Enoxaparin-sodium

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An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

A man in his 70s [exact age at the time of reaction onset not stated] exhibited rectus sheath haematoma (RSH), mesenteric vessel microhaemorrhage and lack of efficacy during treatment with enoxaparin sodium used as an anticoagulant.

The man, who had a medical history of gastroesophageal reflux disease, hypertension, depression and benign prostatic hypertrophy, presented to the emergency department with a chief complaint of worsening dyspnoea. Seven days previously, he had developed a dry cough with sore throat, and was subsequently found to be positive for COVID-19. He had been managing COVID-19 at home on an outpatient basis. Since the COVID-19 diagnosis, his symptoms continued to deteriorate, and upon arrival to the emergency department, he had non-productive cough, dyspnoea at rest, decreased appetite, weakness, fevers and nausea. He had acute hypoxic respiratory failure with oxygen saturation of 68% on room air. On a 15% nonrebreather mask, his oxygen saturation increased to 88%−92%. He also had tachypnoea at 22 breaths/minute and was afebrile. Chest X-ray showed new extensive patchy consolidative opacities about the lungs indicating multifocal pneumonia. His laboratory evaluation was remarkable for elevated fibrinogen, D-dimer, ferritin, WBC count and lactic acid. Enoxaparin sodium [enoxaparin; route and dosage not stated], remdesivir and dexamethasone were commenced as he was admitted to the ICU for inpatient management of acute hypoxic respiratory failure, sepsis, severe COVID-19 infection and viral pneumonia. On day 2 of admission, his repeat D-dimer continued to be elevated. Over the course of the following few days, he reported resolved dyspnoea and improved symptomatology. His acute hypoxic respiratory failure was ameliorating; he was reduced from 90% FiO2 on BiPAP to 45% FiO2, high-flow nasal cannula/BiPAP. His care was transferred to intermediate care from intensive care. His D-dimer increased continuously on hospital admission days 3−5. On the morning of day 6 of hospitalisation, he continued to endorse amelioration of symptoms, including no vomiting, fever, chills or nausea, but he started to complain of constipation. To manage this constipation, he was administered lactulose for symptomatic relief. Later that evening, he had a large bowel movement. Subsequently, he experienced acute onset of severe left lower quadrant abdominal pain. CT scan of the pelvis and abdomen with IV contrast showed several findings. A 4cm well-demarcated area of non-enhancement within the anterior superior spleen congruous with acute infarct was observed. Additionally, there was inflammation within fat surrounding the mesenteric vessels in the left upper quadrant, which was suspected to be thrombosis or microhaemorrhage (mesenteric vessel microhaemorrhage). There were also large haematomas within the bilateral rectus muscles (RSH) beginning just above the umbilicus extending down to the pubis measuring 5.6cm × 18cm on the left and 7cm × 4cm × 10cm on the right. Contrast within the haematomas indicated active bleeding at the time of imaging. Haemoglobin was found to be decreased.

The man's full dose enoxaparin sodium, which was initially commenced because of significantly increased D-dimer, was subsequently withdrawn owing to the presence of actively bleeding haematomas, despite the presence of a splenic infarct. When measured earlier that morning, his D-dimer continued to be elevated. During this time, it was decided to transfer him by helicopter to a tertiary care center for possible interventional radiology embolisation and management of the large rectus haematomas. At this point, he received remdesivir and dexamethasone. He was stable at the time of transfer. Following 2 days of in-patient care at the tertiary center, it was observed that the active bleeding had stopped, and the haematomas remained stable. His COVID-19 symptoms had also ameliorated, and he could maintain adequate oxygenation levels while ambulating. He was discharged to complete his recovery at home. His recovery course had gone well with no complications and as of 2 months after the discharge, he had been able to safely return to normal activity.