Acute pulmonary embolism due to right basilic vein thrombosis

Abstract

A 40-year-old African-American woman presented to the emergency room (ER) with right upper extremity pain for 3 hours after sleeping overnight on that side. She was diagnosed with basilic vein thrombosis; in the ER, she was tachycardic with minimal ambulation, prompting CT pulmonary angiogram, which confirmed right-sided pulmonary embolism. Bilateral upper and lower extremity venous Dopplers did not show any acute deep venous thrombosis. She received appropriate anticoagulation. Risk factors are a smoker and recently started contraceptive pills.

Background

Superficial vein thrombosis (SVT) may be coexistent with deep venous thrombosis in about 5%–50% of patients.¹ Early diagnosis and treatment will prevent the propagation of superficial thrombus progression to deep vein thrombosis (DVT) and pulmonary embolism. Upper extremity deep venous thrombosis contributes to 12%–20% of pulmonary embolisms.² SVT is generally considered a disease of the lower extremity. Upper extremity SVT is likely secondary to intravascular access or prolonged positioning. The incidence of SVT in the upper extremity causing pulmonary embolism is unknown. There are multiple case reports of lower extremity SVT contributing to venous thromboembolism (VTE) and very few case reports of upper extremity SVT contributing to VTE. Though upper extremity SVT complicated with VTE is uncommon, at-risk patients should be evaluated for its complications (pulmonary embolism).

Case presentation

A 40-year-old African-American woman presented to our emergency room with right upper extremity pain, waking her up from sleep. She was completely normal before going to sleep, and she usually sleeps on the right side. She has no significant medical problems and currently takes contraceptive pills for contraception, and she is an active smoker. She never planned kids. Family history is significant for two miscarriages in her older sister. On examination, she is in no distress, well-built and nourished. Temperature is 36.1 °C, respiratory rate is 15/min, pulse rate is 96/min, blood pressure is 120/66 mm Hg in the left arm, mild tenderness over the basilic vein; neurovascularly, she is intact otherwise.

She was diagnosed with acute right basilic (distal) vein thrombosis. She was on telemetry in triage. When she went to the restroom, her heart rate increased to 128 beats per minute. She denied any shortness of breath, chest pain, palpitations. A CT pulmonary angiogram was ordered for an increased heart rate, showing a 1 cm clot in the distal right main pulmonary artery. Essential blood work, including Complete blood picture (CBC), comprehensive metabolic panel (CMP), Prothrombin time/international normalized ratio (PT/INR), is within normal limits. She received intravenous fluids and got admitted for intravenous heparin.

Investigations

She had essential blood work in the emergency room, including CBC, PT/INR, D-dimer, BNP, troponins and a CMP. Except for her elevated D-dimer (1.29 mg/L), the rest of the labs are within normal limits. ECG showed normal sinus rhythm, ultrasonogram (venous imaging) of right upper extremity showed distal right basilic vein thrombus, and remaining veins are compressible (figure 1). CT angiogram chest with and without contrast showed acute right-sided pulmonary embolism, with a 10 mm clot in the distal right main pulmonary artery with no pulmonary arterial enlargement and right heart strain (figure 2).

Figure 1.

Non-compressible right basilic vein.

Figure 2.

1 cm clot in the distal right main pulmonary artery.

Differential diagnosis

• Cellulitis.

• Deep venous thrombosis.

• Septic thrombophlebitis.

• Tendinitis.

• Postphlebitic syndrome.

• Haematoma.

• Migratory thrombophlebitis.

• Erysipelas.

Treatment

Superficial thrombophlebitis is treated conservatively with a crepe bandage and NSAIDs. When she was diagnosed with acute pulmonary embolism, she received a 1-day duration of intravenous heparin infusion, followed by a loading dose of apixaban and then a maintenance dose for 3 months. She was discharged next day on apixaban loading dose followed by maintenance dose for 3 months because of suspected provoked thromboembolism secondary to contraceptive pill use and smoking. The patient was advised to discuss alternative options for contraception with her gynaecologist and nicotine patches to help with smoking cessation at discharge.

Outcome and follow-up

No deep venous thrombosis was seen in bilateral lower extremity venous Doppler at her primary care provider’s office 3 days after discharge. Her right upper extremity symptoms significantly improved within 1 week from the presentation. At a 1 month follow-up, vital signs were stable, tachycardia with ambulation resolved, at the end of the 6 min walk test, saturation was 96%, and pulse rate was 92 bpm. She completed a 3-month course of apixaban with no complications. After 3 months, hypercoagulable workup was done, including antithrombin III mutation, protein C, protein S levels, antiphospholipid antibody panel, factor V Leiden mutation and all the workup was negative. A final diagnosis of pulmonary embolism secondary to right basilic vein thrombosis (SVT) in the setting of contraceptive pill use and smoking was confirmed. She was taken off contraceptive pill 1 month from the diagnosis of pulmonary embolism.

Discussion

SVT is a self-limiting condition treated symptomatically with supportive care like warm compression, NSAIDs and limb elevation. The underlying inflammation contributes to pain, redness and swelling. On examination, it is warm to touch and tender palpable cord along the course of the superficial vein. Clinical assessment alone may underestimate the true extent of thrombosis, so venous Doppler examination is essential in diagnosing SVT.³

Unlike deep VTE, no definitive validated diagnostic algorithms are available for both upper and lower limb SVT. Ultrasonography is diagnostic and able to evaluate the true extent of SVT and exclude DVT. Ultrasound is the standard diagnostic test for superficial thrombophlebitis. The role of D-dimer in the diagnostic accuracy of SVT is not clear. Diagnosis and management of upper extremity SVT should include Constan’s clinical decision score, D-dimer testing and compression ultrasonography (CUS).⁴

If symptoms are very severe or have extensive thrombus and SVT proximity to deep veins, anticoagulation is prescribed to avoid complications like progression to DVT and pulmonary embolism.⁵ A close follow-up with a serial ultrasonogram or surgical thrombectomy is considered if anticoagulation cannot be tolerated. In rare situations, symptoms may persist for more than 3 months. There is no specific guideline to suggest a bilateral upper extremity venous ultrasonogram for SVT. It is prudent to obtain a venous Doppler on both sides to rule out any concomitant asymptomatic deep venous thrombosis in lower extremity SVT.⁶

Once the diagnosis is confirmed, and aetiology is identified, clinical monitoring is sufficient. Serial CUSs are only indicated if patient symptoms are worsening or the patient refuses anticoagulation. The most common risk factor for upper extremity SVT in hospitalised patients is the peripheral intravenous line. The duration of catheterisation, catheter material and catheter-related infection are risk factors for peripheral vein thrombosis. Here initial treatment of SVT is to stop the infusion and remove the peripheral intravenous line. Local anti-inflammatory cream can be applied, and analgesics are commonly used to treat pain associated with SVT.

Currently, there are no data to support the effectiveness of antithrombotic medications in upper extremity SVT. Smoking, overweight, recent surgery, hospitalisation, immobilisation, underlying malignancy, use of oral contraception, hormone replacement therapy in menopause, pregnancy and puerperium are substantial risk factors for VTE in patients with previous SVT.⁷ Our patient has multiple risk factors, including contraceptive pills, active smoking and prolonged sleeping on the same side for over 6 hours. Understanding the risk factors for VTE in superficial thrombophlebitis is key in prevention, early diagnosis and treatment.

Patient’s perspective.

I was surprised by the diagnosis of a blood clot in the lung. I clearly understood the risk of smoking and oral contraceptive pills. I immediately quit smoking with the help of a nicotine patch and followed up with my gynaecologist, and came off oral contraceptive pills. My younger sister is also a smoker and is also on oral contraceptive pills, and I do not want her to go through this, so I discussed smoking cessation with her.

Learning points.

• Superficial venous thrombosis is a relatively common clinical presentation in both inpatient and outpatient settings. It can be isolated or may be associated with underlying deep vein thrombosis (DVT).

• Isolated superficial venous thrombosis in a young female on contraceptive pills and smoker (risk factors for DVT) should prompt a further workup for venous thromboembolism. (Venous Doppler on both upper and lower extremities and CT pulmonary angiogram).

• A hypercoagulable workup should be performed after three months of anticoagulation for provoked SVT/pulmonary embolism to determine further anticoagulation needs.

Ethics statements

Patient consent for publication

Obtained.