Spontaneous ilio-psoas hematoma in severe COVID-19 infection: A rising catastrophic complication.

Discussion

A global pandemic caused by covid-19 infection has begun since December 2019. Since then more than 180 million people were infected with global mortality rate of around 2.1%. Critically ill patients with covid-19 infection are at risk of developing a hypercoagulable state which can lead to thromboembolic events. This is believed due to cytokines storm that alters the systemic inflammatory response syndrome (SIRS) resulting generalized microvascular thrombi and multiorgan failure. Eleven to 70% of covid-19 patients in intensive care unit (ICU) were believed to suffer from this scenario. For that reason, World Health Organization (WHO) has recommended the use of anticoagulant such as heparin or low molecular weight heparin (LMWH) for the prevention of potentially lethal thromboembolic phenomenon.

Spontaneous hemorrhage in covid-19 patients are not uncommon event. Soft tissue hematoma can occur anywhere but mostly in the rectus sheath or iliopsoas muscle. A retrospective study conducted by Vergori A et al. has demonstrated incidence of spontaneous iliopsoas hematoma (IPH) has increased to 7.6 per 1000 ICU admissions for covid-19 patients from 3.8 per 1000 admissions for non covid-19 patients. Its exact pathophysiology has yet to be established but common risk factors identified are age, anticoagulant, high body mass index (BMI) and comorbidities such as hypertension and diabetes. It is hypothesized that increase sensitivity to rupture of pre-existing retroperitoneal microvascular atherosclerosis to trivial events such as cough, vomiting or even changing posture that lead to retroperitoneal bleeding.

A high index of suspicion is required in order to diagnose iliopsoas hematoma (IPH) early as almost all sign and symptoms were non-specific. Vergori A et al. demonstrated it occurs mostly after a median of 35 days (IQR 29 - 50) of admission which much later than in our case. The onset and size of hematoma will determine its associated clinical features. Patients may also present with signs of neurologic compression of ipsilateral lower limbs or just general signs of hypovolemia. On the other hand, anemia is always present.

CT scan of the abdomen is the imaging of choice because valuable information regarding the hematoma can be established such as its actual size, extension and evidence of contrast leak suggesting an active hemorrhage. The majority of IPH cases can be managed conservatively. However, anticoagulation must be stopped and patient is transfused accordingly. In hemodynamically unstable patients, volume resuscitation and supportive measures must be provided prior to definitive therapy. Arterial embolization by interventional radiologist must be considered for such scenario which proven effective with less morbidity when compared to surgery. Typically, L3 and L4 lumbar arteries were the source of bleeding.

It is well known that one of the causes of mortality in covid-19 patients is venous thromboembolism as evidence by altered coagulation profile such as d-dimers. Despite that, optimal dose and duration of anticoagulant specifically in micro-thrombosis remain uncertain with lack of solid evidences. International guidelines pertaining to such issues are evolving. It is important to remember that anticoagulant use is not without risk. Hemorrhagic complications of anticoagulant therapy are relatively common in hospitalized patients, and although most of these are self-limited, morbidity and mortality does occur.

As of today, there is no significant evidence of mortality benefit among covid-19 patients treated with high dose anticoagulant. Anticoagulant trials in covid-19 patients such as (REMAP-CAP, ACTIV-4, and ATTACC) have been stopped due to futility and safety issues. Until further strong evidences available, clinicians should avoid from using high-dose prophylactic doses or initiation of empiric therapeutic anticoagulation. In addition, patients with covid-19 and on anticoagulant prophylaxis should be carefully monitored for early signs of IPH. They should undergo radiological examinations urgently especially when there is significant reduction in hemoglobin level.

The case below illustrates fatal consequences of IPH in covid-19 patient who was prescribed an anticoagulant only during her hemodialysis.

Visual case discussion

A 50 years old lady presented to our hospital with fever and shortness of breath for three days duration. At emergency department, her vitals were stable but tachycardic (110 beats per-minute) and tachypneic (respiratory rate of 28 per-minute) with reduced breath sounds over both her lungs. Her oxygen saturation under room air was only 90% on pulse oximeter. She was managed as covid-19 pneumonia as her PCR swab test was positive for covid-19 with opacities noted on her chest radiograph. Her comorbidities were overweight (weight 60 kg, BMI of 27), hypertension, diabetes mellitus and end stage renal failure on regular hemodialysis. Her initial blood results were; Haemoglobin: 12.2 g/dl, white blood cell counts 5.22 × 103/uL, platelet count: 191 × 103/uL, C-reactive protein of 34.2 mg/L, ferritin; 2021 ug/L and D dimer 0.55 ug/mL (reference < 0.5 ug/mL).

She was managed in intensive care unit (ICU) for severe covid-19 pneumonia (category 4) and required oxygen support via face mask. An intravenous methylprednisolone 100 mg daily was started. A subcutaneous clexane (Enoxaparin) 40 mg stat was given only prior her hemodialysis as she was allergic to heparin. She responded well and was transferred to general ward three days later. Her regular hemodialysis with prophylactic enoxaparin was continued.

On day 15 of admission, a day after her hemodialysis she complained of having right sided abdominal pain aggravated by movement. Her hemoglobin level has dropped from 11.5 g/dl to 6.3 g/dl within two days. Her inflammatory markers a day prior to onset of symptoms were; CRP: 75.2 mg/L, Serum Ferritin > 40,000 ug/L, lymphocyte count: 970/uL, LDH: 1137 U/L, total white blood cells (TWBC): 54.6 × 103/uL, D dimer: negative. Other blood results such as platelet count and INR were normal; 319 × 103/uL and 1.48 respectively.

Her general conditions progressively deteriorated requiring resuscitation and intubation. Clinical examination revealed a large tender vague mass occupying entire right side of her abdomen measuring 20 cm x 15 cm. An urgent CT scan with contrast of the abdomen and pelvis confirmed the diagnosis of large right iliopsoas hematoma (12 cm x 14 cm x 16 cm) with pooling of contrast in both arterial and venous phase suggesting of active bleeding (Fig. 1 ). A diagnosis of spontaneous iliopsoas (retroperitoneal) hematoma in shock was made. Subsequently she was sent to nearby tertiary center for arterial embolization by interventional radiologist. Despite successful embolization of right lumbar 3 and 4 arteries (Fig. 2 ) she passed away few days later.

Fig. 1.

Large right iliopsoas hematoma with contrast leak within suggestive of active bleeding (red arrow).

Fig. 2.

Pre-embolisation image showing an area of blush (contrast leak) from L4 artery; red arrow.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Questions and answers true & false and / or multiple-choice questions

Question 1

Does occurrence of spontaneous IPH in Covid-19 patients correlate with severity of infection?

Answer Options

True

False

Correct Answer = True

Based on case series by Vergori et al., all of their seven cases of IPH occurred in severe covid-19 patients.

All of them required oxygen support with the use of CPAP at least. Its association remains to be established but likely related to cytokines storm and use of anticoagulant.

Reference: Alessandra Vergori, Elisa Pianura, Patrizia Lorenzini, Alessandra D'Abramo, Federica Di Stefano, Susanna Grisetti, Serena Vita, Carmela Pinnetti, Davide Roberto Donno, Maria Cristina Marini, Emanuele Nicastri, Stefania Ianniello, Andrea Antinori & on behalf of the ReCOVeRI Study Group. Spontaneous ilio-psoas haematomas (IPHs): a warning for COVID-19 inpatients. Ann Med. 2021 Dec;53(1):295–301. doi: 10.1080/07,853,890.2021.1875498.

Question 2

What is the earliest and reliable sign/symptoms of IPH?

Answer Options

Respiratory distress

Unexplained rapid onset of anemia

Non-specific visceral pain

Reduced conscious level.

Abdominal mass

Correct Answer = B

Iliopsoas hematoma (IPH) can present in many non-specific signs or symptoms such as sudden onset of visceral pain or swelling in the soft tissue/visceral area but the earliest and reliable sign is sudden unexplained dropped in hemoglobin level. Both case series from Vergogi et al. and Teta M et al. had demonstrated significant reduction in hemoglobin of at least more than 2 g/dL in a day in almost all their patients. Nevertheless gastro-intestinal bleeding has to be ruled out first as it is more common than IPH in any critically ill patients.

Question 3

What is/are the management for spontaneous IPH in Covid-19 patient?

Answer Options

Cessation of anticoagulant and conservative management

Transcatheter arterial embolization (TAE)

Surgical exploration

All of the above

Correct Answer = D

Spontaneous soft tissue hematomas (SSTH) can occur at any locations in the body but most frequently in the rectus sheath and iliopsoas. Most are self-limited and resolved with cessation of anticoagulant and conservative management. The high success rate in conservative management is due to the fact that those hematomas occurred in contained spaces which allow them to be tamponade by adjacent structures. Occasionally, where coagulopathy difficult to be corrected and delay of diagnosis that lead to failed in conservative management (persistent bleeding and hemodynamically unstable), there is a role of transcatheter arterial embolization (TAE). Rarely, surgical exploration might be pursued.

Reference: Michael Teta, Michael J Drabkin. Fatal retroperitoneal hematoma associated with Covid-19 prophylactic anticoagulation protocol. Radiology Case Reports. 2021;16:1618–1621, DOI: 10.1016/j.radcr.2021.04.029