Thanks for your comments so far. We have established that our patient is a 38 year old man who is due to go to theatre today. He has an isolated prolongation of his APTT (at 47 secs) and had a similar result a year ago. You also know that he had a major orthopaedic procedure some years ago, but this was in South Africa, so you have no access to blood results from this period. Apparently he does not recall any particular issues with bleeding at this point.
You were all keen to establish whether this abnormal APTT is due to a clinically less relevant inhibitor such as a lupus anticoagulant, or a clinically concerning inhibitor, such as a an anti-factor VIII antibody which can cause acquired haemophilia. To determine this you would have done a DRVVT (lupus anticoagulant investigation for the non-lab readers) or mixing studies with attention to parallelism. There were also plenty of requests for testing the intrinsic factors (i.e. VIII, IX, XI and XII).
The clinicians might have been less sure about the tests needed but many were shouting for a proper bleeding history, including a family history. You pointed out that an acquired haemophilia would be vanishingly rare in a 38 year old patient, which is a very reasonable point, and that acquired haemophilia patients usually present with severe bleeding, which is not the case with this patient. A number of people suggested a FXII deficiency may be the issue as the patient apparently has no bleeding problems.
So, what happens next?
The lab staff alert you (as the haematologist) to the fact that the patient is listed for theatre today. You ask them to do the intrinsic factors (of course they had already planned that anyway…) whilst getting on the phone to the surgeons to alert them to your concerns.
You find out he is due to have an elective procedure to remove some lumbar osteophytes which have been causing him back pain. He has no significant past medical history. As regards bleeding history he has had major surgery including pinning of his femur after a car accident in South Africa aged 20, which didn’t cause any real bleeding problems. He does recall having some prolonged blood loss after a dental extraction but never needed stitches or other intervention. He doesn’t think anyone else in his family has a bleeding disorder.
He is cancelled from today’s list and you’re pleased he was when you see his factor assay results:
Are you surprised by the lack of bleeding history?
If so can you explain it?
If not, can you tell us why?
How would you plan for this patient’s rescheduled surgery?
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