“Thrombotic aura”: a case report

Abstract

Aura is a Greek word meaning ‘‘air’’ or ‘‘breeze’’. Nowadays in medicine it is used to signify a subjective sensation preceding a migraine attack (‘‘migraine aura’’) or pre-epileptic seizure. With regard to venous thrombo-embolism, a ‘‘thrombotic aura’’ might be what is described in the following case report. A 19-year-old female student (weighing 78 kg and a height of 178 cm) came to our institution complaining of left groin pain. Her past medical history was unremarkable apart from recent use of an oral contraceptive started 3 months prior. Symptoms had begun in the evening preceding referral to our Institution, when pain was also aggravated by movement, and markedly increased during the previous night. In the preceding week she had also suffered from sore throat with oral aphthous lesions without fever. A possible thrombotic disease involving the left lower limb was immediately considered. A pre-test Wells score gave ‘‘unlikely’’ probability (Fig. 1) [1]. The D-dimer level was as high as 4.0 mg/dl (normal values B 0.2 mg/L). A colour-Doppler ultrasonography of the entire lower limb venous system (from the calf up to the iliac system) was independently performed by two trained physicians, who did not confirm any thrombosis. No further imaging modalities were performed, because the clinical picture and the high levels of D-dimer were considered to be compatible with upper airways viral disease and with an US-evidenced reactive left inguino-crural lymphoadenopathy. The patient was discharged with a pain killer (acetaminophen-codeine), and the recommendation to stop the oral contraceptives and enoxaparin 8,000 IU sc/day. She was scheduled to return to our centre for a repeat ultrasound examination and D-dimer study the day after. The day after, the left groin pain was no longer present. Her physical examination as well as ultrasound examination (performed also on this occasion by two different specialists) was negative. However, as the D-dimer level was still positive (2.6 mg/L), she was scheduled to return for a third examination after 48 h. On that occasion, the clinical situation was unchanged, and the leg vein ultrasonography (US) was normal even in the hands of a third specialist. In this case, US was extended to cover investigation of the portal and caval veins. The D-dimer level was slightly lower yet above normal values (1.6 mg/L). Enoxaparin was stopped, and the patient was discharged, but strongly suggested to return should any symptoms appear. Seven days later, the patient was admitted to the emergency department owing to massive oedema in the entire left lower limb. Symptoms had begun the previous evening. In the day preceding admission she had suffered from a syncopal episode when rising from a sitting position. The Wells score was ‘‘likely’’, and ultrasound showed hyperechogenic material in the iliac-femoro-popliteal and calf left veins. An angio-MR confirmed the diagnosis of deep vein thrombosis (DVT), and showed the compression of the left iliac vein at the level of the iliac artery at the cross level, with lumen reduction [2] but no inferior cava vein congenital agenesia [3]. Cardiac ultrasound, chest X-rays, and gynaecological examination were normal. In spite of a high clinical probability of pulmonary embolism [4], a spiral lung scanning was not performed to prevent unnecessary L. Simioni (&) High Intensity Care Unit, Department of Medicine and Rehabilitation, ULSS 2 FELTRE, Regione Veneto, Feltre (BL), Italy e-mail: liviosimioni@libero.it