Fatal iliopsoas and rectus sheath hemorrhage in a critically ill patient with COVID-19 on therapeutic anticoagulation

Pulmonary embolism and thrombosis are two common postmortem findings in novel coronavirus disease 2019 (COVID?19), the fact which led experts to include anticoagulants in the standard management of COVID?19. However, at least until now, no guidelines stated the exact safe yet optimal dose of anticoagulants. We report a case of a 65?year?old man admitted to our hospital with severe acute respiratory distress syndrome due to COVID?19. He showed remarkable improvement during the first 10 days of treatment at our facility but subsequently developed spontaneous iliopsoas hemorrhage (IPH). We discontinued antithrombotic and anticoagulant agents as soon as we confirmed the IPH from the abdominal computed tomography scan. His condition worsened even after he received adequate blood transfusion sets and eventually developed disseminated intravascular coagulation. Due to the limitation of our hospital, we could not perform stent grafting and angiographic embolization. He finally died 6 days after the occurrence of IPH. To the best of our knowledge, this is the first case of COVID?19 with IPH in Indonesia. As a developing country, many hospitals in Indonesia do not have stent grafting and angiographic embolization. This condition urges the dose recommendation for anticoagulant therapy to provide safe and efficient management for COVID?19.