Deep vein thrombosis – more than meets the eye

Introduction: Although portal vein thrombosis is a relatively common complication in patients diagnosed with cirrhosis of the liver, it is considered a rare event in the general population.There are many etiological causes, whether of local or systemic origin, and some of them may be responsible for the development of portal vein thrombosis (PVT), although an association of factors is often identified. Moreover, clinical presentation of this phenomenon is different in the context of acute or chronic onset and depends on the development and extent of a collateral circulation.
Case presentation: We present a case of a 36-year-old, with a history of heavy alcohol use, smoking, and drug abuse that presented with diffuse abdominal pain that persisted in the last two months despite proton pump inhibitors or painkiller administration.His medical history includes left lower limb deep vein thrombosis (DVT) (2005), pulmonary thromboembolism (2005) and right lower limb DVT (2008), the patient admitting low compliance towards the anticoagulant drug that he was prescribed. Following these recurrent thrombotic events the patient was tested for thrombophilia, perfor-ming genetic testing for associated mutations, as well as dosing the serum levels of proteins C and S, that were inconclusive. On admission, the patient was afebrile, BMI 22 kg/sqm, hemodynamically stable, with a heart rate of 70 b.p.m. and blood pressure 120/70 mmHg.
Pulmonary and cardiac physical examinations revealed no abnormalities. Physical examination of the abdo-men revealed spontaneous abdominal pain that inten-sified on palpation in the left flank, varicose veins and stasis dermatitis on both the left and right lower limb. The electrocardiogram shows no pathological changes. Baseline laboratory investigations revealed mild ane-mia, INR 1.78, D dimers 1577 ng/ml, Fibrinogen 530 mg/dl, negative virali makers.The transthoracic echo-graphy showed no evidence of pulmonary hypertensi-on, vegetation or intracavitary thrombi. The abdominal echography results were consistent with hepatospleno-megaly. Computerized tomography scans of the thorax and abdomen revealed complete portal vein and portal branches thrombosis, complete splenic vein thrombosis, superior mesenteric vein thrombosis, postrenal segment hypoplasia of the inferior vena cava. Gastroscopy and colonoscopy showed no abnormalities. We started the patient on unfractionated heparin with favorable results.
Conclusions: Among the causes cited for portal vein thrombosis are abdominal neoplasms, hereditary thrombophilia, antiphospholipid syndrome or myelo-proliferative syndromes. In this case, lower vena cava hypoplasia along with tobacco and cannabinoids use may explain the recurrence of deep vein thrombosis in the lower limbs, but not the portal vein thrombo-sis. Thrombosis of neoplastic etiology seems unlikely given the current clinical context and investigations. We believe that testing for both thrombophilia after the completion of anticoagulation therapy and for antipho-spholipid syndrome is still a viable diagnostic choice.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)