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Bilateral Multifocal Muscular Hemorrhage in Triceps Surae On Anticoagulation Therapy: A Case Report |
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Department of Physical Medicine & Rehabilitation, Jeonbuk National University Medical School, Jeonju, 54907, Republic of Korea 1, Research Institute of Clinical Medicine of Jeonbuk National University - Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, 54907, Republic of Korea2, Translational Research & Clinical Trial Center for Medical Device, Jeonbuk National University Hospital, Jeonju 54907, Republic of Korea3 |
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Young-In Go MD1,2*, Da-Sol Kim MD1,2, Yu-Hui Won, MD, PhD1,2, Sung-Hee Park, MD, PhD1,2, Myoung-Hwan Ko, MD PhD1,2, Jeong-Hwan Seo, MD, PhD1,2, Gi-Wook Kim, MD, PhD1,2† |
Introduction: Hemorrhagic complications occur in about 5% of patients on anticoagulation agents and the overall annual mortality rate from severe anticoagulant-induced hemorrhages is 0.65%. We report a rare case of multifocal muscular hemorrhage in both triceps surae muscles in a patient who was diagnosed with ST-elevation myocardial infarction (STEMI) and underwent percutaneous coronary intervention (PCI).
Case Presentation: A 75-year-old man was initially hospitalized for severe chest pain. He was diagnosed with STEMI and underwent PCI in the proximal segment of the right coronary artery. He was administered oral acetylsalicylic acid and ticagrelor. After 3 days, he complained of bilateral leg pain aggravated during gait and ankle ranges of motion. He visited our rehabilitation medicine department for proper evaluation and management. The patient had a history of myocardial infarction in 2005 and had been taking aspirin daily.
Diagnosis: There was tenderness on both triceps surae muscles, and Homan’s sign was positive with pain aggravated on knee extension and relieved on knee flexion. Straight leg raise test was also positive, on the other hand, Thompson’s test was negative. There was no sign of deep vein thrombosis on Doppler ultrasound. Electromyography showed findings of bilateral lumbosacral radiculopathy, but these findings did not correlate with the patient’s clinical symptoms. A musculoskeletal ultrasound showed a decreased fibrillary pattern on both soleus muscles excluding the gastrocnemius muscle, and a hyper-echoic lesion in the fascia between the two muscles (Fig. 1). Right leg MRI showed multifocal muscular hemorrhagic lesions on the soleus, gastrocnemius, and peroneus muscles (Fig. 2).
Intervention : Conservative treatment such as bed rest, leg elevation, leg compression, icepack use, range of motion exercise, and gait training were administered. We discussed with his cardiologist and changed ticagrelor to clopidogrel to further reduce the bleeding risk.
Outcomes : There was a reduction in the calf pain, and an increment in gait function. However, few days later he showed signs of arteriosclerosis obliterans in his both feet.
Conclusion: Multifocal muscular hemorrhage rarely occurs bilaterally, but early detection is possible with ultrasonography to prevent a worse outcome and treat the patient appropriately.
Keywords : Muscle, hemorrhage, Ultrasonography, Anticoagulant Agents
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Fig. 1. Lower Leg Ultrasonography(Transverse view). (A) Anterior, (B) Posterior compartment.
Fig. 2. T2-weighted Lower Leg Rt MRI. (A) Anterior, (B) Posterior compartment. PL, peroneus longus; TP, tibialis posterior; SO, soleus; GCM, gastrocnemius.
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