We report the case of an 84 yearold patient with AHA who presented replenished bleeding in the muscle and liver tissue.
The patient was admitted in the Emergency Room of the “Sant’Andrea" hospital for acrocyanosis and algia of the right upper limb. He also reported dyspnea the week prior to emergency room access and denied any traumatic event to the affected limb.
He presented a pathological history of COPD, a pulmonary adenocarcinoma in the LID, which was already been treated with CHT and in a state of follow up by another hospital, hypertension, and previous IMA in 2018.
The home therapy included Ramipril, Cardioaspirin, Bisoprolol,Spironolactone, Pantoprazolo and Furosemide.
The patient reported having stopped Clopidogrel about 2 weeks before admission under the advice of his doctor, due to the appearance of a large hematoma on the affected limb.
Physical examination at the entrance: “Alert patient, oriented, pale skin, not sweaty, moderate hemodynamic compensation, right upper limb increased in volume, edematous, brachial and radial pulse not very detectable but present".
Vital signs BP 100/60, HR 90, SpO2 99%.
Hematochemical tests were then performed which documented a normocytic normochromic anemia, HB 7.2 g / dl, RBC 2.5, PLT 263,000, WBC 7.090 with appropriate formula, liver and kidney functions in normal range, INR 1.08, aPTT 2.24, D-Dimer 2856 .
During the period in the emergency room a transfusion with 1U of concentrated red blood cells was administered and requested a chest and upper limb Angio-CT which documented:
"... Is reported the presence of a volumetric increase in the right arm, compared to the contralateral one, due to the presence of ablood collection in the context of the biceps muscle in the perihumeral site…After mdc is observed a blood spreading of mdc as for bleeding in the active phase.
Collaterally to the VII hepatic segment area of focal hypodensity of 3.5cm in which context blood spreading is observed as for bleeding in the active phase. "
An upper limb arteriography was therefore performed and a superselective catheterization, with subsequent embolization.
Despite the procedure, the patient continued to have variability in his hemoglobin and coagulation values.
After that the patient was admitted to the “Medicina d’Urgenza “ department: blood chemistry tests were repeated which confirmed the presence of hemoglobin values of 7.1 g / dl despitetransfusion support, normal liver and kidney function, normal inflammation indices, INR 1.07, aPTT 2.51 (VN 0.8- 1.2) 79sec.
From an interview with the patient and with his son we learned that in the preceding months the patient had made 4 admissions to different hospitals for episodes of acute anemia, without mention of any trauma.
It was decided to carry out a new transfusion and a thorough coagulation screen was performed, showing an isolated factor VIII deficiency (0.7%, reference range 50-150).
At the time of diagnosis, the patient decided to resign against medical advice, giving up therapy, relying on home palliative care.
Tab.1 Coagulation parameters of the patient.
PT
Normal range
0.9-1.2
70-120%
10-13sec
|
1.16
79%
13.9sec
|
aPTT
n.r.
25-35sec
08-1.2
|
74 sec
2.36 ratio
|
D-Dimer
nr < 243
|
5498 ng/ml
|
Fibrinogen
n.r 200-400
|
446 mg/ml
|
Factor VIII
Nr 50-150%
|
0.7%
|
Factor IX
65-150%
|
89%
|