CASE
A 66-year-old male presented to the emergency department (ED) with a 1-hour history of profuse left-sided anterior epistaxis. Cautery with silver nitrate was unsuccessful, and nasal packing was required to stop the bleeding. On examination, numerous spiderlike vascular lesions were present on the fingers, cheek, and tongue (Figure 1). CBC demonstrated microcytic anemia with a hemoglobin (Hgb) of 7.1 g/dL (normal range, 13.5-17.5 g/dL). The patient was admitted for transfusion of 3 units of packed RBCs and further observation. After 3 days, his Hgb level rose to 11 g/dL. The left-sided packing was removed on day 3, resulting in no immediate bleeding.
The patient had had numerous bouts of epistaxis and GI bleeding. He had been transfused on multiple occasions and lived with an Hgb level between 9 and 10 g/dL. His history was also significant for type 1 diabetes, hypertension, gastroesophageal reflux disease, and chronic anemia, for which he received frequent IV infusions of iron. Review of medications revealed no chronic use of anticoagulants or NSAIDs, and he had had several simple cautery and invasive nasal ligation procedures. The patient's mother and a sister, both deceased, had suffered from similar bleeding episodes.
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