DILEMMA OF SYSTEMIC ANTICOAGULATION: A COVID-19 PATIENT WITH SPONTANEOUS CHEST WALL HEMATOMA

Abstract

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: October 18-21, 2020 INTRODUCTION: Systemic anticoagulation use remains a crucial therapeutic strategy in the treatment of COVID-19 disease (respiratory tract infection caused by SARS-CoV-2 RNA) affected patient population By presenting a sporadic case of chest wall hematoma we bring to light factors surrounding this decision CASE PRESENTATION: A 77-year-old Hispanic female with a history of Hypertension, Diabetes, and Obesity presented with myalgias, cough, and dyspnea at rest After being diagnosed with COVID-19 Pneumonia, she was started on Hydroxychloroquine As the patient’s oxygen requirement increased despite receiving Tocilizumab and Remdesivir, systemic anticoagulation with Enoxaparin was initiated Upon receiving therapeutic Enoxaparin subcutaneous for five days, the patient started to complain of left upper chest wall pain, which was noted to have loculated swelling with diffuse ecchymosis Upon development of sudden hypotension, lightheadedness, acute anemia, she underwent CT Angiography of Chest diagnosing arterial hematoma and attributed to systemic anticoagulation The patient received several blood products and evacuation of 600 ml chocolate-colored fluid from loculated hematoma with the placement of an in-dwelling drain She did not require any embolization or surgical intervention, as there was no active arterial diathesis Before discharge, her symptoms resolved, and she was weaned to a nasal cannula She continued to improve, and the catheter was subsequently discontinued The patient was eventually discharged with no further adverse events DISCUSSION: The incidence of spontaneous muscle hematomas in patients using anticoagulant therapy is infrequent The proposed risk factors of pathophysiology in these cases include microangiopathy, diabetes, elderly age, vascular lesions, collagen, or hemostatic disorders1 Current literature suggests COVID 19 to be prothrombotic, with varying degrees of abnormalities noted in coagulation test parameters2,3 Reports suggest better outcomes, lower severity of illness with the use of therapeutic anticoagulation4 Pathology reports show COVID 19 infection to cause proinflammatory changes and microthrombi in arterioles5 However, this patient had a bleeding event contrary to published reports so far, including lower extremity and bowel ischemia6,7 This raises the question of appropriate timing, dosage, and use of anticoagulation in these patients CONCLUSIONS: We aim to throw light into the conundrum surrounding the use of systemic anticoagulation in the COVID19 patient population by highlighting one of the very rare adverse events in the setting of anticoagulation use Reference #1: Dohan A, Darnige L, Sapoval M, Pellerin O Spontaneous soft tissue hematomas Diagn Interv Imaging 2015;96(7-8):789-96 Reference #2: Panigada M, Bottino N, Tagliabue P, et al Hypercoagulability of COVID-19 patients in the Intensive Care Unit A Report of Thromboelastography Findings and other Parameters of Hemostasis J Thromb Haemost 2020 Reference #3: Ranucci M, Ballotta A, Di dedda U, et al The procoagulant pattern of patients with COVID-19 acute respiratory distress syndrome J Thromb Haemost 2020;DISCLOSURES: No relevant relationships by Medhat Ismail, source=Web Response No relevant relationships by Ashesha Mechineni, source=Web Response No relevant relationships by Sushant Nanavati, source=Web Response No relevant relationships by Roberto A Solis, source=Web Response