Challenging differential diagnosis, Unusual setting of medical care, Rare co-existance of disease or pathology
Laura C. Myers, Matthew D. Li, Sanjeeva Kalva, Peggy S. Lai
(Division of Pulmonary/Critical Care, Massachusetts General Hospital, Boston, MA, USA)
Am J Case Rep 2019; 20:1679-1683
Risk factors for venous thromboembolism can include a combination of genetic, anatomic, and physiologic factors, some of which are modifiable. Patients presenting to the hospital with venous thromboembolism may have multiple risk factors that require testing beyond the initial admission labs and hypercoagulability screening panel.
CASE REPORT: We describe a right-handed patient who lifts weights for exercise, who presented with pulmonary infarcts and clot in the right superior vena cava/subclavian vein. These were due to a combination of 1) an acquired hypercoagulability from minimal change disease and 2) dynamic anatomic narrowing of the subclavian vein, which is known as Paget-Schroetter syndrome. Despite normal serum levels of antithrombin, protein C and S, his serum albumin was low, which prompted workup for proteinuria. Testing revealed nephrotic range proteinuria as well as dynamic occlusion of the right subclavian vein on magnetic resonance venography only when the patient lifted and externally rotated his arms.
CONCLUSIONS: This case report highlights the need for a thorough history and physical examination, as well as additional testing in some patients beyond the initial admission laboratory tests and screening panel for hypercoagulability. Tests could include diagnostic imaging testing with provoking maneuvers, which can help elucidate dynamic physiology. Such testing, when appropriate, can help to inform the treatment plan and prevent recurrent thromboses.
Keywords: nephrotic syndrome, Pulmonary Embolism, Thrombophilia, Upper Extremity Deep Vein Thrombosis