March/April 1999

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History: The patient is a 60 year old woman who was admitted to the intensive care unit for prolonged epistaxis, brisk bright red blood per rectum and chest pain. Past medical history was significant for recurrent deep venous thromboses requiring chronic warfarin therapy.

Laboratory Findings: Hemoglobin: 7.0 , Platelets: 180,000, INR: 4.0, EKG: ST elevation consistent with acute ischernia.

The patient stabilized after receiving intravenous hydration, 2 units of fresh frozen plasma, 3 units of packed red blood cells, phytonadione (vitamin K) IM, and sublingual nitroglycerin. One week later she developed a pruritic, erythematous, indurated 5 cm plaque on her upper left arm (Fig. 1).

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