Case Presentation: 74 year old female with past medical history of end stage renal disease on hemodialysis, hypothyroidism and atrial fibrillation on anticoagulation therapy with Apixaban presented to emergency department (ED) after an episode of near-syncope following her dialysis session. In the ED she was hypotensive and tachycardic. Electrocardiogram findings showed Atrial fibrillation(AF) with rapid ventricular response. She received intravenous fluids, albumin and antiarrhythmic agents with some improvement but subsequently required pressors and was admitted to the intensive unit. Blood work was significant for mild anemia with a hemoglobin of 11 and moderately increased alkaline phosphatase with mild elevation of AST. D-Dimer was elevated to 2.21. She was initially started on Heparin drip for suspicion of pulmonary embolism (PE) which was then transitioned to Apixaban at her home dose once PE was ruled out. Initial CT abdomen was remarkable for sludge in gallbladder and multiple exophytic cortical lesions in kidney signifying cysts. Eventually, she was tapered off of vasopressors and her medications for AF were optimized. On day 5, she developed right upper quadrant (RUQ) abdominal pain. RUQ was tender to palpation, without any guarding or rigidity. Ultrasound showed gallbladder wall thickening without cholelithiasis. Decision was made to obtain HIDA Scan as US was inconclusive. However, she became hypotensive. Hemoglobin dropped to 5.9. No external bleeding was noted. Repeat CT scan was done revealing a large right sided renal subcapsular, perinephric and retroperitoneal hematoma measuring 13.2 cm. Since she was Jehovah’s witness, she refused blood transfusion. She received supportive measures with intravenous fluids, Venofer, and Epoetin. Right renal artery and L2 lumbar artery were embolized. Hemoglobin was monitored serially in addition to supportive care. She continued to refuse blood despite being unstable. Eventually, she died on day 17 of admission.

Discussion: Spontaneous renal subcapsular hematoma (SPH) is an uncommon condition in clinical practice. Numerous etiologies have been elucidated. Common causes include renal cysts, tumors and vascular pathologies. Less common causes are antiplatelet/anticoagulant therapy and blood dyscrasias. Often, it can be idiopathic. SPH usually presents with a triad of acute flank pain, tenderness and signs and symptoms of internal bleeding called Lenk’s triad. RUQ pain is a fairly uncommon symptom of SPH. It may mimic conditions like gall bladder disease, dissecting aortic aneurysm and perforated visceral disease, especially in the setting of hypovolemia & shock. Imaging studies may give some sense of direction, however, imaging may need to be done at gradual intervals. CT scans are found to be more sensitive than ultrasound studies in this regard. Treatment can be medical management with blood transfusion and selective arterial embolization. In some cases, nephrectomy can be employed but guidelines are not rigid in this regard.

Conclusions: This case illustrates the diagnostic dilemma associated with SPH. SPH is rare condition and presentation can be quite varied as well. RUQ pain is an uncommon presentation of SPH and should be considered in a patient on anticoagulation therapy and renal cysts. Recognition of this presentation and serial monitoring with imaging studies, is critical for appropriate diagnosis, early intervention and prevention of grave consequences.

IMAGE 1: CT Abdomen & pelvis without contrast showing large right renal subcapsular hematoma and perinephric/retroperitoneal hematoma measuring up to 13 cm.