Case Report

A 61-year-old African American male, with a past medicalhistory of asthma and benign prostatic hypertrophy, presentedfrom an outside hospital with complaints of hematuria andhematemesis. He had initially noted increased bruising twomonths prior to admission. He also had symptoms suggestive ofa non-traumatic thigh hematoma the month prior. He developedhematuria one month prior to admission and underwent anoutpatient cystoscopy one week prior to admission whichwas non-diagnostic. Cystoscopy was repeated on the day ofadmission localizing the hemorrhage to his right kidney with abiopsy specimen suggesting a low-grade papillary neoplasm. Thepatient subsequently developed hemetemesis. Emergent esophagogastroduodenoscopy(EGD) at the outside hospital revealeda Mallory-Weiss tear. Epinephrine was injected with initialhemostasis. EGD was repeated after transfer due to recurrenthematamesis and clips were placed to control the hemorrhage.The patient experienced continued hematuria requiring repeatcystoscopy with laser ablation, as well as biopsy of the right ureterand right mid-pole infundibulum. However, multiple repeatedbiopsies failed to confirm the presence of malignancy.

On admission, he was afebrile, with a heart rate of 94 bpm, bloodpressure of 142/88mm Hg, and oxygen saturation of 100% onroom air. His physical exam was within normal limits .His initialhemoglobin was 7.6 g/dL, white blood cell count of 9,700 cellsper cubic millimeter (cmm), and platelet count 138,000 cellsper cubic millimeter. Coagulation studies revealed an elevatedactivated partial thromboplastin time (aPTT) of 76.5 seconds.An aPTT mixing study was performed with the aPPT correctingto 34.9 seconds (normal 23.6-35 seconds). Incubation was notperformed. Additional laboratory evaluation demonstratedfactor VIII <0.01 U/ml (normal 0.52-1.43 U/ml) and a factorVIII antibody was detected with a measured titer of 33.3Bethesda Units (BU). Von Willebrand antigen and activity levelswere in the normal ranges.