Endgames Case Review

An older woman with spontaneous bruising

BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3863 (Published 21 September 2017) Cite this as: BMJ 2017;358:j3863
  1. Muhajir Mohamed, consultant haematologist, associate professor of medicine12,
  2. Ajay Prakash, senior haematology registrar1
  1. 1Department of medicine, Launceston General Hospital, Launceston, Tasmania, Australia
  2. 2Launceston Clinical School, University of Tasmania, Tasmania, Australia
  1. Correspondence to M Mohamed muhajirbm{at}yahoo.com

An 85 year old woman attended the emergency department with large bruises on her right forearm and left leg, which had appeared four days earlier. She had not sustained any injuries to account for the bruising. There was no bleeding from any other sites. Her only medical history was hypertension. Her medications included amlodipine and calcium supplements and she wasn’t taking aspirin, anticoagulants, or any over-the-counter medications. On examination there were extensive subcutaneous haematomas on the right forearm extending up to the upper arm and on the left leg extending up to the thigh (fig 1, 2). Initial investigations showed low haemoglobin of 95 g/L with a normal platelet count (369 × 109/L). Coagulation assays showed markedly elevated activated partial thromboplastin time of 74 seconds (reference range 25 to 35 seconds). Prothrombin time was normal (12.2 seconds, reference range: 11 to 13 seconds), however, and fibrinogen assay was within normal limits (3.8 g/L, reference range 1.5 to 4.0 g/L). Mixing studies with 1 part of patient’s plasma and 1 part of pooled normal plasma (1:1 mix) showed no correction of elevated activated partial thromboplastin time. Further tests were performed to determine the reason for the elevated activated partial thromboplastin time. Factor assays revealed very low level of factor VIII (<1 IU/dL, reference range 50 – 150 IU/dL), and factors IX, XI, and XII were within normal ranges.

Fig 1 Large subcutaneous haematoma in the right forearm extending to the upper arm

Fig 2 Extensive subcutaneous haematoma in the left foot …

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