Abstract
A 6-month-old exclusively breastfed boy presented with multiple greenish-black ecchymotic nodules on his back progressing over the last two weeks (Fig. 1), along with right-sided facial swelling (Fig.2) for three days. Baby was delivered at home. The perinatal history was insignificant, with no neonatal hospitalization. There was no documentation of receiving any dose of vitamin K at birth. Examination showed an active child with stable vitals and mild hepatomegaly. Positive laboratory tests included significantly elevated prothrombin time (PT > 120 seconds) and partial thromboplastin time (PTT > 140 seconds); anemia (5.3 g/dL); and direct hyperbilirubinemia (total bilirubin 6.42 mg/dL, direct 3.21 mg/dL); hence, the clinical diagnosis of Vitamin K deficiency bleeding (VKDB) was supported by blood reports. After receiving one dose of vitamin K, the coagulation profile improved, swelling reduced, and there was no new bleeding in follow up till next 6 months. Hyperbilirubinemia can hence be attributed to bleeding manifestation and hemolysis. Hepatomegaly and hyperbilirubinemia resolved after administering vit. K.
Hemorrhagic disease of newborn (HDN) or VKDB can be idiopathic or secondary to chronic diarrhea, cystic fibrosis, celiac disease, and hepatobiliary disease. It is also common in babies of mothers who are on anti-tubercular drugs (isoniazid, rifampicin), antiepileptics (phenytoin, barbiturates, and carbamazepine), broad-spectrum antibiotics (cephalosporins), or vitamin K antagonists[1]. The common differential diagnoses include disseminated intravascular coagulation (DIC), thrombocytopenia, especially maternal immune thrombocytopenia, and intussusception (for isolated gastrointestinal bleed). Neonates and infants are prone to VKDB because they have poor store of vitamin K, their immature gut is deficient in vitamin K-producing flora, and breast milk is deficient in vitamin K[2]. Other differentials like leukemia or Immune thrombocytopenic purpura were ruled out with normal Complete blood count (CBC) and peripheral blood smear (PBS) reports. The hemorrhagic manifestations mainly involve the gastrointestinal tract (GIT), central nervous system, skin, bleeding from injection site, hematuria and bleeding from umbilicus[3,4]. Bleeding from GIT, umbilicus, or urinary tract were not evident in this case. We did not go for neuroimaging as there were no neurological sign and symptoms. Late HDN usually presents from 8 days to 8 weeks of age, but can even present up to 6-12 months[5] as in index case.
Fig. 1. Multiple ecchymotic lesions over the back
Fig. 2. Cutaneous bleed in cheek

References:
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(4) Rana MT, Noureen N, Iqbal I. Risk factors, presentations and outcome of the haemorrhagic disease of newborn. J Coll Physicians Surg Pak. 2009 Jun;19(6):371-4. PMID: 19486577
(5) Holla RG, Prasad AN. Haemorrhagic Disease of Newborn presenting as Subdural Hematoma. Med J Armed Forces India. 2010 Jan;66(1):86-7
doi: 10.1016/S0377-1237(10)80109-1. Epub 2011 Jul 21. PMID: 27365716; PMCID: PMC4920894.

Key words: Vitamin k deficiency Bleeding (VKDB), Hemorrhagic disease of newborn (HDN), Coagulopathy, Skin bleeding