Factor VII deficiency

Factor VII deficiency (also known as Alexander’s disease) is a type of clotting disorder. A specific protein is missing from the blood so that injured blood vessels cannot heal in the usual way. This information sheet from Great Ormond Street Hospital (GOSH) explains the causes, symptoms and treatment of Factor VII deficiency and where to get help.

Blood is made up of different types of cells (red blood cells, white blood cells and platelets) all suspended in a straw-coloured liquid called plasma. Platelets are the cells responsible for making blood clot. When a blood vessel is injured, platelets clump together to block the injury site. They also start off a complicated chemical reaction to form a mesh made of a substance called fibrin.

This complicated chemical reaction always follows a strict pattern – with each clotting protein (known as a coagulation factor) turned on in order. When all of the factors are turned on, the blood forms a clot which stops the injury site bleeding any further.

There are a number of coagulation factors circulating in the blood, lying in wait to be turned on when an injury occurs. If any one of the factors is missing from the body, the complicated chemical reaction described above will not happen as it should. This can lead to blood loss, which can be severe and life-threatening.

Each coagulation factor is given a number from I to XIII – they are always written as Roman numerals – and the effects of the missing factor will vary. A clotting (or coagulation) disorder is a medical condition where a specific protein is missing from the blood.

Factor VII deficiency is thought to be the most common of rare clotting disorders, affecting 1 in 300,000 to 500,000 people worldwide. The specific coagulation factor that is missing or reduced is Factor VII. There are two types of Factor VII deficiency:

• Type 1 is where the Factor VII is absent or in low levels in the blood.
• Type 2 is where Factor VII is present but it does not work properly.

Human beings have about 30,000 to 40,000 different genes, each of which has a function in making an individual person. The genes are arranged in pairs (one of the pair from each parent) on 23 chromosomes – inevitably some of these genes are faulty.

Factor VII deficiency is caused by a mutation (change) on the F7 gene, which is inherited in an autosomal recessive manner. This means that a person has to inherit the faulty gene from both parents to develop the disease. Autosomal recessive disorders are more common in areas of the world where marriage between close relatives is common.

Each pregnancy carries a:

• 75 per cent chance of having an unaffected child
• 25 per cent chance of having an affected child

The age at which symptoms appear varies, depending on the amount of Factor VII in the blood and how well it is working.

Children with little or no Factor VII may start to show symptoms soon after birth, whereas those with some functioning Factor VII may not show symptoms until later, often following surgery or injury.

The symptoms of Factor VII deficiency vary in severity, even between members of the same family. In many cases, the symptoms of Factor VII deficiency are so mild that they cause no problems.

People with a severe deficiency of Factor VII can have problems with bleeding – such as bleeding more severely following injury or for a longer time. This is because the level of Factor VII in the blood is too low to complete the clotting process as described earlier. Bleeding may occur inside the body as well as from the skin – this can include bleeds inside the joints. Mouth bleeds following dental work can also occur, as can blood loss during childbirth or heavy menstrual periods.

Factor VII deficiency can be diagnosed before birth (prenatally) if there is a family history. There are several options for this including chorionic villus sampling (CVS) early in pregnancy or amniocentesis around 15 to 20 weeks or so.

In babies, a clotting disorder may be suspected following a bleed inside the brain (intracranial haemorrhage) or if bleeding continues after the umbilical cord is cut or after surgery such as circumcision.

In older children and adults the suspicion of a clotting disorder might arise because of bruising or bleeding or during routine checks before an operation or following an injury. Factor VII deficiency is diagnosed more in females than males due to menstruation and child birth.

Factor VII deficiency can be diagnosed using a sample of blood for testing in the laboratory. A test to measure how long a sample takes to clot may suggest a clotting disorder, which would then be investigated further. The level of Factor VII in the blood will be checked and doctors will try to identify the gene mutation as well, as this can be helpful for planning future brothers and sisters and for testing other family members.

Imaging scans, such as MRI, CT or ultrasound scans may be used to identify any internal bleeds, for instance, inside a joint.

If symptoms are not problematic or the level of FVII is only mildly reduced, treatment may not be needed. In many cases, what treatment is needed is on an on demand basis to treat symptoms as they occur rather than preventative (prophylaxis). Treatment aims to replace the missing or reduce Factor VII with a man-made substitute given as an injection.

It is important that people with Factor VII deficiency should not use Non-Steroidal Anti-Inflammatory Drugs (NSAIDs such as ibuprofen) as this greatly increases the risk of bleeding. Other methods of pain relief should be used instead.

Caution is needed for injections as well – immunisations for instance, should be given subcutaneously (under the skin) rather than intramuscularly (into a muscle) to reduce the risk of a painful bruised swelling (haematoma) developing.

Children and young people with Factor VII deficiency will need regular reviews at their specialist centre to check that they are responding to treatment and not experiencing any side effects. This review will usually involve a check-up from the physiotherapist and dentist as well.

Children and young people with Factor VII deficiency have a normal life span. Some activities may need to be avoided, such as contact sports that carry a high risk of head injury for instance, but most day to day activities will cause few problems.

It is always advisable to wear a medical alert identity necklace or bracelet to alert health care professionals about having Factor VII deficiency – details are available via The Haemophilia Society support organisation. Any surgery or future pregnancy will need careful planning in advance so it is important that all health care professionals involved are aware.

As Factor VII deficiency is a genetic condition that can be passed on from parent to child, it is possible to have genetic counselling before planning a family, both for affected individuals and unaffected carriers. Talk to us about a referral to our Clinical Genetics service.

Children and young people with Factor VII deficiency need life-long monitoring and treatment, so as a child approaches their teenage years, we will start to talk to them about getting ready to move on to adult health services. This is a planned process so that they become more independent as they grow older and able to manage their own health.