Difficulties in laboratory diagnosis of coexistent lupus anticoagulant and factor VIII inhibitors: case report and review of literature.

BACKGROUND: Whereas lupus anticoagulant (LA) and anti-factor VIII (anti-VIII) antibody are both acquired autoimmune coagulation inhibitors, they exhibit different pathophysiologic mechanisms and opposite clinical manifestations. Distinguishing between these two inhibitors is therefore essential for optimizing appropriate management. Harboring both antibodies, which is a rare condition, is of a challenging and confounding laboratory work-up. CASE PRESENTATION: We illustrate a case report of a 39-year-old man admitted for the management of recurrent deep-vein thrombosis. Curiously, the initial physical examination revealed several hematoma and bruises of varying sizes. Biologically, a prolonged activated partial thromboplastin time (APTT) was objectified and was not corrected by the mixing study. The following detection of synchronous LA and anti-VIII was made using specific assays. CONCLUSIONS: Through this case, we illustrate the complexity of diagnosing coexistent LA and FVIII inhibitors. In fact, the biological hallmark of both inhibitors is an isolated prolonged APTT that does not correct by the mixing study. Despite the progress in LA and anti-VIII assays and the ongoing updating of standardized recommendations, the lack of specific tests for LA and the limited availability of VIII quantification tests other than the clot-based assays make it difficult to distinguish adequately between the two inhibitors. Therefore, it is crucial to correlate test results with clinical features and patient evaluation.

Massive transfusion practices in Tunisia and protocol proposal.

INTRODUCTION: Massive transfusion (MT) is a life-saving therapy in situations of major hemorrhage awaiting radical haemostatic treatment. Poor management and control of this therapy may, however, compromise the patient's vital prognosis. The main aim of our study was to take stock of massive transfusion practices in Tunisia. The secondary aim was to propose a massive transfusion protocol. METHODS: An analytical observational study based on a questionnaire was conducted. We targeted physicians brought in their clinical practice to use MT. RESULTS: A total of 124 clinicians responded to the questionnaire. The majority (62%) were anesthesiologists or emergency physicians. More than half of the participants were residents (51%). The use of MT based on a clinical or biological score was only found for a minority (13%). The initial order was for the majority of participants (N=69) made up of red blood cell concentrates (RBC) and fresh frozen plasma (FFP). The FFP: RBC ratio was1:2 for 51% of the participants. A higher ratio was adopted by the rest. Respectively 23.5% and 9.6% of participants transfused platelets and fibrinogen concentrates without waiting for the result of biology. The use of tranexamic acid was systematically advocated by 60.5% of clinicians. The majority (86.3%) adopted a restrictive transfusion strategy (target hemoglobin between 7 and 9 g/dl). The latter was more adopted by the youngest physicians (92.1% of residents versus 55.6% of professors; p=0.008). CONCLUSIONS: The professional practices of MT in Tunisia are heterogeneous. Given the lack of a clear institutionalized procedure which frames this therapy, a MT protocol has thus been proposed.

Subcutaneous Panniculitis-Like T-Cell Lymphoma Presenting with Full Facial Edema and Hemophagocytic Syndrome.

A 42-year-old previously healthy woman presented with a 2-month history of recurrent fever and painful swelling on the left thigh. She was given a presumptive diagnosis of cellulitis and an antimicrobial. Because the response was not significant and fever remained moderate to high grade, with the appearance of gradually increasing periorbital edema (Figure 1), the diagnosis was reconsidered, and she was referred to a tertiary referral center for further study.

Successful resolution of Hemophagocytic lymphohistiocytosis associated to brucellosis in the adult.

Hemophagocyticlymphohistocytosis (HLH) is a proliferation of histiocytes with importanthemophagocytosisoccurring in different organs such as the spleen and the bone marrow. HLH is now increasingly diagnosed in the context of infections, malignancies and connective tissue diseases. Although brucellosis is an endemic infection in Tunisia, its association with HLH is a very rare condition which should be considered in patients with splenomegaly and cytopenia. Here, we describe brucellosis associated HLH in a 31 year-old man. The patient was admitted to our hospital with fever, sweating, and fatigue. Physical and laboratory findings revealed splenomegaly, pancytopenia, elevated serum transaminases, triglycerides, lactate dehydrogenase, and ferritin, and bone marrow hemophagocytosis. The Brucella agglutination test was positive. The patient improved after treatment with Rifampin and doxycyclin.

Thymidylate synthase polymorphism in sporadic colorectal and gastric cancer in Tunisian population: a predictive role in 5-fluorouracil based chemotherapy treatment.

In our study, we investigate the possible association of thymidylate synthase polymorphism, 28 bp tandem repeat in 5'-UTR (transcription enhancer element) with susceptibility of colorectal and gastric cancer in Tunisian population. Because thymidylate synthase provides an effective prediction of chemotherapy treatment based on 5-fluorouracil, our interest in this study was focused on finding an eventual interaction between thymidylate synthase polymorphism and treatment of sporadic colorectal and gastric cancer. Whole blood was collected into EDTA tube, after centrifugation for 15 min, the buffy coat was isolated, and genotyping of TS 5'-UTR polymorphism was carried by polymerase chain reaction method using appropriate primers. Determination of the different genotypes was done directly on the stained agarose gel. Our finding showed that the 5'tandem repeat polymorphism of the thymidylate synthase gene is associated with risk of colorectal cancer; thus, LL (3R/3R) genotype is significantly high in patients with colorectal cancer compared to controls (P = 0.002; OR 2.7; 95 % CI 1.4-5.2). In addition, we found a positive association between SL (2R/3R) genotype in the thymidylate synthase 5'-UTR and gastric cancer risk (P = 0.015; OR 4.46; 95 % CI 1.08-19.64). Furthermore, we found a correlation of thymidylate synthase polymorphism with the fluorouracil-based therapy regimes and also with preoperatory radiation in patients with colorectal cancer. Thymidylate synthase is associated with risk of colorectal cancer but not with gastric cancer; however, heterozygous SL (2R/3R) polymorphism is associated with risk of gastric cancer; moreover, the 5' tandem repeat polymorphism of thymidylate synthase gene was an independent predictor of the clinical treatment.

[Importance of preanalytical step in hemostasis]. / Importance de l'étape préanalytique en hémostase.

The preanalytical conditions are the major component to assure the reliability and validity of results in hemostasis. They extend from the requirement of analysis, patient preparation, blood collection and the conditions of transport, centrifugation and plasma storage until analysis. They are the most important sources of erroneous or inconclusive results; mainly the quality of the analytical stage has seen great progress of instruments and reagents. Control and standardization efforts of these preanalytical conditions are essential to ensure the quality of exploration in hemostasis.

[Prevalence and risk factors of thromboembolic complications in inflammatory bowel disease]. / Prévalence et facteurs de risque des complications thromboemboliques au cours des maladies inflammatoires chroniques de l'intestin.

BACKGROUND: Patients with inflammatory bowel disease (IBD) are at increased risk of thromboembolic complications (TEC), which represent an important cause of morbidity and mortality. AIM: To assess the prevalence and risk factors of TEC in patients with IBD. METHODS: We conducted a retrospective study including all the IBD patients in the gastroenterological department of Charles Nicolle hospital between 2000 and 2010. Only thromboembolic events that had been diagnosed by an imaging procedure were counted. RESULTS: A total of 266 patients with IBD were consecutively included. TE events occurred in nine patients (3.4%); six men and three women. Their mean age was 31 years [15-64 years]. Five patients had Crohn's disease and four had ulcerative colitis. The types of TEC were deep venous thrombosis of the leg in five cases with pulmonary embolism in one of them, cerebral venous thrombosis in two cases, portal thrombosis in one case and jugular vein thrombosis in one case. Active disease was present in all cases at the time TEC occurred. CONCLUSIONS: In our study, the prevalence of TEC is 3.4% in patients with IBD. Deep venous thromboses of the leg are the most common TEC and all our cases occurs during the active phase of IBD.

[Dysfibrinogenemia and thrombosis. A case report]. / Association dysfibrinogénémie et thrombose. A propos d'un cas.

BACKGROUND: Congenital dysfibrinogenemia is a functional disorder of the fibrinogen that represents a rare cause of thrombophilia. AIM: To report a Tunisian case of the association dysfibrinogenemia and thrombosis. CASE: A woman with inherited dysfibrinogenemia associated with mild tendency to bleeding experienced a deep vein thrombosis of the lower-extremity at 26 years of age and a fatal pulmonary embolism a few years later. Paradoxically coagulation function of fibrinogen was markedly altered in vitro with a significantly prolonged prothrombin time, activated partial thromboplastin time and thrombin time, a functional fibrinogen level that was undetected and a severely impaired fibrin polymerisation. The thromboembolic events in the patient could be related to dysfibrinogenemia since the main causes of thrombophilia were excluded. CONCLUSION: Although it is rare, this cause of thrombophilia must not be misdiagnosed, systematic measuring of prothrombin time, activated partial thromboplastin time and functional fibrinogen might be helpful.

[Chronic disseminated intravascular coagulation caused by aortic dissection]. / Coagulation intravasculaire dissiminee revelant une dissection de l'aorte.

BACKGROUND: Disseminated intravascular coagulation (DIC) is a severe disease. It can be caused by loss of pathology. CASE REPORT: We report the case of chronic aortic dissection discovered during the evaluation of disseminated intravascular coagulation (DIC). This case is characterised by the severity of clinical presentation, challenging diagnosis and difficulty of therapeutic approach. Low dose of heparine may reduce the severity of this situation; but vital prognosis remains obscure. CONCLUSION: aortic dissection is a rare but a severe cause of disseminated intravascular coagulation

Bleeding and thrombosis in a patient with secondary antiphospholipid syndrome.

Antiphospholipid antibodies have been associated with occurrence of arterial and venous thrombotic events and fetal loss, which together constitute the antiphospholipid syndrome (APS). However, bleeding is rare in this syndrome. We report a case of systemic lupus erythematosus (SLE) with APS complicated simultaneously by thrombotic and hemorrhagic events. A 34-year-old woman was a known case of diffuse proliferative lupus nephritis associated with APS, on treatment with corticosteroids, cyclophosphamide and anticoagulants. She presented in February 2004 with severe anemia, menorrhagia, gingival bleeding and acute loss of vision in the left eye. Investigations revealed a hematoma in the psoas muscle with thrombosis of the inferior vena cava and occlusion of the retinal vein. Blood tests revealed a strongly positive lupus anticoagulant, factor XI deficiency (35%) and decrease of free protein S (44%). Factor XI inhibitor, anti-prothrombin, and anti-protein S antibodies were absent. The patient was treated with corticosteroids and six pulses of cyclophosphamide, which resulted in a rapid disappearance of bleeding, reduction of hematoma and normalization of hematological abnormalities. She was maintained on corticosteroids, azathioprine and anticoagulant agents were introduced. After a follow-up of 28 months, there was no recurrence of bleeding, the thrombosis had resolved, and there was a decrease in the levels of circulating anticoagulant as well as anticardiolipin antibodies.

[Biological diagnosis of Von Willebrand disease and its difficulties]. / Diagnostic biologique de la maladie de Willebrand et ses difficultes.

Von Willebrand disease is the most common inherited bleeding disorder, with autosomal genetic transmission, dominant in most cases. It is due to quantitative and/or qualitative deficiency of Von Willebrand factor, a multimeric complex glycoprotein that plays 2 central roles in hemostasis, since it is implicated in adhesion and aggregation of platelets under conditions of high shear forces and acts as a carrier for coagulation factor VIII in plasma. Clinically, this disease is mostly characterized by mucocutaneous bleeding and marked clinical heterogeneity, even in the same family, going from severe to uncouth forms or even asymptomatic. Laboratory diagnosis is based on 3 levels of hemostasis testing. Screening tests making suspicion of the disease, must be completed by specific assays to estabilish the diagnosis. Discriminating tests allow accurate characterization of the numerous types and subtypes of the disease, a crucial step to adapt therapeutics. The classification based on the accumulating knowledge of the different phenotypes, differentiate between quantitative (types 1 and 3) and qualitative deficiencies (types 2). Von Willebrand disease's diagnosis is not, often easy. In fact, several technical or genetic factors and different physiopathological circumstances interfere in the interpretation of explorations results and cause diagnostic difficulties that will be discussed.

Heparin-like anticoagulant associated with multiple myeloma and neutralized with protamine sulfate.

A 55-year-old man with multiple myeloma developed sustained bleeding after bone marrow aspiration and cutaneous bleeding. Routine coagulation studies revealed a prolonged activated partial thromboplastin time and thrombin time (> 60 s) with a normal reptilase time. Further evaluation showed failure of the activated partial thromboplastin time to correct completely in a 1: 1 mixture with normal plasma. Treatment of the patient's plasma in vitro with protamine sulfate normalized the thrombin time. The presence of a heparin-like anticoagulant was suspected. The plasma heparin level was 0.73 IU/ml. Intravenous infusion of protamine sulfate appeared to neutralize the anticoagulant activity and stop the bleeding. The cancer cells themselves or the invasive nature of this type of cancer might result in a massive release of a heparinoid. Such coagulopathy appears to be a rare mechanism of bleeding and it is an important entity to consider since it is potentially reversible with protamine sulfate.

Anti-thrombomodulin antibodies and venous thrombosis.

Thrombomodulin (TM) is a cell surface endothelial glycoprotein having anticoagulant properties. It inhibits thrombin, and activates protein C, leading to the inhibition of activated factors V and VIII. TM autoantibodies could theoretically predispose to thrombosis. We have tested 83 unselected patients with deep venous thrombosis, 36 males and 47 females aged from 1 to 70 years [mean +/- standard deviation (SD), 34.2 +/- 14.5 years] for the presence of IgG anti-TM in their plasmas. Tests were performed by enzyme-linked immunosorbent assay (ELISA) using recombinant human TM kindly provided by PAION GmbH (Aachen, Germany). Results are expressed as the optical density (OD) differences between coated and un-coated wells. Plasmas from 83 normal volunteer donors were used to define the cut-off value as the mean of absorbance of the control group + 3 SDs. The median OD of normal controls group was 0.024 (mean, 0.034; SD, 0.066; range, -0.048 to 0.309). The median OD obtained with plasmas from patients was 0.048 (mean, 0.114; SD, 0.215; range, -0.039 to 1.312) and was significantly higher than that of the control group (P < 0.0001). Choosing a cut-off value of 0.232 (mean OD of the control group + 3 SDs), 11 patients are considered as positive for IgG autoantibodies to TM and three normal controls are weakly positive. Selected plasma with IgG anti-TM and purified IgG were further tested by dot blot using recombinant purified TM and were found positive. Purified IgG of positive plasmas inhibits protein C activation by TM and thrombin, suggesting that anti-TM antibodies have a procoagulant effect. Interestingly, in our study, anti-TM antibodies are found in three of six patients with Budd-Chiari syndrome and four of eight patients with cerebral venous thrombosis. In conclusion, thrombomodulin autoantibodies could be a new interesting marker of thrombophilia easily detected by ELISA.