Unprovoked Deep Venous Thrombosis Research Articles

F2c.*C20209T mutation in patients with a history of thrombosis: A case report, retrospective 2 site-results and review of the literature.

G20210A (c.*97G>A) prothrombin gene variant, found in white population has been associated with an increased risk of venous thromboembolism (VTE). Other rare polymorphisms in F2 gene (C20209T) have been reported, more rare and touching black people, but its potential association with VTE remain uncertain. About a 69 years-old Caucasian woman presenting an unprovoked deep venous thrombosis of the leg, we analyzed retrospectively 25.000 thrombophilia tests on a 11-year period of time (2007-2018), at Nice and Marseille University Hospitals, and performed extensive review of the literature. Genetic determination included a similar PCR protocol and sequencing. Twenty-one heterozygous cases out of 25.585 determinations (0.08%) was found. The C20209T mutation detected in our Caucasian patient is rare, with a frequency that differed from what was reported in the previous literature, mainly in non-Caucasian patients (Africans, Africans-Americans, and Caribbeans). One hundred and thirteen patients with this mutation have been described in the literature, of which only one homozygous. This study is the most important on C20209T mutation performed at present, allowing to precise its frequency and its potential role in venous thromboembolism.

Biomarkers Profile in Provoked Versus Unprovoked Deep Venous Thrombosis.

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), represents a substantial healthcare challenge. Provoked and unprovoked DVT cases carry distinct risks and treatment considerations. Recognizing the limitations of this classification, molecular markers may enhance diagnostic precision and guide anticoagulation therapy duration relying on patient history and risk factors. This preliminary, open-label, prospective cohort study was conducted including 15 patients (10 provoked DVT and 5 unprovoked DVT) and a control group of healthy plasmatic subjects. Plasma levels of 9 biomarkers were measured at diagnosis (baseline, day 0, and D0) and after 30 days (day 30-D30). Patient demographics, clinical data, and biomarker concentrations were analyzed. Serum concentrations of D-dimer, von Willebrand factor, C-reactive protein, and Anti-Xa were elevated in DVT groups at D0 compared to controls. No significant differences were observed between the provoked and unprovoked groups on the day of diagnosis and 30 days later. Over 30 days, the provoked group exhibited significant biomarker changes related to temporal assessment. No significant differences were noted in the biomarker profile between provoked and unprovoked DVT groups. This study is indicative of the concept of individualized thrombosis assessment and subsequent treatment for VTE. Larger cohorts are warranted to validate these findings and further define the most appropriate use of the molecular markers.

Deep venous thrombosis, as the earliest presenting feature of gallbladder carcinoma: Case report

Deep venous thrombosis is a common and potentially life-threatening condition that is often associated with various risk factors including underlying malignancy. In this case report, we present a male patient who presented with deep venous thrombosis as the earliest presenting feature of metastatic gallbladder carcinoma. This case report emphasizes the importance of thorough evaluation of patients presenting with unprovoked deep venous thrombosis to early detection of underlying malignancy.

Examining Postpartum Anticoagulation Practices: An International Survey of Healthcare Providers

Background Prophylactic anticoagulation is usually recommended for six weeks postpartum (PPM) for individuals at high risk of developing venous thromboembolism (VTE). However, there are no randomized controlled trials (RCTs) assessing optimal duration of prophylactic anticoagulation post-partum. Moreover, the risk is not equivalent throughout the six weeks as evidenced by a sharp decline in VTE risk following the third week PPM. These observations call into question the optimal duration of PPM thromboprophylaxis and whether a full six weeks is needed. Objective This study sought to determine postpartum anticoagulation practices and to explore practitioners' willingness to consider reduction of the duration of PPM prophylactic anticoagulation. Methods We conducted a cross-sectional study between December 2022 and April 2023 using a self-administered electronic questionnaire on the ‘SurveyMonkey’ platform to gauge international preferences for the use, dose and duration of postpartum anticoagulation . The survey was validated for face and content validity and explored expert preferences across complex PPM scenarios. Physician characteristics, years in practice, specialty and continent of practice were also collected. We employed various methods of dissemination including email, scientific conferences, expert groups, and social media. Results Of the 113 participants that responded to the initial invitation, 78 completed the survey with the following regional distribution: 53.9% from Europe, 23.1% from North America, and 19.0% from Australia and New Zealand. Among the respondents, 60% were haematologists, 20% were general obstetric physicians, and 13% were maternal-fetal medicine (MFM) experts. For prior unprovoked or hormone-associated deep venous thrombosis (DVT) or pulmonary embolism (PE), non-hormone associated provoked DVT/PE, cerebral venous sinus thrombosis (CVST) and splanchnic vein thrombosis, 97.4%, 93.5%, 91.0% and 88.5% of experts selected six weeks of prophylactic anticoagulation with LMWH postpartum compared to 3 weeks or prophylaxis with unfractionated heparin. This practice was also supported by 70.5%, 78.2% and 87.2% of experts in individuals with sickle cell disease (SCD), obstetric antiphospholipid syndrome (APS) and high-risk thrombophilia, respectively. For individuals with a history of unprovoked PE/DVT or history of thrombosis at atypical sites (splanchnic thrombosis or CVST) approximately half of the experts (48.7% and 47.4 %) were willing to offer thromboprophylaxis with 3 weeks of LMWH followed by 3 weeks of aspirin, while approximately one-third (34.6% and 32.1%) would consider 3 weeks of LMWH only (Table 1). Respondents managing more than 10 patients per year (p=0.0001), with over 5 years of practice experience (p=0.0004) and specialization in Haematology or MFM demonstrated a greater willingness to explore shorter durations. For scenarios of individuals with SCD, obstetric APS and myeloproliferative neoplasms (MPNs), with no history of VTE, a higher percentage of respondents (69.2%, 60.3%, 67.9%) would support 3 weeks of LMWH followed by 3 weeks of aspirin or no anticoagulation PPM (Table 1). For SCD, Haematologists were slightly less supportive (68.1%) than MFM (80%) and obstetric medicine physicians (75%) of shorter durations, although the difference was not statistically significant (p=0.45). For MPNs, Haematologists were more supportive of shorter durations (76.6%) than MFMs (60%) and obstetric medicine physicians (50%) (p=0.047). For obstetric APS, there was no significant difference amongst the specialties with respect to explore shorter anticoagulation durations. Conclusion The majority of experts (90%) prescribe a 6 week LMWH regimen for patients with a background of DVT/PE, thrombosis in atypical sites, or high-risk thrombophilias, while fewer adopt this approach for SCD, obstetric APS. Half of the specialists would consider shorter durations of prophylactic anticoagulation PPM for individuals with prior DVT/PE, thrombosis in atypical sites and even more (60-70%) for SCD, obstetric APS and MPNs. Experience and caseload influence acceptance of shorter durations. There is an urgent need for prospective studies addressing peripartum management of anticoagulation such as appropriate type, dosage, initiation timing and duration in different diseases, to provide evidence regarding optimal strategies.

Serial values of hematologic variables and deep venous thrombosis: Red cell distribution width is associated with deep venous thrombosis

IntroductionAs 30 to 50% of deep venous thrombosis (DVT) cases remain idiopathic, an increased focus on hematologic variables may therefore reveal novel correlates of DVT. Very few studies have investigated the association of hematological parameters with DVT and the causal relationship between them is still to be elucidated. Therefore, we aimed to investigate the association between serial values of hematologic variables and DVT. MethodsComplete blood count parameters were serially measured at baseline and then at approximately 3-month intervals for 12 months in 152 adults with the first episode of DVT and 152 age- and sex-matched controls. The odds ratio (OR) with the 95% confidence interval (95%CI) was calculated as a measure of association between hematological parameters and DVT. ResultsThe red cell distribution width (RDW) was the only hematologic variable which showed an independent and consistent association with DVT at all time points (multivariable-adjusted OR [95%CI] 3.38 [1.28 – 8.91] at baseline, 2.24 [0.85 – 5.92] at 3 months and 2.12 [0.81 – 5.55] at 12 months for RDW > 14.0%). This association was higher for provoked DVT than unprovoked DVT and for DVT plus pulmonary embolism than DVT alone. No significant correlation was found between the high RDW and classical thrombotic risk factors, except malignancy. ConclusionsWe demonstrated an independent and consistent association of the high RDW with the first episode of DVT in adult patients. The study was probably underpowered to evaluate the association between the high RDW and recurrent DVT. Further large studies with long follow-up are needed to confirm this association.

Prevalence of Thrombophilia in Indian Patients with Deep Venous Thrombosis – An 8-Year Single-Center Study

Background: Thrombophilia is a recognized risk factor for deep venous thrombosis (DVT) and its recurrence. Routine thrombophilia testing is controversial because of low yield and high cost. However, screening for thrombophilia helps in deciding the duration of anticoagulant treatment. The aim of this study is to determine the prevalence of thrombophilia in DVT patients in India. Materials and Methods: This was a retrospective, prospective, observational study done from April 2012 to April 2020. Thrombophilia screening was done in DVT patients who were <40 years, with unprovoked DVT, or with recurrent DVT. Homocysteine, antithrombin III, protein C and S, factor V Leiden, and lupus anticoagulant (LAC) were assessed. Follow-up was done to assess post thrombotic syndrome (PTS), pulmonary embolism (PE), and recurrence of DVT. Results: One hundred and sixty-six patients selected for thrombophilia out of which 163 were males. Patients were ranging age from 35 to 70 years. 82 (49.4%) patients had abnormal thrombophilia. 66 had one abnormal factor, while 16 had more than one. A total of 102 abnormal factors found in 82 cases, of which 41 had hyperhomocysteinemia, 20 protein S deficiency, 12 protein C deficiency, 15 factor V Leiden mutations, 8 antithrombin III deficiency, and 6 LAC. 10.2% of patients developed PTS, 16.3% recurrence, 2% PE, and 0.3% mortality. Conclusion: DVT patients are at a substantial risk of recurrence. Although laboratory evaluation of thrombophilia is costly but it is essential for monitoring therapy in certain sets of patients. Identification of thrombophilic condition is worth and affects the overall standard clinical management. In our study we found prevalence of thrombophilia in about 50% of DVT patients who are <40 years, with unprovoked DVT or with recurrent DVT. Out of which hyperhomocysteinemia is most common. But more studies including RCTs are required for further clarifications.

Extended Therapy After Unprovoked VTE: Bleeding Risk Is High

Current guidelines recommend continuing anticoagulation indefinitely after a first unprovoked proximal deep venous thrombosis or pulmonary embolism,

Elevated plasma factor VIII levels in a mixed patient population on anticoagulation and past venous thrombosis

BackgroundThrombophilia conditions are associated with an increased risk of venous thromboembolism. Elevated plasma levels of factor VIII (>150 IU/dL) increase the risk of venous thrombosis. The aim of this report is to analyze a subset of patients in whom plasma factor VIII levels were investigated as part of a thrombophilia panel at a specialty venous clinic at a tertiary care hospital. MethodsFrom January 2019 to December 2019, records of all patients (n = 306) who had a plasma factor VIII level assay performed as part of a thrombophilia panel were retrospectively analyzed. Group 1 (n = 92) had normal factor VIII levels (≤150 IU/dL), whereas group 2 (n = 214) had elevated factor VIII levels (>150 IU/dL). Venous thromboembolic events were classified as provoked if there was an association with surgery, trauma, immobilization, orthopedic fracture, peripartum period, or use of hormones. If there was no associated factor identifiable in the patient's history, the event was considered unprovoked. ResultsThe median age for patients in groups 1 and 2 was 55 and 65 years, respectively. Family history of deep venous thrombosis (DVT) was noted in 6 patients in group 1 (6.5%) vs 77 patients in group 2 (36%), P value: .0001. Unprovoked DVT was more commonly noted in group 2 patients (66%) compared with group 1 patients (5%), P value: .0001. In addition, venous ulceration was more commonly encountered in group 2 (23%) than group 1 (11%), P value: .008. Factor VIII level >150 IU/dL was a significant predictor of DVT occurrence itself (odds ratio: 3.3, P value <.005). Factor VIII level >200 IU/dL was a significant predictor of occurrence of two or more episodes of DVT (odds ratio: 12.3, P value < .005). ConclusionsFactor VIII levels were found to be elevated in a significant proportion of patients in whom thrombophilia testing was performed at a specialty venous clinic. This elevation was more common in patients with venous ulceration, a positive family history of DVT, and a personal history of an unprovoked DVT. Levels above 200 IU/dL were associated with DVT recurrence. This has important implications for secondary prophylactic strategies for DVT.

Correlation between climatic and biochemical parameters in etiopathogenesis of unprovoked deep vein thrombosis of the lower limbs.

Beside the intention of early detection and optimal treatment of deep venous thrombosis (DVT), the aim of this study was to investigate the influence of chronobiological rhythms on the etiopathogenesis of unprovoked deep vein thrombosis of the lower limbs with monitoring of seasonal variations in biochemical parameters. The prospective clinical trial included all consecutive hospitalized patients and outpatients diagnosed with DVT at the Vascular Surgery Clinic of the Clinical Center in Niš, starting from January 2013 to December 2014. There was no statistically significant difference in correlation between the distribution of the incidence of DVT of the lower limbs (p = 0.582), sex (p = 0.350), age (p = 0.385) and localization (p = 0.886) and the seasons. Creatinine levels were significantly higher in patients who developed DVT in spring than in those who developed DVT in winter (p < 0.05), while LDL cholesterol levels were significantly higher in patients diagnosed with DVT in winter than in those diagnosed with DVT in autumn (p < 0.05). According to the results of the study, it can be concluded that in the territory of South Serbia, the seasons are not significantly related to the incidence, sex, age and localization of unprovoked DVT of the lower limbs. Creatinine levels were significantly higher in patients who developed DVT in spring than in those who developed DVT in winter, while LDL cholesterol levels were significantly higher in patients during winter than during autumn.

INFERIOR VENA CAVA AGENESIS: ANATOMICAL VARIANT AS CAUSE OF RECURRENT DVT

SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Abnormalities of the inferior vena cava (IVC) are rare causes of deep venous thrombosis (DVT). The clinical presentation is often similar to that of an inherited hypercoagulabe condition. CASE PRESENTATION: A 27-year-old man with a past medical history of premature birth presented to the emergency department (ED) with left lower extremity (LLE) tightness and pain for one day. He had no history of recent travel and family history was negative for clotting disorders. Ultrasound (US) of the left leg showed an occlusive thrombus from the left common femoral to the left popliteal vein. The patient was discharged from the ED on rivaroxaban. Two weeks later, he presented to the ED again with progressive LLE swelling despite medication compliance. Physical exam was negative for testicular masses. Interventional Radiology (IR) performed a LLE venogram, which showed thrombus extention to the common iliac vein. US-assisted catheter thrombolysis (EKOS) was initiated. Heparin infusion was started and the patient was transferred to the intensive care unit. Repeat visualization the following day revealed improved clot in the left femoral and external iliac veins and a chronically thrombosed left common iliac vein. LLE pain and swelling improved and EKOS was discontinued twenty-four hours later. Hypercoagulability work-up was negative except for lupus anti-coagulant, the significance of which was difficult to determine, given prior anticoagulant exposure. On discharge, the patient was transitioned back to rivaroxaban. Five days later, the patient presented to the ED again with worsening LLE pain and swelling after initial improvement. Repeat venous US showed occlusive thrombus throughout much of the left femoral vein with only some flow at the distal aspect. An inferior vena cavogram revealed agenesis of the IVC with azygous continuation. CT angiogram of the abdomen and pelvis confirmed an occluded infra-renal IVC secondary to atresia. Patient was discharged on indefinite rivaroxaban therapy. DISCUSSION: This patient presented with an unprovoked DVT involving the common iliac vein that extended despite appropriate anticoagulation. Eventually, a venogram revealed agenesis of the IVC as the predisposing risk factor. In this condition, venous stasis presumably leads to increased risk of clotting. While bilateral DVTs are rare in the general population (approximately 10% of cases), they have been described in up to three quarters of patients with IVC abnormalities. This patient however, had extensive unilateral clot burden, usually seen in more distal anatomical abnormalities, such as May-Thurner syndrome. His premature birth likely predisposed him for an anatomical malformation. CONCLUSIONS: Unprovoked DVT in a young patient, recurrent DVTs despite medication compliance, and occlusion of the iliac veins, should raise suspicion for anatomical abnormalities, such as IVC atresia. Reference #1: 1. Chee YL, Culligan DJ, Watson HG. Inferior vena cava malformation as a risk factor for deep venous thrombosis in the young. Br J Haematol. 2001;114(4):878. Reference #2: 2. Ruggeri M, Tosetto A, Castaman G, Rodeghiero F. Congenital absence of the inferior vena cava: a rare risk factor for idiopathic deep-vein thrombosis. Lancet. 2001;357(9254):441. Reference #3: 3. Hamoud S, Nitecky S, Engel A, Goldsher D, Hayek T. Hypoplasia of the inferior vena cava with azygous continuation presenting as recurrent leg deep vein thrombosis. Am J Med Sci. 2000;319(6):414. DISCLOSURES: No relevant relationships by Amy Cohen, source=Web Response No relevant relationships by David Cohen, source=Web Response No relevant relationships by Aaron Dickinson, source=Web Response No relevant relationships by Mouhanned Eliliwi, source=Web Response No relevant relationships by Jennifer Meyfeldt, source=Web Response

In patients with an unprovoked deep venous thrombosis, what is the clinical utility of testing for FVL and prothrombin G20210A mutations compared with no testing at all?

Cleveland Clinic Family Medicine Residency, Cleveland, OH The authors declare no conflicts of interest.

Probative Value of the D-Dimer Assay for Diagnosis of Deep Venous Thrombosis in the Coronavirus Disease 2019 Syndrome.

To describe the predictive utility of the D-dimer assay among patients with the coronavirus disease 2019 syndrome for unprovoked lower extremity deep venous thrombosis. Prospective observational study with retrospective data analysis. Academic medical center surgical ICU. Seventy-two intubated patients with critical illness from coronavirus disease 2019. Therapeutic anticoagulation after imaging diagnosis of the first three deep venous thrombosis cases was confirmed; therapeutic anticoagulation as prophylaxis thereafter to all subsequent ICU admissions. Seventy-two patients with severe coronavirus disease 2019 were screened for deep venous thrombosis after ICU admission with 102 duplex ultrasound examinations, with 12 cases (16.7%) of lower extremity deep venous thrombosis identified. There were no differences between groups with respect to age, renal function, or biomarkers except for D-dimer (median, 12,858 ng/mL [interquartile range, 3,176-30,770 ng/mL] for lower extremity deep venous thrombosis vs 2,087 ng/mL [interquartile range, 638-3,735 ng/mL] for no evidence of deep venous thrombosis; p < 0.0001). Clinical screening tools (Wells score and Dutch Primary Care Rule) had no utility. The C-statistic for D-dimer concentration was 0.874 ± 0.065. At the model-predicted cutoff value of 3,000 ng/mL, sensitivity was 100%, specificity was 51.1%, positive predictive value was 21.8%, and negative predictive value was 100%. Lower extremity deep venous thrombosis is prevalent in coronavirus disease 2019 disease and can be present on ICU admission. Screening has been recommended in the context of the pro-inflammatory, hypercoagulable background milieu. D-dimer concentrations are elevated in nearly all coronavirus disease 2019 patients, and the test appears reliable for screening for lower extremity deep venous thrombosis at or above a concentration of 3,000 ng/mL (more than 13-fold above the normal range). Full anticoagulation is indicated if the diagnosis is confirmed, and therapeutic anticoagulation should be considered for prophylaxis, as all coronavirus disease 2019 patients are at increased risk.

SAT-250 A Case of Late Recurrent Cushing’s Disease Presenting with Proximal Myopathy

Patients with Cushing’s disease (CD) present with a variety of symptoms and comorbidities including central obesity, hypertension, hyperglycemia, fatigue, weakness, insomnia and mood changes. Proximal myopathy is one of the classical signs of hypercortisolism and patients typically report difficulty rising from a seated position or climbing stairs. Due to variability in clinical presentation, with some patients showing subtle or few symptoms, the diagnosis of CD can be delayed. We describe a patient with late recurrent CD whose primary symptom was proximal myopathy. A 63 yr. old man presented to our clinic with complaints of progressive muscle weakness and fatigue. He had been successfully treated for CD at age 35 with transsphenoidal pituitary adenomectomy. He had been on hormonal replacement therapy for panhypopituitarism since surgery including levothyroxine, testosterone and glucocorticoids. He noted progressive weakness for several years prior to presentation in our clinic. Earlier evaluations revealed vitamin B12 and vitamin D deficiency, but supplementation did not lead to significant symptom improvement. He suffered two episodes of unprovoked deep venous thrombosis with pulmonary embolism and developed a left biceps tear that required hospital admission. During admission, his muscle weakness was exacerbated by immobility and he was subsequently referred to endocrinology for consideration of steroid induced myopathy. He had been on physiologic glucocorticoid replacement since diagnosed with panhypopituitarism. At the time of our evaluation, he was able to ambulate with a walker, but was unable to climb stairs, drive a car and required assistance with activities of daily living. His only other symptoms were fatigue and insomnia. Laboratory testing after holding prednisone revealed: morning cortisol 31.7 mcg/dl (reference interval [RI], 4.0-22.0), ACTH 128 pg/mL (RI 6 - 50), FSH <0.7 mIU/mL (RI 1.6 - 8.0), LH <0.2 mIU/mL (RI 1.6 - 15.2), testosterone 85 ng/dL (RI 250 - 827), IGF-1 55 ng/mL (RI 41 - 279), prolactin 4.9 ng/mL (RI 2.0 - 18.0), TSH 0.01 mIU/L (RI 0.40 - 4.50), free T4 1.5 ng/dL (RI 0.8 - 1.8), HbA1c 6.8% (RI <5.7%). Prednisone was discontinued and hypercortisolism was confirmed by 1 mg overnight dexamethasone (dex) suppression test (Cortisol 32.4 mcg/dL, dex 517 ng/dL, RI 180-550 ng/dL) and elevated 24 h urine free cortisol 315.4 mcg/24h (RI 4.0 - 50.0). 8 mg DST showed mild cortisol suppression (Cortisol 21.2 mcg/dL, dex >1000 ng/dl). MRI confirmed recurrent tumor (1.2 x 0.8 x 1.3 cm) extending into the right cavernous sinus and the patient underwent repeat transsphenoidal tumor resection. Pathology confirmed ACTH adenoma. Our case report highlights that patients with CD can have late recurrences and require long term monitoring for return of hypercortisolism, even in cases of prior panhypopituitarism.

May-Thurner Syndrome and Recurrent DVT: A Case Report

May-Thurner syndrome/Cockets syndrome/ileocaval syndrome is a rarely diagnosed, anatomical and pathologically variable condition, causing venous flow obstruction in iliocaval territory. We report a case of 64 year old male patient who presented with unprovoked proximal deep venous thrombosis (DVT) of left lower limb. Evaluated for hypercoagulable state, which was negative, the patient underwent catheter guided thrombolysis and anticoagulation for 6 months. Two years later, he developed left lower limb swelling, and venous doppler revealed acute DVT; CT venogram was consistent with left common iliac vein compression by right common iliac artery suggestive of May-Thurner syndrome. Catheter-guided thrombolysis was done, and percutaneous transluminal peripheral angioplasty/stent was placed from inferior vena cava to left common iliac vein. This case highlights the importance of high index of suspicion in managing patients with DVT for possible ileocaval syndrome wherein anticoagulation alone is insufficient and needs more aggressive and definitive treatment to relieve the obstruction and to prevent recurrence.

Role of D-dimer in guiding duration of anticoagulant therapy in the management of first unprovoked proximal lower limb deep venous thrombosis

Background The optimal duration of anticoagulant therapy in management of patients with first episode of unprovoked deep venous thrombosis is uncertain. D-dimer test may play a role in the assessment of duration of anticoagulant therapy to decrease the rate of recurrence. Aim To evaluate if D dimer test can be used as predictor to guide the duration of anticoagulation in patients with first unprovoked proximal lower limb deep venous thrombosis. Patients and Methods One hundred patients with a first unprovoked proximal deep-vein thrombosis who completed 3 months of Vitamin K Antagonists (VKAs) and had elevated d dimer test 1 month after discontinuation of anticoagulation were randomly assigned either to resume (group A) or to discontinue treatment (group B). The patients were followed up for 1 year for recurrent venous thromboembolism and treatment complications. Results The mean age of the patients was 49.96±7.88 and 51.78±7.98 years for group A and B respectively. Male to female ratio was nearly similar in both groups 3:2 . The base line D-dimer level was 3.05±0.84 and 3.15±1.00 for group A and B respectively with no statistical significant difference. The mean duration of follow up was 10.6 months for both groups. The recurrence rate was higher in group B (7 cases) compared to group A (1 case) (P value 0.027) and this difference was statistically significant. No major bleeding or pulmonary embolism have been noticed in any patients during follow up. Conclusion Elevated D dimer test 1 month after discontinuation of 3 months anticoagulation, in the absence of recent thrombosis, could be an indicator for resumption of anticoagulant therapy for another 3 months.

SUN-581 An Unusual Presentation of Hypothyroidism

Introduction: Hashimoto’s thyroiditis (HT) rarely presents with clinical myopathy, with elevated muscle enzymes and acute kidney injury (AKI) due to rhabdomyolysis. A pilot study has suggested an increased prevalence of subclinical hypothyroidism in patients with unprovoked deep venous thrombosis (DVT). We report a case of HT presenting with asymmetric myopathy, AKI, and bilateral lower extremity DVTs, who responded well to thyroid hormone replacement. Case Description: A 58-year-old man with history of psoriasis presented with new erythematous plaques over the trunk and extremities for one month. He had episodic numbness and heaviness in the arms, thighs, and hands, especially when he held objects for sometime (e.g. steering wheel or holding a cell phone). He had difficulty in getting up from a sitting position. He also felt that his calves were swollen. He experienced stiffness in the hands. On examination, he had an asymmetric decrease in muscle power (4/5) in the proximal muscles of the upper and lower extremities. He had small circumscribed psoriatic plaques on the elbows, knees, and trunks. In addition, bilateral pitting edema was noted. Laboratory evaluation was remarkable for elevated creatinine phosphokinase 2310 IU/L, aldolase 15.6 U/L, elevated serum creatinine at 1.34 mg/dl, and elevated CRP at 9.5 mg/dl. Serological tests for connective tissue disease were all negative. Myositis associated and specific antibodies were negative. Electromyography was consistent with myopathic process with changes in numerous muscle groups bilaterally, most prominent in gluteus medius, lumbar, thoracic and cervical paraspinals. Nerve conduction study showed bilateral carpal tunnel syndrome. Three weeks later, his lower extremity swelling worsened. Ultrasound venous dopplers revealed bilateral DVT in the posterior tibial and peroneal veins. Thyroid function tests revealed elevated TSH (103.26 micro-IU/mL) and low free T4 (0.22 ng/dl). He has elevated thyroid peroxidase and thyroglobulin antibodies. He was hospitalized for management of unprovoked DVT and severe hypothyroidism secondary to HT. He was started on levothyroxine. Four weeks later, the myopathy resolved and muscle enzymes normalized. TSH improved to 35 micro-IU/ML. Discussion: HT presenting with clinical myopathy and DVT is extremely rare. Few features in this case raised the question of an alternative etiology for the myopathy – asymmetric proximal muscle involvement, acute to subacute course, and absence of myositis specific antibodies. In a pilot cross sectional study, increased prevalence of subclinical hypothyroidism was found in patients with unprovoked DVT, as noted in our case. This case highlights the atypical presentation of hypothyroidism due to HT. The identification of the hypothyroidism and initiation of thyroid hormone replacement improved the quality of life and physical function in our patient.

M\xe9n\xe9trier\u2019s disease presenting as recurrent unprovoked venous thrombosis: a case report

BackgroundAcquired thrombophilia is a potential sequela of malignancy, chronic inflammation, and conditions characterized by severe protein deficiency (for example, nephrotic syndrome, protein-losing enteropathy). As such, venous thrombosis is often a feature, and occasionally a presenting sign, of systemic disease. Ménétrier’s disease is a rare hyperplastic gastropathy that may lead to gastrointestinal protein loss and hypoalbuminemia. To date, reports of venous thrombosis associated with Ménétrier’s disease are exceedingly scarce.Case presentationWe report the case of a 40-year-old white man who presented with unprovoked deep venous thrombosis, pulmonary embolism, and renal vein thrombosis. Upon receiving therapeutic anticoagulation, he developed severe gastrointestinal bleeding, and endoscopic evaluation led to a diagnosis of Ménétrier’s disease. A laboratory workup revealed deficiency of protein C, protein S, and antithrombin III, as well as markedly elevated levels of factor VIII. He was determined to have an acquired thrombophilia as a direct result of Ménétrier’s disease.ConclusionsThis case describes an acquired thrombophilic state in a patient with Ménétrier’s disease and profound hypoalbuminemia. Although this association is rarely described, we discuss the probable mechanisms leading to our patient’s thrombosis. Specifically, we posit that his gastrointestinal protein loss led to a deficiency of several anticoagulant proteins and a compensatory elevation in factor VIII, as occurs in nephrotic syndrome and inflammatory bowel disease. Of note, this patient’s recurrent venous thrombosis was the initial clinical sign of his gastrointestinal pathology.

Antithrombotic therapy for venous thromboembolism in myeloproliferative neoplasms

In myeloproliferative neoplasms (MPNs) the incidence of venous thromboembolism (VTE) is 0.6–1.0 per 100 pt-years, and the rate of recurrence after VTE is 6.0–6.5 per 100 pt-yrs. Vitamin K-antagonists (VKA) reduces the risk of recurrence after VTE at usual sites (i.e., deep venous thrombosis (DVT) of the legs and pulmonary embolism (PE)) by 48–69%, with a rate of recurrent thrombosis per 100 pt-yrs of 3.4–4.7 on VKA and 8.9–9.6 off VKA; VKA discontinuation produces a 2.2-fold increased risk of novel thrombotic events with respect to continuation. However, the rate of both recurrent thrombosis and major bleeding on VKA is higher in MPN patients than in non-MPN patients, and the risk-benefit balance of long-term VKA treatment is challenging. In the absence of strong evidence, the tailored management of MPN-related VTE should operatively consider the risk categories for recurrence and bleed well established in the non-MPN setting. In summary, MPN patients with VTE are candidates for life-long VKA treatment, especially after unprovoked proximal DVT and PE. Aspirin can offer a moderate benefit in those patients who stop anticoagulation. The use of direct oral anticoagulants should be explored aiming to ameliorate the rate of bleeding.

Inferior vena cava calcification, a possible link with recurrent deep venous thrombosis and pulmonary embolism: a case study and review of literature.

Inferior vena cava (IVC) anomalies have been reported to have an association with deep venous thrombosis of the lower limbs. It is, therefore, necessary to study the IVC in recurrent cases of unprovoked deep venous thrombosis (DVT) and/or pulmonary embolism (PE), where all other causes have been excluded. We report a case of a 65-year-old male, who had recurrent episodes of DVT in the past 5 years; some of which associated with PE of unknown cause. CT thorax abdomen and pelvis did not find an obvious cause for the DVT and/or PE, however, it did highlight a diffuse calcification of the IVC. Only a few cases of calcification of the IVC have been reported in literature, and a number of them have been associated with clot formation and PE. We speculate that, as in other anomalies of the IVC, calcification of the IVC might slow the blood flow, and thus predispose to DVT and/or PE. Our opinion is that in all cases of unexplained DVT and/or PE, a careful examination of the IVC should be performed. Furthermore, when this condition is present, other risk factors for hypercoagulability should be avoided and anticoagulant therapy should be considered.

Deep Vein Thrombosis of the Left Leg: A Case of May-Thurner Syndrome.

A 56-year-old woman presented with gradually worsening shortness of breath associated with dull left leg pain over 5 days. She denied any recent travel, recent surgeries or immobilization.CT pulmonary angiography and CT venography revealed multiple bilateral pulmonary emboli and extensive left pelvic and left lower extremity deep vein thromboses. Contrast-enhanced CT showed that the right common iliac artery crossed the left common iliac vein and compressed it externally, indicative of May–Thurner syndrome. Catheter-directed thrombolysis of the left lower extremity was performed and heparin infusion was started. The patient also underwent left iliac vein balloon angioplasty with stenting and infra-renal inferior vena cava filter placement via the jugular approach to prevent further embolization.LEARNING POINTSMay–Thurner syndrome (MTS) should be suspected in patients in their second to fourth decade of life presenting with unprovoked deep venous thrombosis of the left leg.An iliac venogram is the diagnostic test of choice for MTS.MTS is treated only when it is symptomatic. The goal of treatment is to remove the clot to prevent post-thrombotic syndrome and to repair the anatomical defect.A stent was successfully deployed in the iliac vein of our patient and restoration of blood flow resulted in a dramatic improvement in the patient’s symptoms.