From the Guidelines
The patient with lower extremity hemorrhagic purpura and a hemoglobin of 7.3 g/dL requires urgent evaluation and management with blood transfusion and potential treatment with oral tranexamic acid or intravenous bevacizumab, depending on the underlying cause of the bleeding. This presentation suggests a serious bleeding disorder with significant anemia. The patient should be hospitalized for immediate packed red blood cell transfusion, with a target hemoglobin of at least 8 g/dL, as recommended for patients with hereditary hemorrhagic telangiectasia (HHT) and GI bleeding 1. Concurrently, a comprehensive workup should be initiated including complete blood count with platelet count, coagulation studies (PT, PTT, INR), peripheral blood smear, and tests for potential causes such as immune thrombocytopenia, vasculitis, or coagulopathy. While awaiting results, if thrombocytopenia is present, platelet transfusion may be necessary. For patients with HHT, the expert panel recommends considering the use of oral tranexamic acid for the management of bleeding that does not respond to topical therapies, with dosing starting at 500 mg twice daily, gradually increasing up to 1000 mg 4 times daily or 1500 mg 3 times daily 1. Alternatively, intravenous bevacizumab may be considered for moderate to severe bleeding, with induction dosing of 5 mg/kg every 2 weeks for 4-6 doses, followed by maintenance dosing variable, but potentially 5 mg/kg every 1-3 months 1. Supportive care should include avoiding trauma to affected areas, discontinuing medications that affect platelet function (like aspirin or NSAIDs), and monitoring for signs of internal bleeding. Once stabilized, identifying and treating the underlying cause will be essential for long-term management. Key considerations in management include:
- Grading the severity of bleeding, with mild bleeding potentially managed with oral antifibrinolytics, and moderate to severe bleeding potentially requiring intravenous bevacizumab or other systemic antiangiogenic therapy 1
- Monitoring for potential side effects of antiangiogenic medications, including hypertension, proteinuria, infection, delayed wound healing, and VTE 1
- Shared decision making with patients regarding the risks and benefits of different treatment options 1
From the Research
Lower Extremity Hemorrhagic Purples with Hgb of 7.3
- The patient's condition of lower extremity hemorrhagic purples with a hemoglobin (Hgb) level of 7.3 indicates a severe case of anemia and potential bleeding 2.
- A Hgb level of 7.3 is significantly lower than the normal range, suggesting that the patient may be experiencing active bleeding or significant blood loss 2.
- The study by 2 found that Hgb levels measured within minutes of arrival can identify trauma patients who are actively bleeding, and a Hgb level of ≤10 gm/dL was associated with a greater than three-fold increase in the need for emergent interventions to stop bleeding.
- In cases of severe anemia and bleeding, blood transfusion may be necessary to restore blood viscosity and oxygen carrying capacity 3.
- The use of fresh red blood cells (RBCs) may be superior to stored RBCs in transfusion, as they can provide better oxygen delivery and perfusion to the microcirculation 3.
- However, the management of bleeding and compartment syndrome in the lower extremity can be complex and may require surgical intervention, as seen in the case report by 4.
- The patient's condition requires prompt diagnosis and effective treatment to prevent further complications, such as limb loss or other adverse outcomes 4.