| Case Presentation | No. 13-2018 | A 1½ year old girl with excessive following accidental trauma to the upper labial frenum during playing

Mohammad Mizanur Rahman, Monwarul Aziz, Mohammad Mohsin, Maksuda Begum, Bazlur Rahman, Afroza Akter, Abdullah-Al-Baki and Md. Asaduzzaman

Article Info Presentation of Case otherwise healthy until this incident as well as the mother recovered well after cesarean Departet of Patholog, Ar Medial Dr. Monwarul Aziz (Dental Surgeon): A 1½ year section with no history of prolonged bleeding College Chattogra, Chattogra Ca- toet, Chattogra, Bagladesh old girl of a consanguineous parents was brou- peri- and post-operatively. Her father also MMR; Militar Detal Ceter, Chatto- ght to the emergency and casualty department underwent operation for deviated nasal septum gra Catoet, Chattogra, Bagla- of a secondary care military hospital in Chatto- and recovered well. The patient was desh MA, MA; Departet of Cou- gram Cantonment (South-East part of immunized as per national immunization it Mediie, Ar Medial College Chattogra, Chattogra Catoet, Bangladesh), Chattogram, Bangladesh at 0100 schedule and her milestone of development Chattogra, Bagladesh MM; Co- hours on 19th January 2018 by her parents with was age proportional. However, during ied Militar Hospital, Dhaka Cato- the complaints of excessive bleeding following vaccination, the bleeding was observed and it et, Dhaka, Bagladesh MB; Co- accidental trauma to the upper labial frenum took slightly long time to stop and as it was so ied Militar Hospital, Chattogra during playing for the last six hours. The duty Catoet, Chattogra, Bagladesh minor abnormality that the parents ignored it BR, AA; Departet of Miroiolog, medical officer attended the patient and took and did not bring to the notice of the concerned Ar Medial College Chattogra, detail history. The doctor came to know that the physician. The baby did not suffer from any Chattogra Catoet, Chattogra, baby got accidental trauma to the upper labial serious medical and surgical illness in the past. Bagladesh AAB frenum during playing at 2130 hours on 18th The patient is the only daughter of the parents. For Correspondene: January 2018 followed by excessive bleeding Family history revealed no record of bleeding Mohaad Mizaur Raha from the injury site. disorder. On general and systemic examina- iza@ahoo.o tions, no abnormality was detected. No abnor- As the father of the patient is a paramedic and mality was detected in the dentures, oral Reeied: Ma serving in the same military hospital of mucosa, gum, lips and tongue on local exami- Aepted: Ma Chattogram cantonment, with his medical skill, Aailale Olie: Ma nation other than a 1 x 1 x 1 cm3 wound in the he made an effort to prevent the bleeding by upper labial frenum. As such, abnormal blee- pressure bandage over the injury site in several ding from the upper labial frenum was ISSN: - Olie times and the bleeding decreased meaningfully. unrelated to dental disorders. Therefore, I - Prit After that, the child dozed but at about 0100 referred the case to the child specialist as well hours on 19th January 2018, the parents noticed DOI: ./suj.i. as hematologist for further management. that bleeding resumed and blood wetted the bed and mouth of the baby was filled with fresh Dr. Bazlur Rahman (Pediatricians): The referred Keyords: Bleedig; Laial freu blood. So, the parents took the baby and rushed case had reported to the outpatient department Traua; Vo Willerad disease; Vo th Willerad fator to emergency and casualty department of the of in the morning on 19 January military hospital. 2018. We discussed the case together and Cite this artile: assumed that it might be a case of congenital The attending doctor also examined the injury Raha MM, Aziz M, Mohsi M, Begu bleeding disorder. Therefore, we advised for M, Raha B, Akter A, Baki AA, Asaduz- site and found that the injury was very trivial in complete blood count, blood grouping, blee- zaa M. A ½ ear old girl ith ees- nature. There was no need to stitch and he ding time, clotting time, prothrombin time and sie leedig folloig aidetal trau- again tried to stop the bleeding by putting a to the upper laial freu durig partial thromboplastin time for both the patient pressure bandage and antifibrinolytic agents plaig. Bagaadhu Sheikh Muji as well as parents. The patient was also advised Med Ui J. ; : -. (tranexamic acid). Initially, the bleeding to do serum TSH. stopped but after 5-10 min, the bleeding again Copyright: started. Then he referred the patient to the On 20th January 2018, we got the results of the The opright of this artile is retaied the authors [Atriutio CC-B .] Military Dental Center. I attended the patient laboratory investigations which showed mark- and found that the blood was oozing from the ed prolongation of bleeding time and partial Aailale at: injury site. I again tried to stop the bleeding by thromboplastin time of the patient but all other .aglajol.ifo putting pressure bandage and local anesthetic investigations of the patient and parents were agent such as injection adrenaline but it did not within normal limits. Results of the laboratory work rather more bleeding was observed from investigations of the parents were within nor- the injection site. Then I put hemostatic paste to mal limits. Blood group of the patient was B the injury site and bleeding stopped. As per positive, father O positive and mother B posi- statement of the parents, the baby was deli- tive. Basing on the history, physical findings vered by cesarean section and the baby was and results of the laboratory investigation, we BSMMU J 2018; 11: 168-179 169

Provisional Diagnosis Table I Inherited bleeding disorder Laboratory data In Combined Military Hospi- tal Differential Diagnosis Variable Reference Patient Father Mother range, 1 Dr. Rahman: Several factors were considered while year ¶ constructing the differential diagnosis. First, age Hemoglobin (g/dL) 11.1–13.1 9.0 13.6 9.6 and sex of the patient. Second, sudden onset of prolonged and excessive bleeding following minor ESR (mm in 1st hour) 10–20 15 trauma. Third, consanguineous marriage of the Hematocrit (L/L) 0.3–0.4 0.3 parents and absence of bleeding disorders in the 12 RBC (x10 /L) 3.9–5.1 3.0 4.5 3.2 family. Fourth, results of first line coagulation tests Mean cell volume (fL) 72–84 80 88 88 and blood group of the patient. Fifth, pedigree White cell count (x109/L) 6.0–16.0 9.8 6.8 7.0 analysis. Keeping such factors in mind and after Differential count evaluating the clinical and initial laboratory inves- tigations, the following differential diagnoses were Neutrophils (%) 32 67 50 considered. Lymphocytes (%) 56 26 38 Monocytes (%) 10 5 4 Immune thrombocytopenic purpura Eosinophils (%) 2 2 8 Immune thrombocytopenic purpura is defined as Platelet count (x109/L) 200–550 440 200 280 low platelet count with either normal bone marrow or megakaryocytic hyperplasia in bone marrow and Peripheral blood film Non absence of other causes of thrombocytopenia. specific Patients with immune thrombocytopenic purpura findings presents with distinct purpuric rash, an increased Bleeding time (min) 5-11 23 3.2 4.3 tendency to bleed, easy bruising and ecchymoses in Clotting time (min) 8.0 8.3 9.4 the skin and mucous membrane.1 Immune throm- Prothrombin time (sec) 13 13 13 14 bocytopenic purpura may be presented as acute in Activated partial thromboplastin 30 65 38 32 which children are mainly affected and usually time (sec) follows a viral infection of the upper respiratory Von Willebrand antigen (%) 50–160 3 tract. FVIII activity (%) 60–150 3 Acute immune thrombocytopenic purpura usually HbsAg Negative resolves spontaneously within two months. Chronic Serum TSH (μIU/mL) 0.8–9.1 3.5 immune thrombocytopenic purpura usually occurs in adults without a known etiology and persists Blood group B+ve O+ve B+ve longer than six months.2 Acute immune thrombo- ¶Reference values are affected by many variables, including the demographics and the cytopenic purpura in children is usually mild and laboratory methods used. The ranges used at Combined Military Hospital, Chattogram are self-limited but life threatening intracranial hemorr- for children (1 year) who do not have medical conditions that could affect the results. They hage may occur when the platelet count is less than may, therefore, not be appropriate for all patients 10,000/cmm.3 Such grave situation may be experi- made an interim clinical impression and referred enced in day to day practice in about 0.5–1.0% cases. 4 the case to a tertiary care military hospital, Dhaka However, half of these cases are fatal. In immune cantonment, Dhaka, Bangladesh. thrombocytopenia, platelets are destroyed in the peripheral circulation through an immune mediated Dr. Mohammad Mizanur Rahman (Hematologist): After mechanism. An abnormal auto-antibody, usually reporting to me, I have re-evaluated the case and IgG with specificity for platelet membrane glycol- carefully dissected the history, family pedigree, protein IIb-IIIA or Ib-IX is produced and binds to physical findings and laboratory investigations so circulating platelets.5-7 Such antibody coated far done. As the patient presented only with platelets are destroyed through Fc-mediated phago- prolonged and excessive bleeding from the upper cytosis by mononuclear macrophages, primarily but labial frenum, no family history of bleeding not exclusively in the spleen.8 Spleen plays a signi- disorders, platelet count was 440,000/cmm, ficant role in the pathogenesis of immune thrombo- bleeding time was 20 min and PTT was 60 sec, so cytopenic purpura, not only because platelet auto- my clinical impression was Von Willebrand disease. antibodies are produced in the white pulp but also I referred the case to army referral laboratory, because mononuclear macrophages in the red pulp Dhaka cantonment, Dhaka, Bangladesh for von phagocytes and destroy immunoglobulin-coated Willebrand factor antigen and factor VIII assay. platelets.9 In about 60 percent of cases, auto- 170 BSMMU J 2018; 11: 168-179

antibodies against platelets are detected.10 The due to , recurrent infections due to neutro- incidence of immune thrombocytopenia has sea- penia, bleeding manifestations due to thrombo- sonal variation, with a peak in winter and a nadir in cytopenia, CNS, testes and organ involvement summer. Persistence or chronicity occurred in 36% (lymphadenopathy, splenomegally) or bone pain of children compared with 67% of adults.11 Immune due to leukemic infiltration.20 For the diagnosis of thrombocytopenic purpura is more common in boys acute lymphoblastic leukemia, WHO and National than in girls in case of children.12 Usually women Comprehensive Cancer Network (NCCN) guide- are prone to be affected more than men when lines are the demonstration of ≥20% bone marrow immune thrombocytopenic purpura occurs in lymphoblasts, morphological assessment of bone middle-aged individuals.3 The peak incidence of marrow aspirate smears for blasts population, com- immune thrombocytopenic purpura in children is prehensive flow cytometric immunophenotyping between 1–6 years whereas in adults it may occur at and baseline characterization of leukemic clone to any age but most cases are diagnosed in between 30 unclog ensuing minimal residual disease (MRD) –40 years of age.12 analysis. It is also important to find the risk stratification and treatment planning in patients In this case, the age of the patient and presence of with acute lymphoblastic leukemia. For this, NCCN superficial bleeding suggests the diagnosis of advises further analysis of peripheral or bone immune thrombocytopenic purpura but sex of the marrow lymphoblasts by G-banded metaphase patient, absence of previous history of infection, chromosome study, interphase fluorescence in situ normal platelet count and no purpura and ecchy- hybridization (FISH) for BCR-ABL, MLL, TEL/ moses are the points against the diagnosis of AML-ETV6/RUNX1, CEP4 and CEP10, RT-PCR immune thrombocytopenic purpura. and aCGH for aneuploidy or failed karyotype.21 The Acute leukemia presence of gum bleeding in this patient favors the Acute leukemia is a neoplasm of bone marrow diagnosis of acute lymphoblastic leukemia but hemopoietic stem cells which proliferate uncon- absence of anemia, fever, lymphadenopathy and trolled and replace the normal hemopoietic cells of organomegaly, no immature white cell in peripheral the marrow. According to cell line involved, acute blood as well as normal platelet count disfavors the leukemias are divided into two groups– acute diagnosis of acute lymphoblastic leukemia. myeloblastic leukemia and acute lymphoblastic Aplastic anemia leukemia.13 Acute lymphoblastic leukemia is more frequent form of leukemia in children and Peripheral blood pancytopenia and bone marrow comprises 75% of pediatric leukemia cases. Regar- hypoplasia in the absence of abnormal infiltrate and ding the etiology of acute leukemia, very little is without increase in reticulin are the features that known and most patients have no identifiable risk define aplastic anemia.22 In 1888, Paul Ehrlich factors. However, radiation exposure predisposes to introduced the concept of aplastic anemia but the development of acute myeloblastic leukemia Anatole Chauffard named this disorder aplastic rather than acute lymphoblastic leukemia. Patients anemia in 1904.23 It is thought that aplastic anemia having prior history of Hodgkin lymphoma, small is more common in Asia than the West. In Europe, cell carcinoma and ovarian cancer are more the incidence is two cases per million population.24 susceptible to develop acute myeloblastic leuke- A prospective study conducted in Thailand reveal- mia.14 The incidence of acute lymphoblastic ed the incidence of approximately 4 to 6 cases per leukemia is also low among children with high level million populations. This increased incidence in this of social activity, especially those attending early area may be due to more exposure to environmental daycare nursery than those living in more isolated factors such as pesticides, fertilizers, dying agents as communities and have a reduced exposure to well as toxic chemicals used in the garment and common infections in the first year of life.15 other industries. The increased incidence of aplastic Pathogenesis of acute lymphoblastic leukemia anemia is not observed among the Asians living in varies and a significant portion of acute lympho- United States indicating that genetic factors are blastic leukemia are initiated by genomic mutations more responsible for aplastic anemia in USA and that occur during development in utero. Significant the West.25 No racial predisposition of aplastic susceptibility locus in GATA3:3824662 have been anemia is reported in USA and both sexes are identified in younger adults with acute lympho- equally affected. Biphasic age distribution is blastic leukemia. Individuals with some single observed with peaks at 20–25 years and another neucleotide polymorphism (SNP) in germline such over 60 years.22 The primary defects in or damage to as arylamine N-acetyltransferases 1 and 2, MNP-8 the stem cells or the marrow microenvironment is promoter genotypes, HLA alleles, ARID5B, IKZF1, the theoretical basis of bone marrow failure. Clinical CEBPE, CDKN2A, PIP4K2A, LHPP and ELK3 are and laboratory observations suggest that aplastic prone to develop acute lymphoblastic leukemia.16-19 anemia is an autoimmune disease.26-28 In aplastic Patients with acute lymphoblastic leukemia most anemia, bone marrow examination revealed hemo- commonly presents with signs and symptoms of poietic stem cell elements which are less than 25% bone marrow failure such as generalized weakness and replaced by fat cells. CD34 cell population BSMMU J 2018; 11: 168-179 171 analyzed by flow cytometry are significantly redu- protein results in inherited coagulation disorders. ced in the aplastic anemia.29 However, in most cases Due to such unique feature, most of the inherited of aplastic anemia, the cause is unknown. The coagulation disorders produce similar signs and search for an etiology is often unproductive and symptoms.36 Hemophilia is mainly of two types, should obtain detailed work history including such as hemophilia A and hemophilia B. Hemo- exposure to environmental factors as well as family philia A is an X-lined recessive disorder due to and infectious disease history.30 The chance of deficiency of clotting factor VIII (FVIII). Hemophilia having inherited bone marrow failure is less in the B is also an X-linked, inherited, recessive disorder absence of overt phenotypic features of inherited that results in deficiency of functional coagulation aplastic anemia such as Fanconi anemia, dyskera- factor IX. Both hemophilia A and B may result from tosis congenita, Shwachman-Diamond syndrome, spontaneous mutation and acquired immunologic congenital amegakaryocytic thrombocytopenia, processes.34 Hemophilia has worldwide distribution Bloom syndrome, Diamond-Blackfan syndrome.31 and affects all ethnic groups. The overall incidence The onset of aplastic anemia is usually insidious of hemophilia A is about 1 case per 10,000 births (1 and usually presents with symptoms related to in 5,000 male births), with about one third of anemia, thrombocytopenia or signs of infection. affected individuals does not have family history of Pallor, headache, palpitation, dyspnea, fatigue are hemophilia A. On the other hand, hemophilia B the symptoms of anemia. Gingival bleeding, pur- occurs in about 1 in 50,000 births. Hemophilia B is pura, ecchymoses or petechial rashes occur due to relatively less frequent than hemophilia A. Of all thrombocytopenia. hemophilia cases, 80-85% is hemophilia A, 14% is hemophilia B and the rest are various other clotting Leucopenia, especially neutronpenia leads to mouth abnormalities. or pharyngeal ulceration, recurrent or overt infections with fever. Presence of lymphadenopathy Among the genetic coagulation disorders, or organomegaly as well as immature red or white hemophilia A is the most frequent X-linked cells in the peripheral blood film excludes the mendelian disease and second most common diagnosis of aplastic anemia.32 Patient should also coagulation disorder after Von Willebrand disease. be searched for the presence of hyperpigmentation, Others type of hemophilia include hemophilia C short stature, malformations of the thumb and which is due to deficiency of FXI and para- forearms, skeletal anomalies, small head or eyes, hemophilia due to deficiency of FV.37, 38 As hemo- renal problems, hearing defect, heart disease, philia A and B are both X-lined recessive disorders, gastrointestinal difficulties and hypogonadism.31 females are rarely severely affected. Some females Aplastic anemia is diagnosed by blood and bone with non-functional gene on one of the X chromo- marrow studies. Peripheral blood examination some may be mildly symptomatic. In both hemo- usually shows pancytopenia or bicytopenia and philia A and B, spontaneous bleeding may occur bone marrow biopsy including aspiration is done to with normal bleeding and prothrombin time but a assess the cellularity of the bone marrow. Usually a prolonged partial thromboplastin time. Clinically hypoplastic marrow is found in aplastic anemia. hemophilia is classified as mild when factor activity Cytogenetic study and flow cytometric analysis of is >5–40%, moderate when 1–5% and severe when factor activity is <1%. Patients with severe hemo- the bone marrow should be done to find out the philia presents with bleeding in the joints and genetic factors as well as the presence of PNH in soft-tissue without precipitating clone.24 Therapy for aplastic anemia consists of trauma. Severe disease is more common in children supportive care only or immunosuppressive less than 1 year and comprises 40-75% of hemo- therapy or hemopoietic stem cell transplantation philia A cases. Children between 1 and 2 years (HSCT). Severe aplastic anemia and very severe usually present with moderate disease and are aplastic anemia are hematologic emergency as they about 18-28% of cases. Mild disease occurs in have a mortality rate of greater than 70%. Therefore, children over than 2 years and accounts for 15-31% 33 treatment should be initiated immediately. of cases.39 Patients with severe hemophilia present Gingival bleeding, absence of lympadenopathy and with manifestations of neonatal bleeding (e.g., after organomegaly in this case supports the diagnosis of circumcision). Few neonates may have intracranial acquired aplastic anemia but absence of congenital hemorrhage. However, most neonates may present abnormalities, fever, symptoms of anemia and with severe hematoma and prolonged bleeding normal peripheral blood findings are the points from the cord or umbilical area. Just after neonatal against both acquired and congenital aplastic period, bleeding is infrequent in until they anemia. become toddlers, when injury-induced soft-tissue hematoma occurs. Hemophilia During teeth eruption, old children may also Hemophilia is mainly an inherited genetic disorder experience oral bleeding. It is really problematic for that hampers the capability of the body to make the concerned physicians to manage bleeding from blood clot that is needed to stop bleeding.34, 35 A gum and tongue lacerations because blood oozing deficiencies or abnormality of a single plasma may continue in spite of adopting supportive 172 BSMMU J 2018; 11: 168-179

measures. As the time passes and hemophilic injection. vitamin K injection in the form of phyto- patients mature and begin to take part in various nadione (VK1) may be administered intravenously/ physical activities, hemarthroses and intramuscularly in a dose of 1-25 mg in case of adult occur. If joint bleeding occurs recurrently, chronic and 0.5 to 1 mg in case of .49 Gum bleeding arthropathy usually complicate in a target joint. following trauma is the only symptom in this Treatment of patients with hemophilia involves patient that may be considered as a feature of preventive and supportive measures, management but absence of prematurity of bleeding episodes, treatment of FVIII inhibitors, and no history of bleeding from the umbilical if developed and treatment and rehabilitation of stump after delivery as well as normal prothrombin hemophilic arthropathy.40 The presence of oral time are the features that nullify the diagnosis of bleeding in this girl is in favor of the diagnosis of vitamin K deficiency. hemophilia but sex of the patient, absence of Dr. Maksuda Begum (Pediatrician): I received the bleeding disorders in the family as well as the patient on 7th February 2018 as a referred case from absence of hemorrhage characteristic of hemophilia a secondary level military hospital, Chattogram, disfavor the diagnosis of hemophilia. Bangladesh in a stable state with the past history of Vitamin K deficiency excessive prolonged bleeding from the upper labial frenum following minor trauma got during playing. Vitamin K is an important lipid-soluble vitamin The patient was thoroughly evaluated and which takes part in the vitamin K cycle for the reviewed all clinical and physical findings as well as production of vitamin K-dependent coagulation laboratory investigations done in the military factors. Green, leafy-vegetables and oils such as hospital, Chattogram. As the patient had no clinical soybean, cottonseed, canola and olive oils are the and physical findings at present, therefore I advised rich sources of vitamin K but colonic bacteria also to repeat the complete blood count with PBF, synthesize it.41 Four coagulation factors (FII, FVII. bleeding time, clotting time, prothrombin time, FIX, FX) in the liver are synthesized with the help of activated partial thromboplastin time, factor VIII VK. Production of protein C and S, which are and vWF:Ag assay. On 8th February 2018, I got the anticoagulant proteins, also depends on vitamin investigation reports which are shown in Table I. K.42 The etiology of vitamin K deficiency differs in Analyzing the results of laboratory investigations as infants and adults. In infants, the notable cause is well as the initial patient’s clinical findings I arrived liver prematurity, lack of vitamin K in breast milk, at a diagnosis of Von Willebrand disease. At the sterile guts in neonates and low transplacental same time, to find out from which type of Von transfer of vitamin K.43-46 Neonatal cholestasis Willebrand disease the patient has been suffering, I leading to malabsorption of vitamin K can also advised to perform Ristocetin Induced Platelet result in vitamin K deficiency.42 In adults, mal- aggregation (RIPA) studies, Ristocetin cofactor absorption syndrome, infectious diarrhea, paren- activity (VWF:RCo), collagen binding activity chymal liver disease, inflammatory bowel disease, (VWF:CB) and Von Willebrand factor gene cholestatic disease, malnutrition, chronic illness, mutation. prolonged parenteral nutrition, massive transfusion and multiple abdominal surgery are the etiologies of vitamin K deficiency.47 No age is immune for the development of vitamin K defi-ciency but infants Dr. Aziz’s Diagnosis are most commonly affected.42 Infants younger than Von Willebrand disease 5 days may develop vitamin K deficiency without bleeding manifestation. The prevalence of typical hemorrhagic disease of newborns and infants due to vitamin K deficiency is 0.3-1.7%.48 Discussion The presenting clinical features are related to Dr. Rahman: Von Willebrand disease is a congenital and hemorrhage is the main coagulation disorder caused by the deficiency of clinical symptom, especially in response to minor synthesis of defective Von Willebrand factor. As a trauma. Any parts of the body may be involved but result, the primary hemostatic defect ensues due to the prime presentations are mucosal and defective interaction between the platelets and the submucosal bleeding such as gum bleeding, vessel walls.50 Von Willebrand factor is a large epistaxis, hematoma, hematemesis, melena, menorr- multimeric glycoprotein, circulates in plasma at a hagia, hematuria and oozing from the venipuncture concentration of 10 mg/dL and carries FVIII in a sites or umbilical stump. Treatment of vitamin K non-covalently bound complex. Von Willebrand deficiency depends on the severity of associated factor plays vital roles in the synthesis, action, bleeding, underlying disease state and risk of stabilization, conformation and immunogenicity of inducing a local hematoma at the vitamin K injec- FVIII.51 Von Willebrand factor is released from the tion site. In life threatening bleeding, fresh frozen storage granules in platelets and endothelial cells in plasma should be administered before vitamin K response to various stimuli such as stress, estrogens, BSMMU J 2018; 11: 168-179 173 , malignancy and thyrotoxicosis that ADAMTS -13 is responsible for type 2A disease. cause endothelial activation. Homozygous or heterozygous mutations in Von Willebrand factor gene may result in defective Two main functions of the Von Willebrand factor multimer assembly preventing multimerization of are: a) It mediates the adhesion of platelets to the Von Willebrand factor in the Golgi apparatus. As a site of traumatized blood vessels and b) it fixes and result, there is selective loss of large and medium- stabilizes the FVIII, thereby preventing its degrada- sized multimers leading to decreased Von tion. The plasma half-life of FVIII in presence of Willebrand factor mediated platelet adhesion.58 normal Von Willebrand factor concentration is 12 Type 2B is characterized by the loss of large hours but in the absence of the factor, the half-life of multimers. Multimer