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Deterioration of renal function persisted with creatinine of 8&#46;4mg&#47;dL and oliguria&#46; Haemodialysis without heparin was begun&#46; After thirteen days the patient complained of pain in the hypogastrium and left iliac fossa following a coughing episode&#46; An abdominal mass and anaemia of four points were apparent&#46; An abdominal CT revealed a haematoma of the left anterior rectus sheath &#40;figure 1&#41;&#46; Three concentrates were transfused&#46; A coagulation test including factors was normal except for an Ivy value of ten minutes&#46; Three days later there was new pain in the right iliac fossa&#44; with paralytic ileus and anaemia of three&#160;points&#46; A CT revealed a haematoma in both anterior rectus muscles which extended towards the Retzius space and pelvis &#40;figure 2&#41;&#46; It pinpointed four concentrations of erythrocytes&#46; The departments of surgery and interventional radiology consulted&#44; deciding on conservative expectant treatment and associating antibiotics &#40;clavulanic amocycillin&#41; as well as parenteral nutrition&#46;</p><p class="elsevierStylePara">After one week the ileus was resolved&#44; but the patient began to experience sudden dyspnoea with the normal prescription&#46; A scintigraphy confirmed a multiple pulmonary embolism&#46; Treatment with a heparin pump was started with close monitoring&#46; The haematoma and pulmonary embolism were resolved without consequence but the patient continued to be dependent on haemodialysis&#44; with evidence of negative anti-GBM Ab from the fourth plasmapheresis&#46;</p><p class="elsevierStylePara">Disease caused by anti-GBM Ab is a medical emergency that needs to be ruled out in rapidly progressing renal failure&#44; using an anti-GBM Ab test&#46; Early treatment based on corticosteroids&#44; cyclophosphamide and plasmapheresis appears to play a significant role in the recuperation of renal function<span class="elsevierStyleSup">1-3</span>&#46; Possible complications<span class="elsevierStyleSup">2&#44;3</span> are many&#46; One complication is an alteration in coagulation&#44; brought about by a loss of factors or the use of anticoagulants&#46; However&#44; a massive haematoma of the recti has not previously been described associated with plasmapheresis or disease caused by anti-GBM Ab&#46;<span class="elsevierStyleSup">2&#44;3</span> Plasmapheresis is a delicate technique which should be carried out by experienced professionals&#44; and is gradually being included in the activities of nephrologists&#46;<span class="elsevierStyleSup">4</span> Haematoma of the rectus sheaths is an uncommon process which can simulate intra-abdominal disease&#46; The main predisposing factor is anticoagulation and a cough is the precipitating factor&#46;<span class="elsevierStyleSup">5&#44;6</span> Diagnosis is based on clinical suspicion and confirmed with a CT&#46;<span class="elsevierStyleSup">5&#44;6</span> Our patient&#44; although showing normal coagulation&#44; had received six plasmaphereses&#44; and this raised for us the idea of citrate-induced coagulopathy&#44; deficits in coagulation factors and uremic thrombopathy secondary to renal failure as possible causes&#46; <p class="elsevierStylePara">Treatment for haematoma of the recti is initially conservative&#44;<span class="elsevierStyleSup">5&#44;6</span> surgery should be reserved for progression&#44; infection of the haematoma or haemodynamic instability&#46; Arteriography with selective embolisation can be considered&#46; In the case in question&#44; the haematoma of the recti was completely resolved in forty days&#44; despite requiring anticoagulation for the massive pulmonary embolism&#44; and the patient survived without consequences&#44; now having undergone a successful transplant&#46;</p></p></p><p class="elsevierStylePara"><a href="grande&#47;14318078&#95;f1&#95;375&#46;jpg" class="elsevierStyleCrossRefs"><img src="14318078_f1_375.jpg"></img></a></p><p class="elsevierStylePara">Figure 1&#46; </p><p class="elsevierStylePara"><a href="grande&#47;14318078&#95;f2&#95;376&#46;jpg" class="elsevierStyleCrossRefs"><img src="14318078_f2_376.jpg"></img></a></p><p class="elsevierStylePara">Figure 2&#46; 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Disease caused by anti-glomerular basement membrane antibodies and haematoma of the recti
Enfermedad por anticuerpos antimembrana basal y hematoma de los rectos
Ana Perez de Joséa, Carmen Bernisa, Yolanda Hernandeza, Karina Furaza, Jose Antonio Sanchez Tomeroa
a Hospital Universitario de la Princesa Madrid, Madrid, España,
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    "textoCompleto" => "<p class="elsevierStylePara">Dear Editor&#58;</p><p class="elsevierStylePara">We present a case of disease caused by anti-GBM Ab which&#44; on treatment with plasmapheresis&#44; presented a massive&#160;haematoma of the recti&#44; a serious complication not previously described&#46;</p><p class="elsevierStylePara"><p class="elsevierStylePara">The case concerns a 57 year old female who attended hospital with lumbar pain&#44; haematuria&#44; febricula and flu-like syndrome which had been developing for two weeks&#46; Creatinine of 3&#46;5mg&#47;d was notable&#44; with normal history and sediment with haematuria and proteinuria&#46; Ultrasound normal&#46; Urgent anti-GBM Ab positive in the capacity of 1200 UI&#47;ml with negative ANCA&#46; Renal biopsy showed crescentic glomerulonephritis caused by anti- GBM Ab&#44; with 85&#37; epithelial halfmoons in the cellular phase&#46;</p><p class="elsevierStylePara">Treatment with methylprednisolone&#44; cyclophosphamide and plasmapheresis &#40;anticoagulation with citrate and replacement initially with albumin and later combined with plasma&#41;&#46; Deterioration of renal function persisted with creatinine of 8&#46;4mg&#47;dL and oliguria&#46; Haemodialysis without heparin was begun&#46; After thirteen days the patient complained of pain in the hypogastrium and left iliac fossa following a coughing episode&#46; An abdominal mass and anaemia of four points were apparent&#46; An abdominal CT revealed a haematoma of the left anterior rectus sheath &#40;figure 1&#41;&#46; Three concentrates were transfused&#46; A coagulation test including factors was normal except for an Ivy value of ten minutes&#46; Three days later there was new pain in the right iliac fossa&#44; with paralytic ileus and anaemia of three&#160;points&#46; A CT revealed a haematoma in both anterior rectus muscles which extended towards the Retzius space and pelvis &#40;figure 2&#41;&#46; It pinpointed four concentrations of erythrocytes&#46; The departments of surgery and interventional radiology consulted&#44; deciding on conservative expectant treatment and associating antibiotics &#40;clavulanic amocycillin&#41; as well as parenteral nutrition&#46;</p><p class="elsevierStylePara">After one week the ileus was resolved&#44; but the patient began to experience sudden dyspnoea with the normal prescription&#46; A scintigraphy confirmed a multiple pulmonary embolism&#46; Treatment with a heparin pump was started with close monitoring&#46; The haematoma and pulmonary embolism were resolved without consequence but the patient continued to be dependent on haemodialysis&#44; with evidence of negative anti-GBM Ab from the fourth plasmapheresis&#46;</p><p class="elsevierStylePara">Disease caused by anti-GBM Ab is a medical emergency that needs to be ruled out in rapidly progressing renal failure&#44; using an anti-GBM Ab test&#46; Early treatment based on corticosteroids&#44; cyclophosphamide and plasmapheresis appears to play a significant role in the recuperation of renal function<span class="elsevierStyleSup">1-3</span>&#46; Possible complications<span class="elsevierStyleSup">2&#44;3</span> are many&#46; One complication is an alteration in coagulation&#44; brought about by a loss of factors or the use of anticoagulants&#46; However&#44; a massive haematoma of the recti has not previously been described associated with plasmapheresis or disease caused by anti-GBM Ab&#46;<span class="elsevierStyleSup">2&#44;3</span> Plasmapheresis is a delicate technique which should be carried out by experienced professionals&#44; and is gradually being included in the activities of nephrologists&#46;<span class="elsevierStyleSup">4</span> Haematoma of the rectus sheaths is an uncommon process which can simulate intra-abdominal disease&#46; The main predisposing factor is anticoagulation and a cough is the precipitating factor&#46;<span class="elsevierStyleSup">5&#44;6</span> Diagnosis is based on clinical suspicion and confirmed with a CT&#46;<span class="elsevierStyleSup">5&#44;6</span> Our patient&#44; although showing normal coagulation&#44; had received six plasmaphereses&#44; and this raised for us the idea of citrate-induced coagulopathy&#44; deficits in coagulation factors and uremic thrombopathy secondary to renal failure as possible causes&#46; <p class="elsevierStylePara">Treatment for haematoma of the recti is initially conservative&#44;<span class="elsevierStyleSup">5&#44;6</span> surgery should be reserved for progression&#44; infection of the haematoma or haemodynamic instability&#46; Arteriography with selective embolisation can be considered&#46; In the case in question&#44; the haematoma of the recti was completely resolved in forty days&#44; despite requiring anticoagulation for the massive pulmonary embolism&#44; and the patient survived without consequences&#44; now having undergone a successful transplant&#46;</p></p></p><p class="elsevierStylePara"><a href="grande&#47;14318078&#95;f1&#95;375&#46;jpg" class="elsevierStyleCrossRefs"><img src="14318078_f1_375.jpg"></img></a></p><p class="elsevierStylePara">Figure 1&#46; </p><p class="elsevierStylePara"><a href="grande&#47;14318078&#95;f2&#95;376&#46;jpg" class="elsevierStyleCrossRefs"><img src="14318078_f2_376.jpg"></img></a></p><p class="elsevierStylePara">Figure 2&#46; 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