Infant with Factor VIII Deficiency Develops Complications from Circumcision

Inhibitors are one of the worst outcomes for any hemophilia patient, as these patients have the greatest morbidities of this disease. The difficulty in hemophilia is that it is rare. Despite a very dedicated and motivated network of clinical and research centers, there is little prospective data, and the limited data out there is actively disputed. There are many risk factors related to inhibitor development and they are well known and summarized in every review article on this topic. In this case, intensive treatment, and treatment during a time of inflammation will be contributory. However, the patient was treated before SIPPET results were known so he likely received recombinant FVIII. Even that study, which is a global randomized multicenter study, is not conclusive to many people, but confirmed genetic risk factors (which were known and this patient may have) as an important risk factor. More importantly, it implied that recombinant FVIII was associated with a higher rate of inhibitors. I would say that >95% of new severe hemophilia patients in the USA got recombinant FVIII in 2013-14. In SIPPET, the recombinant group had an incidence of >40%. In general, we think that 30% of all severe hemophilia A patients will develop inhibitors and that 70% of those can be tolerated. In this case, I think that the delay to Dx is a true problem.  I suppose that with more details, the care delivered could be questioned. But whether or not this boy would or would not have developed an inhibitor regardless of this history will always be debatable, even in the presence of risk factors.