A 78-year-old man presented with increase shortness of breath and productive cough. His past medical history was significant for chronic obstructive pulmonary disease (COPD) on long-term oxygen. He was treated as exacerbation of his COPD according to the local policy.
He was initially found to be anaemic with haemoglobin (Hb) of 9.8 mg/dl with a normochromic normocytic picture. This was noted to be chronic. His iron studies showed saturation of 9% with normal B12, folate and coagulation profile. His gastroscopy, haemolytic and celiac screen were negative. During the work up of his anaemia, he started to develop lower grade fever between 38 and 38.5 °C. Investigations, including chest radiograph and urine culture, came back negative. However, blood cultures grew coagulase negative staphylococcus on three different occasions. Subsequently, transoesophageal ECG demonstrated vegetations in keeping with endocarditis. He was started on vancomycin and rifampicin as per microbiological advice. The inflammatory markers fell with treatment. However, his anaemia was noted to be getting worse and required blood transfusion. He was not well enough to have colonoscopy and his faecal occult blood test was positive on three different samples. There was a noted episode of melaena. Aspirin was stopped and subsequent CT of the abdomen and carcinoembryonic antigen (CEA) levels was normal.
In the context of his endocarditis and anaemia, his haemolytic screen was repeated and was negative. However, his coagulation profile was quite deranged with high prothrombin time, high partial thromboplastin time, normal fibrinogen and international normalised ratio (INR) of 4.8, which was not the case on admission. Unfortunately, he did not have d-dimer as part of the work-up. The blood picture support a diagnosis of vitamin K deficiency rather that disseminated intravascular coagulation (DIC) as his platelets and fibrinogen level were normal. Liver function tests were normal and liver texture appeared normal on a CT scan. The patient was started on supplement vitamin K and his rifampicin was stopped. Unfortunately, the patient did not have vitamin K measurement as supplement treatment was started immediately.
He made a good recovery and his anaemia stabilised. His repeated INR was 1.1. He was discharged with follow-up regarding his anaemia.