Hot Seat Case # 113: 4 mo male with diffuse ecchymosis
Posted on: May 22, 2018, by : Nancy Gilchrist MD
Nancy Gilchrist, MD Children’s National Medical Center
with Kathy Brown, MD Children’s National Medical Center
Previously healthy 4 month old male presenting from OSH due to concerns for diffuse ecchymosis. Patient’s family had just moved from Brazil a few days prior and parents brought patient to OSH hospital for the bruising that is spreading.
OSH was concerned about NAT and completed a skeletal survey. Patient noted to have CBC of 33/5.2/16.7/500 with normal CMP other than mild elevation in liver enzymes (80s). OSH reported that patient is well appearing otherwise. Head CT was obtained and within normal limits. Got updating phone call that PT >100 and PTT >200.
In your ED, parents noted patient had bruising to the back and to the legs. Patient appeared to be in pain so parents gave about 2-3 doses of ¼ of an aspirin tablet from another country (parents unsure of dose). Patient had tactile fever yesterday which resolved. Parents deny any possible trauma. Patient received her 2 month vaccinations during which patient had some swelling and bruising at the injection site. Patient is otherwise feeding well and acting like herself.
PMHx: full term, up to date on vaccines with mild bruising at time of vaccinations, Born in Brazil.
FHx: none
Meds: no regular medications
Allergies: NKDA
ROS: Bruising, tactile fever yesterday, recent travel, no vomiting
Vital Signs: Afebrile, HR 151, BP 89/46, RR 36, O2 sat 96% on RA
General: Alert. appropriate for age.
Skin: Warm. no rash. Pale for ethnicity. Bilateral large bruises noted at flanks bilaterally. Bruising noted on upper right thigh and right axilla. .
Head: Normocephalic. atraumatic. Flat fontanelle
Neck: Supple. no lymphadenopathy.
Eye: Pupils are equal, round and reactive to light. extraocular movements are intact. normal conjunctiva. no discharge. no jaundice.
Ears, nose, mouth and throat: Tympanic membranes clear. Oral mucosa moist. No pharyngeal erythema or exudate.
Cardiovascular: Regular rate and rhythm. No murmur. Normal peripheral perfusion.
Respiratory: Lungs are clear to auscultation. respirations are non-labored.
Gastrointestinal: Soft. Nontender. Non distended. Hepatomegaly present.
Musculoskeletal: Normal ROM. normal strength. no tenderness. no swelling. no deformity.
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Cool case!
First of all, there’s no way this child is getting admitted to the floor, btw with a bleeding diathesis and a hemoglobin of 5, so I’d probably get the ball rolling and put in for a PICU (or NICU) bed rather than calling a consultant.
Of course you’re going to confirm some of the levels are correct while getting a type and cross, ordering blood and debating the utility of FFP/cryo….but in the meantime I would look in the abdomen to make sure the kid isn’t bleeding in the belly. I would think an US would be sufficient here at least for starters. If the kid really has hepatomegaly then i guess its conceivable to have a big venous malformation or hemangioendothelioma in the liver, although i would think if this was the case the abdomen would be hugely distended and the infant would be tachypneic from small lung volumes.
I think you have to assume that the child has a major congenital bleeding disorder because there aren’t many things that cause BOTH factors to be prolonged…..especially with a normal albumin and bilirubin. So I would be thinking about Factor X or V deficiency or whatever else is in that final common pathway. Bonus points if you can draw the intrinsic/extrinsic diagram. The platelets being normal makes DIC unlikely, also make Kasselbach Merritt unlikely. And if the albumin and AST/ALT are relatively normal, sounds like fulminant liver failure is unlikely.
I have no idea why aspirin would matter here…i don’t know if 4mo without influenza can get Reye syndrome, but its always fun to call Barb at Poison Control, great thing to ask a resident to do while you ask Ron to draw blood from the smallest vessel assuming it isn’t going to clot off until tomorrow. Great news that the head CT is negative.
Watch out for high output heart failure if the kid continues to bleed. HR of 150 is pretty reassuring to be honest, probably going on for a while and not hyper-acute. maybe the floor will take him. ha!
Cool case. teach us 🙂
While this certainly smells of a bleeding diathesis and less likely NAT, I would be careful not to “rule out” NAT at this point- traumatic bleeding can lead to anemia and coagulopathy, and those with underlying bleeding disorders can still have inflicted trauma- so I would be eager to image the abdomen given the presence of flank bruising and transaminitis. The best test for this would likely be an abdominal CT.