Skip to main content

Spontaneous giant rectus sheath hematoma in patients with COVID-19: two case reports and literature review

Abstract

Introduction

Coronavirus disease 2019, COVID-19, as a global public health emergency, has come with a broad spectrum of clinical manifestations and complications. In this study, we present a unique complication of this disease.

Presentation of cases

(A) A 65-year-old woman with a known case of COVID-19; on the second day of admission, the patient presented sudden tachycardia and hypogastric pain; on abdomen physical examination, a huge lower abdominal tender mass was noticed. (B) A 50-year-old woman with COVID-19, 4 days after admission, started complaining of tachycardia, pain, and mass in the lower abdomen. On abdomen physical examination, a huge lower abdominal tender mass was noticed. Both of the patients underwent an abdomen CT scan which confirmed a huge rectus sheath hematoma (RSH). Both of the patients underwent angioembolization of the inferior epigastric artery. The patient recovered completely and no evidence of further expansion was seen after 2 weeks of follow-up.

Discussion

Hemorrhagic issues in COVID-19 patients remain poorly understood. Physicians should discuss risks of RSH in patients where continuous anticoagulation therapy will be reinstated. With increased clinician awareness of the need for RSH screening in COVID-19 patients with acute abdominal pain, the interprofessional team of healthcare providers can maximize patient safety and reduce hospitalization time, especially in high-risk patients at risk for unnecessary surgery.

Conclusions

These two reports and literature review demonstrate the need of active surveillance for possible hemorrhagic complications in patients with COVID-19 infection.

Background

The superior epigastric artery lies deep into the rectus abdominis muscles and continues to perforate and supply the rectus sheath. Sudden and violent contraction of the rectus abdominis muscles may cause the epigastric arteries to tear. Rectus sheath hematoma (RSH) is a rare complication seen in patients with acute abdominal pain with a mass present in the abdominal wall which may result from several cases, mostly in the use of anticoagulant and/or anti-aggregant medications for various reasons [3, 4, 19]. Coronavirus disease 2019, COVID-19, as a global public health emergency, has come with a broad spectrum of clinical manifestations which ranges from fever, fatigue, myalgia, cough, and dyspnea to pneumonia, and even acute respiratory distress syndrome. Extrapulmonary involvements including gastrointestinal, cardiovascular, and renal to unusual presentations such as encephalitis, acute limb ischemia, and tremors and gait disturbance have been reported as well [13, 17]. Endothelial dysfunction, thrombosis, and deregulated inflammation are reported as associated vascular diseases in patients with SARS-Cov-2 [11, 13]. Due to this reason, anticoagulant therapy with low molecular weight heparin (LMWH) has become part of medical therapy in hospitalized patients with COVID-19. This approach may increase the risk of spontaneous bleeding, epically in elderly patients with comorbidities, which highlights the importance of active surveillance of spontaneous bleeding, which requires the active involvement of medical staff in the emergency setting [1, 16]. Here, we present giant RSH in two confirmed cases of COVID-19 patients, who were under a prophylactic dose of anticoagulation.

Case presentation

Case 1

A 65-year-old woman with a history of diabetes mellitus type 2 on metformin therapy presented to the respiratory emergency department after experiencing a sudden onset of dyspnea on mild exertion. Concomitantly, she was complaining of severe nonproductive cough, fatigue, and weakness for about 4 days of duration. At admission, the patient was afebrile and eupneic in oxygen therapy (pulse oxygen saturation = 95% with simple mask flow 2–4 L/min). Blood investigation revealed a total leucocyte count of 15,000/μL (normal 4000 to 11,000/μL), hemoglobin (HB) 12 g/dL (normal 13 to 18 g/dL), platelet 444 × 103 (normal 140 × 103 to 400 × 103), partial thromboplastin time (PTT) 32 (normal 23 to 35 s), international normalized ratio (INR) 1.4 (normal 0.8 to 1.1), erythrocyte sedimentation rate (ESR) 110 mm/1 h (normal up to 14 mm/h), and C-reactive protein (CRP) 100 (normal < 10 mg/L). The result of the RT-PCR test was positive for SARS-Cov-2, and the chest computed tomography (CT) scan revealed bilateral ground-glass opacities (GGO) (Fig. 1). The patient was admitted to the COVID-19 ward, and based on the local protocol, remdesivir, azithromycin, dextromethorphan (due to violent cough), and prophylactic dose of heparin (5000 every 8 h) had begun. The second day after admission, the patient presented sudden tachycardia and hypogastric pain; on abdomen physical examination, a huge lower abdominal tender mass was noticed (blood pressure 100/80 mmHg, pulse rate 100/min, and respiratory rate 19/min) and there was a 2-g/dL decrease in HB from 12 to 10 g/dL. The patient underwent an abdomen CT scan which confirmed a huge rectus sheath hematoma with no extension to other parts of the body (Fig. 2). On the same day, the patient underwent angioembolization of the inferior epigastric artery. Overall, the patient received isotonic fluids and the trend of blood investigation is shown in Table 1. After 6 days of embolization, she recovered completely and no evidence of further expansion was seen. She was discharged, and after 2 weeks of follow-up, she did not develop any complication.

Fig. 1
figure1

Chest CT scan shows signs of bilateral COVID-19 pneumonia

Fig. 2
figure2

The yellow arrows in the image confirm a huge rectus sheath hematoma

Table 1 The result of blood tests during hospitalization

Case 2

A 50-year-old woman presented to the respiratory emergency department with a chief complaint of shortness of breath on exertion. She reported severe nonproductive cough, fever, and fatigue for about 6 days ago. She has no history of trauma and the patient was otherwise in good health. On physical examination, a decreased breath sounds in the lower lobes of the lungs was heard, bilaterally. At that time, she was febrile (temperature 39 °C) and eupneic in oxygen therapy (pulse oxygen saturation = 96% with nasal oxygen 2–4 L/min). Laboratory blood investigation revealed a total leucocyte count of 14,000/μL (normal 4000 to 11,000/μL), hemoglobin (HB) 12 g/dL (normal 13 to 18 g/dL), platelet 368 × 103 (normal 140 × 103 to 400 × 103), partial thromboplastin time (PTT) 29 (normal 23 to 35 s), international normalized ratio (INR) 1.2 (normal 0.8 to 1.1), erythrocyte sedimentation rate (ESR) 154 mm/1 h (normal up to 14 mm/h), and C-reactive protein (CRP) 75 (normal < 10 mg/L). The result of the RT-PCR test was positive for SARS-Cov-2, and the chest computed tomography (CT) scan revealed bilateral ground-glass opacities (GGO) (Fig. 3). The patient was admitted to the COVID-19 ward, and based on the local protocol, remdesivir, azithromycin, dextromethorphan (due to violent cough), and prophylactic dose of subcutaneous enoxaparin (40 mg every 24 h) had begun. Suddenly, 4 days after admission, the patient started complaining of tachycardia, pain, and mass in the lower abdomen. On abdomen physical examination, a huge lower abdominal tender mass was noticed (blood pressure 120/90 mmHg, pulse rate 110/min, and respiratory rate 19/min). Laboratory tests showed a fall in Hb from 12 to 8 g/dL. Coagulation factors such as PTT, INR, and platelet were in the normal range at that time (Table 2). Overall, the patient was transfused 4 units of packed blood cells, which raised her Hb to 11 g/dL. The patient underwent an abdomen CT scan which confirmed a huge rectus sheath hematoma with no extension to other parts of the body (Fig. 4). The next day, she underwent angioembolization of the inferior epigastric artery. The trend of blood investigation is shown in Table 2. After 6 days of embolization, she recovered completely and no evidence of further expansion was seen. She was discharged, and after 3 weeks of follow-up, she did not develop any complication.

Fig. 3
figure3

The chest CT scan showing typical GGO features in COVID-19 pneumonia

Table 2 The result of blood tests during hospitalization
Fig. 4
figure4

The yellow arrows in the image revealed a huge rectus sheath hematoma

Discussion

Previous studies have documented that RSH frequency is greatest in women over 60, likely due to greater rectus sheath muscle mass in men which provides a degree of cushioning to the epigastric arteries from injury [3, 6]. Common risk factors and causes for RSH include anticoagulant therapy, violent coughing, pregnancy, and trauma [5, 6]. A study at the Mayo Clinic found 70% of patients treated for RSH were undergoing anticoagulant therapy [3]. Patients with RSH typically present with acute abdominal pain, sometimes severe and exacerbated by movements involving abdominal wall contraction. Upon physical examination, RSH patients will exhibit tenderness along the rectus sheath. A palpable abdominal mass has been reported in 63–92% of cases, along with abdominal guarding in 49% of RSH cases [8]. The literature demonstrates that other conditions such as ectopic pregnancy, diverticulitis, incarcerated hernia, and abdominal aneurysm can mimic the presentation of RSH [7, 10]. In patients hemodynamically unstable from the RSH, hypotension and tachycardia may also be observed. Various physical examination procedures have previously been described to distinguish intra-abdominal from abdominal wall origin of the tenderness [12]. Carnett’s sign is one such test whereby increased or unchanged tenderness upon tensing the abdominal muscles suggests likely abdominal wall pathology. A negative Carnett’s test is when tenderness decreases upon tensing the abdominal muscles, likely indicating intra-abdominal pathology [18].

As with all cases of hemorrhage, monitoring hematocrit levels is essential to determine if transfusion is necessary. Hematocrit levels in RSH patients vary depending on the severity, with normal values in small RSH to large reductions in hematocrit levels reported in cases of large RSH [9]. Most cases of RSH are self-limiting and may be managed successfully without the need for invasive surgery [3]. Recovery from RSH can last between 2 and 3 months and most patients recover with no complications [3]. Mortality rates are estimated to be 4%, but rates as high as 25% have been observed in patients on anticoagulation therapy. Angioembolization is the preferred intervention when persistent bleeding is observed [15]. Patients receiving oral anticoagulation must have coagulation factors monitored, and treatment can involve either cessation of the anticoagulation therapy or anticoagulation reversal.

Ultrasonography (US) sensitivity is limiting for RSH diagnosis [14]. Studies have demonstrated US is non-specific and poses a challenge to distinguish RSH from abdominal wall tumors. Abdominal CT, with 100% sensitivity, is preferred over US for the diagnosis of RSH, although US may be preferred in certain patient populations with kidney disease [8]. CT imaging typically reveals a spindle-shaped mass posterior to the abdominal muscles. CT findings are used to classify RSH into three types that are mild, moderate, and severe. Type 1 is mild and does not require hospitalization, while type 3, typically associated with anticoagulation, is severe and requires hospitalization with transfusion and hemodynamic stabilization [2].

Conclusions

This case was a rare example of a RSH in a confirmed COVID-19 patient. Although the hypercoagulable state associated with SARS-Cov-2 infection has received much recent attention, hemorrhagic issues in COVID-19 patients remain poorly understood. Physicians should discuss risks of recurrent RSH in patients where continuous anticoagulation therapy will be reinstated. With increased clinician awareness of the need for RSH screening in COVID-19 patients with acute abdominal pain, the interprofessional team of healthcare providers can maximize patient safety and reduce hospitalization time, especially in high-risk patients at risk for unnecessary surgery.

References

  1. 1.

    Bargellini I, Cervelli R, Lunardi A, Scandiffio R, Daviddi F, Giorgi L, et al. Spontaneous bleedings in COVID-19 patients: an emerging complication. Cardiovasc Intervent Radiol. 2020;43(7):1095–6. https://doi.org/10.1007/s00270-020-02507-4.

    Article  PubMed  Google Scholar 

  2. 2.

    Berna J, Garcia-Medina V, Guirao J, Garcia-Medina J. Rectus sheath hematoma: diagnostic classification by CT. Abdom Imaging. 1996;21(1):62–4. https://doi.org/10.1007/s002619900011.

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Cherry WB, Mueller PS. Rectus sheath hematoma: review of 126 cases at a single institution. Medicine. 2006;85(2):105–10. https://doi.org/10.1097/01.md.0000216818.13067.5a.

    Article  PubMed  Google Scholar 

  4. 4.

    Dalci, K., U. Topal, A. G. Saritas and E. Aydin (2020). “Risk factors in the development of rectus sheath hematoma and treatment modalities.” Authorea Preprints.

    Google Scholar 

  5. 5.

    Edlow JA, Juang P, Margulies S, Burstein J. Rectus sheath hematoma. Ann Emerg Med. 1999;34(5):671–5. https://doi.org/10.1016/S0196-0644(99)70172-1.

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Fitzgerald J, Fitzgerald L, Anderson F, Acheson A. The changing nature of rectus sheath haematoma: case series and literature review. Int J Surg. 2009;7(2):150–4. https://doi.org/10.1016/j.ijsu.2009.01.007.

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Gocke JE, MacCarty RL, Foulk WT. Rectus sheath hematoma: diagnosis by computed tomography scanning. Mayo Clin Proc. 1981;56(12):757-61.

  8. 8.

    Hatjipetrou A, Anyfantakis D, Kastanakis M. Rectus sheath hematoma: a review of the literature. Int J Surg. 2015;13:267–71. https://doi.org/10.1016/j.ijsu.2014.12.015.

    Article  PubMed  Google Scholar 

  9. 9.

    Holmes SJ, Yale SH, Mazza JJ. Rectus sheath hematoma as a cause of acute abdominal pain. Am Fam Physician. 2001;64(10):1681–2.

    CAS  PubMed  Google Scholar 

  10. 10.

    Lohle P, Puylaert J, Coerkamp E, Hermans E. Nonpalpable rectus sheath hematoma clinically masquerading as appendicitis: US and CT diagnosis. Abdom Imaging. 1995;20(2):152–4. https://doi.org/10.1007/BF00201526.

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Ma W-X, Ran X-W. The management of blood glucose should be emphasized in the treatment of COVID-19. Sichuan Da Xue Xue Bao. Yi xue ban= Journal of Sichuan University. Medical Science Edition. 2020;51(2):146–50.

    PubMed  Google Scholar 

  12. 12.

    Maharaj D, Ramdass M, Teelucksingh S, Perry A, Naraynsingh V. Rectus sheath haematoma: a new set of diagnostic features. Postgrad Med J. 2002;78(926):755–6. https://doi.org/10.1136/pmj.78.926.755.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Melissano G, Mascia D, Baccellieri D, Kahlberg A, Bertoglio L, Rinaldi E, et al. Pattern of vascular disease in Lombardia (Italy) during the first month of the COVID-19 outbreak. J Vasc Surg. 2020;72(1):4–5. https://doi.org/10.1016/j.jvs.2020.04.481.

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Moreno Gallego A, Aguayo J, Flores B, Soria T, Hernandez Q, Ortiz SV, et al. Ultrasonography and computed tomography reduce unnecessary surgery in abdominal rectus sheath haematoma. Br J Surg. 1997;84(9):1295–7.

    CAS  PubMed  Google Scholar 

  15. 15.

    Rimola J, Perendreu J, Falcó J, Fortuño JR, Massuet A, Branera J. Percutaneous arterial embolization in the management of rectus sheath hematoma. Am J Roentgenol. 2007;188(6):W497–502. https://doi.org/10.2214/AJR.06.0861.

    Article  Google Scholar 

  16. 16.

    Rogani S, Calsolaro V, Franchi R, Calabrese AM, Okoye C, Monzani F. Spontaneous muscle hematoma in older patients with COVID-19: two case reports and literature review. BMC Geriatr. 2020;20(1):1–6.

    Article  Google Scholar 

  17. 17.

    Samsami M, Bagherpour JZ, Tahmasbi H, Tofigh AM, Shojaee SP, Hatamabadi H. Review of unusual presentations of COVID-19. J Otorhinolaryngol Fac Plast Surg. 2020;6(1):1–5.

    Google Scholar 

  18. 18.

    Thomson H, Francis D. Abdominal-wall tenderness: a useful sign in the acute abdomen. Lancet. 1977;310(8047):1053–4. https://doi.org/10.1016/S0140-6736(77)91885-2.

    Article  Google Scholar 

  19. 19.

    Xu D, Li X, Cui L, Huang L, Mei C, Gao X. Spontaneous rectus sheath hematoma due to prophylactic anticoagulation in a membranous nephropathy patient: a case report. Med: Case Rep Study Protoc. 2020;1(1):e0014.

    Google Scholar 

Download references

Funding

No funding source.

Author information

Affiliations

Authors

Contributions

JZB and BN conceptualized the study, Sh.Q contributed to the acquisition of the data and drafting of the manuscript, and JS revised for critical intellectual concept and approved the version to be submitted. The author(s) read and approved the final manuscript.

Corresponding author

Correspondence to Javad zebarjadi Bagherpour.

Ethics declarations

Consent for publication

Informed consent was obtained from both of the patients for publication of this case report and accompanying images.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Meting: Case A has been registered to Imam Hossein Hospital on 30 Oct 2020, Tehran, Iran.

Case B has been registered to Imam Hossein Hospital on 22 Oct 2020, Tehran, Iran.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Nematihonar, B., Qaderi, S., Shah, J. et al. Spontaneous giant rectus sheath hematoma in patients with COVID-19: two case reports and literature review. Int J Emerg Med 14, 40 (2021). https://doi.org/10.1186/s12245-021-00366-5

Download citation

Keywords

  • COVID-19
  • Vascular disease
  • Sudden adnominal pain
  • Muscle hematoma
  • Case report
  • Rectus sheath hematoma