A Case of Acquired Hemophilia A Complicating Gastric Carcinoma: A Rare Hemorrhagic Condition That Palliative Care Physicians May Encounter

Abstract: We report a case of acquired hemophilia A diagnosed after hospitalization in a palliative care unit. Case: The patient was an 86-year-old man diagnosed with gastric carcinoma one-year prior, who declined treatment but whose progress was being monitored. He was admitted to our hospital due to multiple, systemic, and subcutaneous bleeding and exacerbation of anemia. Blood testing revealed prolonged activated partial thromboplastin time (APTT), but the cause was unknown. Subcutaneous bleeding persisted after hospitalization, accompanied by pain. After admission to a palliative care unit, blood testing revealed only prolonged APTT; hence, a coagulation study was performed, resulting in a diagnosis of acquired hemophilia A. Immunosuppressive therapy was considered but was not performed as the patient’s progress was complicated by aspiration pneumonia for which antibiotics were ineffective, and the patient’s prognosis was determined to be short. The patient died on the 20th day after admission to the palliative care unit. Conclusion: Acquired hemophilia A is a rare hemorrhagic condition, but it is important to suspect it in cases involving prolonged APTT and spontaneous bleeding with no medical history or family history.

A case of burst ketamine therapy for opioid-resistant pain

<b>Purpose</b>: We report a patient with opioid-resistant pain in whom favorable pain control could be achieved with burst ketamine therapy. <b>Case</b>: A female in her fifties had been followed up due to pain associated with recurrence in the right thoracic cavity at the thoracotomy site after surgery for mesopharyngeal and hypopharyngeal cancer, free jejuna autograft reconstruction, and permanent tracheotomy. Oral drug administration became impossible due to dysphagia and nausea, and she was admitted because of unfavorable pain control. Although the opioid dose was increased, pain did not improve, and rescue medication was also ineffective. Opioid-resistant pain was suspected, and burst ketamine therapy was performed. The therapy was initiated with the continuous intravenous administration of 100 mg/day ketamine, which was increased to 300 mg/day and 500 mg/day after 24 and 48 hours, respectively, according to the degree of pain, and was continued for 5 days. As analgesic effects of morphine were obtained during ketamine administration, a higher dose of morphine was administered; as a result, a favorable pain control outcome was achieved, and the patient returned home. <b>Conclusion</b>: Burst ketamine therapy may be effective for the treatment of opioid-resistant pain. Palliat Care Res 2011;6(2): 358-364