Spontaneous bruising in an elderly woman.

Accepted 20 August 1997 A 75-year-old widow who lived alone with little social support was admitted to hospital after she was found by neighbours collapsed. She denied any medical history of note. There was no history of alcohol abuse and she was a lifetime non-smoker. Temperature on admission was 34.9°C rectal. She was noted to have extensive bruising over her legs and had spontaneous bleeding from her gums which were also noted to be abnormal (figure 1). Her weight on admission was 44.7 kg, height 148 cm, and body mass index (BMI) 21. The remainder of the physical examination was unremarkable and neurologically she was intact. Initial investigations included a haemoglobin of 8.9 g/dl and a normal white blood count, platelets, and mean corpuscular volume. A blood film showed schistocytes, a few hypersegmented neutrophils and burr cells. Erythrocyte sedimentation rate was 10 mm first hour, bilirubin 38 ,umol/l (normal < 18), total protein 69 g/dl, albumin 39 g/dl, alkaline phosphatase 157 IU/1, gamma glutamyl aminotransferase 9 IU/l, alanine aminotransferase 8 IU/1, sodium 141 mmol/l, potassium 4.3 mmol/l, urea 22 mmol/l, creatinine 133 gmol/l. Other initial investigations included normal thyroid function, glucose, amylase, calcium, auto-antibody screen, protein strip, serum vitamin B1,2 and serum ferritin. Her serum folate was 0.8 ,ug/l (1.7-13.0), red cell folate 86 ,ug//l (85-500), fibrinogen 2.5 g/l (1.5-4.0), thrombin time 13 s (12-16), prothrombin time 18 s (1014), activated partial thromboplastin time (APTT) 27 s (26-40). A chest X-ray showed a retrocardiac shadow due to a hiatus hernia. A gastroscopy showed a sliding hiatus hernia, erosive gastritis and duodenitis CLO test negative. Biopsy showed a mild chronic gastritis. Two days after admission she was noted to have developed further swelling in both lower limbs with a deterioration in her bruising (figure 2). Her haemoglobin subsequently dropped to 6.8 g/dl and her bilirubin rose to 70 imol/l, the rest ofher liver function tests being normal. Her urea, creatinine and international normalised ratio (INR) corrected promptly with fluid replacement and oral vitamin K but her spontaneous bleeding persisted.