![]() Transthoracic echo was negative for obvious vegetations. The patient was empirically started on IV vancomycin and Zosyn. ![]() Chest X-ray showed no acute infectious process. ![]() The liver function test (LFT) was within the normal range. Methicillin-resistant Staphylococcus aureus (MRSA) nasal was negative, and so were respiratory panel and C. The culture of the wound swab showed no growth, and the same was the case with blood culture, acid-fast bacilli (AFB) wound culture, as well as urine culture and reflex culture. On admission, he had a temperature of 98.1 ☏, a heart rate of 102 beats per minute, a blood pressure of 140/61 mmHg, and an elevated respiratory rate (18). Laboratory workup was done, which showed a white blood cell count of 3.26 x 10 9/L, hemoglobin (Hb) of 10.8 g/dL, c-reactive protein (CRP) of 10.2 mg/L, and procalcitonin of 0.13 ng/ml. The patient was admitted on account of recurrent cellulitis for further evaluation. Examination showed dry skin with hyperkeratotic plaques with peeling and bilateral lower extremity non-pitting edema. Right medial calf open wound was noted and was draining minimal serous fluid with some erythematous streaking, and granulation tissue (Figure (Figure1 1).Ī picture of the cellulitis and associated open wound There was no associated joint pain or swelling, dysuria, chest pain, or abdominal pain. His symptoms had reoccurred after two weeks, which had led him to present back to the ED due to the recurrent cellulitis associated with fever, chills, and wound abscess.Ī review of systems showed fever, drowsiness, genialized weakness, mild confusion, nausea, vomiting, and bilateral lower extremity skin rash. He had initially visited the urgent care facility a few weeks ago for the management of leg pain with erythema and had been treated with antibiotics. In this report, we present the case of a chronically ill elderly patient who developed a non-traumatic intramuscular hematoma of the leg muscle associated with apixaban therapy.Ī 64-year-old male with a past medical history of atrial fibrillation on apixaban presented to the ER in a febrile condition complaining of right leg pain with swelling and serosanguineous drainage. Infected spontaneous hematoma of the lower extremities is very rare and currently, there is no data in the literature on this mysterious entity. ![]() Therefore, a high degree of suspicion is always needed when patients present with pain, edema, and ecchymosis in a lower extremity muscle region. Lower extremities like the calf are an uncommon site of hematoma. In the majority of cases, muscle hematomas affect the abdominal rectus sheath or the gluteal muscles. SMH has a significantly increased incidence in the elderly and frail patients receiving treatment with anticoagulants. Several predisposing or contributing factors have been described, and the most frequent ones include minor trauma, increased abdominal pressure, anticoagulation medications, hypertension, and iatrogenic causes. SMH is an uncommon condition that is often overlooked or misdiagnosed, and it is potentially life-threatening, particularly in elderly and frail patients. While traumatic muscular hematomas can occur in patients of all demographics, spontaneous muscle hematoma (SMH) is more commonly associated with the elderly population receiving treatment with anticoagulants it is reported to occur in approximately 5% of such patients with an annual mortality rate of 0.65%.
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