Published online Apr 26, 2021. doi: 10.12998/wjcc.v9.i12.2838
Peer-review started: November 23, 2020
First decision: January 7, 2021
Revised: January 16, 2021
Accepted: February 22, 2021
Article in press: February 22, 2021
Published online: April 26, 2021
Rhabdomyolysis is a serious complication of heat stroke. Unlike that in acute kidney injury, the risk of muscle bleeding in rhabdomyolysis is often ignored and can substantially increase via the widespread use of anticoagulants, leading to the formation of intramuscular hematoma.
During the summer, a middle-aged man and an elderly man were diagnosed with heat stroke, rhabdomyolysis, and acute renal impairment. Low-dose enoxaparin sodium was initiated for prophylaxis of deep vein thrombosis after the disease was stabilized with continuous renal replacement therapy. After that, the patients' hemoglobin decreased progressively, and no obvious intracranial, thoracic, digestive, or skin bleeding tendency was found. However, one of the patients had hip muscle pain, and computed tomography and color ultrasound confirmed that the patients separately had lumbar back and hip intermuscular hematoma. After discontinuation of anticoagulant drugs and monitoring of the steady increase in hemoglobin, the intermuscular hematomas were gradually absorbed. Following the use of prophylactic anticoagulation therapy, the patients' hemoglobin showed a progressive downward trend. Hematoma formation in the lumbosacral and buttock muscles was confirmed after excluding bleeding in typical regions (such as the digestive tract, thoracic cavity, and abdominal cavity). Anticoagulant drugs were discontinued immediately, and nutritional support was increased. Subsequently, the hemoglobin levels gradually increased, and the hematoma volumes gradually decreased.
Patients with rhabdomyolysis have a risk of muscle bleeding, and inappropriate use of anticoagulants may lead to an increased risk or even to the formation of an intermuscular hematoma. When continuous blood loss is found in the body, the possibility of bleeding in the muscles and more typical sites should be considered.
Core Tip: We report two patients with rhabdomyolysis caused by heat stroke who developed an intermuscular hematoma during prophylactic anticoagulation therapy. We used heparinized continuous renal replacement therapy, and the patients’ conditions gradually stabilized after a few days. However, in the use of anticoagulants to prevent deep vein thrombosis, the two patients had a progressive decline in hemoglobin. After comprehensive examination, common blood loss was excluded, such as gastrointestinal bleeding, retroperitoneal hematoma, and pleural and abdominal hematoma, and the diagnosis of intramuscular hematoma of the lumbosacral region and buttock was finally confirmed.