Keywords
bleeding - Glanzmann's thrombasthenia - hemophilia - von Willebrand disease
Introduction
Bleeding disorders are a group of disorders that result from defect in any one of
the components of hemostasis including defect in vessel wall, platelets, or coagulation
factor. Inherited bleeding disorders result from genetic transmission, that is, they
are passed from a parent to their child. The most frequent inherited hemostatic defects
are hemophilia A, hemophilia B, and von Willebrand's disease (vWD).[1] Hereditary deficiencies of other coagulation factors are significantly less common,
ranging in prevalence from 1 per 500,000 to 1 per million. All are autosomal recessive.
These include afibrinogenemia, hypofibrinogenemia, hypoprothrombinemia, and deficiencies
of factor V, VII, X, XI, XII, and XIII. These recessively inherited bleeding disorders
are more common in those geographic or ethnic populations where consanguineous marriages
are common.
vWD is the most common inherited bleeding disorder that affects both platelet adhesion
(primary hemostasis) and factor VIII level (secondary hemostasis), therefore presenting
with a mixed bleeding profile. vWD affects 1.3% of the population.[2]
[3] It is caused by a quantitative (reduced amount) or qualitative (abnormal function)
deficiency in von Willebrand factor (vWF), combinations of which result in the various
vWD subtypes. vWD commonly presents as a mild-to-moderate bleeding disorder, typically
with easy bruising or bleeding from mucosal surfaces.[4]
Hemophilia A and B are inherited in an X-linked fashion, with males being carriers
of the mutant gene afflicted with the bleeding diathesis and females being obligate
carriers. The incidence is 1 in 10,000 live births for hemophilia A and 1 in 25,000
live births for hemophilia B.[5] Glanzmann's thrombasthenia (GT) is an autosomal recessive disease that is caused
by the lack of expression of or qualitative defects in one of the two glycoproteins
forming the integrin αIIb/β3.[6] There are very few studies from India especially in this region of eastern India
regarding the characterization of vWD and other inherited bleeding disorders.
Aims and Objectives
The present study was conducted with the following aims and objectives:
-
To study the prevalence, clinical spectrum, and hematological profile of inherited
bleeding disorders in this area of eastern India.
-
To study the prevalence and characterizations of vWD among the inherited bleeding
disorders that are diagnosed during the study.
Materials and Methods
The present study was performed in the Department of Pathology, Institute of Medical
Sciences (IMS), Banaras Hindu University (BHU), Varanasi, for a period from June 2011
to June 2013. All the patients with abnormal bleeding, referred to us from the various
departments of Sir Sundarlal Hospital, IMS, BHU or from outside, were investigated
to detect the cause of bleeding. For this purpose, an informed consent was obtained
and detailed proforma containing the nature of bleeding episodes, age of onset, frequency
of bleeding, family history, mode of inheritance, and history of prior medications
including blood transfusion was made along with detailed physical examination. For
coagulation and platelet disorders, blood was collected in a blue cap vacutainer containing
3.2% sodium citrate in the ratio of nine parts of blood to one part of citrate (i.e.,
0.5 mL of anticoagulant and 4.5 mL blood). Two milliliter of blood in ethylenediaminetetraacetic
acid vial was taken for the complete blood count (CBC) including the platelet count.
Finger prick smears were made and stained by Leishman's stain for general blood picture
and platelet morphology. Platelet-rich plasma was prepared by 600 rpm for 3 minutes
for the platelet profile, while platelet-poor plasma was prepared by 2,500 rpm for
10 minutes for the coagulation profile. All the tests of hemostasis were performed
within 4 hours of blood collection. Coagulation test was done either manually or by
a semi-automatic analyzer. CBC was performed by five parts automatic hematology analyzer
(Mindray, China). The screening tests performed for coagulation were prothrombin time
(PT), activated partial thromboplastin time (APTT), and thrombin time. Correction
experiment was also performed to know the specific factor deficiency or inhibitors
present, with normal plasma, normal-aged serum, and Al(OH)3 adsorbed plasma. On the
basis of these assay, specific factor assay was performed further. If all the coagulation
tests were normal, then factor XIII assay (urea solubility test) was performed. Test
for vWD included Von Willebrand factor antigen (vWFAg) by enzyme-linked immunosorbent
assay (Diagnostica Stago, France), ristocetin-induced platelet aggregation (RIPA)
using platelet aggregometer (Chronolog Dual channel model 700) with agonists, ristocetin
cofactor assay (RiCoFAssay) using a kit by Diagnostica Stago, France, Factor VIII
Assay, and bleeding time by the Ivy method. Low-dose RIPA (0.5 mg/mL) was also done
wherever indicated to differentiate vWD type 2B and platelet type (Pseudo vWD). Platelet
aggregation test with adenosine diphosphate (ADP) and adrenaline was done to detect
platelet function defects. On the basis of these tests, all the coagulation disorders,
vWD and its variant, and platelet defects were identified in this study.
Observations and Results
Patients with abnormal bleeding coming to the hematology laboratory of the Department
of Pathology, IMS, BHU, from June 2011 to June 2013 were investigated. After detailed
clinical, personal, and family history and performing appropriate investigation, a
total of 1,204 patients were enrolled in our study. Out of 1,204 patients, 105 patients
were diagnosed as suffering with an inherited bleeding disorder, while in the rest
1,099 patients, an acquired cause of abnormal bleeding was detected ([Table 1]). The age of patients ranged from 13 days to 35 years. The maximum number of patients
was in the age group of 1 to 5 years ([Table 2]). There were predominantly males (95.23%) in the study group, while 4.6% patients
were females ([Table 2]). Family history was present for 22.85% of patients. Consanguinity was present in
2.85% of patients, while 1.9% consanguineous patients gave positive family history
for a bleeding disorder. The most common presenting clinical feature was prolonged
bleeding after cut (76.19%) ([Table 3]).
Table 1
Total number of patients investigated for abnormal bleeding
|
Total no. of patients
|
Inherited bleeding disorder
Number (%)
|
Acquired bleeding disorder
Number (%)
|
vWD among inherited bleeding disorder
Number (%)
|
|
1,204
|
105 (8.72)
|
1,099 (91.28)
|
5 (4.76)
|
Table 2
Age and sex distribution of patients with inherited bleeding disorders (n = 105)
|
Serial
no.
|
Age group (y)
|
Male
|
Female
|
Total
|
|
No.
|
%
|
No.
|
%
|
No.
|
%
|
|
1.
|
< 1
|
5
|
4.76
|
0
|
0
|
5
|
4.76
|
|
2.
|
1–5
|
29
|
27.61
|
2
|
1.90
|
31
|
29.52
|
|
3.
|
6–10
|
24
|
22.85
|
0
|
0
|
24
|
22.85
|
|
4.
|
11–15
|
21
|
20.00
|
0
|
0
|
21
|
20.00
|
|
5.
|
16–20
|
10
|
9.52
|
0
|
0
|
10
|
9.52
|
|
6.
|
21–30
|
8
|
7.61
|
3
|
2.85
|
11
|
10.47
|
|
7.
|
> 30
|
3
|
2.85
|
0
|
0
|
3
|
2.85
|
|
Total
|
100
|
95.23
|
05
|
4.76
|
105
|
100
|
Table 3
Frequency of bleeding symptoms in patients of inherited bleeding disorder (n = 105)
|
Clinical symptoms
|
No. of patient
|
Percentage (%)
|
|
Prolonged bleeding on cut/trauma
|
80
|
76.19
|
|
Ecchymosis/bruise
|
46
|
43.80
|
|
Hemarthrosis
|
38
|
36.19
|
|
Hematoma
|
30
|
28.57
|
|
Petechiae
|
12
|
11.42
|
|
Epistaxis
|
8
|
7.61
|
|
Gum bleeding
|
8
|
7.61
|
|
Bleeding after tooth extraction
|
4
|
3.80
|
|
Menorrhagia
|
4
|
3.80
|
|
Post-circumcision bleeding
|
3
|
2.85
|
|
Umbilical bleeding
|
3
|
2.85
|
|
Hematuria
|
2
|
1.90
|
|
Hematemesis
|
1
|
0.95
|
The mean value of PT was 14.01 ± 1.40 seconds with a p-value of 0.0001, which was highly significant. The standard error of difference was
0.147. The mean value of APTT was 78.84 ± 25.62 seconds, with p-value 0.0001, which was highly significant. The standard error of difference was
2.507. Isolated increase in APTT was seen in 91.42% of patients. Isolated increase
in PT was not seen in any patient. Both PT and APTT were increased in two patients
(1.90%). The mean value of factor VIII was 10.49 ± 2.62 IU/dL with a p-value of 0.0001, which was highly significant. The standard error of difference was
4.233. Factor VIII was reduced in 84 Patients. The mean value of factor IX was 90.76 ± 60.56 IU/dL
with a p-value of 0.2959, which was not significant. The standard error of difference was
12.870. Factor IX was reduced in eight patients. The mean value of vWF was 95 ± 86.7 IU/dL
with a p-value of 0.7956, which was not significant. vWF was reduced in 5 patients out of
14 cases in which vWD was suspected. The PF3 availability test was reduced in two
patients and was normal in six patients. Aggregation with ADP and adrenaline was abnormal
(increased) in three patients.
Out of 105 patients, 97 (92.38%) had coagulation defect, 5 (4.76%) had vWD, and 3(2.85%)
had platelet defect. The most common coagulation defect was hemophilia A (86.59%)
followed by hemophilia B (8.25%), factor XIII deficiency (2.06%), and factor X deficiency,
factor I deficiency, and factor VIII carrier (1.03% each) ([Table 4]). In this study, only platelet defect was GT (100%), which was seen in all three
patients.
Table 4
Incidence of coagulation disorders (n = 97)
|
Coagulation disorder
|
Number
(n = 97)
|
Percentage as total coagulation defect (n = 97)
|
Percentage (%) as of total cases (n = 105)
|
|
Hemopholia A
|
84
|
86.59
|
80
|
|
Hemophilia B
|
8
|
8.25
|
7.61
|
|
Factor X deficiency
|
1
|
1.03
|
0.95
|
|
Factor I deficiency
|
1
|
1.03
|
0.95
|
|
Factor XIII deficiency
|
2
|
2.06
|
1.90
|
|
Factor VIII carrier
|
1
|
1.03
|
0.95
|
The most common age group in hemophilia A patients was 1 to 5 years followed by 6
to 10 years. The most common presenting clinical feature in hemophilia A patients
was prolonged bleeding on cut/trauma (95.23%) followed by ecchymosis/bruise (42.85%),
and hemarthrosis (42.85%). More than half (53.57%) of the patients of hemophilia A
had less than 1% factor VIII concentration. In hemophilia B, the most common age group
was 11 to 15 years (50%). A single case of factor X deficiency was diagnosed in a
13-day-male baby with deficient factor X activity. Two cases of factor XIII deficiency
were diagnosed with the positive urea solubility test. A single case of factor I deficiency
was diagnosed with prolonged PT, APTT, thrombin time, and decreased factor I activity.
A single case of factor VIII carrier was diagnosed in a 28-year-old female with a
positive family history of hemophilia A, reduced factor VIII activity and normal factor
IX, and vWF level.
Out of total 105 cases of inherited bleeding disorders, five patients (4.76%) were
diagnosed as a case of vWD. The age ranged from 4.5 years to 24 years. The most common
age group was 1 to 5 years (60%) followed by 6 to 10 years (20%) and 21 to 25 years
(20%). Gender wise 60% of vWD patients were males, while 40% were females. Most of
the vWD patients had the onset of clinical symptoms in the age group of 1 to 5 years
(80%). The most common presenting clinical feature in vWD patients was prolonged bleeding
on cut/trauma (100%) followed by epistaxis (20%), gum bleeding (20%), and menorrhagia
(20%). Eighty percent of vWD patients had factor VIIIc concentration between 1 and
5%, and 60% of patients had between 5 and 50% vWFAg concentration. Low-dose RIPA was
absent in 100% cases. RiCoFAssay performed in two out of five cases was 0 and 48%.
Bleeding time was in the range of 7 for more than 15 minutes. Forty percent of patients
of vWD disease were type 1, 40% were type 2N, and 20% were type3 vWD. Out of total
105 cases of inherited bleeding disorders, GT was diagnosed in three patients (2.85%).
All three cases show increased platelet aggregation with ADP and adrenaline.
Discussions
Abnormal bleeding is a common clinical presentation, and the approach to the diagnosis
of inherited bleeding disorder necessitates a comprehensive history, thorough physical
examination, and systematic laboratory work-up. A total number of 1,204 patients with
abnormal bleeding manifestations were investigated in this study. Among these, 8.72%
(105/1,204) patients were diagnosed as suffering from inherited bleeding disorders,
whereas in other 91.27% (1,099/1,204) cases, an acquired cause of abnormal bleeding
was discerned.
Among the inherited bleeding disorder, the age of presentation of disease was 13 days
to 35 years. In total, 77.13% (81/105) patients belonged to the pediatric age group.
The mean age was 11.25 ± 8.84 years, the median age was 10 years, and the mode was
15 years. In a study done by Gupta et al, the age at presentation ranged from 2 to
47 years with a median age of 32.2 years.[7] In a study by Sajid et al from Pakistan, the age of presentation ranged from 3 to
57 years with a median age of 17 years.[8] Only patients with mild deficiency were diagnosed in the adult age group. In the
present study, the male-to-female ratio was 20:1. In a study by Gupta et al, the male-to-female
ratio was 4:3, while in the study of Sajid et al the male-to-female ratio was 4:1.[7]
[8] In the present study, 92.38% (97/105) patients had coagulation defect, 4.76% (5/105)
had vWD, and 2.85% (3/105) had platelet function defect. Ahmad et al reported 72.23%
(1,138/1,576) coagulation defect including vWD and 27.77% (438/1,576) inherited platelet
disorders.[9] Manisha et al reported 94.59% (598/630) coagulation defect (including 10.8% vWD)
and 5.07% (32/630) had platelet function defect.[10] These findings were comparable to our study.
In the present study, the most common inherited bleeding disorder was hemophilia A
with a frequency of 80% (84/105) followed by hemophilia B with the frequency of 7.61%
(8/105). Apart from these, two cases of factor XIII deficiency 1.90% (2/105), one
case each of factor X deficiency, afibrinogenemia, and factor VIII carrier were also
seen in the present study (0.95% each). vWD was seen in 4.76% (5/105) of patients
only. Slightly different observations were seen in the study by Manisha et al who
reported hemophilia A in 70.5%, hemophilia B in 14%, and vWD in 10.8% of cases.[10] Although vWD has been described as the most common inherited bleeding disorder with
a prevalence of 1%, in the present study, we found hemophilia A as the most common
bleeding disorder. It suggests that hemophilia A is more severe as compared to vWD,
which is mild, so in a developing country like ours maximum patients ignore mild symptoms
and they do not visit hospitals unless they develop severe symptoms. In the present
study, vWD comprised 4.76% (5/105) and GT 2.85% (3/105) cases. Gupta et al reported
16.8% cases of vWD (94/560) and 8.9% cases of GT (28/ 312) patients with platelet
function defect.[7]
In the present study, five patients of vWD were diagnosed. The age of the patients
ranged from 4.5 to 24 years. The mean age was 9 ± 8.27 years. The most common age
group was 1 to 5 years (60%), followed by 6 to 10 years (20%) and 21 to 25 years (20%).
In our study, for most of the vWD patients, the age of onset of clinical symptoms
was the age group of 1 to 5 years (80%). It was 5 days to 77 years in study done by
Trasi et al, 5 months to 45 years in study done by Kumar et al, and 1.6 to 40 years
in study done by Borhany et al.[11]
[12]
[13] The male-to-female ratio for vWD was 1.5:1. Trasi et al[11] reported the male-to-female ratio of 1.2:1, while Borhany et al[13] reported the male-to-female ratio of 0.83. In the present study, the most common
clinical feature in vWD patient was prolonged bleeding on cut/trauma (100%), followed
by epistaxis (20%), gum bleeding (20%), and menorrhagia (20%).Trasi et al reported
mucocutaneous bleeding along with ecchymoses, epistaxis, and gum bleeding being common
clinical findings among these patients, which was similar to our study.[11] Since vWD affects the process of coagulation at both levels, that is, primary and
secondary hemostasis, it presents with a variety of clinical manifestation; however,
mucocutaneous bleeding was much more common in vWD than the coagulation type of bleeding
such as hemarthrosis and hematoma in these patients. Although exact categorization
in different subtypes was not possible due to the limitation of laboratory assay and
the lack of multimer study, based upon the available laboratory parameters, we have
categorized them in different subtypes as type 1 in 40% (two out of five), type 2
in 40% (two out of five), and type 3 in 20% (one out five) of cases. Both the type
2 patients were further categorized into type 2N type depending upon the concentration
of factor VIIIc and vWFAg. However, vWFAg:FVIIIc binding was not done for confirmation
due to the limitation of assay. One single case of type 3 vWD patient was having RiCoFAssay
concentration 0 (zero), and vWFAg concentration of 1% indicates the severity of the
disease. Most of the studies from India report a high prevalence of type 2 and type
3 vWD, that is, much more severe forms of the disease than type 1 vWD. [Table 5] shows important studies on the prevalence of vWD among the inherited bleeding disorder
and the frequency of its different subtypes in India.
Table 5
Studies on the prevalence of vWD (among inherited bleeding disorder) and frequency
of its different subtypes in India
|
Authors (y of study)
|
Total cases of inherited bleeding disorder
|
Number and (%) of vWD
|
Type-1 vWD
n (%)
|
Type-2 vWD
n (%)
|
Type-3 vWD
n (%)
|
|
Gupta et al (2005)
|
224
|
64 (28.6)
|
14 (21.9)
|
28 (43.3)
|
22 (34.8)
|
|
Trasi et al (2005)
|
822
|
81 (9.8)
|
15 (18.5)
|
16 (19.7)
|
50 (61.8)
|
|
Gupta et al (2007)
|
872
|
94 (16.8)
|
20 (21.3)
|
42 (44.7)
|
32 (34)
|
|
Ahmad et al (2008)
|
1,576
|
136 (8.6)
|
29 (21.3)
|
73 (53.6)
|
33 (24.3)
|
|
Kumar et al (2010)
|
230
|
40 (17.34)
|
17 (42.5)
|
11 (27.5)
|
12 (30)
|
|
Present study (2013)
|
105
|
5 (4.76)
|
2 (40)
|
2 (40)
|
1 (20)
|
Most of the studies from the west report a high prevalence of type1 vWD as compared
with type 2 and type 3 vWD. Scheibel in his study also recorded similar findings.
Out of 250 patients diagnosed as having vWD, type 1was seen in 194 cases, type 2A
in 21 cases, type 2B in 15 cases, type 2N in 2 cases, type 3 in 11 cases, and 7 cases
were of unknown type.[14] Awidi studied 65 cases of vWD and reported type 1 in 36 cases (59%), type 2A in
7 cases (11.5%), type 2B in 11 cases (18%), and severe type 3 in 7 cases (11.5%).[15] Diez-Ewald et al reported 96 cases of vWD in which 88% were of type 1, 2% were of
type 2B, and 4.1% were of type 3.[16] Five cases were not classified.[16] Chuamary and Santosa et al reported 34 patients of vWD, of which 11 cases (32.35%)
were of type 1 and 23 cases (67.65%) were of type 2.[17] No type 3 vWD was observed in their study.[17]
Although according to the literature, vWD is the most common inherited bleeding disorder;
however, this remains an undiagnosed entity in developing countries like India because
of many reasons. Since most of the western literature describes type 1 vWD as the
most common type which has milder symptoms, these symptoms are ignored by the patient
as people in these regions are not aware of their health status, they lack proper
knowledge, and they are of low socio-economic status. Also, there is a lack of screening
in healthy people due to poor resources and limitation of each laboratory assay, all
these in combination rendering delay in diagnosing this disease. Only patients with
severe symptoms come to hospitals, which signify the increased frequency of type 2
and type 3 in this region.
Conclusion
In this study, we reported the prevalence and characterization of vWD along with the
clinical and hematological characteristics of 105 patients with inherited bleeding
disorders. We found that vWD was not so common in eastern India. A large number of
patients with inherited bleeding disorders remain undiagnosed because of the limitation
of coagulation laboratories and lack of awareness among health care professionals
and family members and so the figures presented in this study do not reflect the actual
burden of the crippling disorders in our community. An epidemiological study in the
general population needs to be done to assess the magnitude of this disease in this
area.
