An Unexpected Cause of Catastrophic Bleeding: A Case Report

Abstract

Profound hypothyroidism has been linked to mild bleeding diathesis such as easy bruising and menorrhagia. Bleeding tendency depends on the severity of hypothyroidism. Those with moderate disease are prone to thrombotic events, while those with profound hypothyroidism are prone to bleeding. This paper reports a case of severe intraoperative bleeding during elective rhinoplasty in a patient with missed profound hypothyroidism. The clinical and laboratory findings are presented with a review of the literature. A 43-year-old female was admitted for an elective rhinoplasty. In the theater, the patient developed massive bleeding at the beginning of surgery. On the next day, the patient was discharged home for further assessment with a massive bruise all over her face. Upon history taking, the patient denied any drug abuse or previous bleeding episode or family history of bleeding disorder. Surprisingly, a transverse scar was noted at the lower part of the neck. The patient admitted that she had thyroidectomy done 2 years ago, and she was kept on thyroxine replacement and stopped it by herself 18 months ago. Thyroid-stimulating hormone (TSH) was 70 mU/L, and von Willebrand factor antigen/ristocetin cofactor was normal. A diagnosis of acquired von Willebrand syndrome type 1 was made. The patient was kept on thyroxine 150 µg/day. Six weeks later, TSH was 0.8 mU/L, and all bleeding parameters were corrected. A careful history taking and general examination looking for hypothyroidism is crucial in the preoperative assessment. It might be prudent to include thyroid function test in the routine preoperative investigation of all patients.