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

Behzad Nematihonar,Javad Zebarjadi Bagherpour,Jaffer Shah,Shohra Qaderi

doi:10.1186/s12245-021-00366-5

Abstract

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

Highlights

Coronavirus disease 2019, COVID-19, as a global public health emergency, has come with a broad spectrum of clinical manifestations and complications
These two reports and literature review demonstrate the need of active surveillance for possible hemorrhagic complications in patients with COVID-19 infection
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]

Summary

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]. 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. RSH patients will exhibit tenderness along the rectus sheath. 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]. 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, US may be preferred in certain patient populations with kidney disease [8]. 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

Background

Findings