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Long-Term Sustained Hemorrhage Due to Bone Marrow Biopsy Successfully Treated With Topical Ankaferd Hemostat in a Bleeding-Prone Patient With Secondary Amyloidosis

We have read with great interest the recent article published in the Clinical and Applied Thrombosis Hemostasis journal by Cakarer et al in which the authors suggested that topical Ankaferd blood stopper (ABS) application could be a safe and effective measurement for the bleedings of dental invasive procedures even under anticoagulant therapy without discontinuation of the antithrombotic medication. On average, 66.7% of the ABS-treated dental extraction sockets achieved hemostasis in less than 1 minute, while 80% of the nontreated sockets achieved hemostasis longer than 1 minute. Furthermore, there were no side effects associated with ABS use except a metallic taste in the mouth lasting for approximately 5 minutes. This investigation brilliantly indicates the efficacy of ABS for the clinical bleedings in the setting of acquired hemorrhagic diathesis. Hereafter, we would like to share our experience about topical ABS to control long-term sustained resistant site bleeding due to the bone marrow biopsy procedure in a bleeding-prone patient with secondary amyloidosis. Amyloid diseases can generally be associated with potentially life-threatening hemorrhages. Pathobiological factors contribute to abnormal bleeding tendency in amyloid diseases are heterogeneous depending on the type of amyloidosis and the pattern of organ involvement. A 31-year-old male Turkish patient with familial Mediterranean fever (FMF), secondary renal amyloidosis, and chronic kidney failure had presented with palor, lassitude, fatigue, thrombocytopenia, and deep anemia. His medications included L-thyroxine 1 0.1mg and colchium dispert 1-2 1 orally (po) daily. His familiy history was unremarkable and his parents were nonconsanguineous. In the physical examination, he had a significant pale appearance with numerous petechiaes in the upper body and both extremities. Moreover, massive splenomegaly (16 cm palpable below the left costal margin and extending to the inguinal and pelvic areas) with hypersplenism also complicated the clinical picture. Peripheral blood examination disclosed the hemoglobin level of 8.8 g/dL (13.6-17.2), white blood cell count of 9.0 10/mL (4.3-10.3), with 6.4 10/mL absolute count (70.6%) of neutrophils, and platelet count of 41 10/mL (156-373). Peripheral blood smear showed 61% neutrophils, 38% lymphocytes, 1% eosinophils, poikilocytosis, hypochromia, anisocytosis, and decreased platelets. Nutritional and hemolytic anemia were ruled out. Baseline hemostatic parameters revealed the prolonged prothrombin time (international normalized ratio [INR]=1.4; N: 0.86-1.20) and increased D-dimer (5.88 m/mL; N: 0-0.48) compatible with chronic disseminated intravascular coagulation (DIC). Meanwhile, coagulation factor (F) levels were as follows; factor VIII (FVIII): 57% (N: 53-170), FIX: 42% (N: 60-170), FXI: 59% (N: 70-150), FV: 17% (N: 70120), FVII: 41% (N: 70-130), FX: 32% (N: 70-120), and antithrombin III: 67% (N: 80-120). Platelet function tests were abnormal with ADP (2 mmol/L), ADP (6 mmol/L), epinephrine (10 mmol/L), and collagen (1 ug/mL). Bone marrow aspiration and biopsy have been performed at the spina iliaca posterior superior region of the iliac crest in order to assess amyloidosis. Bone marrow histopathology was normocellular and depicted increments in the megakaryocytes and plasma cells (7%-8%). Amyloid accumulation was detected around the blood vessels with crystal violet staining.