Uncontrolled Nosebleed

From Gabor Varadi, MD, Albert Einstein Cancer Center: Dear George, I would like to discuss with you a nose bleeding case. The patient is a 55 yo female with history of hepatitis C-induced chronic liver disease, alcohol and cocaine abuse who came to us with left nostril bleeding following finger trauma (nose picking). She does not have a history of previous bleeding.

Her platelet count is 205,000/uL, hemoglobin 13.7 g/dL, WBC 6.4. Her coagulation parameters show a prolonged partial thromboplastin time (PTT), 63.7 seconds, prothrombin time (PT) 11.3 seconds, and INR 1.0. Interestingly her thrombin time is also slightly prolonged at 19.3 seconds. She has not received any heparin product. Her mixing studies (preliminary result) did not correct at 0 and 90 minutes. Fibrinogen 192 mg/dL. Her bleeding has stopped after posterior nose packing. Her total bilirubin was 0.4 but AST was 89, ALT 85, albumin 3.5, TP 7.9, creatinine 1.2. We are sending lupus anticoagulant testing. I would like to hear your opinion about the case. Thank you very much and best regards.

Hello, Dr. Varadi, and thank you for your question. While the uncorrected PTT may imply a lupus anticoagulant, LA more typically associates with thrombosis rather than bleeding. You may want to work up your patient for a specific factor inhibitor such as anti-factor VIII, which would fit the symptoms and laboratory results. Contrary to the textbook, some anti-VIII inhibitors may be detected by lack of correction in an immediate mixing study. Let’s see if our participants may have another suggestion.