PICTURES IN CLINICAL MEDICINE
Large Spontaneous Rectus Sheath Hematoma Associated with Severe Anemia Hiroshi Yunokizaki, Kousuke Tamura, Zhao Liang Li and Takashi Abe Key words: rectus sheath hematoma, warfarin, anemia, PT/INR (Intern Med 54: 349, 2015) (DOI: 10.2169/internalmedicine.54.3210)
Picture 2. Picture 1.
mal: 12.0-16.5 mg/dL). The patient was also taking warfarin and cilostazol, and although the international normalized ratio (PT/INR) had consistently been within the therapeutic range prior to this episode, it was currently elevated at >4.5. An abdominal CT scan demonstrated a right-sided rectus sheath hematoma measuring 6×36 cm in size (Picture 2, 3; arrowhead). The patient received a transfusion of 8 units of packed red blood cells, and her condition steadily improved. The occurrence of a large spontaneous rectus sheath hematoma associated with severe anemia in a patient treated with anti-coagulant therapy has not been previously reported (1, 2). Picture 3. The authors state that they have no Conflict of Interest (COI).
A 69-year-old woman was referred to our hospital due to epigastric pain and anemia. She had undergone mechanical prosthetic mitral and aortic valve replacement with a pacemaker for postoperative total heart block eight years earlier and had received hemodialysis. On admission, a physical examination revealed anemic conjunctiva, tenderness in the epigastric region and a palpable abdominal mass (Picture 1). Laboratory tests showed severe anemia (Hb: 4.8 g/dL; nor-
References 1. Miyauchi T, Ishikawa M, Miki H. Rectus sheath hematoma in an elderly woman under anti-coagulant therapy. J Med Invest 48: 216-220, 2001. 2. Gijsbers K, Adriaenssens T, Herregods MC. Success of delayed thrombolysis for metallic tricuspid valve thrombosis. Acta Cardiol 67: 231-234, 2012.
Endoscopy Center, Takarazuka Municipal Hospital, Japan Received for publication May 3, 2014; Accepted for publication July 6, 2014 Correspondence to Dr. Takashi Abe, [email protected]
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