Search

In hospitalized coronavirus disease 2019 (COVID-19) patients, anticoagulation therapy is administered to prevent thrombosis. However, anticoagulation sometimes causes bleeding complications. We herein report two Japanese cases of severe COVID-19 in which spontaneous muscle hematomas (SMH) developed under therapeutic anticoagulation with unfractionated heparin. Although the activated partial prothrombin time was within the optimal range, contrast-enhanced computed tomography (CECT) revealed SMH in the bilateral iliopsoas muscles in both cases, which required emergent transcatheter embolization. Close monitoring of the coagulation system and the early diagnosis of bleeding complications through CECT are needed in severe COVID-19 patients treated with anticoagulants.

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.

Emerging evidence suggest that COVID-19 is associated with hypercoagulability, predisposing patients to increase risk of thromboembolism. Anticoagulation is not without its risks of bleeding and decision to initiate anticoagulation should be carefully considered with close monitoring. Spontaneous retroperitoneal hematoma is a rare complication, and there are only a few documented reports implicating anticoagulant or antiplatelet agents as a potential cause. We report a 57-year-old gentleman with COVID-19 pneumonia who developed hypotension on Day 10 of illness while on prophylactic anticoagulation. Computed tomography scan of abdomen revealed a large right retroperitoneal and psoas muscle hematoma and he underwent surgical exploration to evacuate the hematoma. His condition improved and was discharged well. Although prophylactic anticoagulation may reduce thrombotic complications in severely ill COVID-19 patients, a high index of suspicion for rare bleeding complications should be maintained if patients become hemodynamically unstable. Early diagnosis and appropriate intervention may improve outcome and prevent mortality.

Vertebral fracture with muscle hematoma is occasionally seen in practice. However, air-containing hematoma mimicking abscess has not been reported. We present an 87-year-old man with back pain after a fall. Computed tomography scan demonstrated vertebral fracture of L1 and low-density lesions with air bubble in the left crus of the diaphragm and left psoas muscle that were verified to be muscle hematoma. Muscle hematoma due to vertebral fracture can present radiological findings similar to an abscess. A characteristic “vertebral body cleft continuity sign” might be useful for differentiating between hematoma and abscess. Keywords: Vertebral fracture, Psoas abscess, Psoas hematoma, Abscess, Hematoma

Objective. The aim of this study was to assess muscle injury associated with upper and lower closed limb fracture using ultrasound, and to develop ultrasound classification criteria for muscle injury. Patients and Methods. Thirty patients with limb fracture and muscle injury participated in this study. Ultrasonography was used to assess muscle fibre, hematoma, vascular injury, and diameter growth rate. Injury was classified into three grades according to the ultrasound imaging: scores of less than, equal to, or greater than 9. Results. Of 30 patients, focal fibre rupture was observed in 11 cases; in 9 cases, the injured area exceeded 30% of the muscle area. Six patients had muscle hematoma (the largest reaching 39 mm); in 4 patients, the hematoma showed a honeycombed pattern. Vascular rupture was observed in 6 patients, of which 2 had decreased main arterial diameter and blood flow. The greatest increase in muscle thickness was 17 mm. Of all patients, 11 showed an increase in the diameter growth rate of the muscle exceeding 50%. In addition, among the 30 patients, 11 patients with scores ranging from 4 to 8 received conservative treatment; 9 patients with scores ranging from 10 to 14 received operative treatment; and 10 patients with scores equal to 9 received either conservative or operative treatment. Conclusions. Ultrasonography is useful for diagnosing muscle injury associated with closed limb fracture. The ultrasound classification criteria for muscle injury can be used to assess the severity of injury and guide the decision of treatment.

The International Society on Thrombosis and Hemostasis bleeding assessment tool (ISTH-BAT) was developed to record bleeding symptoms and aid in patient diagnosis. This study was done to investigate the utility of ISTH-BAT in patients suspected to have inherited bleeding disorders. This cross-sectional study was conducted in a tertiary care hospital in Southern India over 3 and 1/2 years. A trained investigator administered the ISTH-BAT questionnaire to 432 patients undergoing evaluation for inherited bleeding disorder prior to routine coagulation screening and confirmatory tests and to 131 healthy volunteers as controls. Among patients, 42(9.7%) had primary hemostatic defect, 150(34.7%) had secondary hemostatic defects and 229(53%) had normal screening coagulogram with mean bleeding scores (BS) being 5.9, 6.9, and 4.2 respectively and the proportion of patients with abnormal BS being 69%, 88.7% and 59.4% respectively; the latter qualifying as unknown hemostatic defect. 11(2.5%) with acquired hemostatic defect on workup were excluded. The mean BS was 1.52 among healthy volunteers. Common bleeding patterns were epistaxis (73.8%), cutaneous bleeding (52.4%), hematuria (54.8%), menorrhagia (50%) in primary hemostatic defect; cutaneous bleeding (72%), muscle hematoma (58.7%), hemarthrosis (46.7%), menorrhagia (58.7%) in secondary hemostatic defects and epistaxis (45.9%), cutaneous bleeding (62.4%), menorrhagia (30.7%) in normal screening coagulogram group. Grade of bleeding was mostly 2 and sometimes 4 in primary, 2–4 in secondary and 1–2 in normal screening coagulogram group. ISTH-BAT is a valuable tool to record lifelong bleeding history. The pattern and score give clues regarding the nature and severity of the bleeding disorder.

Not Available

Iliopsoas muscle hematoma in a patient with alcoholic liver cirrhosis is rarely seen, however it has a high mortality. Thus we should cautiously make a diagnosis and treatment. This is the case of a 60-year-old male. He had a 15-year history of alcoholic liver disease and emphysema. He presented with low back pain after a fall that had happened 2 months before. Due to persistent back pain, he went to see a local physician who, after detailed examination, suspected rupture of bilateral common iliac artery aneurysms and transferred the patient to our hospital. The same presumptive diagnosis was made, and on this basis, an aortic bifemoral Y-graft was implanted. He developed aspiration pneumonia and hepatic and renal dysfunction postoperatively, which led to multiple organ failure and subsequent in-hospital death on postoperative day 62. This was believed to be a case of iliopsoas muscle hematoma developed in a patient with liver cirrhosis, and considering it was a case with poor surgical risk, a conservative treatment option such as transcatheter arterial embolization should also have been considered. Although iliopsoas muscle hematoma with alcoholic liver cirrhosis is rare, an appropriate treatment plan should be determined on a case-by-case basis despite its poor prognosis.

A standardized trauma was inflicted to the lateral side of the calf muscle of 12 New Zealand rabbits, creating a muscle hematoma without external bleeding. The acute hematoma was evaluated within 3 h with radionuclide imaging of red blood cells labelled with 99mTc pertechnetate, ultrasonography and magnetic resonance imaging (MRI). The results were compared with the total volume of the hematomas as calculated from histological preparations of each injured muscle. Scintigraphy and T2-weighted MRI accurately detected all hematomas but the calculated volume did not significantly correlate with histology. T1-weighted MRI did not detect the hematomas. Ultrasonography detected all hematomas and also accurately evaluated the volume. In conclusion, scintigraphy, MR imaging and ultrasonography are all sensitive enough to detect an acute muscle injury, but in this investigation only ultrasonography accurately quantified the volume of the hematoma.

Hemophilia A is an X-linked recessive disease characterized by defective or dysfunctional deficiency of factor VIII in the circulation. The incidence of factor VIII deficiency is lower than the incidence of vWD but it is the most common hereditary factor deficiency among the others. The prevalence of factor VII deficiency is approximately 1/10,000 in liveborn babies. There are three clinical types defined as light, medium and severe. In patients with severe clinical type hemarthrosis and other bleeding, which require factor replacement, may occur from birth. In these patients hemorrhage may occur spontaneously or secondary to trauma. However, severe muscle hemorrhage either spontaneous or secondary to minor trauma is rarely seen. In this report we present a 46 year old male patient with hemophilia A who applied to the emergency service because of abdominal pain following a coughing attack and a swelling on the left side. We detected hemorrhage and hematoma in bilateral iliopsoas muscle which developed due to a previous coughing attack, Hemofili A dolaşımdaki faktör VIII in defektif veya disfonksiyonel sentezi eksikliği ile karakterli X’e bağlı resesif geçişli bir hastalıktır. Faktör VIII eksikliği, vWH sıklığından daha az ancak diğer herediter faktör eksikliklerinin en sık olanıdır. Sıklığı canlı doğan bebeklerde 1/10,000 civarındadır. Hafif, orta ve ağır olmak üzere 3 klinik tipi vardır. Klinik tipi ciddi olanlarda doğumdan itibaren faktör replasmanı gerektiren hematrozlar ve diğer kanamalarda görülebilir. Bu olgularda kanamalar travma sonrası yada spontan olabilir. Fakat spontan veya minör travmayla ciddi kas içi kanama görülmesi nadirdir. Burada öksürük atağını takiben karın ağrısı ve sonrasında sol yan tarafında oluşan şişlik nedeniyle acil servise başvuran ve bilateral iliopsoas kasında hematom saptanan 46 yaşında bir hemofili A olgusu sunuldu.

Acquired hemophilia A is a very rare but life-threatening disorder caused by autoantibody against coagulation factor VIII. The incidence was much rarer in young people. In this case report, a young woman presented with spontaneous muscle hematoma. Because of pain and limited range of motion, she underwent surgery for resolution at first. However, her symptoms and hemorrhage worsened. She was diagnosed with acquired hemophilia A. We started combination treatment with bypassing agent, activated prothrombin complex and immunosuppressants immediately and the results were successful. The acute bleeding was controlled and autoantibody was completely resolved.

Trauma to the wrist and forearm in children resulting in either distal or midshaft fractures are quite common in pediatric surgery practice. The treatment of such fractures is well established and healing in the majority of patients reported as uneventful. However, if there is an extensive muscle hematoma, or extensive swelling due to mangled soft tissue injury, or a heavy bleeding, the situation can suddenly change and run into a disastereous Compartment Syndrome putting muscles, nerves and vessels at risk for destruction. In the following paragraphs our patients collective is presented as an illustrative exemplary and discussed in front of a literature and textbook review.

Abdominal wall hematoma is a rare but potentially serious vascular complication that may develop after coronary angiographic procedures. In particular, an oblique muscle hematoma caused by an injury of the circumflex iliac artery is very rare, yet can be managed by conservative treatment including hydration and transfusion. However, when active bleeding continues, angiographic embolization or surgery might be needed. In this study, we report an uncommon case of injury to the circumflex iliac artery by an inappropriate introduction of the hydrophilic guidewire during the performance of a percutaneous coronary intervention.

Dengue hemorrhagic fever (DHF) and Dengue shock syndrome manifest in various forms, ranging from petechial skin hemorrhage to life threatening cerebral, pulmonary, gastrointestinal and genitourinary hemorrhages. However it is very rare to have muscle hematomas in DHF. We report a rare case of spontaneous Iliopsoas hematoma complicating Dengue hemorrhagic fever.

We report a case of 79-year-old male with prostate cancer and coagulation disorder presented with left shoulder pain. He underwent bone scintigraphy to rule out metastasis, which showed intense foci of tracer activity in the left axilla. Hybrid single-photon emission tomography-computed tomography (SPECT/CT) of the shoulder region localized tracer uptake to the left brachialis muscle hematoma.

Liver cirrhosis is commonly associated with bleeding complications due to portal hypertension or coagulopathy. Spontaneous muscle hematoma is a rare but potentially lethal complication of liver cirrhosis. Here we report three cases of spontaneous muscle hematoma diagnosed in patients with alcoholic liver cirrhosis. All three patients died due to recurrent bleeding and liver failure although they had undergone repeated transcatheter arterial embolization of the actively bleeding vessels. We reviewed 14 cases of spontaneous muscle hematoma that were associated with liver cirrhosis, including our cases, and found that the mortality rate was 86%, despite early diagnosis and treatment. Cirrhosis-associated spontaneous muscle hematoma occurred more frequently in patients with alcoholic liver cirrhosis, who accounted for -93% of cases. Thus, spontaneous muscle hematoma should be considered a life-threatening complication in patients with alcoholic liver cirrhosis, and abstinence from alcohol may help to prevent the occurrence of this deadly condition. (Korean J Med 2014;86:472-477)

Following an analysis of echographic findings in 94 patients with posttraumatic ocular motility disorders, a flow-chart for detecting the basic pathomechanism was worked out. Normal muscle diameter is observed in entrapment of the perimuscular tissues or in a recent palsy, whereas increased muscle thickness suggests hematoma or incarceration, and thinned muscles an atrophy. A lack of change in muscle diameter when the patient looks in the direction in which motility is restricted is characteristic of atrophy or palsy, whereas an increase in muscle diameter is a sign of incarceration if a fracture has also been detected by echography; if not, muscle hematoma can be diagnosed.

Three cases are reported of femoral neuropathy in patients receiving oral anticoagulants. After consideration of the pertinent anatomy, possible pathogenesis and CT demonstration, spontaneous hematoma of the iliac muscle is suggested as the cause of the femoral neuropathy.

Traumatic neuropathies of the common peroneal nerve at the head of the fibula are relatively common, but nerve entrapment at this site is rarely encountered. A 55-year-old man with hemophilia A in whom common peroneal nerve entrapment occurred secondary to a probable muscle hematoma is described.

Background Abdominal wall hematomas are an uncommon cause of acute abdominal pain and are often misdiagnosed. They are more common in elderly individuals, particularly in those under anticoagulant therapy. Most abdominal wall hematomas occur in the rectus sheath, and hematomas within the oblique muscle are very rare and are poorly described in the literature. Here we report the case of an oblique muscle hematoma in a middle-aged patient who was not under anticoagulant therapy. Case presentation A 42-year-old Japanese man presented with a painful, enlarging, lateral abdominal wall mass, which appeared after playing baseball. Abdominal computed tomography and ultrasonography showed a large soft tissue mass located in the patient’s left internal oblique muscle. A diagnosis of a lateral oblique muscle hematoma was made and the patient was treated conservatively. Conclusion Physicians should consider an oblique muscle hematoma during the initial differential diagnosis of pain in the lateral abdominal wall even in the absence of anticoagulant therapy or trauma.