The most common clinical presentation of patients with lupus anticoagulant antibody is arterial or venous thromboembolism1). Hemorrhage is much less common and this is usually attributable to the associated thrombocytopenia, a platelet dysfunction, a prothrombin deficiency or other underlying coagulopathies2, 3). Lupus anticoagulant hypoprothrombinemia (LAHPS) is a rare syndrome. In many cases, steroid is required to treat patients' hemorrhages, and steroid has been noted to promptly correct the hypoprothrombinemia and control bleeding events4).

Herein, we report on a 34-year-old previously healthy man with LAHPS. He was referred to our hospital because of his prolonged coagulation time, which was discovered during his lab work-up for an orthopedic operation. The laboratory studies showed LAHPS with microscopic hematuria; however, any viral infection or other systemic disease was not found. He was successfully treated with corticosteroid before undergoing orthopedic surgery.

A 34-year-old-man was admitted to another hospital for an orthopedic operation. The coagulation studies showed a prolonged prothrombin time (PT) and an activated partial thromboplastin time (APTT). He was treated with fresh frozen plasma, but without success. After 2 weeks, the patient was referred to our hospital. He was not taking any medication, and especially, any anticoagulant and antiplatelet agents. He had no personal or family history of any bleeding disorder. The physical examination was non-specific except for signs of ligament rupture. The initial laboratory tests showed a leukocyte count of 8,200/mm³, a hemoglobin of 14.7 g/dL and a platelet count of 226,000/mm³. The PT was 15.2 sec (normal values (NV): 10.0-13.0 sec), the APTT was 37.7sec (NV: 27.5-34.7 sec). Evaluation of the clotting factors revealed decreased levels of factors II, V, VIII, IX and XI (Table 1). A 1:1 dilution of patient plasma with normal plasma nearly corrected the PT, but this failed to correct the APTT. The diluted Russell's viper venom time (dRVVT, American Diagnostica,) was positive. The anticardiolipin antibodies IgG and IgM were positive. The tests for antinuclear antibodies and anti double stranded DNA antibodies were negative; the C3 and C4 complement levels were low. The patient denied any symptoms that would be suggestive of SLE, and there was no family history of bleeding or connective tissue disease. An extensive infectious disease workup ruled out hepatitis A, B and C, cytomegalovirus and Epstein Barr virus. Finally, we diagnosed the patient as having lupus anticoagulant-hypoprothrombinemia (LAHPS). However, he displayed only microscopic hematuria and he was without SLE or any underlying disease. So, we closely followed the patient's laboratory findings and clinical symptoms for 2 months. He did not show any symptoms or signs of bleeding, yet the abnormal laboratory findings were sustained. We decided to try corticosteroid treatment to prepare the patient for orthopedic surgery and then 2 weeks later, the coagulation studies were significantly improved. He successfully underwent the operation and was discharged. At present, he hasn't any symptoms or signs of thrombosis, hemorrhage and SLE.

Lupus anticoagulant (LA) is an antiphospholipid antibody that causes prolonged in vitro coagulation times. This may be associated with a hypercoagulable state together with thromboembolic events1). A bleeding diathesis is a rare manifestation of lupus anticoagulant, and when it occurs, it was nearly always due to thrombocytopenia or Factor II deficiency2, 3).

Lupus anticoagulant hypoprothrombinemia syndrome (LAHPS) is a rare clinical malady that can occur in association with SLE, transient viral infections, drug reactions or even in healthy individuals5, 6). It mostly occurs in young females, and only rarely in those adults who are without systemic lupus erythematosus, an underlying disease or a preceding illness2).

The clinical findings are generally asymptomatic, but there can be severe hemorrhagic symptoms such as brain hemorrhage, gastrointestinal bleeding and diffuse muscular hemorrhage. These patients may present with severe life threatening bleeding diathesis if the Factor II level is very low (i.e., usually under 10%)2). In our case, the Factor II level was 29% and only microscopic hematuria was observed.

Simel et al. have reported on a case of LAHPS for which the patient did not respond to replacement therapy, and the patient showed a significant response to immunosuppressive drugs7). Most of the cases previously reported in the literature have responded well to administering only prednisone treatment4). A few cases needed an additional immunosuppressive drug such as cyclophosphamide or azathioprine7, 8). Corticosteroid therapy is the treatment of choice for LAHPS associated with SLE; it normalizes the abnormal coagulation times, including the PT, the APTT and the clotting factors. For those cases associated with viral infection, the LAHPS spontaneously reverses itself when the infection has been resolved, and so steroid therapy is not necessary. Our patient had only microscopic hematuria without SLE or any underlying diesese. Therefore, we followed up the laboratory findings and clinical symptoms for 2 months; during this time, he did not display any symptoms and signs of bleeding. However, the abnormal laboratory findings were sustained. We decided to institute corticosteroid treatment for getting him ready for orthopedic surgery; 2 weeks later, the coagulation studies were significantly improved. He successfully received the operation and was discharged. At present, he has no signs or symptoms of thrombosis, hemorrhage and SLE. Prompt, close follow up of these patients is crucial because they may develop, at any time, the full clinical syndrome of SLE and thrombosis because of the presence of LA.