A 10-Year-Old Boy With a 6-Month History of Gingival Bleeding and Epistaxis

Tracie Wong, MD; Pierre Russo, MD; Petar Mamula, MD Series Editors: David A. Piccoli, MD; Petar Mamula, MD


April 17, 2007

Case Presentation

A 10-year-old black boy presented to the emergency department with a 6-month history of gingival bleeding followed by epistaxis in the week preceding presentation. On the day of presentation he developed subconjunctival hemorrhage in both eyes and complained of dizziness. There were no other complaints noted. There was no history of fever, abdominal pain, diarrhea, rashes, or weight loss.

Past medical history was significant for rectal prolapse as an infant. He had no past surgical history. He had no known drug allergies and was not taking any medications. His immunizations were up to date and his social history was unremarkable.

On physical exam, the patient was in the 50th percentile for weight and 75th percentile for height. He was alert and in no distress. Heart rate was 110 beats per minute, with normal respirations and blood pressure. Examination of the eyes, ears, nose, mouth, and throat was significant for subconjunctival hemorrhages noted bilaterally. Cardiovascular and respiratory exams were normal. The abdomen was soft, nontender, with hepatomegaly appreciated. The liver edge was palpated 3 cm below the right costal margin and had a total span of 10 cm. There was no splenomegaly. His neurologic exam was normal.

Laboratory evaluation revealed a normal complete blood count with differential, and a normal chemistry panel. His aspartate aminotransferase (AST) level was elevated as 1642 IU and serum alanine aminotransferase (ALT) was elevated at 1648 IU; albumin level was normal at 3.8 g/dL and total protein was elevated at 10.3 g/dL. Total bilirubin and conjugated bilirubin levels were normal at 1.2 mg/dL and 0, respectively. Alkaline phosphatase was normal at 477 IU and gamma glutamyl transferase was elevated at 116 IU. Prothrombin time at 14.2 seconds and partial thromboplastin time at 35.5 were prolonged, and international normalized ratio was high at 1.32. Additional laboratory values were as follows: white blood cell count, 7.4 cells/mcL3 (segmented cells 47%, lymphocytes 42%, monocytes 9%, eosinophils 1%, and basophils 1%); hemoglobin, 11.9 g/dL; and platelets 242 cells/mcL3.

What is the differential diagnosis?

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