Spontaneous Retropharyngeal Bleeding in a Patient on Chronic Hemodialysis

Dr. S.P. Handa, Saint John Regional Hospital, Box 2100, Saint John, New Brunswick E2L 4L2 (Canada) Dear Sir, In patients undergoing hemodialysis, spontaneous bleeding has been reported in such locations as the mediastinum [1] subdu-ral space [2], retroperitoneum [3], pericardial and pleural cavities [4] and the subcapsular space of the liver [5], but to our knowledge it has not been described in the retropharyngeal space. Here, we present a case of a woman with chronic renal failure who developed a retropharyngeal hematoma during dialysis treatment. A 74-year-old woman, a patient with chronic renal failure was maintained on continuous ambulatory peritoneal dialysis for almost 38 months when she was switched over to hemodialysis for reasons of recurrent peritonitis. Her medications included: Inderal, calcium carbonate, aluminum hydroxide gel and vitamin supplements. Her hematologi-cal tests were: hemoglobin 83 g/l and platelet count 217 × 109/1. Her predialysis blood urea was 31.9 mmol/l (BUN 88.3 mg/dl), and she had a creatinine of 1,202 μmol/l (13.6 mg/dl). Her parathyroid hormone (intact) value was 33.7 pmol/l intact. (Normal range 2-6 pmol/l.) During the 46th hemodialysis session, the patient became diaphoretic and developed weakness and fatigue. She appeared pale and anemic and developed a large area of ecchymosis around the root of her neck. The ecchy-mosis was very substantial in the posterior aspect, but also was evident anteriorly. Findings of generalized osteoarthritis were again noted. A laboratory evaluation included: hemoglobin 60 g/l, hematocrit 180 vol/l, platelets 340 × 10V1, prothrombin time 11.4 s, partial thromboplastin time 33.7 s and bleeding time 8.6 min. Biochemical studies were essentially the same as before. An X-ray of the cervical spine and soft tissues of the neck revealed distention of the soft tissue behind the pharynx and trachea (fig. la, b). Fig. 1. A soft tissue density noted behind the thyroid cartilage and anterior to the cervical spine, a At the time of presentation. b Four weeks later. The patient received three units of packed cells, and she was given intermittent peritoneal dialysis for 48 h before going back on hemodialysis. Four weeks later, a repeat X-ray of the neck showed gradual resorption of the hematoma within the affected area. The patient has remained in satisfactory medical condition since then. Our patient presented with diffuse ecchy-mosis over the nape of the neck, mild hypotension and a significant fall in her hemoglobin. She did not have any fullness of the soft tissue in the anterior neck nor had she complained of hoarseness or dysphagia. The possible causes for this bleeding could include unrecognized local trauma or the recent change in her dialysis