Bilateral Femoral Neuropathy Following Psoas Muscle Hematomas Caused by Enoxaparin Therapy

Abstract

Patient: Female, 64Final Diagnosis: Bilateral femoral neuropathySymptoms: Inability to walkMedication: —Clinical Procedure: NoneSpecialty: Critical Care MedicineObjective:Adverse events of drug therapyBackground:Femoral neuropathy as a result of retroperitoneal hemorrhage most commonly occurs following pelvic and lower extremity trauma, but has been described to develop as a less frequent complication of anticoagulation.Case Report:We present the case of a 64-year-old white woman who was being treated for pulmonary embolism and deep venous thrombosis with enoxaparin. In the course of her treatment, she was noted to be hypotensive, with a sudden drop in hematocrit. She had been previously ambulatory, but noted an inability to move her bilateral lower extremities. A diagnosis of bilateral femoral neuropathy as a result of psoas hematomas caused by enoxaparin was made. Anticoagulation was discontinued and she was treated conservatively, with an excellent outcome. At the time of discharge to a rehabilitation center, she had regained most of the motor strength in her lower extremities.Conclusions:We believe this is the first reported case of bilateral femoral nerve neuropathy following use of enoxaparin. A full neurological examination should always be performed when there is sudden loss of function. The constellation of bilateral groin pain, loss of lower extremity mobility, and decreased hematocrit raised the suspicion of massive blood loss into the cavity/compartment. Thus, a high index of suspicion should be maintained by clinicians when presented with such symptoms and signs, as there can be significant morbidity and mortality when prompt diagnosis is not made.

Femoral Nerve Palsy Secondary to Iliopsoas Spontaneous Haematoma in a Patient Under Warfarin Treatment

“…Retroperitoneal haemorrhage is most commonly encountered as a result of pelvic acute trauma and can be a life-threatening situation [1,5]. Spontaneous haemorrhage of the iliopsoas muscle followed by femoral nerve neuropathy is a rare complication frequently seen in patients who are on anticoagulants [1,2,5]. The neuropathy is a result of the decreased blood flow to the surrounding epineurium or it can befall secondary to the pressure-related ischaemia [1,2].…”

“…The neuropathy is a result of the decreased blood flow to the surrounding epineurium or it can befall secondary to the pressure-related ischaemia [1,2]. The diagnosis is suspected by the patient's past medical history and by a thorough clinical and neurological examination and should be confirmed by CT scan [5].…”

“…Femoral nerve palsy due to retroperitoneal haemorrhage is an unusual complication [1][2][3][4]. In turn, retroperitoneal bleeding is most commonly the result of pelvic or lower extremity acute trauma but has also been described to develop as a less frequent complication in patients under anticoagulant therapy and bleeding disorders [1,5]. However, the incidence of femoral neuropathy secondary to spontaneous retroperitoneal haemorrhage around the iliopsoas muscle is unknown, but on the other hand, is a well-described complication of anticoagulant remedy [2,4].…”

“…These include warfarin, dabigatran, rivaroxaban, apixaban, acenocoumarol, and edoxaban, which are utilized in the treatment of atrial fibrillation, deep venous thrombosis, and pulmonary embolism ischaemic heart disease and for the prevention of thromboembolic events [1,2]. The use, however, of anticoagulant therapy includes high risk of haemorrhage, which is a very common complication, regularly observed in soft tissues, joints, and solid abdominal organs, in the oropharynx, or in the gastrointestinal and the genitourinary tract [2,5].…”

“…Treatment approach to these patients remains controversial [2][3][4][5]. We present a case of a male patient who was under warfarin for atrial fibrillation and developed left femoral nerve palsy, caused by a spontaneous non-traumatic left iliopsoas haematoma.…”