347 DOI: 10.1007/s12328-015-0601-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 08/13/2015] [Indexed: 10/23/2022]
Abstract
A 65-year-old male with no personal or familial history of bleeding disorders underwent percutaneous endoscopic gastrostomy (PEG) for neurogenic dysphagia due to subarachnoid hemorrhage. On postoperative day 6, continuous oozing of venous blood was observed at the stoma. Prothrombin time was within normal range, but activated partial thromboplastin time was prolonged. Cross-mixing test results indicated the existence of an inhibitor, and laboratory findings revealed decreased factor VIII activity and high levels of factor VIII inhibitor. The patient was diagnosed as having acquired hemophilia A, for which steroid monotherapy was effective. Acquired hemophilia A is a rare but potentially fatal disease. Clinicians should be aware of this condition in patients presenting with sudden hemorrhage after PEG or other endoscopic treatments, even in those with no apparent history of bleeding.
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Affiliation(s)
- Takuma Okamura
- Department of Gastroenterology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan.
| | - Michiharu Komatsu
- Department of Gastroenterology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Akihiro Ito
- Department of Gastroenterology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Tetsuya Ito
- Department of Gastroenterology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Tomoaki Suga
- Department of Gastroenterology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Norikazu Arakura
- Endoscopic Examination Center, Shinshu University Hospital, Matsumoto, Japan
| | - Hitoshi Sakai
- Department of Hematology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Eiji Tanaka
- Department of Gastroenterology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
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25
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Franchini M. Next-generation treatment of acquired hemophilia A. Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2015.1017470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Chai-Adisaksopha C, Rattarittamrong E, Norasetthada L, Tantiworawit A, Nawarawong W. Younger age at presentation of acquired haemophilia A in Asian countries: a single-centre study and systematic review. Haemophilia 2015; 20:e205-10. [PMID: 24847520 DOI: 10.1111/hae.12383] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Acquired haemophilia A is a rare bleeding disorder caused by autoantibodies against factor VIII (FVIII). There is a scarcity of acquired haemophilia A studies from Asian countries. The aim of this study was to evaluate clinical characteristics and outcomes of acquired haemophilia A among Asian populations. Data were collected from a retrospective case series and combined with a systematic review. The case series included all patients with acquired haemophilia A from 1999 to 2012 at Chiang Mai University Hospital. The systematic review searched MEDLINE and EMBASE databases for relevant keywords. A total of 111 patients were reviewed in this study (including 26 patients from the present series). There were 56 male (50.5%) and 55 female (49.5%) patients. We compared the demographic data with ECAH2 and UKHCDO studies. The weighted mean (SD) age at diagnosis was 58.10 (16.96) years compared with 75.70 (14.47) years in the European series (absolute difference 17.6 years, 95% confidence interval [CI] 14.20–20.99, P = 0.025). The mean (SD) FVIII activity was 2.97 (3.81) IU dL(−1) and the mean (SD) FVIII inhibitor titre was 26.35 (399.16) BU mL(−1). Fifty-six per cent of the patients underwent immunosuppression with steroids alone. The pool complete remission rate was comparable to the European studies, at 67.2% vs. 66.6% respectively (absolute difference 0.7, 95% CI 0.18 to 1.22, P = 0.99). This study reveals a novel finding of younger age at diagnosis of acquired haemophilia A among Asian patients.
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O'Connor CR. Systematic review of the presentation of coagulation factor VIII inhibitors in rheumatic diseases: A potential cause of life-threatening hemorrhage. Semin Arthritis Rheum 2015; 44:695-709. [PMID: 25595725 DOI: 10.1016/j.semarthrit.2014.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 11/22/2014] [Accepted: 11/28/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To provide a comprehensive review regarding the clinical presentation of acquired factor VIII (FVIII) inhibitors, also known as "acquired hemophilia," in patients with rheumatic diseases. METHODS A systematic MEDLINE search was conducted to identify English-language articles published from 1993 through January 10, 2012, providing details regarding the clinical presentation, laboratory evaluation, and management of a patient(s) with newly or previously diagnosed autoimmune disease coexistent with an acquired FVIII inhibitor. RESULTS In total, 49 patients fulfilled the criteria for inclusion in the review; the greatest percentage (24.5%) had systemic lupus erythematosus, followed by rheumatoid arthritis (16%). The majority (78%) presented with spontaneous mucocutaneous or muscular bleeding. Prolonged activated partial thromboplastin time (aPTT) was identified in all of the 45 patients for whom results were provided. Five patients presented with an asymptomatic prolonged aPTT, which was attributed to a lupus anticoagulant in two patients, only one of whom actually had a coexisting lupus anticoagulant. Invasive procedures led to serious bleeding in both of these patients, one of whom died as a result. The majority (59%) of patients experienced complete or partial remission of their inhibitors, most (96%) after systemic eradicative therapy. A total of three (6%) patients died as a direct result of FVIII inhibitors. CONCLUSIONS Although acquired FVIII inhibitors are rare in patients with autoimmune diseases, prompt diagnosis is essential to avoid extensive bleeding, which could be life threatening. Treatment requires eradication of the factor inhibitors. Rheumatologists must be able to distinguish acquired FVIII inhibitors from lupus anticoagulants.
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Affiliation(s)
- Carolyn Riester O'Connor
- Division of Rheumatology, Drexel University College of Medicine, 245 N. 15th St, Philadelphia, PA 19102.
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Abstract
BACKGROUND Acquired hemophilia A is a rare bleeding disorder caused by autoantibodies to coagulation factor VIII (FVIII). In most cases, bleeding episodes are spontaneous and severe at presentation. The optimal hemostatic therapy is controversial. OBJECTIVES To determine the efficacy of hemostatic therapies for acute bleeds in people with acquired hemophilia A; and to compare different forms of therapy for these bleeds. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 4) and MEDLINE (Ovid) (1948 to 30 April 2014). We searched the conference proceedings of the: American Society of Hematology; European Hematology Association; International Society on Thrombosis and Haemostasis (ISTH); and the European Association for Haemophilia and Allied Disorders (EAHAD) (from 2000 to 30 April 2014). In addition to this we searched clinical trials registers. SELECTION CRITERIA All randomised controlled trials and quasi-randomised trials of hemostatic therapies for people with acquired hemophilia A, with no restrictions on gender, age or ethnicity. DATA COLLECTION AND ANALYSIS No trials matching the selection criteria were eligible for inclusion. MAIN RESULTS No trials matching the selection criteria were eligible for inclusion. AUTHORS' CONCLUSIONS No randomised clinical trials of hemostatic therapies for acquired hemophilia A were found. Thus, we are not able to draw any conclusions or make any recommendations on the optimal hemostatic therapies for acquired hemophilia A based on the highest quality of evidence. GIven that carrying out randomized controlled trials in this field is a complex task, the authors suggest that, while planning randomised controlled trials in which patients can be enrolled, clinicians treating the disease continue to base their choices on alternative, lower quality sources of evidence, which hopefully, in the future, will also be appraised and incorporated in a Cochrane Review.
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Affiliation(s)
- Yan Zeng
- Department of Hematology, General Hospital of Chengdu Military Region, 270#, Rongdu Da Dao, Chengdu, Sichuan, China, 610083
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de Vitry A, Valois A, Weinborn M, Dupuy-de Fonclare AL, Cuny JF, Barbaud A, Schmutz JL. [Acquired haemophilia A: two cases]. Ann Dermatol Venereol 2014; 141:441-5. [PMID: 24951143 DOI: 10.1016/j.annder.2014.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 02/17/2014] [Accepted: 03/03/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Acquired haemophilia A (AH) is an uncommon bleeding disorder that presents as multiple, disseminated spontaneous subcutaneous bleeds. Diagnosis may be made on the basis of prolonged activated partial thromboplastin time (aPTT). The severity of the disease is associated with the low risk of haemoglobin levels and with potential links with other diseases. OBSERVATIONS Two men were hospitalized for extensive and spontaneous subcutaneous hematoma. In both cases, the International Normalized Ratio (INR) was normal, but aPTT was 3 times higher than normal. Autoantibodies against coagulation factor VIII confirmed the diagnosis of AH. The patients received immunomodulatory treatment. In one patient, diffuse large B-cell lymphoma was discovered one year after successful treatment of AH. DISCUSSION AH may be revealed by areas of bruising, subutaneous haematomas mimicking erythema nodosum, and muscle pain. APTT results alone can prompt the biologist to screen for factor VIII inhibitors. Aside from the risk of fatal bleeding, in half of all cases, the prognosis is determined by associated disorders such as blood dyscrasias, solid tumours, autoimmune diseases, use of certain medicines and pregnancy. After treatment for bleeding complications, therapy focuses on restoring the coagulation time. The aim of immunomodulatory therapy is to stem production of autoantibodies against coagulation factor VIII. CONCLUSION AH must be considered rapidly in order to reduce the risk of bleeding emergencies and to screen for potential related diseases.
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Affiliation(s)
- A de Vitry
- Service de dermatologie, batiment Philippe-Canton, CHU, 6, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France.
| | - A Valois
- Service de dermatologie, hôpital d'instruction des armées Legouest, 27, avenue de Plantières, 57070 Metz, France
| | - M Weinborn
- Service de dermatologie, batiment Philippe-Canton, CHU, 6, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
| | - A-L Dupuy-de Fonclare
- Service de dermatologie, hôpital d'instruction des armées Legouest, 27, avenue de Plantières, 57070 Metz, France
| | - J-F Cuny
- Service de dermatologie, batiment Philippe-Canton, CHU, 6, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
| | - A Barbaud
- Service de dermatologie, batiment Philippe-Canton, CHU, 6, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
| | - J-L Schmutz
- Service de dermatologie, batiment Philippe-Canton, CHU, 6, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
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AlJasser MI, Sladden C, Crawford RI, Au S. Bullous Pemphigoid Associated with Acquired Hemophilia A: A Rare Association of Autoimmune Disease. J Cutan Med Surg 2014; 18:123-6. [DOI: 10.2310/7750.2013.13060] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Acquired hemophilia (AH) is a rare autoimmune disease with an annual incidence of one per million and has a mortality rate of up to 22%. It is caused by the development of autoantibodies against factor VIII. Approximately half of the reported cases are associated with autoimmune disorders, pregnancy, malignancies, and adverse drug reactions. Autoimmune diseases are the most frequently associated disorders and include rheumatoid arthritis, systemic lupus erythematosus, cryoglobulinemia, pemphigus vulgaris, and bullous pemphigoid. There are a few reports of acquired hemophilia and bullous pemphigoid in the literature. Method: We report a 73-year-old male who presented with cutaneous blistering, upper gastrointestinal bleeding, and hemoptysis. He later developed right flank pain secondary to a retroperitoneal hematoma. He had a prolonged partial thromboplastin time, a low factor VIII level, and a high factor VIII inhibitor level, all consistent with acquired hemophilia. Skin biopsies were diagnostic for bullous pemphigoid. Results: He was treated successfully with prednisone, cyclophosphamide, rituximab, and intravenous immunoglobulin.
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Affiliation(s)
- Mohammed I. AlJasser
- From the Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC; Division of Dermatology, Department of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Fahad National Guard Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia; Department of Pathology and Laboratory Medicine, University of British Columbia and Vancouver General Hospital, Vancouver, BC; and Division of Dermatology, Department of Medicine, St. Paul's Hospital, Providence
| | - Chris Sladden
- From the Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC; Division of Dermatology, Department of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Fahad National Guard Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia; Department of Pathology and Laboratory Medicine, University of British Columbia and Vancouver General Hospital, Vancouver, BC; and Division of Dermatology, Department of Medicine, St. Paul's Hospital, Providence
| | - Richard I. Crawford
- From the Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC; Division of Dermatology, Department of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Fahad National Guard Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia; Department of Pathology and Laboratory Medicine, University of British Columbia and Vancouver General Hospital, Vancouver, BC; and Division of Dermatology, Department of Medicine, St. Paul's Hospital, Providence
| | - Sheila Au
- From the Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC; Division of Dermatology, Department of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Fahad National Guard Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia; Department of Pathology and Laboratory Medicine, University of British Columbia and Vancouver General Hospital, Vancouver, BC; and Division of Dermatology, Department of Medicine, St. Paul's Hospital, Providence
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Abstract
There is an increased risk not only of bleeding but also of thrombosis in the cancer patient. The double jeopardy creates an additional problem in their management and requires special attention. This review provides information on pathophysiology in the regulation of hemostasis, leading to bleeding and thrombotic complications. The process is complex with multiple factors being involved. In addition to the pathogenesis, a number of clinical syndromes, diagnostic methods and the management of hemostatic abnormalities in the cancer patient are presented. Potential effects of cancer treatment on these risks magnify the hazards encountered by the managing team. Wherever management is discussed, emphasis is placed on the scientific basis for the rationale of the therapeutic approach.
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Affiliation(s)
- Anaadriana Zakarija
- Division of Hematology/Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611-3008, USA.
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Ilkhchoui Y, Koshkin E, Windsor JJ, Petersen TR, Charles M, Pack JD. Perioperative management of acquired hemophilia a: a case report and review of literature. Anesth Pain Med 2013; 4:e11906. [PMID: 24660144 PMCID: PMC3961036 DOI: 10.5812/aapm.11906] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 06/15/2013] [Accepted: 06/22/2013] [Indexed: 11/16/2022] Open
Abstract
Introduction: Acquired hemophilia A is a rare bleeding disorder with a high mortality rate. Diagnosis and treatment of this disorder can be very challenging to anesthesiologists because of lack of a personal or familial abnormal bleeding history. Case presentation: We report a 60-year-old woman who presented to the operating room for an urgent fasciotomy. She was initially diagnosed to have compartment syndrome of her left upper extremity secondary to an expanding hematoma after multiple unsuccessful venipuncture attempts. After surgical intervention, she developed recurrent intramuscular hematomas, became severely anemic, and required surgical re-exploration and multiple blood product transfusions. Ultimately, she was found to have an elevated activated partial thromboplastin time (aPTT), very low FVIII activity, and high FVIII inhibitor titers consistent with the diagnosis of acquired hemophilia A. Conclusions: Treatment strategies in acquired hemophilia are based on two major objectives. During the acute stage, effective control of bleeding is critical. The ultimate therapeutic goal during the subacute phase is the elimination of the inhibitors targeting factor VIII. Here, we present this case and will review current literature regarding therapeutic approaches to this rare condition in the operating room setting and postoperative course.
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Affiliation(s)
- Yashar Ilkhchoui
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, University of New Mexico, Albuquerque, USA
- Corresponding author: Yashar Ilkhchoui, Department of Anesthesiology and Critical Care Medicine, School of Medicine, University of New Mexico, Albuquerque, NM, USA. Tel: +1-5052722610, Fax: +1-5052721300, E-mail:
| | - Eugene Koshkin
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, University of New Mexico, Albuquerque, USA
| | - Jimmy J Windsor
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, University of New Mexico, Albuquerque, USA
| | - Timothy R Petersen
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, University of New Mexico, Albuquerque, USA
| | - Matthew Charles
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, University of New Mexico, Albuquerque, USA
| | - Jeffery D Pack
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, University of New Mexico, Albuquerque, USA
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Zeichner SB, Harris A, Turner G, Francavilla M, Lutzky J. An Acquired Factor VIII Inhibitor in a Patient with HIV and HCV: A Case Presentation and Literature Review. Case Rep Hematol 2013; 2013:628513. [PMID: 24198984 DOI: 10.1155/2013/628513] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 08/29/2013] [Indexed: 12/01/2022] Open
Abstract
Introduction. Despite its low incidence, acquired factor VIII inhibitor is the most common autoantibody affecting the clotting cascade. The exact mechanism of acquisition remains unclear, but postpartum patients, those with autoimmune conditions or malignancies, and those with exposure to particular drugs appear most susceptible. There have been several case reports describing acquired FVIII inhibitors in patients receiving interferon alpha for HCV treatment and in patients being treated for HIV. To our knowledge, this is the first case of a patient with HCV and HIV who was not actively receiving treatment for either condition. Case Presentation. A 57-year-old Caucasian male with a history of HIV and HCV was admitted to our hospital for a several day history of progressively worsening right thigh bruising and generalized weakness. CTA of the abdominal arteries revealed large bilateral retroperitoneal hematomas. Laboratory studies revealed the presence of a high titer FVIII inhibitor. Conclusion. Our case of a very rare condition highlights the importance of recognizing and understanding the diagnosis of acquired FVIII inhibitor. Laboratory research and clinical data on the role of newer agents are needed in order to better characterize disease pathogenesis, disease associations, genetic markers, and optimal disease management.
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Abstract
Acquired haemophilia A (AHA) is a rare but often severe bleeding disorder caused by autoantibodies against coagulation factor VIII (FVIII). AHA occurs more frequently in the elderly and in association with several conditions, such as the post-partum period, malignancies, autoimmune diseases or drug exposure; however, approximately 50% of reported cases are apparently idiopathic. Beside the elimination of the underlying disorder, the therapeutic approach to AHA should be directed toward the control of acute bleed and the eradication of FVIII autoantibody production. In this narrative review, we summarise the current knowledge on the epidemiology, diagnosis and clinical features of AHA, focusing in particular on advances in the management of this challenging bleeding disorder.
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Affiliation(s)
- Massimo Franchini
- Pier Mannuccio Mannucci, MD, Scientific Direction, IRCCS Cà Granda Foundation Maggiore Policlinico Hospital, Via Pace 9, 20122 Milan, Italy, Tel.: +39 02 5503 5414, Fax: +39 02 54 100 125, E-mail:
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35
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Abstract
Acquired hemophilia is a rare disorder with an estimated annual incidence of 0.2-1 cases per million individuals. The etiology of the disorder remains obscure, although approximately half of all cases are associated with other underlying conditions. In acquired hemophilia, the severe hemorrhagic diathesis is caused by the development of autoantibodies directed against a clotting factor, most commonly factor VIII. These autoantibodies inhibit normal coagulation and lead to bleeding complications, which can be life-threatening in a high percentage of cases. Prompt diagnosis and appropriate management of the disorder enable effective control; the short- and long-term aims of therapy are to terminate the acute bleed and eliminate or reduce the inhibitor, respectively. Immune tolerance therapy has been shown to successfully eradicate or suppress inhibitors in patients with congenital hemophilia A and may be applicable to patients with acquired hemophilia. Here we present preliminary data on the use of immune tolerance therapy in patients with acquired hemophilia and discuss possible treatment strategies.
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Affiliation(s)
- Mario von Depka
- Department of Hematology, Haemostasis and Oncology, Hannover Medical School, Germany.
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36
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Borg JY, Guillet B, Le Cam-Duchez V, Goudemand J, Lévesque H. Outcome of acquired haemophilia in France: the prospective SACHA (Surveillance des Auto antiCorps au cours de l'Hémophilie Acquise) registry. Haemophilia 2013; 19:564-70. [PMID: 23574453 DOI: 10.1111/hae.12138] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2013] [Indexed: 01/24/2023]
Abstract
Although extremely rare, acquired haemophilia A (AHA) can cause severe bleeding, which may be fatal. The underlying causes of autoantibody development are not fully understood. Treatment goals are bleeding control and autoantibody eradication. At the time of our study, there was no consensus on a standard treatment strategy for AHA. Previous data were mainly retrospective or from single-centre cohorts. We conducted a prospective, controlled, registry-based study of patients with AHA in France. The prospective French registry (Surveillance des Auto antiCorps au cours de l'Hémophilie Acquise [SACHA]) collected data on prevalence, clinical course, disease associations and outcomes for haemostatic treatment and autoantibody eradication in 82 patients with a 1-year follow-up. Similar to earlier studies, the prevalence of AHA was higher in the elderly, with two thirds of patients aged >70 years. Around half of AHA cases were associated with underlying disease, most commonly autoimmune disease and cancer in younger and older patients respectively. Haemostatic treatment was initially administered to 46% of patients. Complete resolution or improvement of initial bleeding occurred in 22/27 (81%) rFVIIa-treated patients and in all six cases receiving pd-aPCC. The majority of patients (94%) received immunosuppressive therapy, with complete remission at 3 months in 61% (36/59) and in 98% (50/51) at 1 year. Overall mortality was 33%: secondary to bleeding in only three patients but to sepsis in 10. Bypassing agents were effective at controlling bleeding in patients with AHA. Immunosuppressive therapy should be used early but with caution, particularly in elderly patients.
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Affiliation(s)
- J Y Borg
- Haematology Laboratory, Rouen University Hospital and INSERM CIC-CRB 0204, Rouen, France
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Graveleau J, Trossaërt M, Leux C, Masseau A, Ternisien C, Néel A, Fouassier M, Agard C, Sigaud M, Hamidou M. Hémophilie A acquise. Étude d’une série rétrospective monocentrique de 39 patients. Rev Med Interne 2013; 34:4-11. [DOI: 10.1016/j.revmed.2012.10.367] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 10/16/2012] [Indexed: 01/16/2023]
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Kang E, Kim HG, Lee J, Lee M, Bae C, Jeon JY, Ahn MS, Jeong SH, Park JS, Kang SY, Choi J, Lee HW. Acquired hemophilia successfully treated with activated prothrombin complex concentrate and immunosuppressant combination: a case report. Blood Coagul Fibrinolysis 2012; 23:669-72. [PMID: 22918088 DOI: 10.1097/mbc.0b013e32835669e6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Murray NP, Moncada JC, Moran M. Duodenal tumor presenting as acquired hemophilia in an 88-year-old woman: a clinical case and review of the literature. Case Rep Gastrointest Med 2012; 2012:203801. [PMID: 22966469 DOI: 10.1155/2012/203801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 07/30/2012] [Indexed: 11/17/2022] Open
Abstract
Acquired hemophilia is a rare disease, presenting with severe hemorrhage, we present a case caused by a duodenal tumor, the clinical management, ethical implications, treatment recommendations, and a review of the literature.
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Lapalud P, Ali T, Cayzac C, Mathieu-Dupas E, Levesque H, Pfeiffer C, Balicchi J, Gruel Y, Borg JY, Schved JF, Granier C, Lavigne-Lissalde G. The IgG autoimmune response in postpartum acquired hemophilia A targets mainly the A1a1 domain of FVIII. J Thromb Haemost 2012; 10:1814-22. [PMID: 22784315 DOI: 10.1111/j.1538-7836.2012.04850.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acquired hemophilia A (AHA) is a severe life-threatening autoimmune disease due to the development of autoantibodies that neutralize the procoagulant activity of factor VIII (FVIII). In rare cases, AHA occurs in the postpartum period as a serious complication of an otherwise normal pregnancy and delivery. Due to its rarity, little is known about the features of the antibody response to FVIII in AHA. OBJECTIVES Our study wanted to (i) determine the epitope specificity and the immunoglobulin (Ig) subclasses of anti-FVIII autoantibodies in plasma samples from a large cohort of AHA patients, and (ii) compare the epitope specificity of anti-FVIII autoantibodies in plasma samples from postpartum AHA and other AHA patients. PATIENTS/METHODS Seventy-three plasma samples from patients with postpartum AHA (n = 10) or associated with malignancies (n = 16) or autoimmune diseases (n = 11) or without underlying disease (n = 36) were analyzed with three multiplexed assays. RESULTS AND CONCLUSIONS Our results showed a stronger response against the A1a1-A2a2-B fragments of FVIII and more specifically against the A1a1 domain in patients with postpartum AHA than in the other AHA groups (P < 0.01). Moreover, although IgG4 was the predominant IgG subclass in all groups, anti-A1a1-A2a2-B and anti-A1a1 domain autoantibodies of the IgG(1) and IgG3 subclasses were more frequently detected in postpartum AHA than in the other AHA groups. These findings support the involvement of the Th1-driven response in the generation of autoantibodies in women with postpartum AHA compared with the other groups of AHA patients in whom production of Th2-driven IgG4 was predominant.
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Affiliation(s)
- P Lapalud
- SysDiag, UMR3145 CNRS/BioRad, Montpellier, France.
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Vener C, Artoni A, Boschetti C, Fracchiolla NS, Gianelli U, Cortelezzi A, Iurlo A. An acquired factor VIII inhibitor in a myeloproliferative neoplasm presenting with severe retroperitoneal hemorrhage. Leuk Lymphoma 2012; 53:2296-8. [DOI: 10.3109/10428194.2012.682309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Chaari M, Sassi M, Galea V, Gerotziafas G, Elalamy I. Hémophilie A acquise découverte au cours de la grossesse : à propos d’un cas et revue de la littérature. Rev Med Interne 2012; 33:401-4. [DOI: 10.1016/j.revmed.2012.04.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2011] [Revised: 04/03/2012] [Accepted: 04/25/2012] [Indexed: 11/21/2022]
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Zaher G, Adam S. Successful Long Term Eradication of Factor VIII Inhibitor in Patients with Acquired Haemophilia A in Saudi Arabia. Mediterr J Hematol Infect Dis 2012; 4:e2012021. [PMID: 22536478 PMCID: PMC3335817 DOI: 10.4084/mjhid.2012.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 03/29/2012] [Indexed: 11/08/2022] Open
Abstract
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.
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Franchini M, Lippi G. The use of desmopressin in acquired haemophilia A: a systematic review. Blood Transfus 2011; 9:377-82. [PMID: 21839010 DOI: 10.2450/2011.0113-10] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Accepted: 03/09/2011] [Indexed: 11/21/2022]
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47
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Abstract
Acquired haemophilia A is an auto-immune disease caused by an inhibitory antibody to factor VIII. The pattern of bleeding varies but patients remain at risk of life threatening bleeding until the inhibitor has been eradicated. The cornerstones of management are; rapid and accurate diagnosis, control of bleeding, investigation for an underlying cause and eradication of the inhibitor by immunosuppression. Patients should always be managed jointly with a specialist centre even if they present without significant bleeding. Despite an extensive literature, few controlled data are available and treatment guidelines are based on expert opinion. To treat bleeds recombinant factor VIIa and activated prothrombin complex concentrate are equally efficacious but both are superior to factor VIII or desmopressin. Immunosuppression should be started as soon as the diagnosis is made. Commonly used regimens are steroids alone or combined with cytotoxic agents. Rituximab is being used more widely but current evidence does not suggest that it improves outcomes or reduces side effects.
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Affiliation(s)
- P W Collins
- Arthur Bloom Haemophilia Centre, School of Medicine, Cardiff University, Heath Park, Cardiff, UK
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48
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Yano H, Tsunoda M, Onishi T, Mizuno S, Koibuchi H, Kigawa Y, Suzuki T, Nakano H, Oba K. [An elderly patient with senile dementia showing acquired hemophilia A]. Nihon Ronen Igakkai Zasshi 2011; 48:185-189. [PMID: 21778637 DOI: 10.3143/geriatrics.48.185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
We report a case of an 82-year-old woman with senile dementia who was hospitalized at a specialist dementia hospital for 10 months. She had swelling of the left shoulder joint, subcutaneous hematoma in the left upper arm, and anemia was noted on blood examination. Her serum hemoglobin level was lower than normal at 4.6 g/dL, but there was no sign of gastrointestinal disease or gastrointestinal bleeding, and her stool specimens were negative for occult blood. Hematoma subsequently appeared on her chest and back. She had a low activation level of factor VIII (<1%), a high concentration of acquired inhibitors of factor VIII (18.5 BU/mL), and prolonged activated partial thromboplastin time (83.1 seconds). The possibility of drug-induced anemia or hematoma were ruled out. We diagnosed acquired hemophilia A (AHA), and suspected that this was the cause of her hematomas. We began treatment of her AHA with oral prednisolone and intravenous infusion of factor VIII. The bleeding improved, but she later died due to bacterial pneumonia. AHA is very rare, with a reported annual incidence of 0.1/100,000 in Japan. However, it is necessary to consider such a rare disease when we encounter bleeding in elderly patients.
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Affiliation(s)
- Hiroyuki Yano
- Division of Geriatric Medicine, Nippon Medical School
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49
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Abstract
Acquired hemophilia A is a rare but potentially life-threatening hemorrhagic disorder caused by the development of autoantibodies directed mostly against coagulation factor VIII. Acquired hemophilia is frequently associated with several underlying conditions such as malignancy, autoimmune disorders, drug reactions, and pregnancy, although the pathogenesis remains undetermined (idiopathic) in up to 50% of reported cases. The disorder occurs most commonly in the elderly and only rarely affects pediatric patients, who might however experience severe, and sometimes life-threatening, hemorrhage. The maternal transplacental transfer of the autoantibody to the neonate occurs very rarely and also in this circumstance it may be associated with clinically significant bleeding. The management of acute bleeding and the inhibitor eradication are the mainstay of the treatment. The outcome in pediatric patients seems more favorable than in adults because the inhibitors usually resolve more quickly and in a higher rate of patients. The epidemiology, diagnosis, clinical course, and management of this hemorrhagic disorder in children will be addressed in this systematic review.
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Affiliation(s)
- Massimo Franchini
- Servizio di Immunoematologia e Medicina Trasfusionale, Dipartimento di Patologia e Medicina di Laboratorio, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy.
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50
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Bitting RL, Bent S, Li Y, Kohlwes J. The prognosis and treatment of acquired hemophilia: a systematic review and meta-analysis. Blood Coagul Fibrinolysis. 2009;20:517-523. [PMID: 19644360 DOI: 10.1097/mbc.0b013e32832ca388] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The inhibition of factor VIII by autoantibody development, or acquired hemophilia, occurs in approximately one person per million each year and can cause life-threatening bleeding. Due to the disease rarity, there are no randomized studies addressing prognostic features and treatment. The goal of this study is to identify prognostic indictors in acquired hemophilia to guide treatment choices. MEDLINE and EMBASE search from 1985-2008 retrieved 32 studies with detailed clinical information on five or more patients with acquired hemophilia. Univariate and multivariate analysis of the effects of age, sex, underlying condition, inhibitor titer, and treatment regimen were evaluated with regards to complete remission and death. A total of 32 studies containing 359 patients with acquired hemophilia were included in the analysis. The all-cause mortality rate in this cohort was 21%. Multivariate analyses revealed that patients more likely to die are the elderly [odds ratio (OR) 2.4, 95% confidence interval (CI) 1.32-4.36] and those with underlying malignancy (OR 2.76, CI 1.38-5.50). Early achievement of complete remission resulted in improved survival. Complete remission occurred in 94% of patients receiving combination chemotherapy, 82% receiving dual therapy, and 68% receiving steroids alone. Patients receiving immunosuppression had reduced odds of persistent hemophilia, with combination chemotherapy being the most efficacious (OR 0.04, CI 0.01-0.23) and steroid therapy alone being the least (OR 0.38, CI 0.14-0.94). In acquired hemophilia, increased age, underlying malignancy, and lack of complete remission are risk factors for death. Although the included studies were not randomized, patients treated with combination chemotherapy had the greatest odds of remission and the lowest odds of death.
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