Letter to the Editor
Thrombohemostatic disorders in the new emerging H7N9 influenza
Viroj Wiwanitkit
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Wiwanitkit House, Bangkok, Thailand
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array:22 [ "pii" => "S1516848414000206" "issn" => "15168484" "doi" => "10.1016/j.bjhh.2014.03.019" "estado" => "S300" "fechaPublicacion" => "2014-05-01" "aid" => "19" "copyright" => "Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular" "copyrightAnyo" => "2014" "documento" => "simple-article" "licencia" => "http://creativecommons.org/licenses/by-nc-nd/3.0/" "subdocumento" => "cor" "cita" => "Rev Bras Hematol Hemoter. 2014;36:235-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2623 "formatos" => array:3 [ "EPUB" => 161 "HTML" => 1713 "PDF" => 749 ] ] "itemAnterior" => array:18 [ "pii" => "S1516848414000218" "issn" => "15168484" "doi" => "10.1016/j.bjhh.2014.03.020" "estado" => "S300" "fechaPublicacion" => "2014-05-01" "aid" => "20" "copyright" => "Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular" "documento" => "simple-article" "licencia" => "http://creativecommons.org/licenses/by-nc-nd/3.0/" "subdocumento" => "crp" "cita" => "Rev Bras Hematol Hemoter. 2014;36:230-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3363 "formatos" => array:3 [ "EPUB" => 186 "HTML" => 2334 "PDF" => 843 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "<span class="elsevierStyleItalic">De novo</span> alpha 2 hemoglobin gene (<span class="elsevierStyleItalic">HBA2</span>) mutation in a child with hemoglobin M Iwate and symptomatic methemoglobinemia since birth" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "230" "paginaFinal" => "234" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 704 "Ancho" => 1356 "Tamanyo" => 93232 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Hemoglobin electrophoresis in alkaline (A) and acid gel (B), and by isoelectric focusing (C and D). Hb M Iwate is anodal to Hb A in alkaline gel and undistinguishable from Hb A in acid gel. Its color is brown in contrast to the vivid red of Hb A before trichloroacetic acid is applied to the isoelectric focusing gel (C). It runs between Hb F and Hb S (closer to Hb F) after the gel has been fixed and dried (D).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Marcos Borato Viana, André Rolim Belisário" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Marcos Borato" "apellidos" => "Viana" ] 1 => array:2 [ "nombre" => "André Rolim" "apellidos" => "Belisário" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1516848414000218?idApp=UINPBA00005G" "url" => "/15168484/0000003600000003/v3_201411060108/S1516848414000218/v3_201411060108/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Thrombohemostatic disorders in the new emerging H7N9 influenza" "tieneTextoCompleto" => true "saludo" => "Dear editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "235" "paginaFinal" => "236" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Viroj Wiwanitkit" "autores" => array:1 [ 0 => array:4 [ "nombre" => "Viroj" "apellidos" => "Wiwanitkit" "email" => array:1 [ 0 => "wviroj@yahoo.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Wiwanitkit House, Bangkok, Thailand" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Wiwanitkit House, Bangkhae, 10160 Bangkok Thailand." ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">An emerging infectious disease is usually problematic in medicine. Cross-species zoonosis is a current focus. The newly emerging H7N9 influenza infection is an atypical influenza that was detected early in 2013.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The disease was fi reported in China and since then cases have been reported from many different provinces.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> According to the World Health Organization offi report, by the end of May 2013, there were 132 accumulated cases.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Infection can be seen in both genders and in all age groups. This disease is of concern because of the possibility that it may cause a worldwide pandemic. The H7N9 influenza virus, which seems to have originated in birds, causes problematic infections in humans.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> H7N9 influenza can display both a classic acute respiratory illness as well as many atypical clinical symptoms, including hematological disorders. Thrombohemostasis disorders are of great concern<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and will be discussed further in this letter to the editor.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Platelet disorders are very common laboratory fi of the new H7N9 influenza virus.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Joob & Wiwanitkit were the fi to call attention to this problem in their recent article published in the journal Platelets.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> According to a large report on 111 cases of infection, the fi of thrombocytopenia is common.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Concerns are raised about its clinical importance. In another report, a drop in platelet counts are observed within 2 to 3 days after confirmation of H7N9 infection.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> H7N9 influenza virus might carry out several pathological processes to induce thrombocytopenia. Since the induction of thrombocytopenia, as a result of immunopathology, was detected in previous emerging influenza such as the H1N1 swine flu<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> it could be possible to see the same in H7N9 influenza.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Focusing on the clinical importance, the main question is whether thrombocytopenia will cause bleeding or not. Up to now, there is still no report of overt bleeding as a complication of the H7N9 influenza Based on the available data, the decreased platelet level is small (platelet counts in reported cases are between 71 and 75<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L whereas the reference range is 85-303<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Nevertheless, whether the H7N9 can induce thrombocytopenia or not is still questionable. In fact, Lu et al. investigated four patients with one suffering from chronic hepatic schistosomiasis and a possible thrombocytopenic effect.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Similarly, Chen et al. investigated four patients with one suffering from chronic hepatitis B virus infection, and a possible thrombocytopenic effect.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Thus, it is recommended to monitor the platelet count in patients infected with H7N9 influenza as it may refl on the prognosis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">There is only one report that investigated coagulation screening in patients infected by H7N9 influenza.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The available data relates to prothrombin time (PT) and activated thromboplastin time (aPTT). According to the report by Chen et al., some cases have abnormal PT and aPTT.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The PT and aPTT are prolonged by about two and three times their normal time, respectively.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Nevertheless, Chen et al. studied only four patients and half of them had underlying medical disorders that affect coagulation (chronic hepatitis B with possible coagulation disorder and chronic rheumatic heart disease with aortic and mitral valve replacements, and receiving anticoagulant therapy). Chen et al. also reported on disseminated intravascular coagulopathy (DIC). Positive D-dimer tests can be seen in almost all infected cases.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> DIC is observed as disease progresses.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion, abnormalities in thrombohemostasis can be seen in patients infected by H7N9 influenza. It is important to monitor the thrombohemostasis in these patients.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The author declares no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-09-08" "fechaAceptado" => "2013-12-07" "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Understanding H7N9 avian flu" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. 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