Management of Refractory Hemorrhage in a Kala-Azar Patient with Thrombocytopenia and Coagulopathy by Using Recombinant Factor VIIa (rFVIIa).

Objective: Platelet transfusion is used for the treatment of acute hemorrhages in diseases other than immunological events, which lead to severe thrombocytopenia. Besides the diseases in which production of platelets is completely terminated in the bone marrow and the platelet requirement is increased, immune thrombocytopenia and alloimmunization may also result in not being able to achieve the desired platelet levels with platelet transfusion, and life threatening hemorrhages. rFVIIa which is used for the management of life threatening hemorrhages in hemophiliac patients with inhibitors and in cases of acquired coagulopathies has also been used successfully in patients with thrombocytopenia. Here we present a case with a diagnosis of kala-azar, where nasal hemorrhage couldn’t be managed with conventional methods and required continuous replacement, and finally treated successfully by using rFVIIa.

Case: At admittance to hospital, hepatosplenomegaly and pancytopenia were detected in the fifteen year old male patient. He was diagnosed with kala-azar upon the detection of Leishmania donovani amastigote form in the examination for bone marrow aspiration. Treatment with sodium stibogluconate was initiated (60 mg/kg). Replacements were performed in the patient due to thrombocytopenia and anemia, who developed nasal hemorrhage during follow-up and had anterior nasal cushion placed. The patient was supplemented with fresh frozen plasma, vitamin K and fibrinogen for his acquired coagulopathy. Since coagulopathy wasn’t corrected and nasal hemorrhage continued actively, 5-minute infusions of rFVIIa were administered to the patient at a dose of 4.8 mg (120 microgram/dl) three times every two hours. His hemorrhage was stopped by rFVIIa treatment.

Conclusion: Our case demonstrated that use of rFVIIa for the management of hemorrhage in thrombocytopenic patients is also feasible in cases other than coagulopathy and that it may be an option for patients with hemorrhages that can not be managed with intensive platelet and plasma transfusions. This result shows that rFVIIa can be used effectively in other diseases other than hematological disorders that cause hemorrhage due to coagulopathy and thrombocytopenia.