a 57-year - old patient with a diagnosis of chronic itp for 1 year was referred to our emergency department with complaints of left flank pain and diffuse petechial bleeding all over his body .
a complete blood count revealed thrombocytopenia ( 4,000/mm ) , which led to his admission into the clinics of internal medicine . on the third day of chronic itp therapy ,
the patient developed macroscopic hematuria , and we consulted with the patient after the urinary system ultrasound revealed bilateral perirenal hematoma .
we learned from his medical history that he had not previously had any complaints of gross hematuria .
he had previously undergone extracorporeal shock wave lithotripsy ( eswl ) because of a left ureteral distal stone .
the physical examination revealed a relaxed abdominal region with left costovertebral angle tenderness in addition to diffuse petechiae all over his body . in his biochemical analysis , blood urea nitrogen
( 53 mg / dl ) , creatinine ( 3.2 mg / dl ) , and fasting blood sugar ( 167 mg / dl ) levels were also measured .
escherichia coli was detected in the urine culture , and the urinalysis revealed microscopic hematuria and pyuria .
the results of the complete blood count analysis were as follows : white blood cells 27,000/mm , hemoglobin 12.2 g / dl , hematocrit 37.3% , platelet count 4,000/mm , prothrombin time 16.6 seconds ( 9 to 14 ) , and international normalized ratio 1.36 ( 0.8 to 1.19 ) .
owing to suddenly evolving macroscopic hematuria , the patient received prednisolone ( 80 mg / d ) and intravenous immune globulin ( 0.5 g / kg / d ) ( kiovig 10 g/100 ml - eczacba - baxter ) , and an ultrasound examination of the urinary system demonstrated right and left perirenal hematoma and irregular renal contours . a non - contrast computed tomography ( ct )
the ct scan revealed a right perirenal hematoma with dimensions of 212042 mm , a 15-mm stone in the right distal ureter without any marked ectasia , a left perirenal hematoma with dimensions of 15012090 mm ( fig .
1 ) , left distal ureteral ectasia , and a 20-mm distal ureteral stone ( fig .
the patient had an extremely low hematocrit ( 22% ) , hemoglobin ( 7.2 g / dl ) , and platelet counts ( 3,000/mm ) and received 6 iu erythrocytes and 3 iu platelets to improve his hematologic status .
an operation was performed for his distal ureteral stones when his platelet counts reached 89,000/mm .
there was no increase in the size of the hematoma , and regression was even shown on the postoperative control ct scan ( fig .
4 ) , and his blood urea nitrogen was 25 mg / dl and his creatinine was 0.79 mg / dl after 1 year .
chronic itp is an acquired bleeding diathesis with an immune origin . the onset and clinical course of the disease show variations .
mild and moderately severe forms of itp are asymptomatic in the absence of trauma , whereas in severe cases of itp , clinical manifestations consist mostly of mucocutaneous bleeding such as purpura , petechiae , nosebleeds , and gingival bleedings .
gastrointestinal bleeding , hematuria , and intracranial hemorrhages are relatively more severe conditions and occasionally fatal [ 1 - 3,6,7 ] . in a meta - analysis conducted by cohen et al .   in 1,817 patients ,
the rate of age - adjusted fatal hemorrhage risk for patients who were younger than 40 years , between 40 and 60 years , and older than 60 years was 0.004 , 0.012 , and 0.130 , respectively .
spontaneous perirenal and subcapsular renal bleeding are rarely seen clinical manifestations that lead to serious problems .
are chronic hemodialysis , vascular pathologies such as atherosclerosis and arteritis , anticoagulant therapy , and hemorrhagic diathesis [ 2,4 - 9 ] . because the clinical course of the disease in patients with perirenal hematoma varies according to the severity of bleeding , the therapeutic approach is closely related to the clinical condition of the patient . in cases of persistent bleeding and a worsening general health state , surgical treatment predominates , whereas in patients with stable vital parameters , palliative treatment can be performed .
none of the very rarely encountered cases of renal bleeding due to itp reported mortality . in two cases we found during a literature search , bedrest ,
steroid therapy , and platelet suspensions were sufficient without the need for surgical management . according to the guidelines of the american hematologic association
, hospitalization is required for patients with mucocutaneous bleeding and platelet counts less than 20.000/mm ; for candidates for surgery , the american hematologic association recommends increasing platelet counts to above 50.000/mm .
our case of bilateral perirenal hematoma secondary to itp with a concurrent bilateral distal ureteral stone is the first such case report in the literature . in the management of distal ureteral stones , eswl and ureteroscopic lithotripsy
are effective and safe treatment modalities , but in patients with hemorrhagic diathesis , extreme care should be exercised for eswl . in a case report presented in japan , safe use of eswl
was mentioned in a ureteral stone patient with itp . in a study performed in patients with hemorrhagic diathesis , the frequency of severe perirenal bleeding secondary to eswl
did not report any cases of hematoma or bleeding in 17 patients with hemorrhagic diathesis following eswl .
however , in patients with hemorrhagic diathesis , coagulation tests should be done because of the risk of hematoma occurrence , and platelet counts should be increased above 50.000/mm . as far as we know
, our case had undergone a single session of eswl nearly 2 months previously for a left ureteral stone .
even though the risk of development of perirenal hematoma secondary to eswl increases in chronic itp , the absence of any urinary system symptoms in our patient after eswl and the application of eswl targeted to the distal ureter suggest that the bleeding was not a complication of eswl but rather originated from thrombocytopenia due to itp
. still , stasis and compression resulting from hydronephrosis caused by bilateral distal ureteral stones might be influential in the development of perirenal hematoma . in conclusion
, urinary system diseases can be seen in patients with bleeding diathesis , such as chronic itp , and related hematologic test results should be carefully evaluated in the following up and treatment of these patients . in these cases ,
therapeutic procedures targeting urinary system abnormalities can be optimally performed after normalizing hematologic test results while continuing itp therapy without making any change in the current treatment modalities .
 idiopathic thrombocytopenic purpura ( itp ) is an immune thrombocytopenia with a usually benign clinical course . 
 bleedings are mostly of the mucocutaneous type with mild symptoms 
 . massive bleedings requiring transfusion are rarely seen , unless the number of platelets decreases to extremely low levels . in this case , 
 bilateral perirenal hematoma and bilateral distal ureteral stones were detected on a non - contrast computed tomography scan of a 57-year - old male patient who developed macroscopic hematuria during his treatment in the clinics of internal medicine because of left flank pain and diffuse petechial rashes all over his body . 
 the patient , who had been receiving chronic itp treatment for 1 year , had a very low platelet count ( 4,000/mm3 ) . 
 the patient was prescribed bed rest , and his platelet count increased to a safe level for surgical intervention of above 50,000/mm3 with administration of prednisolone , intravenous immune globulin , and platelet suspension . 
 a stone - free state was achieved after bilateral ureterorenoscopy and pneumatic lithotripsy . 
 a conservative approach was followed for the perirenal hematoma . upon regression of the perirenal hematoma , 
 the patient was discharged at 9 weeks postoperatively . 
CASE REPORT
DISCUSSION