Sequential Bilateral Subperiosteal Hematomas
Jenny C Dohlman, Natalie Wolkow, Michael K Yoon
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A 28-year-old man with 2 months of lymphadenopathy, unintentional weight loss, and fevers of unknown etiology initially presented with OD pain, swelling, and binocular diplopia that began while he was sleeping on his right side at home. On examination, he was noted to have 4 mm of relative proptosis and limitation of upgaze, abduction, and adduction but no signs of optic nerve compromise. MRI orbits revealed a large, well-circumscribed, mixed signal intensity mass in the superomedial right extraconal orbit with minimal enhancement and layering T2 hypointense material suggestive of subperiosteal hematoma (Fig. A). Three days later while admitted for antibiotics and further workup, and 2 days after a right-sided cervical lymph node biopsy, the patient developed left-sided eye pain, swelling, and limitation of upgaze, abduction, and adduction. An interval MRI of the orbits revealed the same right orbital mass with new T1 hyperintensity and less susceptibility without enhancement, consistent with evolving blood products, as well as a new left T1 hypointense intraconal mass without enhancement, consistent with new subperiosteal hematoma (Fig. B). The patient was found to be anemic with hemoglobin of 8.8 and hematocrit of 29.1, but prothrombin time and international normalized ratio were within normal limits at 13 and 1.1, respectively. The patient had improvement of ocular symptoms after receiving a 3-day pulse of high-dose steroids and was discharged on a prednisone taper. The results of his systemic workup, including extensive infectious and inflammatory testing, multiple lymph node biopsies, and a bone marrow biopsy were nondiagnostic and consistent with a reactive process
Journal : OPRS
Ref : Orbit Subperiosteal hematoma