Critical Care and Shock

Giant extrathoracic hematoma in a COVID-19 patient

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Case presentation

A 69-year-old lady presented to our emergency department with a two week history of shortness of breath, fever, and dry cough. Chest computed tomography revealed patchy ground glass opacities throughout both lungs, most pronounced in the mid-to-lower lung zones bilaterally, with peripheral distribution. She was admitted to the hospital with the presumptive diagnosis of coronavirus disease 2019 (COVID-19) pneumonia. She received our standard MATH+ protocol (hydroxychloroquine, intravenous ascorbic acid, zinc, thiamine, melatonin, azithromycin, vitamin D3, and enoxaparin). This was followed by oral anticoagulation with warfarin. On day 18, she complained of severe right breast pain. Upon examination she had a large mass in the upper right quadrant breast that had not been present on admission. A chest computed tomography revealed a large density within the right pectoralis minor muscle measuring 14 x 6.8 x 11.5 cm (Figures 1A and B). Despite a very strict anticoagulation protocol, her international normalized ratio (INR) was reported at 8.0. Her anticoagulants were placed on hold, and she was given 5000 units of prothrombin complex concentrate intravenously. Follow up INR was 0.9 the next day. Her large hematoma slowly resolved. She was discharged and upon follow up she has no further issues related to her over anticoagulant.

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