Disclosures: John P. Pianka, MD: No financial relationships or conflicts of interest

Case Diagnosis: A 75-year-old male with a history of multiple sclerosis admitted to acute inpatient rehab with impairments related to a multiple sclerosis exacerbation.

Case Description or Program Description: Patient initially presented to the hospital with multiple falls and progressively worsening lower extremity weakness, and was admitted to inpatient rehabilitation after treatment for an acute exacerbation of multiple sclerosis. Screening duplex ultrasound on admission disclosed bilateral femoral and popliteal deep vein thromboses (DVTs), and the patient was started on therapeutic enoxaparin. Soon after admission he began complaining of right lower extremity pain and tightness. Physical examination revealed suspected spasticity in the bilateral lower extremities, and his home baclofen dose was increased twice over the next two weeks. After this time, new pitting edema was noted at the proximal but not distal right lower extremity, which worsened after 24 hours of observation. There was no erythema or ecchymosis. A CT scan of the proximal right lower extremity was ordered. Of note, hemoglobin had also dropped from 14.0 twelve days prior to 10.3.

Setting: Acute inpatient rehabilitation hospital.

Assessment/Results: The patient was found to have an elevated creatine kinase (CK) of 403 and a C-reactive protein (CRP) of 55.4. His CT scan disclosed a fluid collection within the vastus medialis, measuring almost 30 centimeters superior-inferior, suspected to be a hematoma given his recent anticoagulation. There was no evidence of compartment syndrome. His enoxaparin was held, and the patient was transferred to an acute medical hospital for continued care.

Discussion (relevance): In this case, the patient’s complaints of worsened lower extremity pain and tightness were initially attributed to worsened spasticity secondary to a multiple sclerosis exacerbation. In reality, he was likely developing a quadriceps hematoma after being therapeutically anticoagulated for DVTs in the setting of multiple recent falls at home.

Conclusions: The differential diagnosis of thigh pain is broad, as is the differential for thigh edema, and hematoma should be considered in the appropriate clinical scenario.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/massive-quadriceps-hematoma-masquerading-as-worsened-spasticity-after-a-multiple-sclerosis-exacerbation-a-case-report/