A 70-year-old woman undergoing chronic maintenance hemodialysis had felt a mass in her left hip 4 years prior. As the mass gradually expanded, magnetic resonance imaging (MRI) was performed. The MRI findings showed mosaic patterns with various signal intensities inside the mass and a low-signal band at its periphery. Because of the slow expansion of the mass over a course of at least 4 years and its characteristic MRI findings, the patient was diagnosed with a chronic expanding hematoma (CEH), a comparatively rare type of hematoma. To our knowledge, this is the first report of a CEH occurring in a hemodialysis patient in the English literature

Higashiyama Yasuhito

Hirose Misaki

Kawasaki Satoko

Kitamura Mineaki

Kohno Shigeru

Muta Kumiko

Nakazawa Yuka

Nishino Tomoya

Obata Yoko

Ohtsuka Kouichirou

Uetani Masataka

Uramatsu Tadashi

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Acta Med. Nagasaki 59: 73−75−Introduction　Most hematomas are absorbed spontaneously. In 1968, Freidlander et al.1 first reported a case of a slowly expanding hematoma. Thereafter, Reid et al.2 established the disease concept of a chronic expanding hematoma (CEH) through similar cases. CEH tends to occur after surgery or injury.3 In addition, CEH was reported in patients not only with a bleed-ing tendency or undergoing anticoagulant therapy but also with spontaneous onset. Reported sites of occurrence include the thorax, head, retroperitoneum, and limbs.3　Here we report a case of a CEH extending from the left hip to the thigh that gradually expanded over the course of at least 4 years in a hemodialysis patient. We were able to con-trol the CEH by drainage without any complications. Case Report　The patient was a 70-year-old woman with diabetes; in 2009, she started chronic maintenance hemodialysis for end stage renal disease (ESRD) caused by diabetic nephropathy. The patient started taking antiplatelet drugs for cerebral in-farction in 2003 but demonstrated no bleeding tendency.　In 2006, the patient first noticed a mass in her left hip but left it untreated. The mass gradually expanded and made sitting MS#AMN 07160Case ReportA case of a chronic expanding hematoma in a hemodialysis patientMisaki Hirose1)2),  Yoko Obata1)3),  Satoko Kawasaki1)4),  Kumiko Muta1)5),  Tadashi Uramatsu1),  Mineaki Kitamura6),Kouichirou Ohtsuka7),  Yuka Nakazawa8),  Yasuhito Higashiyama8), Tomoya Nishino1),  Masataka Uetani9), Shigeru Kohno1)1 Second Department of Internal Medicine, Nagasaki University Hospital, Nagasaki, Japan2 Department of Informatics, Nagasaki University Hospital, Nagasaki, Japan3 Medical Education Development Center, Nagasaki University Hospital, Nagasaki, Japan4 Division of Blood Purification, Nagasaki University Hospital, Nagasaki, Japan5 Center for Comprehensive Community Care Education, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan6 Nagasaki Municipal Medical Center, Nagasaki, Japan7 Department of Nephrology, Mito Kyodo General Hospital, Mito, Japan8 Hokusyo Central Hospital, Sasebo, Japan9 Department of Radiology, Nagasaki University Hospital, Nagasaki, Japan　A 70-year-old woman undergoing chronic maintenance hemodialysis had felt a mass in her left hip 4 years prior. As the mass gradually expanded, magnetic resonance imaging (MRI) was performed. The MRI findings showed mosaic patterns with various signal intensities inside the mass and a low-signal band at its periphery. Because of the slow expansion of the mass over a course of at least 4 years and its characteristic MRI findings, the patient was diagnosed with a chronic expanding he-matoma (CEH), a comparatively rare type of hematoma. To our knowledge, this is the first report of a CEH occurring in a he-modialysis patient in the English literature. ACTA MEDICA NAGASAKIENSIA 59: 73−75, 2014Key words: chronic expanding hematoma, CEH, hemodialysis, MRI, hip, thigh　 　Address correspondence: Yoko Obata, MD, PhD Second Department of Internal Medicine, Nagasaki University School of Medicine1-7-1 Sakamoto, Nagasaki 852-8501, JapanTel: +81-95-819-7273; Fax: +81-95-849-7285; E-mail: yobata@nagasaki-u.ac.jp  Received May 7, 2014; Accepted June 27, 201474 Misaki Hirose et al.: Chronic expanding hematoma in hemodialysis patientdifficult; therefore, she underwent a detailed examination in February 2010. Magnetic resonance imaging (MRI) revealed an approximately 11×8×15 cm mass exhibiting a mosaic pattern with various signal intensities inside the mass and a low-signal band on its periphery that extended from the left hip to the thigh (Figures 1A and 1B). Although further ex-amination by a biopsy was recommended, she declined the biopsy and chose a subsequent follow-up examination in-stead.　In early November 2010, the patient was admitted to our hospital with increased swelling and pain extending from the left hip to the thigh. On admission, her blood pressure was 124/62 mmHg, pulse was 81 beats/min, and body tempera-ture was 36.5°C. There were no abnormal cardiac, respira-tory, or gastrointestinal sounds. The area from the left hip to the thigh was swollen and hard with mild tenderness. Clini-cal laboratory test findings are shown in Table 1. No decrease in platelet count was seen, and no rapid decline in hemoglo-bin was observed. C-reactive protein level was slightly ele-vated. MRI showed that the mass had expanded slightly to approximately 11×12×31 cm in the left hip; the lesion had markedly expanded in the thigh, showing high signal ac-companied by low-signal areas on both T1- and T2-weighted MRI (Figures 2A, 2B). The aspirate fluid from the mass was unclotted and chocolate-colored with no malignant findings on cytological examination. There was no uptake in the mass on thallium scintigraphy. Because the mass slowly expanded over the course of at least 4 years with MRI findings sugges-tive of a mixture of old and new hematomas, it was diag-nosed as a CEH. Although surgical treatment was consid-ered, we judged it too difficult due to the complications of ESRD and diabetes. Thus, to minimize expansion of the CEH, the antiplatelet drugs were discontinued and the anti-coagulant used during dialysis was changed from heparin to low-molecular-weight heparin. Thereafter, she was discharged from the hospital without further expansion of the mass.Discussion　Reid et al.2 defined CEH as a hematoma that persists and increases in size more than a month after the initial hemor-rhage. Its pathogenic mechanism is not completely under-stood, but it is hypothesized that inflammation induced by hemorrhaged blood and its degradation products causes vas-cular hyperpermeability and neoangiogenesis. Bleeding from the neovascular microvessels in formed granulation tissue is thought to contribute to the gradual expansion of CEH.1,4 An osmotic pressure gradient due to hemocyte degradation products may also be involved in hematoma expansion.1  This patient had no obvious history of surgery or injury in the left hip or leg. Thus, CEH might be influenced by an unno-ticeable minor wound and antiplatelet drug administration in the present case.Hirose M, et al. Figure 1A BFigure 1.  (A) T1- and (B) T2-weighted sagittal magnetic reso-nance images showing a mass extending from the left hip to the thigh with a mixture of low- and high-intensity signals on the inte-rior. The periphery is surrounded by a low-signal band (arrows).Table 1 <Peripheral blood> <Blood chemistry> RBC          331 × 106/mm3 Hb             10.3 g/dL Hct 31.2% WBC         6860/mm3   Neut  72.4%   Lym  17.4%   Eosino  3.1%   Mono 5.4%   Baso 0.4% PLT       31.5 × 106/mm3      TP  6.2 g/dL Alb  3.5  g/dL T-Bil  0.46 mg/dL AST  15  mU/mL ALT 14  mU/mL LDH  394 mU/mL ALP 559 mU/mL γ-GTP 19 mU/mL Amy 91 IU/L BUN 56.1 mg/dL Cr  7.15  mg/dL UA  7.8  mg/dL Na 137  mEq/L K  4.4  mEq/L Cl  98  mEq/L Ca 7.9 mg/dL P 2.9  mg/dL CRP  4.6  mg/dL Table 1. Laboratory data on admissionA BHirose M, et al. Figure 2Figure 2. (A) T1- and (B) T2-weighted sagittal magnetic reso-nance images showing that the mass expanded slightly in the left hip. In the thigh, the mass expanded further downward, exhibiting a high-signal area accompanied by a low-signal area (arrow).75Misaki Hirose et al.: Chronic expanding hematoma in hemodialysis patient　CEH symptoms vary by lesion site. In addition to self-awareness of local masses, pain, and discomfort, a variety of organ compression symptoms have been seen, such as walk-ing disability caused by a CEH on the anterior part of the knee,5 heart failure due to compression of the left ventricle caused by a CEH on the posterior portion of the left ven-tricle after coronary artery bypass surgery,6 and hydroneph-rosis due to ureteral compression and occlusion caused by a CEH in the retroperitoneum.7　The pathological examination of a resected specimen pro-vides a definitive diagnosis of CEH. It shows a fibrous coat-ing, and granulation, necrotic tissue, vascularization, blood clots, and inflammatory cell infiltration are seen on the inte-rior. However, when mass resection is difficult, MRI is the most important diagnostic imaging technique for CEH. The characteristic finding of MRI is mosaic-like signals reflect-ing new and old blood components. Comparing the findings of MRI and histopathology, Aoki et al.8 found that the mix-ture of irregular low and high signals on T2-weighted im-ages reflects hemosiderin deposition, loose connective tis-sue, granulation tissue, necrosis, fibrin, and blood clots. High signals on a T1-weighted image reflect a fresh hemorrhage. Additionally, a peripheral pseudocapsule of hyaline fibrous tissue often exhibits a low-signal band on T2-weighted im-ages. In considering the differential diagnosis, it is often dif-ficult to distinguish chronic hematoma from malignant tumor which increases in size slowly. In particular, approxi-mately 5% of malignant fibrous histiocytomas are associated with hematomas. 9  Calcific myonecrosis is another enlarg-ing post-traumatic condition in which an entire single muscle is replaced by a fusiform mass with central liquefaction and peripheral calcification.8 In the present case, we were unable to perform a pathological examination, but since the imaging findings were similar to those of studies reported by Aoki et al., we diagnosed the patient with CEH.　Surgery is the first-line therapy for CEH. In one reported case, the capsula fibrosa could not be completely resected and symptoms recurred 10 ; therefore, complete resection is desirable. In our case, we opted to perform puncture and drainage rather than surgery according to the patientʼs wishes when the pain worsened. Although we could control the CEH by drainage without any complications, serious hemor-rhage after drainage was reported in another case.5 Thus, we should pay attention to a subsequent massive hemorrhage when draining a CEH. 　Upon searching the English literature on CEH, we could not find a report of a CEH in a hemodialysis patient. There are some cautions on CEH in the hemodialysis patients. First, antiplatelet drugs for cardiovascular complications and anticoagulants are often used in hemodialysis patients. Thus, we must pay close attention to the development of CEH after bruising or surgery. In the present case, we cannot rule out the possibility that anticoagulant use was a contributor to the relatively rapid expansion of hematoma in the thigh. Second, anemia accompanying hematoma formation might be masked by the complication of renal anemia in the patients on dialysis. Hence, the change in hematoma size must be carefully monitored with the course of anemia.Conclusion　Here we reported the case of a CEH on the left hip that expanded to the thigh in a hemodialysis patient. Although the English report of CEH in hemodialysis patient is only our case, CEH should be considered a differential diagnosis when a mass shows an expanding tendency.Acknowledgments　All authors declare no conflicts of interest.References 1. Friedlander HL, Bump RG. Chronic expanding hematoma of the calf. A case report. J Bone Joint Surg Am. 50:1237-41,1968 2. Reid JD, Kommareddi S, Lankerani M, Park MC. Chronic expanding hematomas. A clinicopathologic entity. JAMA 244:2441-2442,1980 3. Pasku D, Bano A, Lagoudaki E, Alpantaki K, Katonis P. Spontaneous and enormous, chronic expanding hematoma of the lumbar region: a case report. Cases J. 2:9400,2009 4. Labadie EL, Glover D. Physiopathogenesis of subdural hematomas:Part 1, Histological and biochemical comparison of subcutaneous hematoma in rats with subdural hematoma in man. J Neurosurg 45:382-392,1976 5. Sreenivas M, Nihal A, Ettles DF. Chronic haematoma or soft-tissue neo-plasm? A diagnostic dilemma. Arch Orthop Trauma Surg 124:495-497,2004 6. Kainuma S1, Masai T, Yamauchi T, Takeda K, Iwakura K, Ito H, Abe K, Sawa Y. Chronic expanding intrapericardial hematoma after coronary artery bypass surgery presenting with congestive heart failure. Ann Thorac Cardiovasc Surg. 14:52-4, 2008 7. Irisawa M, Tsukuda S, Amanuma M, et al.: Chronic expanding haema-toma in the retroperitoneal space. Radiation Medicine 23:116-120,2005 8. Aoki T, Nakata H, Watanabe H, Maeda H, Toyonaga T, Hashimoto H, Nakamura T: The radiological findings in chronic expanding hemato-ma. Skeletal Radiol 28:396-401,1999 9. Negoro K, Uchida K, Yayama T, Kokubo Y, Baba H. Chronic expanding hematoma of the thigh. Joint Bone Spine 79:192-4,201210. Matsuge S, Hosokawa Y, Yamazaki S, Satoh K, Murakami Y, Yamaka-wa T, Hatakeyama H. Five cases of surgically resected chronic expand-ing hematoma in the chest. Kyobu Geka. 53:768-73,2000

A case of a chronic expanding hematoma in a hemodialysis patient

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A case of a chronic expanding hematoma in a hemodialysis patient

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