J Hematol

Journal of Hematology, ISSN 1927-1212 print, 1927-1220 online, Open Access

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

Journal website https://www.thejh.org

Case Report

Volume 12, Number 3, June 2023, pages 133-137

Treating Acquired Factor VIII Inhibitor and Tumor-Induced Hypoglycemia in a Case of Relapsed Diffuse Large B-Cell Lymphoma

Figure 1. Rotational thromboelastometry (ROTEM) profile of the patient before and after treatment with pulse dose steroids. (a) The ROTEM results at the time of admission. Patient had a severely prolonged clotting time (CT) at 1,043 s, an immeasurably long clot formation time (CFT), consistent with severe coagulopathy. Due to the patient’s immeasurable CFT, the alpha angle (α) could not be measured. (b) The ROTEM results following a 4-day course of high-dose dexamethasone with normalization of CT and the CFT, and α angle normalized as well, consistent with a strong clot strength. Of note, the patient’s maximum lysis time was significantly reduced indicating defective fibrinolysis even after the course of dexamethasone.

**Table 1.** Preoperative Labs Ordered for Inpatient Workup of Relapsed Lymphoma
POC: point-of-care.
Na⁺	129 mmol/L
K⁺	4.2 mmol/L
Cl^-	100 mmol/L
CO₂	18 mmol/L
Blood urea nitrogen (BUN)	17 mmol/L
Serum creatine (Cr)	1.03 mg/dL
Serum glucose	< 20 mg/dL
POC glucose	98 mg/dL
Hemoglobin (Hb)	12.3 g/dL
White blood cell (WBC)	3.92 × 10³/µL
Platelets (Plt)	137 × 10³/µL
Prothrombin time (PT)	13.6 s
Internal normalized ratio (INR)	1.2
Activated partial thromboplastin time (aPTT)	93.3 s

Table 1. Preoperative Labs Ordered for Inpatient Workup of Relapsed Lymphoma

POC: point-of-care.

Na⁺

129 mmol/L

K⁺

4.2 mmol/L

Cl^-

100 mmol/L

CO₂

18 mmol/L

Blood urea nitrogen (BUN)

17 mmol/L

Serum creatine (Cr)

1.03 mg/dL

Serum glucose

< 20 mg/dL

POC glucose

98 mg/dL

Hemoglobin (Hb)

12.3 g/dL

White blood cell (WBC)

3.92 × 10³/µL

Platelets (Plt)

137 × 10³/µL

Prothrombin time (PT)

13.6 s

Internal normalized ratio (INR)

1.2

Activated partial thromboplastin time (aPTT)

93.3 s

**Table 2.** Further Workup of Coagulopathy and Hyperglycemia Identified at Admit
Ig: immunoglobulin; ACTH: adrenocorticotrophic hormone; IGF-1: insulin-like growth factor-1.
Mixing study	71.7 s
Factor VIII	≥ 76%
Factor IX	235%
Factor XI	223%
Factor XII	80%
Factor VIII inhibitor	+ 3.8 Bethesda U
Cardiolipin IgG	9.0 GPL U/mL
Cardiolipin IgM	> 150.0 MPL U/mL
B2 glycoprotein IgG	< 9 SGU U/mL
B2 glycoprotein IgM	101 SMU U/mL
Fibrinogen	149 mg/dL
Fibrin split products	10,240 mg/L
Insulin	7 MU/L
C-peptide	3.4 ng/mL
Pro-insulin	17.3 pmol/L
ACTH	38 pg/mL
Cortisol	16 µg/dL
IGF-1	40 ng/mL
Lactate	1.8 mmol/L

Table 2. Further Workup of Coagulopathy and Hyperglycemia Identified at Admit

Ig: immunoglobulin; ACTH: adrenocorticotrophic hormone; IGF-1: insulin-like growth factor-1.

Mixing study

71.7 s

Factor VIII

≥ 76%

Factor IX

235%

Factor XI

223%

Factor XII

80%

Factor VIII inhibitor

+ 3.8 Bethesda U

Cardiolipin IgG

9.0 GPL U/mL

Cardiolipin IgM

> 150.0 MPL U/mL

B2 glycoprotein IgG

< 9 SGU U/mL

B2 glycoprotein IgM

101 SMU U/mL

Fibrinogen

149 mg/dL

Fibrin split products

10,240 mg/L

Insulin

7 MU/L

C-peptide

3.4 ng/mL

Pro-insulin

17.3 pmol/L

ACTH

38 pg/mL

Cortisol

16 µg/dL

IGF-1

40 ng/mL

Lactate

1.8 mmol/L

**Table 3.** Coagulation Studies and Factor VIII Levels Over Time
Study	At admit	Post-IV steroids	Post-induction chemotherapy
IV: intravenous.
aPTT	93.3 s	56.8 s	32 s
Factor VIII	≥ 76%	≥ 88%	≥ 200%
Factor VIII inhibitor	3.8 Bethesda U	3.4 Bethesda U	Untraceable

Table 3. Coagulation Studies and Factor VIII Levels Over Time

Study

At admit

Post-IV steroids

Post-induction chemotherapy

IV: intravenous.

aPTT

93.3 s

56.8 s

32 s

Factor VIII

≥ 76%

≥ 88%

≥ 200%

Factor VIII inhibitor

3.8 Bethesda U

3.4 Bethesda U

Untraceable