Intensive Care Med DOI 10.1007/s00134-014-3241-8
Muhammad Adrish Hayley B. Gershengorn
IMAGING IN INTENSIVE CARE MEDICINE
A rare cause of extensive facial and neck hematoma
Received: 28 January 2014 Accepted: 4 February 2014 Ó Springer-Verlag Berlin Heidelberg and ESICM 2014 M. Adrish ()) H. B. Gershengorn Division of Critical Care Medicine, Montefiore Medical Center, The University Hospital for Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY10467, USA e-mail: [email protected] Tel.: ?1-917-3752828 H. B. Gershengorn e-mail: [email protected]
A 90-year-old man with a history of hypertension presented with progressively worsening left facial pain, swelling, and ecchymosis of 1 day’s duration. He had no history of trauma or prior bleeding. His physical examination was remarkable for extensive left facial and neck swelling and ecchymosis extending from the left upper face to the right side of the neck (Fig. 1). Ecchymotic patches were also noted on his buccal mucosa and hard palate. Initial workup revealed a normal platelet count with an elevated activated partial thromboplastin time (aPTT) (46.9 s). Factor VIII level was found to be low (1 %) and mixing studies revealed lack of correction of the aPTT. Computed tomography of the neck showed extensive inflammation around the left premolar area with a left masseter hematoma, hemorrhage tracking posteriorly, inflammatory changes extending deep into the left parapharyngeal space, and rightward deviation of adjacent
Fig. 1 Picture shows extensive left facial and neck swelling and ecchymosis extending from the left upper face to right side of the neck
airway (Fig. 2). The patient was empirically started on factor VIIa. Further testing subsequently showed a factor VIII inhibitor level of 4 Bethesda units and treatment was switched to recombinant factor VIII replacement and prednisone as factor VIII inhibitor treatment. Acquired hemophilia A is rare; it is often idiopathic, but can occur in association with malignancy, autoimmune disorders, allergic drug reactions, and pregnancy.
Fig. 2 Computed tomography of neck showed extensive inflammation around the left premolar area with left masseter hematoma (black arrow) with hemorrhage tracking posteriorly to outline the superficial left parotid gland along with inflammatory changes that extended deep into the left parapharyngeal space resulting in masseffect with rightward deviation of the adjacent airway (white arrow) Conflicts of interest
All authors report no conflicts of interest.
Muhammad Adrish Hayley B. Gershengorn
IMAGING IN INTENSIVE CARE MEDICINE
A rare cause of extensive facial and neck hematoma
Received: 28 January 2014 Accepted: 4 February 2014 Ó Springer-Verlag Berlin Heidelberg and ESICM 2014 M. Adrish ()) H. B. Gershengorn Division of Critical Care Medicine, Montefiore Medical Center, The University Hospital for Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY10467, USA e-mail: [email protected] Tel.: ?1-917-3752828 H. B. Gershengorn e-mail: [email protected]
A 90-year-old man with a history of hypertension presented with progressively worsening left facial pain, swelling, and ecchymosis of 1 day’s duration. He had no history of trauma or prior bleeding. His physical examination was remarkable for extensive left facial and neck swelling and ecchymosis extending from the left upper face to the right side of the neck (Fig. 1). Ecchymotic patches were also noted on his buccal mucosa and hard palate. Initial workup revealed a normal platelet count with an elevated activated partial thromboplastin time (aPTT) (46.9 s). Factor VIII level was found to be low (1 %) and mixing studies revealed lack of correction of the aPTT. Computed tomography of the neck showed extensive inflammation around the left premolar area with a left masseter hematoma, hemorrhage tracking posteriorly, inflammatory changes extending deep into the left parapharyngeal space, and rightward deviation of adjacent
Fig. 1 Picture shows extensive left facial and neck swelling and ecchymosis extending from the left upper face to right side of the neck
airway (Fig. 2). The patient was empirically started on factor VIIa. Further testing subsequently showed a factor VIII inhibitor level of 4 Bethesda units and treatment was switched to recombinant factor VIII replacement and prednisone as factor VIII inhibitor treatment. Acquired hemophilia A is rare; it is often idiopathic, but can occur in association with malignancy, autoimmune disorders, allergic drug reactions, and pregnancy.
Fig. 2 Computed tomography of neck showed extensive inflammation around the left premolar area with left masseter hematoma (black arrow) with hemorrhage tracking posteriorly to outline the superficial left parotid gland along with inflammatory changes that extended deep into the left parapharyngeal space resulting in masseffect with rightward deviation of the adjacent airway (white arrow) Conflicts of interest
All authors report no conflicts of interest.
