Abstract

A spontaneous perinephric hematoma is a rare entity that frequently presents with flank pain. We present the case of a 44-year-old female who presented to the emergency department with severe left flank pain, and hypotension. Her initial investigations were remarkable for the presence of a left perinephric hematoma measuring up to 10.1 cm (about 3.98 in). Renal arteriography did not show any signs of active bleeding, hence a conservative approach of not intervening was the initial decision. The hemoglobin on arrival was 10.2 and it remained stable during her hospital stay. She was discharged home with a follow-up visit in 2 months for a repeat computed tomography scan of the abdomen. About 4 weeks after leaving the hospital, she presented again with excruciating flank pain which was managed with analgesics. The repeat CT scan of the abdomen/pelvis showed a stable hematoma of the same size, so once again no intervention was done. Unfortunately, she presented about 4 weeks later with a fever of 101 F, altered mental status, and severe respiratory distress. She had a significant leukocytosis of 37,000 and lactic acid was 15.5 mg/dl. A CT scan of the abdomen showed a left retroperitoneal fluid collection, measuring 16.3 x 19.5 x 25.8 cm which was a perinephric abscess. The fluid collection was drained percutaneously, and surgical cultures grew E. coli. Her blood culture was also positive for E. coli. She received antibiotic therapy for about a month. The patient's hospital stay lasted about a month with about 2 weeks of that stay being in the intensive care unit. The main takeaway point of this case report is the answer to whether conservative management is always the best treatment for a stable perinephric hematoma.