Unexpected haemoglobin drop in a medically fit patient.

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Clinical scenario :

An 87-year-old lady was admitted following a fall at home. She sustained a right proximal humerus fracture and was admitted to hospital where she awaited discharge to a rehabilitation facility.

At the point of discharge she started having unresponsive episodes, during which her blood pressure was dropping as low as 50 mmHg systolic. She denied any bleeding , melena or fresh rectal bleed .

A complete set of bloods was taken which demonstrated a Hb drop from 11.1gm/dl  to 5gm/dl.

No source of bleeding was identified but she was complaining of right lower quadrant pain so a CT abdomen and pelvis was performed.

Investigations :

CT imaging demonstrated a spontaneous acute right psoas haematoma measuring 109mm (AP) x 89mm (mediolateral) x 138mm (craniocaudal) as shown by arrows below.

There was no history of trauma and she was not on any blood thinners aside from Heparin  which was used as VTE prophylaxis. Due to CKD enoxaparin was not used for prophylaxis.

Hospital course :

Her case was discussed with the surgeons who advised no surgical input was required and she should be managed conservatively with blood transfusions.

She received 2 units of packed red cells which rose her Hb to 10.2.

Her Hb remained stable throughout admission until discharge

Teaching message :

This case demonstrates the importance of considering rarer causes of spontaneous Hb drops in the elderly, such as in this case.

It is also important to consider the negative impact that VTE prophylaxis can have on patients who are admitted to hospital.