A young male presented with acute inguinal pain, bilateral quadriceps weakness and hyperesthesia of anterior thighs post-thrombolysis for acute myocardial infarction

A 34-year old male presented with typical anginal pain of duration of one-and-half hours, and he reported a brief transient loss of consciousness. His past reports revealed a history of 4 years of hypertension, hyperlipidemia, and mild renal impairment with baseline serum urea 9.5 mmol/L, creatinine 250 μmol/L (glomerular filtration rate [GFR] 33mL/min), and raised 24-hour urinary protein 677 mg (normal <150 mg). His medication included Aldomet (Methyldopa) 500 mg thrice a day and Lipanthyl (Fenofibrate) 200 mg twice daily.

In the emergency department, his heart rate was 40/min in sinus rhythm and BP 110/60 mm Hg. His peripheral pulses were well felt, and he had no features of ventricular or congestive cardiac failure. He was fully conscious and oriented, and his systemic examination was unremarkable. His electrocardiography showed features of inferior wall myocardial infarction with complete heart block, and the heart rate normalized with intravenous (IV) Atropine (1 mg). The severity of chest pain was reduced with IV Pethedine 50 mg. Laboratory parameters revealed the following: hemoglobin 13 g/dL, white blood cells 15.4×10⁹, platelets 359×10⁹, prothrombin time (PT) 11/11 s, activated partial thromboplastin time (aPTT) 29/30 s, international normalized ratio (INR) 1.0, troponin 0.05 ng/mL, Na 136 mmol/L, K 3.8 mmol/L, urea 18.1 mmol/L, and serum creatinine 398 μmol/L (GFR 19.5 mL/min). After the initial workup, a standard thrombolytic therapy in the cardiac care unit was administered using IV Reteplase (10 IU bolus and repeat after 30 min) followed by Heparin 5000 units bolus and 1000 units/h. Two and a half hours later, he developed bilateral conjunctival hemorrhage and mild hematoma at the jugular puncture site. The Heparin dose was reduced to 800 units/h. Fifteen minutes later, he complained of bilateral moderate to severe inguinal pain. There was no change in hemoglobin and coagulation parameters, but high CK of 5420 IU/L was noted. On Day 2, his jugular hematoma increased in size and hematuria (RBC 4+ in urine) was noted; thus Heparin was stopped. His follow-up hemoglobin was stable with PT 14/11 s, aPTT 107/30 s, and INR 1.3. Passive hip movements aggravated his inguinal pain, and he preferred to lie on the lateral side keeping hips flexed. He could not tolerate the ultrasonographic examination of the abdomen. A drop in his hemoglobin was noticed after 12 hours from 12.6 gm/dL to 9.3 gm/dL, and 1 unit of blood transfusion was subsequently administered. Except for initial hematuria, no obvious major bleeding site was detected clinically. On Day 3, he noticed hyperesthesia over the anterior aspect of both thighs. Motor power could not be assessed due to pain, but absent knee jerks were noted. On day 4, bilateral quadriceps weakness was apparent (MRC grade 2/5) with diminished sensations over anterior thigh. Based on the neurological examination, the possibility of lumbar root or femoral nerve involvement was considered. The urgent ultrasound of abdomen did not reveal any intraabdominal pathology. Noncontrast abdominal computed tomography showed symmetrical prominence of both iliopsoas without any focal blood collection. Magnetic resonance imaging (MRI) of the abdomen showed bilateral enlarged heterogeneous iliopsoas muscles with the areas of hyperintensity (Figure 1). Due to progressive renal impairment, he received hemodialysis. His cardiovascular and neurological status remained stable. He improved over the period of 40 days with physiotherapy and was discharged walking unassisted.

Figure 1.

Gadolinium-enhanced axial inversion time MRI sequences of abdomen revealing bilateral enlarged heterogeneous hyperintense signals in both iliopsoas muscles (arrows).