A 73-year-old man presented to his primary care provider for evaluation of easy bruising. He was in his usual state of health until 10 days prior to presentation when he noticed bruising of his bilateral upper extremities associated with mild swelling and discomfort. He initially attributed this to musculoskeletal pain from doing yardwork, but the bruising and pain did not improve.
The patient denied any personal or family history of bleeding disorders. His medical history was otherwise remarkable for osteoarthritis of the bilateral knees and obesity. He underwent a tooth extraction and an inguinal hernia repair several years ago, which were not complicated by bleeding. He reported taking ibuprofen sparingly in the 10 days prior for his upper extremity pain but denied any other new medications. He was not on any prescription medications, other over-the-counter medications, or herbal supplements. He otherwise denied fevers, chills, night sweats, change in weight, shortness of breath, chest pain, abdominal pain, change in urination, new joint pain, skin rashes, and other bleeding symptoms including epistaxis, mucosal bleeding, hematemesis, hemoptysis, melena, hematochezia, and hematuria.
Upon presentation, vital signs were normal. His physical examination was notable for scattered large ecchymoses involving the right upper arm, left upper arm, chest, and abdomen. A comprehensive metabolic panel was within normal limits, and the remainder of the laboratory workup was remarkable for the following:
White blood cell count 5.5 K/μL 3.8-10.5 K/μL
Hemoglobin 15.2 g/dL 13.6-17.2 g/dL
Platelet count 236 K/μL 160-370 K/μL
International normalized ratio 1.0 0.9-1.2
Activated partial thromboplastin time (APTT) 75.1 seconds 28-37 seconds
APTT after mixing study 62.0 seconds 28-37 seconds
Factor VIII activity 3.2% 60-180%
Fibrogen 219 mg/dL 200-400 mg/dL
WHAT IS THE MOST APPROPRIATE NEXT STEP IN TREATING THIS PATIENT?
A. Recombinant Factor VIII B. Desmopressin
C. Prednisone D. Activated prothrombin concentrate complex