Urgent Rectus Sheath Hematoma Induced by Severe Coughing

Rectus sheath hematoma (RSH) is an uncommon but clinically significant cause of acute abdominal pain, most often associated with anticoagulant therapy, abdominal trauma, or prior surgery. Although coughing is a recognized but rare etiology, cases without anticoagulant exposure are unusual. We report the case of a 57-year-old man with hypertension who presented with acute right abdominal pain after 1 week of persistent cough. Physical examination revealed abdominal wall discoloration, a firm mass, and a positive Carnett sign, suggesting an abdominal wall origin of pain. Laboratory evaluation showed leukocytosis and elevated inflammatory markers, and computed tomography demonstrated bronchopneumonia and multiple hematomas within the right rectus abdominis muscle. The hematomas showed high attenuation, measuring 50-75 Hounsfield units, consistent with acute hematoma. Despite initial hemodynamic stability, the patient rapidly deteriorated with tachycardia and hypotension, necessitating emergency hematoma evacuation. After intensive care and rehabilitation, he was discharged in good condition. This case highlights that cough-induced RSH, although rare, can progress rapidly to hemodynamic instability. Physicians should consider RSH in the differential diagnosis of abdominal pain with abdominal wall discoloration following coughing episodes, even in the absence of traditional risk factors, as timely recognition and intervention are essential to prevent morbidity and mortality.