Prolonged Skin Bleeding Time Research Articles

Active Bleeding in Uremic Patients after Temporary Catheter Implantation: A Case Report and Literature Review

Patients with uremia often develop bleeding diatheses at cutaneous or incisional sites, intra-abdominal or intracranial hemorrhages. We report active bleeding in a uremic patient after she received a temporary catheter for hemodialysis therapy. Active bleeding was considered to be due to platelet dysfunction, diagnosed by prolonged skin bleeding time. Her spontaneous bleeding gradually vanished after receiving blood transfusions with cryoprecipitate. The assessment of skin bleeding time in uremic patients with active bleeding is a crucial step to identify platelet dysfunction.

Novel mutation in the glycoprotein Ibβ in a patient with Bernard–Soulier syndrome

Bernard-Soulier syndrome (BSS) is a rare autosomal recessive disorder characterized by a prolonged skin-bleeding time and thrombocytopenia with giant platelets. The hallmark of BSS is an abnormal platelet attachment to the vessel wall due to reduced or abnormal glycoprotein Ib/IX/V complex. We present a case of BSS in a 14-month-old boy caused by a novel genetic mutation. The patient has the typical clinical findings of BSS, but he was misdiagnosed for a long period. Evaluation of the peripheral blood smear revealed giant platelets and genetic testing confirmed the diagnosis of BSS. The child was found to be homozygous for a nonsense mutation (c.423C > A) in the glycoprotein Ibβ (GPIbβ) gene. Knowing that we are dealing with a very rare syndrome, the detected mutation in our patient was homozygous. Although the parents were nonconsanguineous, we believe that they were related in a distant parental connection, which the parents and their family were not aware of.

Novel Mutation in the Glycoprotein Ibβ in a Patient with Bernard-Soulier Syndrome: Possibility of Distant Parental Consanguinity

Abstract 4689 Introduction:Bernard-Soulier syndrome (BSS) is a rare autosomal recessive disorder characterized by a prolonged skin-bleeding time and thrombocytopenia with giant platelets. The hallmark of BSS is an abnormal platelet attachment to the vessel wall due to reduced or abnormal glycoprotein (GP) Ib/IX/V complex. We present a case of BSS in a 14-month-old boy caused by a novel genetic mutation. Patient and methods:A 14-month-old Syrian boy was referred to our medical center with a history of easy bruisability, epistaxis, and low platelet counts since the age of 5 months. He was the second child of non-consanguineous parents. His parents and siblings were negative for a history of bleeding disorders. His nephew was reported to have low platelets counts. The patient was hospitalized in Syria several times and was initially diagnosed as having idiopathic thrombocytopenic purpura. He received corticosteroids and high-dose intravenous immunoglobulin both of which were ineffective. He also received platelet transfusion for recurrent epistaxis, which improved as per the parents. The possibility of a platelet disorder was raised and he was referred to our center for further investigation.Physical examination showed bruises over the face and extremities. Abdominal examination was negative for hepatosplenomegaly. There were no congenital abnormalities. His platelet count was 100 × 109/l. The presence of giant platelets was noted on blood film inspection. Other blood cell counts, blood chemistry and coagulation studies, including von Willebrand factor (vWF) antigen and activity, were within the normal range. A clinical diagnosis of BSS was made. Peripheral blood was obtained for genetic testing.DNA sequencing and analysisThe initial extraction of the DNA material was done using the PEL-FREEZ extraction kit (PEL-FREEZ, DYNAL, USA) and genomic material stored at −80°C. We performed direct sequencing of the entire coding regions including exon-intron boundaries of the GPIbα and GPIbβ genes (GenBank: NM_000173.5 and NM_000407.4; mutation numbering + 1 corresponds to the A of the ATG-translation initiation codon, respectively). Genomic DNA from patient was amplified by PCR with oligonucleotide primers complementary to flanking intronic sequences. Primers were designed using the Primer3 program (http://www-genome.wi.mit.edu/cgi-bin/primer/primer3.cgi) (primer sequences and PCR conditions are available on request). PCR products were sequenced employing ABI BigDye chemistry (Applied Biosystems, Darmstadt, Germany). The same primers as for PCR were used as sequencing primers. Samples were run and analyzed on an ABI PRISM 3130 genetic analyzer (Applied Biosystems). Conclusion:We present a case of BSS in a 14-month-old boy caused by a novel nonsense mutation (c.423C>A) in the GPIbβ gene. Knowing that we are dealing with a very rare syndrome, the detected mutation in our patient was homozygous. Although the parents were non-consanguineous, we believe that they were related in a distant parental consanguinity which the parents and their family were not aware of. Disclosures:No relevant conflicts of interest to declare.

Platelet function testing in uraemic patients

Introduction: Chronic renal failure (CRF) is associated with excessive bleeding for a variety of reasons. Platelet dysfunction is probably the most consistent and important feature, particularly platelet–platelet and platelet–vessel wall interactions. The skin bleeding time (SBT) is the best established predictor of bleeding in uraemic patients but suffers from poor reproducibility and accuracy. Several newer rapid assays of platelet function are able to provide a means of assessing primary haemostasis, but have not been specifically assessed in uraemic patients.Methods: A single centre, prospective cohort study of patients referred to a tertiary nephrology unit. Patients with both acute and chronic renal impairment were recruited. Laboratory parameters analysed included full blood count, serum creatinine and urea, calculated glomerular filtration rate (GFR) (Cockcroft formulae) APTT PT fibrinogen, SBT, whole blood platelet aggregation (WBPA), platelet function analyzer (PFA-100), thromboelastograph (TEG) and cone platelet analyzer (CPA).Results: This study included 42 patients: nine with CRF (GFR < 30 ml/min) who were not receiving dialysis; 23 with CRF receiving dialysis; seven who presented in acute renal failure; and three assessed with normal renal function but with nephrotic syndrome and who presented prior to renal biopsy. Twenty-two patients were on low-dose aspirin and four patients were on clopidogrel. There was weak correlation between calculated GFR and SBT (r2 = 0·1564) with even poorer correlation with serum creatinine and no correlation with urea levels. Overall, PFA-100 was a poor predictor of SBT. Seven of 12 patients with SBT <7 min had abnormal WBPA, 24 of 26 had abnormal WBPA if SBT >7 min. Of those with SBT <7 min, five had abnormal CPA, and >7 min, 15 of 21 had abnormal results. Nineteen patients had abnormal TEG tracings. Six patients underwent renal biopsies with one bleeding complication.Conclusions: In this pilot study we found that prolonged SBT was not predicted by serum creatinine or calculated GFR. Within the limitations of this study, an alternative in vitro test to replicate the SBT has not been identified.

Bernard-Soulier syndrome (hemorrhagiparous thrombocytic dystrophy).

Bernard-Soulier syndrome (BSS), also known as Hemorrhagiparous thrombocytic dystrophy, is a hereditary bleeding disorder affecting the megakaryocyte/platelet lineage and characterized by bleeding tendency, giant blood platelets and low platelet counts. This syndrome is extremely rare as only ~100 cases have been reported in the literature. Clinical manifestations usually include purpura, epistaxis, menorrhagia, gingival and gastrointestinal bleeding. The syndrome is transmitted as an autosomal recessive trait. The underlying defect is a deficiency or dysfunction of the glycoprotein GPIb-V-IX complex, a platelet-restricted multisubunit receptor required for normal primary hemostasis. The GPIb-V-IX complex binds von Willebrand factor, allowing platelet adhesion and platelet plug formation at sites of vascular injury. Genes coding for the four subunits of the receptor, GPIBA, GPIBB, GP5 and GP9, map to chromosomes 17p12, 22q11.2, 3q29, and 3q21, respectively. Defects have been identified in GPIBA, GPIBB, and GP9 but not in GP5. Diagnosis is based on a prolonged skin bleeding time, the presence of a small number of very large platelets (macrothrombocytopenia), defective ristocetin-induced platelet agglutination and low or absent expression of the GPIb-V-IX complex. Prothrombin consumption is markedly reduced. The prognosis is usually good with adequate supportive care but severe bleeding episodes can occur with menses, trauma and surgical procedures. Treatment of bleeding or prophylaxis during surgical procedures usually requires platelet transfusion.

Platelet dysfunction in myelodysplastic syndromes: a clinicopathological study.

Forty-eight patients with myelodysplastic syndromes and a platelet count greater than 80 x 10(9)/L were the subjects of a study of platelet function. A whole-blood platelet lumi-aggregometer was used for simultaneous measurement of platelet aggregation by the impedance method and of adenosine triphosphate-dense granule release. The results were correlated with skin bleeding time and episodes of clinical bleeding or thrombosis. Thirty-five patients had at least 1 abnormal result indicating platelet hypoactivity; 7 patients had mixed platelet hypoactivity and hyperactivity; and 4 patients had platelet hyperactivity. Only 2 patients had normal results. There was good correlation between platelet hypoactivity and prolonged skin bleeding time (P = .005); however, several patients with platelet hypoactivity had normal skin bleeding times. This finding suggested that whole-blood platelet aggregation studies may be more sensitive than bleeding time in identification of patients at risk of bleeding. Clinical hemorrhage was frequent (32 patients) in this cohort despite platelet counts greater than 100 x 10(9)/L. This finding indicated platelet hypofunction was clinically important. In contrast, only 2 of the 13 patients with thrombotic events had evidence of platelet hyperactivity, suggesting that other clinical factors are probably more important determinants of thrombosis. These observations confirm that platelet dysfunction is common in patients with myelodysplastic syndromes and suggest a useful role for routine whole-blood platelet aggregation studies to identify patients at risk of bleeding.

Aspirin related gastrointestinal bleeders have an exaggerated bleeding time response due to aspirin use.

Gastrointestinal bleeding is related to non-steroidal anti-inflammatory drug (NSAID) use, especially aspirin, but only a small subset of users bleed. To look for risk factors or mechanisms whereby aspirin may promote gastrointestinal bleeding. Sixty one patients with previous aspirin related upper gastrointestinal bleeding and 61 matched controls. Patients and controls were given 375 mg of aspirin and sequential skin bleeding time and blood aspirin levels were measured. Additional studies included platelet lumiaggregation, von Willebrand factor, Factor VIII, and coagulation studies. Baseline skin bleeding time was similar in bleeders and controls, but bleeders had a more prolonged skin bleeding time after aspirin use. Hyper-response was more frequent in bleeders (30% v 9.3%; p < 0.01) and was associated with more than one previous separate bleeding event and a lower packed cell volume during the preceding bleeding episode. No differences were found in other factors studied. Logistic regression analysis identified prolonged skin bleeding time after aspirin use as an independent factor contributing to aspirin related gastrointestinal bleeding (RR = 5.4; 95% CI: 1.8 to 17.1). 30% of patients with a history of aspirin related gastrointestinal bleeding have an exaggerated prolongation of skin bleeding time in response to aspirin, which may be a risk factor for bleeding. This intrinsic defect or to subclinical von Willebrand disease or different aspirin metabolism.

Reversible prolonged skin bleeding time in acute gastrointestinal bleeding presumed due to NSAIDs.

The purpose of this research was to look for a possible mechanism whereby NSAIDs, and particularly ASA, might cause gastrointestinal bleeding. A total of 34 hospitalized GI bleeders and 29 age- and sex-matched controls were studied. Skin bleeding time (SBT) was measured within 6 h of coming to hospital and before any blood products were given. All patients and controls were questioned regarding current NSAID use. This history was supplemented by estimation of serum salicylate and of platelet cyclooxygenase activity to detect unreported current aspirin (ASA) use. Various aspects of platelet function were also tested by lumiaggregation in 28 controls and, after recovery, in 27 of the bleeders. Of 34 bleeders, 26 bled from the upper GI tract, (13 from peptic ulcer) and eight from the lower GI tract, 30 (88%) had a current intake of NSAIDs and of these 22 (73%) used ASA, some in combination with other NSAIDs, whereas 12 of 29 controls were using NSAID's, 11 of which were ASA. SBT in the bleeders was 9.0 +/- 1.02 min versus 4.8 +/- 0.42 min in the controls (p < 0.001). SBT measured 6.6 days later in 28 bleeders was 4.7 +/- 0.22 min (p < 0.0006), and of those tested after recovery all but one had fallen to 6.5 min or less. None had any residual constitutional platelet abnormalities as tested by lumiaggregation. By logistic regression, NSAID intake was strongly associated with prolonged SBT to > 6 min (odds ratio [OR], 16.7; p < 0.0002), whereas NSAID intake (OR 14.6; p < 0.0003) and SBT > 6 min (OR 1.8; p < 0.005) contributed to a bleeding outcome. Almost 90% of GI bleeders had recently consumed NSAIDs, mostly ASA, on an average 15 h before onset of bleeding. Although most of the nonbleeders who had used NSAIDs did not have a prolonged SBT, most of the bleeders who used NSAIDs had an abnormal elevation of SBT, suggesting a possible mechanism for GI bleeding. Retesting approximately 7 days after recovery from bleeding showed normalization of the SBT, indicating that the defect was transient and spontaneously reversible.

Acquired pseudo-pseudo Bernard-Soulier syndrome complicating Gaucher's disease.

To investigate the abnormality in platelet function in two patients with type I Gaucher's disease causing a chronic bleeding tendency despite normalisation of the platelet count after spleen removal. Routine laboratory methods were used to assess baseline coagulation. Platelet aggregometry was used to assess platelet responses to a range of agonists, and abnormalities were further assessed in mixing experiments using washed platelets and patients' plasma. Platelets from both patients with Gaucher's disease failed to agglutinate to ristocetin, despite normal platelet surface glycoprotein (GP) Ib and plasma von Willebrand factor activity. The agglutination of normal washed platelets was abolished by incubation in patient plasma. The inhibitory activity did not lie in the IgG fraction of patient plasma, and was found to be loosely associated with the patient platelet surface. The inhibition of ristocetin induced platelet agglutination in patients with Gaucher's disease causes a prolonged skin bleeding time. This could be due to the accumulated glucocerebroside in the plasma coating the platelet membrane. It is suggested that the term pseudo-pseudo Bernard-Soulier syndrome would be appropriate, as on initial screening, the abnormality has the features of Bernard-Soulier syndrome, but further investigation shows normal plasma von Willebrand activity and platelet surface GP Ib concentrations. The inhibitory activity is not due to a platelet specific antibody as is the case in pseudo-Bernard Soulier syndrome.

Desmopressin: a nontransfusional treatment of hemophilia and von Willebrand disease.

Desmopressin (1-deamino-8-D-arginine vasopressin) is a synthetic analogue of the antidiuretic hormone L-arginine vasopressin. Because it can raise circulating levels of factor VIII and von Willebrand factor, desmopressin is used for nontransfusional treatment of mild and moderate hemophilia and von Willebrand disease. Desmopressin also shortens the prolonged skin bleeding time in patients suffering from von Willebrand disease and is given to prevent or stop excessive bleeding in such conditions.

Platelet function after intramuscular diclofenac

A randomised double-blind controlled study was performed to examine the effect of diclofenac on skin bleeding time and in vitro whole blood platelet aggregation. Twenty thoracotomy patients were studied; 10 were given diclofenac 75 mg intramuscularly at induction of anaesthesia, and 10 formed a control group. Skin bleeding times and platelet aggregation tests were performed the day before and repeated one hour after induction of anaesthesia. Diclofenac prolonged skin bleeding time and reduced platelet aggregation. There were no significant changes in the control group.

Ticlopidine prevents renal disease progression in rats with reduced renal mass

Functional and morphological studies were done in three groups of male Sprague-Dawley rats after removal of the right kidney and infarction of approximately five-sixths of the left. Group 1 received no specific therapy. Group 2 was treated with ticlopidine, 150 mg/kg per os, for 50 days starting 10 days after surgical ablation. Group 3 was given the thromboxane antagonist, GR 32191, 3 mg/kg b.i.d. orally for 50 days, like ticlopidine. Untreated Group 1 rats developed renal insufficiency, systemic hypertension, progressive proteinuria and glomerulosclerosis. In Group 2 treatment with ticlopidine was associated with less severe impairment of renal function. Proteinuria was significantly lower and animals were partially protected from the development of glomerulosclerosis. These animals had significantly prolonged skin bleeding time. In vitro ADP and arachidonic acid (AA)-induced platelet aggregation was inhibited. Systemic blood pressure was significantly lower than in controls. In Group 3 rats GR 32191 failed to influence progressive proteinuria and severity of glomerulosclerosis which were comparable to those in Group 1. Bleeding time was not prolonged, and in vitro platelet aggregation was inhibited only when AA was used as aggregating agent. Systemic blood pressure was not influenced. These studies suggest that a drug like ticlopidine, which has a broad spectrum of pharmacological actions on platelets and platelet-cell interactions, does retard the development of progressive renal injury when nephron number is reduced. Specific blocking of thromboxane A2 (TxA2) biological activity does not influence progressive renal disease in rats with remnant kidney.

Desmopressin: A Nontransfusional Hemostatic Agent

Desmopressin (1-deamino-8-D-arginine vasopressin, DDAVP) is a synthetic analogue of the antidiuretic hormone L-arginine vasopressin. Because it can raise circulating levels of Factor VIII and of von Willebrand's factor, DDAVP is used for nontransfusional treatment of mild and moderate hemophilia and von Willebrand's disease. DDAVP also shortens the prolonged skin bleeding time in patients with uremia, liver cirrhosis, and platelet dysfunctions and is given to prevent or stop excessive bleeding in such conditions. Finally, there is evidence that DDAVP can reduce blood loss and transfusion requirements during and after surgical operations in which blood losses are unusually large. Hence DDAVP is useful as a nontransfusional hemostatic agent in many of the bleeding disorders frequently encountered in clinical practice.

A placebo-controlled, double- blind study of eicosapentaenoic acid-rich fish oil in patients with stable angina pectoris

A study was carried out to evaluate the clinical and haematological effects of dietary supplementation with eicosapentaenoic acid (EPA)-rich fish oil (MaxEPA', 2.8 g EPA daily) compared to placebo (olive oil) in 10 patients with stable angina pectoris. After 3 months, there was a significant increase in red cell deformability (p less than 0.001), reduced whole blood viscosity (p less than 0.02), and prolonged skin bleeding time (p less than 0.001) in the fish oil group compared to the placebo group. Haematocrit, plasma viscosity, fibrinogen concentration, platelet count, and in vitro platelet aggregation were unaltered. No significant symptomatic or objective improvement was noted in angina pectoris in either group despite the significant rheological changes produced in the patients receiving fish oil.

4 Bernard-Soulier syndrome

Bernard-Soulier syndrome (BSS) is a rare autosomal bleeding disorder characterized clinically by prolonged skin bleeding time, normal clot retraction and thrombocytopenia with large and morphologically abnormal platelets, and biochemically by the absence of platelet membrane glycoproteins (GP) Ib, V and IX. GP Ib and GP IX exist in the platelet membrane as a heterodimer complex which acts as the major receptor mediating platelet adhesion to blood vessel subendothelium. Studies with BSS platelets have proved particularly rewarding in the investigation of the GP Ib-IX complex as a multifunctional receptor protein. The transmembrane complex contains binding domains for von Willebrand factor, thrombin, fibrin and quinine/quinidine drug-dependent antibodies as well as an attachment site on the cytoplasmic side of the membrane for a platelet cytoskeleton. In addition, the internal segment of the beta-chain of GP Ib contains a cyclic AMP-dependent protein kinase-associated phosphorylation site which appears to regulate platelet reactivity. Limited proteolytic cleavage of the complex, in particular the GP Ib alpha-chain, has allowed immunological and functional characterization of three distinct domains; a 45 kDa segment at the N-terminal end of the alpha-chain of GP Ib, which contains binding sites for von Willebrand factor and thrombin, a 90 kDa highly glycosylated region of GP Ib alpha and a membrane-associated region consisting of the remnant of GP Ib alpha disulphide-linked to GP Ib beta and non-covalently-complexed with GP IX. This membrane-associated region contains the antigenic epitope(s) for quinine/quinidine drug-dependent antibodies. It is highly probable that the future study of platelets from patients with the Bernard-Soulier syndrome will further clarify the role of the GP Ib-IX complex in platelet physiology.

Clinical application of a new in vitro bleeding time device on surgical patients.

A new in vitro bleeding time (BT) device was applied to various surgical patients. After setting the optimal assay condition, the normal in vitro bleeding time (T2) and volume (V2) were obtained from healthy volunteers, being 114.7 secs +/- 25.8 (SD) and 272.2 microliter +/- 69.1 (SD), respectively. When the T2 was below 210 secs, the platelet count was inversely proportional to the T2 and V2 of the in vitro BT with p less than 0.01. The value of the in vitro BT was not affected by heparin. Agents, which modify platelet functions, such as PGI2, DN9693 (an inhibitor of phosphodiesterase) and aspirin, prolonged the in vitro BT (T2, V2) dose-dependently. Administration of aspirin (660 mg) to volunteers prolonged the T2 from 108 to over 300 secs and the V2 from 253 to over 600 microliter but ticlopidine (500 mg/day for 3 days) had no effect. In 8 patients with liver cirrhosis who underwent hepatectomy, one patient with a prolonged T2 (260 secs) and a normal skin BT bled postoperatively, however, 3 patients with a prolonged skin BT (greater than 15 min) and a normal T2 had no hemorrhagic complications. From these observations it was concluded that in vitro BT is a convenient and useful tool to examine primary hemostasis or platelet function.

Shortening of Bleeding Time by 1-Deamino-8-Arginine Vasopressin (DDAVP) in the Absence of Platelet von Willebrand Factor in Gray Platelet Syndrome

The Gray platelet syndrome is a rare disorder characterised by the absence of platelet alpha-granules and their contents. We describe a new patient and the effects of infusions of 1-deamino-8-arginine vasopressin (DDAVP). The patient had a prolonged skin bleeding time and his platelets had reduced numbers of alpha-granules, increased vacuolation and reduced retention on glass beads. Platelet von Willebrand factor antigen (vWf:Ag) was undetectable and levels of platelet fibrinogen, beta-thromboglobulin, platelet factor 4 and thrombospondin were reduced. All tests of plasma coagulation factors were normal, including Factor VIII (F.VIII:C), vWf:Ag, ristocetin cofactor (R:CoF) and botrocetin cofactor. Platelet ATP, ADP, platelet albumin, surface membrane glycoproteins and 14C-serotonin uptake were also normal. Infusions of DDAVP increased plasma F.VIII:C, vWf:Ag and R:CoF and shortened the bleeding time on two occasions. This suggests that DDAVP shortens the bleeding time by releasing vWf:Ag and/or other proteins from cellular storage sites other than the platelet.

STIMULATION OF FACTOR VIII (ANTIHAEMOPHILIC) ACTIVITY BY TRANSFUSED SERUM.

PATIENTS with factor VIII deficiency and prolonged skin bleeding time (von Willebrand's syndrome) who receive fresh blood or plasma from normal donors or from patients with haemophilia A with very low factor VIII activity show a much higher factor VIII activity in their plasma than could possibly be explained by the amounts given. The maximum factor VIII activity is reached 4–8 h after transfusion and persists longer than in haemophilia A (refs. 1 and 2).