Thrombosis of Internal Jugular Vein in Nephrotic Syndrome Presenting as Neck Pain

Abstract

Sir,Thrombosis is a known complication of nephrotic syn-drome. It has most commonly been described in deep legveins, inferior vena cava and renal veins [1]. We report a 6-y-old boy, a diagnosed case of steroid dependant nephroticsyndrome who failed to go into remission despite 4 wk oforal prednisolone @ 2 mg/kg/d. Kidney biopsy showedfeatures of Focal segmental glomerulosclerosis. Pulse cy-clophosphamide therapy was planned but prior to its initia-tion the child started complaining of dizziness and neckpain. Doppler ultrasound demonstrated right internal jugularvein (IJV) thrombosis. The child was immediatelystarted onLMW Heparin. Over the next one wk the pain subsided andsubsequent dopplers were normal. The child at 2 mo followup has had no fresh complaints and is on oral warfarin.Children with nephrotic syndrome are prone to multiplecomplications due to the disease itself and due to drugs includ-ingsteroids,diuretics,antihypertensives,bloodandbloodprod-ucts, albumin and antibiotics. The overall incidence ofthromboembolic events in patients with nephrotic syndromein a series was 20.4 patients/1000 patient-years [2]. In nonpediatric studies, patients with membranous nephropathy,MPGN and Minimal change disease were found to be at riskofvenous thromboembolism andtherates haverangedfrom8-44%. The median time to diagnosis of thromboembolism inpatientswithnephroticsyndromehasbeenreportedtobe70.5dafter the diagnosis. In our patient the duration was 14 mo. Riskof deep vein thrombosis has been associated with the use ofcentralvenouscatheters(45%)[2]notbeingforthcominginourpatient. Age of onset of greater than or equal to 12 y is anindependent predictor of thromboembolic complications [2].Multiple mechanisms responsible for the increased riskinclude an increase in the prothrombotic factors such asfactor VIII and fibrinogen levels and a concomitant decreasein the Protein C, Protein S and Antithrombin III levels. In astudy conducted in Bulgaria the major iatrogenic risk factorfor thrombosis was identified as the use of furosemide [2]which was also used in our patient at pharmacologic doses.Inthepastcontrastvenographywasconsideredthestandarddiagnostictestbuthasbeenreplacedbyultrasonographywhichis a non invasive and easily available modality. [ 3] The find-ings on USG are a dilated and incompressible vein and anintraluminalclot[4].Despitethiscomplicationbeingcommon,thereisnoevidencetosupportroutineanticoagulationprophy-lactically. Also IJVis a rare site to be involved in this process.Because IJV thrombosis has subtle and non specific clinicalfindingsitisoftenmissed.Weemphasize thatapotentiallylifethreatening complication can be diagnosed early by clinicalsuspicion on complaint of neck pain and confirmed by USGDoppler and early institution of therapy can prove life saving.References