A Novel Complication in COVID-19 Patients: Case Report of Rectus Sheath Hematoma

Abstract

The COVID-19 pandemic has had an enormous impact on the healthcare systems. Along with its common complications, novel complications such as Rectus Sheath Hematoma (RSH) have been reported. We present 2 cases of RSH. (A) A 63-year-old woman with a known case of COVID-19 with severe cough presented sudden tachycardia and hypogastric pain; on physical examination, a huge lower abdominal tender mass was noticed. All the differential diagnoses were ruled out. (B) A 57-year-old woman with COVID-19 started complaining of tachycardia, pain, and a mass in the lower abdomen. On the physical examination, a lower abdominal tender mass was noticed. Both of the patients underwent an abdomen CT scan which confirmed a huge RSH. Conservative treatment and cessation of anticoagulant medications were continued. Both of them recovered and no evidence of further expansion was seen after 4 weeks of follow-up.

Introduction

The first case of CoronaVirus Disease 19 (COVID-19) was reported in Wuhan, China in late December 2019, and based on the latest epidemiologic reports regarding the prevalence and mortality of COVID-19, more than 400 million people have been infected with this virus among which more than 5.5 million people have died. In particular, the infection can present as asymptomatic, symptomatic, or life-threatening and the symptoms of this disease include coughing, fever, dyspnea, anosmia, and myalgia.^1,2 Several factors are associated with poor outcomes and increased risk of mortality such as older age, obesity, diabetes mellitus, hypertension, chronic kidney disease, and cancer. COVID-19 enters human cells via its binding to Human Angiotensin Receptor Enzyme 2 (hACE2) which functions as a receptor for this virus. Also, it must be noted that the affinity of the COVID-19 binding domain for hACE2 is interestingly higher than Severe Acute Respiratory Syndrome Coronavirus2 (SARS-CoV-2), which is suggestive of a more efficient cell entry mechanism. ³

Moreover, several studies reported thromboinflammatory accidents in the microvascular and macrovascular systems of the body such as the central nerve system, lung, liver, kidney, and stomach in people who have been infected with COVID-19. For instance bilateral blindness, corpus callosum hematoma, giant compressive emphysema, Guillain-Barre Syndrome, encephalitis, and transverse myelitis.^4,5 Despite the end of the COVID-19 pandemic several rare complications due to COVID-19 have been reported and being aware of these cases helps practitioners to provide accurate diagnosis and management. Accordingly, this report presents 2 cases of rectus hematoma following COVID-19 pneumonia.

Case Presentation

Case 1

A 63-year-old female with an unremarkable past medical history suffered from coughing, myalgia, and loss of appetite 8 days before hospitalization. She also had dyspnea 4 days before hospitalization. Additionally, despite the administration of favipiravir, the patient experienced no relief and her O₂ saturation level was 74% at the time of hospitalization. Therefore, oxygen therapy was administered and O₂ saturation improved to 89%. Besides, her respiratory rate and heart rate were 29 and 87 respectively, and her Reverse Transcription-Polymerase Chain Reaction (RT-PCR) test was positive for COVID-19. Meanwhile, her Electrocardiogram (ECG) was normal, and chest Computed Tomography (CT) showed the involvement of both lungs with diffused ground-glass opacities (Figure 1a). So, the patient was admitted to the Intensive Care Unit (ICU) afterward and treated with Intravenous (IV) remdesivir 200 mg stat and a daily dosage of 100 mg for 5 days and an IV heparin 5000 IU/mL.

Figure 1.

Computed tomography. (a) The involvement of both lungs with diffused ground-glass opacities. (b) Bilateral rectus sheath hematoma.

Then, 12 days after admission, the patient developed abdominal pain and tenderness in the lower left quadrant. In addition, examination revealed no signs of guarding or rebound tenderness while Carnett’s sign was positive. Meanwhile, ultrasonography revealed a lesion in the left rectus and bladder. Also, contrasted abdominal CT revealed an acute rectus muscle hematoma with an extension into the left iliac and pelvic side with a size of 83 × 74 mm (Figure 1b). Hence, although Prothrombin Time (PT) Partial Prothrombin Time (PTT) and International Normalized Ratio (INR) were normal, the IV heparin injection was ceased immediately. The next day, the patient received 1 unit of packed cells due to her decreased hemoglobin level to 7 g/dL, while angioembolization would have been performed if the hemorrhage had continued to occur. So, conservative treatments were continued and hemoglobin level did not decrease and the hematoma gradually shrank over the following days. Finally, the patient was discharged 28 days after the first day of admission and had 2 follow-ups, 1 and 4 weeks afterward with no sign of recurrence or new complaints.

Case 2

A 57-year-old female patient with a past medical history of hypertension was admitted to the hospital with dyspnea, fever, coughing, headache, respiratory distress, and left lower abdomen pain. The patient had been experiencing these symptoms for 10 days before admission and her RT-PCR test for COVID-19 was positive. Additionally, her O₂ saturation, heart rate, and respiratory rate were 83%, 85, and 21 respectively at the time of admission. Moreover, although heart auscultation was normal, a mild tachypea was present and lung auscultation revealed crackle sounds. Also, abdominal palpation revealed tenderness in the lower left part of the abdomen with no rebound tenderness. Further, her chest CT showed peripheral and diffused ground glass opacities in the upper and lower lobes of both lungs (Figure 2a) and her ECG was normal. So, the patient was then admitted to ICU and treated with IV remdesivir 200 mg stat and a daily dosage of 100 mg for 5 days, methylprednisolone 500 mg and IV heparin 5000 IU/mL were also administered.

Figure 2.

Computed tomography. (a) The involvement of both lungs with diffused ground-glass opacities. (b) Unilateral rectus sheath hematoma.

More importantly, it should be noted that she was referred to the surgery department for consultation due to her abdominal pain 1 day after the start of her hospitalization. Indeed, although the patient had no problem regarding gas passing and defecation, examination revealed tenderness in the lower left abdomen with a soft lesion under palpation, and Cornett’s and Forthergill’s signs were both positive. Moreover, ultrasonography revealed hypoechoic/heteroechoic lesions with a size of 19 × 34 × 37 mm³ and a volume of 6 ccs. Accordingly, anticoagulant medications were ceased and a complete blood count was checked every 6 hours, and she was completely bed-rested afterward. Although no decrease has been revealed in hemoglobin level, the treatments regarding her COVID-19 infection were continued and her O₂ saturation decreased to 81%. Most importantly, her PT, PTT, and INR were normal during the whole time of hospitalization.

Next, on the sixth day of admission, her hemoglobin level decreased to 8 g/dL with a persistent O₂ saturation decrease, so she received 1 unit of packed cells. Seven days after her admission contrasted abdominal CT revealed increased thickness in the left rectus with the size of 27 × 73 × 115 mm³ suggestive of RSH. No pathologic signs were found in the abdominal and pelvic regions (Figure 2b). Subsequently, conservative treatment and cessation of anticoagulant medications continued for another 2 weeks, during which the size of the rectus hematoma gradually reduced. At last, she was discharged 22 days after her first day of admission, and her 2 follow-ups, 1 week and 4 weeks after her discharge, revealed no signs of recurrence or new complaints.

Discussion and Conclusion

RSH is an uncommon complication of abdominal traumatic injury or prolonged use of anticoagulants, and only about 2% of acute abdominal pains are caused by RSH. So, it can be easily misdiagnosed in initial differential diagnosis due to its low prevalence. Accordingly, untreated cases can lead to an unnecessary surgical operation such as laparotomy or even death. Hence, including RSH in the differential diagnosis of acute abdominal pain can lead to a more timely and accurate diagnosis. ⁶ Aligned with our research a case series study was conducted by Hosoda and Soma ⁷ on 673 COVID-19 patients in Japan. Among 201 patients 4 cases developed spontaneous retroperitoneal hematoma 6 to 14 days after receiving prophylactic anticoagulant therapy. All 4 patients discontinued anticoagulant therapy, 3 underwent transfusion therapy, and 1 underwent angiographic intervention with embolization. Finally, 2 of them expired. Similar to our study a case report study by Zandbaf et al ⁸ reported a 60-year-old woman with the chief complaint of shortness of breathing and cough with a history of asthma and diabetes mellitus who was infected with COVID-19. Heparin therapy was initiated on the second day of hospitalization due to pulmonary embolism confirmed by CT angiography. Twenty-one days after hospitalization, the patient experienced abdominal pain without significant tenderness in the abdominal examination and a hemoglobin level dropped to 7.9 mg/dL. An abdominal CT scan confirmed RSH in the left rectus muscle. Indeed, the Rectus Abdominus Muscles (RAMs) are parallel muscles that are connected to the fifth and seventh ribs and reach down to the pubis. Also, it is worth mentioning that the posterior surface of RAMs is only supported by a weak transversalis fascia and the peritoneum. Epigastric arteries, including the superior and inferior epigastric arteries, are the main blood supplies for these muscles, Therefore, as; the inferior artery enters into the muscle through the sheath and joins the superior branches, any injuries or traumas to these arteries can lead to RSH. More importantly, current literature supports the significant association between RSH and the administration of anticoagulant medications. RSH is also more common in female patients than male patients while a possible explanation can be the lower muscle mass in female patients compared to male patients. Additionally, as pregnancy can increase the susceptibility to the progression of RSH in female patients more than male patients, it has been suggested in the literature too. ⁹

All in all, other predisposing factors such as older age, lower muscle mass, iatrogenic trauma during surgery, intense RAMs contractions, and atherosclerosis are associated with RSH too. ¹⁰

Moreover, the main symptoms of RSH include abdominal pain, abdominal tenderness and guarding, abdominal lesion on palpation, and nausea. Indeed, the pain is usually acute and limited to 1 quadrant and tends to increase upon physical movement. Thus, Carnett’s sign should be considered as an important factor, because the pain originates from the intraabdominal region, it is relieved upon pressure and palpation, however, if the pain does not worsen by pressure, it is a sign of other pathologies in the abdominal wall. Also, Fothergill’s sign is another important factor. Therefore, if the palpable lesion remains palpable after RAM’s contraction, RSH is more likely to be the definitive diagnosis. Other signs such as Cullen’s or Grey-Turner which may be present later, cannot be of great help in the differential diagnosis. ⁶ However, important laboratory findings including the reduction of hematocrit level and hemoglobin level due to the loss of volume and hemorrhages should be taken into account. Additionally, leukocytosis could also be an important laboratory finding; yet, it is not a consistent sign in all cases. ¹⁰ In addition, ultrasonography and CT scans should be radiographic modalities of choice. Although ultrasonography may be preferred as the first imaging modality, CT has a 100% sensitivity in the diagnosis of RSH. ¹¹

Above all, if the hematoma does not expand, and hematocrit and hemoglobin levels remain stable, conservative treatment is usually the treatment of choice. However, it is vital to perform angioembolization in more severe and uncontrollable cases. Blood transfusion, complete bed rest, monitoring the blood volume, and pain relief should suffice for the treatment of a self-limiting RSH. Yet, angioembolization is a more invasive treatment for more severe and unstable cases with uncontrollable hemorrhages. ¹² Further, one of the most important interventions in RSH patients with COVID-19 is the cessation of anticoagulative medications and controlling hemorrhages, hematocrit, and hemoglobin levels. On the whole, due to the rising number of reports of RSH in COVID-19 patients, physicians should consider RSH as a viable diagnosis in patients who experience severe coughing, and abdominal pain, or undergo excessive treatment with anticoagulant medications. ¹³

In sum, this case report presented 2 interesting cases of RSH in patients with COVID-19 infection who underwent prophylactic anticoagulant, unlike other case reports that RSH occurred with therapeutic anticoagulant. Accordingly, as the number of RSH cases in COVID-19 patients is rising, RSH should be considered as a possible explanation for acute abdominal pains in these patients who also receive anticoagulation medications. So, the management of RSH in COVID-19 patients usually includes conservative treatment such as volume, hematocrit, and hemoglobin control along with cessation of anticoagulant medications. However, in more severe cases, it may be essential to perform angioembolization.