At 11 pm while working in our low acuity area I saw a 69 year old man with a flare up of left leg pain, swelling, and redness in upper thigh. He had complained of similar symptoms in the same leg on and off for 2 – 3 months with intermittent fevers. His family doctor had treated him with courses of antibiotics for cellulitis/lymph node infection. No immobilisation, surgeries or travel in the last year. He had also had three radiology suite-based lower limb ultrasound exams that were negative for deep vein thrombosis but one study commented on a small popliteal Baker’s cyst. He had good appetite and ate well but admitted to weight loss. No complaints of chest pain, breathlessness or cough.
On exam he was afebrile, not tachycardic nor tachypnoeic. There was erythema of the left proximal thigh, with minimal oedema to the same lower leg. Before a d.dimer result was available POCUS was performed using a standard serial compression technique from the left external iliac to the popliteal vein. This revealed loss of normal compressibility of veins throughout, with echogenic thrombus within, as shown in figure one.
Video: Non-compressible left external iliac vein with echogenic material within the vessel.
Blood test results were later released.
D.dimer 3310 mcg/L.Creatinine 221mmol/L(was 108 mmol/L, 3 months earlier).
With a diagnosis of extensive left iliofemoral and popliteal deep vein thrombosis with an acute kidney injury, once per day Clexane 1 U/Kg was started and the patient was admitted under General Medicine for further investigation of an unprovoked DVT.
Sonography, suite-based ultrasound concurred with POCUS findings, but in addition extended the exam to the inferior vena cava and beyond.
Transverse Plane: Enlarged IVC with echo dense material within.
Longitudinal plane: Poor colour flow signal within IVC.
Transverse view showing an enlarged, hyperechoic right kidney with irregular borders.
On this ultrasound thrombosis extends to the IVC in the vicinity of a large and irregular right kidney.
After IV hydration a contrast CT scan of the chest, abdomen and pelvis confirmed a large invasive right renal carcinoma with tumour extension into the (thrombus laden) IVC and bilateral renal veins. Thrombus extended to the right common iliac and femoral veins also.
The presence of multiple pulmonary nodules was reported to represent metastases. No pulmonary emboli confirmed.
This man was continued on once daily enoxaparin (persisting renal impairment) and referred to oncology and palliative care services.
In summary, despite several negative suite-based ultrasound scans a subsequent ultrasound was indicated given persistence of this man’s symptoms. Access to POCUS enabled earlier diagnosis and appropriate treatment. In this patient with only a few other ultrasound images, the origin of the thrombosis was also readily evident. Local guidelines state that 4 to 10 % of patients with unprovoked venous thromboembolism will be diagnosed with a malignancy within the next 12 months. Apart from occult malignancy some other associations of unprovoked venous thromboembolism include myeloproliferative neoplasms, nephrotic syndrome, pregnancy, antiphospholipid syndrome, and inherited thrombophilia. Specific Venous thromboembolism treatment recommendations vary depending on causes, locations of venous thromboembolism as well as other patient comorbidities. Familiarisation with up to date local guidelines for additional haematologic testing and treatment is recommended.
Case Study Provided By: Dr Mark Rewi, New Zealand FACEM
Reference:
1) Venous Thrombosis Management Guideline . Counties Manukau Health.2019.