Hemolytic Anemia Due to Hematoma Formation After Deep Tissue Massage

Niloofar Yari, MD; Prathyusha M. Chitrapu, MD; and Bernard M. Karnath, MD
University of Texas Medical Branch, Galveston

A 50-year-old man presented with several days of mild fatigue and lack of energy. Previously, he had been physically active as a tennis coach without any history of fatigue. His past medical history was positive for cirrhosis and hypothyroidism. He was a nonsmoker but had a long history of alcohol use. He did not take any medications, and he denied any recent illnesses or sick contacts.

Physical examination. On examination, he had moderate scleral icterus and extensive ecchymoses on his lower abdomen, extending in a band-like fashion to his back. He did not have petechiae or other rashes. Abdominal examination findings were otherwise unremarkable, with no hepatosplenomegaly.

Diagnostic tests. Laboratory studies revealed the following values: white blood cell count, 3200/µL (close to the patient’s baseline value); hemoglobin, 5.8 g/dL (baseline, 12.0 g/dL one year prior to presentation); hematocrit, 16.8%; mean corpuscular volume, 105 µm3; platelet count, 66 × 103/µL; total bilirubin, 8.0 mg/dL (unconjugated bilirubin, 4.0 mg/dL); lactate dehydrogenase (LDH), 789 U/L; and haptoglobin, < 6 mg/dL. Urinalysis results showed 4+ urobilinogen with no hemosiderin and was otherwise negative.

Differential diagnosis. The patient had mild pancytopenia due to his cirrhosis, although the extremely low hemoglobin, elevated LDH, low haptoglobin, and unconjugated hyperbilirubinemia painted a hemolytic picture. Thus, hemolytic causes of anemia were considered at the top of the list, including autoimmune hemolytic anemias, trauma, glucose-6-phosphate dehydrogenase deficiency, or infection such as with human parvovirus B19.

Outcome of the case. The patient was admitted to the hospital, and further history revealed that he had undergone a deep tissue massage of his back and abdomen 3 weeks prior to admission. A consulting hematologist suggested that the hemolytic picture was a result of massive red blood cell breakdown and resorption after the massage, complicated by mild coagulopathy due to cirrhosis. Since the patient was otherwise asymptomatic, the treatment of choice was outpatient observation and monitoring while the hematoma resolved.

At the 3-month follow-up visit, the patient had regained his energy, and his laboratory test results were close to his to baseline—his hemoglobin level had recovered to 11.6 g/dL, hematocrit to 33%, platelet count to 78 × 103/µL, and total bilirubin to 3.6 mg/dL (unconjugated, 2.2 mg/dL).

Discussion. Deep tissue massage (DTM), as the name suggests, targets deeper muscles and connective tissue using more pressure and slower strokes than a conventional massage. The therapists often use elbows for increased pressure. DTM has been popularized for relaxation, pain reduction, and recovery after muscle injury, as well as for its numerous other health benefits.1-3 Kaye and colleagues3 showed that there is a significant decrease in heart rate and a mild, borderline nonsignificant decrease in blood pressure after DTM in predominantly normotensive individuals.

However, complications and adverse effects of DTM have been reported in the literature as early as 1997.4 These include venous thromboembolism (VTE),5 pulmonary embolism,6 spinal accessory nerve neuropathy leading to unilateral shoulder and arm weakness,7 and massive hematomas on the buttocks8 and liver.9 But perhaps most shockingly, one author reported the gradual migration of a venous leg stent to the right atrium after DTM, requiring open-heart surgery for removal.10

Kaye and colleagues3 listed a number of contraindications to DTM, including the presence of advanced osteoporosis and the presence of VTE or a fractured bone. Coagulopathic states, such as cirrhosis as in the case of our patient, should be added to the list of contraindications, although hematomas have been reported even in healthy persons without coagulopathy.8

It is important to educate patients about these findings. While conventional massages generally are safe and may help reduce chronic pain, certain patients—particularly those with coagulopathies—should be discouraged from undergoing DTM. In any case, patients always should be referred to licensed and experienced massage therapists.


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