Case Report: Unprovoked venous thromboembolism in a young adult

A 24-year-old male was presented to us with sudden onset of chest pain and dyspnea for the past one hour. There was no history of calf pain, trauma, surgery, prolonged immobilization, long-haul air travel, bleeding diathesis or any other co-morbidity. The patient denied any addiction history. The Electrocardiogram showed tachycardia with S1Q3T3 pattern. The left arterio-venous Doppler study was suggestive of a thrombus in popliteal vein and sapheno-popliteal junction. The CT-Pulmonary Angiogram scan was suggestive of a massive pulmonary thromboembolism. The patient was thrombolysed with Intravenous Alteplase immediately and was put on tab Rivaroxaban for maintenance. He was later discharged after being stable. Unprovoked venous thromboembolism (VTE) is very rare and has the potential to lead to pulmonary embolism which could be disastrous, especially in young adults. We present such a case where unprovoked VTE was diagnosed and treated. This case suggests that high clinical suspicion is the key for the diagnosis of acute pulmonary embolism, especially in the absence of history suggestive of deep vein thrombosis.

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Case Report: Unprovoked venous thromboembolism in a young adult male

F1000Research ◽

10.12688/f1000research.18202.2 ◽

2019 ◽

Vol 8 ◽

pp. 182

Author(s):

Jeyhan Dhabhar ◽

Varshil Mehta ◽

Nimit Desai ◽

Sameer Dawoodi ◽

Sojib Bin Zaman

Keyword(s):

Pulmonary Embolism ◽

Venous Thromboembolism ◽

Trauma Surgery ◽

Sudden Onset ◽

Vein Thrombosis ◽

Doppler Study ◽

Pulmonary Angiogram ◽

Co Morbidity ◽

History Of ◽

Prolonged Immobilization

A 24-year-old male was presented to us with sudden onset of chest pain and dyspnea for the past one hour. There was no history of calf pain, trauma, surgery, prolonged immobilization, long-haul air travel, bleeding diathesis or any other co-morbidity. The patient denied any addiction history. The heart rate was 114 beats/min, and blood pressure was 106/90 mmHg. Electrocardiogram showed tachycardia with S 1Q 3T 3 pattern. The left arterio-venous Doppler study was suggestive of a thrombus in popliteal vein and sapheno-popliteal junction. The CT-Pulmonary Angiogram scan was suggestive of a massive pulmonary thromboembolism. The patient was thrombolysed with Intravenous Alteplase immediately and was put on tab Rivaroxaban for maintenance. He was later discharged after being stable. Unprovoked venous thromboembolism (VTE) is very rare and has the potential to lead to pulmonary embolism which could be disastrous, especially in young adults. We present such a case where unprovoked VTE was diagnosed and treated. This case suggests that high clinical suspicion is the key for the diagnosis of acute pulmonary embolism, especially in the absence of history suggestive of deep vein thrombosis.

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A Rare Case of Pulmonary Embolism: A Case Report

Nepal Medical Journal ◽

10.37080/nmj.33 ◽

2019 ◽

Vol 2 (1) ◽

pp. 105-109

Author(s):

Tirtha Man Shrestha ◽

Ram Neupane ◽

Bandana Neupane ◽

Reeju Manandhar

Keyword(s):

Risk Factors ◽

Pulmonary Embolism ◽

Chest Pain ◽

Lung Diseases ◽

Troponin I ◽

Sudden Onset ◽

Coagulation Disorder ◽

Coronary Syndrome ◽

Doppler Study ◽

History Of

Pulmonary embolism in an old patient with a history of coagulation disorder, any recent major surgeries or in a chronic heart or lung diseases is widely reported. Also, a recent history of travel by air with flight distance of more than 5000km or BMI greater than 35 kg/m2 increase risk. However, we report here, a suggestive case of acute pulmonary embolism in a previously well male of 38 years, with a BMI of 25.71kg/m2 without any history of chronic illness or acute exacerbations. The patient presented in health facility with sudden onset of radiating chest pain and some other nonspecific symptoms. Neither any other significant personal risk factors except smoking, nor any family history of heart/lung diseases were ruled out during initial assessments. On investigations, other routine examinations were normal but T-wave inversion was noticed in lead V1-4 in ECG, Troponin-I was positive and CPK-MB was slightly elevated (27 U/L). Furthermore, no any remarkable changes were noticed in Chest X-ray. Then, the patient was referred to higher center with cardiac facility with provisional diagnosis of Acute Coronary Syndrome for further evaluation and management. Thereupon, Coronary Angiogram (CAG) was done and the report was normal but echocardiography findings were suggestive of pulmonary Embolism. D-dimer was also elevated (8279.05 ng/ml) but venous doppler study of bilateral lower limb was normal. Finally, CT-PA showed partially occluding thrombus in main pulmonary bifurcation extending into left and right pulmonary artery, its bilateral segmental branches and calcified granuloma was seen in right lobe of liver. Patient was under inj. LMWH and other supportive management during hospitalization. After an uneventful hospital stay for 12 days, general condition was improved and eventually, patient was discharged, with oral warfarin. Keywords: chest pain; Nepal; pulmonary embolism; risk factors.

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Individually Tailored Prophylaxis Using a Risk Score for the Management of Pregnant Women with Increased Risk of Venous Thromboembolism

Blood ◽

10.1182/blood.v126.23.889.889 ◽

2015 ◽

Vol 126 (23) ◽

pp. 889-889

Author(s):

Yesim G. Dargaud ◽

Lucia Rugeri ◽

Chloe Fleury ◽

Helene Desmurs Clavel ◽

Jacques Ninet ◽

...

Keyword(s):

Pulmonary Embolism ◽

Venous Thromboembolism ◽

High Risk ◽

Prospective Study ◽

Pregnant Women ◽

Risk Score ◽

Personal History ◽

Vein Thrombosis ◽

Increased Risk ◽

History Of

Abstract Patients with thrombophilia and/or a history of venous thromboembolism (VTE) exhibit a high risk of thrombosis during pregnancy. A risk score for pregnancies with increased risk of VTE was previously described by our group (1,2). The present work reports the results of a prospective study, evaluating the efficacy and the safety of the prophylaxis strategy based on the same risk score, in 542 pregnancies at high risk of VTE, managed between 2005 and 2015 in Lyon University Hospitals. Among 445 patients included in the study, 26 had several pregnancies during the study period. The mean age of the study population was 33±4.8 years, 132 women (29.7%) were older than 35 years. Fifty three women had a BMI of 30 or over and 61 were smokers. Among these 445 patients, 279 had a personal history of VTE (62.7%), 299 patients (67.2%) had a thrombophilia marker and 131 (29.4%) thrombophilic women had a personal history of VTE. During pregnancy, patients were assigned to one of three prophylaxis strategies according to the risk scoring system. Compression stockings were worn by the majority of the patients throughout the pregnancy and during the postpartum. In antepartum, LMWH prophylaxis was prescribed to 64.5% of patients with high risk of VTE. Among them, 34.4% were treated in the third trimester only and 30.1% were treated throughout pregnancy. In postpartum, all patients received low molecular weight heparin (LMWH) prophylaxis for at least 6 weeks. In this cohort, two antepartum-related VTE (0.37%) and four postpartum-related VTE (0.73%) occurred. One of the ante-partum related VTE was occurred in a patient who was on LMWH prophylaxis with enoxaparin 40mg/day for a personal history of spontaneous pulmonary embolism and homozygous prothrombin G20210A mutation. Despite well conducted LMWH prophylaxis, the patient had a distal deep vein thrombosis (DVT) at week 28. The second VTE was a proximal DVT during a bed resting in the eighth month of pregnancy in a patient with heterozygous FV Leiden mutation and a history of proximal DVT. According to the risk score, LMWH prophylaxis was required during bed-resting but it was not prescribed by the obstetrician. Among four postpartum-related VTE, 3 occurred after the 6 weeks of LMWH prophylaxis, between weeks 8 and 12 of the postpartum period and one was a ovarian vein thrombosis. No case of pulmonary embolism was observed during the study period. The rate of bleeding was 0.37%, no serious bleeding requiring transfusions or surgery was occurred during the study period. There was no evidence of heparin-induced thrombocytopenia or osteoporosis. The use of a risk score may provide a rational decision process to implement safe and effective antepartum thromboprophylaxis in pregnant women at high risk of VTE Dargaud, Y., Rugeri, L., Ninet, J., Negrier, C. & Trzeciak, M.C. Management of pregnant women with increased risk of venous thrombosis. International Journal of Gynaecology and Obstetrics 2005, 90,203-207 Dargaud, Y., Rugeri, L., Vergnes MC, Arnuti B, Miranda P, Negrier, C., Ninet, J., Trzeciak, M.C. A risk score for the management of pregnant women with increased risk of venous thrombomebolism: a multicenter prospective study. Br J Haematol 2009;145:825-35 Disclosures No relevant conflicts of interest to declare.

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Venous thromboembolism in a general hospital. An update with low molecular weight heparin prophylaxis

VASA ◽

10.1024/0301-1526.36.1.17 ◽

2007 ◽

Vol 36 (1) ◽

pp. 17-22

Author(s):

Schulz ◽

Kesselring ◽

Seeberger ◽

Andresen

Keyword(s):

Molecular Weight ◽

Pulmonary Embolism ◽

Venous Thromboembolism ◽

Low Molecular Weight ◽

Trauma Patients ◽

Vte Prophylaxis ◽

Vein Thrombosis ◽

Patients At Risk ◽

Hospital Stays ◽

Event Rates

Background: Patients admitted to hospital for surgery or acute medical illnesses have a high risk for venous thromboembolism (VTE). Today’s widespread use of low molecular weight heparins (LMWH) for VTE prophylaxis is supposed to have reduced VTE rates substantially. However, data concerning the overall effectiveness of LMWH prophylaxis is sparse. Patients and methods: We prospectively studied all patients with symptomatic and objectively confirmed VTE seen in our hospital over a three year period. Event rates in different wards were analysed and compared. VTE prophylaxis with Enoxaparin was given to all patients at risk during their hospital stay. Results: A total of 50 464 inpatients were treated during the study period. 461 examinations were carried out for symptoms suggestive of VTE and yielded 89 positive results in 85 patients. Seventy eight patients were found to have deep vein thrombosis, 7 had pulmonary embolism, and 4 had both deep venous thrombosis and pulmonary embolism. The overall in hospital VTE event rate was 0.17%. The rate decreased during the study period from 0.22 in year one to 0,16 in year two and 0.13 % in year three. It ranged highest in neurologic and trauma patients (0.32%) and lowest (0.08%) in gynecology-obstetrics. Conclusions: With a simple and strictly applied regimen of prophylaxis with LMWH the overall rate of symptomatic VTE was very low in our hospitalized patients. Beside LMWH prophylaxis, shortening hospital stays and substantial improvements in surgical and anasthesia techniques achieved during the last decades probably play an essential role in decreasing VTE rates.

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Familial thrombophilia associated with fibrinogen Paris V: Dusart syndrome

Blood ◽

10.1182/blood.v96.3.1191 ◽

2000 ◽

Vol 96 (3) ◽

pp. 1191-1193 ◽

Cited By ~ 15

Author(s):

Takashi Tarumi ◽

Danko Martincic ◽

Anne Thomas ◽

Robert Janco ◽

Mary Hudson ◽

...

Keyword(s):

Pulmonary Embolism ◽

Venous Thromboembolism ◽

Early Onset ◽

Family Members ◽

Initial Presentation ◽

Pulmonary Emboli ◽

Common Cause ◽

History Of ◽

Prophylactic Anticoagulation ◽

Fibrin Clots

Abstract We report on a family with a history of venous thromboembolism associated with fibrinogen Paris V (fibrinogen A-Arg554→Cys). Ten members experienced thrombotic events, including 4 with fatal pulmonary emboli. Pulmonary embolism was the presenting feature in 4. Those with the mutation and a history of thrombosis had somewhat higher fibrinogen concentrations than those with the mutation and no thrombosis (294 ± 70 mg/dL vs 217 ± 37 mg/dL, respectively). The Paris V mutation consistently caused a prolongation of the reptilase time, and fibrin clots containing the abnormal fibrinogen were more translucent than normal clots. Given the early onset of symptoms and the initial presentation with pulmonary embolism in some family members, it was justifiable to offer prophylactic anticoagulation with warfarin to carriers of the mutation. Fibrinogen Paris V has now been reported in 4 apparently unrelated families, indicating that it is a relatively common cause of dysfibrinogenemia-associated thrombosis.

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Incidence of venous thromboembolism among patients receiving neoadjuvant chemotherapy for advanced epithelial ovarian cancer

International Journal of Gynecological Cancer ◽

10.1136/ijgc-2019-000980 ◽

2020 ◽

Vol 30 (4) ◽

pp. 491-497 ◽

Cited By ~ 3

Author(s):

Julia Rose Salinaro ◽

Kourtnie McQuillen ◽

Megan Stemple ◽

Robert Boccaccio ◽

Jessie Ehrisman ◽

...

Keyword(s):

Ovarian Cancer ◽

Pulmonary Embolism ◽

Deep Vein Thrombosis ◽

Venous Thromboembolism ◽

Adjuvant Chemotherapy ◽

Neoadjuvant Chemotherapy ◽

Epithelial Ovarian Cancer ◽

Primary Outcome ◽

Vein Thrombosis ◽

Deep Vein

ObjectivesNeoadjuvant chemotherapy may be considered for women with epithelial ovarian cancer who have poor performance status or a disease burden not amenable to primary cytoreductive surgery. Overlap exists between indications for neoadjuvant chemotherapy and known risk factors for venous thromboembolism, including impaired mobility, increasing age, and advanced malignancy. The objective of this study was to determine the rate of venous thromboembolism among women receiving neoadjuvant chemotherapy for epithelial ovarian cancer.MethodsA multi-institutional, observational study of patients receiving neoadjuvant chemotherapy for primary epithelial ovarian, fallopian tube, or peritoneal cancer was conducted. Primary outcome was rate of venous thromboembolism during neoadjuvant chemotherapy. Secondary outcomes included rates of venous thromboembolism at other stages of treatment (diagnosis, following interval debulking surgery, during adjuvant chemotherapy, or during treatment for recurrence) and associations between occurrence of venous thromboembolism during neoadjuvant chemotherapy, subject characteristics, and interval debulking outcomes. Venous thromboembolism was defined as deep vein thrombosis in the upper or lower extremities or in association with peripherally inserted central catheters or ports, pulmonary embolism, or concurrent deep vein thrombosis and pulmonary embolism. Both symptomatic and asymptomatic venous thromboembolism were reported.ResultsA total of 230 patients receiving neoadjuvant chemotherapy were included; 63 (27%) patients overall experienced a venous thromboembolism. The primary outcome of venous thromboembolism during neoadjuvant chemotherapy occurred in 16 (7.7%) patients. Of the remaining venous thromboembolism events, 22 were at diagnosis (9.6%), six post-operatively (3%), five during adjuvant chemotherapy (3%), and 14 during treatment for recurrence (12%). Patients experiencing a venous thromboembolism during neoadjuvant chemotherapy had a longer mean time to interval debulking and were less likely to undergo optimal cytoreduction (50% vs 80.2%, p=0.02).ConclusionsPatients with advanced ovarian cancer are at high risk for venous thromboembolism while receiving neoadjuvant chemotherapy. Consideration of thromboprophylaxis may be warranted.

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Venous Thromboembolism

10.2310/vasc.2101 ◽

2017 ◽

Author(s):

Guillermo A. Escobar ◽

Peter K. Henke ◽

Thomas W. Wakefield

Keyword(s):

Pulmonary Embolism ◽

Deep Vein Thrombosis ◽

Venous Thromboembolism ◽

Lower Extremity ◽

The United States ◽

Laboratory Evaluation ◽

Individual Risk ◽

Vein Thrombosis ◽

Clinical Scenarios ◽

Deep Vein

Deep vein thrombosis (DVT) and pulmonary embolism (PE) comprise venous thromboembolism (VTE). Together, they comprise a serious health problem as there are over 275,000 new VTE cases per year in the United States, resulting in a prevalence of one to two per 1,000 individuals, with some studies suggesting that the incidence may even be double that. This review covers assessment of a VTE event, initial evaluation of a patient suspected of having VTE, medical history, clinical presentation of VTE, physical examination, laboratory evaluation, imaging, prophylaxis against perioperative VTE, indications for immediate intervention (threat to life or limb), indications for urgent intervention, and management of nonemergent VTE. Figures show a modified Caprini score questionnaire used at the University of Michigan to determine individual risk of VTE and the indicated prophylaxis regimen; Wells criteria for DVT and PE; phlegmasia cerulea dolens secondary to acute left iliofemoral DVT after thigh trauma; compression duplex ultrasonography of lower extremity veins; computed tomographic angiogram of the chest demonstrating a thrombus in the pulmonary artery, with extension into the right main pulmonary; management of PE according to Wells criteria findings; management of PE with right heart strain in cases of massive or submassive PE; treatment of DVT according to clinical scenario; a lower extremity venogram of a patient with May-Thurner syndrome and its subsequent endovascular treatment; and various examples of retrievable vena cava filters (not drawn to scale). Tables list initial clinical assessment for VTE, clinical scenarios possibly benefiting from prolonged anticoagulation after VTE, indications for laboratory investigation of secondary thrombophilia, venous thromboembolic risk accorded to hypercoagulable states, and Pulmonary Embolism Rule-out Criteria Score to avoid the need for D-dimer in patients suspected of having PE. This review contains 11 highly rendered figures, 5 tables, and 167 references. Key words: anticoagulation; deep vein thrombosis; postthrombotic syndrome; pulmonary embolism; recurrent venous thromboembolism; thrombophilia; venous thromboembolism; PE; VTE; DVT

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Economic Analysis of Rivaroxaban for the Treatment and Long-Term Prevention of Venous Thromboembolism in Portugal

Acta Médica Portuguesa ◽

10.20344/amp.5257 ◽

2014 ◽

Vol 27 (5) ◽

pp. 615 ◽

Cited By ~ 4

Author(s):

Isabel Fonseca Santos ◽

Sónia Pereira ◽

Euan McLeod ◽

Anne-Laure Guillermin ◽

Ismini Chatzitheofilou

Keyword(s):

Pulmonary Embolism ◽

Venous Thromboembolism ◽

Standard Of Care ◽

Quality Adjusted Life Years ◽

Vein Thrombosis ◽

Scenario Analyses ◽

Life Years ◽

Deep Vein ◽

Quality Adjusted Life

Introduction: Venous thromboembolism is a burden on healthcare systems. The aim of this analysis was to project the long-term costs and outcomes for rivaroxaban compared to standard of care (enoxaparin/warfarin) in Portugal for the treatment and secondary prevention of venous thromboembolism. Material and Methods: A Markov model was developed using event rates extracted from the EINSTEIN trials supplemented with literature-based estimates of longer-term outcomes. Core outcomes included per patient costs and quality-adjusted life years reported separately per treatment arm and incrementally, as well as cost per quality-adjusted life years gained. The deep vein thrombosis and pulmonary embolism indications were analysed separately. The analyses were conducted from the Portuguese societal perspective and over a 5-year time horizon. Costs and outcomes were discounted at a 5% annual rate. Several scenario analyses were undertaken to explore the impact on results of varying key modeling assumptions. Results: Rivaroxaban treatment was associated with cost-savings for the treatment of deep vein thrombosis and was both cost-saving and more effective for the treatment of pulmonary embolism, compared with enoxaparin/warfarin. Discussion: The results of the sensitivity and scenario analyses further supported that rivaroxaban is a cost-effective alternative to standard of care treatment. The use of an expert panel to derive some input values and the lack of Portuguese specific utilities were the main limitations. Conclusion: Rivaroxaban represents an efficient alternative to using enoxaparin/warfarin in Portugal, as it’s associated with lower costs (for both indications) and greater quality adjusted life years (for the pulmonary embolism indication). Keywords: Venous Thrombosis; Pulmonary Embolism; Rivaroxaban; Venous Thromboembolism.

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Anticoagulant therapies for acute venous thromboembolism: a comparison between those discharged directly from the emergency department versus hospital in two Canadian cities

BMJ Open ◽

10.1136/bmjopen-2018-022063 ◽

2018 ◽

Vol 8 (10) ◽

pp. e022063 ◽

Cited By ~ 3

Author(s):

Tammy J Bungard ◽

Bruce Ritchie ◽

Jennifer Bolt ◽

William M Semchuk

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Venous Thromboembolism ◽

Severity Index ◽

Vein Thrombosis ◽

Risk Patients ◽

Acute Venous Thromboembolism ◽

Record Review ◽

Deep Vein

ObjectiveTo compare the characteristics/management of acute venous thromboembolism (VTE) for patients either discharged directly from the emergency department (ED) or hospitalised throughout a year within two urban cities in Canada.DesignRetrospective medical record review.SettingHospitals in Edmonton, Alberta (n=4) and Regina, Saskatchewan (n=2) from April 2014 to March 2015.ParticipantsAll patients discharged from the ED or hospital with acute deep vein thrombosis or pulmonary embolism (PE). Those having another indication for anticoagulant therapy, pregnant/breast feeding or anticipated lifespan <3 months were excluded.Primary and secondary outcomesPrimarily, to compare proportion of patients receiving traditional therapy (parenteral anticoagulant±warfarin) relative to a direct oral anticoagulant (DOAC) between the two cohorts. Secondarily, to assess differences with therapy selected based on clot burden and follow-up plans postdischarge.Results387 (25.2%) and 665 (72.5%) patients from the ED and hospital cohorts, respectively, were included. Compared with the ED cohort, those hospitalised were older (57.3 and 64.5 years; p<0.0001), more likely to have PE (35.7% vs 83.8%) with a simplified Pulmonary Embolism Severity Index (sPESI) ≥1 (31.2% vs 65.2%), cancer (14.7% and 22.3%; p=0.003) and pulmonary disease (10.1% and 20.6%; p<0.0001). For the ED and hospital cohorts, similar proportions of patients were prescribed traditional therapies (72.6% and 71.1%) and a DOAC (25.8% and 27.4%, respectively). For the ED cohort, DOAC use was similar between those with a sPESI score of 0 and ≥1 (35.1% and 34.9%, p=0.98) whereas for those hospitalised lower risk patients were more likely to receive a DOAC (31.4% and 23.8%, p<0.055). Follow-up was most common with family physicians for those hospitalised (51.5%), while specialists/VTE clinic was most common for those directly discharged from the ED (50.6%).ConclusionsTraditional and DOAC therapies were proportionately similar between the ED and hospitalised cohorts, despite clear differences in patient populations and follow-up patterns in the community.

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Non traumatic spinal epidural haematoma

Acute Medicine Journal ◽

10.52964/amja.0787 ◽

2019 ◽

Vol 18 (4) ◽

pp. 255-258

Author(s):

Naureen Abdul Khalid ◽

◽

Nainal Shah ◽

Keyword(s):

Magnetic Resonance Imaging ◽

Trauma Surgery ◽

Epidural Haematoma ◽

Rare Condition ◽

Sudden Onset ◽

Resonance Imaging ◽

Spinal Epidural Haematoma ◽

History Of ◽

Magnetic Resonance Imaging Mri ◽

Spinal Epidural

Spinal epidural haematoma is a rare condition, which may be due to trauma, surgery, epidural catheterisation or disorders of coagulation. We report a case of 60 year old lady who was on warfarin for Atrial fibrillation (AF) presented with history of non-traumatic sudden onset pain in both legs and difficulty in walking. Magnetic resonance imaging (MRI) spine demonstrated epidural haematoma which was treated conservatively. Another dilemma was anticoagulation for AF. We examine the options to manage such case.

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