Differential Diagnosis for a 62-year-old Woman with Bleeding Symptoms

Given the patient's symptoms of heavy periods, unexplained bruising, and conjunctival hemorrhages, along with a bleeding assessment score of six and laboratory results showing a von Willebrand antigen of 0.86 and activity of 0.86, the following differential diagnoses are considered:

• Single Most Likely Diagnosis

  • Von Willebrand Disease (VWD): Although the initial thought might be to rule out VWD due to the near-normal levels of von Willebrand antigen and activity, these levels can sometimes be within the normal range in patients with VWD, especially type 1, which is the most common form. The clinical presentation of heavy periods, bruising, and conjunctival hemorrhages, combined with a significant bleeding assessment score, still points towards a possible diagnosis of VWD, particularly if other factors such as stress, inflammation, or other conditions that could transiently elevate von Willebrand factor levels are considered.

• Other Likely Diagnoses

  • Platelet Function Disorders: These disorders can present with similar bleeding symptoms, including easy bruising and heavy menstrual bleeding. The normal platelet count does not rule out platelet function disorders, as these conditions often require specific testing to diagnose.
  • Hormonal Imbalance: In a 62-year-old woman, hormonal changes could contribute to heavy periods. However, this would not fully explain the other bleeding symptoms.
  • Medication-Induced Bleeding: Certain medications, such as anticoagulants or antiplatelet agents, can cause or exacerbate bleeding symptoms. A thorough medication history is essential.

• Do Not Miss Diagnoses

  • Bleeding Due to Malignancy: Although less likely, bleeding can be a symptom of an underlying malignancy, such as leukemia or lymphoma, affecting the blood or bone marrow. It's crucial to rule out such conditions due to their significant implications.
  • Acquired Bleeding Disorders: Conditions like liver disease or severe renal disease can lead to acquired bleeding disorders due to the decreased production of clotting factors or platelets.
  • Autoimmune Disorders: Certain autoimmune conditions, such as immune thrombocytopenic purpura (ITP), can cause bleeding symptoms.

• Rare Diagnoses

  • Ehlers-Danlos Syndrome: A group of disorders that affect connective tissues supporting the skin, bones, blood vessels, and many other organs and tissues. Some types can lead to easy bruising and bleeding.
  • Factor XIII Deficiency: A rare bleeding disorder characterized by a deficiency of factor XIII, which can lead to delayed bleeding after trauma or surgery.
  • Other Rare Coagulation Factor Deficiencies: Deficiencies in factors such as factor II, V, VII, X, or XI can present with bleeding symptoms, although these are less common and often have more severe presentations.