1. PATIENT PRESENTATION
A 6‐year‐old previously healthy female presented with unexplained bruising on multiple extremities as well as non‐traumatic left ankle pain and swelling and intermittent gingival bleeding that began 2 days prior to presentation. Her parent reported she had a recent illness with non‐bloody vomiting and non‐bloody diarrhea, which had resolved 4 days prior to presentation. Her exam revealed dried blood at the gum line of her teeth, tenderness to palpation of the dorsal aspect of her left ankle with moderate swelling, and ecchymosis to her bilateral lower extremities (Figures 1 and 2) and right shoulder (Figure 3). Her parent denied any recent trauma or falls, travel, medication use, ingestions, fevers, or jaundice. She had no contributory family history. Her lab results were remarkable for hemoglobin = 12.5, hematocrit = 36.7, platelets = 216, prolonged aPTT = >150, prothrombin = 46.7, and INR = 3.8.
FIGURE 1.
Left knee
FIGURE 2.
Right leg
FIGURE 3.
Right shoulder
2. DIAGNOSIS
Lupus anticoagulant‐induced antiphospholipid antibody syndrome was diagnosed.
This is a rare but often transient illness in children. It often presents immediately following a viral illness or a new medication. Although hemorrhagic symptoms are only estimated to occur between 10%–20% of patients with lupus anticoagulant, 2 it can be the first presenting symptom and should be considered in children with spontaneous bruising. 1 , 3 Because of the diffuse, large areas of ecchymosis that may occur in this disease process, ingestion, thrombotic thrombocytopenic purpura, leukemia, and non‐accidental trauma must all be considered in the differential diagnoses in a child with these physical examination findings in the acute emergency setting. In this patient, mixing studies did not correct the patient's bleeding time, which indicated the presence of an anticoagulant. The diluted Russell viper venom (DRVV) test was positive, which is consistent with lupus anticoagulant‐induced antiphospholipid antibody syndrome. Initial workup should consist of complete blood count, platelet count, aPTT, PT/INR, and fibrinogen. In most cases, lupus anticoagulant‐induced antiphospholipid antibody syndrome resolves with supportive care and no treatment is necessary; however, patients with severe cases may require blood transfusions and/or treatment with corticosteroids.
Scieszka L, Swan TB. Bruising in a child after a viral illness. JACEP Open. 2020;1:660–661. 10.1002/emp2.12108
REFERENCES
- 1. Anderson AK, Mohan U, Liesner R. Transient lupus anticoagulant: an unusual cause of bruising in children. Emerg Med J. 2003;20:e6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Forastiero R. Bleeding in the antiphospholipid syndrome. Hematology. 2012;17(1):S153‐55. [DOI] [PubMed] [Google Scholar]
- 3. Lee MT, Nardi MA, Hadzi‐Nesic J, Karpatkin M. Transient hemorrhagic diathesis associated with an inhibitor of prothrombin with lupus anticoagulant in a 1½‐year‐old girl: report of a case and review of the literature. Am J Hematol. 1996;51:307‐314. [DOI] [PubMed] [Google Scholar]