Cases corner – 24 year old with bruising

8th October 2019

Olivia, a 24 year old woman, presents to you with a 4 week history of excessive bruising. She first noticed a couple of bruises on her right leg, but could not remember a specific injury that caused them. Since then she has also noted some bruising on her left arm after a person with a large rucksack bumped into her on the tube and an unexplained bruise on her left ankle. Olivia denies any other symptoms and is otherwise feeling well. She does not drink alcohol, lives on her own and does not have a partner. Her last consultation was 14 months ago when she presented with symptoms of otitis externa.

On examination observations are normal, there is no organomegaly or lymphadenopathy. Olivia has various bruises of different sizes and age on her limbs.

What would you do next?

  1. Reassure the patient but offer safety net advice
  2. Order a routine set of bloods including FBC, U+Es, LFTs and clotting screen
  3. Order an urgent FBC (within 48hrs)
  4. Arrange for immediate admission under the haematologists
  5. Refer the patient via the Haematology 2 week wait pathway

Olivia has presented with unexplained bruising, which raises the question of possible leukaemia. NICE Guidelines suggest that you should consider a very urgent full blood count (within 48hrs) to assess for leukaemia in adults with any of the following:

  • pallor
  • persistent fatigue
  • unexplained fever
  • unexplained persistent or recurrent infection
  • generalised lymphadenopathy
  • unexplained bruising
  • unexplained bleeding
  • unexplained petechiae
  • hepatosplenomegaly

Most labs across the country will automatically request a blood film if the full blood count is suggestive of leukaemia. Of note, if the FBC or blood film indicates an acute leukaemia an immediate admission to specialist services is needed.

It is important to also check local guidelines when managing a patient with unexplained bruising. Across london the threshold for investigation is lower and in the case above the patient would meet criteria for a 2 week wait referral to Haematology.