A unique phenotype of acquired Glanzmann thrombasthenia due to non-function-blocking anti-αIIbβ3 autoantibodies

Essentials Acquired Glanzmann thrombasthenia (aGT) is generally caused by function-blocking antibodies (Abs). We demonstrated a unique aGT case due to marked reduction of αIIbβ3 with anti-αIIbβ3 Abs. The anti-αIIbβ3 Abs of the patient did not inhibit platelet function but reduced surface αIIbβ3. Internalization of αIIbβ3 induced by the Abs binding may be responsible for the phenotype. SUMMARY: Background Acquired Glanzmann thrombasthenia (aGT) is a bleeding disorder generally caused by function-blocking anti-αIIbβ3 autoantibodies. Aim We characterize an unusual case of aGT caused by marked reduction of surface αIIbβ3 with non-function-blocking anti-αIIbβ3 antibodies (Abs). Methods A 72-year-old male suffering from immune thrombocytopenia since his 50s showed exacerbation of bleeding symptom despite mild thrombocytopenia. Platelet aggregation was absent with all agonists but ristocetin. Analysis of αIIbβ3 expression and genetic analysis were performed. We also analyzed effects of anti-αIIbβ3 Abs of the patient on platelet function and αIIbβ3 expression. Results Surface αIIbβ3 expression was markedly reduced to around 5% of normal, whereas his platelets contained αIIbβ3 to the amount of 40-50% of normal. A substantial amount of fibrinogen was also detected in his platelets. There were no abnormalities in ITGA2B and ITGB3 cDNA. These results indicated that reduced surface αIIbβ3 expression caused a GT phenotype, and active internalization of αIIbβ3 was suggested. Anti-αIIbβ3 IgG Abs were detected in platelet eluate and plasma. These Abs did not inhibit PAC-1 binding, indicating that the Abs were non-function-blocking. Surface αIIbβ3 expression of a megakaryocytic cell line and cultured megakaryocytes tended to be impaired by incubation with the patient's Abs. After 2 years of aGT diagnosis, his bleeding symptom improved and surface αIIbβ3 expression was recovered to 20% of normal with reduction of anti-αIIbβ3 Abs. Conclusion We demonstrated a unique aGT phenotype due to marked reduction of surface αIIbβ3. Internalization induced by anti-αIIbβ3 Abs may be responsible in part for the phenotype.

Is there an association between blood group O and epistaxis?

Introduction:

Blood group O is associated with lower expression of von Willebrand factor suggesting a relative bleeding tendency. A lower admission rate for epistaxis among Asians compared with Caucasians has also been noted, with one explanation being higher prevalence of blood group O among Caucasians. This study investigates whether blood group O is over-represented in patients admitted with epistaxis.

Methods:

A retrospective study was conducted, using computerised hospital in-patient and blood bank databases to identify Caucasians admitted with epistaxis between January 2000 and December 2005 inclusive. The control group consisted of 500 consecutive patients who had a primary total hip arthroplasty and 500 consecutive patients who gave birth within the delivery suite.

Results:

1261 Caucasians admitted with epistaxis were identified. Among epistaxis patients, 50.44 per cent were blood group O but among the control group this was 45.10 per cent (chi-square testp = 0.008).

Conclusion:

Blood group O appears over-represented in Caucasian patients admitted with epistaxis, compared with the control population, raising the possibility that blood group O is a risk factor for epistaxis.

The relationship between serum urea levels and outcome in acute epistaxis

OBJECTIVES

To establish whether, for the patient presenting with epistaxis, there is a relationship between clinical outcome and serum urea levels measured on initial attendance at the accident and emergency (A&E) department.

METHODOLOGY

Records were reviewed from all patients attending a single teaching hospital A&E department between 1st January 2010 and 11st February 2011 with a diagnosis of epistaxis. Patients were analysed according to their admission serum urea and creatinine levels and then grouped according to clinical outcome.

RESULTS

We identified 278 patients (145 males, 133 females), 82 of which required hospital admission. Eleven required blood transfusion, and five required surgical arrest of the haemorrhage. No patients died. Serum urea and creatinine levels were measured in 119/278 patients. The mean serum urea level was significantly higher in patients admitted for further management of epistaxis than in patients who were discharged from the A&E department (9.35 mmol/l vs. 6.74 mmol/l, respectively; p = 0.003). There was no significant difference in mean serum urea levels between patients who were transfused and patients who were not, or between patients who went to the operating theatre and patients who did not.

CONCLUSIONS

Elevated serum urea levels on hospital admission are related to more severe clinical outcome in epistaxis.

Feasibility of pegylated interferon and ribavirin in hepatitis C-related cirrhosis with neutropenia or thrombocytopenia

AIM

To investigate the feasibility of pegylated interferon plus ribavirin treatment in cirrhotic patients who presented with, or developed while on-treatment, platelet counts ≤ 80,000/μL and/or neutrophil counts ≤ 1,500/μL.

METHODS

A retrospective analysis of prospectively gathered data on 123 cirrhotic patients treated with pegylated interferon and ribavirin. Adverse effects and haematological changes were monitored: bleeding and infectious events were registered and related to platelet and absolute neutrophil counts.

RESULTS

Among the 58 patients (47.2%) with nadir platelets ≤ 50,000/μL during therapy, 6 (10.3%) experienced a bleeding episode; of the remaining 65 patients with platelets constantly >50,000/μL, 3 (4.6%) bled. Of the 11 bleedings, 3 manifested during an infection, while patients had platelets >50,000/μL. Nadir neutrophils ≤ 750/μL occurred in 45 patients (38.2%) during treatment, and 14 of them (29.8%) had an infectious event. Infections were also documented in 18 of the 76 patients (23.7%) with neutrophils constantly >750/μL.

CONCLUSIONS

The study reveals the feasibility of treating cirrhotic patients with cytopenia with pegylated interferon and ribavirin, as bleeding or infectious events under therapy were unrelated to platelet and neutrophil counts. Withdrawal of therapy or variations in the pre-assigned dosages of either pegylated interferon or ribavirin owing to abnormally low haematological parameters seems to no longer be tenable.

Nasal hemophilic pseudotumor: favorable response to radiotherapy

Hemophilic pseudotumors are rare but dangerous complications of Hemophilia. We hereby report a 3-year-old boy with Hemophilia B, presenting with nasal pseudotumor, showing favorable response to radiotherapy after unsuccessful treatment with factor IX replacement therapy. The diagnosis and treatment of this rare condition is also reviewed.

A self-controlled comparative clinical trial to explore the effectiveness of three topical hemostatic agents for stopping severe epistaxis in pediatrics with inherited coagulopathies

OBJECTIVE

The aim of this study was to assess the effectiveness of localized treatments to persistently stop epistaxis in patients with inherited bleeding disorders.

METHODS

In a self-controlled comparative clinical trial, to offer the best solution to stop epistaxis at home (within 10 minutes), patients with inherited bleeding disorders were treated using three different topical hemostatic agents, including Tranexamic acid impregnated tampon, EpiCell tampon prepared from oxidized regenerated cellulose pad, and ChitoHem tampon (reinforced with chitosan). The results of using these different products on three groups of randomly selected patients were ultimately compared using the χ(2) and Fisher's exact test statistics.

RESULTS

A total of 31 patients, 5 females and 26 males with a mean age of 5.6 years, were included in the study. Twenty-three patients had Glanzmann disease, four had von-Willebrand disease, two had Bernard soulier syndrome, two had activated factor VII deficiency, and one patient had impaired secretion of adenosine deaminase. The study exhibited that statistically there was no significant difference between EpiCell tampon and Tranexamic acid impregnated tampon treatments with respect to the hemostasis duration. However, ChitoHem tampon was more efficient than Tranexamic acid impregnated tampon (P value <0.001) and EpiCell tampon (P value < 0.05).

CONCLUSION

ChitoHem tampon, the chitosan-reinforced product, was the best therapy solution to stop epistaxis. We recommend further research on the use of other hemostatic agents for localized bleeding in patients with inherited bleeding disorders.

Is anti-D immunoglobulin still a frontline treatment option for immune thrombocytopenia?

A 5-year-old boy presents with platelet count of 2×10(9)/L and clinical and laboratory evidence of immune thrombocytopenia. He has epistaxis and oral mucosal bleeding. Complete blood count reveals isolated thrombocytopenia without any decline in hemoglobin and he is Rh+. You are asked if anti-D immunoglobulin is an appropriate initial therapy for this child given the 2010 Food and Drug Administration "black-box" warning.

A retrospective analysis of low dose, intranasal injected bevacizumab (Avastin) in hereditary haemorrhagic telangiectasia

The constantly recurring epistaxis means a great reduction of quality of life for patients with hereditary haemorrhagic telangiectasia (HHT). As yet, an ideal treatment has not been found. Vascular endothelial growth factor (VEGF) has been described as a possible new therapy. In particular, the success of submucosal doses <100 mg has not been analysed before. We injected bevacizumab (Avastin) submucosally in addition to Nd:YAG laser therapy. Doses <7.5 mg were used. To investigate the effect of these additional injections in comparison to laser therapy alone, a retrospective analysis was done. For this purpose a standardized patient questionnaire was completed, which included recording the patients' Epistaxis Severity Score (ESS) before and after the antibody treatment. Besides, patient files were analysed to collect objective data like haemoglobin levels and the number of blood transfusions needed. Data for eleven patients could be analysed. A significant improvement in the ESS resulting from additional bevacizumab therapy was observed (p < 0.01). In particular, the frequency of epistaxis (p = 0.011), duration of epistaxis (p < 0.01), severity of epistaxis (p < 0.01) and the need for acute medical treatment (p = 0.014) decreased significantly. The haemoglobin levels increased significantly (p = 0.011) and the number of blood transfusions declined. There were no side effects caused by the antibody treatment. Additional injections of a low dose of bevacizumab seem to be superior to Nd:YAG laser therapy alone. These results justify further studies.

[The significance of bleeding disorders in patients with epistaxis]

BACKGROUND

Epistaxis can have a variety of different local or systemic causes. It is the cardinal symptom of von Willebrand disease (VWD), the most frequent congenital bleeding disorder with a prevalence of approximately 1%. The usual routine coagulation screening tests (PT, APTT, platelet count) are not sufficient to diagnose VWD, factor XIII (FXIII)-deficiency or platelet dysfunction.

METHOD

A prospective study was conducted implementing enhanced coagulation screening for bleeding disorders in a total of 100 inpatients admitted for epistaxis.

RESULTS

A bleeding disorder was found in 13%. In eight patients VWD was diagnosed, in six patients FXIII-deficiency was found, and in one patient both.

CONCLUSION

The prevalence of bleeding disorders in patients with epistaxis is higher than in the general population. Epistaxis can be the primary symptom of chronic inflammatory disease or malignant disease. A thorough anamnesis is necessary and in cases of doubt additional testing for underlying disorders is recommended.

Relationship between blood group and epistaxis among Nepalese

The relationship between blood group and epistaxis among the patients coming to Tribhuvan University Teaching Hospital, Kathmandu with idiopathic epistaxis was studied. A total of 235 patients coming to the Emergency Department or Department of Otorhinolaryngology with active nose bleeding in were included. ABO blood group was performed. Nearly half (45.5%) of the patients belonged to O-group followed by A-group others. O-group people were also had longer bleeding time compared to other blood groups.

[Fever, nosebleeding and myalgic abdominal pain]

A 38 year old patient presented with fever, myalgic abdominal pain, nose bleeding and acute renal failure since five days. A combination of thrombocytopenia, proteinuria, elevated CrP and creatinin is common in hemorrhagic fever with renal syndrome (HFRS) due to Hantavirus infection. The benigne form is called Nephropathia epidemica. Dialysis is infrequently required by patients with the Puumala virus. Other infection (e.g. malaria, leptospirosis, yellow fever) and systemic diseases (e.g. collagenosis or vasculitis) are considered.

[The analysis of plasma Urokinase-type plasminogen activator and Urokinase-type plasminogen activator receptor which unknown factor nosebleed patients]

OBJECTIVE

To investigate the pathogenesis of unknown nosebleed patients.

METHOD

The ELISA test were used to detected plasma Urokinase-type plasminogen activator (uPA) and Urokinase-type plasminogen activator receptor (uPAR) level in 19 cases unknown factor nosebleed patients and 36 health persons.

RESULT

The results showed uPAR and uPA level in nosebleed group (before treatment) uPAR (0.14 +/- 0.04) microg/L, uPA (0.24 +/- 0.09) microg/L; (after treatment) uPAR (0.08 +/- 0.02) microg/L, uPA (0.18 +/- 0.07) microg/L. And normal group uPAR (0.07 +/- 0.03) microg/L, uPA (0.17 +/- 0.05) microg/L. The uPAR and uPA level in nosebleed group before treatment is higher than that in normal group (P <0.05). There is no significant difference between nosebleed group after treatment and normal group (P>0.05).

CONCLUSION

The reasons of uPAR and uPA level high in unknown factor nosebleed patients were not clear, maybe relation to vascular endothelial cell, smooth muscle cell and neutrophil-monocytic release more uPAR and uPA. So uPAR and uPA density of nostril accumulation is more high in its microenvironment, that fibrinolytic system activated increase and result in its hyperactivity, and happened nosebleed when blood be in hypocoagulable state.

Severe aortic valve stenosis and nosebleed

Aortic valve stenosis is known to be associated with loss of high molecular von Willebrand multimers. This can lead to gastrointestinal bleeding in patients with gastrointestinal angiodysplasia, the Heyde syndrome. Here we present a case of anaemia and severe epistaxis associated with acquired von Willebrand syndrome. Gastrointestinal endoscopy revealed no bleeding source. Calcifying aortic stenosis was confirmed by echocardiography. Loss of high molecular weight multimers of von Willebrand factor in our patient was shown by immunoblot analysis. If severe epistaxis occurs in the context of symptomatic aortic valve stenosis, it might be an additional reason to recommend valve replacement surgery to the patient.

Pediatric epistaxis

OBJECTIVES/HYPOTHESIS

Otolaryngologists are frequently consulted for the evaluation and treatment of pediatric epistaxis. There is a lack of consensus as to the optimal approach to this problem. This study evaluated an approach used to evaluate and treat patients referred on an outpatient basis.

STUDY DESIGN

Retrospective study.

METHODS

Charts from 90 patients referred for the treatment of epistaxis were reviewed.

RESULTS

Anemia was identified in 22% of patients. An abnormal coagulation study was identified in 7.8% of patients. Computed tomography (CT) imaging of the sinuses was obtained in nearly 90% of patients and revealed no suspicious masses. Opacification of the sinuses consistent with sinusitis was commonly seen. The majority of cases were resolved by the first follow-up visit with a topical nasal emollient.

CONCLUSIONS

The outpatient evaluation of epistaxis should include a screen for anemia and coagulopathy. Routine CT imaging of the sinuses is unhelpful and is not recommended. The majority of cases are easily treated with rehydration of the nasal mucosa. Consideration should be given to rhinosinusitis as a co-existing factor in patients with epistaxis.

[Important aspects of nasal bleeding pathogenesis]

The review is dedicated to an important multidiscipline problem, nasal bleeding (NB). The presented analysis of Russian and foreign literature on the most important aspects of the problem shows the variety and complexity of the leading pathogenetic mechanisms of NB (the condition of hemostatic and lipid peroxidation systems, the activity of biologically active substances and the kinine system, the condition of local and system blood flow), contradictoriness of data on some aspects, and insufficient knowledge of a range of aspects. The collected data on the pathogenetic mechanisms of NB, despite the high quality of some studies, do not suggest the existence of a common modern theoretical base on this problem.

Stains on the carpet

Some people have red urine and faeces after eating beetroot, but how much do we know about beetroot's ability to intensify the colour of blood, thereby making blood stains impossible to remove?

Blood loss estimation in epistaxis scenarios

Thirty-two members of staff from the Ear, Nose and Throat Department at Warrington General Hospital were asked to estimate blood loss in commonly encountered epistaxis scenarios. Results showed that once the measured volume was above 100 ml, visual estimation became grossly inaccurate. Comparison of medical and non-medical staff showed under-estimation was more marked in the non-medical group. Comparison of doctors versus nurses showed no difference in estimation, and no difference was found between grades of staff.

Vascular endothelial growth factor serum levels are elevated in patients with hereditary hemorrhagic telangiectasia

BACKGROUND

Hereditary hemorrhagic telangiectasia (HHT) is a genetic angiodysplasia affecting multiple organs. Two genes involved in the transduction of TGF-beta signalling are responsible for HHT. An additional role for vascular endothelial growth factor (VEGF) has been proposed. Serum VEGF, which has been evaluated in several diseases characterized by aberrant angiogenesis, has never been measured in patients with HHT.

AIMS

To evaluate VEGF serum levels in HHT patients as compared to normal subjects.

MATERIALS AND METHODS

32 HHT patients (age 47.7 +/- 16.7 years) and a control group of 37 healthy subjects (age 48.2 +/- 15.5 years) were entered in the study. Each patient underwent serum VEGF dosage using a commercial ELISA specific for the human molecule.

RESULTS

The serum level of VEGF in HHT patients was 196.3 +/- 103.2 pg/ml, while it was 152.0 +/- 84.1 pg/ml in the control group. Statistical analysis showed that serum VEGF was significantly higher in HHT patients than in the controls (p < 0.031).

CONCLUSIONS

According to a study performed in a murine model, persistence of the activation phase of angiogenesis might be responsible for an increased production of several angiogenic factors, in particular VEGF, in HHT. Our work is the first to suggest an increased expression of VEGF in the serum of subjects with HHT in agreement with the stimulation of VEGF synthesis proposed in the murine model.

Anesthetic management of juvenile nasopharyngeal angiofibroma resection

OBJECTIVE

To evaluate the anesthetic implications of the surgical resection of juvenile nasopharyngeal angiofibroma (JNA).

DESIGN

Retrospective study.

SETTING

University-affiliated community hospital.

PARTICIPANTS

Ten patients undergoing resection of JNA.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data from the records of 10 patients undergoing resection of JNA were reviewed and analyzed with regard to demographics, history of the disease, characteristics of the tumor, surgical resection techniques, and anesthetic management. Patients were age 11 to 29 years. All had nasal obstruction as presenting symptom. There was no intracranial invasion. Eight tumors were resected via a lateral rhinotomy and 2 endoscopically (after embolization of the tumor's feeding vessels). Duration of surgery was 6 +/- 1 hours for rhinotomy and 6 and 6.5 hours for the 2 endoscopic resections. Anesthesia was induced in a rapid-sequence manner. Arterial and central venous catheters were placed in all patients. Mean arterial pressure was targeted to 55 to 65 mmHg by using increasing concentrations of isoflurane. The estimated blood loss was 4,800 +/- 1,600 mL and blood replacement was 3,200 +/- 1,400 mL in the first group. The 2 other patients lost 600 mL and 1,500 mL. Blood replacement in this group was 0 and 700 mL respectively. No mortality or major morbidity occurred.

CONCLUSION

Resection of JNA should be considered a major procedure with many anesthetic challenges. Isoflurane may be employed to provide deliberate hypotension.

The value of coagulation profiles in epistaxis management

A prospective pilot study was conducted to investigate the role and relevance of clotting profiles in the management of epistaxis patients. Forty-eight per cent of the study patients had abnormal clotting profiles. Half of the abnormal clotting profiles could have been predicted from a routine history, but half could not. The coagulation screens on this group were repeated and 5% of the initial study group were found to have a persistent abnormality. The authors suggest that although coagulation screens will not predict the potential management problems associated with the epistaxis patient, they remain an important part of the clinical investigation. An epistaxis may be the only indication of an underlying coagulation disorder. The diagnosis of such a disorder following an epistaxis may lead to the treatment of an otherwise unknown condition and prevention of more serious sequelae.

Atrial natriuretic peptide levels in children with habitual epistaxis

OBJECTIVE

By virtue of no identifiable causes in the majority of children with habitual epistaxis, it continues to be problematic in pediatric clinical practice. The purpose of this study is to explore the possible change of atrial natriuretic peptide (ANP) levels in the children with epistaxis.

METHODS

Both the plasma and nasal mucus ANP levels have been determined in 30 sick children by a sensitive radioimmunoassay (RIA) technique.

RESULTS

Our results revealed that the plasma and nasal mucus ANP levels were considerably decreased in 24 children with habitual epistaxis when compared with control group (P<0.05), making up 80%, and amongst the interest of these are the nasal mucus ANP levels changing inversely as the times bled from the nose.

CONCLUSION

Although the plasma and nasal mucus ANP levels will not establish the diagnosis of its etiology, it is helpful for us to know the cardiovascular status compensating for chronic blood loss in the children with habitual epistaxis.

[Clinical features of neurohumoral regulation of the vascular tonus in patients with recurrent nasal bleedings]

Norepinephrine (NE), dopamine, histamine and serotonin levels in the blood were measured fluorometrically in 54 patients with nasal bleedings (NB) aged 15 to 23 years. Of them, 18 patients suffered from habitual NB, 36 had NB because of hypertension. Biogenic amines were studied before and after graded exercise (GE). Low basal levels of serotonin, NE and dopamine were found in all the examinees. Patients with habitual NB had also high basal level of histamine. Such correlation of biogenic amines points to abnormal relations between vasoconstrictive and vasodilating mechanisms of neurohumoral vascular regulation disturbing microcirculation in nasal mucosa, suppresses tonicity of the capacitive vessels, leads to their overfilling, progression of circulatory hypoxia and metabolic acidosis, makes bleedings recurrent. Similarity of neurohumoral adaptation reactions to GE in patients with habitual and hypertensive NB suggests the presence of the same mechanisms of NB onset and their recurrences in various primary causes.

Nasal lavage concentrations of free hemoglobin as a marker of microepistaxis during nasal provocation testing

BACKGROUND

The constituents of nasal mucus may be contaminated by plasma if there is epistaxis. Gross epistaxis is apparent as a red lavage fluid, while microepistaxis may yield a clear fluid. If gross or microepistaxis are present, it will be difficult to decide whether plasma protein concentrations are elevated because of plasma exudation or bleeding. In order to discriminate between these two possibilities, we measured erythrocyte-derived free hemoglobin (fHb) in nasal lavage fluids.

METHODS

Single-blinded subjects underwent standard hypertonic saline nasal provocation. Unilateral hypertonic nasal provocation was performed in normal, allergic rhinitis (AR) and nonallergic rhinitis (NAR) subjects (total of 1316 specimens). fHb was measured using the Sigma-Aldrich kit (St. Louis, MO). Grossly bloody specimens were analyzed separately from the remainder. Statistical analysis defined the means and 95th percentiles for fHb and albumin in the nonbloody normal group.

RESULTS

fHb concentrations ranged from below the limits of detection (< 1 microg/ml) to > 164 microg/ml fHb was 79.3 microg/ml +/- 4.7 (mean +/- SEM) in four normal, 31 AR and 25 NAR grossly bloody specimens. The 95th percentile of fHb in the nonbloody normal samples (n = 68 subjects, n = 681 specimens) was 16.5 microg/ml. This value was defined as the threshold to detect potential microepistaxis, and corresponded to approximately 245 000 erythrocytes per ml of lavage fluid. Total protein (P < 0.05) and albumin (P < 0.001), but not markers of glandular secretion, were significantly increased in samples with fHb > 16.5 microg/ml compared to those < or = 16.5 microg/ml. Elevations of fHb without changes in albumin were more prevalent in nonallergic rhinitis.

CONCLUSIONS

Significant bleeding into nasal lavage samples can contaminate the specimens and increase the concentrations of both fHb and plasma proteins. Increased albumin alone would indicate increased vascular permeability. The mechanism(s) leading to elevated fHb without increased plasma proteins require further investigation.

Topical estrogens combined with argon plasma coagulation in the management of epistaxis in hereditary hemorrhagic telangiectasia

The aim of this study was to assess the value of topically applied estrogens in patients with hereditary hemorrhagic telangiectasia. Twenty-six patients with this disorder were treated with argon plasma coagulation and randomized into 2 groups: group A, which had postoperative application of estriol ointment (n = 14), and group B, which had postoperative application of dexpanthenol ointment (n = 12). Over a period of 12 months, the frequency and intensity of bleeding, the patient's satisfaction, and the success of the treatment were evaluated with a questionnaire. Before the operation, more than 90% of the patients in both groups complained of daily episodes of epistaxis. Twelve months after treatment, the frequency and intensity of bleeding had significantly decreased in group A as compared to group B. Of the patients in group A, 93% were satisfied with the treatment. Of the patients in group B, only 42% were satisfied with the treatment. In both groups, more than 90% of the patients were willing to undergo the same treatment again. The combined treatment approach with argon plasma coagulation and topical estriol enables us to significantly prolong the hemorrhage-free interval.

Clinical and laboratory features of 178 children with recurrent epistaxis

PURPOSE

To determine the clinical and laboratory features of 178 children referred for the evaluation of recurrent epistaxis to an outpatient hematology clinic in a university medical center.

PATIENTS AND METHODS

Medical records of 3681 outpatient pediatric hematology referrals were retrospectively review, and 178 children with recurrent epistaxis from 1985 to 1999 were identified. Historic (other bleeding symptoms: gingival bleeding, easy bruising, menorrhagia, and gross blood in the urine or stool: duration and severity of the epistaxis episodes; and family history of bleeding) and laboratory (complete blood count and coagulation tests) data were analyzed.

RESULTS

There were 103 boys and 75 girls with a median age of 84 months (range 15-219 months). Sixty-seven percent (n = 119) did not have a coagulopathy diagnosed and 33% (n = 59) did. The diagnoses included von Willebrand disease in 33, platelet aggregation disorders in 10, thrombocytopenia in seven, mild factor VIII deficiency in three, Bernard-Soulier syndrome in two, factor VII deficiency in one, factor IX deficiency in one, and factor XI deficiency in one, and coagulation inhibitor in one. Of the historic data, only a family history of bleeding was predictive of diagnosing a coagulopathy (P = 0.023). The duration and severity of the epistaxis and the presence of other bleeding symptoms had no predictive value. Children with a coagulopathy diagnosed had a longer median partial thromboplastin time (PTT) (33.1 vs. 30.5 seconds; P = 0.012).

CONCLUSIONS

One-third of children presenting with recurrent epistaxis have a diagnosable coagulopathy. A positive family history and a prolonged PPT are useful predictive data.

Routine coagulation screening in the management of emergency admission for epistaxis--is it necessary?

The role of routine coagulation studies in the management of patients suffering from epistaxis is unclear. In an attempt to address this issue the case notes of all emergency admissions for epistaxis to a large Scottish teaching hospital were retrospectively reviewed over a one-year period. One hundred and forty patients (63 male, 77 female) were admitted between January and December 1998. The patients who had coagulation studies were identified and their results analysed. A total of 121 patients (86.4 per cent) had coagulation studies performed. Of these, 10 (8.3 per cent) had abnormal results and all were taking warfarin or a combination of warfarin and aspirin. No other coagulation abnormalities were identified. This study supports the view that there does not appear to be a role for routine coagulation studies in patients admitted with epistaxis. The investigation for potential haemostatic disorders should be performed when clinically indicated and, if necessary, in consultation with the haematology service.

Coagulation studies in patients admitted with epistaxis--current practice in Scotland

Epistaxis remains the most common ENT emergency. The use of coagulation studies in Scotland to manage these patients was investigated to determine current practice. The study took the form of a postal questionnaire sent to all practising ENT consultants and a telephone survey of ENT senior house officers working in Scotland. Of the 60 questionnaires circulated amongst consultants, 55 responses were received (92 per cent). Thirty-eight consultants (70 per cent) indicated that they did not routinely request a coagulation screen for their patients, however, 30 per cent (16) did. Forty-three of the 45 junior staff were available for interview, 22 (51 per cent) of whom routinely requested coagulation studies. While the majority of consultants did not request routine coagulation studies, there did not appear to be any consensus among the junior staff. Although there is a paucity of scientific information with regard to this aspect of epistaxis patient management, there is support in the literature for targeted rather than blanket testing. There is perhaps a need to address this issue within individual departments, to achieve uniformity of practice, and to improve communication between junior and senior staff.

[The electroencephalographic aspects in stress epistaxis]

The nasal haemorrhage is a symptom whose significance is seldom completely investigated. In this paper we present the results that we have obtained in two groups of patients: a pediatric population who presented for repeated episodes of nasal haemorrhage and a group of first trimester pregnant women who also have noticed the appearance of this symptom. Beside the clinical examination, a paraclinical assessment has been performed, which included a laboratory profile (hematology and biochemistry) and electroencephalography (EEG), in which we found significant changes. We conclude that EEG is a valuable investigation technique for diagnosis and monitoring purposes in nasal hemorrhage. Also, the clinical management of the stress-related nasal hemorrhage must address multiple issues for becoming efficient.

[Recurrent epistaxis in children as an indicator of hemostatic disorders]

OBJECTIVE

To distinguish which nosebleeds in children hide an underlying coagulation disorder, characteristics of recurrent epistaxis were evaluated correlating the severity with a battery of specific tests on primary and secondary hemostasis.

PATIENTS AND METHODS

Epistaxis of fifty-eight children were classified as mild or severe according to frequency, duration, amount of blood lost, proportion of life that nosebleeds have been recurrent and uni- or bilateral bleeding. Epidemiological characteristics were evaluated, as well as hemostatic tests including: platelet count, mean platelet volume, plasmatic fibrinogen level, prothrombine time, activated partial thromboplastin time, thrombin time, bleeding time, von Willebrand factor antigen and ristocetin cofactor, factor VIII coagulant, and platelet aggregation to different agents. The effect of drugs or the presence of tumors was discarded.

RESULTS

In the group of children with mild epistaxis (n = 39) there were three cases with laboratory abnormalities (10.3%). In severe epistaxis (n = 19) abnormalities were found in eleven cases (57.9%) and specific entities were detected in six of them (three children with von Willebrand's disease, one Bernard-Soulier syndrome, one autoimmune thrombocytopenic purpura and one Rendü-Osler-Weber disease). Epistaxis labeled as mild needed less cauterizations and packings, were more related to seasonal prevalence and self-handling, and poorly influenced iron metabolism.

CONCLUSIONS

The five qualities pointed out on recurrent epistaxis in children allow the identification of who must be thoroughly studied by means of specific tests to rule out any kind of hemostatic disorder.

Epistaxis: A retrospective review of hospitalized patients

A 2-year retrospective study (August 1, 1992, to July 31, 1994) reviews medical records of 249 hospitalized epistaxis patients at seven Baltimore-area hospitals. This review represents the first multihospital study of patients hospitalized with epistaxis. The study evaluates multiple factors associated with epistaxis: demographics, underlying medical diseases, use of anticoagulation medication, site of epistaxis, and month of hospital admission. Blood transfusion requirement, hematocrit level, length of stay, treatment, and local/systemic complications are studied as well. The month of hospital admission was evenly distributed without a wintertime predominance, and the mean length of stay was 4 days. Treatment and outcome were similar in all hospitals, and more than 83% of patients responded to packing, balloon placement, local cautery, or a combination thereof. Of the 249 patients reviewed, 30 underwent surgical endoscopic cautery, 3 required formal surgical arterial ligation, and 1 underwent arterial embolization. All 30 endoscopic cauterizations successfully stopped the epistaxis, and this technique proved to be a useful adjunct for patients who required multiple interventions. The review identified a 3% complication rate of epistaxis and its treatment, including synechiae, aspiration, angina, myocardial infarction, and hypovolemia. No deaths were directly attributable to epistaxis or its treatment. (Otolaryngol Head Neck Surg 1997;117:49–53.)

Congenital deficiency of factor VII

A case of congenital factor VII deficiency in a five-year-old child is reported. The patient, born of a non-consanguineous marriage, presented with repeated bouts of epistaxis since childhood. The prothrombin time (PT) was markedly prolonged with a normal bleeding time (BT), partial thromboplastin time with Kaolin (PTTK) and platelet count. The patient has been on follow up for the last four years and is doing apparently well.

[Life threatening epistaxis due to plasma coagulation disorder as a partial manifestation of gluten sensitive enteropathy]

We report on a 73 years old female patient receiving a recurrent epistaxis due to a severe plasmatic malcoagulation. In spite of since twenty years remaining diarrhoea coeliac disease has been diagnosed but now causative of the malcoagulation. On the occasion of this report clinical, current pathogenetical, immunological and pathohistological aspects of coeliac disease have been described. At last we agree to the differential diagnosis of anaemia in coeliac disease and in this connection to the metabolism of vitamin K too.

Bleeding diathesis associated with variant von Willebrand factor in a Simmental calf

A 10-month-old Simmental heifer was examined because of a 10-day history of epistaxis and aural hematomas. Examination of the calf also revealed hemarthrosis. Initial laboratory data indicated that platelet count, platelet size, prothrombin time, and partial thromboplastin time were not different from a clinically normal (control) cow. Mucosal bleeding time was prolonged, and platelet adhesion to glass beads was less than expected. The clinical signs, prolonged bleeding time, and platelet adhesion defect were corrected by infusion of bovine plasma. Subsequent laboratory testing revealed that the affected calf had a truncated multimeric structure of von Willebrand factor (vWF), low vWF activity, and impaired platelet aggregation in response to adenosine diphosphate, but concentration of vWF was not different from that in clinically normal control animals. These data were consistent with a diagnosis of variant von Willebrand disease. The relationship of this disease to the thrombopathy of Simmental cattle is unclear.

Platelet dysfunction associated with clozapine therapy

Clozapine, an atypical antipsychotic agent used in cases of treatment-resistant schizophrenia, is known for its relative absence of extrapyramidal side effects and its potential hazardous effect on white blood cell function. We have described a case of clozapine-associated epistaxis and reduction of the platelet count. Discontinuance of clozapine therapy resulted in cessation of epistaxis followed by normalization of the platelet count. We suggest routine monitoring of platelet count and function in patients treated with clozapine.

Mild bleeding disorders. A clinical and laboratory study

OBJECTIVE

To investigate in-vitro haemostasis in subjects with symptoms suggesting a mild bleeding disorder.

DESIGN

A prospective study in which an extensive range of in-vitro tests were applied unselectively.

SETTING

Patients were referred from community-based practices and hospital outpatient services.

PATIENTS

Ninety-three consecutive patients were examined. Hospital patients with severe illness were excluded.

CLINICAL FEATURES

Patients presented with easy bruising (68%), epistaxis (12%), excessive operative bleeding (7%), menorrhagia (4%), haematuria (3%), dental bleeding (1%) and bleeding from other sites (5%). In no instance was the bleeding life threatening.

OUTCOME MEASURES

Results of laboratory tests for patients presenting with the symptoms of a mild bleeding disorder were compared with the results for a healthy reference group.

RESULTS

Abnormal results of in-vitro tests were found in 53% of the subjects. Thirteen per cent had a prolonged bleeding time, of whom the majority had abnormal results of other in-vitro tests. Von Willebrand's disease was diagnosed in 7% of patients, although only half of these had a prolonged bleeding time.

CONCLUSIONS

Abnormal results of in-vitro tests were prevalent among subjects with symptoms of mild bleeding disorder. Easy bruising was as powerful a clue as any other bleeding manifestation to the presence of an abnormal in-vitro test result.

The effect of early blood transfusion on severe epistaxis

This retrospective study assesses the effect of early blood transfusion on the subsequent progress of patients admitted with severe epistaxis. Both further bleeding and surgical procedures were more frequent in those receiving blood within the initial 24 h. It was concluded that the need for early blood transfusion should be assessed with care.

Modulation of mild bleeding disorder during remissions and exacerbations of Graves' disease

A patient with Graves' disease had a symptomatic thrombocytopathy during periods of remission. When euthyroid, she noticed bruising, petechiae, and epistaxis. Hemostatic abnormalities included prolongation of the bleeding time by aspirin, reduced platelet retention (a second-phase defect), and abnormal thrombin-induced aggregation and serotonin release. When hyperthyroid, bleeding symptoms resolved, and platelet function returned to normal. These observations suggest that mild bleeding disorders may be influenced either directly or indirectly by thyroid hormone levels.

Bleeding tendency as a cause of epistaxis in the dog

Based upon a survey of the pathophysiology of haemostasis, the causes of epistaxis in the dog are discussed, and guidelines for a diagnostic and therapeutic approach are given.

Epistaxis. Examination of hospitalized patients

Thirty-nine patients with epistaxis requiring hospitalization have been examined. Their average age was 57 years, and a relationship was found between hypertension and epistaxis in in-patients, in contrast to out-patients. Other possible general reasons for nose-bleeding have been discussed and, from studies of blood and bleeding, it would appear that it is only the haemoglobin which requires routine control.

Pulmonary arterial haemodynamics and blood gas values of Thoroughbred racehorses with a history of epistaxis during a race

In ten Thoroughbred racehorses which suffered epistaxis during a race, the mean pulmonary arterial diastolic pressure (PADP) was significantly higher, and the mean pulmonary arterial oxygen tension (PaO2) was significantly lower, than the corresponding mean values of a sample of fourteen clinically normal Thoroughbreds in training. The authors conclude that in horses with epistaxis during a race, pulmonary dysfunction may persist for up to two months after the episode, and that the results indicate a need for pulmonary function studies before and after racing, in order to resolve problems concerning exercise-induced pulmonary haemorrhage.

Arterial hypoxemia in patients with anterior and posterior nasal packings

Previous clinical reports indicate that nasal packing is frequently associated with arterial hypoxemia. Anesthesia and surgery in hypoxemic patients can be hazardous, especially when it is associated with acute blood loss. Nine patients with severe epistaxis, who failed to respond to anterior and posterior nasal packing, were anesthetized for emergency internal maxillary artery ligation. Arterial blood-gas and pH changes during the procedure were evaluated. The results indicate some degree of arterial hypoxemia and high alveolar/arterial PO2 difference without significant change in PaCO2 and pH in most of the patients observed. Arterial PO2 was within normal range 24 hours after operation. The anesthetic management is described and the various causes of such arterial hypoxemia are reviewed. It is important to recognize the presence of arterial hypoxemia and treat accordingly during surgery for such patients.