Spontaneous Muscle Hematoma in Patients with COVID-19: A Systematic Literature Review with Description of an Additional Case Series

Abstract

Coagulation abnormalities, thrombosis, and endothelial dysfunction have been described in COVID-19 patients. Spontaneous muscle hematoma (SMH) is a rare complication in COVID-19. The aims of this study are to: (1) perform a systematic review of the literature to better define the clinical SMH characteristics, (2) describe the prevalence and the clinical characteristics of SMH in COVID-19 patients referring to a Department of Internal Medicine (IM) (Federico II University of Naples), a Department of Sub-Intensive Care Medicine (SIM) (Ospedale Del Mare), and a Department of Intensive Care Unit (ICU) (Federico II University). The systematic review was performed according to PRISMA criteria. The local prevalence of SMH in COVID-19 was evaluated retrospectively. The medical records of all COVID-19 patients referring to IM and ICU from March 11th, 2020, to February 28th, 2021 were examined for SMH occurrence. In our retrospective analysis, we describe 10 cases of COVID-19 patients with SMH not previously reported in literature, with a prevalence of 2.1%. The literature review, inclusive of our case series, describes a total of 50 SMHs in COVID-19 patients (57.4% males; mean age 68.8 ± 10.0 years). The SMH sites were ileo-psoas, vastus intermedius, gluteus, sternocleidomastoid, and pectoralis major muscles. Males developed SMH earlier than females (9.5 ± 7.8 vs. 17.1 ± 9.7 days). Ileo-psoas hematoma was more frequent in males (69.2 vs. 30.8%), while pectoralis major hematoma occurred only in females. The in-hospital mortality rate of SMH in COVID-19 patients was 32.4%. SMH is a rare but severe complication in COVID-19 hospitalized patients, associated with high mortality. A gender difference seems to be present in the clinical presentation of the disorder.

Venous Thromboembolism in COVID-19 Compared to Non-COVID-19 Cohorts: A Systematic Review with Meta-Analysis

“…Coronavirus disease 2019 (COVID-19) is a novel coronavirus infection characterized by severe complications, such as arterial and venous thrombotic events, and a high mortality rate [1][2][3][4]. Coagulopathy and a pro-thrombotic state, with high D-dimer and fibrinogen levels, are reported widely in hospitalized COVID-19 patients and are related to high mortality [5][6][7][8].…”

Musculoskeletal Manifestations of COVID-19: Currently Described Clinical Symptoms and Multimodality Imaging Findings

“…COVID-19–related coagulopathy resulting in spontaneous MSK hemorrhage is much less common than thromboembolism. Spontaneous bleeding most commonly occurs in skeletal muscle, especially the iliopsoas, as well as the pectoralis major and rectus abdominis muscles ( 41 , 42 ). A recent study showed that critically ill COVID-19 patients were twice as likely to develop a spontaneous iliopsoas hematoma compared with those in the intensive care unit for other reasons ( 41 ).…”

“…Anticoagulation therapy is the biggest risk factor for developing spontaneous muscle hematoma. Other risk factors include older age, obesity, hypertension, and diabetes mellitus ( 42 ). Several proposed mechanisms may contribute to the pathogenesis of this phenomenon, including prophylactic anticoagulation therapy and renal damage–associated decreased clearance of anticoagulants.…”

Spontaneous Hematomas and Deep Vein Thrombosis during the Recovery from a SARS-CoV-2 Infection: Case Report and Literature Review

“…In the same vein, spontaneous hematomas developed in patients suffering or recovering from COVID-19 were rarely described [7,14], being mostly associated with the treatment with LMWH [1,9,11]. According to the guidelines, LMWH are the treatment of choice for patients with deep vein thrombosis (DVT), and are also used as prophylaxis in COVID-19 [15][16][17]. This therapy should be initiated as soon as possible after establishing the diagnosis to prevent DVT and life-threatening complications, especially pulmonary embolisms (PEs) [1,3,18].…”