"Why did my CPAP beat me up?" Bilateral periorbital ecchymosis associated with continuous positive airway pressure therapy.

T patient is a 63-year-old man with past medical history of hypertension, coronary artery disease, diabetes mellitus, hyperlipidemia, gastroesophageal refl ux disease, and obstructive sleep apnea (OSA) diagnosed at the age of 58. Medications include aspirin 325 mg daily and clopidogrel 75 mg daily for 2 years without complication; clonazepam 1 mg daily, gemfi brozil 600 mg twice daily, metoprolol 12.5 mg twice daily, niacin 500 mg daily, ranitidine 150 mg twice daily, rosuvastatin 10 mg daily, and valsartan 160 mg daily. Two months ago he started using vitamin E 1000 international units per day and fi sh oil supplements. For 5 years he has been compliant with continuous positive airway pressure (CPAP) of 10 cm through a soft nasal pillow interface and soft head gear without complication. CPAP compliance card report indicates 100% CPAP use > 4 h/day, average use 9 h/day, and no signifi cant air leaks. He now presents with 2 episodes of bruising around his eyes upon awakening following nocturnal CPAP use. He initially noticed bruising around the left eye which resolved over the course of one month. He did not pursue evaluation or treatment. Then he noticed new bruising around the right eye. He denied history of trauma, headaches, eye dryness or pain, vision changes, cough, sinus pain, or nasal discharge. He denied strenuous exercise or weight lifting. Signifi cant air leak from his CPAP mask was not detected. He denied any other bleeding, including gums, urinary tract, or rectum.