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      Hematoma espontáneo gigante de pared torácica en paciente anticoagulada por COVID-19 Translated title: Giant Spontaneous Hematoma of the Chest Wall in a Patient Receiving Anticoagulation for COVID-19

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          Abstract

          Presentamos el caso de una paciente de 76 años con antecedentes de hipertensión arterial y panhipopituitarismo, hospitalizada por neumonía por SARS-CoV-2, y en tratamiento con tocilizumab, corticoterapia, oxigenoterapia y heparina de bajo peso molecular (HBPM) a dosis terapéuticas. La evolución inicial fue mala, presentando deterioro respiratorio y tromboembolia pulmonar bilateral. Tras instaurar tratamiento con baricitinib, oxigenoterapia nasal de alto flujo y mantener dosis terapéuticas de HBPM, la paciente presentó mejoría progresiva. Sin embargo, a pesar de tener un riesgo hemorrágico bajo (HAS-BLED score: 1, plaquetas y coagulación en rango normal y filtrado glomerular > 90 ml/min/1,73 m2), la paciente presentó anemización brusca (Hb: 5,5 g/dl) y un hematoma superficial en región dorsolumbar asociado a una gran tumoración infraescapular derecha. La TC mostró una colección de 19 × 8 × 28 cm en la pared torácica derecha sugerente de hematoma (fig. 1 A). Tras estabilización hemodinámica, se llevó a cabo intervención quirúrgica drenándose 1.500 cc de sangre y coágulos sin visualizar sangrado activo (fig. 1B). El período postoperatorio transcurrió sin incidencias. Figura 1 Corte coronal de la TC torácica que muestra una colección de 19 × 8 × 28 cm de eje anteroposterior, transverso y craneocaudal, localizada entre la escápula y el músculo dorsal ancho y los arcos costales derechos que se extiende desde el 1.° arco costal hasta la altura de los últimos arcos costales apreciándose áreas con diferente densidad, hallazgos compatibles con hematoma de pared en diferentes estadios de sangrado (A). Imagen postoperatoria de la paciente en la que destaca la amplia extensión del hematoma superficial (B). A pesar de que la infección por COVID-19 induce un estado protrombótico que puede derivar en un riesgo aumentado de eventos trombóticos venosos 1 , es necesario tener presente la posibilidad de complicaciones hemorrágicas secundarias al tratamiento anticoagulante y/o a la coagulopatía producida por la infección. Financiación Los autores declaran no haber recibido financiación para la realización de este trabajo.

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          COVID-19 and its implications for thrombosis and anticoagulation

          Severe acute respiratory syndrome coronavirus 2, coronavirus disease 2019 (COVID-19)-induced infection can be associated with a coagulopathy, findings consistent with infection-induced inflammatory changes as observed in patients with disseminated intravascular coagulopathy (DIC). The lack of prior immunity to COVID-19 has resulted in large numbers of infected patients across the globe and uncertainty regarding management of the complications that arise in the course of this viral illness. The lungs are the target organ for COVID-19; patients develop acute lung injury that can progress to respiratory failure, although multiorgan failure can also occur. The initial coagulopathy of COVID-19 presents with prominent elevation of D-dimer and fibrin/fibrinogen-degradation products, whereas abnormalities in prothrombin time, partial thromboplastin time, and platelet counts are relatively uncommon in initial presentations. Coagulation test screening, including the measurement of D-dimer and fibrinogen levels, is suggested. COVID-19–associated coagulopathy should be managed as it would be for any critically ill patient, following the established practice of using thromboembolic prophylaxis for critically ill hospitalized patients, and standard supportive care measures for those with sepsis-induced coagulopathy or DIC. Although D-dimer, sepsis physiology, and consumptive coagulopathy are indicators of mortality, current data do not suggest the use of full-intensity anticoagulation doses unless otherwise clinically indicated. Even though there is an associated coagulopathy with COVID-19, bleeding manifestations, even in those with DIC, have not been reported. If bleeding does occur, standard guidelines for the management of DIC and bleeding should be followed.
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            Author and article information

            Journal
            Arch Bronconeumol
            Arch Bronconeumol
            Archivos De Bronconeumologia
            SEPAR. Published by Elsevier España, S.L.U.
            0300-2896
            1579-2129
            31 December 2020
            31 December 2020
            Affiliations
            [0005]Departamento de Cirugía Torácica, Hospital Universitario de Salamanca, Salamanca, España
            Author notes
            [* ]Autor para correspondencia.
            Article
            S0300-2896(20)30557-3
            10.1016/j.arbres.2020.12.016
            7837177
            33509621
            c27d24e0-5920-4772-b321-480fefaf2b8e
            © 2020 SEPAR. Published by Elsevier España, S.L.U. All rights reserved.

            Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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