Interesting coagulation

disorders cases,
common but rare!
Dr Rutvi Dave
Dr Sukesh Nair
Screening Tests for Hemostasis
 Platelet count
 Bleeding Time
 Prothrombin time (PT) - Extrinsic pathway factors-
II,V,VII,X and Fibrinogen
 Activated Partial thromboplastin time (aPTT) – Intrinsic
pathway factors XII, XI,IX,VIII,V,X,II,Fibrinogen

Most important is - History

History
• Key to understanding and diagnosing hemorrhagic disorders
* Without any symptoms an abnormal coagulation test result
has no value
* With a good history you may just need basic tests of
haemostasis in the laboratory for diagnosis
Bleeding
• Failure of any part of the processes leading to a stable clot
• Resultant bleeding manifestations / symptoms which will vary
based on:
• Degree of failure (deficiency or dysfunction): Severity of
bleeding
• On the defective phase
- Primary hemostasis Site of
- Secondary hemostasis Bleeding
 Sites of bleed - Surface bleeds
 Mucosal
 Epistaxis
 Gum bleeds
 Urinary tract bleeds
 GI tract bleeds
 Menorrhagia

 Superficial Cutaneous
 Petechiae
 Purpura, ecchymosis
 Small superficial subcutaneous
hematomas
 Easy bruisability

Primary haemostatic disorder

 vWF
 Platelets
 Platelet Gp adhesion/Aggregation/Secretion
 Sites of Bleed – Deep
• Muscle – Hematomas / Pseudotumour

• Joints - Haemarthrosis.
Fixed Flexion deformity

Secondary Haemostatic defect

Coagulation factor deficiency
Mild bleeding disorder

• Infrequent symptoms
• History of bleeding only after trauma or surgery
• Only mild episodes of muco-cutaneous bleeds
Severe bleeding disorder
 More frequent
 Spontaneous bleeding – no provocation
 Prolonged / extensive bleeding
 Hospital visit – even a single one
 Requiring surgical hemostasis / blood transfusion
ISTH Bleeding assessment tool
• To improve collection and reproducibility of bleeding history.
• Each bleeding symptom is scored from 0 to 4
• 14 categories/symptoms included
• Eg. Epistaxis, cutaneous bleeds, bleeding from minor wounds,
oral cavity bleeding, menorrhagia, surgery, tooth extraction, GI
bleed, hematuria, hematoma, hemarthrosis, PPH, CNS bleed,
Other bleeding.
 ISTH BAT: Cut off

• Children ≥3
• Adult males ≥4 SIGNIFICANT
• Adult females ≥6

M. Elbatarny, S. Mollah, J. Grabell, S. Bae, M. Deforest, A. Tuttle, W. Hopman, D. S. Clark, A. C. Mauer, M.

Bowman, J. Riddel, P. A. Christopherson, R. R. Montgomery, Zimmerman Program Investigators, M. L. Rand, B.
Coller, and P. D. James. Normal range of bleeding scores for the ISTH-BAT: adult and paediatric data from the
merging project. Haemophilia. 2014 November; 20(6): 831–835.
Utility of BAT score

R.G. Dave et al. Utility of ISTH Bleeding Assessment Tool in identifying

bleeders and predicting bleeding severity in inherited primary and secondary
haemostasis defects. https://academy.isth.org/isth/2022
Inherited / Acquired?
• Age at onset
• Early childhood – possibly inherited

• Late – may be acquired

Family History
• Family tree - Pattern of inheritance
• X linked recessive – Hemophilia A/B
(males ; maternal grandfather or maternal uncles/cousins)
• Autosomal dominant – Von Willebrands disease (except type 3
vWD)
• Autosomal recessive – all other disorders
(Consanguineous marriage)
 Patient - X
(For the given history answer the following questions )

• ISTH BAT – bleeding score

• Is this a bleeder or not a bleeder?

• Is it severe or mild?
• Is this a primary haemostatic or secondary haemostatic disorder?
• Is this inherited or acquired?
• If Inherited is it - ? AD, AR or X-linked recessive (XR)
• What is the likely diagnosis?
 Patient 1
• 19 year old girl presented with history of menorrhagia from menarche. She
consulted in a local hospital and was given hormonal therapy and blood
transfusion.
• At the age of 1.5 years, she had prolonged bleeding after fall which required
blood transfusion.
• There is history of multiple episodes of gum bleeding which required tranexaemic
acid.
• At 3 years of age, she had multiple episodes of fresh blood in stools for which she
was consulted in a local hospital and was given blood transfusion.
• She is born to a consanguineous marriage. There is no family history of bleeding.
• Bleeding score ?

• BLEEDER / NON-BLEEDER?
19 Years old lady...

• Mild /Severe?
• Primary / Secondary haemostatic defect?
• Inherited / Acquired?
• Possible mode of inheritance?
• Screening tests of Primary Haemostasis:
Bleeding Time: >15 min (Reference range: 2-6 min)
PFA-200 :
Collagen/ADP: >300 secs (Reference range: 62-100 secs)
Collagen/Epinephrine: >300 secs (Reference range: 82-150 secs)
Platelet count: 3,46,000/cumm

• Screening tests of Secondary Haemostasis:

Prothrombin Time: 12.0 secs (Reference range: 10.0-12.5 secs)
INR: 1.11
Activated Partial Thromboplastin Time: 30.4 secs (Reference range: 27.6-
42.4 secs)
Thrombin Time: 14.4 secs (Reference range: 14-18 secs)

What next?
PFA-100/200 – Screening test
• Whole blood - 5 min platelet function test.
• High shear stress flow system (‘pseudo-
physiological’).
 Clot retraction:
• Normal Control: • Patient:
How do you interpret this clot retraction
test and what are the possible causes for
it?
What is the Gold Standard Test to arrive at
the diagnosis in this case?
What findings do you expect in this case
on performing the Gold Standard test?
How do you confirm this diagnosis by Flow
cytometry?
 17 year old got mixed up
• 17 year old girl presented with history of left sided intermittent blood stained ear discharge
of 3 months duration. She was referred to local doctor and was given antibiotics.
• Due to persistent discharge, she underwent canal wall up mastoidectomy, atticotomy, type
III tympanoplasty. On 3rd post op day, she presented with post aural hematoma. Surgical
drainage of hematoma was done, she but had re accumulation and prolonged bleeding
from wound and was given blood transfusion.
• There is past history of bruises following trivial trauma since childhood requiring
consultation.
• Irregular periods with menorrhagia since menarche treated with hormones and anti-
fibrinolytics.

• Family History:
• Born to 3rd degree consanguineous marriage but there is no family history of bleeding.
 Algorithm
Bleeder / non bleeder?
• --------
Mild /Severe?
• --------
Primary / Secondary?
• ---------
Inherited / Acquired?
• ----------
Mode of inheritance?
• ----------
Diagnosis?
• --------
• Which tests are likely to be abnormal
Results
• PT: 14.9 secs (Range: 9.8 – 12 secs)
• APTT: 69.2 secs (Range: 23 – 34.1 secs)
• What Next?
What next if results are abnormal
(Prolonged time) ???
 Plasma/reagents used for mixing
studies
1) Normal Control plasma / Pooled Normal Plasma (PNP)
Pool of 20 normal plasmas: all factors will average
out ≥ 100% - on mixing will give at least >50% in the
mixture

2) Aged serum / Adsorbed plasma

3) Factor deficient plasma:

- Commercial
- Haemophilia A / B plasma
 ADSORBED PLASMA

IX, X, V
V, VIII, Barium VIII
II, VII, II, VII, I XI
I, XI, IX, X XII
XII XIII

• Barium Sulphate (100mg) is mixed with 1 ml control plasma and keep

it at 37℃ for 3 minutes.
• The mixture is then centrifuged immediately (1700g for 3 mins at
room temp)
• Supernatent plasma is pipetted out: Adsorbed plasma
 AGED SERUM

2 DAYS
IX
IX X VII
V VIII I II X
V VIII
II VII XI
I XI XII
XII XIII
Results
• PT: 14.9 secs (Range: 9.8 – 12 secs)
• PT ½ pt + ½ control: 10.8 secs

• APTT: 69.2 secs (Range: 23 – 34.1 secs)

• APTT Mixing studies:
• APTT ½ pt + ½ control: 32.4 secs
• APTT ½ pt + ½ aged serum: 63/59/68 secs
• APTT ½ pt + ½ adsorbed plasma: 33.0 secs
• APTT ½ pt + ½ Factor VIII deficient plasma: 67 secs
• APTT ½ pt + ½ Factor IX deficient plasma: 34.0 secs

• TT: 14.6 secs (Range: 14.4 – 19 secs)

• WHAT NEXT ?
 MIX
V VIII APTT
I XI V VIII
IX X V II XII NORMAL
XII
II VII I XI XII
I XI XII
ADSORBED PLASMA:
Lacks II, VII, IX, X

Our Patient :
APTT 69.2 sec
MIX
IX X IX X
APTT
VII VII XIII
PROLONGED
XI XII XI XII

AGED SERA: Lacks I, II,

V, VIII

Interpretation?
 MIX
- VIII APTT
PROLONGED

Factor VIII deficient plasma

Our Patient:
APTT 69.2 sec
MIX
- IX
NORMAL

Factor IX deficient plasma

Interpretation?
• What is the possible diagnosis of the 17 years old lady born of
consanguineous marriage ?

A. Haemophilia A
B. Skewed Lyonization in obligate carrier
C. VWD
D. Needs further evaluation
Treatment and further management
• Planned for ENT Surgery
• Given FVIII Concentrate to get the FVIII to 100%
• Bleeding was still persistent

• Why was the patient bleeding?

• Possible cause of bleeding could be:
A. Inhibitors to FVIII
B. Surgical Bleed
C. Factor VII deficiency
D. Factor V deficiency

How will you treat this patient?

Case 3
• 17 year old girl presented with excessive bleeding after trivial injury
since 2 years of age.
• She also has history of easy bruisability requiring consultation and
oozing of blood after brushing of teeth.
• She also had an episode of malena and hematochezia 2 days back for
which she seeked consultation.
• She attained menarche at 13 years of age. Since then she has bleeding
for 20-25 days with passage of clots and changes 5- 7 sanitary pads
per. She is on hormonal medications for the same. She has received
transfusions of packed red blood cells 3 times and once fresh frozen
plasma transfusion.
• Born to 4th degree consanguineous marriage. No family history of
bleeding tendency.
 Algorithm
Bleeder / non bleeder?
• --------
Mild /Severe?
• --------
Primary / Secondary?
• ---------
Inherited / Acquired?
• ----------
Mode of inheritance?
• ----------
Diagnosis?
• --------
• Which tests are likely to be abnormal
Screening tests of Primary Hemostasis:
• Haemoglobin: 11 gm/dL
• Total WBC count: 5700/cumm
• Platelet count: 3,93,000/cumm. Normal platelet morphology.

• Bleeding time: >15 mins (Reference range: 2-6 min)

• Clot retraction: Good.
• PFA-200
Collagen/ADP : >300s ecs (Reference Range 68-142 secs)
Collagen/Epinephrine : >300 secs (Reference Range 89-167 secs)
Screening tests of secondary hemostasis:
• Prothrombin Time: 9.2 secs(Reference range: 9.8 – 12.0 secs)
INR: 0.84
• Activated Partial Thromboplastin Time: 74.4 secs(Reference
range: 25.1-36.7 secs)
• What next?
 MIX
V VIII APTT
I XI V VIII
IX X V II XII NORMAL
XII
II VII I XI XII
I XI XII
ADSORBED PLASMA:
Lacks II, VII, IX, X

PATIENT PLASMA
APTT 74.4 sec
MIX
IX X IX X
APTT
VII VII XIII
PROLONGED
XI XII XI XII

AGED SERA: Lacks I, II,

V, VIII

Interpretation?
 MIX
- VIII APTT
PROLONGED:
70 sec

Factor VIII deficient plasma

PATIENT PLASMA
APTT 74.4 sec
MIX
- IX APTT NORMAL:
35 sec

Factor IX deficient plasma

Interpretation?
• What next?
What is the diagnosis?
A. Haemophilia A
B. Skewed Lyonization in obligate carrier
C. Needs further evaluation
Patient 4
• A 14 years old male child presented with history of frequent
epistaxis lasting for more than an hour which stops on
application of pressure and easy skin bruisability for last 4
months.
• Child had uneventful appendicectomy at the age of 12 years.
• The child is recently diagnosed with CNL.
CBC:
• Haemoglobin: 6.9 gm/dL

• Total WBC count: 76,400/cumm

• Differential WBC Count:

• Blast: 09%
• Myelo/metamyelo: 18%
• Neutrophil: 64%
• Lymphocyte: 05%
• Monocyte : 01%
• Eosinophil: 01%

• Platelet count: 2,15,000/cumm

• 3 nRBCs / 100 WBCs

 PLATELET

BLAST
PLATELET
CLUMPS
TEST FOR PRIMARY HEMOSTASIS
• Bleeding time : 7 min 30 sec

• Clot retraction: Good.

• Closure time(PFA-200)

• Collagen/ADP : 157 secs (Reference Range 68-142 secs)

• Collagen/Epinephrine: 183 secs (Reference Range 89-167 secs)

What is causing prolongation of BT and
PFA200 closure time ?
How do you confirm this diagnosis by Flow
cytometry?
PLASMA COAGULATION TESTS

• Prothrombin Time: 20.0 secs (Reference range: 8.0 – 11.2 secs)

• INR: 1.50

• PT: ½ patient + ½ control: 9.9 sec

• Activated Partial Thromboplastin Time: 52.0 secs (Reference range: 25.2

– 38.0 secs)

• APTT: ½ patient + ½ control: 32.7 secs

• Thrombin Time: 11.8 secs (Reference range: 12.0 – 16.0 secs)

• What next ?
 ?? FACTOR DEFICIENCY

MIX
V VIII PT & APTT
I XI NORMAL
XII

ADSORBED
PLASMA

PATIENTS PLASMA
APTT AND PT ABNORMAL
TT NORMAL MIX
VII IX
X
XI XII PT AND APTT
PROLONGED
AGED SERUM

Interpretation?
What is the final diagnosis?