The 6 cases here provide a sampling of the many possible causes of bruising and a test of your diagnostic acumen.
An otherwise healthy 7-year-old boy has concerning bruising on his distal right fibula and ankle. The lesion began as darkened areas around the ankle that slowly enlarged over 2 or 3 months. The macular area appears as a reddish-brown bruise and is nonpalpable. Note the pin-head sized petechial lesions at the periphery of the involved area. Results of lab tests were normal. What is your diagnosis?
A 77-year-old woman had shortness of breath, intermittent left flank pain, and mild nonbloody diarrhea for a few days. Her medical history includes atrial fibrillation and an embolic cerebral stroke for which she takes warfarin. There is a large, firm, ecchymotic, exquisitely tender mass over the left side of her abdomen. No guarding, rebound, or peritoneal signs are present. She reports she had fallen in her bathroom a few days earlier. What is the most likely cause of her symptoms?
A postmenopausal 52-year-old woman had acute left lower quadrant abdominal pain on the second day of a lower respiratory tract infection associated with severe coughing. Her past medical history was significant for stage 1 hypertension and cough-variant asthma. She noted a small ecchymosis in her left groin and continued sharp pain in the left lower quadrant on the third day and noted increased ecchymosis and a distinct bulge 5 days after that. What caused the patient’s symptoms?
A 20-month-old boy had an unusual bruise on his face that arose after he bumped it against his toy chest 4 or 5 weeks earlier. The very firm reddish-blue nodule felt like there were several lumps within it. There was a “tent” appearance when the skin was stretched. No hepatosplenomegaly was present. A CBC count revealed a normal differential and normal indices. What is the diagnosis? Is there anything about the lesion that would cause you to suspect a malignancy?
A 17-year-old girl presented with a persistent nontender left ankle “bruise” that had appeared after an injury. The ecchymosis had not faded after a repeated injury to the ankle. She experienced pain and swelling and was unable to bear weight. Sixteen months later, her medications were escitalopram, olanzapine, and minocycline. Extension of the blue-gray discoloration into the interdigital spaces supports an endogenous source of pigment. These characteristic features support what diagnosis?
A 72-year-old woman came to the ED with a tender, swollen left leg. Pitting and a positive Homan sign were noted, and she had a small area of ecchymosis on her heel. A presumptive diagnosis of deep venous thrombosis was made, and the patient was hospitalized. She had a history of arthritis but no other factors that might precipitate DVT. She told her physician that the problem started “right at 3 o’clock”-an acute onset that’s unusual in DVT. What is another possible cause of the symptoms?
Bruises occur with injury and for a variety of other reasons-or no apparent reason. The cases in the slides above provide a sampling of the many possible factors and a test of your diagnostic acumen.
Rodeghiero F, Tosetto A, Abshire T, et al on behalf of the ISTH/SSC Joint VWF and Perinatal/Pediatric Haemostasis Subcommittees Working Group. International Society on Thrombosis and Haemostasis/Scientific and Standardization Committee Bleeding Assessment Tool (ISTH BAT). Available from the World Federation of Hemophilia at: http://www.wfh.org/en/resources/bleeding-assessment-tool-isth-batt
Neutze D, Roque J. Clinical evaluation of bleeding and bruising in primary care. Am Fam Physician. 2016 Feb 15;93(4):279-86.
Kodner C, Wetherton A. Diagnosis and management of physical abuse in children. Am Fam Physician. 2013 Nov 15;88:669-75.