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Aaron Auerbach MD MPH

Thanks to the Osler
Organization and the Residents
at Walter Reed Army Medical
Center for providing help with
the creation of this powerpoint.
• 1. Normal coagulation
• 2. Tests of coagulation
• 3. Hemorrhagic and thrombotic

1. Normal coagulation
2. Tests of coagulation
3. Hemorrhagic and thrombotic
• Primary hemostasis
Platelet plug formation
Adhesion and aggregation
• Secondary hemostasis
Coag pathway, form fibrin
• Tertiary hemostasis
– Crosslinking of fibrin and fibrinolysis
z A complicated process that must prevent
both excessive bleeding and excessive
clot formation

z Three key components: blood vessels,

platelets, and plasma components

z Three steps: adhesion, plts release

granules, aggregation
First step--adhesion

• You get an injury to a blood vessel and the

endothelium is ripped apart
• There is circulating von Willebrands factor in
the plasma, and there is also subendothelial
• The circulating vWF in the plasma attaches to
the naked endothelium and subendothelium.
• Then the platelets attach to the vWF using
the glycoprotein Ib/V/IX
= GP1b/V/IX


Damaged endothelium

--Damaged endothelium exposes collagen

--Circulating vWF in plasma attaches to endothelium.
--Then, platelets attach to vWF using GP Ib/V/IX
Then, the platelets release
their granules and change shape
EM Platelet
Alpha granule Delta granule
- -thromboglobulin -ADP dense granule which causes
- P-selectin vasoconstriction
- PF4 - Serotonin
- platelet fibrinogen - Ca++
- Thrombospondin

Alpha granule

Delta granule

Goldman: Cecil Textbook of Medicine, 21st ed

• When the platelets change shape, they
expose their fibrinogen receptors
• GP IIb\IIIa receptor binds fibrinogen
• And aggregation occurs and plugs the
• This is the primary platelet plug
• GPIIbIIIa inhibitors (Abciximab-Reopro,
Integrilin, Aggrastat)
platelet aggregation

= GP1b/V/IX


Primary Hemostasis


Damaged endothelium
understanding this process will help us
understand some diseases

Robbins 6 ed Fig 5-7

Secondary hemostasis
(the dreaded coag pathway)
• Formation of fibrin
• Laying down fibrin over plt plug
• Defects can result in
hematomas, hemarthroses 73_photos/73_306.jpg
Enzymes that, when activated, catalyze activation of sequential
steps that lead to fibrin formation
Bowen, D J Mol Pathol 2002;55:127-144

Mostly made by liver (except vWF, mostly made by endothelial


Copyright ©2002 BMJ Publishing Group Ltd. 2002 BMJ Publishing Group Ltd.
FVIII and V cofactors

Division into “intrinsic” and “extrinsic” based on lab tests,

doesn’t apply in body
Intrinsic path activated by blood in contact with negative
charged glass D J Mol Pathol 2002;55:127-144
Extrinsic path activated by tissue factor (subendothelium) Early
factors in intrinsic path (Kallikrein) usually do not cause
bleeding, but deficiency causes  PTT
Factor VIIa activates X directly, but mainly activates IX
Tissue factor D J Mol
pathway Pathol
inhibitor 2002;55:127-144
bingd to F10aX
Secondary hemostasis

• Thrombin does many things

• It converts fibrinogen- fibrin
• Thrombin activates F5, F8, F11 F13
Tertiary hemostasis

Factor XIII Factor XIIIa

cross links fibrin


Plasmin dissolves fibrin


TPA cleaving plasminogen to plasmin

Plasmin cleaves fibrin into fibrin split products

Inhibiting fibrinolysis
1. Alpha two antiplasmin inhibits plasmin
2. PAI inhibits plasminogen
3. TAFI (thrombin activatable fibrinolysis inhibitor)
Inhibits binding of plasminogen and TPA to fibrin

plasmin dissolves fibrin clots

fibrin D-dimers
split  In pulmonary embolism
Fragment E
• Protein C
Thrombomudulin binds to thrombin to activate protein C; with
its carrier, protein S, APC inhibits FV and FVIII
• Antithrombin
Liver-produced AT binds to heparin and inhibits conversion of II
to IIa; also inhibits Xa action
Protein C, S

z Protein C, S measure level or

activity best to measure functional
z As vitamin K-dependent factors,

may be abnormal during warfarin

z Both acute phase response

proteins; may be falsely normal (in

deficiency) with acute illness
• 1. Normal coagulation
2. Tests of coagulation
• 3. Hemorrhagic and thrombotic
Screening tests
• CBC-platelet count
• PT
• aPTT
• 1. CBC--platelet count
--Put platelets through impedance counter, analyze particles <13 fL
--Tells you nothing about the functional ability of plts

• 2. bleeding time
-worthless test, used to tell if patient might bleed at surgery
-Use blade on pt’s forearm, blot blood with filter paper
time w stopwatch to see when bleeding stops
-Each lab has different normals,
-Does not predict functional bleeding. If you have a
normal or abnormal bleeding time, it will not predict
whether you bleed
-PFA is better
Activated Partial Thromboplastin Time
(aPTT) <40 seconds

Negatively charged surface

+ PPP + calcium chloride
Phospholipid (partial thromboplastin)

Measure time to clot

Measures the intrinsic and common pathway

Measures all factors except 7 and 13
Prothrombin Time (PT) <15 seconds

Citrated (blue top)

-Tissue factor Calcium Chloride
+ Patient’s platelet-poor
Plasma (PPP)

Measure the time clot to clot

Measures the extrinsic and common pathway

INR This formula shows up on boards

⎛ Patient PT ⎞
INR = ⎜⎜ ⎟⎟
⎝ Normal mean PT ⎠
ISI – International Sensitivity Index; related to
amount of tissue factor in reagent
INR--Developed to compensate for reagent
Normal PT, aPTT, platelets
• Mild vWD
• Uremia
• Surgery
• Inherited platelet D/O
• Vascular D/O
• Fibrinolytic D/O
• XIII deficiency
• Dysfibrinogenemia
• Mild factor deficiency
 PT, normal aPTT, normal platelets

• F VII deficiency or
• Coumadin
• Liver disease
• dysfibrinogenemia
Normal PT,  aPTT, normal platelets

• Heparin effect
• vWD
• inhibitor
• Lupus anticoagulant
PT, aPTT, and normal platelets

• Coumadin
• Heparin
• Liver disease
• Vitamin K deficiency
• Dysfibrinogenemia
• Primary fibrinolysis
PT, aPTT,and  platelets
• Liver disease
• Heparin with
Nl PT, Nl aPTT,  platelets
• Destruction
• Sequestration
• Decreased
• Bernard-Soulier
Nl PT, Nl aPTT,  platelets

Myeloproliferative disorders
Additional tests
• Thrombin time
• Reptilase time
• Mixing studies
• Platelet aggregation studies
Thrombin time

Exogenous thrombin
+ Measure the time to clot
Patient’s platelet-poor plasma

Measures common pathway

TT measures conversion of fibrinogen to fibrin
Doesn’t need Ca or phospholipid
↑ paraprotein, amyloid, heparin, dysfibrinogenemia
Reptilase time

Bothrops atrox venom

Mixed with Measure time to clot

Patient’s platelet-poor plasma

Patients on heparin have ↑ TT but normal reptilase time

Giving heparinase + protamine to patient on heparin will correct TT.
Reptilase measures the conversion of fibrinogen to fibrin, but is
insensitive to heparin.
↑Reptilase in dysfibrinogenemia
Mixing Study
Patient plasma Mixed (1:1) with Pooled normal plasma

Perform PT or aPTT
-At 60 minutes

--mixing study w PTT correction = factor deficiency

--mixing study w/o PTT correction = inhibitor (ex. lupus
--Some inhibitors correct w 1:1 mix, so try a 4 (pt plasma) : 1 (nl
plasma) mix.
--Time dependent prolongation = F8 inhibitor will correct and them
prolong after 1-2hrs,
--Dysfibrinogen inhibitor and will only partially correct.
Hypofibrinogen will correct.
Platelet aggregation studies
• Tell you how platelets respond to certain
chemicals to see if they will aggregate
• Use a platelet rich plasma (spin it down to get
a good # of plts)
• Add aggregating agent i.e ristocetin
• Look for a change in light transmission
• We can look for  in turbidity or an  in
• Curve is flipped

Shine light
Through platelets Aggregated platelets


Less light scattering

Low Optical Density
Optical 100
density First phase of
(%)* aggregation (ADP release)

Second phase
of aggregation
(more ADP release
& TXA2 release)

0 3
Time (min)

*w/ aggregation, less light scattering, lower optical density)

What are the aggregating agents
• ADP--normally in platelets
• Ristocetin--physical clumping agent
• Epinephrine
• collagen
• arachidonic acid (used for detecting
aspirin defects)
Platelet aggregation studies
Board high yield factoid

• ADP and Epinephrine are biphasic

• No secondary phase w epi & ADP in

storage pool defects & aspirin
• 1. Normal coagulation
• 2. Tests of coagulation
•3. Hemorrhagic and thrombotic disorders
Platelet vs. factor bleeding

• Petechiae • Hematoma\hemarthrosis
• menorrhagia • Large bruises
• Female • Male
• No family history • + family history
• vWD, BS dz • Coag disorders
• Thrombocytopenia

• Bernard-Soulier Disorder
• Glanzmann thrombasthenia
• May Hegglin

• Adhesion problem (like in beginning of lecture)

• defect GP1b/V/IX (CD42)
• large giant platelet w pseudonucleolus
• thrombocytopenia
• Nl PT, PTT, bleeding time
• impaired ristocetin aggregation

• If you add normal ptls + ristocetin, aggregation will

be nl b/c the abnormality is on the patients plt.


LGPIb Ladhesion,
bleeding occurs
Bernard Soulier Disorder
Glanzmann thrombasthenia

• Aggregation problem, Plts can’t bind fibrinogen

• abnormal GP IIb/IIIa
• normal plt count, morphology (pts dispersed);
• L aggregation ADP, collagen, and EPI, but normal with ristocetin

• Dx: Clot retraction test- clot no retract test tube

• Diff dx: Glanzmanns and afibrinogenemia both defect in

fibrin:fibrin interactions
• Glanzmann’s has nl Pt/PTT, Afibrinogenima has ↑PT + PTT
No aggregation,

Nl adhesion

Glanzmann thrombasthemia
May Hegglin Anomaly
mutated myosin heavy chain 9
Dohle body (RER) + giant plt
Little bleeding
Autosomal dominant
High yield board fact
• Giant Platelets
• ITP, May Hegglin, gray platelet
syndrome, Bernard Soulier, Montreal plt
• Mediteranean macrothromocytosis.
• Sebastian, Fechner, Epstein, and Alport
Storage Pool Deficiency
always on boards, never in clinical

• L plt aggregation due to deficiencies in

either dense granules/ alpha granule
contents or both
• Nl morphology, no granules EM
• Plt agg: NO 20nd wave-ADP, EPI,
• Impaired collagen, AA normal ristocetin
• ↑ ATP:ADP ratio
Storage pool deficiencies

• Gray platelet syndrome • Chediak Higashi

No α granules, No δ granules EM
Large gray plts, no granules
From cardio pulmonary bypass • Hermansky-Pudlak Syndrome
Plt agg blunted with all agents No δ granules EM
except ADP/epi K pigment reticuloendothelial
• Quebec plt disorder • Swiss cheese platelets
No α granules • ↑AK, nevi, tumors, pulmonary
• Wiscott Aldrich syndrome • Puerto Rican/Swiss, ↑vW
No δ granules EM • Thrombocytopenia w absent
Small granulated plts, like FeDa
Thrombocytopenia, infection,
Alpha Granule Deficiency

agranular gray colored platelets

Acquired Disorders of Platelet
• Drugs
• Uremia
– abnormal adhesion, abnormal aggregation
(ADP, epi, collagen)
• Myeloproliferative disorders
• Cardiopulmonary bypass
– Transient plt activation, ↓granules

• L platelet function by acetylation of platelet

cyclo-oxygenase Æ L thromboxane formation
• platelet aggregation studies
L 2nd wave to ADP and epi, absent response
to collagen and arachidonic acid
Other plt type bleeding disorders

• Hereditary Telangectasia • Arteriovenous malformation,

• Osler-Weber-Rendu ↓ plts
• Oral Telangectasia FeDA
• Scurvy, Vit C, bad teeth,
• Ehlers Danlos, Type 4 perifollicular petechiae
• Connect tissue disorder plts
cant stick, bruising and • Marfans, osteogenesis
prupura, loose skin imperfecta, fabry syndrome

• Hemoch-schonlein vasculitis, • Amyloidosis--F10

prupura, thrombocytopenia • Platelets don’t stick,
endothelium coated, lambda
light chains
Von Willebrand factor amd
• vWF binds to F8
• Consists of large multimers which are cleaved
by ADAMTS-13; deficiency of this protein
associated with TTP
• vWD most common genetic plt type bleeding
• chr 12 autosomal dominant
• 1-2% prevalence worldwide.
• ↓vWF-blood type O, old blood sit
• Quant or qual deficiencies
• Secondary vWF deficiency -Wilms tumor,
congenital heart disease, hypothyroid
VWD diagnostic tests
1. Platelet count 5. RIPA Ristocetin induced
Plts ↓sometimes, screening test platelet aggregation
2. FVIIICo measure F8 activity • pts plasma + pt plts + low dose
3. VWF Ag ristocetin = time to aggregation
measures vWF quantity • all or none, does pt aggregate w
blood add F8Æmeasure vWF
4. vWF:Rcof 7. platelet agg studies
measures vWF activity
Pt plasma + nl plts + ristocetin, 8. VWF multimers
then measure time to
• very specific & most sensitive 9. mixing study
• Qantitate pt vWF activity (%)
using ristocetin, standard curve
with quantitative endpoint
von Willebrand factor antigen
(Factor VIII R:Ag
Laurel rocket
(old test probably
on boards) images/
vWD Type I

• associated with low quantity, normal

multimers Functionally normal
• Most common type
• Sometimes all tests are normal
• Only type treated w DDAVP
• Mutations throughout the gene or no
vWD type 2a and 2b
• Type 2a
•  large and medium sized multimers
• a disproportionately low vWF:RCo (quality) relative to vWFAg (quantity)

• Type 2b
• large multimers
• ↑affinity HMW multimers for GP1b
• leads to increase clearance of vWF

• Type 3
• Autosomal recessive, most AD
• Severe marked deficiency
• Absence of vWF, F8 also low
• But may have nl coag parameters
• VWF too low for multimers
vWD multimers analysis
vWF 2M and 2N
• Type 2M
• Defect in GP 1b binding
• vWF made but doesn’t work, vWFRco
• Sometimes nl—RIPA, multimers, vWF Ag, F8
• Suspect when vwf:Rcof < vwf Ag

• Type 2N (Normandy)
• Defective F8 binding
• Vwf decreased affinity for F8
• Hemophilia-like (but AR), women w low F8, think of this dz

• Tests:  VIII:C levels

• Normal RIPA, vWFAg, multimers, nl ristocetin
Pseudo VWF—platelet type

• ↑affinity plt GP1b for plasma vWD receptor

• Plts bind large VWF multimers There are less large
vWF circulating
• Abn RIPA studies
• Spontaneous aggregation with risto
• Needs a higher concentration of ristocetin than 2B.
• Plt agg w cryoprecipitate, unlike 2B
• Plt agg studies show large VWF multimers
• The abnormality is only on the pt plts.
Factor deficiencies

• Bleeding into joints

• PT, PTT or both
• Often nl bleeding time

• Typically X-linked recessive disorders (female

carriers, affected males)
• Hemophilia A – Lfactor VIII
• Hemophilia B – Lfactor IX Symptoms rare if
factor level > 15-20%; severe disease if levels
< 1%

Hemophilia board trivia

• Mixing studies: correction of PTT immediately and

at 1 hour

• F8 carriers
• -woman whos dad has hemophilia
• -mom of hemophiliac child Nl Dad XY, carrier mom XHX

• 50% daughters carriers

• 50% sons affected

• female w mild F8 def is possible w Lyon hypothesis, Turner (XO)

• Chr (Xq28), 50% intron 22 inversion

(Christmas Disease)

• Less common than Hemophilia A (1/20,000)

• Male patients/ X linked recessive.


• Severely affected patient are less common

than in Hemophilia A.
• Inhibitors may develop after treatment, requiring huge amounts
of factors
• Inhibitors don’t correct after mixing studies
• F8 inhibitor corrects initially prolongs after 1hr.

• Bethesda unit is a measure of the strength of the inhibitor

• 1 Bethesda unit = 50% activity
• 2 Bethesda units = 25% activity
• 3 Bethesda units = 12.5% activity

• 20% of patients with Hemophilia A.

• 1-3% of patients with Hemophilia B.
Other factor deficiencies
F9 deficiency FXII deficiency
F9 inhibitors can get anaphylaxis • ↓prekallikrein, ↓HMWF,
when treated • ↑ PTT, but no bleeding.
• Tx: F9 conc—PTcomplex concentrate • ↓F12-Hageman-↑PTT, but thrombosis
• FFP, whole blood, NO cryoprecipate • mixing study prolonged
• F8-100% dose recovery, t1/2 12hrs
• F9-30% dose recovery, 1/1/2 8 hrs F13 deficiency
nl PT, nl PTT,
FX11 deficiency cant crosslink fibrin
• hemophilia C, Jews, • Clot stability test-clot can’t stop 5M
• mild bleeding, urea from dissolving clot < 24hrs,
• Autosomal recessive unlike other nl>24hrs
hemophiliac • 1% monochloracetic acid
• Can’t activate TAFI
Fibrinogen problems
• 50% no symptom, 25% bleed, 25%clot
• Hereditary AD—rare
• Acquired-liver disease

• Afibrinogenemia
• Quantitative, AR
• mixing study corrects
• Dysfibrinogenemia
• AD, thrombophilic, qualitative
• Mixing study partial corrects-inhibitor

• ↑Reptilase time, ↑Thrombin time

• Platelet Agg Tests --Ldec ADP, EPI & AA
• Fibrinogen antigenic assay

• ↑Fibrinogen--acute phase response

Vit K deficiency

• Inc Pt, PTT, nl TT,

• γcarboxylation of glu F2, 7, 9, 10
• ↓ vitK-malabsorbtion, antibiotics, Breast milk,
anticonvulsant, biliary obstruction
• Hemorrhagic disease newborns
Liver Disease
• Loss of many clotting factors
• Vitamin K deficiency in cholestatic liver disease due
to reduced absorption of bile salts
• L plts, PTT PTT, TT, reptilase, BT,
• Decreased Factors I, II,V,VII, IX, X, XI
• Factor 8, VWF, may be increased in acute disease
α2 antiplasmin deficiency

• nl PT, nl PTT, bleed

• ↓euglobulin lysis time--measures the time to
dissolve a clot
• ↓Euglobulin lysis test <2hrs
• also ↓ in fibrinogen, DIC, ↑ tPA

• tx: Amicar, transexamic acid


• Plt type bleeding

• Lproduction
– marrow suppression, drugs, congenital
(Fanconis, Wiscott Aldrich)
• destruction

• Plt clumping in blood prep w EDTA

• antibodies to GPIIb/IIIa causes plts to
• Platelet count in sodium citrate
anticoagulant usually normal
• Platelet satellitism --In vitro platelet
adherence to leukocytes in EDTA
anticoagulated blood
Plt clumping Plt satellitism
Disseminated Intravascular
• Patient bleeding, thrombosing or both, typically with progressive
organ dysfunction
• Acute bleed, chronic clot
• Peripheral smear anemia w schistocytes

• Lab findings
• PT, PTT, TT, Lplt count, Lfibrinogen, LATIII, Lplasminogen
• ↓prot C, S, ATIII, α2antitrypsin,
• FDPs sensitive not specific.
• D-dimer specific,
• Protamine sulfate
TTP/HUS-- a board favorite
• Clinical manifestations: hemolytic anemia w schistocytes, Lplts, fever,
neural probs, renal dysfunction, abdominal pain
• Microthrombi in different organs

• TTP Big vWF multimers, cant cleave, shear RBC causing MAHA
• HUS normal vWF cleavage protease

• HUS--Shiga toxin, salmonella, E.coli 0157:H7

• Labs: same as DIC except fibrinogen normal, (↓DIC)

• Kids present w renal failure
• Adults present w neuo symptoms

• Tx
• TTP: FFP + steroids +Ivig + splenectomy., don’t give platelets
• HUS: supportive + antibiotics
• HUS + TTP are treated differently.

CD 61
• Predisposition to thrombosis from familial or acquired
disorders of hemostasis

• Inherited disorders of thrombosis

– Resistance of activated protein C 6% caucasions
– Prothrombin G20210A mutation 2% caucasions
– Protein C deficiency Less common
– Protein S deficiency
– Antithrombin deficiency
– Hyperhomocysteinemia
• Acquired disorders of thrombosis
– Lupus anticoagulant
– Heparin Induced Thrombocytopenia
Activated Prot C resistance
• Most common cause of thrombophilia
• usually due to point mutation in factor V, which prevents inactivation by
protein C, so prothrombin production is unchecked and you get fibrosis

• Factor V gene Mutation:

1. Arg for gln at position 506 (Factor V Leiden)
2. Arg for threonine at position 306 (Factor V Cambridge)
• 1. Functional assay-(PTTresistance ratio)
• Screening test
• Normal Add ProtC should ↑ PTT >2:1
• APCR add Prot C, ↑ PTT <2:1

• 2. PCR for Factor V Leiden mutations

Protein C Deficiency
• neonatal fulminans, homozygous
• Heterozygous
– Type I: reduced protein
– Type II: defective protein
• Venous thromboembolism
• Coumadin Æ skin necrosis
• Laboratory diagnosis:
– Patient must be off Coumadin
– Heterozygous levels may overlap normal
Protein S Deficiency
• Prevalence not known. Autosomal dominant
– Type I: low total and free Protein S
– Type II: normal total and free, decreased activity
– Type III: normal total, decreased free Protein S
• Venous thromboembolism
• Laboratory diagnosis:
– Patient must be off Coumadin
– Heterozygous levels overlap with normal
Protein S def

• Prot S is a cofactor to Prot C

• 60% Protein S binds to C4b binding protein
• Only 40% is free, that is the functional protein S

• C4b is an acute phase reactant, C4b, LProtein S

• Thus ↓ Prot S during stress

• Labs: protein S
2. total protein S
3. protein S activity (best test)

• Autosomal dominant
Antithrombin III deficiency
• Antithrombin binds to heparin to inhibit factors II and X.
• In ATIII deficiency, patient presents w ↓response to heparin

• Acquired- liver, nephrotic dz, DIC,

Prothrombin G20210A Mutation
• Point mutation leads to high prothrombin levels

• Guanidine to adenine substitution in the 3’

untranslated portion of prothrombin gene on Chr 11
Anti-phospholipid Syndrome
• antibodies against phospholipids
- most commonly to β2-glycoprotein,
also anticardiolipin, anti lupus anticoagulant

• Clinical features:
– Systemic Lupus Erythematosis (15-30% of cases)
– Venous thrombosis
– Peripheral arterial thrombosis
– Myocardial infarction
– Stroke or ischemic attacks (<55 years)
– Recurrent fetal loss
– Thrombocytopenia

– Lplatelets but thrombosis

• You do not have to have lupus
anticoagulant to have this syndrome
Antiphospholipid antibody tests

• 1.PTT

• 2. Dilute Russell viper venom test (AKA strypven test)

• Russell Viper venom + Factor V, phospholipid and calcium
activates Factor X. Plasma containing lupus antibodies prolongs

• 3. Lupus anticoagulant antibodies

• ↑PTT (staclot), fails to correct w mixing study, but partial
correction w adding phospholipid

• 4. Anticardiolipin antibody--ELISA. NO ↑PTT

• 5. β2 Glycoprotein I antibodies--immunoassay
• 6. platelet neutralization procedure
PTT fails to correct w mixing study, but PTT
corrects when you add hexagonal phase
phosphatidyl ethanolamine

• 7. Kaolin clotting time

• 8. Nontreponemal VDRL/RPR
falsely positive in LA,
Heparin induced thrombocytopenia and
• IgG Ab to heparin PF4 complex in α granules
• Occurs in 8% unfractionated heparin, much less in LMW or porcine
• L platelets and thrombosis
• ↓ plts usually after 5-8 days

• Dx:
z Numerous assays; patient blood add heparin look for coagulation

• serotonin release assay

• Measure plt granule release
• Pt given low dose heparin, radioactive labeled serotonin released
• Pt given high dose heparin,immune complexed destroyed, so no serotonin
• PF4 ELISA-best test, measures Abs
• rapid turnaround, but often false +

• Tx:
• -Stop heparin/don’t give plts, no warfarin
• - thrombin inhibitors, monitored by PTT,
• Sulfhydryl amino acid needed for the formation of cysteine and
• level associated with venous thrombosis/atherosclerosis
• AR, lens dislocate, MR, peripheral neuropathy,
• sometimes folate ↓

• Dx:
• 1. serum levels
• 2. Methyl tetrahydrofolate reductase
• mutation 3. Mutation in CBS cysathionine
Board Questions/facts
• vWF made in Megas and endothelial cells
• Bernard Soulier
• vWF different subtypes/tests
• Platelet aggregation studies
• Differences b/t alpha and delta granules
• Storage pool disorders
• Differences b/t TTP and HUS
• Liver disease