Diagnosis on Sight: Neck Bruising Leads to a Surprise Diagnosis
A 76-year-old female with a history of HTN, TIA, CAD, left CEA, and CKD presented to the emergency department for evaluation of neck bruising and swelling. The patient stated that the night before, she was eating popcorn and choked on a kernel. She states that she coughed to clear her throat and shortly after she developed swelling and bruising to the left side of her neck, which has progressively gotten worse. The patient has a remote history of left carotid endarterectomy and was concerned that her symptoms could be related to the prior surgery. On examination, she had ecchymosis and a hematoma/mass to the left side of her neck without palpable thrill or bruit. A well-healed CEA scar was noted. A CTA of the neck was obtained to determine the source of the ecchymosis/hematoma. What is the diagnosis?
A large neck mass with venous bleeding causing cervical hematoma and ecchymosis.
Explanation:
Image 2. This axial CT angiogram image shows the large left-sided mass with vessels and hemorrhage, which appears to originate from the inferior parotid.
Spontaneous cervical hematoma is an uncommon condition, which can be life-threatening [1]. This first case of spontaneous neck hematoma was described by Capps who observed this condition in a patient with a parathyroid adenoma [2]. Symptoms of neck hematoma include the classic triad named for Capps, which consists of:
- tracheal and esophageal compression
- neck edema and ecchymosis
- tracheal displacement
The condition can be caused by a variety of etiologies including bleeding from masses, underlying coagulopathies, rupture of aneurysms, and infections [1]. CT angiography is typically the test of choice to evaluate the source and extent of bleeding [3]. Large hematomas can lead to airway compromise and require airway and surgical/IR intervention. Smaller, stable hematomas may be observed and can be self-limited. The underlying etiology of the hematoma should be sought and treated.
Case Conclusion:
The hematoma and ecchymosis resolved over time without intervention. The patient underwent ultrasound-guided lymph node biopsy by interventional radiology. Pathology revealed an aggressive double expressor diffuse large B-Cell lymphoma. A pet scan revealed lymphatic involvement on both sides of the diaphragm. The patient was counseled on treatment options including chemotherapy and after discussion palliative radiation was pursued. Ultimately, the patient transitioned to hospice care.
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References:
- Cohen O, Yehuda M, Adi M, Lahav Y, Halperin D. Spontaneous neck hematoma in a patient with fibromuscular dysplasia: a case report and a review of the literature. Case Rep Otolaryngol. 2013;2013:352830. PMID: 24191215.
- Zammit M, Siau R, Panarese A. Importance of serum calcium in spontaneous neck haematoma. BMJ Case Rep. 2020 Sep 6;13(9):e237267. PMID: 32895253.
- Haynes J, Arnold KR, Aguirre-Oskins C, Chandra S. Evaluation of neck masses in adults. Am Fam Physician. 2015 May 15;91(10):698-706. PMID: 25978199.
A 37-year-old female presented to the emergency department for evaluation of numbness and discoloration to her left fourth finger, which had started the day before. The patient stated that she was gardening the previous day and afterward she noticed the discoloration and pain. The patient denied taking any medications. She reported recreational methamphetamine and heroin use. She denied any chest pain or difficulty breathing. She denied any history of Raynaud’s phenomenon, venous thromboembolism, or history of trauma. The patient was afebrile with normal vital signs. Physical exam revealed cyanotic discoloration to the left distal fourth finger. Sensation was intact to light touch and strength was 5 out of 5 in the finger. The capillary refill was diminished. Radial and ulnar pulses were 2+ bilaterally. Initially, a warm pack was placed to the patient’s finger with slight improvement, but without resolution of the pain and cyanosis. What is the diagnosis?