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INTRACTABLE COUGH CAUSING SPONTANEOUS RECTUS SHEATH HEMATOMA

      TOPIC: Signs and Symptoms of Chest Diseases
      TYPE: Medical Student/Resident Case Reports
      INTRODUCTION: Cough is a physiologic mechanism that causes airways to be cleared of foreign materials and excess secretions. The violent expiration is associated with rapid contraction of the diaphragm and the abdominal wall muscles leading to an increase in intraabdominal pressures. Longstanding untreated cough can lead to spontaneous abdominal wall hematomas. (1)
      CASE PRESENTATION: A 65-year-old gentleman presented to the Emergency Room with right lower quadrant abdominal pain of one-week duration. He had no past medical history. He was noted to have a persistent intractable cough for one month. Prior to the onset of cough, he had one week of loss of taste and smell, nasal congestion, nasal discharge and postnasal drip. According to him, the cough was so bad that he felt like he was going to burst. Although his family insisted, he did not get the cough evaluated. His vital signs were stable. Physical examination showed ecchymosis, a small palpable mass and tenderness in the right lower quadrant. Lung exam was unremarkable. Lab work unremarkable with normal platelet count and coagulation profile. Computed Tomography (CT) of the abdomen/pelvis showed an intramuscular vascular mass of 9 cm within the right rectus abdominis suggestive of a hematoma which was managed conservatively. Of note, he was not on any anticoagulants. On 1 month follow-up, he had complete resolution of abdominal pain, ecchymosis, mass and tenderness in the right lower quadrant. However, he continued to have a persistent cough for which he was referred to pulmonology. He visited the pulmonary clinic after 5 months of referral. At that time, he had become dependent on over-the-counter (OTC) oral decongestants and antihistamines. He had no reflux symptoms, no allergies, was a lifetime nonsmoker, employed as a banker and had a Labrador for 11 years. CT chest showed normal lung parenchyma. Pulmonary function tests revealed features of mild obstructive lung disease. His OTC medications were stopped and he was given a course of oral prednisone along with fluticasone and azelastine nasal spray with dramatic improvement and complete resolution of cough.
      DISCUSSION: Sustained cough results in over contraction and overstretching of abdominal muscles with an increase in intra-abdominal pressures. (2) Vigorous coughing plausibly generates shear forces high enough to tear superior and inferior epigastric vessels along the posterior aspect of long rectus muscle which results in rectus sheath hematomas. Almost 29% of spontaneous rectus sheath hematomas are the result of sustained cough the risk of which increases with the use of anticoagulants. (3) While these hematomas are conservatively managed, patients should undergo a thorough evaluation and treatment of cough to prevent its recurrence.
      CONCLUSIONS: This case highlights the potential of sustained vigorous cough to cause abdominal wall hematomas even in the absence of anticoagulants.
      REFERENCE #1: 1. Fuller RW, Jackson DM. Physiology and treatment of cough. Thorax. 1990;45(6):425-430. doi:10.1136/thx.45.6.425
      REFERENCE #2: 2. Kodama K, Takase Y, Yamamoto H, Noda T. Cough-induced internal oblique hematoma. J Emerg Trauma Shock. 2013;6(2):132-134. doi:10.4103/0974-2700.110789
      REFERENCE #3: 3. Cherry WB, Mueller PS. Rectus sheath hematoma: review of 126 cases at a single institution. Medicine (Baltimore). 2006;85(2):105-110. doi:10.1097/01.md.0000216818.13067.5a
      DISCLOSURES: No relevant relationships by Fady Jamous, source=Web Response
      No relevant relationships by Swaminathan Perinkulam Sathyanarayanan, source=Web Response