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Pale man with recurrent epistaxis
  1. Hiroki Matsuura1,
  2. Kenji Imajo2
  1. 1 General Internal Medicine, Okayama City Hospital, Okayama, Japan
  2. 2 Hematology, Okayama City Hospital, Okayama, Japan
  1. Correspondence to Dr Hiroki Matsuura, Genral Internal Medicine, Okayama City Hospital, Okayama 700-0962, Okayama, Japan; superonewex0506{at}

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Clinical introduction

A 78-year-old man with a recent history of general fatigue, exertional dyspnoea and recurrent epistaxis presented to our ED. His medical history was mild hyperlipidaemia. He denied chest pain, dyspnoea, leg swelling, drug abuse or facial trauma. His vital signs were stable. Physical findings also revealed pale skin and conjunctival pallor. His oral exam is shown in figure 1. Laboratory examination showed a haemoglobin of 4.8 g/dL (reference range 13.7–16.8 g/dL) and decreased mean corpuscular volume of 74.1 fL (reference range 83.6–98.2 fL).

Figure 1

Patient’s oral exam.


What is the most likely cause?

  1. Maffucci syndrome

  2. Hereditary haemorrhagic telangiectasia.

  3. Blue rubber bleb nevus syndrome.

  4. Systemic sclerosis.

For …

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  • Contributors HM contributed to the writing of the manuscript, discussion, diagnosis and patient care. KI contributed to discussion and patient care.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.