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Center for Hemorrhagic and Thrombotic Diseases, General University Hospital of Udine, Udine, Italy
Hypo- or hypercoagulable state? Haemorrhagic or thrombotic risk? Normally, the real difficulty is to balance these two aspects of haemostasis, our case report showed the complicated situation that incurred the patient when he is simultaneously underwent to hemorrhagic and thrombotic risk. A correct balance between two therapies is fundamental for his heathly. National and international guidelines established clearly which are the immediately treatments for acquired haemophilia A, for VTE and for reversal anticoagulation, but when these opposite situations occurred together their management is very difficult. Our patient, a man 63-year-old, was admitted to hospital for suspected DVT, following not instrumentally confirmed, during antithrombotic therapy, he has subsequently expressed an acquired hemophilia A, onset with serious bilateral ileopsoas hematoma needed immediate suspension of anticoagulants and treatment with vitamin K, RBC to restore haemostasis and pdFVIII. to improve FVIII:C. In this patient, cause co-morbities and prolonged immobilization, use of by-passing agents was controindicate. Despite this attention the TC scan revealed a presence of pulmonary embolism, that needed immediate restore to antithrombotic therapy. In this moment, the patient had a simultaneous presence of haemorrhagic risk due to acquired haemophilia, in treatment with pdFVIII and of venous thromboembolism, in treatment with low molecular weight heparin. A correct balanced treatment anticoagulant/coagulation factor subsequently allowed a rapid improvement in the medical state of this patient.
Our case report seeks to underline the importance of a careful initial analysis of the patient, followed by instrumental and laboratory diagnosis, that allow instantly have all the necessary information. The wrong diagnosis of DVT or delayed diagnosis of FVIII deficiency, can lead to use inappropriate treatment and delay the correct therapy. The balance between haemorrhagic and thrombotic risk is already generally difficult to obtain, though initially more are missing some important data about the coagulation status of the patient, the situation is very difficult to control.