Life-Threatening Psoas Hematoma due to Retroperitoneal Hemorrhage in a COVID-19 Patient on Enoxaparin Treated With Arterial Embolization: A Case Report

Patel, Ishan; Akoluk, Arda; Douedi, Steven; Upadhyaya, Vandan; Mazahir, Usman; Costanzo, Eric; Flynn, Daniel

doi:10.14740/jocmr4256

Cited by 46 publications

(58 citation statements)

References 12 publications

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“…A recent case in New Jersey demonstrated the retroperitoneal bleeding complication in patient with COVID-19 after receiving therapeutic dose low molecular weight heparin (LMWH) while on antiplatelet in the light of the deranged coagulation profile, which results in haemorrhagic shock. 3 A retrospective study of 355 patients with COVID-19 done by Musoke et al 7 also convinced that therapeutic anticoagulant is significantly associated with increased risk of bleeding and mortality compared with subtherapeutic (intermediate dose) or prophylactic dose. In the UK, British Thoracic Society and Scottish Intercollegiate Guidelines Network currently suggest use of prophylactic dose LMWH for patients who are managed on a ward and intermediate-dose LMWH (twice daily standard prophylactic dose) for patients on critical care.…”

Section: Discussionmentioning

confidence: 99%

“…Recently, there are rising numbers of papers reporting major internal bleeding such as retroperitoneal haemorrhage as a complication of COVID-19. 3–6 Pelvic haematoma is defined as the presence of blood clot or fluid in the retroperitoneal zone III region, which is bordered with the dome of the bladder as anterior, sacrum as posterior and iliac wings as lateral borders. Spontaneous retroperitoneal haematoma secondary to anticoagulant therapy is one of the well-known but self-limiting conditions.…”

Section: Discussionmentioning

confidence: 99%

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Double-edged sword effect of anticoagulant in COVID-19 infection

Ohn

et al. 2021

BMJ Case Rep

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Coagulation predominant-type coagulopathy such as microthrombosis and macrothrombosis is a well-known recognised complication found in COVID-19 infected critically ill patients. In the context of high incidence of thrombotic events in patients with COVID-19, supplementation with anticoagulant therapy has been routinely recommended and shown to reduce mortality. However, the recommended type, dose, duration and timing of anticoagulant has not been determined yet. Spontaneous retroperitoneal haematoma secondary to anticoagulant therapy is one of the well-known but self-limiting conditions. We report a 51-year-old COVID-19 positive woman, who was taking intermediate-intensity heparin therapy for venous thromboembolism prophylaxis and died from complication of retroperitoneal bleeding. Further studies are needed to verify the risk–benefit ratio of anticoagulant therapy in patients with COVID-19. Although anticoagulant deems appropriate to use in patients with COVID-19, clinicians should be cautious about major bleeding complication such as retroperitoneal haemorrhage even when full therapeutic dosage is not used.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Double-edged sword effect of anticoagulant in COVID-19 infection

Ohn

et al. 2021

BMJ Case Rep

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“…Anticoagulation treatment and additional anti-platelet medications, increase the risk of major bleeding complications like retroperitoneal haemorrhage [ 9 , 10 ]. In a French ICU, 19 out of 92 (21%) COVID-19 patients on full anticoagulant treatment had 22 haemorrhagic events, and five of them were gastrointestinal [ 21 ].…”

Section: Discussionmentioning

confidence: 99%

“…IPH is a potentially lethal condition frequently reported as a complication of anticoagulation therapy that can arise during the hospitalization, especially in intensive care units (ICUs) [ 9 ]. To date, a single case of spontaneous IPH in a COVID-19 patient has been reported [ 10 ]. Here, we report seven cases of spontaneous IPHs occurring in patients with severe COVID-19 pneumonia admitted to our Institute.…”

Section: Introductionmentioning

confidence: 99%

Spontaneous ilio-psoas haematomas (IPHs): a warning for COVID-19 inpatients

et al. 2021

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Introduction Critically ill patients with COVID-19 are at increased risk of developing a hypercoagulable state due to haemostatic changes directly related to the SARS-CoV-2 infection or to the consequence of the cytokine storm. Anticoagulation is now recommended to reduce the thrombotic risk. Ilio-psoas haematoma (IPH) is a potentially lethal condition that can arise during the hospitalization, especially in intensive care units (ICUs) and frequently reported as a complication of anticoagulation treatment. Materials and methods We report a case series of seven subjects with SARS-CoV-2 pneumonia complicated by Ilio-psoas haematomas (IPHs) at our COVID-Hospital in Rome, Italy. Results Over the observation period, 925 subjects with confirmed SARS-CoV-2 infection were admitted to our COVID-hospital. Among them, we found seven spontaneous IPHs with an incidence of 7.6 cases per 1000 hospitalization. All the reported cases had a severe manifestation of COVID-19 pneumonia, with at least one comorbidity and 5/7 were on treatment with low weight molecular heparin for micro or macro pulmonary thrombosis. Conclusions Given the indications to prescribe anticoagulant therapy in COVID-19 and the lack of solid evidences on the optimal dose and duration, it is important to be aware of the iliopsoas haematoma as a potentially serious complication in COVID-19 inpatients. KEY MESSAGE Critically ill patients with COVID-19 are at increased risk of hypercoagulability state and anticoagulation therapy is recommended. Ilio-psoas haematoma (IPH) is found to be a complication of anticoagulation regimen especially in severe COVID-19 cases. An incidence of 7.6 cases per 1000 admission of IPHs was reported. Hypoesthesia of the lower limbs, pain triggered by femoral rotation, hypovolaemia and anaemia are the most common symptoms and signs of IPHs that should alert physician.

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“…Additionally, multiple post-mortem autopsies have identified splenic involvement secondary to COVID-19 infection 2 , 3 , 4 , 5 , 6 . There have also been two cases of psoas hematoma [ 20 , 21 ]. As of yet, there has been only one prior report of rectus sheath hematoma secondary to COVID-19 coagulopathy [13] .…”

Section: Discussionmentioning

confidence: 99%

Splenic infarction and spontaneous rectus sheath hematomas in COVID-19 patient

Dennison

Carlson

Faehling

et al. 2021

Radiology Case Reports

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Multiple studies and reports have suggested that coronavirus disease-19 (COVID-19) promotes arterial and venous thrombotic events (VTE) in multiple organ systems, although the mechanism leading to a hypercoagulable state is still unknown. Few cases of splenic infarction associated with COVID-19 have been reported, of which half were found incidentally upon autopsy. This may be due to a clinically silent presentation or the symptoms being wrongfully attributed to pain caused by the effects of COVID-19. Due to the rarity of the condition and its lack of consistent symptomatology, splenic thromboembolism can be difficult to diagnose. Awareness of the condition and high clinical suspicion will help the clinician identify and manage the problem. Hemorrhage in patients with COVID-19 is uncommon in the hypercoagulable state that threatens thrombus formation in patients with COVID-19 infection. Despite prophylactic treatment with anticoagulation therapies, patients are more prone to developing clots. It is also well-known that therapeutic anticoagulation can place patients at a higher risk of bleeding. Thus, this unique population is at risk of developing both thrombotic and hemorrhagic events. We report a rare case of splenic infarction in a patient with confirmed COVID-19 infection despite prophylactic treatment with low-molecular-weight heparin (LMWH) which was found incidentally during workup for two other rare conditions: spontaneous rectus sheath hematoma and microhemorrhage or thrombus of the mesenteric vessels.

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Life-Threatening Psoas Hematoma due to Retroperitoneal Hemorrhage in a COVID-19 Patient on Enoxaparin Treated With Arterial Embolization: A Case Report

Cited by 46 publications

References 12 publications

Double-edged sword effect of anticoagulant in COVID-19 infection

Double-edged sword effect of anticoagulant in COVID-19 infection

Spontaneous ilio-psoas haematomas (IPHs): a warning for COVID-19 inpatients

Splenic infarction and spontaneous rectus sheath hematomas in COVID-19 patient

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