{'fraction_non_alphanumeric': 0.023900137007154817, 'fraction_numerical': 0.013396255137768306, 'mean_word_length': 5.5503489531405785, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Acute Progressive retro-peritoneal hematoma in COVID19 patients with sub cutaneous ecchymosis

Introduction and importance: COVID19 is a multifunction disease where hematological disorders are reported. Coagulopathy is seen in these patients, indicated by thromboembolic events. Case presentation We present case of 11 COVID19 who were presented with localized skin ecchymosis lesions in different areas of the body and retroperitoneal hematoma in the posterior wall of the abdomen and chest. Clinical discussion Increased INR and bleeding and ecchymosis in Corona patients require discontinuation of anticoagulants and, FFP, essential and tri amino injections are needed. Conclusions Diagnosis and management of hematoma is important to avoid fatality.


Introduction
Global upsurge in COVID19 cases has been marked with systemic manifestations. Clinical studies have indicated thromboembolic events and vascular injuries in COVID19 patients [1]. In such cases, morbidities, poor prognosis and even mortality is reported. Monitoring thrombotic event through coagulation blood testing such as that of D-dimers and fibrinogen is indicated in such patients to reduce the risk of fatality [2,3]. Cytokine storm and elevation in the production of inflammatory cytokines in the known pathophysiological mechanism behind coagulopathy in COVID19 patients [4,5]. These patients were under anticoagulants (blood thinners) to reduce ischemic risks [6][7][8].
Intake of anticoagulants is known for increased risk of hematoma [9][10][11]. A few case studies have reported similar in severe COVID19 patients. In this case series, we present COVID19 patients who were treated with anticoagulants and were seen to be presented with retroperitoneal hematoma.

Methods
Patients on anticoagulant therapy and severe COVID19, susception of hematoma was made, based on the clinical symptoms such as loss of movement of the limbs along with swelling and tenderness of abdomen and peritoneum. Contrast CT or MRI scan was performed to confirm the diagnosis. Biochemical parameters were also analyzed in these patients.
Fresh froze plasma and blood transfusion was performed and emergency consultancy with hematologist was made.
Unique identifying number is: researchregistry7870. The methods are stated in accordance with PROCESS 2020 guidelines [12].

Results
The occurrence of coagulopathy is critical and immediate consultation is required. Bleeding in the upper airway system requires hospitalization in the ICU and ENT consultation and anterior or posterior tampons are used to control bleeding.
In COVID19 patients with coagulopathy and bleeding, a skilled nurse is required for each ICU bed at night. Occurrence of ecchymosis on the skin and trunk requires measurement of fibrinogen coagulation factors, calcium, serial control of hemoglobin and blood culture for sepsis and DIC (disseminated intravascular coagulation).
Occurrence of ocular bleeding and sclera involvement, especially in patients who have positive PCR sampling of eye secretions, that cause vasculitis, requires orbital CT scan and ocular consultation.
Patients with positive PCR and the presence of active retroperitoneal hematoma, seen by expansion of abdomen in CT scan, administration of anticoagulants with hematologist consultation is required and 4 units blood transfusion in the patients can be helpful. Increased INR and bleeding and ecchymosis in Corona patients require discontinuation of anticoagulants and, if necessary, FFP, essential and tri amino injections (except hematology) are needed (Table 1).

Discussion
COVID19 is a multifunction disease where hematological disorders are reported. Coagulopathy is seen in these patients, indicated by thromboembolic events. These abnormalities are associated with poor prognosis and increased mortality rate. Alterations in activated partial thromboplastin time, International Normalized Ratio of the prothrombin time along with increase in D-dimer and fibrin degradation products and prothrombin time. DIC is also seen to be correlated with deaths [13][14][15]. Increased levels of inflammatory markers like C-reactive protein and IL-8 in COVID19 patients, is similar to that in vasculitis [16].
Scialpi, Russo [17] reported first case of retroperitoneal hematoma in a COVID19 patient that indicated significance of the use of contrast CT scan for the detection. Since then, a few case studies are reported in this context. Patients on anticoagulant therapy and other comorbidities are at the greater risk of hematoma and/or ecchymosis and fatality [18,19]. In a recent case report, Nakamura, Ouchi [20] presented a case of iliopsoas hematoma in two patients who were under anticoagulant therapy due to severe COVID19. The study showed that retroperitoneal hematoma is such patients are underreported and might not be suspected easily. Other factors contributing to retroperitoneal hematoma in COVID19 patients are atherosclerosis and small trauma to blood vessels due to persistent cough. Furthermore, coronavirus can also bind to angiotensin-converting enzyme 2 receptors on endothelial cells of the blood vessel and cause damage [20]. Ottewill, Mulpeter [21] also reported the case 3 patients under anticoagulant therapy after COVID19, who were presented with spontaneous hematoma.
Timely diagnosis and management of hematoma is important to avoid fatality. COVID19 patients, who are given anticoagulants, should be closely examined for the presentation of hematoma. Alterations in biochemical parameters should also be monitored closely.

Provenance and peer review
Not commissioned, externally peer-reviewed.

Ethical approval
All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Sources of funding
No funding was secured for this study.

Author contribution
Dr. Saeid Marzban-Rad: conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript. Dr. Ebrahim Khalighi: Designed the data collection instruments, collected data, carried out the initial analyses, and reviewed and revised the manuscript.Dr. Hamid Reza Taheri: Coordinated and supervised data collection, and critically reviewed the manuscript for important intellectual content.

Consent
Not applicable.

Declaration of competing interest
The authors deny any conflict of interest in any terms or by any means during the study.