International Journal of Clinical & Medical Images

Case Presentation: A 59-year-old man on anticoagulation therapy with warfarin complained of sudden, progressive and severe pain and tenderness around right gluteus muscles and all the way down to the calf muscles of right leg. Two days earlier he slipped and suffered a trauma to gluteal region and both lower limbs. Over the past couple of days, he complained of debilitating pain and wasn’t able to sit, sleep or move. His past history was unremarkable apart from the diagnosis of primary antiphospholipid syndrome.

On physical examination, the patient was fully conscious with stable vital signs, and no abnormality was detected other than large ecchymosis and bruises all over right gluteal, quadriceps and calf muscles with similar but to a much lower extent on left side. Laboratory investigations showed elevated international normalized ratio (INR) of 4.8 (prescribed ratio 2-3), hemoglobin dropped from 14.5 gm/dl down to 11.3 gm/dl.

Lumbar and Pelvic Magnetic Resonance Imaging (MRI) sections demonstrated a big right sided collection extending in between the gluteus maximus and gluteus medius measures 20 × 2.3 × 11 cm presented as low to iso signal in T1 sections and high signal in T2 sections, associated with completely abnormal high signal of the gluteus medius muscle in T2 sections with lobulated collection inside having fluid- level measures about 8 × 4.5 cm in keeping with intramuscular hematoma with extra muscular blood spillage (Figures 1-4).