Friday, January 23, 2009


This 65 year old male presents with the dramatic skin changes shown above. He has new onset fatigue, weakness, gingival bleeding, and ecchymoses. Recently, he's had multiple infections as well. Fundoscopic examination reveals hemorrhages and exudates.

Challenge: What procedure do you need to do for definitive diagnosis?

Image shown under fair use.


CodeDog said...

What we see in the picture is bleeding under the skin known as ecchymoses.
Gingival bleeding and ecchymoses are symptoms of blood problems.
Either not enough clotting factor to begin with or too much clotting in the wrong place that uses up all the clotting factors.
The bleeding is causing anemia which is causing the fatigue and weakness.
Multiple infections also indicate a blood problem possibly with the WBC.

Now assuming no ones been abusing this elderly patient lets look at the differential for bleeding problems:

Hemophilia A, B, Von Willebrand disease or some other deficiency of any clotting factor; there’s no mention of a history of clotting problems in the patient or his family so let’s rule this out.

There are medications which could cause this problem but again no mention of the patient being on any blood thinners he may have over dosed.

Thrombocytopenia; there’s no mention of a platelet count so we’ll have to assume its normal for now.

Disseminated intravascular coagulation; hmm how can we get DIC?
Unfortunately what we may be looking at here is Acute Myelogenous Leukemia with associated DIC.
The Risk of acute myelogenous leukemia increases with age, with the average age being 65. It is also more prevalent in white males. AML symptoms include sudden onset fatigue, weakness, bleeding gums, multiple ecchymosed and a history of infections that do not respond well to antibiotics.
Another possibility is Hairy Cell Leukemia, however it is rarer. (The picture looks exactly like my father in law did when he had Hair Cell)
Other types of cancer have also been known to cause DIC once they get to the metastatic phase.
I’m not sure about this one. Without blood tests, this is a shot in the dark.

Alex said...

thought it was leser-trelat sign, but could also be some sort of platelet problem.

deardoc said...

Acute Myelogenous Leukemia....probably. diagnosis is by bone marrow aspiration and smear examination

Craig Chen said...

Excellent analysis!

The image shows the widespread plaques of acute myelogenous leukemia cutis. AML is the most common adult leukemia and presents with symptoms related to pancytopenia. Definitive diagnosis requires an adequate bone marrow aspiration and biopsy.

Sources: UpToDate; AccessMedicine, image originally from Lichtman’s Atlas of Hematology.