Cutaneous Hematomas Research Articles

Report of two cases of subconjunctival haemorrhage as first sign of post‐pregnancy acquired haemophilia a (AHA)

AbstractPurpose: To show that subconjunctival haemorrhage may be the first sign of post‐pregnancy acquired A haemophilia (AHA), a potentially fatal bleeding disorder.Methods: Case reports.Results: Two thirty‐year‐old caucasic women at first pregnancy presented slight pain without visual loss 2 weeks after uncomplicated spontaneous full‐term delivery. The only clinical findings were a subconjunctival bleeding for both and a small haematoma in the first case. The clinical history was negative for spontaneous bleeding also in infantile age and at previous surgery and no bleeding tendency was observed in the main relatives. The first patient was lost on follow‐up and admitted to urgent haemathologic evaluation due to large multiple cutaneous hematomas, a massive deep muscle haematoma, asthenia and dyspnea. In the second case quick routine coagulation labs were performed immediately after the subconjunctival bleeding. In both cases PTT ratio was increased. An extensive study of blood coagulation suggested the presence of a circulating inhibitor against factor VIII [1,2], confirming the diagnosis of AHA. First case was treated with a bypassing agent, however the eradication was obtained only with immunosuppressive therapy. Second case was initially placed in close follow‐up, since the post‐pregnancy form is often self‐limiting, however an immunosuppressive therapy was set after clinical progression due to the appearance of spontaneous hematoma.Conclusions: AHA is a relevant acquired bleeding disorder that can be fatal if not quickly recognized and treated even when the initial clinical signs are minor [3], how it can happen in post‐pregancy mainly in the first month [4]. Since it may present as spontaneous subconjunctival haemorrhage, routine hemathological and coagulation labs should be performed to exclude this serious condition or once identified, allow for proper clinical management.

Acquired Hemophilia Following COVID-19 and Influenza Vaccination: A Systematic Review

Introduction Acquired hemophilia (AH) is a rare disorder with an incidence of 1.48 per million per year and inhibitor to factor VIII (fVIII) is mostly implicated. The most common identifiable causes of acquired hemophilia A (AHA) include malignancies, pregnancy, and autoimmune disorders. AH following SARS Co-V2 vaccination has recently been reported. Here we provide the results of a comprehensive literature review of AH following SARS Co-V2 and influenza vaccinations. Methods We searched PubMed, Embase and Scopus database for all relevant articles from database inception to July 1, 2022. Articles were included if the study described AH following vaccination. A total 1006 records were screened by title and abstracts out of which 21 full-text articles met eligibility criteria. Title and abstracts of all articles were retrieved using the search strategy were initially screened, reviewed, and verified independently by two authors (KP and SS), with disagreements mediated through discussion with a third review author (DG). Most of the data included case reports except 3 case series and 2 letters. Additionally, Vaccine Adverse Event Reporting System (VAERS) database was also queried to assess for reports of hemophilia associated with receipt of vaccine till July 29, 2022. However these studies were not included in the analysis. Results Out of 21 articles, 18 described AH following SARS Co-V2 vaccination and 3 AH following influenza vaccination with a total of 29 patients (Table 1). All patients developed factor VIII inhibitor except 1 case of factor IX inhibitor described by Chiasakul et al. The median age of AH following SARS Co-V2 vaccination was 68 years (SD 15.4 years) and 66 years (SD 3 years) following influenza vaccination. The complication has been reported more frequently in males (61%). Most patient developed cutaneous hematomas following COVID-19 vaccine but single cases of hemothorax, melena, knee hematoma and oropharyngeal bleeding was also described. Three patients developed hematuria, and 2 patients developed extensive retroperitoneal hemorrhage following vaccination. AH has been described following the Pfizer (53% of the cases we identified), Moderna (28% of the cases we identified), Astra Zeneca (19% of the cases we identified) vaccines. Within this small cohort, most patients (47%) developed AH following second dose of primary vaccination followed by AH developing after first dose (28%). Few patients developed AH following both doses of primary vaccination (19%) and 1 developed AH following booster dose. Only 1 case had history of COVID-19 infection. The average duration for onset of symptoms from SARS Co-V2 vaccination was 2 weeks 4 days and was 2 weeks following influenza vaccination. For inhibitor management, 11 patients received rituximab (RTX) with prednisone and 7 patients received cyclophosphamide with prednisone. Triplet therapy (steroids, RTX and cyclophosphamide) was used in 3 patients. Most patients developing AH following SARS Co-V2 vaccination improved except 2 deaths from abdominal bleeding and sepsis; 1 patient died from severe retroperitoneal bleeding after influenza vaccination. We found 13 cases of AH and 2 cases of bleeding without diagnosis on VAERS database following COVID-19 vaccination and 2 cases developed factor IX inhibitor. Conclusions Autoantibodies to FVIII (or FIX) can develop following SARS Co-V2 and influenza vaccines. The rate of this complication appears to very low, but it can lead to serious bleeding, with an average onset of symptoms 2 weeks from vaccine administration. We found more reports of males who developed AH after SARS Co-V2 vaccination, but neither the overall frequency nor the relative frequency (males vs. females) is known. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Acquired hemophilia A following COVID-19 vaccination – The importance of prompt diagnosis: A case report

Acquired hemophilia A (AHA) is a rare coagulopathy characterized by hemorrhagic manifestations. It has been linked to various conditions, including autoimmune disorders, drugs, tumors, lymphoproliferative disorders, and infections. We present a case of AHA in a 71-year-old male patient with cutaneous hematoma occurring 8 days after vaccination for COVID-19. This report aims to highlight the risk of FVIII inhibitor development following an immune stimulus, thus improving our knowledge regarding possible vaccination-related adverse events. Furthermore, we underline how the potential risk of not recognizing disease manifestations promptly, together with specific coagulation alterations, could significantly affect the patient's outcome. Adequate management plans and the diffusion of shared guidelines are of fundamental importance in order to prevent the development of life-threatening complications and initiate appropriate treatment as soon as possible. Data AvailabilityAll data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.

Local complications associated with labial salivary gland biopsy for diagnosis of Sjögren's Syndrome: A retrospective cohort study.

BackgroundTo describe local or systemic complications related to the labial salivary glands biopsy (LSGB) used as diagnostic tool for the diagnosis of Sjögren’s Syndrome (SS). Material and MethodsClinical databases from a cohort of patients, who underwent LSGB with provisional clinical diagnosis of Sjögren’s Syndrome, were retrospectively reviewed. Pain, assessed by registering the intake of analgesic drugs in the first week following the biopsy, and any further relevant clinical information regarding complications after biopsy were recorded. Results50 patients received LSGB. 10 of them (9 women and 1 man) showed histopathological findings compatible with SS. Ten patient (20%) receiving labial biopsy developed local complications: three of them (6%) reported a sensory defect at the surgical site that lasted at most few weeks; three patients (6%) reported pain sensation needing the assumption of analgesic drugs, while one patient (2%) described a transient local burning sensation, which resolved in few days. Three patients (6%) showed cutaneous haematoma in the surgical area and two patients (4%) showed mild mucosal inflammation at the biopsy site. ConclusionsLSGB is associated with to few and mild complications and it is a useful tool in the diagnosis of SS. The complications usually resolved in few weeks after the biopsy. Key words:Sjögren’s syndrome, labial salivary glands biopsy, adverse events, diagnosis.

Acquired Hemophilia in a Patient With Rheumatoid Arthritis: Case Report and Literature Review

Acquired hemophilia (AH) is a rare bleeding disorder caused by the spontaneous development of autoantibodies against coagulation factors, most commonly factor (F) VIII (acquired hemophilia A, AHA). The clinical manifestation of AHA includes mostly spontaneous hemorrhages into skin, mucous membranes, muscles, soft tissues, or joints. AHA should be suspected when a patient with no history of hemorrhages presents with bleeding and an unexplained prolonged activated partial thromboplastin time. The diagnosis is based on the clinical picture, the presence of low FVIII activity and evidence of FVIII inhibitor. In around half of patients, an underlying disorder (rheumatic diseases, malignancy, infections) or taking some drugs are associated with AHA; the remaining cases are idiopathic. Rheumatoid arthritis is a chronic inflammatory condition, marked by swelling and tenderness of small joints; it is usually treated with steroid and immunosuppressive drugs such as methotrexate, TNF-alpha inhibitors, and other biologic therapies (abatacept, tocilizumab, rituximab).We presented a patient with rheumatoid arthritis who developed acquired hemophilia A with hemarthroses; starting from this case, we focused on the literature about AHA in rheumatic diseases. We found 35 cases, 15 in systemic lupus erythematosus and 12 in rheumatoid arthritis, while the remaining cases were reported in Sjögren’s syndrome, polymyalgia rheumatica, systemic sclerosis, and psoriatic arthritis. Ecchymosis and cutaneous hematomas were the main clinical features while hemarthroses was quite a rare condition, shown in just three patients.

Acquired Hemophilia A in the South of Tunisia: A Single Center Study

Acquired hemophilia A (AHA) is a rare and severe bleeding disorder characterized by the development of autoantibodies against factor VIII. There is no previous study published in our country for AHA. The aim of this study that to describe the clinical symptoms, diagnostic criteria and treatment strategies in patients with AHA in the south of Tunisia. We retrospectively collected all patients diagnosed with AHA in the Department of Hematology of Hedi Chaker Hospital (Tunisia) from 2000 to 2017. The diagnosis was established in the presence of clinical hemorrhagic features associated with the isolated prolongation of the activated partial thromboplastin time (APTT), not corrected after two hours by incubating patient plasma with equal volumes of normal plasma, and with factor VIII less than 50%. We collected five patients with AHA in the South of Tunisia. There were 4 females and 1 male with the median age of 32 years old. The median FVIII C was 7% and the median value of FVIII inhibitor was 11 UB. The most common clinical symptoms were post-partum hematoma in 3 patients (60%), extensive cutaneous hematoma in one patient and hemorrhagic tooth extraction in one patient. All patients were treated in first-line therapy with bypassing agent FVIIa with successful response in 80% of cases. The first-line treatment of bleeding in AHA requires a bypassing agent and the optimal therapeutic strategy to eradicate the inhibitor include immunosuppression with corticosteroids alone or corticosteroids in combination with cyclophosphamide.

From dizziness to severe ataxia and dysarthria: New cases of anti-Ca/ARHGAP26 autoantibody-associated cerebellar ataxia suggest a broad clinical spectrum

In 2010, a novel anti-neuronal autoantibody, termed anti-Ca, was described in a patient with subacute cerebellar ataxia, and Rho GTPase-activating protein 26 (ARHGAP26) was identified as the target antigen. Recently, three additional cases of anti-Ca-positive cerebellar ataxia have been published. In addition to ataxia, cognitive decline and depression have been observed in some patients. Here, we report two new cases of anti-Ca-associated autoimmune cerebellar ataxia.Patient 1 presented with dizziness and acute yet mild limb and gait ataxia. Symptoms stabilized with long-term oral corticosteroid therapy but transiently worsened when steroids were tapered. Interestingly, both initial occurrence and worsening of the patient's neurological symptoms after steroid withdrawal were accompanied by spontaneous cutaneous hematomas. Patient 2 initially presented with an increased startle response and myoclonic jerks, and subsequently developed severe limb and gait ataxia, dysarthria, oculomotor disturbances, head and voice tremor, dysphagia, cognitive symptoms and depression. Steroid treatment was started five years after disease onset. The symptoms then responded only poorly to corticosteroids. At most recent follow-up, 19 years after disease onset, the patient was wheelchair-bound.These cases extend the clinical spectrum associated with anti-ARHGAP26 autoimmunity and suggest that early treatment may be important in patients with this rare syndrome.

Post-traumatic cutaneous hematomas in geriatrics hospital: A neglected disease?

BackgroundFalls in elderly are common and associated to heavy morbidities requiring hospitalizations. Bone and neurosurgical injuries are evaluated in emergency care but many cutaneous hematomas are misdiagnosed or neglected. We aimed to show the epidemiological importance of these skin hemorrhages and help for their management. MethodsA retrospective review from specialized consultations reports was performed in the department of geriatrics of the university hospital of Geneva. Measurements were incidence of severe skin hematomas, their epidemiological and clinical characteristics. Details on consecutive care lead to the proposition of a guided structured management. ResultsA total of 112 (53‰ – 95% CI=44.64) hematomas were seen between 2007 and 2010 during 2092 dermatological and surgical consultations at the department of geriatrics of the university hospital of Geneva. Mean age of the patients was 87.4±7.5 years and a majority of them were women (83.9%). Out of the 112 patients with hematomas 12.5% had diabetes, 39.3% were under antiaggregant therapy and 61.6% under anticoagulant therapy. There was a significant difference concerning sex, age, and anticoagulant therapy between patients presenting with severe hematomas and the geriatric population without hematomas during the observational period (P<0.001). Among all hematomas, 26 were deep dissecting hematomas. Medicosurgical care included 43 evacuation and drainage, three skin grafts, one vacuum-assisted-closure (VAC) therapy and five transfusions. ConclusionsHematomas often lead to serious morbidity and severe consequences such as anemia or extended wounds. Surgical interventions are required and consequently increase the length of hospital stay and costs. Prevention and management should be clarified.

Treatment with rtPA of stroke associated with intravenous immunoglobulins perfusion

Information about the security of intravenous recombinant tissue type plasminogen activator (rtPA) in immunoglobulins related stroke can only be ascertained from singular cases as it was not assessed in clinical trials. Only two cases of stroke associated with IVIg treated with rtPA were described in literature. We report the outcome of two patients with IVIg associated stroke that were treated with rtPA. In our patients there were hemorrhagic complications - remote cerebral haemorrhage and diffuse cutaneous hematomas.

Métastases cutanées de mélanome à type d’hématomes : à propos de cinq cas

IntroductionMelanoma is an aggressive tumor with high metastatic potential. We described herein five patients with metastatic cutaneous hematoma variant from melanoma. ObservationsPatients were four men and one woman, four were already known for melanoma. In one case, the occurrence of hematoma leads to the diagnosis of metastatic melanoma. These hematomas were true hematomas, which had appeared spontaneously and in some cases a nodule or lymphadenopathy was clinically found. A biopsy was performed in two cases, showing the sub-cutaneous metastasis with hemorrhages (histological hematoma) and vascular proliferation within tumor cells. Patients were not treated by anti-coagulants or antiagregants and biological tests were not exhibiting any coagulation trouble. Evolution was rapidly dramatic with generalized metastatic disease and death. DiscussionMetastatic cutaneous hematoma is a particular type of cutaneous metastasis, poorly reported in the literature. This phenomenon could be explained by local tumoral neoangiogenesis and hematogenous metastatic spread. ConclusionWe report five cases of metastatic cutaneous hematomas of melanoma. This clinical presentation doesn’t seem to be so rare. This clinical variant should be known from oncologists in order to perform a biopsy looking for a metastatic cutaneous involvement from melanoma.

Histologic Evidence of Repetitive Blunt Force Abdominal Trauma in Four Pediatric Fatalities

In cases of acute fatal child abuse, certain injuries, including cutaneous blunt force trauma, skull fractures, subdural hematomas, intra-abdominal hemorrhage, and retinal hemorrhages are common and well described in the pediatric and forensic literature. These gross findings at autopsy, when taken into consideration with scene investigation and interviews with caregivers, may indicate both a clear manner and cause of death. In such cases, the discovery of additional pathologic changes attributable to older abusive injuries helps support a conclusion of death due to inflicted trauma. We discuss four cases of fatal child abuse in which acute blunt force abdominal trauma was the cause of death. In each of these cases, careful examination with proper sectioning and microscopy of select abdominal tissues revealed that the acute tissue trauma was superimposed on a background of older, healing injury. This older trauma was characterized by classic histologic elements of tissue repair, including fibroblast proliferation, early scar formation, increased vascularity, and hemosiderin-laden macrophages. Iron and trichrome stains were used to confirm the presence of hemosiderin and fibrosis in all four cases, but the recognition of fibroblast proliferation and a reactive vascular pattern was best seen on routine hematoxylin and eosin stains. The gross and microscopic autopsy findings, along with available investigative information, established the diagnosis of chronic physical abuse.

Hématomes cutanés et sous-cutanés vus en dermatologie : 17 cas

Cutaneous hematomas are a cause of hospitalization in departments of dermatology. Their clinical diagnosis can be difficult, particularly since they can masquerade as thrombophlebitis or abscesses. We conducted a retrospective study so as to specify their frequency, clinical aspects and circumstances of occurrence. The search for hospitalizations was conducted, using a computer data coding and key word "hematoma", from January 1997 to March 2003. The following items were studied: age, gender, clinical aspect on admission, topography, use of anti-platelets or anticoagulants, the existence of documented overdosing, treatment before hospitalization and existence of fever. The 17 patients hospitalized for hematomas were 9 women and 8 men with a mean age of 71 years. Thirteen patients were treated with: antivitamin K (5 cases), low molecular weight heparin (3 cases), anti-platelets (4 cases), or a combination of antivitamin K and anti-platelets (1 case). Four patients had no antivitamin K or anti-platelet treatment; their coagulation control was normal and they were younger than the patients taking a treatment (55 versus 76 years). The hematomas always involved the lower limbs. The clinical aspect was: simple hematoma (3 cases), inflammatory or over-infected hematoma (11 cases) and post-hematoma ulceration (3 cases). Seven patients were febrile either before or during their hospitalization. A context of trauma was noted in 10 patients. In the 9 patients treated with antivitamin K or low molecular weight heparin, overdosing was documented in 5. The treatments received before hospitalization were: general antibiotherapy (7 cases), local antibiotherapy (1 case) and low molecular weight heparin (7 cases). Hematomas of the legs usually occur in elderly patients, treated with anticoagulants or anti-platelets. They present in the form of ecchymotic tumefaction, frequently inflammatory or febrile. Therapeutic overdosing is common. The ratio with the erysipelas hospitalized in our department is of 1/8; over the past 5 years we have observed a mean of 3 cases per year. Hence they are not uncommon and dermatologists must be aware of their clinical aspects and the circumstances in which they occur.

Ticlopidine Improves Dialysis Clearance of Solutes in Uremic Patients by Reducing Blood Clotting in Dialyser Fibers

Ticlopidine, a platelet aggregation inhibitor was tested, in a double blind comparative cross-over study versus placebo, in 51 dialysed uremic patients who had increased dialyser blood clotting (> 25 fibers clotted/dialyser). At the end of a 7-day treatment period with 250 mg daily, the clearance of urea, creatinine and phosphate was determined at 30 and 210 minutes of dialysis, as well as the number of fibers clotted at the end of dialysis. Ticlopidine improved dialyser clearances for urea, creatinine and phosphate from 165 +/- 41 to 182 +/- 35 (p < 0.01), 135 +/- 37 to 143 +/- 35 (p < 0.05), and 120 +/- 36 to 130 +/- 35 (p < 0.05) ml/min, respectively, at 30 min of HD and a similar effect was seen after 210 min of dialysis. The number of dialyser fibers clotted after dialysis was reduced by ticlopidine therapy from 110 +/- 48 to 15 +/- 8 (p < 0.01). Ticlopidine reduced the initial dialysis-induced drop in leucocyte count by 20% (p < 0.05); no change in platelet or erythrocyte count was observed. Two out of 51 patients experienced an adverse reaction from ticlopidine (cutaneous haematoma and minor gingival bleeding). We conclude that ticlopidine is an efficient and safe drug for dialysed uremic patients since it can reduce blood clotting and thereby increase dialysis efficiency.

Submucosal gastric hemorrhage following extracorporeal shock wave lithotripsy of bile duct stones

Recently, experience with extracorporeal shock wave lithotripsy (ESL) for bile duct stones has been reported in several studies.5 Fragmentation occurs in over 90% of patients. Rates of early stone clearance vary with the degree of endoscopic intervention. Although usually minor and transient, complications occur in up to 40% of patients; cutaneous hematoma, hematuria, hemobilia, and biliary pain are the most common adverse effects. We report a case of diffuse submucosal gastric hemorrhage following ESL therapy of bile duct stones, a complication heretofore undescribed.