Phenotypical variability in congenital FVII deficiency follows the ISTH-SSC severity classification guidelines: a review with illustrative examples from the clinic
Received 20 November 2017
Accepted for publication 17 April 2018
Published 19 November 2018 Volume 2018:9 Pages 211—218
Checked for plagiarism Yes
Review by Single-blind
Peer reviewers approved by Ms Justinn Cochran
Peer reviewer comments 2
Editor who approved publication: Dr Martin Bluth
Shilpa Jain,1,2 Jennifer Donkin,3 Mary-Jane Frey,4 Skye Peltier,5 Sriya Gunawardena,6 David L Cooper6
1Hemophilia Center of Western New York, Buffalo, NY, USA; 2Department of Pediatrics, Division of Pediatric Hematology-Oncology, John R. Oishei Children’s Hospital, University of Buffalo, Buffalo, NY, USA; 3Hemostasis and Thrombosis Center, Children’s Hospital Los Angeles, Los Angeles, CA, USA; 4Children’s Hospital of Michigan, Detroit, MI, USA; 5Center for Bleeding and Clotting Disorders, University of Minnesota, Minneapolis, MN, USA; 6Clinical Development, Medical and Regulatory Affairs, Novo Nordisk Inc., Plainsboro, NJ, USA
Background: One of the most common rare inherited bleeding disorders, congenital factor VII (FVII) deficiency typically has a milder bleeding phenotype than other rare bleeding disorders. Categorizing severity in terms of factor activity associated with hemophilia (severe <1%, moderate 1%–5%, mild 6%–40%) has led to the observation that bleeding phenotype does not follow closely with FVII activity. Over the past decade, large-scale global registries have investigated bleeding phenotype more thoroughly. The International Society on Thrombosis and Haemostasis has reclassified FVII deficiency as follows: severe, FVII <10%, risk of spontaneous major bleeding; moderate, FVII 10%–20%, risk of mild spontaneous or triggered bleeding; mild, FVII 20%–50%, mostly asymptomatic disease.
Case reports: Eleven illustrative cases of congenital FVII deficiency adapted from clinical practice are described to demonstrate the variability in presentation and in relation to FVII activity levels. Severe FVII deficiency usually presents at a young age and carries the risk of intracranial hemorrhage, hemarthrosis, and other major bleeds. Moderate FVII deficiency tends to present later, often in adolescence and particularly in girls as they reach menarche. Milder disease may not be apparent until found incidentally on preoperative testing, during pregnancy/childbirth, or following unexplained bleeding when faced with hemostatic challenges.
Conclusion: It is important for health care professionals to be aware of the new definitions of severity and typical presentations of congenital FVII deficiency. Failure to appreciate the risks of major bleeding, including intracerebral hemorrhage in those with FVII activity <10%, may put particularly young children at risk.
Keywords: blood coagulation disorders/classification, blood coagulation factors/physiology, humans’ rare diseases/classification, Severity of Illness Index
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