Spontaneous psoas muscle hematoma is a rare condition, its incidence varies between 0.6% and 6.6% [1] and can be potentially lethal. Although traumatic hematomas are more reported, spontaneous ones are relatively more frequent.

Spontaneous iliopsoas hematomas usually appear with coagulopathy due to hemophilia or anticoagulants/antithrombotic. Clinically, patients present right iliac fossa pain, groin or back pain, with a flexed hip or even signs of hypovolemia. Femoral compression neuropathy may be present, leading to sensory numbness or paresthesia of the ipsilateral inferior member, and quadriceps muscle weakness [2].

This case highlights several important features and considerations in the presentation of high bleeding in severe hemophilia. In a case series described by Ashrani et al., patients with iliopsoas homatoma had an average duration of symptoms of 3.8 days before seeking medical attention, with an average hospital stay of 12.3 days [ 3], our patient was hospitalized for 18 days.

Iliopsoas hematoma can be difficult to diagnos, even on patients with known severe hemophilia. While imaging exploration, especially CT and MRI, have become increasingly sensitive. This is furtherly complicated by the fact that the presenting symptoms like hip, groin, thigh or lower back pain can be caused by various etiologies, that can be trivial or even fatal in certain situations such as hip hemarthrosis, osteonecrosis of the femoral head, appendicitis or incarcerated hernia [3]. This requires the think of several differential diagnoses, and to carry out the additional examinations necessary to exclude etiologies which can be fatal.

Treatment of iliopsoas hematoma mainly includes conservative treatment, ultrasound- or CT-guided percutaneous drainage, embolization, incision, and surgical or laparoscopic retroperitoneal drainage. The therapeutic modality is chosen according to the clinical manifestations and the severity of the hematoma.

Conservative treatment is recommended for patients with light bleeding and no apparent symptoms of nerve compression, which includes the stop of anticoagulant medication as in the current case, bed rest, and blood transfusion.

For patients with significant pain, percutaneous drainage and decompression guided by ultrasound or CT scan may be indicated. Angiography may be considered for high life-threatening massive hemorrhages, if pulsating artery injury is identified, arterial embolization can be the treatment of choice.

For patients with complete paralysis of the femoral nerve by compression with the hematoma, decompression by surgical incision and drainage is indicated, retroperitoneal laparoscopic treatment may also be considered.

In this case, we opted for a conservative treatment given to significant risk of bleeding which can compromise the vital prognosis of our patient, on the expense of the functional prognosis, the same attitude was recommended for an 22-year-old patient who presented a spontaneous hematoma of the psoas muscle complicating Gaucher disease, descripted by J.Seltona et al [5].

While in a case of an 80-year-old patient at the Strasbourg University Hospital [1] who presented an VKA therapy accident with an I.N.R of 8, surgery was performed after antagonization by a concentrate of prothrombin complexes and vitamin K.

For Qanadli SD et al in the department of radiology at the University René-Descartes Paris [6], if an active bleeding site inside the hematoma of the psoas is highlighted, an aortogram with selective catheterization of the arteries that bleeds (internal iliac and lumbar arteries) must be carried out immediately as well as a hemostatic embolization.

Iliopsoas hematoma is a rare and particularly dangerous complication of severe hemophilia. Given the low prevalence and the complex nature of this disease, many of these patients are cared for in specialized structures.

This case highlights the need, for the emergency doctors, to have a solid understanding of this disease and its potential complications, as early detection and immediate intervention can be vital on one hand and saving the member on the other hand [4].