Upper airway obstruction due to factor VIII inhibitor deficiency

A 62-year-old male patient with known hepatitis C and human immunodeficiency virus coinfection presented with symptoms of acute upper airway obstruction (UAO) requiring endotracheal intubation. The patient was recently placed on warfarin therapy for a newly diagnosed deep venous thrombosis. Imaging of the chest and neck initially suggested an acute/subacute inflammatory/infectious process of the upper airways. He had a prolonged coagulation profile that did not correct with multiple transfusions of blood products. Urgent surgical exploration revealed massive hemorrhage into the muscle and soft tissues of the neck extending to the mediastinum. Hematology abnormalities included a factor VIII activity of 4%, positive mixing studies, and a Bethesda assay 2ĝ€‰BU (Bethesda unit) (low responder) consistent with factor VIII deficiency. The patient1/4s condition eventually improved after blood product replacement and surgical decompression. He was successfully extubated and discharged home. The UAO was likely due to a bleeding complication secondary to either congenital or acquired factor VIII deficiency. It is possible that the use of warfarin contributed to the bleeding. It is critical for the clinicians to consider bleeding disorders and medication complications in patients presenting with UAO and difficult to control coagulopathy or persistently elevated active partial thromboplastin time.