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Case Report
Open Access Peer-reviewed

Iliopsoas Hematoma in Warfarin Treatment: Case Report and Review of Literature

Chukwuemeka A. Umeh
American Journal of Medical Case Reports. 2020, 8(8), 244-246. DOI: 10.12691/ajmcr-8-8-8
Received April 05, 2020; Revised May 07, 2020; Accepted May 14, 2020

Abstract

Iliopsoas hematoma is a rare complication in patients on warfarin and usually presents as lower abdominal, groin or thigh pain. The author presents a case of spontaneous iliopsoas hematoma in an 89-year-old female that was initially suspected to be a hip fracture. A review of 12 case reports on iliopsoas hematoma in patients on warfarin shows that the mean age of reported cases was 72 years. Patients present with lower abdominal, groin, flank or thigh pain (100%), lower extremity weakness and/or difficulty in walking (50%) and loss of or abnormal sensation in the lower extremity (17%). Forty two percent of the hematoma cases were in patients with therapeutic or sub-therapeutic international normalized ratio (INR). Iliopsoas hematoma should be considered in elderly patients on warfarin who present with lower abdominal or groin pain, even in patients with therapeutic or sub-therapeutic INR.

1. Introduction

Patients on warfarin frequently become over anticoagulated which can lead to hemorrhage. 1 Iliopsoas hematoma is a rare complication in patients on warfarin and usually presents as lower abdominal, groin or thigh pain even in patient with therapeutic international normalized ratio (INR). 2 The risk of bleedings tends to increase with age and supratherapeutic INR and care providers should suspect iliopsoas hematoma in patients, especially the elderly, on warfarin presenting with spontaneous or post traumatic lower abdominal or groin pain. 1, 3 The author presents a case of spontaneous iliopsoas hematoma that was initially suspected to be a hip fracture.

2. Case Presentation

89-year-old female patient with underlying hypertension and atrial fibrillation on warfarin presented with concern of left groin and left thigh pain of one-week duration. Patient says that pain is constant, sharp, non-radiating, worse with movement, and about 7 out of 10 in intensity. Patient denies any fall, trauma or injury. Patient denies dysuria, urinary frequency or urgency, diarrhea, constipation, nausea, vomiting, headache, fever, cough, or back pain.

On examination, blood pressure was 176/88, heart rate was 78, temperature was 97.7F, and respiratory rate was 16. There was mild tenderness in the left lower abdominal quadrant and anterior left thigh and patient was unable to flex her left hip. Sensations in the lower extremities were intact.

On admission, hemoglobin was 11.2g/dl, INR was 7.6, prothrombin time (PT) was 91, partial thromboplastin time (PTT) was 88, white blood cell (WBC) 8,200/ml, platelets 197,000/ml, and liver and kidney markers were normal. X-ray of left femoral and left knee showed no fracture. CT pelvis showed left iliopsoas fluid collection (hematoma) measuring approximately 6.4 x 6.4 x 16.4 cm that extends into the distal iliopsoas muscle near its insertion on the lesser trochanter.

Warfarin was discontinued, patient was given Vitamin K and admitted to the floor with consult to the surgeon. Surgeon advised conservative medical management. The next day, patient INR was 3.4, PT 40.2, PTT 54.7 and hemoglobin was 10.3. Patient was started on physical therapy and discharged to a skilled nursing facility.

3. Discussion

The risk of major bleeding in patients on warfarin is dependent on the degree of anticoagulation, patient’s concurrent use of other medications such as NSAIDs, patient’s characteristics such as age and presence of other comorbidities such as kidney disease. 1, 3

  • Table 1. A Review of 12 Case Reports on Iliopsoas Hematoma in Patients on Warfarin

  • View option

The author searched Pubmed and Google scholar for case reports of iliopsoas hematoma in patients on warfarin and found 12 case reports. Analysis of the 12 case reports on iliopsoas hematoma in patients on warfarin shows that the mean age of reported cases was 72 years (Table 1). 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 Patients present with lower abdominal, flank, back, groin or thigh pain (100%), lower extremity weakness and/or difficulty in walking (50%) and loss of or abnormal sensation in the lower extremity (17%).

Majority of the bleeding occurred spontaneously without any reported trauma (67%) and majority of the patients with hematoma had supratherapeutic INR level (58%). Though bleeding risk generally correlate with the intensity of anticoagulation, bleeding has also been reported in patients with therapeutic or sub-therapeutic INR. 6, 8, 9, 10, 12, 15 Sixty seven percent of the cases had a left sided iliopsoas hematoma, 25% had right sided hematoma and 8% had bilateral hematoma. For most of the patients (92%), warfarin was discontinued, apart from a patient within therapeutic INR with extensive cerebral venous thrombosis where anticoagulation with warfarin (with the same target INR interval of 2–3) was continued under strict clinical and INR monitoring. 9 In one of the cases (17%), the hematoma was surgically evacuated after an unsuccessful ultrasonographic guided aspiration of the hematoma while another patient underwent an unsuccessful CT-guided hematoma drainage. 5, 6 In three of the cases with therapeutic or subtherapeutic INR, warfarin was held without reversal of the warfarin effect with vitamin K or prothrombin complex concentrate. 6, 8, 12 In all the cases with supratherapeutic INR, warfarin effect was reversed with Vitamin K and/or prothrombin complex concentrates or fresh frozen plasma.

According to the American Society of Hematology (ASH) 2018 guidelines patient with serious or life-threatening bleeding requires a reversal of the warfarin, while those with minor bleeding or supratherapeutic warfarin level without bleeding may be best managed by holding the warfarin without reversal of the warfarin effect. 16 For patients on warfarin with life-threatening bleeding with an elevated INR, the ASH guideline suggests cessation of warfarin and administration of IV vitamin K and 4-factor prothrombin complex concentrates (PCCs). 16

For patients who survive an episode of major bleed and require long-term or indefinite anticoagulation because of moderate to high risk for recurrent venous thromboembolism, they may resume anticoagulation therapy within 90 days if they are not at high risk for recurrent bleeding. 16

4. Conclusion

Iliopsoas hematoma is a rare complication in patients on warfarin and usually presents as lower abdominal, groin or thigh pain even in patient with therapeutic INR. This case report and review of literature highlights the need for emergency physicians to consider Iliopsoas hematoma in elderly patients on warfarin who present with lower abdominal or groin pain, even in patients with therapeutic or sub-therapeutic INR.

References

[1]  Hull RD, Garcia DA, Vazquez SR. Biology of warfarin and modulators of INR control. Leung LLK, Tirnauer JS, editors. UpToDate [Internet]. Waltham, MA: UpToDate Inc. Available from https://www.uptodate.com (Accessed on December 14, 2019).
In article      
 
[2]  Ekiz T. Spontaneous iliopsoas haematoma presenting with groin pain under warfarin therapy. Pain physician. 2015 Nov; 18: E1145-6.
In article      
 
[3]  Garcia DA, Crowther M. Risks and prevention of bleeding with oral anticoagulants. Leung LLK, Kasner SE, editors. UpToDate [Internet]. Waltham, MA: UpToDate Inc. Available from https://www.uptodate.com (Accessed on December 14, 2019).
In article      
 
[4]  Conti S, Ciuffetti M, Vedovati MC. Thrombotic Risk after a Major Bleeding During Anticoagulation: A Clinical Case. J Cardiovasc Echogr. 2017; 27(1): 26-28.
In article      View Article  PubMed
 
[5]  Kheiri B, Al Salihi M, Maldonado D, Nakhleh R, Bachuwa G. Warfarin-induced spontaneous iliopsoas hematoma - An unusual complication. Clin Case Rep. 2018; 6(8): 1639-1640. Published 2018 Jun 22.
In article      View Article  PubMed
 
[6]  Kong WK, Cho KT, Lee HJ, Choi JS. Femoral Neuropathy due to Iliacus Muscle Hematoma in a Patient on Warfarin Therapy. J Korean Neurosurg Soc. 2012; 51(1): 51-53.
In article      View Article  PubMed
 
[7]  Watanabe Y, Koutoku H, Nagata H, Oda Y, Kikuchi H, Kojima M. Rhabdomyolysis with Acute Kidney Injury Caused by Bilateral Iliopsoas Hematoma in a Patient with Atrial Fibrillation. Intern Med. 2019; 58(19): 2887-2890.
In article      View Article  PubMed
 
[8]  Kaya BB, Icagasioglu A. Ultrasound therapy in iliopsoas hematoma. North Clin Istanb. 2017; 4(2): 180-184. Published 2017 Aug 26.
In article      
 
[9]  Fernandes C, Pereira P, Rodrigues M. Spontaneous iliopsoas muscle haematoma as a complication of anticoagulation in acute cerebral venous thrombosis: to stop or not to stop (the anticoagulation)?. BMJ Case Rep. 2015; 2015: bcr2014206410. Published 2015 Mar 6.
In article      View Article  PubMed
 
[10]  Sharma D, Saker R, Govind A. Emergency department ultrasound diagnosis of spontaneous iliopsoas haemorrhage in a patient on warfarin. BMJ Case Rep. 2013; 2013: bcr2013201291. Published 2013 Nov 15.
In article      View Article  PubMed
 
[11]  Ozkan OF, Guner A, Cekic AB, Turan T, Kaya U, Reis E. Iliopsoas haematoma: a rare complication of warfarin therapy. J Coll Physicians Surg Pak. 2012 Oct 1; 22(22): 673-4.
In article      
 
[12]  Spengos K, Anagnostou E, Vassilopoulou S. Subacute proximal leg weakness after a minor traffic accident in a patient treated with anticoagulants. BMJ Case Rep. 2012; 2012: bcr0220125731. Published 2012 May 23.
In article      
 
[13]  Zago G, Appel-da-Silva MC, Danzmann LC. Iliopsoas muscle hematoma during treatment with warfarin. Arq Bras Cardiol. 2010 Jan; 94(1): e1-3.
In article      View Article  PubMed
 
[14]  Lee KS, Jeong IS, Oh SG, Ahn BH. Subsequently occurring bilateral iliopsoas hematoma: a case report. J Cardiothorac Surg. 2015; 10: 183. Published 2015 Dec 11.
In article      View Article  PubMed
 
[15]  Kearon C, Ginsberg JS, Kovacs MJ, Anderson DR, Wells P, Julian JA, MacKinnon B, Weitz JI, Crowther MA, Dolan S, Turpie AG. Comparison of low-intensity warfarin therapy with conventional-intensity warfarin therapy for long-term prevention of recurrent venous thromboembolism. New England Journal of Medicine. 2003 Aug 14; 349(7): 631-9.
In article      
 
[16]  Witt DM, Nieuwlaat R, Clark NP, Ansell J, Holbrook A, Skov J, Shehab N, Mock J, Myers T, Dentali F, Crowther MA. American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy. Blood advances. 2018 Nov 27; 2(22): 3257-91.
In article      View Article  PubMed
 

Published with license by Science and Education Publishing, Copyright © 2020 Chukwuemeka A. Umeh

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

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Chukwuemeka A. Umeh. Iliopsoas Hematoma in Warfarin Treatment: Case Report and Review of Literature. American Journal of Medical Case Reports. Vol. 8, No. 8, 2020, pp 244-246. http://pubs.sciepub.com/ajmcr/8/8/8
MLA Style
Umeh, Chukwuemeka A.. "Iliopsoas Hematoma in Warfarin Treatment: Case Report and Review of Literature." American Journal of Medical Case Reports 8.8 (2020): 244-246.
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Umeh, C. A. (2020). Iliopsoas Hematoma in Warfarin Treatment: Case Report and Review of Literature. American Journal of Medical Case Reports, 8(8), 244-246.
Chicago Style
Umeh, Chukwuemeka A.. "Iliopsoas Hematoma in Warfarin Treatment: Case Report and Review of Literature." American Journal of Medical Case Reports 8, no. 8 (2020): 244-246.
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[1]  Hull RD, Garcia DA, Vazquez SR. Biology of warfarin and modulators of INR control. Leung LLK, Tirnauer JS, editors. UpToDate [Internet]. Waltham, MA: UpToDate Inc. Available from https://www.uptodate.com (Accessed on December 14, 2019).
In article      
 
[2]  Ekiz T. Spontaneous iliopsoas haematoma presenting with groin pain under warfarin therapy. Pain physician. 2015 Nov; 18: E1145-6.
In article      
 
[3]  Garcia DA, Crowther M. Risks and prevention of bleeding with oral anticoagulants. Leung LLK, Kasner SE, editors. UpToDate [Internet]. Waltham, MA: UpToDate Inc. Available from https://www.uptodate.com (Accessed on December 14, 2019).
In article      
 
[4]  Conti S, Ciuffetti M, Vedovati MC. Thrombotic Risk after a Major Bleeding During Anticoagulation: A Clinical Case. J Cardiovasc Echogr. 2017; 27(1): 26-28.
In article      View Article  PubMed
 
[5]  Kheiri B, Al Salihi M, Maldonado D, Nakhleh R, Bachuwa G. Warfarin-induced spontaneous iliopsoas hematoma - An unusual complication. Clin Case Rep. 2018; 6(8): 1639-1640. Published 2018 Jun 22.
In article      View Article  PubMed
 
[6]  Kong WK, Cho KT, Lee HJ, Choi JS. Femoral Neuropathy due to Iliacus Muscle Hematoma in a Patient on Warfarin Therapy. J Korean Neurosurg Soc. 2012; 51(1): 51-53.
In article      View Article  PubMed
 
[7]  Watanabe Y, Koutoku H, Nagata H, Oda Y, Kikuchi H, Kojima M. Rhabdomyolysis with Acute Kidney Injury Caused by Bilateral Iliopsoas Hematoma in a Patient with Atrial Fibrillation. Intern Med. 2019; 58(19): 2887-2890.
In article      View Article  PubMed
 
[8]  Kaya BB, Icagasioglu A. Ultrasound therapy in iliopsoas hematoma. North Clin Istanb. 2017; 4(2): 180-184. Published 2017 Aug 26.
In article      
 
[9]  Fernandes C, Pereira P, Rodrigues M. Spontaneous iliopsoas muscle haematoma as a complication of anticoagulation in acute cerebral venous thrombosis: to stop or not to stop (the anticoagulation)?. BMJ Case Rep. 2015; 2015: bcr2014206410. Published 2015 Mar 6.
In article      View Article  PubMed
 
[10]  Sharma D, Saker R, Govind A. Emergency department ultrasound diagnosis of spontaneous iliopsoas haemorrhage in a patient on warfarin. BMJ Case Rep. 2013; 2013: bcr2013201291. Published 2013 Nov 15.
In article      View Article  PubMed
 
[11]  Ozkan OF, Guner A, Cekic AB, Turan T, Kaya U, Reis E. Iliopsoas haematoma: a rare complication of warfarin therapy. J Coll Physicians Surg Pak. 2012 Oct 1; 22(22): 673-4.
In article      
 
[12]  Spengos K, Anagnostou E, Vassilopoulou S. Subacute proximal leg weakness after a minor traffic accident in a patient treated with anticoagulants. BMJ Case Rep. 2012; 2012: bcr0220125731. Published 2012 May 23.
In article      
 
[13]  Zago G, Appel-da-Silva MC, Danzmann LC. Iliopsoas muscle hematoma during treatment with warfarin. Arq Bras Cardiol. 2010 Jan; 94(1): e1-3.
In article      View Article  PubMed
 
[14]  Lee KS, Jeong IS, Oh SG, Ahn BH. Subsequently occurring bilateral iliopsoas hematoma: a case report. J Cardiothorac Surg. 2015; 10: 183. Published 2015 Dec 11.
In article      View Article  PubMed
 
[15]  Kearon C, Ginsberg JS, Kovacs MJ, Anderson DR, Wells P, Julian JA, MacKinnon B, Weitz JI, Crowther MA, Dolan S, Turpie AG. Comparison of low-intensity warfarin therapy with conventional-intensity warfarin therapy for long-term prevention of recurrent venous thromboembolism. New England Journal of Medicine. 2003 Aug 14; 349(7): 631-9.
In article      
 
[16]  Witt DM, Nieuwlaat R, Clark NP, Ansell J, Holbrook A, Skov J, Shehab N, Mock J, Myers T, Dentali F, Crowther MA. American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy. Blood advances. 2018 Nov 27; 2(22): 3257-91.
In article      View Article  PubMed