What is the appropriate management for a patient presenting with spontaneous bruising and bursitis, potentially indicating an underlying bleeding disorder?

Management of Spontaneous Bruising with Bursitis

A patient presenting with spontaneous bruising and bursitis requires immediate evaluation for an underlying bleeding disorder through comprehensive history, targeted laboratory testing, and appropriate management of both conditions simultaneously. 1

Initial Clinical Assessment

Obtain a detailed bleeding history to determine if laboratory evaluation is warranted:

• Personal history: Document any prior episodes of spontaneous bruising, excessive surgical bleeding, prolonged bleeding from minor cuts, or mucosal bleeding (nosebleeds, gum bleeding) 1
• Family history: Specifically ask about named bleeding disorders (von Willebrand disease, hemophilia, factor deficiencies) or unexplained bleeding in blood relatives 1
• Medication review: Document all anticoagulant or antiplatelet medications (aspirin, clopidogrel, warfarin, DOACs) 1
• Trauma history: Determine if the bursitis resulted from identifiable trauma or appeared spontaneously 2, 3
• Drug use: Ask about intranasal drug use or other substances that may affect coagulation 1

Laboratory Evaluation Strategy

If the history suggests a bleeding disorder (spontaneous bruising without adequate trauma, family history, or concerning bleeding patterns), initiate laboratory testing focused on the most prevalent conditions: 1

Initial Screening Panel:

• Complete blood count with platelet count (to detect thrombocytopenia) 1
• PT/INR and aPTT (to screen for coagulation factor deficiencies) 1
• Von Willebrand factor testing (antigen, activity, and factor VIII levels) - given VWD prevalence of 1/1000, this is the most common bleeding disorder 1

Critical Testing Considerations:

• Von Willebrand factor is an acute phase reactant and may be falsely elevated during acute illness; testing may need to be repeated up to 3 times for reliable results 1
• aPTT can be falsely prolonged with lupus anticoagulant or factor XII deficiency (which doesn't cause bleeding) 1
• Ensure proper specimen handling - coagulation tests are highly sensitive to collection and processing errors, leading to false-positive results 1

Management of Bursitis Component

Treat the bursitis conservatively while the bleeding evaluation proceeds: 2, 3

• Ice, elevation, and relative rest of the affected joint 2, 4, 3
• NSAIDs should be used cautiously or avoided if bleeding disorder is suspected, as they impair platelet function 2, 4
• Avoid bursal aspiration in the setting of suspected bleeding disorder until coagulation status is clarified, as aspiration carries risk of hemorrhage and iatrogenic septic bursitis 3
• Do NOT inject corticosteroids until bleeding disorder is ruled out, as this could precipitate significant hemorrhage into the bursa 3

Distinguishing Septic from Hemorrhagic Bursitis

If the bursa is warm, erythematous, and fluctuant, septic bursitis must be excluded: 3, 5

• Ultrasonography can help distinguish bursitis from cellulitis 3
• If infection is suspected AND coagulation parameters are acceptable (platelet count >50,000, INR <1.5-2.0), perform bursal aspiration with fluid analysis: Gram stain, culture, cell count, glucose, and crystal analysis 3, 5, 1
• Hemorrhagic bursitis (from bleeding disorder) typically presents with rapid swelling, minimal warmth, and bursal fluid showing blood without infection 3

Hematology Consultation Triggers

Consult pediatric hematology (if child) or adult hematology if: 1

• Initial screening tests suggest a bleeding disorder
• Expanded testing for rare conditions is needed
• Von Willebrand disease testing requires interpretation (given complexity of repeated testing)
• Patient requires specific factor replacement therapy

Management Based on Bleeding Disorder Findings

If Von Willebrand Disease is Confirmed:

• Desmopressin (DDAVP) 0.3 mcg/kg IV can be used for mild to moderate Type I VWD to increase factor VIII and VWF levels for procedures or bleeding episodes 6
• Desmopressin is NOT indicated for severe VWD (factor VIII <1%) or Type 2B/3 VWD 6
• Factor VIII/VWF concentrates may be required for severe cases or inadequate response to desmopressin 6, 7

If Hemophilia A is Identified:

• Factor VIII replacement is indicated for factor VIII levels >5% with bleeding episodes 6, 7
• Desmopressin may be tried in mild hemophilia A (factor VIII 5-40%) for minor bleeding 6

If Platelet Disorder is Found:

• Avoid antiplatelet medications and NSAIDs 1
• Platelet transfusion may be needed for severe thrombocytopenia with active bleeding 1

Critical Pitfalls to Avoid

• Do NOT assume normal PT/INR and aPTT rule out all bleeding disorders - von Willebrand disease often has normal routine coagulation tests 1
• Do NOT attribute spontaneous bruising to bursitis alone - the combination demands bleeding disorder evaluation 1
• Do NOT perform invasive procedures (bursal aspiration, corticosteroid injection) until coagulation status is clarified 1, 3
• Do NOT interpret a single normal VWF level as definitive - repeat testing may be necessary 1
• Do NOT overlook medication-induced coagulopathy - antiplatelet agents significantly increase bleeding risk 1, 8

Follow-Up and Monitoring

• If bleeding disorder is confirmed, establish care with hematology for long-term management 1
• If initial testing is normal but clinical suspicion remains high, repeat testing or proceed to specialized coagulation studies 1
• Monitor bursitis resolution with conservative management; if not improving after 2-4 weeks, consider alternative diagnoses 2, 3
• Document any recurrent bleeding episodes to establish pattern and severity 1