Acquired isolated factor VII deficiency in a patient with myxoid pleomorphic liposarcoma, case report

INTRODUCTION

Acquired factor VII (FVII) deficiency is a rare condition with various causes, including acquired inhibitors to FVII, liver disease, and malignancies. Myxoid pleomorphic liposarcoma is a rare and aggressive form of soft tissue sarcoma that can cause a range of clinical manifestations, including bleeding and clotting disorders.

PATIENT CONCERNS AND DIAGNOSIS

We present a case report of a 21-year-old man with severe acquired FVII deficiency due to mediastinal myxoid pleomorphic liposarcoma. The patient presented with elevated International normalized ratio (INR) and a severe reduction in FVII coagulant activity, unresponsive to conventional therapy. While an acquired inhibitor to FVII was initially suspected, negative results from laboratory testing, including protein G sepharose adsorption and a Bethesda assay using Immunoglobulin G purified from patient plasma, made the diagnosis of an acquired inhibitor to FVII uncertain.

INTERVENTIONS AND OUTCOME

The patient underwent surgical resection of the tumor, supported by recombinant FVII infusion, leading to the normalization of coagulation parameters. However, a relapse of the disease was detected 6 months later when he was noted to have a decline in FVII levels.

CONCLUSION

This case highlights the importance of considering rare causes of bleeding and clotting disorders, particularly in unresponsive or atypical presentations. It also underscores the need for close monitoring and follow-up in patients with acquired FVII deficiency, even after successful treatment.

Patient with congenital factor VII deficiency undergoing brain tumor neurosurgery successfully treated with recombinant factor VIIa and fresh frozen plasma: A case report and literature review

RATIONALE

Congenital factor VII deficiency is the most common among rare bleeding disorders, characterized by spontaneous or traumatic bleeding. The clinical manifestation is heterogeneous, ranging from asymptomatic phenotype to life-threatening hemorrhages. Intracranial hemorrhage is a common complication of brain tumor neurosurgery, which significantly challenges the perioperative management of patients with hemostatic defects.

PATIENT CONCERNS

This report presented a 55-year-old man with congenital factor VII deficiency, who had no history of hemorrhage or family history. He underwent a craniotomy for the treatment of papillary craniopharyngioma.

DIAGNOSES

The patient was diagnosed as papillary craniopharyngioma, factor VII deficiency, and atrial fibrillation.

INTERVENTIONS

To prevent bleeding, a total of 8 doses of recombinant activated factor VII and 1 dose of fresh frozen plasma were administered as the perioperative replacement therapy. This scheme was guided by a pharmacodynamic evaluation, laboratory tests, and imaging examinations.

OUTCOMES

No excessive surgical bleeding was observed during the 22-day treatment. The patient was found to have compound heterozygous mutations, Ala304Thr (c.910G > A) and IVS5-2A > G (c.572-2A > G), in the F7 gene.

LESSONS

This is the first reported case in which surgical hemorrhage secondary to brain tumor resection was successfully controlled in the presence of congenital factor VII deficiency. Perioperative coagulation state, hemostasis, and thrombosis events should be closely observed, and the interval and dosage of recombinant factor VIIa should be adjusted accordingly.

Acquired factor VII deficiency in pediatric inflammatory bowel disease: Report of three cases

Bleeding disorders can exacerbate gastrointestinal bleeding in inflammatory bowel disease (IBD) at the time of diagnosis or flares. Factor VII (FVII) deficiency is a life-threatening rare congenital bleeding disorder in childhood. This study describes three adolescent patients with IBD accompanied by acquired FVII deficiency. This is the first case series of patients with IBD accompanied by FVII deficiency. We hypothesized that inflammation, accelerated consumption, disease severity, and weight loss can cause decreased FVII activity in patients diagnosed with IBD. To control intestinal bleeding, we must keep in mind factor deficiencies in IBD.

Undiagnosed Factor VII Deficiency in Cardiac Surgery Complicated by Bleeding: A Case Report

Rare bleeding disorders in the perioperative period call for targeted resuscitation strategies. Factor VII deficiency, for instance, is often corrected with exogenous administration of recombinant factor VIIa. This activated clotting factor, initially designed for patients with hemophilia A or B with factor inhibitors, is gaining popularity as a salvage therapy for severe and persistent traumatic and surgical bleeding. This article describes the management of a cardiothoracic surgical patient with undiagnosed isolated factor VII deficiency who experienced significant postoperative bleeding which subsided after the administration of recombinant factor VIIa. In this case, EXTEM failed to detect a clotting factor deficiency.

Factor VII Padua in Iran: clinical and laboratory findings of three unrelated patients

The congenital factor VII (FVII) deficiency with an estimated incidence of one per 300 000 is the most common rare congenital bleeding disorder. The heterogeneous clinical pictures, including asymptomatic to life-threatening manifestations, are seen in patients with FVII deficiency. A variety of gene variants throughout the FVII ( F7 ) gene have been reported so far. In this setting, very rare FVII Padua polymorphism provokes an interesting condition in which results of prothrombin time and FVII activity are different based on the thromboplastin sources used in these tests. The current study aimed to report the phenotype and genotyping of patients with Padua variant. During the workup of the laboratory for FVII deficiency for diagnosis of FVII Padua, all patients with FVII deficiency who had prolonged prothrombin time, normal activated partial thromboplastin time, and variable FVII activity results using different sources of thromboplastin were included. Demographic data and clinical findings were recorded. For the molecular study, the F7 gene sequencing was performed using the Sanger sequencing technique. Five patients with FVII Padua and a history of mild-to-moderate bleeding, including easy bruising, epistaxis, gingivorrhagia, and bleeding after surgical challenges (including dental extraction and tonsillectomy), were detected during the study. DNA sequencing revealed a heterozygote CGG to CAG (Arg364Gln) variant in exon 9 at nucleotide position 1091, consistent with the genetic variant of FVII Padua. Timely diagnosis of FVII Padua is vital to avoid unnecessary exposure of patients to replacement therapy.

Reproductive health and hemostatic issues in women and girls with congenital factor VII deficiency: A systematic review

BACKGROUND

Congenital factor VII (FVII) deficiency is an inherited bleeding disorder, with heterogenous bleeding symptoms. Women with FVII deficiency face hemostatic challenges during menstruation, ovulation, and childbirth. This systematic review evaluated prevalence and management of bleeding symptoms associated with gynecological and obstetric issues in women with FVII deficiency.

METHODS

Databases (BIOSIS Previews, Current Contents Search, Embase, and MEDLINE) were searched for studies reporting FVII deficiency and gynecological or obstetric issues in women. Articles were screened using Joanna Briggs Institute checklists and relevant data extracted.

RESULTS

One hundred fourteen women were identified from 62 publications. Forty-six women had severe deficiency (FVII:C < 5% or <5 IU/dl). Heavy menstrual bleeding (HMB) was the most common bleeding symptom (n = 94; 82%); hospitalization and urgent medical/surgical interventions for acute HMB episodes were required in 16 women (14%). Seven women reported ovarian bleeding (6%); other bleeding symptoms varied. Patient management was inconsistent and included hemostatic and hormonal treatments. Only four women (7%) reporting vaginal bleeding during pregnancy. Postpartum hemorrhage (PPH) occurred following 12/45 deliveries (27%; 5 [42%] requiring blood transfusion) and was not necessarily prevented by prophylaxis (8 women).

CONCLUSION

Women with congenital FVII deficiency have an increased risk of HMB, ovarian bleeding, and PPH, impacting quality of life. Recognition of a bleeding disorder as the cause is often delayed. Management of bleeding complications is heterogeneous due to lack of treatment guidelines. Harmonizing severity classification of FVII deficiency may help standardize treatment strategies and development of specific guidelines for these women.

Acquired and Isolated Deficiencies in Factor VII

BACKGROUND

Acquired and isolated deficiencies in FVII are exceptional. They have mainly been reported during states of severe sepsis by the presence of proteases destroying the factor or neoplastic pathologies by the presence of an inhibitor. Consequently, very few cases have been published.

METHODS AND RESULTS

We report two cases of isolated and acquired deficiency of factor VII due to the presence of inhibitors which were related to bacterial sepsis in the first patient and to squamous cell carcinoma in the second patient, diagnosed in the Hematology Laboratory of the CHU Ibn Rochd.

CONCLUSIONS

Factor VII deficiency is a rare and poorly described deficiency that can be acquired or constitutional. The search for anti-factor VII antibodies by diluted thromboplastin time should be requested depending on the clinical context.

Investigation of a common canine factor VII deficiency variant in dogs with unexplained bleeding on autopsy

The factor VII (FVII) protein is an integral component of the extrinsic coagulation pathway. Deleterious variants in the gene encoding this protein can result in factor VII deficiency (FVIID), a bleeding disorder characterized by abnormal (slowed) clotting with a wide range of severity, from asymptomatic to life-threatening. In canids, a single FVIID-associated variant, first described in Beagles, has been observed in 24 breeds and mixed-breed dogs. Because this variant is present in breeds of diverse backgrounds, we hypothesized that it could be a contributing factor to unexplained bleeding observed in some canine autopsy cases. DNA was extracted from paraffin-embedded tissue samples from 67 anticoagulant-negative autopsy cases with unexplained etiology for gross lesions of hemorrhage. Each dog was genotyped for the c.407G>A (F71) variant. Experimental controls included 3 known heterozygotes and 2 known homozygotes for the F71 variant, 2 normal dogs with known homozygous wild-type genotypes (F7WF7W), and 5 dogs with bleeding at autopsy that tested positive for anticoagulant rodenticide and were genotyped as F7WF7W. All 67 cases tested homozygous for the wild-type allele, indicating that the common FVIID variant was not responsible for the observed unexplained bleeding. Our work demonstrates the usefulness of retrospective studies utilizing veterinary diagnostic laboratory databases and tissue archives for genetic studies. In the case of FVIID, our results suggest that a singular molecular test for the F71 variant is not a high-yield addition to postmortem screening in these scenarios.

Thromboelastometry as an Ancillary Tool for Evaluation of Coagulation Status after rFVIIa Therapy in a Pregnant Woman with Severe Hypoproconvertinemia-A Case Series and Review of the Literature

Introduction: Factor VII (FVII) deficiency is a rare hemorrhagic diathesis. In females, heavy menstrual and postpartum bleeding can appear as a consequence of its deficiency. Supplementation of the recombinant FVIIa is widely accepted. The supplementation effect in FVII-deficient subjects is difficult to predict, and severe hemorrhage has been described even when FVII levels after supplementation were within normal ranges. The aim of this report is to present the application of thromboelastometry to control the coagulation status in a patient with severe FVII deficiency during pregnancy and delivery, supplemented by rFVIIa per protocol complicated with life-threatening venous thromboembolism. Methods: Rotational thromboelastometry (ROTEM) was performed in 16 pregnant women: in one 28 year old primigravida at 35 weeks of pregnancy with congenital FVII deficiency after rFVIIa administration and 15 healthy women at 38 gestational weeks. The results were compared. Results: The thromboelastometry results showed significant shortening of the clotting time in the extrinsic and the intrinsic pathway in the hypoproconvertinemia patient after rFVIIa administration in relation to healthy pregnant women. A significant reduction in maximum lysis of the clot after FVII supplementation was observed. Conclusions: The thromboelastometry results showed a significant hypercoagulable state with hypoproconvertinemia. Thrombotic complications after delivery might be prevented by the reduction in rFVIIa guided by thromboelastometry. Thromboelastometry performed on a pregnant woman with factor VII deficiency during the supplementation of rFVIIa in peripartum time might be helpful in order to determine an individual, effective dosage regimen of rFVIIa to ensure full correction of clotting disorders without the tendency to develop thrombosis, but further studies are needed.

Acquired Factor VII Deficiency Presenting with Bleeding Diathesis in a 52-Year-Old Black Man in Botswana

BACKGROUND

Factor VII is one of the vitamin K-dependent coagulation factors synthesized in the liver and has a short circulating half-life of 4 - 5 hours.

METHODS

We report a case of a 52-year-old black man who presented with life-threatening bleeding from multiple sites.

RESULTS

We determined that it was caused by acquired factor VII deficiency of less than 5%. He had a septic pelvic focus which was managed empirically with antibiotics. The bleeding was stopped by fresh frozen plasma and factor VII plasma levels gradually increased to normal levels over the course of 4 months.

CONCLUSIONS

We emphasize the importance of extensive evaluation including septic, autoimmune, and malignant work-up in patients with new onset acquired bleeding.

Peculiar Congenital Factor VII Defect with the Proposita and Her Mother Showing the Same Compound Heterozygosity for Thr384Met and Arg413Gln

OBJECTIVE

To investigate a family with factor VII (FVII) deficiency from Argentina.

PATIENTS AND METHODS

The proposita is a 14-year-old girl who presented with a mild to moderate bleeding tendency. Menorrhagia is controlled with periodical administration of small doses of recombinant FVII concentrate. The mother of the proposita has a similar bleeding tendency.

RESULTS

FVII activity in both patients was 20% of normal; FVII antigen was 35% of normal. Molecular biology investigation revealed that the proposita was compound heterozygote between Thr384Met and Arg413Gln. The mother had the same mutations. This was due to the fact that the father of the proposita and her maternal grandfather both carried, in spite of no relation, the same mutation, namely Arg413Gln.

CONCLUSIONS

The identical defect which presented in the propositaand her mother could be explained by the genetic analysis of the father and maternal grandfather of the proposita who happened to have the same mutation (Arg413Gln).

Unprovoked Pulmonary Embolism in Factor VII Deficiency

Thrombotic events in bleeding disorders such as hemophilia A or B, Von Willebrand disease, afibrinogenemia, factor VII deficiency, and factor XI deficiency are rare but have been reported. These events usually occur in the presence of prothrombotic risk factors such as recent surgery, trauma, or factor replacement therapy. We present a case of a 68-year-old Hispanic female with a history of factor VII deficiency who presented with shortness of breath, chest pain, and palpitations and was found to have pulmonary embolism. Our patient did not have any of the above-mentioned thrombotic risk factors. Our case and review of the literature show that factor VII deficiency does not provide protection against thrombosis.

Clinical and Laboratory Findings in Jewish and Bedouin Patients in Southern Israel Who Were Diagnosed with Factor VII Deficiency

BACKGROUND

Congenital factor VII deficiency is a rare recessive autosomal bleeding disorder with a wide spectrum of clinical manifestations.

OBJECTIVES

To compare the clinical and laboratory findings in Jewish and Bedouin patients with factor VII deficiency.

METHODS

The clinical and laboratory findings of patients with factor VII deficiency treated at Soroka Medical Center, a tertiary hospital in Israel, from 2005 to 2015 were analyzed regarding blood factor levels, illness severity, treatment administration, and disease outcome.

RESULTS

Seventy-eight patients were enrolled (1:13,000 of the population in southern Israel) of whom 26 were diagnosed with severe factor VII deficiency (1:40,000). Sixty (76.9%) patients were Jewish and 18 (23.1%) were Bedouin. In univariable analysis, Bedouin patients exhibited a more severe illness, with significantly higher complication and fatality rates, and required more preventive treatment than the Jewish patients.

CONCLUSIONS

The prevalence of congenital factor VII deficiency (including severe deficiency) in the Jewish and Bedouin populations of southern Israel is higher than previously reported. The clinical spectrum of the disease was found to be more severe in the Bedouin population.

A new perspective on perioperative coagulation management in a patient with congenital factor VII deficiency: A case report

RATIONALE

Congenital factor VII (FVII) deficiency is a rare coagulopathy. There are little clinical data for congenital FVII deficiency and no evidence-based medicine guidelines for treatment.

PATIENT CONCERNS

A 48-year-old woman with gallbladder stones suffered from intermittent abdominal pain for 2 months that was accompanied by an abnormally prolonged prothrombin time.

DIAGNOSES

The woman was diagnosed as having cholecystolithiasis with cholecystitis and congenital FVII deficiency.

INTERVENTION

Preoperative evaluation confirmed the necessity of recombinant activated factor VII (rFVIIa) replacement therapy. We monitored the plasma factor VII activity (FVII:C) and coagulation function, determined the half-life of rFVIIa in the patient, and administered personalized rFVIIa replacement therapy.

OUTCOMES

Laparoscopic cholecystectomy was performed successfully, and the patient recovered well without any complications.

LESSONS

The clinical manifestations and severity of bleeding in patients with congenital FVII deficiency can vary widely. The history of massive bleeding and plasma FVII:C are the decisive factors when implementing a replacement therapy. The actual half-life of rFVIIa can be determined from intensive monitoring results of plasma FVII:C at the beginning of replacement therapy, which could further guide the personalization of rFVIIa replacement therapy.

Delayed Presentation of Compartment Syndrome of the Thigh in a Previously Undiagnosed Factor VII-Deficient High School Football Athlete: A Case Report

CASE

We describe a case of delayed presentation of compartment syndrome in the anterior aspect of the thigh in a high school athlete. The patient had sustained a blow to the thigh 8 days prior to presentation, and had continued to practice football in the setting of undiagnosed coagulopathy. He presented with severe thigh pain and the inability to contract the thigh muscles.

CONCLUSION

A high index of suspicion for compartment syndrome is indicated for patients with disproportionate pain, especially in the setting of relatively minor trauma. Underlying coagulopathy should be investigated in patients with compartment syndrome because there is a high incidence of bleeding disorders in this population.

F7 gene variants modulate protein levels in a large cohort of patients with factor VII deficiency. Results from a genotype-phenotype study

Congenital factor VII (FVII) deficiency is a rare bleeding disorder caused by mutations in F7 gene with autosomal recessive inheritance. A clinical heterogeneity with poor correlation with FVII:C levels has been described. It was the objective of this study to identify genetic defects and to evaluate their relationships with phenotype in a large cohort of patients with FVII:C<50 %. One hundred twenty-three probands were genotyped for F7 mutations and three polymorphic variants and classified according to recently published clinical scores. Forty out of 123 patients (33 %) were symptomatic (43 bleedings). A severe bleeding tendency was observed only in patients with FVII:C<0.10 %. Epistaxis (11 %) and menorrhagia (32 % of females in fertile age) were the most frequent bleedings. Molecular analysis detected 48 mutations, 20 not reported in the F7 international databases. Most mutations (62 %) were missense, large deletions were 6.2 %. Compound heterozygotes/homozygotes for mutations presented lower FVII:C levels compared to the other classes (Chi2=43.709, p<0,001). The polymorphisms distribution was significantly different among the three F7 genotypic groups (Chi2=72.289, p<0,001). The presence of truncating mutations was associated with lowest FVII:C levels (Chi2=21.351, p=0.002). This study confirms the clinical and molecular variability of the disease and the type of symptoms. It shows a good correlation between the type of F7 mutation and/or polymorphisms and FVII:C levels, without a direct link between FVII:C and bleeding tendency. The results suggest that large deletions are underestimated and that they represent a common mechanism of F7 gene inactivation which should always be investigated in the diagnostic testing for FVII deficiency.

Diagnostic Error of a Patient with Combined Inherited Factor VII and Factor X Deficiency due to Accidental Ingestion of a Diphacinone Rodenticide

BACKGROUND

To explore the characteristics of laboratory examination and confirm the diagnosis of a patient with combined inherited FVII and FX deficiency after he ingested diphacinone rodenticide accidentally.

METHODS

The coagulant parameter screening tests and coagulation factor activities were tested many times in the patient due to accidental ingestion of a diphacinone rodenticide. After the patient was treated for more than one year, gene analysis of correlated coagulation factors was analyzed in the patient and other family members by DNA direct sequencing. 106 persons were selected as controls from routine health examinations.

RESULTS

After the patient was admitted to hospital, routine coagulation screening tests revealed the prolonged prothrombin time (PT) and activated partial thromboplastin time (APTT) and low levels of vitamin K-dependent coagulation factors (FII, FVII, FIX, FX) activity, which was 102.4 seconds, 88.5 seconds, 7%, 3%, 8%, and 2%, respectively. During more than one year of treatment, the value of PT and APTT still showed significantly prolonged activity and FVII and FX activity levels were about 5%. While FII and FIX activity levels were in the normal range after 12 weeks of treatment. Two homozygous mutations, g.11267C>T of F7 gene resulting in the substitution Arg277Cys and g.28139G>T of F10 gene leading to the substitution Val384Phe, were identified in the patient. The patient's parents and sister was heterozygous for Arg277Cys and Val384Phe mutations. FVII and FX antigen levels in the patient were 7% and 30%, respectively.

CONCLUSIONS

There were many similarities in the characteristics of laboratory examination between combined inherited FVII and FX deficiency and acquired vitamin K deficiency. The best way to identify them was gene analysis.

Isolated acquired factor VII deficiency: review of the literature

OBJECTIVES

Isolated acquired factor VII (FVII) deficiency is a rare haemorrhagic disorder. We report what is currently known about the pathogenesis, clinical features, diagnosis, treatment and prognosis of acquired FVII deficiency.

METHODS

We performed a literature search and included all articles published between 1980 and August 2015.

RESULTS AND CONCLUSIONS

Acquired FVII deficiency has been reported in 42 patients. There are well-established clinical diseases associated with acquired FVII deficiency, most notably infections, malignancy and haematological stem cell transplantation. The exact pathogenesis of the diseases is still unknown, but different pathophysiological hypotheses have been suggested. The clinical manifestation of acquired FVII deficiency varies greatly in severity; asymptomatic course as well as severe life-threatening bleeding diathesis and fatal bleedings have been described.

[A RARE CLINICAL CASE OF CONGENITAL HYPOPROCONVERTINEMIA]

The paper reports a rare clinical case of congenital hypoproconvertinemia in an elderly woman repeatedly admitted to the Cardiological Department for the management of coronary heart disease and arterial hypertension. The detection of low prothrombin index in a series of analysis requiredfurther hematological examination that revealed the history of postoperative and postnatal hemorrhage along with markedly reduced factor VII level. These results were interpreted as evidence of a rare congenital pathology, hypoproconvertinemia.

Long-term successful percutaneous coronary intervention in factor VII deficiency

Factor VII deficiency (FVIId) is a congenital coagulation disorder with a wide spectrum of bleeding phenotypes. Percutaneous coronary intervention requires full anticoagulation during stent implantation to avoid acute coronary thrombosis and long-term dual antiplatelet therapy. Feasibility of percutaneous coronary intervention in FVIId is not described in literature. We present a successful case of percutaneous coronary intervention in a 55-year-old male with FVIId, discussing briefly the periprocedural handicaps (anticoagulation regimen and hemostasis at arterial puncture site) as the safety of long-term antiplatelet therapy, and future implications for recombinant FVIId administration in a patient with a previous coronary stent.

[Significant decrease in factor VII activity by tissue thromboplastin derived from rabbit brain in a patient with congenital factor VII deficiency (FVII Padua)]

Congenital factor VII (FVII) deficiency is a bleeding disorder that requires optimal hemostatic management for each case due to its wide variety of bleeding symptoms. We experienced a patient with inherited FVII deficiency who demonstrated different FVII activities depending on tissue thromboplastins used for assays. An 82-year-old woman without any episodes of abnormal bleeding was found to have different FVII activities of 1.4% and 32% when assayed using thromboplastins from rabbit brain and human placenta, respectively. DNA sequencing analysis revealed a homozygous missense mutation of G10828A (FVII Padua) that caused an amino acid substitution of Arg304 to Gln (R304Q). Carriers of 304Q alleles are usually clinically asymptomatic and do not require FVII replacement therapies even in cases of homozygotes. In case a prolonged prothrombin time or reduced FVII activity is detected, re-examination using thromboplastins of other sources can be helpful for preliminary diagnosis of R304Q, in order to prevent unnecessary FVII replacement therapies.

Recurrent intracranial haemorrhages in a patient with factor seven deficiency: a case report

Inherited factor VII (FVII) deficiency is a rare autosomal recessive hemorrhagic disorder. Clinical bleeding can vary widely and does not always correlate with the level of FVII coagulant activity measured in plasma. Most severe cases of factor VII (FVII) deficiency are diagnosed during childhood, often during the first 6 months of life. In infancy, the most common sites of bleeding occur in the gastrointestinal tract or CNS, accounting for 60-70% of bleeds in this age group. Recombinant factor VIIa (rFVIIa) is one such agent, which has been shown to prevent hematoma expansion and improve outcome in acute intracranial haemorrhages. The purpose of this case report is to share our experience regarding the usefulness of rFVIIa in the management of acute intracranial haemorrhage.

Congenital combined deficiency of coagulation factors VII and II in a young adult

We present herein a case of a young female with congenital combined coagulation factor VII (FVII) and factor II (FII) deficiencies. She was completely asymptomatic and found to have a prolonged prothrombin time during a routine preoperative evaluation. Low levels of plasma FVII and FII in the absence of an inhibitor confirmed the diagnosis in our patient. Congenital combined FVII and FIX deficiency as well as combined FVII and FX deficiency have been previously reported. The congenital combined deficiency of FVII and FII in our patient is exceptional and represents the first such instance in the English literature. Furthermore, we hypothesize that she had not shown any bleeding manifestations because of possible compensation for the missing factors II and VII by enhanced activity of some intrinsic coagulation pathway components or depression of fibrinolysis.

[The influence of factor VII deficiency on cardiac operations with extracorporeal circulation]

During preoperative blood coagulation testing the factor VII (FVII) deficiency was found in two patients. No liver disease or cardiac insufficiency was found. No history of bleeding episodes existed. The latent (mild) deficiency of the FVII was diagnosed. The treatment with vitamin K (Vitacon) was administered in order to exclude vitamin K deficiency. The treatment showed no impact on the level of the FVII. Mixing study corrected the deficit (normal PT was found). Both patients underwent cardiac surgery with extracorporeal circulation. The epsilon-aminocapronic acid and fresh frozen plasma were used to prevent bleeding. The postoperative bleeding was compared to average of the year. No difference was found. The patients with mild FVII deficiency may safely undergo cardiac surgery with extracorporeal circulation.

[Serious congenital deficiency of FVII and acquired idiopathic thrombocytopenic purpura--the rare combination of two bleeding disorders]

The congenital deficiency of FVII is an autosomal recessive rare disorder. We have observed 15 patients with this deficiency in our haematology department including the only one patient with the FVII level < 1%. The deficiency with the FVII level < 2% is associated with serious bleeding complications including the joint bleeding, bleeding in the retroperitoneum, gastrointestinal system and in central nervous system (CNS). Serious acquired thrombocytopenia can originate from the impairment of platelets production, from their higher sequestration in the spleen but even from the elevated thrombocytes disintegration. The raised thrombocytes disintegration caused by the autoantibodies is the most frequent source of the acute life threatening thrombocytopenia with the massive bleeding in tissues, gastrointestinal system or CNS. We list the case report of a young patient with congenital FVII deficiency (FVII level < 1%) and acute idiopathic thrombocytopenic purpura with yet unknown aetiology of which has not been fully clarified although the very favourable effect of prednisone therapy indicates the autoimmune mechanism.

Japanese collaborative study to assess inter-laboratory variation in factor VII activity assays

BACKGROUND

The clinical phenotype manifest by patients with factor VII (FVII) deficiency correlates poorly with that predicted by laboratory tests. Despite its importance, there are no data on the variability of inter-laboratory determinations of low to very low plasma FVII activity (FVII:C).

METHODS

We distributed three FVII-deficient plasma samples, prepared by immunoaffinity chromatography, to 58 laboratories in Japan. All samples were assayed using standardized reference plasma as a calibrator. Recombinant thromboplastin was also supplied as a common reagent.

RESULTS

In the case of sample A, which had a very low FVII:C, the use of standardized reference plasma and thromboplastin, lowered the variability of inter-laboratory measurements, when compared with the variability observed when samples were assayed using the respective laboratory's routine method.

CONCLUSIONS

The data obtained indicated that results for samples with a very low FVII:C were greatly influenced by the number of plasma dilutions used in constructing a standard activity curve, and also by the type of calibrator and thromboplastin. Such variability was not seen for samples with moderate FVII:C. We conclude that it is necessary to develop a more sensitive and accurate FVII:C measurement system for the diagnosis and treatment of FVII deficiency.

Second trimester antenatal diagnosis in rare coagulation factor deficiencies

Prenatal diagnosis is sought after for those genetic disorders, whose management is not satisfactory either because of the outcome or owing to extreme cost involved in the management of the patients affected by a specific disorder. Severe hemophilia and homozygous thalassemia are the 2 disorders for which there is an increasing demand for prenatal diagnosis in India. Rare severe deficiencies of coagulation factor X (FX) and factor VII (FVII) may present with severe bleeding manifestations. Because of their rarity the laboratory offering prenatal diagnosis for severe hemophilia and thalassemia may not be in a position to provide genetic diagnosis in the fetus. In this communication, we describe 2 families, 1 with an index patient of severe FVII deficiency and the other with severe FX deficiency where successful prenatal diagnosis was given after cordocentesis between 17 and 19 weeks using a battery of coagulation factor assays. Follow-up studies were performed 3 to 4 months after delivery and the diagnoses were reconfirmed on these babies by a repeat factor assay for FX and FVII deficiency, respectively.

An unusual complication of ice skating and the emergence of a previously undiagnosed bleeding disorder

We report the case of an 8-year-old boy with no prior abnormal bleeding history who presented with severe central abdominal pain following a freak accident at a local ice rink. Clinical examination confirmed a tender periumbilical mass. An ultrasound scan confirmed a large haemorrhagic fluid collection adjacent to the second part of his duodenum that was causing a subacute small-bowel obstruction. He was found to have a persistently prolonged prothrombin time between 17.3 and 18.1 s but normal liver function tests. There was no suggestion of dietary vitamin K deficiency. Further investigations confirmed factor VII deficiency with levels between 30.4 and 33.6 IU dL-1. His prothrombin time did not normalize with intravenous vitamin K. He was subsequently treated with three 30 microg kg-1 body weight doses of novoseven at 4-h interval and made an excellent recovery. The haematoma virtually resolved completely confirmed by a follow-up ultrasound scan 3 months after the initial event.

[Factor VII deficiency--case report]

We describe the hypoproconvertinemia - a hereditary factor VII deficiency, diagnosed in 55-years-old female. Prolonged menstruations resulted in planned hysterectomy. Both her sons also have agent VII deficiency, however without any symptoms of hemorrhagic diathesis.

Factor VII deficiency and developmental abnormalities in a patient with partial monosomy of 13q and trisomy of 16p: case report and review of the literature

Background

Unbalanced chromosomal translocations may present with a variety of clinical and laboratory findings and provide insight into the functions of genes on the involved chromosomal segments.

Case Presentation

A 9 year-old boy presented to our clinic with Factor VII deficiency, microcephaly, a seizure disorder, multiple midline abnormalities (agenesis of the corpus callosum, imperforate anus, bilateral optic nerve hypoplasia), developmental delay, hypopigmented macules, short 5^th fingers, and sleep apnea due to enlarged tonsils. Cytogenetic and fluorescence in situ hybridization analyses revealed an unbalanced translocation involving the segment distal to 16p13 replacing the segment distal to 13q33 [46, XY, der(13)t(13;16)(q33;p13.3)]. Specific BAC-probes were used to confirm the extent of the 13q deletion.

Conclusion

This unique unbalanced chromosomal translocation may provide insights into genes important in midline development and underscores the previously-reported phenotype of Factor VII deficiency in 13q deletions.

Potential predictors of bleeding risk in inherited factorVII deficiency. Clinical, biological and molecular criteria

Due to the wide molecular and clinical heterogeneities of inherited factor VII (FVII) deficiency, consensus guidelines for management of this coagulation disorder are not currently well established. Therefore, potential clinical, plasmatic or genetic criteria, that could be predictive for bleeding tendency in this condition, have been evaluated. Genotypic criteria including FVII genotypes and thrombophilic mutations are of particular interest to better understand some of the variations observed in bleeding phenotypes but they are still poorly informative for the management of surgery in FVII-deficient patients. Up to now, no plasma parameters have been found to be reliable predictors of bleeding risk. Nevertheless, tissue factor and platelet pathways remain to be explored. Finally, clinical history appears to be the best predictor of bleeding risk after haemostatic challenges in inherited FVII deficiencies. Furthermore, the absence of history of bleeding or mild bleeding phenotypes including menorrhagia, bruises and epistaxis (not inducing iron deficiency anaemia or requiring blood substitutive treatment) could enable minor surgery to be performed in FVII-deficient patients without blood replacement therapy.

[Gene diagnosis of antithrombin deficiency and factor VII deficiency]

Since 1996 we have performed gene diagnosis of hereditary antithrombin deficiency and factor VII deficiency. We studied twenty-three patients with antithrombin deficiency and identified eighteen distinct gene mutations including single nucleotide substitutions, small nucleotide deletions, a small nucleotide insertion, and whole gene deletions. In two patients, however, we couldn't find out any mutations. We studied three patients with factor VII deficiency and identified three missense mutations. Two patients were homozygous for the mutation, respectively. Unexpectedly one patient was heterozygous for a missense mutation in the EGF domain though her plasma level of factor VII was reduced to 7% of normal. These results revealed that the genetic backgrounds and molecular mechanisms of antithrombin deficiency and factor VII deficiency were highly heterogeneous.

Hemorrhagic stroke in a child with protein S and factor VII deficiencies

A 12-year-old previously healthy male, with a family history of protein S deficiency, presented with confusion, aphasia, and right upper extremity weakness after a 10-day febrile illness. Imaging studies revealed sinovenous thrombosis and left parietal hemorrhagic stroke. On further investigation he was found to have both protein S and factor VII deficiencies.

Clinical picture and management of congenital factor VII deficiency

In patients with congenital FVII deficiency, bleeding manifestations and clinical presentation vary widely, ranging from asymptomatic subjects to patients with haemorrhages that may cause important handicaps. Owing to menorrhagia, which occurs in about two-thirds of women of fertile age, bleeding is more frequent in women than in men. Gum bleeding and easy bruising are also more frequent in females. FVII:C levels are not a good predictor of bleeding tendency as there is a wide overlap between bleeders and asymptomatic patients. We propose a three-grade system of classification based on clinical considerations. Therapy for congenital FVIII bleeding is discussed, with the advantages and disadvantages of each treatment, and the suggested single dose given.

A rare inherited coagulation disorder: combined homozygous factor VII and factor X deficiency

The combined presence in the homozygous state of more than one recessively transmitted coagulation defect may rarely occur in countries with a high rate of consanguinity. In an Iranian family consisting of two parents (second cousins) and two affected siblings, initial phenotypic analysis led to a diagnosis of mild FX deficiency (10-19% FX activity, 42-54% FX:Ag), and genotyping revealed a new homozygous missense mutation in the corresponding gene (Ser3Cys). As both of the sibs had a severe bleeding history that was not compatible with mild deficiency of FX, further phenotypic analysis revealed the additional presence of severe FVII deficiency (<1% FVII activity; 63-111% FVII:Ag) associated with the homozygous missense gene mutation Cys310Phe. In this kindred, lack of identification of the double coagulation defect might have led not only to incomplete understanding of the clinical phenotype but also to an incorrect prenatal diagnosis.

Analysis of biological phenotypes from 42 patients with inherited factor VII deficiency: can biological tests predict the bleeding risk?

BACKGROUND AND OBJECTIVES

Inherited factor VII (FVII) deficiency is a rare bleeding disorder characterized by a poor relationship between reported FVII clotting activity (FVII:C) and bleeding tendency. Our study was aimed at defining biological parameters that are possibly predictive for bleeding risk in this condition.

DESIGN AND METHODS

Forty-two FVII-deficient patients (FVII:C <30%) were classified into two opposite clinical groups defined as severe and non-or-mild bleeders. For each patient, plasma samples were collected and then investigated for FVII:C (using a sensitive method and human recombinant thromboplastin as the reagent), FVII antigen, activated FVII coagulant activity (FVIIa:C) and the free-form of tissue factor pathway inhibitor.

RESULTS

None of these tests could be used as highly accurate predictors of bleeding. Nevertheless, both FVII:C and FVIIa:C differed significantly between the two clinical groups. Using ROC-curve analysis, two critical values of 8% and 3mIU/mL for FVII:C and FVIIa:C, respectively, could be proposed to discriminate between severe bleeders and non-or-mild bleeders.

INTERPRETATION AND CONCLUSIONS

A highly accurate diagnostic test for predicting bleeding tendency in inherited FVII deficiency still eludes definition, highlighting the fact that factors other than FVII itself interfere with the expression of bleeding phenotypes in this condition. Nevertheless, potential critical values using sensitive FVII:C and FVIIa:C methods may be useful in clinical laboratories for FVII-deficient patients. Those patients with FVII:C levels higher than 8% FVII:C or FVIIa:C higher than 3 mIU/mL, with no other hemostatic defect, seem to have a minimal risk of severe bleeding. Extended clinical studies are needed to support these findings.

Congenital factor VII deficiency: a case report

Factor VII deficiency is a rare congenital blood disorder. Its clinical features are rather variable and ranges from epistaxis to massive intracranial haemorrhage. Treatment involves replacement therapy, which constitutes use of fresh frozen plasma, prothrombin complex concentrates or recombinant activated factor VII. Although it is a rare entity, one still needs to consider it as a probable diagnosis in a newborn with coagulopathy. We report here a case of Factor VII deficiency in a newborn who presented with subdural haemorrhage at day 4 of life.

Factor VII deficiency

As yet, there have been neither systematic reviews nor reports of randomized, controlled trials involving factor VII (FVII) deficiency. Hence, a picture of this disorder can only be drawn by reviewing and summarizing the data that is available. This article provides an overview of the understanding of this rare, inherited disorder of coagulation. In particular, the status of current knowledge of the disorder's prevalence, clinical presentation, diagnostic characteristics and molecular genetics is reviewed, followed by a summary of currently available options for its treatment and management.