Surgical repair of rectus abdominis rupture with rectus sheath hematoma due to chronic cough and prolonged anticoagulant therapy in a COVID-19 patient: A case report

Introduction and importance Herein, we present an unexpected rectus sheath hematoma (RSH) complication due to chronic COVID-19 related cough and prolonged anticoagulation therapy. COVID-19 usually presents with respiratory symptoms, such as cough. Anticoagulants are used in severe cases of COVID-19 as well as in mechanical heart valve replacement to prevent thrombosis. However, there is a high risk of bleeding. Case presentation We report a rare case of a 74-year-old woman who presented with a COVID-19 related cough persistent over two months, and was also undertaking warfarin daily for 10 years due to mechanical mitral valve replacement. Computed Tomography (CT) scan revealed retroperitoneal and rectus sheath hematoma (RSH) as well as rectus abdominis muscle rupture. She had hemorrhagic shock due to rapid hematoma expansion to the right and left flank as well as to the back. Thus, she required an emergency surgery in which the hematoma was excised and the rectus abdominis muscle was sutured. The patient was discharged and has completely recovered. Clinical discussion Many factors and mechanisms contribute to the formation of the RSH and the rupture of rectus abdominis muscle, including severe cough and anticoagulants. Conclusion Although the use of anticoagulants is necessary for patients who underwent mechanical valve replacement or for COVID-19 patients as a prophylaxis of thrombotic complication, RSH should be kept in mind and carefully monitored as it may require surgical intervention in severe cases.


Background
During the COVID-19 pandemic, cough was the most common symptom accompanied with COVID-19 [1].It is classified as acute (less than 3 weeks), subacute (3-8 weeks), and chronic (more than 8 weeks); and can result in many complications in different organ systems, such as cardiovascular, gastrointestinal, musculoskeletal, neurologic, and respiratory complications [2].
Thrombosis is one of the most important complications in patients with mechanical heart valves or COVID-19.Therefore, to reduce thrombotic events and mortality rates, many patients with mechanical heart valves undertake lifelong anticoagulation therapy, while COVID-19 patients undertake prophylactic anticoagulants [3,4].
However, both anticoagulants and severe cough predispose patients to high risk of bleeding [3].
We present a rare case of a surgical removal of retroperitoneal and rectus sheath hematoma in COVID-19 patient who presented with chronic cough while on anticoagulation therapy for 10 years.This case was reported according to the SCARE 2023 guidelines [5].

Case presentation
A 74-year-old woman presented with signs of severe cough and acute abdomen.She had generalized abdominal pain with constipation, and abdominal distention.The physical examination showed peritoneal irritation, and rebound tenderness.She also had bruising and ecchymosis in the right and left flank extended to the back.
Two months prior to admission, she was diagnosed with COVID-19.She had fever, cough with sputum, and was treated with Azithromycin and Dexamethasone.Although she recovered, the cough was gradually increasing throughout the past two months.Two days before the admission, the patient's continuous cough suddenly increased accompanied by a sudden onset of pain in the left flank.The pain transferred to the umbilicus, right flank, epigastrium in order; until it was generalized and accompanied by abdominal distention.
During this period, she lost weight because she could not eat well due to abdominal pain.
The patient does not smoke or drink alcohol.She has 10 children, all normal birth.Her past medical history includes type II diabetes mellitus for two years and atrial fibrillation.She had mechanical mitral valve replacement 10 years ago.As a result, she has been taking warfarin 5 mg since then.The patient Eastern Cooperative Oncology Group (ECOG) score was 3, she had a degree of muscular atrophy due to advanced age.
On admission, the Ultrasound (US) of the abdomen and pelvis showed distended oedematous cystic formation with turbid content in the left and right hypochondria (Fig. 1).Everything else was normal.
Abdominal X-ray denied gastric or enteric perforation.No free air was found (Fig. 2).
Computed tomography (CT) scan was performed, and showed asymmetrical increased thickness at both sides of the rectus abdominus and in the posterior wall of the stomach, possibly due to inflammatory infiltration.The maximal thickness was 29 mm and 2-19 mm Fig. 2.An abdominal X ray, no air was found.respectively (Fig. 3).This indicates the presence of retroperitoneal and rectus sheath hematoma (RSH), and rectus abdominis muscle rupture.
Due to the hematoma rapid and continuous expansion, she was hemodynamically unstable and had hemorrhagic shock.She had tachycardia with hypotension.Thus, she needed an emergency surgery.Complete blood count (CBC) showed decreased hemoglobin levels of 8.6 g/dl and hematocrit levels of 25 %; and elevated white blood cells levels of 14,200/cmm, INR of 4.5 and PTTK levels of 40.3 s.As a result, the warfarin was stopped the day before the emergency surgery, and she received 4 units of fresh frozen plasma and one unit of whole blood in order to adjust her INR and hemoglobin levels.In addition, she received paracetamol.
The operation was done by a surgical doctor.A small midline incision was made, and a large hematoma was seen inside the aponeurosis of the left and right rectus abdominis muscles with blood infiltration in the peritoneal cavity.The hematoma was excised, the rupture in the rectus abdominis muscle was sutured, and the abdomen was closed with a drainage tube.
The day after the surgery, she used nasal cannula because her respiratory rate decreased due to abdominal pain.After the surgery, PTTK and INR were prolonged, and she was started on heparin pump 25,000 IU/ml at rate of infusion of 2 ml/h.The heparin pump was gradually stopped the next day and she was back on warfarin.Her general state gradually improved, and she was finally discharged from the hospital.
A week after the surgery, WBC and hemoglobin levels were normal.INR was 2.3.

Discussion
In light of previous literature; Rectus sheath hematoma (RSH) is a condition that could result either from the rupture of the superior or inferior epigastric arteries or due to the tear of the rectus abdominus muscle.RSH has several risk factors mentioned in the literature including: trauma, surgery, anticoagulation, cough or intense rectus muscle contractions, and pregnancy [6].
As a result of rectus sheath hematoma (RSH), the intraperitoneal bleeding cases are escalating during Covid-19 pandemic.RSH can occur due to the recommended administration of anticoagulation therapy for prophylaxis of thrombotic events that are caused by COVID-19 [7,8].We identified a summary of these cases in the table below (Table 1).In these cases, most of the patients were female and elderly; most of them presented with different severity of coughing.All patients were on anticoagulation therapy (enoxaparin/warfarin/heparin…) with either prophylactic or therapeutic doses and for different intervals (Table 1).
However, none of them presented with rectus abdominis muscle rupture.
In this case; the cause of RSH was due to a combination of several factors.The patient had persistent chronic COVID-19 related cough for 2 months.In addition, she has been taking warfarin daily over a 10-yearinterval for the mechanical valve replacement.She also had a degree of muscular atrophy due to advanced age.These factors caused the rupture of the rectus abdominis muscle and the hematoma formation.
Severe episodes of cough resulting from infection have caused very rare cases of diaphragmatic rupture in COVID-19 and COPD patients, although these patients had no anticoagulants intake [14,15].In addition, anticoagulants intake and cough caused many RSH cases unaccompanied by muscle rupture [16,17] as severe cough could cause a tear in epigastric arteries due to the produced tension [13].In this case, the patient presented with severe cough for more than 30 days prior to the rupture.
During the cough's forced movement; the abdominal wall muscles contract and cause the diaphragm to move upwards while the ribs are pushed downward, this opposing pressure may cause either dislodgement of the abdominal muscles or a rupture in the muscles similarly to our case.These effects of coughing on the abdomen are rare and require a surgical intervention [18,19].
The most common symptom of RSH is abdominal pain which could be either acute or gradual and is described as sharp, persistent and nonradiating pain; usually associated with a palpable mass, tenderness and abdominal guarding [6,9].As described, the patient in this case had severe pain that she could barely move or lie down; it started on the left quadrant and shifted to the other side of the abdomen.
RSH has been and is still misdiagnosed in many cases [6,9].However, serial hematocrit measurements and imaging must be made.Large reductions in hematocrit levels were reported in cases of large RSH,15.US and CT are commonly used to help confirm the diagnosis, with US being the first line diagnostic test in emergency, and CT being more accurate [6,9].
The management of RSH is conservative management as first-line treatment [20].However, when the patient is hemodynamically unstable then follows embolization (radiology or transcatheter) or surgery in which the hematoma is evacuated; another option is ligation surgery, which involves the ligation of the inferior epigastric artery [21,22].In this case, the hematoma was rapidly expanding to the right and lefts flank as well as to the back, the patient had hemorrhagic shock with tachycardia and hypotension, thus required an emergency surgery where we excised the hematoma and sutured the rectus abdominis muscle.While in other cases, the bleeding and hematoma were treated  with conservative therapy with blood and plasma transfusions and only 2 patients underwent surgical intervention of embolization to control the bleeding of the hematoma (Table 1).
To the best of our knowledge, this is the first reported case of RSH and rectus muscle rupture following severe cough in a COVID-19 patient that was surgically treated in the literature.

Conclusion
We point out that practitioners should pay extensive attention to each patient with severe cough and on warfarin or other anticoagulants use and consider the rising possibility and risk of the formation of RSH and rupture of the rectus muscle; it is therefore recommended for patients with severe bouts of consistent cough to have limited anticoagulants therapy and be under continuous observation to test prothrombin time (PT) and efficacy of anticoagulants to stay clear of any harmful consequences.

CT
computerized tomography US ultra sound RSH rectus sheath hematoma ARDS acute respiratory distress syndrome MSOF multisystem organ failure

Ethical approval
Not required for case reports at our hospital.Single case reports are exempt from ethical approval in our institution.

Fig. 3 .
Fig. 3. (a, b).CT of the abdomen with a Hematoma of the right and left rectus abdominis muscles.

Table 1
Summary of similar cases.