J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

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Case Report

Volume 2, Number 3, June 2011, pages 132-137

Acquired Factor V Inhibitor Developing After Percutaneous Ethanol Injection Therapy for Hepatocellular Carcinoma

Figure 1. Plain abdominal CT image of the patient after PEIT. A low density SOL in deep S8 region where ethanol was injected, along with another SOL in S1 with residual ethiodized oil (Lipiodol^®) was observed.

Figure 2. Clinical course. PT-INR was suddenly elevated 26 days after PEIT. Blood Hb levels decreased after PEIT, then stayed in 10 - 12 g/dL by additional administration of darbepoetin, although transient hematochezia had been complained on the 112th day after PEIT. The activity of factor V inhibitors was not identified (0 BU/mL) on the 157th day after PEIT.

Figure 3. Cross-mixing test. Each PT was measured by adding the indicated amount of normal plasma to the sample obtained from the case with and without incubation.

Figure 4. Possible pathogenic mechanism of factor V inhibitors. In addition to the possibilities reported previously [2-5, 12], ethanol in this report was described as an intrinsic causative agent.

**Table 1.** Laboratory Findings of the Case
Blood Chemistry		CBC
All results were obtained 29 days after PEIT.
TP (g/dL)	6.2	WBC (/µL)	3410
Alb (g/dL)	2.6	RBC (x 10⁴/µL)	284
BUN (g/dL)	53	Hb (g/dL)	9.7
Cr (mg/dL)	2.95	Hct (%)	28.1
Na (mEq/L)	138.8	Plt (x 10⁴/µL)	11.5
K (mEq/L)	4.19	Neutrophil (%)	59.0
Cl (mEq/L)	104.5	Lymphocyte (%)	25.2
ALP (U/L)	122	Basophil (%)	0.6
AST (U/L)	50	Eosinophil (%)	2.3
ALT (U/L)	24	Monocyte (%)	12.9
LDH (U/L)	219	PT-INR	4.84
γGTP (U/L)	91	APTT (sec)	110.4
Choline Esterase (U/L)	43	AFP (ng/mL)	25.3
CPK (U/L)	63	CA19-9 (U/mL)	91.4
Total Bilirubin (mg/dL)	0.51

Table 1. Laboratory Findings of the Case

Blood Chemistry

CBC

All results were obtained 29 days after PEIT.

TP (g/dL)

6.2

WBC (/µL)

3410

Alb (g/dL)

2.6

RBC (x 10⁴/µL)

284

BUN (g/dL)

Hb (g/dL)

9.7

Cr (mg/dL)

2.95

Hct (%)

28.1

Na (mEq/L)

138.8

Plt (x 10⁴/µL)

11.5

K (mEq/L)

4.19

Neutrophil (%)

59.0

Cl (mEq/L)

104.5

Lymphocyte (%)

25.2

ALP (U/L)

122

Basophil (%)

0.6

AST (U/L)

Eosinophil (%)

2.3

ALT (U/L)

Monocyte (%)

12.9

LDH (U/L)

219

PT-INR

4.84

γGTP (U/L)

APTT (sec)

110.4

Choline Esterase (U/L)

AFP (ng/mL)

25.3

CPK (U/L)

CA19-9 (U/mL)

91.4

Total Bilirubin (mg/dL)

0.51

**Table 2.** Laboratory Findings Related to Coagulation
Parameters
All parameters were obtained 4 days after transfusion of 4 units of fresh frozen plasma (34 days after PEIT). FDP: fibrin degradation product; BU: Bethesda unit.
PT INR	4.34
APTT (sec)	111.0
Fibrinogen (mg/dL)	222
FDP (µg/mL)	< 2.5
Thrombotest INR	1.18
Hepaplastin test (%)	64.9
PIVKA II (µg/mL)	15
Anti-cardiolipin Ab IgG (U/mL)	< 8
Anti-cardiolipin Ab IgM (U/mL)	< 5
Factor V inhibitor (BU/mL)	30
Protein S activity (%)	25
Protein C activity (%)	75

Table 2. Laboratory Findings Related to Coagulation

Parameters

All parameters were obtained 4 days after transfusion of 4 units of fresh frozen plasma (34 days after PEIT). FDP: fibrin degradation product; BU: Bethesda unit.

PT INR

4.34

APTT (sec)

111.0

Fibrinogen (mg/dL)

222

FDP (µg/mL)

< 2.5

Thrombotest INR

1.18

Hepaplastin test (%)

64.9

PIVKA II (µg/mL)

Anti-cardiolipin Ab IgG (U/mL)

< 8

Anti-cardiolipin Ab IgM (U/mL)

< 5

Factor V inhibitor (BU/mL)

Protein S activity (%)

Protein C activity (%)

**Table 3.** Activities of the Coagulation Factors
	I	II	III	IV	V	VII	VIII	IX	X	XI	XII	XIII
Coagulation factors involved in the examinations (PT and APTT) and the diseases (liver dysfunction, vitamin K deficiency and factor V inhibitors) are depicted as a closed circle. The activity (%) of each coagulation factor in the reported case is described in the bottom.
PT	•	•	•		•	•			•
APTT	•	•			•		•	•	•	•	•
Liver dysfunction	•	•			•	•		•	•	•	•
Vit K deficiency		•				•		•	•
Factor V inhibitors					•
This case (% activity)	―	12	―	―	0	41	48	16	43	13	29	144

Table 3. Activities of the Coagulation Factors

III

VII

VIII

XII

XIII

Coagulation factors involved in the examinations (PT and APTT) and the diseases (liver dysfunction, vitamin K deficiency and factor V inhibitors) are depicted as a closed circle. The activity (%) of each coagulation factor in the reported case is described in the bottom.

•

APTT

•

Liver dysfunction

•

Vit K deficiency

•

Factor V inhibitors

•

This case (% activity)

―

144