A Rapid Fatal Outcome of Iliopsoas Hematoma: Clinical and Autopsy Findings

Abstract

A case of massive muscular bleeding of iliopsoas resulting in lethal exsanguination is presented. The intramuscular bleeding occurred spontaneously in an old man with heart failure, presented to the emergency department after the acute onset of shortness of breath, and treated with therapeutic doses of antiplatelets and heparin to prevent thrombosis. On the sixth day of recovery, pain in the left lumbar region develops while there was a decrease in hemoglobin level. Computed tomography (CT) scan revealed a 10 × 3 cm hematoma of the left iliac muscle. The treatment was immediately stopped, but within 6 hours, the death was confirmed. The autopsy revealed that the hematoma, and its increased size since the latest imaging assessment, was the leading cause of death. Particularly in older patients with comorbidity, even in those with clotting parameters in the therapeutic range, the potential for fatal result of iliopsoas muscle bleeding should be considered. Identifying potential patience with increased risk of this complication could be important, especially in pandemic time of COVID-19, when the use of anticoagulant therapy—both for treatment and for prevention of severe disease—has become massive and addressed also to people without previous and specific pathologies.

Clinical Case Analysis of Iliopsoas Hematoma Causing with Femoral Nerve Compression

“…Our study identi ed coagulation disorders as the primary cause of IPH [5] . Furthermore, in the current study patients, common etiologies included anticoagulant medication use (32.14%), hemophilia (25%), and trauma from falls (21.42%).…”

“…Coagulation disorders (warfarin [13,18] , heparin [5,15] , and edoxaban use); 2: Hemophilia [7,10] ; 3: Traumatic injury [2] (e.g., sports injuries, falls, high-impact trauma, and car accidents); 4: Other causes [10,12,19,20] (including spontaneous bleeding due to Mediterranean anemia [21] , cirrhosis [17] , and splenomegaly-related bleeding [21] )…”

“…However, the morbidity of it is low, often appearing in the literature as case reports. The primary cause of IPH is coagulation dysfunction, which is linked to anticoagulant medication use [4][5][6] , patients with hemophilia [7] , and the presence of secondary coagulation disorders [8,9] . Furthermore, IPH is rarely observed in patients with normal coagulation function [10] .…”

“…For example, patients with coagulation disorders regularly exhibit no apparent triggers or experience mild falls before the onset of lower back or hip pain [12] . However, in severe cases of this hematoma, lower limb neurological impairment, organ dysfunction, and even death can occur [5,13] . Such patients and the primary attending medical personnel commonly overlook these symptoms initially, misidentifying them as lumbar strains or similar injuries.…”

“…Additionally, IPH is routinely missed or misdiagnosed as other conditions during diagnosis because of its location deep within the pelvis and inconspicuous surface appearance. Subsequently, hematoma enlargement and femoral nerve paralysis develop, along with secondary symptoms, including lower abdominal pain, numbness, lower limb weakness, and restricted hip joint movement [5] . IPH diagnosis typically becomes apparent during further investigations.…”