Acute ‘pathological haematoma’ without significant antecedent trauma as an unusual presentation of undiagnosed malignancy

Abstract

The authors report two cases of malignancy that presented initially with acute haematomas without any history of significant trauma. The first case was a 31-year-old male who presented with a large haematoma in the anterior triangle of the neck following minor trauma during a rugby match. This was shown to be due to haemorrhage into an undiagnosed papillary thyroid tumour. The second case was a 41-year-old male who developed a spontaneous sternocleidomastoid haematoma after laying flagstones and without any history of direct trauma. This was due to haemorrhage into a nodal deposit of non-Hodgkin’s lymphoma. These cases highlight that sudden onset haematomas without obvious explanation may be the result of underlying malignancy. In such instances further investigation must be considered and re examination of the patient is essential after the haematoma has resolved.

Background

It is important to detect malignancy at the earliest opportunity. We present a previously undescribed phenomenon of haematoma as the presenting symptom for two different types of malignancy and suggest an appropriate algorithm for investigating these patients.

Case presentation

Case 1: a 31-year-old man noticed a large swelling on the right side of his neck following minor trauma sustained during a rugby match earlier in the day. He was otherwise fit and had no pre-existing medical problems. The swelling was painful and caused him pain on turning his head and on swallowing. On examination, he had a tender non-pulsatile soft mass in the right anterior triangle. There was no associated lymphadenopathy or vascular abnormalities. His chest was clear and neurological and abdominal examination was completely normal.

Case 2: a previously healthy 41-year-old man attended the emergency department with an acute onset painful left-sided neck swelling the day after laying flagstones. There was no history of trauma to the neck and there was no significant medical history. On examination, he had a fluctuant, tender swelling in the left anterior triangle of the neck. There were no other palpable swellings in the neck, groins or abdomen. Neck movements were restricted only by discomfort in the swelling but there was no neurological or circulatory abnormality. Chest examination was clear and his chest x-ray was normal. A provisional diagnosis of a sternocleidomastoid haematoma was recorded and reassessment was arranged for the following week (after the haematoma had dispersed). On this occasion, clinical examination revealed left supraclavicular lymphadenopathy.

Investigations

Case 1: ultrasound assessment demonstrated a haematoma, which contained an unusual mass, which was proven to be a papillary thyroid tumour lying within a large haemorrhagic cyst (figure 1).

Figure 1.

Papillary thyroid tumour lying within a large haemorrhagic cyst.

Case 2: an ultrasound scan showed that the haematoma was associated with a mass which, on ultrasound guided biopsy, was shown to be a non-Hodgkin’s lymphoma.

Treatment

Case 1: this gentleman went on to have a total thyroidectomy and region VI neck dissection, with subsequent radioisotope administration and suppressive thyroxine replacement therapy. He is currently in remission.

Case 2: chemotherapy was commenced and he is currently in remission.

Discussion

It is a well-documented fact that the earlier a tumour is detected, the better the prognosis will be.^{1 2} The clinical signs of early malignancy may be very subtle and could be easily missed. The most common presenting symptom of non-Hodgkin’s lymphoma is a painless swelling of a lymph node in the neck, axilla or groin. Patients commonly present with non-specific symptoms such as fever, unexplained weight loss and anorexia, fatigue, night sweats etc. In papillary thyroid tumour, the most likely initial finding is a painless lump in the neck. Some patients present with persistent cough, difficulty breathing, or difficulty swallowing. Other symptoms such as pain, stridor or vocal cord paralysis are rare. Haemorrhage into malignant tumours is well described although this usually occurs in advanced tumours with associated tumour necrosis. As far as we are aware these are the only reported cases of a haematoma being the presenting sign of either a non-Hodgkin’s lymphoma or a papillary thyroid tumour.

A haematoma is a collection of blood within a body tissue or cavity, which most commonly results from rupture of a blood vessel. This is usually associated with a traumatic event although spontaneous haematomas can occur within the context of clotting abnormalities such as haemophilia. In the first of these cases there was a history of minor trauma although this was not proportionate to the degree of swelling that occurred. In the second case there was no history of trauma and in neither case was there any history of haematological abnormality. We believe the mechanism behind the pathological haematoma formation in these cases was infiltration of blood vessels by the tumour leading to stasis and rupture of the capillary net. This mechanism has been described in a similar case reported by Alimehemeti and Locatelli who outlined the presentation of an atraumatic chronic subdural haematoma resulting from an underlying non-Hodgkin’s lymphoma.³

Learning points.

• ‘Pathological haematoma’ should be suspected when it occurs without a history of antecedent trauma and in the absence of clotting abnormality.

• In such cases investigation in the form of an initial ultrasound and repeat examination once the haematoma has subsided is recommended.