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.