Clinical Geriatrics

Introduction

We report a case of spontaneous iliopsoas hematoma presenting with femoral neuropathy in an 84-year-old anticoagulated patient. Spontaneous iliopsoas hematoma is a rare but well-recognized complication of anticoagulation that may result in significant neurological disability. Pain or weakness in the groin or thigh of an anticoagulated patient should raise the suspicion of an iliopsoas hematoma and prompt urgent imaging, ideally with contrast-enhanced computed tomography (CECT). Both conservative and invasive management strategies may be adopted depending on the patient’s stability and comorbidities.

Case Presentation

An 84-year-old Caucasian female presented to the medical admissions unit with a 2-week history of increasing left groin pain; she reported no relief with simple analgesia or change in position. The patient described progressive weakness of the left leg over this period and said that she had been unable to stand for several days. She denied back pain or urinary symptoms. Past medical history included atrial fibrillation (AF) and hypertension. Medications were warfarin 2 mg daily, digoxin 125 mcg daily, and bendroflumethiazide 2.5 mg daily.

On examination, the patient was apyrexial and hemodynamically stable. Neurological examination of the left lower limb revealed normal tone; power was decreased in the hip flexors to grade 0/5, with minimal wasting of the quadriceps evident. Sensory loss was apparent in the L2, L3, and L4 dermatomes, and the left knee jerk was absent. Extension of the left hip was painful.

Investigations revealed an elevated international normalized ratio (INR) of 4.6 and low hemoglobin of 12.4 g/dL. The remainder of the patient’s complete blood count was normal, as were electrolytes, renal function, and liver function tests. Electrocardiograph demonstrated rate-controlled AF. A subsequent CECT scan of the abdomen revealed a large left psoas hematoma with no radiological evidence of ongoing bleeding (Figure).

A conservative approach to management was adopted with reversal of her anticoagulation. In view of her hemodynamic stability and chronicity of both of her symptoms and radiological findings, surgical decompression was not attempted. Motor recovery was minimal, with eventual quadriceps power of 1/5 and the development of marked wasting. Following prolonged inpatient rehabilitation, the patient was discharged home without any further anticoagulation. She remained wheelchair-bound and was able to transfer independently.