Spontaneous rupture and hematoma of the sartorius muscle secondary to rivaroxaban therapy

Case report of unique presentation of spontaneous calf hematoma

INTRODUCTION AND IMPORTANCE

The presentation of spontaneous hematomas remains different between all affected populations, but advanced age and use of anticoagulants are common risk factors in the majority. The progression of the hematoma may require some time to be detected; however, it can prove fatal if it reaches a significant size. A spontaneous calf hematoma can be mistakenly diagnosed as deep vein thrombosis, and the management of both conditions is varying.

CASE PRESENTATION

A 26-year-old man had recently undergone multiple left lower limb surgeries and was using Rivaroxaban for deep vein thrombosis prophylaxis. He presented with a painful contralateral calf swelling for a duration of one month, which was later diagnosed as a spontaneous chronic calf hematoma. Despite the fact that blood tests were within the normal range, imaging confirmed the diagnosis. After extensive discussion among multidisciplinary teams, a surgical exploration was conducted, resulting in the complete evacuation of the hematoma. Subsequently, a meticulous monitoring of the re-administration of anticoagulant was conducted. CLINICAL DISCUSSION: spontaneous calf hematoma is not common pathology and affecting elderly and presentation in young is unique and diagnosis will not be reached easily especially in chronic case.

CONCLUSION

A spontaneous calf hematoma can occur in a young, fit population with coexisting anticoagulant administrations. A thorough history, examination, and imaging must be applied urgently in order to reach a diagnosis.

Infected Leg Hematoma: A Rare Cause of Recurrent Leg Cellulitis

Intramuscular hematoma most commonly occurs following trauma; however, spontaneous hematomas may be seen in elderly patients due to anticoagulation. Intramuscular hematomas may not be chronically expanding, and their signs and symptoms vary, ranging from asymptomatic to swelling that may be expanding in size. In some cases, chronic hematoma may become infected as we witnessed in the case we present in this report. Our patient reported recurrent cellulitis and occasional fever with no other history of probable cause of the recurrent cellulitis. Such an atypical presentation poses a risk of delayed or missed diagnosis of a condition that can threaten the limb of a patient, as seen in our case.

Delayed lumbar plexus palsy due to giant psoas hematoma associated with vertebral compression fracture and direct oral anticoagulants: a case report

Background

Osteoporotic vertebral compression fractures (VCFs) are commonly observed in elderly people and can be treated by conservatively with minimal risk of complications in most cases. However, utilization of direct oral anticoagulants (DOACs) increases the risks of secondary hematoma even after insignificant trauma. The use of DOACs increased over the past decade because of their approval and recommendation for both stroke prevention in non-valvular atrial fibrillation and treatment of venous thromboembolism. It is well known that DOACs are safer anticoagulants than warfarin in terms of major and nonmajor bleeding; however, we noted an increase in the number of bleeding events associated with DOACs that required medical intervention. This report describes the first case of delayed lumbar plexus palsy due to DOAC-associated psoas hematoma after VCF to draw attention to potential risk of severe complication associated with this type of common and stable trauma.

Case presentation

An 83-year-old man presented with his left inguinal pain and inability to ambulate after falling from standing position and was prescribed DOACs for chronic atrial fibrillation. Computed tomography angiography revealed a giant psoas hematoma arising from the ruptured segmental artery running around fractured L4 vertebra. Because of motor weakness of his lower limbs and expansion of psoas hematoma revealed by contrast computed tomography on day 8 of his hospital stay, angiography aimed for transcatheter arterial embolization was tried, but could not demonstrate any major active extravasation; therefore spontaneous hemostasis was expected with heparin replacement. On day 23 of his stay, hematoma turned to decrease, but dysarthria and motor weakness due to left side cerebral infarction occurred. His pain improved and bone healing was achieved about 2 months later from his admission, however the paralysis of the left lower limb and aftereffects of cerebral infarction remained after 1 year.

Conclusion

In patients using DOACs with multiple risk factors, close attention must be taken in vertebral injury even if the fracture itself is a stable-type such as VCF, because segmental artery injury may cause massive psoas hematoma followed by lumbar plexus palsy and other complications.