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Hepatic haematoma after allogeneic transplantation

A 60-year-old woman with acute myelogenous leukaemia refractory to conventional chemotherapy underwent allogeneic peripheral blood stem cell transplantation after conditioning with idarubicin, fludarabine and cytarabine. Upon stem cell infusion, the patient began to experience abdominal pain, with slight distension of the abdomen. Laboratory tests showed a white blood cell count of 0AE1 · 10 ⁄ l, a haemoglobin level of 8AE3 g ⁄ dl, a platelet count of 50 · 10 ⁄ l, activated prothrombin time of 13AE4 s, and an activated partial thromboplastin time of 28AE9 s. Computerized tomography (CT) scans of the abdomen revealed a large (9AE5 cm high · 6AE0 cm wide · 17 cm long) liver lesion with an abnormal fluid level consistent with an intraparenchymal and subcapsular hepatic haematoma (top left and right). Thirty-four days later, CT scans of this lesion showed enlargement of the haematoma to 11AE5 · 8AE0 · 20AE0 cm (bottom left). The haematoma was managed conservatively with bed rest, maintenance of platelet count at more than 70 · 10 ⁄ l, administration of antihypertensives, and red-cell transfusions. The patient recovered, and a subsequent CT scan (84 d after transplantation) of the abdomen showed that the hepatic haematoma had encapsulated and stabilized to 13AE5 · 8AE5 · 15 cm (bottom right). Traumatic haemorrhages have been reported as a complication of trauma, massage, liver biopsy, extracorporeal lithotripsy, laparoscopic cholecystectomy and use of anticoagulation. Non-traumatic spontaneous hepatic haemorrhages are rare, usually occurring in association with arteriovenous malformations, aneurysms, hepatic malignancies (primary and metastatic), hepatic adenoma, vasculitis (polyarteritis nodosa or rheumatoid arthritis), pregnancy [including HELLP (haemolysis, elevated liver enzymes, and low platelet count) syndrome], and primary hepatic amyloidosis. Thrombocytopenia-induced hepatic haematoma has been observed in HELLP syndrome but not reported in an oncology setting. Spontaneous hepatic haemorrhage is unusual in patients with significant and prolonged thrombocytopenia; we have experienced no previous cases associated with stem cell transplantation at our institution. Current treatment strategies cover a broad range, from observation to surgical ligation, hepatic arterial embolization and liver resection. In this case, early interventions involving surgery or intra-arterial hepatic artery occlusion after transplantation might have exposed this patient to unnecessary risks.