Bleeding After Central Venous Catheter Placement in a Patient With Undiagnosed Acquired Hemophilia A: A Case Report

Abstract

Acquired hemophilia A is a rare condition caused by autoantibodies against endogenous coagulation factor VIII, which results in spontaneous bleeding. Workup of a patient with difficult hemostasis after removing and placing a central venous catheter led to the diagnosis of acquired hemophilia A. A 64-year-old man was transferred with an intramuscular right thigh mass. Initial biopsy at an outside facility showed degenerated muscle and coagula and he was transferred for incisional biopsy and definitive treatment. The patient had difficult venous access, and a right internal jugular venous catheter was placed. The catheter insertion site showed slow continuous bleeding. Achieving adequate hemostasis after removing the catheter was difficult, and a hematoma formed after the placement of an infraclavicular axillary venous catheter under ultrasound guidance. Coagulation studies revealed a prolonged activated partial thromboplastin time at 96 seconds. The patient was then diagnosed with acquired hemophilia A by enzyme-linked immunosorbent assay using anti-factor VIII antibodies. Even if ultrasound-guided central venous catheterization is performed carefully, bleeding may occur in some patients, suggesting the possibility of coagulopathy. Decision-making for performing central venous catheterization requires extensive knowledge of coagulopathies to understand the causes of bleeding complications.

Keywords: acquired hemophilia a; activated partial thromboplastin time; difficult hemostasis; mechanical complication; ultrasound-guided central venous catheterization.

Figure 1. Intramuscular mass in the right thigh

The dotted white oval shows an intramuscular mass in the right thigh on a T2-weighted magnetic resonance image.

Figure 2. Infraclavicular axillary venous catheterization

A: The guidewire is inserted in the infraclavicular axillary vein (short-axis view). The guidewire position is also verified in the long-axis view, the dilator is inserted and removed, and then the catheter is placed. B: The catheter is shown in the infraclavicular axillary vein without any hematoma. V: infraclavicular axillary vein.