61 year-old Indian female with history of hypercholesterolemia
presents to an outside hospital (OSH) with
worsening vaginal bleeding, hematochezia, nausea, and
vomiting starting three days prior to admission. Patient
also had a global persistent headache for approximately
24 hours at the time of admission. Otherwise, the patient
denied any fever, chills, abdominal pain, or trauma. The
patient noted no previous episodes of bleeding or easy
bruising in her past. She notes that her menstrual periods
were always regular and not subjectively heavy. Last
menstrual period was 10 years ago. Patient has had two
pregnancies in her obstetric history for which she
delivered vaginally without bleeding complications. The
patient denied recent antibiotic use. She had no change
in diet and no prior transfusions. At the OSH, the
patient was noted to be orthostatic at presentation with
mild tachycardia but was stabilized with intravenous
fluids and transfusions of packed red cells. Patient’s
nausea and vomiting resolved with antiemetics at the
OSH. Nasogastric lavage was negative for blood.
Laboratory results revealed patient to have markedly
elevated prothrombin time (PT) and activated partial
thromboplastin time (aPTT) with an INR greater than
20. The patient was initially treated with fresh frozen
plasma (FFP) and high doses of vitamin K. The patient
denied any warfarin use and she did not know anyone
currently on the medication. CT scan of the head showed
left subdural hematoma without midline shift or
hydrocephalus. The patient was immediately transferred
to the Jefferson Neurosurgical service. The patient was
subsequently deemed a poor surgical candidate and was
continued on supportive treatment with blood products
and vitamin K. At time of transfer to the medicine
service, the patient developed respiratory distress with
severe hypoxia requiring intubation. The patient was
admitted to the intensive care unit (ICU) for ventilatordependent
respiratory failure secondary to Transfusion
Related Acute Lung Injury (TRALI). After five days, the
patient was extubated and transferred to the medicine
floor team in stable condition for further management
of her bleeding diathesis.