Chronic retroperitoneal hematoma with femoral neuropathy in a case of factor-II deficiency: an interesting case report

Authors

  • Saravana Kumar I. Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India https://orcid.org/0000-0003-0693-2338
  • Selvaganesan M. Purushothaman Department of Radio-diagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

DOI:

https://doi.org/10.18203/2349-2902.isj20250158

Keywords:

Chronic hematoma, Retroperitoneal mass, Coagulopathy

Abstract

Chronic expanding hematoma is a rare condition that develops following surgery, trauma, or injury. It can occur in the retroperitoneal region after minor trauma, potentially leading to femoral neuropathy. In this case report, we present a 22-year-old male who experienced a trivial trauma during childhood, resulting in a right retroperitoneal swelling. Clinical examination revealed a swelling measuring 18×16 cm over the right lumbar and right iliac regions, which was mobile and non-tender. Central nervous system examination showed muscle atrophy in the right thigh, an absent right knee reflex, and a complete loss of sensation in the left thigh in the L2, L3, and L4 dermatomes, corresponding to femoral and obturator nerve territories. Given the patient's history of recurrent epistaxis during childhood, coagulopathy was suspected. Investigations revealed an altered coagulation profile, and the patient was diagnosed with factor II deficiency. Contrast-enhanced computed tomography (CECT) of the abdomen and pelvis and magnetic resonance imaging (MRI) with pelvic contrast suggested differential diagnoses of chronic hematoma and soft tissue sarcoma. The diagnosis was confirmed through ultrasound (US)-guided fine-needle aspiration cytology (FNAC) of the lesion. The patient underwent retroperitoneal hematoma evacuation under general anesthesia. Intraoperative findings revealed a cavity measuring 15×10 cm in the extraperitoneal plane, bordered laterally by the iliac wing, medially by a thickened peritoneal sheath, extending inferiorly to the true pelvic brim, and superiorly to the lower border of the right kidney. Postoperative recurrent bleeding was managed with fresh frozen plasma (FFP) transfusions based on a calculated formula and daily on-demand therapy. Radiological imaging confirmed complete resolution of the hematoma post-operatively. We conclude that early surgical evacuation of chronic hematomas is critical to prevent complications such as femoral neuropathy. In this patient, delayed intervention resulted in persistent femoral nerve weakness and loss of power in the affected nerve territory.

Metrics

Metrics Loading ...

References

Reid JD, Kommareddi S, Lankerani M, Park MC. Chronic expanding hematomas. A clinicopathologic entity. JAMA. 1980;244:2441-2. DOI: https://doi.org/10.1001/jama.244.21.2441

Yamasaki T, Shirahase T, Hashimura T. Chronic expanding hematoma in the psoas muscle. Int J Urol. 2005;12:1063-5. DOI: https://doi.org/10.1111/j.1442-2042.2005.01209.x

Aisner SC, Seidman JD, Burke KC, Young JW. Aspiration cytology of biphasic and monophasic synovial sarcoma. A report of two cases. Acta Cytol. 1993;37(3):413-7.

Naito N, Ozaki T, Kunisada T, Kawai A, Dan'ura T, Morimoto Y, et al. Synovial sarcoma with a large hematoma in the inguinal region. Arch Orthop Trauma Surg. 2000;120(9):533-4.

Costa MJ, McGlothlen L, Pierce M, Munn R, Vogt PJ. Angiomatoid features in fibrohistiocytic sarcomas. Immunohistochemical, ultrastructural, and clinical distinction from vascular neoplasms. Arch Pathol Lab Med. 1995;119(11):1065-71.

Romero JA, Kim EE, Moral IS. MR characteristics of epithelioid sarcoma. J Comput Assist Tomogr. 1994;18:929-31. DOI: https://doi.org/10.1097/00004728-199411000-00015

Goodfellow J, Fearn CBd’A, Matthews JM. Iliacus haematoma. A common complication of haemophilia. J Bone Joint Surg (Br). 1967;49:748-56. DOI: https://doi.org/10.1302/0301-620X.49B4.748

Brower TD, Wilde AH. Femoral neuropathy in hemophilia. J Bone Joint Surg (Am). 1966;48:487-92. DOI: https://doi.org/10.2106/00004623-196648030-00007

Kettlekamp DB, Powers SR. Femoral compression neuropathy in hemorrhagic disorders. Arch Surg. 1969;98:367-8. DOI: https://doi.org/10.1001/archsurg.1969.01340090143027

Labadie EL, Glover D. Physiopathogenesis of subdural hematomas. Part 1: Histological and biochemical comparisons of subcutaneous hematoma in rats with subdural hematoma in man. J Neurosurg. 1976;45:382-92. DOI: https://doi.org/10.3171/jns.1976.45.4.0382

Heijdra JM, Cnossen MH, Leebeek FWG. Current and Emerging Options for the Management of Inherited von Willebrand Disease. Drugs. 2017;77(14):1531-47. DOI: https://doi.org/10.1007/s40265-017-0793-2

Peyvandi F, Mannucci PM. Rare coagulation disorders. Thromb Haemost. 1999;82(4):1207-14. DOI: https://doi.org/10.1055/s-0037-1614361

Peyvandi F, Di Michele D, Bolton-Maggs PH, Lee CA, Tripodi A, Srivastava A; Project on Consensus Definitions in Rare Bleeeding Disorders of the Factor VIII/Factor IX Scientific and Standardisation Committee of the International Society on Thrombosis and Haemostasis. Classification of rare bleeding disorders (RBDs) based on the association between coagulant factor activity and clinical bleeding severity. J Thromb Haemost. 2012;10(9):1938-43. DOI: https://doi.org/10.1111/j.1538-7836.2012.04844.x

Akhavan S, De Cristofaro R, Peyvandi F, Lavoretano S, Landolfi R, Mannucci PM. Molecular and functional characterization of a natural homozygous Arg67His mutation in the prothrombin gene of a patient with a severe procoagulant defect contrasting with a mild hemorrhagic phenotype. Blood. 2002;100(4):1347-53. DOI: https://doi.org/10.1182/blood-2002-01-0243

Nobel W, Marks SC, Jr, Kubik S. The anatomical basis for femoral nerve palsy following iliacus hematoma. J Neuro-Surg. 1980;52:533-40. DOI: https://doi.org/10.3171/jns.1980.52.4.0533

Dauty M, Sigaud M, Trossaërt M, Fressinaud E, Letenneur J, Dubois C. Iliopsoas hematoma in patients with hemophilia: a single-center study. Joint Bone Spine. 2007;74(2):179-83. DOI: https://doi.org/10.1016/j.jbspin.2006.05.014

Parmer SS, Carpenter JP, Fairman RM, Velazquez OC, Mitchell ME. Femoral neuropathy following retroperitoneal hemorrhage: case series and review of the literature. Ann Vasc Surg 2006;20:536-40. DOI: https://doi.org/10.1007/s10016-006-9059-2

Giuliani G, Poppi M, Acciarri N, Forti A. CT scan and surgical treatment of traumatic iliacus hematoma with femoral neuropathy: case report. J Trauma. 1990;30(2):229-31. DOI: https://doi.org/10.1097/00005373-199002000-00019

Liu PT, Leslie KO, Beauchamp CP, Cherian SF. Chronic expanding hematoma of the thigh simulating neoplasm on gadolinium-enhanced MRI. Skeletal Radiol. 2006;35:254-7. DOI: https://doi.org/10.1007/s00256-005-0042-8

Naito N, Ozaki T, Kunisada T, Kawai A, Dan'ura T, Morimoto Y, Inoue H. Synovial sarcoma with a large hematoma in the inguinal region. Arch Orthop Trauma Surg. 2000;120(9):533-4. DOI: https://doi.org/10.1007/s004029900109

Imaizumi S, Morita T, Ogose A, Hotta T, Kobayashi H, Ito T, Hirata Y. Soft tissue sarcoma mimicking chronic hematoma: value of magnetic resonance imaging in differential diagnosis. J Orthop Sci. 2002;7(1):33-7. DOI: https://doi.org/10.1007/s776-002-8410-5

Aoki T, Nakata H, Watanabe H, Maeda H, Toyonaga T, Hashimoto H, et al. The radiological findings in chronic expanding hematoma. Skeletal Radiol. 1999;28(7):396-401. DOI: https://doi.org/10.1007/s002560050536

Bissett GS III. MR imaging of soft-tissue masses in children. Magn Reson Imaging Clin N Am. 1996;4:697-719. DOI: https://doi.org/10.1016/S1064-9689(21)00394-9

Moulton JS, Blebea JS, Dunco DM, Braley SE, Bisset GS 3rd, Emery KH. MR imaging of soft-tissue masses: diagnostic efficacy and value of distinguishing between benign and malignant lesions. AJR Am J Roentgenol. 1995;164(5):1191-9. DOI: https://doi.org/10.2214/ajr.164.5.7717231

Gomez P, Morcuende J. High-grade sarcomas mimicking traumatic intramuscular hematomas: a report of three cases. Iowa Orthop J. 2004;24:106-10.

Silverstein A. Neuropathy in hemophilia. JAMA. 1964;190:554-5. DOI: https://doi.org/10.1001/jama.1964.03070190074023

Daneshi M, Naderi T, Tabibian S, Shams M, Rashidpanah J, Dorgalaleh A. Congenital Prothrombin Deficiency. J Cell Mol Anesth. 2018;3(4):146-54.

United Kingdom Haemophelia Centre Doctors’ Organisation. Guidelines on the selection and use of therapeutic products to treat haemophilia and other hereditary bleeding disorders. Haemophilia. 2003;9(1):1-23. DOI: https://doi.org/10.1046/j.1365-2516.2003.00711.x

Kushimoto S, Fukuoka T, Kimura A, Toyoda K, Brainsky A, Harman A, et al. Efficacy and safety of a 4-factor prothrombin complex concentrate for rapid vitamin K antagonist reversal in Japanese patients presenting with major bleeding or requiring urgent surgical or invasive procedures: a prospective, open label, single-arm phase 3b study. Int J Hematol. 2017;106(6):777-86. DOI: https://doi.org/10.1007/s12185-017-2311-4

Mumford AD, Ackroyd S, Alikhan R, Bowles L, Chowdary P, Grainger J, et al; BCSH Committee. Guideline for the diagnosis and management of the rare coagulation disorders: a United Kingdom Haemophilia Centre Doctors’ Organization guideline on behalf of the British Committee for Standards in Haematology. Br J Haematol. 2014;167(3):304-26. DOI: https://doi.org/10.1111/bjh.13058

Rahimi A, Philbert R, Willoughby JH, Jackman DS. Hypoprothrombinemia (factor II deficiency): report of a case and review of literature. J Oral Maxillofac Surg. 1991;49(1):84-7. DOI: https://doi.org/10.1016/0278-2391(91)90273-O

Irisawa M, Tsukuda S, Amanuma M, Heshiki A, Kuroda I, Ogawa F, et al. Chronic expanding hematoma in the retroperitoneal space: a case report. Radiat Med. 2005;23(2):116-20.

Marquardt G, Angels Barduzal S, Leheta F, Seifert V. Spontaneous haematoma of the iliac psoas muscle: a case report and review of the literature. Arch Orthop Trauma Surg. 2002;122:109-11. DOI: https://doi.org/10.1007/s004020100310

Ymamoto S, Momose T, Aoyagi M, Ohno K. Spontaneous intracerebral hematomas expanding during the early stages of hemorrhage without rebleeding. Report of three cases. J Neurosurg. 2002;97:455-60. DOI: https://doi.org/10.3171/jns.2002.97.2.0455

Irisawa M, Tsukuda S, Amanuma M, Heshiki A, Kuroda I, Ogawa F, et al. Chronic expanding hematoma in the retroperitoneal space: a case report. Radiat Med. 2005;23:116-20.

Downloads

Published

2025-01-28

How to Cite

Kumar I., S., & Purushothaman, S. M. (2025). Chronic retroperitoneal hematoma with femoral neuropathy in a case of factor-II deficiency: an interesting case report. International Surgery Journal, 12(2), 247–254. https://doi.org/10.18203/2349-2902.isj20250158

Issue

Section

Case Reports