We report a case of classic-onset hemorrhagic disease due to vitamin K deficiency, revealed by bilateral subdural and subarachnoid hemorrhages with extra-axial subdural blood products from C6 to lumbosacral region in a 4-day old, full-term infant.

Classic-onset VKDB occurs between 2-7 days of life and is mainly idiopathic but has been seen with offending medications (i.e. certain antiepileptics, anti-tuberculosis medication, antibiotics, and vitamin K antagonists) and exclusive breastfeeding and is associated with bleeding of the epithelium, rarely intracranial.

Exclusively breastfed male aged 4 days old, re-admitted for decreased PO intake and lethargy. There were no pregnancy complications. Mother did not take any offending medications. Delivery was complicated by nonreassuring fetal heart tones and need for an emergent c-section. APGAR scores: 2 at 1 minute and 7 at 5 minutes. At birth he had small, bilateral cephalohematomas with a head circumference of 36 cm. He did not receive vitamin K after birth. No family history of bleeding disorders. On presentation, he was lethargic with a bulging anterior fontanelle and multiple areas of ecchymoses on arm, neck, and flank. Head circumference was 36 cm. Labs were notable for: hemoglobin 3.3, hematocrit 10, platelets 150, fibrinogen 180 and PT/INR 93 and 9.8 respectively. Head ultrasound revealed a grade 1 left germinal matrix hemorrhage. IV vitamin K administration normalized the coagulation profile. Follow up MRI brain w/wo contrast revealed diffuse bi-hemispheric hypoxic injury with sparing of the brainstem and cerebellum and bilateral subdural, subarachnoid, and retrocerebellar hemorrhages. MRI c-spine notable for extra-axial subdural blood products from C6 down to the lumbosacral region. Skeletal bone survey was negative for nonaccidental trauma. Surgical intervention was not indicated.

At the international level, it is recommended to give 1 single dose of 1 mg IM vitamin K to all neonates at birth as prophylactic therapy against VKDB.