Spontaneous bleeds is rather unusual in the absence of a normal orifice! The given history actually mentions that one fine day the skin over the occiput actually bled?! If there was some arterio-venous malformation one could expect that it could be traumatised and bleed. One can only presume that the child didn't have any such lesion prior to the onset of spontaneous bleeding. On examination it is however mentioned that there are additional skin bleeds detected which would indicate a bleeding problem in the absence of hematoma or viscus bleeds or muscular bleeds. If the skin and joints are normal, we could consider a thrombocyte problem either ITP or a Thrombasthenia. When you look at the photograph one again wonders whether the red discolouration at teh nape of the neck represents a malformation present before the bleed whcih is now complicated similar to a Kaselbach Merrit Syndrome? The presence of a liver could indicate sepsis as is suggested or even a part of CCF or is there a similar AV malformation in the liver? The investigations reveal anemia probably due to blood loss or destrcution especially since the bilirubin is raised; normal WBCs not really suggestive of a sepsis; Thrombocytopenia suggestive of peripheral destruction or decrease production. The coagulation workup is normal however an INR should have been recorded instead of just a control and patient's value for PT. These investigations available suggest Thrombocytopenia and anemia secondary to blood loss or consumption as seen in peripheral destruction like in a DIC. DIC would be systemic indicating a very sick child not suggested by details available like in Gram Negative Sepsis. Therefore it raises the question whether the child has an Immune Thrombocytopenic Purpura ITP or if our suspicion of the preexisting red patch or mass at the nape of the neck was truely a malformation like Kaselbach Merrit Syndrome, then Thrombocytopenia would be an entity to follow such a problem. We need details of the lesion prior to the bleeding. We need to do a bone marrow to confirm the status of the bone marrow and of course confirm the fact taht the child is not sickly and with a negative blood culture.
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