Spontaneous Subcapsular Renal Haematoma in a Patient with Renal Sarcoidosis: A Case Report

IntroductionSarcoidosis is a disease of unknown aetiology that is characterised by the formation of non-caseating granulomas in affected tissues. It is a multisystem disorder and can affect the renal system in a variety of ways, most commonly hypercalciuria, hypercalcaemia and renal calculi. Glomerular disease and end-stage renal disease are more rarely seen. 1,2

Spontaneous Subcapsular Renal Haematoma is an uncommon presentation. The known causes include renal tumours, vascular disease, infectious disease, severe pre-eclampsia and coagulopathy.³ Until quite recently, the mainstay of treatment in patients in whom an aetiology was not identified was radical nephrectomy, presuming a tumour was the underlying cause. However, there have been an increasing amount of case reports in the literature where conservative management has been employed successfully.

On AssessmentT: 36.7ºC RR: 20 Sats: 95% OA HR: 157

BP: 200/136 BM: 9.8 GCS: 15

Distressed, Cool peripherally, shocked.

Cardiovascular and Respiratory exams Normal.

Abdominal Exam:

Obese with soft abdomen.

Very tender in left flank with guarding.

Bowel sounds present.

Management and Outcome

Preparations were made to thrombolyse the patient. However, owing to the unusual presentation, the case was discussed urgently with both Urology and Renal specialists in another centre, both of whom felt that an infarct would not be sufficient to cause such a deterioration in renal function. Thrombolysis was therefore not carried out overnight and the patient was admitted to the ICU under the Medical team.

The following morning, owing to ongoing uncertainty about the diagnosis, a second opinion on the original CT was sought and the diagnosis of a left renal haematoma was suggested. This was confirmed with ultrasound scanning.

The patient was managed conservatively in the ICU with ongoing input from the Urology and Renal teams. He required haemodialysis. The patient was also reviewed by the haematology team, who found no underlying abnormality to explain a spontaneous bleed. On repeat scans, there was no increase in the size of the bleed.

The cause of the bleed was never identified. The Urology consultant involved discussed it with colleagues and the general consensus was that the underlying sarcoid disease must be the cause. The patient was successfully discharged but remains on haemodialysis.

Dr Meadhbh RiceSHO in Emergency Medicine, Sligo Regional Hospital

Presenting ComplaintThe patient is a 40 year old man who presented to

the Emergency Department at 19:30:• 2 hour history severe (9/10) left sided abdominal

pain.• No history of trauma.• Nausea but no vomiting. • No bowel/urinary symptoms.• No chest pain• Cyclomorph from GP: no relief.

References:1. Michael C. Iannuzzi, M.D., Benjamin A. Rybicki, Ph.D., Alvin S.

Teirstein, M.D. “Sarcoidosis”. N Engl J Med 2007; 357:2153-2165

2. Bergner R, Hoffmann M, Waldherr R, Uppenkamp M. “Frequency of kidney disease in chronic sarcoidosis” Sarcoidosis Vasc Diffuse Lung Dis 2003; 20:126.

3. Sik Lee, Sung Kwang Park, Gong Yong Jin, Jong Heon Kim, Sung Nam Cho, Sung Kyew Kang, Won Kim “Spontaneous renal subcapsular haematoma and acute renal failure complicated by severe pre-eclampsia”Nephrol. Dial. Transplant. 2003 18: 625-626.

4. Maggs F, Mallet M. “Mortality in out-of-hours emergency medical admissions--more than just a weekend effect”. J R Coll Physicians Edinb. 2010 Jun;40(2):115-8

5. Baishya RK, Dhawan DR, Sabnis RB, Desai MR. “Spontaneous subcapsular renal hematoma: a case report and review of literature” Urol Ann 2011;3:44–46.

6. Park, Byoung-Won, et al. "Spontaneous Renal Hematoma Caused by Hypertension with Left Ventricular Hypertrophy." Journal of the Korean Society of Hypertension 18.2 (2012): 71-74.

7. Qing Zhang, Jian, Julia R. Fielding, and Kelly H. Zou. "Etiology of spontaneous perirenal hemorrhage: a meta-analysis." The Journal of urology 167.4 (2002): 1593-1596.

Acknowledgements

Thanks to Dr Kieran Cunningham, who provided guidance in the selection of this case and the preparation of the report.

DiscussionPatient SafetyStudies have shown that mortality is increased in patients who are admitted as medical emergencies at nights and weekends.4 It is therefore important to maintain access to specialist advice and services out-of-hours to minimize this effect. If not for the co-operation and communication between the Emergency Department and various Medical, Surgical and Radiology teams, this patient would likely have been thrombolysed- probably with catastrophic consequences.

Sarcoid vs HypertensionThe cause of this patient’s spontaneous haematoma is likely never to be certain. The agreement among the Urology team is that the sarcoid disease itself is the probable aetiology. Two recent case studies reported a 38 year old woman and a 43 year old man, both with uncontrolled hypertension who presented with a spontaneous subcapsular renal haematoma in whom the cause was thought to be the hypertension itself.5,6 Given our patient’s very elevated blood pressure on presentation, this may be an alternative aetiology.

Recommended ImagingIf this diagnosis is suspected in the Emergency department, ultrasound scanning is a very useful first line investigation, with CT confirmation. A 2001 study showed that ultrasound identified 56% and CT 100% of renal haematomas.7 With the increased use of ultrasound within the Emergency Department, this is an imaging modality that can be quickly accessed out-of-hours and which could therefore minimize the time to diagnosis and definitive treatment.

Case ReportThis poster documents the presentation of a man to

the Emergency Department, outside normal working hours, with what was eventually identified as a spontaneous subcapsular renal haematoma. It will explore both the medical and logistical dilemmas encountered in his case.

Past HistorySarcoidosis• Renal - advanced CKD• Cardiac - heart block, cardiac arrests, pacemaker

Previous sepsis with AKI requiring dialysis

Gout

Hypertension

Not on anticoagulants

InvestigationsErect CXR: No subdiaphragmatic free air. Normal.

ECG: Bifascicular Block. Narrow Complex Tachycardia.

Bloods: Creatinine 590 (baseline 297)

Electrolytes normal.

Inflammatory markers normal.

Coagulation screen normal

Haemaglobin 11.9 g/dL

Progress in the EDThe patient was seen by Surgical Registrar, Medical Registrar and ICU registrar. The cause of the patient’s symptoms was not clear and discussions were held with regard to CT scanning overnight. The surgical team felt this could wait until morning. However the patient continued to deteriorate and it was felt he required admission to the ICU. The ICU team were not happy to admit without a CT scan and a more firm idea of the underlying cause. The ED consultant on duty attended and a CT angiogram was carried out around midnight.

CT result: ? Renal Infarct. No Thrombus visible

Fig. 1High Resolution CT Angiogram showing significant swelling of the left kidney with pararenal fat stranding. Thought to be a result of infarct.

Fig. 2Ultrasound scan confirming the presence of a left subcapsular renal

haematoma.