Bleeding disorders

In this case discussion, Rajiv Pruthi, MD and Taha Bat, MD walk through a patient with acquired hemophilia A, a rare bleeding disorder caused by autoantibodies against clotting factor VIII. They review how the diagnosis is reached (especially distinguishing it from congenital hemophilia), discuss the challenges in management (bleeding control, immunosuppression, and inhibitor eradication), and present clinical decision points based on published evidence and expert experience.

Key Learning Points:

• Patients often present with new, unexplained bleeding in adulthood — especially soft tissue, mucosal, or spontaneous bleeding — with no prior personal or family history of bleeding.
• Key labs include prolonged aPTT that does not correct on mixing studies, measurement of factor VIII levels (low), and detection/quantification of FVIII inhibitors (Bethesda assay or variations).
• In active bleeding, bypassing agents (e.g. recombinant activated factor VII or activated prothrombin complex concentrates) are used to control hemorrhage, rather than conventional factor VIII replacement that is neutralized by inhibitors.
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In this session, Adam Cuker, MD and Taha Bat, MD present a case-oriented dive into immune thrombocytopenia (ITP). They review the pathophysiology of platelet autoantibody-mediated destruction, the diagnostic workup focused largely on exclusion, and a tiered approach to therapy based on severity, bleeding risk, and patient factors.

Key Learning Points:

• ITP is characterized by autoantibody-mediated platelet destruction and sometimes impaired platelet production by megakaryocytes.
• Diagnosis is one of exclusion: labs, peripheral smear, ruling out secondary causes (e.g. lupus, HIV, hepatitis).
• Not all patients need immediate treatment; decisions consider platelet count, bleeding symptoms, and patient comorbidities.
• +2 more points...