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08 October 2020 : Case report  Singapore

Spontaneous Epidural Hematoma of the Cervical Spine in an Elderly Woman with Recent COVID-19 Infection: A Case Report

Challenging differential diagnosis, Rare disease

Shawn Wen-Yang Lim1BEF*, Evelyn Wong1E

DOI: 10.12659/AJCR.926784

Am J Case Rep 2020; 21:e926784

Abstract

BACKGROUND: This report presents the case of a woman with no known coagulopathy, use of anticoagulants, or history of trauma who spontaneously developed an epidural hematoma of the spine. This is an uncommon condition, with the potential for missed diagnosis and potential harm to the patient.

CASE REPORT: The patient was an elderly woman with a history of Type 2 diabetes mellitus and hyperlipidemia. Of note, she had recently recovered from COVID-19. Because the woman presented with right-sided weakness and pain in the back of her neck, the stroke team was activated. A computed tomography (CT) scan of her neck revealed a very subtle hyperdensity, which on further investigation was found to be an acute epidural hematoma at C2–C3 space through the C6 vertebra. While awaiting surgery, the patient had spontaneous improvement of her right-sided weakness and her condition eventually was managed conservatively.

CONCLUSIONS: Spontaneous spinal epidural hematoma is an uncommon condition, and a high index of suspicion is required to accurately diagnose and appropriately manage it. In the case presented here, the hematoma was subtle on the CT scan, and the patient’s weakness easily could have been misdiagnosed as an ischemic stroke. That may have resulted in administration of thrombolytics, potentially causing significant harm. In addition, the patient had recently recovered from COVID-19 disease, which may or may not be incidental. Further observation will be required to determine if there is a spike in similar cases, which may be temporally associated with the novel coronavirus.

Keywords: COVID-19, Hematoma, Epidural, Spinal, Spinal Stenosis

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American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923