I am currently working as an attending clinical hematologist. Current I am having to deal with a difficult case of bleeding due to unknown coagulopathy. A 16-year-old man was admitted to our Emergency Department due to a painful swollen left calf after sport-related trauma. On admission, X-ray of lower leg showed fracture in his left tibia. He was given an external fixator to stabilize his bone fracture. Ultrasound also detected hematoma in the left calf muscle. Routine laboratory assays revealed normal prothrombin time, activated partial thromboplastin time and normal fibrinogen level. After the compartment symdrome had been diagnosed, we performed fasciotomy surgery to relieve his caft tension. After surgery, the incision oozed continuously. Because of the patient’s bleeding and his unremarkable routine coagulation results, factor XIII quantitative assay, PFA-100 assays, von Willebrand factor antigen and activity quantification and a set of ROTEM tests including INTEM, EXTEM and FIBTEM were ordered to rule out any possible hemostatic disorder. His plasminogen level and activities of factor XIII, α2-antiplasmin and PAI-1 (Plasminogen activator inhibitor-1) were also checked. All the assay results were normal, except the factor XIII quantitative result is 34%. We reperformed the factor XIII quantitative, the result was 132 %. Oozing form his wound has been observed for more than 2 months, only stopping temporarily after cryoprecipitate transfusion.

I would like to hear your expert opinions regarding the diagnosis of this case and how to treat his excessive bleeding. I know that it may not be appropriate to ask a purely clinical question like this here, but I do not know where else to connect with so many experts in the field.

Any comment is welcome.