Life Threatening Spontaneous Hematoma in Unusual sites in patient with Covid-19 on Anticoagulant Therapy (4 case reports)

Introduction: Thromboembolic manifestations is a common phenomenon in patients affected by Corona virus (SARS CoV-2). Recent studies have shown that patients with Acute Renal Failure are also at a greater risk of venous and arterial thromboembolism, 15-30% in ICU, 7% inpatient care. However, frequently unjudicial use of anticoagulant may develop severe life-threatening hematoma. In our Hospital settings we had a dedicated COVID Unit with Hemodialysis facility. Our Nephrology department had managed 381 patients being COVID positive along with renal impairment from March 2020 to January 2022. Among these patients, four patients developed spontaneous non traumatic hematoma in unusual sites. On admission all the patients received treatment according to our national guidelines for Covid-19. Method(s): It is a retrospective analysis in a single-centered hospital. Four cases with confirmed COVID-19 with acute kidney injury and on anticoagulant therapy had developed sudden concealed bleeding. These patients had no previous history of anticoagulant therapy before admission. Case 1: Developed hemorrhage in Right lower anterior paramedian deep parietal wall of abdomen, Case 2: Had hematoma in retroperitoneal space and in lower third of Iliopsoas, Case 3: Developed hemorrhage in left cerebral hemisphere, Case 4: Had Intramuscular Hematoma in left rectus abdominis. Out of these four patients two of them required Hemodialysis and one of them went into shock. Result(s): All patients included were male. The mean age was 57+/-19.64 years. All the four patients were initially managed conservatively with keen monitoring and with proper volume resuscitation, blood transfusion and discontinuation of the anticoagulants. Three of the patients survived with conservative management and one patient died due to sudden massive cardiac arrest. Conclusion(s): The use of therapeutic anticoagulant can increases the risk of bleeding in atypical sites and may exhibit higher patient death with COVID-19 if not identified at early stage. So a risk-benefit ratio of usage of anticoagulants should be kept in mind and further clinical trials needed to justify its random use in COVID-19. No conflict of interestCopyright © 2023

Iliopsoas haematoma during extracorporeal membrane oxygenation: A registry report from the COVID-19 critical care consortium across 30 countries.

INTRODUCTION: Iliopsoas haematoma (IPH) during extracorporeal membrane oxygenation (ECMO) is a rare bleeding complication that can be fatal due to its progression to abdominal compartment syndrome, but its incidence and risk factors are not well known. We have previously reported an IPH incidence rate of 16% in Japan. Among possible reasons for this high incidence, ethnicity has been hypothesised to play a role. Therefore, we used an international multi-centre cohort registry to test this hypothesis by determining the incidence rate of IPH. METHODS: This study was performed using the COVID-19 Critical Care Consortium database, conducted in 30 countries across five continents between 3 January 2020, and 20 June 2022. RESULTS: Overall, 1102 patients received ECMO for COVID-19-related acute respiratory distress syndrome. Of them, only seven were reported to have IPH, indicating an incidence rate of 0.64%, with comparable rates between the countries. The IPH group tended to have a higher mortality rate (71.4%) than the non-IPH group (51%). CONCLUSIONS: Overall incidence of IPH in the studied COVID-19 ECMO cohort was 0.64%. Most cases were reported from Japan, Belgium, and Italy. In our study, this rare complication did not appear to be confined to Asian patients. Due to the high fatality rate, awareness about the occurrence of IPH should be recognised.

Post-COVID-19 non-traumatic iliopsoas hematoma: A case report

Background: Critically ill COVID-19 patients have an elevated risk of experiencing hypercoagulable conditions. Currently, many COVID-19 patients have been administered anticoagulation or antiplatelet therapies to lower the risk of systematic thrombosis. Iliopsoas hematoma is a potentially fatal and rare complication of bleeding disorders or anticoagulation therapy which sometimes grows to become clinically significant. The main purpose of this case review is to emphasize the importance of diagnosing iliopsoas hematomas and the possibility of antiplatelet contribution to its development. Case Presentation: We are reporting a rare presentation of non-traumatic iliopsoas hematoma in a non-anticoagulated patient. The patient is a 59-year-old male, with known type-2 diabetes, on oral hypoglycemic medications, 3-weeks post-COVID-19. He had started aspirin 81 mg orally, once daily, to prevent thrombotic events associated with COVID 19 infection, with no anticoagulant use and no other medications. He came in through the ED, presenting with two weeks history of progressive right lower limb weakness in which an iliopsoas hematoma diagnosis was confirmed based on radiological investigation. Conclusion: The possibility of iliopsoas hematoma should be considered in non-anticoagulated patients with no inherited or acquired coagulation disorders presenting with limb weakness. The link between antiplatelet use in a COVID-19 patient and the development of soft tissue bleeding (e.g., iliopsoas hematoma) must be studied further. © 2022 [The Author/The Authors]

Massive iliopsoas haematoma during the course of COVID-19 pneumonia.

This report presents a case of life-threatening iliopsoas haematoma in an immunosuppressed 86-year-old man with a history of prostate cancer during the clinical course of coronavirus disease 2019 (COVID-19). The patient was hospitalized for COVID-19-associated pneumonia. One week after admission, he complained of pain in his right thigh when he changed his position. Laboratory findings revealed markedly progressive anaemia and elevated creatine phosphokinase levels. Chest computed tomography revealed a massive haematoma in the right iliopsoas muscle spreading to the retroperitoneal space. Considering the advanced age and status of the patient, he was treated with red blood cell transfusions and bed rest. Fortunately, the anaemia was improved, and the haematoma gradually reduced in size. It should be noted that even during isolation, careful physical examination is important. In addition, physicians who administer heparin to patients with COVID-19, even if prophylactic, should be aware of bleeding complications.

Post-COVID-19 non-traumatic iliopsoas hematoma: A case report

Background Critically ill COVID-19 patients have an elevated risk of experiencing hypercoagulable conditions. Currently, many COVID-19 patients have been administered anticoagulation or antiplatelet therapies to lower the risk of systematic thrombosis. Iliopsoas hematoma is a potentially fatal and rare complication of bleeding disorders or anticoagulation therapy which sometimes grows to become clinically significant. The main purpose of this case review is to emphasize the importance of diagnosing iliopsoas hematomas and the possibility of antiplatelet contribution to its development. Case Presentation We are reporting a rare presentation of non-traumatic iliopsoas hematoma in a non-anticoagulated patient. The patient is a 59-year-old male, with known type-2 diabetes, on oral hypoglycemic medications, 3-weeks post-COVID-19. He had started aspirin 81 mg orally, once daily, to prevent thrombotic events associated with COVID 19 infection, with no anticoagulant use and no other medications. He came in through the ED, presenting with two weeks history of progressive right lower limb weakness in which an iliopsoas hematoma diagnosis was confirmed based on radiological investigation. Conclusion The possibility of iliopsoas hematoma should be considered in non-anticoagulated patients with no inherited or acquired coagulation disorders presenting with limb weakness. The link between antiplatelet use in a COVID-19 patient and the development of soft tissue bleeding (e.g., iliopsoas hematoma) must be studied further.

A Rapid Fatal Outcome of Iliopsoas Hematoma: Clinical and Autopsy Findings.

A case of massive muscular bleeding of iliopsoas resulting in lethal exsanguination is presented. The intramuscular bleeding occurred spontaneously in an old man with heart failure, presented to the emergency department after the acute onset of shortness of breath, and treated with therapeutic doses of antiplatelets and heparin to prevent thrombosis. On the sixth day of recovery, pain in the left lumbar region develops while there was a decrease in hemoglobin level. Computed tomography (CT) scan revealed a 10 × 3 cm hematoma of the left iliac muscle. The treatment was immediately stopped, but within 6 hours, the death was confirmed. The autopsy revealed that the hematoma, and its increased size since the latest imaging assessment, was the leading cause of death. Particularly in older patients with comorbidity, even in those with clotting parameters in the therapeutic range, the potential for fatal result of iliopsoas muscle bleeding should be considered. Identifying potential patience with increased risk of this complication could be important, especially in pandemic time of COVID-19, when the use of anticoagulant therapy-both for treatment and for prevention of severe disease-has become massive and addressed also to people without previous and specific pathologies.

Effect of BMI on Tightness of Iliopsoas Muscle in Students due to Prolonged Sitting for Online Classes during COVID-19 Pandemic

Introduction: Muscle tightness is produced by a reduction in a muscle’s capacity to deform. As a result of prolong sitting pelvic position can be changed which can lead to iliopsoas tightness. During the COVID-19 pandemic, as a result of online classes, student’s hours of sitting have increased drastically. Aim: To compare iliopsoas muscle tightness in students who were engaged in prolonged sitting due to online classes with higher Body Mass Index (BMI) and students with normal BMI. Materials and Methods: This cross-sectional study was conducted in Department of Physiotherapy at Institute of Applied Medicine and Research, Ghaziabad, Uttar Pradesh, India, from April 2021 to January 2022 on 101 students. Height and weight of the subject were measured by the ruler and digital weighing machine respectively for the BMI calculation. Two groups were made, group with normal BMI students and group with High BMI students. Using modified Thomas test, iliopsoas muscle were measured for the flexibility. Independent sample t-test was used for statistical analysis. Results: Total 51 students were with normal BMI and 50 were with higher BMI were included in the study. The mean age of the subjects was 19.59 years including 59 females and 42 males. The significantly increased Modified Thomas Test (MTT) angle was found in students with higher BMI when compared to students with normal BMI for both right (p-value=0.003) and left side (p-value <0.001). Iliopsoas muscle tightness was present in more in higher BMI group as compared to normal BMI group. Conclusion: The study concluded that both the groups had the iliopsoas muscle tightness but the students with higher BMI had more muscle tightness.

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

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.

Global vision and clinical reasoning in complexity: An endangered competency in Internal Medicine in the CoViD era. Case series in an Internal Medicine unit CoViD-free

Background: During SARS-CoV-2 pandemic management of internist patient is even more complex: hospital acquired infection, resources devolved to CoViD-19, round visit with PPE, minor interrelation, post-CoViD patients. Presentation of the case series: 1. A 75-year old man had dysphagia, fever, low back pain, shoulder pain. Anamnesis: CoViD pneumonia (P/F143, TTS18/20), goiter, bladder neoplasm, T2DM. CT showed pneumomediastinum, pneumotorax, iliopsoas haematoma. He underwent broad spectrum antibiotic, arthrocentesis, culture tests. We concluded for pneumomediastinum due to CoViD-19 pneumonia, MSSA sepsis, septic arthritis, dysphagia due to goiter and pneumomediastinum, UTI. He is transferred to OSCO (surgery delayed) - 2. A 72-year old woman presented respiratory failure, fever, bacterial pneumonia. Anamnesis: stroke at age 50, APS diagnosis, AOCP, kidney failure. We performed antibiotics. Near to discharge, she had profuse haematemesis due to acute esophageal necrosis. She underwent PPI infusion and tests for risk factors and triggers (as APS or neoplasm). - 3. A 45-year old man had severe sepsis and intestinal obstruction. Anamnesis: paraplegia, previous intestinal obstruction. He underwent antibiotics, rehydration, NGT. Colonoscopy and gastrografin enema ruled out stenosis, but occlusion persisted. After collegial discussion surgical approach was proposed, but the patient had unfavorable outcome due to CoViD-19 infection. Discussion: These cases share high level of complexity: need of subintensive care, difficult management of patients' need. Clinical judgment, assessment of EBM priorities are essentials, underestimated skills.

Spontaneous iliopsoas hematoma: A warning for CoViD-19

Background: Patients with CoViD-19 are at high risk of thromboembolic events due to hemostatic changes directly related to the SARS-CoV-2 infection or to the consequence of cytokine storm. Anticoagulation with heparin is recommended to reduce the thrombotic risk. Spontaneous iliopsoas hematoma (IPH) is a potentially life-threatening complication of anticoagulation therapy described in CoViD-19 patients. Materials and Methods: We report two cases of association with IPH and SARS-CoV-2 pneumonia treated with heparin. Results: Over a 5-month period (November 2020-April 2021) 252 subjects with SARS-CoV-2 infection were admitted to our CoViD hospital. We found two cases of spontaneous IPH during the clinical course of CoViD-19. Diagnosis of IPH was made by CT angiogram. Coagulation parameters and platlet count were normal. One patient (an 83-year-old woman) was on prophylactic low weight molecular heparin (LWMH). The other patient (a 79-yearold man) received a therapeutic dosage with LWMH for pulmonary thrombosis and died, after urgent transarterial embolization, because of hemorrhagic hypovolemic shock. Conclusions: Although case reports are scarce for conclusion, our two cases, in addition to previous reports, suggest that CoViD-19 patients treated with anticoagulants are at risk of IPH. Given the indications to prescribe anticoagulation in CoViD-19 and the lack of solid evidences on the optimal dose and duration, it is important to be aware of IPH as a potentially serious complication. Rapid diagnosis and timely intervention are crucial to ensure good patient outcomes.

A case of Candida albicans septic sacroiliitis complicating severe COVID-19 infection

Case report-IntroductionBacterial and fungal infections are recognised complications of viral pneumonia, particularly in patients who are critically ill. We describe a case of fungal sacroiliitis complicating severe COVID-19 pneumonia following a prolonged intensive care unit (ICU) admission.Candida albicans sacroilitis is a rarely reported infection with few case reports in the literature. Candida osteoarticular infections can present as septic arthritis, with knee involvement in 75% of cases, or osteomyelitis. The latter presentation differs based on age-vertebral involvement (51%) is more common in adults while children are more likely to present with infection in the long bones, ribs, or sternum.Case report-Case descriptionA 48-year-old Afro-Caribbean gentleman with a history of hypertension and obesity was admitted to the ICU with clinical, laboratory and radiographic features of COVID-19 infection despite persistently negative swabs. Whilst in ICU he required mechanical ventilation. His stay was further complicated by multiple infections, pulmonary emboli, and the presence of a cavitating lesion in the left lung. Cultures from bronchoalveolar lavage and a central venous catheter line grew Serratia Mascense, candida glabrata and pseudomonas were isolated from his urine. He was treated with multiple antibiotics including meropenem, tazocin, ceftazidime and avibactam.After 61 days in the ICU he was transferred to the ward. He developed severe pain in his right hip which was worse on movement. This was followed by urinary incontinence and sensory deficit in the right L2/L3 dermatome. He underwent magnetic resonance imaging (MRI) of his spine and sacroiliac joints which showed right sided sacroiliitis and oedema around the iliopsoas muscle. He was started on vancomycin, later changed to ceftazidime avibactam and metronidazole. An echocardiogram did not show any vegetations. He underwent a biopsy of his sacroiliac joints which confirmed the presence of leucocytes, extended cultures yielded candida albicans in one out of two biopsy specimens.Considering ongoing pyrexia, pain and inflammatory markers, intravenous fluconazole was added to his antibiotic regimen which resulted in a marked improvement in mobility. After four weeks, ceftazidime, metronidazole and avibactam were stopped, and fluconazole was administered as oral tablets. 6 days later he became febrile and IV fluconazole was restarted.A repeat chest CT showed resolution of the cavity but ongoing changes suggestive of organising pneumonia. A repeat MRI of the sacroiliac joints revealed minor improvement. Intravenous Fluconazole was continued for a total of 8 weeks and was changed to tablets for complete a total of 12 weeks.Case report-DiscussionThis is a severe case of COVID-19 infection who despite 9 negative PCR tests, on day 53, had positive IgG for SARS-CoV-2 infection, confirming our clinical suspicion. Particularly in the ICU setting, individuals are approximately ten times more likely to have secondary bacterial/fungal infections with more frequent detection of multidrug-resistant Gram-negative pathogens.This case highlights several difficulties. Urine cultures had confirmed candida albicans, likely to be related to catheter related urinary tract infections, and a possible source for our patient but also a resistant pseudomonas aeruginosa species. Furthermore, cultures were positive for Serratia Mascense, candida glabrata. He had also already been treated with prolonged, broad spectrum antimicrobial treatment. Considering this, establishing the aetiology of the septic sacroiliitis was challenging. The rarity of candida sacroiliitis and presence of the organism in just one specimen made this more difficult. This led to the decision of a repeat sacroiliac biopsy to supply sufficient samples for further microbial analyses such as 16S, 18S and mycobacteria culture, all of which were negative.He became febrile after the discontinuation of antimicrobials and a switch to oral fluconazole therapy. He was extensively re-investigated and despite resolution of t e lung cavity, there were changes which could have been consistent with an organising pneumonia. At this point he was neutropenic, mildly eosinophilic, and therefore a drug reaction was also considered.Repeat MRI revealed resolving muscle inflammation and minimal change at the bone site, with erosions and possible reactive bone marrow oedema. Following discussion with microbiology the decision was made to persist with intravenous Fluconazole. He continued to improve, and his inflammatory markers normalised after 8 weeks of treatment. Prednisolone was started for COVID-19 related pneumonitis. Long-term antifungal treatment is advisable, and we aim to complete 12 weeks of treatment.Case report-Key learning points Patients with SARS-CoV-2 infection, particularly those requiring ICU admission were at risk of developing superinfections with multidrug-resistant Gram-negative bacteria or fungal infections.Candida albicans sacroiliitis is rare therefore early aspiration/biopsy is essential for the management.Longer treatment is needed in osteoarticular candida infections, even up to 6 or 12 months, therefor long-term close monitoring of this patients is essential.The utility and timing of reimaging patients following such infections is still unclearClose multidisciplinary and interdisciplinary team collaboration is essential in the management of this complex patients.

Iliopsoas hematoma in patients with COVID-19 on low-molecular-weight heparin treatment.

Patients with COVID-19 are at high risk of thromboembolic events; for this reason, the use of heparin is largely recommended but, in addition to thrombotic complications, bleeding is a significant cause of morbidity in patients with COVID-19. Idiopathic iliopsoas hematoma is a very rarely described hemorrhagic complication in patients with COVID-19. We report here two cases of iliopsoas hematoma in male patients with COVID-19 and being treated with heparin.