IntroductionAs the COVID-19 pandemic evolves periodically, becomes evident that although affects primarily the respiratory system, its ability to trigger a significant inflammatory response, combined with neuropathy and coagulopathy, often evolves into complex systemic responses as opposed to a purely respiratory disease. This can lead into severe respiratory distress and failure, septic shock, arrhythmia and a multiple organ dysfunction; Circumstances where first-line non-invasive medical therapies become suboptimal and advanced lifesaving intervention including, but not limited to induced coma, intubation and veno-venous extracorporeal membranous oxygenation (VV-ECMO) might be required.Case PresentationAuthors present a rare case of a 58 year old male with a rapid deterioration following COVID-19 infection, requiring immediate intubation at the Emergency Department, which escalated with transfer to a VV-ECMO unit due to unresponsiveness on all standard medical therapies. During the induced coma under VV-ECMO, a bilateral psoas haematoma (PH) insidiously developed, with subsequent lumbar plexopathy complicated by a COVID-19-related mononeuritis multiplex, diagnosed only at a later stage during rehabilitation. Early haematoma evacuation was deemed unsafe, because of his frailty. To the best of our knowledge, this is the first description of a complex bilateral PH, requiring 198 days of in-hospital stay, combined efforts of 3 Teaching hospitals and an ad-hoc multidisciplinary team, for its management.ConclusionsAs the pandemic persists more patients might require VV-ECMO, which however is not risk-free mainly due to the fine balance between COVID-19 coagulopathy and VV-ECMO anti-coagulation protocols. Authors hope to increase awareness around complications and clinical challenges, providing reflections on their early recognition and management.

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