“Raccoon Eyes”

A 58-year-old man with type 2 diabetes, nephrolithiasis, and benign prostatic hyperplasia presented with bilateral periorbital ecchymoses and left subconjunctival hemorrhage. The ecchymoses had spontaneously appeared 3 days earlier; the patient had no history of trauma or falls. He also had difficulty in voiding, characterized by increased frequency, hesitancy, and diminished urine stream. The urinary symptoms had been progressively worsening for a week and were now accompanied by severe intermittent abdominal pain.

The patient had no petechiae and no other ecchymoses or signs of hemorrhage. Palpation elicited mild tenderness in all abdominal quadrants; the pain was worse in the suprapubic region. There was no fullness or palpable masses. The rectal examination revealed a markedly enlarged, nontender prostate.

The patient was asked to urinate under observation. During micturition, he strained with tremendous effort, which caused marked facial plethora and diaphoresis. He then stated that he routinely strained for 6 to 7 minutes, with only minimal urine production. Placement of a Foley catheter relieved 1.2 L of urine. His abdominal pain immediately resolved.

Laboratory results showed a blood urea nitrogen level of 98 mg/dL, serum creatinine level of 11.9 mg/dL, normal complete blood cell count and coagulation studies, and a prostatic-specific antigen level of 134 ng/mL. A renal ultrasonogram revealed hydronephrosis with nephrolithiasis in multiple calices bilaterally.

The periorbital ecchymosis slowly faded over the next few days. The creatinine level at discharge was 1.3 mg/dL. An outpatient prostate biopsy revealed adenocarcinoma.

“Raccoon eyes” or bilateral periorbital ecchymoses can result from direct trauma to the eye and surrounding soft tissues,¹ basal skull fracture,² rhinoplasty,³ amyloidosis, ^4,5 malignancy,^6-8 trigeminal autonomic cephalgia,⁹ and vigorous sneezing¹⁰ or coughing.¹¹ This patient’s periorbital ecchymoses were most likely caused by the increased pressure in the capillary beds surrounding the palpebral region that occurred during straining. This Valsalva maneuver–like mechanism is similar to that of prolonged sneezing or coughing.

Although the combination of renal failure and periorbital purpura aroused suspicion of amyloidosis initially, a renal biopsy or fat pad biopsy was deferred because the creatinine level normalized after the outflow obstruction was relieved and no other clinical manifestations of systemic amyloidosis were observed. Platelet dysfunction secondary to uremia was a possible risk factor for bleeding in this patient; however, this disorder is more common in those with chronic renal failure.^12,13