The 28-Year-Old with Recurrent Epistaxis and a Coagulation Result
A 28-year-old woman presents with recurrent left-sided epistaxis over 3 months, each episode lasting 20-30 minutes and requiring pressure. She also reports easy bruising and heavy menstrual bleeding since adolescence. She takes no medication. Anterior rhinoscopy shows a small telangiectasia on the left septum but no obvious bleeding point. Full blood count is normal; platelet count 210 × 10⁹/L. Her activated partial thromboplastin time (APTT) is mildly prolonged at 42 s (reference 26-36 s), with a normal prothrombin time. She asks whether the nosebleeds are simply 'dry air' and whether she needs any further tests.
1. What is the likely unifying diagnosis, and how does the coagulation result support it?
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The combination of lifelong mucocutaneous bleeding (epistaxis, menorrhagia since adolescence, easy bruising) with an isolated prolonged APTT and normal platelet count points to an inherited bleeding disorder, most plausibly von Willebrand disease (vWD) or a mild haemophilia (less likely in a woman with this pattern).
Reasoning:
- vWD is the commonest inherited bleeding disorder; it typically causes mucocutaneous bleeding and may prolong the APTT because von Willebrand factor stabilises factor VIII (low FVIII → prolonged APTT). Platelet count is usually normal (except in type 2B/platelet-type variants).
- The lifelong history (menorrhagia since menarche) argues against an acquired cause and against 'dry air' alone.
- A single mildly prolonged APTT is not diagnostic; it is a screening signal requiring specific testing.
So the epistaxis is likely a manifestation of an underlying disorder, not a local problem alone.
2. What specific investigations would you request, and what would you do about the epistaxis in the meantime?
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Specific investigations:
- von Willebrand factor antigen, vWF activity (ristocetin cofactor or equivalent), and factor VIII level - the core panel for vWD.
- If these are normal but suspicion remains, repeat testing (vWF is an acute-phase reactant and can be falsely normal during stress/illness/inflammation), and consider platelet function testing.
- Coagulation factor assays (e.g. factor IX, XI) if vWD excluded.
- Consider referral to haematology.
Immediate epistaxis management:
- Local measures: pressure, topical haemostatic agents, and cautery of a visible point if appropriate - but be cautious with cautery in a patient with a possible bleeding disorder.
- Avoid aspirin/NSAIDs.
- For significant or recurrent bleeding, tranexamic acid (oral or topical) is useful in mucocutaneous bleeding disorders; desmopressin may be used for vWD under haematology guidance.
- Treat the underlying disorder once diagnosed rather than repeatedly cauterising.
The key judgement is to investigate the systemic cause rather than attribute recurrent epistaxis to environmental factors in a patient with a clear bleeding history.