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Recurrent Intramuscular Hematomas in a 40-Yr-Old Female Renal Transplant Recipient

Chen, Heidi MD; Yuan, Xiaoning MD, PhD; Siddiqi, Asad R. DO; Beckley, Akinpelumi A. MD, MBA

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American Journal of Physical Medicine & Rehabilitation: December 2021 - Volume 100 - Issue 12 - p e186-e187
doi: 10.1097/PHM.0000000000001798
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A 40-yr-old woman with lupus with anticoagulant positivity and end-stage renal disease status after right-sided kidney transplantation complicated by retroperitoneal hematoma and lumbar plexopathy presented with recurrent right medial thigh intramuscular (IM) hematomas. The first IM hematoma occurred 1 yr after transplant following leisurely horseback riding. Her examination was significant for ecchymosis from the right pubis to the medial midthigh, 4/5 pain-limited hip flexion and adduction strength, 5/5 knee flexion and extension strength, with intact sensation and reflexes throughout. Ultrasound (US) revealed an IM adductor longus hematoma measuring 6.3 × 12.9 × 2.2 cm (Fig. 1). Computed tomography of the right lower extremity excluded other pathology, such as sarcoma. She was managed conservatively with acetaminophen for pain and continued her home exercise program focusing on lumbopelvic, gluteal, hip flexor, and adductor strengthening. Ultrasound-guided aspiration was offered for persistent or worsening symptoms. However, the hematoma self-resolved in 2 mos.

F1
FIGURE 1:
Ultrasound imaging of the right adductor longus hematoma. A, Longitudinal, expanded field-of-view image of a heterogeneous mass (asterisk) with multiple hyperechoic internal septations within the right AL, measuring 6.3 (width, not pictured) × 12.9 (length) × 2.2 (depth) cm, consistent with an IM hematoma of the right AL. Layers from superficial to deep: skin and SQ, adductor longus and IM hematoma, and AM. B, Transverse image of an IM hematoma (asterisk) of the right adductor longus with CD and PWD Doppler, demonstrating pulsatile, arterial flow within the hematoma. Images obtained by radiology with a GE Logiq E9 ultrasound machine. AL, adductor longus; AM, adductor magnus; CD, color; PWD, pulsed wave; SQ, subcutaneous tissue.

A year later, she returned with right medial thigh pain, swelling, and bruising after performing adductor stretching at home. Her examination was significant for right medial thigh ecchymosis with 5/5 strength and preserved reflexes and sensation throughout. High-resolution diagnostic US of the lower abdomen and medial thigh was notable for an IM gracilis hematoma measuring 3.5 × 16.6 × 1.6 cm (Fig. 2A). Side-to-side comparison revealed hyperechoic, atrophic appearance of the right gracilis, adductor magnus (Fig. 2B), and internal oblique (Fig. 2C) muscles and subtle echogenic changes with decreased bulk of the right adductor longus and brevis muscles (Fig. 2D) compared with the left. These right-sided findings were possible sequelae of fibrous scarring after severe, recurrent muscle injury and/or lumbar plexopathy diagnosed 2 yrs prior. The right iliohypogastric, ilioinguinal, and obturator nerves, as well as the iliacus and quadriceps muscles, appeared normal. Her second hematoma self-resolved in 4 wks with no residual functional deficits.

F2
FIGURE 2:
Ultrasound imaging of the lower abdomen and medial thigh. A, Longitudinal, expanded field-of-view image of a complex mass (asterisk) with hyperechoic internal septations within the right G, measuring 3.5 (width, not pictured) × 16.6 (length) × 1.6 (depth) cm, consistent with an IM hematoma of the right gracilis. Layers from superficial to deep: skin and SQ, gracilis and IM hematoma, AM (proximal), and VM (distal). B, Transverse side-to-side comparison views of the bilateral G and AM muscles. Note the hyperechoic changes and loss of muscle fiber architecture of the right gracilis and the superficial portion of the right adductor magnus. C, Transverse side-to-side comparison views of the bilateral lower abdomen. Note the hyperechoic appearance with decreased bulk of the right IO (dashed outline), and the hypertrophy and increased bulk of the right EO. D, Transverse side-to-side comparison views of the bilateral medial thighs. Note the more subtle hyperechoic changes of AB and AL that arise from loss of some hypoechoic muscle fibers with increased density of hyperechoic connective tissue (dashed outline), which result in a small decrease in overall muscle bulk compared with the contralateral side. Images obtained by the authors with a GE Logiq S8 ultrasound machine and 3- to 12-MHz linear transducer. AB, adductor brevis ; Abd, abdominal contents; AL, adductor longus; AM, adductor magnus; EO, external oblique; G, gracilis; IO, internal oblique; SQ, subcutaneous tissue; TrA, transversus abdominis; VM, vastus medialis.

TEACHING POINTS

  1. Normal muscles have a characteristic “starry night” appearance on US with hypoechoic muscle fibers arranged in fascicles, interspersed with hyperechoic perimysium.1,2 After denervation changes, muscle tissue appears grossly hyperechoic because of atrophy and loss of hypoechoic muscle fibers.1
  2. After severe or recurrent muscle injury, fibrous scars may form, appearing as focal, hyperechoic linear, or stellate lesions, whereas the majority of surrounding muscle tissue appears normal in echotexture.3
  3. Ultrasound appearance of IM hematomas vary with age. Acute IM hematomas appear hyperechoic because of transient muscular edema, whereas subacute IM hematomas appear hypoechoic or heterogeneous with mixed echogenicity.1,2

REFERENCES

1. Zamorani MP, Valle M: Muscle and tendon, in: Bianchi S, Martinoli C (eds): Ultrasound of the Musculoskeletal System. Germany, Springer-Verlag Berlin Heidelberg, 2007:45–96
2. Peetrons P: Ultrasound of muscles. Eur Radiol 2002;12:35–43
3. Lee JC, Healy J: Sonography of lower limb muscle injury. Am J Roentgenol 2004;182:341–51
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