BACKGROUND: Spontaneous retroperitoneal hemorrhage (SRH) is a rare and difficult-to-diagnose entity. It is not associated with trauma, pathology, or iatrogenic manipulations. Few cases have been reported, with the only precipitating factor recognized being bleeding diatheses such as anticoagulation states, inherited coagulopathies, and hemodialysis. However, none of these have been described in combination with septic shock, which itself is associated with platelet dysfunction, coagulation dysfunction, and vasculopathy.

CASE REPORT: Our case involves an elderly man presenting with altered mental status of unknown etiology, in addition to hemodynamic instability, presumably due to septic shock, without any overt signs of bleeding. After his initial exam revealed lower-extremity edema and decubitus ulcers, a venous Doppler was performed, which revealed extensive deep vein thrombosis. It was unknown whether the sepsis or DVT occurred first. Therapeutic anticoagulation with heparin was subsequently started. On hospital day 4, a CT abdomen with contrast identified retroperitoneal hematoma after the patient’s hemoglobin lowered without any overt signs of bleeding. The diagnosis of spontaneous retroperitoneal hematoma was one of exclusion and posed a therapeutic dilemma (conservative versus invasive management).

CONCLUSIONS: Sepsis-related coagulopathy and heparin use in an elderly patient predisposed him to an iliopsoas hematoma. In this case, conservative management with reversal of anticoagulation and blood transfusion was sufficient to stabilize the patient.

Keywords: Blood Coagulation, Hematoma, Hemorrhage, Shock, Septic