Heterotopic ossification in COVID-19 patient on anticoagulation with limited treatment options

Abstract

Abstract Introduction: There is limited research on the treatment of heterotopic ossification in patients with contraindications to nonsteroidal anti-inflammatory drugs. Patient concerns: A 59-year-old man with a past medical history of diabetes, hypertension, and recurrent pulmonary embolism on anticoagulation (apixaban 5 mg twice a day) presented to the emergency department with dyspnea and was noted to have bilateral pleural effusion and severe acute respiratory syndrome coronavirus 2. The patient was admitted for coronavirus disease 2019 treatment and was subsequently intubated. While intubated, he received physical therapy and had progressive hip pain by day 23, which interfered with therapy. Computed tomography of the abdomen and pelvis on day 30 of intubation showed no significant bony abnormalities. He was extubated after 43 days, stabilized, and admitted for acute rehabilitation for intensive care unit-associated weakness 15 days later. He continued to experience worsening hip pain. Diagnosis: Bilateral hip radiographs were obtained on rehabilitation day 35 (day 103 of overall hospitalization), which demonstrated Booker Grade 3 heterotopic ossification on the right and Booker Grade 2 on the left. Interventions: A multidisciplinary approach to treatment was sought using consultants from orthopedics, endocrinology, radiation oncology, pharmacy, and physical therapy. Owing to his anticoagulation status, nonsteroidal anti-inflammatory drugs were not recommended. Radiation therapy and bisphosphonates are also not recommended. The patient's pain was managed with tylenol as needed and tizanidine. Outcomes: Tylenol and tizanidine were effective in controlling pain and allowing the patient to participate in therapies. He had no treatment-related complications. Conclusion: Prolonged intubation and intensive care unit stay are risk factors for heterotopic ossification development and should be considered early on admission. Prompt identification and early treatment with an aggressive range of motion should be considered. This case exemplifies the challenges of treating heterotopic ossification in patients with severe coronavirus disease 2019 and contraindications to further anticoagulation.