Cases from the Osler Medical Service at Johns Hopkins University

Presenting features A 77-year-old Chinese man with hypertension presented with spontaneous bruising that worsened over several months. In addition to his prescription medications (enalapril, terazosin, and hydrochlorothiazide/triamterene), he was also taking wood ear mushroom and Chinese tea. He denied any use of aspirin or other over-the-counter medications. He had no prior history of bruising or bleeding, and there was no family history of bleeding diathesis. Physical examination revealed a thin, elderly man in no distress. He was afebrile, with a blood pressure of 159/81 mm Hg and a pulse of 86 beats per minute. A grade II/VI early diastolic murmur was present at the left upper sternal border. The chest examination was normal, and the abdominal examination revealed no masses or areas of tenderness. The extremity examination revealed right ankle edema and a large ecchymosis that extended from the right posterior thigh to the ankle (Figure 1). There were also smaller ecchymoses on the abdomen and on the extensor surfaces of the arms (Figure 2). Figure 1. Ecchymosis of the right posterior leg. Figure 2. Ecchymosis of the left lateral arm. Laboratory studies were notable for a hematocrit of 25%, with a mean corpuscular volume of 93.3 fL and a platelet count of 110,000/mm3. The reticulocyte count was 2.8%, lactate dehydrogenase level was 234 IU/L (normal, 122 to 220 IU/L), and haptoglobin level was <6 mg/dL (normal, 36 to 95 mg/dL). The international normalized ratio was 1.4, activated partial thromboplastin time (aPTT) was 34.5 seconds (normal, 23.4 to 33.5 seconds), and bleeding time was normal at 4.0 minutes. A mixing study corrected the aPTT with a 1:1 dilution. The fibrinogen level was 114 mg/dL (normal, 150 to 450 mg/dL), fibrin degradation products were positive at a 1:32 dilution, and a D-dimer test was positive at a 1:8 dilution. A peripheral blood smear showed a low platelet count, normochromic red blood cells, and fragmented red blood cells (Figure 3). Figure 3. Peripheral blood smear showing red cell fragmentation (arrows). What is the diagnosis?