A lthough coagulation disturbances h av e b een d e w ho enjoyed - PDF document

Gingival Bleeding: Initial Presentation of Prostatic Cancer Susan M. Shepherd, MD, and W. K. Lyon, MD, CCFP Toronto, Ontario A lthough coagulation disturbances h av e b een d e­ w ho enjoyed an active life. H e w as a n o n sm o k er and did scribed as potential com plications o f prostatic n o t drink alcohol. c a n c e r,1 -3 gingival bleeding is rarely the presenting O n exam ination, h e w as seen to b e a healthy-appearing sy m p to m .2 In fact, bleeding gum s in an otherw ise healthy m an w h o looked his stated age. V ital signs w e re stable, patien t is frequently considered to b e trivial. T his case and th ere w as n o orth o static d ro p in b lo o d pressure. illustrates ho w gingival bleeding u n co v ered a m o re om i­ E xam ination o f th e head an d n eck sh o w ed diffuse oozing n ous diagnosis o f p ro static carcinom a. o f blood from the gum s w ith o u t an y obvious gingival inflam m ation. F u n d o sco p y rev ealed flam e-shaped retinal hem orrhages. T h ere w as no scleral icteru s o r cervical lym phadenopathy. In sp ectio n o f th e h an d s show ed nu­ CASE REPORT m erous splinter hem orrhages. T h e card io v ascu lar and res­ p iratory system s w ere unrem ark ab le. T h e liver edge was A 72-year-old m ale p atien t o f the F am ily M edicine C en ter felt about 3 cm below th e co stal m argin. T h e spleen could telephoned the resid en t o n call one S atu rd ay m orning, not b e palpated. O n rectal exam ination, th e p ro state gland com plaining o f bleeding gum s. T h e patien t rep o rted co n ­ w as fo und to be h ard and enlarged. S tool fo r o ccu lt blood tinuous oozing o f blood from his gum s fo r the p a st w eek. w as negative. H e w as also alarm ed b y a 1-day history o f painless hem a­ Initial blood w o rk results included hem oglobin 12.8 g/L turia. H e denied hem optysis, m elena, hem atem esis, (128 g/dL), w hite cell count 6.4 x 109/L (6.4 x 103//uL), epistaxis, o r bruising. T h e patien t w as th en en couraged to and a greatly d ecreased platelet co u n t o f 26 x 109/L (26 x com e to the hospital fo r fu rth e r assessm en t. A m o re co m ­ 103/m m 3) (norm al levels 250 to 400 x 109/L ). T h e blood plete h istory w as tak en at th a t tim e. Findings o n func­ sm ear w as leukoerythroblastic. T h e p ro th ro m b in time tional inquiry w ere norm al ex cep t fo r a long-standing w as elevated at 17.1 seconds, co n tro l 12.3 seconds, and history o f p rostatism . T he patien t felt o th erw ise w ell and the partial thro m boplastin tim e w as 30.3 seconds, control had no fatigue, dizziness, w eight loss, o r night sw eats. 28.7 seconds. E lectro ly tes w ere norm al. B lood glucose P ast m edical history rev ealed a 2-y ear h istory o f non­ w as 9.2 m m ol/L (166 m g/dL). T h e u re a nitro gen w as 7.2 insulin-dependent diabetes m ellitus, an d a p ast episode o f m alaria, treated w ith quinine. T h ere w as no history o f m m ol/L (20 m g/dL), and creatinine 112 p,m ol/L (1.3 mg/ liver disease o r p rio r surgery, and th ere w as no fam ily dL ). T h e urine specim en w as grossly b loody w ith protein­ history o f bleeding disorders. T h e p atien t’s only m edica­ uria (+ 1). T he electrocardiogram an d ch e st x -ray results tion w as chlorpropam ide, 125 m g daily. H e specifically w ere w ithin norm al lim its. denied recen t u se o f nonsteroidal anti-inflam m atory m ed­ T he greatly dim inished platelet co u n t a n d prolonged ications. T h e patien t w as a retired adm inistrative w o rk er prothrom bin tim e and partial throm boplastin tim e pointed to a com bined th ro m b o cy to p en ia an d coagulopathy. The patien t w as trea ted im m ediately w ith vitam in K , 10 m g given subcutaneously, an d tw o units o f fresh frozen Submitted June 12, 1989. plasm a. A bone m arrow aspirate an d bio p sy w ere then attem pted w ithout success. T he iliac c rest w as ro c k hard, From the Department of Family Medicine, Toronto Western Hospital. At the time this article was written, Dr Shepherd was a resident in family practice, Toronto and the tro ca r could n o t b e ad v an ced through th e cortex. Western Hospital. Requests for reprints should be addressed to Susan M. Shep­ T he patien t w as th en adm itted to th e hospital. A s there herd, MD, Toronto Western Hospital, Family Practice Unit, 750 Dundas St W, Toronto, Ont M6J 3S3 w as still active gingival bleeding, h e receiv ed six units of 1990 Appleton & Lange 98 THE JOURNAL OF FAMILY PRACTICE, VOL. 30, NO. 1: 98-100,1990