Spontaneous Perirenal Hematoma due to Periarteritis Nodosa

Dr. Fehmi Akcicek, Mithatpasa Cad. 776/13, Kopru, TR-35280 Izmir (Turkey) Dear Sir, Spontaneous perirenal hematoma (SPH) of the kidney is a rare entity and SPH of both kidneys is even more unusual. In this letter we present a patient who underwent bilateral nephrectomy 1 month apart due to retroperi-toneal hemorrhage as a result of kidney rupture. A 50-year-old white female was referred to Ege University Hospital because of progressive renal insufficiency, and hypertension. Her previous history revealed intermittent skin eruptions of her upper extremities and trunk since 4 years. Physical examination showed a blood pressure of 150/110 mm Hg, and mild tenderness in right hypochondrium and loin. Hematocrit (Htc) 40%, blood urea nitrogen (BUN) 70 mmol/l (175 mg/dl), crea-tinine 222 μmol/l (2.52 mg/dl), ESR 26 mm/ h, urine protein ( ), and 10-15 RBCs in urine sediment. While these investigations were being completed, the patient suddenly developed agonizing right flank pain and went into shock. A rapidly growing mass in the right loin was palpated. Upper abdomen ultrasonogram (US) and computerised tomo-gram (CT) revealed a perirenal mass having liquid ecogenity. The patient was immediately operated. At operation, a large retroperi-toneal hematoma was found and continuous bleeding from lacerations on the kidney surface which could be controlled only by right nephrectomy. Light microscopy showed fi-brinoid necrosis of the small and medium-sized arteries with numerous neutrophils in and around the walls (fig. 1). Several aneurysms and hematomas were also present. The majority of the glomeruli had crescents. The overall picture suggested a necrotizing vasculitis, especially periarteritis nodosa (PAN). Postoperative laboratory analysis displayed: Htc 21%, BUN 71.6 mmol/l (179 mg/dl), creatinine 786.8 μmol/l (8.94 mg/dl), HBsAg (-), ANA (-), anti-DNA (-). Chest and sinus radiographies were normal. In skin biopsy specimen perivascular lymphocyte infiltration in addition to Clq accumulation in der-moepidermal junction was observed. Methyl-prednisolone 1 gi.v./day together with cyclo-phosphamide 500 mg i.v./week as pulse therapies were begun. Her clinical condition improved gradually.