A 79-year-old lady with diabetes and advanced Alzheimer's dementia presented with a sudden, spontaneous swelling over her left cheek. She was not on antiplatelets, anticoagulation, or traditional remedies.

Investigations revealed prolonged activated partial thromboplastin time of 76 seconds (23.9–32.2 seconds), uncorrected with mixing (47.8 seconds; control: 27.9 seconds), undetectable factor VIII levels (<1%), and increased factor VIII inhibitors (240 BU). Renal profile, liver profile, autoimmune workup, blood film, and other bleeding markers were normal. Imaging revealed a right breast nodule and concentric thickening of the rectum. No further investigations were pursued as comfort was being prioritized.

The patient was given blood transfusions, factor VIII inhibitor bypass activity (FEIBA), and immunosuppression. She responded well after three cycles of rituximab with no further bleeding, bruising, or drop in hemoglobin levels ([Figs. 1] [2] [3]).

Further history revealed multiple easy bruising; most significant initially in her left arm, 5 days after third dose of coronavirus disease 2019 (COVID-19) vaccination which was treated conservatively as senile purpura. Two months later, she developed spontaneous worsening facial hematoma. It is unclear if this was due to COVID-19 vaccination as we could not establish temporal association.[1] Hematoma in the face is an atypical presentation of acquired hemophilia. Differentials include trauma, tumors, vessel malformations, or abscesses.[2] [3] In elderly with severe bruising, atypical hematoma with a significant decrease in hemoglobin levels should be investigated promptly and acquired hemophilia should be considered in this group.[4]