Case report
A 78-year-old Nepalese male was admitted to our Grande International Hospital with a history of a sudden onset of pain and swelling over his left leg. He didn’t complain of fever, chest pain, shortness of breath, cough, or syncope. A family history of thrombophilia, autoimmune diseases, and hematological malignancies were absent. His personal history included 15 years of alcohol abuse, which he ceased 10 years ago. Medical history included hypertension under anti-hypertensive medications since 5 years, and had open angle glaucoma for 8 years. He denied any history of recent trauma or surgical intervention or any immobilization. On examination, his vital signs and systemic examinations were unremarkable. Besides his general appearance, he looked well-nourished and had a body mass index (BMI) of 26.03. Local examination showed ecchymosis, raised temperature, with pitting edema around the left knee with multiple blisters. There was no compromise in the perfusion or motor functions of the leg; deep tendon reflexes were preserved; and muscle power was 4/5. In addition, his mid-thigh circumference and mid-calf circumference measured 22 inches and 12 inches, respectively, as shown in Figure 1.
The patient’s history and physical findings pointed towards a likely diagnosis of deep vein thrombosis (DVT) with a modified Wells criteria score of 4 points.7 An urgent venous Doppler ultrasound of the left leg vein was performed, which revealed acute DVT involving the left superficial femoral, common femoral, external iliac, common iliac veins, and lower part of the inferior vena cava (IVC). Minimal re-canalization of the mid and distal superficial femoral veins with slow flow was noted. Partially occlusive thrombus was also found in the popliteal and proximal posterior tibial veins with diffuse subcutaneous edema. Following that, he was immediately started on low molecular weight heparin 120 mg/day subcutaneous route and oral warfarin 5 mg/7.5 mg on alternate days. The laboratory results are discussed separately in Table 1. The complete blood count (CBC), kidney, and liver functions were all normal. Meanwhile, serum homocysteine levels was > 50 mol/L(normal 5-15mmol/L), D-dimer was 2.15 mg/l (normal range,< 0.5 mg/l), and Fibrin degradation product (FDP) was 200 ng/ml. The thrombophilia profile (factor V Leiden, anti-thrombin III, protein C, and protein S) were negative.
During his stay in our ward on the second day, we observed the patient developed a sudden onset of cough, resting tachycardia, tachypnea, disorientation status, and mild cognitive impairment. He had bilateral decreased air entry and oxygen saturation was maintained at 0.5 liters of oxygen via nasal cannula. We had to shift him to the intensive care unit (ICU) as a pulmonary embolism was suspected. Computed tomography (CT) -pulmonary angiography was done, which ruled out pulmonary embolism. However, extensive images of the abdomen showed IVC thrombosis as shown in Figure 2 and Figure 3. He received monitoring, chest physiotherapy, and mobilization in the ICU. His echocardiography showed normal right atrium and right ventricle, normal left ventricular systolic function with grade I left ventricular diastolic dysfunction. Mild tricuspid regurgitation (TR) with an estimated pulmonary artery systemic pressure of 30 mm of mercury was noted. Low molecular weight heparin injection and oral warfarin were stopped and was started on the novel oral anticoagulant rivoraxaban at 30 mg/day for 2 weeks, then 20 mg/day as a maintenance dose. He was then shifted to ward for further treatment. The patient was started on methylcobalamin and folic acid treatment and responded well to our treatment during his stay in the ward. As his symptoms started to subside, he was then discharged. On the day of discharge, his mid-thigh and mid-calf circumference were 21 inches and 10.5 inches, respectively, as shown in Figure 1. We advised him to continue oral rivaroxaban and anti-hypertensive medications and come for follow-up after a week.
On follow-up, repeat venous Doppler ultrasound showed good recanalization of the left common femoral, superficial femoral, and popliteal veins, with slow flow in the lumen of these veins. No obvious thrombus was observed inside the calf veins. Very minimal to no recanalization of the left common iliac and external iliac veins. Our patient reported decreased swelling without any other complications. Since then, he has been on anticoagulant and was further advised to follow up after 3 months.