An acquired factor VIII inhibitor responsive to high-dose gamma globulin

A 55-year-old previously well woman noted easy bruising and developed a swollen, painful leg after minimal trauma. A compartment syndrome was diagnosed, and medial and lateral fasciotomies were performed with evacutation of a massive hematoma. However, blood rapidly reaccumulated in the wound. The VIII:C level was 2%, and 4 Bethesda units of factor VIII inhibitor were detected. After initial treatment with clotting factor concentrates and corticosteroids failed to control bleeding or reduce inhibitor titers, gamma globulin, 25 g dily for 5 days, was administered. The inhibitor became undetectable, VIII:C levels rose, and bleeding stopped. However, 5 days later VIII:C levels were again low and bleeding recurred. A second course of gamma globulin, 50 g daily for 2 days, was accompanied by a prompt increase in VIII:C, and uneventful recovery. In conclusion, in this patient with an autoantibody to VIII:C, a response to gamma globulin was observed on two occasions, and the second response came when steroids were being tapered and the patient was on no other medication.