Spontaneous Hemorrhagic Brachial Plexopathy in Acute‐on‐Chronic Liver Failure

A 46-year-old male reported painful weakness of the right upper extremity. He had chronic alcohol use disorder, acute-on-chronic liver failure (ACLF), hepatorenal syndrome, pulmonary arterial hypertension, and severe coagulopathy (INR 6.1). Examination suggested severe jaundice (Figure 1a,b). Power testing was hindered due to pain across the right shoulder and elbow. Shoulder abduction, elbow flexion, and extension were MRC 2/5, 2/5, 4/5, respectively. Wrist movements and intrinsic hand muscles were severely weak (1/5) with sensory loss in C6-T1 dermatomes. Swelling and ecchymosis (Figure 1a,b) were noted over the right arm extending till axilla and thoracic wall, suggestive of underlying hematoma likely involving the right brachial plexus which was confirmed with regional MRI (Figure 1c,d). Electromyography was not performed due to severe coagulopathy. He had no improvement and succumbed to the liver failure after 8 weeks. Hemorrhagic brachial plexopathy is rare and usually traumatic or anticoagulation drug-related [1-3]. ACLF is a well-known risk factor for spontaneous hemorrhages. However, spontaneous brachial plexopathy secondary to hematoma due to ACLF has never been reported in literature [3, 4]. The presumed precipitating factor might be continuous pressure over the right side during sleep with deranged coagulation profile leading to spontaneous hemorrhage in the superficial and deeper planes. The authors have nothing to report. The article does not involve any human subject trial or animal experiments. Informed consent was obtained prior to writing of the draft for submission and publication. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.