Coagulation

Aaron Auerbach MD MPH

AFIP
 Thanks to the Osler
Organization and the Residents
at Walter Reed Army Medical
Center for providing help with
the creation of this powerpoint.
 Outline
• 1. Normal coagulation
• 2. Tests of coagulation
• 3. Hemorrhagic and thrombotic
disorders
 Outline

1. Normal coagulation
2. Tests of coagulation
3. Hemorrhagic and thrombotic
disorders
• Primary hemostasis
Platelet plug formation
Adhesion and aggregation
• Secondary hemostasis
Coag pathway, form fibrin
• Tertiary hemostasis
– Crosslinking of fibrin and fibrinolysis
 COAGULATION
z A complicated process that must prevent
both excessive bleeding and excessive
clot formation

z Three key components: blood vessels,

platelets, and plasma components

z Three steps: adhesion, plts release

granules, aggregation
 First step--adhesion

• You get an injury to a blood vessel and the

endothelium is ripped apart
• There is circulating von Willebrands factor in
the plasma, and there is also subendothelial
vWF.
• The circulating vWF in the plasma attaches to
the naked endothelium and subendothelium.
• Then the platelets attach to the vWF using
the glycoprotein Ib/V/IX
 adhesion
= GP1b/V/IX

platelet
vWF

Damaged endothelium

--Damaged endothelium exposes collagen

--Circulating vWF in plasma attaches to endothelium.
--Then, platelets attach to vWF using GP Ib/V/IX
 Then, the platelets release
their granules and change shape
 EM Platelet
Alpha granule Delta granule
- -thromboglobulin -ADP dense granule which causes
- P-selectin vasoconstriction
- PDGF - ATP
- PF4 - Serotonin
- platelet fibrinogen - Ca++
- Thrombospondin
- VWF

Alpha granule

Delta granule

Goldman: Cecil Textbook of Medicine, 21st ed

 Aggregation
• When the platelets change shape, they
expose their fibrinogen receptors
• GP IIb\IIIa receptor binds fibrinogen
• And aggregation occurs and plugs the
hole.
• This is the primary platelet plug
(monolayer)
• GPIIbIIIa inhibitors (Abciximab-Reopro,
Integrilin, Aggrastat)
platelet aggregation

= GP1b/V/IX

= GPIIb/IIIaX

platelet
vWF
 Primary Hemostasis

Aggregation
Adhesion

Damaged endothelium
understanding this process will help us
understand some diseases

Robbins 6 ed Fig 5-7

 Secondary hemostasis
(the dreaded coag pathway)
• Formation of fibrin
• Laying down fibrin over plt plug
• Defects can result in
hematomas, hemarthroses

www.azer.com/.../magazine/73_folder/ 73_photos/73_306.jpg
THROMBOPHILIA BLEEDING
 Enzymes that, when activated, catalyze activation of sequential
steps that lead to fibrin formation
Bowen, D J Mol Pathol 2002;55:127-144

Mostly made by liver (except vWF, mostly made by endothelial

cells)

Copyright ©2002 BMJ Publishing Group Ltd. 2002 BMJ Publishing Group Ltd.
 FVIII and V cofactors

Division into “intrinsic” and “extrinsic” based on lab tests,

doesn’t apply in body
Intrinsic path activated by blood in contact with negative
Bowen,
charged glass D J Mol Pathol 2002;55:127-144
Extrinsic path activated by tissue factor (subendothelium) Early
factors in intrinsic path (Kallikrein) usually do not cause
bleeding, but deficiency causes  PTT
Factor VIIa activates X directly, but mainly activates IX
Bowen,
Tissue factor D J Mol
pathway Pathol
inhibitor 2002;55:127-144
bingd to F10aX
 Secondary hemostasis

• Thrombin does many things

• It converts fibrinogen- fibrin
• Thrombin activates F5, F8, F11 F13
Tertiary hemostasis
fibrin

Thrombin
Factor XIII Factor XIIIa

cross links fibrin

 Fibrinolysis

Plasmin dissolves fibrin

 fibrinolysis

TPA cleaving plasminogen to plasmin

Plasmin cleaves fibrin into fibrin split products

Inhibiting fibrinolysis
1. Alpha two antiplasmin inhibits plasmin
2. PAI inhibits plasminogen
3. TAFI (thrombin activatable fibrinolysis inhibitor)
Inhibits binding of plasminogen and TPA to fibrin
Noble
 fibrinolysi
s

plasmin dissolves fibrin clots

D D
fibrin D-dimers
split  In pulmonary embolism
products
E
Fragment E
 Anticoagulation
• Protein C
Thrombomudulin binds to thrombin to activate protein C; with
its carrier, protein S, APC inhibits FV and FVIII
• Antithrombin
Liver-produced AT binds to heparin and inhibits conversion of II
to IIa; also inhibits Xa action
 Protein C, S

z Protein C, S measure level or

activity best to measure functional
activity
z As vitamin K-dependent factors,

may be abnormal during warfarin

treatment
z Both acute phase response

proteins; may be falsely normal (in

deficiency) with acute illness
 Outline
• 1. Normal coagulation
2. Tests of coagulation
• 3. Hemorrhagic and thrombotic
disorders
 Screening tests
• CBC-platelet count
• PT
• aPTT
• 1. CBC--platelet count
--Put platelets through impedance counter, analyze particles <13 fL
--Tells you nothing about the functional ability of plts

• 2. bleeding time
-worthless test, used to tell if patient might bleed at surgery
-Use blade on pt’s forearm, blot blood with filter paper
time w stopwatch to see when bleeding stops
-Each lab has different normals,
-Does not predict functional bleeding. If you have a
normal or abnormal bleeding time, it will not predict
whether you bleed
-PFA is better
 Activated Partial Thromboplastin Time
(aPTT) <40 seconds

Negatively charged surface

+ PPP + calcium chloride
Phospholipid (partial thromboplastin)

Measure time to clot

Measures the intrinsic and common pathway

Measures all factors except 7 and 13
 Prothrombin Time (PT) <15 seconds

Citrated (blue top)

-Tissue factor Calcium Chloride
-Phospholipids
+ Patient’s platelet-poor
Plasma (PPP)
+

Measure the time clot to clot

Measures the extrinsic and common pathway

 INR This formula shows up on boards

ISI
⎛ Patient PT ⎞
INR = ⎜⎜ ⎟⎟
⎝ Normal mean PT ⎠
ISI – International Sensitivity Index; related to
amount of tissue factor in reagent
INR--Developed to compensate for reagent
differences
 Normal PT, aPTT, platelets
• Mild vWD
• Uremia
• Surgery
• Inherited platelet D/O
• Vascular D/O
• Fibrinolytic D/O
• XIII deficiency
• Dysfibrinogenemia
• Mild factor deficiency
(VIII, IX, XI)
  PT, normal aPTT, normal platelets

• F VII deficiency or
inhibitor
• Coumadin
• Liver disease
• dysfibrinogenemia
 Normal PT,  aPTT, normal platelets

• Heparin effect
• vWD
• VIII, IX, XI
deficiency
• inhibitor
• Lupus anticoagulant
 PT, aPTT, and normal platelets

Common
• Coumadin
• Heparin
• Liver disease
• Vitamin K deficiency
• DIC
• Dysfibrinogenemia
• Primary fibrinolysis
 PT, aPTT,and  platelets
Common
• DIC
• Liver disease
• Heparin with
thrombocytopenia
 Nl PT, Nl aPTT,  platelets
Common
• Destruction
• Sequestration
• Decreased
production
• Bernard-Soulier
Nl PT, Nl aPTT,  platelets

Myeloproliferative disorders
 Additional tests
• Thrombin time
• Reptilase time
• Mixing studies
• Platelet aggregation studies
 Thrombin time

Exogenous thrombin
+ Measure the time to clot
Patient’s platelet-poor plasma

Measures common pathway

TT measures conversion of fibrinogen to fibrin
Doesn’t need Ca or phospholipid
↑ paraprotein, amyloid, heparin, dysfibrinogenemia
 Reptilase time

Bothrops atrox venom

Mixed with Measure time to clot

Patient’s platelet-poor plasma

Patients on heparin have ↑ TT but normal reptilase time

Giving heparinase + protamine to patient on heparin will correct TT.
Reptilase measures the conversion of fibrinogen to fibrin, but is
insensitive to heparin.
↑Reptilase in dysfibrinogenemia
 Mixing Study
Patient plasma Mixed (1:1) with Pooled normal plasma

Perform PT or aPTT
-Initial
-At 60 minutes

--mixing study w PTT correction = factor deficiency

--mixing study w/o PTT correction = inhibitor (ex. lupus
anticoagulant)
--Some inhibitors correct w 1:1 mix, so try a 4 (pt plasma) : 1 (nl
plasma) mix.
--Time dependent prolongation = F8 inhibitor will correct and them
prolong after 1-2hrs,
--Dysfibrinogen inhibitor and will only partially correct.
Hypofibrinogen will correct.
 Platelet aggregation studies
• Tell you how platelets respond to certain
chemicals to see if they will aggregate
• Use a platelet rich plasma (spin it down to get
a good # of plts)
• Add aggregating agent i.e ristocetin
• Look for a change in light transmission
• We can look for  in turbidity or an  in
transmission
• Curve is flipped
PLATELET AGGREGATION STUDIES

Shine light
Through platelets Aggregated platelets

Add
Agent

Less light scattering

Low Optical Density
 Optical 100
density First phase of
(%)* aggregation (ADP release)

50
Second phase
of aggregation
(more ADP release
& TXA2 release)

0 3
Time (min)

*w/ aggregation, less light scattering, lower optical density)

What are the aggregating agents
• ADP--normally in platelets
• Ristocetin--physical clumping agent
• Epinephrine
• collagen
• arachidonic acid (used for detecting
aspirin defects)
Platelet aggregation studies
 Board high yield factoid

• ADP and Epinephrine are biphasic

• No secondary phase w epi & ADP in

storage pool defects & aspirin
 Outline
• 1. Normal coagulation
• 2. Tests of coagulation
•3. Hemorrhagic and thrombotic disorders
 Platelet vs. factor bleeding

• Petechiae • Hematoma\hemarthrosis
• menorrhagia • Large bruises
• Female • Male
• No family history • + family history
• vWD, BS dz • Coag disorders
• Thrombocytopenia
 Congenital

• Bernard-Soulier Disorder
• Glanzmann thrombasthenia
• May Hegglin
 Bernard-Soulier

• Adhesion problem (like in beginning of lecture)

• defect GP1b/V/IX (CD42)
• large giant platelet w pseudonucleolus
• thrombocytopenia
• Nl PT, PTT, bleeding time
• impaired ristocetin aggregation

• If you add normal ptls + ristocetin, aggregation will

be nl b/c the abnormality is on the patients plt.
Bernard-Soulier

platelet
vWF

LGPIb Ladhesion,
bleeding occurs
Bernard Soulier Disorder
 Glanzmann thrombasthenia

• Aggregation problem, Plts can’t bind fibrinogen

• abnormal GP IIb/IIIa
• normal plt count, morphology (pts dispersed);
• L aggregation ADP, collagen, and EPI, but normal with ristocetin

• Dx: Clot retraction test- clot no retract test tube

• Diff dx: Glanzmanns and afibrinogenemia both defect in

fibrin:fibrin interactions
• Glanzmann’s has nl Pt/PTT, Afibrinogenima has ↑PT + PTT
 No aggregation,
bleeding
Fibrinogen

Nl adhesion
VWF

Glanzmann thrombasthemia
 May Hegglin Anomaly
mutated myosin heavy chain 9
Dohle body (RER) + giant plt
Little bleeding
Autosomal dominant
 High yield board fact
• Giant Platelets
• ITP, May Hegglin, gray platelet
syndrome, Bernard Soulier, Montreal plt
syndrome,
• Mediteranean macrothromocytosis.
• Sebastian, Fechner, Epstein, and Alport
syndromes
 Storage Pool Deficiency
always on boards, never in clinical
practice

• L plt aggregation due to deficiencies in

either dense granules/ alpha granule
contents or both
• Nl morphology, no granules EM
• Plt agg: NO 20nd wave-ADP, EPI,
• Impaired collagen, AA normal ristocetin
• ↑ ATP:ADP ratio
 Storage pool deficiencies
• Gray platelet syndrome
No α granules,
Large gray plts, no granules
From cardio pulmonary bypass
Plt agg blunted with all agents
except ADP/epi
• Quebec plt disorder
No α granules
• Wiscott Aldrich syndrome
x-linked
No δ granules EM
Small granulated plts, like FeDa
Thrombocytopenia, infection,
eczema
 malignancy
• Chediak Higashi
No δ granules EM
• Hermansky-Pudlak Syndrome
No δ granules EM
K pigment reticuloendothelial
cell
• Swiss cheese platelets
• ↑AK, nevi, tumors, pulmonary
fibrosis
• Puerto Rican/Swiss, ↑vW
• Thrombocytopenia w absent
radii
Alpha Granule Deficiency

agranular gray colored platelets

Acquired Disorders of Platelet
Function
• Drugs
• Uremia
– abnormal adhesion, abnormal aggregation
(ADP, epi, collagen)
• Myeloproliferative disorders
• Cardiopulmonary bypass
– Transient plt activation, ↓granules
 Aspirin/NSAIDS

• L platelet function by acetylation of platelet

cyclo-oxygenase Æ L thromboxane formation
• platelet aggregation studies
L 2nd wave to ADP and epi, absent response
to collagen and arachidonic acid
 Other plt type bleeding disorders
• Hereditary Telangectasia
• Osler-Weber-Rendu
• Oral Telangectasia FeDA
• Ehlers Danlos, Type 4
• Connect tissue disorder plts
cant stick, bruising and
prupura, loose skin
• Hemoch-schonlein vasculitis,
prupura, thrombocytopenia
• Arteriovenous malformation,
↓ plts
• Scurvy, Vit C, bad teeth,
perifollicular petechiae
• Marfans, osteogenesis
imperfecta, fabry syndrome
• Amyloidosis--F10
• Platelets don’t stick,
endothelium coated, lambda
light chains
 Von Willebrand factor amd
disease
• vWF binds to F8
• Consists of large multimers which are cleaved
by ADAMTS-13; deficiency of this protein
associated with TTP
• vWD most common genetic plt type bleeding
disorder
• chr 12 autosomal dominant
• 1-2% prevalence worldwide.
• ↓vWF-blood type O, old blood sit
• Quant or qual deficiencies
• Secondary vWF deficiency -Wilms tumor,
congenital heart disease, hypothyroid
 VWD diagnostic tests
1. Platelet count 5. RIPA Ristocetin induced
Plts ↓sometimes, screening test platelet aggregation
2. FVIIICo measure F8 activity • pts plasma + pt plts + low dose
3. VWF Ag ristocetin = time to aggregation
measures vWF quantity • all or none, does pt aggregate w
ristocetin
blood add F8Æmeasure vWF
4. vWF:Rcof 7. platelet agg studies
measures vWF activity
Pt plasma + nl plts + ristocetin, 8. VWF multimers
then measure time to
aggregation
• very specific & most sensitive 9. mixing study
test
• Qantitate pt vWF activity (%)
using ristocetin, standard curve
with quantitative endpoint
von Willebrand factor antigen
(Factor VIII R:Ag
Laurel rocket
electrophoresis
(old test probably
on boards)

pathology.mc.duke.edu/coag/ images/29_rgb.jp
 vWD Type I

• associated with low quantity, normal

multimers Functionally normal
• Most common type
• Sometimes all tests are normal
• Only type treated w DDAVP
• Mutations throughout the gene or no
mutations
RIPA
 vWD type 2a and 2b
• Type 2a
•  large and medium sized multimers
• a disproportionately low vWF:RCo (quality) relative to vWFAg (quantity)

• Type 2b
• large multimers
• ↑affinity HMW multimers for GP1b
• leads to increase clearance of vWF
• K RIPA, No DDAVP

• Type 3
• Autosomal recessive, most AD
• Severe marked deficiency
• Absence of vWF, F8 also low
• But may have nl coag parameters
• VWF too low for multimers
• No DDAVP
vWD multimers analysis
RIPA
 vWF 2M and 2N
• Type 2M
• Defect in GP 1b binding
• vWF made but doesn’t work, vWFRco
• Sometimes nl—RIPA, multimers, vWF Ag, F8
• Suspect when vwf:Rcof < vwf Ag

• Type 2N (Normandy)
• Defective F8 binding
• Vwf decreased affinity for F8
• Hemophilia-like (but AR), women w low F8, think of this dz

• Tests:  VIII:C levels

• Normal RIPA, vWFAg, multimers, nl ristocetin
 Pseudo VWF—platelet type

• ↑affinity plt GP1b for plasma vWD receptor

• Plts bind large VWF multimers There are less large
vWF circulating
• Abn RIPA studies
• Spontaneous aggregation with risto
• Needs a higher concentration of ristocetin than 2B.
• Plt agg w cryoprecipitate, unlike 2B
• Plt agg studies show large VWF multimers
• The abnormality is only on the pt plts.
 Factor deficiencies

• Bleeding into joints

• PT, PTT or both
• Often nl bleeding time

• Typically X-linked recessive disorders (female

carriers, affected males)
• Hemophilia A – Lfactor VIII
• Hemophilia B – Lfactor IX Symptoms rare if
factor level > 15-20%; severe disease if levels
< 1%
•
 Hemophilia board trivia

• Mixing studies: correction of PTT immediately and

at 1 hour

• F8 carriers
• -woman whos dad has hemophilia
• -mom of hemophiliac child Nl Dad XY, carrier mom XHX

• 50% daughters carriers

• 50% sons affected

• female w mild F8 def is possible w Lyon hypothesis, Turner (XO)

• Chr (Xq28), 50% intron 22 inversion

 HEMOPHILIA B
(Christmas Disease)

• Less common than Hemophilia A (1/20,000)

• Male patients/ X linked recessive.

L

• Severely affected patient are less common

than in Hemophilia A.
 Inhibitor
• Inhibitors may develop after treatment, requiring huge amounts
of factors
• Inhibitors don’t correct after mixing studies
• F8 inhibitor corrects initially prolongs after 1hr.

• Bethesda unit is a measure of the strength of the inhibitor

• 1 Bethesda unit = 50% activity
• 2 Bethesda units = 25% activity
• 3 Bethesda units = 12.5% activity

• 20% of patients with Hemophilia A.

• 1-3% of patients with Hemophilia B.
 Other factor deficiencies
F9 deficiency
F9 inhibitors can get anaphylaxis
when treated
• Tx: F9 conc—PTcomplex concentrate
• FFP, whole blood, NO cryoprecipate
• F8-100% dose recovery, t1/2 12hrs
• F9-30% dose recovery, 1/1/2 8 hrs
FX11 deficiency
• hemophilia C, Jews,
• mild bleeding,
• Autosomal recessive unlike other
hemophiliac
• Can’t activate TAFI
FXII deficiency
• ↓prekallikrein, ↓HMWF,
• ↑ PTT, but no bleeding.
• ↓F12-Hageman-↑PTT, but thrombosis
• mixing study prolonged
F13 deficiency
nl PT, nl PTT,
cant crosslink fibrin
• Clot stability test-clot can’t stop 5M
urea from dissolving clot < 24hrs,
nl>24hrs
• 1% monochloracetic acid
 Fibrinogen problems
• 50% no symptom, 25% bleed, 25%clot
• Hereditary AD—rare
• Acquired-liver disease

• Afibrinogenemia
• Quantitative, AR
• mixing study corrects
• Dysfibrinogenemia
• AD, thrombophilic, qualitative
• Mixing study partial corrects-inhibitor

• ↑Reptilase time, ↑Thrombin time

• Platelet Agg Tests --Ldec ADP, EPI & AA
• Fibrinogen antigenic assay

• ↑Fibrinogen--acute phase response

 Vit K deficiency

• Inc Pt, PTT, nl TT,

• γcarboxylation of glu F2, 7, 9, 10
• ↓ vitK-malabsorbtion, antibiotics, Breast milk,
anticonvulsant, biliary obstruction
• Hemorrhagic disease newborns
 Liver Disease
• Loss of many clotting factors
• Vitamin K deficiency in cholestatic liver disease due
to reduced absorption of bile salts
• L plts, PTT PTT, TT, reptilase, BT,
• Decreased Factors I, II,V,VII, IX, X, XI
• Factor 8, VWF, may be increased in acute disease
 α2 antiplasmin deficiency

• nl PT, nl PTT, bleed

• ↓euglobulin lysis time--measures the time to
dissolve a clot
• ↓Euglobulin lysis test <2hrs
• also ↓ in fibrinogen, DIC, ↑ tPA

• tx: Amicar, transexamic acid

•
 Thrombocytopenia

• Plt type bleeding

• Lproduction
– marrow suppression, drugs, congenital
(Fanconis, Wiscott Aldrich)
• destruction
– ITP, DIC, TTP
 Pseudothrombocytopenia

• Plt clumping in blood prep w EDTA

• antibodies to GPIIb/IIIa causes plts to
clump
• Platelet count in sodium citrate
anticoagulant usually normal
• Platelet satellitism --In vitro platelet
adherence to leukocytes in EDTA
anticoagulated blood
Plt clumping Plt satellitism
 Disseminated Intravascular
Coagulation
• Patient bleeding, thrombosing or both, typically with progressive
organ dysfunction
• Acute bleed, chronic clot
• Peripheral smear anemia w schistocytes

• Lab findings
• PT, PTT, TT, Lplt count, Lfibrinogen, LATIII, Lplasminogen
• ↓prot C, S, ATIII, α2antitrypsin,
• FDPs sensitive not specific.
• D-dimer specific,
• Protamine sulfate
 TTP/HUS-- a board favorite
• Clinical manifestations: hemolytic anemia w schistocytes, Lplts, fever,
neural probs, renal dysfunction, abdominal pain
• Microthrombi in different organs

• TTP Big vWF multimers, cant cleave, shear RBC causing MAHA
• HUS normal vWF cleavage protease

• HUS--Shiga toxin, salmonella, E.coli 0157:H7

• Labs: same as DIC except fibrinogen normal, (↓DIC)

• Kids present w renal failure
• Adults present w neuo symptoms

•
• Tx
• TTP: FFP + steroids +Ivig + splenectomy., don’t give platelets
• HUS: supportive + antibiotics
• HUS + TTP are treated differently.
TTP

CD 61
THROMBOPHILIA BLEEDING
 Thrombophilia
• Predisposition to thrombosis from familial or acquired
disorders of hemostasis

• Inherited disorders of thrombosis

– Resistance of activated protein C 6% caucasions
– Prothrombin G20210A mutation 2% caucasions
– Protein C deficiency Less common
– Protein S deficiency
– Antithrombin deficiency
– Hyperhomocysteinemia
• Acquired disorders of thrombosis
– Lupus anticoagulant
– Heparin Induced Thrombocytopenia
 Activated Prot C resistance
• Most common cause of thrombophilia
• usually due to point mutation in factor V, which prevents inactivation by
protein C, so prothrombin production is unchecked and you get fibrosis

• Factor V gene Mutation:

1. Arg for gln at position 506 (Factor V Leiden)
2. Arg for threonine at position 306 (Factor V Cambridge)
 Dx
• 1. Functional assay-(PTTresistance ratio)
• Screening test
• Normal Add ProtC should ↑ PTT >2:1
• APCR add Prot C, ↑ PTT <2:1

• 2. PCR for Factor V Leiden mutations

 Protein C Deficiency
• neonatal fulminans, homozygous
• Heterozygous
– Type I: reduced protein
– Type II: defective protein
• Venous thromboembolism
• Coumadin Æ skin necrosis
• Laboratory diagnosis:
– Patient must be off Coumadin
– Heterozygous levels may overlap normal
 Protein S Deficiency
• Prevalence not known. Autosomal dominant
– Type I: low total and free Protein S
– Type II: normal total and free, decreased activity
– Type III: normal total, decreased free Protein S
• Venous thromboembolism
• Laboratory diagnosis:
– Patient must be off Coumadin
– Heterozygous levels overlap with normal
 Protein S def

• Prot S is a cofactor to Prot C

• 60% Protein S binds to C4b binding protein
• Only 40% is free, that is the functional protein S

• C4b is an acute phase reactant, C4b, LProtein S

• Thus ↓ Prot S during stress

• Labs:
1.free protein S
2. total protein S
3. protein S activity (best test)

• Autosomal dominant
 Antithrombin III deficiency
• Antithrombin binds to heparin to inhibit factors II and X.
• In ATIII deficiency, patient presents w ↓response to heparin

• Acquired- liver, nephrotic dz, DIC,

•
 Prothrombin G20210A Mutation
• Point mutation leads to high prothrombin levels

• Guanidine to adenine substitution in the 3’

untranslated portion of prothrombin gene on Chr 11
 Anti-phospholipid Syndrome
• antibodies against phospholipids
- most commonly to β2-glycoprotein,
also anticardiolipin, anti lupus anticoagulant

• Clinical features:
– Systemic Lupus Erythematosis (15-30% of cases)
– Venous thrombosis
– Peripheral arterial thrombosis
– Myocardial infarction
– Stroke or ischemic attacks (<55 years)
– Recurrent fetal loss
– Thrombocytopenia

– Lplatelets but thrombosis

• You do not have to have lupus
anticoagulant to have this syndrome
 Antiphospholipid antibody tests

• 1.PTT

• 2. Dilute Russell viper venom test (AKA strypven test)

• Russell Viper venom + Factor V, phospholipid and calcium
activates Factor X. Plasma containing lupus antibodies prolongs
PTT.

• 3. Lupus anticoagulant antibodies

• ↑PTT (staclot), fails to correct w mixing study, but partial
correction w adding phospholipid

• 4. Anticardiolipin antibody--ELISA. NO ↑PTT

• 5. β2 Glycoprotein I antibodies--immunoassay
 tests
• 6. platelet neutralization procedure
PTT fails to correct w mixing study, but PTT
corrects when you add hexagonal phase
phosphatidyl ethanolamine

• 7. Kaolin clotting time

• 8. Nontreponemal VDRL/RPR
falsely positive in LA,
 Heparin induced thrombocytopenia and
thrombosis
• IgG Ab to heparin PF4 complex in α granules
• Occurs in 8% unfractionated heparin, much less in LMW or porcine
heparin
• L platelets and thrombosis
• ↓ plts usually after 5-8 days

• Dx:
z Numerous assays; patient blood add heparin look for coagulation

• serotonin release assay

• Measure plt granule release
• Pt given low dose heparin, radioactive labeled serotonin released
• Pt given high dose heparin,immune complexed destroyed, so no serotonin
released
• PF4 ELISA-best test, measures Abs
• rapid turnaround, but often false +

• Tx:
• -Stop heparin/don’t give plts, no warfarin
• - thrombin inhibitors, monitored by PTT,
 Homocysteine
• Sulfhydryl amino acid needed for the formation of cysteine and
methionine
• level associated with venous thrombosis/atherosclerosis
 Homocysteinemia
• AR, lens dislocate, MR, peripheral neuropathy,
• sometimes folate ↓

• Dx:
• 1. serum levels
• 2. Methyl tetrahydrofolate reductase
• mutation 3. Mutation in CBS cysathionine
βsynthase
 Board Questions/facts
• vWF made in Megas and endothelial cells
• Bernard Soulier
• vWF different subtypes/tests
• Platelet aggregation studies
• Differences b/t alpha and delta granules
• Storage pool disorders
• Differences b/t TTP and HUS
• Liver disease
QUESTIONS