DS21 Perils of a 3-mm punch biopsy

An 83-year-old woman underwent a 3-mm diagnostic punch biopsy from a Bowenoid patch on her right cheek. Her medical background was significant for invasive cholangiocarcinoma and she was on active treatment with gemcitabine under the care of oncology. In terms of anticoagulation she was on aspirin 75 mg as a preventative measure. Unfortunately, the patient developed ongoing bleeding from the biopsy site and presented to the emergency department. She was reviewed in the emergency department, the wound was sutured and haemostasis was noted. Over the next few days, she had progressive bleeding from the biopsy site. A plastic surgeon was consulted and the site was examined, cauterized and resutured. During the procedure haemostasis was achieved. The patient was discussed with haematology, and tranexamic acid for 3 days was recommended and aspirin was held. Routine bloods and a coagulation screen were sent. It was noted there was an isolated prolongation of the activated partial thromboplastin time. A diagnosis of acquired factor VIII deficiency was made following a coagulation screen in the department. She was transferred to the National Coagulation Centre for management and replacement of factor VIII. She was commenced on prophylactic FEIBA (anti-inhibitor coagulant complex) intravenous three times per week. Acquired haemophilia A is a rare but severe autoimmune bleeding disorder caused by circulating autoantibodies that inhibit the coagulant activity of factor VIII. It is more frequent in older patients and is associated with several conditions such as malignancies, the postpartum period, autoimmune diseases and drug exposure. This is a rare presentation; however, it highlights the risks involved with even minor dermatological surgical procedures and the importance of consenting patients for these possible complications.