(1673) Hemorrhagic Shock After Dental Procedure: How Avoiding Anchoring Led to a Rare and Lethal Diagnosis

Introduction: Most oral bleeding is minor and subsides after topical interventions. Major oral bleeding requiring transfusions is a rare event. Mucosal bleeding is usually regarded as “platelet-type” bleeding. Immune thrombocytopenia (ITP) and antiplatelet agents have been shown to increase this risk, but rarely is bleeding this severe.

Description: A middle-aged female with a history of ITP and anemia, not on antiplatelets, presented to the ED with oral bleeding and hemorrhagic shock after a molar extraction. After failure of local packing with tranexamic acid, she was intubated for airway protection. Lab work revealed acute on chronic kidney injury and consumption coagulopathy. The patient was appropriately resuscitated with a balanced transfusion strategy. Despite resuscitation, correction of the coagulopathy, and later applying sutures to the involved area, the patient continued to hemorrhage, albeit more slowly.
Her ITP was treated with steroids and intravenous immunoglobulin (IVIG) and she was diagnosed with disseminated intravascular coagulation (DIC). Peripheral smear was unremarkable. Abdominal imaging at that time showed persistent splenomegaly, first noted months prior. This abnormality led to a bone marrow biopsy, that showed high-grade myeloid neoplasm and increased blasts (16-18%) - immature monocytes by flow cytometry. She was started on all-trans retinoic acid and cytarabine until t(15:17) returned negative. Suddenly she developed recurrent shock and CT angiogram demonstrated a splenic artery bleed. Emergent embolization was performed, the patient had a cardiac arrest and died. The final diagnosis was an acute myeloid transformation of Chronic Myelomonocytic Leukemia-2 (CMML).

Discussion: Rare presentations of common diseases and lack of response to treatment should prompt a re-evaluation of prior diagnosis with the new information. This case highlights the importance of a thorough workup of thrombocytopenia and the need to rule out occult malignancies. Avoiding anchoring bias led to a diagnosis of CMML, a rare hematopoietic stem cell disorder characterized by splenomegaly (25%), peripheral monocytosis and dysplasia of cell lineages with a 1 in 100,000 incidence.