Spontaneous inferior epigastric artery hemorrhage in a COVID-19 patient with membranous nephropathy on anticoagulant therapy: a Case Report

Background: The management of Coronavirus disease 2019 (COVID-19) is complicated by coagulopathies that increase both thrombotic and hemorrhagic risks, particularly in patients with comorbidities such as membranous nephropathy (MN) who require anticoagulation. Spontaneous inferior epigastric artery (IEA) hemorrhage is a rare but life-threatening complication in this setting. Case presentation: A 63-years-old woman with M-type phospholipase A2 receptor (PLA2R)-positive MN was admitted for COVID-19 pneumonia and acute respiratory distress syndrome (ARDS). Despite prophylactic anticoagulation with dalteparin, her respiratory status deteriorated, requiring intensive care. On day 24, she developed sudden hemorrhagic shock due to a rectus sheath hematoma from spontaneous IEA rupture, confirmed by imaging and surgical exploration. The hemorrhage was managed with ligation, transfusion, and discontinuation of anticoagulation. Her recovery was marked by resolution of pulmonary and hemorrhagic complications by day 46, and 3-months follow-up showed no recurrence of bleeding or thrombotic events. Conclusion: This case highlights the critical balance between thromboprophylaxis and bleeding risk in COVID-19 patients with MN. It underscores the need for individualized anticoagulation strategies, pharmacodynamic monitoring, and multidisciplinary decision-making to mitigate risks in this high-risk population. The interplay of COVID-19-induced coagulopathy, renal impairment, and immunosuppressive therapy amplifies both thrombotic and hemorrhagic tendencies, necessitating extreme vigilance in clinical management.