Exchange transfusion and pulse steroid therapy in a hemophiliac with inhibitor.

In Thailand, the management of bleeding in hemophiliacs with inhibitor is still a challenging aspect. The source of Factor VIII is locally prepared fresh frozen plasma and cryoprecipitate. The Factor VIII concentrate and other commercial blood products are not available because of the remarkably high price. Successful management of bleeding in a 3-year-old hemophiliac boy with moderate inhibitor level (11.82 BU) was reported. He had active bleeding from a 1 cm size cut wound at upper gingivo-buccal fold and did not respond to local measures and supportive treatment. He received exchange transfusion, intravenous cyclophosphamide and high dosage of cryoprecipitate. The bleeding stopped and the inhibitor declined to 2.6 BU. A week later, the bleeding recurred with an anamnestic response of inhibitor to 5 BU. The second exchange transfusion and methylprednisolone as pulse steroid therapy were given daily for 3 days. No cryoprecipitate was infused. The bleeding gradually stopped within 48 hours and the inhibitor level declined to 3.2 BU which was still at low level for at least 2 months. Exchange transfusion and methylprednisolone as pulse steroid therapy may be an alternative treatment for controlling bleeding in a hemophiliac with moderate inhibitor level in countries where a high concentrate of Factor VIII or other blood products are not available. It is practical, simple, effective and of low cost.