Spontaneous psoas haematoma secondary to antiplatelet therapy: a rare cause of atraumatic hip pain

Fatal iliopsoas and rectus sheath hemorrhage in a critically ill patient with COVID-19 on therapeutic anticoagulation

Pulmonary embolism and thrombosis are two common postmortem findings in novel coronavirus disease 2019 (COVID-19), the fact which led experts to include anticoagulants in the standard management of COVID-19. However, at least until now, no guidelines stated the exact safe yet optimal dose of anticoagulants. We report a case of a 65-year-old man admitted to our hospital with severe acute respiratory distress syndrome due to COVID-19. He showed remarkable improvement during the first 10 days of treatment at our facility but subsequently developed spontaneous iliopsoas hemorrhage (IPH). We discontinued antithrombotic and anticoagulant agents as soon as we confirmed the IPH from the abdominal computed tomography scan. His condition worsened even after he received adequate blood transfusion sets and eventually developed disseminated intravascular coagulation. Due to the limitation of our hospital, we could not perform stent grafting and angiographic embolization. He finally died 6 days after the occurrence of IPH. To the best of our knowledge, this is the first case of COVID-19 with IPH in Indonesia. As a developing country, many hospitals in Indonesia do not have stent grafting and angiographic embolization. This condition urges the dose recommendation for anticoagulant therapy to provide safe and efficient management for COVID-19.

Bilateral multifocal muscular hemorrhage in the triceps surae during antiplatelet therapy: a case report

Hemorrhagic complications are often reported following antiplatelet therapy; however, simultaneous multifocal hemorrhages in both legs are uncommon. The patient was a 75-year-old man diagnosed with ST elevation myocardial infarction who underwent percutaneous coronary intervention in the right coronary artery. He was prescribed oral acetylsalicylic acid and ticagrelor. Three days after initial drug treatment, he complained of bilateral leg pain that was aggravated by walking and moving his ankle across a broad range of motion. No deep vein thrombosis was detected on Doppler ultrasonography; however, muscular hemorrhage was suspected according to musculoskeletal ultrasonography. Multifocal muscular hemorrhage was confirmed in the soleus and gastrocnemius muscles on magnetic resonance imaging. To reduce the risk of bleeding, we changed the medication from ticagrelor to clopidogrel. The patient performed leg elevation exercises, compression, and applied an ice pack. He also performed range of motion exercises and gait training in addition to receiving drug treatment. With these therapies, his pain score improved from 5 to 3 on a visual analog scale, without further complications. Multifocal muscular hemorrhage rarely occurs bilaterally; however, when it does occur, an appropriate treatment plan can be developed based on musculoskeletal ultrasonography.