Vincent Chou, Day 4, Nephrology with Director Chen

For the past 4 days we have seen a 71 year old female who has been in the hospital for 11 days. She presented to the ER with fever and convulsions. UTI and urosepsis was suspected, and a carbapenem was administered. Hb and platelets were slightly below normal limits. Fever did not improve. Abx was switched to cefuroxime.

CXR, renal echo, and CT were performed and demonstrated fluid within the right perirenal fascia. A urologist was consulted--perirenal abscess was suspected and he performed a percutaneous nephrostomy. However, during the procedure he discovered blood in the fascia and stopped immediately. Labs were redrawn and showed an even lower Hb and platelet level, as well as increased D-dimer and FDP. 

In hindsight, the procedure was unnecessary--it could have been reasoned that it was a perirenal hematoma with lab findings. At this point, the bleeding needed to be stopped. There were three options:

1. nephrectomy, which may result in more blood loss if the post-surgical wound bleeds similarly
2. vascular angiography to determine the site of bleeding and promote clotting in that area
3. conservatively provide blood transfusions, platelets and clotting factors until bleeding has halted, assuming blood will not leak from the perirenal fascia

The conservative treatment was used and Hb and platelet count eventually increased and stabilized. Transfusion-related acute lung injury (TRALI) was cautiously monitored for by checking CVP level. In the past four days I have seen this patient, it seems her condition has improved. This is a rare case with an unknown cause of or spontaneous perirenal hematoma. Rare in and of themselves, perirenal hematomas are usually due to trauma, malignancy, or connective tissue diseases. In one case, it was even due to excessive hula-hooping: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2633086/