Case study - A woman with unexplained bruising

A young woman notices bruises on her limbs and trunk. Dr Tillmann Jacobi investigates the cause.

A 27-year-old woman attended the surgery with concerns about some bruising she had noticed over the past six to eight weeks.

CORDELIA MOLLOY / Spl

The size and appearance of bruises are relevant to finding the cause

It occurred over her limbs and trunk, but spared her face. She did not recall injuring herself on any occasion. She was usually well in herself and there were no medications or allergies on her medical records.

Truly spontaneous bleeding (purpura) suggests a problem of the vascular or platelet part of the wound closure process. On the other hand, if bruising or bleeding only occurs after a degree of trauma, then a problem with the clotting cascade is more likely.

Epistaxis or bleeding from the gums, unless either is excessive, are not always very helpful to distinguish between these two main types of bleeding problem.

Blood in the urine or the bowel motions would be more significant in this context - but the patient denied any problems.

The size and appearance of the bruises are relevant. The same applies to the distribution and any possible patterns.

This patient had several resolving bruises of different sizes and stages over her legs, groin and neck. She denied any self-inflicted trauma or an attack, and from the appearance this seemed unlikely.

There were no abnormal physical findings otherwise. I wondered about the cause and significance of this and about further investigations or even a referral at this point.

Genetic disorders
Generally, bruising disorders are genetic or acquired, but there might also be bruising for other reasons.

Genetic disorders that can lead to easy bruising typically show up early in life. They include rare conditions such as haemophilia or connective tissue disorders and syndromes like Von Willebrand's disease.

Haemophilia A is due to a deficiency of factor VIII. Being X-linked recessive, it only affects males (about one in 10,000).

The severity can vary depending on the degree of deficiency. If it is substantial then it will significantly shorten life expectancy.

Haemophilia B is even rarer than haemophilia A and linked to a deficiency of factor IX.

It seemed very unlikely that this patient was affected by a genetic disorder.

Acquired causes
Acquired causes of bruising can be manifold and are often reversible.

Low platelets cause bleeding on a cellular and 'mechanical' level within the blood. Thrombocytopenia means that the platelet count is lower than 100,000/mm3, but it may not lead to increased bleeding or bruising until levels as low as 50,000/mm3 have been reached.

Bruising may be caused by medication or infections

Thrombocytopenia may occur due to reduced production or decreased average survival of platelets (normally 10 days).

Typical systemic conditions include malignancies such as leukaemia and myeloma, aplastic anaemia and immune-modulated situations (idiopathic, heparin-induced, or associated with rheumatological disorders such as vasculitis).

Systemic problems such as liver or kidney disease, leukaemia and other malignancies, as well as general bone marrow dysfunction can lead to thrombocytopenia.

Generally, all cases of thrombocytopenia, even if they are an incidental finding and not (yet) symptomatic should be considered for a haematological referral.

However, I did not suspect a platelet problem in this young woman.

Medication, infections and nutritional deficiencies (particularly malabsorption of vitamin K or C, or proteins) can also cause bruising.

Simple intervention
After a thorough discussion with the patient, it turned out that she had been started on the contraceptive Pill for the first time three months ago by the family planning clinic, which she had not mentioned earlier.

After consulting with her, I decided to stop the Pill for a few weeks before investigating further. Indeed, the problem resolved readily with this simple intervention.

  • Dr Jacobi is a salaried GP in York

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