Massive epistaxis in a patient with Eisenmenger syndrome: illustrating the clot-versus-bleed conundrum.

Eisenmenger syndrome (ES) causes polycythaemia and thrombocytopenia, thus rendering patients at risk from both thrombosis and haemorrhage. The clinical dilemma lies in how to treat one without precipitating the other. Our case demonstrates this important clinical problem. A 35-year-old lady with ES taking aspirin with clopidogrel for thrombo-prophylaxis presented with massive epistaxis. Blood tests showed polycythaemia, thrombocytopenia and normal clotting studies. A bone marrow biopsy ruled out leukaemia and normal imaging made pulmonary haemorrhage unlikely. Drug induced platelet dysfunction on a background of thrombocytopenia was the most likely cause of her epistaxis. Despite cessation of her dual anti-platelet therapy and multiple nasal packing, heavy epistaxis continued. She was given an infusion of platelets, and once her counts normalised, she was re-started on anti-platelet therapy.