Case Presentation: 63-year-old female with past medical history of type II diabetes, Roux-en-Y bypass, alcoholic hepatitis, osteoarthritis of bilateral knees post-total left knee arthroplasty (2014), presented with acute left knee pain and new functional decline. She denied any trauma, fevers, or chills. Exam was notable for warmth over the joint, diffuse pain with palpation and movement, and significant joint effusion. X-ray of the left knee showed no evidence of hardware failure or acute fracture. Aspiration of the left knee yielded 50 mL of frank blood. Aspirate studies revealed 3 million RBCs, hematocrit of 41%, and no evidence of crystals or bacteria, leading to a diagnosis of hemarthrosis. The patient denied any family history of bleeding disorders, prior spontaneous bleeding, or use of chronic anticoagulation. Coagulation studies overall were inconsistent with acquired hemophilia with an elevated PT/INR (2) and PTT (38.8) which corrected with mixing study, low factor V, IX, and XI activities, and elevated VW and factor VIII activities. Abdominal ultrasound revealed cirrhotic hepatic morphology with increased parenchymal echogenicity, confirming a diagnosis of liver cirrhosis. Given the patient’s history of roux-en-y bypass there was concern for underlying vitamin K deficiency contributing to her coagulopathy. The patient was treated with 3 days vitamin K 10 mg po daily with some improvement in PT/INR. By the third day of treatment, swelling and warmth to the left knee had improved.
Discussion: Cirrhosis is a common cause of coagulopathy due to the liver’s impaired synthetic function, resulting in lower levels of factors V, VII, IX, X, XI, XIII, fibrinogen, and prothrombin. There are also reciprocal increases in VW and factor VIII activities to offset the decreased levels of aforementioned pro-coagulant factors [1]. Non-gastrointestinal bleeding in cirrhosis including gum bleeding, ecchymosis, and epistaxis are common due to thrombocytopenia. However, spontaneous hemarthrosis, a condition typically seen in single factor deficiency diseases, is a rare presentation in a cirrhotic patient. In this case, a likely exacerbating factor that contributed to bleeding was vitamin K deficiency induced by poor dietary intake, absorption, and cholestasis.
Conclusions: This case illustrates a rare presentation of spontaneous knee joint hemarthrosis secondary to coagulopathy from underlying liver cirrhosis and probable co-existing vitamin K deficiency. Treatment for hemarthrosis usually begins with non-operative modalities such as RICE therapy and joint aspiration, before more invasive treatments including embolization, arthroscopy, or open synovectomy are considered [2]. This case illustrates the importance of concurrent evaluation for an underlying coagulopathy in patients presenting with hemarthrosis.