Muscle hematoma： A critically important complication of alcoholic liver cirrhosis

An iliopsoas hematoma can occur either spontaneously or secondary to trauma or bleeding tendency due to hemophilia and anticoagulant therapy. Although liver cirrhosis is commonly associated with coagulopathy, iliopsoas hematoma is very rare. We herein, present a case of bilateral iliopsoas hematoma in a patient with alcoholic cirrhosis, and review the literature on muscle hematoma associated with cirrhosis. A 56-year-old man with alcoholic cirrhosis was admitted in a state of shock with anemia. The cause of anemia could not be detected, and the patient was treated conservatively. The site of bleeding was not detected with either gastroduodenal endoscopy or upper abdominal computed tomography, the latter of which did not include the iliopsoas muscle. He died on the 10th day of admission and bilateral iliopsoas hematomas were found on autopsy. An iron stain was positive in the iliopsoas muscle. Eight cases of muscle hematoma associated with cirrhosis, including the present case, were found in a review of the literature. Four of these cases involved the rectus abdominis muscle, 3 involved the iliopsoas muscle and 1 involved combined muscles. Alcoholic cirrhosis accounted for 75% of the cases. One case （12.5%） was associated with virus- related cirrhosis, and another with combined virus- and alcohol-related cirrhosis. The mortality rate was 75% despite early diagnosis and low risk scores for cirrhosis. Muscle hematoma in patients with cirrhosis is closely related to alcoholism, and the mortality rate of the condition is extremely high. In conclusion, muscle hematoma should be recognized as an important complication of cirrhosis.     

Femoral compressive neuropathy from iliopsoas haematoma complicating dengue hemorrhagic fever

Dengue fever is a debilitating mosquito-borne disease caused by dengue virus. We reported a case of femoral compression neuropathy due to iliopsoas hematoma complicating dengue hemorrhagic fever. Iliopsoas muscle hematoma can cause femoral neuropathy with resultant pain and paralysis. Such manifestations are not well documented in the literature. The pathogenesis of hematoma and compressive neuropathy with its appropriate management is discussed.     

A case of rectus sheath hematoma]

The following is a rare case of rectus sheath hematoma. The patient was a 78-year-old man with a past history of axillo-femoral bypass operation. He contracted a cold, and when he coughed severely, acute lower abdominal pain occurred. Abdominal echography and CT scanning confirmed the presence of a hematoma in the rectus abdominis muscle. Before, patient was diagnosed as acute abdomen and surgery was performed. Recently, accurate diagnosis has been made easily by echography or CT.     

Hematoma of the anterior rectus abdominis muscle as the first manifestation of lymphoproliferative disease after renal transplantation

Rectus sheath hematoma results from the rupture of rectus muscle vessels by trauma, coagulation disorders or anticoagulant therapy, but it can occur spontaneously too. Its prognosis is good. On the other hand, posttransplant lymphoproliferative disorders (PTLD) are serious and potentially fatal complications in transplant recipients. Patients with PTLD have a mononucleosis-like syndrome or develop extranodal masses which involve various organs. We report the case of a renal transplant recipient who develop a rectus sheath hematoma as the first clinical feature of PTLD.     

A case of group B streptococcal pyomyositis

The group B streptococcus is an opportunistic pathogen that causes a variety of serious infections including bacteremias, puerperal sepsis, and neonatal meningitis. Group B streptococcal infections of muscle are rare. We report here an unusual case of group B streptococcal pyomyositis. Pyomyositis arises predominantly from infections caused by Staphylococcus aureus and, occasionally, Streptococcus pyogenes. Because of the rarity of pyomyositis in temperate climates, the common lack of localizing signs or symptoms, and the frequently negative blood cultures, considerable delay often precedes the diagnosis of pyomyositis; in fact, the infection has been initially misdiagnosed as muscle hematoma, cellulitis, thrombophlebitis, osteomyelitis, or neoplasm. Diagnosis may be greatly aided by radiologic techniques that can demonstrate the sites of muscle enlargement and the presence of fluid collections. The response to antibiotics is usually rapid, but resolution of the infection may require aspiration of deeply situated muscle abscesses. This report describes a diabetic patient with an unusual presentation of pyomyositis that mimicked an acute abdomen.     

Treatment with recombinant activated factor VII in a patient with hemophilia A and an inhibitor: advantages of administration by continuous infusion over bolus intermittent injections.

Recent studies have shown that treatment with a continuous infusion of recombinant activated factor VII (rFVIIa) is far more convenient than administration by bolus intermittent injections and may allow a substantial reduction in the dose. We present the case of a 26-year-old patient with hemophilia A, who had a high-titer inhibitor to both human and porcine factor VIII, and who had recently been admitted to hospital because of a bilateral severe ilio-psoas hematoma. Two subsequent courses of treatment with rFVIIa by bolus intermittent injection showed only a partial efficacy. A further administration of rFVIIa was therefore carried out using a continuous infusion regimen that proved to be fully efficacious. During the continuous infusion course levels of factor VII coagulant activity were in the range 18.2-5.2 U/ml, while the prothrombin time, expressed as an International Normalized Ratio, remained within the range 0.57-0.71. The continuous infusion, compared with the administration of the bolus intermittent infusion, reduced the amount of rFVIIa required by approximately 40-50%. Statistical analysis demonstrated that there was a strong positive correlation between the rate of infusion of rFVIIa and levels of factor VII coagulant activity (r = +0.941; P < 0.001), and a very significant negative correlation between levels of factor VII coagulant activity and prothrombin time values (r = -0.897; P < 0.001). In accordance with previous findings, our experience confirms that, when prolonged therapy is required, treatment with rFVIIa by continuous infusion is more convenient than administration of bolus intermittent injections, and may allow the saving of a large amount of drug. Moreover, we suggest potential additional advantages of the continuous infusion regimen over bolus intermittent injections, such as a better efficacy and a stronger correlation between prothrombin time and factor VII coagulant activity levels.     

Neurological complications of anticoagulation therapy: a neurologist's review.

Anticoagulant-induced bleeding may involve the brain, spinal cord, or peripheral nerves. It may occur with either coumarin or heparin anticoagulants, in the absence of trauma, and while prothrombin times, clotting times, or partial thromboplastin times are in accepted therapeutic ranges. Bleeding involving the brain occurs usually as a subdural hematoma, with intracerebral or subarachnoid hemorrhages occurring less frequently. There may be diagnostic problems in the recognition of these anticoagulant-related subdural hematomas. The spinal cord involvement usually appears in the form of an extradural hematoma. This condition can progress rapidly, and prompt recognition of its presence, localization with myelography, and laminectomy for surgical evacuation are necessary. The peripheral nerve most frequently compressed is the femoral nerve, due to bleeding into the iliacus muscle. Other nerves can be involved, and surgical evacuation may be necessary at times.     

Esophageal obstruction due to intermuscular hematoma following pneumatic dilatation.

A case of incomplete esophageal perforation with an intermuscular hematoma is presented. Unlike previously described submucosal or intramural perforations, this case involved mucosa, submucosa, and the inner circular muscle layer but was limited by the outer longitudinal layer. Nonsurgical treatment was followed when the clinical picture of an incomplete perforation without mediastinal soilage was considered. Surgery was done when evidence of impending extension of the process outside the esophagus developed.     

Peritonitis and fulminant sepsis due to spontaneous rupture of iliopsoas abscess.

We report a 25-year-old woman who presented with features of peritonitis. At laparotomy, the cause of the pyoperitoneum was found to be a left-sided ilio-psoas abscess. This was drained, but the patient continued to deteriorate with sepsis, and died on the fourth post-operative day.     

Traumatic subdural hematoma in the lumbar spine

Traumatic spinal subdural hematoma is rare and its mechanism remains unclear. This intervention describes a patient with mental retardation who was suffering from back pain and progressive weakness of the lower limbs following a traffic accident. Magnetic resonance imaging of the spine revealed a lumbar subdural lesion. Hematoma was identified in the spinal subdural space during an operation. The muscle power of both lower limbs recovered to normal after surgery. The isolated traumatic spinal subdural hematoma was not associated with intracranial subdural hemorrhage. A spinal subdural hematoma should be considered in the differential diagnosis of spinal cord compression, especially for patients who have sustained spinal trauma. Emergency surgical decompression is usually the optimal treatment for a spinal subdural hematoma with acute deterioration and severe neurological deficits.     

Morphodynamics and pathology of blood vessels II. Morphodynamic study of constriction of umbilical blood vessels and its application to coronary artery disease

The morphodynamic changes of the umbilical artery from full distension to total occlusion within 45 seconds of delivery is very striking. On gross examination, the constricted artery shows a small, round, outer contour and reduced external diameter. On microscopic examination, it shows a small, compressed or completely obliterated lumen with an irregular wavy luminal outline, plump endothelial cells with ovoid nuclei, remodeling of the inner muscle layer with smooth muscle cells reoriented towards the luminal center, wrinkled elastic fibrils dispersed in the inner muscle layer and/or wrinkled thick internal elastic lamina, contracted smooth muscle cells with plump cellular outline and squeezed nuclear deformity, and thickened muscle bundles. A total occlusion of the umbilical arterial lumen is accomplished by maximal contraction of smooth muscle cells in the outer muscle layer. This contraction creates thick muscle bundles, generates a constrictive force to reduce the outer circumference and external diameter, and then causes the inward projection of the inner muscle layer to obliterate the lumen.The morphological changes of smooth muscle cells and the remodeling of the arterial wall by muscle contraction and constriction can also be found in the coronary arteries of patients who died of occlusive coronary artery disease. Coronary artery constriction or spasm can cause (1) remodeling of soft atheromatous plaques, resulting in nonthrombotic occlusion; (2) volcano-like eruption of soft atheromatous plaques, resulting in thrombus formation; and (3) tearing of the nonatherosclerotic arterial wall, resulting in dissection and compressive hematoma in the arterial wall.Presented in part at the 30th Annual Meeting, International College of Angiology, Amsterdam, The Netherlands, June 1988     

Femoral nerve palsy secondary to anticoagulant induced iliacus hematoma. A case report

A case of femoral neuropathy from iliac muscle hematoma occurring in a patient treated with urokinase, subcutaneous heparin and aspirin for myocardial infarction is reported. Diagnosis of this complication was suspected on the basis of clinical signs and on the fact that the patient had received anticoagulants. Computed tomography allowed direct and clear visualization of the hematoma. Anticoagulant suspension followed by an early surgical decompression seems to be the ideal treatment for this neuropathy; however, our patient died for a reinfarction after stopping heparinic administration. This may indicate that, in some patients "at risk", it is better to reduce rather than stop anticoagulant therapy.     

Iliopsoas hematoma presenting with sudden knee extensor weakness: A case report

Rationale:Hematoma of the iliopsoas muscle is a rare condition. Prolonged pressure conditions due to hematoma of the femoral nerve can cause severe pain in the affected groin, hip, and thigh, and quadriceps weakness. We report a rare case of a spontaneous iliopsoas muscle hematoma that caused sudden femoral neuropathy.Patient concerns:A 71-year-old woman presented sudden left hip pain and knee extensor weakness. The pain was aggravated with left hip extension. She had a bilateral total hip replacement surgery due to avascular necrosis. She was diagnosed as mild stenosis of the cerebral artery and took aspirin to prevent cerebral artery atherosclerosis.Diagnosis:A hip computed tomography scan demonstrated a suspicious fluid collection at the left iliopsoas bursa. We considered the possibility of lower limb weakness due to neuralgic amyotrophy and performed electromyography and enhanced lumbosacral magnetic resonance imaging (MRI). Electromyography finding showed left femoral neuropathy of moderate severity around the inguinal area was diagnosed. On MRI, left iliopsoas bursitis or hematoma, and displacement of the left femoral nerve due to the iliopsoas bursitis/hematoma were observed.Intervention:Ultrasonography (US)-guided aspiration of the left iliopsoas hematoma was performed. We started steroid pulse therapy for 8 days.Outcomes:After US-guided aspiration and steroid pulse therapy, the patient''s knee extension motor grade improved from grade 1 to 2, and the pain was slightly reduced. At 3 weeks after the aspiration procedure, her hip flexion motor grade had improved from grade 3+ to 4 at follow-up.Lessons:Imaging studies are fundamental to diagnose of iliopsoas hematoma. Electromyography examination plays an important role in determining the prognosis of patients and lesion site. Despite the negligible change in sitting position, hematoma can develop. Physicians should consider hematoma that cause femoral neuropathy.     

Intramural duodenal hematoma of pancreatic origin.

Non-traumatic intramural hematoma of the duodenum is an unusual clinical entity. Indeed, in a majority of 70% of patients intramural hematoma of the duodenum is caused by a blunt, frequently minor abdominal trauma. The main etiology of non-traumatic intramural hematoma of the duodenum in the adult is overdose anticoagulant therapy. Rarer causes include pancreatic disease, blood dyscrasia or vascular collagen disease. In this presentation a case of pancreatitis-induced intramural duodenal hematoma is discussed and compared with corresponding data in the literature.     

Pseudosepsis: rectus sheath hematoma mimicking septic shock

There are many noninfectious disorders in the critical care unit (CCU) that mimic sepsis. Pseudosepsis is the term applied to noninfectious disorders that mimic sepsis. Fever/leukocytosis is not diagnostic of infection but frequently accompanies a wide variety of noninfectious disorders. When fever/leukocytosis and hypotension are present, sepsis is the presumptive diagnosis until proven otherwise. After empiric therapy for sepsis is initiated, the clinician should rule out the noninfectious causes of pseudosepsis. The most common causes of pseudosepsis in the CCU setting are pulmonary embolism, myocardial infarction, gastrointestinal hemorrhage, overzealous diuretic therapy, acute pancreatitis, relative adrenal insufficiency, and (rarely) rectus sheath hematoma. Rectus sheath hematoma may occur secondary to trauma/anticoagulation therapy and may present as an acute surgical abdomen mimicking sepsis. Rectus sheath hematoma should be considered when other causes of pseudosepsis or sepsis fail to explain persistent hypotension unresponsive to fluids/pressors. The diagnosis of rectus sheath hematoma is by abdominal ultrasound or computed tomography scan. If the abdominal computed tomography scan is negative for other intra-abdominal pathology and other causes of pseudosepsis are eliminated, then the diagnosis of pseudosepsis caused by rectus sheath hematoma is confirmed by demonstrating a hematoma in the rectus sheath. Treatment of rectus sheath hematoma is surgical drainage and ligation of any bleeding vessels. Evacuation of the rectus sheath hematoma rapidly reverses the patient's hypotension and is curative. We describe a case of pseudosepsis caused by rectus sheath hematoma in an elderly man with hypotension unresponsive to fluids/pressors and mimicking septic shock. Clinicians should be aware that rectus sheath hematoma is a rare but important cause of pseudosepsis in patients in the CCU.     

Pyomyositis. Report of 18 cases in Hawaii

Eighteen patients with pyomyositis were seen at a large hospital in Hawaii. Most were healthy young men or boys, and eight had never traveled abroad. Fever, muscle pain and swelling, and leukocytosis were common, but only seven had erythema or fluctuance. A single large muscle was infected in 14, and two to three muscles were infected in the others. Pyomyositis mimicked cellulitis, muscle hematoma, thrombophlebitis, appendicitis, and neoplasm. Staphylococcus aureus was found in 13, and Streptococcus pyogenes was found in two. Bacteremia occurred in 29% (5/17). Drainage and antimicrobial agents were usually effective therapy, but one patient died and another had CNS damage. The pathogenesis is uncertain, but 12 had nonpenetrating muscle injury and 13 had pyoderma, suggesting that bacteria invade injured muscle via the bloodstream or lymphatic system.     

Traumatic rectal hematoma following anal rape

We describe the case of a 28-year-old male prisoner with a traumatic rectal hematoma caused by anal rape. Barium enema showed a large rectal mass confirmed to be a hematoma by proctoscopic examination. Surgery was performed due to a falling hemoglobin level, and an 800-mL hematoma was evacuated. The patient became febrile following surgery, and computed tomography revealed a pelvic mass consistent with recurrent hematoma or abscess. Repeat surgery showed recurrent hematoma. The patient recovered uneventfully.     

Aortic intramural hematoma: aspects of pathogenesis 2011

Non-invasive tomographic imaging modalities have recently contributed to identifying aortic intramural hematoma, a variant form of classic dissection, which is characterized by the absence of an intimal tear and thus the absence of direct flow communication, and which represents an important disease entity in acute aortic syndrome. Clinical investigations have revealed that intramural hematoma has characteristic clinical features and that the natural remodeling process of hematoma is different from that of classic aortic dissection. These findings suggest that intramural hematoma is not just a precursor to aortic dissection, but may be a unique disease entity with a more favorable prognosis compared to aortic dissection. There is regional heterogeneity regarding the relative incidence of this hematoma, with higher incidence seen in Eastern countries. Due to favorable outcomes with medical treatment in Asian patients with type A intramural hematoma, a tailored or individualized approach based on risk stratification using initial clinical information and including imaging studies and timely surgical repair has been suggested in hemodynamically stable patients; however, these results need to be confirmed in other patient populations. The concept of a "micro-tear" which cannot be easily visualized using conventional imaging modalities has been raised: "echo-free space" on transesophageal echocardiography and "focal contrast enhancement" on ultra-fast computerized tomography have drawn many physicians' attention, and the possibility of a pathophysiologic link between classic aortic dissection and intramural hematoma has been discussed. Further investigations are needed to test whether intramural hematoma begins with an initial intimal tear and a different aortic status--characterized by a more rigid and non-compliant aorta associated with old age or long-standing hypertension--and results in an apparently absent intimal flap.     

Sonography: a method for localization of hematomas in hemophiliacs.

Sonography was used to visualize hematomas in hemophilic patients. The method is especially helpful for the diagnosis of psoas hematoma and retroperitoneal hematoma and allows the follow-up of hematomas of the cervical region and muscle hematomas. The method is simple, rapid, painless and has no known adverse effects.     

Spontaneous rupture of the superficial femoral artery treated via an endovascular approach

Isolated spontaneous rupture of the superficial femoral artery is very uncommon. To our knowledge, only 5 other cases have been reported in the medical literature. Herein, we report the case of an 86-year-old woman who was admitted to our hospital with a 4-day history of progressive swelling of the left thigh. The presence of a pulsating mass with paresthesia of the lower limb and anemia suggested a hematoma of the thigh. A computed tomographic scan revealed a 4-cm-diameter pseudoaneurysm of the left superficial femoral artery and a large hematoma of the medial muscle compartment. A nitinol-polytetrafluoroethylene VIABAHN self-expanding stent-graft (5-mm diameterx50-mm length) was placed beyond the arterial lesion, and a fasciotomy of the thigh was performed. On the 10th postoperative day, the patient was discharged from the hospital in good condition. In cases of spontaneous swelling of the thigh in the absence of trauma or other apparent causes, spontaneous rupture of the superficial femoral artery should be suspected. Surgical treatment is preferable in young patients. In patients who are elderly or in poor condition, endovascular therapy is preferable when there is diffuse atherosclerosis of the artery.