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Fırat Üniversitesi Sağlık Bilimleri Tıp Dergisi
2006, Cilt 20, Sayı 4, Sayfa(lar) 327-329
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Intracranial Hemorrhage Due To Vitamin K Deficiency In An Infant Despite Prophylaxis At Birth
Kaan DEMİRÖREN1, Haluk YAVUZ2, Saadet DEMİRÖREN3
1Çağrı Tıp Merkezi, Çocuk Sağlığı ve Hastalıkları Bölümü, Elazığ -TÜRKİYE
2Selçuk Üniversitesi, Meram Tıp Fakültesi, Çocuk Sağlığı ve Hastalıkları Anabilim Dalı, Konya – TÜRKİYE
Keywords: Infant, Intracranial hemorrhage, Prophylaxis, Vitamin K
Summary
Vitamin K deficiency bleeding is rare in infants who received vitamin K prophylaxis at birth. We present a case of a 7-week-old infant with intracranial hemorrhage due to vitamin K deficiency bleeding, who received intramuscular vitamin K prophylaxis at birth. In his history, he had used a parenteral antibiotic four days ago. We noticed on that the use of an antibiotic may play a role in late vitamin K deficiency bleeding and it may be responsible for insufficiency of single dose vitamin K, administered at birth.
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  • Summary
  • Introduction
  • Case Presentation
  • Disscussion
  • References
  • Introduction
    Vitamin K deficiency bleeding (VKDB) is manifested by two patterns, according to American Academy of Pediatrics Committee on Fetus and Newborn 1, early (from birth to 2 weeks of age) and late (onset from 2 weeks to 12 weeks of age) VKDB.

    Late VKDB is observed almost exclusively in breastfed infants who did not receive vitamin K at birth 2. The rate of late VKDB (often manifesting as sudden central nervous system hemorrhage) ranges from 4.4 to 7.2 per 100 000 births 1. When a single dose of oral vitamin K has been used for neonatal prophylaxis, the rate has decreased to 1.4 to 6.4 per 100 000 births 1. However, VKDB has been reported in infants who received vitamin K at birth 2-6. Vitamin K prophylaxis at birth in our country is routinely administered by a single injection of 1 mg intramuscular vitamin K.

    We report a case with intracranial hemorrhage (ICH) due to VKDB, who received intramuscular vitamin K prophylaxis at birth.

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  • Summary
  • Introduction
  • Case Presentation
  • Disscussion
  • References
  • Case Presentation
    A male infant aged seven weeks was referred to Department of Pediatrics, Selçuk University, Meram Medical Faculty because of coma, fever, convulsions and ICH, detected by cranial computed tomography (CT), from State Hospital. A parenteral antibiotic (sulbactam-ampicilline) treatment had been begun four days ago because of a respiratory tract infection. His sucking had impaired gradually. In the last day, he had suffered convulsion. In the history, his delivery was uneventful and his development was normal. He was breastfed, born at term of healthy mother, in hospital. Intramuscular 1 mg vitamin K had been administered at birth. The family history was negative for any bleeding disorder. At the admission, he was in coma. Physical examination was revealed anterior fontanel bulging, weak pupil reaction, anisocoria, increased muscle tonus, decreased deep tendon reflexes, absence of neonatal reflexes. There were no ecchymoses and petechiae.

    Laboratory investigations revealed coagulopathy as follows: protrombin time (PT) was >70 s (normal range: 11-13.5 s), partial thromboplastin time (PTT) >120 s (normal range: 28-36 s), fibrinogen 168 mg/dl (normal range: 125-300 mg/dl), hemoglobin 7.2 g/dL, platelets 230,000´109/L, leukocytes 8380´109/L, SGOT 36 IU/L, SGPT 18 IU/L, total bilirubin 0.5 mg/dl, direct bilirubin 0.2 mg/dl, urea 10 mg/dL, sodium 138 mmol/L, potassium 5.2 mmol/L, calcium 10.3 mg/dL, glucose 187 mg/dL. Microscopic examinations of urine and stool were normal. Lumbar puncture did not indicate meningitis but revealed hemorrhagic fluid. Cultures of blood, urine, stool and cerebrospinal fluid were normal. One day after the vitamin K administration (2 mg intravenously), PT was 12.7 s and PTT 30.6 s. Cranial CT showed intraventricular hemorrhage (Figure 1).


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    Figure 1: .

    Ventricular tap, mannitol, phenobarbital, and packed red blood cells were administered. Nevertheless, hydrocephaly was developed. The patient was referred to neurosurgery department because of ventriculoperitoneal shunt surgery. At the follow-up, the patient was experienced epilepsy, developmental delay and blindness.

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  • Introduction
  • Case Presentation
  • Disscussion
  • References
  • Discussion
    In a bleeding infant, a prolonged PT without any finding considering other bleeding disorders is almost diagnostic of VKDB. Rapid correction of PT and/or cessation of bleeding after vitamin K administration are confirmative the diagnosis 7. In the present case, the marked prolongation of the values of PT and PTT had improved in a short time after the administration of vitamin K and any finding considering other bleeding disorder was not identified.

    Late VKDB is often secondary to diarrhea, malabsorption, neonatal hepatitis, or prolonged antibiotic therapy. Many infants with late VKDB had acute ICHs which can be the first manifestation of the disease 2,8. The localizations of the ICHs were reported as follows: parenchymal (31.3-91%), subarachnoid (27.3-90.6%), subdural (0-37.5%) and intraventricular (12.5-27.3%) 9-11.

    In the present case, there was no evidence of diarrhea, malabsorption, liver dysfunction, disseminated intravascular coagulation. The possible risk factors of the present case despite prophylaxis at birth are a low level of vitamin K in the mother's milk, use of a parenteral antibiotic. Latini et al. 3 and Solves et al. 4 reported that two cases with ICH due to VKDB despite vitamin K prophylaxis at birth did not have any secondary cause. Suzuki et al. 5 reported that a case with ICH due to VKDB despite prophylaxis had a history of use of oral antibiotic given two days before the onset of bleeding. Loughnan et al. 6 reported two premature infants who developed late VKDB despite intravenous vitamin K prophylaxis. One of them had hepatitis and the other did not have any secondary cause.

    We speculate that the use of a broad spectrum antibiotic may play a role in late VKDB and it may be responsible for insufficiency of single dose vitamin K administered at birth for prophylaxis. Therefore, additional vitamin K supplementation may be considered to prevent late VKDB in the use of a broad spectrum antibiotic.

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  • Introduction
  • Case Presentation
  • Discussion
  • References
  • References

    1) American Academy of Pediatrics Committee on Fetus and Newborn. Controversies concerning vitamin K and the newborn. Pediatrics 2003; 112: 191-192.

    2) Zipursky A. Prevention of vitamin K deficiency bleeding in newborns. Br J Haematol 1999; 104: 430-437.

    3) Latini G, Quartulli L, De Mitri B, Del Vecchio A, Vecchio C. Intracranial hemorrhage associated with vitamin K deficiency in a breastfed infant after intramuscular vitamin K prophylaxis at birth. Acta Paediatr 2000; 89: 878-880.

    4) Solves P, Altes A, Ginovart G, Demestre J, Fontcuberta J. Late hemorrhagic disease of the newborn as a cause of intracerebral bleeding. Ann Hematol 1997; 75: 65-66.

    5) Suzuki K, Fukushima T, Meguro K, et al. Intracranial hemorrhage in an infant owing to vitamin K deficiency despite prophylaxis. Child's Nerv Syst 1999; 15: 292-294.

    6) Loughnan PM, McDougall PN, Balvin H, Doyle LW, Smith AL. Late onset haemorrhagic disease in premature infants who received intravenous vitamin K1. J Paediatr Child Health 1996; 32: 268-269.

    7) Sutor AH, von Kries R, Cornelissen EA, McNinch AW, Andrew M. Vitamin K deficiency bleeding in infancy. ISTH Pediatric/Perinatal Subcommittee. International Society on Thrombosis and Haemostasis. Thromb Haemost 1999; 81: 456-461.

    8) Sutor AH, Dagres N, Niederhoff H. Late form of vitamin K deficiency bleeding in Germany Klin Padiatr 1995; 207: 89-97.

    9) Aydinli N, Citak A, Caliskan M, Karabocuoglu M, Baysal S, Ozmen M. Vitamin K deficiency: Late onset intracranial haemorrhage. Europ J Paediatr Neurol 1998; 2: 199-203.

    10) Bor O, Akgun N, Yakut A, Sarhus F, Kose S. Late hemorrhagic disease of the newborn. Pediatr Int 2000; 42: 64-66.

    11) Chaou WT, Chou ML, Eitzman DV. Intracranial hemorrhage and vitamin K deficiency in early infancy. J Pediatr 1984; 105: 880-884.

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  • Summary
  • Introduction
  • Case Presentation
  • Discussion
  • References
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