A 66 year-old presented to the emergency room with a several-day history of left leg swelling and ecchymoses two months after receiving a deceased donor renal transplantation (DDRT) for end stage renal disease. He was found to have a Hb 6.6 g/dL (baseline about 11 g/dL), prothrombin time (PT) of 36.1 seconds and activated partial thromboplastin time (aPTT) of 121.6 seconds (baseline PT and aPTT normal). There is no other bleeding history. He had an appendectomy at age 45, without incident. There is no family history of abnormal bleeding, elevated PT/aPTT, coagulopathy or other hematological conditions. He is a past smoker and drinks several glasses of wine each week. He works as a management consultant. He is taking atorvastatin, famotidine, prednisone, and mycophenolate mofetil. He has no known allergies to drugs.
Prior to seeing him, you are told that an MRI of the leg shows “diffuse enlargement of the left rectus muscle along its entire length with fluid-filled levels and T1 hyperdense signal suggestive of liquefying hematoma that measures 4.9×5.7×28 cm.”