An Unusual Cause of Perirenal Hemorrhage

Dear Editor,

Crimean–Congo hemorrhagic fever (CCHF) is a fatal viral infection characterized by liver dysfunction, thrombocytopenia, extensive bleeding together with shock, and disseminated intravascular coagulation.^1,2 We herein reported a case of perirenal hemorrhage related with CCHF.

A 49-year-old male with the complaints of weakness, nausea, vomiting, abdominal pain, hemorrhagic diarrhea, and fever was admitted. He pronounced that these symptoms had begun 3 days before and he had a picnic last weekend in natural side. On admission, his temperature and blood pressure were 37.5°C and 120/80 mmHg, respectively. The sticked tick was detected on the right lateral abdominal wall on physical examination. His laboratory findings included platelet count 23 × 10⁹/L, prothrombin time (PTT) 10.1 s and partial thromboplastin time (APTT) 38.8 s, serum creatinine 1 mg/dL, AST 231 U/L, ALT 165 U/L. Serum creatine kinase was found mildly elevated at 764 U/L. Urine examination of the patient was normal. CCHF was considered clinically and diagnosed by using polymerase chain reaction and IgM-specific serology. Immediately, a loading dose of oral ribavirin of 2 g was given, followed by 15 mg/kg every 6 h for 4 days, and then 7.5 mg/kg every 8 h for 6 days. After the first week of therapy, his hematological and biochemical parameters improved dramatically without supporting the fresh frozen plasma and thrombocyte transfusion. Unexpectedly, lumber and abdominal pain was developed on the 10th day of admission. Right costovertebral angle tenderness was positive on physical examination and ultrasonography (USG) was performed immediately. It revealed 83 × 34 mm of size, irregular, hyperechoic lesion that appropriate with hematoma in right anterior perirenal region. Urologic surgeon evaluated the patient and decided the follow-up with consecutive USG and hb/hct. PTT and APTT were normal at this time. Hematoma was not enlarged and spontaneous resolution was observed. However, fever was occurred at the second week of the therapy. Computerized tomography showed a single and large lesion consistent with an abscess located anterior perirenal region which was considered as an infected hematoma. Abscess was completely improved with percutaneous ultrasound-guided drainage and antibiotic treatments for 21 days (intravenous cephtriaxon 2 × 1 g/day and metronidazole 3 × 500 mg/day). Patient was discharged with health in sixth week and there was no relapse during 6 months.

CCHF is a viral systemic infection caused by a tick-borne virus. Endemic areas related this virus has substantially enlarged and fatality rates of infection, which are significantly increased in recent years. The symptoms such as fever (39–40°C), malaise, nausea, hemorrhagic diarrhea, myalgia, rigor, severe headache, and abdominal pain are the most common manifestations of CCHF, but clinically a more important complication is hemorrhage.^1,2 Bleeding from petechia to wide ecchymosis in skin, nose, gums, and buccal cavity occurs usually. Life-threatening bleeding may occur in gastric, uterine, intestinal, genitourinary, cerebral, and pulmonary areas with decreasing frequency due to thrombocytopenia, disseminated intravascular coagulation, vascular endothelial injury, and liver damage. However, hemorrhage may occasionally occur in unexpected areas except them.^1–5 We describe a case of perirenal hemorrhage associated with CCHF, which has not been reported previously.

We present this case to place the emphasis that spontaneous visceral hemorrhages may be seen during the course of CCHF. Clinicians should be aware of this complication on follow-up period of each CCHF case and should consider this entity in differential diagnosis of atypical hemorrhages, particularly in the areas where this infection is endemic.

Mevlut Ceri

Department of Nephrology, Sanliurfa Education and Research Hospital, Sanliurfa, Turkey

[email protected]