Unusual Bleeding Research Articles

Acute dysphagia after myocardial infarction: an unusual complication of anticoagulation therapy

Antiplatelet medications such as aspirin, clopidogrel or prasugrel are commonly used in patients with myocardial infarction (MI) and stent implantation. Additionally, thrombolytic therapy is recommended for patients in whom a coronary intervention cannot be performed in a timely manner. Both classes of drugs put patients at risk for major bleeding complications. However, also unusual bleeding complications can lead to serious complications. A 55-year-old male contacted the emergency medical service with acute onset of chest pain beginning 1.5 h before. The ECG showed typical ST-segment elevations (Fig. 1). An inferior MI was diagnosed, and a pre-hospital thrombolytic therapy with 10,000 units of tenecteplase was administered. On admission to our hospital, the chest pain was still present but reduced. The ECG showed persistent ST-segment elevations and a rescue percutaneous coronary intervention was performed. An additional 6,000 IE of heparin were given for the intervention. An acute occlusion of the right coronary artery was successfully reopened and a drug-eluting stent (tacrolimus-eluting-stent, TAXUS®, Boston Scientific) was placed (Fig. 2). In the clinical course, cardiac ultrasound showed a moderate impairment of left ventricular function (LVEF 40%). The patient was treated with aspirin 100 mg/d and prasugrel 10 mg/d. Two days later, the patient developed a progressively sore throat and reported new-onset dysphagia. Within the next few hours, a progressive swelling of the left cervical region occurred. Emergency computed tomography of the neck showed a massive left sided tumour, consistent with a large bleeding into a thyroidal cyst. The diameters of the haematoma were 13 × 7 × 6 cm, with displacement and compression of trachea to 6 mm (Fig. 3). To secure the airways, the patient was endotracheally intubated without problems. An immediate left hemithyreoidectomy with decompression of the haematoma was performed. The patient recovered quickly after the operation. Histological findings showed no evidence of malignancy. Spontaneous haemorrhage into a thyroid cyst is a rare condition. When causing airway obstruction, this life-threatening situation requires immediate airway protection before complete obstruction occurs. In the literature, some cases of retropharyngeal or thyreoideal haematoma have been reported as complications of medical manoeuvres such as intubation or thyroid puncture, or as a complication of chronic anticoagulation therapy with warfarin or marcumar. To the best of our knowledge, this is the first description of a spontaneous haemorrhage into a thyroid cyst under aspirin and prasugrel. Prasugrel is known to lead to more pronounced platelet inhibition than clopidogrel, resulting in a four to five times longer bleeding time and a faster onset of action. Clearly, the faster and more effective platelet inhibition obtained by prasugrel may lead to an increased risk of major and even atypical bleeding events after previous fibrinolytic therapy.

Bleeding from the eyes and through intact skin: Physiologic, structural, spiritual, or faked?

Patients with an apparent bleeding disorder can usually be diagnosed by a careful history, physical examination, and screening laboratory tests. However, at times the constellation of bleeding signs and symptoms fail to be explained by test results and/or our current understanding of hemostatic mechanisms. One such patient is the subject of the current report. She is a 13-year-old female with a history of striking bleeding manifestations, including spontaneous hemorrhage from her eyes, scalp, hands, and feet. She was evaluated by one of the authors at a teaching hospital in Mumbai, India in March 2009 during the filming of a National Geographic Channel documentary characterizing puzzling medical disorders encountered in India. Given her unusual bleeding manifestations, she received international media attention at the time. National Geographic and a film company in the United Kingdom subsequently expressed interest in highlighting the patient to document her seemingly rare hematologic disorder and contacted the American Society of Hematology to identify an American hematologist to further investigate the case. With consent of the family and collaboration with a hematologist practicing at a teaching hospital in Mumbai, filming commenced during March 2009 in an attempt to capture the patient's diagnosis and the cultural and medical milieu in which the bleeding events occurred.

Syndrome de Willebrand acquis : étude d’une série de neuf patients et revue de la littérature

PurposeWhereas von Willebrand disease is the most common constitutional bleeding disorder, acquired von Willebrand syndrome is rare. MethodsRetrospective, monocentric descriptive study of consecutive cases of acquired von Willebrand syndrome diagnosed between 2000 and 2012. Diagnostic criteria included: absence of a past history of mucocutaneous bleeding, with low plasma levels of factor VIII (FVIII) and von Willebrand factor (VWF), ristocetine cofactor activity (RCo) and antigen (Ag). ResultsNine men were diagnosed with von Willebrand syndrome. Six of them presented with recent mucocutaneous bleeding. In eight cases, the biological phenotype was a type 2 von Willebrand disease, with decreased VWF:RCo/VWF:Ag ratio. A lymphoproliferative disease with circulating paraprotein was identified in all patients, including one chronic lymphoid leukemia, three Waldenström and one marginal zone lymphomas, four monoclonal gammapathies of unknown significance. Screening for an anti-VWF inhibitor was negative. Symptomatic treatment using infusion of VWF concentrates was administrated in the presence of severe mucocutaneaous bleeding. Five patients received intravenous immunoglobulins with a good response only in patients with G isotype paraprotein. A chemotherapy was initiated if indicated for the underlying disorder. Three of the four patients who achieved remission of the associated lymphoma had a subsequent improvement of plasma VWF levels, while all other patients remained deficient. ConclusionAcquired von Willebrand syndrome is a rare but potentially serious disease. The diagnostic should be suspected in adults with unusual mucocutaneous bleeding, with or without prolonged partial thromboplastin time (PTT), and confirmed with a decreased plasma level of VWF (Ag and RCo). An associated haematological, neoplastic or cardiac valvular disease must be searched.

Unusual rectal bleeding caused by penetration of an intra‐pelvic migrated guide pin

Digestive EndoscopyVolume 25, Issue 4 p. 469-470 Letters, Techniques and Images Unusual rectal bleeding caused by penetration of an intra-pelvic migrated guide pin Fang-Jung Yu, Fang-Jung Yu Department of Internal Medicine, Faculty of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, TaiwanSearch for more papers by this authorChe-Jen Huang, Che-Jen Huang Department of Surgery, Faculty of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, TaiwanSearch for more papers by this authorJan-Sing Hsieh, Jan-Sing Hsieh Department of Surgery, Faculty of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, TaiwanSearch for more papers by this author Fang-Jung Yu, Fang-Jung Yu Department of Internal Medicine, Faculty of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, TaiwanSearch for more papers by this authorChe-Jen Huang, Che-Jen Huang Department of Surgery, Faculty of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, TaiwanSearch for more papers by this authorJan-Sing Hsieh, Jan-Sing Hsieh Department of Surgery, Faculty of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, TaiwanSearch for more papers by this author First published: 21 May 2013 https://doi.org/10.1111/den.12122Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume25, Issue4July 2013Pages 469-470 RelatedInformation

Symptomatic Primary (AL) Amyloidosis of the Stomach and Duodenum

Primary (AL) amyloidosis of the gastrointestinal tract is relatively rare, and symptomatic amyloidosis of the stomach is even more seldom. We present the case of a patient who was referred to upper endoscopy because of weight loss, nausea, and vomiting. Large areas of intramucosal hemorrhages were seen, and biopsies resulted in profuse bleeding stopped with endoscopic clips. The biopsies showed amyloid depositions and further workup revealed that the patient also had cardiac and neuropathic involvements. The patient started treatment with dexamethasone, melphalan and bortezomib. After treatment was started the nausea and epigastric discomfort improved, and a reduction in the biochemical markers troponin T, NT-proBNP, and M-component was observed. Gastric amyloidosis is rarely seen at upper endoscopy in patients without a previously established diagnosis, but the unusual endoscopic findings and bleeding tendency after biopsy should be kept in mind by gastroenterologists.

ENT bleeding and leech bite

Sir, The recent report on otorrhagia bleeding due to leech bite is very interesting.[1] Askari et al. concluded that “Leech infestation is a rare cause of otorrhagia and should be suspected in the endemic region in all of unusual bleeding; it can be diagnosed and treated by exact inspection and removal.”[1] Indeed, the leech infestation in the Ear-Nose-Throat (ENT) tract is sporadically seen in remote area of tropical countries. The root cause is usually due to the drinking of contaminated water. In Thailand, there are sporadically cases of ENT bleeding due to leech infestations, but the cases are usually not scientifically reported (some cases in the local document have the long history of infestations, more than three months: Thai Rath, 2012-11-04). Based on Thai experience, the intranasal leech infestation is usually seen in rural ethnic patients. Most cases were children and had the history of diving in the stream in the forest.[2,3] The chief complaint of the indexed cases included nasal congestion and occasional epistaxis.[3] Removal using alligator forceps and a rigid endoscope is the main therapeutic method.[2,3] In addition to the intranasal leech infestation, the other reports from Thailand on leech bit are usually in female genitourinary tract.[4,5] The important consideration is the good history-taking and physical examination to determine the infestation.

Diagnostic Dilemma in Postextraction Bleeding

Hemophilia is a disease of blood coagulation inherited as a sex linked recessive. The disorder is attributed to decreased blood levels of procoagulant factor VIII. However, mild forms of the disease with almost inapparent clotting defects have been reported. Patients with hemophilia often give a history of unusual bleeding associated with minor trauma. The disease may however remain undetected without such history. This article describes a case of a 5 years old with no positive history of any bleeding disorder, and the hemophilia remained undetected until the extraction of teeth.

Late-Onset Bowel Perforation and Iliac Artery Erosion After Prominent Anterior Spinal Instrumentation

Case report. To report a rare complication of anterior spine surgery and instrumentation. Anterior spinal fusion and instrumentation are now frequently used for the treatment of a variety of complex spinal disorders. Several authors have discussed the complications of such procedures. Late perforation of large bowel along with erosion of major vessel after anterior spinal instrumentation is a rare occurrence. We present a case of 53-year-old woman who presented with unusual abdominal pain and bleeding of the rectum. She had undergone spine surgery for L5 burst fracture 5 years ago. A detailed evaluation showed perforation of rectosigmoid colon and erosion of left common iliac artery by the anterior spine implants. The bowel was repaired and arterial reconstruction was done along with spine implant removal. The patient had complete recovery of symptoms after the treatment. Delayed visceral injury with anterior spine surgeries is rare. Early diagnosis is possible with a high degree of suspicion. Meticulous surgical techniques may avoid this complication.

Gynaecologic cancer symptom awareness, concern and care seeking among US women: a multi-site qualitative study

With limited screening options, early detection of gynaecologic cancers can depend on women recognizing the potential significance of symptoms and seeking care. We investigated women's concern about symptoms that might be related to gynaecologic cancers, the underlying conditions they associated with symptoms and their actual and hypothetical response to symptoms. Fifteen focus groups with women aged 40-60 years were conducted in Chicago, Los Angeles, Miami and New York City. Participants were given an untitled list of symptoms that could indicate various gynaecologic cancers and asked if any would concern them, what could cause each and what they would do if they experienced any of them. Overall, participants expressed greater concern about symptoms clearly gynaecologic in nature than other symptoms. Participants generally did not associate symptoms with any form of cancer. Some women who had experienced symptoms reported waiting an extended period before seeking care or not seeking care at all. The belief that a symptom indicated a benign condition was the most common reason given for delaying or foregoing care seeking. Strategies participants reported using to supplement or replace consultations with health care providers included Internet research and self-care. Raising awareness of symptoms that can indicate gynaecologic cancers may lead to earlier detection and improved survival. In particular, women should be informed that gynaecologic cancers can cause symptoms that may not seem related to the reproductive organs (e.g. back pain) and that unusual vaginal bleeding should prompt them to seek care immediately.

An update on pediatric bleeding disorders: Bleeding scores, benign joint hypermobility, and platelet function testing in the evaluation of the child with bleeding symptoms

Evaluating a child with symptoms of easy bruising and/or bleeding remains a challenge in pediatric hematology, and there is no "one size fits all" approach. This review focuses on recent research in three elements of the evaluation of a child with a suspected bleeding disorder. We will first discuss the development of the standardized Pediatric Bleeding Questionnaire, and its applications in research and clinical settings. We will then discuss the relationship between benign hypermobility syndromes and hemostasis, and the importance of including a Beighton Score in the physical examination of any child presenting with unusual bruising or bleeding. While prolonged bleeding times and abnormal platelet aggregation are common findings in children with benign hypermobility, normal coagulation studies do not exclude the presence of a connective tissue disorder in a child presenting with easy bleeding and joint hypermobility on examination. Finally, we will discuss the current state of knowledge regarding the laboratory evaluation of platelet function in children. Platelet function disorders are among the most common inherited bleeding disorders. However, testing for such disorders is time-consuming and requires a step-wise approach. We will review the indications for and limitations of the most commonly utilized platelet function laboratory studies.

Otorrhagia bleeding due to leech bite

Leeches are blood-sucking hermaphroditic parasites that attach to vertebrate hosts, bite through the skin, and suck out blood. When leeches feed, they secrete an anticoagulant (hirudin), which helps them get a full meal of blood. This is the first report of leech removal from external auditory canal. Previous leech involvement cases were explained in nasopharynx, larynx, pharynx, eye, and gastrointestinal tract. Prominent sign of all cases was active bleeding from the leech attachment site; that stopped with leech removal. A 24-year-old man was presented to Al-Zahra hospital with left otorrhagia and otalgia from 2 days ago. After suction of ear a small soft foreign body was seen in the external ear near the tympanic membrane, then the ear filled with glycerine phenice, the patient explained decreased movement of foreign body. Four hours later the bloody discharge stopped and otalgia decreased. After suction of clots, a leech was extruded from external auditory canal by alligator. Leech infestation is a rare cause of otorrhagia and should be suspected in the endemic region in all of unusual bleeding; it can be diagnosed and treated by exact inspection and removal.

Anticorps antipublic et prothèse totale de genou

We report the perioperative management of a woman expressing an antibody against high frequency red cell antigen (anti-Kel4 antibody anti-kpb) who was scheduled for a total knee replacement. A specific strategy was designed to afford this major orthopedic surgery, considering specially the occurrence of unusual bleeding higher than the average bleeding assessed in our hospital in this indication. The transfusion of incompatible red cells may be responsible for acute hemolytic reaction. An autologous transfusion program, including cryopreservation, erythropoietin and iron support, was provided. Three autologous red cells units were collected before surgery. Compatible homologous red cells units were also available at the French bank for rare blood groups. We report logistical and medical problems that have occurred during the perioperative period.

Unusual case of postextraction bleeding

Vascular anomalies often affect the soft tissues though primary intraosseous lesions are uncommon. A 29-year-old patient reported to the Oral and Maxillofacial Surgery department of SCB Dental College, Cuttack, with the complaint of unusual bleeding from his extracted tooth socket. After undergoing routine hematological and radiological investigations and an angiogram, a diagnosis of arteriovenous malformation of the right posterior maxilla involving the posterior superior alveolar artery was established. Subsequently, the patient was treated by right external carotid artery ligation followed by partial maxillectomy. Follow-up has been satisfactory all through.

Surgical management of unusual gastrointestinal bleeding and a left ventricular assist device

There is growing evidence that patients treated with continuous flow ventricular assist devices are at increased risk for bleeding complications beyond what would be expected for those requiring anti-coagulation therapy. However, the management of these patients is typically medical. We present a case of unusual gastrointestinal bleeding successfully managed with surgical intervention in a patient with a Heartmate II ventricular assist device.

Hepatobiliary and Pancreatic: Multiple sexually transmitted infections

Sexually transmitted infections continue to be a significant medical problem in men who have sex with men. Some of these patients will be seen in gastroenterology and hepatology clinics while others will attend clinics for sexually transmitted disorders. Although the recognition of acquired immunodeficiency syndrome (AIDS) was followed by the use of safer sex practices in the 1980s, epidemiologic studies now indicate increasing rates for at least some infections such as anorectal gonorrhea and syphilis. The common anorectal infections in homosexual men are herpes simplex virus, Neisseria gonorrhoeae, syphilis and Chlamydia trachomatis. Common symptoms include anal pain, an anal discharge, pruritis and pain with defecation. In patients who have diarrhea (without AIDS), common causative organisms are the protozoa, Giardia lamblia and Entamoeba histolytica, as well as bacterial pathogens such as Campylobacter and Clostridium difficile. Homosexual men also have a higher than expected frequency of hepatitis B and, to a lesser extent, hepatitis C. Again, risks for these infections increase in those with multiple sexual partners and with anal-receptive intercourse.The susceptibility of these patients to multiple gastrointestinal and other infections is illustrated by the following report. The patient was a 55-year-old man who was admitted to hospital with jaundice, an unusual rash and rectal bleeding. Apart from jaundice, he had small round papules on his palms and soles

Unusual duodenal polyp and GI bleeding: a word of caution! (with video)

Aortoduodenal fistulae are the most frequent aortoenteric fistulae. They may be primary, caused by spontaneous communication between an aortic aneurysm and an intestinal loop, or secondary, caused by surgical repair of aneurysms with prosthetic implants. An aortoduodenal fistula is a life-threatening complication of aortic graft surgery and a rare cause of upper GI bleeding. Upper endoscopy with evaluation of the distal duodenum is an important investigative procedure for early diagnosis. A high index of suspicion is needed because the period during which this procedure may be performed is brief, and a prompt diagnosis will lead to a timely surgical intervention.

Ultrasonographic Evaluation of Achilles Tendon Repair After Percutaneous Sectioning for the Correction of Congenital Clubfoot Residual Equinus

Most cases of congenital clubfoot treated with the Ponseti technique require percutaneous Achilles tenotomy to correct the residual equinus. Clinical evidence suggests that complete healing occurs between the cut tendon stumps, but there have not yet been any detailed studies investigating this reparative process. This study was performed to assess Achilles tendon repair after percutaneous section to correct the residual equinus of clubfoot treated with the Ponseti method. A prospective study analyzed 37 tenotomies in 26 patients with congenital clubfoot treated with the Ponseti technique, with a minimum follow-up of 1 year after the section. The tenotomy was performed percutaneously with a large-bore needle bevel with patient sedation and local anesthesia. Ultrasonographic scanning was performed after section to ascertain that the tenotomy had been completed and to measure the stump separation. In the follow-up period, the reparative process was followed ultrasonographically and assessed at 3 weeks, 6 months, and 1 year posttenotomy. The ultrasonography performed immediately after the procedure showed that in some cases, residual strands between the tendon ends persisted, and these were completely sectioned under ultrasound control. A mean retraction of 5.65 mm+/-2.26 mm (range, 2.3 to 11.0 mm) between tendon stumps after section was observed. Unusual bleeding occurred in one case and was controlled by digital pressure, with no interference with the final treatment. After 3 weeks, ultrasonography showed tendon repair with the tendon gap filled with irregular hypoechoic tissue, and also with transmission of muscle motion to the heel. Six months after tenotomy, there was structural filling with a fibrillar aspect, mild or moderate hypoechogenicity, and tendon scar thickening when compared with a normal tendon. One year after tenotomy, ultrasound showed a fibrillar structure and echogenicity at the repair site that was similar to a normal tendon, but with persistent tendon scarring thickness. There is a fast reparative process after Achilles tendon percutaneous section that reestablishes continuity between stumps. The reparative tissue evolved to tendon tissue with a normal ultrasonographic appearance except for mild thickening, suggesting a predominantly intrinsic repair mechanism.

Retropharyngeal haematoma – an unusual bleeding site in an anticoagulated patient: a case report

IntroductionAnticoagulation is used widely for the primary prevention of embolic events in patients with atrial fibrillation. Bleeding is the most common complication with oral anticoagulation. We describe the case of a patient who developed a massive retropharyngeal haematoma after a fall. Whilst the retropharyngeal space is an uncommon site for bleeding complications, it is clinically important as the development of upper airway obstruction may be life threatening.Case PresentationWe present the case of an 85-year-old Caucasian woman on warfarin, who developed a massive retropharyngeal haematoma after a fall. She initially presented with pulmonary oedema and Type 2 respiratory failure. She was commenced on treatment for this with a good clinical response. She subsequently deteriorated, developing stridor and bruising to the neck. She was urgently intubated and ventilated. Computerized Tomography scan showed a massive retropharyngeal haematoma. The baseline International Normalized Ratio (INR) was 4.9. The patients was managed conservatively and treated with Vitamin K and Prothrombin Complex Concentrates (PCCs). The INR was rapidly corrected to 1.1 and the patient made a full recovery.ConclusionRetropharyngeal haematoma should be considered in anticoagulated patients presenting with abrupt respiratory distress after minor head trauma. It can develop after minor traumatic events, such as falls. It can result in upper airway obstruction, which can be life threatening. Patients should be urgently assessed for intubation and ventilation. Computerized Tomography imaging of the neck and mediastinum is diagnostic. Correction of the International Normalized Ratio with Vitamin K and Prothrombin Complex Concentrates is essential. Management is mainly supportive. However, in very large haematomas surgical drainage may be considered.

Idiopathic Factor VIII Inhibitor Autoantibody in a Man Presented After Accident

Acquired hemophilia A is a rare but severe autoimmune bleeding disorder caused by autoantibodies against factor VIII activity and is a potentially life-threatening hemorrhagic disorder. The incidence of acquired hemophilia A has been estimated as 1.48 cases per million per year. The overall rate of death from all causes of acquired hemophilia reaches up to 22%. In this article, the authors describe the case of a 55-year-old man who presented with unusual bleeding after an accident and the fluctuation of his hemostatic parameters during 13 months of follow-up. Initially he had 43 Bethesda unit (BU) inhibitor to factor VIII and <1% of factor VIII activity. The patient was given prednisone and azathioprine therapy (30 and 100 mg/day, respectively) for 4 months, but his hemostatic parameters did not improved during this phase. Then, 2 g cyclophosphamide was injected every 2 days, but no remarkable improvement was observed. Nine months later his inhibitor titers were high. The inhibitor and factor VIII concentrations were assessed 11 times during these 13 months, and the mean level of factor VIII inhibitor was 44 BU (with a minimum of 2 BU and a maximum of 103 BU); the minimum and maximum factor VIII concentrations were <1% and 20%, respectively. The patient experienced hemarthroses, severe epistaxis, hematoma, and gastrointestinal bleeding episodes during this phase. His factor VIII concentration spontaneously and gradually improved and increased to 51.5% 8 months after stopping the treatment with undetectable factor VIII inhibitor.

Abnormal uterine bleeding as a presentation of metastatic breast disease in a patient with advanced breast cancer

Extragenital carcinomas secondarily involving the uterus are very rare and they usually occur as a manifestation of widespread disease. When the metastases involve the endometrium in a diffuse, permeative pattern, sparing the glands, they may cause problems in the diagnosis. A case of metastatic carcinoma to the endometrium with a decidua-like pattern is reported. The patient had a history of breast carcinoma and presented with vaginal bleeding. The pathologic findings in the uterine curettings raised the differential diagnosis between metastatic breast carcinoma and non-neoplastic stromal lesions. The presence of nuclear atypia and mitotic activity along with the appropriate immunohistochemical findings revealed the neoplastic nature of the endometrial lesion and confirmed its origin from the breast. Unusual uterine bleeding in a patient with breast cancer should alert the gynecologist to the possibility of metastatic breast disease. Furthermore, the metastasis to the uterus and to other organs of the genital tract can be considered as a preterminal event.