Fatal iliopsoas and rectus sheath hemorrhage in a critically ill patient with COVID-19 on therapeutic anticoagulation.

Pulmonary embolism and thrombosis are two common postmortem findings in novel coronavirus disease 2019 (COVID-19), the fact which led experts to include anticoagulants in the standard management of COVID-19. However, at least until now, no guidelines stated the exact safe yet optimal dose of anticoagulants. We report a case of a 65-year-old man admitted to our hospital with severe acute respiratory distress syndrome due to COVID-19. He showed remarkable improvement during the first 10 days of treatment at our facility but subsequently developed spontaneous iliopsoas hemorrhage (IPH). We discontinued antithrombotic and anticoagulant agents as soon as we confirmed the IPH from the abdominal computed tomography scan. His condition worsened even after he received adequate blood transfusion sets and eventually developed disseminated intravascular coagulation. Due to the limitation of our hospital, we could not perform stent grafting and angiographic embolization. He finally died 6 days after the occurrence of IPH. To the best of our knowledge, this is the first case of COVID-19 with IPH in Indonesia. As a developing country, many hospitals in Indonesia do not have stent grafting and angiographic embolization. This condition urges the dose recommendation for anticoagulant therapy to provide safe and efficient management for COVID-19. Copyright:

INTRODUCTION

The novel coronavirus disease 2019 (COVID-19) is no stranger to most countries globally, including Indonesia. With the first suspected patient in the country being diagnosed in March 2020, the national death toll has reached more than 133,000 cases per August 2021.[1] Autopsies conducted on postmortem patients showed microvascular lung thrombosis, vein thrombosis, and pulmonary embolism.[2] The high incidence of thromboembolism has led some researchers to even suggest giving a higher prophylactic dose.[3] However, this comes at the cost of higher bleeding events.[4] In this case report, we describe a fatal case of with extravasation into the pararenal space, as well as a left rectus sheath hematoma in one of our COVID-19 patients.

CASE REPORT

A 65-year-old male was referred due to worsening symptoms of COVID-19. He reported 8 days of progressive dyspnea, which became worse in the last 2 days, along with intermittent fever. He had a history of hypertension and ischemic stroke 10 years prior, and was still taking oral amlodipine 5 mg and cilostazol 100 mg regularly. Upon presentation, he was alert and oriented, with blood pressure 147/91 mmHg, heart rate 79 bpm, respiratory rate 30/min, and 100% peripheral oxygen saturation (SpO2) under 15 L/min (LPM) oxygen with a nonrebreather mask (NRM), with a ROX index value of 3.45. Physical examinations showed generalized rales on both lungs, with an initial chest X-ray revealed pneumonia and cardiomegaly. Electrocardiogram showed a normal sinus rhythm.

As per hospital protocol, we prescribed remdesivir (initial dose 200 mg, followed by 100 mg every 12 h for 7 days) PO, methylprednisolone 62.5 mg every 12 h IV, enoxaparin 60 mg every 12 h SC, levofloxacin 750 mg every 24 h IV, meropenem 1 g every 8 h IV, acetylsalicylate 80 mg every 24 h PO, atorvastatin 40 mg every 24 h PO, Vitamin C 1 g every 12 h IV, Vitamin D3 5000 IU every 12 h PO, zinc 80 mg every 24 h PO, N-acetylcysteine 200 mg every 8 h PO, and nebulized lidocaine 80 mg and budesonide 1 mg every 6 h.

He experienced worsening dyspnea after 6 h of treatment, so a high-flow nasal cannula at 60 LPM flow with 100% oxygen fraction (FiO2) was initiated. On the 3rd day of treatment, the symptoms improved, and he was put back on oxygen with 15 LPM per NRM again. We kept down-titrating the FiO2 gradually as his blood gas analysis improved [Table 1], and on the 10th day of treatment, he was able to breathe normally in room air.

Table 1

Laboratory result comparison between the first day and the tenth day of treatment

Parameters	Day 1	Day 10	Normal range	Units
Hemoglobin	14.7	14.6	13.2–17.3	g/dL
Hematocrit	43.8	44	40–52	%
Platelet	150 ×103	401 ×103	150-450 ×103	/µL
Leucocytes	12.1 ×103	9.11 ×103	3.8-10.6 ×103	/µL
Neutrophils	94.7	90.5	50-70	%
Lymphocytes	3.8	4.2	1-3.7	%
Glucose	118	118	60-120	mg/dL
Blood urea	10.8	20.7	6-23	mg/dL
Creatinine	0.61	0.75	0.67-1.17	mg/dL
AST	149	40.2	<40	U/L
ALT	47.6	40.4	<41	U/L
PT	10.3	8.9	7.9-10.3	seconds
APTT	34.3	29.4	20-30.3	seconds
INR	0.98	0.87	N/A	N/A
D-dimer	811.93	705	<500	ng/mL
Procalcitonin	1.02	<0.05	<0.5	ng/mL
Fibrinogen	666	290	200-400	mg/dL
hs-CRP	148.8	34.3	<10	mg/L
IL-6	11.52	8.6	≤1.8	pg/mL
Sodium	137.9	137.3	136-145	mmol/L
Potassium	3.29	3.8	3.5-5.5	mmol/L
Chloride	108.2	107	96-105	mmol/L
Arterial pH	7.44	7.40	7.35-7.45	N/A
Arterial pCO2	39.2	37.9	35-45	mmHg
Arterial pO2	86	113	60-100	mmHg
HCO3	27	23.8	22-28	mmol/L
BE	3	−1	−2-2	mmol/L
SaO2	97	99	90-100	%
Lactate	1.19	1.17	0.5-1.0	mmol/L

AST: Aspartate transaminase, ALT: Alanine transaminase, PT: Prothrombin time, APTT: Activated partial thromboplastin time, INR: International normalized ratio, CPR: C-reactive protein, IL-6: Interleukin-6, pCO2: Partial pressure of CO2, pO2: Partial pressure of O2, BE: Base excess, SaO2: Arterial oxygen saturation, N/A: Not available

The following morning, he complained about severe abdominal pain. His hemoglobin had fallen to 9.1 g/dL, hematocrit to 27%, and platelet count was 267 ȕ 103/μL. A bedside-focused assessment with sonography in trauma examination identified no free fluid in the abdomen or pelvis. A subsequent computed tomography (CT) scan of the abdomen and pelvis identified a hematoma in the left psoas major-quadratus lumborum muscle with extravasation to the left posterior pararenal space, as well as a left rectus sheath hematoma [Figure 1]. Consultation with the attending surgeon concluded that this case would be managed conservatively. Both enoxaparin and acetylsalicylate were stopped, while adding tranexamic acid 1000 mg IV every 8 h.

Figure 1

(a) Hematoma of the left major psoas muscle and hematoma of the left rectus abdominis muscle; (b) Hematoma appears pressing the bladder and part of the urethra

Blood count was evaluated in the afternoon, and the hemoglobin level dropped to 8.1 g/dL with 24.1% hematocrit. Four units of packed red cells (PRCs) were ordered, but due to the limitation of the medical care setting, it would take about 2 h for the blood to be ready. While waiting for the blood, fluid resuscitation with 2000 mL Ringer's lactate and 500 mL 5% albumin were started, but his vital signs were deteriorating as his pain worsened. His blood pressure dropped to 65/30 mmHg, heart rate rose to 142 bpm, respirations at 30/min, and SpO2 was 80%−81% on 15 LPM of oxygen per NRM. The patient was intubated, and dopamine and norepinephrine infusions were initiated.

On day 15, the patient developed disseminated intravascular coagulation. By day 16, despite adequate blood transfusion (10 units of PRCs, 8 units of thrombocyte concentrates, and 4 units of cryoprecipitates), IV fluid resuscitation, vasopressor support, and invasive mechanical ventilation, the patient developed irreversible cardiac arrest.

DISCUSSION

Venous thromboembolism is a renowned cause of mortality in COVID-19. For this reason, the administration of prophylactic or therapeutic anticoagulant agents is prescribed to our patients. The incidence of IPH is said to be increasing, especially in patients receiving anticoagulant therapy.[56]

Spontaneous retroperitoneal hematoma is one well-known complication of anticoagulant therapy. Psoas hematoma is a life-threatening condition with mortality rates as high as 30%.[7] A recent study in the non-COVID population reported an incidence of IPHs of 3.8 cases per 1000 admissions in ICUs.[8] However, Vergori et al.[9] reported an incidence of 7.6 cases over 1000 hospitalizations. As for rectus sheath hematoma, the incidence is 1.8% among patients admitted to the hospital with abdominal pain and undergoing ultrasonography for diagnosis.

The treatment of choice in IPH remains debatable.[579] Initial treatment involves cessation of anticoagulant drugs, volume resuscitation, and blood transfusion. Discontinuing the anticoagulation agents in the COVID-19 setting could be harmful. In such setting, it is essential to take IPH as a potentially life-threatening condition.[6] As currently there is no recommendation on therapeutical management of IPH in COVID-19 patients, the treatment of choice should be made individually, taking the risk and benefit of stopping the anticoagulants into account.

A decision for surgical intervention in IPH is exceptionally problematic and precarious because the hematoma may occasionally turn into persistent bleeding.[5] Stent grafting and angiographic embolization are described to be effective but may be limited by availability, as in the presented case.

CONCLUSION

Antithrombotic and anticoagulation therapy is essential in the management of COVID-19. However, we must closely monitor for any drug-related complications. IPH is considered an emergency complication and may lead to fatality. Therefore, prompt management and the presence of stent grafting and angiographic embolization are critical when the bleeding cannot be ceased with conventional management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's daughter has given her consent for the images and other clinical information to be reported in the journal. She understands that the names and initials will not be published, and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Research quality and ethics statement

This case report did not require approval by the Institutional Review Board/Ethics Committee. The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines, specifically the CARE guideline, during the conduct of this research project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.