Case Report: Acquired Hemophilia by the presence of anti-factor VII autoantibodies associated with an antiphospholipid syndrome: a case report and review of literature

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However, a few cases of anti-factor VII (FVII) autoantibodies have been reported in the literature. We report a case in this regard. Case report A 28-year-old woman with no family or personal history presented with a severe hemorrhagic syndrome made of very abundant metrorrhagia with multiple compressive cervical hematomas, associated with pulmonary embolism and thrombosis. of the right external iliac vein. On the biological assessment, the patient presented with an undetectable PT with a factor VII titer less than 6%. The hemorrhagic syndrome was aggravated by infusions of activated factor VII (FVIIa) with the appearance of hemoptysis and hematomas in all four limbs. Etiological assessment concluded the presence of anti-factor VII autoantibodies as well as circulating lupus anticoagulant. Other antiphospholipid syndrome (APS) antibodies as well as antibodies against other hemostasis factors were absent. A treatment combining corticosteroid therapy (1mg per kg per day of prednisone) and Mycophenolate mofetil (MMF) (3g) was initiated. Faced with the persistence of the hemorrhagic syndrome, rituximab was administered according to the rheumatological protocol (1g on D1 and 1g on D15). Metrorrhagia improved initially but recurred with the resumption of menstruation with a drop in hemoglobin from 9 to 7 g/dl. Plasmapheresis sessions were attempted but thromboses on the catheters occurred each time. Immunoglobulin (IVIg) courses were administered. No anticoagulant was administered. TP increased to 23%. Levels of neutralizing antibodies fell from 512 to 2 IBU at the last follow-up at five months from the bleeding event. The circulating lupus anticoagulant was present on the follow-up test after 12 weeks, thus confirming the diagnosis of APS. Conclusion Our patient presents an extremely rare case of acquired haemophilia. The combination of corticosteroid therapy, conventional and biological immunosupressives, IVIG and plasmapheresis saved the patient. In the absence of consensus on the treatment, it remains adapted according to the severity of the haemorrhagic syndrome and the associated comorbidities. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/13-824", "name": "Case Report: Acquired Hemophilia by the presence of anti-factor VII..." } } ] } Home Browse Case Report: Acquired Hemophilia by the presence of anti-factor VII... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Abida H, Arfaoui B, Gueddiche NEH et al. Case Report: Acquired Hemophilia by the presence of anti-factor VII autoantibodies associated with an antiphospholipid syndrome: a case report and review of literature [version 1; peer review: 1 approved] . F1000Research 2024, 13 :824 ( https://doi.org/10.12688/f1000research.153980.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Case Report: Acquired Hemophilia by the presence of anti-factor VII autoantibodies associated with an antiphospholipid syndrome: a case report and review of literature [version 1; peer review: 1 approved] Houssem Abida https://orcid.org/0009-0007-6391-5952 1 , Bilel Arfaoui https://orcid.org/0000-0002-3257-8857 1 , Nour El Houda Gueddiche 1 , Faida Ajili 1 , Sameh Sayhi https://orcid.org/0000-0001-8774-3824 1 , Nadia Ben Abdelhafidh 1 Houssem Abida https://orcid.org/0009-0007-6391-5952 1 , Bilel Arfaoui https://orcid.org/0000-0002-3257-8857 1 , [...] Nour El Houda Gueddiche 1 , Faida Ajili 1 , Sameh Sayhi https://orcid.org/0000-0001-8774-3824 1 , Nadia Ben Abdelhafidh 1 PUBLISHED 23 Jul 2024 Author details Author details 1 Internal medicine department, Military Hospital of Tunis, Tunis, 1008, Tunisia Houssem Abida Roles: Conceptualization, Data Curation, Resources, Writing – Original Draft Preparation, Writing – Review & Editing Bilel Arfaoui Roles: Conceptualization, Resources, Supervision, Writing – Review & Editing Nour El Houda Gueddiche Roles: Supervision, Validation Faida Ajili Roles: Resources, Supervision Sameh Sayhi Roles: Resources, Supervision Nadia Ben Abdelhafidh Roles: Conceptualization, Data Curation, Resources, Supervision, Validation OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Introduction Acquired hemophilia is a rare disease characterized by the presence of neutralizing autoantibodies against hemostasis factors, most often factor VII. However, a few cases of anti-factor VII (FVII) autoantibodies have been reported in the literature. We report a case in this regard. Case report A 28-year-old woman with no family or personal history presented with a severe hemorrhagic syndrome made of very abundant metrorrhagia with multiple compressive cervical hematomas, associated with pulmonary embolism and thrombosis. of the right external iliac vein. On the biological assessment, the patient presented with an undetectable PT with a factor VII titer less than 6%. The hemorrhagic syndrome was aggravated by infusions of activated factor VII (FVIIa) with the appearance of hemoptysis and hematomas in all four limbs. Etiological assessment concluded the presence of anti-factor VII autoantibodies as well as circulating lupus anticoagulant. Other antiphospholipid syndrome (APS) antibodies as well as antibodies against other hemostasis factors were absent. A treatment combining corticosteroid therapy (1mg per kg per day of prednisone) and Mycophenolate mofetil (MMF) (3g) was initiated. Faced with the persistence of the hemorrhagic syndrome, rituximab was administered according to the rheumatological protocol (1g on D1 and 1g on D15). Metrorrhagia improved initially but recurred with the resumption of menstruation with a drop in hemoglobin from 9 to 7 g/dl. Plasmapheresis sessions were attempted but thromboses on the catheters occurred each time. Immunoglobulin (IVIg) courses were administered. No anticoagulant was administered. TP increased to 23%. Levels of neutralizing antibodies fell from 512 to 2 IBU at the last follow-up at five months from the bleeding event. The circulating lupus anticoagulant was present on the follow-up test after 12 weeks, thus confirming the diagnosis of APS. Conclusion Our patient presents an extremely rare case of acquired haemophilia. The combination of corticosteroid therapy, conventional and biological immunosupressives, IVIG and plasmapheresis saved the patient. In the absence of consensus on the treatment, it remains adapted according to the severity of the haemorrhagic syndrome and the associated comorbidities. READ ALL READ LESS Keywords Antiphospholipid syndrome; Acquired hemophilia, immunosupressive therapy Corresponding Author(s) Houssem Abida ( [email protected] ) Close Corresponding author: Houssem Abida Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2024 Abida H et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Abida H, Arfaoui B, Gueddiche NEH et al. Case Report: Acquired Hemophilia by the presence of anti-factor VII autoantibodies associated with an antiphospholipid syndrome: a case report and review of literature [version 1; peer review: 1 approved] . F1000Research 2024, 13 :824 ( https://doi.org/10.12688/f1000research.153980.1 ) First published: 23 Jul 2024, 13 :824 ( https://doi.org/10.12688/f1000research.153980.1 ) Latest published: 23 Jul 2024, 13 :824 ( https://doi.org/10.12688/f1000research.153980.1 ) Introduction Acquired hemophilia, a rare condition, is characterized by the presence of neutralizing autoantibodies against most often Factor VIII (FVIII) and in rare cases, Factor VII (FVII). These antibodies effectively inhibit the activated form of FVII by binding to its light chain. This binding disrupts the interaction between FVIIa and tissue factor (TF). The exact mechanism responsible for the development of this condition is poorly understood. Some researchers propose a paraneoplastic context, while others suggest a link to infections and autoimmune diseases, particularly Antiphospholipid syndrome (APS). In this case, we present a new instance of an inhibitor to FVII in a young woman experiencing a severe hemorrhagic syndrome. Notably, the symptoms were exacerbated by the administration of recombinant factor VII, and the patient had a history of APS. Case report In October 2022, a previously healthy 28-year-old woman presented with sudden left elbow hemarthrosis and spontaneous gingival bleeding. She had no prior personal or family history of abnormal bleeding. Upon admission, her hemoglobin concentration and platelet count were normal, but her prothrombin titer (PT) was low (11%, normal range: 70-100%), and her INR was high (7.1, normal range: 0.8-1.2). The baseline factor VII level was 6%, while the levels of other factors were normal. The patient received 5 mg of recombinant factor VII (rFVII) and was discharged the next day. Three weeks later, the patient returned to the emergency department experiencing dyspnea and dysphagia for two days. Physical examination revealed a right cervical hematoma. A cervical computerized tomography (CT) scan without contrast showed bleeding in the retropharyngeal space, causing compression of the airways and digestive tract. Her hemoglobin concentration was 10 g/dL, and PT was still at 11%. She was admitted to the hospital and received 5 mg of rFVII. The following day, the size of the cervical hematoma increased and became bilateral. The patient developed hemoptoic sputum and ecchymosis on the right arm. PT decreased to 6%. The treatment with rFVII was resumed at a higher dose (15 mg per kg every 6 hours), and two units of red blood cells were transfused. However, the hemorrhagic syndrome worsened the next day, with heavy metrorrhagia and multiple ecchymosis on both upper and lower limbs. A second CT scan revealed an extension of the retropharyngeal hematoma into the posterior mediastinum and retroperitoneal area, along with pericardial and pleural effusion. Treatment with tranexamic acid (1 g every 6 hours) and blood transfusion were initiated. The PT was undetectable this time, indicating the presence of an inhibitor to factor VII. The antibody titer was quantified as 428 Bethesda units (BU). Lupus anticoagulant was also detected, but other Antiphospholipid syndrome (APS) antibodies and antinuclear antibodies (ANA) were negative. The patient started treatment with methylprednisolone (1 g per day) and mycophenolate mofetil (3 g per day). Bleeding stopped within 24 hours, but the PT remained undetectable. A week later, the patient developed deep vein thrombosis (DVT) in the left lower limb, and a bilateral segmental pulmonary embolism was incidentally discovered during a follow-up CT scan. Enoxaparin (2000 IU every 12 hours) was initiated for anticoagulation. One month after admission, the patient experienced heavy metrorrhagia again, and her hemoglobin concentration dropped to 8 g/dL. The FVII antibody titer increased to 542 IUB. Anticoagulation was discontinued, and the patient continued taking prednisone (1 mg per kg per day) and mycophenolate mofetil (3 g per day). Rituximab infusions were administered (1 g on day 1 and 1 g on day 14), which stabilized the genital bleeding. The PT increased to 8%, and the FVII antibody titer decreased to 415 BU ( Figure 1 ). Figure 1. Evolution of Prothrombin titer and factor VII inhibitor’s titer. Two weeks later, the patient experienced heavy menstruation with a decreased hemoglobin concentration of 7 g/dL. Plasmapheresis was attempted, but only one session was successful, as the patient developed local catheter thrombosis during subsequent sessions. Intravenous Immunoglobulin (IVIg) therapy (0.4 g per kg per day) was administered for four days, leading to the cessation of bleeding by the third day. PT increased to 9%, and FVII antibody titer decreased to 62 BU. The patient’s prednisone dose was gradually reduced by 5 mg per week. Antibody titers continued to decrease to 23.5 and then 18.2 BU. A control test after two and a half months showed the presence of lupus anticoagulant. After a 90-day hospitalization, the patient was discharged in April 2023. She was prescribed a daily dose of 15 mg of prednisone and 2 g per day of mycophenolate mofetil. No anticoagulation therapy was recommended. Since her discharge, she has not experienced any bleeding. Her menstruations have resumed with a normal flow and duration. Her hemoglobin concentration was 10 g/dL, PT was at 23%, and the FVII antibody titer was 2 BU. Discussion Acquired inhibitors of coagulation are rare but severe conditions. Among them, inhibitors to factor VIII (acquired hemophilia A) are the most common, and management recommendations have been established. On the other hand, factor VII inhibitors are rarer and less well-known. These autoantibodies can be isolated or associated with various diseases. The first case report of factor VII deficiency due to the presence of its inhibitor dates back to 1980, as a paraneoplastic syndrome associated with bronchogenic carcinoma. 1 Few other similar cases associated with malignancies have been reported afterward. This condition has also been found in the context of infections, mostly HIV-related. 2 It has also been described in association with autoimmune diseases, mainly APS. 3 Additionally, it has been reported as secondary to drug administration, particularly penicillins. 4 Therefore, when encountering acquired hemophilia, thorough screening for these associated diseases is necessary before concluding its idiopathic or isolated nature. Clinical presentations of factor VII inhibitor cases seem to be correlated with antibody titers. Severe hemorrhagic syndromes and mortality have been observed with titers above 5 Bethesda units (BU). 5 To our knowledge, the titer in our report is the highest reported so far. However, the presence of neutralizing antibodies has been noted in some populations, such as patients with APS, without any clinical manifestation, making it uncertain to establish a clinico-biological correlation. 6 Unfortunately, treatment strategies and objectives have not been clearly defined yet. For the symptomatic management of acute bleeding, procoagulant agents like tranexamic acid have been used in some cases. 7 In our case, the use of tranexamic acid was not possible due to the patient’s thrombotic complications related to APS. Another particularity of our case is the possible role of recombinant factor VIIa (rFVIIa) in maintaining and stimulating the autoimmune process leading to the synthesis of these antibodies. Although not used in previous cases, rFVIIa has been suggested as a possible option for severe cases. 8 For therapeutic options, the most common first-line choice has been a combination of glucocorticoids (GC) and immunosuppressive agents, with successful results in some cases. 9 The choice of the immunosuppressive agent should take into consideration associated comorbidities to target both if possible. Cyclophosphamide and rituximab (RTX) have been commonly used. RTX has been employed for both remission induction and maintenance. 10 To the best of our knowledge, this is the first reported case of a factor VII inhibitor treated with mycophenolate mofetil (MMF). 11 For severe acute hemorrhages and refractory forms, intravenous immunoglobulin (IVIg) has been used with good outcomes. 12 Lastly, plasmapheresis can be a potential alternative for life-threatening presentations. However, it is preferably performed before the administration of immunosuppressive drugs or IVIg to avoid increasing their clearance and thereby diminishing their pharmacological action. 13 Conclusion In this case report, we describe a successful treatment regimen for a severe and biologically challenging presentation of acquired factor VII inhibitor. Our approach relied on a combination of conventional immunosuppression, immunotherapy, intravenous immunoglobulin (IVIg), and plasmapheresis (PE). By employing this comprehensive treatment strategy, we effectively managed the patient’s condition and achieved positive outcomes. This highlights the importance of a multidimensional approach in the management of severe acquired factor VII inhibitors, considering both the clinical and biological aspects of the condition. Ethics and consent Signed informed consent was obtained from the patient regarding the use of patient information for the purposes of writing a case report publication. Data availability No data are associated with this article. References 1. Deschiens MA, et al. : Autoantibodies to factor VII in a case of acquired haemophilia. Br. J. Haematol. 1980 Feb; 44 (2): 319–327. Publisher Full Text 2. Collins PW, et al. : Acquired haemophilia in association with HIV infection: a report of two cases. Br. J. Haematol. 1992 Nov; 80 (3): 126–127. Publisher Full Text 3. Knoebl P: Acquired inhibitors of coagulation. Semin. Thromb. Hemost. 2012 Feb; 38 (1): 01–04. Publisher Full Text 4. Suárez-Cortina L, et al. : Acquired hemophilia A associated with penicillin allergy: a case report. Ann. Allergy Asthma Immunol. 2016 Oct; 117 (4): 264–272.e4. Publisher Full Text 5. Lacroix-Desmazes S, et al. : Acquired factor VII deficiency associated with autoimmune disorders: two case reports and literature review. Haemophilia. 2015 Nov; 22 (6): 268–275. Publisher Full Text 6. Johnson EA, et al. : Factor VII inhibitor presenting as a life-threatening hemorrhage during pregnancy: a case report. Obstet. Med. 2019 Sep; 12 (3): 157–160. Publisher Full Text 7. Smith JM, et al. : Acquired factor VII deficiency: a case report and review of the literature. Blood Coagul. Fibrinolysis. 2020 Jul; 31 (5): 324–329. Publisher Full Text 8. Lee G, et al. : A rare case of acquired factor VII inhibitor presenting with severe bleeding: a case report. BMC Hematol. 2022 Jan 21; 22 (1): 1. Publisher Full Text 9. Franchini M, et al. : Successful treatment of acquired factor VII inhibitor with cyclophosphamide and corticosteroids. Ann. Hematol. 2004 Nov; 83 (11): 720–722. Publisher Full Text 10. Boggio LN, et al. : Successful treatment of acquired factor VII deficiency with glucocorticoids and rituximab: a case report and review of the literature. J. Pediatr. Hematol. Oncol. 2013 Jul; 35 (5): e203–e205. Publisher Full Text 11. Bachoud-Levi AC, et al. : Mycophenolate mofetil for acquired factor VII inhibitor. Ann. Hematol. 2002 May; 81 (5): 288–289. Publisher Full Text 12. Piovella F, et al. : Intravenous immunoglobulin as first-line therapy in acquired factor VII deficiency. Blood Coagul. Fibrinolysis. 2018 Oct; 30 (7): 246–248. Publisher Full Text 13. Giangrande PL, et al. : Plasmapheresis in acquired factor VII deficiency associated with lupus anticoagulant. Br. J. Haematol. 1994 Jan; 87 (1): 148–152. Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 23 Jul 2024 ADD YOUR COMMENT Comment Author details Author details 1 Internal medicine department, Military Hospital of Tunis, Tunis, 1008, Tunisia Houssem Abida Roles: Conceptualization, Data Curation, Resources, Writing – Original Draft Preparation, Writing – Review & Editing Bilel Arfaoui Roles: Conceptualization, Resources, Supervision, Writing – Review & Editing Nour El Houda Gueddiche Roles: Supervision, Validation Faida Ajili Roles: Resources, Supervision Sameh Sayhi Roles: Resources, Supervision Nadia Ben Abdelhafidh Roles: Conceptualization, Data Curation, Resources, Supervision, Validation Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 23 Jul 2024, 13:824 https://doi.org/10.12688/f1000research.153980.1 Copyright © 2024 Abida H et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Abida H, Arfaoui B, Gueddiche NEH et al. Case Report: Acquired Hemophilia by the presence of anti-factor VII autoantibodies associated with an antiphospholipid syndrome: a case report and review of literature [version 1; peer review: 1 approved] . F1000Research 2024, 13 :824 ( https://doi.org/10.12688/f1000research.153980.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 23 Jul 2024 Views 0 Cite How to cite this report: Schreuder M. Reviewer Report For: Case Report: Acquired Hemophilia by the presence of anti-factor VII autoantibodies associated with an antiphospholipid syndrome: a case report and review of literature [version 1; peer review: 1 approved] . F1000Research 2024, 13 :824 ( https://doi.org/10.5256/f1000research.168950.r332507 ) The direct URL for this report is: https://f1000research.com/articles/13-824/v1#referee-response-332507 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 13 Nov 2024 Mark Schreuder , University of Sydney, Sydney, Australia Approved VIEWS 0 https://doi.org/10.5256/f1000research.168950.r332507 In this case report, Dr. Houssem and co-authors present a rare instance of acquired hemophilia resulting from factor VII autoantibodies. The patient’s biological assessment also showed persistent lupus anticoagulant, indicating an underlying antiphospholipid syndrome. The authors detail the successful treatment ... Continue reading READ ALL In this case report, Dr. Houssem and co-authors present a rare instance of acquired hemophilia resulting from factor VII autoantibodies. The patient’s biological assessment also showed persistent lupus anticoagulant, indicating an underlying antiphospholipid syndrome. The authors detail the successful treatment of the patient with a regimen that included corticosteroids, immunosuppressants, immunoglobulin therapy, and plasmapheresis. This case is both intriguing and thoroughly described, providing valuable insights into the management of such complex conditions. I only have a few minor comments: In the abstract, the authors wrote that “Acquired hemophilia is a rare disease characterized by the presence of neutralizing autoantibodies against hemostasis factors, most often factor VII”. I assume the authors mean factor VIII. It would be helpful to add y-axis descriptions and units in figure 1 to better visualize which axis belongs to which curve and to understand what the curve represents. In addition to the previous comment, it would be helpful to mention in the text or in the figure caption what point in time represents the start of the figure 1 curves. As I understand, the PT was first measured in October 2022 and was subsequently tested in further episodes. The BU was measured first about three weeks after the patient was presented to the hospital, which would be October/November 2022. Yet the figure 1 curves start in December 2022. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: My area of research is in coagulation factors and bleeding diseases, including hemophilia. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Schreuder M. Reviewer Report For: Case Report: Acquired Hemophilia by the presence of anti-factor VII autoantibodies associated with an antiphospholipid syndrome: a case report and review of literature [version 1; peer review: 1 approved] . F1000Research 2024, 13 :824 ( https://doi.org/10.5256/f1000research.168950.r332507 ) The direct URL for this report is: https://f1000research.com/articles/13-824/v1#referee-response-332507 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 23 Jul 2024 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 Version 1 23 Jul 24 read Mark Schreuder , University of Sydney, Sydney, Australia Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Schreuder M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 13 Nov 2024 | for Version 1 Mark Schreuder , University of Sydney, Sydney, Australia 0 Views copyright © 2024 Schreuder M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions In this case report, Dr. Houssem and co-authors present a rare instance of acquired hemophilia resulting from factor VII autoantibodies. The patient’s biological assessment also showed persistent lupus anticoagulant, indicating an underlying antiphospholipid syndrome. The authors detail the successful treatment of the patient with a regimen that included corticosteroids, immunosuppressants, immunoglobulin therapy, and plasmapheresis. This case is both intriguing and thoroughly described, providing valuable insights into the management of such complex conditions. I only have a few minor comments: In the abstract, the authors wrote that “Acquired hemophilia is a rare disease characterized by the presence of neutralizing autoantibodies against hemostasis factors, most often factor VII”. I assume the authors mean factor VIII. It would be helpful to add y-axis descriptions and units in figure 1 to better visualize which axis belongs to which curve and to understand what the curve represents. In addition to the previous comment, it would be helpful to mention in the text or in the figure caption what point in time represents the start of the figure 1 curves. As I understand, the PT was first measured in October 2022 and was subsequently tested in further episodes. The BU was measured first about three weeks after the patient was presented to the hospital, which would be October/November 2022. Yet the figure 1 curves start in December 2022. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise My area of research is in coagulation factors and bleeding diseases, including hemophilia. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Schreuder M. Peer Review Report For: Case Report: Acquired Hemophilia by the presence of anti-factor VII autoantibodies associated with an antiphospholipid syndrome: a case report and review of literature [version 1; peer review: 1 approved] . F1000Research 2024, 13 :824 ( https://doi.org/10.5256/f1000research.168950.r332507) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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