Intramuscular Hematomas and Compartment Syndrome - an Inevitable Consequence in the COVID-19 Saga

Introduction: Anticoagulation in COVID-19 induced hypercoagulable state remains to be balanced with bleeding complications. Spontaneous muscle hematomas (SMH) often occur in the rectus sheath or gluteal muscles. Risk factors include trauma, increased abdominal pressure, anticoagulation, and hypertension. We describe two cases of non-iatrogenic SMH in therapeutically anticoagulated COVID-19 patients. Case Report: 1. 64 year old Caucasian male with ARDS due to COVID-19 was treated with mechanical ventilation, proning, methylprednisolone, tocilizumab (TOZ), and azithromycin/hydroxychloroquine. Right popliteal-posterior tibial vein DVT led to full anticoagulation (FA) with enoxaparin. Later the hemoglobin dropped (12.2 to 6.1 g/dl). Imaging showed SMH in the left posterolateral chest wall and gluteus minimus requiring blood transfusions and cessation of FA. D-dimer was 1.2 μ g/ml. A week later, imaging showed increased hematoma size in the left chest wall and right gluteal area. After hemoglobin stabilized, he was started on DVT prophylaxis. He required tracheostomy/PEG tube and placement in a long term acute care (LTAC) facility where he had decannulation and PEG tube removal. Patient recovered fully and is home with normal function. 2. 27 year old Caucasian female with sepsis due to COVID-19 was treated with mechanical ventilation, dexamethasone, TOZ, convalescent plasma, colchicine, and remdesivir. D-dimer was 1.6 μ g/ml and FA was started with enoxaparin. After intubation, hemoglobin dropped (11-6.9 g/dl). Imaging showed SMH in left biceps and pectoralis. Decreased radial pulse and increased capillary refill time with enlarging forearm hematoma prompted arterial US and CT angiogram. No flow was seen in the distal left upper extremity. Fasciotomy of the left forearm and carpal tunnel was performed with adequate perfusion of radial and ulnar arteries. Debridement was required for the non-viable flexor carpi radialis, flexor digitorum superficialis and flexor digitorum profundus. Patient was extubated and did well thereafter. Discussion: Thrombosis contributes much to the morbidity and mortality in COVID-19 patients. In a recent Veterans Health Administration study, deep vein thrombosis, pulmonary embolism, and cerebral ischemia/infarction comprised 9.3% of these patients. Despite the study's limitations, HESACOVID has shown that therapeutic enoxaparin is associated with fewer days on the ventilator and large reductions in D-dimer levels. Monitoring for SMH should be routinely performed on these patients. Research on optimal anticoagulation is necessary to assess the risk/benefit in this population. The bleeding risks are however less likely to cause mortality or disability as compared to the coagulation problems.