Perinephric Hematoma and Hemorrhagic Shock as a Rare Presentation for an Acutely Obstructive Ureteral Stone with Forniceal Rupture: A Case Report.

Firas G Petros,Geoffrey N Box,Ketul K Shah,Debra L Zynger

doi:10.1089/cren.2016.0033

Abstract

Background: Spontaneous perinephric hematoma (SPH) secondary to a forniceal rupture as the first presenting sign for an obstructive ureteral stone in a patient without history of urolithiasis has not been described previously.Case presentation: We report a 70-year-old Caucasian male patient who presented to our emergency room with fever, altered mental status, and left flank pain. He had a temperature of 103.3°F, tachycardia, but stable blood pressure. He had left flank tenderness. A computed tomography scan of the abdomen/pelvis with intravenous contrast revealed an intracapsular hematoma (13.3 × 10.0 × 6.4 cm) with an active bleeding and a 1.1 cm left proximal ureteral stone. The patient became quickly hemodynamically unstable and was taken for emergent exploratory laparotomy and left nephrectomy. An active bleeding was encountered secondary to a (2.4 × 2.0 cm) lateral capsular defect in the kidney.Conclusion: Hemorrhagic/septic shock as a presenting sign for an obstructive ureteral stone may require an emergent nephrectomy in a hemodynamically unstable patient.

Highlights

Acute ureteral obstruction secondary to ureteral stones in septic patients is considered a life-threatening event requiring immediate decompression of the obstructed kidney and treatment with empiric antibiotic therapy.[1]
Subscapular hematoma in association with urolithiasis has been described after extracorporeal shock wave lithotripsy[4] and ureteroscopic lithotripsy.[5]
Because of the complicated nature of the combined issues of active renal hemorrhage with hemorrhagic/septic shock, the patient was subsequently taken for emergent exploratory laparotomy and left nephrectomy

Summary

Introduction

Acute ureteral obstruction secondary to ureteral stones in septic patients is considered a life-threatening event requiring immediate decompression of the obstructed kidney and treatment with empiric antibiotic therapy.[1]. Abdominal examination revealed distended abdomen and left flank tenderness to palpation. He was found to have severe leukopenia with white blood cell count of 0.7 K/lL and a serum creatinine (sCr) of 1.64 mg/dL with a normal coagulation profile. Hemodynamically unstable 1 hour after presentation to the emergency room His blood pressure decreased to 70/ 40 mmHg and Hgb dropped to 9.5 g/dL (from 11.3) that required initiation of blood transfusion and infusion of vasoactive pressor medications. Because of the complicated nature of the combined issues of active renal hemorrhage with hemorrhagic/septic shock, the patient was subsequently taken for emergent exploratory laparotomy and left nephrectomy. Histopathologic examination of the kidney showed acute and chronic interstitial and intratubular inflammatory infiltrate with acute hemorrhage with no evidence of malignancy (Fig. 4)

Discussion

Conclusion