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Rare Complication of Cough
Accepted Manuscript Title: A Rare Complication of Cough Author: Surujpal Teelucksingh, Sateesh Sakhamuri PII: DOI: Reference:
S0002-9343(17)31018-5 https://doi.org/doi:10.1016/j.amjmed.2017.09.032 AJM 14313
To appear in:
The American Journal of Medicine
Please cite this article as: Surujpal Teelucksingh, Sateesh Sakhamuri, A Rare Complication of Cough, The American Journal of Medicine (2017), https://doi.org/doi:10.1016/j.amjmed.2017.09.032. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
A RARE COMPLICATION OF COUGH Surujpal Teelucksingh FRCP(E) and Sateesh Sakhmuri DM, FCCP Department of Clinical Medical Sciences, The University of the West Indies. St Augustine. Trinidad. W.I.
Corresponding author: Sateesh Sakhamuri, The University of the West Indies Clinical Medical Sciences EWMSC St. Augustine, TRINIDAD AND TOBAGO 18687417184 [email protected]
CofI: None Funding: None Both authors had access to the data and are responsible for the article’s content.
To the Editor: A 71-year-old man with a 5-day history of flu-like symptoms presented with severe left-sided abdominal pain following a bout of coughing. The pain was initially felt in the left lower abdominal quadrant but later extended to his entire left side, was aggravated by coughing, sneezing and movement. Bowel and bladder functions were unaffected and there was no history of vomiting. His past medical history was significant only for type 2 diabetes mellitus and dyslipidemia for which he was taking metformin 500 mg twice daily and rosuvastatin 10 mg daily, respectively. There was no history of a bleeding diathesis.
Page 1 of 3
On examination, the patient was hemodynamically stable. There was marked local guarding and the presence of a firm, non-pulsatile, tender mass just left of the midline at the level of the umbilicus. Appreciation of increased pain and tenderness (Carnett’s sign) and persistent palpability (Fothergill’s sign) with head rising lead to a clinical diagnosis of left rectus sheath hematoma1,2. CT scan confirmed a large type II hematoma3 of the left rectus muscle (Figure 1A and 1B) with no evidence of hemoperitoneum. He was treated for an upper respiratory tract infection and symptomatically with analgesia and anti-tussive therapy. Despite significant blood loss (hemoglobin dropped from a baseline 14 to 10 g/dl), he remained stable and was discharged for outpatient follow-up after hospitalization for one day. One week after discharge he returned with ecchymosis over the periumbilical area (Cullen’s sign) and in flanks (Grey Turner’s sign) (Figure 1C and 1D), but his abdomen pain and cough were resolved.
Spontaneous rectus sheath hematoma is a relatively uncommon occurrence which can be encountered after violent coughing or physical activity. Old age, female gender, anticoagulant and antiplatelet therapies have been acknowledged as potential risk factors in the literature4,5. Statin therapy is reported to predispose to muscle rupture6, but its contribution in this case is uncertain. The occurrence of a large hematoma with ecchymosis and a significant hemoglobin drop in the index case may point toward the inferior epigastric artery as the source of the bleeding, which can be explained by the limited support to the posterior wall of rectus muscle below the arcuate line. Conservative therapy is the mainstay in the majority of the cases, but occasionally severe blood loss may require aggressive resuscitation7.
Page 2 of 3
Non-traumatic rectus sheath hematoma is rarely seen. Triggering factors like vigorous cough, anticoagulant use and its clinical similitude as an acute abdomen should be deliberated during the diagnosis.
References 1. Osinbowale O, Bartholomew JR. Rectus sheath hematoma. Vasc Med. 2008;13:275–279. 2. Thomson H, Francis DM. Abdominal-wall tenderness: A useful sign in the acute abdomen. Lancet. 1977;2:1053–1054. 3. Berná JD, Garcia-Medina V, Guirao J, Garcia-Medina J. Rectus sheath hematoma: diagnostic classification by CT. Abdom Imaging 1996;21(1):62-4. 4. Cherry WB, Mueller PS. Rectus sheath hematoma. Review of 126 cases at a single institution. Medicine. 2006;85:105–110. 5. Linhares MM, Lopes Filho GJ, Bruna PC, Ricca AB, Sato NY, Sacalabrini M. Spontaneous hematoma of the rectus abdominis sheath: a review of 177 cases with report of 7 personal cases. Int Surg. 1999;84:251–257. 6. Ekhart C, de Jong L, Gross-Martirosyan L, van Hunsel F. Muscle rupture associated with statin use. Br J Clin Pharmacol. 2016;82(2):473-7. 7. Hatjipetrou A, Anyfantakis D, Kastanakis M. Rectus sheath hematoma: a review of the literature. Int J Surg. 2015;13:267-71.
Figure 1A and 1B. CT abdomen showing left rectus abdominis hematoma (green line), and thickening of adjacent muscles and interfacial edema (green arrowheads). 1C and 1D. Ecchymosis over anterior abdomen wall (Cullen’s sign) and in left flank (Grey Turner’s sign).
Page 3 of 3
S0002-9343(17)31018-5 https://doi.org/doi:10.1016/j.amjmed.2017.09.032 AJM 14313
To appear in:
The American Journal of Medicine
Please cite this article as: Surujpal Teelucksingh, Sateesh Sakhamuri, A Rare Complication of Cough, The American Journal of Medicine (2017), https://doi.org/doi:10.1016/j.amjmed.2017.09.032. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
A RARE COMPLICATION OF COUGH Surujpal Teelucksingh FRCP(E) and Sateesh Sakhmuri DM, FCCP Department of Clinical Medical Sciences, The University of the West Indies. St Augustine. Trinidad. W.I.
Corresponding author: Sateesh Sakhamuri, The University of the West Indies Clinical Medical Sciences EWMSC St. Augustine, TRINIDAD AND TOBAGO 18687417184 [email protected]
CofI: None Funding: None Both authors had access to the data and are responsible for the article’s content.
To the Editor: A 71-year-old man with a 5-day history of flu-like symptoms presented with severe left-sided abdominal pain following a bout of coughing. The pain was initially felt in the left lower abdominal quadrant but later extended to his entire left side, was aggravated by coughing, sneezing and movement. Bowel and bladder functions were unaffected and there was no history of vomiting. His past medical history was significant only for type 2 diabetes mellitus and dyslipidemia for which he was taking metformin 500 mg twice daily and rosuvastatin 10 mg daily, respectively. There was no history of a bleeding diathesis.
Page 1 of 3
On examination, the patient was hemodynamically stable. There was marked local guarding and the presence of a firm, non-pulsatile, tender mass just left of the midline at the level of the umbilicus. Appreciation of increased pain and tenderness (Carnett’s sign) and persistent palpability (Fothergill’s sign) with head rising lead to a clinical diagnosis of left rectus sheath hematoma1,2. CT scan confirmed a large type II hematoma3 of the left rectus muscle (Figure 1A and 1B) with no evidence of hemoperitoneum. He was treated for an upper respiratory tract infection and symptomatically with analgesia and anti-tussive therapy. Despite significant blood loss (hemoglobin dropped from a baseline 14 to 10 g/dl), he remained stable and was discharged for outpatient follow-up after hospitalization for one day. One week after discharge he returned with ecchymosis over the periumbilical area (Cullen’s sign) and in flanks (Grey Turner’s sign) (Figure 1C and 1D), but his abdomen pain and cough were resolved.
Spontaneous rectus sheath hematoma is a relatively uncommon occurrence which can be encountered after violent coughing or physical activity. Old age, female gender, anticoagulant and antiplatelet therapies have been acknowledged as potential risk factors in the literature4,5. Statin therapy is reported to predispose to muscle rupture6, but its contribution in this case is uncertain. The occurrence of a large hematoma with ecchymosis and a significant hemoglobin drop in the index case may point toward the inferior epigastric artery as the source of the bleeding, which can be explained by the limited support to the posterior wall of rectus muscle below the arcuate line. Conservative therapy is the mainstay in the majority of the cases, but occasionally severe blood loss may require aggressive resuscitation7.
Page 2 of 3
Non-traumatic rectus sheath hematoma is rarely seen. Triggering factors like vigorous cough, anticoagulant use and its clinical similitude as an acute abdomen should be deliberated during the diagnosis.
References 1. Osinbowale O, Bartholomew JR. Rectus sheath hematoma. Vasc Med. 2008;13:275–279. 2. Thomson H, Francis DM. Abdominal-wall tenderness: A useful sign in the acute abdomen. Lancet. 1977;2:1053–1054. 3. Berná JD, Garcia-Medina V, Guirao J, Garcia-Medina J. Rectus sheath hematoma: diagnostic classification by CT. Abdom Imaging 1996;21(1):62-4. 4. Cherry WB, Mueller PS. Rectus sheath hematoma. Review of 126 cases at a single institution. Medicine. 2006;85:105–110. 5. Linhares MM, Lopes Filho GJ, Bruna PC, Ricca AB, Sato NY, Sacalabrini M. Spontaneous hematoma of the rectus abdominis sheath: a review of 177 cases with report of 7 personal cases. Int Surg. 1999;84:251–257. 6. Ekhart C, de Jong L, Gross-Martirosyan L, van Hunsel F. Muscle rupture associated with statin use. Br J Clin Pharmacol. 2016;82(2):473-7. 7. Hatjipetrou A, Anyfantakis D, Kastanakis M. Rectus sheath hematoma: a review of the literature. Int J Surg. 2015;13:267-71.
Figure 1A and 1B. CT abdomen showing left rectus abdominis hematoma (green line), and thickening of adjacent muscles and interfacial edema (green arrowheads). 1C and 1D. Ecchymosis over anterior abdomen wall (Cullen’s sign) and in left flank (Grey Turner’s sign).
Page 3 of 3