University of Sharjah

Hematology II
 Chapter 24
Disorders of Hemostasis and Thrombosis:
Just to recap:
• Hemostatsis:
– stops bleeding when a blood vessel is injured 
preventing s blood loss through an intact blood vessel
– prevents excessive clotting (thrombosis) formation.
• Hemostatic disorders:
– Bleeding disorders (hemorrhage)
– thrombotic disorders
 Bleeding Disorders
• Type of bleeding may indicate the defective
component of the hemostatic mechanism.
• Defective primary hemostasis usually results in
bleeding from skin or mucous membranes (e.g. nose).
• Bleeding symptoms in patients with coagulation factor
abnormalities are usually internal & commonly involve
deeper tissues and joints.
 Terminology
Capillary bleeding  leads to
Petechiae, which are
• Small red-purple spots on skin; <3mm in
diameter involving extremities because
of the high venous pressure.
• Poor capillary integrity allows
erythrocytes to leak out of capillary
beds into tissue.
• Petechiae close together may merge into
a larger bruise area known as purpura.
• Petechial lesions are characteristic of
abnormalities in platelets and blood
vessels; not common in coagulation
factor disorders.
In certain situations purpura may be palpable. In all situations,
petechiae, ecchymoses, and purpura do not blanch when pressed
and usually they are spontaneously
Bleeding from vessels  leads to
Ecchymoses, which are bruises that
are >3mm (1-2 cm) in diameter
• Caused by blood escaping through
endothelium and subcutaneous tissue
from vessels larger than capillaries.
• Red-purple when first form  turn
yellowish-green as Hb is converted to
bilirubin  brownish as bilirubin is
converted to hemosiderin.
• May arise spontaneously or with
trauma; may also occur due
abnormalities in blood vessels,
platelets, or coagulation factors.
Hematoma
• Bruises that occur when blood leaks from
an opening in a vessel & collects beneath
intact skin or other organ.
• Blue-purple in color, slightly raised, occurs
in any organ/tissue & may be in the form
of a clot.
Purpura
• Name = purple
• Generally refers to both petechiae &
ecchymoses (hemorrhage into skin, mucous
membrane, & internal organs).
• Purpura is used as part of the name of
diseases in which these typical symptoms
occur.
• When ecchymoses and petechiae are found
in greater than normal numbers and with
less than usual trauma, the condition is
termed “easy bruisability”
A. VASCULAR DISORDER
• Hemorrhage from microcirculation into the skin, mucous
membrane & internal organs surfaces  Purpura.
• First appears as red areas then turns purple or yellow-brown.
• If platelet numbers are normal, likely cause of purpura is damage
to blood vessels = Nonthrombocytopenic purpura resulting from:
1. direct damage to endothelial cells (mechanical damage, toxics, drugs,
insect bites, or immunological damage).
2. damage to connective tissue (diabetes, senile purpura, high doses of
corticosteroid therapy).
3. decreased mechanical strength of microcirculation (scurvy, bleeding
gum).
4. paraprotein disorders (multiple myeloma, Waldenstrom’s
macroglobulinemia, amyloidosis).
5. mechanical disruption of small venules (around ankles after prolonged
standing).
6. abnormal intravascular coagulation  formation of micro thrombi.
7. vascular malignancy (Kaposi’s sarcoma and vascular tumors).
Laboratory Investigations of Vascular Disorders
• Diagnosis of blood vessel disorders is most often made by
exclusion  finding no positive evidence for a disorder of
platelets, coagulation factors, or fibrinolysis.
• Screening tests of bleeding disorders may include:
– Platelets Count: Normal
– PT: Normal
– APTT: Normal
– Bleeding Time: Abnormal, early case (normal)
– Tourniquet Test (Rumpel-Leede Capillary-Fragility Test) which
involves the application/inflation of a blood pressure cuff to the
midpoint between systolic & diastolic blood pressures for 5 min:
test is positive if there are more than 10-20 petechiae/square
inch.
B. PLATELETS ABNORMALITIES
Characteristic manifestations of excess bleeding seen in
patients with platelets disorders may include:
– Petechiae
– Excess bleeding from superficial area of the body such
as skin and mucous membranes
– Epistaxis (nose bleeding)
– Easy bruisability
– Gingival bleeding (gums)
• It is either qualitative (functional) or quantitative
(thrombocytopenia or thrombocytosis)
Qualitative (Functional) Platelet Disorders
• Remember: primary hemostasis (1ry plug formation)
involves platelets adhesion, aggregation, release of ADP
& generation of TXA2.
• Abnormalities in any of the above  defective formation
of primary plug and abnormal bleeding.
• Screening tests include:
– Platelet count: Normal
– Bleeding time: Prolonged
– PT: Normal
– PTT: Normal
Could be hereditary or acquired
Disorders of Platelets Function
Hereditary Disorders of Platelets Function
1. Bernard-Soulier syndrome:
– Defective platelet adhesion function due to hereditary deficiency of GPIb
– Rare, autosomal recessive.
– Characterized by very large platelets (Giant Platelets syndrome).
– Bleeding time: Prolonged
– Platelets aggregation test: normal with ADP, collagen and epinephrine
2. Glanzmann’s Thrombasthenia
– A disorder of platelets aggregation function due to hereditary deficiency
of GP IIb/IIIa
– Rare autosomal recessive
– Bleeding time: Prolonged
– Platelets aggregation test: abnormal with ADP, Collagen, and epinephrine
3. Disorders of platelets secretions (storage pool disease)
– Defects in the mechanism of release from granules or membranes. 
common examples: defective TXA2 synthesis & Gray platelets syndrome
(lack of α-granules  appearance of agranular plts on peripheral blood
smear).
– Bleeding time: prolonged
– Platelets aggregation: Normal with ADP, collagen and epinephrine
Acquired causes of platelet dysfunction
• Uremia
Bleeding is caused by accumulation of waste products in circulation
mainly affects the function of vWF.
Bleeding time: prolonged
Platelets aggregation test: Decreased
• Hematologic Disorders
• Acute leukemia: defective aggregation of platelets
• Multiple myeloma
• Drugs
• Aspirin: prevent the synthesis and release of TXA2  prevents
platelet aggregation and adhesion. Aspirin intake should be stopped
for 7 days before BT is tested.
• Alcohol: ingestion of large quantities of alcohol over a long period of
time may lead to platelet dysfunction as alcohol consumption
inhibits prostaglandin synthesis
• Antibiotics: penicillin and cephalosporine coats platelet membrane 
block ADP and epinephrine receptors  alter platelet aggregation
function.
Abnormal Platelet Morphology
a. Wiskott-Aldrich syndrome: an X-linked disorder
characterized by production of very small platelets and
thrombocytopenia.
b. May-Hegglin anomaly: Very large platelets
c. Alport’s syndrome: Giant platelets and thrombocytopenia
Quantitative platelet disorders
• Normal range of platelets is 150-450X 109/L
• Disorders of platelets count include thrombocytopenia or
thrombocytosis.
(i) Thrombocytosis
• occurs when platelets count exceeds 450 X 109/L.
• Causes of thrombocytosis include:
– Chronic blood loss
– Chronic inflammatory conditions
– Chronic infection
– Malignancies
– Myeloprolifrative disorders
– Autoimmune hemolytic anemia
(ii) Thrombocytopenia
Lab Tests include:
• Platelets count: Decreased
• Bleeding time: prolonged (depending on count)
• PT and PTT: Normal
Causes of thrombocytopenia:
1. Increased destruction in peripheral blood resulting from:
A) Immune mechanisms:
– Idiopathic thrombocytopenic purpura (ITP)
– alloimmune thrombocytopenia (neonatal and blood transfusion)
B) Nonimmune mechanism(consumption): Disseminated intravascular
coagulation (DIC), Thrombotic thrombocytopenic purpura (TTP), and
hemolytic uremic syndrome.
2. Decreased platelet production resulting from:
1. Chemotherapy and radiation therapy of malignant disease
2. Aplastic anemia
3. Myelodysplastic syndrome
4. Leukemias and lymphomas
5. Megaloblastic anemia
6. Wiscott-Aldrich syndrome
7. May-Hegglin anomaly
3. Disorder of platelet distribution & dilution.
• Defined as excessive pooling of platelets in spleen (Splenic
Sequestration).
• Normally, 30-45% of total circulating platelet pool is sequestered in
spleen  can be readily mobilized when needed.
• In conditions associated with splenomegaly, 50-90% of platelets may
be sequestered. For example, Gaucher disease (an LSD ? due to
deficiency in glucosylceramidase ), thrombocytopenia is secondary to
hypersplenism/ splenomegaly.
Pseudothrombocytopenia or spurious thrombocytopenia is an in-
vitro sampling problem which may mislead the diagnosis towards the more
critical condition of thrombocytopenia.
• Typically caused by EDTA-dependent platelet aggregation (change the
anti coagulant)
• platelet counts reported by automated counters may be much lower
than the actual count in the blood because these devices cannot
differentiate platelet clumps from individual cells.
C. DISORDER OF COAGULATION FACTORS
• Arise either by inheritance of a defective gene, or by the
acquisition of a deficiency secondary to another
condition.
• In the inherited disorders, the genetic defect causes either
the failure of synthesis of one of the proteins or the
production of a defective protein.
• Rate of fibrin formation is slow &/or ineffective  patient
may experience abnormal bleeding.
Clinical Symptoms:
• Bleeding from small arterioles into deep muscular tissues and
joints.
• Hematoma is common
• Ecchymoses
• Petechiae not usually seen in secondary hemostasis (common
in primary hemostasis)
• GI bleeding
• Hematuria and hypermenorrhea

Laboratory screening tests:

Platelets, PT, PTT, thrombin time (TT), coagulation factor assay,
fibrinogen levels, D-dimer tests, and anti-thrombin levels.
Hereditary disorders of secondary Hemostasis

• Inherited as: autosomal dominant, x-linked recessive, or

autosomal recessive disorders.
• Inherited coagulation factor disorders usually involve a
single coagulation protein.
• Common examples include:
– VWD
– Hemophilia (due to factor VIII, IX, or XI)
– Fibrinogen (Factor I) Deficiency
vWF deficiency:
• vWF is synthesized in megakaryocytes or endothelial cells.
• When secreted from activated platelets or exposed endothelial
tissue, it binds with factor VIII in plasma forming VIII/vWF
complex.
• In primary hemostasis, vWF enhances platelets adhesion by
serving as a bridge between receptors on activated platelets
and exposed collagen of injured vessel.
• In secondary hemostasis, it complexes with and stabilizes
circulating coagulation factor VIII in plasma.
vWFD (cont)

• Deficiency of vWF is inherited as autosomal dominant

(chromosome 12)  qualitative or quantitative defects in vWF.

• It is the most common inherited bleeding disorder

(125cases/million).

• Patients with VWFD have an altered primary and secondary

hemostasis functions.

• Levels of circulating factor VIII are reduced in a manner

proportional to reduction of vWF.

* Plasma of type B blood group has up to twice the vWf as type O

plasma, WHY?
Effect of O blood group on bleeding disorders
• The ABO antigen is also expressed on the von
Willebrand factor (vWF) glycoprotein.
• Having type O blood predisposes to bleeding (30% ) of
total genetic variation observed in plasma vWF is
explained by the effect of the ABO blood group).
• Individuals with group O blood normally have
significantly lower plasma levels of vWF (and Factor
VIII) than do non-O individuals.
• vWF is degraded more rapidly due to higher prevalence
of blood group O with the Cys1584 variant of vWF (an
amino acid polymorphism in VWF):
Classification of vWFD
• VWFD is classified into three major categories depending on
whether the patient has a quantitative or a qualitative defect.
Type 1:
• Most common type (70-80%); known as the classic type.
• Mild form of vWFD because of partial quantitative deficiency
with normal structure and function
Type 2:
• Qualitative disorder of various kinds of functionally abnormal
vWF; mainly affects platelet adhesion function.
Type 3:
• Very rare
• A severe type of disease that is characterized by an absolute
absence of vWF in platelets and plasma.
Clinical findings
• Variability is a hallmark of VWFD; severity of bleeding symptoms
differs in individuals within the same family members and within
same individual at different times.
• Symptoms may not begin until second decade of life or begin early in
life.
• Severity of bleeding disorders in VWFD depends on the inheritance
pattern (being heterozygous or homozygous).

Bleeding features may include:

• Hemorrhage in mucosal and cutaneous tissues.
• Epistaxis
• Hypermenorrhea
• Bleeding after dental extraction
• Gingival bleeding and easy bruising
Laboratory Findings in vWFD:

• Platelets: normal
• Platelets aggregation: Normal
• Bleeding time: increased
• APTT: normal or increased
• PT: Normal
• Thrombin time: Normal
• Factor VIII assay: Decreased
• Factor IX assay: Normal
• vWf assay: Decreased
Hemophilia
Mutations in CF genes on X chromosome(IX,VIII) ; grouped into 3 different
types.
Hemophilia A
• Deficiency of factor VIII
• Patients have normal circulating level of vWf  normal bleeding time and
normal platelets adhesion function.
• Abnormal bleeding is caused by delayed / inadequate fibrin formation.
• More common than hemophilia B (>70% of hemophilia)
Hemophilia B
• Deficiency of factor IX.
• The VIII/vWf complex is intact  normal primary hemostatic plug.
• Less common than hemophilia A (<30%)
 Hemophilia C

• Deficiency of factor XI
• Mostly seen in Jewish people.
• it has autosomal recessive inheritance, since the gene
for factor XI is located on chromosome 4 (close to the
prekallikrein gene); and it is not completely recessive.
Clinical Aspects of Hemophilia
• Severity of diseases varies with amount of factor present. (Severe-
Mild)
• In severe cases, bleeding may begin at time of circumcision.
• Hemarthrosis (bleeding into joints) is most common feature in severe
cases  blood fills joints leading to inflammation & destruction of
joints which manifests as child starts to walk; hemarthrosis is not
seen in moderate & mild cases.
• excessive bleeding after traumatic injury is characteristics of
moderate -mild hemophilia
• Subcutaneous hematomas causing purple discoloration of the skin.
• Hematuria and bleeding after dental extraction.
• Epistaxis is rare in hemophilia

• Most common cause of death: intracranial hemorrhage, which may

occur spontaneously or after trauma.
Laboratory Evaluation of the Hemophilia

• Platelets count: Normal

• Bleeding time: Normal
• Platelets aggregation test: Normal
• PT: Normal
• APTT: Increased in all types
• Factor VIII assay: Decreased in hemophilia A
• Factor IX: Decreased in hemophilia B
• vWf assay: Normal in both.
• APTT: Prolongation is inversely related to plasma levels of factor
in question. For levels below the sensitivity of test (<20 U/dL for
factor IX and <30 U/dL for factor VIII), APTT will be prolonged.
Fibrinogen (Factor I) Deficiency

• There are 2 autosomal recessive forms of fibrinogen deficiency:

– Afibrinogenemia is the homozygous form of the disease in
which levels of fibrinogen is close to nil (< 5mg/dL).
– Hypofibrinogenemia is a heterozygous form in which plasma
levels of fibrinogen are between 20 and 100 mg/dL (normal.
range = 200-400 mg/dL).
• A third form (dysfibrinogenemia) is inherited as autosomal
dominant.
• Abnormalities may include abnormal polymerization of fibrin
monomers, defective cross-linking of fibrin monomer, or both.
• >50% of patients have no bleeding symptoms or other clinical
manifestations.
Factor I deficiency (Cont.)

Lab Investigations Platelets PT APTT TT Fib A

Count

Afibrinogenemia N A A A Absent

Hypofibrinogenemia N N N A decreased

Dysfibrinogenemia N N N A Variable

N = Normal, A = abnormal
Miscellaneous Coagulation Factor Deficiencies

• Prothrombin (Factor II) Deficiency

– Extremely rare; autosomal recessive
– PT & PTT are prolonged
– TT and BT are normal
• Factor V deficiency
– Very rare; autosomal recessive
– PT and PTT are prolonged.
– TT normal
• Factor VII deficiency
– A very rare autosomal recessive disease, only 150 cases
have described.
• Factor XI deficiency
– Is the fourth most common inherited bleeding disorder
Acquired Disorders of Secondary Hemostasis

• More common than hereditary ones.

• Characterized by multiple factor defects, bleeding from more
than one site, & deficiency in naturally occurring inhibitors.
• Include the following categories:
– Disseminated intravascular coagulation
– Liver disease
– Vitamin K deficiency
– Acquired pathologic inhibitors.
1. Disseminated Intravascular Coagulation (DIC)
• A condition in which normal balance of hemostasis is altered
• Clot formation and lysis within blood vessels are out of control
& faster than normal.
• Leads to ↑ consumption of clotting proteins & naturally
occurring inhibitors and platelets.
• Consequences:
– acquired deficiency in multiple hemostatic components,
– formation of excess amounts of FDP  excessive
fibrinolysis.
– patients begins to bleed while disseminated clotting is taking
place.
Incidence of DIC:
– Frequency is 1/1000 hospital patients
– 20% of cases are asymptomatic
– Occurs mostly in the very young and in the elderly
Etiology of DIC :
1. Infection: bacterial, viral fungal, protozoal
2. Complications of pregnancy
3. Neoplasms (malignancies)
4. Massive tissue injuries (burns, trauma, head injury,
extensive surgery)
5. Vascular injury
6. Miscellaneous (snake bite, heat stroke)
Pathophysiology of DIC
• Injured/inflamed tissues release TF to blood where it initiates platelet
adhesion & aggregation and activates fibrin formation through the
extrinsic pathway.
• Cytokines (IL-1 and IL-6) released into tissue in response to infection
activate endothelial cells leading to release of more TF & contact
factors  activation of intrinsic pathway.
• Net result = formation of thrombin within the circulation 
generalized/systemic activation of coagulation.
• The unregulated expression of thrombin leads to consumption of
fibrinogen, factor V, VIII and XIII (natural substrates of thrombin), as
well as depletion of prothrombin.
• Thrombin is a potent agonist of platelets activation, adhesion ,and
aggregation.
• Thrombin activates conversion of plasminogen to plasmin triggering
aggressive fibrinolysis.
• As plasmin is generated plasminogen is depleted; coagulation inhibitors
like AT-III, proteins C & S are consumed in DIC
Laboratory Evaluation of DIC
• Diagnosis of DIC is primarily made by the physician based on clinical
symptoms.
• No single test can establish definitive DIC diagnosis, nor any combination of
tests are specific for DIC.
• Laboratory tests are ordered only to confirm suspected clinical diagnosis.
Screening tests include:
• Platelets: Decreased
• PT: Increased
• PTT: Increased
• TT: Increased
• Fibrinogen: Decreased
• D-dimer: Increased
• Plasminogen: Decreased
• Antithrombin III: decreased
• Protein C: varies
• Protein S: varies
• Blood Film: Schistocytes
2. Liver disease
• Liver disease affects all hemostatic functions (fibrin
formation, fibrinolysis, and inhibitors).
• This is because almost all hemostatic factors are made in
liver
• Normally, liver macrophages remove activated factors
and products of activation, such as FDP and plasminogen
activators.
• When liver is diseased, these functions are diminished.
• Laboratory tests in liver disease are mostly similar to DIC.
3. Vitamin K Deficiency
• Vitamin K is needed by hepatic cells for synthesis of
factors: II, VII, IX, and X and protein C and S.
• Sources of vitamin K include green vegetables in diet,
and synthesis by bacteria in the GI tract.
• Deficiency of vitamin K results in induced functional
deficiencies of all such proteins.
• Causes of vitamin K deficiency include malabsorptive
syndromes, prolonged broad-spectrum antibiotic therapy.
• Vitamin K administration corrects the deficiency within
24 hours.
Lab findings in vitamin K deficiency
• Platelets: Normal
• PT: Increased
• PTT: Increased
• TT: Normal
• Fibrinogen: Normal
• D-dimer: Normal
• Plasminogen: Normal
• Antithrombin III: Normal
• Protein C: Decreased
• Protein S: Decreased
4. Acquired Pathologic Inhibitors

• Acquired inhibitors of blood coagulation

(circulating anticoagulants) often appear in
patients with certain disease states but could
arise without an underlying condition.
• All inhibitors are immunoglobulins, either IgG
or IgM or both, and can be either
alloantibodies or autoantibodies.
a. Inhibitors of Single factors

• With the exception of antibodies to factors VIII and IX, they

are extremely rare.
• Inhibitor to factors VIII and IX are mostly associated with
hemophilias.
• 15% to 20% of hemophilia A develops alloantibodies against
factor VIII
• Only 1% to 3 of hemophilia B develops alloantibodies to
factor IX.
• Inhibitors to factor VIII are also could be found in
nonhemophilic patients (autoantibodies):
Examples include: elderly males, females during pregnancies,
auotimmune diseases, lymphoproliferative diseases and multiple
myeloma.
b. Lupus Anticoagulant
• Lupus anticoagulant (LA); first discovered in patients with SLE;
~6-16% of patients with SLE develops LA.
• LA is also found in other autoimmune disorders, neoplasias,
certain infections, and administration of certain drugs such as
procainamide.
• LA is a family of autoantibodies (IgG or less commonly IgM)
specific for phospholipids
• LA antibody binds the phospholipids surface of test reagents used
in APTT and occasionally the PT  prolonging the test results.
• LA is just a laboratory phenomenon; it doesn’t associate with
clinical bleeding symptoms; however, 30-40% of affected
patients demonstrate thrombosis.
Lab Findings in Lupus Anticoagulant

• Platelets: Normal
• PT: Increased
• PTT: Increased
• TT: Normal
• Fibrinogen: Normal
• D-dimer: Normal
• Plasminogen: Normal
• AT-III: Normal
• Protein C: Normal
• Protein S: Normal
 Antiphospholipid syndrome
• or antiphospholipid antibody syndrome (APS or APLS) is
an autoimmune, hypercoagulable state caused by antiphospholipid
antibodies.
• APS provokes blood clots (thrombosis) in both arteries and veins as well
as pregnancy-related complications such
as miscarriage, stillbirth, preterm delivery, and severe preeclampsia.
• antiphospholipid antibodies (anticardiolipin antibodies and lupus
anticoagulant) react against proteins that bind to anionic phospholipids
on plasma membranes.
• Diagnosis:
1. (lupus anticoagulant) .
2. solid phase ELISA assays (anti-cardiolipin antibodies).