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Self‐medication and intractable cough

Copyright © 2010 Society of Hospital Medicine

A 60 year old man presented with a 1‐month history of severe, dry cough. His medical history is significant for lymphoma (4 years), bone marrow transplant (8 months), stable graft‐vs.‐host disease, with a negative bleeding history. He self‐medicated his cough with 6 to 8 tablets daily of an analgesic containing 250 mg acetaminophen, 65 mg caffeine, and 250 mg aspirin. He developed severe stabbing pain in his right lower quadrant exacerbated by coughing. Several days later he developed severe pain of his left upper abdomen. The abdominal wall was tender. Laboratory tests revealed a hematocrit of 31%, platelet count of 246,000, international normalized prothrombin ratio of 1.0, and activated partial thromboplastin ratio of 0.8. Abdominal computed tomography (CT) without contrast revealed 2 rectus sheath hematomas. A 4‐cm 2‐cm 2‐cm collection consistent with hematoma was contained within the left rectus abdominis muscle sheath above the level of the umbilicus (white arrow, Figure 1A, top). An additional collection measuring 6 cm 6 cm 4 cm was present below the umbilicus and between the posterior aspect of the right rectus abdominus muscle (black arrows, Figure 1A bottom; B and C) and the anterior surface of the bladder (arrowhead, Figure 1A and C). Aspirin was stopped and he was started on moxifloxacin for pneumonia. He was discharged 3 days later with improved cough resulting in improved pain control.

Figure 1

Abdominal computed tomography (CT) without contrast revealed 2 rectus sheath hematomas. (A) A 4‐cm × 2‐cm × 2‐cm collection consistent with hematoma was contained within the left rectus abdominis muscle sheath above the level of the umbilicus (white arrow, top). (bottom A; B, C) An additional collection measuring 6 cm × 6 cm × 4 cm was present below the umbilicus and between the posterior aspect of the right rectus abdominus muscle (black arrows) and the anterior surface of the bladder (A, C; arrowhead).

Rectus sheath hematoma may be contained with the fascia when above the arcuate line, located about 5 cm below the umbilicus. Below the arcuate line a rectus sheath hematoma may dissect posteriorly into the prevesicular space of Retzius. Both are seen in this case. Rectus sheath hematoma are usually associated with cough in the setting of coagulopathy, and may require transfusion or surgical evacuation. High dose aspirin, in this case up to 2000 mg per day, may lead to hemorrhage associated with intractable coughing.

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