Butt Muhammad Umer, Buzsaki Lili A, Smyth Susan S, Elayi Samy-Claude
Department of Internal Medicine, Gills Heart Institute, University of Kentucky, Lexington, KY, USA.
Department of Preventive Medicine, College of Public Health, University of Kentucky, Lexington, KY, USA.
Am J Case Rep. 2017 Oct 30;18:1148-1152. doi: 10.12659/ajcr.905628.
BACKGROUND Spontaneous retroperitoneal hemorrhage (SRH) is a rare and difficult-to-diagnose entity. It is not associated with trauma, pathology, or iatrogenic manipulations. Few cases have been reported, with the only precipitating factor recognized being bleeding diatheses such as anticoagulation states, inherited coagulopathies, and hemodialysis. However, none of these have been described in combination with septic shock, which itself is associated with platelet dysfunction, coagulation dysfunction, and vasculopathy. CASE REPORT Our case involves an elderly man presenting with altered mental status of unknown etiology, in addition to hemodynamic instability, presumably due to septic shock, without any overt signs of bleeding. After his initial exam revealed lower-extremity edema and decubitus ulcers, a venous Doppler was performed, which revealed extensive deep vein thrombosis. It was unknown whether the sepsis or DVT occurred first. Therapeutic anticoagulation with heparin was subsequently started. On hospital day 4, a CT abdomen with contrast identified retroperitoneal hematoma after the patient's hemoglobin lowered without any overt signs of bleeding. The diagnosis of spontaneous retroperitoneal hematoma was one of exclusion and posed a therapeutic dilemma (conservative versus invasive management). CONCLUSIONS Sepsis-related coagulopathy and heparin use in an elderly patient predisposed him to an iliopsoas hematoma. In this case, conservative management with reversal of anticoagulation and blood transfusion was sufficient to stabilize the patient.
背景 自发性腹膜后出血（SRH）是一种罕见且难以诊断的病症。它与创伤、病理或医源性操作无关。仅有少数病例被报道，唯一被认可的促发因素是出血性疾病，如抗凝状态、遗传性凝血障碍和血液透析。然而，这些因素均未被描述为与感染性休克同时出现，而感染性休克本身与血小板功能障碍、凝血功能障碍和血管病变相关。病例报告 我们的病例是一位老年男性，除了血流动力学不稳定（推测是由于感染性休克）外，还出现了病因不明的精神状态改变，且无任何明显出血迹象。在其初步检查发现下肢水肿和褥疮后，进行了静脉多普勒检查，结果显示广泛的深静脉血栓形成。尚不清楚是败血症还是深静脉血栓形成先出现。随后开始使用肝素进行治疗性抗凝。在住院第4天，患者血红蛋白降低且无任何明显出血迹象，腹部增强CT检查发现腹膜后血肿。自发性腹膜后血肿的诊断是排除性诊断，这带来了治疗困境（保守治疗还是侵入性治疗）。结论 老年患者的败血症相关凝血障碍和肝素使用使其易患髂腰肌血肿。在本病例中，通过抗凝逆转和输血进行保守治疗足以使患者病情稳定。
