Bruised Black and Blue: Acquired Hypoprothrombinemia

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Bruised Black and Blue: Acquired Hypoprothrombinemia Li-Wen Huang, MD, Sarah Anand, MD, Syed Hassan, MBBS, Oluwatoyosi Onwuemene, MD, MS The American Journal of Medicine Volume 128, Issue 11, Pages e7-e11 (November 2015) DOI: 10.1016/j.amjmed.2015.06.011 Copyright © 2015 Elsevier Inc. Terms and Conditions

Figure 1 Ecchymosis of upper extremities and hematuria. (A) The patient presented with diffuse ecchymoses over her upper extremities. (B) She also had a hematoma over her hand. (C) She developed hematuria requiring continuous bladder irrigation. The American Journal of Medicine 2015 128, e7-e11DOI: (10.1016/j.amjmed.2015.06.011) Copyright © 2015 Elsevier Inc. Terms and Conditions

Figure 2 Approach to evaluating coagulopathy. The first step to approaching a coagulopathy is to isolate where the defect is in the coagulation pathway. A prolonged PT indicates a defect in the extrinsic pathway, and a prolonged aPTT indicates a defect in the intrinsic pathway. When both PT and aPTT are prolonged, there is a defect in the common pathway. After isolating the defect, the next step is to determine whether there is a factor deficiency or a factor inhibitor with mixing studies. If the prolonged time corrects with mixing with normal plasma, there is a factor deficiency. If the prolonged time does not correct with mixing, there is a factor inhibitor, and specific factor activity assays and inhibitor titers should be performed. aPTT = acquired partial thromboplastin time; DIC = disseminated intravascular coagulation; HMWK = high-molecular-weight kininogen; PT = prothrombin time. The American Journal of Medicine 2015 128, e7-e11DOI: (10.1016/j.amjmed.2015.06.011) Copyright © 2015 Elsevier Inc. Terms and Conditions

Figure 3 Factor II assay. The patient's factor II assay could not be quantified due to the presence of an underlying inhibitor. With serial dilutions, a factor level could be detected, with a mean corrected result of 33%. CR = corrected result; CV = coefficient of variation. The American Journal of Medicine 2015 128, e7-e11DOI: (10.1016/j.amjmed.2015.06.011) Copyright © 2015 Elsevier Inc. Terms and Conditions

Figure 4 Trend of INR, aPTT, and factor II activity over hospital course. Arrows indicate initiation of treatment with steroids, IVIg, activated PCC, and rituximab. With steroids and IVIg, there was a gradual downtrend in INR (red squares, y-axis on left) and aPTT (green triangles, y-axis on right), but with no change in factor II activity (purple circles, y-axis on right). With activated PCC and rituximab, there was a notable decrease in INR and aPTT as well as increase in factor II activity. aPTT = acquired partial thromboplastin time; FFP = fresh frozen plasma; INR = international normalized ratio; IVIg = intravenous immunoglobulin; PCC = prothrombin complex concentrate; PRBC = packed red blood cells. The American Journal of Medicine 2015 128, e7-e11DOI: (10.1016/j.amjmed.2015.06.011) Copyright © 2015 Elsevier Inc. Terms and Conditions