# 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

## TL;DR

A 74-year-old woman with chronic cough from COVID-19 and long-term anticoagulant use developed a rare rectus sheath hematoma and muscle rupture requiring emergency surgery.

## Contribution

This case report highlights a rare complication of rectus sheath hematoma and muscle rupture in a COVID-19 patient on long-term anticoagulation.

## Key findings

- A 74-year-old woman developed rectus sheath hematoma and rectus abdominis rupture due to chronic cough and anticoagulant therapy.
- Emergency surgery was required to excise the hematoma and repair the muscle rupture.
- The case underscores the risk of RSH in patients with prolonged anticoagulation and persistent cough.

## Abstract

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.

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.

Many factors and mechanisms contribute to the formation of the RSH and the rupture of rectus abdominis muscle, including severe cough and anticoagulants.

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.

•Giant left atrium (GLA) is a rare condition often associated with rheumatic heart disease and can lead to cardiac and extra-cardiac complications.•A 54-year-old woman with a 25-year history of mitral stenosis caused by rheumatic heart disease presented with symptoms of dyspnea, orthopnea, and palpitations.•The chest X-ray results indicated cardiomegaly and pleural effusion on the right side.

Giant left atrium (GLA) is a rare condition often associated with rheumatic heart disease and can lead to cardiac and extra-cardiac complications.

A 54-year-old woman with a 25-year history of mitral stenosis caused by rheumatic heart disease presented with symptoms of dyspnea, orthopnea, and palpitations.

The chest X-ray results indicated cardiomegaly and pleural effusion on the right side.